Hashimoto’s Thyroiditis with Lara Zakaria: Rational Wellness Pocast 383

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Lara Zakaria discusses Hashimoto’s Thyroiditis with Dr. Ben Weitz.

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Podcast Highlights

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Lara Zakaria is an Integrative Pharmacist, Certified Nutrition Specialist and an IFM certified Practitioner. Combining her background in pharmacy and training in Personalized Nutrition, Functional Medicine, and herbalism, Lara designs personalized protocols that incorporate whole food, herbs, nutrigenomics/pharmacogenomics, medication history, and lifestyle modification to help patients achieve their health goals.  Her website is LaraZakaria.com.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

 

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Podcast Transcript

Dr. Weitz:  Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz. com. Thanks for joining me, and let’s jump into the podcast. Hello, Rational Wellness Podcasters.

Today we’ll be having a discussion with Lara Zakaria, the foodie pharmacist, about how to help patients with autoimmune hypothyroidism, also known as Hashimoto’s thyroiditis. Which is the most common autoimmune condition in the United States?  I’m going to talk for a few minutes about the prevalence of hypothyroid, and I wanted to give you a little background about the history of iodine supplementation, [00:01:00] which kind of changed the landscape of thyroid conditions in the United States. So, the prevalence of hypothyroid in the U. S. has been increasing.  From 2012 to 2019, the prevalence increased from 9.5 percent to 11.7%. The prevalence of untreated hypothyroid has increased from 11.8 percent to 14.4%. Greater than 78 percent of patients treatment consists only of T4, also known as Synthroid. In the body, T4 is then converted into T3, which is actually the active form of the hormone.

And hypothyroidism is nine times more likely in women than in men. Now, overt hypothyroidism is defined as elevated thyroid stimulating hormone. in combination with 3T4 below the reference range. Then there’s something [00:02:00] called subclinical hypothyroidism, and this is defined by elevated TSH, but normal 3T4.

So now I want to talk for a couple of minutes about the history of hypothyroidism in the U. S. So today, over 90 percent of those with hypothyroidism have Hashimoto’s, which means it’s an autoimmune condition not arising from an iodine deficiency. Prior to 1924, the main cause of hypothyroid in the US was iodine deficiency, especially across the northern part of this country and across Appalachia, where the soil was iodine deficient and this was known as the Gorder Belt. Iodine deficiency leads to enlargement of the thyroid known as goiter, and in extreme cases, this leads to [00:03:00] impaired neurological function, stunted growth, and physical deformities known as cretinism.  But then, starting in 1924, a hundred years ago, we instituted iodized salt, and rates of goiter dropped to very low levels. Unfortunately, rates of Hashimoto soared. And in fact, this same pattern was repeated in other countries around the world. So that’s to set up the background a little bit.

Lara Zakaria, I hope I pronounced that properly, is an Integrative Pharmacist, Certified Nutrition Specialist, and an IFM Certified Practitioner.  Combining her background in pharmacy and training in personalized nutrition, functional medicine, and herbalism, Lara designs personalized protocols that incorporate whole food herbs. Nutrigenomics, Medication History, and Lifestyle Modification to Help Patients Achieve [00:04:00] Their Health Goals. Welcome, Lara.

Lara Zakaria: Thank you so much for having me, Ben. There we go.

Dr. Weitz: So, what is the thyroid gland and why is it so important?

Lara Zakaria: Great place to start, right? Let’s set up the foundation. So the thyroid gland is a butterfly shaped gland that sits right at the base of the throat. So very often you’ll see imagery of butterflies.  In fact, the blue butterfly has been adopted as the symbol for the thyroid gland. And it, its job is to produce the metabolic master hormone thyroid. And you know, not to sound melodramatic, but this is literally the hormone that is probably most responsible for activating or slowing down our metabolic process.  It’s essential from every step of life, from conception to to gestation through childhood growth, making sure that everything, all, all the different cells and organs are growing healthfully. And as [00:05:00] we grow into adulthood, ensuring that we have a healthy metabolism, it’s lockstep with the way like our insulin hormones function, our other metabolic hormones function, and is responsible for, you know, the basic foundational stuff, heart rate, respiration rate, digestion, as well as some of the things that we consider superficial like hair growth, nail growth, skin texture, and quality. So very often we can easily assess that there’s something metabolically happening from some of the superficial function, and then when we start to see that metabolic decline, it starts to get more and more insidious and more and more serious.  We start to see changes. in digestive function, in menstruation, in fertility, and then eventually we start to see things like outright primary hypothyroidism and outright conditions that really start to cause disruptions in metabolic function.

Dr. Weitz: So when they have outright hypothyroidism, what sorts of symptoms do you see then?

Lara Zakaria: So most people will present with fatigue, brain fog, energy issues. You’ll also see sometimes joint pain or difficulty recovering from workouts. That’s even if they can get themselves to do the workout. For a lot of people, it’s again, those superficial symptoms, changes in hair texture or hair quality, the rate at which their hair might be growing, their skin changes.  It doesn’t have that. Luster to it as much. It might be drier or might even have to be so dry that it’s causing irritation or scratching changes in the nail bed quality, the length, the growth, and the strength of the nails, and a lot of these symptoms actually very closely mimic it, anemia, or iron deficiency.  And so for some folks, that first step is often distinguishing whether they have an iron deficiency that might be causing some of these disruptions, because that’s a very important mineral, of course, or if this is caused by metabolic issues from [00:07:00] the hormonal dysfunction. The other piece of it is that we actually need iron as part of our process to make Thyroid.  So the two are intertwined. So just because they have iron deficiency doesn’t mean it’s not impacting their thyroid and vice versa.

Dr. Weitz: Great. So let’s go into the proper testing for thyroid. Which tests should be run? Which tests do you like to run? And what do they tell us?

Lara Zakaria: Okay, so this is, this is a controversial topic because the guidelines recommend that we test the TSH.  There are some recommendations to either get a T4, what’s called a reflex T4. In other words, a reflex T4 is if you test A TSH and it’s out of range, it’ll, the lab will automatically run a T4 or you outright ask for a T4, and most clinicians will recommend a free T4, meaning it’s unbound to protein,… 

Dr. Weitz: And this is all to save an extra $10 for the insurance company.

Lara Zakaria: Well, to be fair, I’m going to run the list of the various [00:08:00] labs that I would recommend, but I would say that this is an okay starting point if we add the T4 at least, right? That’s an okay starting point. The problem with TSH on its own, one, the reference ranges on most labs are so wide, it’s very easy to miss an outlier that might cause that TSH to look like it’s normal, number one.  Number two if you have a normal TSH, we’re not directly measuring the thyroid activity. We’re measuring the activity of the hormone that stimulates thyroid production. If there’s no issue with that part of the process but the issue is further down the line, we might potentially miss that. So if the issue is from converting T4 to T3 and we never measured a T3, Or even better yet, a reverse T3, then we’re missing the potential conversion issue, which is all, a couple of steps down from TSH production, right?  So when you think about it, there, let’s, let’s back up a little bit, and let’s just do a quick refresher of the, the biology of thyroid production, right?

Dr. Weitz:  Accepted range in conventional medicine for the TSH. Is it 0.5 to 4.5 or so? 

Lara Zakaria: It depends on the lab. It can vary from lab to lab. The average that I see is usually somewhere between 0.5, maybe 1.5 on the low end up to 4 or 4.5 on the high end. That’s, that’s what I typically see on most standard lab testing. Some labs are going to vary because what they’re doing is they’re taking a population average. And sometimes they’re doing that local population. So if they’re doing it in New York or they’re doing it in California, there might be a variation on what that average looks like.  So that’s why you’ll see slight variations on that. That said, that that recommended range is based on what a quote, healthy population could potentially fluctuate in their TSH. And that’s fair, but you’re taking an average, right? You’re not necessarily honing in on what’s optimal and you’re not necessarily honing in on all the various factors that can impact that average.  Age, Gender, Inflammation, Nutritional Status. All these factors can [00:10:00] impact where that TSH might land. And then there’s bio individual differences of where somebody’s TSH might be. 

Dr. Weitz: And we could argue that the average American is far from being healthy, so. 

Lara Zakaria: That’s a very good point. What is defined as healthy, right?  Right. Just because somebody doesn’t have TSH, maybe a diagnosis of hypothyroidism. They could call that healthy but they might have another physiological or metabolic condition that might alter again that TSH level and that function. So I think that’s, that’s a basic problem. So if we’re just relying on one marker in order to diagnose Transcripts What essentially could be multiple conditions, right, because there’s hypothyroidism, hyperthyroidism, autoimmune, there’s Graves, there’s Hashimoto’s, there’s subclinical.  So there’s multiple things that could be happening, multiple reasons why those could be happening, but we’re only looking at one marker to try to identify. I think we’re putting a lot of pressure on TSH, frankly. I’m not saying throw it out. I’m just saying maybe that’s not enough and one good [00:11:00] basic step might be to add that T4 maybe I, I don’t know.  I kind of like a total T4 with a free T4 as a basic starting point. ’cause then I know how much of that binding globulin might be holding onto T4 and how much of it is actually bioavailable. That gives me a clue as to what might be happening physiologically to the rest of the hormones, let alone to the T3 and everything else down the line.  Now that said, we got to now convert T3 to T4, excuse me, to the active T3. That takes its own step. Then we’ve got to take that T3 and we’ve got to shuttle it over to the rest of the cells and they’ve got to engage with the cell receptors, fit that lock and key, so that we can then activate those cells and turn the metabolic process on.

A couple of things could go wrong there. We could potentially not have. Primarily enough T4 being produced. And we would catch that with a, with a T4 or free T4 measure. We could be [00:12:00] converting T4 to reverse T3 instead of to active T3. And again, if we’re not measuring reverse T3, T3 and free T3, then we’re not potentially catching that.  We might have a lot of binding globulin. We talk about sex hormone binding globulin when it comes to testosterone and estrogen levels and how that could potentially impact hormones. But those same. Binding globulin, I call them Ubers. They’re like the Ubers of our hormones. Our hormones can’t just walk down the street on their own.  They’ve gotta take, they can, they need a ride, right? Right. So they call the Uber. That’s the binding globulin. Thyroid has its own binding globulin, and very often the amount of binding globulin for thyroid MI mimics that of the sex hormones. So if there’s something that’s activating, increased. There’s more Ubers on the road.

For example, if somebody’s on estrogen therapy, that could increase their sex hormone binding globulin. That could also potentially increase their thyroid binding. So you’d have more bound thyroid than free thyroid. So again, measuring the bound [00:13:00] versus the free can be really helpful in identifying Is it a problem of too many thyroid’s not getting out of the car, or is it the problem somewhere in the conversion?  Or, if I measure reverse T3, I can now see if stress might be, or inflammation might be, activating that conversion from an active T4 to a reverse T3. 

Dr. Weitz: And for that reason, is it good to measure the thyroid globulin as well?

Lara Zakaria: You can, it’s a little bit harder to get. And so kind of, I’ll come back to this point about kind of choosing, choosing your own adventure based on the access, the lab that you’re using and the cost.  But if you can, you, you sure can, but I think you can actually get enough information from just getting the bound and the free, but if it’s available and you, you want the extra data to confirm your findings, I think that’s. That’s reasonable. And then kind of going back to go down the line, you have now that T3, it gets in its uber, it goes to the cell site, it gets to the receptor, that key does not open the lock.  Again, we talk about insulin resistance and we talk about [00:14:00] insulin resistance being an issue with the receptor activation and the acceptance of that insulin into the cell. Thyroid has a similar activity it has to go through. So if there’s an issue with the cell receptor sensitivity to the thyroid hormone, that’s also going to create another barrier for activating metabolism.

So when we can kind of get that full picture, when we can understand just from a hormonal perspective. TSH plus free total T four, free T four total, T three, free T three, reverse T three in my opinion. That would be foundational. And then from there we can start to get a little bit fancier. We can start to assess some of the nutrients that are involved in those steps.  We can start to understand some of the we can look at autoimmune factors from there, if we wanna assess to see if there’s an autoimmune process that’s that’s creating the thyroid dysfunction. And then we can start looking at things like stool testing, hormonal testing, et cetera, to see if there’s these other factors that might impact a thyroid function.

Dr. Weitz: Well, given the fact that most [00:15:00] cases of thyroid problems are autoimmune, shouldn’t we automatically be measuring the TPO, the TGB, and perhaps the TSI?

Lara Zakaria: I think so. I think if you have a family history of autoimmune disease autoimmune diseases tend to run in clusters. So if we see them particularly on the maternal side, because they do, they are more prominent on in women than men.  If you particularly see a history of it, I think it’s a good idea to at least, you know, annually, if not every couple of years, to run that autoimmune panel, especially if you already have either symptoms of hypothyroidism or hyperthyroidism for that matter. Or if you have a diagnosis of hypothyroidism.  I have seen it over and over and over again, where somebody gets that diagnosis of hypothyroidism, they get, medicated or it’s either, you know, it’s either a borderline. And so they’re not medicated yet, or they get started on HRT for thyroid, but they never go back and recheck that [00:16:00] autoimmunity, right.  They, they checked it the first time it was within range. But at some point, it pops up. So it’s a little, it’s a little deceptive. If it’s not triggered, and if you’re not in an auto, in an immune flare, you may not catch that autoimmunity. And so it’s really important, in my opinion, especially if you have a history of hypothyroidism, if, especially if your hypothyroid systems are not fully resolved with hormonal replacement therapy, to periodically check for autoimmune disease.  Because as you said, Ben, it is the Hashimoto’s is the number one cause of hypothyroidism.

Dr. Weitz: Good, so that’s a good clinical pearl. You have a patient, they test negative for thyroid antibodies, so you decide they don’t have autoimmune thyroid, check it again at some point in the future because they may actually have it and those markers just may not have been elevated at that time.

Lara Zakaria: Absolutely, absolutely. And I would do all of the thyroid antibodies. I think we often stop at antithyroplobulin, but I think doing all of [00:17:00] them comprehensively is a good idea because that really gives us a better perspective because the way that that autoimmune presentation shows up, might be a little, again, it might be a little insidious and it might I’ve seen cases, Hashimoto’s is notorious for flipping between hyper thyroid symptoms and hypo thyroid symptoms.  And I think that’s that presence of the variation in the way those antibodies are showing up. So I think it’s a good idea to sort of throw a wide blanket on it until you get a good sense of what their triggers are, what that process looks like for them. And that really can be so validating for patients that keep saying like, I don’t feel good.

Like I’ve been taking my medications. I’m so meticulous about taking and taking away from food. I still don’t feel good. That could be really validating to say, Hey, it’s actually not your thyroid. It’s actually your immune system. That’s causing some of that issue. Let’s address the immune dysfunction and let’s treat that root cause.  And that usually really helps to keep them stable and they feel so much better. And those symptoms start to resolve. 

Dr. Weitz: I’ll tell you what, why don’t we go into that first and then we’ll get into directly treating the thyroiditis. How do we address the autoimmune condition?

Lara Zakaria: Okay, so we’re going to zoom out now, right?  Autoimmune disease, right? Autoimmune disease versus thyroid disease, right? So number one, I think conventionally we have, a lot of us have been trained that autoimmune disease is like a subset, the Hashimoto’s is a subset of thyroid disease. And I actually don’t look at it that way. I look at it as a different disease altogether.  It’s a disease that impacts the immune system that happens to target the thyroid. Similar to how Crohn’s is an autoimmune disease, it’s an immune disease dysfunction that happens to target the thyroid. The colon, right? So I think that’s a really important distinction. It means that we still need to treat the thyroid.

We need to address the hypothyroidism, but we actually also have a responsibility to look a little bit more upstream and actually balance the immune system. And I’m seeing [00:19:00] the approach change significantly. I used to hear a lot from my patients saying, like, Well, my doctor said it is Hashimoto’s, but there’s nothing they could do about that.  So I just keep taking my levothyroxine and call it a day. And I’m like, whoa, whoa, whoa, pump the brakes. There’s actually so much we can do. Number one, balancing the immune system with nutrition, making sure that you have all the basics when it comes to reducing oxidative stress. balancing the immune system, optimizing your vitamin D levels, your beta carotene and vitamin A levels, making sure your vitamin C is optimized.  We can use things like quercetin, and we can really like focus in on that nutritional aspect. Antioxidants, things like EGCG and resveratrol all have been proven to to sort of balance that immune response. Selenium is really interesting. Actually, selenium and zinc, they’re kind of buddies, are really interesting because both have direct antioxidant activity.  And that’s why they’re so central in both primary hypothyroidism and autoimmune hypothyroidism because not only are they part of the physiological process of making thyroid, they’re also involved in [00:20:00] the conversion and activation of thyroid and they have antioxidant activity as well. So they directly kind of impact that intersection between the autoimmune and the primary hormonal dysfunction.

And then other factors are gut health. That’s probably foundational. I would say that’s probably foundational for primary hypothyroidism too, but it’s especially important when it comes to autoimmune conditions, ensuring that we balance out any microbiome disruptions, any dysbiosis is addressed, any overgrowth is addressed, we’re addressing any intestinal permeability, and that we’re making sure that folks are balancing their make, they’re pooping every day, that they’re getting their, their stuff out on a daily, regular basis.  They’re having healthy, robust formed stool every day is really, really important. Again, this is, sits at the intersection of both primary hypothyroidism as well as autoimmune, but really kind of like a foundational piece in my [00:21:00] opinion and for anybody who’s managing autoimmune patients. Another factor we kind of.

Glossed over is the adrenal piece and the stress piece. I always tell my patients, your adrenal glands and your thyroid glands are buddies. If your adrenal glands, we’re not keeping your adrenal glands happy. Your thyroid gland is going to tell us about it. They are two peas in a pod. So when we have thyroid disruption, we often see issues with catecholamine production and cortisol production and vice versa.  If you are stressed and you’re not dealing with the stress primarily, you’re not going to see the benefits on your thyroid as effectively. So I think that’s a really important factor. So addressing stress, you know, foundational stuff, finding ways to manage our stress. We can’t completely avoid it right away from it, but finding ways to manage that and making sure that we are also accounting for cortisol dysfunction, high or low.

I very often find folks with thyroid issues tend to actually run on the low side and that their circadian rhythm sort of disrupts the [00:22:00] amount of cortisol that they produce and they’re sort of sluggish and dragging and don’t like have that energy in the morning. So if they’re telling me that, I definitely want to support their adrenal in one way to help to actually improve their adaptive response. If they’re super high stress, wired, having trouble sleeping, you’ve seen that elevation of the cortisol later in the day, then we want to neutralize and bring that cortisol down and then addressing sort of that catecholamine, the, the, the, the excess caffeine use because they’re trying to take advantage of that energy surge because they’re exhausted.

We want to make sure that we are addressing any low dopamine issues because they’re taking all that dopamine and they’re making epinephrine and norepinephrine instead. So they’re turning over those stress hormones very quickly and then doing all and then addressing how that’s impacting their gut function and, and all the other factors in terms of hormone balance.

Dr. Weitz: Right. And so let’s go into how do we treat the [00:23:00] Hashimoto’s? And why don’t we, would you rather start with diet and supplements? Or would you rather start with drugs? How would you like to handle it? 

Lara Zakaria: Let’s start with the medication. Let’s start with the way it’s usually addressed. And then let’s use it with some of the, you know, all the good stuff that we can do more.

Dr. Weitz: Right. Okay. So we just give the patient Synthroid, end of the story, right?

Lara Zakaria: Yeah. That’s it. Call it a day. End of podcast. Right. So I will never, I, there’s a lot of also kind of chatter about, Oh, Synthroid is bad. Levothyroxine is bad. It’s synthetic. It’s, it’s fine. It, so many people do so well on Synthroid and there’s arguably some Hashimoto’s folks actually do better on Synthroid.  And it just has to do with the way their body utilizes it and how it can convert it. So. If level, if you’re on levothyroxine, that does not mean that we have to discontinue levothyroxine. However, to the point you made earlier in the introduction, that’s only a T4. So if we’re not addressing conversion from T4 to T3, or there’s [00:24:00] additional dysfunctions that are slowing down that conversion, then we either have to optimize that conversion through nutrition and lifestyle factors.  Or we need to then go in and add a T3. So it is possible, you know, we could do that as well through medication. You can do bioidentical hormones. That’s totally fine. You can also do it through traditional prescriptions. And I think it’s important to note that because for some people, the availability cost wise.

Some people can’t afford to do, you know, their insurance doesn’t cover it. They need to go with what their insurance covers. Number two, there are supply issues sometimes with some of these medications, but specifically the bioidentical hormones and the sort of older grandfathered bioidentical hormones that are available on the shelf, like R morthyroid, et cetera.  And so that could be a challenge. Also, thyroid is a very narrow therapeutic index. The great thing about levothyroxine is it comes in a quarter microgram increment. So you really can hyper personalize a dose. And for people with Hashimoto’s, they might change [00:25:00] their dose on a day to day basis. They’re feeling a little bit too high, they might cut the dose down.  So having that ability to adjust the dose by that fraction of a, of a microgram can really help them to, really empower them to make those changes very quickly. On the other hand, your armor thyroids, etc. Those don’t have a very wide dosing range. And so again, you might not feel good on them simply because it’s, you just can’t get that right.  You know, like you put on a shoe and the half size up is too big and the half size down is, it’s kind of like that but more serious because you feel like. Crud, right? So, it’s, it’s I think important to kind of know that we need to choose the medication that’s going to work best for the patient and then work on it from there, right?

Whether we need to add a T3, that’s one option, or we can really focus on those factors that are going to improve conversion from T4 to T3. So, from, from a, from a conversion perspective, Stress and inflammation play a huge role. So if you’re managing somebody that’s on a [00:26:00] levothyroxine and you’re not addressing foundational aspects of stress management and you’re not addressing any other of the root causes of inflammation, that’s going to impact how well they can make that T3 and potentially might increase the reverse T3 that they’re making.  In addition to that, Nutrients, Selenium and Zinc. I told you those guys are buddies and those are the star of the show when it comes to thyroid, but also vitamin A, vitamin E, and I would say antioxidants in general can be really helpful for that conversion piece. 

Dr. Weitz: So just to clarify for people who are listening out there who are not really familiar with thyroid medication we’re talking about straight synthetic T4, which is known as Synthroid or Levothyroxine, as compared to what you’re referring to as bioidentical, which is thyroid from ground up pig’s glands, essentially, that contains T4, but also contains some T3 and even some T2 and T1.  And so having a [00:27:00] balance of some T3 with the T4 is more of a natural type of sub of medication and may make it easier for the person to feel better because some of the T4 is already in the active T3 form. Or another option is you can add a synthetic T3 to their T4 if the person’s having trouble converting the T4 to T3 perhaps, right?

Lara Zakaria: Yes and no. What, what I’m saying is that, that different people will respond to different formulations, right? Because for example, in the the, I, the, in the versions, for example, like Armor Thyroid, or those are porcine derived to your point, there’s a combination of all the potential, it’s a glandular formula.  And so there is a combination of T4, T3, and yes, even T2, which is less bioactive. And we don’t really talk about it as much as sort of the by product of T3 breakdown. However, we can’t always, [00:28:00] you’re not going to have consistency in the amount of T4 and T3 that are in those formulas. For some people who are hypersensitive, that variation from batch to batch or the wideness of that dosing parameter, the way that it comes in a capsule or tablet, it’s going to miss them.  It’s either going to be too high, too low. We’re not going to get the Goldilocks out of it. We’re not going to get the just right dosage. In those cases, they actually, those folks might actually do better either on a customized bioidentical formula, a compounded formula that’s very exact and precise. Some people do better on synthetic and they don’t do as well on bioidentical.

And by the way, bioidentical in this case is not accurate. If it’s porcine derived, that’s not bioidentical, that’s porcine derived, right? Synthetic is actually closer to bioidentical because it actually looks exactly like the one that humans make. And then there’s the compounded that could be either porcine derived.  They could also be derived from cattle instead of porcine. So if there is a [00:29:00] kosher or halal consideration, that’s also sometimes an option. And then there’s obviously synthetic instead. So there’s the, the, it really honestly depends. And what I, I too, there’s two myths I want to bust when it comes to medication and HRT when it comes to thyroid.

Number one, that the goal is always getting off of the thyroid HRT. I don’t think that’s necessary. I think some people have a reduced capacity to produce the hormones, and we need to supplement it, and if they feel good on it, that’s great. Like, that goal should be that they feel awesome, right? What we want to do is optimize it, and if they don’t need it, yeah, reduce the dose or eliminate it.

If it’s unnecessary, go ahead and de prescribe it. Myth number two is that bioidentical or animal derived is always superior to synthetic, and that’s not necessarily always the case. And true individualized and personalized medicine should actually respect what actually works best for the patient, and, and we should be kind of using [00:30:00] all of those options in our toolkit to make it fit for them, not only to make them feel great, but also, you know, what they feel is best for them, what their their own beliefs are in terms of what’s appropriate for their therapy.

Dr. Weitz: Yep. And then another issue that a lot of times we might want to deal with is prescription medications are typically have added additional ingredients like food dyes and coloring agents and a bunch of stuff that perhaps gluten even that we don’t necessarily want or that the person may be sensitive to.

Lara Zakaria: Absolutely. I think that’s a great layer to add to that. The bottles that we’re pulling off the shelf in a pharmacy if they’re coming from a standard manufacturer, are not going to have that layer. They’re not paying attention to gluten and they are using dyes. On one hand, it’s a safety concern, right one hand.  The binders that they’re using are safe. They, we know that they’re not interfering with the [00:31:00] bioavailability of the thyroid hormone. Those colors aren’t interfering with the bioavailability of the tho thyroid hormone and arguably. really help us identify giving the right dose. So when we’re sitting there dispensing as pharmacists, the color usually cues us.  Most pharmacists that work in community pharmacy could probably tell you what color goes with what dose because it’s so ingrained in our head because we dispense so much of it. And that could be a really helpful like seeing the color and go, Oh, that’s not the right color. Oh, I grabbed the wrong bottle.

On the other hand, if you have a patient who is sensitive to those, and I’ve seen it where patients will say, I don’t feel good when I take this brand, I feel okay. When I take this one, I don’t feel as good. And I’ve seen where pharmacies will dismiss those concerns. So on the other end of that spectrum is we need to also be really open minded as clinicians and hear out our patients and hear out their feedback and try to work with them to really find.  Again, that ideal formulation that’s going to work for them.

Dr. Weitz: That’s great. I wanted to mention one issue that sometimes is not, is ignored [00:32:00] concerning thyroid testing, which is that depending upon the lab, if the person is consuming biotin, especially in higher levels. That can affect the way the test comes out.  And how do you address that?

Lara Zakaria: Well, usually we just have folks discontinue their biotin supplements or B complex as sometimes we’ll contain a biotin. We’ll usually have folks discontinue. I usually recommend if it’s not something that you have to be on, like, if it’s not something like, if I don’t take this, I can’t function today.  Go ahead and discontinue it before testing at least a couple days before. My general rule of thumb for my patients is if it’s water soluble, I’ll tell them two or three days is usually enough to flush it out. If it’s fat soluble, I usually kind of make the judgment call because it’ll take weeks for some fat soluble vitamins to really adjust.  So from there, I’ll say, let’s say I really want to get an accurate vitamin D level. I rarely tell my patients to get off vitamins before I test it, but I might say, you know what, let’s take a break from the vitamin D for two or three weeks [00:33:00] and let’s just see what happens when we get your blood work done.  Again, there might be very unique individual cases where that’s necessary, but to your point, very often those nutrients might interact with the way that the lab runs a test. And that’s really the reason we might recommend that we get off. It’s not so much the level, but the interaction with the testing method.

Dr. Weitz: Right. The biotin is water soluble. So two, three days.

Lara Zakaria: Yeah, exactly.

Dr. Weitz: Okay. So, let’s go into iodine. I mentioned a bit about the iodine. Some people advocate iodine supplementation. There’s a lot of thyroid supplements that contain iodine. Most multivitamins contain a modest amount of iodine. And then there are some clinicians advocating really high dosages of iodine.

Lara Zakaria: Yeah, I, I’ve seen cases where there was one clinician that had a patient go very high on the iodine, and at the same time, she has an MTHFR mutation, so they had them go [00:34:00] very high dose on methylated folate, and my suspicion is, is that is what triggered her severe Hashimoto’s. She had Hashimoto’s, that was very difficult to put into remission.  So I think that’s a great warning that excessive amounts of iodine can be dangerous, that’s for sure. However, I’ve also seen cases where you have a Hashimoto’s or even a Graves disease and they do great on iodine. I think at the end of the day, there’s a couple of factors. One are they deficient in iodine?  If they’re not deficient in iodine and you add more iodine, You’re at best going to have a net neutral reaction. At most, you could be triggering autoimmunity, and we’ve seen this in Hashimoto’s. Number two Iodine is a halide. Halides, like fluoride, chloride, and bromide, have a very unique chemical property that makes them want to attach to each other.

It’s actually kind of the magic between, with iodine and how we make thyroid has to do with this chemical property. It wants to attach and it is facilitated by the [00:35:00] presence of cofactors and enzymes. If you have excess amounts of other halides, like you’ve got exposure to chlorine from water, you’ve got exposure to bromide from formidated flour, you’ve got exposure to fluoride from fluorinated multivitamins or something like that, that could potentially knock out an iodine and create sort of like a wonky thyroid.

And in that case, that thyroid looks like a thyroid, but does not exactly behave like a thyroid. And in those cases, because it looks a little bit different, that could also potentially kind of confuse the immune system. So there’s also part of the, the theory is that the fact that these halogens are so much more available, so much more found so much environmentally more that they can actually knock out the iodine, outcompete the iodine.

So in some cases, adding more iodine can help it compete to create a better iodine better thyroid compound. That said, [00:36:00] I, I think that we have to be careful. Number one, the safest way if you want to add more iodine to somebody’s diet is, is to add it through food rather than add it through supplementation because the body will naturally then absorb the iodine it needs.

It’s going to compete with other nutrients in the food and it’ll sort of taper off. You’re not going to get the super high surge. Whereas if you supplement directly with iodine, it’s going to absorb more directly and that could potentially be excessive. That’s number one. Number two I considered actually topical application of iodine.

I’ve seen that really work well for folks, particularly if we, we need a little bit more iodine. We’re worried about overabsorption. Topical application can be really helpful. The trick is you don’t want the clear iodine, you want the one that has got a color. You stick it on the skin, a visible area, and if it absorbs, usually that means that person’s iodine deficient, and if it doesn’t absorb, that usually means they’re replete.

Again, it’s not like 100%, but it’s a very useful way to, to, to decide whether or not you need to be a little bit [00:37:00] more aggressive with your iodine therapy. You can do lab testing. Probably the best way to do it is looking at urine analysis. It’s a little bit of a pain in the butt to do, so it’s not my favorite and it’s, there, there’s not great information about what the targets should be.

So that’s not my favorite way, but if you can, by all means, especially if you could get multiple assessments every few months or something like that, that’s available, then that would be probably the ideal way to make sure that we’re not targeting too high on iodine, we’re not excessively supplementing, and at the same time, we’re not missing any opportunity to optimize iodine.

Dr. Weitz: Yeah, my experience is, iodine typically makes Hashimoto’s patients worse, but it is the case that a lot of drinking water is purified with chlorine, I know in L. A. we have chlorine in the water, they also add glycine. They, they also add fluorine to the water.

Lara Zakaria: Yep.

Dr. Weitz: So, and then a lot of people are no longer [00:38:00] consuming iodized salt, but are consuming Redmond sea salt or Himalayan pink salt, it’s the sea salt, etc.

Lara Zakaria: Not eating fish and not eating seaweed. And so they’re really, those are really the only two options when it comes to getting your iodine levels up. Yeah.

Dr. Weitz: Right. I know for myself, cause I, I have Hashimoto’s and I’m not on thyroid medication and I’ve been able to manage it nutritionally for the most part.  But I tried the high dose 12 and a half milligrams of iodine and my TSH shot up to like 25. So yeah, it did not like it. It was very clear. Did not like it.

Lara Zakaria: Yeah. I, I usually so I’m very careful. I usually will give folks formulations that are like thyroid specific and I sort of choose. depending on the situation.  My out the gate for a Hashimoto’s condition, I don’t, I’ll choose one that’s iodine free. However, I usually will add that on if we’re noticing either they don’t, they’re to your point, not eating enough sources of [00:39:00] iodine. Because at the end of the day, it’s not about like, they can’t have iodine, it’s not like an allergy to iodine, right?  It’s excess amounts of iodine that will trigger that response. So, that totally makes sense.

Dr. Weitz: I know for me, increasing selenium and adding a lot more zinc and, and not consuming iodine made a huge difference.

Lara Zakaria: Absolutely. Actually, studies actually also show that selenium, selenium on its own, there’s studies that show selenium on its own can actually naturalize auto antibodies for Hashimoto’s.  Combining selenium and zinc has also been shown. So again, specifically, I should say, especially if there’s a zinc deficiency, I think that combination is a magical combination. Right, yeah,

Dr. Weitz: I did the NutraEval and I was super low in zinc, despite the fact that I was consuming zinc. What about myoinositol?  That’s kind of an interesting nutritional compound hypothyroid.

Lara Zakaria: Yeah, I, I wonder sometimes if it’s so much of a direct benefit or because myonocytal also has sort of a neurological [00:40:00] benefit to it. And so that might be part of the cat that again, that relationship between stress and adrenal function and thyroid production.  But yeah, definitely another interesting option. I don’t necessarily always use it immediately, but it’s one of those things that is in the arsenal in specific populations. If there’s hormonal dysfunction. History, particularly in my women that might have a history of PCOS, or you know, if, if somebody, you know, kind of strikes me as that more nervous constitution, that’s usually a great add on.

Dr. Weitz: What about diet for patients with hypothyroid?

Lara Zakaria: So if there was going to be one diet, which I don’t believe that there’s really one diet for everybody. So let me, let me start off by saying that there is not one thing that works for everybody. But if there’s one thing that I could say that we have some evidence for is that eliminating gluten is generally favorable for folks, particularly with Hashimoto’s, possibly with people with primary hypothyroidism.  There’s a theory that there is a molecular mimicry between [00:41:00] gluten and thyroid and that that might have been what instigated that autoimmune response. I don’t know that that has really borne out to be accurate, to be true. However, I think there’s a lot that could be said that comes with gluten containing diets that might be triggers for both the autoimmune piece and the hormonal dysregulation.

One would be gut function. You know, the microbiome we know that gluten itself can trigger intestinal permeability it’s for some people more than others, but even more so, so much of our gluten containing products, particularly wheat, have glyphosate with them. So, it’s hard for us to distinguish, is it the glyphosate, is it the gluten, you avoid the gluten, you tend to also avoid the glyphosate.  And in that case, we know very significantly, can impact not only the gut piece, the microbiome, the intestinal permeability, the inflammation, but also directly impacts thyroid function. So I think from that, [00:42:00] from, from that perspective, if we’re struggling to sort of get it under control, you got a recent diagnosis, you, again, you’re, you’re medicated, but not feeling great.

I think it’s a great starting point to do a gluten elimination and see how that works. I’ve not seen any other evidence, either clinically or in the research, that sort of says, Oh, going on dairy free or removing eggs or that, you know, going keto or anything like that is directly beneficial for Hashimoto’s, but that’s going to be different for different people.  If a person has a dairy reaction, then obviously removing the dairy makes sense for that person. So it might, in my practice, I might start with a basic elimination diet. At least those, the three big ones to me are going to be well I should say four. Gluten, Dairy, Soy, and Egg would be my top ones.  And then I do that for at least four to six weeks, and then we do a reintroduction, a challenge of those foods, because I think it’s really important to challenge so [00:43:00] that we understand whether or not those foods were actually triggers or not. So I do a careful challenge. We identify if anything is still a trigger and or anything is questionable, and then we might continue to eliminate them if they turn out to be a problem, and then I come back in six months to a year, and we try to challenge again, just to make sure, because very often some of those sensitivities, they’re not true, they’re not true allergies, could actually clear up on their own when you do the gut work, you improve the microbiome, you address the intestinal permeability, you balance the immune system, very often they can reintroduce those foods back.

If not moderately, they can bring them back, you know, in a, in a healthy balanced way. Other than that, I really focus on those foundation, foundational nutrients, get their macros balanced, make sure they’re getting enough fiber in, and they’re getting tons of protein, right? So making sure we’re emphasizing that as a foundation.

Sometimes we go keto. If there’s a lot, there’s some evidence that keto can be really great as an anti inflammatory intervention. So if there’s a lot of inflammation, there’s other metabolic issues happening, keto could be a good way to [00:44:00] sort of clean some of that up, but that’s not appropriate for everybody.

So again, case by case basis. Once you get those macros in order, I’m really focusing in on bringing tons of fruits and vegetables in and bringing in all the specific nutrients, those antioxidants getting a lot of color. I talk to them about eating the rainbow and getting a variety of all those phytonutrients and polyphenols in because of the benefits that those are all going to have on the immune balance and on the gut microbiome.

I’m a big fan of the WALS protocol actually, so I, I do talk to them a lot about the WALS protocol and although she used it more for MS. I found it to be beneficial in my Hashimoto’s patients. So I sort of dial it up and down depending on what their specific needs are. And, and I think to your point, Ben, some people show up with Hashimoto’s and they’re very much a thyroid case.  Like their symptoms are very much like hypothyroidism fatigue, you know, they’ve gone showing all those symptoms, but some people show up and all that stuff looks good on paper, but their autoimmune symptoms, their gut health, their adrenal function, they don’t. Hormone Health [00:45:00] is all, is all a struggle.  And so we sort of positioned the diet depending on what we need to most directly support.

Dr. Weitz: When it comes to diet, do you think the concept of some vegetables as being goitrogens is something that we should pay attention to?

Lara Zakaria: I love this question. 

Dr. Weitz:  Is broccoli going to make my thyroid worse?

Lara Zakaria: Okay, goitrogens, when they’re cooked, go away.  We don’t have to worry about them. So that said, there is something to be said about raw goitrogenic foods like broccoli that could be triggers for some. However, goitrogens typically are called goitrogens because they increase goiter. They are hyper, they create high amounts of thyroid production. So in an autoimmune case like Hashimoto’s, where you’re fluctuating between high and low, and if we still don’t have that under control and it’s triggering, just avoid the raw ones.  Get it under control and you should be able to [00:46:00] tolerate cooked versions. But this is one of my pet peeves because those goitrogens tend to be those sulfa rich vegetables, right, your cruciferous vegetables, which are a powerhouse. They’re such a powerful food as antioxidants. They help us make glutathione.  They reduce inflammation. They help with detoxification. They balance hormones. They are such a powerhouse. So this idea that we have to completely remove them from the diet is, misinformation.  Cooks them to be safe. That’s probably easier on your digestion anyway. It eases some of that the, the, makes the fibers a little bit easier to digest as well.  In fact, it improves the bioavailability of some of those phytonutrient compounds. When you see that broccoli start to steam up and it like gets super bright green, that’s when you know you’ve optimized those phytonutrients so they’re even more bioavailable. So that’s my suggestion. To be safe, cook them.  If you’re in remission, if you are well controlled, then you should be fine, even if you have them raw.

Dr. Weitz: I, I, I’ve heard this one story on several podcasts where some woman [00:47:00] consumed like two pounds of raw bok choy for an extended period of time and died herself. 

Lara Zakaria: Yeah, don’t do that. I, I don’t, I can’t imagine why you would do that, but don’t do that.  Bok choy is delicious, but so much more delicious cooked with some garlic and some soy sauce, gluten free soy sauce.

Dr. Weitz:  And, and, and poor broccoli is kind of a maligned vegetable because it’s a high FODMAP food. It’s a goitrogen…. 

Lara Zakaria: Poor broccoli.

Lara Zakaria: Don’t get me started on the high FODMAP thing too. Oh.  Actually, that does remind me though you know, kind of going back to the making those connections and digestion, folks with Hashimoto’s and folks with primary hyperthyroidism are more prone to SIBO and digestive, I know, right? It just wants to, it wants to be part of the show, but folks with Hashimoto’s are at higher risk for developing SIBO and [00:48:00] IBS. And so to your point, so many of these things kind of, you know, they show up like, Oh, I’m going to avoid broccoli because broccoli is you know, is a goitrogen. Oh, I feel so much better off of it. Well, do you feel better because it was triggering your SIBO and we need to address your SIBO actually and get that microbiome in check and get your motility going?  Because when you have low thyroid, your motility is going to be too slow. Slow motility increases your risk for SIBO. And that’s really the connection there. 

Dr. Weitz: So there’s also an autoimmune connection too, because the latest research shows that SIBO has an autoimmune component.

Lara Zakaria: Yes, correct. And it has to do with the autonomic nervous system.  And again, that connection back to the brain. And yes, absolutely. So I think, again, these kind of simplistic, just take this out, take out this food, and that’ll solve the condition. We need to start thinking a little bit more upstream, right? We need to start thinking about what is actually the foundational role.  What’s the physiology that’s happening there? Where’s it going wrong and how do we address it?  And we have to identify those bio-individual variances in people. Why one person might be more prone to one aspect versus somebody else that shows up a little bit differently. There’s definitely not one size fits all.  Everybody needs their own bio individual approach. And we need to start thinking a little bit more with nuance when we approach it.

Dr. Weitz: That’s great. It’s been a great discussion. Tell everybody how they can get in touch with you and find out about what you have to offer.

Lara Zakaria: Amazing. Thank you, Ben. It’s been a pleasure being here.  If you want to keep this conversation going, I spend a lot of time on Instagram and LinkedIn, so feel free to find me there. You could search my name or look for Foodie Pharmacist. That’s 2F, so Foodie, F O O D I E, Pharmacist. F, A, R, M, A, C, I, S, T. You can also come to my website, larazaccaria. com. And I do have a screening guide and a guide that talks about better assessment available on my website, as well as a collaboration with the Better Nutrition Program on a coached a one month thyroid optimizer [00:50:00] program that’s useful whether you have primary hypothyroidism or autoimmune hypothyroidism.  It’s a great starting point. If you’re not sure where to start, you’re trying to identify what might be the area that you need to focus on on more, that’s what we built it for. And you get the four week program. It’s easy to follow in the app. Plus you get the added benefit of working with a coach as well.

Dr. Weitz: That’s great. Thank you, Lara.

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Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review.  As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help. overcoming a gut or other chronic health condition and want to prevent chronic problems and want to promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111.  And we can set you up for a consultation for functional medicine. And I will talk to everybody next week.