Dietotherapy in Hashimoto’s disease

1. The meaning and purpose of dietotherapy

Nutrition can have a negative or positive influence on the development and course of
Hashimoto’s disease. It should be emphasized that there is no one universal diet recommended
for people suffering from Hashimoto’s disease. The patient’s diet should be adjusted
individually, taking into account their needs and preferences. The whole process of dietotherapy
is dependent on the course of the disease and other intercurrent illnesses.

The main goal of dietotherapy is to improve the patient’s health condition and well-being as
well as to slow down the inflammatory processes occurring during Hashimoto’s disease.
Therefore, it is necessary to properly nourish the body and provide the required amount of
nutrients needed for the synthesis of thyroid hormones. The last very important element is
decreasing the risk of occurrence of other autoimmune diseases through diet.

IMPROVEMENT OF EATING
HABITS

ELIMINATION OF INTOLERABLE
BETTER MOOD
FOODS

BETTERMENT OF HEALTH PROVISION OF MINERALS

CONDITION

SMALLER RISK OF INTERCURRENT

ILLNESSES INCLUDING STABILIZATION OF THE
AUTOIMMUNE ONES CARBOHYDRATE METABOLISM

SLOWER DISEASE DEVELOPMENT THE SLOWDOWN OF THE

INFLAMMATORY PROCESS

SYNTHESIS OF THYROID
HORMONES

2. Dietary Recommendations
Dietotherapy in Hashimoto’s disease relies on the principles of rational nutrition, adequate
energy balance, and providing essential nutrients. The proposed nutrient plan should be anti-
inflammatory, with a consideration of individual dietary exclusions. Each recommendation
should be suited to the individual case while taking into account and correcting the patient’s
eating habits. Below are presented the most important elements of a diet and the most common
dietary solutions in autoimmune thyroiditis.

Energy balance

The energy value in Hashimoto’s disease should be adjusted to the patient individually, and
what should be considered is, above all, the patient’s physical activity and mode of life. The
patient’s caloric intake should be developed taking into account a prospective reduction of body
mass. However, it is important that the caloric intake in Hashimoto’s is not too low, as too high
restriction can cause the metabolic processes to slow down. The recommended energy deficit
should not surpass 400 calories a day.

The table below presents formulas necessary for establishing the energy value of a diet. The
basic method to determine the number of calories in a diet is to count the Total Metabolic Rate
(TMR) on the basis of the Basal Metabolic Rate (BMR) and the Physical Activity Level (PAL).
The following table presents the way of counting TMR with the use of the formula (the Harris-
Benedict equation), which determines BMR.

Formulas determining BMR and TMR

FORMULA WOMEN MEN

BMR 655,09 + 9,56W + 1,84H – 4,67A 66,47 + 13,75W + 5H – 6,75A
PAL 1,2 – non-active people
1,5 - moderately active people who exercise 2-3 times a week
(Examples)
1,9 – sportspeople and people who work physically
TMR BMR× PAL

The supply of macronutrients

Appropriately customizing the supply of individual macronutrients for the patient is an

extremely important issue due to the intended effect of dietotherapy. The recommended
macronutrient distribution in Hashimoto’s disease is presented in the table below. When
customizing the supply of individual macronutrients other intercurrent diseases should be
considered as they can modify the recommended supply.
 The supply of macronutrients

Macronutrient Daily supply

PROTEIN 15-25 % (min. 1,3 g/kg of body mass)
FAT 20-35% [34] sometimes a ketogenic diet is recommended
CARBOHYDRATES 45-60%

The supply of protein for people with Hashimoto’s disease should be bigger than for healthy
people. This macronutrient boosts metabolism and, therefore, has a positive influence on the
energy balance. An equally important feature of the increased supply of protein is the reduction
of hair loss that often accompanies Hashimoto's disease.

Complex carbohydrates are a much better choice than simple ones. Products containing
complex carbs usually have a low/medium glycemic index. It is an important difference for
those with autoimmune thyroiditis as they often suffer from carbohydrate metabolism disorders.

People with Hashimoto’s disease should also be supplied with appropriate amounts of fat. It
should also be noted that low-fat diets are not recommended, because they can cause vitamin
A, D, E, and K deficiency, as these vitamins are fat-soluble. A significant aspect is the source
of the fat, vegetable fat and fish should be chosen. High-fat animal products are not
recommended as they are high in cholesterol, which can contribute to the development of
cardiovascular diseases. This is especially important as patients with Hashimoto's disease tend
to have higher levels of total cholesterol, triglycerides, and LDL cholesterol in the blood
compared to healthy people. The n-3 fatty acids are equally important in dietotherapy as they
show anti-inflammatory properties, stimulate the conversion of triiodothyronine into thyroxine
and reduce the concentration of triglycerides in the blood serum. It can also be noted that they
inhibit lipogenesis, which has a positive effect on obesity that often occurs in patients.

Meals

A very important matter when it comes to diet in autoimmune thyroiditis is the amount and time
of meal consumption. It is recommended to eat 4-5 meals a day at similar intervals. The best
solution is to keep the food intake time fixed, preferably every 3-4 hours. The first meal should
be consumed within a few hours after waking up, remembering to keep at least 30-minute break
after taking the medication containing levothyroxine. The last meal should be eaten 2-3 hours
before bed. This consumption pattern will undoubtedly have a positive influence on the
patient’s metabolism, and the body will get used to fixed times of meals.

Fiber

Dietary fiber is an essential part of dietotherapy in Hashimoto's disease. This substance binds
toxic compounds in the intestines, and thus prevents their absorption into the body. There are
two types of fiber, each responsible for a different effect. Soluble fiber has a positive influence
on decreasing glucose and cholesterol absorption in the intestines, which causes the levels of
glucose and cholesterol in the blood serum to drop. Insoluble fiber is responsible for the
regulation of intestine peristalsis and thus contributes to the reduction of constipation, which
very often accompanies the disease. Studies also show that increasing the supply of fiber in
patients with Hashimoto’s disease boosts the process of body mass reduction. In addition, this
substance grows in volume after consumption, which may contribute to the greater satiety of
the patient.

Fiber, despite its numerous advantages, can also have a negative effect in the event of excessive
supply in the diet. It can hinder the absorption of minerals, such as calcium, zinc, or iron, due
to the ability to bind minerals in the intestines. Another important issue is the malabsorption of
drugs containing levothyroxine, which may result in less effective pharmacotherapy. According
to the World Health Organization, dietary fiber intake is recommended at 27-40g/day. Good
sources of fiber are whole grains, vegetables, and fruit, which additionally provide minerals,
vitamins, and antioxidants. When consuming a large amount of products containing fiber, one
must remember about proper, increased hydration.

Minerals influencing thyroid functioning

The diet of patients with Hashimoto’s disease should be rich in all nutrients. It is worth noting,
though, that the following vitamins and minerals play a vital role in influencing the
inflammatory processes in Hashimoto’s disease.

• Iodine – an element necessary for the production of thyroid hormones and proper
functioning of the thyroid. In the case of a deficiency, the production is very limited,
which causes the TSH levels to increase and the thyroid hormones levels T4 and T3 to
drop. These hormonal changes directly contribute to the growth of the gland and the
formation of goiter. It is also important to monitor the patient in the event of an excess
of iodine due to the excessive load on the thyroid gland. It is worth noting that iodine
 deficiency can also cause deficiencies in other essential nutrients such as selenium, iron,
zinc, and vitamin A.
• Selenium – it plays a very important role in the functioning of the thyroid, being a
component of enzymes responsible for the conversion of T4 to T3 thyroid hormones
and their breakdown. Too little selenium in the body contributes to the malabsorption
of iodine. At the same time, the optimal amount of this element effectively protects from
the dangerous excess of iodine. People with Hashimoto's disease should pay attention
to selenium deficiencies due to the link between thyroid diseases and too little selenium
in the body.
• Zinc- its role is as important in the context of thyroid functioning and the entire
autoimmune system. Just like iron and selenium, it actively participates in the
conversion of thyroid hormones as well as the production of TSH. In the case of zinc
deficiency, serious disturbances of the above processes may occur. It is also worth
mentioning that zinc is directly involved in metabolic processes as well as protein, fat,
and carbohydrate conversion.

Recommended and contraindicated products

In Hashimoto's disease, an important dietary issue is the introduction of foods that can alleviate
inflammation and support hormone production, and the elimination of foods that potentially
aggravate the condition.

Products recommended in dietotherapy include, above all, foods providing big amounts of
protein. The best source of this macronutrient is animal produce as it contains complete protein
necessary for a healthy thyroid, as well as iron and B vitamins. Good quality, low-fat meat e.g.
lean poultry is particularly recommended. An equally good source of protein in the diet is fish,
especially marine ones, due to the abundance of omega-3 fatty acids, which are also important
in autoimmune diseases. If the patient is on a meat-free diet and excludes the aforementioned
products from the diet, a very good alternative is the supply of protein from legumes, which
also contain valuable nutrients such as iron and B vitamins. Legumes can also add variety to
the diet that includes meat and fish. However, it should be remembered that this group of
products can often cause problems with the digestive system in patients.

Macronutrients that are as important in the diet of patients with autoimmune thyroiditis are
plant-based fats, which should be consumed in bigger amounts than animal fats. Plant oils and
avocado are especially recommended, and in well-balanced diet in terms of omega acids, good
sources are nuts and seeds. It is worth noting that a diet rich in fish, apart from good-quality
protein, provides the body with the necessary unsaturated fatty acids, including omega-3 acids,
which contribute to reducing inflammation in the body and thus significantly improve the
patient's health. An additional advantage of omega-3 acids, proven by research, is the positive
effect on increasing insulin sensitivity, thanks to which patients are less exposed to type 2
diabetes and insulin resistance. Another special property is the inhibition of lipogenesis, which
is an important aspect in the context of weight loss in the presence of excess weight and obesity.
Animal fats should be eliminated from the diet due to the high content of saturated fatty acids
and cholesterol, which are not recommended as they may predispose to the development of
cardiovascular diseases. This is especially important because of the higher levels of
triglycerides and total cholesterol in the blood that often occurs with people suffering from
Hashimoto's disease, in comparison to healthy people.

Carbohydrates are the last macronutrient needed for the proper functioning of the body.
Recommended sources of this macronutrient are primarily products rich in complex
carbohydrates, such as whole grain, cereal products due to their much lower glycemic index
than in the case of refined flour products. They also contain large amounts of minerals, vitamins,
and fiber. Fruit and vegetables with a low glycemic index in the raw or slightly heat-treated
form will be an equally good source. The especially non-recommended products include
products containing high amounts of simple sugars, including confectionery, sweets, and fruit
juices containing high amounts of fructose. Patients should also avoid drinking tea due to the
presence of fluoride and contamination with pesticides, which increase inflammation in the
body. Alcohol is worth excluding from the diet due to methylation disorders often occurring in
patients and problems with removing toxins from the body which result from it. Similar to tea,
alcohol can contribute to the increase of inflammation.

It is worth noting that in some cases these recommendations will change. A good example is
the ketogenic diet, which is being more commonly recommended to patients with Hashimoto’s
disease. It primarily assumes the supply of energy mainly from fat and reducing the supply of
carbohydrates to a minimum in order to obtain energy from ketone bodies.

Hydration

Water should be the main source of fluids, a minimal quantity is 1,5l a day. More accurately,
the body’s demand for fluids is 30 ml for 1kg of body mass. Due to deficiencies often present
with the disease, mineral water or highly mineralized water is recommended as it contains over
1500 mg of minerals per liter. Equally important is the degree of water saturation with carbon
dioxide, which should be low. A relevant aspect is also the material from which the bottles are
made. Research shows that bisphenol (BPA) contained in plastics may modulate the work of
the endocrine system and increase the risk of intercurrent diseases. Thus, it is recommended to
choose glass bottles that do not contain BPA.

The Autoimmune Protocol (AIP)

The Autoimmune Protocol is a diet that aims to soothe the autoimmune system, cause the
remission of the disease, and improve the functioning of the intestinal mucosa. The main
assumption of AIP is to exclude products that can contribute to the increase of inflammation in
the patient’s body. The diet is a kind of extended version of the paleo diet, which is based on
the way Paleolithic people ate.

The AIP is a fairly restrictive diet, which, in order to bring the expected results, must be obeyed
100%. It is recommended to exclude the following products from the diet:

• Milk and dairy- It is recommended to eliminate these products as they contain two
substances potentially harmful to the patient. The first is the hard-to-digest protein, i.e.
casein, which can provoke food hypersensitivity and increase inflammation. The second
is milk sugar, i.e. lactose. Very often lactose intolerance can be observed in patients
with Hashimoto’s disease, that appears through i.a. diarrhea which irritates the intestines
and can cause mineral deficiency e.g. calcium and iron.
• Eggs- The protocol involves the elimination of eggs due to the possible allergenic
potential of both egg white and yolk.
• Leguminous vegetables- They are excluded from the diet due to the lectins present in
them, which, like gluten, can irritate the intestinal mucosa. In addition, they intensify
the agglutination of erythrocytes. It is important to note that cooking and soaking
legumes reduce the amount of lectin and its effect. In the case of the AIP protocol,
however, it is necessary to exclude them due to the need to eliminate all products
potentially negatively affecting the human body.
• Nightshade vegetables- Elimination of this group of vegetables is recommended
because they contain glycoalkaloids, which have a negative influence on the intestinal
mucosa.
• Cruciferous vegetables- They are excluded from the diet due to goitrogen content, which
has an adverse effect on the concentration of iodine in the human body. However, the
 newest research has shown that cruciferous vegetables lose a significant amount of this
substance after heat treatment. This deactivation makes this group of vegetables
harmless to people with autoimmune thyroiditis.
• Gluten- The elimination of products containing gluten is recommended due to the
problem of the leaky gut, which is often associated with autoimmune diseases, and is
characterized by impaired digestion of proteins, in particular gliadin. More and more
studies have been showing a correlation between gluten intolerance and Hashimoto’s
disease. It is presumed that this mechanism is based on the structural similarity of
antigens to tissues in the human body. Therefore, there is a high probability that the
antibodies, after entering the body of gliadins, will attack both this substance and
structurally similar tissues of the thyroid gland. It is also worth mentioning that celiac
disease in people suffering from Hashimoto's is up to 15% more common than in healthy
people.
• Cereals and pseudocereals- They are excluded from the diet due to cross-reactions that
often occur.
• Nuts and seeds- Due to the high content of omega-6 acids, which increase inflammation
in the body, and the ratio of omega-3 to the previously mentioned omega-6 fatty acids,
they are not recommended. In addition, these products are distinguished by difficult
assimilability and low digestibility, which do not help with autoimmune diseases.
• Food additives- It is equally important to exclude highly processed products due to their
content of food additives, which often contribute to gastrointestinal discomfort.
• Nonsteroidal anti-inflammatory drugs (NSAID) and proton-pump inhibitors (PPIs)-
These drugs negatively affect the gastrointestinal tract, causing the pH of the stomach
to change and weakening the intestinal microflora.

It is worth noting that the elimination of these products is only necessary in the case of the
autoimmune protocol. The best solution is to use this food plan as a basis and customize the
diet individually to each patient. It is especially important because of the exclusion of many
products and thus the removal of a big amount of vitamins and nutrients distinctive for each
group. In addition, the psychological aspect should be taken into account. After the exclusion
of this amount of products the patient can get discouraged, especially because of the removal
of legumes, cereals, and pseudocereals which makes the diet low in carbohydrates, and can
cause the patient to feel weaker and less energetic.
Products recommended in the diet based on the AIP include the remaining vegetables, good
quality meat, plant oils, fermented foods, and some fruit.

The Autoimmune Protocol also includes a change of lifestyle. It is important to reduce stress
levels, get enough sleep, eliminate cigarettes and alcohol, and engage in such physical activities
that will not lead to the increase of inflammation in the body.

It is worth noting that the autoimmune protocol is recommended with any autoimmune disease
and thus it eliminates a lot of groups of products that can, but do not have to negatively influence
the course of Hashimoto’s disease. Therefore, the best solution is to base the diet on the AIP
protocol and adjust it to the patient individually. Certainly, designated laboratory tests will help
to establish potentially dangerous products.

3. Dietary supplements

As a part of the dietotherapy of autoimmune thyroiditis, an important element is the

supplementation of minerals and vitamins. This is used to prevent and replenish possible
deficiencies.

• Probiotics and prebiotics- These preparations are recommended due to the frequent need
to support the work of the intestines, and thus the microbiome, which affects both the
functioning of the thyroid and the entire body. Research shows that up to 20% of the T3
hormone is converted in the gut, and any problems with the bacterial flora can disrupt
the proper functioning of the gland.
• Selenium - Supplementation of this element is especially recommended as 80% of
selenium is stored in the thyroid gland, and selenium deficiencies significantly impair
its work and hormone production.
• Zinc- It has many functions regarding the regulation of the thyroid gland. People with
autoimmune diseases are especially prone to the deficiency of this element, so in most
cases, its supplementation is necessary as zinc is not stored in the body, which leads to
its low concentration. Symptoms of zinc deficiency include poorly healing wounds,
disturbed sense of taste, thin, brittle nails, and fatigue. It is important to note that zinc
should not be taken together with selenium as their combination significantly interferes
with the absorption of these elements by the body.
• Iron- its deficiency can lead to anemia, which occurs quite often in patients with
Hashimoto’s disease. It is worth remembering that iron supplementation should be
consulted with a doctor.
 • Vitamin D3- It is produced by the body through exposure to the sun. It is responsible
for a number of processes taking place in the human body. In the Polish population,
deficiencies of this vitamin are very common, both among healthy and sick people.
Therefore, vitamin D3 supplementation is recommended based on the laboratory test
result - 25(OH)D3.
• B vitamins- They play an important role in processes related to metabolism, brain
function, blood cell production, and detoxification of the body. Supplementation with
B vitamins may result in increased energy levels, better blood sugar regulation, and
improved mood, which will undoubtedly have a positive effect on a patient with
autoimmune thyroiditis.
• Magnesium- It is an extremely important micronutrient in the context of the work of the
thyroid gland and Hashimoto's disease. An adequate supply of magnesium can improve
blood sugar regulation, reduce constipation and improve sleep quality.
• Ashwagandha- this adaptogen is known for its many positive features. It is especially
recommended to patients with Hashimoto’s disease as it increases the level of T4. It
also improves well-being, regulates sleep, and increases training efficiency.
• Omega 3- One of the main tasks of omega-3 acids is to regulate the concentration of
pro-inflammatory cytokines, the high levels of which contribute to the development and
progression of inflammation occurring in autoimmune diseases. Preparations containing
omega-3 fatty acids have a positive effect on the regression of the disease by reducing
inflammation in the body.
• Milk thistle and glutathione- Supplementation of these preparations is especially
important in the case of problems with the digestive system because they ensure the
correct pH of the stomach and have a regenerating effect on the liver.

4. Iodine prophylaxis program in Poland

Iodine is a basic component of thyroid hormones- thyroxine and triiodothyronine and its
deficiency carries serious consequences for the whole human body. It regulates all metabolic
pathways and influences the proper development of the brain. It is also one of the strongest
antioxidants that protect against inflammation processes and cancer. It is an especially
important aspect in the context of Hashimoto’s disease.

Extreme iodine deficiency during pregnancy can lead to brain underdevelopment of the fetus.
However, this problem was completely eliminated by the iodine prophylaxis introduced in 1935
in Poland. Moderate deficiencies of this element manifest in a significant decrease in brain
functions, which include activities such as the ability to learn, remember and associate. Iodine
deficiency also increases the risk of thyroid diseases, including thyroid cancer, and leads to the
formation of goiters.

5. Conclusion

On the basis of the author’s own research and critical literature analysis, it is accepted that
dietotherapy is a key support in treating Hashimoto’s disease. Bearing this in mind, an adequate
supply of macronutrients should be provided and the patient’s energy balance should be
customized and monitored. Moreover, the time and number of meals, hydration, and the supply
of fiber are taken into account. An equally important element of the diet is supplementation
based on the results of the patient's laboratory tests. Apart from the above, the introduction of
the autoimmune protocol (wholly or partly) brings positive results in many cases.