Graves’ Disease Triggers and the 5-R Protocol
While some people with Graves’ disease will get into a temporary state of remission when taking antithyroid medication, in order to truly restore one’s health you need to find and remove the Graves’ disease triggers, as well as heal the gut. The episode is an introduction to Graves’ disease triggers, and I also discuss the 5-R protocol, which is important for anyone with an increase in intestinal permeability (leaky gut).
During this episode you’ll learn:
- The four main categories of autoimmune triggers
- A discussion of the 5-R protocol, and why following ALL of the steps is necessary to heal the gut
- What you need to know about prebiotics and probiotics
- Some of the more common “leaky gut” triggers
- Action steps you can take
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Here is the transcript for this episode:
Welcome back to the Save My Thyroid podcast. I’m Dr. Eric Osansky, and in this episode, I am going to discuss Graves’ Disease triggers, and I will tie this into the triad of autoimmunity and the 5-R protocol.
Let’s begin by discussing the triad of autoimmunity. The triad of autoimmunity, there are three components necessary for autoimmunity to develop, according to this triad. Component #1 is a genetic predisposition. The good news is that while genetics is a factor in the development of conditions such as Graves’ Disease, the other two factors I am about to mention are even greater factors.
Component #2 is exposure to one or more environmental triggers. I will be discussing some of the different triggers associated with Graves’ Disease as well as other autoimmune conditions shortly.
The third component of the triad is an increase in intestinal permeability, which is also known as a leaky gut.
According to this triad of autoimmunity, you need all three of these components in order for autoimmunity to develop.
Next, I’d like to discuss the four main categories of triggers. The first category is food. Certain food allergens can be potential triggers of autoimmunity. This includes gluten, dairy, corn, and salt. In the research salt also is associated with an increase in TH-17 cells, which are associated with autoimmunity. I commonly recommend some natural sea salt, so I am not saying you have to completely avoid salt. The problem is if you are eating a lot of packaged foods, processed foods, all of these include salt. So most people eat too much salt, and they associate salt with a higher risk of increased blood pressure. That can be the case, too. What I would recommend is try to eat whole, healthy foods, and a little bit of sea salt, like Celtic sea salt, which isn’t usually a problem in most people.
Category #2 is stress. Of course, we all deal with stress. There is both emotional and physical stressors. We are not going to completely eliminate the stress from our life. At least, I know I won’t be able to do that. That’s why you want to try to do everything you can to improve your stress handling skills. Of course, if you can minimize the stressors, that would be great.
The third category includes chemicals. We definitely live in a toxic world. Just as we can’t eliminate stress from our lives, we can’t eliminate all the chemicals that we’re exposed to, just because there are so many. Some examples of chemicals, not all chemicals necessarily trigger autoimmunity. According to the research, mercury, bisphenol A (BPA), breast implants. There isn’t any association with breast implants and autoimmunity in the research, but I have seen my patients where breast implants could be a potential health trigger. So just because something is not in the research doesn’t mean it can’t be a trigger. Maybe it is in the research, but I haven’t seen the research as far as them being a potential autoimmune trigger. But just from the experience of others. There are other environmental toxins, which can also be a factor, not just the ones I mentioned here.
The fourth category of triggers includes infections, such as gut infections like H-pylori and Yersinia enterocolitica. Viruses such as Epstein-Barr and Cytomegalovirus. Stealth infections like Lyme disease or bartonella. So these can also be potential triggers as well.
I’d like to briefly discuss the autoimmunity timeline. With autoimmunity, it’s not like you’re exposed to a trigger, and the next day you develop autoimmunity. First of all, you have different stages. Stage one is the pre-autoimmune stage. This is what takes place before you develop autoimmunity. These are the predisposing factors. It could go way back to being a baby or child where you have a history of antibiotics. Even the birth process, if you are born via a C-section or are bottle fed instead of breastfed, all of these could set the stage.
I’m not saying that you are definitely developing autoimmunity if these are your circumstances, but these could affect your gut microbiome and lead to a decrease in what is called immune tolerance, and over the years, set the stage for you developing an autoimmune condition.
Stage two is the silent autoimmune stage. In this stage, the autoimmune process has already started, but there has been little or no tissue damage. The pre-autoimmune stage is before you are exposed to the trigger, but maybe you are developing dysbiosis of the gut, a leaky gut, one of the factors in the triad of autoimmunity. In the silent autoimmune phase, you have already been exposed to one or more triggers. The autoimmune process has started, but you are not experiencing any symptoms because there has been little tissue damage. If you did a blood test, you might see antibodies. In the case of Graves’ or Hashimoto’s, elevated thyroid antibodies. But the symptoms are probably not going to be present at this stage. You might not even see the antibodies yet in this silent autoimmunity stage.
With stage three, symptoms are present with some tissue damage. This is when the autoimmune condition becomes more advanced, and the person starts experiencing symptoms. For any reason, if the antibodies didn’t show up in stage two, there is a greater chance of them showing up in stage three. I should mention that some people will just have negative antibodies, even those with Graves’ and other autoimmune conditions. We can’t just rely on antibodies, but for those who develop antibodies, usually they will be present in either stage two or stage three, along with symptoms developing in stage three.
Stage four is where symptoms are present, and there is a greater amount of tissue loss. This is when the person’s symptoms will get even worse. In the case of Graves’ Disease, the thyroid blood tests are positive. They might become positive in stage three as far as the thyroid panel. I mentioned the thyroid antibodies. They will be positive before the thyroid hormone levels and TSH are affected. Those antibodies can be elevated as early as stage two, but not often until stage three, and as far as the thyroid hormone levels and TSH, sometimes they can start changing in stage three, but definitely by stage four, you will see the elevated thyroid hormone levels and depressed TSH levels.
Now I would like to discuss the 5-R protocol. This protocol is important to have a healthy gut microbiome. Once again, part of that triad of autoimmunity is an increase in intestinal permeability, which is a leaky gut. In order to heal the gut, you need to incorporate the 5-R protocol. It’s not just about finding and removing triggers.
The first component of the 5-R protocol is Remove. Second is Replace. Third is Reinoculate. Fourth is Repair. Fifth is Rebalance. Let’s discuss these in further detail.
As far as Remove, in order to develop autoimmunity, exposure to one or more environmental triggers is required. It’s necessary to find and remove the trigger in order to reverse the autoimmune component.
When I say reverse, I am not suggesting that we can permanently cure autoimmunity. I have been in remission from Graves’ Disease since 2009. I feel like I have been cured, but there is still that genetic predisposition. There is always a chance that anyone could relapse. Some people you might hear will have autoimmune flares. If you are in remission and maintaining a state of wellness, ideally you shouldn’t have those flares. I like to use the term “permanent remission” instead of “cure.” Either way, you need to find and remove the trigger in order to achieve that state of permanent remission.
Same is true when it comes to healing a leaky gut. You need to find and remove the leaky gut trigger. It’s not always easy to find out what the leaky gut trigger is. Some of the factors that cause a leaky gut are similar to the factors that could directly trigger an autoimmune condition such as Graves’ Disease.
There are food allergens such as gluten and corn oil. Red wine is not necessarily a trigger of autoimmunity, but it can increase intestinal permeability. I label it as a potential leaky gut trigger.
There are infections such as H-pylori, which is a bacteria in the gut. Blastocystis hominis, which is a type of parasite. Also, giardia.
Candida and SIBO. Candida is not an infection. There is no evidence where it could directly trigger autoimmunity, but it can potentially increase intestinal permeability. Candida overgrowth. Candida is normal in the body. It’s not an infection. Same thing with SIBO. That is too much bacteria in the wrong place, the small intestine. So these aren’t infections, but they can cause a leaky gut. I classify these as leaky gut triggers as well.
Certain medications such as NSAIDs, antibiotics, proton pump inhibitors. These all can potentially cause a leaky gut.
I also did some research, which I will be presenting in a future episode, where unfortunately antithyroid medication, specifically methimazole and PTU, can cause a leaky gut as well. There is a time and place for these. I am not telling people they should stop these. I am mentioning them because they can negatively affect the gut.
Stress can potentially be a factor with a leaky gut. Even systemic inflammation can also be a factor.
I am spending a lot of time on the Remove part of the 5-R protocol because many people skip over this part. They will take probiotics and digestive enzymes and do things for gut repair, but they don’t do anything to remove the factor that is causing the leaky gut. All of these are important of course, but don’t skip over the first R.
The second component is Replace. You might need to replace certain things such as digestive enzymes; gastric acid, so betaine HCL. Or perhaps you can take some digestive bitters or some apple cider vinegar to stimulate your own body’s production of stomach acid. Hydrochloric acid activates pepsinogen into pepsin, which breaks down proteins. You not only need digestive enzymes to break down protein, but also sufficient hydrochloric acid. Bile salts, you might have to replace. Some people might take ox bile for example. Dietary fiber is something some people might need to replace. You want to do as much as you can with all of these through diet and not supplement with everything, but there is a time and place for supplementation.
The next R is Reinoculate. Once again, you want to try to do as much as you can through diet. Probiotics, I do like probiotic supplements and commonly recommend them, but you can also do things through diet, such as fermented foods like sauerkraut, kimchi, and kombucha.
As far as why we have to reinoculate, unfortunately, the toxic world is one reason. The toxins, things like glyphosate, which is the active ingredient in Roundup, kills off the good bacteria. So we want to try to do as much through diet, although supplementation can be beneficial here. Medications can also have a negative effect on the gut microbiome. I think that just about everybody needs to be reinoculated. That doesn’t mean that everybody needs to do it through supplements, but at the very least, through food. You can of course be reinoculated through diet and supplementation, so that is an option.
When it comes to discussing probiotics, I want to expand a little bit. Food sources of probiotics include sauerkraut, kimchi, kombucha, kefir, yogurt. If you are following a paleo or AIP diet and trying to avoid dairy, you should eat coconut kefir, not dairy kefir. Non-dairy yogurts, too.
I mentioned earlier that I recommend getting probiotics from both supplements and food sources. There are some people who absolutely don’t want to get them from food sources because they might not like these fermented foods, or the inconvenience, even though you don’t have to make your own sauerkraut or kimchi or kombucha.
There is also soil-based probiotics such as bacillus subtillis or bacillus coagulans. Not as much research on the soil-based probiotics. But some people swear by them. When they take them, they notice a great difference. There are some people who take them and don’t notice much of a difference. That goes for regular probiotic supplements, too, that have lactobacillus and bifidobacterium. Some people notice a huge impact on their health when they take probiotics, and others don’t really notice much of a difference.
Another option is fecal microbiota transplant. That is a little bit extreme. Most people don’t need those. I did have one patient who got that done by a practitioner in Florida. In the United States, as of recording this, it’s only approved for C. diff. The patient didn’t have C. diff, but she went to a practitioner who does do fecal microbiota transplants for other conditions as well. As far as I understand, I don’t think the practitioner will do it for everyone. It really depends on the person.
Also, I need to mention prebiotics, because there are limitations with probiotics. When you purchase a probiotic supplement, there is only going to be a few different strains. You want to get strain-specific probiotics because a lot of probiotic supplements just list the species. Either way, there is only going to be 10-15 strains or species of probiotics in many supplements. Sometimes less than that. But there are a lot more of those species and strains in our gut. Prebiotics are beneficial because they feed the probiotics. You want to try to do as much as you can through diet, but sometimes you can supplement by taking inulin or acacia fiber.
Let’s discuss Repair, the fourth component. I discussed the leaky gut earlier. This occurs when the tight junctions of the small intestine become compromised. There are different ways of testing for a leaky gut. I don’t do a lot of testing. In the past, I did testing. I used a test called intestinal permeability antigenic screen from Cyrex Labs. It’s also referred to as the array #2. There is also the lactulose mannitol test. There are other ways to measure a leaky gut. Some stool panels look at zonulin, which I don’t think is too accurate. But that is another method. I think the array #2 is pretty good.
I just feel that most people don’t need to spend a few hundred dollars to determine if they have a leaky gut. There are benefits of testing. One benefit is you have a baseline, and then you can retest. But not everybody has the money to spend on all these tests.
I assume most people have a leaky gut. The reason for that is when I used to do leaky gut testing on many patients, I found that most people did test positive. Rather than have everybody get a leaky gut test, I just assumed they have a leaky gut. But you do have the option if you want to test. The lactulose mannitol test is a urine test. If you have high levels of lactulose in the urine, that’s indicative of a leaky gut.
When it comes to repairing, a lot of people take supplements. That definitely is an option, but I would say try to do a combination. Try to do as much as you can through diet, but if you are going to do supplements, you want to do both. You don’t want to just rely on taking supplements. Some examples of supplements that can help support and heal the gut include L-glutamine, Vitamin A, zinc. And then there are demulcents such as slippery elm, DGL licorice, marshmallow root. These also support the gut mucosa. You can also then do certain things through diet, like drinking bone broth, or if you are a vegan or vegetarian cabbage juice, fermented foods.
The fifth and final component is Rebalance. This relates to rebalancing the parasympathetic nervous system. You have the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system is known as the fight or flight system, whereas the parasympathetic nervous system is the rest or digest system. You want to do everything you can to activate the parasympathetic nervous system.
You are going to rebalance your body through sleep and stress management. I can’t stress enough how important stress management is. Blocking out time on a daily basis. It doesn’t have to be an hour or two per day although some choose to do that. Even if you are blocking out five to ten minutes per day. I recommend starting with five minutes per day to get into the routine of stress management. Proper sleep is essential for healing, especially for a healthy parasympathetic nervous system.
You also might want to incorporate certain vagus nerve exercises. Some examples include two minutes of vigorous gargling, hot and cold showers, singing loud either in the shower or somewhere else. Coffee enemas. Someone to follow is Dr. Datis Kharrazian, who taught me about the vagus nerve exercises. He has a lot of knowledge when it comes to rebalancing the parasympathetic nervous system. He also has a great book on the brain that if you’re interested, you might want to check out as well.
You might be wondering if you can address more than one of these components at a time. Do you have to do one R at a time? The good news is that it isn’t necessary to focus on each of these components one at a time. You can do them all at once. I’ll just say to make sure you focus enough time on the Remove component. As I mentioned before, many people jump into taking digestive enzymes and probiotics and L-glutamine, and they don’t end up finding what is causing the leaky gut trigger. Make sure that you address all five of these I mentioned. They are all important.
That’s what I want to discuss, but I want to give some action steps. Of course, you want to start with diet and lifestyle. Eat a healthy diet, consisting of whole, healthy foods. I would refer to episode #4 where I discussed hyperthyroid diet tips.
Incorporate mind/body medicine on a regular basis. Maybe start with five minutes of yoga, meditation, deep breathing. Choose something and do it every day. You don’t have to use the same technique; you can mix things up. The point is to try to get into that routine.
Doing things to reduce your toxic load. You want to do as much as you can through diet, eating mostly organic. Also use natural cleaners and cosmetics in your home. Purifying your water as well as your air. Getting an air purifier and a water filter. You could also buy Mountain Valley Springs out of a glass bottle. You want to do as much as you can to get that toxic load down. There are other methods I will discuss in future episodes, such as infrared saunas, doing things to sweat out the toxins.
Also, maintaining healthy Vitamin D levels is very important for overall immune system health. Reducing inflammation is also important. It’s not just about bone health. You can easily test Vitamin D in the blood. I would recommend 25 OH or 25-hydroxy vitamin D test.
We didn’t discuss testing to detect triggers because I think this is best saved for a future episode. At least that’s the approach I take. There are some practitioners who might not do this; everyone is different. But many do test, and I am one of those who like to test rather than guess.
Then you want to incorporate the 5-R protocol. As I mentioned, part of that triad of autoimmunity is an increase in intestinal permeability, that leaky gut. You want to follow the recommendations I gave when it comes to the 5-R protocol. Find and remove that leaky gut trigger. Replace if necessary. Reinoculate with prebiotics and probiotics. Repair either through supplementation, diet, or both. Rebalance that parasympathetic nervous system.
That does it for this episode. I hope you learned a lot when it comes to Graves’ Disease triggers and the 5-R protocol. When it comes to the triggers, I admit I didn’t go real deep into the triggers. I will be dedicating future episodes just to food triggers, stress, chemicals, and infections. This episode would have been super long if I went deep into each of these. This is really an overview when it comes to triggers. Hopefully you still found it to be beneficial. Thanks again for tuning in. I look forward to catching you in the next episode.