The Stall Slayer by Amy Berger

Amy Berger, MS, CNS, is a U.S. Air Force veteran and Certified Nutrition Specialist who helps people do "Keto Without the Crazy."™ She writes about a wide range of health and nutrition-related topics, such as insulin, weight loss, diabetes, Alzheimer's disease, thyroid function, and more. She has presented internationally on these issues and is the author of The Alzheimer's Antidote, The Stall Slayer, and co-author of End Your Carb Confusion, written with Eric Westman, MD. She is the lead nutritionist for Adapt Your Life Academy, where she helps create course content and coaches people through implementing low-carb keto diets safely and effectively.

Being a nutritionist who specializes in helping people with low-carb and ketogenic diets, people contact me all the time for help with stubborn weight loss. They're doing all the right things -- keeping carbs very low, not overdoing concentrated fats (like heavy cream, nuts, and cheese), some are exercising, and when they test for ketones, they're always in ketosis. So why won't those extra pounds budge? There's nothing more frustrating and disappointing than putting genuine effort into something only to be getting nowhere.

Over nearly a decade of helping people with low-carb -- not to mention navigating my own personal experience -- I've come to realize that undiagnosed or improperly treated hypothyroidism is a common roadblock to fat loss. When thyroid hormones aren't at their optimal levels, it can be very difficult to lose weight regardless of how disciplined someone is with their diet and exercise. For reasons that could be a whole book unto themselves (and in fact, I'm writing one as we speak), the "normal" ranges for various thyroid hormones are controversial. It's critical to understand that normal does not mean optimal. Just because your levels of certain hormones fall within the "normal" ranges does not mean that you will feel your best.

The other issue is that the most commonly prescribed thyroid medication -- levothyroxine (brand name Synthroid) -- is ineffective for many people. So if you're "taking thyroid medicine," but you still feel awful, and you're still dealing with all the same bothersome signs & symptoms you had before you started the medicine, consider that you might need a different type of medication. It can be difficult to get a doctor to prescribe these other forms, but don't be afraid to advocate for yourself. Nobody wants you to feel better more than you do. Find a new doctor if necessary. Remember: they work for you. They are providing you a service, and if you are dissatisfied with the service you are receiving, don't hesitate to "shop around" for someone who might be a better fit.

Bottom line: don't let an undiagnosed or improperly treated hormonal issue stand in the way of you getting the results you are working so hard to achieve. This excerpt all about thyroid from my book, The Stall Slayer, will arm you with the information you need to pursue better testing and treatment, if necessary.

If you're struggling with stubborn fat loss on a low-carb or keto diet, my Stall Slayer Masterclass online course is starting soon. It's based on the book, and there's an entire lesson just on thyroid, plus, of course, all the dietary and lifestyle factors that can get in the way of fat loss -- and what to do about them. The course includes 3 weeks of dedicated support, plus live Q&A sessions with me. See here for details: The Stall Slayer Masterclass.

I also recommend watching this video if you are taking thyroid medicine but you still experience depression and/or it's very difficult to lose weight: Critical Info on Thyroid.

-Amy Berger

The Stall Slayer - Book Excerpt

Low Thyroid Function

If you've taken a detailed look at your diet and in your honest, not-kidding-yourself assessment, excess carbs and fat aren't what's standing in the way of your fat loss, thyroid function is another good place to look. Suboptimal thyroid function is much more common among women than among men, but men aren't immune to it. I've lost count of how many clients I've worked with who had low thyroid function and didn't even know it, or who were actually already on thyroid medication but were not on the right type or the right dose, so they continued to experience all the signs and symptoms of hypothyroidism - including weight gain or difficulty losing weight.

Role of Thyroid Hormones in Metabolism

Let's start with a brief overview of what the thyroid does. The thyroid gland (which is located at the front of your neck, below the Adam's apple and in front of the windpipe), is often called the "master regulator" of metabolism, owing to its profound influence on how the body uses energy. Healthy thyroid function is crucial for fat loss and weight maintenance, good energy levels, and even a positive mental outlook. The thyroid helps establish your basal metabolic rate. This is the amount of energy your body uses - the "calories you burn" - while doing absolutely nothing. It's the rate at which your body uses energy just to run all the processes that keep you alive (such as breathing, your heart beating, and your kidneys filtering your blood). Differences in thyroid hormone levels may partly account for why some people seem to have very "fast" metabolisms even when they eat a junkfood diet and do no exercise at all, and why others fight like hell to lose mere ounces while following a strict diet and exercise plan.

I cannot emphasize this enough: your basal metabolic rate is responsible for the vast majority of calories you burn - or, rather, energy your body utilizes - regardless of how much food you eat or how much exercise you do. If your thyroid hormones are out of whack, you will have a very hard time losing body fat no matter how disciplined and diligent you are with regard to diet and exercise. If your body's thermostat is simply set too low, your entire metabolism will be sluggish, regardless of what you eat and how much you move. You cannot exercise your way out of a slow metabolic rate due to low thyroid. You won't burn anywhere near as much energy on a treadmill or in a weight room in 1 or 2 or even 3 hours a day as your body will use all by itself the other 21-23 hours of the day just keeping you alive - assuming your metabolism is not set to super-slow mode.

If your thyroid hormones are out of whack, you will have a very hard time losing body fat no matter how disciplined and diligent you are with regard to diet and exercise.

Owing to its critical role in metabolism and the efficient functioning of many processes in the body, reduced output of thyroid hormone results in an overall slowdown that affects just about everything.

How can you tell if your thyroid hormones aren't at the optimal levels for you? You can have blood tests to measure them and I'll cover that in a bit, but first, let's start with signs and symptoms that can clue you in. It's important to know that you don't have to experience all the symptoms below in order to have an underactive thyroid or thyroid hormones that aren't at optimal levels. Hypothyroidism can manifest slightly differently in different people, so if you find yourself saying yes to several of the points below, problems with thyroid hormones could be the reason for your fat loss stall, and I recommend getting a comprehensive thyroid assessment. (Details on this in a minute.)

Signs & symptoms of low thyroid:
  • Weight gain (or inability to lose weight)
  • Hair loss
  • Constipation
  • Depression; apathy
  • Fatigue
  • Low libido; loss of sex drive
  • Cold hands and feet; feeling cold all the time
  • Dry skin
  • Hoarse voice
  • Loss of the outer third of the eyebrows
  • High cholesterol (total and LDL)
  • Low blood pressure
  • Slowed heart rate
  • Brain fog; cognitive impairment
  • Edema (water retention; especially in the lower legs - to the point where your ankles or lower legs look like tree trunks at the end of the day)

Considering the effects of thyroid hormones on metabolism, these signs and symptoms are no surprise. Everything in the body slows down: the heart rate, generation of heat, and even the movement of waste through the colon. (Hence the constipation.) Thyroid hormones are required for proper functioning of the LDL receptor, so that's why LDL accumulates in the bloodstream and cholesterol is elevated when thyroid hormones are low.

Low thyroid function doesn't just affect the body; it affects the mind and spirit, too. Many people with hypothyroidism experience depression, so we could say that a sluggish thyroid has physical and mental or psychological effects, but depending on how you look at this, mental and psychological effects are physical - or, rather, they're biochemical. When someone with hypothyroidism experiences depression, it is not - repeat, not - "all in their head." It has its origins in hormonal dysregulation, and telling someone affected by this to "just cheer up" or "look on the bright side" is absolutely not a solution. The depression is driven by an underlying hormonal abnormality that can be corrected. The point is, when thyroid hormones are low, the physical body slows down, but even thoughts and emotions slow down. And you can't talk-therapy your way out of it because these terrible thoughts aren't something you've fabricated for no reason. They're not imaginary. They have a biochemical/hormonal basis. At best, you can fake it until you (and your doctor) actually correct the underlying problem.

Testing Thyroid Hormones

The most important thing to know is that if you suspect your thyroid is on the fritz, you must ask for a comprehensive thyroid panel. You absolutely must insist on this. Thyroid hormone testing is complex and many doctors look at only a fraction of the relevant measurements - a fraction that tells them very little about the overall situation. As a result, countless patients are told their lab values are "normal," yet they will continue to suffer from the sometimes debilitating effects of underactive thyroid. Considering the impact on quality of life when thyroid symptoms are severe, this is truly one of the great medical tragedies of our time. (If this wasn't common as heck, there wouldn't be a book called Why Do I Still Have Thyroid Symptoms? When My Lab Tests Are Normal. Seriously. Someone wrote an entire book about this.)

If you've been following a solid ketogenic diet without overdoing carbs or fat, and your body fat absolutely isn't budging, and you have obvious signs and symptoms of suboptimal thyroid hormone levels, insist on proper comprehensive testing. Don't allow an uninformed medical professional to dismiss your concerns or make you feel like you're imagining everything.

In order to get a complete picture of thyroid function and understand what's really going on, several different hormones must be measured. A proper assessment of thyroid hormones can help guide treatment because there might be a roadblock in a particular pathway, or in some cases the problem isn't with the thyroid gland at all, but somewhere else in the body and the thyroid is simply reacting to that other issue. Measuring only one or two hormones, as many doctors do, is insufficient for uncovering these hidden issues.

A comprehensive thyroid panel should include:

Thyroid stimulating hormone (TSH): TSH is not produced by the thyroid gland itself, but rather, by the pituitary gland (located in the brain). It does exactly what it sounds like it does: it stimulates the thyroid to produce its hormones. TSH is often high in individuals with low thyroid function because if the thyroid gland doesn't respond to the "stimulation" by secreting its hormones, more TSH is generated in order to send a more forceful signal. In less common cases of low thyroid function, TSH will be low, which means the thyroid gland doesn't receive an adequate stimulus in the first place. Knowing your TSH is important, but it doesn't stand alone. A TSH that's high or low tells you only that TSH is high or low; it doesn't tell you why. For that, you need to look at a few other hormones.

Thyroxine (T4): This is the primary hormone produced by the thyroid gland. It consists mainly of the amino acid tyrosine bound to four atoms of iodine. (This is where the "4" in T4 comes from.) T4 is not the most powerful form of thyroid hormone. T4 is secreted into the blood and other tissues must convert it to T3, which is more potent. T4 is measured as total T4 (the total amount of T4 in the blood) or free T4. Most hormones cannot travel freely in the bloodstream or they would latch on anywhere and wreak all kinds of havoc. Most are attached to a binding protein of some sort, which keeps them inert or inactive until they reach their target tissues. Free T4 is the amount of T4 that is unbound to other molecules and is thus "free" to perform its actions. Low total or free T4 could be a factor in hypothyroidism, and thus, difficulty losing body fat.

Triiodothyronine (T3): T3 is the more potent or "bioactive" form of thyroid hormone. It's responsible for most of the effects we associate with healthy thyroid function and a metabolism that hums along speedily. The thyroid secretes small amounts of T3 but most T3 is produced from T4 in other parts of the body. The enzyme that converts T4 to T3 is called a de-iodinase - it removes one iodine atom from T4, leaving 3. (Hence the "3" in T3. Neat, huh?) This enzyme is selenium-dependent, which is why you might have heard the mineral selenium is important for thyroid function, in addition to the obvious iodine. As with T4, T3 is also measured as total or free T3, with free T3 being a better indicator of thyroid hormone status than total T3.

In my opinion, free T3 is the most telling measurement when you're experiencing signs of thyroid dysfunction. Other hormones are important too, but believe it or not, many doctors don't measure T3 at all! (Neither total nor free.) They measure TSH only! Their thinking goes like this: if your TSH is normal, then your T3 is probably normal and your thyroid is fine. They assume that if your thyroid wasn't fine, your T3 would be low, which would signal the pituitary gland to pump out more TSH. But since the TSH is normal...Oy! You can see now why testing only TSH - which, sadly, is very common - is not good enough!

Reverse T3 (rT3): Think of this as a T3 impostor - it fits into the receptor for T3 but doesn't have the same hormonal effect. In fact, it blocks the real T3 from doing its job. (It's considered a "biologically inactive" form of T3.) I wish they would call it impostor T3, because that might help us be more aware of what it does. rT3 is sometimes elevated during periods of heavy stress or a serious illness, as the body's way of conserving energy. Remember, thyroid hormone - free T3, in particular - is responsible for how quickly your body burns through energy. If you're running around doing a million different things at once with no breaks and no downtime, from a biological/evolutionary standpoint, that would be pretty dangerous. So rT3 comes along to force you to slow down. Or, rather, since you won't slow down, your body will. Your heart will. Your brain will. Your colon will. So you'll have a low heart rate. You'll be depressed, cold, constipated, fatigued, and all the other fun stuff that comes along with hypothyroidism. Reverse T3 often goes hand-in-hand with high cortisol. If cortisol is the gas pedal, rT3 is the brake, trying to keep the car (your body) from careening out of control.

Thyroid antibodies: These include thyroid peroxidase (TPO) antibodies and thyroglobulin antibodies (TgAb). Elevations in these indicate an autoimmune attack on the thyroid gland, in which case the underlying problem is not actually in the thyroid, but rather, with an overactive immune system. Autoimmunity that results in hypothyroidism is called Hashimoto's disease, and autoimmunity leading to hyperthyroidism (overactive thyroid function) is known as Grave's disease.

Thyroglobulin is a kind of proto-thyroid hormone, or a precursor to thyroid hormone. Thyroid peroxidase is an enzyme that attaches iodine atoms to the tyrosine molecules in thyroglobulin, which creates the thyroxine hormone (T4). Antibodies to either of these compounds can mean that you won't produce adequate thyroid hormones. Thyroid peroxidase is a heme protein, which means it contains iron. (Like the hemoglobin in your blood.) So adequate iron is necessary for healthy thyroid hormone synthesis. This is one among many reasons why fatigue is a hallmark of iron deficiency anemia.

It seems like whenever people hear about hypothyroidism, they assume it's Hashimoto's. "Hashi's" is very common and probably underdiagnosed, but not all thyroid problems are autoimmune in nature. Low thyroid function, or endocrine disturbances elsewhere that affect the thyroid downstream, can happen for a number of reasons, and probably some that haven't even been identified yet.

Bottom line: Measuring TSH alone is nearly worthless. The various thyroid-related hormones are like a Rubik's cube: they interact and influence each other's production, and it's important to look at all of them in order to help things fall into place. (Anyone reading this old enough to remember the Rubik's cube?)

Having a normal TSH does not mean your thyroid is working properly or that all the other thyroid-related hormones are at optimal levels for you. If you've only had TSH or T4 tested and your doctor said your thyroid is "normal," but you have obvious signs & symptoms of low thyroid, you need better tests...or a better doctor.

Having a normal TSH does not mean your thyroid is working properly. If your doctor has tested only TSH and told you your thyroid "is fine," yet you know darn well you feel awful and are living with multiple signs and symptoms of thyroid dysfunction, you have some options:

  1. Politely request that your doctor order a comprehensive thyroid panel.
  2. Order one yourself. In the US, you can do this via DirectLabs (https://www.directlabs.com) except in Maryland, New Jersey, New York, and Rhode Island. See the note at the end of this chapter for the tests I recommend.
  3. Get a new doctor. Don't let a well-intentioned but ignorant physician be an obstacle to you reclaiming your quality of life.
Lab Ranges for Thyroid Hormones

Something to keep in mind when assessing your thyroid status is that "normal" is a relative term. Lab ranges differ slightly between testing companies, so what's considered low or high might be different, too. Depending on the lab used, the very same value could be considered normal or be flagged as out of range. The key is to go by your symptoms. Lab values are a guide and they can help validate or rule out a thyroid problem, but how you feel is much more important. More than the numbers on a lab printout, your signs and symptoms should guide you and your doctor toward the appropriate course of action.

Far too many people with obvious signs and symptoms of suboptimal thyroid function are told they're "normal" and are provided with no relief. This is partly because some of the signs and symptoms of hypothyroidism are non-specific and can be attributed to other things. For example, weight gain or difficulty losing weight, constipation, fatigue, and depression can be signs of any number of other issues, so thyroid testing isn't always the first place your doctor's mind will go. That being said, as I mentioned earlier, when you have several classic signs of low thyroid, a medical professional ought to at least send you for proper testing. Armed with the results, you'll be able to identify whether you actually do have a thyroid problem or rule it out if you don't. Either way, you'll know for certain and can proceed from there more strategically, rather than guessing blindly.

Even though lab ranges are only a guide, here are the basics, with the understanding that you might experience issues related to hypo- or hyperthyroidism even if you fall within the reference ranges.

Also, as is true for many other measurable biomarkers, conventional allopathic medicine has its preferred ranges, while functional medicine practitioners see things a little differently. You'll notice that some of the ranges overlap, but some have slight differences. Functional medicine practitioners typically interpret lab values with an eye toward what is optimal and will have someone feeling their best, rather than what some random laboratory has deemed "normal." If you experience signs and symptoms of thyroid dysfunction even though your lab values fall within the normal range as defined by conventional medicine, you might find resolution of symptoms by working with a more open-minded doctor who understands the shortcomings of the traditional lab ranges. (The ones here were provided by Justin Marchegiani, DC. Also note that many labs use different units, so if you're comparing your values against these, make sure you're comparing apples to apples.)

If you've been following a solid ketogenic diet without overdoing carbs or fat, and your body fat absolutely isn't budging, and you have obvious signs and symptoms of suboptimal thyroid hormone levels, insist on proper comprehensive testing. Don't allow an uninformed medical professional to dismiss your concerns or make you feel like you're imagining everything. (You'd be amazed - or horrified, maybe - at how often this happens. Dealing with a thyroid problem is not for the faint of heart!) Don't let them tell you to eat more fiber for the constipation, or to eat less and move more to get your weight moving, or to give you a statin for the high cholesterol and an antidepressant for your mood. All of these problems are coming from one source, and yes, you might need medication to correct it, but not the medications so many people with hypothyroidism are given to mask the symptoms being caused by the low thyroid hormones. If the thyroid is the problem, then the thyroid needs to be addressed. Putting on a sweater because you're cold all the time might warm you up temporarily but it doesn't address the reason why you're cold all the time. Laxatives can help you have a bowel movement in the short term, but they do nothing to correct why you're chronically constipated. In order to correct the fundamental root cause, you need to address the thyroid, or whatever other endocrine factors are affecting the thyroid.

If you've already had your thyroid tested and were told everything's normal, get a copy of your results and see if a comprehensive testing panel was performed, or if your medical professional is basing her or his evaluation based solely on TSH and/or T4. I'm sure it's crystal clear by now that those are not always sufficient.

Does Keto Affect Thyroid Function?

You might have read some scaremongering pieces online saying that keto is bad for the thyroid, or that people with hypothyroidism shouldn't follow a low carb or ketogenic diet. Neither is accurate.

The truth is, some people with hypothyroid issues find things improve when they go low carb or keto. This tends to be more common among people with Hashimoto's than other forms of thyroid dysfunction, but others have reported improvements as well. On the other hand, some people who start off feeling great find that after a while of being keto, they start to have symptoms of low thyroid. What gives? Is it possible that a way of eating that has such wonderful benefits for so much of the body could be harmful for the thyroid?

The effect of low carb diets on thyroid function is a controversial issue. Some people following keto find that their T3 decreases after a while. (And remember, T3 is the most active or potent form of thyroid hormone.) At first glance, we might take this to mean that keto causes a slowdown in metabolism, or maybe it has other negative downstream effects. On the other hand, physicians and researchers who've spent decades improving the lives of their patients with low carb and ketogenic diets have not reported adverse effects on thyroid function. So what's the deal?

Well, this is why lab tests are a guide and a good starting point, but they shouldn't be the sole arbiter of your health and wellbeing. If your T3 has decreased a bit after you've been following a low carb or ketogenic diet for a while but you feel fine, then it's not a problem. In fact, that's true of this entire chapter on thyroid: if you feel well, you probably don't have a thyroid problem. But if you're having a heck of a time losing fat on keto, and you're dealing with some of the other signs and symptoms of low thyroid, then it's something you should look into.

Back to a lower T3: looked at through the lens of a ketogenic diet, a decrease in T3 doesn't automatically mean your thyroid function is being compromised. In fact, it may be that the improvements in metabolic efficiency people experience while being a fat-burner rather than a sugar-burner result in a heightened sensitivity to T3, and therefore a decreased need for higher levels. That is, their body gets the same effects from a lower level of the hormone. (It's kind of like insulin sensitivity versus insulin resistance: when you are insulin sensitive, you need less of the hormone to provoke its effects than someone who is resistant.) Dr. Stephen Phinney, MD, PhD, who's been doing clinical research on ketogenic diets since the 1980s, has written that this is most likely what's happening, and he's noted that there is no published research showing that well-formulated ketogenic diets induce hypothyroidism. No one really knows for certain what's going on in this situation, though, so this is speculation for now, but it makes sense in light of the physiological mechanisms at work.

What if you've been following a ketogenic or low carb diet, you notice a drop in your T3, and you do become symptomatic? This is uncommon, but not unheard of. It's possible this is the result of unintentional caloric restriction. Keto diets tend to induce satiety more easily than high carb diets - meaning, people feel satiated and stay fuller longer on fewer total calories when they're eating low carb than when they ate high carb. (Not everyone experiences this on keto, but most people do. In fact, not feeling hungry all the time is one of the nicest things about eating this way.) For some people, this increased satiety might mean that, without even trying, they eat a lot less than they did before they switched to low carb. If this happens over the long term, it could affect thyroid function.

But the thing is, any diet that results in a very drastic caloric deficit, especially for an extended period of time, would do the same thing. This has been observed in people who lose a lot of weight, especially if it was done through severe calorie restriction. It's called "famine response hypothyroidism."1-3 In a nutshell, it's a metabolic slowdown in response to drastic energy restriction. Not carb restriction, but total food restriction, particularly when combined with a lot of exercise and a generally stressful life.

Remember, your thyroid sets your basal metabolic rate. If you are burning through a lot of energy in a go-go-go lifestyle and doing a lot of exercise on top of that without giving your body the fuel it needs to get through that, your body is going take matters into its own hands and correct the situation. You can't go on like that forever or you'll burn out, so as a protective step, you produce less T4 and/or T3, and more reverse T3 - more of the impostor molecule that prevents the real T3 from doing its job. Because you won't slow down and rest or get adequate nutrition voluntarily, your body forces you to slow down by making you fatigued, constipated, cold, and depressed. Try hitting the gym when you're fatigued and depressed: your body won't let you. And as for fat loss, well, when your body perceives it's in this crisis, the last thing it's going to do is get rid of its energy reserves. You already don't have enough food coming in; your body's going to conserve the stores it does have rather than burning through them quickly, which would really put you into a precarious situation.

Thyroid slowdown, or "famine response hypothyroidism" isn't a unique effect of keto; it's an effect of your body trying to conserve energy because there's been so little of it coming in. When this happens on keto, the assumption is that you need more carbs, or that going so low carb caused the thyroid problem. But it's not the lack of carbs that did it; it's the lack of adequate total food energy. The solution here isn't necessarily to add back some carbs; the solution is to ensure adequate caloric intake.

A bit of speculation here again, but I suspect unintentional drastic caloric reduction is the culprit behind people becoming symptomatic with regard to low thyroid function on keto. These changes are more common among women than men, and women are more likely to under-consume food energy, whether deliberately or unintentionally. Many women have been living with "diet mentality" for nearly all their lives, and even on a keto diet it can be difficult for them to embrace it being okay to eat substantial portions of meat, bacon, cheese, and other fatty foods. They might still be trapped in Lettuce Land, afraid to really let themselves be nourished by adequate amounts of food, particularly when they might have considered these foods "off limits" for most of their life.

Low thyroid function on keto may also be a result of long-term inadequate caloric intake combined with over-exercising. When you work out hard, you have to rest hard and eat hard, too. Your body needs rest and nutritional replenishment. People who push and push without giving their bodies a chance to rest, repair, and rejuvenate often don't mean to do this; it's just that decades of brainwashing have led them to think that 3 ounces of chicken breast and a pile of romaine lettuce is sufficient to "refuel" after an intense workout. So it's not exactly a big shock that they feel better adding sweet potatoes, white rice, or even oatmeal back into their diet.

Maybe it's the carbs, but maybe it's also the calories. Coming from the old diet mentality, some people might feel "safer" incorporating some starches into their diet rather than having a larger steak or an extra pork chop. It's possible someone who thinks keto gave them a thyroid problem would be just fine if they increased their total food intake sticking to low carb foods.

But then again, maybe it is the carbs. Some people really, truly, do feel better when they increase their carb intake. I have nothing against that. Not everyone needs to be keto 24/7 to look, feel, and perform their best. Thyroid slowdown on keto tends to occur in people who were already pretty lean and active to begin with - people who didn't need to lose much weight - if any - and who already exercised frequently and intensely. These people likely didn't "need" a ketogenic diet anyway, and simply adopted it to experiment, or because their friends were doing it, or because they were convinced by some social media outlet that keto is the only way to go. It's not.

That being said, you're reading this because your fat loss is stalled. Assuming you're still looking to lose a significant amount of fat, you probably didn't start keto already being lean and an exercise fiend. So those last couple paragraphs probably don't apply to you, but I had to write them because I know a lot of people worry about these issues, and you might have even seen articles online sounding alarms about keto and thyroid function. People can add carbs back to their diet if they feel best that way - some people do. But not everyone needs the carbs.

Thyroid Medication

The following is meant only as a general introduction to thyroid medication. A comprehensive discussion of the different kinds of medication and proper dosing is beyond the scope of this book. If you're already taking thyroid medication, this will give you some insights as to whether the type and dose of medication you're taking are optimal for you, and if you're not taking medication but think you probably should be, this can help inform a discussion with your doctor.

There are several different types of thyroid medication, and different ones work best for different people. There's no right or wrong here; there's only what works for you.

T4 medications: These medications provide T4 only. Some people do wonderfully on T4-only meds, but remember that your body has to convert T4 into T3. This conversion is impaired in some people, and for them, T4 by itself is not sufficient to resolve thyroid symptoms. I've worked with many clients who were taking T4-only medication and still had every sign and symptom of hypothyroidism they had before the meds. If you are taking a T4-only compound and still feel awful, T4 alone is not enough for you. Testing your total and free T3 levels will tell you whether your body is converting the T4 into T3. (The most common brand name of T4 medication is Synthroid®. Other common brands are TIROSINT® and Levoxyl®. The generic name is levothyroxine.)

T3 medications: These medications provide T3. Since the body gets T3 directly this way, it bypasses problems with the T4 conversion. Since T3 is the more potent form of thyroid hormone, some people feel best when taking T3 in addition to T4. (The most common brand name of T3 medication is Cytomel®. The generic name is liothyronine.)

Natural desiccated thyroid: These medications come from animal thyroid glands, mostly from pigs (porcine). Because they are made from actual thyroid glands, they provide both T4 and T3, plus other thyroid-related compounds not present in synthetic drugs. They are sometimes standardized to contain precise amounts of T4 and T3, but because they come from animal glands and are not synthesized artificially, some brands may have slight variations from lot to lot. Overall, the amount of active hormone in each pill should be similar, though. (There are several different brands available; the most common are Armour® Thyroid and Nature-Throid®)

These compounds go by other brand names outside the US. Regardless of where you live, if you're taking thyroid medication, look up the brand and find out what type of medication it is so you'll know if you're on T4, T3, both, or a natural desiccated thyroid product.

Determining the optimal dose can be a long process. Some people feel better quickly on a relatively low dose of medication; others need higher doses that might take time to work up to. If you start with a certain dose but don't feel any better after a few days or weeks, talk to your doctor about trying a higher dose. Don't give up and assume the medication simply doesn't work for you. It sometimes takes a bit of trial and error to identify the right kind of medication and the right dose that will make you come back to life, so be an advocate for your own health and wellbeing.

Finding the right type and dose of medication can take time, but know that there's hope. If you're dealing with hypothyroidism, you've probably felt awful for a long time. Now at least you know there's a reason why, and there's something you can do about it. There's a light at the end of the tunnel.
My Personal Thyroid Story

I speak from experience here. I'm on thyroid medication, myself, after a few years of feeling absolutely awful. I had the hair loss, the constipation, weight gain, edema, depression - you name the symptom, I had it. The depression was the worst. At that time, I didn't know as much about all this as I do now. When I first tried thyroid medication, I took it for a full month and felt no difference. Zero improvement in any of my symptoms. What I didn't know at the time was that I was taking a very low dose. I trusted the doctor to know what was best for me. Since I didn't know it was a teeny, tiny dose, after the month's supply was gone, I figured the medication wasn't going to help me and I just kind of gave up. BIG MISTAKE!

I suffered through two more years of debilitating symptoms before things became so unmanageable that I decided to try again. I went to a different doctor, one whose approach was very different. This doctor started me on a very low dose, but the difference was, she told me it was a low dose, and explained to me how to find the dose I needed. She instructed me to take one tablet for 3-4 days, and if I felt no different, to take two. Take two tablets for 3-4 days, and if I felt no different, take three. I was to keep increasing the dose every few days until I felt better. When I felt well, that was the dose I needed. What a revelation! Turns out the dose I needed was much, much higher than the one I started with, so it's no wonder I felt no better the first time around. I might as well have taken nothing.

Even after identifying my optimal dose, things haven't always been easy. Thyroid medication is a bit of a tightrope walk: sometimes I have symptoms of being over-medicated, so every now and then I have to reduce my dose a little, and if I feel low thyroid symptoms creeping back, I have to bring it back up. It's a balancing act, and I don't always get it right, but in all honesty, my worst day now is better than my best day was before this medication. (If you've never experienced severe chronic constipation, you can't appreciate how magical it is to have regular bowel movements with no pharmaceutical intervention...no laxatives, no magnesium powder, nothing. Just sit down and go!)

And I wasn't kidding above when I used the phrase "come back to life." That's what it felt like when the depression lifted: like I had been hibernating, closing myself off from the world in a dark, stuffy room, and someone suddenly turned the lights on and opened a window.

Finding the right type and dose of medication can take time, but know that there's hope. If you're dealing with hypothyroidism, you've probably felt awful for a long time. Now at least you know there's a reason why, and there's something you can do about it. There's a light at the end of the tunnel. It might take some time to get there, but you will get there.

Additional Thyroid Resources

The following books and websites can be very educational, but please note that they are not keto-specific.

Written by Amy Berger, MS, CNS
Published: May 21st, 2022

Blog: http://www.tuitnutrition.com/
YouTube: Tuit Nutrition - https://www.youtube.com/channel/UCmDz-SYYhoerycynsCm7L8g/videos
Twitter: @Tuit Nutrition - https://twitter.com/TuitNutrition
Online courses: http://adaptyourlifeacademy.com/

Books by Amy Berger


Amy Berger MS CNS

End Your Carb Confusion