Podcast transcript

Denise Furness: There were lots of signs and symptoms but I didn’t really pay any attention to them. And honestly, before becoming unwell, I thought I was very, very healthy.

I thought I ate well, I didn’t eat junk food, I actually prided myself. When I first got the diagnosis I was like, how can I be sick? I haven’t eaten McDonald’s or takeaway food in nine years.

So that was my interpretation of health. But, in reality, I was not very healthy. I was working at a very high level, always pushing myself, overachiever, you know. Obviously lots of study, done my PhD which really did push me, and then obviously my post doctoral fellowship. But of course that’s not enough, I had a little side business in the fitness industry, I socialised, I went out every weekend, I wasn’t prioritising sleep, I wasn’t prioritising recovery after exercise, I trained quite hard.

And I was the kind of person particularly in my twenties - because my diagnosis was in my early thirties - who thought about nutrition not as nourishing the body, but really about calories and a lot about weight. It was probably a lot more about the outside appearance rather than my true health. So if I had a piece of cake, you know, during the day, because it was someones birthday at work I then go, “oh I might not have dinner”, or “i’ll just have a little dinner”. Instead of thinking about the nutrients I need, I was thinking about calories.

Danny Urbinder: You're listening to Denise Furness describe her life just before being diagnosed with Graves Disease. An autoimmune disorder that results in the over production of thyroid hormones, otherwise known as Hyperthyroidism.

My name is Danny Urbinder, and in this episode of Patient Journeys, Denise tells her story. Taking us through the numerous challenges she faced with the serious disease, as well as the important lessons learned along the way, allowing her to return to a state of wellness.

You’ll also hear from a variety of experienced integrative and holistic healthcare practitioners as they provide their insights for treating a patient with Graves Disease.

I went on to ask Denise what warning signs alerted her to the fact that her health was being affected.

Denise Furness: I was diagnosed, or you know, high blood pressure was picked up multiple times at the doctor. And I didn’t take it too seriously because my mother had been on blood pressure medication since she was young, in her twenties. And she had also not been overweight, takes good care of herself. So, I knew there was a genetic thing there and I was like, ‘oh, well. You know, high blood pressure’. And I kept saying to the doctors, ‘I’ll exercise more. I’ll keep my weight down. I don’t need to be on medication’.

So the blood pressure was definitely a sign and I now know, through, through experience and things, that it’s definitely linked with my thyroid because when my thyroids fine, my blood pressures fine.

I remember loosing so much hair and getting out of the shower and just seeing this hair on the floor. And really when I pin point it now, they were often at the times that I was training at my highest level. So I’m thinking a lot to do with low protein as well.

Keonie Moore: For me, hair loss is a bit of a one where I’m like, ‘ooh’, - that always sparks a bit of an interest for thyroid.

Danny Urbinder: That’s Keonie Moore, a leading Melbourne naturopath with a strong interest in thyroid health. I asked Keonie what investigations she would consider if presented with a patient with Denise’s signs and symptoms.

Keonie Moore: So, we normally start with an in-house testing session. So we will do blood pressure, heart rate, we’ll do a urinalysis, we'll do some of those basics to start to get an idea of whats happening.

Certainly, we would also look at what pathology had been done previously and have a look if there was any gaps in that.

So, particularly I think if you look at some of those early symptoms; weight loss, palpitations, there can be some crossovers with other areas. Say, palpitations for example are really common with iron deficiencies, really common in women. But certainly you want to go okay, well, is there actually an iron deficiency that might be contributing to this.

Denise Furness: And then one thing that really, that I did take seriously and I did go to the doctor about was palpitations.

So these happened a bit closer to the diagnosis. I would say I noticed them within a year of being diagnosed where things like the blood pressure and the hair loss, they were kind of years before. And I’m sure there was lots of other little things too, that I didn’t sort of take notice of.

But in that year leading up to being diagnosed with Graves, I was having palpitations and it did scare me and I spoke to the doctor and they just said it was stress.

Tara Nelson: You know, Graves is very aggressive on the body. Those high thyroid hormones are stimulating every single cell’s in the body internal metabolism, so everything’s going fast. Heart rates increasing, the digestion you know motility’s increasing, its increasing symptoms of anxiety, restlessness, you know heart palpitations.

So the whole body is burning through the reserves of pretty much every nutrient, you know the immune systems overactive. It’s just so you’re really burning through a lot of like nutrients and muscle and protein and carbohydrates, so the body does end up in a state of exhaustion.

Danny Urbinder: That’s Tara Nelson, a Perth based naturopath who treats a lot of thyroid patients. I explained to Tara that around that same time, Denise had also experienced severe abdominal pain.

Denise Furness: I actually, at the time, kind of went, ‘oh, okay. It’s just stress. I’ll get over it’. But the other thing that started happening after the palpitations, was some, sort of gut issues. I remember eating a yogurt, like this was probably the very first time I ever noticed it, I was just eating a yogurt at my desk, but the pain - which was very unusual for me - the pain that I had was very serious. Not just like a little bit of bloating, I was like this is really weird, and then I thought oh, maybe the yogurt was off or something. But from that moment, I started getting a lot of pain. A lot of gut symptoms and unexplained pain. Like pain in under my ribs, in my back, in my shoulder. So yeah, pain and gut symptoms probably in that, at least six months leading up, probably longer actually again, probably a year leading up to the diagnosis.

Danny Urbinder: What Denise is possibly describing is an acute abdomen. Thyroid storm is a known cause of medical acute abdomen, which is caused by gut hyper-motility and the release of pro-inflammatory, pain-mediating cytokines.

Now, this can be quite a serious condition and it’s critical to ensure that the patient has been evaluated for potential surgical causes. That being said, if confirmed, medical cute abdomen and all its associated gut inflammation likely indicates an important factor that could be contributing to the development of intestinal permeability and in turn, the progression of Graves disease.

Keonie Moore: So, we know that you - to develop an autoimmune condition you have to have increased permeability, that increase in, I guess crosstalk between what’s happening in the gut, the gut microbiome, the bacteria that are there and the immune system in the lamina propria just on the other side of the gut wall.

It’s not sufficient to - it’s not like everyone that has increased intestinal permeability is going to develop an autoimmune condition, but you do have to have that as part of the process.

Then we’re going to see, I guess, increased bacterial translocation, increase in endotoxins or LPS that are going to really trigger off that inflammatory process in a body that’s already primed for autoimmunity.

Danny Urbinder: Given this increased risk for autoimmunity in individuals with intestinal permeability, I was interested to know if Denise had a family history of autoimmune disease.

Denise Furness: I do have a family history of Graves. So, I’ve mentioned a few times that mum had the high blood pressure. And I definitely was aware of my mums family history, but not of my dads.

So I think it’s part of the, the generation is you know the dads and grandpas don’t complain about their health. So I actually didn’t know that I had a family history of autoimmune disease and Graves, but it’s actually a very, very strong family history from my dad's side.

But we didn’t find that out until after I was diagnosed and he said 'oh, that’s, you know, your aunties and grandma have had that and I had an issue with my thyroid when I was 27’, so I found that out later.

Tara Nelson: Yeah so, we do know that there are definitely many genetic and environmental factors in the development of Graves disease.

And the condition can definitely cluster within families and you’re more at an increased risk of having a close relative such as a father, or also another autoimmune condition.

So, the research around the genetics of Graves disease is that there’s no real, one specific gene, but rather it’s a bit of a cluster. So there’s various genes that are being linked to Graves, but also particularly the genes that weaken or modify the immune response. So our immune modulator genes such as CD genes, the FOXE genes and particularly the various HLA genes such as DR3 and the DQ.

Danny Urbinder: Those HLA genes code for a group of proteins responsible for presenting foreign substances from viruses and bacteria to cells of our adaptive immune system. That’s how we acquire our immunity. They’re also highly polymorphic, meaning there are several possible variations of the same gene.

Those individuals who’ve inherited HLA-DR and DQ variants risk having a modified adaptive immune response that affects the bodies ability to distinguish its own protein, from foreign protein. As a result, they have a greater risk for developing autoimmune disease such as Graves disease.

Interestingly, the HLA-DQ variants are also found in patients with Coeliac disease. I asked Keonie Moore what relevance this might hold in Denise’s case.

Keonie Moore: That is a question that I would have posed as a practitioner in this case. Because certainly, there’s potential benefit of a gluten free diet to look at intestinal permeability and improving that from a Graves disease point of view.

But, certainly I always make sure that I rule out things like Coeliac disease before I put someone on a gluten free diet, because there are a big portion of patients with Coeliac disease that don’t actually show any specific symptoms.

Obviously in this case, there actually was quite a lot of history of abdominal symptoms that you would really want to look at that in more detail as well. But one of the mistakes that I made in earlier practice was missed cases of Coeliac just because they didn’t have gut symptoms. And so, certainly kind of coming back to that later on in their case and just realising hey, this is something that we don’t just want to exclude if we’re not seeing gut issues.

Denise Furness: When things really went downhill, this was just before moving to Melbourne, I actually got sick.

So, I hadn’t been sick in many, many years. This was before I had children and exposed to coughs and colds and things. I hadn’t been sick for many years but did get some kind of virus, flu-y thing and I just didn’t recover.

So I didn’t - even though I think there were many, many factors leading up to me getting sick, there is this one point where I got this infection, I think it was a virus. I was sort of wiped out for a few weeks and the biggest thing that was really noticeable was I started loosing my strength.

Because I trained and I went to the gym, I know how much I could lift. I know what I could do, how I could perform. I was just slowly getting weaker and weaker and more and more fatigued and I had to stop going to the gym. I just couldn’t lift weights anymore. I was too exhausted and wasn’t strong enough.

Keonie Moore: Viral infections are commonly known to trigger autoimmunity. So you might have a genetic predisposition sitting there, but only 10% of people with that predisposition are gonna go on to develop an autoimmune condition.

We know that there’s going to be some changes in intestinal permeability sitting there, there’s often those nutritional deficiencies there, all setting up the environment that allows that final blow to tip it over and that often is a viral infection. So that is working through, just causing some changes in the immune responses, particularly the innate immune system following on to adaptive responses.

Often through molecular mimicry, where there’s going to be some cross, I guess, issues with the response from the immune system to the virus and then to the bodies own organs.

Denise Furness: I was just starting to struggle, with just everything. And you know thyroid effects your mental health and I’m a very optimistic, go-getter kind of personality but I was just struggling with, life really. I was negative, I think like most people with thyroid issues I was kind of playing the blame game and the victim and I was unhappy with the whole system and my job and just, I was really in a bad place. Thankfully, I’d met Ryan who’s now my husband, and he sort of kept saying, ‘well what do you want?’ And I’m like, ‘oh I’ve gotta get out of research and the whole grant system’, and you know just whinging about everything and decided to leave my job, move to Melbourne and was trying to do things to make me feel better because something was wrong, like I wasn’t happy.

However, we got to Melbourne, and of course that didn’t fix all the problems and actually I moved into a house that had a bit of mould.

Danny Urbinder: I spoke to professor Mark Cohen, a Melbourne based GP, university professor and a pioneer of integrative and holistic medicine to get his perspective on the potential impact mould could have on Denise’s health.

Dr. Mark Cohen: The environmental issues and mould specifically, can be just devastating. And it’s so ubiquitous and so common and often it’s under the radar, people aren’t that aware of it but that can trigger a whole range of autoimmune conditions.

It’s not actually the mould itself, it’s the ecological war that happens between the mould and the bacteria and other little mites and parasites because mould is just a signal of damp, and then they’ll start decomposing the materials of your home. That’s what mould’s designed to do. To decompose the wood or the plaster board or whatever it is and then that creates food for bacteria.

But then, rather than having that symbiotic colony of bacteria and yeast as you do with a kombucha scoby where they’re working together, here the mould are trying to suppress the bacteria and the bacteria are trying to suppress the mould. And they secrete biotoxins and humans get caught in the crossfire.

In terms of the health impacts of that, very often there are long term, chronic health consequences which focus really around autoimmune but certainly thyroid is a big issue with mould-related issues.

Keonie Moore: But certainly mould exposure in a mould sensitive person is going to cause an array of flow on effects from immune responses that are going to be detrimental. So, certainly in terms of thinking of it as a danger associated molecular pattern, it’s going to have that impact on the immune system and certainly create increase in certain cytokines or inflammatory mediators that are going to then worsen your autoimmune condition.

Danny Urbinder: Denise thought that her move to Melbourne was the change she needed to start feeling better. However, not only was she faced with the health impacts of moving to a mouldy home, Denise was then presented with an additional challenge that only served to create more confusion and uncertainty.

Denise Furness: So, yeah we moved to Melbourne. All these little things going on in the background, not really thinking that I have an autoimmune disease, and then I got pregnant.

This was not planned. A blessing obviously, but not planned. And I think that’s where the confusion happened, because I was pregnant and these symptoms that come with autoimmune disease are quite varied and can crossover with being pregnant. So when I was complaining about being nauseous all the time, they said ‘you’re just pregnant’. I said I can’t eat, ‘you’re just pregnant’. You know I’m hot, ‘you’re just pregnant'. Everything is your just pregnant and I honestly, I felt like I was a whinger.

And I do recall saying to the doctor, ‘I feel like I’ve got the worst hangover of my life every single day’. I said, 'this is not just a little bit of nausea’. I said, ‘my head is pounding, I can’t tolerate food you know, I can’t even drink water’. And she said ‘Ugh, you know you’re just one of those ones. You’ll get over it. You’ll be fine’.

Danny Urbinder: I asked Mark Cohen what investigations he would have done, given Denise’s signs and symptoms.

Dr. Mark Cohen: Thyroid function test is a standard antenatal screening test. So, it’s disappointing that that didn’t happen because that should have just been picked up when she first fell pregnant.

But then, I mean things do get missed, and that’s one of the reasons why you do thyroid function test is it's one of these masquerades. It can masquerade as both hypothyroidism and hyperthyroidism and it can masquerade as so many other different conditions. So it can be gut problems, it can be anxiety, it can be cardiac problems, you know and palpitations. So you do want to exclude it for a whole range of symptoms.

Danny Urbinder: The thyroid gland takes its direction from both the hypothalamus, and pituitary gland. The hypothalamus releases thyrotropin-releasing hormone, which then triggers the pituitary gland to produce thyroid stimulating hormone or TSH. It’s TSH that signals for the thyroid gland to release thyroid hormones, known as T4 and T3, but without TSH, the system would fail.

So when it comes to thyroid function testing, TSH’s are often measured first, then T3 and T4 if TSH is abnormal. Thyroid antibodies can also be measured to diagnose autoimmune thyroid disease. I asked Keonie Moore about her approach to thyroid function testing.

Keonie Moore: So, usually at least T3 and T4, but preferably thyroid antibodies as well. Because this is a common, I guess, misunderstanding within clinical practice that generally you’re going to see thyroid antibodies be elevated first, before you see a detrimental impact on T3 and T4. Particularly with low thyroid function for example.

So, you don’t want to be waiting until it’s already having an impact on thyroid function before you’re detecting hey, there’s something going on here that needs addressing.

Danny Urbinder: With Graves disease, the immune system makes an antibody called Thyroid Stimulating Immunoglobulin, or TSI. TSI attaches to thyroid cells and acts like TSH, causing the thyroid to produce excessive amounts of T4 and then T3. Thus stimulating the metabolism of almost every tissue in the body. The fact that this was missed in Denises medical screening, meant that her symptoms continued to worsen.

Denise Furness: It's kind of devastating that they didn’t take all of this seriously because I slowly got worse and worse and obviously I’d left my job, but I was meant to be writing up some papers and doing some research, I couldn’t even use my brain.

I would be at the computer for an hour, things weren’t making sense. I’d go and lay down for an hour and then I’d get up, I’d try to eat. Then there was kind of this joke in the house before I became really, really sick and Ryan would just sort of call me “shit-spew”, because I would dry retch or go to throw up and then the pressure with Graves, everything sped up you know a million miles an hour and I would loose control of my bowels.

I couldn’t go out anymore, like it got to the point where I couldn’t actually go out in public because I couldn’t control my bodily functions. It was terrible.

Danny Urbinder: So how far into the pregnancy was this?

Denise Furness: To be honest, the first 12 weeks weren’t too bad. Which should have been another sign for the doctors. If my first twelve weeks I wasn’t nauseous and then I get sicker as time goes on, that should be a red flag.

Around 20 weeks, I just really stopped being able to function. I was just in bed all the time, the pain. I can’t describe the pain. Just those little niggles I said I had, the pain became so like, stabbing in my lower back or under my ribs. And there were quite a few nights that Ryan wanted to take me to emergency and looking back, I don’t know why I was so against it. But I just, I didn’t want him to touch me, you know. I became very, I just wanted to be by myself. If he came into the room, I went to the spare room. I didn’t speak to anyone on the phone. I just wanted to be on my own and I was in a really bad place too.

Danny Urbinder: Given that Denise’s condition seemed to be having a marked impact on her mood, I asked Mark Cohen what might be going on.

Dr. Mark Cohen: Well, with Thyrotoxicosis, it’s not depression as much as anxiety. Often, hypothyroidism is very often associated with depression and hyperthyroidism is often associated with this sort of mild anxiety and you feel jittery and butterflies in your tummy all the time and things aren’t quite right. And often, as I said, that’s associated with hyperventilation as well. Your over-breathing, you’re anxious, you’ve got this very sort of high level of alertness and your pulse is up and your tremoring and your whole bodies on sort of in this hyper alert level which feels very uncomfortable because you can’t relax and you can’t really settle down.

Danny Urbinder: Tara Nelson went on to further expand on this point.

Tara Nelson: Look, I think Graves disease has a lot of you know, study, research that definitely we need to perform on it. But you know when I look at people with chronic, long tern Hashimoto’s disease in comparison, there are some early studies going into that. Even just looking at the cross-reactivity of the antibodies into the cerebellum, and that can definitely effect those symptoms of low mood, anxiety, brain fog which is actually, brain fog is actually quite common in both Hashimoto’s and Graves disease.

Gluten, there’s a lot of research around even gluten increasing that cross reactivity in the brain, in the brain cerebellum.

So it’s quite new research going on at the moment, but it’s quite exciting and it really makes sense when we’re thinking about those brain symptoms that people with thyroid autoimmune conditions do suffer from.

Danny Urbinder: Denise’s condition continued to worsen, and now, there were fears for her pregnancy.

Denise Furness: I’d had so many doctors tell me there was nothing wrong with me, that I, you know, I started feeling almost guilty, or like I was making it up. It was a really strange place. I mean, Ryan supported me the whole time but I didn’t feel like I could go to the doctor. I didn’t feel like I had someone I could talk to and I was really questioning the pregnancy. As I said, I’m a very optimistic, I’m a very positive person. But I started just feeling like, I knew something was wrong. I just kept thinking, ‘something’s wrong’, and I kind of was blaming the baby. I was like, this baby’s killing me and then by 27 weeks, Ryan did rush me to the hospital one night because of the severe pain. I was curled up in a ball, I was vocal. Such serious pain I was vocal, I couldn’t hold it in. So, we went to the hospital and they said you are having preterm labour, and we think you’re going to have the baby tonight. They said you’ve got pre-eclampsia and it was all, it was very scary. Very, very scary.

Danny Urbinder: Now that diagnosis was based on what?

Denise Furness: Based on, they thought the pain was contractions and then my high blood pressure.

Danny Urbinder: Okay, so what happened then?

Denise Furness: I wasn’t in preterm labour. I was there for hours. I wasn’t dilating. You know, they’re doing all those lovely invasive tests and things like that and they’re like, ‘Oh. She’s not actually having the baby’.

No one really knew what was wrong. They did think it was pre-eclampsia though, which was a shock to me because I’d done nine plus years of research in the world of pre-eclampsia. I’m like, wow. I always thought when I got pregnant I would be so healthy. I’m going exercise everyday and eat so well, and my pregnancy was not like that at all. So I went home and went okay, so I’ve got pre-eclampsia.

However, I then had to go to Adelaide to have a meeting. Long story short, I turn up, I walk in, just like, just crazy. I’m so grateful I went for this meeting but it should never of happened like this. I walk into the meeting and everyone just, jaws drop. They look at me and they’re - I’m sure if they could use words, they would have just been lots of swear words, like the look on people faces.

And Dee, Dee McCormack, who’s an amazing obstetrician, I used to work with her in the recurrent miscarriage unit, grabbed my arm, she said ‘We’re going to outpatients’. So, we walk to outpatients and I’m a bit pissed off right. Cause I’m thinking ‘Hang on. I’ve flown all the way for this meeting. We need to talk science. This is a big effort for me’. And she said, ‘You don’t look well’, and she said, ‘You know what’s going on?’, and she said, ‘You know you’re shaking’. And I said 'I am a bit, oh I think it’s hypoglycaemia’.

And that’s the other thing I didn’t mention, I had a tremor. Not just in my hands. So in Graves, they tell you you get a tremor in your hands, I had my whole body, my legs had a tremor. And again, I just put it down to because I couldn’t eat, I was so low in sugar.

So I’d made up all these little stories in my mind that just to sort of, you know, of what it possibly could be, but obviously I was wrong. So yeah, the tremor and she just said to me, ‘You’re shaking’, and I said, ‘Oh yeah, it’s cause I can’t really eat, it’s just the pregnancy I’m so sick'.

So we went and had bloods, we went back, they cancelled the meeting, and I’m sitting in Dee’s office and I’m like, ‘Dee you know, I’m here for the meeting’. She said, ‘We’re not, we’re definitely not having the meeting’, and she’s ringing the lab trying to get the blood results. They did them multiple times, my bloods were so, like not just out of the reference range, like off the charts. And they diluted my blood, just to try and get all this - and I was basically thyrotoxic. They were concerned that I was going to loose the baby very quickly and basically it was actually the team of people that had worked with me and my old PhD supervisor who diagnosed me.

His name was Bill, Bill Hague. So she sent me to Bill after the bloods, he’s in endocrinology, and in some ways it was probably good that it was people that knew me because I would have been really reluctant to go on medication, particularly the medication that I was given. Nine tablets a day, very high dose which were not safe in pregnancy, but they kind of explained to me that you either take the tablets or you lose the baby. Like you’re really, really sick.

Danny Urbinder: Denise was prescribed beta blockers for her tremor and palpitations. She was also given carbimazole, an antithyroid agent that reduces the formation of thyroxin. I asked Mark Cohen what implications this might have during pregnancy.

Mark Cohen: During pregnancy, it’s very important to monitor that very closely because there is an overlap between proopiomelanocortin, which is the pro-hormone for - which is secreted by the pituitary gland and that creates melatonin, creates thyroid stimulating hormone and also Beta-HCG which you know, maintains the placenta. So, there’s an overlap there where you can have high thyroid stimulating hormone, TSH, but no clinical symptoms. But if you over-treat, then you can cause hypothyroidism and that can be really serious in the foetus because low thyroid levels in the foetus causes cretinism. So it drops the IQ of the foetus. So, that’s a potentially serious condition and carbimazole does cross the placental barrier and will drop the thyroid hormone level in the foetus, and that effects brain development.

So that’s why areas with low iodine have high levels of cretinism, because of the hypothyroidism. So, you know, you have to be very careful treating, or over-treating thyroid disease in pregnancy.

Danny Urbinder: Denise went on to describe the impact of her diagnosis.

Denise Furness: And it was really scary, like Graves disease. To be honest, I’d never even really heard of it and it’s such a terrible name. I just remember getting really hung up on the name and I held myself together. I didn’t cry, these are my colleagues they’ve known me for many years, I tried to put on a good front. They all seemed pretty calm, I guess thats their job. They all seemed very calm but as soon as I had a moment to myself, I went off to the bathroom and I was just balling my eyes out.

And I rang Ryan, I’m going to get upset, but I just sort of said to him you know, ‘I’ve got Graves disease’. And you know I said, ‘I don’t even really know what it is’, I said, ‘I could loose the baby. I’ve gotta have this medication’. I said, ‘I’m reading through the medication on the back, I’ve got the little leaflet. It says ‘Do not have it in pregnancy’. I’m like what do I do, and Ryan was just great and he said, ‘take the medication. You know you are sick’. He’s like, ‘Thankfully we’ve found out there’s something wrong with you’. He’s like, ‘just take it’, and Ryan’s like me. He’s very much about natural health, I trust him, he’s always got my back and he said just take it.

I had to stay in Adelaide, in hospital a little bit longer for a while, just to monitor me, just to get my fluids up and it was just so, so scary. But at the same time, such a relief because I knew something was wrong and no one was listening to me.

So you know, I took the medication. The doctor who you know, that I knew who’d been my supervisor since, oh, you know, my mid twenties, Bill, he said, ‘You’ll feel better in a couple of weeks’. So I kept - I was holding onto that thought so much, like, your gonna get better in a couple weeks because honestly life, I didn’t even know if I wanted to live life anymore. That’s how bad it got.

So I was like great, you know, I’m going to feel better in a few weeks and in a way I did. The medication stopped the headaches. The medication took the tremor away. The medication stopped the nausea. I could eat, but, I didn’t feel good. Inside me, I still knew something was wrong. It’s so hard to explain and I think if someone hasn’t had an autoimmune disease or something wrong, it's very, very hard to explain because on the outside, the symptoms are going away.

Your blood pressure’s down, your tremors gone, the headaches gone. So to the doctors, they’re like, ‘You’re better’. But I'm like, there’s just something inside me. I’m waking up, I'm starting to sleep better, I'm not hot - oh my god I didn’t even tell you how hot I was. Like, just so hot. So I wasn’t hot anymore, I didn’t feel like I was overheating, but something wasn’t right. But I was just so happy that I was able to eat and I put on 30kg pretty quickly, I was starving, so that was interesting.

Danny Urbinder: Denise was diagnosed with Graves disease when she was 27 weeks pregnant. She went on to describe the remainder of her pregnancy once she was on the medication.

Denise Furness: So for a few months, I was, you know, just kind of getting by and I guess getting myself back together. As I said, I put on a lot of weight, I was eating and just trying to sort of get through the pregnancy. I was still having a bit of pain, so that was interesting in that the pain didn’t go away.

And about a week before I went into labour, which was at 37 weeks spontaneously, the week before I went into labour I remember I was driving, and the pain was so bad that I had to kind of expand and reach over because I thought Harry was sort of putting his foot in my rib. I’ve now had another baby and I know that it’s not that painful to have another child. But I was just in so much pain and I remember actually ringing my dad - Ryan was working - and saying, ‘I can’t drive anymore because I’m a bit concerned I can’t concentrate I’m in so much pain’. And I had said to my dad, ‘Well, you know, your retired, you don’t live too far away, I’m in Melbourne now, your going to have to drive me around to my doctors appointments’, cause I was actually having a lot of regular visits with the doctor because I was obviously a high risk pregnancy. So yeah, I decided I couldn’t drive because I was a bit concerned that the pain meant that I would possibly get into an accident or something because I just couldn’t concentrate.

And the other thing, the weakness. So even though I said the medication helped with a lot of the symptoms, the pain didn’t go away and I was still very weak. I just had no strength at all. So even though the medication - I guess it takes a while to build back the strength, but the medication didn’t help with my strength or the pain.

Danny Urbinder: While her pain and weakness remained, many of Denise’s signs and symptoms had improved for the remainder of her pregnancy. While she was disappointed at how late she got her diagnosis, Denise was thankful for the fact that the medication had saved hers, and her baby’s life. I wanted to know how Denise’s health faired after she gave birth.

Denise Furness: So, after I had Harry - which I had him naturally - it wasn’t easy because I guess I wasn’t well, I did manage do it all naturally, that was important to Ryan and I. And once he came home I actually felt a lot better.

After, when he kind of came out, I was a bit like, phew. Thank goodness, you know just so, yeah. I think once - my body was really struggling with the pregnancy, so once he was born I did have a little bit of my, I felt like I had a bit of myself back. And I just wanted to get well for him, you know for my baby but also for myself and I made massive changes to my diet. A bit of the real me came back and I was like, I know how important food is. I mean I studied as CSIRO, Human Nutrition. Even though in my early twenties I was caught up on calories, by this stage, I knew by now the importance of good nutrition, well and truly. So I really worked on my diet.

Danny Urbinder: I asked Tara Nelson what her dietary considerations would be in a case such as Denise’s.

Tara Nelson: Interestingly with Graves disease and hypothyroidism, T3 is carbohydrate dependant. So, the more carbohydrate in the diet when there’s already a really high T3, can exacerbate that T3. So, one way to modify that T3 response, is to lower the carbohydrates and often we see low protein. So, if someones having a very high carbohydrate diet that’s increasing the T3, there’s often low protein. When we're looking at that catabolism, we’ve talked about that increased metabolism going on, that’s burning through protein. So there’s a need for a high protein, and a low carbohydrate to stop that production of T3 and increase and gives, you know the body, because it’s burning through so many nutrients, more protein.

Danny Urbinder: While not extensively researched, there are some studies to demonstrate that high carbohydrate diets are associated with significantly higher serum T3 concentrations when compared with low carb diets. Of course, a typical high carb diet is also likely to be rich in grains and therefore gluten. Which, as Keonie Moore went on to explain, also needs to be addressed.

Keonie Moore: I would definitely recommend that people with auto immune conditions do be gluten free long term. Certainly, there is evidence to suggest at the very least it’s going to be having an impact on intestinal permeability, which we know is fundamental in autoimmunity but then looking at that cross-reactivity in her profile as well.

Danny Urbinder: Given these key recommendations, I asked Denise if these were considerations she made for her own diet.

Denise Furness: It was very paleo-like in the fact that you know, your removing all of your processed and packaged foods. It did have meat, I am a meat eater, I do like meat, but not high meat. So I was having good, lean protein, lots and lots of vegetables, you know healthy snacks, you know veggies, things like that. Fruit and really just whole food, whole food. I wasn’t 100% gluten free, I wasn’t 100% dairy free, but I was having very low gluten and very low dairy.

I did trial no gluten, it didn’t seem to make a difference at the time, but now I try to be gluten free most of the time because I realise it’s a trigger now and I developed other things.

Danny Urbinder: Iasked Denise what other changes she had taken on to improve her health.

Denise Furness: Because I’d done my PhD in methylation, you know, epigenetics and I guess this is part of me - one, I had a gut feeling that I could recover. But also, I think all my years of research and my understanding cellular physiology, genetics, gene expression, epigenetics, I believed wholeheartedly that I could turn my health around. I know how quickly the body can change and adapt if you put the right things in you know, I hadn’t been putting the right things in. It was stress, it was this, it was that, I needed to take care of myself.

And so with the supplements, I was well aware of the importance of nutrients and when I started thinking about - as I said initially when I first got the diagnosis I was shocked, because I thought hang on. how could I get an autoimmune disease. I was so healthy for so many years, but as I said to you at the beginning, really my perception of health was not right. And then when I started really, being realistic about the lifestyle I led, I realised how harsh I was being to my body with that excessive training and work and socialising, not sleeping, not eating well.

So when I came to terms with all of that, I made a huge effort to nourish my body with food. I was putting all the supplements in, I was thinking about sleep, minimising stress, and all of that definitely worked within my favour.

Within 7 months, I started going back to the gym which I did struggle with. I had a lot of fatigue but I persevered and yeah, within 10 months I was off the medication and I would say by the time Harry was 1, I felt awesome. Like I was back. I was like, ‘Yeah. I’m here. I’m back’.

Danny Urbinder: I wanted to know more about Denise’s decision to get off her medication.

Denise Furness: Me getting off the medication was not supported by the doctor. I was told that it was life-long, but I think I just, I don’t know, I didn’t really - at the time that wasn’t what I was focusing on. I was just focusing on not losing my baby.

Then when I saw the endocrinologist when I was back in Melbourne, he basically said, ‘This is a very aggressive case of Graves’, you know, ‘You’re not going to recover’. He was very direct and said to me that ‘Once you have the baby, we need to have thyroid ablation’, so radioactive iodide. If i wasn’t comfortable with that, they could remove my thyroid, but that’s not really what they do these days. He said radioactive iodide and then sort of go from there.

And I did, I mean, I’m not, you know I didn’t - I wasn’t combative in any way but I definitely wasn’t happy with that. So I sort of said, ‘Well, what are my options’. He basically said, ‘If you don’t do what I say, you’ll die early and you won't have any more children’. So I was in tears, left the office, told Ryan who was pretty angry, and we got a second opinion from someone within the same hospital. Big, big you know, main hospital in Melbourne. And the next endocrinologist we saw - who also was a professor and head of the field and etcetera, you know, high up is what i’m trying to get to, - he said straight away, ‘There is no way I would give a woman in her reproductive years radioactive iodide if you want to have another baby’. He said, ‘We just don’t do that’. And I said, ‘Well, the last endocrinologist said if I don’t do it, I’ll die early and never have another child’, and he said, ‘Well this is the way that I do things’, he said, ‘You can stay on medication’, - again assuming I’d never get off it - he said, ‘You stay on medication until you have your next baby’, because I made it clear that I wanted to have one more child. He said, ‘You stay on the medication and then when you have the baby, then, after that child, then you have the radioactive iodide'. So he, he still thought that was my path but wanted to do things a little bit differently.

But yeah, he was nicer in the fact that he sort of gave me an option to stay on the medication, because the other thing that really threw me in that first appointment was he said I’d have to be away from my baby for a few days. You know, I mean, I’m a new mum. I want to be breastfeeding, things like that. It wouldn’t have worked. He said, ‘You have that, you can’t touch anyone for a few days. You can’t be near your baby, you can’t do this, you can’t do that. You can’t travel for a certain amount of time because you can't go through the things at the airport, it picks it up’, and I’m just going, how can that be good for my health? How can that be good? Like, it just honestly, it just did not make sense to me. I was thinking, if I can’t touch my baby and anyone else, how can this be good for my body.

But sadly, a lot of people don’t question it and just go down that route because that is the mainstream model. That’s how you treat Graves. You have the medication to ease things and then you have the radioactive iodide and it’s basically, most people become hypothyroid and then you’re on thyroxin. So you’re on hormones the rest of your life. I mean it just didn’t seem like a great option to me at all.

Danny Urbinder: I asked Tara Nelson how she perceived Denise’s approach to her treatment.

Tara Nelson: When you look at, you know, from the medical paradigm Graves disease is very destructive on the body. When you look at those excessive thyroid hormones, they put a big strain on our heart. And that’s the big thing there, when they can’t get Graves disease under control through medication and they’re still experiencing anxiety, restlessness, loose stools, tachycardia, arrhythmia, that high pulse rate you know. The Graves disease pulse rate is sitting at around eighty, ninety, one hundred every day. It’s very, very aggressive on the body and that’s dangerous long term.

So, from a medical point of view, they wanna get that person out of that position as soon as possible and that’s all they’ve got. But, us as natural practitioners have so many amazing nutrients and herbs and diet, the diet alone can bring so much relief it’s quite amazing.

Keonie Moore: I think, certainly first and foremost, is patient safety. So you don’t want to be risking, I guess, someones wellbeing and let’s remember that you know, thyroid storm is potentially life threatening. So we definitely want to work within the realms of - I like to work collaborative, with the specialists and making sure that there is appropriate monitoring going on.

But what you can often do is buy time. So rather than say no no, I’m not going to do that at all, I often will converse with specialists and say, ‘Okay. Let’s give us eight weeks. Let's see what we can do in that time and if we’re seeing it trend down, then we will continue on that path. If not, then we’ve got another discussion to have’.

So I found that to be quite useful like, you do need to have the right healthcare team that suits your goals. And I certainly, I don’t advocate for doctor shopping, but if the doctor you’re working with isn’t in line with your own values, then sometimes getting additional opinions - like in this case the second opinion was quite different to the first. So certainly, I guess exploring those options is really important.

But I personally have worked with patients, lots of patients, with Graves disease. Right through from very mild symptoms to quite severe and I have a lot of faith in our medicines and working alongside in that kind of collaborative approach, we’ve actually had many patients actually avoid having to go on and doing radioactive iodine, which I think’s really valuable.

Danny Urbinder: Denise went on to describe how she navigated the medical advice she was given, alongside her commitment to get well through diet and nutritional medicine.

Denise Furness: I tried to have open conversations with some wonderful GP’s up here in Noosa and just said, ‘Do you think the diet could have any impact on my thyroid at all’, and they just looked me deadset in the eyes and said, ‘No. Your diet has nothing to do with it’.

So, when I’m told things like that, I just realise I need their help. I need the blood tests, I need, you know at some point you need medications. I mean that’s not all doctors by the way, there are plenty of doctors and I think there are more and more that are becoming aware of the importance of nutrition and environmental medicine. But majority don’t actually believe that you can get well and that your diet and lifestyle make a difference. That can be difficult when you're trying to work closely with your doctor.

One thing I didn’t mention is, when I got pregnant, they did do a number of tests. Not the investigations that I would request now, but I did find out that I was vitamin D deficient and for those that know a little bit about autoimmune disease, one of the risk factors is being low in vitamin D. That’s so important for the immune system and I am 99.999% certain I was deficient in lots of other things as well.

Danny Urbinder: Denise’s vitamin D levels where below 30 nanomoles per litre. A serious deficiency state that may have been compounded by the fact that she’d inherited a number of genetic variants that may have effected her vitamin D metabolism and receptor function. This was further explained by Keonie Moore.

Keonie Moore: Keeping those vitamin D levels optimal is going to be absolutely key. So I’d be aiming for a vitamin D level of one hundred and ten to one hundred and thirty, so a good kind of level where we’re not going to be dropping down like, less than 30 is incredibly low isn’t it.

So there’s going to be obviously some vitamin D supplementation and monitoring to look at those vitamin D levels. But it’s not even as simple as that in this case, because you’ve gotta think about the vitamin D receptor. So, if we’ve got a vitamin D receptor issue and a vitamin D deficiency, then it’s actually a compounded issue. Because what we're seeing with the vitamin D receptor is not so much about the vitamin D levels per-say, although being deficient and having less availability will exacerbate it. But it’s more about how the shape of the vitamin D receptor and how vitamin D is being assimilated and having its beneficial impacts on the body.

So in that case, I’m gonna look at something like sulforaphane. So, and that’s been shown to enhance the function of the vitamin D receptor when we see those genetic SNPs.

Danny Urbinder: Sulforaphane is a bioactive compound present in cruciferous vegetables like broccoli and Brussel sprouts. It functions as a natural epigenetic modulator, capable of increasing vitamin D receptor expression and therefore improving the body's ability absorb and utilise vitamin D. Beyond these effects, sulforaphane seems to be a particularly important consideration for the Graves disease patient.

Keonie Moore: We're looking at a situation where sulforphane is an Nrf2 activator so, if we think about this from that oxidative stress point of view and Graves is incredibly linked with oxidative stress. So not only in terms of thyroid itself, but also all of the flow on effects particularly in cardiovascular health.

So Nrf2 activator is going to increase our production of glutathione, heme oxygenase-1, PON1, so we're going to have a really nice anti-inflammatory and antioxidant activity.

Danny Urbinder: I asked Denise if there were any additional blood tests she had done.

Denise Furness: So I had - I did request my homocysteine and a few bloods like that because obviously my interest in methylation and interestingly, it was up around about, the homocysteine was about 11. And for those who know the reference range you’re kind of looking at 5-15, we say under 9 is optimal, and I thought, oh, that’s not too good. But interestingly, when I had my bloods done later, it was down to like 4 which is actually too low. I guess my body had been through so much and sort of chewing through the homocysteine to make methionine and glutathione etcetera like that. So everything, - even though I’d been taking supplements for a long time, I had a whole heap of bloods done afterwards which were because I found an integrative doctor, and everything was low. But that was all later, that was all later and that was after the diet and the supplements. So that’s when I’d been working on my health and thought I felt better but I was still quite low in lots of things.

Danny Urbinder: Micronutrient deficiencies in Graves disease is a common observation, and as Tara Nelson explains, can have some serious implications.

Tara Nelson: Well, definitely Graves disease I’m looking at vitamin D and we’ve talked about that already. So vitamin D is probably up there.

Selenium is the other one. You know every single thyroid patient needs selenium and particularly with Graves disease they’re burning through a lot of their selenium very fast.

Generally, our RDA for selenium is about 150mcg. I have used up to 400mcg in Graves disease, so when I’m seeing very high hormones, very high TRAb antibodies, a lot of oxidative stress, I’m going to go in with about 400mcg. 300-400mcg of selenium for, you know, a short while. Maybe six weeks or something, six to eight weeks and then lower it down. Because again, they’re burning through a lot of their selenium quite fast. So the highest concentration of selenium is found in the thyroid gland, it’s a component of our deiodinase enzymes that are needed for thyroid hormone development. And when you think of Graves disease, we’re over producing all those hormones, so we’re burning through all that selenium. It’s becoming very deficient. There is some studies that selenium deficiency is induced by Graves disease and it’s a big antioxidant so we’re seeing a lot of oxidative stress and selenium is going to help mop up that oxidative stress and inflammation, so it’s a big one. Vitamin D and selenium.

Magnesium as well. We’re burning, you know, we’re thinking about that muscle turnover, that increased protein turnover, you know we’re burning through magnesium quite a lot, the heart muscle having a rapid heart rate, tachycardia. We’re burning through magnesium, like we’re thinking about running a marathon, we think of magnesium. That’s what’s happening in the body while we’re standing still. So magnesiums a big one there, it’s more of a supportive nutrient.

Danny Urbinder: Keonie Moore went on to echo these considerations as she detailed the relevance of additional nutrient deficiencies.

Keonie Moore: And I think first and foremost, we’ve gotta remember that with Graves disease, literally the body is burning through its nutrients super fast. So I've not seen a single case of Graves disease that haven’t had multiple micronutrient deficiencies. So it’s always an interesting question, which comes first the chicken or the egg?

Do they have the onset of that auto-immune condition because they were micronutrient deficient. We know that certainly, that at the very least vitamin D is going to be making an influence on susceptibility, but selenium particularly with Graves. So they’ve found that patients with Graves disease that have the eye protrusion have lower levels of selenium and that actually correcting that deficiency can help with that particular symptom.

But they also found link too that particular symptom, high copper levels. So immediately, I’d be wanting to look at the copper to zinc ratios in the serum and really getting an idea of zinc status.

Danny Urbinder: Denise I imagine would have been quite low in both those nutrients. But just thinking of zinc then, what type of dosing, I mean what sort of ballpark are we thinking about here for someone like Denise?

Keonie Moore: Absolutely. I tend to stick around the 50mg per day so that I can use that long term. Certainly you can easily go up higher up to 100mg on a short term basis, depending on how deficient someone is and really looking at what they’re going to benefit from. But certainly I find the 50mg a day tends to be sufficient to improve their status.

Danny Urbinder: Once Denise had her child, she focused on getting well. She spent time with her baby, ate well, and was mindful of the stressors that effected her health. But over time, old patterns began to creep back into her life.

Denise Furness: To be honest, if I’m completely honest, I think I was fluctuating between health and hyper, I didn’t - I was always concerned, a little scared that I was going to fall back into Graves.

I didn’t talk about it openly because I think, you know, moving into this world of integrative medicine at this point I felt this sort of pressure to be very, very healthy, but I don’t think that I was as healthy as I wanted to be. I was working at a medical practice in Melbourne and then I also got a part time job at the gym.

Now I love exercise and it was okay for a while, but I think it ended up being too much for me. As my hours started increasing, again the same thing. Having a little one and Harry was over one by this stage, but the exercise for me and stress is a big trigger and as I got fitter and stronger and fitter and stronger again I fell back into those habits of training quite at a high level. I was doing half marathons, I was lifting very heavy, loving all that but probably putting a bit too much pressure on myself.

Danny Urbinder: Mark Cohen had an interesting and insightful perspective on the impact of excessive exercise on someone like Denise, who’s trying to manage their hyperthyroidism.

Mark Cohen: Well if you’ve got a thyroid condition, you’re already tachycardic, your already hyper-vigilance, you’re already hyperventilating. Very often you're anxious and we haven’t talked much about that, but we talked a little about you know, when you have the cold water and the “ha-ha”, the hyperventilation. Well, when you’re anxious and when you’re thyrotoxic, your naturally hyperventilating which means your blowing off carbon dioxide that makes your blood slightly alkaline. But when your blood becomes alkaline, haemoglobin becomes more sticky to oxygen. So it actually - even though your breathing more, your cells have less oxygen delivered to them because the haemoglobin doesn’t release that oxygen. So your sort of starving yourself from oxygen and you’re sort of - talking about homeostasis, you’re moving on the side of anxiety.

If you add exercise on the top of that, your cells which are already starved of oxygen, your breathing harder when you exercise, so your trying to force more efficiency out of your cells but they’re not going to be as efficient because your started at this baseline that’s already over in one direction. So I think that can definitely exacerbate it.

Now, there’s all these different breathing techniques that help you build up carbon dioxide tolerance where you're actually trying to breath less. Whether that’s buteyko technique, or different, you know pranayama techniques, where you try and breath less but do more. And funnily enough, by breathing less and building up your carbon dioxide tolerance, you’ll actually release more oxygen into your cells. So it’s sort of a paradox you know, breath less but you’ll get more oxygen in your cells. Yeah so, just doing aerobic exercise when you’re thyrotoxic can actually exacerbate the situation.

Danny Urbinder: For someone who has significant clinical hyperthyroidism, it's as if they’re already running on a treadmill all day, every day, even in their sleep. Adding exercise on top of this, particularly intensive aerobic exercise, can pose significant risks.

For the untreated hyperthyroid patient, exercise places excessive stress on the heart that may have the potential to cause cardiopulmonary complications, often leading to atrial fibrillation, congestive heart failure, and an increased risk of myocardial infarction.

Also, the elevated metabolism associated with Graves disease needs increased energy expenditure leading to weight loss, declines in muscle mass and reductions in bone mineral density.

For Denise, the risks associated with a demanding exercise and work routine played out in a distressing way.

Denise Furness: Nothing ever really got picked up, but I would I say I was putting a bit of pressure on myself. I wasn’t as healthy as I could have been, and then I wanted to have another baby and we fell pregnant instantly. Which was great, but I lost it, and that was, I guess a bit of a scary thing for both of us. I wasn’t too bad, I had worked in the recurrent miscarriage clinic. I’m a scientist, I looked at it - the whole situation very differently to Ryan. I kind of put my science hat on and went, ‘ones normal. Like, we fell pregnant straight away, you know. I’m okay with it you know. We’ll just have another baby’.

But Ryan, probably for the first time he ever opened up to me. Oh my god, I’m going to get upset again but he was just like, ‘I can't do this anymore’. He was like, ‘I can’t have another baby with you'. He was like, ‘I almost lost you the first time’ and I didn’t even know what he’d been through because he’d never - he’s not a chatty kinda guy. And he just opened up to me and said you know, ‘Please. I just don’t want to have another child. I can’t, I can’t do this.’ And I didn’t realise the miscarriage really affected him.

So we kind of had to pull back and he had a big chat to me about my lifestyle and how much I try to take on and it was a, it was a good chat. I probably needed to hear it and realise the pressure I put on him. And so I quit the gym like that night, wrote a letter because he was just - I said, ‘How can I make this work, because I really want to have another child. I promise you that I’m going to do what I can to be well’, and he just said ‘You push yourself so hard, do you know’. I said ‘What if I quit the gym?’, He’s like ‘Yep’. He said, 'I don’t want to try for at least 6 months’, he said, ‘But I don’t want you to be working more than part time’. He said, ‘I want to know that your health is just all in check before we even consider having another baby’.

So, that was kind of our agreement because he was absolutely no, but we chatted about how we could make it work because I said to him, ‘I really, really want to have another baby’.

So yeah, I stopped working at the gym. I was just part time. I started feeling really good and my health was good. We fell pregnant again pretty quickly which was great and then had Estelle. Great pregnancy compared to Harry and then after I had her, just all that same typical stuff again. You know, not sleeping so much, I was working, I was traveling. I lost weight pretty quickly and deep down I was like, ‘Yeah!’ However, I knew that it’s not that easy to lose weight. I did have a couple of little thoughts of, ‘Oh I hope it’s not my thyroid’, and then one day I felt the palpitations and went, ‘Oh. Here we go.’ So I went straight to the doctor, went on medication, just one tablet nothing too much and I felt great. That one tablet was enough.

Danny Urbinder: What medication did you take?

Denise Furness: Just the carbimozole. Just the antithyroid so not the beta blocker or anything like that. Even though it was a palpitation, we didn’t give me the beta blockers to stop it, we knew that the - we checked my levels and my thyroid was high again. So we just went on the antithyroid, had the one tablet. Felt better like, went in within 3 months and said, ‘I’m great. Like, I feel good. My palpitations are gone, that’s all I needed’. However my blood levels hadn’t changed and unfortunately the doctors aren’t concerned with how you feel, they’re concerned with the blood levels. And even though the symptoms were gone, my sleeping was better, she insisted I move up to 2 tablets.

And even though I didn’t want to, I just thought, ‘I’ve gotta do the right thing. I just I shouldn’t play around with this, this is my health’. So I took the two tablets, started slowing me down a bit, didn’t feel great, and then went back and my bloods still hadn’t really changed. And she wanted to put me on more medication and I was - I actually said no. I said, ‘honestly, I’m feeling tired. I’m, you know, I don’t think I could do another, more medication.’ So she sent me off to the endocrinologist and long story short, it took me in all honesty, probably around 18 months to get well.

And I think the first time it was such a scare, the second that I had my head together I just focused on my diet and lifestyle. But this time was a bit like, ‘Oh. I know how to get over it, I’ve just got to fix up my diet I’ve got over it once I’ll get over it again’. But it wasn’t that easy and getting on top of my diet when you’ve got two children now and your traveling and your trying to work, it was just, it was tough and actually that's, there’s no regrets. It’s definitely changed the way that I am as a practitioner because now, I actually don’t focus on diet as a number one even though it’s essential. The reality is, when you’re tired and stressed and busy, it’s actually more of a stress to try and eat really well because it became a stress.

Food actually became a stressful thing for me, it was a challenge because I was always getting disappointed or angry. If I was at the airport eating something or if I was out for dinner - there were a lot of dinners in the job that I was doing at the time - I would then be upset with myself and that was not a healthy or a good thing and I started having a bit of a bad relationship with food. So yeah, the diet stuff didn’t work out for me the second time.

Danny Urbinder: So what did you do?

Denise Furness: So I, I just kept thinking too, Estelle was a really bad sleeper for over three - she’s four now and she still wakes up once or twice a night sometimes, but I just kept thinking the sleep. That’s probably why it took a while as well, as soon as I sleep, l’ll be fine.

Mark Cohen: You know once you improve sleep, then everything else improves. Because again, during sleep you go back into homeostasis. So things you can do to enhance sleep, and again it’s a whole other topic we can talk about, whether it’s, you know a hot bath, or a sauna before you go to bed, or creating a great environment to sleep in. Once you improve sleep, your body detoxifies. You know, not eating before you go to bed, you know a few hours before because then you’re processing food rather than trying to detoxify your body from the day and that’s what sleep is for.

I mean, we still don’t fully understand sleep. Even after all the research that’s been done with, you know sleep labs and things, you know we’re still unraveling the complexities of sleep. But we do know that if you can improve sleep, then you feel better, you're physiology improves, autoimmune conditions improve, pain conditions improve, anxiety conditions improve, depression improves. So it's one of the most important things you can do is to try and maintain good sleep patterns.

Danny Urbinder: Denise wanted to better understand the underlying factors that were effecting her sleep and overall health. She decided to do a Dried Urine Test for Comprehensive Hormones, otherwise known as DUTCH, to give her further insights into her endocrine function.

Denise Furness: So the DUTCH, from a, from a sort of reproductive capacity and things like that, it was all absolutely fine. However, my melatonin was so low and my cortisol was high. High but, high as in, you know I was having high levels during the day, but my reserves kind of low.

So this was, sort of - and interestingly I didn’t think I felt too bad at the time. This was after the miscarriage because I wanted to get pregnant and I just thought well, you know, I’m gonna check this stuff out. And as I said from a - looking at progesterone and things like that, because I was getting older as well, all of that was fine, absolutely fine.

But it was a little bit of a wake up call. You know Ryan had said to me he thought that I was a bit overworked. I didn’t think I was, but when I’m looking at my melatonin being so low and cortisol and, as I said the reserves being low, it definitely gave me some information where I was like, ‘Hmmmmm, thats interesting, it really is time for me to pull back because this is, not a good, this is not a good picture’.

Tara Nelson: When we look at her results of melatonin, cortisol, you know melatonin and cortisol are in a direct opposite relationship. So when melatonin is high, cortisol should be low and vice versa. And when either of these get out of balance, then our ability to sleep is affected and also our ability to control our stress response is effected too.

So you know, her cortisol and melatonin is directly opposite for where it should be, so that’s going to directly effect her ability to sleep. We know that like, sleep is just the biggest reset. It is just essential to look at sleep in our patients with any auto immune condition, particularly Graves disease. If someone is not sleeping, it should be the first thing we’re actually treating and getting under control.

Danny Urbinder: Given that Denise’s sleep was being affected and this was clearly being reflected in her melatonin and cortisol levels, she decided to adopt some new strategies to get herself back on track.

Denise Furness: So, I just thought, I really need to start using all the tools that are out there because there are so many tools. So I learnt about Yoga Nidra, which is because I wasn’t getting a lot of sleep at night you know, twenty minutes of Yoga Nidra which is like a breathing thing apparently is the equivalent of almost two hours sleep. You can just get into a very relaxed state and it helps kind of with the brain waves and even though you’re not getting your deep, deep sleep, it’s very restorative. It’s just, it’s not like a yoga, you’re not doing poses it’s just breathing.

Danny Urbinder: So how and where would you do that?

Denise Furness: I would do it anywhere I could. If I was on the plane, if I was in a hotel, I used to have a lot of trouble even when I was away. At night before going to bed, just really, for me, stress is a big thing as well. So I was really focusing on breathing, I was focusing on my sleep because I knew I was having such broken sleep. I started going to bed earlier, just trying to catch up on as much - I would say that sleep and relaxation where number one. I just thought I need to, I need to relax and I need to sleep as much as possible. I’m not going to worry about going to the gym anymore, I don’t want any stress. I’m not going to put so much pressure on myself about food. I’m just going to try to relax, so I was like you need to relax. Relax, relax, relax.

Mark Cohen: It’s amazing how powerful the breath is to bring us back into the present moment. Because when you’re exposed to these environmental insults and whether it’s you know, it’s the mould or a thyroid condition or whatever it is, that means your body is trying to cope with something all the time. So, it stops it being fully present in the moment and to be really well means you can be fully present, or as present as possible in that moment.

So a practice like Yoga Nidra is really valuable, because that brings you back into that present moment. You know, usually the breath and the mental imagery is a big part of that and once you can sink down to that balanced point, because when your in that you know, they call it yogic sleep you know, Yoga Nidra is a sort of a conscious form of sleep, but it brings you back down to homeostasis and when you can do that, then your body resets.

Danny Urbinder: While the definition of Yoga Nidra simply translates to yogic sleep, there are some complex things going on at a neurological level.

Yoga Nidra shifts your brain into the zone between sleeping and waking states. It’s like your body sleeps, while your mind remains conscious and clear. Brain wave studies show higher levels of alpha and theta brain waves, which reflect an increased state of relaxation and alertness.

A study in 2002 showed a single Yoga Nidra session resulted in a 65% increase in dopamine release, showing the practice regulates conscious states at a synaptic level.

Once Denise was able to bring this practice into her daily life, she was then able to focus on other aspects of her health.

Denise Furness: The second time was, after focusing on relaxation and pushing the diet to the side, was the supplements. And I became very compliant and I was taking quite a few supplements as I said. Not, not just anything but a lot to do and I’d learnt so much over time so I was thinking you know, I need to support my immune system. I had my Omega 3s, I had my vitamin D tested the second time. That time I was up living up here and my vitamin D had gone up to ninety nine and so that was okay but I -

Danny Urbinder: How much fish oil where you taking?

Denise Furness: I was taking about 4 capsules a day and-

Danny Urbinder: A 1000mg?

Denise Furness: A 1000mg and every now and again if I wanted to, I would take more, but I tried to have a minimum of four. My children also love them.

Danny Urbinder: Were you taking the vitamin D as well in capsules, or?

Denise Furness: I stopped taking the vitamin D because my vitamin D was at ninety nine. Now, I look back and even now actually I’m starting to think that vitamin D, even though I live here in the sun, I’m actually inside most of the time. So I am going to get my vitamin D tested again pretty soon.

Danny Urbinder: How much were you taking beforehand?

Denise Furness: So I - when I was in Melbourne I was taking like 5000IU, yes and I needed at least that. And that was a really good learning experience for me too, because after nine years in the public hospital, we never gave more than 1000IU, ever. So 5000 was a big jump to me, that was something that’s not really heard of in the world that I’d come from, so I definitely learnt a lot. So coming from you know, the public hospital, if you needed vitamin D you’d just have 1000IU. It didn’t matter what your levels were, it didn’t matter about your genetics, that’s kind of how it rolled. So, definitely I realised that some people need more than that.

I’d done a lot of gut testing, I had blasto, I also had dientamoeba, so a few gut things going on and I did attempt a gut protocol, attempt. And interestingly, the antimicrobials, I had a very bad reaction, so I had not - now if I was to go through or talk to someone about a gut protocol, I now know how important it is at least for that week to be having some things to kind of support the gut. Some nice things to sort of minimise those reactions, those negative side effects. I didn’t do that. I went straight into the antimicrobials and I had a lot of pain and a lot of bloating and things like that. So I didn’t stick with the protocol properly but it was the first time I took probiotics, and my body loved them.

So some people have probiotics and don’t notice anything, I didn’t realise how much of an issue I was having with my stools because I never really focused on it. I knew when I was sick I had issues from, you know constipation to diarrhoea and losing control of my bowels, but I’d never really actually focused on what my stools looked like and how regular and all those things. So, once I started the probiotics, I just was having more regular healthy bowels movements, so my body really liked the probiotics so I did stick with those. I don’t take them anymore, but I did stick with the probiotics for a few years. I think I sort of got to the point where I didn’t really need them anymore.

Keonie Moore: I think it’s a really important one because there’s so much controversy about dientamoeba and blasto and whether they are clinical considerations that even need to be dealt with. And there’s plenty of, I guess, literature suggesting that hey, plenty of people have these things that are, you know, asymptomatic, so therefore do we need to treat it. But certainly, in context of this case, then you’re going to be thinking well, anything that’s going to increase irritation and immune responses in the gut is going to have a potential detrimental impact.

Certainly with those antimicrobials, yes it’s going to be having that impact on those parasites, but it’s going to be having an impact on some bacteria as well and potentially increase release of endotoxins and LPS if you haven’t addressed intestinal permeability. Then I could absolutely see that, that would make things worse.

Danny Urbinder: So, your approach would be start to reduce some of the inflammation first, start to do some repair and soothing of the gut lining and then address any sort of parasites.

Keonie Moore: Exactly. So we will always start with reducing inflammation then look at okay, intestinal permeability and how do we actually improve the function of the tight junctions. And then once we have restored that, then we go okay. We’ve got an opportunity here to go in with that antimicrobials. We often use a pulsing regime so that were looking at okay, let’s clear out some of the undesirables, make some space but then really very selectively work with prebiotics and probiotics so that were shifting the microbiome in a beneficial way.

Danny Urbinder: I asked Tara Nelson what other considerations she might have with regards to the assessment and treatment of Denise’s gut health.

Tara Nelson: I also look at other things like, you know food intolerances, you know stress is going to impact that gut, that bidirectional pathway, I might look at things like H. pylori. I like the breath test just to rule out that SIBO so I’ll look at you know, SIBO testing if indicated, also looking at you know gut acidity, low gut acidity is very common in thyroid auto immunity and low digestive enzymes. So supporting that and just addressing lifestyle issues such as chewing well and eating mindfully and not eating on the run is like, you know, is Digestion 101.

But also screening for things like you know PPI use, antibiotic use in the past, and also even NSAID use. If there’s pain and inflammation going on, you know how often are they using NSAIDs which can then definitely effect that gut integrity. So I think it’s definitely a combined approach for gut health. Removing what’s causing the issue, and then looking at, you know healing and sealing that gut and getting some integrity.

Danny Urbinder: By this point, Denise had done numerous functional lab assessments including DUTCH for her hormone levels and a complete digestive stool analysis to assess her gut health. She also did some gene testing to better understand her genetic predispositions and how these could be addressed to reduce her risk of another flare and to optimise her overall health.

Denise Furness: So, I have been doing genetic testing for a long time and you know with the methylation stuff I did that back when I was working in the hospital too. And I knew that, that wasn’t a big issue for me but as the years have gone on, I’ve looked you know, at more and more of these things and realise that I definitely am predisposed to sort of being pro-inflammatory, you know. There's a lot of things with my immune system aside from the HLA’s which are linked with Coeliac and autoimmune.

Danny Urbinder: What specifically, what genes would have shown up to give you that indication?

Denise Furness: Yeah, so I’ve got genetic variations within interleukin-10 which means that I don’t dampen the immune response as quickly, so not so good for autoimmune disease. Some of the other cytokines, some of the other interleukins, tumour necrosis factor-alpha, which is sort of a big player in sort of turning on lots of different cytokines. I’ve got a genetic variation there and tumour necrosis factor-alpha not only is linked with increased risk for autoimmune disease, but also IBS, Coeliac, things like that.

So I have quite a few things in that whole immune area and that second time when I treated myself, after working on the relaxation and the sleep and then the supplements, with those supplements I did things very differently to the first time. You know my knowledge of supplements is so much more, so I got onto things like, you know the curcumin, you know quercetin, quercetin, however you want to say it you know these things. My body loves that. As I said I started getting the psoriasis, I started getting some allergies, when I take the quercetin, oh my god like it’s, it’s fine.

Keonie Moore: Even in a situation where we might have a gut microbiome that’s making plenty of butyrate, that’s going to influence interleukin-10 production. But if you’ve got those homozygous gene stamps, then your still not going to have that level of interleukin-10 that’s going to help develop more T regulatory cells and in terms of T cell differentiation and looking at immune tolerance. So that’s going to naturally lead to heightened levels of you know, T helper-17, T helper-2, T helper-1, because your not going to be able to bring those regulatory controls in. If we also put on top of that the TNF-alpha promotor that has been specifically linked to Graves disease, and certainly will be having an impact on inflammation on that greater systemic level.

And I think no matter what you look at, in terms of the thyroid itself, the immune system or the gut, really just focusing on those anti inflammatory agents are going to be really, really impactful. So curcumin, resveratrol, quercetin, the sulforaphane like I mentioned are going to have a really nice effect.

Danny Urbinder: After building a foundation for her health, Denise began to adopt a more targeted therapeutic approach.

Denise Furness: So, I started learning some of these things that really worked for me and focused a lot on the immune support and particularly for thyroid antibodies. I started taking selenium, zinc, you know minerals that are going to help with thyroid function.

And then when I got off my medication the second time, I felt again that the doctors weren’t very supportive and I just weened off. I got to the point where I, actually very confident now that I can ween off the medication because I felt I was going a little hypo, and the doctors don’t mind if you go a little hypo after you’ve been hyper.

They actually said to me, ‘Oh your thyroid might just burn out and you’ll just become hypo and that’s fine and we won’t do the radioactive iodide, you can just go on thyroxin'. I obviously don’t want my thyroid to burn out, that seems like an okay outcome for them, but not for me. But I knew that I was going hypo because of the bloods and how I felt. I was really struggling with my weight, I was very tired, I was doing all the right things, I’m a little hyper. I’m cold, I’m never cold, dry skin. I had all these symptoms and I’m like, I’m hypo, I’m going to start weening myself -

Danny Urbinder: What were those symptoms that you were experiencing when you were sent into that hypo state?

Denise Furness: Yeah so, extreme fatigue in the morning, not wanting to get out of bed even though I know that I was getting enough sleep and doing all the right things. Very cold, very cold. Which you know I live on the Sunshine Coast, it’s pretty warm and I’ve never been a colder person. I run hot thats how I am, so I was cold. My hair did start falling out, dry skin, and I started getting some of my pimples and things back again, but the weight was probably the biggest one. I was like, ‘Wow, I’m actually putting on a lot of weight pretty quickly’, and I know that my weight is something as you’ve heard from this interview that I’ve always kind of been aware of. And I know how much I can eat and how much I can exercise, and my body does respond very well to exercise and changing diet quite quickly usually, unless my thyroid’s controlling the situation. And my thyroid was definitely controlling the situation. I was just putting on weight, even though I shouldn’t have been.

Danny Urbinder: And that’s because, you were still on the medication, the dose that put you into that hypothyroid state.

Denise Furness: 100%. Yep. The medication I was - and I knew it was pushing me hypo. My TSH for the doctors, they weren’t too worried. I was kind of getting up to around 3, I’d never had a TSH of 3. Obviously the reference range can kind of go up to 4. Optimal I think is about sort of 1 you know, 1.5 or 2. But my TSH was sort of getting up over 3 and my thyroid hormones, my T3 and T4, were quite low in the reference range but very much at the lower end. So on paper, I looked okay. I was like, ‘Oh, okay, her TSH is you know, in the higher end but it’s still in the normal range. Her T3, T4 are at the bottom but they’re in the range’, but I’m like, hang on. I’ve always ran a little like - we have our metabolic set point and there’s actually research for this.

You know we have a metabolic set point, everyones thyroid is slightly different. Some people function better and feel better a little bit lower, that’s just their personality. It’s who they are, they’re a bit more chilled. But then there are other people that have a bit of a higher metabolic set point. So for me, I now realise where that sort of metabolic, where that healthy range is, where I feel good. I’m not too tired. I’m not edgy and anxious, you know it’s having, it’s being in the middle but for me, I definitely felt hypo and I did explain that to them multiple times. I said, ‘I honestly feel like I’m hypothyroid’, and actually I said to one of the doctors, I said, ‘I’m only getting through the day with coffee’. And I said ‘and I know that coffee’s not good for my thyroid, not good for my adrenals, but I’m dependant on coffee’. And the doctor kind of laughed and went, ‘oh, I’m dependent on coffee too’. So, that didn’t mean anything to them at all.

So I decided that it was safe for me to ween off the medication. I felt safe to do that so I did that over a period of about six months and started feeling much better. Went in, had my bloods, didn’t tell the doctor that I was off the medication. My bloods were fine and I waited until I had the result and thankfully my TSH hadn’t changed from the three months before.

And I think honestly, you are the best guide of your - how you feel and your body. So if I had of felt like, at any moment it wasn’t - it wouldn’t be irresponsible if I was getting the palpitations or I just didn’t, if I felt off in any way I wouldn’t of done it. But I was feeling better and better and then when I had the bloods done, I then said to the doctors, ‘So, I’m not taking the medication’. And it was a different endocrinologist this time and she looked a little shocked. We had a bit of a conversation, very awkward conversation, I felt like I was a naughty child. And they kind of just said, ‘Alright, we’ll come back in three months and we’ll see’. And then thankfully in three months, my bloods had gone down a little bit but not too bad.

And then I went back in again in three months and they were fine and they basically said, ‘We’re now going to do it annually, like we’ve done it’. So I just have to have an annual checkup on my thyroid.

But there was a moment after I went off the medication where I thought to myself - I was having some trouble sleeping and that’s one of the signs of Graves, you can't get to sleep. And I started learning about herbs and what I can’t believe, because I have so many integrative doctors and naturopath friends, is that no one told me about the amazing herbs that you can take.

So, I started looking into the herbs and learnt about motherwort and bugleweed and I had already heard about you know, I knew that lavender was calming. Ryan had done some reading and told me about lemon balm, and I had a few teas here and there and things like that but, I'd never actually taken actual herbs, like tinctures or anything like that.

So, this is definitely not what everyone should do. You should obviously work with a practitioner, but with my level of knowledge and research I felt comfortable to get some of these herbs myself. So I purchased some herbs and started taking the motherwort which again, you could tell my body really liked it. I don’t have it now - and the bugleweed - and I just noticed a difference in - so when I actually, I think it was the second lot of blood tests, I asked for my antibodies. And the doctors aren’t really in favour of doing antibodies with the checkups because, the explanation I’ve been given, is that the antibodies will always be there. They won’t go away and that doesn’t - what we’re interested in is your TSH really, or T3, T4 but mainly TSH. And now I don’t know if it’s, you know, the selenium which can help or those kind of things, but I think it might have been he bugleweed and motherwort. But my antibodies had gone all the way down as well.

So yeah, I was just a bit scared going back in to have those follow up blood tests. There was that little part of me that was like, ‘Oh, what hap’- you know there’s a bit of anxiety around it. I’m like, ‘God, I’m having my bloods done. What happens if my levels are out again. Are they gonna put me on medication or they gonna say that’s it. You’ve gotta have the radioactive iodide’. So I had these herbs as my backup.

And of course I wasn’t doing daily assessments to know, but I just felt like my body really loved them and I actually do think they were the final part of me really just, kind of kicking my thyroid disease to the curb. And then it got to the point where my TSH and all that - because I think, you know, I think it does help you bring everything down. Then I think I went a little bit too far on the herbs. I felt like I was going a bit hypo again, so I quickly stopped the herbs and have been off everything now aside from a few supplements to help me and things like that for a good year. But I’ve got the herbs in the fridge, in case I need them.

But I really did notice a difference having them as in just a bit calming. Very, very good with my bloods and actually I think if I stayed on them, they may have pushed me a little to the other side, so I think they’re quite effective.

Keonie Moore: So, I love herbal medicine and certainly I would be making that a cornerstone of any kind of treatment for Graves disease. So, yes, I tend to take approach of looking at yes, okay, lemon balm, motherwort, specifically, are two of my favourite herbs for hyperthyroidism. And particularly motherwort is going to help with those palpitations as well, but then we also need to take a more generalist approach with the immune system. Hemidesmus, rehmannia, and then in combination with withania. Withania and rehmannia are two of my favourites because they’re the adaptogens as well as really going to be helping with those immune responses.

Tara Nelson: Yeah so, bugleweed, motherwort, things like lemon balm. I employ things like hemidesmus, rehmannia for Graves disease, so working on that, you know autoimmune side of things.

Particularly bugleweed and motherwort work on - they’re anti-thyroid blockers. So, perhaps it would be interesting to see Denise’s tests around that time, that perhaps her thyroid hormones were already at a reduced state or in range and she’s just, she didn’t need them anymore.

So again, that’s where testing is very important. And we are lucky when someone is working with with a GP or endocrinologist with Graves disease or hypothyroidism and they’re put on those anti-thyroid blocking medication - well PTU is another one, they will be tested every pretty much 6-8 weeks, if not every 4 weeks. So perhaps that her thyroid hormones, her T4 and T3, had come into range and it was suppressing them even more. So she was possibly flipping over to the hypo side.

And this is where we do have to be really careful and where testing does come in. We really want to see what’s going on because yeah, those therapeutic agents and our herbs are very affective at reducing the thyroid hormone.

Danny Urbinder: And should be treated like a medication-

Tara Nelson: Absolutely-

Danny Urbinder: Because they’re not like nutrient supplements where you have them every day-

Tara Nelson: Yes-

Danny Urbinder: And you just think you’re managing your thyroid.

Tara Nelson: Yeah, yeah. We’re very lucky to have those herbs in our toolkit if you’re a herbalist to use, because they are highly effective in, in really supporting Graves disease and hyperthyroidism.

Danny Urbinder: I wanted to know if there were any other important therapeutic considerations for treating the Graves disease patient. Interestingly, both Keonie Moore and Tara Nelson had similar thoughts.

Keonie Moore: The only other thing that, I guess I do tend to use is acetyl-l carnitine. Particularly with Graves there’s really good, I guess evidence for that but just clinically I’ve really seen how - from a fatigue point of view - how much improvement that you get from that inclusion as well.

Danny Urbinder: And is that addressing the mitochondria sort of energy, metabolism aspect of the condition?

Keonie Moore: Yeah, the literature tends to focus on the depletion of carnitine from the muscle tissue that happens as a consequence of the Graves disease and having that elevated basal metabolic rate and repletion of that definitely helps in terms of muscle tone. But, it actually has been shown to reduce the symptoms of Graves as well. So, I think there’s more to be understood about that relationship.

Danny Urbinder: I’m sure there is yeah, but it sounds like that burning through of nutrients to that high metabolic rate is a big issue that needs to be addressed.

Keonie Moore: Exactly.

Danny Urbinder: Yeah, yeah.

Tara Nelson: L-Carnitine has been found to be very low in thyroid - sorry Graves patients and it’s - hyperthyroidism increases you know the urinary excretion of carnitine and it actually is a peripheral antagonist of thyroid hormone production. And it inhibits the entry of thyroid hormones into the mucus of cells. So, I bring that in as a thyroid hormone antagonist.

So around about the 2000-3000mg a day, can help to actually block - work with our anti-thyroid blocking medications - to block thyroid hormone production. So it’s a really nice one. Really good in Graves disease because we're seeing those really high thyroid hormones.

Carnitine can help to improve the heart rate, you know body temperature, nervous system, insomnia and tremors. It’s a really, really nice one but it needs to be at the higher dose for those effect - that, that effect.

Denise Furness: Last year I have to say, I hit a point where I was like, ‘Oh my god. This is what life should be about. This is how you wanna feel, you know this is way better than taking medication’. And yes, it’s been a long journey, but the more I learn about my health, the more I learn how to treat my body, like it's just, it’s so - I can’t explain to everyone how much better this approach is. Even though it’s not the easy approach, because as I explained when I had the medication initially, yes it takes away the symptoms, but I knew something wasn’t right.

When you start to address all the underlying things whether it’s the stress, the deficiencies, infections, even though there seems to be a bit of a gut thing there, you know you start to feel good again. And that’s really when I started coming out again last year and telling my story, because I was like, ‘Oh my god. I’m actually like 100% back. I was like, this is what I was waiting for. Here I am!’

So, I have definitely come a long way and I am really happy to share my journey because I do feel like, you know, there’s no reason for me to ever have any of these symptoms again. I now know what went on, what the triggers were. It doesn’t mean that life is easy because I have to think about things like gluten or how much coffee I have, but you know I’ve definitely come a long way. And I want everyone to know that if they do work on their health, I can’t say that you will definitely recover, but you will reduce your symptoms.

For me, I think one of my biggest triggers is stress. And I am - I don’t know what the gene is, but I’m genetically predisposed to just wanting to do everything. I’m excited by life, like I love life. So for me, I’m constantly having to balance this enthusiasm and excitement to just, you know, yes. I want to get in and I want to do that. I want to be involved with that and I have to go hang on, how is that going to work for - you know, are you going to have time to eat well, to be with your children, to manage your business. So I am just learning to, I think I mentioned it before or if I haven’t yet you know that - the balance.

So, something I’m always working on is trying to sort of come back to centre and be relatively balanced. And I now know that there is no perfect balance. Even though the last three or four years, when new years comes around, I’m like this year I am going to achieve work-life balance. Well, now I’ve accepted that life is always going to be just a little bit skewed, you know. One point I’ll be focusing on my health, one point I’m focusing on my business, one point I’m focusing on my children, at one point you might have a sick parent. Life will always throw things at you, but you just need to come back to that centre. Remember what the priorities are because you need a little piece of everything and in there should be some fun too, you know. We should be socialising, we should be connecting, you know. Spirituality you know, having a purpose. All of these little things need to come together for you to be truly, truly well.

And the genetics is great, it gives you insight to your predispositions, but it’s just one little bit. You need to address so many little things to kind of achieve that balance. But it doesn’t mean you have to be perfectly balanced, it just means you are taking good care of yourself and then you can take better care of those around you.

Danny Urbinder: If you would like to learn more about the integrative medicine approach to Graves disease, be sure to visit the IMH website. There, you’ll find a library full of CPD and CPE accredited educational videos, resources, and interviews on this, as well as many other health related topics.

Also, be sure to download the IMH app so you can join the discussion on this topic with other healthcare practitioners in the IMH community.

I'd like to thank our guests, Dr. Denise Furness, Keonie Moore, Professor Mark Cohen, and Tara Nelson who so generously provided their time to share their knowledge for this production. I’m Danny Urbinder and this has been a Patient Journeys podcast.