Thyroid Health Strategies for Adolescents with Hashimoto's and Hypothyroidism

Pediatric thyroid disorders, which are among the most common endocrine disorders in children, are a group of thyroid diseases, including hypothyroidism, hyperthyroidism, thyroid nodules, cancer, and goiter. Hypothyroidism accounts for nearly 90% of pediatric thyroid disorders. (20) 

Effectively managing hypothyroidism in the adolescent population is of paramount importance due to the significant impact thyroid function has on overall health, growth, and development during this critical stage of life. Implementing effective strategies becomes crucial for alleviating symptoms, optimizing thyroid function, and empowering adolescents with the knowledge and tools necessary to actively participate in their well-being. This article explores key strategies encompassing dietary considerations, lifestyle modifications, regular monitoring, and education to promote optimal thyroid health outcomes in adolescents.

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Understanding Hashimoto's and Hypothyroidism in Adolescents 

The thyroid gland is located in the neck. It synthesizes thyroid hormones, thyroxine (T4) and triiodothyronine (T3), which influence all aspects of metabolism, including heart rate, blood pressure, body temperature, digestion, cognition, growth, and development. When the thyroid gland does not produce sufficient thyroid hormone – a state called hypothyroidism – these metabolic functions slow down, leading to classic symptoms like fatigue, cold intolerance, weight gain, and constipation.

There are two types of hypothyroidism in children: congenital (present at birth) and acquired (develops after birth). One out of every 4,000 to 5,000 thousand babies born in the United States has hypothyroidism. The most common cause of acquired hypothyroidism in children and teens in the United States is Hashimoto's thyroiditis. Evidence suggests an increasing prevalence of autoimmune thyroid disease in people less than 22 years old. Hashimoto's is an autoimmune disorder characterized by the immune system mistakenly attacking the thyroid gland, leading to insufficient production of thyroid hormone as a consequence of inflammation and damage to the thyroid. Roughly 50% of children with Hashimoto's thyroiditis have a family history of autoimmune thyroid disease. (8) 

Untreated hypothyroidism in teens has negative implications for growth and development, putting the child at risk for delayed puberty, anemia, heart failure, and neurological deficits (1, 7). The majority of children with hypothyroidism who are compliant with their medication grow and develop normally.

The Importance of Regular Thyroid Function Testing

Thyroid hormone replacement is weight- and age-based, so frequent thyroid monitoring is needed as children and teens are actively growing. Thyroid function testing evaluates various components of the hypothalamic-pituitary-thyroid (HPT) axis, a hormonal regulatory system that determines the set point for thyroid hormone production. Abnormalities within this axis indicate a hormonal imbalance. Before discussing the tests used to measure thyroid function, we must first understand the HPT axis and the indications for thyroid tests.

What Is the HPT Axis?

The HPT axis regulates the production and release of thyroid hormones. This axis involves the interaction between the hypothalamus, pituitary gland, and the thyroid gland, working in a coordinated manner to maintain thyroid hormone homeostasis.

The process begins with the hypothalamus, which releases thyrotropin-releasing hormone (TRH) in response to signals indicating a need for thyroid hormone adjustment. TRH then stimulates the pituitary gland to release thyroid-stimulating hormone (TSH). TSH, in turn, acts on the thyroid gland to stimulate the synthesis and secretion of thyroid hormones, primarily T4 and T3. (21) 

The negative feedback loop is a fundamental mechanism within the HPT axis that helps maintain balance. As thyroid hormone levels rise in the bloodstream, they exert a feedback effect on the hypothalamus and pituitary gland, inhibiting the release of TRH and TSH, respectively. This negative feedback loop is essential for preventing excessive production of thyroid hormones. Conversely, if thyroid hormone levels drop, the lack of inhibition allows the hypothalamus to release more TRH, stimulating the pituitary gland to release TSH. This increased TSH prompts the thyroid gland to produce and release more thyroid hormones, restoring balance. Disruptions in this axis lead to imbalances in thyroid hormone levels and subsequent health issues. (26) 

Indications for Thyroid Function Testing

Thyroid function testing is warranted in adolescents when symptoms suggestive of hypothyroidism are present. These symptoms may include unexplained fatigue, weight gain, constipation, cold intolerance, depression, and disruptions in menstrual cycles for females. 

Screening adolescents with a family history of thyroid disease is another indication for thyroid function testing. Family history can increase the likelihood of genetic predisposition to thyroid disorders, necessitating early detection and intervention. 

Clinical guidelines recommend thyroid function testing in teens with a personal history of diagnosed hypothyroidism to monitor treatment effectiveness and hormone levels. Regular assessments help healthcare providers tailor hormone replacement therapy, ensuring that thyroid levels remain within the optimal range. Thyroid function testing is recommended annually for stable patients and more frequently for patients who are symptomatic or have recently modified their thyroid replacement dose. 

Thyroid Function Tests

TSH is the standard, first-line screening test for thyroid function. Elevated TSH indicates a hypothyroid state, whereas depressed levels indicate a hyperthyroid (or overmedicated) state. Standard screening algorithms recommend using TSH as a standalone test and only using other thyroid markers if TSH is abnormal. However, research indicates that TSH can miss up to 7% of hypothyroid cases. This is why functional medicine doctors usually always measure TSH with free T4 and free T3. 

Free T4 and free T3 measure the unbound portions of thyroid hormones in circulation, free to enter cells and exert their physiological actions. Free T4 and free T3 represent endogenous (i.e., made by the thyroid) and exogenous (i.e., medication) hormones. Low levels indicate insufficient amounts of circulating hormone, whereas elevated levels indicate an excess in circulation. 

Thyroid antibody tests, including anti-thyroid peroxidase (TPO) and anti-thyroglobulin (TG) antibodies, help confirm the diagnosis of Hashimoto's thyroiditis. Elevated levels of these antibodies indicate autoimmune thyroid disease and provide insight into the underlying cause of hypothyroidism.

All five of these thyroid markers can be ordered together on a comprehensive thyroid panel, such as the one offered by Access Medical Laboratories. 

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The Role of Diet in Managing Thyroid Health for Adolescents 

Following a well-balanced, nutritious diet can help improve thyroid function and hypothyroid symptoms by ensuring adequate intake of key nutrients required to manufacture thyroid hormones, including vitamins A, Bs, C, D, and E, iron, iodine, magnesium, selenium, zinc, and tyrosine. Consuming a variety of nutrient-dense foods, including fruits, vegetables, whole grains, and lean proteins, ensures that the body receives essential vitamins and minerals necessary for proper thyroid function. Additionally, antioxidants found in fruits and vegetables can help reduce inflammation, which is particularly relevant in autoimmune conditions like Hashimoto's thyroiditis. A 2022 review that aimed to evaluate the link between food intake and thyroid disorders found that patients with Hashimoto's thyroiditis more frequently consumed processed foods and animal fat compared to healthy controls. The researchers of this study concluded that a Mediterranean-like diet, characterized by a high intake of plant-based foods and fish, may play a beneficial role in preventing thyroid disease. (19, 23)

Supplements and Herbal Remedies

The use of supplements and herbal remedies for thyroid health in adolescents with hypothyroidism should be administered under the guidance of healthcare professionals. 

Iodine

In areas where iodine deficiency is prevalent, iodine supplementation may be considered. However, it is important to recognize that too much iodine can inhibit thyroid gland hormone synthesis. In a prospective cohort study conducted in China, the incidence of autoimmune thyroiditis was significantly higher in individuals with excessive iodine intake than in those with mildly deficiency iodine intake. 

The primary food sources of iodine in the United States are dairy products, seafood, and eggs. The recommended daily allowance (RDA) for iodine for males and females ages 14-18 is 150 mcg. Depending on the patient's iodine status, a healthcare professional should guide any additional iodine supplementation to ensure a safe and effective dosing regimen.

Selenium

Selenium is an integral component of a family of proteins called selenoproteins. Regarding thyroid health, two selenoproteins are particularly important: deiodinases and glutathione peroxidase. Deiodinases are enzymes responsible for converting T4 to T3 and regulating the availability of active thyroid hormones in tissues. The thyroid gland is vulnerable to oxidative stress due to its high metabolic activity. Glutathione peroxidase is an antioxidant enzyme involved in neutralizing reactive oxygen species, protecting the thyroid gland from oxidative damage. (37) 

Research suggests that selenium deficiency may be linked to an increased risk of thyroid disorders. Additional research shows that supplementation with 200 mcg of selenium daily significantly reduces TPO antibodies. 

Vitamin D

Over one billion people worldwide are estimated to have vitamin D deficiency or insufficiency. Low vitamin D levels have been associated with hypothyroidism and autoimmune thyroid disease. The proposed mechanisms behind this correlation are poor intestinal absorption and improper vitamin D activation. Vitamin D deficiency can contribute to the musculoskeletal symptoms experienced by patients with hypothyroidism. (41) 

If optimal vitamin D status cannot be achieved through exposure to sunshine, then vitamin D supplementation is required. Administering vitamin D to patients with hypothyroidism has been shown to improve TSH and thyroid antibody levels. 

Adaptogenic Herbs

The body releases cortisol as a compensatory mechanism in stress states. While cortisol fulfills many functions the body requires, it can negatively impact thyroid function. Cortisol suppresses the release of TRH and TSH and impairs the conversion of T4 into T3, resulting in decreased total thyroid hormone and suboptimal levels of active thyroid hormone in circulation.

Adaptogenic herbs help the body adapt to stress by modulating the neuroendocrine system involved in cortisol secretion. Ashwagandha, for example, reduces morning cortisol levels and prevents oxidative stress within the thyroid gland. Administering 300 mg of ashwagandha root extract twice daily to patients with subclinical hypothyroidism for eight weeks resulted in measurable increases in T4 and T3 and significant reductions in TSH.  

Lifestyle Modifications for Thyroid Health for Adolescents

Establishing healthy lifestyle habits is a very important aspect of encouraging and maintaining healthy thyroid function. Poor sleep, a sedentary lifestyle, high stress, and an inflammatory diet negatively affect thyroid health. Fortunately, the opposite rings true – sufficient sleep, regular physical activity, managing stress, and eating a balanced diet (discussed above) result in positive thyroid-associated clinical outcomes. 

Sleep deprivation alters the HPT axis and is associated with altered levels of TSH, T4, and T3. A correlation has been made between poor sleep quality and subclinical hypothyroidism. (31) Insufficient sleep is associated with increased cortisol secretion and higher levels of perceived stress. The American Academy of Sleep Medicine recommends that teenagers ages 13-18 sleep 8-10 hours per 24 hours. However, a 2015 national survey showed that 72.7% of high school students sleep less than eight hours on school nights. (39) 

A 2019 study assessing the effects of an aerobic exercise program on the plasma concentrations of thyroid hormones in adolescents concluded that 30-45 minutes of aerobic exercise three times weekly significantly decreased TSH and significantly increased T3 and T4 after 16 weeks. The CDC recommends that children and adolescents ages 6-17 participate in at least 60 minutes of moderate-to-vigorous physical activity daily.

Teens express significantly elevated stress levels during the school year, surpassing what they consider healthy and exceeding the reported stress levels of adults. Even during the summer, teens report stress levels above their perceived healthy threshold. Chronic stress can interfere with sleep and lead to cortisol imbalances, which, as discussed previously, negatively impact thyroid function. Educating teens about stress management techniques, including biofeedback and mediation, equips them with powerful tools to reorient to stressful triggers and modulate the body's stress response.

Addressing Autoimmune Aspects of Hashimoto's

A functional medicine approach to Hashimoto's thyroiditis differs slightly from that for non-autoimmune hypothyroidism in that it must address the underlying triggers for autoimmunity. The etiology of Hashimoto's is multifactorial, including genetic predisposition, infections, intestinal permeability, and exposure to environmental toxins. To effectively dampen the hyperstimulation of the immune system and restore self-tolerance, the root causes of autoimmunity must be identified and corrected. (12, 45)

Some of the effective adjunctive therapies specific to Hashimoto's thyroiditis, such as vitamin D and selenium, have already been discussed. To mitigate inflammation of the thyroid gland and prevent irreversible thyroid damage, incorporating omega-3 fatty acids from sources like fish oil, flaxseeds, and walnuts, as well as integrating anti-inflammatory spices like turmeric or curcumin, can be beneficial. 

Gluten, a protein found in wheat and related grains, can trigger an immune response in individuals with celiac disease, leading to damage in the small intestine. Patients with celiac disease have a four-times increased prevalence of autoimmune thyroid disease. Even without a confirmed diagnosis of celiac disease, research suggests that gluten sensitivity may also be linked to Hashimoto's, as reductions in thyroid antibodies have been noted in individuals who have adopted a gluten-free diet. (10)

Educating Adolescents and Caregivers

The diagnosis of hypothyroidism in teens can have a significant impact not only on the affected individuals but also on their families. Understanding the implications of this condition is crucial for adolescents and their caregivers. Education is pivotal in empowering teens and their families to navigate the complexities of thyroid health, treatment adherence, and necessary lifestyle modifications. By equipping them with knowledge and resources, healthcare providers contribute to the overall success of managing hypothyroidism in the adolescent population.

It is essential to provide comprehensive information about hypothyroidism, its causes, and the importance of adhering to prescribed treatments. Clear communication on the potential impact of hypothyroidism on growth, puberty, and overall well-being helps foster awareness and proactive management. Encouraging open dialogue between healthcare providers, adolescents, and their families creates a supportive environment for addressing concerns and uncertainties. Emphasizing the collaborative nature of managing hypothyroidism and involving teens in decision-making processes regarding their treatment plan fosters a sense of autonomy and responsibility. In addition to the family unit, support mechanisms, such as peer groups or counseling services, can provide emotional and psychological assistance to teens facing the challenges of hypothyroidism. 

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Thyroid Health Strategies for Adolescents: Key Takeaways

Effectively managing thyroid health in adolescents with Hashimoto's and hypothyroidism involves a comprehensive approach that encompasses dietary considerations, lifestyle modifications, regular thyroid function testing, and education. Prioritizing a well-balanced diet with attention to thyroid-supportive nutrients while considering potential triggers like gluten can positively impact thyroid function. Lifestyle modifications, including stress management and regular exercise, contribute to overall well-being. Consistent monitoring through thyroid function tests ensures timely adjustments to treatment plans. Education empowers adolescents and their families with the knowledge to make informed decisions, adhere to prescribed treatments, and actively participate in their health.