Ketogenic diets, which are high-fat/low-carbohydrate/moderate-protein diets, are a hot topic in the health and wellness community.
My readers have a lot of questions, including is a ketogenic diet a little too high in fat and low in carbohydrates to be healthy, and how does it impact those with Hashimoto’s?
Based on the growing popularity of this type of diet, and the interest people have expressed, I have carefully evaluated the pros and cons of doing a ketogenic diet to consider whether a high-fat, low-carbohydrate diet may be an option for those with Hashimoto’s thyroiditis and other autoimmune conditions.
In this article, I’ll cover:
- What a ketogenic diet is and how it works
- The potential benefits of a ketogenic diet
- The potential drawbacks of a ketogenic diet
- Strategies to optimize a ketogenic diet with Hashimoto’s
What is a Ketogenic Diet?
The ketogenic diet, which is a high fat and very low carb diet, has recently become a popular choice for people wanting to lose weight and a few inches. Historically, the diet has been used to help with the symptoms of pediatric epilepsy, until pharmaceutical companies took over with antiepileptic agents. The ketogenic diet puts our body in a state of ketosis — where it burns fat, either from food or within our own fat cells, for fuel. Fat becomes the main source for fuel, as opposed to glucose from carbohydrates and sugar.
Low-carbohydrate diets, such as the ketogenic diet, have been used as ways to reduce body fat. Part of this weight loss is due to caloric restriction, as a result of the removal of a significant amount of carbohydrates. Traditional ketogenic diets generally limit the intake of carbohydrates from fruit, grains, and starches to fewer than 15 grams per day; however, different people have different thresholds of how many carbohydrates they can consume without being “kicked out” of the state of ketosis.
Those following a ketogenic diet consume liberal amounts of fat, moderate protein, and non-starchy vegetables, and focus less on consuming foods that contain higher amounts of carbohydrates. This makes the diet very satiating, and for the most part, easier to follow than other diets due to the abundance of fats that help to satisfy us.
There are benefits of a ketogenic diet which I’ll dive into further as you read along, but in short, it can help to improve energy, blood sugar balance, pain, inflammation, migraines, and oxidative stress. It may also contribute to better brain function and mood regulation. Research has shown that ketogenic diets may be helpful in a variety of conditions, ranging from neurological issues, including multiple sclerosis and epilepsy, to reactive hypoglycemia. However, there are some precautions to consider.
How Does a Ketogenic Diet Work?
To understand how ketogenic diets work, we first need to take a look at how the body converts the food it takes in, to the fuel that powers our cells.
The body typically utilizes glucose as its primary fuel source. When it doesn’t receive glucose from dietary sources, the body looks to its energy storage units, called glycogen. Muscle cells contain glycogen, but most of the glycogen our body utilizes comes from the liver. However, the liver can only store about 100 grams (or 400 calories) of glycogen, which can quickly become depleted.
When we no longer have sufficient levels of glucose (either from food, or from glycogen, the body’s backup glucose), the body doesn’t just shut down. Instead, we have a backup fuel called ketone bodies, or ketones.
Ketones are water-soluble molecules, produced in the liver from fatty acids. There are three types of ketones – β-hydroxybutyrate (BHB), acetoacetate, and acetone. These ketones can become the brain and body’s main energy source when glucose is not available.
Restricting one’s carbohydrate intake can shift the body’s fuel source from glucose to ketones, as this limits circulating blood sugars. This shifts the body from utilizing glucose to utilizing fat, which gets repackaged as ketones. This metabolic state, in which some of the body’s energy supply comes from ketone bodies in the blood, is called ketosis. Fasting or starvation can put the body’s metabolism into a state of ketosis, as can a very low-carbohydrate, high-fat ketogenic diet.
While, in theory, one could remain in a state of ketosis indefinitely without harmful effects, experts are divided on if, and how long, a person should follow a ketogenic diet, with some touting it as a healthy lifestyle, and others using it as a short-term solution for weight loss.
What Does a Ketogenic Diet Look Like?
The classic ketogenic diet contains a 4:1 ratio by weight of fat to combined protein and carbohydrates. Ketosis typically occurs within two to four days of eating fewer than 20-50 grams of carbohydrates daily, although everyone has a different metabolism, and individual results will vary.
While this amount of fat is far more than what most people eat in their diet, it may not necessarily be unhealthy. Although dietary fat once got a bad reputation, today we see that fat quality is a more important factor, and that certain fats, like coconut milk and avocados, can even have health benefits. (You can read more about the benefits of good fats here.)
In the traditional ketogenic diet, high-fat foods, including various meats, eggs, cheese, fish, nuts and seeds, avocado, butter, and oils, form the foundation. A few other foods, such as non-starchy vegetables and small amounts of berries, lemons, and limes, are also allowed. Keep reading to see how to tailor a ketogenic diet to compliment a Hashimoto’s healing journey.
Ketogenic Diet and Hashimoto’s
It can be difficult to determine how to use a ketogenic diet for Hashimoto’s because most studies focus on how keto diets can affect appetite and weight loss, as well as specific conditions such as type 2 diabetes, rather than the impact on thyroid function.
One important thing to mention is that traditional ketogenic diets use copious amounts of dairy for the fat component, (especially cheeses!), and we know that dairy can be a trigger for Hashimoto’s. The use of MCT or coconut oil for a fat source, may be more of a thyroid friendly approach.
If followed mindfully, by removing common reactive foods, including gluten, dairy, soy, and grains, the ketogenic diet can be a very nourishing diet for Hashimoto’s. Removing these foods, in addition to sugar sources, contributes to the healing benefits of the ketogenic diet.
People with autoimmune thyroid conditions, however, oftentimes need additional support beyond a standard ketogenic diet, and may find that they need to eliminate other commonly reactive foods, including nuts, nightshades, and eggs. (You can learn more about this in my article on common food sensitivities in those with Hashimoto’s.)
Some studies that have looked at the impact of low-carbohydrate diets on T3 and T4 thyroid hormones, as well as thyroid antibodies, show mixed results.
For example, in a 2016 study that looked at the effects of low-carbohydrate diet therapy in people with autoimmune thyroid conditions, 180 people with Hashimoto’s were randomized, and a control group ate a low-calorie, low-carbohydrate diet with food restrictions and guidelines. Their diet contained 12-15 percent carbohydrates, 50-60 percent protein, and 25-30 percent fats. In addition to eating only lean parts of red and white meat, and fish with veggie-rich meals, those on the study diet also eliminated eggs, legumes, dairy products, bread, pasta, fruit, rice, and goitrogens.
After just 21 days, all the patients in the study group showed a significant decrease in their thyroid antibody levels. Based on the way this study was conducted, however, it’s difficult to tell whether the carb restriction, removal of highly reactive foods (gluten, dairy, soy, eggs), or all of the above, played a role in improving patient outcomes. (You can read more about my analysis of this study here.)
In another study, the effects of a ketogenic diet on the thyroid of 120 children with epilepsy were monitored for one year. Free T3, T4, and TSH levels were measured at 1, 3, 6, and 12 month intervals. The normal rate of hypothyroidism among preadolescent children is roughly 1 in 1250; however, as a part of this study, 1 in 6 of the children became hypothyroid and required thyroid replacement therapy. It was ultimately concluded that children undergoing a ketogenic diet to treat epilepsy should be closely monitored for thyroid dysfunction.
However, it is important to consider that this could be due to a connection between epilepsy and thyroid hormones. Studies have shown that thyroid hormone abnormalities may be more common in those with epilepsy, and that the use of antiepileptic drugs can impact thyroid function as well. One study found the following rates of subclinical hypothyroidism after 12 months of using various anti-seizure medications: “28% in valproate, 21.4% in oxcarbazepine, 18.2% in phenobarbital, 13.9% in carbamazepine, and 0% in levetiracetam groups.”
Another study, published in Diabetes, Obesity and Metabolism, found that a ketogenic diet resulted in lowered T3 levels and raised reverse T3 levels in healthy subjects. These were noted to be the same changes seen in cases of starvation, where the body kicks into survival mode and slows down its metabolic rate.
I have personally seen positive outcomes in my clients and myself, through eating a lower-carbohydrate, higher-fat diet, and have heard of others seeing improvements in their thyroid health while trying a keto diet. However, I’ve also seen negative outcomes for other people, who were not my personal clients, with the keto diet. It’s important to consider that diet is not a one-size-fits-all approach to healing, and that it should be individualized to our own needs.
There may be also other factors which need to be addressed, in order to get the best outcomes with this type of diet. I’ll cover some of those later in this article, but first, let’s look at some of the potential benefits of a ketogenic diet.
Oxidative Stress Reduction and Increased Energy
Normal cellular metabolism and environmental factors produce reactive oxygen species (ROS), highly reactive molecules that can damage cell structures. A healthy body is well-equipped to handle a certain amount of ROS, with the help of antioxidants.
However, autoimmune conditions, including Hashimoto’s, can shift that balance between ROS and the body’s antioxidant defense with what we call “oxidative stress.” Researchers have found that oxidative stress contributes to several inflammatory and immune-mediated disorders, including Hashimoto’s thyroiditis.
One study that looked at the pathogenesis and progression of Hashimoto’s found that oxidative stress could be a risk factor in the development of overt hypothyroidism in Hashimoto’s. Increased oxidative stress can also deplete levels of glutathione, an important antioxidant. (Read more about that here.)
Ketogenic diets can reduce the generation of these ROS by uncoupling proteins and increasing levels of antioxidants, including glutathione.
Interestingly, a study on traumatic brain injury in mice found that a ketogenic diet could decrease oxidative stress as well as boost energy levels, as the mice who were on a ketogenic diet were found to have greater cerebral function, despite their post-traumatic brain injury, than the mice who were on a standard diet. The results suggested that a ketogenic diet can improve the function of mitochondria, the little power plants within our cells that create energy.
Since hypothyroidism itself is a state of increased oxidative stress, reducing that stress with a ketogenic diet may help normalize thyroid function and increase one’s energy levels.
Chronic inflammation goes hand-in-hand with Hashimoto’s and can be caused by diet, injuries, unbalanced gut flora, and low-grade infections. A well-designed ketogenic diet that incorporates plenty of anti-inflammatory foods can, however, help reduce inflammation.
One study that focused on rheumatoid arthritis, an autoimmune condition often seen in those with Hashimoto’s, found that ketogenic diets could play an anti-inflammatory role because the ketone β-hydroxybutyrate (BHB) inhibits inflammasomes, which are responsible for the activation of inflammatory responses.
Thus, it’s possible that reducing inflammation with a ketogenic diet may help to improve symptoms related to autoimmune thyroid disease.
Improvements to Blood Sugar Levels
Researchers in Poland have found that up to 50 percent of patients with Hashimoto’s have an impaired intolerance to carbohydrates. This means that after consuming carbohydrate-rich foods, their blood sugar goes up too high, too quickly. This leads to a rapid, sometimes excessive release of insulin (the hormone that allows the body to use glucose from foods).
These insulin surges can cause low blood sugar, which can result in unpleasant symptoms such as nervousness, lightheadedness, anxiety, and fatigue. (You can read more about blood sugar issues and Hashimoto’s here.)
Since a well-designed ketogenic diet is naturally low in sugar and refined carbohydrates, it can help balance blood sugar levels.
The effect that ketogenic diets can have on blood sugar is highlighted in a recent study where 28 overweight individuals with type 2 diabetes were placed on a diet consisting of less than 20 grams of carbohydrates per day, for a period of 16 weeks. At the end of the study, the ketogenic diet had improved glycemic control in the patients to such a degree that diabetes medications were discontinued or reduced in most participants!
Given this, ketogenic diets have the potential to balance blood sugar levels in those with Hashimoto’s.
Improvements to Brain Fog and Other Mood-Related Symptoms
Blood sugar-balancing ketogenic diets may also have a positive effect on the brain. Many Hashimoto’s clients note that regularly consuming sugar results in brain-related symptoms such as headaches, dizziness, brain fog, anxiety, depression, fatigue, and insomnia.
Since ketogenic diets are very low in sugar, many people note that once the body adapts, they feel a mild euphoria that eliminates the brain fog, mood swings, and other symptoms associated with Hashimoto’s. That mental clarity likely comes from blood sugar balance and the brain utilizing ketones as fuel. (You can read more about how sugar impacts Hashimoto’s and blood sugar levels here.)
Another thing to note is that ketones can easily cross the blood-brain barrier. The brain utilizes ketones efficiently, converting them into an energy source called adenosine triphosphate molecules. In fact, research shows that the brain can source 75 percent of its energy from ketones. Thus, a keto diet may help improve mental symptoms in some individuals.
Precautions with a Ketogenic Diet and Hashimoto’s
While a ketogenic diet can potentially improve certain factors associated with Hashimoto’s, there are some important concerns to consider, before utilizing this type of diet with an autoimmune thyroid condition.
Reactive Foods on the Keto Diet
While a ketogenic diet restricts or eliminates some reactive foods such as gluten, the plan allows others such as soy and dairy. These foods are generally high in fat (and therefore keto-approved). However, they are two of the most problematic foods for the majority of those with Hashimoto’s.
While a thyroid-friendly, healthy ketogenic diet without dairy and soy is possible, it can be easy to turn to less than healthy foods on this type of diet. I sometimes see people eating inflammatory foods such as fast-food cheeseburgers (without the bun), nuts and seeds roasted in vegetable oils, and “keto-friendly” desserts that contain artificial sweeteners and other reactive ingredients.
While these would fall under the ketogenic umbrella, they are not healthy. (As with any diet, along with removing foods that can trigger thyroid flares, incorporating quality foods into your meals matters. Getting the right low-carb foods to help heal the body – like organic plant foods, grass-fed meats, seafood rich in omega-3 fatty acids, and healthy oils like extra-virgin olive oil, MCT oil and coconut oil – is crucial when following a ketogenic diet.)
Keto Diet and Candida Issues
Ketogenic diets might also exacerbate Candida overgrowth, which is a potential co-occurring infection and root cause seen in many with Hashimoto’s. While keto diets cut out simple carbohydrates to help starve the fungus, they also usually allow nuts, seeds, mushrooms, fruit, dairy, and some alcohol, which may continue to feed the Candida. Taking the beneficial probiotic S. Boulardii is one of my favorite ways to support the body in managing Candida.
Liver health is another concern with ketogenic diets. A congested liver is one of the many reasons why people’s bodies don’t utilize their thyroid medications effectively and don’t convert T4 to the active T3 hormone correctly. It can also lead to a greater buildup of toxins, an issue that might create new symptoms altogether or worsen those existing ones as a result of Hashimoto’s.
My experience has taught me that supporting the liver is an important part of re-establishing healthy thyroid function and eliminating the many symptoms associated with Hashimoto’s. (I discuss the role of liver support in Hashimoto’s here.)
There are a couple of potential problems with ketogenic diets and the liver. Since the mitochondria within the liver cells primarily produce ketone bodies, utilizing ketones as a predominant fuel source means extra demand for this already-hardworking and overburdened organ.
Toxins also congregate in fatty tissue. When someone eats conventional meat that was fed corn, grain, and other inflammatory foods, these substances may enter the body. Since ketogenic diets are very high in animal fat, increasing one’s intake of meat may result in the liver working harder to detoxify the body.
Optimizing the liver detoxification pathways is important for ketosis and thyroid health, so you may wish to focus on supporting your liver before considering a ketogenic diet.
Keto Diets and Their Effect on Thyroid Health
While ketogenic diets can benefit those with Hashimoto’s, some of my readers and clients have seen thyroid panel imbalances when following a ketogenic diet.
One potential cause of this could be that insufficient carbohydrates can trigger the release of reverse T3, leading to hypothyroid symptoms in light of “normal” lab values. (Perhaps reverse T3 induces a “hibernation” state that once helped us survive long winters as cavemen and cavewomen, by preserving our metabolic function when we couldn’t drive down to the market, and only had limited amounts of food available.)
These concerns should be taken on a case-by-case basis, paying attention to whether a person’s blood work and symptoms improve on a ketogenic diet. Some people feel great and see optimal lab results when eating a high-fat, low-carbohydrate diet. For others, thyroid levels and Hashimoto’s symptoms worsen when they reduce their intake of carbohydrates.
Oftentimes, this can be resolved by adding more nutrient-dense carbohydrates (like those found in fruits and vegetables) to one’s diet, until an ideal threshold is found.
Another potential root cause of a sudden onset of symptoms after starting a ketogenic diet is something called the “Keto Flu.” As the body shifts from glucose to ketones as its dominant fuel, some people experience symptoms such as nausea, headaches, aches, cramps, brain fog, difficulty sleeping, and sugar cravings.
Many of the symptoms of keto flu can overlap with those of Hashimoto’s, so there might be some confusion about their underlying cause. Keto flu symptoms usually subside once the body becomes accustomed to using ketones for energy; however, for some people, this process can feel agonizing and last days or even weeks!
Staying hydrated with sufficient amounts of filtered water and electrolytes can help with the keto flu, as very low-carbohydrate diets can deplete fluid levels. Electrolyte imbalances are common with ketogenic diets and can lead to cramping and other symptoms. (Many of my readers find taking an electrolyte supplement, like Electrolyte Blend by Rootcology, as well as sipping on bone broth, can help replenish those electrolytes.)
Most people report feeling energetic after starting a ketogenic diet, which may last from days to months, or even years for some. However, others — especially athletes and active individuals — may start to feel more fatigued.
This can be a sign that the body needs more carbohydrates, and may be resolved by gradually increasing one’s intake of whole, unprocessed vegetables, low-sugar fruits, nuts, and seeds, and seeing if they provide more energy. Many people do well “flirting” with ketosis by slightly lowering dietary fats and increasing healthy carbohydrates.
Consuming berries is a great way to do that. They are full of phytonutrients and antioxidants, and they are less likely to spike blood sugar compared to other fruits. Furthermore, blueberries are a rich source of myo-inositol, a nutrient that has been shown to improve thyroid function and blood sugar. If possible, try to buy organic fruit with limited exposure to pesticides.
Some people on ketogenic diets also use medium-chain triglycerides (MCTs), a fatty acid found in coconut oil, which can provide an important source of energy while also keeping the body in ketosis.
Digestive Enzyme Support
Another potential cause of low energy levels on a ketogenic diet is digestive enzyme deficiencies. Low energy levels could be due to low stomach acid, rather than the restriction of carbohydrates. Many people that don’t do well on a high-fat, moderate-protein diet, will find that they have deficiencies in digestive enzymes, specifically those that digest proteins and fats. As these macronutrients become the primary fuel sources on a low carb diet, this can lead to malabsorption, inflammation and nutrient deficiencies.
In these cases, essentially the body becomes starved of vital nutrients (through inefficient extraction), and overloaded with toxic byproducts from poorly digested foods, which, in turn, leads to low energy.
I recommend trying betaine with pepsin before determining if a ketogenic diet is the right choice for you. Betaine HCl and pepsin are naturally occurring components of gastric juice that make nutrients and amino acids from our protein containing foods more bioavailable by breaking down protein bonds. They are especially important for proper absorption of protein, calcium, B12, and iron.
There aren’t too many tell-tale signs of low stomach acid, other than perhaps feeling full and tired after meals, as well as experiencing acid reflux like symptoms. Nonetheless, low stomach acid is very common in Hashimoto’s. Signs and symptoms that would lead me to believe that a person with Hashimoto’s had low stomach acid include: acid reflux (this condition that is conventionally treated with acid suppressants can actually be caused by low stomach acid), low B12, ferritin, or iron levels, fatigue despite thyroid medications, and constipation/diarrhea. You can read more about this in my articles about Hashimoto’s and Low Stomach Acid and Using Enzymes to Overcome Hashimoto’s.
I have found that difficulty with digesting fats (fat malabsorption) commonly affects 40 to 50 percent of people with Hashimoto’s. In fact, research has found links between thyroid disease, fat malabsorption, and gallbladder issues. A healthy liver, gallbladder, and pancreas are all required to produce and store bile, as well as pancreatic enzymes, that the body uses to break down digested fats. When these systems are impaired, the body cannot properly absorb fats – resulting in a long list of symptoms from digestive issues, to skin conditions and hormonal imbalances.
Some people might find that a ketogenic diet supports their body’s ability to heal, while others find that it makes them feel worse. Some clients do very well on high-fat diets, while others feel best with an approach that incorporates more protein and healthy carbohydrates.
Everyone is unique and will have different macronutrient needs based on their condition, and ratios may need to be adjusted accordingly. As such, some people are going to thrive on higher-protein diets, while other people will thrive on higher-fat diets, like ketogenic diets.
Keto diets can produce great results for some, but it’s important to address potential inhibiting factors, like digestive enzyme deficiencies and a congested liver, in addition to considering all the pros and cons mentioned earlier in this article, before jumping into a keto diet.
If you believe a ketogenic diet might work for you, I strongly encourage you to consider tailoring the diet to a version that works for you, rather trying to make your body eat a one-size-fits-all approach. Remember, the bottom line is that you have to adjust the diet to your needs, and your needs may change!
To help you along your healing journey, my new cookbook, Hashimoto’s Food Pharmacology: Nutrition Protocols and Healing Recipes to Take Charge of Your Thyroid Health, is now available! In addition to containing 125 delicious recipes — many of which are low-carbohydrate and keto-friendly — this cookbook also includes information regarding how to tailor your diet to your needs, and how to address specific symptoms with nutrition, complementary nutrients and digestive enzymes!
Finding the right lifestyle and dietary interventions that are unique to YOU is part of the journey, but you’ll get there! As always, I wish you nothing but success on your path to optimal health!
P.S. Sign up for my weekly newsletter to keep posted on easy-to-understand information that may help you feel better more quickly! In doing so, you’ll receive a free Thyroid Diet Guide, 10 thyroid-friendly recipes, and the Nutrient Depletions and Digestion chapter of my first book. You can also follow my Facebook page to keep up with updates about new research, resources, giveaways, and helpful information.
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