Doctor Detective with Bryan Walsh


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In this week’s case study, we meet a woman who can’t lose weight despite following a good diet and exercise program. Problem is, her low thyroid symptoms don’t show up on a conventional lab panel. Here, we use a more extensive thyroid assessment to identify her problem and put her on the road to recovery.

Eat less and exercise more. It’s generally a great prescription for improving health and improving body composition. However, it doesn’t always work.

Even with an awesome exercise plan and a rock-solid diet, some people suffer from mysterious symptoms and complaints that seem puzzling, given how much effort they put into their fitness and health.

When we meet clients who have problems that exercise and nutrition — not to mention their own doctors — can’t seem to solve, we know there are only a few experts on the planet to turn to. One of them is Bryan Walsh. 

Dr. Walsh has a sharp mind, a fitness background, a degree in naturopathic medicine, and extensive additional training and certifications. His wife is a naturopath too. (We bet his kids are the healthiest on the planet.)

When tough cases arise, Dr. Walsh turns from mild-mannered dad and husband into forensic physiologist. He pulls out his microscope, analyzes blood, saliva, urine, lifestyle – whatever he has to, in order to solve the medical mystery.

When Dr. Walsh volunteered to work on a regular case study feature with us, we jumped at the chance. By following along with these fascinating cases, you’ll see exactly how a talented practitioner thinks. You’ll also learn how to improve your own health.

In today’s case, we meet a woman who struggles with her weight and energy levels. Find out how Dr. Detective looks deeper into the mystery of the “invisibly low thyroid”.


The thyroid hormone is key to maintaining a healthy weight. In a general sense, the thyroid is involved in controlling the body’s metabolic “idling speed”. When the thyroid is running too low (aka hypothyroidism), it’s as if the body’s functions “slow down”, almost like a cold engine.

Symptoms of low thyroid include:

  • difficulty losing weight, or weight gain
  • cold hands and feet
  • mild depression, “brain fog”, irritability, or just “the blahs”
  • sluggish digestion and constipation
  • decreased sex hormone production and libido (in women, this can include disrupted menstrual cycles)
  • dry and brittle hair and nails
  • muscle fatigue, weakness, and cramping; poor recovery from workouts

Sometimes people will suffer from these symptoms but lab tests suggest that their thyroid function is fine.

But, as today’s case demonstrates, most lab tests fail to tell the complete thyroid hormone story. And much of what we’ve been taught about thyroid hormone needs to be reconsidered.

The client

Amanda, an upbeat 50-year-old, came to our office looking help with recent unexplained weight gain.  Despite following a consistent PN-type diet and exercise program, she’d not only failed to lose weight, but had actually gained about 1 pound a month for the past 9 months.

At about 5’9” and 149 pounds, Amanda was far from being overweight, but given her excellent nutrition and exercise program, her lack of results pointed to deeper physiological imbalances.

Time for Dr. Detective to get to work.

The client’s signs and symptoms

Amanda was an intelligent, well-spoken, and straightforward woman who didn’t complain about any particular symptoms except for unexplained weight gain.  However, a bit of prodding revealed a few more clues:

Signs / Symptoms My thoughts – potential issues
Unexplained weight gain, cold hands/feet, mild depression (aka “the blues”) Thyroid hormone imbalances, sex hormone imbalances
Craves salt Possible adrenal hormone imbalance
Cannot stay asleep Possible adrenal hormone imbalance, possible blood sugar imbalances

Although interesting, these symptoms were too general to provide answers in themselves. So,  as always, we started with a good blood chemistry.

The tests and assessments

Typically we start with a basic blood chemistry panel but, because Amanda had so many low thyroid symptoms, we decided to run a more complete thyroid panel along with our standard panel.

The test results

Blood chemistry panel

Amanda’s blood chemistry did reveal a few physiological imbalances, but pertinent to her unexplained weight gain, we saw the following:

Marker Result Lab Reference Range Thoughts
Alkaline phosphatase 35 IU/L 25-100 Borderline low – possible zinc and/or vitamin C deficiency
Total Cholesterol 140 mg/dL 100-199 Borderline low – possible inflammation; liver dysfunction; nutritional deficiency
HDL cholesterol 81 mg/dL >39 Borderline high – possible inflammation
Triglycerides 44 mg/dL 0-149 Borderline low – possible inflammation; nutritional deficiency
TSH 1.46 mg/dL 0.45-4.5 Normal
T4 (thyroxine) 7.6 ug/dL 4.5-12.0 Normal
Hemoglobin 11.9 g/dL 11.5-15.0 Borderline low – possible anemic tendencies
Ferritin 14 ng/mL 13-150 Borderline low – low iron stores; heavy menses; parasites; nutritional deficiency; other blood loss
Vitamin D, 25-hydroxy 39.3 ng/mL 32-100 Borderline low

Amanda showed a number of borderline markers indicating some deeper physiological issues (e.g. inflammation), but none of her markers offered insight into the unexpected weight gain, including the two thyroid markers on this panel, TSH (thyroid-stimulating hormone) and T4.

  • TSH tells the thyroid to dial production up or down. If TSH is too high, it means that the thyroid isn’t getting the signal and TSH is cranking up to compensate. When TSH is normal, as in Amanda’s case, it can mean that the problem is “downstream”, in the thyroid itself, rather than in the pituitary, where TSH is secreted.
  • T4, or thyroxine, is the more abundant but less powerful thyroid hormone. It gets converted to the more active T3. If T4 is normal but T3 is low, this tells us that T4 isn’t getting properly converted.

This first panel told us only that TSH and T4 were normal. However, the second, more in-depth thyroid panel provided greater insight.

Marker Result Lab Reference Range Thoughts
T4, free 1.27 ng/dL .82-1.77 Normal
Total T3 (triiodothyronine) 80 ng/dL 71-180 Borderline low – underconversion
Free T3 2.3 pg/mL 2.0-4.4 Borderline low – underconversion

Amanda’s T4 (thyroxine) was normal but her T3 (triiodothyronine), the active form of thyroid hormone, was borderline low.

So, as indicated, her thyroid gland seemed to be producing adequate amounts of T4.

But if T4 is not converted to the more active T3, patients can still suffer from all the low thyroid symptoms including the unexplained weight gain, depression, and cold hands and feet that Amanda had mentioned.

Alternative medicine practitioners are often taught that the enzyme responsible for T4 to T3 conversion – 5’deiodinase – is a selenium-dependent enzyme, which means that it needs selenium to work properly.  However, poor conversion has a number of other causes, including heavy metals, oxidative stress and lipid peroxidation, inflammation, and elevated cortisol.

What, in particular, was going on for Amanda? Time for more detective work.

The prescription

Given that Amanda was possibly low in certain nutrients such as zinc, iron, and vitamin C, and that she showed signs of inflammation, we decided to support her system with some additional selenium and antioxidants.

Step 1 – Diet

To help reduce her possible inflammation, we started Amanda on an elimination diet.

Step 2 – Thyroid conversion support

Second, we put her on a product designed to support thyroid hormone conversion with compounds like selenium, zinc, vitamin C, n-acetyl tyrosine, and guggul gum extract (Thyro-CNV by Apex Energetics), giving her two capsules twice a day.

Step 3 – Antioxidant/anti-inflammatory support

Again to reduce inflammation, we suggested Amanda take broccoli seed extract, curcumin, green tea leaf extract and resveratrol (Nrf2 Activator by Xymogen), one capsule, twice a day.

Step 4 – Iron support

Iron supplementation can be highly inflammatory. So even though Amanda’s ferritin was borderline low, with the apparent the possible inflammatory processes going on in her body, we opted to try to increase her iron levels through diet rather than supplements.  We encouraged her to increase consumption of green leafy vegetables, and also added two tablespoons of blackstrap molasses per day.

The outcome

Thirty days later, we re-ran Amanda’s thyroid panel:

Marker Result Lab Reference Range Thoughts
TSH 1.29 mg/dL 0.45-4.5 Normal
T4 (thyroxine) 7.2 ug/dL 4.5-12.0 Normal
T4, free 1.19 ng/dL .82-1.77 Normal
Total T3 (triiodothyronine) 59 ng/dL 71-180 Low
Free T3 1.9 pg/mL 2.0-4.4 Low

Yikes. That was the exact opposite direction we wanted Amanda’s thyroid conversion to go.  Back to the drawing board!

Th1 and Th2

Clinicians often speak of the immune system as having two “arms”, known as Th1 and Th2. You can read more about this here.

Compounds traditionally considered to be antioxidants can stimulate one arm of the immune system called the Th2 system, which in some individuals this creates positive effects.  However, in patients with already dysregulated immune systems, they can actually make the situation worse! It looked as though this is what had happened with Amanda.

To address this problem, we decided to forget antioxidant support for the time being and instead nutritionally support the other arm of her immune system, the Th1 side.

For 30 days we asked  Amanda to take a number of Th1 stimulating botanicals including echinacea, andrographis, medicinal mushrooms and astragalus.

Two months later, these were her follow-up results.

Marker Result Lab Reference Range Thoughts
TSH 1.37 mg/dL 0.45-4.5 Normal
T4 (thyroxine) 6.5 ug/dL 4.5-12.0 Normal
T4, free 1.07 ng/dL .82-1.77 Normal
Total T3 (triiodothyronine) 77 ng/dL 71-180 Borderline low
Free T3 2.2 pg/mL 2.0-4.4 Borderline low

Amanda’s T3 markers were slightly better than the previous test, but it still appeared as though she was underconverting T4 to T3.

Hmmmm. This was proving to be a tougher case than we’d expected!

At this point we had a conversation with Amanda.  With enough lab testing and digging for answers, I’m certain we could have come up with some insight as to why she was not optimally converting T4 to T3.  However, Amanda initially contacted us because she was concerned about gaining weight.  So we gave her a choice.

  1. Option one was to continue running lab tests and trying different nutritional protocols to get to the bottom of her underconversion issue.
  2. Option two was to take her lab results to an open-minded endocrinologist in hopes of being put on thyroid hormone replacement.

Wanting to lose weight as soon as possible, Amanda chose the second option, and went on medication.

After only one week on thyroid hormone replacement, Amanda reported more energy and improved mood. And she started losing weight within about a month.

Summary

So what can we take away from Amanda’s story?

  1. People struggle to lose weight for many reasons. Thyroid problems are just one possibility. If you’re doing everything “right”, being honest and consistent with your good PN habits, and still not having any success (or worse, are gaining fat while maybe feeling crummy too), then consider an underlying factor such as a hormone imbalance.
  2. Thyroid problems are not as simple as many people believe. The thyroid gland itself may be working optimally, but if inactive T4 is not converted to active T3, low thyroid hormone symptoms will still exist. While many alternative practitioners explain dysfunctional T4 to T3 conversion as a function of selenium deficiency,  there are actually a number of different reasons for poor T4 to T3 conversion.  Sometimes they are easy to determine, while other times they are not.
  3. Most conventional doctors only run TSH and total T4 when assessing thyroid function.  However, a more complete thyroid panel must be run to fully evaluate if there are issues in thyroid hormone physiology.  A complete panel includes TSH, total T4, total T3, free T4, free T3 and T3 uptake. If you’re experiencing low thyroid symptoms but a conventional thyroid panel hasn’t shown anything unusual, request a complete panel.
  4. Ideally, start with less-invasive therapies, such as dietary change or nutritional support. But don’t rule out conventional medicine options. If you have a complex problem, you may need all hands on deck to help you solve it.

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