Dr Rupy: Symptoms are messengers. So the body is on your side, it is trying to do the right thing.
Dr Amy: For sure.
Dr Rupy: And we have to be intuitive and listen to our bodies.
Dr Rupy: I want to start by talking a bit about how you got into it. We've known each other for a little while now through ACNEM and just me living. Actually, when was it? Do we meet at one of Fiona Tuck's events or something? Was that the first time?
Dr Amy: We we did a talk. Yeah, we did a talk. There were a few guest speakers including Fiona and I think she'd invited you as well. So I think that was up in, yeah, it was in Sydney and I did a little talk on gut and thyroid.
Dr Rupy: That's amazing because this is when I was getting into the whole social media side of things and I was very new to it and I was working in Mona Vale and this event was up in the northern beaches somewhere. And I came along, it was a whole new world for me. I think it was, it must have been like 2014, 2015, something like that. Years and years ago now.
Dr Amy: Yes, long time ago.
Dr Rupy: Yeah. So tell me a bit about how you got into it. What was the impetus?
Dr Amy: Yeah, so I guess if I if I go back to my time in London, I I studied in London, I did my medical qualification in London, worked as a GP there for several years. I was drawn to general practice because I liked all the specialties. I couldn't make my mind up on what I wanted to do, but I loved the concept of general practice and that continuity of care and seeing the whole family and everything and just encompassing all the specialties. And I went straight from my registrar year into a partnership and I was working in an inner city practice, very busy, a lot of complex cases, ethnic minorities, and it was, as NHS GP jobs are, very stressful, 10 minute appointments and it started to take its toll. I recognised that I was interested in a lot of other things. So even back then, I started to do a little little courses that I just saw around. I did a CBT course, I found a medical acupuncture course. So I started just delving into little things I was interested in and and I also found, interestingly, the the Masters in in Guildford for nutrition, but at that stage I actually wasn't ready to embark upon a Masters or leave my job or anything like that. But I did my own reading and research and everything. And as the years passed, I it got to that point where I thought it was just getting quite stressful, frustrating, feeling quite burnt out. And I always had an interest to travel and work abroad and around that time, so many of my friends were going to Australia, New Zealand, just doing six months, a year. And I thought, it would just be great just to get a holiday and also just to experience what medicine's like elsewhere. Is it just the UK? Is it just the NHS? Is it just, you know? So I actually went to New Zealand first for a year, I did an A&E job there. And then I had passed Sydney on the way to New Zealand and I thought, I I just fell in love with Sydney. I thought, I'm coming back here. So I got a job in Sydney as a normal GP. And it was actually during that,
Dr Rupy: A normal GP, quote unquote.
Dr Amy: A normal GP. And it was a standard GP job and it was during that time I I saw a flyer in one of the GP magazines and it was for a nutrition in medicine conference organised by ACNEM, which is the Australasian College of Nutritional and Environmental Medicine. And I thought, well, this just sounds like a pathway here. And I went along to the conference. It was just for the weekend and I just spoke to lots of other delegates there and some of them were embarking upon some other training organised by ACNEM. And you know, they had a fellowship program where you can just do various modules in all the different specialties like, you know, paediatrics, women's health, metabolic disease, etc. And I was just, I just loved the conference and I just loved what I heard from fellow delegates and I thought, this is definitely a path for me. And so I took myself down that path. I started doing, you know, module after module. And the thyroid adrenal module was very interesting. You know, I was learning things that I'm thinking, did I miss that lecture at medical school? I haven't heard about selenium and zinc and reverse T3 and how so much is involved in the thyroid. It's not just about the thyroid. And I also at around that time started in a holistic clinic. So up in the northern beaches as well, in Narrabeen. Started seeing a lot of patients there across the whole variety of different conditions, but saw a lot of women mainly with a lot of thyroid symptoms and also symptoms where there was just no diagnosis. And I was getting so many patients like that and coupled with the learning I was doing through ACNEM and also later on, the Australasian Society of Lifestyle Medicine and the Institute of Functional Medicine. So I I came across all those later, I hadn't come across them before whilst I was in the UK. It was more, you know, as you get to know people in this world, you sort of get to know this this whole world sort of opens up. So I guess I started to get an understanding of what's actually going on here. So common scenarios would be, you know, someone's been diagnosed as hypothyroid or Hashimoto's, they're on thyroxine, but they're coming in, they're still not feeling well. There may have been some improvement with the medication, but they're still fatigued, they've still got brain fog, they're still not losing weight. And I'm thinking, what's going on? But with that background of that extra knowledge I had now, I was able to sort of make some sense of that. And as well as obviously seeing people who didn't have any formal diagnosis and recognising why that may be, that they're in a subclinical hypothyroidism scenario or their hormones are normal but their antibodies hadn't been tested. So it was quite enlightening. So yeah, my my journey started there and I guess Sydney for me has been a turning point in how I've practiced medicine and from a time when I was thinking of giving up medicine when I was in London, I mean, you know, I I love what I do now.
Dr Rupy: This might seem like an odd question, but you know, along the arc of your career, which has spun over 20 years now from being an inner city GP in the UK to going to New Zealand, getting involved in general practice in Australia and now into a more holistic approach. How how has your own health been affected? Have you have you sort of sought things along your educational journey that you've put into practice on a daily basis now that you've seen the results personally? Or is this something really that was a reflection of the need that you saw within the community of patients that you were treating?
Dr Amy: It was definitely both. Certainly for myself, you know, I I was feeling stressed and burnt out and I knew something had to change. And you know, now I can look back and think, you know, how I I had, you know, all those sort of thyroid symptoms myself as well and how I've been able to with this new knowledge, improve my own life and lifestyle as well. So yeah, I would say it's a bit of both, my own personal journey in terms of finding something I love to do, and also just finding that purpose and feeling more aligned in myself as well. And and also, of course, meeting the needs of patients who are largely unheard in conventional general practice, unfortunately.
Dr Rupy: Yeah, yeah. And within that, you know, when GPs go down this path of looking at nutritional medicine and, you know, integrative and functional, even sometimes I feel like, you know, my my back gets up a bit like, oh, my my skepticism radar just goes straight up. Is it the same in Australia? I mean, we were just talking before we started about how like we met and I was, you know, in Australia with you and we met at one of these talks, but is it more accepted in that part of the world or is it just as sort of frowned upon?
Dr Amy: I I feel it is more accepted. I feel integrative medicine here is is busy. There are so many practitioners across all the all the major cities, especially in Sydney, Melbourne, Brisbane. So there's certainly a need where patients are seeking it and are more open to it, I think as well. Of course, there's still, you know, there is still in terms of conventional general practice and conventional specialists as well. I still have patients come back saying, you know, they they saw their gastroenterologist or their endocrinologist and they asked about diet and they were told, no, diet's got nothing to do with it and why are you off gluten? And, you know, it's surprising that there is some ignorance still out there, but I would say overall, people are more open to it. And I think it's more accessible because there certainly seems to be, I feel more practitioners here as well, across not just integrative medicine, but also allied health as well.
Dr Rupy: Yeah, yeah. Maybe it's the access to water, fresh air, good produce. Like, wow, Australia seems pretty good.
Dr Amy: Yeah. And yeah, the lifestyle, the lifestyle here is is fantastic, which is, yeah, just been a big part of of, you know, how my my life has changed as well. So,
Dr Rupy: Well, we're in the depths of winter right now, so I'm missing it massively. Like December is like ideal time to be in Sydney right now. But anyway, we're going to move quickly on from that. You mentioned you recognised your own thyroid health symptoms. Would you mind going into a bit more detail about that? What did you notice within yourself?
Dr Amy: Yeah, just not wanting to get up in the morning and pressing the snooze button and and, you know, thinking I've got some sleep but not not wanting to wake up and go to work and, you know, just the monotony of of work and and the stress when you get to work of just, you know, I guess, yeah, and also just feeling frustrated and helpless that you can't always help people that you just, you know, giving out medication and then more medications got their side effects. So combination of things, but certainly low energy and just not feeling fulfilled. Yeah, for sure.
Dr Rupy: Yeah, yeah. Okay. Well, we're going to talk a lot more about thyroid health in general today, but I think, you know, just to take the listener on a journey with us without having to pull open a medical textbook and look up the abbreviations and jargon that we're going to unfortunately use at some point during the pod. Why don't we give people sort of an overview idea of what thyroid health actually entails? Because I think, you know, as a as a person who who isn't in medicine, they've probably heard things like Hashimoto's and Graves and subclinical hypothyroidism and, you know, thyroid health in general. And it's a really, really confusing world because there are so many different ways in which you can describe thyroid health, quote unquote. So I wonder if you can give us sort of like a broad idea of what we mean by underactive, overactive, what the other terms and how those fit into those broad categories and and other sort of areas that you feel that we need to define before we dive deeper into the mainstream approach to thyroid health and then the sort of, I don't want to say alternative, but you know, the sort of nutritional and lifestyle approaches to thyroid health.
Dr Amy: So the thyroid gland is a small gland in the neck. It's butterfly shaped. It weighs about an ounce and for a tiny little gland, it does a lot. There are thyroid receptors everywhere in the body and it controls so many functions. So, for example, it upregulates metabolism, neurotransmitters, it's needed for protein metabolism, for growth, development, it's needed for gut function and intestinal motility. A wide range of of functions and hence a wide range of symptoms. Think of the thyroid gland as a thermostat. It's very sensitive to what's going on around it or it's like a canary in the coal mine. And in fact, the word comes from thyros, which is a Greek word meaning shield. So there's links between the thyroid and every other part of the body. The most common scenario is hypothyroidism and hypo is a general word meaning low. So it's low functioning thyroid and that's the most common scenario that we see. So when we have hypothyroidism or underactive thyroid, there are various factors which we'll which we'll go into, whereby the thyroid function is slowing down. So imagine, yeah, just everything is slowing down. So the common symptoms that people would present with would be fatigue, it's low energy. So even if they may have had a good night's sleep, they're just tired on waking or often have that dip around that two, three o'clock time needing chocolate, coffee, etc. There can be brain fog, memory loss, forgetfulness, cognitive symptoms as well. There can be hair loss, which is quite a disturbing symptom in women. And there can be weight issues as well. So that's also another common scenario whereby people aren't losing weight or they're doing the right thing seemingly, you know, they're exercising more, they've reduced their calories, they think they should be losing weight, but they're not. There may be gut symptoms and often even constipation can be one of the only symptoms that that someone may have because the thyroid gland is so so important for gut health as well. So there may be IBS type symptoms, there may be, you know, gut dysbiosis, which means an imbalance in the gut microbiome between the good and the bad bacteria. And there may be gynaecological symptoms, so often heavy or painful periods, there could be fertility issues, recurrent miscarriages and so forth. So because the thyroid gland is is, you know, it's part of so many other functions, there can be wide ranging symptoms. So, like I said, it's much more common in women than men. So probably about a 10 to one ratio, but it's important to remember because we often see men with those similar symptoms, but people don't think of thyroid when it comes to a male. But when we do the testing and the relevant testing, you realise, oh, actually you've got Hashimoto's and hence the symptoms. So men can be forgotten and I think it's important to remember that as well. So hypothyroidism is is the commonest thyroid disorder. So in Australia, it's said to affect about one in 30 people and when we refer to Hashimoto's, this is autoimmune. Hashimoto's is the most common autoimmune condition. And the most common cause of hypothyroidism is Hashimoto's. But we have to remember it's it's not just black and white. It's it's, you know, there's that whole, you know, shades of grey. So someone could start to develop a few antibodies. At that stage, they may be okay, they may just have subtle symptoms. When you do their thyroid testing, everything's totally fine. But if those insults to the body, to the thyroid gland continues and that inflammation to the thyroid gland continues, then we'll start to see more symptoms and in time, their their thyroid hormone levels may be out of the range such that it's then picked up later. But again, the point here is, you know, the earlier we can pick this up by doing the correct testing and interpreting the test correctly and not just saying, oh, this is only a few antibodies, it doesn't matter. It does matter because the studies have shown that when people have even low levels of antibodies or hormone levels that aren't optimal, over time, it can progress to overt hypothyroidism, which is where they really are underactive and they they likely will need medication. And the earlier we can intervene,
Dr Rupy: The analogy I like to draw between that, like, oh, just a few antibodies, that's fine. It's like, well, you're in the pre-diabetic range, so you don't have to worry about it too much, just clean up your diet a little bit more. That's actually saying a lot, the fact that you're pushing your body up to that limit because a lot of other things have had to happen along that journey of you becoming a little bit metabolically inflexible. So, yeah, I I I really, I just wanted to punctuate that point.
Dr Amy: In in Hashimoto's, the earlier that we can pick pick it up, it just means that there's going to be less destruction to the thyroid gland because often what we see clinically is that it's, you know, it may have been there for years, but people haven't had the right testing done. And as a result, they're at the stage where the thyroid gland has shrunk or atrophied so much that they do need external thyroid hormones. On the other hand, just to put things into perspective, we have hyperthyroidism, which is overactive thyroid. It's it's not as common. The autoimmune thyroid is called Graves disease. And that's a speeding up of everything. So often there will be weight loss, there'll be anxiety, palpitations, you know, there can be some overlap. And in fact, even people with hypothyroidism or Hashimoto's can actually get flare ups where there's this sudden release of thyroid hormone because of destruction of the thyroid cells and they actually temporarily have hyperthyroid symptoms. So it can get confusing and that's where you need to do the adequate testing as well and obviously a thorough history.
Dr Rupy: Absolutely. And so within the different causes of hypo, let's just focus on hypo for a second. Autoimmune is the most common. What are the other sort of insults that can lead to to hypo?
Dr Amy: So globally, iodine deficiency is the most common cause of hypothyroidism. That said, it's still low in Australian soil as well. So it's still something that is relevant to test for in any thyroid condition because, you know, it's it's not just a a problem in the developing world. So, but iodine deficiency is certainly the most common in terms of globally. In terms of general causes of Hashimoto's, the broad categories that we can use, stress is a big one, diet, gut dysbiosis and gut infections and environmental toxins. So I would say they're your big broad categories in terms of what's underlying Hashimoto's and indeed many autoimmune conditions. And as we know, autoimmune conditions generally are on the rise and Hashimoto's is definitely increasing as well. Um, again, is that increased incidence, increased rates of it being picked up, probably both. More recently, it's also been shown that COVID and even the the vaccine have can contribute to thyroiditis as well. And one of the reasons for that is that the thyroid gland is rich in these ACE receptors which the spike protein of of COVID can can attack as well. So that's also something to bear in mind, especially given the current situation with COVID.
Dr Rupy: And with those constellation of symptoms that you just described for hypothyroidism earlier, so vague, right? So you've got your gastro symptoms, you've got mental health symptoms, you've got weight symptoms, all these different things. And they could, you know, not all of them happen all together. And so you can imagine the journey of a patient or maybe even someone listening to this bouncing from clinic to clinic, seeing different specialists, you know, in their own silos and not really thinking about the broader picture. So you know as a GP, somebody coming into the office and saying, I've got these symptoms, you're you're thinking of hypothyroidism that you're going to test for, but I guess you're also going to be thinking about your differential. And so what are the other things that people should be thinking about as well as hypothyroidism when they they, you know, might be suffering with with these with these symptoms?
Dr Amy: Everything leaks in with everything. So with the thyroid, we've got to think about the adrenals, we've got to think about the gut, we've got to think about the the the hormone levels, the oestrogen progesterone ratios as well. There's been some interesting research a few years ago around anxiety and depression such such that they suggested that if someone has anxiety and depression, we should be screening for thyroid conditions and vice versa. So, and in terms of gut symptoms, like I said, constipation can be one of the only sort of or main symptom that that someone may have. And again, it can be easy to forget about thyroid and people just hone in on on the on the gut side of things. Other autoimmune conditions. So even though it's said that the thyroid gland is quite sensitive and it's if there's going to be an autoimmune condition, that that's often one of the first things to be affected. It's also important to look at look at other autoimmune conditions as well. So there is a link between, for example, Hashimoto's and celiac disease. So again, if if someone has one, they're more likely to have another as well. Going back to obviously stress is one of the the main underlying factors when it comes to autoimmunity and certainly Hashimoto's. Obviously the adrenal glands can get affected, so people just have that low energy and I think another important point to bring up is how we we take it for granted. We we're all stressed and it's almost like it's just part of life and it's normal. And in the same way that, for example, women might have heavy or painful periods and it's just seen as normal, but it's not normal. So there's a lot of things that we've normalised around stress and period problems and even gut symptoms that we've almost just become to accept that as the norm, but it's not the norm. So, yes, it's important to look at all the systems and, you know, take that thorough history and a comprehensive blood test to evaluate all the different symptoms as well, not not just thyroid hormones.
Dr Rupy: Yeah, yeah. And are there certain times in life where you see an increased spike of of hypothyroidism or thyroid health problems that people should be looking out for as well?
Dr Amy: So I would say most presentations seem to occur between the 30s and 50s. There can be a shift around the menopause and there can also be a shift in the immune system after pregnancy. So Hashimoto's or thyroiditis can occur after pregnancy and it's often often can be misdiagnosed as just baby blues. So I think that's really important to consider as well because there's just that shift in the immune system. And certainly around menopause as well, again, just that complex interplay of all the hormones, that can have an impact as well. Many other factors involved there as well. For example, we know that with menopause, you can get bone loss and osteoporosis and as we know, that's one of the areas that we we store toxins like heavy metals, so they can get released into the system and then that can also then further aggravate the thyroid gland and and other other systems as well. So, yeah, those areas, but what's interesting is that I'm starting to see younger and younger people with autoimmunes as well, even teenagers, which is quite disturbing. And I think, again, that's it's not so much as we know it's our genetics that has changed, that that's the environmental toxins, you know, we we never used to see girls in their teenagers with with Hashimoto's. So, yeah, that's a complex interplay of factors, including obviously stress, toxins, etc.
Dr Rupy: Yeah. I definitely want to touch on the propensity of bone loss postmenopausal and the potential link between environmental toxins and and the the thyroid. That's a really interesting idea. I don't think I've looked into that too much. So I think we've given like a rich idea of the thyroid, what it does, the different types of thyroid health issues, the most common ones, the type of person that would have thyroid issues and the other sort of differentials that we're thinking about. Let's talk a bit about how somebody would be diagnosed in a typical general practice setting or maybe even secondary care setting, the bloods that they would have and the treatments. And then we can go into sort of, okay, that's great as a baseline, but like what what's missing? So how how would a typical patient that let's say it was it was Dr Amy before, you know, you were educated on all this wide rich variety of of different, you know, content that you consumed and and read and all that kind of stuff. What would Dr Amy do, you know, prior to to all this stuff?
Dr Amy: So we would do the TSH, which is the thyroid stimulating hormone. So that's the standard test in any country actually. So that's the hormone that is made from the pituitary gland, which then basically stimulates the thyroid gland to make the thyroid hormones, mainly T4, which is thyroxine, which some listeners may be familiar that that's the medication that's given as well. So TSH is the test that's done. And certainly here, the the Medicare ruling is that if the TSH is normal, there is no justification to do the T3 and the T4 levels and nor the thyroid antibodies. That's also the case, yeah, in in in many other countries as well. So, yeah, previously I would have done the TSH, done the thyroid test, and it's there's no red stars. I was like, yeah, there's nothing wrong with you. You know, because when you're in that busy setting, looking at all the results, you're just looking for the one that have marked as abnormal. So it wouldn't get picked up if it was in the range. So generally speaking, when it comes to primary hypothyroidism, the higher the TSH, that's implying the more underactive the thyroid gland is. So generally when it comes out of that range, so let's just say the range went up to say three or four, it can vary in different countries and different labs even. Once it comes out of that range, let's just say it's five, then it will get flagged as abnormal and then it's like, oh, there's there's underactive thyroid. So it's higher because
Dr Rupy: Let's just, sorry, I I just want to, just from the listener because I know it's implicit in the name to us, like thyroid stimulating hormone, but I just want to underline that point exactly how that hormone released from the pituitary interacts with the thyroid gland. So just take us through that that little bit one more time and then we can talk about why, you know, you you would do the other tests as well.
Dr Amy: Yeah. So there's a negative feedback mechanism. So there's a like a balance between the thyroid stimulating hormone and the thyroid hormones. So the TSH stimulates the sort of gets secreted from the pituitary gland and then stimulates the thyroid cells to make thyroxine, which is T4. So that's the main hormone that that's made. When the T4 or thyroxine level reaches a an appropriate level, then there's a negative feedback back to the brain saying, okay, we don't need any more TSH here. So there's this constant sort of feedback and talk between all the different glands just to get the right levels of everything. So thyroxine itself, T4 is is, as I said, is the main hormone that's produced from the thyroid cells. However, it's not the most active. It then has to get converted to T3, which is the most metabolically active hormone. The interesting part is that most of that T4 to T3 conversion does not happen in the thyroid gland. It actually happens outside in the peripheral tissues, such as the liver and kidney and heart and, you know, just other other tissues. So hence the importance of the whole body and not just the thyroid gland when we're discussing thyroid health.
Dr Rupy: You've got T4, it's out in the system, it gets converted to T3. How is that T4 uptaken by the liver cells, the the muscle cells, the gut cells? Like what in what form is it taken in? Is it literally T4 and then there's like a T4 receptor on the cells of these different parts of the body or is it within the the surface or, you know, just talk us through that. I know it's a bit geeky. We'll just dive into that and then we can dive right back out.
Dr Amy: T4 is produced and that is then converted to T3, which is the most active hormone, but it is important to remember that yes, even though T3 is the most metabolically active, about four or five times as much as T4, both hormones are important. So even the thyroxine, the T4 itself has a direct impact at the cellular level or the to to to, for example, in the gut to cause intestinal motility, for example. T3 also, you know, there's receptors at the cell surface and also mitochondria as well. So that is involved in upregulating energy, neurotransmitters and so forth as well and and improving and increasing mitochondrial numbers and function as well. So both have their independent functions as well. Often we can get caught up in only T3 is important, but both are important at the cellular level for sure.
Dr Rupy: Yeah, yeah. I think that's a really important point that that because I I I think in a lot of people's heads it's like, oh, yeah, T4 is converted to T3, so we're just going to focus on T3, whereas I think just to underline that point, T4 is important. It's not like, you know, a junk hormone molecule in the pathway of everything else. It's, you know, it is important. So, yeah.
Dr Amy: So, and as I said, the other key key fact of note is that most of that conversion happens via these enzymes called deiodinases, which are located in the periphery, not, you know, so most of that conversion is happening outside the thyroid gland. And again, as with any enzyme, there can be genetic defects. So that can also be a reason why people don't convert as well from T4 to T3 and and why for some people, thyroxine isn't enough and they do need extra T3 given as well. Broadly speaking, in terms of the factors needed for that T4 to T3 conversion, I mean, the deiodinases require selenium, it's a selenium dependent enzyme. But generally for thyroid function, we need selenium, magnesium, iron, zinc, B vitamins, vitamin C, vitamin D, and on the other hand, the things that can stop that conversion happening and the production of thyroid hormones, stress, as we said, is a big one, toxins like other halogens like fluoride and chlorine, gut infections, plastics, heavy metals like mercury, which can actually concentrate in the brain as well and affect the TSH secretion. So if we think about on the one hand, we've got factors that we need for that thyroid hormone conversion to happen, and then on the other hand, we've got the factors that stop the production. So if we have a situation where we don't have enough nutrients like zinc, selenium, iodine, etc, or we have too much of the factors that are impeding that conversion such as stress and toxins and gut infections, then the body or the brain perceiving stress says, whoa, there's stress here, we need to slow things down. So what then happens is that T4 starts to get shunted towards making another hormone called reverse T3. Reverse T3 is the mirror image of T3, it's the it's the isomer. And but it's inactive. And it's actually a hibernation signal in mammals. So, again, I personally didn't have an appreciation of that in my old Dr Amy days. That's just these are just things I've learned, you know, as I've done this further training. So the body is trying to actually do the right thing because it's perceiving stress, whether that's nutritional deficiency or emotional stress or toxins and saying, we don't want to waste away here, you know, because the thyroid gland is involved in in metabolism, etc. and so it's it's trying to do the right thing. It's a survival mechanism to say, well, we've got to slow things down here. And so that T4 to reverse T3 shunting happens, so there's less T3 and then obviously we can then start to manifest those symptoms of hypothyroidism like fatigue, weight, which is annoying, but it's the body trying to do the right thing. So giving medication, yes, can help, but we need to see what's going on because if something has come out of balance, let's try and bring it back into balance.
Dr Rupy: I just want to underline that point. I think that's a really important point there because it goes towards this sort of concept of cortisol steal. So maybe we could just back up a bit and just talk a bit about what what we mean by cortisol because I think again, it's one of these terms like, oh, like, you know, measure your cortisol, your cortisol is high, whatever. What does that actually mean? Because it's it's very high up the sort of food chain of of hormones and it can have that sort of effect downstream, particularly on on thyroid hormones. So let's start with with cortisol, where it's released and and how that impacts the these other pathways that we've already described.
Dr Amy: Yeah. So cortisol is a is like the stress hormone that's made in the adrenal glands. But in the hypothalamus, which is part of the brain, that makes a hormone called corticotropin releasing hormone, which then stimulates the pituitary gland to make ACTH, adrenocorticotropic hormone. And then that then stimulates the adrenal glands to make cortisol. So that's a a feedback loop in itself. So often known as the HPA axis or the hypothalamus pituitary adrenal axis. And then we also have the hypothalamus pituitary thyroid axis. Cortisol has many functions and CRH, ACTH, they can also suppress TSH as well. So if we if we're in a stress situation, again, the body's trying to do the right thing, it wants to slow things down, it actually the effects actually start upstream where you get a reduced TSH and then hence the thyroid hormones as well. And obviously cortisol's effects on increasing reverse T3 by reducing that conversion of T4 to T3.
Dr Rupy: Yeah. So this is where you have an environment where your TSH might be in the normal range or the high normal range, but there is still an issue going on because you haven't perhaps through, even, you know, I'm sort of more leaning towards like taking a really thorough history. You don't have to do, you know, all these extra functional tests in my view. You can simply ask the questions about stress and that can potentially explain normal TSH results with the presence of a thyroid condition.
Dr Amy: Yes, yeah, absolutely. And as you said, you know, we we we need that full full history and obviously appropriate examination as well. And and also to look at the actual results and not just look at what's in range. So, you know, to to consider what is the TSH, but what are the T4 and T3 levels? I mean, obviously that's further test that, you know, that can can be done later and I I routinely would ask for for all those, especially if there are thyroid symptoms. So even then when we look at the T4 and T3, it's it's not just in range, but is it optimal? So, and obviously the thyroid antibodies, I I would do, especially if I'm suspecting Hashimoto's. So we we're justified to do those blood tests if there are the clinical symptoms and that's where, you know, Medicare would would support further testing if we have have clinical relevance.
Dr Rupy: Medicare being the sort of equivalent for the NHS but in Australia.
Dr Amy: Yes, that's right. Yeah. Yeah. And also, obviously when we're doing the blood test, we'll we'll we'll do, you know, a comprehensive set of blood tests. And that that can include the adrenal hormones. So, you know, it's not the most accurate in the blood test, but they can be done to give us an idea. And, you know, at least if if they're very high or very low, that tells us there's some obviously adrenal function going on here as well. There's also another adrenal hormone called DHEA that that we measure as well and that that also tells us a little bit about adrenal function as well. Depending on other symptoms, I may also run other autoimmune tests. So, for example, many patients with Hashimoto's, even though they may not have celiac disease, have the celiac gene. So that's one of the genetic predispositions to developing autoimmunity, not just celiac disease. So I find that most of my patients with Hashimoto's do have the gene, even though they may not have celiac disease, but obviously they're at increased risk for that. There may be other, you know, other auto antibodies I may run again, depending on the symptoms, but ANA, which is anti-nuclear antibody, if that's positive, then we can do more thorough testing which can indicate whether they might have connective tissue disease or lupus, for example. Nutrients like iron, B12, plasma zinc, serum copper, I I I test for as well.
Dr Rupy: How how accurate are the bloods that look for specific mineral or trace minerals in in blood? Because my understanding is depending on the nutrient, you know, a serum level doesn't tell you much and you're really looking for an intracellular level, but there aren't many tests that can give you that sort of that can delineate between the two, which is quite important.
Dr Amy: Sure, sure. So it it's a guide. It's um, it's more to to assess if there's a if there's a a significant deficiency. So, for example, magnesium is is a difficult one to test for. We can test for red blood cell magnesium, but it has to be pretty low for it to be to to show up. But certainly, I I find it can help in terms of, for example, plasma zinc and serum copper because that that ratio is important. Like we know that low zinc to high copper, there can be a correlation with anxiety, for example. And high copper can also deplete other minerals as well. So it's a guide, but there are also other functional tests that can be done, but because they're the tests that can potentially be done on Medicare, you know, it can be done as a screening and also depending on on other symptoms like if there's hair loss, for example, then it'll be more relevant to do to do some of those bloods.
Dr Rupy: Okay, so you've got these, you've got these bloods. Let's say you've got a perfect patient that's like, give me all the tests. I want all the tests. I want to know. I've got an analytical mind. Um, you've done all these. What what are some of the, we've already talked a little bit about what about what could predispose or preempt the hypothyroidism, the low thyroid condition. What what are the some of the things that you are seeing that you're like, ah, I found it and then I'm going to fix that. What what are the main sort of root causes that that you're seeing these days?
Dr Amy: So certainly the blood tests are important in terms of, I guess it's never one thing, it's always a combination of many many factors. Stress and and how that manifests in terms of the level of the cortisol DHEA is is certainly a factor. There are often nutrient deficiencies, often iron and B12. So, you know, even in people who, for example, you know, they may not be vegan or vegetarian, but they can still have low iron and often it's microscopic loss through the gut wall because of a leaky gut and and that obviously is one of the key things that we we then need to address later is is the gut and the diet. Sex hormones, so for example, there might be an oestrogen dominance, which again is very common in women and generally what that means is is in the there should be a specific ratio of oestrogen to progesterone. So what's common in women these days is that the oestrogen is relatively higher to progesterone. And that can manifest as PMS symptoms, fibroids, endometriosis, ovarian cysts, breast cysts, for example. So that also impacts thyroid function because high oestrogen levels increase something called TBG, which is thyroid binding globulin. As a result, that means there's less free thyroid hormones circulating in the blood. So basically high oestrogen generally does correlate to low thyroid function as well. So it is an interplay between all these different glands. Nutrient deficiencies I do find are quite common. B12 deficiency can can occur and that's again, that could be absorption often as well. So again, even in people who are not necessarily vegan. People may have Helicobacter pylori infection and that that's also been shown to be one of the triggers in Hashimoto's as as one of the potential infections that can contribute towards triggering Hashimoto's. And of course, there's, you know, there's autoimmune conditions involved in the stomach like pernicious anaemia where we just can't absorb that as well. So they may also have that as a coexisting autoimmune condition as well.
Dr Rupy: I just want to dive into iron and B12 because I think as a vegetarian yourself, I think this is quite an important area because there is a misconception that, you know, if you've got red meat in your diet or you eat, you know, a selection of animal products, you're going to be fine from a B12 and iron point of view. But you mentioned leaky gut there or intestinal hyper permeability. What how how does that manifest in someone who is eating or consuming enough B12 in their diet presumably?
Dr Amy: In terms of the the main factors, it could be, again, there's very various factors. There's something called the autoimmune triad. So there's three factors there. One is the celiac gene or genetic predisposition to developing autoimmunity. Then there's intestinal permeability and then there's triggers. So some of the things that can can contribute towards so-called leaky gut, gluten, like the gliadin in wheat especially has been shown to increase intestinal permeability. Infections is a big one. So bacteria, even certain parasites have been shown to also contribute towards leaky gut as well. So what we mean by leaky gut is it's it's it's actually at the microscopic level this description. So essentially speaking, if we have, you know, adjacent cells, there's a tiny little gap between those two cells to allow nutrients to get absorbed back into the bloodstream and toxins to get excreted. But what can happen is is if that barrier is damaged because of say certain foods like gluten, infections, toxins, that gap can widen and then what that potentially can mean is that nutrients can get lost when they should be getting reabsorbed back into the bloodstream and it also means that that toxins can can enter the bloodstream as well.
Dr Rupy: The the hyper permeability element is very much in the name. It's hyper because intestinal permeability is a normal phenomenon. Whenever whenever we eat anything, there are going to be gaps in those tight junctions of our our digestive cells all along the the digestive tract, largely in the large intestine. And that's to facilitate the movement of nutrients into the bloodstream that we need. The excess of that process which allows things that should be maintained in the gut and not pass through the gut wall into the bloodstream, that's when you can get into problems. And I I I believe, you know, the the gliadin proteins for certain people and and and people with particular allergies to certain types of food, this is what can manifest in in this issue. Is that have I got that right?
Dr Amy: And it is a combination of factors. I wouldn't say there's ever just one thing. And when when it comes to that diagnosis being made, it's, you know, it's sometimes it's the straw that broke the camel's back. You know, if we then look back at the history and their life, there's been a lot of insults, whether it's emotional stress or, you know, many, many factors, you know, diet related. So, yeah, it's it's a process. It doesn't just happen, but um, there's often things that have been happening for for a while and then it can just be, you know, a life event that can just sort of trigger someone.
Dr Rupy: Okay. And so let's let's dive out a bit into, I think the the autoimmune triad was very important, you know, the genetic predisposition, the permeability of the gut and and particular triggers as well. Actually, another sidebar before we carry on because I I I noticed um, you said infections and the the thing that most people think of are things like H. pylori, but there are other infections, aren't there? There's there's Epstein-Barr virus, there are infections that we might have had as kids and just completely forgotten about, but these can manifest quite a lot later on in life, right?
Dr Amy: Gut dysbiosis, for example, which describes that imbalance between the good and the bad bacteria. So, for example, you know, there could be certain bacteria that can can act as a trigger as well and and parasites. And one of the things that we we see in the gut microbiome test is is an overgrowth of, for example, streptococcus. So strep, as we know, is a bacteria, is is commonly, you know, we've all been exposed to it in some form in terms of tonsillitis, strep throat, chest, ear, sinus infections. And what what we know about streptococcus, which is quite interesting is that it can persist in the system. We we don't always get rid of it. There has been research where because of the various toxins it produces, including lactic acid, it can actually contribute towards chronic fatigue syndrome, fibromyalgia, it can also be that trigger through molecular mimicry in autoimmunity as well. So that's certainly one of the common things that we tend to find as well. Um, and again, this is digressing a little bit, but but the the acronym PANDAS, which is paediatric autoimmune neuropsychiatric conditions associated with streptococcus, it's a well-known thing, especially in the states, not so much perhaps in the UK or or Australia, but that can also then persist into adulthood if that strep is still there. I just thought of Dr Alessio Fasano's quote. He's he's the the obviously the the gastro who who's done a lot of research into zonulin and leaky gut and he he says, you know, the gut is not like Las Vegas, so what happens in the gut does not stay in the gut.
Dr Rupy: Yeah, yeah, yeah, exactly. Okay, so when it comes to managing hypothyroidism, right? So someone comes into your clinic, you've done the tests, they've got low levels of of the thyroid hormones in their blood. What how how do you manage the acute phase, like someone needs like a fix right now versus, you know, some of the other things that might take a little bit of work. So talk us through your structure of how you see a patient comes in, you're going to treat them, you're going to, you know, improve the management of this condition that is lifelong as best as possible. Talk us through that process.
Dr Amy: So in terms of medications, again, it depends on the extent of the symptoms and if if the levels are quite low and they're quite symptomatic, then we can certainly start treatment and you know, I would have that discussion, you know, on that individual basis of of whether we we start thyroxine, T3 or a combination. Obviously, it's not the first line, but if if that's needed, you know, depending on on the severity of the symptoms, then it's totally justifiable. But my general framework is to look and look at all the foundations, which starts with lifestyle and environmental factors. Now, obviously, this is a longer term approach. It's, but I think that that's important for the long term. But certainly medications in the in the short term at least can help with the knowledge that later on, we may be able to reduce that medication, maybe even stop it all together, depending on on the actual scenario. So, so yes, thyroxine may be necessary. If we have done their reverse T3 and they've got a low T3, a T3 in addition may also be justifiable as well. And that's again, that's also a common scenario where we see people coming who who are already on thyroxine, but they're still not feeling great and that further testing reveals this low T3 and high RT3 and they start to feel much better on T3. If that's not sufficient, then there is another treatment that can be used called thyroid extract, which was interestingly the the original treatment before the pharmaceutical companies started manufacturing thyroxine. And this is just very briefly, it's porcine or bovine derived glandular extract from the thyroid, which is made by compounding pharmacies. I know there's not that many in the UK, but there's certainly a lot of compounding pharmacies in Australia and it's quite quite easy to get. And the the good thing about that is that it's naturally got T4 and T3 because it's from the thyroid gland and it's obviously it's got other other thyroid hormones, T1, T2, it's got other nutrients like selenium, for example, as well. So that can suit some people. And when T4, even with the addition of T3 isn't enough to control symptoms, I often find that once they're put on thyroid extract, it does help. So, again, that's also very individual and some people may not want to take it that's anything that's animal derived, but there's certainly some good research on it and T3 is not commonly prescribed by by practitioners. So yes, T3 is available as a medication that is used by endocrinologists, but it's a synthetic version. We can also have T3 compounded in different doses, but it's not it's not your your general one that most GPs would prescribe. That that's generally in the realms of integrative and functional medicine doctors.
Dr Rupy: I just want to clarify, levothyroxine, what are we referring to? And when we say T3, is there another particular word that people use?
Dr Amy: Yeah. So levothyroxine is is thyroxine or T4 is what we commonly call it. T3 is liothyronine, which which is the the technical term, but yeah, it's T3. So essentially, as as we know, that's a tyrosine backbone with four iodine molecules, that's T4. T3 is the tyrosine amino acid backbone with three iodine molecules. And as we know, the thyroxine is is the general treatment that that any any GP would would be familiar with. T3, at least here, I don't know about the the UK, but here, some endocrinologists do prescribe a branded version called Tertroxin, which is a 20 microgram dose. But thyroid extract is not prescribed conventionally. It's it's only prescribed by integrative and functional medicine doctors.
Dr Rupy: Yeah, yeah. I haven't actually heard of thyroid extract before. And I guess what what would be the potential downfall of having a thyroid extract? Is it because they're not regulated like most pharmaceuticals, you could get a different dose depending on which compounding pharmacy you go to?
Dr Amy: Because it's a natural product, it has it has iodine in it and some people can be, especially with Hashimoto's can be quite sensitive to iodine. So it can actually it can actually flare. Iodine is um, you know, it's it is very individual. Yes, we need it, but too much can actually can actually worsen thyroid function. It depends on the compounding pharmacy. So I use specific ones which which we know that they're certified to the extent that what we get is is that actual dose. But yes, there can be that variation because a lot of some compounding happens at the back of retail pharmacies. It's not as well regulated in terms of the conditions and everything. So it it does depend which compounding pharmacy you use.
Dr Rupy: Yeah, yeah. That that's a really good point to make. So let's talk about, so we've got the medications, you've got your selection of different drugs of which we've just clarified there. In terms of those foundations, what what how how do you go through those in a in a stepwise fashion?
Dr Amy: Main categories, obviously stress, sleep, nutrition, movement, environmental toxins. So they're the sort of things I'm I'm going through in my in my head. There may be many things that need changing or improving in someone and I I like to do that as an overview, but we also have to, you know, it's it's a personal it's personalized medicine and, you know, we have to take it one step at a time depending on the individual. Not everyone can sort of radically change their diet and, you know, change their life in a matter of days. But it's important to manage stress. And as we know, it's something that we take for granted, but it's important to take steps to to mitigate some of that day-to-day stress. Even if it's saying, okay, well, let's start a short meditation practice once a day or do something like yoga nidra, which is like a lying down progressive muscle relaxation meditation, which has a lot of great research around helping to improve sleep as well and balancing the autonomic nervous system. So strategies around stress, stress management. As in anything, it's about meeting the person where they are and, you know, some people are not open to doing meditation. It's it's, you know, finding something that they're comfortable with. Sleep is also really important. So, again, I think this is something that doesn't get talked enough about. We we take it for granted and we think we'll we'll be okay with a few hours of sleep, but as we know, there's so much evidence on on why sleep is important and, you know, sleep itself has been shown to affect thyroid function, not surprisingly, it will it will suppress TSH as well. So really important to to talk around the sleep hygiene. Even if it's saying, right, let's go to bed at 10 or 11 rather than one or two, you know, just just little little strategies around that as well. In terms of diet, again, there are specific diets that have been shown to help with Hashimoto's, but, you know, long term, we want a, obviously, a healthy whole food plant-based diet. So, you know, I would talk through through the principles of that. But in terms of Hashimoto's, gluten and dairy free diets have been shown to reduce the antibodies. They do help to reduce inflammation. A lot of the studies that have been done have been done over like a six month period. So it's important to to tell someone this is not just a few weeks worth, you know, you might need to do it for longer. It doesn't necessarily have to be forever, but at least initially while we're trying to improve things and improve the gut function and reduce leaky gut, let let's just do the best we can. So the gluten dairy free diet can can, you know, is is one of the the main things that I would I would start with. There is also another diet called the autoimmune protocol, which is commonly used by many practitioners. That's much more strict and I I personally don't start this straight away because it can be quite restrictive and also quite difficult to do if you are vegetarian. And that, you know, as we know, that cuts out grains, legumes, nightshade vegetables, like so many things. But the studies are positive in terms of they have been shown to reduce inflammatory markers. In one study, it didn't actually reduce the thyroid antibodies, but the study was only done over a short period of time. So again, you know, changes can take a while for for them to show up. But anecdotally, clinically as well as from what the research is showing, they're they're the sort of diets that can be helpful. But it also depends on what else is going on with the patient. So, you know, there may be IBS and a low FODMAP diet could be tried. There may be small intestinal bacterial overgrowth and we might need to think about a SIBO diet. We might need to take into consideration the fact that someone's vegetarian or vegan as well. So potentially a wide variety of diets that can be used. I wouldn't say there's one Hashimoto's diet or anything like that. In terms of movement, too much or too little movement is pro-inflammatory. So sitting is the new smoking as they say, you know, we we know from studies that prolonged sitting, you know, can can increase inflammation as well. So, you know, simple strategies like, you know, if someone's, you know, sitting down all day, just just to get up every hour or so, just have a little bit of a stretch and walk around for a bit. But also too much exercise has also been shown to be pro-inflammatory and also even contribute towards leaky gut. They've done studies on long distance running and marathon training where that that can affect sort of the the gut function as well as thyroid function as well. So we need the right amount of movement. Obviously in many situations, people are just tired, they don't want to do anything, but there again, it's just a case of just meeting them where they're at and even if just a little walk, a little bit of stretching, a bit of tai chi, qigong, restorative yoga, often that's the sort of thing that we need to think about, not Bikram yoga. Yeah, yeah. Totally. I just wanted to touch on the nutrition element. I think it's, yeah, really important. I've had a family member actually recently go on an autoimmune protocol diet as a result of a hypothyroid diagnosis. And I think when you do these things in isolation, particularly people want to do something that they feel is more tangible than just optimizing their sleep or reducing their stress or doing some breathing exercises. And so they go all in on a quite a restrictive diet. And like you said, it's bloody hard to do an autoimmune protocol diet because you're literally removing a lot of very, very healthy ingredients and you end up just having things like soup, you know, because there's literally nothing else to eat. So part of me is like, is it the ingredients? Is it the fact that you're on a low calorie diet? Is it the fact that, you know, you're not going to have any permeability because you're basically not eating anything? You know, there's there's a whole bunch of like holes that people can fall in. So I think doing something very basic like removing the crap from your diet as a first point of call, that a lot of people who perhaps see you have already done. So maybe that's why they need to go down the, okay, well, let's trial a GF and a DF diet. But removing a lot of the elements that are pervasive in our in our food landscape, emulsifiers, additives, high amounts of sugar and salt, that toxic combination could be enough for for a lot of people as a first point before they entertain more sort of extreme measures.
Dr Amy: Yeah, absolutely. And I think it's always important to get that balance and and, you know, always discussing what are the components of of like a whole food plant-based diet are and for them to, you know, as you say, just just try to eliminate or at least reduce some of the some of the pro-inflammatory foods and drinks that they're having as well, you know, whether it be alcohol or excessive caffeine or, you know, having having gluten every day, takeaways, you know, even takeaways, even though they might be Thai or Indian, they could be seen to be sometimes potentially healthy, they're not because of the oils they've been cooked in, etc. So, so yeah, I think all those basic principles are really important before embarking on anything. But yeah, as you say, often by the time people come and see integrative practitioners, you know, people have already been down this rabbit hole of different diets and I do believe in balance totally. I remember a patient who had colitis and you know, on a strict diet, went to Italy, had a holiday, was eating pizza, pasta, everything and they were fine. So, so many factors. And again, we can digress into the wheat in Italy is different from the wheat here. It's all sorts of things like that, but I do believe in balance totally.
Dr Rupy: Yeah. I I I think there's a mindset element as well. I've got a friend of mine, one of my closest friends who um, who's definitely lactose intolerant. And he went to America. Uh, he went to like uh, you know, um, like Disneyland, something like that. Uh, and uh, it's like a favorite place in the world. Stress-free, you know, loving life, had all the cheese he wanted, didn't have any symptoms. He was like, it can't be the quality of the dairy that I was eating. I was eating like the worst type of dairy. It was his mindset. It was his mindset, like when he's back here in the UK, like he's running a company, super stressed and all that kind of stuff. So I think there's a rich interplay between our perception and our gut as well, as we know through the gut brain axis. So I think that's that's really important. I want to touch on uh, an uncomfortable truth about environmental toxins. We've talked to Professor Shanna Swan on the podcast before and she she really like made me worried about everything. And so at the risk of like, you know, painting a really bleak picture to the listener about the state of our environment, we should probably talk about toxins and and the impact on thyroid health as well. How do you approach that subject with with your patients?
Dr Amy: Chronic illness as well as autoimmunity is on the rise. You know, a large part of that being because of environmental toxins including heavy metals, plastics, parabens, things that are just found ubiquitously everywhere. Awareness for for for one, so that you know, I sort of give them resources around um, what they can do practically. So simple practical strategies may may be for example, you know, especially for a woman, the their moisturizers and makeup and cosmetics to try and at least use natural products because, you know, the the parabens and phthalates etc found and all the chemicals found in in these products, you know, are are endocrine disruptors, not not just for thyroid, but for insulin resistance, etc as well. So simple strategies like just converting over to something that's that's more natural and you know, luckily there are so many more products like that available now which are, you know, more environmentally friendly. Water, drinking water is is important, like in terms of trying to get that filtered because again, that can have either halogens like chlorine and fluoride which can, you know, compete with the iodine and that can also worsen thyroid function as well. As well as obviously heavy heavy metals, etc. So, you know, filtering their their water, um, again, there's many companies here that are available. It can be done quite inexpensively as well. And and again, that's also another point when we're talking to patients about strategies, it's we've got to be practical, you know, it's everything can cost money. Um, so, um, you know, coffee cups, for example, like drink coffee out of a normal cup because even the plastic lining of takeaway cups and the lids, that's plastic. So when you've got hot hot acidic coffee, that's leaching out the plastics as well. And um, in terms of plastics overall, like BPA free isn't good enough because we know even BPA free has other plastics that are just as bad if not worse than BPA as well. So, yeah, awareness around all those different environmental factors as well, for sure.
Dr Rupy: Yeah, yeah. Um, it it yeah, it's a it's an absolute minefield, I think. There are some simple things you can do. Um, one of the things I've been taking to doing is um, just trying to get into my park as much as possible. Um, instead of, and I do really strange things like, and I I I doubt it's having much of an effect, but if I'm going somewhere in London, I try and take the scenic route. So I try and look for parks along the way and try and go along those routes rather than going alongside roads. And it's a stupid thing and maybe it's, you know, the the placebo effect or whatever, but I just feel like I'm filling my lungs with a slightly cleaner air, but I mean, yeah, there's pollution everywhere, so you can't really do much apart from moving to the countryside, which I'm trying to convince my partner to do. Um, with regards to supplements, so, you know, obviously you're going to be personalizing it according to whatever deficiencies you might be finding, whether it be selenium, magnesium, etc, iron, B12 that we talked about earlier. Are there specific herbal supplements that you think are particularly interesting from a research point of view or a personalized medicine point of view?
Dr Amy: Yeah, so in terms of for thyroid specifically, like for example, there's certain herbs like um, Nigella, Hemidesmus, curcumin that have been shown to improve thyroid function. Aloe vera is an interesting one. There was actually a recent study where they found that aloe vera uh, reduced thyroid antibodies as well. So you actually see um, you know, aloe vera, Nigella within supplements these days as well. Hemidesmus is another herb which has been shown to have immunomodulatory effects as well. Um, curcumin, obviously, as we know, that's good for everything. There's nothing it's not good for. Because obviously inflammation is one of the key things, you know, key factors that's that's that's happening within any any of these patients. So that's good obviously for reducing inflammation, for liver, cognitive cognition, etc. So, yes, a wide variety of herbs, often as part of formulations, so they're not having to use everything separately. So I'm quite mindful of how many supplements we use because obviously, I always say, look, the more we can do from lifestyle, the better because, you know, we we don't then need to use as much. And obviously to incorporate whatever herbs we can in the cooking. So even obviously turmeric in the cooking, um, yeah, for example. You know, even teas, like, you know, dandelion tea is is great for the for the liver. So we don't always have to have specific supplements because I think obviously too many supplements can be not just overwhelming, but it can get expensive for people. So incorporating whatever great herbs and nutrients that obviously you can in the diet as well, for sure.
Dr Rupy: Yeah, yeah. Like a a herby, spicy diet that's full of colour is uh, is basically good for everything. Something I'm discovering when chatting to all these people.
Dr Amy: Yeah. And as we know, when it comes to the gut, it's and the gut microbiome, it's diversity and variety are the key words. We want a variety of different coloured foods and veggies and fruit and everything because that is what creates a diverse microbiome, which is then beneficial to our health. And again, studies have shown that there is a a diminished and a changed gut profile in in people with Hashimoto's as well. And interestingly, there's been research on how specific nutrients influence specific bacteria as well. So zinc, selenium, magnesium, they've all been shown to influence good bacteria as well. So, so yes, lots of good interesting research coming out.
Dr Rupy: Really interesting. That's awesome. Amy, this is this has been great. I think we've really taken the listener on a on a journey of of understanding their thyroid, even if they don't have a thyroid problem. I think it's really important to understand the sort of how interconnected everything is and how, you know, you can't treat anything in isolation. You've really got to be thinking casting the net wider when you you think about certain elements and how this can interplay with the menopause, cardiovascular problems, off cholesterol ratios, um, weight, gut problems, you know, everything is really interconnected and and thyroid, I think doesn't get as much attention as it should do. Um, particularly as it affects a certain part of the population more so than others. So this is great. I I love your work. I love the book. Um, and uh, we're going to we're going to do this again some some other time when I'm next in Australia.
Dr Amy: Definitely. Have to catch up soon.
Dr Rupy: I'll write that. That's awesome. Thanks, Amy.
