Posted on April 30th, 2020by RMANY

Ep 17: Why It Could Be Your Thyroid, with Dr. Bojana Jankovic Weatherly

Fertility Forward Episode 17:

Dr. Bojana Jankovic Weatherly is an award-winning physician, and double board-certified in internal and integrative medicine. After completing an internal medicine residency, she did a fellowship in integrative medicine, trained in functional medicine, nutrition, and mindfulness. Her approach is rooted in evidence-based medicine that is personalized to each individual she works with. She partners with her patients to discover and address the root causes of their conditions and develops individualized plans to support and empower each individual to achieve her or his health goals. She has a specific passion for working with women who have various thyroid conditions, and in this episode, Dr. Bojana gives us a fascinating and insightful Thyroid 101 lesson.

Transcript of Episode 17

Rena: Hi everyone! We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Dara: Dr. Bojana Jankovic Weatherly is an award winning physician, double board certified in internal and integrative medicine. She completed medical school, master of science and bachelor of science degrees at the University of British Columbia in Vancouver, Canada. She then completed her internal medicine residency at Cedars Sinai Medical Center in West L. A. Veterans Affairs in Los Angeles. A lifelong learner, she completed a fellowship in integrative medicine established by Dr. Andrew Weil at the University of Arizona and continues to train in functional medicine. Her approach is rooted in evidence based medicine that is personalized to each individual she works with. Throughout her academic career, Doctor Bojana performed research in endocrinology and oncology, has published papers in peer review journals and has presented her work at various academic conferences. She partners with her patients to discover and address the root causes of their conditions and develops individualized plans to support and empower each unique individual to achieve her or his health goals. She has a specific passion in working with women who have various thyroid conditions. On today's episode, we discuss how the thyroid, other immune conditions, and stress can all impact fertility. We also discuss the signs and symptoms to look for regarding potential thyroid issues and also address the importance of a thorough panel to help a physician see the whole picture regarding the thyroid. I am over the moon to have my dear friend on today, Dr. Bojana Jankovic Weatherly. She's a friend of mine from school. We were matched up together as buddies when she moved from California to New York. She is born in Serbia but she grew up in Canada. Hopefully I'm not ruining this, but I'm so excited today to have you on to speak about the thyroid.
Bojana: I'm so excited to be here. Thank you so much for having us. And I'm so glad that they paired us up as buddies. Now, a little over two years ago when we moved here and happy that our paths are not only crossing personally, but also professionally. And this is such an important topic, and so happy to be here to talk about it.
Dara: So happy to have you. So you are a internist and what else do you do?
Bojana: So I went to medical school in Canada then went on to do my internal medicine residency training by the time I already moved to Los Angeles at Cedar Sinai. And then after practicing medicine as a primary care physician, I just realized over time that I wanted to find ways to bring more value to my patients in the way of lifestyle transformation and helping to provide guidance in terms of nutrition and stress management and sleep. Because these are all areas that are so important when it comes to not only chronic disease but just overall in health optimization and living our best lives. And I was finding that often times I would be seeing patients for chronic fatigue, depression, anxiety, other chronic gut symptoms or auto-immunity, and they were just not improving, and conventional medicine had reached the peak of what it was able to provide. So I really went on this path to learn, well what else is there? What else has been studied and practiced? And so this is how I discovered integrative medicine, which I then went on to do a fellowship in at University of Arizona at a program that was started by Dr. Andrew Weil, who was the pioneer in integrative medicine and then went on to get board certified and then went on to study functional medicine and mindfulness based stress reduction and all these wonderful, wonderful modalities. So now what I do is I incorporate all of these different modalities into visits with my patients and into the customized plans that I create for my patients.
Rena: Wow! You sound like my dream, doctor.
Bojana: Thank you.
Dara: It’s so smart to actually connect everything together to learn the stem, the reason why, the root cause of a certain conditions. So not just treating, but also looking at where could it have come from. Was it stress related? Is it related to something else and not necessarily going straight for the…the medical route?
Bojana: Absolutely. And you know, I was really shocked on the one hand shocked and on the other hand, not so surprised by the statistic that 75 to 90% of medical visits are, in one way or another related to stress. So when you're talking about that root cause, that is an area that we always have to address. How much is this currently impacting what's going on with our symptoms? How are we gonna manage that stress to, to deal with the symptoms? Because again, a lot of chronic conditions such as chronic pain as well as other autoimmune conditions as well as conditions of, you know, one of the things that we’re going to be discussing the thyroid in the context of fertility and again, all of these things cause a significant amount of stress burden. And we can always improve and learn on how do we cope? How do we be our best selves despite these things that are going on? And how do we make the best out of any situation but also be mindful of how stress is affecting those conditions and symptoms?
Dara: For sure.
Rena: I mean, that's a line that comes up a lot in my work with patients, you know, too from the mental health perspective. How much of a role does stress play - they all ask. Well, did a procedure not work because I was stressed? So I guess from your perspective, what would you say to that?
Bojana: I was just about… when you said that I was just about to ask you. I'm so curious what you say. I mean, that's a great and I get that question a lot when it comes to other physical symptoms that people may have. So I don't think there can be a clear cut answer of yes or no. And I think that certainly stress is not to blame for everything. There needs to be, you know, there's this concept of the alastatic load that I often like to refer to. What and that refers to how much can we take before something breaks down? Right? So this alastatic load may refer to our environment maybe the processed or junk food that we're consuming, the unhealthy relationships that we’re engaging in the toxic work environment or whatever that might be. And as you again increase that burden of, not really just stress in the in the kind of form that we usually refer to stress but if you consider toxins that we're ingesting in our body as stress, we can kind of reach reach this peak, and I think it's that cumulative effect. So so the way that I usually talk to my patients about it is that I often start with, you know, what do you think? Because I think that we are all our best as much as physicians and dieticians and therapists…we all have our areas of expertise and areas that we study and we're up to date on our evidence on and that we have clinical experience with. However, the patient is the expert in their condition, and they are really the only ones that truly know. Okay, well, how is stress really impacting me? What do I feel when I feel stressed out. Am my constantly having palpitations and waking up in the middle of the night? And is my digestion off when I get really stressed out? So oftentimes I'll start by asking the patient to gain more insight if I haven't yet into how much stress plays a role, and then we discuss that it's one piece of the puzzle, and again, in some people it's more and others it's less. But I often hear and again, this is really very anecdotal because fertility per se is not my area of expertise, so not all of my patients are struggling with fertility. But I often have heard anecdotally that just when a couple gives up is when it actually happens. And I wonder how often you guys see that in practice because it's something that you see all the time. And I wonder if again there is sort of something that just happens energetically or with our nervous system, or how it effects our cytokines, which are, you know, inflammatory signals and so on.
Rena: Sure, I mean, I definitely see a lot of my practice, it’s those patients who they first started out there doing kind of everything they can to control the process, you know, is it they’re eating a certain way, being very regimented there. I mean, the pineapple core which is, you know, it’s supposed to help with fertility. They're exercising in a certain way. They're trying to get, you know, a specific amount of sleep, and then after a while they're not getting the results they want, they say screw it. I'm gonna go I’m gonna eat pizza. I'm going to do what I want. I'm gonna relax a little bit and right. That's when they then come back and they say Oh, my test was positive, and I say I knew it because I see it happen a lot,
Bojana: Right, right.
Dara: Or even, vacation. That's when I often see success with my patients. We could see that they’re really busy at work. And it's not a acute stresses it’s that chronic long term stress from work from home life from trying to get pregnant. And then when they go on vacation, which I always try to encourage, it doesn't have to be somewhere far or expensive. But just taking that time, whether it's for themselves or with their partner or with a close family friend that's often with it, is more likely to happen. Or at least what I see. Because, yeah they're not thinking about it all day long.
Bojana: Right. I think that completely makes sense. You know, we let our guard down, and and interestingly, now that you mention that vacation concept, I often that's that's kind of again one of those questions that I ask and I often will hear. Well, my gut symptoms got better when I was on vacation, so we clearly know, Okay, well, let's look it your life. Let's look at your day to day.
Dara: And I'm sure, besides the stress, it also connects with sleep, which I know you. We've spoken a lot about how sleep also can play a role in elevating stress, elevating certain hormones and hunger hormones as well.
Bojana:Exactly. Yeah, in just changing the lectin and ghrelin hormones that are involved in in our satiety and hunger and also in terms of affecting our immune system, you know, And I think, and then our cognitive performance memory. I mean, I think sleep is the number one. I always tell my patients if they're if we're working on kind of looking at optimizing lifestyle and optimizing habits that are going to get them to certain health results, sleep is always my number one. Meditation is important. Very, very, very important. If they're going to start with one thing, it's sleep because when you get a great night of sleep, you're gonna make better decisions about your food, about how you spend your time about how efficient you are at work. With your relationships, you're gonna be more present. You're gonna show up, you're gonna process stress better. So I always say, start with sleep, and then we'll do everything else. If that's if sleep habits to be a problem area
Dara: I often say that too. You could eat all the great food in the world, but if you're not getting great sleep your food, well, your food may not be digesting properly. Your hormones, the hormones that you don't want to be elevated may be elevated or just be in non balance.
Bojana: Right. Exactly. Yeah.
Rena: So what would you say is an optimal amount of asleep?
Bojana: So I persononally, I think that for each individual it varies. I think that generally, if you know people are in the ballpark of eight hours, I think that's great. There's some studies on the immune system, so looking at, they actually believe it or not that these studies where they would inoculate people with a virus with a respiratory virus and just put it in their nasal passages and then they would quarantine these people and see whether there was a correlation between the number of hours of sleep and who presented with clinical symptoms of an upper respiratory infection because they were literally just infected and they found that people who slept more than seven hours did a lot better. So had a lot less symptoms than people who slept less than five hours. So they’re studies like that where we can look at for specific distinctions. I think it's all a gray scale. But in general I would say eight hours is great. Again, if somebody's needing 10 hours of sleep and they're still waking up tired, then I start to think, Okay, well, what else is going on? Is there obstructive sleep apnea? Is there something else going on some other type of sleeping disorder? Thyroid issues? And that's when I start to kind of worry it’s a little too much.
Dara: Yeah, so that’s a great segue into the thyroid. said weight into it. I know, Bojana, you're very passionate. You are so knowledge in terms of speaking about thyroid conditions, and it's really a complex system. Very complex. I know the thyroid gland is connected to a lot of different things. in our body in terms of metabolism. Explain to listeners a basic 101 about the thyroid and the conditions associated.
Bojana: Sure. Yeah so thyroid is one of my favorite organs.
Dara: is it an organ or a gland?
Bojana: It’s a glad. Yeah, so yeah, I guess we should maybe back that up. So thyroid is my favorite gland, and it's, Ah, butterfly shaped gland in the base of our neck. And it's really special because it produces thyroid hormones, which are implicated in a number of different processes in our body. So the thyroid hormones regulate in part our heart rate. They also regulate our digestive system. They regulate our skin, even our hair and of course, they also are implicated in our energy levels, right? We know that people who have an under active thyroid gland, they tend to be very tired, and it's usually one of the first presenting symptoms of hypothyroidism. Hypothyroidism, meaning underactive thyroid. One of the first presenting symptoms is fatigue. But before we get into the different thyroid disorders let's just talk a little bit more about thyroid hormones. So the thyroid gland is the only gland. The only part of our body that will actually take up iodine and why iodine is important is because iodine is a building block. It's part of the thyroid hormones that the thyroid gland produces. So the thyroid gland, what it does is it puts tyrosine, an amino acid, together with four different iodine atoms to create a thyroid hormone called T4. And then there's another, more active kind of thyroid hormone called T3 that has again that same tyrosine amino acid linked with three iodine atoms. So very easy. Three iodines, you've got a T3. 4 iodines, you have a T4. And those are the 2, the 2 major T4 for being the predominant type of hormone that thyroid gland produces. Now what happens? I mentioned that DeForest the dominant one, but then the T3 is more active. So what happens there? Well, what happens is the T4 then travels through our body and it gets converted to the more active form T3 which then acts on end organs. So whether that be our gut or heart or whatnot. That conversion T4 to T3 happens in the liver. It happens in the gut. It happens in several different parts of our body. That conversion is really important. For the most part, it should be very, very tightly regulated and really be regulated in such a way to to kind of help us optimally function. However, when we're dealing with nutrient deficiencies, when we're dealing with extreme stressors, with extreme calorie deprivation, we can run into problems in converting that T4 into the active form T3. Now the other really important point is in, and again, I really don't like to make the distinction because I practice both the integrative and the conventional medicine, but previously when I was only doing conventional medicine, I would only check for TSH the thyroid stimulating hormone which is the gold standard of how we measure thyroid function. And if that was abnormal, then we would check the T4 hormone. I now tend to, especially if patients are persistently symptomatic and we can talk a little bit more about the symptoms. I tend to do a full thyroid hormone panel because oftentimes the subtleties like this conversion T4 to T3, there can be blockages in that way and oftentimes we don't obviously recognize them if we don't check .
Dara: So better to check, to ask for a full panel. When you say full panel to a doctor to endocrinologist and do you do you check them or is it something that an endocrinologist checks or both?
Bojana: Great question. Yes, So I check them, endocrinologists check them and I would say general internal medicine doctors as well as primary care physicians who maybe family medicine also would check them. But the standard of care is really only to check the TSH the thyroid stimulating.
Dara: So the minimum?
Bojana: The minimum. Exactly.
Dara: So you have to take an active approach. And if you feel like your thyroid is underactive or overactive to ask for a full panel.
Bojana: Exactly. So what I generally would recommend you know, the cases in which you really want to kind of ask your health care provider, you know, is when you're still having significant symptoms. So let's say so we can kind of dive into the hypothyroid symptoms, so this means underactive thyroid symptoms. These would include, as I mentioned fatigue either weight gain or inability to lose weight, despite various strategies that normally would be effective. Also, oftentimes, people feel that there is a cognitive slowing. Their memory isn't quite there. They might also notice mood changes. They might be depressed. They may find that they need to sleep more and again, are just not feeling restored are just not having the energy. They also may find that their skin is dry. They may experience hair loss. They might also experience constipation. So these are some of - their heart rate may slow down. So these are some of the symptoms that I would say if these symptoms are persistent and that TSH value, which is a screening test which may be perfectly adequate for somebody who is not having these symptoms. But if you're having these persistent symptoms and then especially I would say infertility, it's very, very important to have the whole panel checked. Then I would say ask your health care provider, can we check my thyroid hormones as well to get the complete picture of what is going on in my body?
Dara: And there's also free T4 and free T3. It's so you know, I'm a dietitian, not as medical, and I went to an event once with Bojana teaching us more about about the thyroid and it's a very complex system, but it's interesting if one thing’s out of whack, something else usually takes over. And that's when sometimes those symptoms can manifest.
Bojana: Absolutely. And then the other thing that we were talking about stress and how that can affect the thyroid Well, stress hormones can actually affect that TSH, the thyroid stimulating hormone, which I didn't mention before. But this is produced by the pituitary gland, which then signals to the thyroid gland, make thyroid hormone, make thyroid hormone. So TSH is just kind of like this signal that tells us, how strongly do we have to stimulate the thyroid gland to to squeeze out to produce and squeeze out more thyroid hormone? So if TSH is within the normal level, generally it means that there are no - and this is why it's the gold standard test - generally, it means that there's no disorder, no thyroid disorder, because downstream everything is very tightly regulated except in extreme stress, calorie deprivation, infections, and nutritional deficiencies where we may see that again, that regulation isn't optimal because of those stressors that I mentioned and then of course, with the stress hormones affecting the TSH, thyroid stimulating hormone, you can imagine that that signal to the thyroid isn't sufficiently saying, okay make thyroid hormone so we can affect thyroid hormone production. But it can also, stress hormones can also affect thyroid hormone conversion from T4 to T3. So it's all, and unfortunately, we don't have a visual here but there are if you imagine in your head there are all these feedback loops, you know, going into the thyroid, then going to the thyroid hormones, because again what are body tries to do it, it tries to stay in a state of homestasis or a state of balance. So all of these systems are far more intelligently designed than what we could ever come up with at least now in terms of fine tuning. Our body’s already doing that for us. But when we have something externally that throws the system out of balance, that's really a great opportunity to intervene.
Dara: And there's different types also of hypothyroid. There's ones that could be, I believe, genetic and then ones that are autoimmune. Right?
Bojana: So the autoimmune, so the most common type of hypothyroidism is Hashimoto's thyroiditi, which is an autoimmune process. And it's characterized by and again, we don't routinely biopsy people's thyroid glands to prove that they have Hashimoto's or autoimmune thyroiditis. But if we were to do that, it's characterized by white blood cells infiltrating or going into the thyroid gland, and so we see that there's an attack so to speak on the actual thyroid gland. And because of this attack on the thyroid gland, we see that over time when there is this autoimmune attack over time, many individuals will then develop what's clinical hypothyroidism or underactive thyroid because if you imagine if you're attacking and killing the thyroid gland, eventually you're going to deplete and diminish, really, its ability to produce enough thyroid hormone for the normal body function. So autoimmune thyroiditis is in part genetic.
Dara: OK
Bojana: But there is also an environmental component, and this is an area that has been studied. But I think that there's still so much opportunity and much need for research. So autoimmune thyroiditis, interestingly, has also been linked to various infections such as the Epstein Barr virus infection, other viral infections, parasite infections. So there are a lot of case reports and they’re studies coming out, but again, it's oftentimes difficult to pinpoint and say, well this one particular thing caused it. Oftentimes it's we see it running and families so often times I'll have patients say, well, my mom had this, and my grandma had it so oftentimes there is definitely a genetic component. But then there's also something else, or a number of other things that are environmental triggers.
Dara: So they might have the gene, but it may not be turned on, and, you know, until there's some sort of whether it’s stress or an environmental factor that can actually trigger it to be an issue.
Bojana: Exactly. Yes.
Rena: And Hashimoto's right can play a role in fertility?
Bojana: Right. Absolutely. So with Hashimoto's so one of the elements that I didn't mention in terms of presenting symptoms is it can definitely play a role in cycles, so we definitely can see that when in cycles will change with either hypo or hyperthyroidism. And they may have heavier cycles in Hashimoto's. But it'll also affect thyroid conditions will also affect ovulation.
Dara: And that's what I I see with a lot of my patients that have ovulation issues, and they're coming in, presenting with Hashimoto's or even Grave's disease, which is the overactive.
Bojana: Exactly. Graves is the overactive. So with Hashimoto's, typically, I told you what we don't do, but I didn't say what we do do! So we don't take biopsies of thyroids, but we check for antibodies that are very sensitive upwards of 80 to 90% sensitive for Hashimoto's. So, typically, the antibodies checked our TPO antibody and thyroglobulin antibody, and one or both may be positive, and it is very likely to be positive in individuals with Hashimoto's thyroiditis. Now, with Graves, it's the opposite end of the spectrum. It's when people have antibodies called the thyroid stimulating immunoglobulin that stimulate the thyroid so it's still an antibody, it’s still an autoimmune mediated process, but it goes in the other direction because it stimulates the thyroid gland to release more and more thyroid hormone. And this is where we see symptoms to be the opposite of what I just said for underactive thyroid.
Dara: The sweating?
Bojana: Exactly the sweating. And if you've ever seen a patient who was just about to get you know radioactive iodine ablation or pretreatment, you'll often see that they're shaking they’re very excited, very sweaty. Their heart rate makes me nervous actually because it’s in the 120s, 130s.
Dara: Hungry all the time.
Bojana: Hungry all the time yet losing weight and having more frequent bowel movements. And so their presentation is the opposite of that. But that's definitely and they can, and again you know, the way that it impacts our mental health, so while people with hypothyroidism may tend towards depression, people with hyperthyroidism actually may tend towards mania. So the other end of the spectrum And so and this is one of the reasons to me why it’s so fascinating, is that it affects all these different systems that we think are unrelated. But yet it kind of all…it really kind of helps our the different body systems it kind of orchestrates them. It's like this beautiful symphony when everything is going right with the thyroid hormones and when not there are many different areas that go that are just completely out of order.
Dara: So I know with my patients a lot of them who Hashimoto's or Graves they’re typically put on a medication protocol, Synthroid or perhaps another type of protocol. But in terms of other areas that they can naturally, I know what I do, but in terms of Bojana, I'm sure you have a specific protocol in the nonmedical realm.
Bojana: Yeah, that's a great question. So again, another area of it really warrants further study and investigation. So a lot of practitioners in the functional medicine world, you know, when we talk about different nutritional protocols, we often talk about different types of elimination diets with the goal of removing any possible toxins or any possible triggers to autoimmunity. And part of this just to back up a little bit, is really the concept that a lot of the kind of one of the leading factors in why autoimmunity develops besides the genetic predisposition, which is absolutely there is the whole gut connection. So when we think about gut, of course we think about nutrition and what we're ingesting. But we also think about that interface between the inside of our gut, the inside of her intestine. And then how does that communicate to to the rest of our body? And so what happens is normally our gut lining is such that we should have a very tight seal that is very selective in terms of what goes from the gut into the bloodstream and versus what doesn't pass through. And this seal is kept by something called tight junctions that really bind the cells of the gut lining together. What happens is when and again this could be due to a number of different reasons: infections, stress, small intestinal bacterial overgrowth, toxins that we're investing in our body and poor diet. All of these things, over use of antibiotics sometimes as well, that wipe out our normal gut flora. What can happen is these tight junctions start to not be so effective anymore at doing their jobs. So we're getting a lot of toxin exposure.
Dara: Is that leaky gut?
Bojana: Leaky gut, exactly. So this intestinal permeability or leaky gut concept. So we're getting a lot of this toxin exposure, and then our gut associated immune system starts to react to it and starts to be inflamed as a result. And so this is why a lot of the times and this is why I think in particular, it's so important to do further research on how infections, especially gut infections, are connected with autoimmune disorders. Because we do see that oftentimes, that linkage between a gut infection that triggered the autoimmune disorder. And again, it's all about that alastatic load. If you have enough insults and finally reached that peak of what you're able to withstand, you will see clinical disease or you're going to see something breakdown. So let's say it's the infection that kind of just tips the scale the other way, well, oftentimes, when the infection is healed, we see that the autoimmunity also tends to calm down. So you know this is what's important to the attention of the gut and therefore pay attention to nutrition to then calm down the inflammatory process, which can then at the very least, hopefully stabilize the process.
Dara: But isn't it true also in terms of - sorry for interrupting you - in terms of autoimmunity? Usually, if you have an underactive or overactive thyroid, which is autoimmune, you know, something like celiac disease or also being autoimmune issue and so that could be potentially connected.
Bojana: Absolutely. I'm glad you mentioned that. It is actually connected.
Dara: OK good.
Bojana: Yeah, yeah I’m so glad you said it. So celiac disease is definitely connected with autoimmune thyroiditis, and actually they're, some of the guidelines actually say that in every individual that is diagnosed with autoimmune thyroiditis, they should be screened for celiac disease. Even though celiac disease is only about 1% of the total population, it is more prevalent in individuals with autoimmune thyroiditis. And that is definitely something that with the autoimmunity and if somebody is actively ingesting gluten, if they don't know they have celiac. Or maybe they're having a hard time sticking to a gluten free diet they’re, absolutely causing damage to those intestinal villi and making it more difficult to absorb nutrients. And so, yes, there is absolutely that linkage.
Dara: Or even a gluten intolerant. If it's not necessarily a defined celiac. But if they're more sensitive to gluten, so that's often I know I speak to my patients about trying to minimize or even possibly trying to eliminate and see how they feel.
Bojana: Definitely. And we're seeing gluten sensitivity more and more. And I think that, and I mean it's it's really kind of an interesting topic on its own. I'll just share very briefly from research that I've reviewed and from other leading physicians and experts in the functional medicine space, kind of what the bullet points are so with gluten. So there's several factors that are thought to contribute to this increase in gluten intolerance. One of them is just the way that gluten-containing crops are now and the way that they're hybridized to contain more gliadin protein than before. The way that food that containing gluten such as pasta and bread, the way that it's prepared now compared to how it used to be before or even how it's still prepared in Europe, usually, yeast is used in the process of making bread and pasta, and or maybe just in making bread I don’t know if it’s pasta. So usually yeast is used in the process of making bread. And so just to give you an example, typically the yeast would be kept overnight so that it can start digesting some of these gliadan proteins. However, now we're speeding up that process. And again, the gluten that were exposed to is so, so different from what it used to be. Not to mention, if we're consuming a product that's not organic that's sprinkled with a little bit of glyphosate, which is in round up, a pesticide, we're seeing that that is affecting intestinal permeability, gluten and glyphosate together. So…
Dara: The combination…
Bojana: The combination.
Dara: Can make it even more detrimental, and also I think we're having a lot more a greater portion of bread consumption and pasta, especially in America.
Bojana: Exactly the SAD. The standard American diet is so different from how our ancestors used to eat and what our body is used to and so this is one of the things that initiated this again kind of movement in okay, well, what is the ideal autoimmune protocol? And so there is an actual autoimmune protocol that I know there was a recent study that was done, and I actually listened to a great podcast by Chris Crestor, where he's a leading functional medicine professional and he interviewed a group that performed a small study on individuals with Hashimotos thyroiditis where they looked at the impact of the autoimmune protocol diet. And in the autoimmune protocol, you are eliminating some of the foods that are thought to be inflammatory. So these may include eggs, night shades, seeds…
Dara: Dairy.
Bojana: Nuts, dairy, exactly. So so there are a lot of things that are eliminated, obviously gluten, And so they have found again it was a small study, and they did find that a subset of patients seems to have gotten better, but they didn't really get as significant results. So again, I think that it's it's still something that we need to actively research and look at the evidence. But what I generally counsel my patients to do is, so, in part, with the elimination diet it's really on trial and error process. And with any nutrition plan, it's important to keep in mind that if we're going to restrict somebody's diet and I'm sure you have the same philosophy as well, we shouldn't do that for a long term. You know, the general consensus is that we all should have a colorful diet. It all should be rich in plants and though there are certain subtleties of well is this pro or anti inflammatory. And there's also a lot of conflicting nutrition research, in part is based on poor quality of data collection and of collecting food frequency questionnaires, which we know are not are far from perfect. I mean, if somebody asked me to tell them what I had last week or even on Monday, I don't think that I would reliably tell them. So there are great limitations to this research and that in part as well as the population heterogeneity and looking at the different populations. That's why a lot of the times it, it seems, as though we're getting conflicting results. But we all can agree. You know, whether somebody is in the paleo are vegan camp or keto or anything. We all can agree that eating more plants is good for you.
Dara: Yeah, I think its true what you said in terms of not necessarily focusing on the negative of the things that you have to get rid of…
Bojana: Right.
Dara: But perhaps flipping it and saying, what are the things that you can and should incorporate? So maybe omitting some of those potential triggers like the gluten and the dairy. But instead of focusing on you can't have that, perhaps focusing on what you can have.
Bojana: Yes. What you can have. Yes, there was a really interesting study done in Croatia, where they looked at individuals with autoimmune thyroiditis, and they looked at what these individuals consumed. And they found that people who consumed more vegetables, more plant based foods did a lot better in terms of their thyroid antibodies compared to individuals that consumed more dairy.
Dara: So veggies, eat your veggies. Your parents instructed you when you were younger and find fun ways that make them interesting. It doesn't have to be steamed or raw. You can grill or roast them, I'm sure.
Bojana: Exactly. And then just also, like use spices use, I mean, there's so many different ways in which we can prepare, and I find that that often really can be a barrier. But it's one of those things that's that really should be the most important. Because literally, what we're putting in our body is the information that’s feeding every single cell in our body to communicate to it are we in a safe place? Are we anti-inflammatory? Are we increasing and promoting inflammation and disease?
Dara: I feel like, so the patients that I work with they tend to be quite stressed coming in. What do I do? What should I not do? And I think you actually said it best at the beginning. You mentioned that you should listen to your own body. You know yourself more than anyone else.
Bojana: Yes.
Dara: And if something doesn't feel right, stop eating it or try something else.
Bojana: Absolutely, yes. And a couple of nutrients specifically that I wanted to touch on. I mean, there are a number of different nutrients that affect the thyroid gland thyroid function, and I actually wrote an article talking about more than what I'm gonna mention now, but just briefly about iodine. So we know that I mentioned that Iodine is the building block of these thyroid hormones, right? So we definitely want to make sure that we're ingesting enough iodine. At the same time Iodine excess can also cause more problems and more thyroid auto immunity, on the other hand, so it's really important to either have your iodine levels checked if you suspect that you may not be consuming enough iodine a lot of the times now, I mean, we're getting it from iodide salts, from seaweed, but it is in the guidelines that 150 micrograms of Iodine should be part of every prenatal vitamin formula. But I think that it doesn't hurt to check levels if you suspect that again if either thyroid function tests are abnormal, or if you suspect that you may be at risk of deficiency and just asking your physician. Another question that I often get and that often comes up is about selenium. So selenium is a great antioxidant. It's it has the potential in individuals who are low in selenium and have autoimmune thyroiditis, it has the ability to lower those thyroid antibodies. But again, if you have enough selenium and you start supplementing, there is a risk of side effects.
Dara: So not too much.
Bojana: Exactly so another thing really important to discuss with your dietician, your physician. Do you need levels checked? Do you need it supplemented, or can you just have a couple of Brazil nuts and call it a day? Because it’s excellent source of selenium.
Dara: Also good for men for sperm. So all you need is, I believe a portion size is three so you don't need to be consuming all that much every day.
Bojana: Yes, exactly.
Dara: Yeah, that's great. So selenium is important, and Iodine is important and potentially being mindful of gluten and potentially be mindful of dairy?
Bojana: Exactly. Yes. And again, I would say with any nutritional protocol, anything like that, I always advised that people be under the guidance off a healthcare provider and qualified healthcare professional, because again we do by eliminating too many things we do run the risk of nutritional deficiencies. I mean, we all know that we should be eliminating processed foods and sugar and that kind of stuff. But if I think that if anyone listening they feel that, well, you know, I have multiple triggers, definitely talk to someone before changing your diet to make sure that you're still going to get a nutrient dense diet. Even if you try an elimination diet protocol, I think it's so important to do it under professional guidance.
Dara: I agree, and also getting that support. So you're not doing it alone. You're having someone's champion you along the way because it can seem overwhelming. I feel like really the thyroid gland we just touched upon it, there’s much more to it. But I appreciate you being here today, Bojana, to give us that little taste. So the way we always end our sessions is asking you what you're grateful for today. So a little bit of gratitude, which I know there's a lot to be grateful for but what are you grateful for at this moment?
Bojana: Oh, I love that. I am grateful for the fact that my mom is actually coming to visit today from Serbia en route to Canada, and we're expecting her in a couple of hours and actually the kids and I so she's really big into Halloween and loves all the scary stuff. And although we normally don't do this yesterday we went to the Halloween store and we got all this scary stuff that we decorated the house with. So my kids are going to scare her when she arrives today.
Rena: What a warm welcome!
Bojana: I am so excited and grateful for that experience today. It’s gonna be fun.
Dara: Oh, nice. Rena?
Rena: Well, you know, I'm so grateful to have someone so smart and knowledgeable like you Bojana to come on it feel like I was just listening and soaking everything in. And I think this was fascinating and really it’s just a taste on the thyroid. It’s so important. Dara?
Dara: I'm grateful for my friendship with Bojana. I feel like it was serendipitous that we were connected at school and found out that we have so much in common growing up in Canada, being in the health world, and I really, I, you were a wealth of information, and it's just so great to be friends with you and to learn from you and to work in the same environment. So thank you.
Bojana: Thank you. It's really been such a pleasure. And I'm so grateful to know you and so happy to have met you today.
Dara: We need to have you back. So yes, thanks.
Dara: Thank you so much for listening today. And always remember, practice gratitude. Give a little love to someone else and yourself. And remember, you are not alone. Find us on Instagram @Fertility_ Forward. And if you're looking for more support, visit us at and tune in next week for more Fertility Forward.

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