Graves' disease is an autoimmune disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Although the condition is rooted in a malfunctioning immune system, A Functional Medicine Approach to Graves disease can help alleviate common symptoms associated with this disorder.
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CC: Anxiety, Insomnia, Acid reflux, Bloating, Hyperthyroidism, and Graves Disease Thyroiditis
40-year-old female Angela presented with a recent Grave's 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 suffering from extremely high levels of anxiety, insomnia, hair loss, extreme body heat, rapid weight gain and loss of 20 pounds, irregular menses, and diffusely enlarged thyroid.
Upon initial visit, digestive history was revealed for the last two years. The patient was suffering from persistent bloating upon waking and symptoms of acid reflux, both of which were heavily triggered by any food intake.
Patient History
Patients' diet at the time was limited as most food consumption triggered painful 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 patients' symptoms were brassica vegetables, potatoes, corn, dairy, and large quantities of lentils and beans.
She had very strong sugar cravings at night but avoided eating past 5 pm to prevent painful 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 recommended to the patient with the intention of challenging and reintroducing foods back in once her thyroid numbers stabilized. Foods to avoid are gluten, dairy, eggs, sugar, alcohol, soy, citrus, nuts/seeds, nightshades (tomatoes, peppers, cayenne, paprika, chili flakes), chocolate/caffeine, white potatoes.
She was asked to drink ½- 1 cup bone broth daily to support protein intake and support healing of 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 nutrient intake.
Pre and probiotic foods were recommended daily while awaiting results of the stool panel.
Lifestyle factors were also reviewed with the patient to support lymphatic drainage 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 told 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 recommended a 100 mg capsule of L theanine (Integrative Therapeutics) 3 times daily to help reduce stress response and improve feelings of relaxation and improve sleep.
The patient was given Melissa officinalis /Lemon Balm glycerite (Wise Woman Herbals) 1 full dropper 2x daily to help reduce overactive thyroid. 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 entirely independent 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 destruction.
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, eliminating these strains is essential to improving patients' chief complaints.
Interventions
Due to high bacterial and parasitic strain levels, liver support was given 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 reduce pro-inflammatory cytokines and increase secretory IgA levels.
The following extensive diet work was done as the patient is highly compliant with diet recommendations:
- Due to the parasitic action of pumpkin seeds, eat up to one cup of pumpkin seeds a day as a whole, blended or floured form.
- Garlic and onions – immune-boosting vegetables with anti-parasitic effects due to the sulfur compounds and antioxidants that destroy pathogenic organisms.
- Herbs – like oregano, turmeric, and ginger, have antibacterial and anti-parasitic effects.
- Pineapple, papaya, and their juices contain compounds that can help decrease the production of pro-inflammatory cytokines that result in colon inflammation. Their juices can also have anti-parasitic effects.
- Low sugar fruit one servings max daily- blueberries, blackberries, raspberries.
- Coconut oil – due to antibacterial and anti-microbial properties.
- Probiotic-rich/fermented foods– to keep parasites in check and improve the health of the gut microbiome.
- Apple cider vinegar helps restore healthy pH balance and support 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 feeling 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 dramatically 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 told 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 patients' grave disease will need addressing if patients 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 excellent 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 treat to support her ongoing autoimmune disease.
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