If you have Hashimoto's or Hypothyroidism and weight loss feels impossible, then you need to read this patient case study.
This is a case study from my office and I want to share it with you guys so you know that feeling better is NOT impossible.
It's not uncommon for me to receive emails like these:
But for many patients out there suffering in the insurance model, it can be difficult to get the care they need.
If you fit into this category you can find resources to help you find a knowledgeable doctor here.
So let's talk about what it takes to lose 50+ pounds, drop 40 inches and reduce Hashimoto symptoms by almost 100%.
**Update 12/2/16: Patient now down to 191.2 pounds from starting weight of 250. 50+ pounds lost over 9 months so far with pictures below and progress below:
You can find the exact same program this patient used to get these results by clicking here.
**Update 8/22/16: This patient has now lost 40+ pounds and over 40+ inches...
Hashimoto's Weight Loss Case Study
Here is the bottom line:
This patient has a family history of thyroid problems (all of which were undertreated or misdiagnosed), and ever since she was a child she had issues with weight, fatigue and decreased energy.
At an early age, she underwent radioactive iodine ablation, but 30% of her thyroid remained functioning as estimated by her Doctors at that time.
Despite this ablation and because of her "normal" lab values she was only placed on a low dose of levothyroxine and felt terrible for about 20 years.
Over this time period, she gained weight while on levothyroxine and never really felt better so she eventually stopped taking the medication.
She was kicked around from Doctor to Doctor until she was at her highest weight of 270 pounds.
Not satisfied with this result she took matters into her own hands and was able to lose 30 pounds by changing her diet and adding in exercise despite feeling exhausted 24/7.
She was able to do this with a keto type diet but eventually hit a plateau and was unable to lose any further weight around 250 pounds.
Even after losing this weight she still didn't feel well.
Optimal vs Normal Thyroid Lab Tests: Why she was undertreated for years
The most interesting part of her story is that she was only ever treated with a low dose of levothyroxine despite seeking care from multiple endocrinologists and primary care physicians.
She was always told her lab tests were "normal" but after her insistence, she was finally given some thyroid medication even though it didn't make a difference.
And this is where things get very interesting.
One of the primary reasons that she was never treated correctly is because her Doctors were most likely using the "standard" reference range for determining if her thyroid was functioning optimally.
What they were missing is the body's remarkable ability to maintain serum levels of thyroid hormone despite missing 70% of her thyroid.
So let's see what her labs looked like knowing that she only has about 30% thyroid function:
As you can see the majority of her lab tests do fall within the "normal" range with the exception of her CRP and thyroglobulin antibody levels.
But let's go over the rest of the labs to help you understand the difference between "optimal" and "normal" and why she had great results when we finally replaced the deficient thyroid hormone in her body.
List of abnormal lab results:
- Suboptimal TSH: When not on thyroid medication optimal TSH levels should be < 2. In fact, I've never seen a healthy patient with a TSH > 1.0 (you can read more about why TSH levels can be inaccurate here)
- High Reverse T3: Indicating poor thyroid conversion. Reverse T3 should generally be < 15 for optimal thyroid function.
- Elevated thyroglobulin antibodies: Indicating a component of autoimmune thyroiditis contributing to poor thyroid function. You can read more about how to lower antibody levels here.
- High fasting insulin: Fasting insulin should be < 5. High levels contribute to weight gain and weight loss resistance and may make reverse T3 levels higher.
- Elevated CRP: Indicating inflammation is present in the body, optimal levels should be as low as possible.
- High leptin levels: High levels make TSH less accurate and promote high reverse T3 levels.
Compare this evaluation to the previous notion that she was completely "normal".
Using these functional and optimal reference ranges it's easy to see that she is in fact NOT normal and that she has multiple hormone abnormalities contributing to both her symptoms and weight loss resistance.
So what is happening in her body and how does this explain her symptoms?
Most likely she was suffering from tissue level hypothyroidism since her ablation at a young age which contributed to her initial weight gain.
Putting her on thyroid medication at that time was probably the best option for her but unfortunately, she was placed on a low dose of the wrong type of thyroid medication.
As a result of her undertreated thyroid for many years her body was put in a situation which allowed her to develop several other hormone imbalances such as leptin resistance and insulin resistance.
These hormone imbalances lead to further weight gain and contributed to poor thyroid conversion and ultimately high levels of reverse T3.
Because her Hashimoto's was never addressed (beyond the addition of thyroid hormone) she most likely also had further damage to the 30% of her functioning thyroid gland over time.
Ultimately she finally presented to me with these lab results and symptoms.
It's also important to note that when we discuss serum levels of thyroid hormone we are more concerned about how much thyroid hormone is getting into the cells not necessarily how much thyroid hormone is floating around in the serum.
"Normal" levels of thyroid in the blood do NOT mean that the tissues are getting enough thyroid hormone and this was certainly the case in this patient.
Her serum levels of free T3 and free T4 remained relatively preserved but she remained quite symptomatic.
For this reason, the most sensitive measure of thyroid function is the relationship between Free T3 and reverse T3.
And this patient is just screaming that she is hypothyroid with a ratio of 0.128!
The secret to diagnosing and treating many hypothyroid patients is this ratio because it will identify most hypothyroid patients when all other lab tests are "normal".
Treatment Plan + How to Approach a patient like this
The most important part of this patients evaluation is her management.
What I mean is how we treat her.
Many patients believe that if they can get all the "right" tests that their Doctor will finally treat them appropriately or change their medication or increase their dose.
This rarely happens.
And when it comes to getting results like this patient you really need to find someone who is willing to not only order and interpret the right tests but to also provide appropriate treatment.
So how do you approach a patient like this with multiple problems who is severely undertreated?
You have to take a comprehensive approach that includes treating the following areas:
If these areas are not all addressed at some point then you're not really treating the problem.
And this is a REALLY important point:
Make sure you don't get what I call "thyroid tunnel vision".
This is the idea that every problem that exists in your body is related to your thyroid and the solution is to simply change/increase/swap thyroid medications.
Patients tend to fall into this category especially when they have extra weight to lose.
They wrongly assume that increasing their thyroid medication will result in significant weight loss.
At most changing or adding in thyroid medication will result in a 5-10 pound weight loss.
If you have more weight to lose this extra weight is most likely related to other factors.
Let me use this patient as an example:
I've been treating this patient for 9+ months and over this period she has had significant weight loss and almost complete resolution in her symptoms.
But what is interesting is that her hypothyroid symptoms were almost completely gone within the first 3 months of her treatment, but she only lost 20ish pounds or so during that time.
The remainder of her weight loss came in months 3 through 9 and without changing her thyroid medication.
She was able to lose this weight because during those months we focused on the other hormone imbalances that were a result of decades of low thyroid function but not directly due to thyroid hormone itself.
Unfortunately replacing thyroid hormone will help with symptomatic relief but rarely ever does it result in significant weight loss because adding T4 and T4 doesn't alter insulin/leptin levels very much.
This means appropriate treatment must include evaluation and management of these other hormone imbalances if weight loss is the goal.
- Bottom line: When searching for a provider to help with your Hashimoto's/Hypothyroidism make sure your provider also understands hormone imbalances that contribute and potentiate weight gain and weight loss resistance.
T4 vs NDT & Reverse T3
Why did this patient respond so well to Nature-throid when she didn't respond to levothyroxine previously?
A big part of the reason has to do with conversion mechanics between T4 only medications and T4/T3 combination medications in physiologic conditions.
T4 only medications (like Levothyroxine, Synthroid and Tirosint) can work for some people but fall short in patients who have high levels of inflammation or insulin/leptin resistance.
One of the primary reasons for this is because the body must convert T4 into either T3 (active thyroid hormone) or reverse T3 (inactive thyroid metabolite) and this conversion process is influenced by factors like inflammation.
If the body is in a state of inflammation then providing more T4 (in the form of thyroid medication) is like adding fuel to the fire: your body will take the T4 and turn it right into reverse T3 making hypothyroid symptoms worse.
So how is T4 only medication different NDT formulations like Nature-throid?
Natural desiccated thyroid preparations contain a combination of T4 and T3 together. Each grain of Nature-throid contains 38mcg of T4 and 9 mcg of T3.
The benefit of adding T3 to T4 dosing is that the T3 can directly bypass the conversion pathway and hasa direct action on the nuclear receptors of your cells.
That means that you don't have to worry about your body converting T4 into reverse T3 because by providing T3 directly you have bypassed that pathway.
So generally the more inflammation, autoimmunity, stress, and hormone imbalances a person has the better they will do on T3 formulations of thyroid hormone.
Hopefully, this is making sense to you!
So how do you find the right dose?
Nature-throid Dosing and Self-Titration - How to Dose your Medication
I started this patient on a base dose of Nature-throid and included a self-titration dose.
If you've never heard of self-titration let me explain:
This is the idea of slowly but steadily increasing your dose every 10-14 days (depending on the patient) based on a combination of symptoms, lab results and other factors (like resting heart rate/body temperature).
The benefit of self-titration allows for a slow and steady increase in thyroid hormone over weeks to months. This allows the body to adapt to thyroid hormone and prevents sudden and abrupt changes to thyroid dosing.
While self titrating I have my patients keep track of their basal body temperature and resting heart rate so we can monitor how effective the thyroid dosing is to ensure that we do not use too much thyroid medication.
The patient in this case study titrated her dose up to a total of 2.5-3 grains of Nature-throid (around 195mg).
As I mentioned previously as she increased her dose many of her hypothyroid symptoms disappeared over the first 3 months or so.
Finding the Best Diet: AIP vs Nutritional Ketosis vs other diets
Diet is critical to treating and reversing Hashimoto's and if used correctly it can also directly impact insulin and leptin levels.
What you need to realize though is that changing diet is usually not enough to impact weight significantly, especially if you have hypothyroidism.
I've written about the various diets you can use to help reduce antibodies and inflammation here.
In this particular patient, I started her on the autoimmune protocol (or AIP diet).
I generally don't recommend this type of restrictive diet for most patients this case is unique in that she had multiple autoimmune conditions including idiopathic thrombocytopenic purpura (1) (AKA ITP) in addition to Hashimoto's.
Because of this, I started her on the AIP diet and she did have a favorable response with a reduction of inflammation and a decrease in joint pain over time.
Some patients wrongly believe that simply switching to the AIP diet will result in weight loss. While the AIP may result in reduced inflammation which may improve T4 to T3 conversion, generally patients do not experience significant weight loss with dietary changes alone.
This is especially true in patients with other hormone imbalances.
Prior to working with me, she had tried the ketogenic diet or nutritional ketosis with minor success.
This particular diet is high in fat and low in both protein and carbohydrates. Very low carbohydrates promote fat breakdown and part of this metabolic break down is the production of ketone bodies (assuming carbohydrates are low enough).
This particular diet can be helpful for those with insulin and leptin resistance if used correctly.
So did switching to AIP in this patient result in her weight loss?
Most likely not, but it certainly helped.
At the end of the day make sure to tailor your diet to the needs of your body, energy levels, adrenal function, and thyroid function.
Using LDN for Autoimmunity and Inflammation
LDN can act as an immune modulator and help to reduce inflammation in some patients with autoimmune disease.
It doesn't work in every patient but I've found it to be particularly helpful in patients with autoimmune disease and chronic pain/chronic joint pain.
In low doses, naltrexone may help to regulate immune function and balance multiple different neurotransmitters (4) which translate to symptomatic benefit in many patients.
LDN can also be used as a novel anti-inflammatory agent (5) which may help promote thyroid conversion and thyroid function overall.
In addition to all of these other benefits, naltrexone can help promote weight loss through hypothalamic changes (6) which mediate body set point and appetite triggers.
In this particular patient, LDN was used to help reduce inflammation and joint pain.
At one point during her therapy, she attempted to take herself off of the LDN and noticed a flare-up of chronic pain and joint inflammation, due to this she was placed back on the medication and has been on it since.
The Right Nutrients to Help Thyroid Function
Replacing lost nutrients is very important to proper thyroid function.
Over 13 nutrients are required for proper thyroid production, conversion and cellular activation (you can read about all of them here).
As a reminder:
Supplements can certainly help improve and reduce symptoms of hypothyroidism and Hashimoto's if used correctly and targeted toward specific nutrient deficiencies.
To get the best possible results supplements and nutrients should be used to augment existing therapies and dietary changes.
In this specific case this patient needed and did well on the following nutrients (she has been on various supplements through the 9 months of treatment but these have remained consistent):
- Vitamin B12 Injections - For Vitamin B12 deficiency (learn more about why B12 shots are better for patients with Hypothyroidism and Hashimoto's here).
- Zinc + Selenium - Zinc and selenium act to lower inflammation, balance immune regulation and promote T4 to T3 conversion (helpful in patients with high reverse T3).
- Adrenal support - Cortisol dysregulation is common among patients with hypothyroidism and adrenal function should be treated along with thyroid hormone replacement.
- Probiotics - Decreased motility of the GI tract is common among hypothyroid patients due to thyroid action on peristalsis, GI dysfunction should be a cornerstone of treatment
- Liquid Vitamin D + K2 drops - To replace low Vitamin D and to promote immune function
Detoxing Endocrine Disrupting Chemicals
Detoxification of endocrine disrupting chemicals is an important part of treating Hashimoto's and Hypothyroidism.
EDC's are everyone nowadays, and it's almost impossible to avoid them.
What's worse is that some of them are fat-soluble and hide away in your fat cells (7).
Then, once you start burning fat as an energy source, they are released and can sometimes cause worsening thyroid function and halt weight loss.
To eliminate these toxins I had this particular patient start with weekly FAR IR sauna therapy in addition to high-intensity strength training and high-intensity aerobic interval training to promote sweating and toxin elimination.
Sauna therapy combined with this type of exercise promotes hormone balance, helps burn more calories and helps eliminate waste through sweating and triglyceride elimination.
Recap of Treatment and Therapies
Proper weight loss therapies result in a steady 5-10 pounds of weight loss each and every month.
Some patients wrongly believe that weight loss needs to be rapid and noticeable within 2-4 weeks and this is not accurate.
Weight gain is a slow and steady process (usually) and weight loss is the exact same.
As long as you stay dedicated and consistent weight loss will be the same.
Let's recap the initial treatment:
Initial 3-month Results:
30 Pound weight loss, 27 inches lost, 80% reduction in symptoms, improvement in hormonal balance by blood tests.
For the next 3 months, we are going to work on reducing and reversing Insulin resistance, balancing out testosterone levels and helping her lose another 30 pounds.
I expect her to continue to lose 10 pounds per month on average until her body reaches a physiologic balance.
I will plan to keep this updated every couple of months with more progress to give you a realistic idea of how long it takes to reverse Hashimoto's and achieve long-lasting weight loss.
Leave your questions or comments below!
I want to know if you've had success with weight loss with your Hashimoto's, why or why not? What has worked for you and what hasn't?
Update #1 6 month results (8/22/16):
Patient has now lost 20+ inches and another 15+ pounds.
She continues to do well and has managed to lose the weight and more importantly KEEP it off using this treatment plan.
The following are email screenshots including her results and measurements:
Update #2 9 month results (12/2/16):
Update #3 (2018):
For those of you wondering, this person is doing great! She hit her goal to get under 200 pounds and she has successfully kept her weight off for over 2 years.
This patient continues to lose weight and inches.
She broke through her goal of losing 200 pounds and is now down to 191.2 pounds from a starting weight of 250.
Her initial waist was 39.5 inches and she is down to 30.5 inches.
In addition, she is now exercising, has more energy and has remained consistent with her supplements and medications.
Update #3 (2019):
For those of you wondering, this patient is doing great!
She has successfully kept her weight off and she continues to feel better.
It IS possible to lose weight AND keep it off if you have Hashimoto's.
I know that losing weight may seem difficult or even impossible if you have Hashimoto's or Hypothyroidism but it doesn't have to be.
You can lose this kind of weight too as long as you target your hormone imbalances.
The most important part of this patients weight loss was targeting her leptin and insulin levels and treating those.
Replacing her thyroid hormone resulted in resolution of her symptoms, but her weight and inches didn't fall off until we addressed these issues.
You can see other case studies of patients just like you losing weight as well, just take a look around the site.
You can find more information about my hormone and weight loss mastery guide (the program that this patient underwent) by clicking here.
Do you have any questions about this case study?
Leave them below in the comments section!
References (Click to Expand)