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Clinical Pearls of Thyroid Assessment with Natalie Douglas

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Clinical Pearls of Thyroid Assessment with Natalie Douglas

Your patient has a thyroid issue, but why has it developed in the first place? This is the important question Nutritionist and Dietician Natalie Douglas always asks when she treats a patient with thyroid dysfunction.  

In this episode loaded with practical clinical advice and tips, Natalie takes us through using pathology to help identify and treat thyroid dysfunction and Hashimoto’s disease, including what tests to use, what certain results might indicate, common signs and symptoms that indicate testing might be appropriate, and the importance of taking a thorough and complete patient history. 

Covered in this episode

[00:57] Welcoming Natalie Douglas
[01:52] Pathology testing for Hashimoto’s and thyroid dysfunction 
[06:29] Preventing the formation of thyroid antibodies
[10:24] When to test for thyroid hormones - common signs and symptoms
[13:55] Never stop looking for the root cause
[15:48] Spotting patterns in the pathology
[22:05] Reverse T3
[25:38] Viral load and Hashimoto’s
[27:17] Common root causes of thyroid dysfunction
[31:33] Gluten sensitivity vs Coeliac disease
[42:49] Additional pathology red flags
[46:06] Taking a complete patient history
[48:17] Additional resources
[50:00] 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 dietician 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 online program called Thyroid Rescue, which is a 90-day health and energy transformation program for women with an underactive thyroid or Hashimoto's disease.

Welcome to FX Medicine, Natalie Douglas. How are you?

Natalie: I'm good. Thank you, it's good to be back.

Andrew: Now, Nat, how do we properly test for Hashimoto's? This is a question which is fraught with issues, not the least of which are how do you get the tests done.

Natalie: Oh, totally. And it's sometimes the most frustrating thing in practicing and I'm sure I'm not alone in that. I'm sure there's many people listening that are like, "Yeah, it's really hard to get anything other than a TSH."

So for me the first line of testing would be to run a complete thyroid panel. So as a bare minimum, that would be a TSH, a free T4, free T3, and thyroid antibodies, so those being thyroglobulin antibodies and thyroid peroxidase antibodies, with the latter being more specific to Hashimoto's. And look, you don't need to run thyroid receptor antibodies unless you suspect Graves' disease, in my opinion. I ask for it just because if you're already asking for the rest, then why not? Sometimes you'll get a willing doctor to order all those tests. If not, then you can order them privately, of course.

Technically, from my understanding at the moment, to be diagnosed with Hashimoto's by most doctors they will actually need to see an elevation in thyroid antibodies as well as low thyroid function. However, thyroid antibody elevation in the absence of thyroid hormone abnormalities is still considered an early warning sign. And antibodies can actually be elevated about 8 to 10 years, I believe, before we see changes to markers such as TSH and free T4 and free T3, for example. 

And unfortunately in the conventional medical model Hashimoto's or thyroid issues generally aren't treated or paid any attention to until thyroid function has been affected. Which to me seems silly because we know from the research that even things like selenium and inositol can be tools in decreasing thyroid antibodies, and that is going to help stop the progression or further destruction of the thyroid tissue.
I think one thing to mention here though, is that while 80% to 90% of people with Hashimoto's will have either TPO or thyroglobulin antibodies, or both, there are actually a small subset of people that don't. So these people usually have a less aggressive version of Hashimoto's known as antibody-negative or serum-negative Hashimoto's. And in that situation probably the next port of call would be to do a thyroid ultrasound to look for physical changes in the thyroid gland that point to Hashimoto's. 

So when they're doing an ultrasound, they're looking for things like changes in size, texture, density of the tissue and nodules. And if nodules are there, which in simple terms is just abnormal growth, then if they look suspicious, a nodule biopsy would usually be the next step.

So you can kind of see how relatively frustrating it is that most people are just getting a TSH done. And I think it's really important that we, as natural medicine practitioners, are advocating for proper testing. And sometimes that does mean out-of-pocket stuff, but I think it's worth it.

Andrew: But at least once you have those results for the out-of-pocket, then the proof is there. So you could then go back to your doctor and say, "Look, it is elevated, I do have antibodies." And of course then you go on that journey. 

Can I just ask first though, when you're mentioning free TSH and free T4, what's the relevance with thyroid-binding globulin here?

Natalie: So thyroid-binding globulin is basically like the taxi that carries around the free T4 and free T3. And look, you can definitely do more thorough testing in terms of doing total T4, total T3, and then looking at the free stuff that I find, you can get enough information just from the free hormones.

Andrew: Yes.

Natalie: Because that is what is going to be most active. You can certainly request to measure thyroid-binding globulin, which is like the taxi, but I find sometimes it's a bit more difficult. A lot of the time it's a struggle even just to get free T4 and free T3. But I feel like that in conjunction with really thorough symptom-taking and note-taking on that can just be enough to put your case together.

Andrew: And with regards to thyroid antibodies, it's obvious you've obviously created antibodies to your own tissue. But are there remedial therapies that we can take to thwart that from happening, or decrease it from happening?

Natalie: Yeah, yeah. There's plenty of things that you can use to help decrease that. Selenium and inositol are two things that have been really thoroughly researched in relation to decreasing those antibodies. And certainly making dietary changes and going after root causes, as well, in relation to thyroid stuff. Which I know we're going to do a separate podcast on it soon, as well, which will be helpful. Because yeah, there's absolutely plenty you can do.

I think probably one of the reasons why the conventional medical system pays no attention until your thyroid labs are out of range is because they have nothing to offer. The treatment for them is just thyroid hormone replacement. And if someone has just got elevated thyroid antibodies but their thyroid labs are in range, then for them they don't have any options in their toolkit, whereas we do. We have plenty of things that we can do to help stop that from progressing into a place where the thyroid markers are completely off.

Andrew: That's a really interesting thing you say. Because I'm reminded by something, it was Professor Tom Borody who said this. And he said, "I'm not going to treat if I can't change anything." And that's a quandary which, I guess, any practitioner is really in, that you've got to see a benefit, you've got to be able to see a benefit. 

Now when you're talking about thyroid disease, if all you've got is the hormone and that's not necessarily the issue, well, you're in a bit of a quandary as to when you can use it.

Natalie: Yeah, totally.

Andrew: So prevention is really out for standard medicine.

Natalie: And this is where I think we, as natural health practitioners, have so much power. I kind of think of thyroid issues generally as thyroid is like the canary in the coal mine, usually it's happened because something else is often...it's kind of a warning sign. And we, looking at the whole body and treating the whole person, it's amazing how good of a result you can do. Because it's providing the body the tools it needs to do the healing itself.

Andrew: Yeah. And also I guess there's that issue with the thyroid is an extremely efficient pump, so there can be a lot of damage. You were just mentioning it before, that you can be euthyroid with regards to hormones, but your antibodies can be rampant. And so there can be this amazing destruction, but you won't see the deleterious effects on hormones until way down the track.

Natalie: Exactly. And there's also the problem that the reference ranges for TSH, and even free T4 and free T3, are just wrong, in my opinion, especially TSH. I think it's something like 0.5 to 4.5 or 5 at the moment. But for me, when I'm looking at someone's TSH, I'm going to pay attention if it's starting to creep up above about 2.5. Because generally that's when I start to see a lot of symptoms happening. And I think symptoms can tell you so much and I really encourage every practitioner to never just base things off pathology. Because I think that we all function with...there's a range for a reason and different people are going to function better or worse at certain ends of that range.

Andrew: Yeah.

Natalie: And I think the symptoms are what tell you whether that level of thyroid hormone is working for that person.

Andrew: Okay, so there opens up another little can of worms. Thyroid governing the rate and rhythm of every cell in our body, but probably one of the big hallmarks of thyroid underactivity would be fatigue. And fatigue can be due to so many issues. 

When would you test for thyroid issues? What patients present as red flags? And when would you tease that apart and go, "That's not really the thyroid type of fatigue, that's more of an immune type fatigue," or a stress fatigue or a depression fatigue, or that sort of thing?

Natalie: Yeah, totally. Because thyroid symptoms are so nonspecific. And you're right, many of the symptoms in an underactive thyroid could be attributed to so many different things.

So look, I think for me in my head when I'm thinking about this, definitely those with a family history of Hashimoto's or Graves' disease, or even just a history of autoimmunity in their family generally, assuming that they're also coming to you with some symptoms. And I'd also say those with existing autoimmune conditions, because we know that when you have one autoimmune condition, you'll more likely to have or get another.

Beyond that, I think a really good, thorough symptom history is important. And, as I said, this can be a bit challenging in some ways because there are so many potential symptoms of an underactive thyroid and they can, as I said, seem really nonspecific.

So I guess some of the main symptoms that a lot of people would be familiar with would be things like brain fog, weight gain, weight loss resistance. Particularly if they feel like they're coming to you and they're like, "Look, I'm doing absolutely everything I can to lose weight and it's not happening." 

Low mood or depression, dry skin, brittle nails, poor hair growth or hair loss. A history of miscarriages is another red flag for me. Heavy periods. That puffiness, people will feel like they're puffy. And sometimes you won't always be able to see that, especially if you're seeing the person for the first time. You might just assume, "Oh, that's what they look like." So that's where asking them that question is important, not just basing it off observation. Infertility, cold hands and feet, or intolerance to cold generally.

Andrew: Yeah.

Natalie: Inability to sweat properly, carpal tunnel syndrome. IBS, particularly constipation. Because if you think of thyroid hormone in its simplest terms, making things move, then constipation is a big red flag. Excessive sleeping or feeling fatigue. And I guess here what I ask people is, "Do you"... Because so many people are tired these days, right?

Andrew: Yeah.

Natalie: And generally speaking most people I ask, "What are your energy levels like? Are you tired?," most people will be, "Oh, yeah, I'm a bit tired." What I'm more interested in is, are you tired even after you get adequate sleep?

Andrew: Right.

Natalie: And that's a little bit of a hint for me. So yeah, I think if you've got a person sitting in your office with at least a handful of those symptoms, in my opinion it's worth investigation. It's not a huge cost to look at and could potentially be a game-changer for that person, or at the very least help rule out something, and then lead you down a different path. 

So it's kind of just doing your due diligence and starting to rule out certain things to help lead you to a diagnosis. So that's probably what I'd say in relation to who I'm thinking about testing.

Andrew: Yeah. And again, I'm just trying to picture these patients. And when you're talking about fatigue even after adequate rest, I still have this little bell ringing in my head about sleep apnoea, and there are so many other causes that we have to tease apart that can be very, very dangerous. And if we're treating what we might think is a thyroid disease and they have sleep apnoea, we cannot be doing them a favour at all. 

But then you get the chance of tying in other symptoms, like you mention puffiness, there's that loss of the outer third of the eyebrows, the raised cholesterol, the constipation. Then you get this...slowly you get a clearer picture and you, I guess, might have more of a suspicion of thyroid disease, and then you can try and confirm it with testing? I'm imagining that's your last thing rather than your first, is that right?

Natalie: Yeah. And even when I find, or if I find, an issue with the thyroid, I don't stop looking. I think that sometimes you can...as soon as we find something... 

Andrew: Well done.

Natalie: This is what I did in the past as an early practitioner, I would find something and be like, "Aha, I found it, that's it, that's the problem, no need to keep looking." But for me I'm like, "Okay, so I found a thyroid issue, but why has it developed in the first place and why is it there?" And I definitely think that looking really thoroughly at every single element of someone's health is super important. Including, as you mention, I think sleep apnoea is a huge thing, dental health is a huge thing, breathing properly. I know you had my friend and colleague Lewis on the podcast who would have spoken about that.

Andrew: Yes.

Natalie: And that's really opened up my eyes to that side of things, as well. I think a lot of us don't connect oral health with overall health, and I see that a lot. The more I ask about it now the more I'm like, "Oh my gosh. Wow, it's an issue."

Andrew: Okay, so moving on from that, are there any common thyroid patterns in the results that you see that might help us understand what might be driving this thyroid issue?

Natalie: Yeah, absolutely. And I think here is definitely where I want to get a bit more practical. Because I know when I'm listening to all these wonderful practitioners on the podcast, there's nothing I love more than some tips that I can actually use in practice the next day. And I want to give a shout-out here to Rachel Arthur whose education has definitely helped me develop my skills in this area. 

Andrew: Yes.

Natalie: And anyone listening, she has a few thyroid MasterClass series and things like that which I have found really practical, as well.

So look, in terms of patterns, etc., I think one thing that is a great clinical clue in understanding what's happening in the thyroid gland is looking at, not just the amount of TSH and free T4 and free T3, but the ratios of them and their response to each other.

So a simple first example would be someone with an elevated TSH but low T4 and/or low or normal T3. What this is telling us usually is that the brain is sending the message to the thyroid to make thyroid hormone, but the thyroid doesn't have the resources it needs to actually make that happen. So I'd be thinking in this case things like zinc, iron, iodine, tyrosine, or just adequate protein intake, selenium. I just think about what does it actually take to make thyroid hormone and convert it, and they're the big things that I'd be thinking about.

Another really great clue is looking at the free T4 to free T3 ratio, which should be generally about three to one. And when we see an increase in this ratio, usually it's an indication that the conversion from T4 to T3 is poor. Which can come from several different causes, but the ones I see most commonly would be selenium deficiency, high cortisol, low carb diet, and inflammation. And on the flip side of that, if you see a ratio less than three to one, this can indicate an iodine deficiency.

So you obviously would need to go on to test that using... Personally I use a random urinary iodine test. And there's no perfect way to test iodine, that's just the way I choose to use it, alongside symptoms. And I'd also make sure that if you're testing iodine and you've got someone in front of you that you're thinking, "Well, I might be giving this person iodine supplementation," also running a thyroglobulin antibody test there, as well. And the reason I say that is because those people with elevated thyroglobulin antibodies in particular seem to be at a higher risk of adverse effects from high-dose iodine supplementation.

And then the other thing I think is really interesting and that I actually see a fair bit too, is the suppression of the whole HPA/HPT axis. So there will usually be in this case a low-ish TSH and low T4 and either...and usually a low T3, to be honest, as well. And sometimes this happens in patients with a history of chronic under-eating or eating disorders involving calorie restriction. Because we know that being malnourished or going through periods of starvation or even going through low carb diets with calorie restriction results in what's called “low T3 syndrome.”

So to my knowledge there are a few theories around it. So one being this kind of idea of your set point altering and also the peripheral conversion being impaired. And it's kind of like the response to thyroid-releasing hormone by TSH is kind of suppressed. So it's a shutdown probably as a protective mechanism at a brain level. Because if someone is starving, or perceived to be starving by malnutrition, the body needs to become efficient at running off very little and can't afford to turn up the engine and burn through more fuel, if that makes sense.

And I think while research shows that in some people simply repleting key nutrients alongside protein and overall calorie intake can definitely be enough to reverse it, it actually isn't the case for everyone. And from what I've read in the research so far, the main two possibilities or theories are that, one being the actual gland has shrunk due to prolonged lack of stimulation from TSH because of that kind of shutdown. So we know TSH literally stimulates the gland...

Andrew: Atrophy, yeah.

Natalie: Yeah. And then the other one is kind of like this reduced biological effect due to structural changes in the TSH molecule.

So I don't really know much more than that, admittedly, but my kind of go-to in these situations first is obviously to re-feed these people and ensure carbohydrate intake is also adequate, and to try and reduce any other kind of HPA axis issues and restore any micronutrient deficiencies. If that fails and this person is symptomatic, then sometimes a small amount of thyroid hormone replacement can be a big difference to their quality of life.

So quite a few patterns to look over. And that's certainly not all of the things I see, but those would be the most common. And I think it can be just so helpful in understanding what's happening. And what I'd encourage people to do is really understand thyroid physiology and the negative feedback and the building blocks for that. 

Because I think if you understand how something works, it's easier than just kind of rote learning and remembering it from just, I guess, that kind of view. If you understand what's happening, it's much easier for you to join the dots.

Andrew: Yeah. The thyroid is just probably the poster child of the negative feedback system, isn't it?

Natalie: Yeah, totally.

Andrew: I have a question with what you were saying a little bit earlier. So T4 to T3 being at a ratio of three to one, correct?

Natalie: Yes.

Andrew: Okay. What about reverse T3 here?

Natalie: Yeah, great question. And I used to measure reverse T3 a lot, these days I don't as much.

Andrew: Okay.

Natalie: I do when I can. And the reason why I don't is usually because of the expense of it and because I make the assumption that, well, most people that I am seeing are quite stressed, do have all of that going on. And the treatment to reducing reverse T3 is usually reducing or regulating cortisol and inflammation, and I'm going to be doing that anyway. 

So I think that it's a great tool to have. And if you can order it, absolutely do. But you don't... For me personally, I know that I'm going to treat the cause of the elevated reverse T3 if it's there anyway regardless of whether I see it properly or not.

In terms of measuring it and understanding it, what I'm looking for with a reverse T3 is that it's no more than 100 times greater than the T3 level. So that's what I would be looking for. Because it is relative to the free T3 that you have. 

So when you're looking at the result, you're looking at the free T3 that you've got and making sure that the reverse T3 is no more than 100 times greater of that free T3 on that test for that person, as opposed to just a random reference range that you usually get for reverse T3.

Andrew: Yeah. And stress is one of the biggest triggers of reverse T3. There was also though heavy metals, right? Mercury, is that right?

Natalie: Yeah.

Andrew: And cadmium, is that right?

Natalie: Yeah. Mercury more so, but definitely cadmium. And even just other heavy metals, as well, because they have such an affinity for the thyroid gland. But mercury for sure is a big one. And to be honest, sometimes I will just run a blood mercury as a first port of call, and obviously doing a lot of questioning. 

And this is where it's important to question around dental health and stuff, as well. Because how many people have fillings, or have gotten them removed without doing anything to help clear toxins or stuff like that after? So just really good history-taking is important.

Andrew: I was really interested when, I think it was, Ron Erlich, Lewis' uncle, telling me that dental dams were actually an approved device for mercury removal, that they were indicated. It wasn't just a nicety that some dentists did, it was like, that was standard practice. It was really interesting to me. I don't know a dentist other than an integrative one that uses them.

Natalie: Yeah, I know, it's amazing, isn't it? And it's really hard for patients. Because how do they... You don't know what you don't know. And unless we are teaching them how to be advocates for their health, so if they do have to get their mercury fillings removed, then how do we give them the information so they can be an advocate for their health? 

Because realistically there isn't a holistic dentist everywhere where all of our patients will be. But we can teach them to ask the right questions so that they are having a safe removal of those fillings if that's what's happening for them.

Andrew: Yeah. We like to think about the causes. And stress is obviously a major factor in many people's lives, I get it. But EBV, for instance. So the viral load, bringing on the classic fatigue. And that can indeed induce Hashimoto's, correct?

Natalie: Yeah, absolutely. And it's not just isolated to EBV. Any virus, like cytomegalovirus.

Andrew: So VS.

Natalie: Yeah. Anything from that herpes family can definitely be a trigger, as well. I think EBV is the most well-known one, maybe because of that Medical Medium celery juice guy.

Andrew: Yeah.

Natalie: But to his defence, he's right, EBV is absolutely one. And I think it's going after and just being really thorough in assessing these things. And obviously we can't completely rid the body of viruses, but we can certainly help decrease their reactivation. And so I think that's really important to know. And I just...I've observed definitely, treating so many thyroid patients, how many people have multiple chronic viral infections and viral loads.

And so I think it's definitely something that needs to be paid attention to. But again, I think something to come back to is even if you find that, don't stop looking, make sure you're still thorough. Because very rarely, in my experience, is it just one thing. And so you really need to just be thorough and not prematurely stop your case investigation, basically.

Andrew: Darn these complex patients.

Natalie: I know, right?

Andrew: So let's talk a little bit about that, the most common root causes that you see in clinical practice that drive thyroid disease. I guess specifically Hashimoto's, but there's others, as well.

Natalie: Yeah, yeah. So I would say there is a handful of ones that are kind of the frequent flyers. And I'd say nutrient deficiency, so things like inadequate protein intake, because then you're not getting enough tyrosine to even build the thyroid hormones. Low iron, selenium, zinc, and iodine would be the top ones. And I'd say that isn't necessarily specifically driving Hashimoto's, that would be driving more so inadequate thyroid hormones, with or without Hashimoto's.

Other things, definitely heavy metals and viral infections, as you mentioned. Gut issues are a huge one. So that could be SIBO, parasites, dysbiosis. And that's not just exclusive to Hashimoto's, also in Graves'. I had a patient not too long ago who had Graves' disease, got diagnosed with Graves' disease, was just in this massive flare. We used plenty of things to try and calm that down alongside medication, and then we started doing the work at looking at the underlying root causes and we found SIBO in her. Treated the SIBO, Graves' is in remission. So it goes to show you just need to be thorough in that case. 
And definitely there is a very high rate of patients that have Hashimoto's that also have SIBO. Because if you think about everything slowing down in Hashimoto's or an underactive thyroid, it makes it a lot easier for bacteria to overgrow if everything is not moving through that whole system very well.

And the other thing that often happens with thyroid patients because they're so tired, a lot of them will be eating or grazing throughout the day just to try and keep their energy levels up. And we know that kind of grazing throughout the day on food doesn't give much time for your digestive system to rest and for that migrating motor complex in your small intestine to actually do its sweeps of movement. So it's kind of a bit multifaceted there.

There is some correlation, as well, with H. pylori and Hashimoto's.

Andrew: Huh?

Natalie: Correlation, not causation.

Andrew: Yeah.

Natalie: So I think that's where it is at this stage. And I think same with Klebsiella and a few other ones that I can't remember right now. But again, correlation, not causation. And so I think it's something to be aware of. But again, once you find it, don't stop looking everywhere else.

Andrew: I wonder if, like the EBV picture, it's not necessarily just the EBV, when you consider that 95% of us have been infected. 

Natalie: Totally.

Andrew: Not 95% of us suffer the fatigue associated with it. So there seems to be these other antecedents that are around that cause this perfect storm and I wonder if this is the case with the H. pylori, the Klebs, all of that sort of thing, as well.

Natalie: Yeah, totally. And I think we have to remember that realistically we are far more bacteria and virus than we are human cells.

Andrew: Yeah.

Natalie: And it's really about how do we exist with them without it being a problem and how do we create more balance. I think a lot of the time it's this kill, kill, kill approach and no other way. And certainly there's a time to kill things, but there's also something to be said about how do we build resilience in the system and restore balance, as well. So I think that's a whole other can of worms in relation to gut health and parasites and dysbiosis and viral load, but definitely something that is worth attention.

And I think the other root causes I see a lot would be undiagnosed Coeliac disease and/or gluten sensitivity, mould illness, chronic inflammation, and I'd say high cortisol levels, or just general HPA axis dysregulation. Because the thyroid and the adrenals are such good friends, and so rarely are you going to see one off without the other being effected.

Andrew: How do you tease apart gluten sensitivity versus coeliac?

Natalie: Yeah. So I would first of all definitely be making sure that I am looking at running, first and foremost, a coeliac antibody test. Not perfect by any means, but a screening tool. It's kind of complicated because a lot of the patients that come to see me already are gluten-free and have been gluten-free for a long time. And so most of them, to be honest, don't feel well when they reintroduce gluten and don't want to. And how can I accurately test if they have coeliac disease without them having that...

Andrew: Without challenge.

Natalie: Yeah. And so I guess, a bit of a tangent here, but the discussion I have with people is that I'm not going to force them to anything, but I see my role as giving them the education that they need to make an informed decision. And the reality is that if I suspect that there's any chance that they have coeliac disease, then I will say to them, "Look, you have two options. One is that you eat gluten again and then we do a colonoscopy and an endoscopy and we get the correct gold standard diagnosis to say 'yes' whether you have it or 'no' whether you don't." And that kind of is the end, that's it, that's your answer. 
If you're not willing to do that, then my recommendation to you is that you assume you have coeliac disease. Because if you've got coeliac disease and you continue to eat gluten, there's just so much stuff...

Andrew: Even a small amount.

Natalie: Yeah. So much stuff that could go wrong. And a lot of people, to be honest, a lot of my patients, are just like, "Well, I'm happy to just act as if I do." And then I will go through coeliac education with them because it's so important that you do that. And I think there are some practitioners out there that will just be like, "The only option for you is you have to eat gluten and you have to do that test properly." But a lot of people are just going to go, "Well, I'm not going to do that," and then they don't understand the seriousness of actually being really diligent with it.

Andrew: Yeah.

Natalie: So I think it's just about presenting people with their options so they can make an informed choice. Because I'm definitely all about empowering people in that way. I think that too often we outsource our own health to other people, including practitioners. I think we're there to guide people, but they also have to be part of that process.

So yeah, I guess gluten sensitivity, coming back to your question, gluten sensitivity versus coeliac disease would more be process of elimination. So trying to go through the coeliac diagnostic process first, and if that has been cleared, there is no coeliac disease there, and they react to having gluten, then that's when I assume that there is an issue for them.

To be honest, most of the time I get people to eliminate it for 30 to 60 days, and then reintroduce it and see how they feel and educate them on the kind of symptoms that they might feel. So going back to it not just being a gut reaction, but are there any other symptoms that you feel, like an increase in brain fog, irritability, mood issues, is your skin funny, just all these different nonspecific symptoms.

And that way it teaches them how to understand what different foods are doing in their body, and then it's up to them, right? "This is the reaction you get when you have gluten, this is what's happening at a cellular level," or an inflammation level. Now you can make the decision of is that something you want to consume and it's worth it for you? Or is it something you want to avoid? I think that's really empowering for people to understand why they're doing something and what the consequence is, as opposed to just coming out and being like, "You can't eat this ever." Because that feels really, I don't know, really disempowering to me. If I was a patient, to hear that I would feel like, "Well, I'm not going to stick to something unless I know why." So I think education is part of that process.

Andrew: Well, I like the way that you prioritise that for the patient health. If you're not going to test, if you're not going to challenge, assume that you have it. Because just having a little bit can cause really bad effects, with even nutrient depletion and even future risk of other things. 

But I'm still sort of caught up though with regards to gluten sensitivity. If we're talking about what you said about resilience, and another word that goes hand-in-hand with that is nourishing the body, have you gotten to a stage where people, because they've healed their gut, they've settled the inflammation down in their body, they've addressed inflammation, triggers from other external events, like stress, can you get rid of or minimise gluten sensitivity?

Natalie: Yeah. Look, I think so. I think many of my patients who have gone through that process and then reintroduced things will find that they can tolerate more than they used to. And if they choose to eat gluten, some of them do tolerate it completely well as long as it's small amounts. And what I often tell people is the times to maybe indulge a little bit more if you're finding that you are okay with gluten, at least to an extent, then the times to do that might be when your stress levels are low and when your overall load on your system is much less. So when people are on holidays, a lot of them find they can get away with so much more.

Andrew: Right.

Natalie: And I think it's just about educating people about, in the body it's all about the load of stress. And that can come from so many different ways, emotional stress, environmental stress, physical stress, chemical stress, all these different things. And you have to make sure that your bucket isn't overflowing and recognising what things are filling that up and so that you're not adding too much on.

I would say, to be honest, any patient of mine that has a diagnosis of Hashimoto’s, I personally do encourage to avoid gluten for the long term if they can because of that stronger association between coeliac disease and Hashimoto's. So that's maybe where I'd be a little bit more like, "Look, my opinion on this is that if I was you and I had Hashimoto's, I would avoid gluten because I don't want to have any risk of triggering an additional autoimmune condition if I can easily avoid it." And nowadays mostly, it's pretty damn easy to eat gluten-free. And I think maybe it might have been a different story a long ago where it might have been socially isolating to eat gluten-free or more difficult or more expensive, but these days pretty much every restaurant or cafe that you walk in has gluten-free options.

Andrew: And reasonably tasty ones.

Natalie: Yeah, exactly. And I think the other thing that I'm really passionate about is making sure that when you're encouraging someone to go on a gluten-free diet, it's not like, "Here's a gluten-free product to replace your gluten-containing product." It's like, "How do I increase the nutrient density of this diet using whole foods that naturally don't contain gluten?" I think certainly there's a time for gluten-free products because we all love a slice of bread or love those kind of things here and there. 

But really when I'm trying to heal someone's body, not just am I looking at what am I taking out, but what am I putting back in. And that's kind of how I approach dietary changes, is providing people with what to put in, as opposed to what to take out. Because I think that it feels more achievable, as opposed to just giving them this long list of, "Don't eat this, that, this, that." It can feel really like, "Oh, what am I going to eat?" So yeah, that's my approach.

Andrew: Yeah, I'm trying to figure this out in my mind about the safety aspect versus the pragmatic aspects. And so I'm still caught on this coeliac versus gluten sensitivity. And I'm wondering if somebody has willingly excluded gluten from their diet but they don't have demonstrable coeliac disease because they refuse to challenge, but then every now and again they might sneak a little bit of gluten. Would you therefore maybe test something like iron in, say, a year or something if their fatigue continues? And I know this is getting off the track of thyroid, but I think it's an important issue to keep track of for health's sake.

Natalie: Oh, totally. I absolutely think that it's really important to be thorough in looking for the other clues, as coeliac disease or malabsorption. And I think definitely running iron studies six-monthly or yearly is important. And I would still go back, I would still...I'm very strong on those two options to people in terms of, if you're not willing to challenge you must, for your health, make sure that you are avoiding gluten like you have coeliac disease.

Andrew: Right, right.

Natalie: And I feel like I've done my job then. Because I can't force someone to do something that they don't want to do. But I can educate them on the consequences if they don't do what I'm saying, basically. And I think you can certainly still run more comprehensive coeliac antibody testing, there are more comprehensive sensitivity testing that you can do besides just the standard one that you get through Medicare. Oh, there's just so many that you can do. But personally I find doing challenges, like food challenges, to be really telling for people, either in conjunction with the testing or just on their own.

But I think at the end of the day if you can get someone to properly assess whether they have coeliac disease by encouraging them to eat gluten for a period of time, then I think that sometimes that it can be the better option because a lot of people require actual solid evidence for them to be really diligent in avoiding. But there are those people, and we all have them as patients, that are just like, "There is no way." And I totally understand that because this was my decision, as well. There's no way I'm going to eat that again, I know it doesn't make me feel well and I'm willing to assume that I have it and avoid it exactly like that.

Andrew: But I do love your advice about including other foods rather than just restricting those foods, the gluten. And you look for options rather than just restriction. I like that.

Natalie: Exactly. Thank you.

Andrew: Are there any other tests we should be running to pick up thyroid disease? We've gone through nutrient stuff.

Natalie: Yeah.

Andrew: We've gone through the hormones. Cholesterol is not sensitive. What else have we got?

Natalie: Yeah. Look, I love testing and I think that there's so much that you can get through a standard blood test without going down the functional route. Although I love functional testing sometimes, it's just not affordable for some people. So look, in terms of what I do personally, I look at a complete blood count to see what's happening with the immune system, I look at iron studies. I look at CRP, usually high-sensitivity CRP, to see what's happening in terms of inflammation. I might look at zinc and copper, selenium, vitamin D just from an immune and autoimmune protective standpoint. I do look at random urinary iodine if I can. And if they've presented with thyroid antibodies, I'd usually be screening them for any other autoimmune conditions, perhaps doing something like the coeliac serology, ANA and ENA.

And I also have to say that if it's a female client, I do also like to check to see what's happening with their oestrogen levels. Because we know that elevated oestrogen can elevate thyroid-binding globulin. And if you've got too much thyroid-binding globulin, which are like the taxis, then you're not going to have enough passengers, AKA thyroid hormones, out on the street, so not enough thyroid hormones actually free to kind of run about and do their thing, and that's going to cause symptoms.

And then beyond that, in my head I'm kind of going through the checklist above in relation to, like what I mentioned before, in relation to the root causes and any red flags that would indicate, for example, that this person has a gut issue or heavy metal exposure or mould issues.

And the other thing that I guess isn't really specific pathology testing but that I find particularly helpful, which I get all of my patients to do either on their own or I'll help them through it, is doing a health timeline. Because you'd be surprised at how many people's Hashimoto's is triggered by emotional stress or trauma. And we have to remember that, although for us, we assume that, well of course emotional trauma or stress or a divorce or a breakup or moving cities or going through a stressful job or anything like that, of course us as holistic health practitioners are like, "Oh, yeah, of course that's going to affect your physical health." But not all of our patients, or many of them, really will actually connect that dot unless you question them.

And so I find just asking them a lot of questions really helpful, and not going into any consultation with assumptions. So that's my number one rule which I've learnt the hard way, is never assuming that if someone doesn't tell you something it's not there, because often they're just not aware that it's an important piece of information for you.

Andrew: The antecedent, it brings back time and time again the value of a detailed and thorough family and patient history.

Natalie: Yeah, exactly. And I think sometimes one thing that's helped me, again a little bit of a sidestep, but something that's really helped me over time in clinical practice is that we only have a certain amount of time with a patient, like in an initial consultation. 

What I like to do is have a really thorough pre-consult questionnaire that they fill out. Because then I've kind of screened a lot of the questions. Because you'll find in a conversation with a patient they're not… people are generally storytellers. And so they're not just going to, most of the time, answer your question as a "yes" or "no," which means that the consultation ends up being really long. 

Whereas if you can get them to fill out a pre-consult questionnaire beforehand, you know where you need to further question this person and get out more information, as opposed to spending an hour or 90 minutes just asking question after question and hearing - and I know this sounds harsh - but hearing stories that maybe aren't helping you get closer.

I definitely think listening to people and taking time to hear the way they're speaking and the way they are is really important, as well, but I think you can only tick so many boxes. So a really thorough pre-consult questionnaire going through things like dental history, family history, gut symptoms, do you have a history of low iron, all these, have you lived in a water damaged building, all these different questions. Because if they answer "no" to something like, "Have you ever lived in a water damaged building, or are you currently in that, or have you had any mould issues that you're aware of?" you at least know that, "Okay, so I've screened them for that, so maybe I won't focus my attention here, I'll focus it on the fact that they've got a billion gut issues that they're ticking 'yes' to."

Andrew: So I would imagine that you've got a voluminous amount of intake forms.

Natalie: Yeah.

Andrew: So where can people get further information? Have you got things on your website? I understand you've developed a course?

Natalie: Yeah. So the course is for patients.

Andrew: Right.

Natalie: And it's a 12-week online course in relation to that. I am looking at, in the future, to look at opening up some mentoring around thyroid issues and just helping practitioners understand how to assess it better and treat it better. There's plenty of information on my podcast that I run, which is called The Holistic Nutritionists Podcast. And there's also information on my website, just in terms of blog posts and stuff like that. And I would say, not my information, but Rachel Arthur has some great practitioner-centred education around that.

Andrew: Yes.

Natalie: So that's probably where I'd direct people.

Andrew: Yes. Can I ask you what's your favourite textbook with regards to thyroid health?

Natalie: Gosh. I don't think I have one, to be completely honest with you. I think I've gathered most of my information around thyroid health from doing different courses, through Rachel Arthur's stuff, through reading the research. Through a lot of Izabella Wentz, who I know you had on the podcast a long time ago.

Andrew: Yes.

Natalie: I think she's got some really fantastic information and a lot of links to study. So I think just... Amy Meyers, who we had at the Bioceuticals Research Symposium. I think that's where I get most of my information, I don't particularly have a textbook, so to speak.

Andrew: Natalie Douglas, thank you so much for taking us through. This is a quandary, let's face it. And it does require ongoing education. And you've got some really great practical information not just for patients, but importantly for all of us practitioners to review and to keep on top of so that we can help our patients better. And thank you so much for taking us through some of these today.

Natalie: You're welcome. Thanks for having me.

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


other episodes with natalie include

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Natalie Bourke

Natalie is a holistic dietitian and nutritionist, author, podcaster, speaker and fitness instructor. She is part of the practitioner support team at one of Australia's leading providers of therapeutic supplements and runs Health By Whole Foods, a nutritional consulting business with a clinical focus on thyroid dysfunction, HPA axis dysregulation (or “adrenal fatigue”), and gut health.  Nat is passionate about helping women build a healthy relationship with food and their body; she achieves lasting results for her clients using whole food nutrition, functional medicine and holistic lifestyle advice. You can catch her fortnightly on The Holistic Nutritionists Podcast, with fun and quirky interviews that aim to dispel nutrition myths and guide listeners on a balanced approach to health. Her eBook, Healing Digestive Discomfort, is an industry-leading guide with accessible guidance for anybody looking to start improving their gut health.