WEBVTT
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Welcome to episode 47.
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Today, our topic is going to be the malabsorption of nutrients in thyroid.
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So I feel like this is an under appreciated issue when it comes to thyroid treatment and thyroid symptoms in particular.
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So most specifically today, I wanna dive into iron metabolism, when to suspect it, how we diagnose it, how it interacts with thyroid activity and production, and when iron deficiency might be a big clue about coexisting other autoimmune disorders in a patient with hypothyroidism or Hashimoto's disease.
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So let's get started.
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You're listening to the Beyond the Thyroid podcast.
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I'm your host, Dr.
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Dana Gibbs.
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I'm an ENT surgeon and hormone specialist.
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For years, I struggled with my own unrecognized thyroid problems before and even after I was regularly performing thyroid surgeries.
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Then, one day, I learned something that turned my health around and opened my eyes to the limits of mainstream medicine in treating more subtle thyroid abnormalities.
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I spent the next 20 years fine tuning my hormone expertise in disorders like Hashimoto's disease, perimenopause, and stress related illness.
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Come join me as I share this new approach to hormones that empowers you to take control of your own thyroid and hormone imbalances.
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Let's dive in.
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Hello and welcome back to Beyond the Thyroid.
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If you are new here, welcome.
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I am happy to have you here.
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I'm Dana Gibbs, md.
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I'm a thyroid specialist, a former thyroid surgeon, and a thyroid patient at the same time.
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I wanna start today with a story that I recently heard from a patient.
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'cause it's a story that I hear versions of all the time.
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So this patient had Hashimoto's disease.
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They'd been diagnosed maybe two years before I heard this story, and at the time of diagnosis, her TSH was really bad.
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High, over a hundred.
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She was started on levothyroxine and was told it's gonna take time for your levels to come down and for your body to recover.
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Instead of improving, she felt worse.
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Over the next two years, she developed extreme fatigue.
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She was often bedridden.
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She had dizziness, severe brain fog, weakness, muscle and joint pain, and air hunger.
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That's the sensation where you can't quite get a full breath.
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Even though your lungs are technically working, she went back to her doctor repeatedly.
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She explained how severe the symptoms were, how they were ruining her life, and each time she was told this was still likely her Hashimoto's and that her thyroid just needed a little more time.
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Her TSH did come down, but her symptoms didn't improve.
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In fact, they kept getting worse.
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Eventually, she was so afraid.
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She convinced herself something catastrophic was being missed, cancer, lung disease, severe infection.
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So she went to the emergency room fully prepared to hear devastating news.
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Instead, she was told that everything looked normal and follow up with her primary care physician.
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And at that next visit, she did something that I actually recommend that most patients ought to do.
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She came prepared.
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She had written down every symptom.
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How severe it was and how it was affecting her day-to-day existence.
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And for the first time, her doctor did something different.
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He checked her ferritin and it was 12.
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While that's still technically inside the reference range, it's actually shockingly low, and especially for someone who has Hashimoto's disease.
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We'll go over this detail in just a few minutes.
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Her TSH was also still slightly high out of range, but it had gotten close.
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Her vitamin D test was also very low.
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She was deficient in vitamin D, so she started iron supplementation and within a week she started noticing improvement, her dizziness, her brain fog lifted.
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Her breathing started feeling easier, and her energy started to come back, and she was really stunned.
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Not just by how much better she felt, but by how long she had suffered with something common and measurable and treatable.
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So this story matters because it highlights one of the biggest blind spots in thyroid care.
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When someone has Hashimoto's, every symptom tends to get blamed on the thyroid, and that's not just true with Hashimoto's or thyroid disease.
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If you get a complex diagnosis.
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Everything gets blamed on that diagnosis, even when it turns out something else treatable is driving the symptoms, and it's not just by the doctor, but by uninformed patients as well.
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So today I wanna go deeper.
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That because iron and every other symptom provoking nutrient deficiency in thyroid patients might not be just about not enough iron or whatever nutrient it is.
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Thyroid dysfunction absolutely does cause symptoms, but it doesn't mean we should focus exclusively on that.
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It's about malabsorption.
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Malabsorption is common in thyroid patients and sometimes it's hiding something more sinister like celiac disease.
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So first let's talk about iron.
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So I have gone over symptom list in exhaustive detail in earlier podcast episodes, and maybe I should do another one of those, but one of the categories of symptoms of not enough thyroid hormone activity in the body is GI tract, slow motility in the GI tract.
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Lower secretion of neurotransmitters by the GI tract, lower stomach acid and digestive enzymes, and lower absorption activity.
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You can also get symptoms from GERD and reflux all the way at the top, all the way down to constipation with SIBO, which is the backing up of bacteria from your colon into your small intestine to nutrient malabsorption in the middle.
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Today I really wanna talk and focus on malabsorption because two of the most common nutrients that are malabsorbed in thyroid problems are iron and vitamin D.
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So it also makes sense that medications can be poorly absorbed, especially your thyroid medicine.
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If you're taking some already.
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So you'll note that I said not enough thyroid hormone activity in the body.
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And this can be the case regardless of the level of your TSH and T4 and frequently, even if T3 is testing inside the normal range, but it's just not quite sufficient.
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It's just one of the many reasons I treat people with combination thyroid medicine, unless their labs and their symptom resolution clearly indicate that they're doing great on just levothyroxine.
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So let's talk about the relationship of iron stores to thyroid hormones.
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This is a complex relationship and it actually goes both ways.
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Not only does low thyroid activity lower your absorption of iron, but if your iron is low, it impairs your thyroid activity and function in several ways.
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So the first one is thyroid peroxidase.
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So thyroid peroxidase as a key component of that enzyme iron and thyroid peroxidase is responsible for the initial steps of thyroid hormone synthesis.
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It adds the iodine atoms to the thyroid hormone structure inside the thyroid gland.
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So low iron can impair the activity of that thyroid peroxidase enzyme, which will lead to a reduced production of thyroid hormones and contributing to hypothyroidism.
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Iron deficiency can lower thyroid hormone levels and raise TSH all by itself.
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So the next one is T4 to T3 conversion because iron is also required for the activity of the dianadase enzymes, particularly in the liver, which those dianadase enzymes convert inactive prohormone T4 into its active form T3, and the enzyme can't work if it doesn't have iron.
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Severe iron deficiency shifts metabolism towards a different pathway, which is the use of dease type three, which creates reverse T3, which has no positive effect on metabolism or symptoms.
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So severe iron deficiency especially really shifts away from T3 production.
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The last one is receptor binding activity.
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So iron deficiency has been shown in studies to reduce the binding of T3 active thyroid hormone to the receptors in your cells in tissues like liver and muscle.
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So it can impair the body's response to T3.
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Even if you do have enough.
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So low thyroid activity feeds back to reduce the production of healthy red blood cells and push you towards anemia.
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So it's also going to affect you with symptoms of anemia, which includes the air hunger that I was talking about.
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So low iron is a vicious cycle.
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So to tie a bow on that cycle, low iron levels are associated with a higher risk of developing thyroid auto antibodies, such as those found in Hashimoto's disease that are thought to activate the immune system towards damaging your thyroid.
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Iron has a bunch of other functions in our bodies besides being a key component of hemoglobin, which is the oxygen carrying molecule in our blood cells.
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I'm gonna list them here, but you're gonna notice how tightly these parallel the functions of T3 thyroid hormone.
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So the first one is muscle metabolism.
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There's a molecule called myoglobin.
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Iron is a key component of myoglobin which is a protein inside muscle cells that stores transports and releases oxygen.
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So that's crucial for muscle contraction and endurance.
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If you don't have oxygen, they can't really do their job.
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It's also a key component in energy production or ATP production inside mitochondria because iron acts as a co-factor for enzymes in the electron transport change that produces ATP.
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That ATP is the body's primary energy currency.
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If you don't have ATP, you really can't produce much energy at all.
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Iron is also helpful in the production and maturation of immune cells, particularly lymphocytes, which help your body fight infections.
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Iron is a co-factor in enzymes for synthesizing DNA and neurotransmitters.
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Iron plays a role in cognitive development, memory concentration, and braiding function.
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And it also supports the health and tissues of hair, skin, and nails with deficiencies often leading to hair loss.
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Iron also assists in maintaining your normal body temperature.
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So you can see if you look back up that list, a lot of those have to do probably with the impairment of T3 activity in your body cells.
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All right, so what is ferritin?
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I mentioned that in the story.
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So ferritin is the protein that stores your iron.
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Your reserve serum iron is the small amount that's circulating in your bloodstream at any moment.
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Hemoglobin, the oxygen carrying iron containing protein and red blood cell tests and indexes reflect whether iron deficiency has progressed far enough to affect blood production, but you now know that blood production is really not the only use iron has in your body.
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Ferritin drops really early when iron absorption gets impaired.
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So blood counts and iron levels can look normal for months or even years before hemoglobin shows up low, which is why people can feel awful long before they're told their anemic Vitamin D deficiency often travels alongside iron deficiency for the same reason, which is damaged absorption in the gut.
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This is why some patients develop iron and vitamin D deficiencies before their TSH even looks abnormal.
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And why?
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Simply replacing nutrients without addressing the underlying cause may only temporarily help.
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I'm gonna come back another day and discuss vitamin D'cause today I really wanna focus and stay focused on the iron issue right now.
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But if B12 deficiency is also present that causes body inflammation and it can make your ferritin look elevated or normal when the other labs actually have already started to show an iron deficiency.
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So this is because ferritin is also an acute phase reactant, and what that means is that it rises in the presence of inflammation in your body.
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So B12 is another nutrient that's critical for red blood cell production among other things, and can also be malabsorbed when thyroid function is low, or for other reasons.
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This is why I test iron and the TIBC, that's the total iron binding capacity and transferrin or iron saturation, along with ferritin when history seems to suggest that I ought to be looking there because meaningful iron deficiency often shows up before anemia, so waiting for your hemoglobin to get low misses the window where the intervention is actually easier.
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Here's another thing about anemia, hematologists classify anemia whether the red blood cells are too big, they call that macrocytic from B12 deficiency or too small, Microcitic from iron deficiency.
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So if one or the other is noted, it's another red flag that can be seen before your blood cell count or your actual hemoglobin starts to go low.
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But the funny thing is, if both of them are there, then the effect might even cancel itself out.
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Leaving us again without this early warning sign.
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So ferritin screening is reasonable in patients who complain of persistent fatigue, weakness, and shortness of breath or exercise intolerance if they have hair loss, brittle nails and intolerance to cold.
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Restless legs is also a weird and very common symptom with iron deficiency.
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Also, headaches, dizziness, brain fog, Hashimoto's, autoimmune disease.
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Women who are still menstruating, if their periods are heavy postpartum patients who may have lost a lot of blood or patients with GI symptoms like reflux or who are on acid blocking medications or who have symptoms like IBS or known autoimmune gastritis.
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So that actually removes your ability to make stomach acid if you have autoimmune gastritis.
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Anybody who has hypothyroid symptoms persisting despite a normal TSH, the failure of your TSH to drop into the normal range with thyroid medicine or other poor response to thyroid hormone therapy.
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People who have any of those should probably be screened for a ferritin and iron studies test.
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Alright, let's talk about the lab ranges.
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So when you get a ferritin test, what should it normally be?
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The reference range for ferritin in women is 13 to 150, and for men it's about 30 to 400.
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So when the reference ranges for ferritin were decided the testing labs did not exclude all people with that list of symptoms and conditions above that I just listed to you, they excluded just people with.
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Definitive diagnosis of iron deficiency or anemia.
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This means that the published reference range is probably way too broad, especially when it comes to Hashimoto's or hypothyroidism.
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So the AFP, the American Association of Family Practice doctors, their large primary care medical society has recently changed its recommendation for ferritin to a minimum number of 45.
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And that's for healthy people in symptomatic patients.
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Some specialty societies are now targeting an ideal level of 70 to 80.
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And that's women.
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So before you start taking an iron supplement, there's a couple of things you ought to know.
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First, iron toxicity is a thing and it is no joke.
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High levels of iron deposit themselves in your body tissues causing oxidative stress, and that's the same as inflammation.
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Oxidative stress can damage key organs, including the liver, the heart, pancreas, and the endocrine glands.
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Like thyroid.
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Oh wow.
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Symptoms vary in duration and severity and range from fatigue and joint pain to life threatening complications such as cirrhosis or cardiomyopathy or hepatic failure.
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We're still talking about iron toxicity here.
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So iron supplementation should always happen under the guidance of a physician.
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Second, there are several factors that can make taking an iron supplement a lot less useful.
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The first one is a pretty new finding, like anything toxic that we can ingest from our environment, our bodies have evolved a way to block iron in case of overdose, and there's a peptide, it's called hepcidin, and it's the regulator of iron absorption into our bodies.
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So when we take an iron pill, it hits our digestion all at once, and hepcidin ramps up and degrades the iron transport protein, which is called ferroportin.
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And ferroportin stays degraded for about 24 hours, and that blocks the absorption of iron for that period of time.
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So if you're taking an iron supplement, it seems to work better to take it every other day.
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Better than taking it every day.
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Go figure.
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The second factor is competition.
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If you're taking your iron in a multivitamin or with other minerals like calcium, or even with high calcium foods like dairy, they compete with your iron for the transport proteins that absorb the iron, both from vegetable and animal sources, it can cut the absorption by half.
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A third factor that can block the absorption of iron and other minerals, if you are making a big effort to eat healthy is something called phytates.
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Phytates, or phytic acid, is a chemical that's in whole grains, nuts, seeds, and legumes that can act as a potent binder of iron and inhibitor of iron and other mineral absorption because it binds to vegetable source, iron in the digestive tract rendering it.
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Insoluble and poorly absorbed.
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So high consumption of unrefined grains can significantly decrease the bioavailability of the iron that you're taking and contribute to iron deficiency anemia.
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Phytic acid is a storage molecule in grains and other plant foods, and it has the affinity to bind or chelate zinc, iron, magnesium, calcium, potassium, manganese, and copper, and even small amounts of phytate can inhibit the absorption.
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So these high phytate diets, it's about 23% of non-heme iron absorption.
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So if you're eating your minerals with your whole plant-based proteins, they are not gonna generally be as available for absorption.
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But there is a way to counteract this problem.
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There's several ways.
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You can do this with food preparation.
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So soaking or sprouting of grains and seeds and legumes activates enzyme that break down the phytic acid or phytate.
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Molecule fermentation like sourdough specifically breaks down phytic acid during bread making, and in my opinion, a much easier way is to add vitamin C or ascorbic acid from citrus or berries or peppers.
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This reverses the inhibition caused by phytic acid or phytates, so my favorite iron supplements also have vitamin C included in the tablet.
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So that's a great thing.
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All right.
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So say your doctor found low ferritin on your lab test and you feel awful and things aren't getting any better, even though you've been following all these recommendations above and taking an iron supplement, what's the next step?
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An iron infusion usually given by a hematologist or at an infusion center.
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Could be the answer if your ferritin stays really low despite adequate oral supplementation, or if you're having really bad GI side effects, and it makes it hard to keep taking the iron supplement, or if there's ongoing blood loss like.
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Heavy menstrual cycles.
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I also need to be putting in a plug for early colon cancer screening here because it is one of the biggest causes of unrecognized blood loss in adults.
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If you have severe symptoms and your ferritin is below 20, you might need an iron infusion to get things started.
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Also, if you need, for any reason to get your iron levels up faster than you're getting them with an oral iron supplement, like you're significantly weak or you're having significant shortness of breath and low blood oxygen levels or if you have very low stomach acid or gut inflammation.
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And then the last one is if you have a known or suspected autoimmune gastritis or celiac disease.
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All right, so one reason why iron deficiency is so common in Hashimoto's is not just random.
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It's not just bad luck.
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Hashimoto's, of course, is an autoimmune condition and autoimmune diseases cluster.
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So once your immune tolerance is disrupted and the immune system begins targeting your body tissues, your self tissue, the likelihood of having or developing additional autoimmune conditions really goes up.
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That means that people with Hashimoto's are more likely to develop other immune mediated conditions that can affect lots of things, but particularly today we're talking about digestion and absorption and vice versa.
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So one of the most common is autoimmune gastritis.
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Autoimmune gastritis overlap with Hashimoto's disease has been discussed to be between 10 and 40%.
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40%.
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That's huge.
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So in autoimmune gastritis, your immune system attacks specific cells in your stomach lining called parietal cells.
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And when these cells are destroyed, you lose your ability to produce stomach acid and also another molecule called intrinsic factor.
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An intrinsic factor is required to absorb vitamin B12.
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Stomach acid is essential for iron absorption, so without it iron, even from meat, may not be absorbed efficiently.
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So patients can take an oral iron faithfully and never see their ferritin rise up.
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Over time, if you lose completely, lose your intrinsic factor production, you can't absorb B12.
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This can eventually lead to pernicious anemia, and that's an autoimmune B12 deficiency state characterized by macrocytic anemia, meaning your blood cells are too large, neurologic symptoms, numbness, tingling, memory issues, and mood disturbances.
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It's a pretty severe issue.
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The progression is really slow.
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First, the iron deficiency shows up, then the low B12, and then the anemia probably comes later.
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But the neurologic symptoms can come before obvious lab abnormalities.
00:25:08.248 --> 00:25:20.643
So diagnosis typically involves checking antibodies to parietal cell tissue and intrinsic factor antibodies along with gastro levels and B12 levels.
00:25:20.972 --> 00:25:31.833
In some cases you might have an upper endoscopy to assess your stomach lining, but it has to occur to your doctor to look before these very specific tests are gonna get ordered.
00:25:32.307 --> 00:25:41.011
Another major failure of iron metabolism is caused by celiac disease and celiac's kind of rare globally.
00:25:41.011 --> 00:25:45.301
About 1% of the population has biopsy confirmed celiac disease.
00:25:45.721 --> 00:25:52.592
However, if you already have autoimmune thyroid disease, the prevalence is between two and 6%.
00:25:52.951 --> 00:25:54.122
That may not sound dramatic, but.
00:25:54.537 --> 00:25:59.906
Represents a meaningful increase over baseline, especially when the symptoms are there.
00:26:00.686 --> 00:26:05.366
Celiac disease is a permanent immune mediated reaction to gluten.
00:26:05.906 --> 00:26:30.044
Gluten is a protein that's found in wheat, barley, and rye in these genetically susceptible in individuals carry gene markers called HLAD Q2 or H-L-A-D-Q eight, and when they consume gluten, the immune system mounts an inflammatory attack that specifically damages the lining of the proximal small intestine.
00:26:30.044 --> 00:26:34.848
That means the upper part, the first part, where all the nutrient absorption is supposed to be happening.
00:26:35.355 --> 00:26:37.752
Specifically, it damages the vii.
00:26:37.752 --> 00:26:50.292
These are those tiny little finger-like projections responsible for absorbing all the nutrients when those VII are flame inflamed or flattened or damaged, nutrient absorption declines.
00:26:50.833 --> 00:26:59.952
This matters enormously because iron and vitamins and other critical nutrients are absorbed exactly there in that region of the small intestine.
00:27:00.702 --> 00:27:04.603
And here's the part that gets missed a lot.
00:27:04.932 --> 00:27:09.432
Many people with celiac disease don't have obvious digestive symptoms.
00:27:09.942 --> 00:27:12.897
They may not have diarrhea or weight loss or abdominal pain.
00:27:13.442 --> 00:27:23.792
Instead, the very first sign could be low ferritin with fatigue and hair loss and weakness, and shortness of breath with exertion and brain fog or cold intolerance.
00:27:24.093 --> 00:27:29.553
Symptoms that look exactly like hypothyroidism, but are pretty common in low iron levels.
00:27:30.468 --> 00:27:38.897
These people can often commonly have headaches, restless leg syndromes, neuropathies, bone loss, or diffuse itchiness.
00:27:39.018 --> 00:27:44.262
Some people develop dermatitis herpetiformis, which is a blistery rash.
00:27:44.262 --> 00:27:45.613
That's intensely issue.
00:27:45.972 --> 00:27:49.063
That is actually a skin manifestation of celiac disease.
00:27:49.843 --> 00:27:58.663
And iron deficiency is often the first clue because the iron stores are so dependent on absorption from that particular part of your small intestine.
00:27:59.113 --> 00:28:06.813
Ferritin drops early and if it isn't suspected, patients are gonna continue to feel worse and worse while being told their labs are fine.
00:28:07.237 --> 00:28:13.218
Here's the thing about this, if you have Hashimoto's and you've been told, oh, you need to stop eating gluten.
00:28:13.938 --> 00:28:20.748
If you are off gluten, completely off gluten, and they go to do celiac testing on you, the testing can be normal.
00:28:21.278 --> 00:28:26.738
Testing can show nothing and then you get this complacent,"oh, I can have a little gluten every now and then." No.
00:28:27.082 --> 00:28:36.201
It's really if you're gonna decide,"Hey, I'm gonna stop eating gluten", it is really a good idea to get a celiac test, at least a ferritin test.
00:28:36.442 --> 00:28:41.991
Get that ferritin test early, and go ahead and get the celiac testing if your ferritin is already low.
00:28:43.132 --> 00:28:49.041
Vitamin D deficiency often travels alongside iron deficiency for the exact same reason.
00:28:49.071 --> 00:28:50.541
It's fat ab soluble.
00:28:50.541 --> 00:29:00.801
It's absorbed right there in the small intestine, and low vitamin D worsens immune dysregulation, which increases the risk for developing even more autoimmune diseases.
00:29:01.071 --> 00:29:06.878
It also contributes to bone loss and amplifies pain, muscle weakness and fatigue.
00:29:07.598 --> 00:29:15.759
So when you see low ferritin and low vitamin D and persistent fatigue in a patient with Hashimoto's, it's a pattern that we gotta pay attention to.
00:29:16.868 --> 00:29:18.939
Alright, so I mentioned diagnosing celiac.
00:29:19.269 --> 00:29:20.138
How do we do that?
00:29:20.798 --> 00:29:30.519
Proper diagnosis of celiac disease requires that a patient be eating gluten for several days at the time of testing and not just a few bites.
00:29:31.028 --> 00:29:39.999
Screening typically begins with blood tests, which are tissue transglutaminase, IGA, and a total IGA level.
00:29:40.118 --> 00:29:41.259
Those are the first two.
00:29:41.648 --> 00:29:42.824
If those are positive.
00:29:43.338 --> 00:29:50.298
Adult diagnosis generally requires confirmation with an upper GI endoscopy and small bowel biopsies.
00:29:50.598 --> 00:29:56.929
And if you've been eating gluten, when you go in to your upper GI endoscopy, they may find it.
00:29:56.959 --> 00:30:03.798
If you have been avoiding gluten, they may not find it because the damage can be healed.
00:30:04.314 --> 00:30:08.183
Although it'll come right back once you eat the gluten again.
00:30:09.023 --> 00:30:17.574
For more specific confirmatory blood tests, we can use the endometrial antibody EMA-IGA test.
00:30:18.233 --> 00:30:25.134
Highly specific for celiac disease and often used to confirm a positive tissue transglutaminase result.
00:30:25.763 --> 00:30:31.034
There are also two more called DGPIGA and DGPIGG.
00:30:31.084 --> 00:30:44.463
DGP stands for Deamidated Gliadin Peptide, and it's used as an alternate test, particularly in children under two, or for people who have an IGA deficiency.
00:30:45.273 --> 00:30:57.213
We can also test for those genetic markers that I mentioned, the HLAD Q2 or HLADQ-8, although those just suggest the tendency for celiac, not the actual disease.
00:30:57.933 --> 00:31:01.023
So treatment of celiac is very simple.
00:31:01.203 --> 00:31:15.054
Strict, lifelong elimination of gluten, not an option, not a sensitivity, where mostly gluten-free is okay, and even small exposures can continue to drive immune activation and intestinal injury.
00:31:15.473 --> 00:31:30.594
And this means even cross-contamination like shared toasters, cutting boards, restaurant fires, sauces and seasonings that contain even a trace of gluten can prevent healing even when somebody believes that they're being careful.
00:31:31.193 --> 00:31:35.153
So symptom improvement does not necessarily equal intestinal healing.
00:31:35.723 --> 00:31:38.203
So who are we gonna screen for celiac?
00:31:38.713 --> 00:32:02.811
In thyroid patients, we should consider screening if iron deficiency is there and it persists and stays low despite supplementation, or if your vitamin D was very low and remains low despite supplementation, if the fatigue is still unexplained or if restless legs are present, or if your brain fog continues despite your thyroid levels looking optimal.
00:32:03.237 --> 00:32:09.416
Or if there's autoimmune clustering or a family history of autoimmune disease.
00:32:09.926 --> 00:32:13.826
So ferritin thresholds also deserve attention.
00:32:14.186 --> 00:32:21.176
So traditionally, a ferritin below 15 was considered deficient, but that's really a very late stage deficiency.
00:32:21.176 --> 00:32:28.707
So increasingly, ferritin levels below 45 are recognized as deficient in patients who have symptoms.
00:32:29.186 --> 00:32:55.717
Failure of oral iron supplementation should definitely trigger workup for celiac, and an iron infusion really ought to be considered when ferritin stays low despite adequate supplementation or if symptoms are severe or if ferritin is below 20, or if malabsorption is confirmed and infusion bypasses your gut and in the right patient can be really transformative symptom-wise.
00:32:57.241 --> 00:32:57.571
Woo.
00:32:57.571 --> 00:32:58.321
That's a lot.
00:32:58.321 --> 00:33:09.392
So to wrap up for today, if you have hypothyroid symptoms and they are not resolving, and your TSH isn't normalizing, the thyroid may not be the whole story or even the main story.
00:33:09.842 --> 00:33:33.061
So when iron or other nutrient levels refuse to normalize, despite supplementation, it is worth asking why celiac disease and autoimmune gastritis are not rare in autoimmune thyroid patients, and both can silently drive fatigue, cognitive dysfunction, hair loss, weakness, and poor response to thyroid treatment in general.
00:33:33.571 --> 00:33:36.842
So sometimes the problem is not your thyroid medication dose.
00:33:37.082 --> 00:33:47.912
Sometimes the problem is that the thyroid signaling is not being addressed, and sometimes the immune system is a bigger story than you originally understood.
00:33:48.481 --> 00:33:59.491
So iron deficiency is common autoimmune diseases, cluster celiac disease is more common in Hashimoto's patients and malabsorption can undermine your recovery.
00:33:59.866 --> 00:34:02.717
Long before anybody connects the dots.
00:34:03.136 --> 00:34:09.157
So when you address the malabsorption, the entire clinical picture begins to make sense.
00:34:10.088 --> 00:34:10.748
Woo.
00:34:11.018 --> 00:34:12.307
That's all for today.
00:34:12.398 --> 00:34:22.811
Thank you for listening to Beyond the Thyroid and if you are looking for a doctor to help you manage your thyroid disease, then come and check me out.
00:34:22.811 --> 00:34:29.561
My website is danagibbsmd.com, and you can check on a free discovery call right now.
00:34:29.561 --> 00:34:35.981
Today I am planning at the end of April to raise the prices for comprehensive thyroid workup.
00:34:36.280 --> 00:34:39.400
So I'm taking four more new patients before then.
00:34:39.731 --> 00:34:45.771
If you want to get in on the current pricing, then make your discovery call today.
00:34:45.800 --> 00:34:47.150
Thanks for listening.
00:34:47.271 --> 00:34:47.570
Bye.
00:34:55.469 --> 00:34:58.409
Thank you for listening to this episode of Beyond the Thyroid.
00:34:58.775 --> 00:35:05.324
If you found this information valuable, it would mean so much to me to take a few seconds and give the podcast a five star review.
00:35:05.724 --> 00:35:10.425
It helps other people who need this information find the show and it's really easy.
00:35:10.695 --> 00:35:16.715
Just search and click on the name of the show, Beyond the Thyroid, and scroll to the bottom to ratings and reviews.
00:35:17.224 --> 00:35:19.175
I truly do read and appreciate.
00:35:20.460 --> 00:35:29.110
Remember, when it comes to hormones, there will always be more to discover, so follow the show so you get the next episode as soon as it's released.
00:35:29.519 --> 00:35:39.440
And if you or someone you care about needs a caring doctor to help figure out how to heal hormone problems that other doctors have dismissed, check out my website at www.
00:35:39.650 --> 00:35:39.809
danagibbsmd.
00:35:40.460 --> 00:35:40.579
com.
00:35:42.284 --> 00:35:47.625
And if you're not a physician, please keep in mind, while I'm a doctor, I'm not your doctor.
00:35:48.005 --> 00:35:53.985
The content of this podcast is my opinion and it's for educational and entertainment purposes only.
00:35:54.425 --> 00:36:01.994
This is not meant to be individual medical advice and you should consult your own physician for any medical issues or diagnoses that you may have.
00:36:02.804 --> 00:36:06.655
I look forward to continuing this journey with you beyond the thyroid.
00:00:02.009 --> 00:00:03.839
Welcome to episode 47.
00:00:04.200 --> 00:00:09.660
Today, our topic is going to be the malabsorption of nutrients in thyroid.
00:00:10.050 --> 00:00:21.210
So I feel like this is an under appreciated issue when it comes to thyroid treatment and thyroid symptoms in particular.
00:00:21.210 --> 00:00:44.039
So most specifically today, I wanna dive into iron metabolism, when to suspect it, how we diagnose it, how it interacts with thyroid activity and production, and when iron deficiency might be a big clue about coexisting other autoimmune disorders in a patient with hypothyroidism or Hashimoto's disease.
00:00:44.215 --> 00:00:45.835
So let's get started.
00:00:56.722 --> 00:00:59.371
You're listening to the Beyond the Thyroid podcast.
00:00:59.762 --> 00:01:00.932
I'm your host, Dr.
00:01:00.932 --> 00:01:01.671
Dana Gibbs.
00:01:01.781 --> 00:01:04.242
I'm an ENT surgeon and hormone specialist.
00:01:04.762 --> 00:01:12.391
For years, I struggled with my own unrecognized thyroid problems before and even after I was regularly performing thyroid surgeries.
00:01:12.876 --> 00:01:21.667
Then, one day, I learned something that turned my health around and opened my eyes to the limits of mainstream medicine in treating more subtle thyroid abnormalities.
00:01:21.677 --> 00:01:29.606
I spent the next 20 years fine tuning my hormone expertise in disorders like Hashimoto's disease, perimenopause, and stress related illness.
00:01:29.876 --> 00:01:37.206
Come join me as I share this new approach to hormones that empowers you to take control of your own thyroid and hormone imbalances.
00:01:37.876 --> 00:01:38.537
Let's dive in.
00:01:50.483 --> 00:01:53.034
Hello and welcome back to Beyond the Thyroid.
00:01:53.243 --> 00:01:55.703
If you are new here, welcome.
00:01:56.093 --> 00:01:57.563
I am happy to have you here.
00:01:57.804 --> 00:01:59.243
I'm Dana Gibbs, md.
00:01:59.243 --> 00:02:04.712
I'm a thyroid specialist, a former thyroid surgeon, and a thyroid patient at the same time.
00:02:05.353 --> 00:02:08.924
I wanna start today with a story that I recently heard from a patient.
00:02:09.014 --> 00:02:12.718
'cause it's a story that I hear versions of all the time.
00:02:13.288 --> 00:02:15.899
So this patient had Hashimoto's disease.
00:02:15.899 --> 00:02:23.868
They'd been diagnosed maybe two years before I heard this story, and at the time of diagnosis, her TSH was really bad.
00:02:23.899 --> 00:02:25.218
High, over a hundred.
00:02:25.609 --> 00:02:31.609
She was started on levothyroxine and was told it's gonna take time for your levels to come down and for your body to recover.
00:02:32.413 --> 00:02:34.963
Instead of improving, she felt worse.
00:02:35.383 --> 00:02:38.443
Over the next two years, she developed extreme fatigue.
00:02:38.774 --> 00:02:40.093
She was often bedridden.
00:02:40.093 --> 00:02:45.554
She had dizziness, severe brain fog, weakness, muscle and joint pain, and air hunger.
00:02:45.854 --> 00:02:48.794
That's the sensation where you can't quite get a full breath.
00:02:49.153 --> 00:02:54.433
Even though your lungs are technically working, she went back to her doctor repeatedly.
00:02:54.433 --> 00:03:06.283
She explained how severe the symptoms were, how they were ruining her life, and each time she was told this was still likely her Hashimoto's and that her thyroid just needed a little more time.
00:03:06.794 --> 00:03:10.394
Her TSH did come down, but her symptoms didn't improve.
00:03:10.424 --> 00:03:12.794
In fact, they kept getting worse.
00:03:13.033 --> 00:03:15.163
Eventually, she was so afraid.
00:03:15.899 --> 00:03:22.049
She convinced herself something catastrophic was being missed, cancer, lung disease, severe infection.
00:03:22.229 --> 00:03:27.118
So she went to the emergency room fully prepared to hear devastating news.
00:03:27.568 --> 00:03:32.788
Instead, she was told that everything looked normal and follow up with her primary care physician.
00:03:33.748 --> 00:03:39.568
And at that next visit, she did something that I actually recommend that most patients ought to do.
00:03:39.778 --> 00:03:41.038
She came prepared.
00:03:41.098 --> 00:03:43.139
She had written down every symptom.
00:03:43.473 --> 00:03:47.794
How severe it was and how it was affecting her day-to-day existence.
00:03:47.973 --> 00:03:51.183
And for the first time, her doctor did something different.
00:03:51.484 --> 00:03:54.274
He checked her ferritin and it was 12.
00:03:54.753 --> 00:04:02.628
While that's still technically inside the reference range, it's actually shockingly low, and especially for someone who has Hashimoto's disease.
00:04:03.459 --> 00:04:05.799
We'll go over this detail in just a few minutes.
00:04:06.248 --> 00:04:10.899
Her TSH was also still slightly high out of range, but it had gotten close.
00:04:11.229 --> 00:04:14.618
Her vitamin D test was also very low.
00:04:14.739 --> 00:04:25.329
She was deficient in vitamin D, so she started iron supplementation and within a week she started noticing improvement, her dizziness, her brain fog lifted.
00:04:25.329 --> 00:04:31.509
Her breathing started feeling easier, and her energy started to come back, and she was really stunned.
00:04:31.749 --> 00:04:39.699
Not just by how much better she felt, but by how long she had suffered with something common and measurable and treatable.
00:04:39.999 --> 00:04:45.819
So this story matters because it highlights one of the biggest blind spots in thyroid care.
00:04:46.658 --> 00:04:54.879
When someone has Hashimoto's, every symptom tends to get blamed on the thyroid, and that's not just true with Hashimoto's or thyroid disease.
00:04:55.059 --> 00:04:57.158
If you get a complex diagnosis.
00:04:57.499 --> 00:05:08.899
Everything gets blamed on that diagnosis, even when it turns out something else treatable is driving the symptoms, and it's not just by the doctor, but by uninformed patients as well.
00:05:09.168 --> 00:05:11.059
So today I wanna go deeper.
00:05:11.463 --> 00:05:24.093
That because iron and every other symptom provoking nutrient deficiency in thyroid patients might not be just about not enough iron or whatever nutrient it is.
00:05:24.574 --> 00:05:30.843
Thyroid dysfunction absolutely does cause symptoms, but it doesn't mean we should focus exclusively on that.
00:05:31.324 --> 00:05:33.303
It's about malabsorption.
00:05:33.553 --> 00:05:42.343
Malabsorption is common in thyroid patients and sometimes it's hiding something more sinister like celiac disease.
00:05:42.853 --> 00:05:44.774
So first let's talk about iron.
00:05:45.733 --> 00:06:05.403
So I have gone over symptom list in exhaustive detail in earlier podcast episodes, and maybe I should do another one of those, but one of the categories of symptoms of not enough thyroid hormone activity in the body is GI tract, slow motility in the GI tract.
00:06:05.543 --> 00:06:13.524
Lower secretion of neurotransmitters by the GI tract, lower stomach acid and digestive enzymes, and lower absorption activity.
00:06:13.913 --> 00:06:28.928
You can also get symptoms from GERD and reflux all the way at the top, all the way down to constipation with SIBO, which is the backing up of bacteria from your colon into your small intestine to nutrient malabsorption in the middle.
00:06:29.858 --> 00:06:41.079
Today I really wanna talk and focus on malabsorption because two of the most common nutrients that are malabsorbed in thyroid problems are iron and vitamin D.
00:06:41.528 --> 00:06:47.588
So it also makes sense that medications can be poorly absorbed, especially your thyroid medicine.
00:06:48.108 --> 00:06:49.384
If you're taking some already.
00:06:50.369 --> 00:06:55.019
So you'll note that I said not enough thyroid hormone activity in the body.
00:06:55.598 --> 00:07:07.809
And this can be the case regardless of the level of your TSH and T4 and frequently, even if T3 is testing inside the normal range, but it's just not quite sufficient.
00:07:08.288 --> 00:07:20.048
It's just one of the many reasons I treat people with combination thyroid medicine, unless their labs and their symptom resolution clearly indicate that they're doing great on just levothyroxine.
00:07:20.439 --> 00:07:24.790
So let's talk about the relationship of iron stores to thyroid hormones.
00:07:25.360 --> 00:07:30.040
This is a complex relationship and it actually goes both ways.
00:07:30.339 --> 00:07:41.769
Not only does low thyroid activity lower your absorption of iron, but if your iron is low, it impairs your thyroid activity and function in several ways.
00:07:42.610 --> 00:07:44.920
So the first one is thyroid peroxidase.
00:07:44.920 --> 00:07:58.144
So thyroid peroxidase as a key component of that enzyme iron and thyroid peroxidase is responsible for the initial steps of thyroid hormone synthesis.
00:07:58.444 --> 00:08:04.055
It adds the iodine atoms to the thyroid hormone structure inside the thyroid gland.
00:08:04.535 --> 00:08:17.105
So low iron can impair the activity of that thyroid peroxidase enzyme, which will lead to a reduced production of thyroid hormones and contributing to hypothyroidism.
00:08:17.795 --> 00:08:23.555
Iron deficiency can lower thyroid hormone levels and raise TSH all by itself.
00:08:24.154 --> 00:08:46.774
So the next one is T4 to T3 conversion because iron is also required for the activity of the dianadase enzymes, particularly in the liver, which those dianadase enzymes convert inactive prohormone T4 into its active form T3, and the enzyme can't work if it doesn't have iron.
00:08:47.110 --> 00:09:02.860
Severe iron deficiency shifts metabolism towards a different pathway, which is the use of dease type three, which creates reverse T3, which has no positive effect on metabolism or symptoms.
00:09:02.860 --> 00:09:08.860
So severe iron deficiency especially really shifts away from T3 production.
00:09:09.581 --> 00:09:13.416
The last one is receptor binding activity.
00:09:13.416 --> 00:09:26.586
So iron deficiency has been shown in studies to reduce the binding of T3 active thyroid hormone to the receptors in your cells in tissues like liver and muscle.
00:09:27.135 --> 00:09:30.086
So it can impair the body's response to T3.
00:09:30.826 --> 00:09:32.176
Even if you do have enough.
00:09:32.865 --> 00:09:40.716
So low thyroid activity feeds back to reduce the production of healthy red blood cells and push you towards anemia.
00:09:41.015 --> 00:09:47.437
So it's also going to affect you with symptoms of anemia, which includes the air hunger that I was talking about.
00:09:48.006 --> 00:09:50.527
So low iron is a vicious cycle.
00:09:50.826 --> 00:10:07.217
So to tie a bow on that cycle, low iron levels are associated with a higher risk of developing thyroid auto antibodies, such as those found in Hashimoto's disease that are thought to activate the immune system towards damaging your thyroid.
00:10:07.758 --> 00:10:17.268
Iron has a bunch of other functions in our bodies besides being a key component of hemoglobin, which is the oxygen carrying molecule in our blood cells.
00:10:17.628 --> 00:10:25.758
I'm gonna list them here, but you're gonna notice how tightly these parallel the functions of T3 thyroid hormone.
00:10:26.418 --> 00:10:28.697
So the first one is muscle metabolism.
00:10:28.798 --> 00:10:31.378
There's a molecule called myoglobin.
00:10:31.857 --> 00:10:40.562
Iron is a key component of myoglobin which is a protein inside muscle cells that stores transports and releases oxygen.
00:10:40.923 --> 00:10:43.982
So that's crucial for muscle contraction and endurance.
00:10:43.982 --> 00:10:46.562
If you don't have oxygen, they can't really do their job.
00:10:47.192 --> 00:11:02.793
It's also a key component in energy production or ATP production inside mitochondria because iron acts as a co-factor for enzymes in the electron transport change that produces ATP.
00:11:03.192 --> 00:11:06.903
That ATP is the body's primary energy currency.
00:11:06.903 --> 00:11:11.043
If you don't have ATP, you really can't produce much energy at all.
00:11:11.592 --> 00:11:20.562
Iron is also helpful in the production and maturation of immune cells, particularly lymphocytes, which help your body fight infections.
00:11:21.133 --> 00:11:26.322
Iron is a co-factor in enzymes for synthesizing DNA and neurotransmitters.
00:11:26.923 --> 00:11:32.982
Iron plays a role in cognitive development, memory concentration, and braiding function.
00:11:33.403 --> 00:11:41.327
And it also supports the health and tissues of hair, skin, and nails with deficiencies often leading to hair loss.
00:11:42.432 --> 00:11:46.332
Iron also assists in maintaining your normal body temperature.
00:11:46.513 --> 00:11:56.457
So you can see if you look back up that list, a lot of those have to do probably with the impairment of T3 activity in your body cells.
00:11:57.482 --> 00:11:58.863
All right, so what is ferritin?
00:11:58.863 --> 00:12:00.332
I mentioned that in the story.
00:12:00.602 --> 00:12:04.173
So ferritin is the protein that stores your iron.
00:12:04.173 --> 00:12:10.712
Your reserve serum iron is the small amount that's circulating in your bloodstream at any moment.
00:12:11.163 --> 00:12:29.082
Hemoglobin, the oxygen carrying iron containing protein and red blood cell tests and indexes reflect whether iron deficiency has progressed far enough to affect blood production, but you now know that blood production is really not the only use iron has in your body.
00:12:29.947 --> 00:12:34.207
Ferritin drops really early when iron absorption gets impaired.
00:12:34.538 --> 00:12:55.898
So blood counts and iron levels can look normal for months or even years before hemoglobin shows up low, which is why people can feel awful long before they're told their anemic Vitamin D deficiency often travels alongside iron deficiency for the same reason, which is damaged absorption in the gut.
00:12:56.437 --> 00:13:03.187
This is why some patients develop iron and vitamin D deficiencies before their TSH even looks abnormal.
00:13:03.638 --> 00:13:04.177
And why?
00:13:04.177 --> 00:13:09.967
Simply replacing nutrients without addressing the underlying cause may only temporarily help.
00:13:10.418 --> 00:13:18.128
I'm gonna come back another day and discuss vitamin D'cause today I really wanna focus and stay focused on the iron issue right now.
00:13:19.177 --> 00:13:32.854
But if B12 deficiency is also present that causes body inflammation and it can make your ferritin look elevated or normal when the other labs actually have already started to show an iron deficiency.
00:13:33.153 --> 00:13:44.403
So this is because ferritin is also an acute phase reactant, and what that means is that it rises in the presence of inflammation in your body.
00:13:44.974 --> 00:13:57.423
So B12 is another nutrient that's critical for red blood cell production among other things, and can also be malabsorbed when thyroid function is low, or for other reasons.
00:13:57.874 --> 00:14:23.774
This is why I test iron and the TIBC, that's the total iron binding capacity and transferrin or iron saturation, along with ferritin when history seems to suggest that I ought to be looking there because meaningful iron deficiency often shows up before anemia, so waiting for your hemoglobin to get low misses the window where the intervention is actually easier.
00:14:24.703 --> 00:14:41.359
Here's another thing about anemia, hematologists classify anemia whether the red blood cells are too big, they call that macrocytic from B12 deficiency or too small, Microcitic from iron deficiency.
00:14:41.538 --> 00:14:50.808
So if one or the other is noted, it's another red flag that can be seen before your blood cell count or your actual hemoglobin starts to go low.
00:14:51.019 --> 00:14:56.808
But the funny thing is, if both of them are there, then the effect might even cancel itself out.
00:14:57.168 --> 00:15:00.874
Leaving us again without this early warning sign.
00:15:02.553 --> 00:15:16.491
So ferritin screening is reasonable in patients who complain of persistent fatigue, weakness, and shortness of breath or exercise intolerance if they have hair loss, brittle nails and intolerance to cold.
00:15:17.022 --> 00:15:22.692
Restless legs is also a weird and very common symptom with iron deficiency.
00:15:23.111 --> 00:15:27.642
Also, headaches, dizziness, brain fog, Hashimoto's, autoimmune disease.
00:15:28.091 --> 00:15:46.654
Women who are still menstruating, if their periods are heavy postpartum patients who may have lost a lot of blood or patients with GI symptoms like reflux or who are on acid blocking medications or who have symptoms like IBS or known autoimmune gastritis.
00:15:47.195 --> 00:15:53.705
So that actually removes your ability to make stomach acid if you have autoimmune gastritis.
00:15:54.335 --> 00:16:07.985
Anybody who has hypothyroid symptoms persisting despite a normal TSH, the failure of your TSH to drop into the normal range with thyroid medicine or other poor response to thyroid hormone therapy.
00:16:08.705 --> 00:16:15.274
People who have any of those should probably be screened for a ferritin and iron studies test.
00:16:15.995 --> 00:16:17.825
Alright, let's talk about the lab ranges.
00:16:18.215 --> 00:16:21.154
So when you get a ferritin test, what should it normally be?
00:16:21.674 --> 00:16:29.289
The reference range for ferritin in women is 13 to 150, and for men it's about 30 to 400.
00:16:30.039 --> 00:16:42.899
So when the reference ranges for ferritin were decided the testing labs did not exclude all people with that list of symptoms and conditions above that I just listed to you, they excluded just people with.
00:16:43.414 --> 00:16:46.384
Definitive diagnosis of iron deficiency or anemia.
00:16:46.865 --> 00:16:54.725
This means that the published reference range is probably way too broad, especially when it comes to Hashimoto's or hypothyroidism.
00:16:55.355 --> 00:17:09.160
So the AFP, the American Association of Family Practice doctors, their large primary care medical society has recently changed its recommendation for ferritin to a minimum number of 45.
00:17:09.250 --> 00:17:12.579
And that's for healthy people in symptomatic patients.
00:17:12.579 --> 00:17:17.710
Some specialty societies are now targeting an ideal level of 70 to 80.
00:17:18.122 --> 00:17:18.902
And that's women.
00:17:19.622 --> 00:17:23.882
So before you start taking an iron supplement, there's a couple of things you ought to know.
00:17:24.451 --> 00:17:28.886
First, iron toxicity is a thing and it is no joke.
00:17:29.247 --> 00:17:37.406
High levels of iron deposit themselves in your body tissues causing oxidative stress, and that's the same as inflammation.
00:17:37.946 --> 00:17:44.457
Oxidative stress can damage key organs, including the liver, the heart, pancreas, and the endocrine glands.
00:17:45.017 --> 00:17:45.737
Like thyroid.
00:17:46.307 --> 00:17:46.936
Oh wow.
00:17:47.336 --> 00:17:58.406
Symptoms vary in duration and severity and range from fatigue and joint pain to life threatening complications such as cirrhosis or cardiomyopathy or hepatic failure.
00:17:58.436 --> 00:18:00.747
We're still talking about iron toxicity here.
00:18:01.166 --> 00:18:06.537
So iron supplementation should always happen under the guidance of a physician.
00:18:07.737 --> 00:18:13.777
Second, there are several factors that can make taking an iron supplement a lot less useful.
00:18:14.547 --> 00:18:32.201
The first one is a pretty new finding, like anything toxic that we can ingest from our environment, our bodies have evolved a way to block iron in case of overdose, and there's a peptide, it's called hepcidin, and it's the regulator of iron absorption into our bodies.
00:18:32.412 --> 00:18:44.342
So when we take an iron pill, it hits our digestion all at once, and hepcidin ramps up and degrades the iron transport protein, which is called ferroportin.
00:18:44.791 --> 00:18:53.342
And ferroportin stays degraded for about 24 hours, and that blocks the absorption of iron for that period of time.
00:18:53.582 --> 00:18:58.501
So if you're taking an iron supplement, it seems to work better to take it every other day.
00:18:58.846 --> 00:19:01.007
Better than taking it every day.
00:19:01.277 --> 00:19:01.906
Go figure.
00:19:01.957 --> 00:19:04.267
The second factor is competition.
00:19:04.626 --> 00:19:22.567
If you're taking your iron in a multivitamin or with other minerals like calcium, or even with high calcium foods like dairy, they compete with your iron for the transport proteins that absorb the iron, both from vegetable and animal sources, it can cut the absorption by half.
00:19:23.376 --> 00:19:33.301
A third factor that can block the absorption of iron and other minerals, if you are making a big effort to eat healthy is something called phytates.
00:19:33.721 --> 00:19:52.652
Phytates, or phytic acid, is a chemical that's in whole grains, nuts, seeds, and legumes that can act as a potent binder of iron and inhibitor of iron and other mineral absorption because it binds to vegetable source, iron in the digestive tract rendering it.
00:19:53.376 --> 00:19:55.567
Insoluble and poorly absorbed.
00:19:55.866 --> 00:20:05.946
So high consumption of unrefined grains can significantly decrease the bioavailability of the iron that you're taking and contribute to iron deficiency anemia.
00:20:06.846 --> 00:20:29.150
Phytic acid is a storage molecule in grains and other plant foods, and it has the affinity to bind or chelate zinc, iron, magnesium, calcium, potassium, manganese, and copper, and even small amounts of phytate can inhibit the absorption.
00:20:30.049 --> 00:20:36.470
So these high phytate diets, it's about 23% of non-heme iron absorption.
00:20:36.740 --> 00:20:44.180
So if you're eating your minerals with your whole plant-based proteins, they are not gonna generally be as available for absorption.
00:20:44.569 --> 00:20:46.490
But there is a way to counteract this problem.
00:20:46.490 --> 00:20:47.329
There's several ways.
00:20:48.380 --> 00:20:51.019
You can do this with food preparation.
00:20:51.619 --> 00:21:01.339
So soaking or sprouting of grains and seeds and legumes activates enzyme that break down the phytic acid or phytate.
00:21:01.849 --> 00:21:18.470
Molecule fermentation like sourdough specifically breaks down phytic acid during bread making, and in my opinion, a much easier way is to add vitamin C or ascorbic acid from citrus or berries or peppers.
00:21:18.859 --> 00:21:28.759
This reverses the inhibition caused by phytic acid or phytates, so my favorite iron supplements also have vitamin C included in the tablet.
00:21:28.984 --> 00:21:30.424
So that's a great thing.
00:21:31.444 --> 00:21:31.714
All right.
00:21:32.313 --> 00:21:44.432
So say your doctor found low ferritin on your lab test and you feel awful and things aren't getting any better, even though you've been following all these recommendations above and taking an iron supplement, what's the next step?
00:21:44.623 --> 00:21:50.022
An iron infusion usually given by a hematologist or at an infusion center.
00:21:50.087 --> 00:22:06.228
Could be the answer if your ferritin stays really low despite adequate oral supplementation, or if you're having really bad GI side effects, and it makes it hard to keep taking the iron supplement, or if there's ongoing blood loss like.
00:22:06.702 --> 00:22:08.593
Heavy menstrual cycles.
00:22:09.282 --> 00:22:18.333
I also need to be putting in a plug for early colon cancer screening here because it is one of the biggest causes of unrecognized blood loss in adults.
00:22:19.272 --> 00:22:28.192
If you have severe symptoms and your ferritin is below 20, you might need an iron infusion to get things started.
00:22:28.823 --> 00:22:48.042
Also, if you need, for any reason to get your iron levels up faster than you're getting them with an oral iron supplement, like you're significantly weak or you're having significant shortness of breath and low blood oxygen levels or if you have very low stomach acid or gut inflammation.
00:22:48.492 --> 00:22:55.303
And then the last one is if you have a known or suspected autoimmune gastritis or celiac disease.
00:22:56.413 --> 00:23:04.272
All right, so one reason why iron deficiency is so common in Hashimoto's is not just random.
00:23:04.663 --> 00:23:05.982
It's not just bad luck.
00:23:06.403 --> 00:23:11.442
Hashimoto's, of course, is an autoimmune condition and autoimmune diseases cluster.
00:23:11.833 --> 00:23:25.123
So once your immune tolerance is disrupted and the immune system begins targeting your body tissues, your self tissue, the likelihood of having or developing additional autoimmune conditions really goes up.
00:23:25.633 --> 00:23:39.883
That means that people with Hashimoto's are more likely to develop other immune mediated conditions that can affect lots of things, but particularly today we're talking about digestion and absorption and vice versa.
00:23:40.363 --> 00:23:44.323
So one of the most common is autoimmune gastritis.
00:23:44.373 --> 00:23:51.633
Autoimmune gastritis overlap with Hashimoto's disease has been discussed to be between 10 and 40%.
00:23:52.022 --> 00:23:52.893
40%.
00:23:52.893 --> 00:23:53.492
That's huge.
00:23:54.093 --> 00:24:00.663
So in autoimmune gastritis, your immune system attacks specific cells in your stomach lining called parietal cells.
00:24:00.903 --> 00:24:08.702
And when these cells are destroyed, you lose your ability to produce stomach acid and also another molecule called intrinsic factor.
00:24:09.093 --> 00:24:13.472
An intrinsic factor is required to absorb vitamin B12.
00:24:14.163 --> 00:24:21.813
Stomach acid is essential for iron absorption, so without it iron, even from meat, may not be absorbed efficiently.
00:24:22.053 --> 00:24:26.823
So patients can take an oral iron faithfully and never see their ferritin rise up.
00:24:27.722 --> 00:24:35.492
Over time, if you lose completely, lose your intrinsic factor production, you can't absorb B12.
00:24:36.377 --> 00:24:51.887
This can eventually lead to pernicious anemia, and that's an autoimmune B12 deficiency state characterized by macrocytic anemia, meaning your blood cells are too large, neurologic symptoms, numbness, tingling, memory issues, and mood disturbances.
00:24:52.008 --> 00:24:53.508
It's a pretty severe issue.
00:24:54.288 --> 00:24:56.807
The progression is really slow.
00:24:57.117 --> 00:25:02.548
First, the iron deficiency shows up, then the low B12, and then the anemia probably comes later.
00:25:02.938 --> 00:25:07.768
But the neurologic symptoms can come before obvious lab abnormalities.
00:25:08.248 --> 00:25:20.643
So diagnosis typically involves checking antibodies to parietal cell tissue and intrinsic factor antibodies along with gastro levels and B12 levels.
00:25:20.972 --> 00:25:31.833
In some cases you might have an upper endoscopy to assess your stomach lining, but it has to occur to your doctor to look before these very specific tests are gonna get ordered.
00:25:32.307 --> 00:25:41.011
Another major failure of iron metabolism is caused by celiac disease and celiac's kind of rare globally.
00:25:41.011 --> 00:25:45.301
About 1% of the population has biopsy confirmed celiac disease.
00:25:45.721 --> 00:25:52.592
However, if you already have autoimmune thyroid disease, the prevalence is between two and 6%.
00:25:52.951 --> 00:25:54.122
That may not sound dramatic, but.
00:25:54.537 --> 00:25:59.906
Represents a meaningful increase over baseline, especially when the symptoms are there.
00:26:00.686 --> 00:26:05.366
Celiac disease is a permanent immune mediated reaction to gluten.
00:26:05.906 --> 00:26:30.044
Gluten is a protein that's found in wheat, barley, and rye in these genetically susceptible in individuals carry gene markers called HLAD Q2 or H-L-A-D-Q eight, and when they consume gluten, the immune system mounts an inflammatory attack that specifically damages the lining of the proximal small intestine.
00:26:30.044 --> 00:26:34.848
That means the upper part, the first part, where all the nutrient absorption is supposed to be happening.
00:26:35.355 --> 00:26:37.752
Specifically, it damages the vii.
00:26:37.752 --> 00:26:50.292
These are those tiny little finger-like projections responsible for absorbing all the nutrients when those VII are flame inflamed or flattened or damaged, nutrient absorption declines.
00:26:50.833 --> 00:26:59.952
This matters enormously because iron and vitamins and other critical nutrients are absorbed exactly there in that region of the small intestine.
00:27:00.702 --> 00:27:04.603
And here's the part that gets missed a lot.
00:27:04.932 --> 00:27:09.432
Many people with celiac disease don't have obvious digestive symptoms.
00:27:09.942 --> 00:27:12.897
They may not have diarrhea or weight loss or abdominal pain.
00:27:13.442 --> 00:27:23.792
Instead, the very first sign could be low ferritin with fatigue and hair loss and weakness, and shortness of breath with exertion and brain fog or cold intolerance.
00:27:24.093 --> 00:27:29.553
Symptoms that look exactly like hypothyroidism, but are pretty common in low iron levels.
00:27:30.468 --> 00:27:38.897
These people can often commonly have headaches, restless leg syndromes, neuropathies, bone loss, or diffuse itchiness.
00:27:39.018 --> 00:27:44.262
Some people develop dermatitis herpetiformis, which is a blistery rash.
00:27:44.262 --> 00:27:45.613
That's intensely issue.
00:27:45.972 --> 00:27:49.063
That is actually a skin manifestation of celiac disease.
00:27:49.843 --> 00:27:58.663
And iron deficiency is often the first clue because the iron stores are so dependent on absorption from that particular part of your small intestine.
00:27:59.113 --> 00:28:06.813
Ferritin drops early and if it isn't suspected, patients are gonna continue to feel worse and worse while being told their labs are fine.
00:28:07.237 --> 00:28:13.218
Here's the thing about this, if you have Hashimoto's and you've been told, oh, you need to stop eating gluten.
00:28:13.938 --> 00:28:20.748
If you are off gluten, completely off gluten, and they go to do celiac testing on you, the testing can be normal.
00:28:21.278 --> 00:28:26.738
Testing can show nothing and then you get this complacent,"oh, I can have a little gluten every now and then." No.
00:28:27.082 --> 00:28:36.201
It's really if you're gonna decide,"Hey, I'm gonna stop eating gluten", it is really a good idea to get a celiac test, at least a ferritin test.
00:28:36.442 --> 00:28:41.991
Get that ferritin test early, and go ahead and get the celiac testing if your ferritin is already low.
00:28:43.132 --> 00:28:49.041
Vitamin D deficiency often travels alongside iron deficiency for the exact same reason.
00:28:49.071 --> 00:28:50.541
It's fat ab soluble.
00:28:50.541 --> 00:29:00.801
It's absorbed right there in the small intestine, and low vitamin D worsens immune dysregulation, which increases the risk for developing even more autoimmune diseases.
00:29:01.071 --> 00:29:06.878
It also contributes to bone loss and amplifies pain, muscle weakness and fatigue.
00:29:07.598 --> 00:29:15.759
So when you see low ferritin and low vitamin D and persistent fatigue in a patient with Hashimoto's, it's a pattern that we gotta pay attention to.
00:29:16.868 --> 00:29:18.939
Alright, so I mentioned diagnosing celiac.
00:29:19.269 --> 00:29:20.138
How do we do that?
00:29:20.798 --> 00:29:30.519
Proper diagnosis of celiac disease requires that a patient be eating gluten for several days at the time of testing and not just a few bites.
00:29:31.028 --> 00:29:39.999
Screening typically begins with blood tests, which are tissue transglutaminase, IGA, and a total IGA level.
00:29:40.118 --> 00:29:41.259
Those are the first two.
00:29:41.648 --> 00:29:42.824
If those are positive.
00:29:43.338 --> 00:29:50.298
Adult diagnosis generally requires confirmation with an upper GI endoscopy and small bowel biopsies.
00:29:50.598 --> 00:29:56.929
And if you've been eating gluten, when you go in to your upper GI endoscopy, they may find it.
00:29:56.959 --> 00:30:03.798
If you have been avoiding gluten, they may not find it because the damage can be healed.
00:30:04.314 --> 00:30:08.183
Although it'll come right back once you eat the gluten again.
00:30:09.023 --> 00:30:17.574
For more specific confirmatory blood tests, we can use the endometrial antibody EMA-IGA test.
00:30:18.233 --> 00:30:25.134
Highly specific for celiac disease and often used to confirm a positive tissue transglutaminase result.
00:30:25.763 --> 00:30:31.034
There are also two more called DGPIGA and DGPIGG.
00:30:31.084 --> 00:30:44.463
DGP stands for Deamidated Gliadin Peptide, and it's used as an alternate test, particularly in children under two, or for people who have an IGA deficiency.
00:30:45.273 --> 00:30:57.213
We can also test for those genetic markers that I mentioned, the HLAD Q2 or HLADQ-8, although those just suggest the tendency for celiac, not the actual disease.
00:30:57.933 --> 00:31:01.023
So treatment of celiac is very simple.
00:31:01.203 --> 00:31:15.054
Strict, lifelong elimination of gluten, not an option, not a sensitivity, where mostly gluten-free is okay, and even small exposures can continue to drive immune activation and intestinal injury.
00:31:15.473 --> 00:31:30.594
And this means even cross-contamination like shared toasters, cutting boards, restaurant fires, sauces and seasonings that contain even a trace of gluten can prevent healing even when somebody believes that they're being careful.
00:31:31.193 --> 00:31:35.153
So symptom improvement does not necessarily equal intestinal healing.
00:31:35.723 --> 00:31:38.203
So who are we gonna screen for celiac?
00:31:38.713 --> 00:32:02.811
In thyroid patients, we should consider screening if iron deficiency is there and it persists and stays low despite supplementation, or if your vitamin D was very low and remains low despite supplementation, if the fatigue is still unexplained or if restless legs are present, or if your brain fog continues despite your thyroid levels looking optimal.
00:32:03.237 --> 00:32:09.416
Or if there's autoimmune clustering or a family history of autoimmune disease.
00:32:09.926 --> 00:32:13.826
So ferritin thresholds also deserve attention.
00:32:14.186 --> 00:32:21.176
So traditionally, a ferritin below 15 was considered deficient, but that's really a very late stage deficiency.
00:32:21.176 --> 00:32:28.707
So increasingly, ferritin levels below 45 are recognized as deficient in patients who have symptoms.
00:32:29.186 --> 00:32:55.717
Failure of oral iron supplementation should definitely trigger workup for celiac, and an iron infusion really ought to be considered when ferritin stays low despite adequate supplementation or if symptoms are severe or if ferritin is below 20, or if malabsorption is confirmed and infusion bypasses your gut and in the right patient can be really transformative symptom-wise.
00:32:57.241 --> 00:32:57.571
Woo.
00:32:57.571 --> 00:32:58.321
That's a lot.
00:32:58.321 --> 00:33:09.392
So to wrap up for today, if you have hypothyroid symptoms and they are not resolving, and your TSH isn't normalizing, the thyroid may not be the whole story or even the main story.
00:33:09.842 --> 00:33:33.061
So when iron or other nutrient levels refuse to normalize, despite supplementation, it is worth asking why celiac disease and autoimmune gastritis are not rare in autoimmune thyroid patients, and both can silently drive fatigue, cognitive dysfunction, hair loss, weakness, and poor response to thyroid treatment in general.
00:33:33.571 --> 00:33:36.842
So sometimes the problem is not your thyroid medication dose.
00:33:37.082 --> 00:33:47.912
Sometimes the problem is that the thyroid signaling is not being addressed, and sometimes the immune system is a bigger story than you originally understood.
00:33:48.481 --> 00:33:59.491
So iron deficiency is common autoimmune diseases, cluster celiac disease is more common in Hashimoto's patients and malabsorption can undermine your recovery.
00:33:59.866 --> 00:34:02.717
Long before anybody connects the dots.
00:34:03.136 --> 00:34:09.157
So when you address the malabsorption, the entire clinical picture begins to make sense.
00:34:10.088 --> 00:34:10.748
Woo.
00:34:11.018 --> 00:34:12.307
That's all for today.
00:34:12.398 --> 00:34:22.811
Thank you for listening to Beyond the Thyroid and if you are looking for a doctor to help you manage your thyroid disease, then come and check me out.
00:34:22.811 --> 00:34:29.561
My website is danagibbsmd.com, and you can check on a free discovery call right now.
00:34:29.561 --> 00:34:35.981
Today I am planning at the end of April to raise the prices for comprehensive thyroid workup.
00:34:36.280 --> 00:34:39.400
So I'm taking four more new patients before then.
00:34:39.731 --> 00:34:45.771
If you want to get in on the current pricing, then make your discovery call today.
00:34:45.800 --> 00:34:47.150
Thanks for listening.
00:34:47.271 --> 00:34:47.570
Bye.
00:34:55.469 --> 00:34:58.409
Thank you for listening to this episode of Beyond the Thyroid.
00:34:58.775 --> 00:35:05.324
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00:35:05.724 --> 00:35:10.425
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00:35:29.519 --> 00:35:39.440
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00:35:39.650 --> 00:35:39.809
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00:35:40.460 --> 00:35:40.579
com.
00:35:42.284 --> 00:35:47.625
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00:35:48.005 --> 00:35:53.985
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00:35:54.425 --> 00:36:01.994
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00:36:02.804 --> 00:36:06.655
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