Healing Hashimoto’s Disease with Andrea Nakayama

In this episode of The Dr. Hedberg Show, I interviewed Andrea Nakayama in a discussion about strategies for healing Hashimoto’s disease.  We talked about her “3 Tiers to Epigenetic Mastery” and how they relate to Hashimoto’s disease and thyroid health.  Within the 3 tiers we discussed stress, gut health, infections, micronutrient deficiencies, adverse childhood experiences, SIBO, reproductive hormones, goitrogens, iodine, and all the various diets that people are following these days.

Dr. Hedberg: Well, welcome everyone to “The Dr. Hedberg Show.” This is Dr. Hedberg and I’m really looking forward to my conversation today with Andrea Nakayama. And she actually had me on her show, “The 15-minute Matrix,” talking about infections and Hashimoto’s disease. And she’s extremely knowledgeable. She knows a lot about thyroid issues and Hashimoto’s, which we’re gonna get into today. So Andrea, welcome to the show.

Andrea: Thank you so much, Dr. Hedberg. I’m so pleased to be here.

Dr. Hedberg: So for the people who don’t know that much about you, why don’t you just give everyone a little bit about your background and what you’re working on these days in functional medicine?

Andrea: Yeah, thanks for asking. I’m a functional-medicine nutritionist, and I’ve created a curriculum for practitioners where I train into the theories of a functional-nutrition approach, both the science and the art of working in what I consider to be the gap in functional-medicine or holistic-medicine approaches. So I have a school called Functional Nutrition Lab. We have about 4,000 graduates in over 65 countries at this point. And we also have a virtual clinic where we work with patients directly and serve, again, the underserved population. I think of the people we serve as the big bigs. They have big health issues and they’ve already made a big effort, sometimes working with the top doctors around the country. So that’s the work that I do that I feel really passionate about. And I myself, I’m a patient. I have Hashimoto’s. I have had quite a life journey that led me to uncovering my own autoimmune disease. And I manage it so that I can live the best life possible.

Dr. Hedberg: Let’s jump into the what you call the three tiers of epigenetic mastery. And so, this is a kind of a system or approach to healing and functional medicine. So can you walk everyone through this approach that you’ve created?

Andrea: Yeah, absolutely. I definitely see, like I said, that there is a gap in functional medicine. And I am completely in service to the functional medicine model. I really believe that we have to see the person as a whole. We have to look at the roots. We have to work in therapeutic partnership. And we have to see through systems, a systems-based approach, both biological systems and understanding the web of interconnections, but also a systematic approach that allows us to work with those who are sick and not getting better. So if we honor the truth of bio individuality and see every single individual as unique in their own way, not just a diagnosis like Hashimoto’s or like I experienced with my husband having a brain tumor, you know, he was treated like a brain tumor, if we’re to see each individual and each patient as unique, we still need a systematic approach. Otherwise, we’re constantly in the dark looking for solutions.

And that’s why I created the three tiers to epigenetic mastery. I saw it as a way to teach into honoring the individuality of each patient. So the three tiers are, tier one, what I call the non-negotiables. Tier two, deficiency to sufficiency. And tier three, dismantling the dysfunction. And what I see in functional medicine is that we often go to the tier three approach. We often want to skip to the sexy infection or the thing that’s happening in the body that may be one of the roots. And yet, there is so much terrain surrounding that root. There’s the soil that we also need to address. So these are those three tiers. And we could look at them, in particular to Hashimoto’s, and think through that lens. I also just wanna say that the three tiers are not necessarily linear. They are things that need to be addressed all at the same time. So it might not be that we’re bypassing one to just look at one of the others.

Dr. Hedberg: Yeah, you bring up a good point about going after what might be on the surface. When I launched “The Infection Connection” in around 2010, 2011, I’ve gotten so many emails from practitioners who, you know, went through the training and learned how to treat infections like Epstein-Barr virus. And I’ll get an email saying, you know, “I’ve been treating the Epstein-Barr and, you know, it’s still positive and they’re still not doing well.” And then, I asked them, “Well, you know, what else are you really working on?” Because, I mean, you can go in and you can attack the virus and suppress it but if you’re not really addressing the reasons why it’s active in the first place, then you’re not really going to get anywhere.

Andrea: Exactly, exactly. And we have to think about these three tiers again as the soil in which that root exists. And I think one of the mistakes that we’re making in functional medicine is that there’s so much focus on the root cause that patients are now seeing it as the quick fix. “If I get this test done, if I find the root and address that root, everything will be better.” And they’re not necessarily seeing that in a state of chronic stress or with certain deficiencies at stake, that it is very difficult to address that root, that it might not work. It might not actually be a quick fix. And I think that, again, is one of the mistakes that we’re making.

Dr. Hedberg: Yes, let’s build on that a little bit. I’m glad you’re here to talk about this. And I had Chris Kresser on the show a few months ago and we talked a little bit about this as well because I have concerns about functional medicine. Sometimes it feels kind of like the Wild West. And, you know, you and I both train clinicians in functional medicine. And one of the issues is that you can take a patient with, say, Hashimoto’s disease, and they can go to…let’s just say you send them to 10 completely different functional medicine practitioners, you know. They could be people who are highly-seasoned, you know, well-trained, and you’re still going to get variation in how the patient is approached. Even within functional medicine, there’s gonna be preferences on certain labs that don’t really make sense other than the practitioner just says, “Well, this is what I feel the most comfortable with.” Or, you know, the supplements are gonna be highly variable and the types and the doses and the frequency. The diet will be variable.

I mean, you know, the patient with Hashimoto’s, they could go to 10 practitioners and there’s not going to be 10 identical diets for that particular patient. You know, one practitioner might be, you know, on the keto train or autoimmune paleo, or vegan. I mean, we have difficulty with some kind of standardization and I can see why conventional medicine can be very skeptical of what we do. So how do you see that whole issue and how do we move forward in the right way with developing some kind of consistency across practitioners?

Andrea: Yeah. I mean, I think scope is very very important. And I like to say I train the allied functional medicine practitioner. And the truth is that there isn’t one diet for any individual no matter what their condition. Let’s say, we’re talking about brain tumors and we know the research shows that a ketogenic diet can be beneficial in this situation. If that brain tumor patient is in the midst of going through treatment, chemotherapy, radiation, surgical intervention, it might not be the right time for a ketogenic diet. We cannot just look at situations in relation to a diet. And this is, again, where I think the allied functional medicine practitioner comes in to really assess who is this patient, where are they. And diet is not just a handout. We really need to understand what is this person capable of in their life and what is the necessary intervention right now, and where is it tiered.

So somebody getting a handout or being sent to a blog post or a Pinterest page with autoimmune paleo may not be appropriate for them given the other stressors in their life. And this is, again, where I see the need for a practitioner who can work with the reality that that individual is in, and not just say, “This is the right diet. This is the right test.” I like to say all information that we gather from the patient is true but partial. And that’s why, in our practices, we do very very deep assessment. And that assessment includes what I like to call the story where we look at the antecedents, triggers, and mediators. The soup, where we look at the biological function, and the skill, where is this patient right now and what are the necessary next steps that will take them on this journey towards healing as opposed to saying that there is a quick fix.

So we need to, through a tier-one approach, those non-negotiables, those are gonna be individualized. And I think that is how we honor the practice of functional medicine. We say that we are looking at the whole person and that it’s an individualized approach and all information is true but partial. And the best partner on the case is the patient. And it’s our job to educate the patient to be their best partner as opposed to us sitting in the seat that we’re the god or the goddess with all the answers.

Dr. Hedberg: Right, right. So, as you said in the beginning, you’re a patient as well and you have Hashimoto’s. So why don’t we dig into that a little bit because a lot of the listeners have Hashimoto’s. And so, where, in this three-tier system specifically for Hashimoto’s, where are you going to dig first and how are you going to approach the patient?

Andrea: Yeah. So if we think through the tier-one approach, the non-negotiables, the first thing I like to do is what I call clear the muddy waters. How do we see what’s contributing to the stressors in life and in the body? So stress, as we know, is a huge factor that can inhibit proper production of thyroid hormones. Of course, infection and trauma are also factors that can inhibit proper production of thyroid hormones, but I wanna look at what are all the stressors on the body, where are their toxic stressors or metals, you know, how are we ingesting fluoride or what’s in the body, in the diet that’s also causing stress. So I like to say if you’re not sleeping, pooping, and your blood sugar isn’t balanced, it’s very hard to pass go. So those become part of the non-negotiables for me.

And, of course, there’s a lot of individuality in those issues. So if one patient with Hashimoto’s isn’t pooping, it may be for different reasons or different deficiencies than another patient. And that’s where the discovery comes in. But, of course, with Hashimoto’s patients, because of motility issues, because of the slowed metabolism, we do need to look at elimination and where the lack of elimination may be causing a buildup of extra toxins that’s leading to further stress. So I do like to think about how are we eliminating and how do we get that going for that individual? Is sleep functional, meaning, is it giving you the best rest possible? Again, we have to do some deep assessment to see, are they falling asleep? Are they waking in the night? Are they waking feeling rested? What are the appropriate interventions and recommendations based on their sleep problems? And is blood sugar balanced for that individual? Which, for each of us, could mean something very different.

But I see the hormones as a sort of pyramid with that blood sugar and insulin balance at the very base of that pyramid. And thyroid hormones exist somewhere up above that. So building that foundation as part of our non-negotiables and looking at what that means for each and every individual. And, of course, deficiencies, our tier-two issues, could be a non-negotiable. And you speak about this beautifully. There could be a nutrient deficiency, whether it’s iron, or one of the B vitamins, or vitamin D, or zinc, or selenium. Those can be a tier-two issue, a deficiency that becomes a tier-one non-negotiable for that individual because they’re so deficient.

Dr. Hedberg: Right, right. If they have a ferritin of 5, that’s…

Andrea: Exactly. A non-negotiable.

Dr. Hedberg: Yeah, I mean, that’s borderline. This patient might actually need intravenous iron, you know, just to actually function. So the gut, sleep, and blood sugar, those are kind of the top three and those are three really important places to start. So I think that the adrenals would also tie into there. You mentioned stress, and so that’s an area that you’re looking at. And I guess we could tie that into…

Andrea: Blood sugar.

Dr. Hedberg: Adverse childhood experiences trigger, trauma, relationships, work, all those kinds of things.

Andrea: Yes. When I had you on “The 15-minute Matrix Podcast,” we mapped infections and autoimmunity. And we mapped that on the functional nutrition matrix. And that does help us to look at and assess story which includes, again, those antecedents, those triggers, like adverse childhood experiences, those mediators, what do we know works for us and doesn’t work for us and how do we honor that in our care. So the story, the soup got being a huge part of our starting point, as you said, not just with elimination but with digestion and absorption, all the way through from the brain, all the way through to elimination. And then that skill section, what are we doing to care for ourselves with our exercise and movement, our nutrition and hydration, each piece that we bring into the skills arena. So it’s a full-systems approach where we’re not just targeting one area and addressing it but seeing how they’re all interrelated.

Dr. Hedberg: Right, right. So the gut, you know, very important. And I’m currently writing an article on SIBO and Hashimoto’s and, unfortunately, there’s only two papers ever published on that connection. There’s a few more on hypothyroidism and SIBO. Is there anything that you’ve found in your research with SIBO and the thyroid that you’d like to add?

Andrea: Well, I think there’s a definite barrier issue, just energetically, if we look at SIBO as a trespassing of the bacteria into the wrong location in the body. I think that all throughout we have to be looking at where are there barrier systems in our life, in our gut, in our heart, in the way we conduct ourselves throughout life? But, certainly, when we have an infection at that level, we are triggering an entire immune response through the whole body that confuses and really falters the entire immune response and can cause that tissue attack. So I think we have to look at infections and look at calming the immune system down overall. But as you know, SIBO is difficult to address. It’s not an easy condition. And I think, again, it takes this full-body systems approach.

Dr. Hedberg: Right. Let’s talk a little bit about hormones. And would you put hormones usually around tier-three further downstream, or where do you put reproductive hormones like estrogen, and testosterone, progesterone?

Andrea: Yeah. I mean, it depends what we’re seeing. So if we’re testing or if we’re able to determine that there is a hormone, a sex hormone imbalance, I definitely still go what I call upstream or what we in functional medicine call upstream, which is gonna be tier one, tier two for me. So, again, with hormones, if we look at it like a pyramid, I see blood-sugar balance, insulin, cortisol, thyroid hormones, and sex hormones. The sex hormones are so delicate, those chemical reactions in the body, that I’ve found that if we bring balance to the hormonal function from that base, from that blood-sugar balance, and deal with the gut elimination and liver function where we can detox the “bad estrogens,” we actually can start to resolve the symptoms associated with sex hormone imbalances as opposed to targeting them in a tier three approach. So let me just say I’m not against that intervention. I’m not against bioidentical hormone replacement therapy. But I see that we can intercept that and sometimes not have to go there, and also that we’re better served when we do both and when we really pay heed to diet and lifestyle modification in addition to doing the tier three interventions.

So this is where it really becomes the complexity of how we look at the whole systems. And it’s a yes-and approach. I’m not against any medical…well, I shouldn’t say any medical intervention. There are some medical interventions that I would be against. But in many situations, it’s the yes-and. How do we say, “Yes, that intervention is needed and what do I, as a patient, what can I do to support myself?” And I think, Dr. Hedberg, education of the patient is key here. And, again, you do this so well in your work, but we need to educate the patient about what’s going on in their body because there is a tendency to look for the quick fix of any sort. And the more we understand our bodies and how they function, the better we can get into our own care in what we do every day between our doctor’s visits.

Dr. Hedberg: Right. And that can be difficult sometimes, getting that message across about patients and people who are really…I mean, everyone who isn’t feeling well wants to get better as quickly as possible. But they also have to understand that it can take a lot of time and it can take some really difficult decisions sometimes in our work and in our personal relationships and things like that. So do you refer much for things like psychotherapy, EMDR, somatic experiencing, things like that? Or what do you like to use for the psychoneuroimmunology aspect of Hashimoto’s?

Andrea: Yeah, this is a realm that I see is really necessary for partnership all around what we do in the realm of the allied functional medicine practitioner. I think it’s a missing realm. I think it’s actually not identified. Sometimes I feel like I’m shining a light in a dark hole and saying, “Look, this is missing. We’re not thinking properly about the detail of diet and lifestyle modification.” And I’m saying we solve it at the same time. So I know we all pay heed to it in functional medicine but it’s really where we dive in and spend our time and attention. And that means we’re seeing all parts and making referrals as necessary. So that referral may be for some sort of relaxation technique like acupuncture. It may be for EMDR therapy to deal with past trauma. It may be for an osteopathic intervention to deal with getting the body in alignment and getting that vagal nerve stimulation in place with some support.

So really seeing what does this particular patient need, and maybe finding a functional medicine doctor where that can work with us and really be in partnership on seeing the entirety of the patient. So we very much make recommendations, whether it’s for therapy, for EMDR, for acupuncture. Like I said, anything that is integrative and fully supportive of the patient on their journey. And, you know, for myself, I have had to do this. I have a busy life. I lost my husband to a brain tumor, which was very much a trigger in my own journey with Hashimoto’s. And I am a single mom running a business, very busy and active. And I’ve had to find for myself, what are my non-negotiables so that I can live my best life, so that I can widen the space between the flares and make sure the flares are as short as possible. And that’s a journey. It’s not a quick fix.

And we have to understand, both as patients and practitioners, like you said. It took us a long time to get here. There were numerous factors that brought us to this diagnosis. So it likely won’t just reverse overnight.

Dr. Hedberg: Right, right. Let’s just get into a few practical points for people to take home. And I just wanna ask your opinion on some specific food questions. So, I mean, one of the big ones is carbohydrates. I mean, generally, there’s not too much debate about protein and healthy fats when it comes to thyroid and Hashimoto’s, but carbs, you know, there’s limited research on that. There’s a good study on a low carb diet and Hashimoto’s. But how do you usually approach people, know it’s difficult to give a general recommendation, but where do you see carbohydrates fitting into Hashimoto’s and hypothyroidism?

Andrea: Yeah, it’s a great question, and it’s being met with more and more controversy right now as we look at the propensity for a low-carb diet. So one thing I wanna say is I like to get patients eating as diverse of a diet as possible because that’s where we get the most nutrients from our diet. And that doesn’t mean that I have them eating foods that don’t work for them. Personally, I wouldn’t eat any gluten and wouldn’t recommend it for anybody with any autoimmune condition. Dairy is very similar for many of us. I myself can’t eat eggs and have to really be careful with some other foods as well, as well as that macronutrient balance for myself. But I think we have to remember that therapeutic diets are limited and that they’re not meant to be adhered to for very long periods of time. So even an autoimmune paleo protocol, which is essentially a low carbohydrate, one way of doing a low carbohydrate diet, is limited. And it’s meant to be done for a short period of time, 30 to 60 days, before looking at reintroductions.

And I think that we, as patients, with all the information that’s on the Internet, can get hooked into these limited diets for too long of a period of time where we start to induce nutrient deficiencies by the diet that we’re eating. And without the right support, we’re not repleting those deficiencies. So this is where I think we have to gain support from people like you and myself and other people who are trained to look at that full picture and consider those factors. Because I do think people are eating lower and lower carb diets. They’re starting to limit their foods because they’re not doing the internal healing. So we see patients come into our practice eating three to five foods because they’ve eliminated foods because they feel like they can’t tolerate them. So they’re using diet as the fix as opposed to saying, “Yes, the diet is so that I don’t put salt in the wound, but I have to actually heal the wound.”

So carbohydrates, to get back to that question, with that understanding, I think are necessary depending on what they are and how they’re tolerated by the individual. I don’t think grains are horrible. They may not be tolerated by the individual and we have to look at why, but they’re also rich in certain key nutrients that can be very depleted for the Hashimoto’s or other autoimmune patient. So I think it really depends on the individual but also on the time in their healing journey. Are carbohydrates appropriate right now or not? And also the time in the day and what form of carbohydrates. So I’m cautious about speaking to any one macro nutrient as good or bad because it comes in many forms and it can be used and utilized in many different ways.

Dr. Hedberg: Yeah. And, unfortunately, there’s just too much tribalism and dogma when it comes to diet. And especially carbs these days. And I don’t know about you but I just see more and more people coming in just getting a lot worse on like the autoimmune paleo diet and low carb diet. So let’s just talk briefly about goitrogens because I know this is also kind of a controversial topic on the Internet. And there just really isn’t good science behind regular consumption, say, moderate amounts of goitrogens in the diet. In fact, like I’ve said before, goitrogenic foods, they have compounds like kaempferol which actually improve thyroid function at the same time and just a lot of other micronutrients and things like that. So how do you talk to people who are scared of goitrogens?

Andrea: Yeah, it’s amazing how many things we can start to be scared about with our good foods. And I think, you know, just going back to interject a little bit more before I say anything about goitrogens, about the diets that people are eating, I do really worry about the kind of propensity to adopt a ketogenic diet right now for weight loss. And weight is something that a lot of patients with Hashimoto’s can struggle with. But we don’t even have the research. And I think we have to be evidence-informed and not evidence-enslaved, but we don’t have enough research about a ketogenic diet for weight loss versus a healthy diet, perhaps versus a standard American diet. But I do really worry about that amount of fat consumption and whether somebody is properly getting their body into ketosis and using it appropriately. So, a lot of times, a lot of people, because they’re not getting to that place, are actually just eating a whole bunch more fat and not necessarily fats that their body can process. Especially if we’re looking at anything going on in the small intestine like SIBO where fats are primarily digested.

And so, it could cause more problems than good. And this is where I really think we have to think through the lens of symbiosis where food meets physiology and not just looking at diet as a theory that exists out there without looking at what it’s doing in the individual body. So I just thought I’d interject that because I think it’s one of those trends that is really worrisome to me right now that I see with patients. Goitrogens, similarly, I think that it’s very rare that we can eat the amount of goitrogenic foods that are going to be damaging to the thyroid. And so, making sure that we’re not eliminating important food groups, like you said, the goitrogens, the Brassica, are loaded with phytonutrients that are very necessary for many functions of the body including the liver. The sulforaphane is so important for elimination and for the detoxification that our bodies need to function properly.

So making sure that we’re eating cooked goitrogen, if we’re fearful of them. Tuning into our body and seeing what feels good, what feels bad is really where we can start to make that difference, that distinction for ourselves as opposed to eliminating really critical food groups. I’d prefer for a diet to be as vast as possible not just in nutrients but in phytonutrients. So really adopting a very colorful diet based on consuming all the phytonutrients, and fruits and veggies that we can, weighted towards the veggie sector for more blood sugar balance but not eliminating food groups that are so critical for our body’s function.

Dr. Hedberg: Exactly. And that just leads me into the last topic I wanted to cover which is iodine. So, the last time I did a real deep dive into iodine was about 2007, 2008. And Dr. Jeff Moss also put out a really great series on iodine. I think it was maybe 12 or 15 articles on that. And I came away at the time, at least the research at the time was clear that you had to be extremely cautious in Hashimoto’s and iodine supplementation. So what are you seeing in your research on iodine and Hashimoto’s? And if someone is deficient in iodine and they have Hashimoto’s, is some seaweed once a week okay or is a small amount of supplementation okay? And as a patient with Hashimoto’s, I know this is something that is near and dear to your heart. So can you speak a little bit about iodine?

Andrea: Yeah, yeah. It’s again one of those controversial topics. And we do have to recognize that iodine is a factor that contributes to proper production of thyroid hormones. So we don’t wanna wipe it off the table. The truth is, most of us are getting sufficient iodine in this country at least and in our diets these days. And I am not a fan with supplementation of iodine in most Hashimoto’s patients. I’m also not opposed to eating some sea vegetables, some nori, kelp, dulse, using a little bit of seaweed in cooking liquids, whether it’s broths for soups or stews, or if you are eating non-glutinous grains, in the cooking liquid there. And there are other ways to get iodine, if you’re able to eat eggs, if you eat seafood. Even strawberries have some iodine in them.

So I think we have to think about iodine through a food factor, first and foremost, of course our iodized salt, but really just thinking about if we’re getting enough of the nutrient to help with the thyroid production. In the Hashimoto’s patient, if I’m to think of the non-negotiables, and, again, non-negotiables are that tier one factor, the first thing we have to be thinking about as a non-negotiable is balancing that overactive immune response. How do we bring that immune response down so that the immune system isn’t attacking the cells and the tissues of the thyroid which are contributing to what seem to be hypothyroid symptoms? So how do we suppress or get that down from that heightened state? And that really does mean that we’re clearing the muddy waters. We’re looking at stress. We’re really thinking through the factors that stop that overactive immune response.

When we’re not in that overactive response, we don’t need to worry so much about the iodine in our food. When we are in that overactive response, that’s where I might be more cautious about bringing in any iodine that’s contributing to thyroid hormone production that might be at risk for that attack. So it’s really just making sure, from a tier one perspective, we’re looking at Hashimoto’s through an immune lens, and then, not necessarily sequentially, but simultaneously looking at the production of the hormones. So to answer your question, I’m not opposed to iodine in food, unless we have a very very active immune response and the thyroid antibodies are extremely high. Otherwise, I think it’s a nice balancing act to support thyroid hormone function in a mitigated immune response.

I’m not a fan of iodine supplementation. I just feel like it’s controversial. It’s not proven that it’s appropriate for Hashimoto’s patients. And so, I just feel like it’s likely not necessary for most, although there might be some instances where we’re looking at a severe deficiency where that might be, and I’d switch that opinion depending on the individual.

Dr. Hedberg: Yeah, yeah. That’s pretty much how I approach it. You know, nothing is black and white in functional medicine and the body. But this is one area where we have to use extreme caution. So this has been really great, Andrea. And I know you have a website and a Hashimoto’s companion site. Can you share with everyone where you’d like them to find you online and your websites?

Andrea: Yeah. You can definitely find us at fxnutrition.com. That’s the main website. If you’re a practitioner, patient, a doctor who’s looking for support from an allied functional medicine practitioner, you can find everything there. And the Hashi Companion, which is an eight-chapter book, an audio book, with visuals and resources can be found at fxnutrition.com/hashimotos.

Dr. Hedberg: Fantastic. So, to all the listeners, go to drhedberg.com and under the podcast section you’ll see our interview there. I’ll have a full transcript posted of this with links to Andrea’s FX Nutrition sites and the Hashimoto’s Companion guide. So thanks for tuning in everyone. Take care and we’ll talk to you next time.