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Approaches to Thyroid Health with Natalie Douglas

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Approaches to Thyroid Health with Natalie Douglas

What are some approaches practitioners can use to optimise thyroid function in patients with an underactive thyroid or autoimmune thyroid condition?

Nutritionist and Dietician Natalie Douglas returns to FX Medicine to discuss the strategies she uses in her own clinical practice to treat thyroid patients. She talks about educating clients on how to read food labels, when to avoid gluten (and when not to), and her favourite supplements. 

Covered in this episode

[00:58] Welcoming back Natalie Douglas
[01:50] Using a nutritional approach to combat underactive thyroid
[08:27] Checking labels for industrial seed oils
[10:37] Strategising time of day for carb consumption
[15:22] Different perceptions of “normal” and “healthy” 
[17:16] Should Hashimoto’s patients avoid gluten?
[20:54] How can we tell if food is making a difference?
[26:13] Suggestions for supplementation
[29:31] Iodine supplementation
[33:14] Other important areas to address
[35:56] Talking about trauma in a consult
[37:47] Safety considerations
[41:43] Thanking Natalie and closing remarks

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Natalie Douglas who's a qualified dietitian and nutritionist, a functional-medicine practitioner, fitness instructor, naturopathic student, podcaster, author, speaker, and yoga teacher. 

Nat specialises in helping women with an underactive thyroid or Hashimoto's, reclaim their energy and thyroid health. She does this using the power of functional testing, real food, gut health, smart supplementation, quality sleep, stress management, appropriate movement, and spiritual well-being. 

Nat has developed a 12 week health and energy online program for her patients called "Thyroid Rescue" for women with an underactive thyroid or Hashimoto's disease. 

Welcome to FX Medicine, Nat, how are you? 

Natalie: Thanks, I'm good. It's good to be back. How are you?

Andrew: Good, thank you. Thanks for joining us again today to talk more about your approaches to thyroid health. And today we're talking about the practical approaches. So, obviously, we're going to be discussing some of the quandaries that you've come across in your practice. 

So, let's start with diet because this is the big one that I guess most people are reluctant to change, it's ingrained with them. So, what strategies do you use to help heal an underactive thyroid, and how does this differ if it's autoimmune in nature?

Natalie: Yeah, great question. So, look, for me it depends where someone is at and how much they have or haven't tried already. For the person who's coming from a standard Australian diet, I'd start with just probably removing gluten and dairy and focusing on including more nutrient-dense unpackaged whole foods and see how things go with that first. I'd initially just be looking at a nice balance between the macronutrients and focusing more so on food quality.

Now, if someone is coming to me and has already done the above, that's when I'd go one of two ways based on what's happening. So, firstly, if they have Hashimoto's and quite elevated thyroid antibodies and they are at a point where they want to do anything it takes...which, I would say I'm pretty blessed in that way because a lot of people, by the time they come to me, they are at that point where they're like, "Please, I'll try anything." 

Andrew: Right.

Natalie: And, so, if that's the case, then something similar to the autoimmune Paleo diet for a period of about 30 to 60 days. And for a lot of people, this actually works like quite amazingly. And I think it definitely is something that we agree - like me and the patient agree - is a temporary therapeutic intervention and that they keep working with me to reintroduce foods after we've gone through that really anti-inflammatory low-allergenic approach and we continue to focus on balance of macros and quality food. Because I think it is, to a degree, quite restrictive.

So, for those listening, basically, the autoimmune Paleo diet is...and the way I use it isn't a meat-heavy diet, it's more just focusing on whole foods and still very much plant-based but with high-quality animal protein in there. And taking things out that a lot of people, at least what I've seen, have intolerances to things like eggs or nuts because these are the things that people are just eating every single day without breaks from them. And when you've got someone with a leaky gut or intestinal permeability and a very alert immune system, to me, it's a bit of a recipe for food intolerances developing easily. And I just find by taking out a lot of those higher allergenic foods and really focusing also on the flip side of this focusing on nutrient density. So, not is it only about, "What can we eliminate to reduce inflammation?" but it's, "what can we include to maximise nutrient density to help someone have the tools to heal so we can minimise the amount of supplements, for example, that we need to use?"

So, I offer that to people as an option but, if someone is just not there yet, because as I said, it is quite a restrictive protocol if you're not coming from a place where you've already started to make steps in the right direction, then I would just start with starting to focus on more unpackaged unprocessed foods really looking at quality, getting out anything that we know is really inflammatory, like industrial seed oils, sugar, alcohol. And for me, I do eliminate gluten and dairy because I find clinically people just feel so much better without it. And then they have the opportunity to reintroduce it down the track and see for them whether it makes a difference or not.

Now, if they don't have autoimmunity present, then I'd still use the principles of whole foods and I'd alter their diet depending on what was causing the thyroid issue. So, as an example, if it was a gut issue driving the thyroid issue, then I'd alter it based on the type of gut issue. So, if it was SIBO, for example, then we would focus on treating the SIBO using that particular diet. Because that ultimately is going to help the thyroid because we're reducing the inflammation from the SIBO load and just making everything work a little bit better there.
If it was that they had high oestrogen levels, then I might be really focusing on getting in more fibre and cruciferous vegetables. If it's an adrenal issue or they're quite stressed generally, and that's what's kind of driving that for them, I'd encourage them to be including whole food carbs with all of their meals. And I'd also make sure that they aren't doing any prolonged fasting because of the stress that it places on the HPA axis. 

And then, if they're iodine deficient, I'd temporarily be getting them to be mindful of not having too many goitrogenic vegetables or soy, while we correct that iodine deficiency, but with the idea that once that is corrected, we add those foods back in again. Because I think a lot of people get on the Google bandwagon if they've got an under active thyroid and posts all over the internet is like, "Don't eat a goitrogen ever." And I just don't see that being the case. I have definitely seen people juicing their hearts out with kale and broccoli and all these types of things in the...

Andrew: Yuck.

Natalie: Yeah, they're not your people...in the presence of an iodine deficiency. And for sure that can create an issue because we know that there's that competitive uptake in the thyroid gland. But it's not the case if you are iodine replete. So, I think that's something that I try and educate people on. Otherwise, they're missing out on the amazing benefits of cruciferous vegetables and things that could probably help them. 
So, it's just about education and really making sure that you're not being too dogmatic in any particular way but just looking at who the person is in front of you and what their thyroid story is.

Andrew: Industrial seed oils, let's discuss that a little bit, versus things like olive oil or coconut oil.

Natalie: Yeah. So, I guess define what I'm talking about when I'm talking about industrial seed oils, things like vegetable oil, canola oil, safflower oil, rapeseed oil, grapeseed oil, these kind of oils that you can even just google or youtube, or whatever you want to do, the process that goes on to actually turn something like that into an oil. They get pressurised, deodorised, sprayed. You're trying to get an oil out of a tiny like little seed or vegetable. And you can imagine how much you'd have to, I guess, manipulate that to make that happen. And we know that those things create inflammation in the body. And, so, it's quite an easy switch, if you're doing a lot of home cooking, to just switch out something like canola oil or vegetable oil for something like olive oil or ghee or coconut oil, whatever you want there, or macadamia oil.

But where it becomes a problem is when you're buying a lot of packaged foods. Because it's hidden everywhere. Every second packet that you turn around has one of those oils in them because they're cheap and so the food industry likes them. And I think, unless people know and actually turn labels around and look at them, I think we have a bit of a culture of looking at the kind of nutrition label from a perspective of, "Oh, how much sugar? How much carbs? How much fat?" And while that's certainly a step in the right direction, a lot of people are forgetting that there's also an ingredients label and to look there and say, "Well, what is this food made up of? Is there any ingredients that I don't recognise and, therefore, my body probably won't recognise either? And is there large amounts of industrial seed oils in here?" and starting to educate people on, "You need to do this. You can't just read the front of a label and assume that they have your best interest."

Andrew: They've got your back, huh?

Natalie: Yes. Yeah.

Andrew: What about meal portion size? Now, this is a huge one for most of us who are overweight. But when you've got hunger, when you've got fatigue, you're trying to offset that. And, of course, there's...for instance, fatigue very often leads to this immediate need for energy and so we use stimulants like coffee. And there's that urge in some people to go for the carb. How do you manage this with your patients?

Natalie: Yeah, great question. And it definitely does come into play particularly when someone's got fatigue. Although, there's this interesting thing in women in particular with thyroid issues, this balance between...a lot of them are desperately trying to lose weight and will be restricting their intake. But then they kind of get to a point where they're like, "I can't do this any more," and they will just go for those quick hits.

So, what I try and do is balance their blood sugar. So, instead of focusing on the extremes of everything, the first step for me is “How do I create balance on this person's plate so that they're not having these big spikes and dips in their blood sugar on top of already feeling quite fatigued?”

Another strategy that I like to use for a number of my thyroid patients is having them have more of a lower-carb breakfast and having more of their carbs towards the end of the day. So, I don't really… and the reason for that is because it seems to have a more positive effect on them not having cravings and of them feeling a little bit more clear-headed. Because a lot of people with thyroid issues tend to have, at least in my clinical-practice experience, do have some degree of blood sugar dysregulation. I find having a more high-protein high-fibre kind of breakfast stabilises their blood sugar or gets them off to a good start. And then having a little bit of those carbohydrates at night time helps to promote sleep a little bit better. And that's what works.

In saying that, there's always exceptions to the rules and not every single thyroid patient of mine does that. Some of them just have a normal serve of whole-food carbohydrates, usually from vegetables or fruit at their three main meals. It just really depends. But there's different strategies that you can use and see how people feel. But I would say high-protein breakfast of at least 30 grams of protein in the morning really really helps stabilise their blood-sugar levels and prevents that kind of hunger an hour, or 2 hours after they've eaten.

Andrew: Right. Now, this was very interesting that you said that about a little bit of carbs at night increasing the serotonin and restful sleep. Talk us through this, how do you manage that so that you're setting your body up the next day, or indeed at night, for not having a food craving, not having that, “sugar swing” that leads to the midnight snacking?

Natalie: Yeah. I think the way I do it is it's not like, "Have a carb feast at night," it's just like, "have a normal amount of carbohydrates with your dinner." Or if you're someone who really likes dessert, then have something like a banana with something else that balances blood sugar. So, it might be a little bit of nut butter, it might be a dollop of coconut yoghurt. I don't encourage people to eat carbohydrates alone because I think that's what can create that backlash or that swing of, "Here's an increase in blood sugar," and then you've got that dip. And sometimes that can cause people to actually wake up in the middle of the night because blood sugar dips too low and then cortisol kicks in to bring that back into balance and then they wake up.

So, it's a bit of trial and error in terms of the amount that will work for that particular person and also a bit of trial and error in terms of how soon before bed they have it. Some people, where I get people to start is just including it at their dinner meal and then allowing their digestive system to rest for 2 to 3 hours before they go to sleep. Other people that doesn't work for and they might have a snack, like I just said, maybe like an hour before bed, and that seems to work really well for them. But it's certainly not supposed to be a sugar binge or a carb binge before bed, it's really just including what would be a normal serve for someone of slow-digesting carbohydrates. Or if it's not a slow-digesting carbohydrate, then pairing it with something that helps that blood-sugar spike.

Andrew: Okay, you've said a couple of interesting words there, "normal" and "healthy." How much do you have to work on what you perceive as being normal and healthy and what the patient perceives as being normal and healthy? Because sometimes these can be quite disparate.

Natalie: Yes, definitely. So, with my patients, I do give them amounts more so...so I might start somewhere, if it’s a female who is maybe between 60 and 70 kilos, let's say for an example, I'd get them to start off with half a cup of starchy carbohydrates with their dinner meal. If they're a little bit bigger than that, if they are particularly active, I might say a little bit more as well. But, generally, between half a cup and one cup of starchy carbohydrates is where I'd start. And then, based on their response, I would increase or decrease from that.

Another really easy way to do it is getting people to just have a closed handful of it. If they're not into using cups and measurements in that way, you can use hands. Like, for example, for protein I usually just tell people, "Look at your palm and have a palm size." And, obviously, that's going to depend on how big your palm is but that's the point. Because, obviously, if you're a bigger person, you're going to need a little bit more. 

So, really you just have to gauge where people are at with their relationship with food as well and what makes them...like some people need really specific instructions and that makes them feel empowered and they don't have that really neurotic feeling around food. But then other people, they do. And, so, that's when I would be like, "Hey, just look at your palm and do that," so they're not getting it too obsessive. You really just have to pick up on what they are like and what's going to work best for them.

Andrew: Yeah. I was just wondering about is there enough research to back up these common recommendations about Hashimoto's patients avoiding gluten?

Natalie: Yeah. So, I think it depends. So, let's start with celiac disease. The connection between celiac disease and Hashimoto's is definitely there in the research. And I've seen, for some people with celiac disease and Hashimoto's, simply going strictly gluten-free has put their active Hashimoto's into remission in terms of it's decreased their antibodies to a normal amount. And that makes sense with what we know about autoimmune conditions kind of following each other.

But then we have this much larger group of people without celiac disease who have thyroid issues or Hashimoto's, and this is where it gets a little bit grey. The truth is that the research on what we call non-celiac gluten sensitivity is actually mixed. So, there are some correlations there but the specific part of the gluten-containing food that someone is reacting to hasn't been definitively found, as far as I know, in that context. And there's some really interesting, in my opinion, and very plausible hypothesis. And people like I think Alessio Fasano, I'm sure, would have more information on this.

And I think for me the lack of comprehensive indisputable studies doesn't make me think, "Well, if science hasn't proved it definitely yet, I'm not going to encourage removing it." Because, in my opinion, you're removing a huge potential for healing based on so much anecdotal evidence out there, which I think is still evidence. And really, if it's done properly, nothing terrible is going to happen. And there's enough good quality gluten-free options out there that are pretty easy to find, either by just not eating processed food or teaching someone how to read a food label.

So, I don't feel like in most cases there's a huge social impact on removing it to see if it helps them. And, in my clinical experience, an overwhelming number of my patients with any form of autoimmune condition, gut imbalance, or thyroid issue do actually do far better off gluten than on it. And I personally think the best way to figure that out is remove it properly, reintroduce it, track symptoms and labs and see how they feel. 

And I think, when I say, "Track symptoms," I don't mean just whether someone gets diarrhoea after eating gluten. I mean, it can manifest in many ways. So, you know, do they have digestive discomfort? Is there any return in their brain fog or moodiness? Which I see as a big one when they reintroduce it. Is there any joint pain? Do they feel grumpy? Are having sleep issues or behaviour change or skin changes? Or are their antibodies starting to increase? I think that, one thing I'm really passionate about is just giving people the options. And, if it's something that's not going to cause them harm and I can guide them through doing it properly, it's worth it to me.

But to answer your questions specifically, the evidence on gluten sensitivity and Hashimoto's is mixed. And, so, I don't think I could stand here and say it's absolutely indisputable for sure. I think that there's some plausible stuff there but it's not conclusive.

Andrew: Yeah. I mean it's really interesting because, when we're talking about these subjective measures, increasing moodiness and brain fog and things like that, there's so many other variables that can concurrently affect that. You know, did you sneak in some sugar? Are you stressed? All of this sort of stuff. 

And, so, we would then try and find a black-and-white lab to say yes or no. Antibodies would be the classic. But then it may be that antibodies are sort of the last thing that goes up and we might need to be looking at let's say, some evidence of leaky gut, fraught with issues, trying to measure that when there's no gold standard. So, it's kind of like, "What do we measure? Do we look at interleukins? Where do we look for this evidence that that food is making a change to our body?

Natalie: Yeah. And I think, as you kind of alluded to, there's no perfect way to do it. And I think the best way is a comprehensive way or a varied way in terms of, "Yeah, look at thyroid antibodies, see if they've increased." But I think what you have to do in this situation is make sure that you're getting someone to keep a food and symptom diary. So that includes asking them at the bottom about their level of stress, how much sleep they got, what else is going on so that you can really understand the context in which they are either having a reaction or not having a reaction. 

Andrew: Got it.

Natalie: And then I think for sure, run other labs that could maybe give you some indication as well. Because there's no perfect way and there's no really definitive way. We're so complex and it is so varied. And I think that that can be really difficult but I still think it's worth just doing your best to try and assess that for people.

And also trusting that they do… We know our bodies better than anyone else. Like, as a patient, I always tell my patients, "You know your body better than anyone else, including me. But you have to pay attention and then you have to share what you're noticing with me so I can help interpret that for you." Because I think that feels really empowering to people because so often we go into a doctor's office, a nutritionist's office, a naturopath's office, a specialist's office and we give the power out away from us. And it feels like we don't know our bodies, whereas I really am passionate about including people in the process and really listening to what they're telling me, their body is telling them, and never being like, "No, that doesn't make sense. That's not it." 

If they say something that maybe doesn't make sense to you, just, "Okay, cool, interesting. Thanks for sharing that with me." You don't have to disempower them with “No, it wouldn’t be that kind of thing.”

Andrew: Well, how often have we been wrong?

Natalie: Yeah, right, I know.

Andrew: But you make a very important point about including all of those variables which might affect their symptomatology, including the mood, including the sleep, including that. And then you can get a feel for, "Okay, this was bad. This was bad. And that was bad, and that, and that. It's all bad." And your symptoms peaked when you introduced a certain food or groups of food. Yeah. 

I was interested when you were mentioning goitrogenic foods as well because I have seen somebody who was, "Soy this, soy that. Soy cereal, soy bread, soy everything," wonder of wonders they ended up with multi-nodular thyroid disease. Now, you know, that's an after-the-fact blame, if you like, but a pretty fair culprit there.

And I guess the issue is, we think one thing is healthy and therefore we go way too far with it. Rather than, dare I say the word, spreading the love amongst a broad base of foods. What was the old axiom? Eat a variety of foods, not too much, you know, that sort of thing.

Natalie: Yeah, yeah. I think it was Michael Pollan who said that.

Andrew: Pollan, yes.

Natalie: Yeah. Yeah, totally. And I think it's hard because we're in a culture where we want to belong somewhere and we want to belong to a certain way of eating because it makes us feel like we belong. So, we tend to overdo things. Or we're told so often that one particular food is amazing. But every food, like everything pretty much in excess can cause a problem. It's really like there's this Goldilocks Zone. And I do really believe in variety being key and that being the end goal. 

I think there's a time for therapeutic interventions and “restriction” but the end goal should always be, "How can I include the most amount of foods with the least amount of symptoms?" Because I think there's so much we don't know about what's in our food as well in terms of, we can only measure what we can. Like there are so many phytochemicals in our vegetables and fruits that we probably have no idea about yet. And, so, you really, by eating a variety, you're kind of just giving the power back to nature.

Andrew: What about supplementation, Nat? I mean there's a role for it, but I do like the way that you favour whole food and things like that as the foundation for treatment.

Natalie: Yeah. Yeah, look, I think supplementation is so powerful in thyroid autoimmunity and also thyroid issues generally. I think, in terms of my favourites in relation to particularly decreasing antibodies would be selenium. And usually at a dose between 100 to 200 micrograms a day. Inositol usually at a dose of about 600 milligrams a day. So, there was a study where those two were used together, I think it was just under 100 micrograms of selenium and 600 milligrams of inositol were used in the same study for...I think it was either 6 or 8 weeks. And that did decrease thyroid antibodies, which is great. Like two really simple nutrients, cheap, easy-to-use, and definitely effective.

Nigella sativa or black cumin is also a really good one that's been clinically trialled. And I believe it was at a dose of about 2 grams per day. And then the other one that doesn't necessarily decrease antibodies but can help with decreasing TSH and increasing T4 is withania, or ashwagandha. And I believe it was about 600 milligrams a day for that. So, those are probably my favourites or my frequent flyers in that area of decreasing antibodies and really changing that side of things.

Outside of that, it depends on what's going on. So, I'm a big fan of B vitamins, zinc, magnesium for most of these people. I think that trio is just amazing for so many different things. And we know that all three of those nutrients are involved in just so many reactions in the body. So, that's my like trio...

Andrew: And you don't have to go massive doses with these, zinc, B6, magnesium, you know. And even foods, if you like oysters, great, there's a zinc supplement. You know, things like pecan nuts, pepitas, one of my favourite favourite foods. So we can really look at these foods as therapeutic interventions. To a certain extent, I don't know a food that's massive in magnesium, for instance. You know, all greens have got magnesium but I don't know of a high-dose sort of food.

Natalie: Yeah, I definitely...like pretty much all of my patients are on magnesium, at least some. I think it's really powerful. And I think we have to remember that thyroid issues don't happen in isolation. I've never met a thyroid patient that doesn't have something else going on with their hormones or with their adrenals. And zinc, B's, magnesium can be so helpful in that kind of context.
The other things that I will use are things like vitamin D, especially if they're deficient and just to support immune health. Vitamin A can really help as well in terms of the actual entry of thyroid hormones into the cells. So, a really simple way to get that into someone in a balance is like cod-liver oil, vitamin A, vitamin D, some omega-3s. I find that to be helpful. You don't always have to do it that way, that's just one way that sometimes I will do it. 

Iodine depends and I will...

Andrew: Yeah, that was my next question.

Natalie: Yeah, talk about that. So, that depends. And then, I do quite like mushrooms. I find that they're quite nourishing to your immune system. But they wouldn't be my first go-to. I'd say the ones that I've mentioned just there would be my main ones that I would start with before exploring further. But I think we've got so many different options at our fingertips with these things. And I absolutely do use them alongside food and find that they work really really well.

Andrew: Sure.

Natalie: My personal opinion on this is that iodine supplementation at, you know, RDI amounts, 150 micrograms a day, relatively low doses, even in Hashimoto's patients, in most cases is completely safe and necessary. Because we need iodine for other things besides just thyroid function. However, I'd always be checking someone's thyroglobulin antibodies before I considered giving them anything over the RDI. Because we know the presence of thyroglobulin antibodies in particular increases the risk for a negative reaction to iodine supplementation.

And I think, in terms of it going wrong, I've definitely seen it go wrong. Even just the other week I had someone who had been put on megadose iodine, no antibodies, no issues before, and suddenly, an issue has been created and now there is autoimmunity there and quite raging. So that's not the first time that that's happened. And not me putting someone on on that and someone coming to me after that's happened.
What basically can happen is, when there's a mega dose of iodine given, it can result in what's called the Wolff-Chaikoff effect. Which is, in a nutshell, is basically reduced thyroid hormone production in response to getting such a whopping dose of iodine. And it basically temporarily inhibits thyroid peroxidase, which means there isn't any significant iodination happening because that enzyme is, essentially, responsible for doing that job. There also has previously been some research linking excessive intake, which I believe they defined as over 300 micrograms, I think, I'd have to double check that for you, I'll find the paper, and that appears to increase the risk of thyroid cancer, autoimmune thyroiditis, hypothyroidism and hyperthyroidism.

So, I think, look…when we think about the principle, in natural medicine, as first doing no harm, I feel like personally the risk outweighs the benefit. And we definitely can't argue that there aren't...there definitely are people out there who have benefited from mega dosing of iodine, but there are also people who have created autoimmune conditions that weren't there beforehand. And I just think that's not a risk I'm willing to take for my patient. But I do find it very fascinating. And there's definitely other people that know way more than I do on this particular topic but that's my approach, in clinical practice, is low dose is fine. If I want to go any...usually, if I want to go any higher than maybe about 250 micrograms per day, I will make sure I'm checking their thyroid globulin antibodies and checking whether they even need iodine, based on looking at the patterns of their thyroid labs and also looking at their random urinary iodine. Which we do need to take with a grain of salt because it's not perfect.

Andrew: Okay. So, outside of diet and supplementation, what else can we use to help our patients manage Hashimoto's?

Natalie: Yeah, great question. So, I think really it comes back to basics like stress management. And that can look however you want it to look. I think meditating, bringing more play, connection, community into someone's life or encouraging them to move in that way. I think releasing any old trauma or moving through it, and that might mean working with a psychologist or a body-mind therapist, something like that. I think if you'll find, like a lot of health timelines with people, that so many of my thyroid patients have history of childhood trauma or early-teen trauma or adult trauma. And that can take many forms. It doesn't have to be abuse in a physical sense. It can be a divorce, like anything. It can just be anything, I think it's really important to not underestimate the power of undealt trauma. 

I think movement can also be helpful but, you know, letting them know what a sensible amount of exercise is for them. I prefer to steer people in the direction of a few resistance-training sessions a week with weights and yoga and walking, as opposed to encouraging them to do a lot of HITT training because that can just place more stress on that HPA, HPT axis, which is already compromised in a lot of these people.
I also think there's some interesting research around laser therapy like on the thyroid gland itself. And I think that that can be an adjunct to other things. But really where I focus on is stress/sleep, dealing with the mindset side of things and old trauma. And I think, particularly if people have been chronically unwell for a long time, I find there's this attachment to, "I am my disease," instead of, "This is what I'm experiencing." And sometimes that can keep people trapped and they'll look for reasons why they are staying exactly where they are. Because I think, as humans, we like what we know, we like what is familiar. And for a lot of these people, they've been stressed, fatigued, sick for a really long time. And, as soon as they start feeling good again, sometimes, subconsciously, that old pattern of, "Oh, no, this is too good to be true," will come in and they will go backwards. So, I think really working on the mindset side of healing can be incredibly powerful.

Andrew: Do you discuss with your patients the issues of trauma or do you have that on your intake form? And what I'm getting at here is do you actively encourage talk, given that some people may be quite reticent, particularly on first visit, to open up about, let's say, a sexual abuse or an abusive relationship, physically abusive relationship. Whereas, if it's in an intake form and you just talk about and you just mention trauma, emotional trauma or something like that, they can tick or cross and you know there's something there. Whether they take that up with you is up to them.

Natalie: Yes, the latter, that's exactly what I do. I put it on the intake form and if they've ticked yes, I will ask the question to them, "Have you worked through this with anyone?" And that kind of opens up the conversation. And if they want to share, they will. But even if they do share, I'm obviously not a qualified psychologist or anything like that so I will listen and I will hear them and make sure they feel heard and validated and then give them recommendations to someone that they can talk with about it and explain the link between how dealing with this emotional stuff is going to help them physically and attach it to something that's going to motivate them to change. 

Because a lot of the time it's painful to revisit a lot of that stuff. And, unless someone has an understanding and motivation to deal with it, it's easier to just kind of suppress it and push it down. So, I just see my role as connecting someone with the right practitioner for them and explaining to them why it's worth doing the work.

Andrew: Last question for you, Nat, safety considerations. Now, we've gone through a few of them, particularly with iodine, but what about when things go west? What about when patients don't respond to the things that they should be responding or indeed there's a spike in, not just their symptomatology, but even proven labs? How do you rescue the patient there?

Natalie: Yeah, I think I make sure that I haven't left any stone unturned. So, if someone is not progressing, to me that means...well, I first make sure that they've done what I've asked and, if they have and things still aren't moving in the right direction, I kind of go back to the drawing board and think, "Okay. So, where have I not looked thoroughly enough?" 

I'm absolutely not opposed to thyroid medication, by any means, I actually think it can be really helpful. And that's something else that I really concentrate on educating patients on because a lot of people come in with the goal of, "I want to get off my medication," or, "I don't want to end up on medication." And for me I see my role in that as explaining the benefits of it and that it's just a tool in our tool kit and that it's not a failure and make sure that they are getting their labs checked through their doctor regularly. Particularly in the beginning phase where we're trying to normalise something. And again, if a practitioner that they're seeing isn't responding to that appropriately, then I see my role as connecting them with someone who I know maybe will alter their medication type or dose or look at further things.

So, I think I do my best and make sure that I've done my job thoroughly. And if I get to a point where I'm like, "Man, I have no idea what's happening now," I'll refer on to a functional-medicine practitioner or an integrative GP, if they can afford to do so, just to have another set of eyes to look over it. I think sometimes you can't see everything. And I love working with other practitioners, I might even discuss like their case with another one of my colleagues, just to get a different perspective. 

So, I really just make sure that they're not... especially in that acute stage, that they're not seeing me in place of their GP but we're working alongside each other to get the best patient outcome.

Andrew: Yeah. You know, that's a really salient point, what you're talking about is don't be afraid to refer on if you don't think you're getting anywhere. It's not bad to have another set of eyes to look at what you think is, what you're seeing even.

Natalie: Yes, totally. And I think, particularly for me who nowadays tends to see a lot of similar patients all the time, I find it really helpful to discuss, obviously confidentially, but discuss people's cases with other practitioners or refer on. Because I don't think that I'm perfect, I don't think I know all the answers. And I think even just in sharing a case, sometimes you're like, "Oh, yeah. Forgot about that." And I think, if you feel...like there's no shame in that. As a practitioner, there's no shame in not having all of the answers or missing something, like we all miss something here and there. And I think the more you feel okay to discuss cases or refer on, the more you learn. And then you won't miss that thing next time because it's now on your radar.

And I'm really passionate about that and passionate about not putting anyone on a pedestal but just recognising that we all have different perspectives and different ways of thinking and questioning and different experience. And the more we work together, the better it is for the patient. And that's really what all of us want at the end of the day.

Andrew: Well, Natalie Douglas, it is indeed your humility and the way that you question yourself which is one of the reasons I put you up on a pedestal. You are amazing. And thank you so much for taking us through what is really very involved and requires a lot of expertise and training. But you've given us a few hints and tips today so that we can help our thyroid patients, particularly those patients with Hashimoto's. 

Thanks so much for taking us through this today on FX Medicine.

Natalie: My pleasure. Thanks.

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.



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