Doctor Detective with Bryan Walsh


In this week’s case study, Doctor Detective meets a woman suffering from thyroid issues.  Low thyroid can affect many people — especially women — in all shapes, sizes, ages and stages of life. The symptoms are many and treatment is complicated.  But Doctor Detective knows just what to do.  Find out how treating the underlying cause of a thyroid problem often gets better results than just taking thyroid medication.

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.)

So, when clients have nowhere else to turn, 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. And he frees up the physiological jam.

That’s why, when Dr. Walsh volunteered to work on a monthly 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; and you’ll also learn how to improve your own health.

In today’s case, we’ll meet a client who came to Dr. Walsh with a host of complicated symptoms including high cholesterol, unwanted hair growth, stubborn weight gain, and excessive gas and bloating.

Learn how “Doctor Detective” Walsh unraveled the mystery and helped this client achieve surprising results.

Last month, in our first Doctor Detective episode, we met Jill, a young woman suffering from acne and hormonal imbalances. After a successful nutritional intervention, Jill no longer suffered from the symptoms that brought her into our office. But not only that, she also ended up getting pregnant, a lifelong desire of hers that she had all but forgotten about after years of unsuccessful attempts.

About six months after giving birth to a healthy little girl, Jill contacted us again. She hadn’t bounced back after her pregnancy. She was feeling tired, mildly depressed, and generally blah. Her doctors chalked it up to being postpartum depression. We knew it was something else entirely.

But before we tell you the rest of Jill’s story, we need to tell you about someone else first.

The client

The mother of a 19 year old woman contacted us for help with her daughter, Mary. Mary had been having problems for a while, which had stumped several health care providers.

High cholesterol: Mary’s high cholesterol was not coming down, despite having tried several medications.  Mary’s doctors, and her mother, were very concerned.

PCOS and stubborn weight gain: As a first-year college freshman, Mary was feeling the pressure to be thin. Unfortunately, Mary had already been diagnosed with polycystic ovary syndrome (PCOS), which will often make it difficult for a woman to lose weight.

Multiple medications: Mary was on a handful of medications, including Synthroid (thyroid hormone), Yasmin (birth control prescribed for her PCOS symptoms), statins (cholesterol lowering medications), and spironolactone (typically a high blood pressure medication, but is used off-label for acne). No 19-year-old should be on this many medications and suffering as much as she has been.

Between the cholesterol, PCOS, stubborn weight loss, and pharmaceutical potpourri, Mary was feeling pretty discouraged. It was a mystery, all right.

Mary and her mother came to our office with stacks of lab work that had already been run by her doctors at Johns Hopkins medical center.  It was time for the Dr. Detective team to go to work.

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The client’s signs and symptoms

Mary’s primary complaints were of unwanted facial hair growth, irregular periods, mood swings and difficulty losing weight.  “Diet and exercise don’t work for me,” she said.  She had tried many different diets and stuck to them religiously, yet the weight never budged.

Here are her signs and symptoms, and our first instincts:

Signs / Symptoms My thoughts – potential issues
Mood swings Neurotransmitters, sex hormones, thyroid hormone, blood sugar balance
Difficult weight loss Sex hormones, thyroid hormone
Excess gas and bloating Digestive infection, poor digestion/absorption
Unwanted hair growth Sex hormones
Excessive sweating Likely a side effect of spironolactone
Elevated cholesterol Thyroid hormone, diet, unmanaged blood sugar

Mary’s signs and symptoms all point to some common threads: thyroid issues and sex hormone imbalances, with possible blood sugar issues and some degree of digestive dysfunction.  At this point, we definitely have some important clues.

The tests and assessment

Mary is taking thyroid hormone, which tells us she has already been diagnosed with hypothyroidism.  But the question remains: why?  At a young 19 years of age, why is her thyroid gland already not working?

We considered more diagnostic tests. Mary already had a stack of blood test results, so we didn’t need to run a complete blood chemistry panel. We did, however, decide to run a thyroid antibody test to see whether her thyroid issues were related to the immune system.

Also, with a diagnosis of PCOS, we knew she had sex hormone imbalances, but wanted to evaluate those for ourselves, so we ran a salivary hormone panel.

The test results

Blood chemistry panel

Here’s what Mary’s previous blood chemistry panels found:

Marker Result Lab Reference Range Thoughts
Fasting glucose 79 mg/dL 65-99 Borderline low – possible reactive hypoglycemia, but more likely early insulin resistance
Albumin 3.9 g/dL 3.5-5.5 Borderline low – likely poor liver function, including the ability to metabolize and clear out sex hormones
Lactate dehydrogenase (LDH) 129 IU/L 100-250 Borderline low – further confirming the inability to get glucose into cells (i.e., early insulin resistance)
White blood cells (WBC) 4.5 x10^3/uL 4.0-10.5 Borderline low – possible immune suppression
Mean corpuscular volume (MCV) 95 lF 80-98 Borderline high – B12/folic acid deficiency (common with digestive issues)
Red blood cells (RBC) 4.95 x10^6/uL 3.80-5.5 Borderline high – possible dehydration, elevated testosterone, or both
Thyroid-stimulating hormone (TSH) 10.8 uIU/mL 0.45-4.50 Elevated – despite being on Synthroid, which would typically lower TSH
T4 (thyroxine) 6.0 ug/dL 4.5-12 Borderline low – possibly due to Synthroid
T3 (triiodothyronine) 59 ng/dL 71-180 Low – underconverting active thyroid hormone from inactive T4
Total cholesterol 259 mg/dL 100-169 Elevated – possibly due to low thyroid hormone, blood sugar dysregulation
HDL cholesterol 89 mg/dL >39 Elevated – probable inflammation
Vitamin D 18 ng/mL 32-100 Low – cause unknown

The findings above tell us that Mary has some issues with handling blood sugar and getting glucose into cells to be used as energy (which is insulin’s job).  This is not surprising, as blood sugar/insulin issues usually go along with PCOS.

Also, her liver appears to not be working as well as we’d like and she may have issues with B12/folic acid deficiency causing sub-clinical anemic tendencies, though with the elevated red blood cells, this is impossible to judge.

Thyroid: The missing link

But that wasn’t the key finding in her blood work. Here’s the “smoking gun” from our thyroid antibody panel:

Mary has significantly increased thyroid antibodies, both the thyroid peroxidase and antithyroglobulin antibodies. This tells us that she has an autoimmune thyroid condition called Hashimoto’s syndrome, in which the thyroid gland comes under fire from the immune system.

Once this happens, thyroid production decreases and thyroid antibodies increase — as you can see from Mary’s lab work. The thyroid is inflamed and can’t do its job of helping metabolism run efficiently and effectively. People gain weight, feel cold and cranky, have sluggish digestion, blood sugar ups and downs… and high cholesterol.

The symptoms match, and the lab tests complete the picture. We were closing in on the problem.

Approximately five years ago, Mary was put on Synthroid due to poor thyroid hormone production from her thyroid gland. Now it’s clear that her thyroid wasn’t being lazy: her immune system probably attacked her thyroid gland. Her body also wasn’t converting thyroid hormones: inactive T4 wasn’t being transformed to the active thyroid hormone T3. Again, we assume this is from her immune system dysregulation.

This finding is critical: If she has one known autoimmune condition, she likely suffers from more. When the immune system becomes dysregulated it usually doesn’t just attack one tissue or gland in the body, but many. Based on her elevated thyroid antibodies, our first goal is to bring balance to her immune system.

Hormone panel

Surprisingly, Mary’s salivary hormone panel looked pretty good.  Her cortisol was within a normal range and the rhythm was normal.  Her testosterone, androstendione and estradiol were all normal, but her progesterone was a little low.

We are still interested in her hormones and will likely run a month-long salivary hormone panel to track her hormones over the course of the month, but for now, the immune system is our top priority.

It’s easy to want to tackle a bunch of things simultaneously. But it works better to do one thing at a time.

The prescription

Mary had several seemingly unrelated issues – high cholesterol, mood swings, difficult weight loss, gas and bloating, and inconsistent monthly cycles – but we found one possible connection between all of these symptoms: the immune system.

The immune system

The immune system is one of the most ubiquitous systems in the entire body.  Unlike other systems, the immune system doesn’t have a home – its chemicals are secreted by virtually every cell of the body, and every cell of the body responds to immune system chemicals.

Job #1: Get the immune system working.

Issue #1 – Blood sugar imbalances

Blood sugar imbalances mean insulin and hormone fluctuations. This is hard on the immune system.

We recommended that Mary eat regular, protein-based meals and avoid going longer than 3 hours between eating.  Mary admits that in college, eating this way is difficult, but we coached her on some ways of bringing healthy snacks to class, which she agreed to do. Fans of Precision Nutrition will know that eating regular meals that include lean protein is one of the top habits for getting lean and healthy — which is especially true for folks like Mary with blood sugar problems.

Issue #2 – Digestive function

There’s a surprising power player in keeping your immune system healthy: the digestive system.  Estimates suggest that as much as 80% of the body’s immune system is found in and around the gastrointestinal tract.  Any digestive dysfunction means some immune system problem.

We didn’t want to wait three weeks for lab results to come back. We wanted to fix the digestive problems immediately.  This included:

  1. An elimination diet – Mary is sensitive to inflammatory foods. Because of the positive thyroid antibodies, she needs to be off of gluten, dairy and soy pretty much for life.  Other foods we asked her to avoid: eggs, corn, nightshades (i.e. tomatoes, peppers, eggplant, potatoes), and most grains except for rice.
  2. Digestive support – This included a digestive enzyme supplement (Digestzyme by Designs for Health), 2-3 capsules per meal, to help improve the breakdown of food for easier absorption.
  3. Gut nutrients – There are many compounds that have been shown to help improve the health of the digestive tract.  We had her use 1-2 scoops of Designs for Health GI Revive.
  4. Probiotics – We generally do not blindly recommend probiotics for people, but Mary had a history of antibiotic use, so we decided to add this to her protocol.  We used Therabiotic Complete by Klarie labs, 2 capsules twice a day, preferably on an empty stomach, for thirty days, then halved the dose for the next 60 days.

Issue #3 – Liver Support

Technically, poor liver function won’t affect immune system function as some other systems, at least from a clinical perspective.  However, if her liver is not working well, we want to get an accurate picture of our progress. Antibodies are in part, metabolized by the liver.

In other words, if Mary’s liver is not working well, she might not be able to clear out her antibodies. If we rerun a thyroid antibody panel, thyroid antibodies may still be elevated — this time, not because of her immune system, but rather because she can’t remove antibodies.  So we added 2 capsules of Amino-D-Tox (Designs for Health) to her program.

Issue #4 – Immune Support

We aren’t currently riding the Vitamin D bandwagon that has been driving around the medical community for the past few years, but there is some pretty compelling research correlating vitamin D levels and autoimmune conditions.

Based on this research, and Mary’s low levels, we prescribed 6,000 IU of vitamin D, along with other fat soluble vitamins, for 30 days, then dropping down to 4,000 IU thereafter, and retesting in 90 days. We also included 1 gram of fish oil a day for its potential anti-inflammatory and immune system benefits in autoimmune conditions.

Issue #5 – Other

Mary might have had vitamin B12 deficiency, which can cause a sub-clinical anemic tendency, so we gave her sublingual B12, 1 mg taken three times a day.

We plan on doing much more with Mary, but our first goal is to get her immune system to calm down a bit before going forward with other options.

The outcome

A few weeks into the program, Mary contacted us to say that the gas and bloating had completely disappeared, she no longer suffered from mood swings, and overall she was feeling better and more energetic than she had in a long time.  She also told us that she had lost 10 lbs in the past three weeks, and her clothes were fitting better.

When actively working with a patient, we typically rerun blood chemistries every three months, cortisol every 30 days, and other sex hormones approximately every 6 weeks.  Since she wasn’t due for any of these, and since antibodies can take a while to clear out of the body, we decided to keep her on the elimination diet and supplement protocol for three more weeks.

At the end of six weeks, we re-ran her blood chemistry, including a thyroid panel.  Significant findings included:

  1. Her thyroid antibodies dropped by half. This means her immune system is calming down and lowering its attack on her thyroid.
  2. Her total cholesterol dropped 45 points, likely due to improved thyroid hormone conversion and blood sugar balance.
  3. Her total T3 increased from 59 to 84, which is still low, but is good progress. This probably means her immune system is becoming more balanced. And it’s probably why she’s got more energy and is losing weight.
  4. Her RBC dropped a bit, indicating she was staying better hydrated.
  5. Some other problems still exist: Her albumin was still low, glucose and LDH still low, and her MCV still elevated.

We haven’t “fixed” the autoimmunity, but we’re making headway.  Which takes us back to Jill, the subject of our original case study…

So what happened to Jill?

When Jill contacted us after having her baby, we ran a blood chemistry panel. Her thyroid panel showed the following.

Given that the primary cause of hypothyroidism today is Hashimoto’s, we ran her antibodies which came back like this:

High TSH and elevated thyroid antibodies. Look familiar?

Yep, both women have Hashimoto’s, which is unfortunately more common today than people realize.  We’re not sure what triggered it in Mary, but Jill’s trigger was likely her pregnancy.

Luckily, the tests told us what to do to help Jill feel better. She now follows a gluten- and dairy-free lifestyle, keeps her hormones and blood sugar in check, has stabilized her energy levels, is enjoying time with her now 2 year old daughter. Plus, she’s pregnant once again.

Low thyroid can affect many people — but especially women — in all shapes, sizes, ages and stages of life.


So what can we take away from Mary’s (and Jill’s) stories?

  1. Sometimes symptoms can all be from unrelated physiological imbalances but often, they have a single underlying cause.  In Mary’s case, her immune system probably damaged multiple tissues in her body, including her thyroid gland.
  2. Hypothyroidism (low thyroid function) is now very common. Synthroid is one of the top four most prescribed medications in the US.  While there are a number of possible causes for hypothyroidism, Hashimoto’s tops the list.  And when an autoimmune condition presents, it is no longer just a”thyroid condition” but rather, a broader immune system condition.
  3. To begin correcting immune system imbalances, including autoimmune conditions, eliminate anything that could make the immune system worse.  This includes managing blood sugar with regular well-balanced meals, eliminating foods that trigger immune responses (such as wheat and dairy), and improving the function of the digestive system.
  4. Once we cover the basics, we can help balance the immune system further… but only once we remove the major triggers.
  5. The fundamental habits of Precision Nutrition style eating can be part of an overall treatment plan. Eating every 3-4 hours, and including lean protein with each meal, are two of the cornerstone habits of successful body transformation, athletic performance, and general wellness. We had to modify the details of Mary’s meal composition to work with her elimination diet, but in general, eating PN-style is a great approach for most health conditions.

If you’re a coach, or you want to be…

You can help people build nutrition and lifestyle habits that improve their physical and mental health, bolster their immunity, help them better manage stress, and get sustainable results. We'll show you how.

If you’d like to learn more, consider the PN Level 1 Nutrition Coaching Certification.