S2 E3: Supporting Autoimmune Thyroid Disorders with Nicole Fennell

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Amanda: Hey, this is Amanda, women’s health dietitian.
Emily: And I’m Emily, nutritional therapy practitioner.
Amanda: And this is the Are You Menstrual? podcast where we help you navigate the confusing world of women’s hormones and teach you how to have healthy periods.
Emily: Each week we will be diving into a different topic on women’s health and sharing our perspective using nutrition, female physiology, and metabolic health.
Amanda: Our goal is to help you wade through conflicting health information and empower you on your healing journey.
Emily: We hope you enjoy it.

Amanda: In this episode of the Are You Menstrual? podcast we are continuing our conversation around thyroid health and focusing specifically on supporting autoimmune thyroid disorders. I invited my friend and colleague Nicole Fennell from @chewsfoodwisely on Instagram to discuss this topic. Since Nicole really specializes in autoimmunity, she’s going to share her own journey with thyroid autoimmune disorder.

And if you’re wondering who Nicole is, she’s a registered dietitian and licensed nutritionist certified in integrative and functional medical nutrition therapy. After years of working as a clinical inpatient dietitian, her personal journey with thyroid autoimmunity led her to eventually start a private practice that challenged the status quo of what it means to be healthy since following the “diet rules” is what made her sick in the first place. Her work with those who have autoimmune thyroid disease is a root cause approach, marrying a flexible food framework and personalized lab data to create sustainable and realistic lifelong changes. Nicole takes a nourishment over deprivation approach and helps women mend their metabolism, banish brain fog, enhance energy, and redefine their relationship with food in their bodies.

So you can see why I would appreciate Nicole’s approach. Everything that we’ve ever talked about in the podcast you basically summarized it in what you do. But thank you so much for being here, Nicole.

Nicole: Well, I’m so honored to be here with you and just continue that conversation around hypothyroidism but coming from the lens of autoimmunity. I feel like this is such an underserved and kind of misunderstood population. And so I want to shed some light into this because it’s just so common.

Amanda: Yes, and we’re going to talk about just how common it is in a little bit, but do you want to go first into your own health journey? Like, I’m just so curious of, like, how you got diagnosed with an autoimmune condition, what that looked like for you, and like, what were you going through at that time?

Nicole: Yeah, and I think that sharing this journey is such a valuable piece of many women’s healing journey, because I feel like it mirrors so many people’s path to diagnosis. And, you know, the diagnosis of autoimmunity, like, studies show that it can take up to seven years for people to identify their autoimmune disease. And the hypothyroid autoimmunity or Hashimoto’s is especially tricky because the lab testing isn’t always done. And so I think that knowing what to ask for, knowing what the symptoms are, and not just waiting until things are bad enough to have a concrete diagnosis is really important, because the immune system is malleable and flexible and adaptive. And so there is so much that you can do that’s in your control.

But around the time of my diagnosis, I would say that symptoms were going on for years and years, but I was kind of being treated in a compartmentalized fashion. So, you know, having, I remember being just so tired and being told by the doctors that, you know, I’m just getting older or I’m just, like, stressed out. At the time I was working full time in long term acute care, which basically is like acute care setting, but people are there for a really long time. So it’s sort of like people being in an ICU or an intensive care unit for a really long time. So it was really high acuity patients, and I was a baby dietitian, it was one of my first jobs, which, you know, is stressful in and of itself working alongside doctors and nurses who have been doing this for years and years. So I think that it was chalked up to being really stressed out which played a huge part in that. But I remember showing up to the ICU one day and having heart palpitations and being really scared and one of the nurses even hooked me up to the telemetry machine and, like, checked my heart rate and heartbeat and whatnot. I remember going to the doctor for migraines. I was getting migraines every single day, my cholesterol was elevated, and I’m like, what, that’s so interesting. I’m a dietitian, like, I should know how to eat healthy, and I am eating healthy, hey, I’m vegan, I’m running marathons, like, I’m the epitome of health, or at least that’s what we were taught at the time is like what is healthy.

And so it took a lot of time and a lot of diagnostics, and even going as far as taking steroids every day for 10 days to treat my daily migraine. So treating the symptoms but never really getting to the root of the issue. Honestly, I really just think it was fate or luck or coincidence that I happened to make an appointment with an OBGYN who was close to my hospital that I was working at. And I told her my symptoms and so she was forward thinking enough to run a full thyroid panel, look at some additional lab tests and said, hey, you have Hashimoto’s. And I was like, oh, what the heck is that? I have no idea what that even is. And my only knowledge at that time of hypothyroidism was taking Synthroid and that’s all I knew. So I feel like going through that journey which went on for years and years, and treating a lot of my symptoms with medications, including birth control and steroids and antibiotics and really getting worse throughout that entire process.

In working in the hospital setting, it was so valuable to really learn disease pathophysiology and, like, learn high level acuity patients, but I found that I was getting to people after the fact, you know, they were already really sick. And they were already kind of like at the end of their rope and not really getting to people or even connecting to people through food. Most of the people that I saw were on tube feedings or TPN. And so with my own journey, I decided, golly, like, there’s this entire population of underserved and totally misunderstood people who are dealing with autoimmunity. One, without even being identified, but two, feeling like they’re just kind of stuck. If they’re lucky enough to be identified as having antibodies against their thyroid, and I’m saying, you know, lucky kind of in the context of having an autoimmune disease and hypothyroidism, but you know, a lot of times the recommendation is, we’ll just wait until it’s bad enough to go on medication, which, as somebody who’s been in that, that seat is a really traumatizing thing to hear. I don’t want to just sit idle while my body is breaking itself down, like, tell me what to do, because there’s so much that is changeable and fixable with diet and lifestyle.

So it’s with that and, like, combining that with the knowledge of nutritional science and the power of nutrition that I decided, gosh, there’s, there’s so many people dealing with this and, like, they need to know this information. Somebody opened my eyes to this, and I feel like it’s my duty to pay it forward to other people. So that’s where my private practice ballooned. And I’ve just been so fortunate to be able to help so many women just be less intimidated by food and really focus on nourishing their bodies as opposed to depriving their bodies, because I think that we’re just so engrained with a deprivation mentality when it comes to diet.

Amanda: It, like, blows my mind that you found that OBGYN. The, how it’s not even not an endocrinologist not, no, you know, what I mean? Like, no specific specialty for thyroid health. And she was, like, oh, let’s run a full panel. And usually when you hear full panel, it’s TSH. And then if your TSH is bad, then they’ll automatically run for usually just T4, sometimes T3 but not antibodies.

Nicole: No, not at all. I feel like it’s something that you really have to fight for. And that’s why I feel like being in this position of empowering people through education and just teaching people who are dealing with these symptoms, what to look for, can really speed up that process to identifying the autoimmune activity. Ninety percent, or studies estimate that 90% of hypothyroidism is related to Hashimoto’s or autoimmune thyroid disease. So that’s a massive percentage of the population. Now, you know, I am not anti-doctor and I’m not anti-medication, but I am pro, like, informed consent and just know what’s going on in your body. And that’s why I consider myself an educator to teach people what to look for and what questions to ask. And so dietitians and nutritionists can really be a liaison between a patient and provider, so that they have the skill set to know what to ask for. Because a lot of the symptoms of hypothyroid, regardless of whether or not it’s autoimmune or non-autoimmune, a lot of the symptoms are kind of vague: fatigue, weight gain, some hair loss, difficulty sleeping. Well, heck, that can be chalked up to a lot of stuff. And so sometimes if you don’t know what to specifically ask for, the doctor may not pick up on that. So I think that it’s important to know and to be really upfront with what you’re requesting with your lab panels.

Amanda: And I think, too, the other frustrating piece is I get a lot of women that are like, I’ve asked my doctor, they run the labs, which is great, thank goodness, right? Because sometimes you have to really, really fight for that. But I have quite a few women that I’ve worked with or that are in my membership, that have great relationships with their doctors and their doctors trust them and will also advocate for them. But then they get the test results back and they’re like, okay, like it’s not necessarily going to change their plan of care, which I think is the frustrating part. But it’s usually that you’re going to a conventional medicine doctor and looking for a functional medicine solution.

And I mean, obviously I would love for those two worlds to collide and work together eventually, and have, since we know how much, especially for autoimmunity, just how much nutrition, gut health, genetics, stress, inflammation, like, impact it. It’s, like, yeah, we’d love for them to kind of combine forces but until then if they really…it ends up, like, I think of my clients with endometriosis—they become like PhDs, you know, and, like, experts in that area. I, a lot of women with Hashimoto’s, same thing, because they can’t, they know they have this condition, they know that they’re, they’re, like, wondering why is their body attacking itself and what they can do about it. But I think that can kind of lead down to many rabbit holes, lots of food restrictions and stuff like that, which we’ll get into.

But let’s just talk about, like, how does someone know, how does someone know if they have an autoimmune thyroid condition and, like, what does it mean? Why is Hashimoto’s hypothyroidism different from regular hypothyroidism? Same thing with Graves’, the, you know, autoimmune version of hyperthyroid?

Nicole: Yeah, absolutely. So I mean, step one, when you’ve been diagnosed and/or suspect that you have hypothyroidism is testing and figuring out what camp you fall into. Are you autoimmune or non-autoimmune? And so the best way to do that is by testing what are called antibodies. And I think having a good understanding of what those antibodies are, are attacking is especially important. You know, the medication management of hypothyroidism really doesn’t change regardless of the root cause—whether it’s autoimmune or non-autoimmune. And so I think that that’s where there’s a lot of misunderstanding with how to manage if there are antibodies present. And so when I’m working with clients, if they suspect and/or have hypothyroidism diagnosed, taking that step and identifying what camp they fall into is important.

So while there are a lot of similarities in the management, nutritionally speaking, and with supplementation and lifestyle and all of that, there are a little bit of offshoots that are especially specific for autoimmunity. You know, when it comes to, like, the creation of thyroid hormone and, like, where autoimmune falls in, and, like, what to look at on a lab test. The main antibody or the main lab values to look at is going to be, number one, TPO antibodies or antithyroid peroxidase antibodies. And so this is going to be very specific and sensitive to the diagnosis of Hashimoto’s. So some studies show that up to 95% of people who have Hashimoto’s test positive for TPO, the thyroid peroxidase antibodies. The other antibody to look at is going to be the thyroglobulin or antithyroglobulin antibody. This one’s not going to be as specific. Some studies show that it’s like roughly 60-70% of people with Hashimoto’s are going to have this one. Sometimes people with Hashimoto’s have one, sometimes it’s both.

One of the big things that I want to recommend is not trying to DIY your thyroid diagnosis, because there is some crossover with the presence of antibodies with Graves’ disease, which would sort of be, like, the autoimmune hyperthyroid, hyperthyroidism I should say, versus the Hashimoto’s hypothyroid. So there is a little bit of crossover there. And so the big thing to look out for when it comes to the Hashimoto’s or Graves’ diagnosis is whether or not there’s the presence of the TSH receptor antibodies, sometimes called the thyrotropin receptor antibodies. And so that can be kind of, like, the defining antibody level. So you definitely, if you have the presence of one or more of those antibodies, you want to work with the doctor to, like, really solidify your diagnosis, because, you know, hyperthyroid and hypothyroid are completely different. And so I think having that understanding is going to be important.

But going back to the creation of thyroid hormone proper. And sometimes just, like, understanding what’s going on behind the scenes and then understanding, like, the, the area in which the autoimmune activity happens…I don’t know, maybe I’m nerdy, but I find that really, really fascinating, because it also helps you to appreciate how powerful nutrition and lifestyle can be for the management of autoimmunity. And so simply put, and sometimes seeing this visually can help if you’re a visual person like I am, but basically, you know, our body is so dynamic and everything is connected in the body. But when it comes to creating thyroid hormones, you know, our, our bloodstream carries lots of nutrients, but our little follicles inside the thyroid hormone, the thyroid gland, pick up sodium and iodide and then it transports it all through there.

And then we have something called thyroglobulin, which is basically, I call it, like, the skeleton of thyroid hormone. It’s kind of considered like a blank canvas, and it has a lot of tyrosine in it. So tyrosine is an amino acid. It’s a conditionally essential amino acid, so we usually produce a lot of that, but under certain times, like a lot of stress, that tyrosine is just not going to be very abundant. So anyway, so thyroglobulin has to combine with iodine. And TPO, that thyroid peroxidase, really helps with that combination or the iodination of the thyroglobulin. And so when you have antibodies to that thyroid peroxidase, it can impact how well that’s combining. The second place where the thyroid peroxidase is going to be active is coupling up. So you have thyroglobulin and it can either combine with one iodine or two iodine. And so from there, it can either turn into T3 which would be, you know, one iodine plus two equals T3 or two iodine plus two iodine equals T4. And so the autoimmune activity can happen there as well.

And so when you’re measuring TPO, those are really the specific places that you’re measuring. And then the antibody to the antithyroglobulin is to the thyroglobulin itself or that, like, pre-protein or, like, the skeleton to the thyroid hormone. Sometimes it can impact the endoplasmic reticulum inside the cell, but a lot of times it’s going to be pretty specific to that thyroglobulin. And then I, as I mentioned, what will differentiate Graves’ between, just on testing, is going to be the presence of the TSH receptor antibodies. So those are the three main antibodies to look at. So if you had the TPO and the TG but no TSH receptor, then that’s going to be the Hashimoto’s.

And this is especially important because you might be thinking, okay, well, one is hyperthyroid, and one is hypothyroid, so wouldn’t that be totally obvious? But it’s not, and I’ll tell you why. There are kind of stages of autoimmunity. And I’m going to talk specifically about, like, the Hashimoto’s autoimmune spectrum, because that’s what I specialize in. Initially, you can have the presence of antibodies and no symptoms at all—that would be called silent. Stage two is going to be autoimmune with elevated antibodies and kind of like mild onset of symptoms. I find in this stage two is when women are going to kind of wax and wane between hyper and hypothyroidism. This happens because as the autoimmune attack happens, and there’s thyroid site destruction or destruction of the thyroid follicle or the cell, the thyroid starts to release hormone into circulation. What that’s going to do is kind of give, like, a false sense of hyperthyroidism. And so sometimes women will get misdiagnosed or diagnosed as Graves’ disease, and then over time, get the destruction of the thyroid and eventually get that diagnosis of Hashimoto’s. So that stage two autoimmune reactivity is kind of like the messy middle where it’s really helpful to have all of those antibodies tested to just kind of fast track and solidify that diagnosis.

Amanda: That’s a good point to test for all of them. Because I also feel like most of the time, when you ask for antibodies they assume Hashimoto’s, because it definitely is more common. But like you said, it’s like, you do want to rule that out. Because say you only have one of the Hashimoto’s ones present, like, maybe it’s not the TPO ones, but the other antithyroglobulin ones, then that could still be present with the TSH receptor ones that are also high with Graves’. So I love that you mentioned that and hopefully people wrote that down if they are trying to figure out if this is what’s going on with them.

And really quick, I want to summarize, because that was, I think this is, people are kind of, like, what’s the difference between hypothyroidism and autoimmune hypothyroidism, and you really stated it beautifully with the antibodies are attacking the specific sites of formation, right? So it’s like, right before the iodine is gonna connect, and then as you’re making the T3 and T4, that coupling. So that’s different from, I mean, if you have kind of your conventional hypothyroidism, yes, stress impacts that for sure. And we’ll talk about stress and autoimmunity in a bit. But it also, like, nutrition, which nutrition will impact autoimmune as well, but like nutrition deficiencies, stress, undereating, not getting enough of certain macronutrients, I feel like those are a little bit more specific to conventional hypothyroidism, where if you improve those things, then it could fix your issue. Whereas with autoimmunity, we’re really looking at okay, these antibodies are present, they’re causing the problem. So it’s more of figuring out how are we going to reduce these antibodies? It sounds like is the key for treating and improving it?

Nicole: For sure. Yeah, so there’s definitely a lot of congruencies with the nutritional and lifestyle approaches, regardless of whether it’s autoimmune or not autoimmune. But I think knowing that is important, because when you have Hashimoto’s and you have hypothyroidism because of the Hashimoto’s, it’s an immune system issue first that’s causing the thyroid issues. So if you jump straight to thyroid supporting supplementation and, you know, a thyroid diet and avoiding goitrogenic foods, like all of that stuff, like, sure that could be great, because that’s sort of, like, the conventional management of hypothyroidism, which is a whole thing. But understanding your unique immune system issues, and everybody’s immune system is completely different and is affected by different things. And we all go through different circumstances in our life, whether it’s physical stress or emotional stress that shape our immune system.

So our bodies as humans, but just as like living beings, we’re designed to adapt, and our, our adaptive immune system is what allows for the autoimmune disease to happen. So that can be a good thing or a bad thing. I like to empower people and teach them that your immune system is adaptive, and it can change. It learned how to attack your body, and it can unlearn that stuff—it just has to feel safe. There’s a lot of stuff that’s not in our control, but there’s also a ton of stuff that we can control. So how you feed yourself and the level of stress that you’re facing and how well you rest and the type of movement that you do. All of that has a positive impact on really shaping that adaptive immune system. So it can seem a little bit crippling to get an autoimmune diagnosis, because it’s a lifelong diagnosis, but I like to flip the switch and just kind of change the mindset about getting that type of diagnosis.

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Amanda: Can you talk a little bit more about, like, what it means to have an autoimmune condition? Like, obviously, with thyroid it’s, like, specifically impacting the thyroid. But in general, like you mentioned it’s your immune system. What does that look like?

Nicole: Yeah, so, you know, your immune system doesn’t discriminate. And so it will have a higher affinity for certain joints or glands, too, kind of dependent on the person. And so it’s, like, part genetic predisposition part gut function, because so much of our immune system is housed inside of our GI tract. And then part tipping point, or you can kind of count tipping point as, like, stress which can be physical stress and emotional stress. And so autoimmunity is kind of a perfect storm of all of those things. You know, your genetics you can’t change, but you can change how your genetics are manifesting themselves, which is called epigenetics. And so whether or not these genes turn on or off is going to be very much dictated by your environment. And your environment is not just, like, the environment in which you live, but the environment inside your body. So the state of your gut health, the thoughts that you have about yourself, and your relationships, and your body, and your food and all of that. So that’s where, you know, dietitians and nutritionists can be really helpful is, you know, decreasing that load of stress on your body through your food choices and your relationship with yourself and with food and all of those things.

But anyway, going back to autoimmunity is, it’s kind of like a confused immune system, if you will. In the case of Hashimoto’s, it’s specific to the thyroid, in which case there’s enough destruction and inflammation that you don’t produce enough thyroid hormone, and that leads to hypothyroidism or low thyroid function. Having autoimmunity will naturally predispose you to developing other autoimmune disease. So you can kind of consider it as a progressive disease. Again, not to scare anybody, but to just really hammer the point home of taking care of your body and alleviating stress as best as you can—again, both physical stress and emotional stress—and really finding ways to pour into your body, to nourish your body, to really calm it down and feel safe so that it’s not having this hyperactive immune response.

Amanda: I love, like, how you, you’ve outlined this, like, a few, in a few places, like, on your blog and on your Instagram. But you talk about those major connections of, like, the genetic predispositions, the having poor gut health, which I want to dig into more, then, like, the tipping point. Can we talk about what are some of the genetic predispositions that can increase someone’s chances of developing an autoimmune condition first, and then we’ll kind of go into each area?

Nicole: Yeah, so there are a lot of genetic mutations. I could rattle off all the acronyms, but I, I’m sure that would bore people, I’m happy to send it to you to like put in the show notes. One of the other predisposing factors that you know, just as women, and this is for a variety of reasons, but women are much more susceptible to autoimmunity. And so some studies show that 70% of those diagnosed with autoimmunity are women, and that there’s a 10:1 ratio of female to male when it comes specifically to autoimmune thyroid disease. So women are 10 times more likely to develop autoimmune thyroid issues, specifically Hashimoto’s. One of the biggest reasons behind that or, like, one of the suspicions is our fluctuations in hormones. And that can be just, like, natural fluctuations and our menstrual cycle. But on top of that, hormonal fluctuations like puberty and pregnancy and postpartum and perimenopause…oddly enough, they all start with P. So you know being on the pill, having your period, being pregnant, postpartum and perimenopause, having period irregularities. So having like PCOS, all of that stuff. Because of the immunostimulant and immunosuppressive properties of our hormones, just by nature that leaves women a little bit more vulnerable to developing autoimmunity is those natural hormone fluctuations.

Amanda: I’ve seen, like, a lot of studies around developing it either during pregnancy or postpartum. I feel like that’s probably one of the most common times. I didn’t even think about menopause. But that’s true, you have a huge drop in hormones and, like, shift in estrogen and progesterone. But around pregnancy, that, do you see that a lot in your clients that they’re developing either during or after?

Nicole: Yeah, so I’m simplifying this a lot, and nothing with science, as much as we want it to be 100% it’s just not, especially nutritional science, but simply put estrogen and prolactin are going to be a little bit more immunostimulating. And then testosterone and progesterone are a little bit more of an immunosuppressant, which makes sense. So think about during pregnancy, you know, you, you don’t want your body to abort a baby. So your immune system is naturally going to be a little bit more suppressed, which is a natural phenomenon. And then after when you’re postpartum, and you have that increase in prolactin, and then over time your estrogen is going to increase on top of the whirlwind of postpartum with stress and sleep deprivation. And that postpartum time is a really vulnerable time for the onset of autoimmunity. But what I do find clinically is that during pregnancy a lot of women’s antibodies get a little bit lower. And then they kind of have a rebound during postpartum. A little bit is to be expected, but again, that’s going to be a pretty vulnerable time for thyroid flares and postpartum thyroiditis where you’re, like, having major Hashimoto’s flares postpartum.

And there’s a lot that you can do. So making sure that you’re nourishing yourself and, you know, I’m saying this with a grain of salt of somebody who has three kids, like, postpartum is hard. And so just being gentle on yourself and getting nourishing food in and reframing your expectation of what postpartum could and should look like. Meaning like trying not to do too much just giving yourself a lot of downtime with having a baby. But, you know, like trying not to get all the laundry and the dishes and this and that done. And just like being really gentle with yourself postpartum.

Amanda: I love that. And I’m curious for you, were you diagnosed before you had kids or after?

Nicole: Before. Yeah, so I was actually, it was, like, right before my wedding, and I was, you know, trying to fit into my wedding dress. And so I was training for the Houston Marathon, I was following a vegan diet, I was on birth control, because I was, like, having really bad acne, and I didn’t want to have acne on my wedding day. So just all of the things that I thought were the right thing to do. So I was diagnosed well before having kids, but I just, I find it so interesting that, and I tell people that, like, when I was doing all the things to be healthy was when I was actually my unhealthiest. And, like, that’s when I had my diagnosis.

But I think just knowing how hormones impact your, not just your immune system, but also your thyroid health is really empowering information. Because as women, like, we’re naturally going to have fluctuations in our hormones just during our cycle, but then also, like, in each season of life. So leading up to perimenopause and, like, menopause proper, you know, like, a lot of times that coincides with estrogen surges Well, hey, wait, if you have a relative estrogen dominance that increases thyroxin-binding globulin, which can lead to some hypothyroidism. And estrogen can also increase your risk of autoimmunity. And so I think just knowing this stuff can help you prepare for it, as opposed to being blindsided and trying to, like, pick up the pieces after the fact.

Amanda: I think that makes sense. And even just knowing like, okay, I’m being mindful of, like, the stress piece, because I feel like what’s within your control, you know, during that time. And not, obviously not all stress, I don’t think we need to eliminate all stress. I’m always talking about, like, building resiliency to stress. And like, you know, like you said, nourishing your body,

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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