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Long Term Weight Loss for Thyroid Patients: Hormonal Factors That Affect Diets An Interview with Kent Holtorf, MD By Mary Shomon Thyroid Disease Expert; & “Long Term Weight Loss-More Than Will Power?” by Ken Holtorf in

Long Term Weight Loss for Thyroid Patients: Hormonal Factors That Affect Diets
An Interview with Kent Holtorf, MD

By Mary Shomon
Thyroid Disease Expert

– Kent Holtorf, MD
Kent Holtorf, MD is a California-based expert on hormonal medicine. Kent Holtorf, MD
Updated December 16, 2014.

Written or reviewed by a board-certified physician. See’s Medical Review Board.

Kent Holtorf, MD has a long history of working with patients who have hormone imbalances — including thyroid, adrenal, and reproductive hormones. He runs the Holtorf Medical Group in California, where he specializes in complex endocrine dysfunction, including hypothyroidism, adrenal insufficiency, and insulin resistance.
Dr. Holtorf has been working with a number of his patients — many of whom have an underactive thyroid — who have found it difficult or seemingly impossible to lose weight. What he discovered is that while there are many factors involved in the inability to lose weight, almost all the overweight and obese patients he treats have demonstrable metabolic and endocrinological dysfunctions that are major contributors to the weight challenges of these patients. In particular, Dr. Holtorf has, based on some of the latest research, focused on evaluating two key hormones — leptin and reverse T3 (rT3)– and treating any identified irregularities to help his patients lose weight.

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I’m pleased to be able to bring you this interview with Dr. Kent Holtorf, discussing his approaches to help thyroid patients achieve long-term weight loss.

Mary Shomon: You have said that you feel that two key hormones — leptin and reverse T3 — are playing a key role in regulating weight and metabolism. Can you tell us a bit about leptin, first, and what it has to do with weight loss challenges?

Kent Holtorf, MD: The hormone leptin has been found to be a major regulator of body weight and metabolism. Leptin is secreted by fat cells and the levels of leptin increase with the accumulation of fat. The increased leptin secretion that occurs with increased weight normally feeds-back to the hypothalamus as a signal that there are adequate energy (fat) stores. This stimulates the body to burn fat rather than continue to store excess fat, and stimulates thyroid releasing hormone (TRH) to increase thyroid stimulating hormone (TSH) and thyroid production.

Studies are finding, however, that the majority of overweight individuals who are having difficulty losing weight have varying degrees of leptin resistance, where leptin has a diminished ability to affect the hypothalamus and regulate metabolism. This leptin resistance results in the hypothalamus sensing starvation, so multiple mechanisms are activated to increase fat stores, as the body tries to reverse the perceived state of starvation.

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The mechanisms that are activated include diminished TSH secretion, a suppressed T4 to T3 conversion, an increase in reverse T3, an increase in appetite, an increase in insulin resistance and an inhibition of lipolysis (fat breakdown).

These mechanisms may be in part due to a down-regulation of leptin receptors that occurs with a prolonged increase in leptin.

The result? Once you are overweight for an extended period of time, it becomes increasingly difficult to lose weight.

Mary Shomon: You’ve said that you feel that leptin levels above 10 may warrant treatment. Can you explain a bit more about leptin levels?

Kent Holtorf, MD: Most underweight or normal weight individuals will have leptin levels below 10, although most major labs will use a reference range of 1 to 9.5 for men and 4 to 25 for women. (It must be remembered that this range includes 95% of so-called normal people and includes many who are overweight.) Almost all patients who are of healthy weight will have a leptin less than 10.

Mary Shomon: How do you treat leptin resistance in your practice?

Kent Holtorf, MD: Treatment can be focus on treating the elevated leptin — leptin resistance. An elevated leptin also indicates, however, that the TSH is an unreliable marker for tissue thyroid levels, as the TSH is often suppressed, along with significantly reduced T4-to-T3 conversion. In short, if your leptin is elevated, you have reduced tissue thyroid levels. Also, almost all diabetics are leptin resistant, which has been shown to reduce T4-to-T3 conversion in diabetics by as much as 50% without an increase in TSH, making it very difficult for type II diabetics to lose weight.

Because there is poor T4-to-T3 conversion, timed-released T3 is the optimal treatment — although T4/T3 combination medications such as natural desiccated thyroid (NDT) can be used.

We check the resting metabolic rate (RMR) in our patients, and interestingly, those with elevated leptin levels indicative of leptin resistance have RMRs that are consistently below normal. These patients are often burning 500 to 600 calories less each day than someone of equal body mass.

Thus, to have a reasonable chance of losing weight, these patients can either try and reduce calories by 500 to 600 calories a day (just to keep from gaining weight), exercise for an hour or two a day (just to keep from gaining weight) or normalize the thyroid and metabolism.

Humans are a very successful species because we can store energy (fat) very well. There are many mechanisms to gain weight and leptin resistance is just one of them, so we use a multisystem approach; there is no one magic bullet, although any one treatment can have a dramatic effect on a particular patient.

In addition to optimizing the thyroid (remember, giving thyroid hormone to lose weight is not appropriate, but that’s not what we are doing, here we are correcting a deficiency), Symlin (pramlintide) and/or Byetta (exenatide) can be very effective for many. Human Chorionic Gonadrotropin (HCG) is another potential option that works for some. While I’ve found that the antidepressant Wellbutin (bupropion) does not work well for weight loss, a combination of Wellbutrin and low-dose naltrexone (LDN) is having some surprisingly good results. Topamax (topiramate) is an option for some but is not always well tolerated. Standard appetite suppressants, which boost metabolism, can be used, especially if the RMR is low.


Kent Holtorf Headshot
Medical Director, Holtorf Medical Group

Long Term Weight Loss – More Than Will Power?

Obesity has become a major health epidemic and has dramatically increased over the last decades. Studies show that approximately one-third of the U.S. population is classified as obese and over two-thirds are significantly overweight. While the cause is multifactorial, studies are clear that almost all overweight individuals have metabolic and endocrinological dysfunction that is causing or contributing to their inability to lose weight.

It is not simply a problem that individuals are taking in more calories than they are consuming or lack of exercise or willpower, but rather it is a complex vicious-cycle of endocrinological and metabolic dysfunction. Contemporary medicine has failed to address these dysfunctions in overweight individuals and doctors and patients continue to believe that all cases are a matter of willpower and lifestyle. Thus, it is no surprise that obesity is reaching epidemic proportions.

Research is demonstrating that dysregulation of two key hormones may be a cause or major contributor of weight gain or inability to lose weight in the majority of overweight people. The first is leptin and the second is reverse T3. The exciting part is that doctors can now test for the presence of these physiologic barriers to weight loss and prescribe appropriate treatments with potentially dramatic results.


The hormone leptin has been found to be a major regulator of body weight and metabolism. The body secretes leptin as weight is gained to signal the brain (specifically the hypo¬thalamus) that there are adequate energy (fat) stores. The hypothalamus should then stimulate metabolic processes that result in weight loss, including a reduction in hunger, an increased satiety with eating, an increase in resting metabolism and an increase in lipolysis (fat breakdown). New research has found that this leptin signaling is dysfunctional in the majority of people who have difficultly losing weight or are unable to lose weight.

The problem is not in the production of leptin, but rather, studies show that the ma¬jority of overweight individuals who are having difficulty losing weight have a leptin resistance, where the leptin is unable to produce its normal effects to stimulate weight loss. This leptin resistance is sensed as starvation, so multiple mechanisms are activated to increase fat stores, rather than burn excess fat stores. Leptin resistance also stimulates the formation of reverse T3, which blocks the effects of thyroid hormone on metabolism (discussed below).

Testing: A leptin level can be ordered by your physician. If greater than 10, it demonstrates there is a degree of leptin resistance contributing to an inability to lose weight. The higher the number the more significant the leptin resistance.

Treatment: There are currently two medications are shown to be able to treat leptin resistance and can result in significant weight loss. One is Symlin and the other is Byetta. These are currently approved for the treatment of diabetes but can be prescribed “off-label” for the treatment of leptin resistance. They are showing significant promise in the non-diabetic population with the ability to produce dramatic weight loss in a large percentage of overweight patients. The amount of weight loss varies according to the study design, but a significant percent of patients are experiencing weight loss, despite little or no change in diet.

The leptin resistance is not permanent and is shown to improve with weight loss so diet and exercise can be beneficial. The “catch-22″ is, however, that it is difficult to lose weight with leptin resistance. High carbohydrate diets and in particular high-fructose corn syrup is shown to significantly increase leptin resistance and is a likely mechanism that high fructose corn syrup is associated with obesity, especially in children. Avoidance of high fructose corn syrup and carbohydrates would be recommended for those with high leptin levels.

Reverse T3

It is well known that thyroid hormones regulate metabolism and that low thyroid hormone production (hypothyroidism) causes low metabolism, but it has only recently been understood that thyroid production can be fine but there can a problem of activation of the hormones inside the cells that can be a major cause of low metabolism.

The thyroid gland secretes an inactive thyroid hormone called thyroxine, also known as T4. This is regulated by thyroid stimulation hormone (TSH) produced by the brain (specifically the pituitary). Normally, the inactive T4 is converted inside the cell to the active thyroid hormone called triiodothyronine (also known as T3). Most doctors will check TSH and T4 levels to see if thyroid levels are normal.

The studies are showing that it is not the production of thyroid that is the problem, but rather it is problem inside the cell that the inactive T4 is not converted to T3 but rather to a mirror image of T3 called reverse T3. The reverse T3 has the opposite effect of T3, blocking the effects of T3 and lowering rather than increasing metabolism.

It is an evolutionary fall-back that was useful in times of famine or in hibernating animals to lower metabolism. Studies are showing that stress and dieting (especially yo-yo dieting) can set this hormone into action as well as chronic illness such as diabetes, chronic fatigue syndrome and fibromyalgia.

The production of reverse T3 is found to be a major method by which the body ‘tries” to regain any lost weight with dieting. As soon as the body senses a reduction in calories, the production of reverse T3 is stimulated to lower metabolism. With chronic dieting or stress, the body often stays in this “starvation mode” with elevated levels of reverse T3 and decreased levels of T3, which is a major reason for the regaining of lost weight with dieting as well being the mechanism behind stress induced weight gain (it is not due to increased cortisol).

Testing: There has been a long held belief by endocrinologists and other physicians that adequate thyroid levels can be determined by testing the TSH and T4 levels. Studies are showing that such standard testing will miss 80% of thyroid dysfunction so most endocrinologists and other doctors will tell their patients that their thyroid is fine based on this usual testing. The doctors must run a free T3/reverse T3 ratio. Generally, a healthy person will have a ratio greater than 2 so a person with a ratio less than 2 should also be considered a candidate for thyroid supplementation. Many endocrinologist and physicians are not yet aware of the significance or ability to run this ratio so it may take some searching.

Treatment: The standard treatment of hypothyroidism involves the supplementation with T4, including Synthroid and Levoxyl. These are not effective to remedy such a situation because the problem is not the amount of T4 but rather the excess conversion of T4 to reverse T3, blocking effects of the active T3. One must bypass the abnormality by supplementing with physiologic doses of T3, not T4 (preferably timed released T3). It is not appropriate to give thyroid hormone for weight loss, but rather to correct an abnormality diagnosed by appropriate blood tests.

In summary, emerging evidence demonstrates that a significant number of overweight patients have a metabolic problem rather than a problem of willpower or lifestyle. Identification and correction of these metabolic abnormalities, including leptin resistance and cellular thyroid dysfunction, can result in dramatic long term successful weight loss.

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Yes, Thyroid Issues in Hawaii

One of my physicians says that people in Hawaii have a high incidence of thyroid issues.  He says most doctors don’t recognize that, but since he does, he asks every person he sees thyroid questions (although they may not be aware the questions are related to thyroid problems).

Soooo . . . I am reposting here an article by a Dr. Nikolas Hedberg.  I happened to come across it on the internet and wanted to keep it here as a reminder.

Action Plan – The Thyroid Diet

by Dr. Nikolas Hedberg on March 4, 2011

If you have a thyroid problem, the way you should eat is very similar to that of an individual who does not have a thyroid issue.  Organic foods contain fewer amounts of chemicals and pesticides which, as you know from the thyroid-disrupting chemical chapter, can have a negative effect on the thyroid gland.  The main goals of a thyroid diet are those which remove any stress from the thyroid gland itself and any systems that may be affecting the thyroid gland. 

The first major priority in eating to have a healthy thyroid is to make sure you do not have blood sugar swings.  This requires consistent eating throughout the day of high-quality protein at every meal without eating too many carbohydrates.  Remember that blood sugar swings not only affect the thyroid gland itself but also indirectly affect adrenal gland function which, as previously discussed, is highly connected to thyroid physiology. 

The ideal protein/carbohydrate intake for someone with thyroid gland dysfunction is to eat a moderate- to low-carbohydrate diet with the exception of post-exercise carbohydrate consumption.  The food you consume after you exercise and the meal following your post-workout meal can contain more carbohydrates than you would normally eat.  You can do this because your body is much better at handling carbohydrates and blood sugar after you have participated in exercise.

The next important step in optimizing thyroid function is to alkalize your body.  Your body contains approximately sixty trillion cells which are involved in six trillion chemical reactions every second.  Your cells work best to carry out these chemical processes in an alkaline environment versus an acidic environment.  The machinery in your cells that produce energy and burn fat can most easily do their job when the pH is alkaline. 

Eating foods that drive you into an acidic environment will put undue stress on your cells leading to sub-optimal energy production and function.  The best way to find out if you are in an acid or alkaline state is to do a first morning pH test with Hydrion pH strip paper.  You should be aiming for a pH of 6.5-7.5.  A pH below 6.5 indicates an acidic cellular environment that could be contributing to a decrease in your metabolism.  At the same time, you should not be too alkaline which would be a pH above 7.5.  This would indicate a catabolic state meaning your body is breaking down its tissues rapidly due to some kind of metabolic or chemical stress.  Start by taking your first morning urine pH for five days consecutively.  Eliminate the highest and the lowest of the five readings and then average the middle three to attain your pH. 

So how do you become more alkaline?  The first thing you must do is eat a vegetable or fruit or both at every meal.  Produce contains alkaline-forming substances including calcium, magnesium, potassium and zinc.  These are “buffering” agents meaning they help to reduce acid by-products of metabolism.  The way foods are designated as acid or alkaline is based on the “ash” that is left over when they are burned:  the more buffering minerals in the ash, the more alkaline the food.  In addition, the protein content of a food will also determine its acid/alkaline status.  The presence of more amino acids (protein) in a food leads to more acidity in the body due to amino acid metabolism in the liver resulting in acidic by-products.

Adding sweet potatoes and yams as well as lentils will enhance your alkalinity.  In addition, try to eat at least two cups of alkalinizing greens such as kale, mustard greens, turnip greens, or collard greens each day.  Lean towards the three most alkalinizing grains:  oats (gluten-free if you have Hashimoto’s or Graves’), quinoa and wild rice.

There are many other strategies you can use to become more alkaline.  Taking an alkalizing bath of one-cup epsom salts and a half-cup of baking soda will aid in alkalizing your body.  The epsom salts contain magnesium which is a buffering mineral that will assist in the elimination of acid residues that result from metabolism and detoxification.  The baking soda is also extremely alkaline and will aid in neutralizing acidic compounds that the skin is eliminating.  Take one of these baths every day, and if you are an athlete, take one at the end of your training day to enhance healing of acidic muscle tissue that has been broken down. 

The next thing you can do to alkalize is to drink a morning cocktail of a quarter- to half-teaspoon of unrefined Celtic sea salt, a juiced half-lemon or lime, a greens supplement and a half-teaspoon of buffered vitamin C powder.  This cocktail will flood your system with alkalizing agents that mop up acid residues in the body.  Please be sure to use unrefined Celtic sea salt which is extremely alkaline as opposed to table salt or sodium chloride which is extremely acidic.  Table salt has been stripped of its alkaline minerals resulting in a toxic and acidic product.

Your evening ritual should consist of taking 200 mg of potassium bicarbonate and 100 mg of magnesium glycinate before bed.  Increase by one of each until you achieve an alkaline first morning urinary pH.

Acids and bases in the body are also controlled by your breath.  Each time you inhale fresh oxygen into the system, your body is preparing to exhale carbon dioxide which, if too high, creates an acidic environment in the blood.  Many people in this society are hyperventilators, not taking in full breaths of oxygen and fully exhaling carbon dioxide.  The way to remedy this is to engage in deep-belly breathing for five minutes in the morning and five minutes at night.  Breathe deeply into the abdomen as if filling your stomach with air and then passively exhale the air without effort.  This is how a baby breathes.  Concentrate on your breath without thinking about anything else.  In time, this will become second nature and you will enjoy doing this twice a day.  You can also incorporate this into your meditation practice which you may already be doing.  Those of you who do not meditate will reap some of the benefits of meditation as this is a great starting point to learning how to meditate.  Focusing on your breathing will focus your thought only on this one task instead of the multitude of things that you think about.

In addition to buffered vitamin C powder, there are a few supplements that can aid in alkalizing the body.  Magnesium, potassium bicarbonate, calcium, zinc, fish oil, probiotics and virtually all medicinal herbs will have an alkalizing effect.  Herbs and spices that you use for cooking such as turmeric, thyme, oregano, etc. all help to alkalize.  In general, meat, dairy and grains are acidic but fruits and vegetables are alkaline.  Remember that it is extremely important to eat protein at every meal so do not underconsume protein in fear of becoming too acidic. 

As long as you are eating vegetables and fruits with each meal, you will become more alkaline.  Use the other strategies I have outlined to enhance this process.  You will notice many health benefits as you become more alkaline such as an improved sense of well-being, increased energy, fat loss, improved sleep, clearer/sharper mind, improved digestion and a reduction in allergies.  Your pH is a sign of your alkaline mineral reserves so be patient in this process.  You didn’t become acidic overnight so it will take time to reverse an acidic state.  It may take you a few months to reach a consistent alkaline state. 

How Much Protein Should You Consume?

In addition to developing an alkaline pH, adequate protein intake is a major fundamental aspect of achieving optimal thyroid health.  According to the vast majority of nutrition textbooks, healthy individuals should ingest a minimum of 0.8 g of protein per kilogram body weight every day.

Unfortunately, this calculation is not accurate for everyone, because we all have different activity levels, stress levels, and genetics.  Another flaw in this calculation is that some of the scientific literature shows that one must ingest 1.2-1.8 g of protein per kilogram body weight every day if there is a protein deficit.  Therefore, on average, I prefer for those who are chronically ill to consume 1.2 g of protein per kilogram body weight every day as a minimum.  The one exception to this rule is the patient who is producing high amounts of C-reactive protein which is a marker of inflammation.  Eating protein will further feed its production by the liver possibly exacerbating your condition. 

Another important factor in these calculations is the quality of protein.  Not all protein is created equal.  So, the amount of protein consumed is heavily dependent on protein sources.  Sometimes it can be difficult to get adequate protein intake from diet alone.  This is where protein and amino acid supplements come into the picture.  Before beginning any kind of protein supplementation, you should be sure that you are eating the highest-quality protein from food sources.  These include:

  • Eggs (ideally organic and free range)
  • Types of fish known to be relatively low in heavy metals.
  • Chicken (ideally organic and free range)
  • Non-commercial forms of red meats such as grass fed, locally raised beef; grass fed buffalo; and grass fed lamb. 
  • Dairy products (ideally organic from locally raised dairy cows)
  • Nuts and seeds, particularly almonds, pecans and walnuts (ideally organic)
  • Legumes (ideally organic)
  • Soybeans

Since soy allergies are very common, this may be one of the foods on the list that you will need to avoid.  In addition, soy products tend to be highly processed.  Only soy products that are fermented such as tempeh and miso should be consumed as protein sources from soy.

Dairy is also problematic because of the high allergenicity, processing, and reliability of sources.  Dairy can also be very hard to digest and is often contaminated with antibiotics, hormones and toxins from the cows.  Dairy is of course an excellent source of protein, but I recommend that the amount of protein consumed from dairy should be minimal.

People are most willing to follow a dietary plan when there are a variety of food choices.  This is why I recommend both animal and vegetable-based protein sources eaten in rotation.

Vegan diets can also be a concern regarding protein for a few reasons.  If we review the primary protein source of a typical vegan diet in the United States, it is found that soy is the main protein source.  Unfortunately, soy is low in sulfur-based amino acids.  This is important, because sulfur-based amino acids are required for optimal liver detoxification, the building of glutathione (a powerful antioxidant) and tissue repair.  In addition, plant-based foods contain virtually all of the nutrients necessary for optimal health with the exception of vitamin B12.  I find that many, many patients are deficient in B12 and therefore require supplementation.  Vegans must have a tremendous amount of knowledge for proper food-combining and supplementation in order to achieve optimal protein and amino acid intake for a healthy body.

When it comes to protein and amino acid supplementation, there are a variety of healthy choices.  I recommend whey protein for those who are not sensitive/allergic to dairy.  Rice, pea and hemp protein sources can also provide high quality protein and amino acids.  Protein powder products are the most beneficial to those who have good digestive function.  For those who have impaired digestive function, I like to use free-form amino acid products for direct delivery of protein building blocks into the system.  Some people require HCl or digestive enzymes in order to optimize digestion and absorption of amino acids.

If you have been diagnosed with Hashimoto’s thyroiditis or Graves’ disease, you must avoid gluten indefinitely.  One of the ways to test for gluten intolerance is the anti-gliadin antibody test which measures an immune response to gliadin, the main protein portion of gluten.  A negative anti-gliadin antibody test in saliva, stool or blood does not rule out gluten intolerance.  You can still have gluten intolerance and have false negatives on these tests.  If the test is positive in saliva, stool or blood then this is a very strong indicator that you are gluten-intolerant.  In most cases, there has to be some damage to the lining of the small intestine for the test to be positive in blood or saliva. 

It is very important to understand that traditional medicine only recognizes blood testing or small intestine biopsy as diagnostic of gluten intolerance.  Your traditional physician will have you go through a “gluten challenge” diet for four to six weeks and then test your blood to see if the gliadin antibody is elevated.  This is the worst possible way of detecting gluten intolerance for two reasons.  The first is that if someone is gluten-intolerant and you force her to eat gluten for four to six weeks, you are significantly harming her body.  The second reason is that this test can be negative even if the person is gluten-intolerant making this test a poor method of diagnosis.

Your traditional doctor may want to order a biopsy of the small intestine to look for damage to the lining of the small intestine.  He is looking for what is known as “villous atrophy” meaning the villi that line the gut have been damaged and are worn away from the immune system attack on the dietary gluten intake.  The problem with this test is that you can have gluten intolerance but not have villous atrophy.  Seventy percent of the negative effects of gluten occur outside of the intestine.  This can result in only mild inflammation of the intestine but extra-intestinal damage to organs such as the thyroid, bones, pancreas, brain, adrenals, etc.  I would not feel comfortable having a piece of my small intestine cut out just to perform a test that is not completely accurate.

The best thing you can do is to fill out our gluten questionnaire and have the blood, saliva or stool test done to see if there is a positive antibody in any of these.  If only one is positive and you have many of the indicators of gluten-intolerance, then you should avoid gluten indefinitely.  Most people avoid gluten for a few months and then sneak something in such as a piece of bread and they end up feeling horrible after eating it.  Remember –  it is estimated that up to 40 percent of Americans are gluten-intolerant so it is very important to know if you are as well.  It can mean the difference between a major autoimmune attack on your thyroid or none at all.

The following grains contain gluten:

  • Wheat
  • Oats (not in nature but 99 percent of oats in the US are processed in machinery used for other gluten-containing grains)
  • Rye
  • Barley
  • Spelt
  • Kamut
  • Triticale
  • Bulgar
  • Semolina
  • Couscous
  • Durum flour

*Gluten can be hidden, so read labels carefully. Be wary of modified food starch, dextrin, flavorings and extracts, hydrolyzed vegetable protein, imitation seafood, and creamed or thickened products such as soups, stews, and sauces.

The following grains do not contain gluten and are acceptable for gluten-intolerant individuals and of course those who are not:

  • Corn
  • Millet
  • Rice
  • Taro
  • Teff
  • Arrowroot
  • Wild Rice
  • Tapioca
  • Buckwheat
  • Quinoa
  • Amaranth
  • Wheat Grass
  • Barley Grass
  • Barley Malt

Goitrogens are compounds in certain foods that inhibit the uptake of iodine into the thyroid gland.  Goitrogens can be neutralized by lightly steaming, fermenting or cooking these foods.  Foods that contain goitrogens include:  kale, cabbage, turnips, rape seeds, peanuts, cassava, sweet potatoes, soybeans, kelp and Brassica vegetables such as broccoli and brussels sprouts.  All of these foods eaten in their raw state could have goitrogenic activity on the thyroid gland.