Graves' disease is an autoimmune disorder that can lead to the overproduction of thyroid hormones (hyperthyroidism). Although the condition is related to an immune system that may not function optimally, a Functional Medicine Approach to Graves' disease may help manage common symptoms associated with this disorder.
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CC: Anxiety, Insomnia, Acid reflux, Bloating, Hyperthyroidism, and Graves Disease Thyroiditis
A 40-year-old female, Angela, presented with a recent Graves' disease diagnosis. For the last month, she had been under the care of an endocrinologist who was helping to stabilize her thyroid lab results; however, the patient was still experiencing high levels of anxiety, insomnia, hair loss, extreme body heat, rapid weight changes, irregular menses, and an enlarged thyroid.
Upon initial visit, digestive history was revealed for the last two years. The patient was experiencing persistent bloating upon waking and symptoms of acid reflux, both of which were triggered by food intake.
Patient History
The patient's diet at the time was limited as most food consumption triggered bloating and slight acid reflux symptoms.
Breakfast was coffee with creamer. Lunch was a small portion of rice, chicken, and lentils. Dinner was an avocado accompanied by a handful of rice, chicken, and lentils.
Known foods that triggered the patient's symptoms were brassica vegetables, potatoes, corn, dairy, and large quantities of lentils and beans.
She had strong sugar cravings at night but avoided eating past 5 pm to prevent bloating from affecting sleep. Bowel movements were daily, well-formed, and easy to pass. Negative for blood, mucus, and undigested food. Hydration was 9-12 8oz glasses daily; no other liquids were consumed.
The patient was a stay-at-home mom to 3 kids under the age of 10 who had immigrated to Chicago from Peru with her husband five years prior. Her father had passed away eight months ago suddenly from COVID. She could not be with him or attend his funeral due to travel restrictions. This was a great source of pain for the patient, as she was very close with her family and significantly affected by his passing.
There is no family history of thyroid disease or autoimmune conditions in her immediate family.
Interventions
An autoimmune paleo diet was suggested to the patient with the intention of challenging and reintroducing foods back in once her thyroid numbers stabilized. Foods to consider avoiding include gluten, dairy, eggs, sugar, alcohol, soy, citrus, nuts/seeds, nightshades (tomatoes, peppers, cayenne, paprika, chili flakes), chocolate/caffeine, and white potatoes.
She was encouraged to drink ½- 1 cup bone broth daily to support protein intake and potentially support her gut lining, to avoid raw vegetables to reduce demand on the digestive system, and to emphasize foods high in selenium, zinc, vitamin D, and magnesium to support thyroid health.
Pre and probiotic foods were suggested daily while awaiting results of the stool panel.
Lifestyle factors were also reviewed with the patient to support lymphatic health through skin dry brushing 3x weekly, lymphatic teas like burdock root, nettle leaf, lemon balm**(3-4 cups a day), dandelion root, green tea, and lymphatic massages. Discussed daily exercise, which the patient loved, modifying it to high intensity and early in the morning to avoid the midday heat.
The patient was also advised to begin applying alternating hot and cold compresses to the thyroid area, hot towel 3 minutes then replaced with a cold towel for one minute, done three times for the first week, then only once in the morning for another 30 days.
We discussed avoiding endocrine-disrupting toxins. She was educated on the benefits of high-quality water and air filters and opting for clean body care, makeup, and cleaning products.
For patients with a high level of anxiety, stress reduction techniques like meditation, yoga, and exercise are reviewed.
The patient was suggested a 100 mg capsule of L-theanine (Integrative Therapeutics) 3 times daily to help manage stress response and support relaxation and sleep.
The patient was given Melissa officinalis /Lemon Balm glycerite (Wise Woman Herbals) 1 full dropper 2x daily to help support thyroid health. This formula supports the immune, digestive, and nervous systems.
Lab Work
Comprehensive Stool Test Results
- Commensal Overgrowth: HIGH
- Pathogenic Overgrowth: POSITIVE for pseudomonas aeruginosa
- Pancreatic Elastase LOW
- Parasitic overgrowth: MANY DETECTED dientamoeba fragilis
- Fecal Secretory IgA: SLIGHTLY ELEVATED
Lab Analysis
Baseline labs indicate a high level of hyperthyroidism with the low TSH level indicating the thyroid was acting independently of TSH and pituitary gland control. This is consistent with the high level of autoimmune antibodies causing a high fluctuation of thyroid hormone directly into the bloodstream due to thyroid cell changes.
Iodine levels were within normal, likely unrelated to the onset of autoimmune Graves' disease.
The stool panel indicated a slight dysbiotic overgrowth, slight pathogenic bacteria overgrowth, and a high number of a single parasitic strain. Due to the inflammatory nature and increased propensity of symptoms, both autoimmune and gastrointestinal, related to parasitic overgrowth, managing these strains is essential to improving patients' chief complaints.
Interventions
Due to high bacterial and parasitic strain levels, liver support was suggested for two weeks before beginning the anti-microbial digestive protocol. Utilized Liver Cleanse (Thorne) 1 cap morning for three days, then increased to 2 caps morning and one at night.
At two weeks, the patient began a 6-week protocol of Kirkman Biofilm Defense morning and night, followed 30 minutes later by one capsule of oregano oil and one capsule of grapefruit seed extract.
After two weeks on this protocol, the patient began one nightly capsule of saccharomyces boulardii to help manage pro-inflammatory cytokines and support secretory IgA levels.
The following extensive diet work was done as the patient is highly compliant with diet recommendations:
- Due to the potential benefits of pumpkin seeds, eat up to one cup of pumpkin seeds a day as a whole, blended or floured form.
- Garlic and onions – immune-supporting vegetables with potential benefits due to the sulfur compounds and antioxidants.
- Herbs – like oregano, turmeric, and ginger, may have supportive effects.
- Pineapple, papaya, and their juices contain compounds that can help support digestive health. Their juices may also have supportive effects.
- Low sugar fruit one servings max daily- blueberries, blackberries, raspberries.
- Coconut oil – due to its supportive properties.
- Probiotic-rich/fermented foods– to help support the gut microbiome.
- Apple cider vinegar helps support healthy pH balance and HCl production in the stomach.
- Cooked fresh vegetables. Vegetables are rich sources of protective compounds that help nourish the gut, provide the fiber that encourages regular bowel movements, and feed commensal bacteria.
- Avoid pork and raw seafood – Can potentially be contaminated with parasites.
Six Week Follow Up
The patient is feeling great and only experiencing occasional acid reflux-related burning when overeating, which is happening more frequently as she has an appetite again and zero bloating and abdominal pain.
The patient did mention she was losing a lot of hair and had to cut a significant amount off as her hair was so thin.
Her anxiety has improved, with only 1 episode of anxiety noted in the last two weeks. The patient is also sleeping 7-8 hours again nightly without the need for her previous melatonin gummies, 3 mg.
She is doing daily meditation, at least 30 minutes of vigorous exercise, and spending time outside for natural vitamin D.
The patient was advised to stop all supplements except Saccharomyces boulardii and begin vitamin D3 plus K2 at 5,000 iu daily, repeat full thyroid panel and Ova/Parasite sample in 8 weeks and follow up.
Two Month Follow Up
Ova & Parasite:
NEGATIVE
Follow Up Labs
Four Month Follow Up
Genova NutraEval was run at the two-month follow-up due to the patient's thyroid lab values proving unstable, regardless of being almost symptom-free. Results showed deficiencies in the following vitamins and minerals:
- Alpha-lipoic acid
- Riboflavin
- Pyridoxine
- Biotin
- Folate
- Cobalamin
- Vitamin C
- Glutathione
- Plant-Based antioxidants
- All nutritionally essential amino acids except valine
Interventions
- Direct Supplementation of alpha-lipoic acid, liposomal glutathione, and pre-methylated stress B complex was provided, while high vitamin C foods were recommended.
- Meat and plant-based protein sources and target protein amount reviewed with the patient- 20 grams per meal for a total of 60 grams daily.
- Patient continued the paleo diet while beginning to challenge previously eliminated foods on an autoimmune paleo diet, like nuts and seeds, gluten-free grains like quinoa and amaranth, citrus, lastly, challenging nightshades.
- She continues with a gluten-free, dairy-free, sugar-free, alcohol-free diet until autoimmune levels drop- as monitored by the endocrinologist.
6 Month Follow Up
The patient continues to see improvements with her anxiety level staying low and manageable, sleep consistent and restful, and overall digestion is doing well. Her weight is stable, and she has no longer noticed massive hair loss, but hair growth is very slow.
She has noticed only minimal symptoms of acid reflux returning when overeating plantain or cassava chips or if she skips a meal during the day. She continues to reintroduce more foods without symptoms returning. She is getting labs drawn at the end of the month to look at a complete thyroid panel, including thyroid antibodies.
Summary
The patient is due to return with her follow-up thyroid and antibody labs to determine the efficacy of treatment from a lab standpoint. However, her reduction in hyperthyroid-related symptoms and improved gastrointestinal health is the goal of a successful treatment.
The autoimmune component of the patient's Graves' disease will need addressing if pending autoimmune thyroid labs do not improve after six months of a dedicated anti-inflammatory diet and anti-microbial protocol.
Looking into other potential sources of immune system triggers like heavy metals, environmental toxins, mold/mycotoxin exposure, and repeating micronutrient and stool panels to ensure systems optimized should help provide a path to ongoing care.
This case was an example of how underlying parasitic and pathogenic overgrowth can disrupt the microbiome, leading to dysbiosis and inflammation within the intestinal tract. This patient's connection between her gut health and immune system activation was essential to address to support her ongoing autoimmune disease.
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