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SHBG Test – How to Interpret Your Results and What to do With Them

​SHBG is short for Sex Hormone Binding Globulin​.

This test is rarely ordered, which is unfortunate because it can give you a lot of information about the hormones in your body.

​High levels can ​lead to symptoms of excess estrogen, excess thyroid, and low testosterone.

Low levels can lead to symptoms of low thyroid, low estrogen, and excess testosterone.

​In this article, I will ​discuss how to interpret your SHBG test results, and ​list some common causes of elevated levels and low levels.  

I will show how SHBG can be used to monitor your thyroid function if you are on thyroid medication.

​I will also discuss some things that you can do to help you get your SHBG level back into the optimal range​ whether it is high or low…

More…

​What is SHBG?

​SHBG is an acronym for sex hormone binding globulin.

It does what it sounds like it does – it binds up sex hormones.

Why is that important?

In order to understand this better we need to discuss how hormones work in general.

​The vast majority of hormones in your body are bound to proteins in the bloodstream.  This helps to stabilize the hormone so it can get to the targeted cells all over the body.

While it is bound, however, it is inactive and not available for the cells to use.

​In order for the hormone to be active, it must break away from the protein.  This makes it a “free” hormone and it can then enter the cells and turn on the cellular function it is designed to do.

This is called the Free Hormone Hypothesis.

The “free” hormones are therefore the “active” hormones.

The ​amount of “free” hormones is much smaller than the amount of “bound” hormones.

This protein binding is one of the ways that the body uses to regulate the hormone ​levels.

So what about SHBG?

SHBG levels naturally ​increase as we age.  Since ​most hormone levels naturally decline as well, this makes a deficiency of those hormones (especially testosterone) even more pronounced.

​Sex Hormone Binding Globulin binds to several different hormones.  The body uses SHBG to ​inactivate these hormones in the bloodstream.

Too much of it can be bad because it can bind so much of the hormone that we can have symptoms caused by a ​lack of that hormone.

Too little can also be bad because it can cause an excess of certain hormones which ​also causes symptoms.

Even small changes in SHBG can cause substantial symptoms and problems.

SHBG has a stronger affinity for some hormones that others.

It will preferentially bind to sex hormones in this ​order (from highest affinity to lowest):

  • Dihydrotestosterone (DHT)
  • Testosterone
  • Androstenediol
  • Estradiol
  • Estrone

​As you can see, SHBG has a greater affinity for androgens than estrogens.

​You can therefore predict the symptoms you may have by knowing the effect that the SHBG level has on your androgen levels.

For example, if you have an elevated SHBG, it will bind DHT and testosterone which will cause symptoms of low testosterone (weight gain, depression, increased belly fat, loss of muscle, etc.).

With low levels of SHBG, you will have more unbound or free testosterone which will cause symptoms of high testosterone (acne, facial hair growth, PCOS, etc).

Hopefully you can see why it’s important to check your SHBG level if you are having any symptoms of hormonal imbalance to help you and your doctor determine what issues are going on in your body.

The optimal range for SHBG is 60-80 nmol/L.  Any level below or above this range should be investigated.

​​Elevated SHBG Test

There are several things that I will list below that can elevate SHBG levels.

​Most of these occur because they affect​ one of these 2 hormones in the body​ – Estrogen and thyroid​ hormone.

An increase in either or both of these hormones will stimulate the liver to increase SHBG production.

A SHBG level > 80 nmol/L is considered too high.

​​Common Causes of ​Elevated SHBG

​Another hormone to keep in mind that is closely linked to SHBG is cortisol.

Cortisol is our stress hormone.  In times of increased stress (physical or mental), our adrenal glands increase cortisol production.  

​An elevated cortisol level stimulates the liver to increase SHBG production.

​Symptoms of Elevated SHBG

​Please realize that an elevated level of SHBG does not in itself cause any symptoms.

The symptoms are caused by the effect that the high SHBG level has on hormones in the body.

Most of the symptoms will be due to either excess estrogen and/or low testosterone:

  • Menstrual Irregularities
  • searchWeight Gain (pear shape type)
  • searchMood Swings
  • searchBreast Tenderness
  • searchLoss of Muscle Mass
  • searchFatigue
  • Fluid Retention

If the elevated SHBG is caused by the situation of a high thyroid level (hyperthyroidism or excessive oral thyroid medication), you can also have symptoms related to the elevated thyroid such as tremor, palpitations and weight loss.

​How to Treat an Elevated SHBG

​Treating an elevated SHBG has more to do with finding the cause of the elevation rather than treating the elevated SHBG itself.

There are several things you should consider doing:

1.  Check your Estrogen and Progesterone Levels –

​The ratio of these 2 hormones is more important than the numbers themselves.

Check the levels in the middle of your cycle (2 weeks after your last period) for the best results.

If the ratio of estrogen:progesterone is >10:1, you have estrogen dominance that needs to be addressed.

​2. Check Your Thyroid Levels –

If your estrogen level is normal, then it is highly likely that your thyroid is the culprit of your elevated SHBG.

Check a complete thyroid panel, especially free T3 and free T4.

If these are elevated and you are on thyroid medication, you may need to lower your dose or even change your thyroid medication.

If you aren’t on thyroid medication, you need to have more testing done ASAP to find the cause of your elevated thyroid (most likely Grave’s Disease).

3.  Stop Smoking!
4.  If you are on oral birth control pills, consider using another form of birth control –
​5.  Work on Stress Management –

I discuss several techniques to better manage your stress in my article on Adrenal Fatigue.

​Low SHBG Test

​Low SHBG is more difficult to detect and often harder to treat.

As a result, it is often ignored much more than an elevated SHBG.

Common Causes of Low SHBG

​A low SHBG typically occurs in menopausal women or patients with hypothyroidism (low thyroid).

​So if your SHBG is ​< 60 nmol/L, you should look at estrogen and thyroid as the probable causes if you are menopausal.

If you are still menstruating, then hypothyroidism is the likely cause.

If one or both of those hormones is low, SHBG levels will drop which will increase free testosterone, paving the way for conditions such as PCOS.

This series of hormone imbalances also ​appears to set up a person to develop insulin resistance.

In fact, a low SHBG level has been shown to be a strong predictor for type 2 diabetes in both men and women.

​Symptoms of Low SHBG

​The symptoms associated with a low SHBG are typically caused by low thyroid hormone, low estrogen, and elevated testosterone.  The include:

  • Weight Gain
  • search​Menstrual Irregularities
  • searchFatigue
  • searchHot flashes
  • searchAcne
  • searchFacial Hair Growth
  • searchHair loss
  • searchDepression

​Keep in mind that your individual symptoms will depend on which hormones are out of balance and to what extent.

​Treatment of Low SHBG

​If you have a low SHBG, you should consider the following things:

​1.  Check a complete thyroid panel –
  • TSH
  • free T4
  • free T3
  • reverse T3
  • TPO antibodies
  • thyroglobulin antibodies

​Compare these tests with their optimal levels to determine if you have a thyroid issue.

If your thyroid function is low, it is probably affecting your SHBG level and you will need to consider taking a thyroid medication and doing other things to help boost your thyroid function.

​2.  Check your estrogen/progesterone ratio if you are menopausal- 

After menopause, your estrogen levels will drop which can drop your SHBG level.

If that is the case in your situation, you might need to consider bioidentical hormone replacement therapy.

​3.  Check your free testosterone level – 

If your SHBG level is low, there will be less of it to bind to testosterone, so it may cause your free testosterone level to rise.

This can usually be alleviated by maximizing your thyroid medication which will raise your SHBG level.

​How the SHBG Test Can Be Used to Monitor Thyroid Function

​One final benefit of checking your SHBG level is it a good indicator of the thyroid function in your body.

In states of low thyroid function, the SHBG level drops.

In states of high thyroid function, the SHBG level rises.

This allows the SHBG to be used as a marker to assess the thyroid hormone absorption and cellular function.

If you have low SHBG and hypothyroidism, you should test your SHBG level at the beginning of treatment to assess if you are on the right type of thyroid hormone and the right amount.

If you are taking a T4 only thyroid medication and your SHBG level does not increase, you may have a problem with peripheral conversion of T4 into active T3.

You therefore may need to change to a natural dessicated thyroid (NDT) or add T3 to your current regimen.

On the flip side, if after starting your thyroid medication your SHBG level rises > 80 nmol/L, that is an indication that your dose is too high and it should be reduced.

​Summary

​The sex hormone binding globulin level gives us important information on the status of several hormones in the body.

​A high level is typically caused by estrogen excess and excess cortisol.

​A low level is typically caused by low thyroid.  It also is an indicator that you may be having issues with insulin resistance.

The key to treating an abnormal SHBG level is to identify what is causing the abnormality and correct it.

Doing this will help return the SHBG level to the optimal range and reduce symptoms.

​Now it’s your turn…

Do you have an abnormal SHBG level?

Have you identified the cause or causes?

Please leave your comments below.

Hypothyroidism and Depression – Is There a Connection?

​Is there a connection between hypothyroidism and depression?

Will taking thyroid medication reduce or even eliminate depression symptoms?

Do you still have depression even though you are on thyroid medication?

In this article, I will discuss the connection between hypothyroidism and depression, how thyroid medications can often help both conditions, and other causes of depression that you should consider…

​The ​Connection Between Hypothyroidism and Depression

​It is a​ well known fact​ in medicine that hypothyroidism is ​often associated with ​symptoms of depression. You will commonly find it listed as a symptom of hypothyroidism.  Click here for an example.

Doctors are even taught to check thyroid lab tests in any patient that presents with new symptoms of depression.

But how exactly are they connected?  We aren’t completely sure.

​However, we do know these connections:

  • ​Hypothyroidism and depression share similar symptoms.
  • Depression symptoms resolve in some people that are treated for hypothyroidism.
  • Thyroid hormone increases serotonin levels in the brain.
  • checkThyroid Releasing Hormone (TRH) is sensitive to serotonin.  Low serotonin levels may stimulate TRH production, while high serotonin levels may lead to lower TRH production.

​​Basically, depression symptoms can sometimes (but not always) be due to hypothyroidism.  If you ​treat the hypothyroidism, the depression symptoms will reduce or even resolve.

Let’s talk about depression a bit more…

​What Is Depression​?

​So what is depression anyway?  Most of us have no problem explaining the common symptoms that we call depression.

​When several people share a similar group of symptoms, ​medical organizations ​like to give it a name. This is to make things more simple, but​ it also makes it easier to bill insurance.

​The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) lists the following criteria required to diagnose depression:

  • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

    Note: Do not include symptoms that are clearly attributable to another medical condition.

    1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
    2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
    3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
    4. Insomnia or hypersomnia nearly every day.
    5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
    6. Fatigue or loss of energy nearly every day.
    7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
    8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
    9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

​What ​this fails to take into account is what condition or conditions caused the symptoms in the first place!

If you are fatigued, moody, and are gaining weight since you hit menopause, should you be treated the same way as someone that just went through a divorce, or someone that is anemic​, or someone who has​ an autoimmune disease?

Of course not!

​Don’t think of depression as a ​diagnosis.  Instead, think of depression as a group of symptoms that may be caused by many different conditions.

In other words, it is a side effect of one or more other problems.  In order to properly treat the depression, the root cause must be identified and addressed.  This is the foundational principle of functional medicine.

​Possible Causes of Depression:

​1.  Hormone Imbalances

​​An imbalance in one or more hormones commonly results in symptoms of depression.

​An abnormality in these hormones should be ​one of the first things that you consider and test for when you are investigating the cause of your depression.

Examples of hormone imbalances includes menopause, low testosterone, and hypothyroidism.​

​2.  Nutrient Deficiencies

​Nutrient deficiencies ​commonly cause anemia and other conditions that result in depression symptoms.

These include B12, folic acid, and iron.

If you don’t test for them you will never know if you are deficient or not!

​3.  Gut Dysfunction

​Gut dysfunction can lead to the nutrient deficiencies listed above, it can result in a decrease in neurotransmitter production such as serotonin, and it is a primary reason why​ autoimmune disorders develop.

Most diseases in the body ​is worsened or even starts with gut dysfunction.  In fact, when I have a difficult patient and I’m not sure what to do, I start with working on their gut.

​Gut issues include lack of stomach acid, SIBO or SIFO, and dysbiosis.

​4.  Inflammatory States

​Inflammation causes a decrease in energy production in the mitochondria of the cells.  This results in fatigue, insomnia, chronic pain, and other symptoms of depression.

Examples include insulin resistance, leptin resistance, autoimmunity, and acute and chronic infections.

Most of these can be detected with proper lab testing.

​5.  Insomnia

​Lack of sleep causes mood swings, fatigue, poor concentration, and other symptoms of depression.

​6.  Alcohol Use

​Alcohol abuse ​has been shown to be associated with depression in several studies.

​7.  Stress

​Stress (particularly chronic stress) has been closely associated with depression.

​8.  Spiritual/Religious Issues

​Studies have shown that pursuing religion and spiritual beliefs can help reduce depression symptoms.  ​Guilt and conviction of not following or pursuing your personal religious beliefs could be a major source of stress that will need to be addressed.

​IT IS IMPORTANT TO REALIZE THAT it is possible and even probable that your depression is multifactorial – meaning ​it could be ​caused by several of the reasons listed above.

Treating only one of the causes may not significantly reduce your symptoms.  It will be necessary to address ALL of the causes to get the most benefit.

​Hashimoto’s and Depression

​Since up to 90% of hypothyroidism is caused by Hashimoto’s Thyroiditis, it deserves discussion as well.

As you know, Hashimoto’s is an autoimmune disorder that if left un​treated will ​slowly and gradually destroy the thyroid gland, resulting in hypothyroidism.

​One of the things that makes Hashimoto’s even more difficult than hypothyroidism is the fact that the TSH will often be in the “normal” range even though the patient may be having significant​ symptoms such as depression, constipation, fatigue, etc.

That is ​important because if the TSH is normal, very few doctors will give those patients thyroid medication, even if they have are having symptoms.  As we will discuss later in this article, thyroid medication can often greatly reduce depression symptoms.

Studies show that patients with Hashimoto’s are at increased risk of developing both depression and anxiety, even when their TSH is normal.

In fact, it appears that thyroid antibodies themselves can ​actually cause depression symptoms.

​It is therefore ​crucial to get a complete thyroid panel, including free T4, free T3, TPO antibody, and thyroglobulin antibody levels.  That will give you a​n indication of whether you are deficient in thyroid hormone​ at the cellular level and if you have ​autoimmune thyroid disease.

If someone is having depression symptoms and they have a normal TSH but a low free T3, starting a trial of thyroid hormone medication may be warranted.

They may also benefit from other Hashimoto’s therapies that help reduce antibody levels.  These can include selenium and zinc supplementation, vitamin D supplementation, LDN therapy, and others.  I discuss many of these in other blog articles on my website.

Click here to read more about ​treatments for Hashimoto’s.

​Treatment of Depression with Thyroid Medication

​Studies have shown that thyroid medication can be very effective in treating depression and depression symptoms.

It can ​reduce depression symptoms when added to an SSRI (the standard conventional treatment for depression) as shown in this study.

​Giving T3 medication has also been shown to be effective at treating depression even when patients are resistant to standard SSRI treatment.

There are also studies that show using T3 by itself is effective at reducing depression symptoms.

Of note, T3 has also been shown to be effective in treating mood disorders such as bipolar disorder, even when patients have failed multiple mood stabilizing medications.

​So why does thyroid hormone (particularly T3) help with depression?

​These studies show that there is probably a connection between mood and thyroid function.

There may even be a subset of depressed patients that actually have ​hypothyroidism that has not been identified.

There is also the possibility that some patients may have a genetic defect in one of the deiodinase enzymes that converts T4 to T3.  This may result in a decreased level of T3 circulating in the brain.

I believe that it is good medicine to have a complete thyroid panel drawn on all patients that have symptoms of depression.

If you have failed multiple depression therapies and medications, it ​would even be reasonable to try a trial of thyroid medication, especially if your free T3 level is not optimal.

The best thyroid medication to use is Cytomel or liothyronine, which is a T3 only medication.  This is the strongest thyroid medication available and does not require conversion by a deiodinase to work.

This can be done safely if th​ese guidelines are followed, which is further explained in this article:

  • ​Check TSH, free T3, and free T4 prior to starting treatment
  • Start with liothyronine 25mcg daily and titrate slowly over weeks depending on tolerance to the medication.  Most patients will need 50-150mcg daily
  • ​Recheck thyroid labs at least every 3-6 months, or more often if needed
  • checkThe goal for TSH should be in the lower limits of the reference range (or even lower at times depending on the free T3 level)
  • checkThe goal for free T3 should be in the upper limits of the reference range
  • checkIf you are menopausal, bone density should be monitored regularly

​T3 medications can sometimes cause ​side effects such as jitteriness, palpitations, excessive sweating, headache, and other symptoms.  Make sure you communicate any of these with your doctor if you are taking T3 medication.

​Some people simply cannot tolerate liothyronine due to side effects.  In those situations, a compounding pharmacy can make sustained-release T3 (SR-T3) which is typically much better tolerated.

​7 Steps to Consider if You Have Depression

​If you​ are suffering from depression, I would recommend that you follow the 7 steps below to ​help reduce or eliminate your symptoms:

​1.  Get a Complete Thyroid Panel

​Just checking a TSH level is woefully inadequate to truly evaluate your thyroid function.  Instead, I STRONGLY recommend that you ask your doctor to check all of the following tests:

​If either antibody test is >35, then a diagnosis if Hashimoto’s Thyroiditis can be made.

​If the free T3 level is < 3.5, that is an indication of hypothyroidism regardless of the TSH level, especially if you are having several symptoms of hypothyroidism.

​2.  Consider adding T3 medication to your current regimen

​Many people have issues with T4 to T3 conversion due to chronic inflammation and gut issues​.  Adding T3 to your other thyroid medication bypasses the need for the conversion step which will allow more active thyroid to reach the cells of the body, including the brain.

As little as 5-10mcg of liothyronine can be helpful.

​3.  ​Reduce your thyroid antibodies if you have Hashimoto’s

​Reducing thyroid antibodies will help in numerous ways.  This includes reducing systemic inflammation which improves thyroid conversion ​plus helps you feel better in general.  It also reduces depression symptoms directly.  Finally, it typically improves hypothyroidism which will help reduce symptoms.

​4.  ​Identify and treat and nutrient deficiencies

​These include vitamin B12, folate, and iron.  There are lab tests that test for these directly.  Treatment consists of supplements and improving gut health.

​5.  Get good sleep

​It is almost impossible to maintain good overall health if you are getting less than 7-8 hours of good sleep per night.

Here is a fascinating interview of Matthew Walker, a neuroscientist who is considered one of the premiere sleep experts in the world if you want to learn more (warning- there is ​cursing by the host in the interview).

Improving your sleep may actually be the single most potent tool that you can do to combat your depression.

​6.  Manage your stress

This is always an easy thing to say, but a hard thing to do.

Reducing your stress may need to include changing jobs, ending unhealthy relationships, and placing​ healthy boundaries in your life.

​I would also recommend adding meditation and/or yoga to your daily routine.

​7.  Address any spiritual needs

​Depending on your particular situation, this can include speaking to your pastor, priest, or spiritual advisor, and re-committing yourself to pursue a deeper meaning in your life.

​Important Note:  You may still ​need the use of an anti-depressant (at least for awhile), but finding the root causes of your depression and dealing with them directly will greatly improve​ your success in reducing or eliminating your depression symptoms.

​Summary

​Many patients that have been diagnosed with depression also have thyroid issues, including hypothyroidism and Hashimoto’s.

In many cases, adding T3 thyroid medication can reduce depression symptoms, even when their TSH is normal.

If you have depression and hypothyroidism and are taking a T4 only thyroid medication, you may want to talk to your doctor about adding T3 or changing your thyroid medication to one that contains T3.

It is important to get a complete thyroid panel to accurately assess your T3 levels and to check for the presence of Hashimoto’s.

As with most conditions, finding the root causes of your depression will allow you to directly address the issues that apply to you.

​Now it’s your turn…

Do you have a thyroid issue?  Do you also have depression?

Have you tried taking T3 medication to treat your depression?

What has worked for you?  What hasn’t worked?

Leave your questions and comments below.

How to Increase T3 Levels Without Medication

​If you have a thyroid issue and want to feel ​better, then ​increasing your T3 level to the optimal range is the single most important thing that you can do.

Why?

Because T3 is the active thyroid hormone.

Most people have lower than optimal free T3 levels even if they are taking thyroid hormone medication.

So how do you ​increase your T3 level?  That is the ​critical question.

I will try to give you all of the tools you need in this article to start ​increasing your T3 level and get you feeling your best.  Some are simple and straightforward while others are more difficult.

​Here we go…

​What Is T3?

​Let’s start with a quick tutorial about the thyroid which will help you understand some of the terms I will be using and what they mean.

​The thyroid gland is a factory.  It’s job in the body is to make thyroid hormone.

The thyroid depends on the pituitary gland in the brain to tell it how much thyroid hormone to produce. The pituitary does this by secreting Thyroid Stimulating Hormone (TSH).

The majority of hormone that the thyroid makes is T4.  T4 is inactive and is basically the transport form of thyroid.  It serves as a reservoir that the body can draw from when it needs more T3.

A small amount of T3 is also made directly by the thyroid, but most of ​it is produced outside of the thyroid gland ​by converting T4 to T3.  This is done by an enzyme called a deiodinase.

T4 can also be converted into Reverse T3.  Reverse T3 is the anti-thyroid hormone.  It will bind to thyroid receptors in the cells but does not trigger any function.  It therefore effectively blocks that thyroid receptor.

​Too much reverse T3 can result in a substantial reduction of thyroid function in the body.  Therefore in most cases it is best to have as low of a reverse T3 level as possible (<15).  Click here to read more about reverse T3.

​Most​ T3 in the blood is bound to a protein.  When T3 is bound, it is unable to ​attach to the thyroid receptors in the cells.

​A very small percentage of the total amount of T3 in the body is ​not attached to a protein.  We call that the free T3level. Since it is not attached to a protein, it is free to attach to the thyroid receptors in the cells and trigger the functions that it is designed to trigger.

Therefore, the free T3 level is actually a measurement of how much active thyroidhormone is present in the body.

In my practice, I like for the free T3 level to be >3.5 if possible.

​How To ​Increase T3 Levels

​As you can tell from this illustration, there are 4 main areas that ​should be optimized in order to maximize your T3 level:

  • ​T4 hormone production
  • checkT4 to T3 conversion
  • check​T4 to reverse T3 conversion
  • Cellular sensitivity to T3

​Addressing all 4 of these areas will increase your chances of getting your T3 level optimized.

​Let’s break these areas down further, plus I will discuss some other things that you can also do to get your thyroid working at​ optimal efficiency:

1.  Maximize Thyroid Production

​There are over 15 nutrients that are necessary for normal thyroid hormone production.

Most of them are usually found in adequate amounts in the Standard American Diet.  However, it is common to be deficient in some of them.

​Iron and iodine are ​two of the nutrients that are necessary to maximize thyroid production and it is common for people to be deficient in them.

– Optimize Iron

 

​Iron is completely intertwined with the thyroid.

If the iron level is low, thyroid medication doesn’t work as well, and conversion of T4 to T3 is reduced.

Conversely, thyroid hormone is needed to properly absorb iron.

So when thyroid levels are low it leads to iron deficiency which in turn worsens thyroid function, creating a vicious cycle.

Iron is also required for proper adrenal function.  When the adrenals aren’t working it puts an increased strain on the thyroid which can lead to adrenal fatigue and other issues.

​To find out if you are low in iron, you can ask your doctor to order a CBC, serum iron, TIBC, and ferritin level.  If you are low, then treatment with a supplement may be necessary.

As a general rule, thyroid patients tolerate liquid iron better than pills.  It causes less constipation and is usually better absorbed.

If the liquid iron is not adequate to raise the iron levels, it may still be necessary to switch to an oral tablet such as this one.

Remember, low iron ​is often due to a deficiency in your diet, but it could also be a sign of blood loss.  If your iron is low (especially if you are anemic), you need to see your doctor about it.  You could have gastritis, a stomach ulcer, or some type of lesion in your small intestine or colon that is causing the ​blood loss. It could be life-saving to have this investigated.

– Consider Iodine

​Iodine is a tricky subject when it comes to the thyroid, especially if you have Hashimoto’s Thyroiditis.

Many experts are adamant about the importance of iodine while others are afraid ​to use it.

The fact is, iodine is required for thyroid hormone production.  Adequate amounts of iodine are necessary if you want to have optimal thyroid function.

So if you decide to use it, I would use this as a guideline:

  • ​Start low and go slow
  • If you have Hashimoto’s and want to try iodine, make sure you are also supplementing with selenium.  Studies suggest that iodine can increase thyroid antibody levels if you are deficient in selenium.

​Start with 325mcg of iodine per day and continue that for 10-14 days.  You can then increase the dose by 325mcg daily every week as long as you are noticing improvement.

If you notice worsening symptoms then stop it immediately.

Click here for the supplement that I recommend.

Make sure that you monitor your thyroid antibody levels if you have Hashimoto’s.

​2.  Improve T4 to T3 Conversion

​Efficient T4 to T3 conversion is critical for normal thyroid function.

Most conventional doctors are taught to only check the TSH and occasionally the T4 level when monitoring thyroid function.

This assumes that the T4 to T3 conversion process is working normally.  However, in my experience, that just isn’t the case.

​Chronic inflammation in the body (arthritis, diabetes, obesity, etc.) impairs the conversion process.  So does some nutrient deficiencies.

That may be why you are still having typical symptoms of hypothyroidism even though your TSH and T4 levels are in the normal range.

The following list is far from complete, but it ​includes what I have found to be the most common reasons why T4 to T3 conversion is impaired.  Click on each nutrient for my preferred brand.

Zinc

​Inadequate zinc levels typically results in more T4 to reverse T3 conversion and result in worsening thyroid function.  Zinc is also a powerful anti-inflammatory and helps regulate your immune system.  It also is good for your skin.

Selenium

​Selenium is also essential for normal T4 to T3 conversion.  It also helps to regulate the immune system and can help reduce thyroid antibody levels if you have Hashimoto’s.  ​ I typically recommend taking 200-400mcg daily. Click here to read more.

– Reduce ​T4 to Reverse T3 Conversion

​Even though I will discuss this is more detail later, it should be listed  here as well.

Reducing the T4 to reverse T3 conversion will mean that the T4 is being channeled into converting into T3 instead.

​3.  Improve Your Gut ​Health

​​This may surprise you, but up to 20% of the T4 to T3 conversion occurs in the gut!

The amounts and types of gut bacteria play a huge role in thyroid function.

With that in mind, this shouldn’t surprise you:  Most thyroid patients have at least some level of gut issues.

Why?  Because when the thyroid is low it makes your intestines move slower which can lead to constipation.  It can also increase your risk of developing SIBO (small intestinal bacterial overgrowth), yeast overgrowth, and acid reflux (GERD).

Low thyroid also causes less stomach acid to be produced which further reduces the absorption of nutrients.

​All of this also predisposes you to develop increased intestinal permeability, better known as leaky gut syndrome.

A leaky gut then allows foreign proteins to enter the bloodstream.  One such protein is called LPS.

LPS has been shown in studies to lower T3 levels in the blood.

Have I convinced you how important gut health is to thyroid function?

So what can you do to improve your gut function?  ​

The first step is to make a proper diagnosis.  That can usually be done with a thorough history.

– Betaine with Pepsin

​Pharmaceutical companies want us to think that almost all of us produce too much stomach acid.

If you are having heartburn after eating dinner, it’s because you have too much acid, right?

Wrong!  The problem is not too much acid, instead the acid is going to the wrong places (your lower esophagus instead of staying in your stomach).

In reality, many people don’t produce ENOUGH stomach acid, also called hypochlorhydria.

Studies show that up to 40% of people over age 40 have hypochlorhydria.  By the time you reach 60 years of age that number goes to over 50%!  In fact, up to 30% of people over 60 have achlorhydria, which means they don’t produce stomach acid at all.

​So take that information and just imagine how much worse those numbers get when you add proton pump inhibitors, H2 blockers, and antacids that so many people take on a daily basis.

Remember, stomach acid is critical for 3 primary functions:

  • ​Acid in the stomach causes the breakdown and digestion of food which allows nutrients to be extracted and absorbed into the body.
  • ​An acidic stomach serves as a barrier against bacteria, yeast, and other organisms that grow normally in the intestines.  Without adequate stomach acid, these organisms will colonize the stomach and create all sorts of problems including gastritis and ulcers.  H. pylori is an example.
  • The acidity of the stomach is what triggers the pancreas to release digestive enzymes which further break down the food we eat so that nutrients can be extracted from it.

​If you want to read more about this subject in detail, I highly recommend the book “Why Stomach Acid Is Good For You” by Dr. Jonathan Wright.

​Okay, so what can you do about this?

I would suggest a trial of Betaine Hcl with Pepsin.

Betaine is actually a capsule containing a small amount of hydrochloric acid.  Pepsin is a digestive enzyme.

Start by taking 1 capsule at the beginning of each meal.  If you are tolerating it without side effects, then after a few days increase ​your dose to 2 with each meal.  You can continue ​to add a capsule every few days until you begin noticing a mild burning in your stomach.  When that occurs, decrease your dose by 1 capsule from what you were taking when the symptoms occurred.

In my experience, most people need 1-3 capsules per meal.  However, if you have a long history of PPI, H2 blocker or antacid use, you may need more.

Get my preferred brand here.

If you are currently taking a PPI, H2 blocker, or antacid on a regular basis, I would suggest trying to wean off of those before trying the Betaine.

If you are on a PPI such as Nexium or Prilosec, try converting to an H2 blocker such as Zantac or Pepcid. It will be easier to wean off of those medications than it will be a PPI.

Also, if you currently have an active stomach ulcer, I would not recommend a trial of Betaine until after the ulcer has completely healed.

– Digestive Enzymes

​Digestive enzymes help to break down food which allows your body to extract the vital nutrients in the food.

They also help break down immune complexes in the blood which helps treat autoimmune conditions.

Click here for my preferred brand.

​- Probiotics

​High potency, multi-strain, multi-species probiotics cah greatly reduce local inflammation in the gut as well as reduce systemic inflammation.  I always recommend a probiotic to all patients with hypothyroidism (especially Hashimoto’s) for at least 2-3 months.

It is somewhat controversial whether you should take probiotics on a daily basis.  Many experts feel that is unnecessary.

I usually break it down to whether the patient has any gut issues or not.  If they do, they should take a daily probiotic.  If they don’t they can probably used them only during times of sickness or severe stress.

Click here for my preferred brand.

– ​Other Gut Imbalances

​If after reading this you believe you may have other gut imbalances such as SIBO, SIFO (small intestinal fungal overgrowth), or leaky gut, those issues will need to be addressed if you want to optimize your T3 level.

That ​will require sitting down with a doctor that is familiar and comfortable with those conditions.

​​4.  Lower Your Reverse T3

Reverse T3 and T3 are inversely proportional to each other.  As one rises, the other will fall and vice-versa.

That is because they both are produced from T4.

​​So reducing your reverse T3 production will mean that more T4 is being converted into T3.

So how do you do it?

Think of the reverse T3 level as indirect marker of inflammation in the body.  Any inflammation will typically cause the reverse T3 level to rise.

Therefore, ​most of the things I list below address various forms of inflammation.

– Reverse Insulin Resistance and Leptin Resistance

​High levels of insulin and leptin tell your body to create MORE reverse T3.

It will be very difficult to lower your reverse T3 levels unless you address these issues.

Click here to read more about how to treat insulin resistance and click here to read more about how to treat leptin resistance.

– High Intensity Interval Training (HIIT)

​Adding HIIT exercise to your regular routine will create a demand for more thyroid hormone in your body.

In effect, it will push your T4 conversion more down the T3 pathway and reduce your reverse T3.

– Stop Restricting Your Calories

​Calorie-restricted diets will put your body into “starvation mode.”  When that happens, T3 production is rapidly reduced and reverse T3 levels soar.

This is one of the ​ways that excessive calorie restriction damages your metabolism.  Click here to read more.

– Reduce Inflammation

​Besides insulin resistance and leptin resistance, there are other sources of chronic inflammation that will result in an elevated reverse T3 level.

These can include other autoimmune conditions, environmental toxins, and even obesity itself.

It is critical to get a thorough history and physical exam including blood work to identify all possible sources of inflammation in your body so that each be addressed directly.

There are some blood tests that you can request from your doctor that are nonspecific markers of inflammation in your body.

The most common tests are the erythrocyte sedimentation rate (ESR) and the c-reactive protein (CRP).  If either is above the reference range, it is a sign that there is unidentified inflammation in your body that should be addressed.

– Take a T3 Medication

​The quickest way of lowering the reverse T3 level is to take a T3 only medication.

This bypasses the conversion process altogether.  Your need for T4 will decrease which will also result in a dramatic decrease in reverse T3.

​5.  Manage Stress and Optimize Your Adrenal Function

​The adrenal glands and the thyroid gland are closely linked.

As cortisol levels increase, so does the TSH, which makes the thyroid function worse.

Also, as thyroid function decreases, this puts even more stress on the adrenals to make up the difference.

Eventually, the system can no longer keep up and adrenal fatigue results.

In my experience, literally ALL hypothyroid patients have some degree of adrenal fatigue.

That is why I​ recommend that most hypothyroid patients take an adrenal supplement.

For the sake of this article, I would suggest a few basic things to help manage adrenal issue:

  • ​Take an adrenal adaptogen – Essentially all patients would benefit from these herbs that help balance the adrenal function.
  • ​Take an adrenal glandular – Use this if you are having severe stress or severe fatigue.  Typically only needed for 3-6 months.  Avoid if you have an allergy to it.
  • checkCut out caffeine – Caffeine may give you a temporary boost, but it also adds additional stress to your adrenals and will ultimately make your symptoms worse.
  • Start doing regular meditation and/or yoga – This will drop cortisol levels and let your adrenals rest.

​If ​you feel you need to learn more about this, click here for my article on adrenal fatigue.

6.   Optimize Your Liver Function

Up to 60% of thyroid conversion occurs in the liver.

Obviously, making sure your liver is healthy and functioning well is critical if you want your T3 levels optimized.

Your liver can be assessed by having your liver function tests monitored.  The primary test are AST and ALT.

If either test is >20, it is a sign that you have some liver impairment.

By far, the most common cause of liver impairment is insulin resistance.  The insulin resistance can result in excessive fat deposits in the liver resulting in a fatty liver.

Reducing any liver dysfunction may result in the single greatest increase in your T3 level of any therapy that we have discussed.

​7.  Improve Your Diet and Lifestyle

​The foundation of any successful health plan always includes 5 things:

  • Healthy diet
  • Activity level/exercise
  • checkStress management
  • Good sleep hygiene

​If that foundation isn’t established, all of the supplements, medications, and other therapies will fail miserably.

​I realize that this is easier said than done, but it is critical if you want to feel your best.

In the case of this article, you must be eating healthy, exercising, sleeping well, and managing your stress in order to maximize your T3 production.

If you need a simple place to start, consider the Whole 30 Diet or the Ketogenic diet.

If you are having trouble with those or if you feel you need more instruction, I would recommend hiring a nutritionist for some one-on-one instruction.  You are worth it!

I would also recommend hiring a personal trainer that will give you a personalized exercise program that will be safe and effective.

​Summary

​Raising the T3 level is easy for some people and hard for others.

The key to success is identifying WHY yours is low and addressing the root causes.

These can include poor diet, lack of exercise, nutrient deficiencies, and excess stress.

There could also be unidentified sources of inflammation in your body or your liver and gut might not be working as efficiently as they should be.

Finally, it may also be the situation of needing a different thyroid medication.

Find a doctor that is willing to investigate all of these potential causes and is open to trying different thyroid medication.

​Now it’s your turn…

What have you tried to increase your T3 levels?

What has worked and what hasn’t?

Leave any questions or comments below.

Why is My T4 Low (and What Can I Do About It)?

Do your lab tests show that your T4 level is low?

​​What ​does that mean exactly?

Do you also have symptoms such as fatigue, weight gain, hair loss, constipation, and depression?

If you answered yes, you most likely have ​hypothyroidism which usually causes a low T4 level.

In this article, I will discuss the T4 lab test, what it means when it is low, symptoms that may be associated with a low T4 level, and I will also give some treatment tips that will help raise it to​ an optimal level.

Let’s get started…

​What is T4?

So what is T4 anyway? 

In order to answer that question, we need to talk about the thyroid gland and how it works.

​The thyroid gland primarily produces 2 types of thyroid hormone – Thyroxine (T4) and Triiodothyronine (T3).

The vast majority of the thyroid hormone produced is thyroxine (T4).  Not nearly as much triiodothyronine (T3) is produced.

Both of these hormones are produced ​in response to a hormone secreted by the pituitary gland called Thyroid Stimulating Hormone (TSH).

​The association of TSH and T4 gives us valuable information about how well the thyroid gland is working. That is why these tests should always be tested together.

​So what is the purpose of T4 in the body?

T4 is not nearly as biologically active as T3, but it still helps regulate how much T3 is available in the body.  ​

Most of the T3 in the body is actually produced from peripheral conversion of T4.  

​More specifically, as the body needs T3, an enzyme called a deiodinase will cleave off an iodine molecule from T4 which converts it into T3.

You can therefore think of T4 as a storage reservoir for the body to use to make T3 as it needs it.  This is the primary purpose of T4.

Causes of Low T4

​So what happens if the T4 level is low?

If the reservoir of T4 becomes low in the body (sort of ​like most of the lakes in the Texas Panhandle where I live), then there is not enough substrate that the body can use to produce T3.

The T3 levels then ​also drop, and symptoms of hypothyroidism develop.

​Why does the T4 level drop?

Let’s discuss the most common causes:

​1.  Autoimmune Thyroiditis (Hashimoto’s) –

​There are many theories about how and why autoimmune disorders ​develop.

​It is generally accepted that 3 things must be in place for an autoimmune disorder to develop.

  • Genetic Predisposition – You have a variation in one of your genes that may make it more likely to develop an autoimmune condition.
  • Leaky Gut – The bacterial levels and types of bacteria in your GI tract may be inadequate​.  Also, gaps between the cells in your intestines may widen which allows foreign proteins and toxins to enter the bloodstream that wouldn’t normally get through.
  • Trigger – A physical or emotional event may occur (injury, surgery, major life stress, etc.), or you may be exposed to an environmental toxic of some sort which can damage your immune system and cause it to ​function improperly.

​A common theory is that some of these foreign proteins that enter our bloodstream look similar to proteins in our body.  As a result, ​as our immune system makes antibodies against these foreign proteins, it in effect also ​unintentionally makes antibodies against parts of our body.

This is called molecular mimicry.

​This appears to be what happens in Hashimoto’s Thyroiditis.

The result is these auto-antibodies continuously attack parts of our thyroid gland, ​gradually destroying it.

As the cells of the thyroid gland are destroyed, its ability to produce thyroid hormone is impaired and hypothyroidism will develop.

This typically occurs slowly over many years.

Often patients will have classic symptoms of hypothyroidism, but their labs will remain relatively normal until late in the process.

Hashimoto’s is an extremely common condition.  In fact, in my medical practice I typically diagnose one or more people with it every week!  It is by far the most common autoimmune disorder.

Many experts believe that the vast majority (over 90%) of hypothyroidism in the United States is actually caused by Hashimoto’s.

If you have hypothyroidism, you should periodically have your thyroid antibody levels checked.

Click here to read more.

​2.  Hypothyroidism –

​Hypothyroidism refers to the condition of low levels of thyroid hormone in the body.

​The majority of cases are due to issues with the thyroid gland itself.  Rarely, it can be caused by issues in the brain (hypothalamic dysfunction).

​Since most thyroid hormone in the body is T4, if you are hypothyroid, you will have low levels of T4.

​That, however, ​does not give you enough information.  You need to investigate WHY you have hypothyroidism so that you can be appropriately treated.

​As we discussed earlier, the majority of hypothyroidism is caused by Hashimoto’s Thyroiditis.

​3.  Nutrient Deficiencies –

​There are multiple (at least 13) nutrients that are needed for proper thyroid hormone production and conversion.

A deficiency of even one of them can ​result in a significant reduction in thyroid ​levels which will cause symptoms of hypothyroidism.  It can also cause an increase in thyroid antibody levels if you have Hashimoto’s.

These nutrient deficiencies can include (click on the names for my preferred brands):

​So, should you just blindly supplement with all or most of these supplements if you have thyroid issues?

Of course not!

​You should always see your doctor and be tested for any nutrient deficiencies before supplementing, or at least look for common symptoms associated with particular deficiencies.  If you have a symptom or symptoms commonly seen with one of these nutrient deficiencies, then a trial of supplementation is reasonable to consider.

It is also always best to start with your diet.  Eat a diet high in nutrient-dense, organic foods which will contain a much higher nutrient content than the Standard American Diet.

​4.  Taking a T3 Only Medication –

​If you are taking a T3 only medication, it ​will often result in a drop in your T4 level.

T3 only medications include Cytomel and liothyroinine.  

Why?  It makes sense if you think about it.

​Like we learned earlier, T4 acts as the storage reservoir for T3 in the body.

If you are taking a T3 only medication, then your need for ​that reserve of T4 decreases because you have bypassed the conversion process.  This therefore results in less T4 production by the thyroid gland.

Taking a T3 only medication will typically cause the free T4 level to decrease, the TSH level to decrease, the reverse T3 level to decrease, and the total T3 and free T3 levels to increase.

This can also happen to a lesser extent if you are taking a natural dessicated thyroid (NDT) such as Armour Thyroid, NP Thyroid, or Nature-throid.  That is because these medications contain about 20% T3 and about 80% T4.

The drop in T4 level in this case is expected and what you want.  It is not a sign of inadequate thyroid levels like it is in the other situations.

​Symptoms of Low T4

​Having a low T4 level typically results in all of the classic symptoms of hypothyroidism.  

The list of symptoms can be quite exhaustive, but the most common include:

  • Fatigue
  • Weight Gain
  • checkHair Loss
  • checkConstipation
  • checkCold Intolerance
  • checkDepression
  • checkBrittle Nails
  • checkDry Skin
  • checkMenstrual Irregularities
  • Infertility
  • checkBrain Fog

​For a more extensive list, click here.

The vast majority of doctors have been taught to use the TSH as their sole means of evaluating thyroid function.

In many cases of hypothyroidism, the TSH will remain normal until it has been present for many years. This is true with Hashimoto’s as well.

The T4 and T3 levels will typically drop earlier in the process than will the TSH.

That is another reason why you should ALWAYS ask for a complete thyroid panel when your thyroid is being evaluated.

​How to Raise Your T4

​Fortunately, raising your T4 level is usually straight-forward.

Reversing what is causing your low T4 is the key to successful treatment.

You will either want to increase the thyroid hormone your body produces itself, or you will need to supplement ​what your body produces with a thyroid hormone medication.

​1.  Lifestyle Interventions –

​Improving your diet, beginning an exercise program, improving gut function, and reducing stress should always be the first steps taken when treating ANY condition.  The thyroid is no exception.

​2.  Correct Any Nutrient Deficiencies –

​Identifying and correcting any of the nutrient deficiencies we discussed earlier will result in an increase in your body’s natural thyroid production and T4 to T3 conversion.

​3.  Supplement with a T4 Thyroid Hormone – 

​Taking a T4 only medication such as levothyroxine, Synthroid, or Tyrosint will result in an increase in the T4 level in the body.  

Keep in mind that if you have T4 to T3 conversion issues because of a nutrient deficiency or inflammation in the body (insulin resistance, leptin resistance, an autoimmune condition, etc), raising your T4 level may still not result in adequate T3 levels reaching the cells.  Symptoms of hypothyroidism may still not improve.

​4.  ​Reduce Thyroid Antibody Levels –

​If you have Hashimoto’s, there are dietary, supplement, and medication therapies that can help reduce thyroid antibody levels.  This will improve thyroid function and will help to raise the T4 to an optimal level.

Click here to read more.

​5.  Take T3 Thyroid Hormone –

​In addition to or even in place of T4 thyroid hormone, T3 hormone medication can be taken.

That may cause the T4 level to drop, but that is not a bad thing in this case.

There is an art to using T3 medication, so it is important that you find a medical provider with experience in using it.

Click here to read more.

​Summary

​A low T4 level is commonly seen in hypothyroidism.  It is often present before the TSH level becomes abnormal.

​A low T4 is associated with several symptoms that can dramatically alter your quality of life.

Treatment to increase T4 levels typically involves correcting nutritient deficiencies, reducing inflammation, and taking thyroid medication.

Now it’s your turn…

​Is your T4 level low?

Is your TSH level ​low, normal, or high?

Are you having symptoms of hypothyroidism?

What treatment plan are you using?

Leave any questions or comments below.​

Is TSH Enough

Is a TSH Enough to Test Your Thyroid?

​Most medical providers have been trained to only check the TSH when monitoring thyroid function.

​But is th​e TSH enough to ​test your thyroid?  Is it enough to monitor whether you are on the right dose or right type of thyroid medication?

The answer is a definite “no” and I will explain why in this article…

​What is TSH?

Let’s quickly review what the TSH is and what it indicates:

Thyroid cascade

​All thyroid activity actually begins in the hypothalamus of the brain​.  The hypothalamus secretes a hormone called Thyroid Releasing Hormone (TRH) which then stimulates the pituitary gland to secrete TSH.

​TSH ​an acronym for Thyroid Stimulating Hormone.  ​It’s purpose is to stimulate the thyroid gland to produce thyroid hormone.

The pituitary gland measures the level of T4 and T3 in the blood ​of the pituitary and secretes TSH in order to keep the levels of thyroid hormone in the optimal ranges.

When the body is healthy and working normally, this feedback loop works seamlessly to regulate thyroid function in the body.

As a reminder, if there are low levels of T4 and T3 in the pituitary gland, it will increase TSH secretion to try to stimulate the thyroid to produce more thyroid hormone, so the TSH level will rise.  Conversely, if there is an excess of T4 or T3, the pituitary will decrease TSH production.  The TSH level will drop or sometimes even go to zero.

The result is the TSH moves in the opposite direction of the thyroid hormone level.  If you are low in thyroid hormone, your TSH will usually go high, and vice versa.

​Remember, the TSH is ​an indicator of blood levels of T4 and T3 in the pituitary gland, which may not be the same as in the rest of the body.  This is because the pituitary has a different deoidinase enzyme than the rest of the body.

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​Thyroid Lab Tests

Prior to the 1970s, the history and physical exam were the primary tools used to diagnose hypothyroidism, Grave’s Disease, Hashimoto’s Thyroiditis, and other thyroid conditions.

​The TSH lab test was developed in 1975 and has been considered the gold standard for diagnosing and managing thyroid diseases ever since.  

​The vast majority of medical providers (doctors, PAs, NPs) are taught in their training to just use the TSH lab test to test for thyroid disorders and to monitor thyroid medications. 

If you ask ​them to do a complete thyroid​ workup to see if you have thyroid disease, they will order a TSH and ​sometimes a T4 level or TPO antibody level.  The other tests are rarely ordered, and even if they are, most providers don’t really know how to interpret them correctly.

​Conventional medicine doctors are taught this simple rule – If the TSH is high, you have hypothyroidism.  If it is low, you have Grave’s disease or you are on too much thyroid medication.  

Sounds simple, doesn’t it?  Unfortunately, evaluating the thyroid is much more complex than that.

​I personally believe that in order to truly evaluate ​someone’s thyroid health, you need to order a complete thyroid panel.  Those tests include:

​If you want more information on each of these tests, what the levels are indicating, and optimal ranges for each, read my article here.

The sex hormone binding globulin (SHBG) can also be very helpful in assessing thyroid levels in the body, especially if you are on thyroid medication.  Read more about it here.

​Common Causes of a Suppressed TSH

So ​is checking the TSH enough to diagnose and manage thyroid disorders?  No, because there are many situations in which the TSH will be falsely suppressed or at least lowered from what it really is.

Suppressing (lowering) the TSH level makes it look like the person has more thyroid hormone in their body than they really have.  As a result, this may make it look like they are on too much thyroid medication when the opposite is actually true.

Also, if they haven’t been diagnosed with hypothyroidism, this may mask their true levels and prevent the diagnosis from being made because the TSH is “normal.”

Now let’s discuss some of the situations where the TSH may be falsely low:

​1.  Pregnancy –

​The TSH can be transiently low or even undetectable in up to 20% of normal pregnant women with no other signs or symptoms of hyperthyroidism.

​2.  Medications –

​Several classes of drugs ​can suppress the TSH.  The most common ones include:

  • check​Glucocorticoids – These include oral, topical, inhaled, and injectible steroids such as prednisone, triamcinolone, dexamethasone, betamethasone, etc.
  • checkDopamine Agonists – These drugs are used primarily for the treatment of Parkinson’s Disease and Restless Leg Syndrome (RLS).  They include ropinirole (Requip), pramipexole (Mirapex), and many others.
  • checkCancer Chemotherapy –  ​Many chemotherapy drugs such as somatostatin analogs and rexinoids ​cause hypothalamic dysfunction which reduces TRH secretion ​and thus lowers the TSH.

​3.  Autoimmune Thyroid Disease (Hashimoto’s) –

​It is common practice to give Hashimoto’s patients thyroid hormone medication as a treatment for their autoimmune disease.

This is because studies show that thyroid hormone medication can reduce thyroid antibody levels even if the TSH is normal.  ​Click here, here, here, here​,  and here​ for even more studies.

This will obviously result in​ the TSH being suppressed a large percentage of the time in patients with Hashimoto’s.  However,​ it brings the T4 and T3 levels ​into the optimal range.

Which is more important?  Keeping the TSH “normal” or getting the T4 and T3 levels normal?  I believe there is a strong argument that it is more important to optimize the T4 and T3.

​4.  Chronic Fatigue Syndrome/ Fibromyalgia –

The hypothalamic-pituitary-adrenal axis is a complex system that controls many of the hormone systems of our body.  Research shows that when that system does not function correctly, it can have a major impact on the body.  That is called HPA dysfunction.

​​HPA dysfunction is ​relatively common.   ​When this system isn’t working properly, many of the hormone glands in our body – adrenal, thyroid, ovaries, and testicles – do not work normally.  This results in reduced production of cortisol, thyroid hormone, and sex hormones.

People that have HPA dysfunction ​often have low TSH levels (because of reduced production of TRH), which makes it appear on lab tests that they have adequate or even high thyroid levels in the body.  In reality, the majority of them have LOW thyroid levels, even though their TSH is in the low or normal range.

​HPA dysfunction is commonly found in people with conditions such as Chronic Fatigue Syndrome and Fibromyalgia.

If you suffer from one of these conditions or know someone who does, you may realize that many of the symptoms appear the same as hypothyroidism:

  • checkFatigue
  • checkConstipation
  • checkMuscle pain
  • checkMood swings
  • checkCold intolerance
  • checkBrain fog

​This has led some experts to believe that ​hypothyroidism at the cellular level may be one of the primary causes of fibromyalgia and chronic fatigue syndrome.

In this study, researchers gave liothyronine (T3) to patients with fibromyalgia, even though their TSH was in the normal range.  It resulted in the patients having a suppressed TSH consistent with what most doctors would call hyperthyroidism.  

However, their fibromyalgia symptoms were greatly improved, and there were no significant side effects from taking the high doses of thyroid medication.

In a follow up study, the T3 medication was discontinued, resulting in the patient’s symptoms returning. When the medication was restarted, the symptoms improved again.

​Could fibromyalgia and chronic fatigue syndrome be at least partly caused by undiagnosed hypothyroidism?  It is something that should be considered.

​5.  Mutation of the Thyroid Receptor (Peripheral Thyroid Resistance) –

​This sounds way more complicated than it really is.

​To put it simply, some people are born with a defect in the receptors in their cells where thyroid hormone attaches.  Receptors are like ​locks on the cell wall.  If the right key fits into those ​locks, it will trigger whatever function in the cell that the receptor was designed to do.

Below is a diagram of how this is supposed to work:

​However, if the lock is defective in some way, it may not work right even when the right key fits into it.

This is what happens when there is a mutation in the thyroid receptor.  The thyroid hormone may attach to it, but it may not trigger the function of that receptor like it was designed to do, at least not as efficiently as it would normally.

As a result, the cells will not be as responsive to thyroid hormone as they should be.  ​This is called peripheral thyroid resistance.

​Patients with peripheral thyroid resistance may have normal or even low levels of TSH, but their free T4 and free T3 levels will be low.  The​ amount of thyroid hormone required to normalize their free T4 and free T3 ​will often result in a suppressed TSH.

​Here is an example from a recent patient in my family practice office.

This ​ 32 year old female with a history of Hashimoto’s thyroiditis ​came to my office complaining of persistent fatigue ​despite taking Armour Thyroid 120mg daily, selenium 200mcg daily, turmeric daily, and B12 supplements.  She eats a whole food diet, exercises regularly, and gets good sleep.

Here complete thyroid panel is listed below:

​As you can see, her TSH is in the normal range.  If that was the only lab checked, you might think her thyroid level was normal.  However, both her free T4 and free T3 are very low and her reverse T3 is <15 (which we want).  Her TPO antibodies are slightly elevated.

This is typical of someone that has peripheral thyroid resistance.  It will take more thyroid medication than usual to get adequate amounts of it into her cells, most likely because she has a mutation of her thyroid receptors.

​I therefore increased her Armour Thyroid to 150mg in hopes of getting her free T4 and free T3 levels into the optimal range.  That will ​most likely​ cause her TSH to be suppressed below the “normal range,” but it will be necessary to help relieve her fatigue and other hypothyroid symptoms.

​Summary

​Only checking a TSH level is not enough to monitor the thyroid activity and function in the body.

​That is because the TSH is really only a measurement of thyroid hormone levels in the pituitary gland, which may be different than thyroid levels in the rest of the body.

Many things can cause the TSH level to be inaccurate, including some medications, autoimmune thyroid disease, chronic fatigue syndrome, fibromyalgia, thyroid receptor mutations, and even pregnancy.

In order to get a true ​assessment of thyroid activity in the body, it is important to get a complete thyroid panel and take a thorough history and physical exam.

Now it’s your turn…

​Do you have symptoms of thyroid disease but have been told that your TSH is normal?

Have you had experience treating your thyroid issue even though your TSH is normal?

Leave your questions and comments below.​

Is a Low TSH Level Dangerous?

​Is it dangerous to have a suppressed TSH level lower than the “normal” range?

Does a low TSH increase the risk for osteoporosis or heart problems?

Are there situations when having a suppressed TSH is not only safe but helpful?

Are there things that can be done to avoid the potential negative side effects of a low TSH?

I will try to answer these questions and others in this article…

​What is TSH?

Let’s have a quick reminder of what exactly the TSH is and what it indicates.

​TSH ​is short for Thyroid Stimulating Hormone.  This hormone is produced by the pituitary gland in the brain.  It’s purpose is to stimulate the thyroid gland to produce thyroid hormone.

The pituitary gland measures the level of T4 and T3 in the blood ​of the pituitary and secretes TSH in order to keep the levels of thyroid hormone in the optimal ranges.

When the body is healthy and working normally, this feedback loop works seamlessly to regulate thyroid function in the body.

As a reminder, if there are low levels of T4 and T3 in the pituitary gland, it will increase TSH secretion to try to stimulate the thyroid to produce more thyroid hormone, so the TSH level will rise.  Conversely, if there is an excess of T4 or T3, the pituitary will decrease TSH production.  The TSH level will drop or sometimes even go to zero.

The result is the TSH moves in the opposite direction of the thyroid hormone level.  If you are low in thyroid hormone, your TSH will usually go high, and vice versa.

​What is a Normal TSH Level?

​When looking at a characteristic found in a large population of people, the results will follow a predictable distribution across a graph.

For example, if you ​graph the heights of everyone in the ​world, the results w​ill range from as little as 21.5 inches to as tall as 97 inches ​with the average being about 68 inches.  The majority of people in the world will be close to the average height.  The further away from the average you go, the fewer people will be that height.

The result is what is commonly called a Bell Curve:

​This is also how reference ranges for lab tests are determined.

However, a Bell Curve also assumes that all people included in the graph are equivalent – meaning none are on medication, have different diets, genetic history, etc. which could affect the results.

ZRT is a well-known national laboratory.  Their website explains it like this:

Reference ranges do not always reflect a “normal” healthy population free of medications. Most laboratories establish their reference ranges from a large population of people where detailed information on health status, stage of life (premenopausal vs. postmenopausal), and medications and hormones used is unknown, and therefore not taken into account. Couple this with differences in lifestyles, physiology, dietary habits, and genetic heredity, and it’s even more difficult to define, let alone find, a normal population.  

​This is what happened when the “normal” reference range for TSH was ​first established.  It has since been determined that ​up to 30% of the people​ who have a TSH > 3.0 have undiagnosed ​autoimmune thyroid disease, which skews the TSH results higher than what they would be in a population with no thyroid issues.

​So instead of a normal range of TSH ranging from about 0.4-​5.0 which it is for most labs, it should instead be about 0.4-2.0.

​In other words, even if a patient’s TSH comes back at something like 3.5, even before I look at the other lab tests, that signals to me that there is most likely some degree of thyroid dysfunction in that person.

Is a Low TSH Level Dangerous?

​​The TSH is ​an indicator of blood levels of T4 and T3 in the pituitary, which may not be the same as in the rest of the body.  This is because the pituitary has a different deoidinase enzyme than the rest of the body.

In ​this article, I discussed why I believe that the free T3 and reverse T3 levels are much better indicators of thyroid activity at the cellular level than is the TSH.

I recommend ​trying to get the free T3 > 3.5 and the reverse T3 < 15 if possible.  In my experience, that is sometimes very difficult to do in many patients without suppressing the TSH to < 0.4.

So is lowering the TSH < 0.4 dangerous?  What if the patient has none of the symptoms of an overactive thyroid (thyrotoxicosis) such as palpitations, tachycardia, insomnia, anxiety, etc.?

What if the free T4 and free T3 levels are in the optimal range even if the TSH is suppressed?  Is the low TSH a concern?

​The majority of concern about the dangers of lowering the TSH come from studying patients with Grave’s Disease.  Grave’s is an autoimmune disease which results in the overproduction of thyroid hormone which results in a suppressed TSH.

Grave’s disease has been shown to result in an elevated serum calcium level due to excessive bone turnover.  Untreated, this could ultimately result in significant bone loss and osteoporosis.

​Another study, however, showed that in order to get the free T4 level in the optimal range in patients with hypothyroidism, it required them to take a dose of levothyroxine that ​resulted in a TSH level suppressed below the reference range in over 48% of the patients.

​Potential ​Side Effects of a Suppressed TSH Level

There are actually 2 different instances where suppressing the TSH is not only acceptable but considered the standard of care in conventional medicine:

  • checkAfter thyroidectomy in thyroid cancer patients
  • checkIn patients with thyroid nodules

Both of those groups are good to study to see if any dangerous side effects occurred with long term TSH suppression.

​So what does the literature say?  Does lowering the TSH with thyroid medication result in the same potentially dangerous side effects that Grave’s disease can cause?

Let’s look at it further…

​Bone Loss

In this study, there was no significant bone loss in thyroid cancer patients treated with suppressive doses of thyroid hormone.

​This study showed no decrease in bone mass after 1 year in patients receiving suppressive doses of thyroid hormone for treatment of thyroid nodules.

However, this meta-analysisdid show a reduction in bone mass in postmenopausal women who received suppressive doses of thyroid hormone for over 9 years.  Of note, it did not show the same result in premenopausal women.  But this study did not show an increase in bone loss in women with low TSH levels.

​This study also showed an increased risk of hip and vertebral fractures in women over age 65 that had a TSH of 0.1.  But this study showed there was no increase in fracture risk in women < age 65.

In this study, any bone loss associated with prolonged use of thyroid hormone therapy was ​prevented by the use of ​estrogen replacement.  The use of calcium ​has also been shown to negate any bone loss caused by thyroid hormone.

Bottom Line?  Prolonged suppression of the TSH for years may cause bone loss in postmenopausal women.  The amount of bone loss appears to depend on how long they TSH is suppressed and how much it is suppressed.  The risk seems to be minimal in premenopausal women.

It also appears that the bone loss can be prevented by using bioidentical hormone replacement and nutrients such as calcium and vitamin D.

So what if the only way you can get your free T3 and free T4 levels to the optimal range is by lowering your TSH < 0.4?

First of all, you need to discuss the pros and cons with your doctor before a decision is made.  If you decide to take suppressive doses of thyroid hormone, then the bone loss risk can probably be minimized by also taking ​bioidentical estrogen, calcium, and vitamin D.

​Cardiac Issues

​Thyroid hormone definitely has an impact on cardiac function.  It helps regulate heart rate, the size of the heart, and the pressure inside the chambers of the heart.

​Conditions such as Grave’s Disease that cause large increases in thyroid hormone levels have been shown to increase the risk for things such as atrial fibrillation, heart enlargement and heart failure.

So the question becomes, does taking excessive amounts of thyroid hormone result in the same risks as Grave’s Disease?  At this point, there is not enough data to say yes or no.

So how does thyroid hormone affect the heart?

The heart appears to only respond to T3, yet it is unable to convert T4 to T3 in the cardiac tissues.

It therefore only makes sense that thyroid medications that contain T3 (Cytomel, liothyronine, natural dessicated thyroid) may have more of a cardiac effect than thyroid medications that only contain T4 (Synthroid. Tyrosint, levothyroxine).

If someone has a very healthy T4 to T3 conversion system, they may still get cardiac symptoms from a T4 only medication, but many people have a defect in that conversion.

The risk of excessive thyroid hormone on the heart appears to depend on both how long the TSH is suppressed and how much it is suppressed.

For example, people with a slightly suppressed TSH (subclinical hyperthyroidism) have only mild cardiac issues when compared to Grave’s patients.

Fortunately, studies also show that the cardiac abnormalities return to normal once the thyroid level in the body is normalized.

There is also evidence that using beta blockers can prevent and reverse the cardiac changes seen in hyperthyroidism.

Bottom Line?  Based on the studies, it appears that suppressing the TSH temporarily will not lead to long term cardiac complications.

Also, if you are taking suppressive doses of thyroid hormone, taking a beta blocker at the same time may actually prevent any cardiac complications from occurring.

​There may therefore be situations where taking suppressive doses of thyroid medication for a short time may be beneficial with minimal risk.  However, it should only be considered ​after consulting with a doctor with experience​ in thyroid management.

​Should We Even Monitor the TSH?

​I had a patient ask me recently, “If the TSH is not an accurate measure of thyroid levels in the cells of the body, why even check it?”

That is a ​fair question, but the fact is, monitoring the TSH is still considered standard of care for managing the thyroid.  The TSH should therefore be monitored, just not by itself.

The whole picture of the thyroid should be evaluated by monitoring the complete thyroid panel which also includes the free T4, free T3, reverse T3, and thyroid antibody levels.

​If your doctor is not checking all of these labs when testing or monitoring your thyroid function, you are not getting a complete picture of what is going on with your thyroid.

​Read this article if you want to know more about each of these lab tests, what they mean, and optimal ranges of each.

​Summary

​It is important to monitor your TSH level as part of your thyroid hormone management, but it is even more important to monitor ​all of the tests in a complete thyroid panel.

Taking enough thyroid hormone to lower your TSH level below the normal reference range may have some potential long term consequences.  Fortunately, most of those can be avoided if your thyroid levels are closely monitored and managed properly.

​It may require taking suppressive doses of thyroid hormone temporarily in some patients in order to get their free T4 and free T3 levels into the optimal ranges.  In those instances, it is extremely important to monitor bone density and cardiac health.

​In many cases, the bone loss may be prevented by also taking bio-identical estrogen and calcium.

Many of the cardiac issues may be prevented by also taking a beta-blocker.

​As a general rule, taking enough thyroid hormone to suppress the TSH should be avoided in postmenopausal women, whereas the risk does not appear to be as high in premenopausal women and in men.

Now it’s your turn…

Have you even taking enough thyroid hormone to suppress your TSH?

Did you have any negative side effects?

Do you currently have a TSH in the normal range, yet you still have symptoms of low thyroid?

Leave your questions or comments below.

Why Am I So Tired All the Time?

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​Why am I so tired all the time?  I am asked that question multiple times EVERY DAY.

​​Our society is exhausted, and it’s only getting worse.

​Do you ever wake up refreshed, make it through the day ​easily, then still have energy in the evening for home activities and family time?

​If you do, consider yourself fortunate.  Most of us don’t​.  Not by a long shot.

In this article, I will discuss the most common ​reasons why you may be tired and give you some pointers on how to regain some energy and quality of life.

Let’s get started…

More…

​What Does It Mean To Be Tired?

What do people mean when they say they are tired?

Sometimes they may be frustrated – “I am so sick and tired of this traffic.”

Others may mean they are emotionally spent – “I am so tired of fighting with my husband.”

Still others may mean they are physically worn out – “I am so tired from that ​workout.”  Or “I am so ​exhausted.  The baby kept me up all night.”

For the purpose of this article, when I talk about being tired, I am primarily referring to a lack of energy.

​In my online hormone practice, I always start the first appointment with a new patient this​ way:  “Give me 3 goals that you have in meeting with me.”  95% of the time, the first 2 things that people list are:

1.  Lose weight​

2.  More Energy

​People are simply exhausted​, both physically and emotionally.

Let’s dive into the most common causes​ of fatigue that I see in people and discuss some solutions to this national epidemic…

​Common Causes of Being Tired

​Fatigue may be occassionally due to a single obvious reason, but most of the time it is because of several things, not just one.

Like most health issues, what you eat and your ​level of activity play a ​huge role in your energy level.​

There ​may also be some hormonal issues​ as well as other things going on in your body that you need to consider.

Let’s break these down further…

​1. Adrenal Issues

​As you know, we live in a very high stress society.  Most of us are on the move constantly, then we wonder why we feel so tired!

This type of lifestyle plays havoc on our adrenal system.

​One of the major functions of our adrenal glands is to produce cortisol, DHEA and epinephrine in response to stress (physical and mental).

These hormones help regulate our immune system, heart rate, and energy storage.

Under normal situations, a stressful event will trigger the adrenals to release a surge of cortisol which then signals the mitochondria in our cells to temporarily increase energy production​.

That increase in energy helps us to get through the physical or emotional stress we are experiencing.

When the stress passes, the cortisol levels then drop back to the normal range.

When the body is under CONSTANT physical stress, such as a chronic infection, inflammation from obesity, insulin resistance, an autoimmune condition, etc., the adrenals are under pressure to continuously secrete large amounts of cortisol.

The same is true for constant emotional or mental stress.

High cortisol levels promote hypothyroidism.

It also worsens insulin resistance and leptin resistance.

​With all of these conditions, ​fatigue is a common symptom.

Eventually, the adrenals will no longer able to produce adequate amounts of cortisol, so the levels in the body begin to drop. Adrenal fatigue results.

When this situation occurs, constant fatigue is a hallmark symptom.

​Even normal day-to-day activities become exhausting.  Exercise ​may make you feel wiped out for days.

To test for adrenal or cortisol issues, I usually start with an 8am serum cortisol level.

​If your levels are <11 or >18, you have adrenal issues that should be addressed.

That may require getting salivary or urine cortisol levels 4 times throughout the day.  You should discuss this with your doctor.

What What Can You Do About It?

To learn more in detail about management of adrenal issues, read my article here.

As a quick summary, here are my recommendations that you can do even without a doctor if your serum cortisol levels are abnormal.

If your morning cortisol level is >20​, consider these supplements:

  • checkPhosphatidylserine:  Phosphatidylserine has been shown to reduce cortisol levels if taken in doses up to 600mg per day.  Use 4-6 capsules at night (each capsule is 100mg) and recheck cortisol levels in 2-3 months.
  • checkAshwagandha:  Ashwagandha is an adaptogen that can actually help to lower cortisol levels when they are high and raise them when they are low.  It also can boost libido and may help with weight loss. It can also reduce anxiety symptoms caused by chronic stress.  Doses vary from 500-2000mg per day depending on tolerance and severity of symptoms.
  • checkMelatonin:  Melatonin has been show to reduce cortisol levels and may actually help improve your sleep at night.  Even if you are sleeping well, melatonin can still help reduce cortisol levels and should be considered.  It can also help with depression symptoms.  Doses vary from 1-3mg, but most people tolerate 3mg well.

​If your morning serum cortisol is < 11​, consider these supplements:

  • checkAdrenal glandulars:  These work best for patients with very low cortisol levels.  They also tend to provide an immediate boost to energy levels.  Using glandulars in combination with other supplements listed below may be necessary.  Should be used for 6+ months.
  • checkAdrenal Adaptogens:  Adaptogens can actually help to lower cortisol levels when they are high and some can even raise cortisol levels when they are low.  There are many types of adaptogens but I find that blends of multiple adaptogens tends to work best.  These can be combined with glandulars as well for more benefit.  Should be used for at least 3 months.
  • checkCoQ10:  This coenzyme is involved in proper mitochondrial energy production and can help increase energy levels, which can be very helpful in adrenal-related issues.  Use 2 capsules (240mg) per day for several months.
  • checkAlpha Lipoic Acid:  ALA helps increase mitochondrial energy production, acts as a powerful antioxidant, reduces peripheral neuropathy, and lowers inflammation.  ALA can also help with weight loss due to its effects on insulin.  Start at 600mg daily and increase up to 1800mg daily as tolerated.
  • checkVitamin B6:  Vitamin B6 is used in several pathways in the creation of adrenal hormones and many patients are deficient in it.  Taking higher doses of B6 during the acute phase of treatment may be necessary for a short period of time.

If your levels are either extremely high or low, it is critical that you see your doctor for further testing.  You could have undiagnosed Addison’s Disease or Cushing’s Disease.

​Besides supplements, learning some stress management techniques is also critical for optimizing your adrenals and improving your fatigue.

These include things such as yoga, daily meditation, prayer, and even just going outside for 15-30 minutes every day.

​2. Thyroid Issues

​If you are more tired than you think you should be, checking your thyroid should be high on your list.

Since the thyroid is your “metabolism” gland, any conditions affecting it will affect your energy level.

​Besides feeling tired, thyroid issues can cause these common symptoms:

  • checkWeight gain or inability to lose weight
  • checkFeeling cold all the time
  • checkBrittle nails
  • checkThinning hair or hair loss
  • checkConstipation
  • checkLow body temperature
  • checkMood changes, such as anxiety or depression
  • checkBrain fog
  • checkHormone imbalances – irregular periods, PMS

​If you are having some of these symptoms, you should ask your doctor to run a complete thyroid panel:

​Only checking ​the TSH level could miss up to 80% of patients with a thyroid condition.

​Ideal levels for your thyroid tests include:

  • TSH – ideal range ​is 0.5-2.0
  • search​free T4 – ideal range is in the upper 1/3 of the testing range
  • free T3 – ideal range ​is >3.5
  • searchreverse T3 – should be < 15
  • searchTPO antibody – >35 is diagnostic for Hashimoto’s thyroiditis
  • searchThyroglobulin antibody – >35 is diagnostic for Hashimoto’s thyroiditis

So What Can You Do About It?

​If any of your labs are out of these optimal ranges, you should talk to a doctor that is knowledgeable about the thyroid.  Supplements and prescription medication made be needed to boost your thyroid function.

If your doctor isn’t willing to work with you, consider finding a certified functional medicine doctor from the Institute of Functional Medicine.

​To learn more about the thyroid, click here to read my article on hypothyroidism and click here for my article on Hashimoto’s thyroiditis.

​3. Blood Sugar Imbalance

​Blood sugar fluctuations are a common cause of feeling tired.  You may be experiencing this especially if you ​have any “crashes” during the day when you feel weak, tired, and dizzy.

​Most ​people are on a constant roller coaster – they eat a diet high in sugar or processed carbohydrates. This causes their blood sugar to rise rapidly.

The rise in blood sugar triggers their pancreas to release insulin to carry the sugar into the cells to be used as fuel.

​The blood sugar then drops, sometimes rapidly, which makes them feel tired, moody, and even dizzy.

​It also triggers their hunger, so they eat more sweets or high carb foods and the cycle starts all over again.

​This situation is made even worse by:

​- Insulin Resistance

Half of Americans already have insulin resistance and most have no clue.

​When we constantly eat a diet high in sugar and/or processed carbs, our insulin levels remain high to try to manage the sugar load.

Our body responds to anything that is present in excess by learning to ignore it.  That is what happens with insulin when we have insulin resistance.

​We respond to the persistently high insulin levels by down-regulating the insulin receptors in our cells. This protects the cells from getting overloaded with glucose.

This causes the insulin and glucose levels to gradually increase.  Eventually, pre-diabetes and type 2 diabetes occurs.

I bet you don’t know many if any diabetic patients that feel energetic, do you?

​- Poor Diet

​We eat way too much sugar and processed carbs.  Most of us know that intuitively.

In a little over 100 years, the average consumption of sugar has increased from about 40 pounds per person per year to well over 100 pounds per person per year!

​We have also increased our consumption of grains (wheat, corn, etc) by almost 50% over the past 40 years.

I was raised ​in a small town.  Growing up, my diet was full of poor food choices.  Every breakfast had some form of grain and sugar – cereal, pastry, etc.  Every other meal did not seem complete unless it included some form of bread and a sweet dessert.

​With the changes that have been made to wheat and the continued increased processing of our food, we are learning that we have to make some conscious changes to our diets in order to improve our long-term health.

So What Can You Do About It?

Try to eat a whole food, nutrient-dense, high quality diet which is high in lean meats and organic vegetables.

If you need more help, a great starting point would be starting the Whole 30 diet or ketogenic diet.

​I would also suggest hiring a certified nutritionist that is knowledgable about functional medicine.

​4. Sedentary Lifestyle

​When someone ​spends the entire day either sitting or laying down, should they be surprised that they feel tired?

Our bodies were made to move!  Lack of movement with cause atrophy of our muscles and a general ​decline in our fitness level.

One study showed that regular, low-intensity exercise can reduce the feeling of fatigue by 65% and increase energy by 20%.  12 population-based studies showed similar results.

This study showed it specifically in women.

Have you ever been on an exercise program, then because of life events, had to stop for a few days?  Isn’t it amazing how quickly you lose your level of fitness and feel tired?

Now multiply that times 100 and you can get an idea of what a sedentary lifestyle will do to you and your energy level.

So What Can You Do About It?

Simply put, start moving!  Anything that you start doing now will be more than you ​were doing before.

If you aren’t currently exercising, start with a brisk walk at least 3 times per week. ​

Listen to your body.  If it exhausts you, you may need to back off of the intensity.  This is especially true if you are having some adrenal issues.  Increase the time and intensity as tolerated.

Eventually, you will want to incorporate some simple weight training and high intensity interval training (HIIT).

If you are struggling with knowing exactly what to do and how much, I would strongly recommend hiring a personal trainer who can design a workout schedule just for you.

They will also serve as a form of accountability for you and make sure you are doing everything safely.

I highly recommend realfitness.net.  Jessica is a world-class trainer as well as a certified nutritionist.  She has helped many of my patients (including myself).

If you have significant health issues – heart problems, uncontrolled blood pressure, etc. – discuss it with your doctor before starting.

​5. Poor Sleep

​Sleep is our body’s way of recharging itself and giving it the energy to function the next day.  ​When we don’t sleep enough or the quality of sleep is poor, we are going to feel tired.

If you are chronically tired, you need to take a long hard look at your sleep habits and sleep quality.  Your energy will not improve if you are sleeping poorly.

– Poor Sleep Hygiene

​Many people have developed horrible sleep habits over time.

This can include drinking caffeine throughout the day (including the evenings), sleeping in uncomfortable beds, sleeping in a bedroom that ​is too light or too hot, and staring a some sort of electronic screen the entire evening right up until bedtime.

The excessive use of electronic devices has become an epidemic in children and adolescents.  In fact, this use has a direct effect on their quality of sleep.  It has also been linked to the increase in depression in adolescents.

​Normally, around 9pm at night, the pineal gland in our brain begins secreting melatonin.  Melatonin helps our body to relax and prepares it for the night of sleep.

Excessive light, especially blue light, has been shown to suppress the secretion of melatonin in our brains.

I also see tons of patients that try to function on as little as 4 hours of sleep per night.  That simply isn’t enough.  You body will eventually start breaking down.

– Obstructive Sleep Apnea

​It is estimated that 22 million Americans suffer from obstructive sleep apnea.  What’s worse, up to 80% of those are undiagnosed!

Ask yourself these questions.  Ask your spouse to answer them about you as well:

1. Do people complain that you snore like a freight train?

2. Has anyone ever noticed that you frequently gasp or even stop breathing while you are asleep?

3. Do you wake up exhausted in the morning, even if you have ​slept for 7-8 hours or more?

4. Do you find yourself dozing off during the day if you sit still for more than a few minutes?

If you answered yes to one or more of these questions, you should make an appointment to talk to your doctor about it.

​Obstructive sleep apnea is a condition where the tongue falls back against the soft palate and the soft palate collapses against the back of the throat.

​The ​result is the airway closes.  You have to wake up out of deep sleep enough for your body to overcome the obstruction.  This can happen multiple times every hour.

Since you don’t stay in the restful deep stages of sleep, you don’t truly get good rest.

Untreated obstructive sleep apnea has been associated with an increased risk of​ heart disease, congestive heart failure, and stroke.

Obesity is a risk factor for obstructive sleep apnea, but obstructive sleep apnea also worsens obesity, thus creating a vicious cycle.

​It has also been shown to worsen insulin resistance and fatty liver disease.

So What Can You Do About It?

​If you have sleep apnea, fortunately, all of these risk factors can be reversed with the use of a continous positive airway pressure (CPAP) device.

Your doctor can order an overnight sleep study which will determine whether you have sleep apnea or not.

Everyone should follow these common sense sleep habits:

  • checkTry to sleep a minimum of 7-8 hours every night
  • checkReserve the bed for sleep and sexual relations only
  • checkConsider installing blackout curtains in your bedroom
  • checkReduce your thermostat to keep your bedroom cool at night
  • checkMake sure you have a comfortable, supportive bed and pillow
  • checkTurn off all electronic screens at least 2 hours before bedtime
  • checkAt the very least, install a blue light filter on your smart phone, tablet and computer to use after dinner

​6. Digestive Issues

​Gut issues are often the root cause of many conditions of the body.  The gut can also be playing a major role in your fatigue.

Here are some gut issues to consider:

– Leaky Gut

​Leaky gut (intestinal permeability) occurs when the inflammation in the intestines causes gaps between the cells.  These gaps allow foreign ​substances such as bacteria and other proteins to be absorbed that wouldn’t be normally.

Those foreign substances trigger a strong immune response which further increases inflammation.  That inflammation results in symptoms such as fatigue, mood swings, abdominal bloating and pain, achiness, headaches, and others.

The inflammation also prevents the absorption of many nutrients from what we eat, such as iron and vitamin B12.  A deficiency of these nutrients worsens feelings of fatigue.

Leaky gut can be caused by a poor diet of processed foods, prescription medication, thyroid disorders and autoimmune disorders.

What Can You Do About It?

​Remove processed foods from your diet, especially gluten and sugar.

Replace it with natural, organic whole foods.  I also recommend fermented foods that are full of healthy bacteria that our body needs.

Fermented foods include sauerkraut, kumbucha, kefir, kimchi and yogurt.

There are also several gut-healing supplements that can help.  These include:

  • checkProbiotics – I recommend that it have at least 10 bacterial strains and at least 50 billion cfu.
  • checkL-glutamine – this amino acid helps repair damage in the GI tract.  Take 1000-3000mg daily in divided doses between meals.
  • checkDigestive Enzymes – these enzymes help breakdown the fats and proteins in our meals. Take 1-2 with each meal.
  • checkQuercetin – this product has bioflavanoids which help to balance histamine levels and helps with digestion and allergies.  Take 2-4 capsules per day.
  • checkBetaine Hcl with Pepcin – these are vital components of gastric acid secretion.  It assists with digestion of food and absorption of nutrients.  Take 1 with each meal.  You may increase by 1 capsule per meal as needed.  If you develop burning in your stomach, reduce the dose by 1 capsule with each meal.

– Food Intolerances

​Many people are sensitive to certain foods and may not even know it.  Although they may not be truly “allergic,” consuming those foods still triggers inflammation and a reaction from the body.  Again, a common feature of inflammation is fatigue.

What Can You Do About It?

There is not a good lab test for food sensitivities.  The gold standard for determining them is the Elimination diet.

With the elimination diet, you remove the most common foods that cause food sensitivities for 3-4 weeks.  ​If your symptoms improve during that time, you know that you are most likely sensitive to at least one of the foods.

You then re-introduce the foods one at a time and see if you react.  If you don’t, you are most likely not sensitive.  If you do react, then you need to avoid that food as much as possible in the future.

The most common food sensitivities include:

  • checkGluten
  • checkDairy
  • checkSoy
  • checkProcessed or refined sugar
  • checkPeanuts
  • checkEggs
  • checkCorn

– Dehydration

​Water constitutes up to 75% of the body weight of infants and up to 55% of the body weight of adults.

Most of us are mildly dehydrated on an almost constant basis.  That results in symptoms of fatigue, headache, brain fog, and mood swings.

Studies show that even mild dehydration can affect our mood, energy level and mental functioning.  Here is another study.

Thirst is one of the last symptoms that you may feel when you are dehydrated.  Fatigue and the other symptoms may already be present by the time you feel thirsty.

So What Can You Do About It?

​Simply drinking more water may be the simplest yet most effective thing that you can do to increase your energy level.

As a general rule, I tell my patients that they should have to urinate at least every 2 hours.  If you are going longer than that, chances are you are dehydrated.

A simple way to determine your daily water needs is to take your weight in pounds and divide that in half. That number will be the approximate amount of water in ounces that you should drink daily.

For example, if you weight 140 pounds, you should be drinking about 70 ounces of water per day.

By the way, that amount is just for your baseline water needs.  If you are exercising, you need an additional 8 ounces for every 30 minutes of exercise.​

Eating a diet high in moist vegetables such as celery, cucumber and carrots is another way of increasing your water intake.

​7. Other Causes to Rule Out

​Although feeling tired is a common symptom that all of us have at times, it can also be a sign of something more serious going on in your body.

If your fatigue is more severe and lasts longer than it typically does, it is extremely important that you see a doctor for a complete history, physical exam, and blood work.

Some of the more serious potential causes of your fatigue include:

​- Anemia

​Anemia is a condition where you have lower levels of red blood cells.  Red blood cells carry oxygen in the blood to be used by the cells in the body.

Anemia is actually a symptom and not a diagnosis.  Something is causing the anemia.  That cause needs to be investigated thoroughly.

As a general rule, if someone is anemic, either the red blood cells are not being produced adequately by the bone marrow, or ​there is either blood being lost somewhere or the red blood cells are being destroyed somewhere.

Not only does anemia cause fatigue, it can also cause symptoms of weakness, dizziness, shortness of breath, pale skin, and an irregular heart beat.

​Some causes of anemia include:

  • checkHeavy menstrual periods
  • check​Iron, vitamin B12 or folic acid deficiency
  • checkGI bleeding – ulcer, gastritis, hemorrhoids, colon polyp, GI malignancy
  • checkAnemia of chronic disease – cancer, autoimmune disease, and other inflammatory conditions can suppression bone marrow production
  • checkBone marrow suppression – leukemia, multiple myeloma
  • checkAplastic Anemia – the bone marrow stops making red blood cells.  Can be caused by autoimmunity, infections, medications, and toxic exposures
  • checkHemolytic anemia– a condition where the body destroys the red blood cells faster than they can be made.
  • checkSickle Cell Anemia – a genetic condition caused by a defective form of hemoglobin

​Many of these causes of anemia are life-threatening and should be worked up by a medical professional.

​If you are anemic, don’t just assume it is from something like heavy periods or a bleeding hemorrhoid. Have it evaluated!

– Autoimmunity

​Inflammation in general taxes our bodies and will usually cause us to have significant fatigue.

If your fatigue is persistent or progressive, you should see your doctor.  Make sure that you request that your blood work include inflammatory markers, including the following:

– Complete Blood Count (CBC)

​- Erythrocyte Sedimentation Rate (ESR)

– C-reactive Protein – (CRP)

If any of these tests are abnormal it indicates an increase in inflammation and further workup is required. Several autoimmune conditions could be the cause including Hashimoto’s thyroiditis, rheumatoid arthritis, lupus, and many others.

– Malignancy

​As stated above, various different malignancies may have fatigue as one of the​ primary symptoms.  This could include cancers of the blood, gastrointestinal system, reproductive system, and lungs.

It is critical that you see a doctor for evaluation if your fatigue is persistent and an obvious source has not been found.

​Summary

​If you are tired, there are probably several reasons that you should consider.

You may have some hormonal issues such as insulin resistance and thyroid dysfunction.

Your diet and activity level ​are also probably playing a role.

You should also look into your stress, sleep habits, gut function, and level of hydration.

​There are also many potentially serious causes that need to be considered.  Therefore, it you are excessively fatigued, see your doctor!

Now it’s your turn…

​Are you tired?

​What ​did you ​find that cause​d your fatigue?

Any advice you would have for others?

Leave your questions and comments below.​

Why Am I So Fat? 9 Reasons to Consider

​That may seem like a harsh title, but I am asked that question almost daily in my medical practice.  ​People that struggle with their weight are desperate for answers.

​As most people would guess, diet and exercise ​​play a huge role in your ability to lose weight, but​ there are​ multiple other things ​also going on that are making ​it ​difficult for you to drop the pounds.

In this article, I will discuss 9​ commonly ignored reasons that anyone should consider if ​they are ​failing in their weight loss attempts.

These include thyroid issues, stress, poor sleep habits, insulin resistance, and many others…

More…

​9 Reasons That May Be Making Weight Loss ​Difficult

​Most Americans need to lose weight.  The latest statistics show that 7 out of 10 people are overweight or obese.  ​Interestingly,  only 36% of people think they need to lose weight.

If you are reading this article, ​I suspect that you need to lose weight but you don’t know how.

I’m going to discuss 9 reasons that may be a hurdle in your weight loss journey.  All of them may not apply to you and your specific situation, but chances are most of them do.

​1.  Standard American Diet

​Let’s start with the obvious.  ​What we are eating in America is slowly killing us.

If you don’t get your diet under control, nothing else that I discuss in this article will be enough to help you lose weight.  What you eat is the cornerstone for everything else.

As the percentage of Americans that are considered obese continues to skyrocket, so are conditions such as heart disease, cancer, and Type 2 diabetes.

A big reason why is obviously our diets.  Many people have chosen convenience over health.  Eating out has replaced cooking at home for a large portion of Americans.  This includes fast-food restaurants.

​Even if you choose “healthy” options from a good restaurant, you have no input on the quality of food that is served (for instance, grass-fed beef vs corn-fed), what kinds of oils are used, how much sodium and other chemicals are added, etc.

Our priorities are totally out of whack.

According to the USDA, almost 1000 calories per day in the Standard American Diet (SAD) come from saturated fats and sweeteners.  Fruits and vegetables account for only about 200 calories!

​The biggest source of calories comes from grains, which is a 45% increase ​from 50 years ago.  Not only that, the quality of the grains consumed has changed.  Read “Wheat Belly” by Dr. William Davis if you want to learn more.

Even more concerning is the fact that sugar consumption has gone from about ​40 pounds per person per year in 1900 to ​​over 100 pounds per person per year today!

Source: http://wholehealthsource.blogspot.com/2012/02/by-2606-us-diet-will-be-100-percent.html

Last but not least, about 2/3 of the calories in the standard American diet (SAD) come from food-like substances and processed food.  It’s not even real food!

http://wholehealthsource.blogspot.com/2012/02/by-2606-us-diet-will-be-100-percent.html

​Note that the typical SAD diet consists of about 2500 calories per day.  

Depending on your metabolic rate, most people burn about 1800-2000 calories per day.

While I don’t prescribe to or recommend the “calorie in, calorie out” model of weight loss, it ​only makes sense that if you continue to consume more calories than you burn each day, you aren’t going to lose weight.

This is especially true if you have some of the other issues going on that I will discuss in this article.

​So What is the Solution? –

You should immediately change to a nutrient-dense, high quality, real whole food diet.

As a general rule, I recommend the ratio of the macromolecules in your diet to be in these ranges:

  • check50-70% good, healthy fats
  • check20% protein
  • check10-20% carbohydrates

​A good starting point would be to start with one of these diets.  There is a ton of online information and recipes for each:

Whole 30 Diet

Ketogenic Diet

Paleo Diet

All these diets have been shown in studies to help with weight loss and reduce insulin resistance.

– Intermittent Fasting

​Another tool that can be extremely helpful with weight loss is intermittent fasting.  Learning when NOT to eat is just as important as learning WHAT to eat.

When used appropriately, intermittent fasting can actually INCREASE your resting energy expenditure.

I typically recommend 2 types of fasting:

14-16 hour fast – Eat an early dinner, then don’t eat again until lunch the next day. 

2 consecutive 24 hour fasts – For example, eat a good dinner on Friday night, then don’t eat again until Saturday night​.  You have 30 minutes to eat at that time.  Then don’t eat again until Sunday night.

Fasting is ​so effective that you need to be careful if you have severe adrenal fatigue or if you are diabetic and are on certain medications that increase insulin.  In these situations it can cause ​your blood sugar to drop to dangerous levels.  Talk to your doctor first and monitor your blood glucose closely.

​If you want to learn more about intermittent fasting, read my article here.

You may ultimately need the help of a knowledgeable nutritionist if you are having difficulty.

​2.  Lack of Exercise

​While there is no amount of exercise that by itself will get you to your goal weight, it can be an invaluable tool to help ​with your journey.

​Exercise has been shown to directly help ​reduce weight.  ​It has also been shown to increase growth hormone levels which increases lean body mass and ​results in weight loss.

Exercise not only helps with weight loss, it has been shown to increase cognitive function and overall quality of life.  It also reduces symptoms of anxiety and depression.

​It is important to know what ​KIND of exercise and how ​MUCH of it to do.  Too little of it will not have enough of an effect while too much exercise can actually be harmful.

If you have adrenal issues, even light exercise may exhaust you.  Get your adrenals functioning well first.

​If you are currently not exercising at all, then start doing ​SOMETHING.  A brisk walk for 15-30 minutes 4-5 days per week is a great start.  Let your fatigue level guide you on how much you can progress.

Ultimately, you will want to​ add high intensity interval training (HIIT).  HIIT has been shown to reduce abdominal and total body fat.

HIIT consists of doing all-out, maximum bursts of exercise followed by 30-60 seconds of recovery time then repeating the cycle 5-6 times.​

This can be done with any equipment you have (elliptical, treadmill, bike, rowing machine, etc), or even by jogging/walking or using a jump rope.

HIIT training only needs to be done 1-3 times per week for 10-15 minutes.  Yes, you have time for that!

If you want to lose weight, get started with an exercise program TODAY!.

​3.  Stress

​If you have ever read any of my other articles, you know that I mention stress as a factor in almost all medical conditions.

The fact is, stress undermines our health on multiple levels.  You will never reach your maximum health potential if you don’t learn how to better manage your stress.

When I say stress, I am talking about physical, emotional and mental stress.  This could include an injury or illness, work stress, relationship stress, death of a loved one, and many others.

Stress causes our adrenal glands to secrete cortisol, which signals the mitochondria in our cells to increase energy production to get us through that stressful time.

This is great for acute stresses, but bad when the stresses are chronic and continuous.

Cortisol has been associated with insulin resistance and leptin resistance.  It also promotes hypothyroidism.  All three of these conditions lead to obesity (I will discuss them more shortly).

​So What is the Solution?

Remove ​any stressors in your life that you can.  That may include changing jobs, getting rid of toxic relationships, ​or getting marriage counseling.

If there are major stressors that can’t be removed such as an illness in a family member, kid troubles, etc., you will need to work on improving your coping mechanisms.

​Ways of reducing your stress ​includes:

  • checkYoga or a similar relaxation exercise
  • check20 minutes of prayer or meditation once or twice daily
  • checkStart a hobby that you enjoy
  • checkCount your blessings and write them down
  • checkGo for a walk outside
  • checkDo something nice for someone without expecting anything in return
  • checkMake yourself smile everyday (even when you don’t feel like it)

If you feel you need more help on this subject, read my article on adrenal fatigue.

​4.  Poor Sleep Habits

Lack of sleep has been directly linked to obesity.  It increases inflammation in the body and causes weight gain.

Your quality of sleep directly impacts your melatonin level which increases your cortisol.  Your sleep quality also impacts your metabolism which affects your body weight.

You should be getting at least 7 hours of quality sleep per night.  When you wake up, you should feel refreshed and energized.

If that doesn’t describe you, consider making the following changes:

  • checkGo to bed the same time every night and get up the same time every morning
  • checkNo electronic screens (phone, computer, tv, tablet) for at least 2 hours before going to bed
  • checkKeep your bedroom cool and dark
  • checkAvoid stimulants (coffee, nicotine, decongestants) in the evening
  • check​Reserve your bed for sleep and sexual relations only

​If you are still having sleep issues, you should consider talking to your doctor about ​testing you for obstructive sleep apnea.  In this condition, the muscles in your throat and neck collapse as ​you fall asleep which in effect chokes you, sometimes dozens of times per hour.

Your brain has to wake you in order to overcome the muscle relaxation so that you can breathe.  As a result, you never get into the restful stages 3 and 4 of sleep which are required for you to be refreshed.

This may require you to undergo a sleep study, which will​ consist of sleeping in a sleep lab while you are monitored.  

If you have obstructive sleep apnea, you may need to sleep with a nasal CPAP machine which will keep the air pressure in your airway high enough t​o prevent your airway from collapsing while you sleep.

​If you can lose the weight you ​need to lose, there is a high likelihood that your sleep apnea will resolve and you will no longer need a CPAP machine.

If obstructive sleep apnea has been ruled out but you are still struggling with sleep, supplements may be necessary.  My favorites are below:

How to Supplement to Improve Your Sleep

Why I Like It

May help improve energy levels

May help to decrease levels of inflammation

May help reduce brain fog and mental slowness

Requires lifestyle change for best results

How to Tell if You Need It

    • You should be getting 8 hours of quality sleep every night.
    • If you find yourself waking up exhausted then you should consider checking for sleep apnea or a trial of the following supplements to improve sleep

How to Use

    • Take each supplement as indicated on the bottle or as recommended below
    • In addition to these supplements make sure you practice adequate sleep hygiene, that means: black out curtains for your bedroom, noise cancelling ear plugs, having a consistent sleep schedule, and avoiding all electronics 3 hours prior to your scheduled bed time

My Recommended Brand and Product

For minor sleep issues start with supplements containing 5-HTP which may promote proper melatonin production and induce sleep naturally (take 100mg 30 minutes before your scheduled bed time):

Get 5-HTP Here

For more difficult cases consider the addition of melatonin + 5-HTP, start with 1-3mg of melatonin and don’t be afraid to use melatonin if you need it.

Get 5-HTP and Melatonin Here

For more the most difficult cases consider using serotonin and GABA potentiators. These supplements help enhance GABA and serotonin neurotransmitters in the brain and help induce deep sleep.

Get GABA/Serotonin Potentiators Here

​5.  Thyroid Issues

​The statistics show that over 12% of the population is hypothyroid.  Some experts suggest that it could actually be closer to 40%.

​About 2/3 of people with thyroid issues don’t even know they have it!

Since the thyroid is the ​”metabolism factory” of the body, it only makes sense that people who are struggling with their weight may have an issue with their thyroid.

In my practice, I see people with undiagnosed and untreated or undertreated thyroid conditions several times a day.

The vast majority fit into the following 3 categories:

– Hypothyroidism

​The thyroid should always be one of the first things assessed in someone who is overweight.

That is especially true if the person also has many of the other common symptoms seen in hypothyroidism – fatigue, constipation, cold intolerance, hair loss, brittle nails, etc.

​Only checking the TSH blood test may miss a large percentage of hypothyroid patients.

That is why you need to ask for a complete thyroid panel:

​If your doctor is unwilling to ​run all of these tests, I would STRONGLY suggest you find a doctor who will.  Your thyroid status cannot be fully evaluated without them.

Read more about how to interpret your results in my article here.

– Hashimoto’s Thyroiditis

​Hashimoto’s is the common name given for autoimmune thyroiditis.  

It is estimated that up to 10% of the population has Hashimoto’s.  It is 7 times more common in women than in men.

​Some experts estimate that Hashimoto’s is the cause of up to 90% of hypothyrodism.

That’s why it is important to have your thyroid antibody levels checked if you are hypothyroid.  If either the TPO antibody level or the thyroglobulin antibody level is >35, the diagnosis of Hashimoto’s can be made.

Hashimoto’s can cause the same symptoms that you see in hypothyroidism (including weight gain), but it may have some additional symtoms as well.  These include joint pain, muscle aches, throat swelling, and even low grade fever.

​Click here to learn more about how to treat Hashimoto’s thyroiditis.

– Reverse T3 Dominance

​Reverse T3 is an inert hormone that is made normally by the ​body in small amounts.  

It binds to the thyroid receptors on the cells of the body, but it does ​it has no function.  In effect, it serves as a “brake” for our metabolism.

​It is another way that the body can regulate its own metabolism.

In acute situations (such as an infection or injury), it helps the body to reserve its energy stores by lowering the metabolism.

​However, many people have chronic inflammation in their body due to things such as obesity, insulin resistance, leptin resistance, poor diet, etc.  All of these conditions cause the reverse T3 level to be chronically elevated, which is called reverse T3 dominance.

​When this occurs, the TSH and T4 levels may be normal, but the elevated reverse T3 ​blocks the action of the active T3 on the cells of the body.  Hypothyroidism at the cellular level results.

The above labs are from one of my recent patients.  If you just looked at the TSH, it would show that she has normal thyroid function.  The free T3 and reverse T3 tell the true story.

If your reverse T3 level is >15 or if your free T3 to reverse T3 ratio is ​< 0.2, you have reverse T3 dominance (also called thyroid resistance) that needs to be addressed.​​​

Read my article on Reverse T3 Dominance to learn more.

​6.  Metabolic Damage from Yo-yo Dieting

​Most people that I know ​who struggle with their weight have tried tons of different diets.  Some have worked, some haven’t.

Many of these diets such as the HCG diet require severe calorie restriction (as low as 500-600 calories per day).  

This severe calorie restriction can damage your metabolism for many years and make it impossible to lose weight and keep it off.

The typical story goes like this – the first time they went on the diet they lost 40 pounds, the next time 25 pounds, then next time 10 pounds, then next time none at all.

​The​se diets cause this by​ re-setting your basal metabolic rate.  Instead of burning ​the usual 1800-2000 calories per day, after severe calorie restriction, your body may only burn about 800 calories per day.

That’s why you eat less than anyone else you know but still gain weight.

Never go on a severe calorie-restricted diet or recommend any friends or family to do it.  It can be devastating to your body.

Correcting this can be very difficult and will require the help of a knowledgeable doctor and/or nutritionist. It will most likely take a long time to fix.

​7.  Insulin Resistance

Insulin is a hormone made by the pancreas.

Its function is to bind to ​glucose (sugar) in the bloodstream and carry​ it into the cells where it can be used for energy production.  It also carries the glucose into the fat cells and liver cells where it is stored to be used later.

With insulin resistance, the process doesn’t work like it should.

​When people eat a diet too high in sugar (as in the standard American diet), the cells in the body become so bombarded with the sugar that it can become toxic to the cells.

As a protective measure, the cells down-regulate the insulin receptors, meaning it reduces the number of insulin receptors that are available for the insulin to attach.  As a result, the insulin level in the bloodstream increases (as does the sugar levels).

Eventually, the sugar level increases to the point that it measures high on a blood test.  Pre-diabetes or diabetes is then diagnosed.

In other words, diabetes is really just advanced insulin resistance.

Having high levels of insulin is bad in many ways.

​Insulin causes us to gain weight by increasing the size of our fat cells.

​Insulin is one of the most inflammatory substances in our body​.  That inflammation increases our cancer risk.  ​Insulin resistance has been shown to be directly linked to thyroid disorders which also results in more weight gain.

A hemoglobin A1c level > 5.3 is suggestive of insulin resistance.  A total fasting insulin level >5 also indicates insulin resistance.

Anyone who has the diagnosis of pre-diabetes or type 2 diabetes by definition also has insulin resistance.

To learn more about how to diagnose and treat insulin resistance, read my article here.

8.  Leptin Resistance

What in the world is leptin resistance? 

In order to understand leptin resistance, you need to understand the function of leptin.

Leptin is a hormone made by fat cells.  Yes, they do more than just make ​our clothes to not fit!

Leptin is our “satiety” hormone.  It’s primary function is to signal to our brain that we have plenty of fat stored in our body and we don’t need anymore.

The brain then increases our metabolism and reduces our hunger until the leptin levels drop.

In leptin resistance, something happens that is similar to what happens in insulin resistance.  Our brain becomes desensitized to the high leptin levels and basically ignores the signal.

As a result, our metabolism becomes locked in the “low” setting and our hunger sensation stays locked in the “high” setting, a perfect storm that results in weight gain and obesity.

The weight gain results in more fat cells which results in more leptin production, and the cycle feeds itself (literally!).

Leptin resistance typically occurs simultaneously with insulin resistance.

Leptin resistance also triggers an increase in reverse T3 production (reverse T3 dominance) that also results in weight gain.

Leptin resistance is diagnosed by checking a serum leptin level.  If it is >12, the diagnosis can be made.

​Long term successful weight loss will not be possible until the leptin resistance is treated and eradicated.

Click here to learn more about leptin resistance and its treatment.

​9.  Unresolved Emotional Issues

​If you have ever watched a show where they follow ​people on their weight loss journey, a common theme emerges.

They lose a little weight, then the weight loss stops.  They ​don’t begin losing weight again until they have a “breakthrough” regarding a​ trauma​ from their past.

Emotional, physical, and mental trauma from childhood has been shown to affect eating habits and it is directly linked to obesity in adulthood.

Many of these traumas may have been locked away in your brain.  You may not recall them, but they may be subconsciously sabotaging your life in many ways.

This may or may not be playing a role in your particular situation, but you owe it to yourself to deal with any past trauma if you have any.

I strongly recommend ​that anyone struggling with their weight should see a licensed professional counselor to ​assess if ​they have any past issues that need to be addressed.

Seeing a counselor is a sign of strength, NOT weakness.  It means you love yourself enough to deal with any issues that are impacting your quality of life.

​Summary

​50% of the US population is either overweight or obese.

Many reasons are to blame.  While diet and exercise play a major role, hormonal and metabolic issues are most likely involved as well.

If you can’t lose weight, it is important for you to consider and address your diet, exercise, stress level and your sleep quality.

You should also be tested for any thyroid issues, insulin resistance, and leptin resistance.

If you have a history of severe low calorie dieting, your metabolism may be damaged which will require long term, intensive treatment.

Finally, you need to address any past trauma in your life to finally release its grip on you.

​Now it’s your turn…

​Have you ever asked the question in this article title?

If so, what has helped you with your weight loss?

What have you tried that didn’t work?

Leave your comments below…

Low Dose Naltrexone for Hashimoto’s and Weight Loss

Research has shown the benefit of using low dose naltrexone for Hashimoto’s thyroiditis and other autoimmune conditions.

​If you have ​an autoimmune condition such as Hashimoto’s thyroiditis, reducing the inflammation in your body is crucial to help you feel better and lower your antibody levels.

​If you don’t lower the inflammation, it will be next to impossible to lose weight or feel as good as you can.

Lose dose naltrexone has been shown to substantially lower inflammation.  It also helps to raise endorphin levels which makes you feel better overall.

There is ​also a lot of anecdotal evidence that LDN can help ​some people lose weight.

​In this article, I will discuss LDN and what some of the research is showing about it.  I will explain how ​it can be used to potentially lower antibody levels, help with chronic pain, and ​maybe even help ​people with ​Hashimoto’s to lose weight.

Let’s get started…

More…

​What is LDN?

​LDN is short for low dose naltrexone.

Naltrexone was developed in the 1980s to treat patients with opioid withdrawal.  It is a sister drug to the well-know Narcan (naloxone).

​It is an opioid antagonist, which means it blocks opioid receptors in the brain.

When taken in doses of 50-100mg, it completely saturates the opioid receptors which prevents the person from experiencing the “high” that they normally would get from taking opioid (narcotic) medications.

It is therefore used by people in drug or alcohol rehab to help them stay off of their drug of abuse.

Dr. Bernard Bihari performed research ​in which he discovered that naltrexone in low doses helped reduce symptoms and inflammatory markers in patients with autoimmunity, cancer, and HIV.

How does LDN work?

Endorphins are our “feel good” chemicals.  They are associated with feelings of pleasure, sexuality/sensually, euphoria and pain relief. Essentially, endorphins make us feel good and give us a sense of well-being. 

Endorphins are what cause the “runners high” when ​we exercise.

Low levels of endorphins are associated with the opposite effects: physical and emotional pain (including chronic pain found in disorders such as fibromyalgia), and addiction.

Low doses of naltrexone (from here on I will refer to it as LDN) appears to increase the level of endorphins in the brain by only partially blocking the opioid receptors when the endorphin levels are at their highest (3-4am).

This signals to the body that the levels are low, so it temporarily increases endorphin production.

Endorphins appear to modulate the immune system.  Therefore, raising the endorphin levels (like LDN does), impacts the immune system in a positive way.  

LDN has also been shown to decrease inflammation in chronic pain conditions, which is why the people that have the most success using LDN typically have chronic pain as one of their main symptoms.

​Low Dose Naltrexone for Autoimmune Conditions

​People with autoimmune conditions typically have lower levels of endorphins than people without autoimmunity.

So it makes sense that if LDN raises endorphin levels, it would help someone with an autoimmune condition feel better.

​Also, autoimmune conditions are associated with an increased level of inflammation.  So the anti-inflammatory effects of LDN would obviously also help ​lower the overall inflammation in the body.

​In addition to the benefits listed above some studies have shown that the use of LDN can help to improve the immune system and reduce auto antibodies in some autoimmune conditions.

​The m​ajority of research regarding LDN that I found ​​dealt with how it can impact multiple sclerosis (MS), Crohn’s disease, and fibromyalgia.  However, it has also been used to in many other conditions.

​​Now let’s see what impact LDN has on thyroid disease (particularly Hashimoto’s).

​Low Dose Naltrexone for Hashimoto’s

To learn more about Hashimoto’s thyroiditis, read my article here.

I discuss natural treatments for Hashimoto’s in this article.

​LDN appears to improve Hashimoto’s (and all hypothyroidism for that matter) by:

​Much of the evidence of LDN impacting Hashimoto’s is anecdotal, meaning doctors and patients give their personal experiences using it.  To this point, the number of research studies are small and sporadic.

However, a quick Google search will take you to websites such as http://www.lowdosenaltrexone.org/ that will show you much of the research and patient testimonials about LDN.

I myself have had several patients that reported feeling much better when taking LDN.  Some even showed a reduction in their antibody levels.

​Does LDN Help with Weight Loss?

​The answer is yes in some studies, no in others.

​LDN should never be prescribed for the sole purpose of weight loss, but some patients have had some significant weight loss while taking it.

​It appears that LDN helps with weight loss by affecting the following:

  • Reduces Insulin Resistance – Insulin resistance is a common cause of weight gain, so it makes sense that reducing it will result in weight loss.
  • Increases Growth Hormone – Growth hormone increases lean muscle mass and increases fat burning, both of which help with weight loss.
  • ​​Modulates Appetite – LDN may help to normalize the appetite in people with a damaged metabolism which helps to match their appetite with the amount of energy they burn. https://www.ncbi.nlm.nih.gov/pubmed/9226337
  • Decreases Inflammation – High levels of inflammation cause several hormonal changes including insulin resistance, leptin resistance, poor T4 to T3 conversion, high estrogen and low testosterone.  All of these lead to weight gain.
  • Improves Sleep – Lack of sleep has been shown to increase inflammation and weight gain.  Studies show that LDN ​improves sleep in patients with sleep apnea and chronic pain syndromes

​Naltrexone can be found in a currently marketed drug for weight loss – Contrave.  However, the doses in this pharmaceutical drug are higher than the ones I recommend in this article.

​How to Take LDN

LDN is a prescription medication, so it must be prescribed by a medical professional – doctor, nurse practitioner, or physician assistant.

The vast majority of doctors have little to no experience writing it.  You may have to do your own research to find a doctor that is knowledgeable about LDN and willing to prescribe it for you.

Naltrexone is not available in most retail pharmacies in the low doses we are discussing in this article.  You will have to purchase it from a compounding pharmacy.

Insurance will not cover it.  Fortunately, it is usually less than $50 per month, so it is still affordable.

​How to Dose LDN –

​I have had the most success with LDN by starting on a low dose then stepping up the dose every 2 weeks until we get to the target dose.

My typical prescription looks like this:

Take 1.5mg daily at bedtime for 2 weeks, then 3.0mg daily at bedtime for 2 weeks, then 4.5mg at bedtime thereafter.

​Side Effects of LDN –

​LDN has virtually no side effects, which makes it a great medication to try in people with autoimmune conditions, especially those with chronic pain.

Rarely, patients may complain of vivid dreams or muscle spasms when taking the 4.5mg dose.  If that happens, reducing to 3mg usually resolves the problem.  

The patient can try to go back up to 4.5mg a few weeks later if the 3mg is not adequate to resolve their symptoms.

Remember, LDN partially blocks opioid receptors.  So if you are taking a opioid (narcotic) medication regularly, it could block the effects of your pain medication.

​Therefore, if you are on regular narcotic pain medications, ​you should ​​NOT take LDN at least until you reduce or stop your pain medications.  At the very least, you will want to take your pain medications at a different time to try to prevent the interaction.

​If you take your pain medication at the same time (or close to it) as you take LDN, it could block the effect of ​the ​narcotic medication on the opioid receptors which would in effect reverse its action.

This could result in a​ sudden increase in your pain level.  While it is not life-threatening, you could experience a lot of pain until the LDN wore off and you were able to take more pain medication.

If you are interested in trying LDN, it is critical that you give your doctor a complete list of all of your current medications.  This will help him or her to know if you can safely try LDN.

​If you have Hashimoto’s and you decide to try LDN,. it is important that you watch your thyroid levels closely.  LDN may decrease your thyroid antibody levels which could cause your thyroid hormone level to increase and cause symptoms of hyperthyroidism.

That would be a great thing ultimately, but it could be potentially dangerous at first.  You may therefore need to lower your thyroid medication dose.  

​Summary

​Low dose naltrexone is a seldom used, yet potentially helpful medication in people with Hashimoto’s and other autoimmune conditions.

Studies show that it can lower inflammation in autoimmune conditions.  It also raises endorphin levels in the brain which makes the person feel better.

​It is especially helpful in people who suffer from chronic pain, although it should not be taken at the same time as an opioid pain medication because it can block the effect of the pain medicine.

​If you are interested in trying it, you will need to find a medical provider with experience in prescribing it.  It will need to be purchased from a compounding pharmacy and insurance will not cover it.

Now it’s your turn…

Have you ever tried LDN?

If so, what was your experience with it?

Leave your comments below.

Selenium Deficiency and the Thyroid

​Selenium is crucial for normal thyroid function.

In fact, if you have undiagnosed selenium deficiency, it could be making your thyroid function worse.

If you have chronic digestive issues, there is a good chance that you have inadequate selenium levels.

​Selenium is especially important if you have an autoimmune thyroid disease such as Hashimoto’s or Grave’s Disease.

In this article, I will discuss selenium deficiency and the thyroid, how to know if you are selenium deficient, give you some great food sources of selenium, and discuss how and when ​you should consider using a supplement.

Let’s get started…

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Why is Selenium Important for Normal Thyroid Function?

​Bear with me as I quickly describe the science behind selenium and its important role in the body.

Selenium is required for the proper function of some proteins in our body called selenoproteins.

​These proteins perform many important functions in the body including:

     – Conversion of T4 to T3

     – Production of antioxidants

     – Energy productions and metabolism

​Let’s discuss some of these functions in a little more detail:

​1.  Increases T4 to T3 Conversion

Selenium is required for the ​optimal conversion of T4 into T3 in the peripheral tissues.

​​Selenium is ​needed for the ​proper function of the deiodinase enzymes​ which perform the conversion process.

As a quick reminder, the thyroid gland produces primarly T4, which is a thyroglobulin molecule with 4 iodine molecules attached to it.  This is the transport form of thyroid and is mostly inactive.

In order for the body to be able to use the thyroid hormone, an iodine molecule must be cleaved off of the T4 by the deiodinase enzyme, which converts it into T3​.  T3 is the active thyroid hormone.

2.  Decreases Autoimmunity

​Selenium has been shown in studies that it reduces autoimmune inflammation in patients with Hashimoto’s Thyroiditis.  It​ has been shown to reduce the TPO antibody levels.

​3.  Strengthens Your Immune System

​Having a deficiency of selenium does not in itself cause illness.

It appears instead that being deficient in selenium just makes us more susceptible to illnesses due to its role in normal immune function. 

In other words, having an optimal selenium level helps to ensure that our immune system is working at its maximal level.

​This is because ​selenium plays a huge role in increasing antioxidant levels in the body.

In fact, selenium supplementation has been shown to improve immune function in patients that were deficient.

​4.  ​Reduces Thyroid Damage from Iodine

​Iodine is a controversial issue in regards to thyroid health.

There is plenty of evidence that shows that low iodine is a huge cause of thyroid disease worldwide.

However, there is also evidence that excessive iodine can also damage the thyroid gland and may even increase the incidence of autoimmune thyroid disease such as Hashimoto’s.

One study showed that taking iodine in the presence of LOW levels of selenium may actually increase your risk for thyroid tissue damage.​

Conversely, if you supplement with selenium in the presence of low iodine levels, it can also worsen hypothyroidism.

It appears that iodine is dangerous to the thyroid ONLY when selenium levels are low or high.

Optimizing the selenium level allows the thyroid to tolerate a wide range of iodine levels.

The selenium appears to protect the thyroid from iodine at least in some part because it increases ​regulatory T cell levels.

​What if you have Hashimoto’s?  

I believe the evidence shows that it is okay to take iodine if you have ​Hashimoto’s as long as you are also supplementing with selenium.

​How Do You Know if You Have Selenium Deficiency?

​Selenium deficiency doesn’t necessarily cause any obvious symptoms, but there are some signs to look for that can indicate that you may be low. 

Let’s discuss some of the big ones below:

1.  You have a history of ​digestive problems

​Selenium deficiency is common in patients that have chronic digestive issues such as Crohn’s disease, Celiac disease, etc.

This is felt to be due to malabsorption caused by the inflammation that is occurring in the gut.

Selenium deficiency is commonly associated with vitamin B12 deficiency because ​they both are affected by poor gut absorption.

​So if you have B12 deficiency or any type of chronic gut inflammation, there is a strong chance that you are deficient in selenium.

​2.  You have a low free T3 level

​As I discussed earlier, selenium is important for the conversion of T4 to T3.

​When that conversion process is reduced, the free T4 levels will begin to rise and the free T3 levels will begin to fall.

To make matters worse, if you go see your doctor and he or she ​only checks your TSH and T4 and not your free T3 level, it will look like your thyroid levels are “normal” or even “high.”

Meanwhile, your hypothyroid symptoms continue to worsen because you are low in active thyroid hormone.

​Not a good situation at all.

That’s why it is critical that you find a doctor that will check a complete thyroid panel and will listen to you and your symptoms, and not solely depend on lab results to manage your thyroid problem.

​3.  ​You have hair loss or brittle nails

​Let me start with an obvious statement:  Not all hair loss is caused by selenium deficiency (you’ve seen my photo and my selenium level is good!).

However, selenium deficiency has been shown to cause changes in hair​.

It also can cause your nails to get brittle and crack easily.

Replacing low selenium levels has been shown to improve hair growth and nail growth.

If you suffer from unexplained hair loss or brittle nails, you should consider getting a further workup.

At a minimum, you should look at these micronutrients as possible culprits:  iron, zinc, selenium, and biotin.

You should also get a complete thyroid panel.

​4.  Your RBC Selenium level is low

​There is a lab test to measure the selenium level in the body, specifically in the red blood cells.

It is called an RBC Selenium Level.

I do not routinely check ​this on patients.  If I suspect a selenium deficiency, I start treatment.

However, if a patient continues to have signs or symptoms of selenium deficiency, it can be checked to make sure they are absorbing the selenium ​from their food or supplements.

​How to Treat Selenium Deficiency

​So if you think you have a selenium deficiency, what should you do about it?

Selenium is a micronutrient, meaning only small amounts are needed.

It can be replaced in your body either through increasing your consumption of foods that are high in selenium and/or by taking a selenium supplement.

​Food Sources of Selenium

​Without a doubt, it is always safest to use ​food to increase nutrient levels in our body.

Most Americans eat so poorly that simply improving their diet can do wonders for helping them to regain their health.

​The food with the highest amount of selenium is brazil nuts.

​Eating 2 brazil nuts per day will increase your selenium level as much as 100mcg of selenomethionine.

​Other foods with good selenium content include:

  • checkmushrooms
  • checkfish – cod, halibut, tuna, salmon
  • checkshrimp
  • checkchicken
  • checkeggs
  • checkturkey

​It’s always best to start with natural food sources such as these.

However, that is not always possible.  

For instance, I ​am personally allergic to brazil nuts and I don’t have a big fondness for fish (unfortunately). Therefore, I use a supplement periodically to ​keep my selenium level optimized.

Selenium Supplements

​When using supplements, it is always critical to use a good quality supplement from a respected company that uses​ quality control standards when making their products.

My preferred brand for supplementing selenium is below:

How to Supplement with Selenium

Why I Like It

May reduce antibodies in patients with Hashimoto’s

Also acts as an  anti-inflammatory

May help reduce anxiety symptoms

Helps boost T4 to T3 conversion (helpful in those with high reverse T3)

Who Should Use It

    • Patients with hair loss or hair thinning
    • Patients with a known thyroid disorder and hair loss
    • Patients with other nutrient deficiencies like zinc or iodine
    • Patients who frequently take acid blockers for acid reflux
    • Patients with other GI related issues (IBS, gas/bloating, IBD)
    • Patients also taking zinc

How to Use

    • Take 200-400 mcg per day (do not exceed 400 mcg daily)

My Recommended Brand and Product

Get Selenium Here

​I prefer selenomethionine because of it’s high bioavailability.

I typically recommend supplementing for only a few months (3-6) which should restore the levels in the body to the optimal range.

​Like most things, you can overdo selenium supplementation as well.

Excess selenium can cause a variety of symptoms, including GI upset, white blotchy nails, hair loss, fatigue, irritability, and mild nerve damage.

One study even showed a possible increased risk of prostate cancer in patients with excessive selenium.

Once you have repleted the tissues and changed your diet, continued supplementation should be unnecessary.

The only exceptions would be if you have poor absorption from chronic digestive tract conditions such as inflammatory bowel disease, IBS, Celiac diease, etc.

​Summary

​Selenium is a vital micronutrient for normal thyroid function, immune system function, energy production, and metabolism.

Selenium deficiency is common but can be difficult to diagnose.

It is always best to treat selenium deficiency by eating food rich in selenium.

​If that isn’t possible or if you have absorption issues due to chronic GI issues, adding a good quality selenium supplement may be necessary.

You should not take a selenium supplement indefinitely.  Usually taking it for a few months is sufficient unless you have a chronic GI problem.

If you have a selenium deficiency, it is also important to look for other micronutrient deficiencies such as iron, zinc and iodine.

Now it’s your turn…

​Do you think you have a selenium deficiency?

What have you used to treat it.  Has it helped?

Leave your comments below.​