Thyroid Tune-up Checklist

Imagine that all the cars in your neighborhood run poorly because nobody bothers to tune-up their autos. I show you how to tune your car and, lo and behold, 80% of the cars now run great. But 20% of cars still run poorly because their transmissions are bad. In other words, tuning the engine works when that’s the only problem with the car; if something else is wrong, then you car will not run properly.

So it goes with eliminating wheat from the diet. It works for the majority of people: substantial weight loss and shrinking waist size; reduced blood sugar and blood pressure; relief from arthritis, leg edema, acid reflux, irritable bowel syndrome symptoms, etc. But some people complain that, despite saying goodbye to all things wheat, they still have problems. Obviously, as big a problem as modern wheat is, there are other causes for health conditions besides wheat consumption. There are  infections, injuries, sensitivities to other foods, inherited conditions, etc. While wheat exposure is a cause for an incredible amount of human suffering, it is not the only cause.

How about weight loss? If all things wheat are eliminated, most people can expect substantial weight loss. Some people will also need to reduce exposure to other carbohydrates, especially if a lot of body weight needs to be lost and/or pre-diabetic or diabetic patterns are established. We cannot say “eliminate wheat and eat all the ice cream and candy you want.”

Then there are people who do all that and still cannot lose weight. This is when it’s time to give serious consideration to thyroid dysfunction.

By “thyroid dysfunction” I am referring to various degrees of hypothyroidism, i.e., low thyroid hormone levels. (I’m going to ignore hyperthyroidism, since this is much less common and does not impose any limitation on weight loss.) This is a big issue, so I’m going to cover it as a check list, a series of bullet points that you can run down to cover as much territory as possible. There are three blood tests that everyone should have assessed to even start thinking about thyroid dysfunction: TSH (thyroid stimulating hormone), free T3, and free T4. Optionally, a reverse T3 and thyroid antibodies (to identify thyroid inflammation/autoimmunity) can also be helpful. You do not need all the other nonsense often run, such as total T3 and FTI; these are outdated and often misleading.

Important issues to consider in deciding whether hypothyroidism is contributing to stalled weight:

Hypothyroid symptoms–Beyond stalled weight loss, the most common symptoms of low thyroid hormone status include cold hands and feet; low energy; mental “fog;” increased loss of hair and eyebrows; constipation; leg edema.

Low first a.m. oral temperature–While not validated in clinical trials, anecdotally an oral temperature immediately upon awakening can help you decide whether a thyroid question is present or not. Using a digital thermometer, take your oral temperature immediately upon arising. If it is consistently below 97.3 degrees F, then hypothyroidism is likely; the lower the temperature, the more likely and severe the thyroid dysfunction. However, note that disruptions of cortisol can do the same. (Contrary to some older discussions from the 1960s, axillary temperature should not be used due to excessive variation.)

Iodine deficiency–Though it’s not even on most people’s radar, iodine deficiency is a common and underdiagnosed cause for inadequate thyroid hormone production. The thyroid requires iodine to manufacture thyroid hormones, T3 and T4, the “3″ and “4″ referring to the number of iodine atoms per thyroid hormone molecule. Iodine deficiency was a huge public health issue up to the last half of the 20th century, pretty much solved by the introduction of iodized salt. Now that salt overexposure in some populations has been fingered as a potential health problem, the FDA and other “official” providers of health advice tell us to reduce salt and sodium. But what about the iodine? Everyone forgot about the iodine.

Many people, including physicians, assume that iodine intake from diet is sufficient. Nope. Even the NHANES data have uncovered substantial deficiency in some demographic groups, such as women of childbearing age, using their relatively lax definition of iodine deficiency. I’m seeing iodine deficiency and even goiters (enlarged thyroid glands due to iodine deficiency) frequently. Beyond having a goiter, a low free T4 and highish TSH (e.g., 3.5 mIU) is suggestive of iodine deficiency.

Iodine is not optional; it is necessary for health, including breast health, oral/gastrointestinal health, and the health of a developing fetus. The RDA for non-lactating adults is 150 mcg per day, the quantity required to not have a goiter, but not necessarily ideal thyroid health. I’ve therefore been advising 500-1000 mcg per day from an iodine supplement, such as kelp tablets (dried seaweed), available at health food stores (not pharmacies). The only adverse effects of iodine arise in people who have inflammatory thyroid disease, such as Hashimoto’s thyroiditis, unsuspected thyroid nodules, or longstanding and severe iodine deficiency. In most cases, very low doses of iodine, e.g., 100 mcg per day, can be introduced and increased gradually over months. (Ideally, this would be undertaken by your healthcare provider, but good luck finding one knowledgeable about iodine.)

For most people, restoration of iodine usually develops over 3-6 months.

Ideal TSH–Notice I didn’t say “normal” or “reference range” TSH. I look for ideal TSH. Contrary to the values often cited as “normal” or “reference range” on laboratory values, ideal TSH is in the range of 1.5 mIU or less. This is the level at which thyroid dysfunction no longer contributes to stalled weight loss, as well as distortions of lipid (“cholesterol”) values and cardiovascular risk. The higher the TSH above 1.5, the greater the hypothyroidism.

Ideal free T3 and free T4–The upper half of the “reference range” quoted by your laboratory can serve as a reliable guide to desirable or ideal levels of these thyroid hormones. In particular, low free T3 levels are becoming a common problem and a frequent cause of stalled weight loss. It is not clear why T3 levels are impaired, but potential explanations include disturbed circadian variation of cortisol levels and exposure to organochemicals such as perchlorates (residues of synthetic fertilizer in your produce and water) and others. Unfortunately, the endocrinology community (which is woefully unhelpful with thyroid issues except in the most severe cases) sooner prescribe antidepressants than treat low T3 levels, which they regard as a non-issue. (I had low T3 personally with normal TSH and free T4, along with flagrant symptoms of hypothyroidism and a body temperature of 94.6 F, all corrected with thyroid hormones that included T3.)

Reverse T3–Less commonly, some people develop a T3 thyroid hormone mimic, reverse T3, or rT3, that blocks the activity of T3 in the body. In this situation, it is worth more seriously considering disrupted circadian cortisol variation and using higher doses of T3 thyroid hormone to overcome the blockade.

Should prescription thyroid hormone replacement be chosen, most people do best by including the T3 thyroid hormone, liothyronine, along with T4, levothyroxine. They can be taken separately and as a single tablet in desiccated thyroid gland preparations like Armour thyroid and Naturethroid. Alternatively, if you already take a T4 preparation like Synthroid or levothyroxine but have stalled weight loss or persistent symptoms of hypothyroidism, then adding T3 nearly always solves the problem.

Unfortunately, the biggest hurdle in obtaining helpful feedback on your thyroid is usually your doctor, who will declare your thyroid status normal usually by just looking only at TSH and seeing whether it is in the “reference range” quoted by the laboratory–if he/she even bothers to check it at all. Lately, the naturopath community has been very helpful to many people in my area eager to have their thyroid status intelligently assessed. As a last resort, you can purchase fingerstick test kits to obtain thyroid measures, such as the ZRT test kits we make available in my Track Your Plaque heart disease prevention program.

Once properly corrected, the majority of people enjoy resumption of weight loss, not to mention feel happier, more energetic, with improved overall health, including reduced cardiovascular risk. Add that to the health and weight benefits of wheat elimination, and you can make substantial strides in regaining ideal health.

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247 Responses to Thyroid Tune-up Checklist

  1. marleen says:

    Dear Dr. Davis, would elimination of wheat be helpful for gout?

    • Boundless says:

      > … would elimination of wheat be helpful for gout?

      It has been reported by users on this blog. Favorable outcomes are unsurprising, particularly if you follow the WB guidelines, and replace the removed wheat with fats and non-starchy carbs, rather than high glycemics. Also, reduce fruit intake and zero-out added fructose altogether (as it leads to uric acid).

      For anyone who might already be obese and have gout, eliminating the wheat has multiple benefits, because obese commonly have a bacterium that converts fructans to fructose. The primary dietary source of fructans? Wheat.

  2. WannaGetWell says:

    There are some doctors out there with really interesting perspectives. Years ago I had gotten to the point that I had to lie down on the couch when I got home from work–couldn’t even make it to the bedroom to change clothes. Went to a doctor who tested TSH (it was over 20) who said “that was certainly a lab mistake,” and then to another who said “I don’t diagnose non-specific symptoms like ‘no energy’,” I finally found a doctor who diagnosed hypothyroidism. That was nearly 20 years ago. As I’ve gotten older, my TSH would rise and then my dosage of levothyroxine would be raised. My current PCP was really happy with his treatment that kept my hypothyroidism “well-controlled” (as defined by the TSH) despite the fact that I was depressed, still losing eyebrows, mid-day temperature running 96-97 degrees, brittle nails, cholesterol elevated, and the like. My lack of initiative has really put me in fear of, if not losing my job, making it difficult for me to progress in my career.

    After I started being wheat-free, grain-free, and low carb (under 25 per day), I didn’t lose any weight. I read all the information Dr. Davis provided about thyroid and did some independent research. Armed with data, I went to my doctor’s appointment and told him about my inability to lose weight, despite the fact that I’d eliminated wheat, grains, carbs, sugar, and was regularly exercising. I asked about T3 and he said “that won’t help.” He went on to explain how the T4 I’m taking works and all is well in the world since my TSH was 1.71.

    Thanks to Dr. Davis’ checklist, I went out on my own and got Free T3, Free T4, and RT3 tests which showed that my T4 was high, T3 was low, and RT3 was very much elevated. The ratio of Free T3 to RT3 was over 25!

    Yesterday I saw an endocrinologist who took one look at the test results I ordered and said, “we need to introduce T3 along with your levothyroxine. You have tissues that are starved for T3.” I was so relieved. I didn’t even have to show him the results of my literature search. I just started to take the T3 along with a reduced dosage of T4. It is amazing that my next labwork orders include Free T4, Free T3, thyroid antibodies, adrenals (serum cortisol and DHEA, whatever that is). He didn’t even order a TSH test. Wow. I had not been hopeful, based upon my own experiences with internal medicine doctors and the posts here about many endocrinologists.

    Now I have some hope. Too early to tell yet how effective it will be, but I feel as if I may be on the right track now.

    • Dr. Davis says:

      Wow! You found an exceptionally rare thing in this world: an open-minded endocrinologist!

      Please come back in a few weeks and update us on your progress. I predict wonderful things as your T3 dose is adjusted to the ideal range.

  3. WannaGetWell says:

    Dr. Davis, thanks for your information–I would never have known anything was amiss (except how I feel) without it. And I wouldn’t have realized it was possible for me order lab tests on my own and challenge my PCP with the results.

    Incidentally, I found my new endocrinologist on propublica.org prescriber checklist (which I learned about from a post on the Wheat Free Forum). Looked for one that had T3 and Armour Thyroid in his top prescribed drugs. I just looked you up and saw that your number 1 is T3 and Armour is also on your list.

    Thanks again!! Will keep you all posted.

    • Jeanne says:

      Hello, I am trying to find a doctor in my area that prescribes T3 and am on the web site mentioned. I input a doctor but where does it list the drugs prescribed?? Please reply

  4. Julie says:

    Wondering if you would entertain interpreting more results:

    T3= 2.8
    TSH= 0.52
    T4= 0.99

    Doctor believes this is normal. Friend reports they look low from her experience. I have no clue how to read.

    Thanks!

  5. Hechy says:

    I am seriously wondering if the low carb diet has caused my thyroid problem. I never had a thyroid problem and up to a couple of weeks ago I did not have the symptoms. I have been wheat/grain free for a couple of months and then decided to restrict my carbs to 30gr a day a couple of weeks ago. So I took out the almond breads/pizza’s and such. Now only eating vegetables, eggs, cheese, meat and fish. I suddenly started experiencing hot flashes at night, a constant feeling that I have drunk too much coffee, and fatigue. On top of that I noticed I had much more hair loss then usual. I went to the doctor for a blood test. I was informed last Friday that I have lower Thyroid values (I didn’t get the values) and that they would do another test in 6 weeks time. My sister who started the diet with me a couple of months, also experienced the same things in the last couple of weeks when we went low carb (max 30gr carbs). By doing some research I do think that the symptoms are caused by the radical decrease in carbs. That does not seem to be working well for everybody. I will therefore increase my carb intake again and see if the symptoms dissapear and then gradually decrease it again.This is one of the sites I found: “http://drcate.com/going-low-carb-too-fast-may-trigger-thyroid-troubles-and-hormone-imbalance/”
    What do you think Dr. Davis?

    • Dr. Davis says:

      There can be a relative increase in iodine need with a reduction in carbohydrates.

      For this reason, I have all of my patients supplement iodine, 500 mcg per day, from kelp tablets or other iodine supplement.

  6. Valora says:

    TSH 2.1 up from .86 1/2013…T3 is 2.3, T4 is 1.3. Endo is saying this is in normal range. Even though I’ve been on Wheat Belly diet for 8 weeks with no weight loss.

    • Dr. Davis says:

      You have marginal hypothyroidism, possibly impaired 5′-deiodinase conversion of T4 to T3.

      Expect absolute ignorance or resistance to this notion from your endocrinologist. Find yourself a functional medicine practitioner or naturopath, someone more openminded and better read in the new arguments on thyroid health. Sadly, this almost never comes from the drug pushers who work for the drug industry called endocrinologists.

      • Faye says:

        Valora, use the prescriber checkup (http://projects.propublica.org/checkup/) to find a physician in your area who prescribes T3 or Armour. I was able to get my PCP to refer me to an endocrinologist who prescribes T3 and Armour so I was able to get my meds adjusted

        • Faye says:

          I am also happy to say that the endocrinologist I chose does not even check TSH. Only Free T4 and Free T3 (and thyroid antibodies, for a data point–she suspects I have Hashimoto’s).

      • Valora says:

        Thank you for your response…I am impressed you take the time to address the comments/concerns. I asked my endocrinologist to consider a trial on some thyroid meds, she said there are too many side effects to treat someone with normal lab results. I should add I have TI Diabetes…this complicates things. I have read Dr. Bernstein’s Diabetes Solution and have adapted the Wheat Belly diet accordingly but with no weight loss; in fact I gained 3 lbs. Very discouraging as I only want to drop 10-20 lbs; I am 51, 5’4″ and 146# so, menopause is complicating things, too. I am not sure what else I can do, my endo has no answers for me in regards to what else I can do to loose weight, which I find disappointing. Seems as though I am more than lab results…I am going to search for an additional provider who will treat me as a whole. Thanks for your time, Dr. Davis.

  7. Stacey Evans says:

    After a few years of suffering and poor responses from GP and EndoPrats – I had many symptoms including low body temps, fatigue, weigh gain, thinning hair and eyebrows, low mood etc etc – but the usual ‘normal’ TSH – I did my own research and now self treat on T3. Using support of Thyroid Patient Advocacy and seeing a private (unfortunately no longer under the General Medical Council) Dr Peatfield diagnosed. I now wake albeit briefly around 3am and pop a T3 pill under my tongue and go back to sleep. This helps with the circadian/cortisol and when I awake I no longer feel dreadful, many of my symptoms have gone and although I still have some weight to lose, I hope going wheat and gluten free and introducing things like coconut oils and flours etc will help.

    why are so many people allowed to suffer this awful thing? How can someone in one country be diagnosed and treated at TSH 2 and in another (UK) over TSH 5 and in many cases holding back till people hit TSH 10.

    I work with people over 65 in social care and when I do assessments I am seeing a lot of hypothyroid listed in their med notes – along with atrial fib and other health issues – not least dementia which I think could be prevented by proper diagnoses and use of things like T3, Natural Desiccated Thyroid etc – scary to be at the mercy of un-co-operative medical profs who are unbending and blinkered.

    So – despite presenting at my GP saying look at me now after taking T3 they still would not prescribe me T3 – very telling how much they are controlled b the bigger so called health bods!

    Your website has been a brilliant education for me, I will use it as a resource to help me back to even fuller health.

    Thank you.
    Stacey