Remission of Graves' Disease Through Lifestyle Interventions

Graves' disease, caused by autoimmune thyrotropin receptor antibody-mediated activation of the thyroid, is characterized by hyperthyroidism, orbitopathy, dermopathy, and acropachy. Graves' disease is treated by anti-thyroid drug therapy, radioactive iodine ablation, or total thyroidectomy. We report the case of a 39-year-old female patient with hyperthyroidism secondary to Graves' disease that was managed through lifestyle interventions only. On presentation, she reported intermittent headaches and had an undetectable thyroid-stimulating hormone (TSH) level. Two weeks later, repeat testing showed an undetectable TSH, free thyroxine (free T4) 2.7 ng/dL (normal range: 0.70-1.48 ng/dL), total triiodothyronine (T3) 5.08 ng/mL (normal range: 0.40-1.93 ng/mL), thyrotropin receptor antibody (TRAb) 20.3 IU/L (reference range: ≤1.75 IU/L), thyroid stimulating immunoglobulin (TSI) 2.3 IU/L (reference range: ≤0.54 IU/L), thyroid peroxidase antibody (TPO) 7.66 IU/mL (reference range: <5.61 IU/mL), confirming hyperthyroidism due to Graves' disease. An iodine-123 (I-123) thyroid uptake and scan showed homogeneously increased iodine uptake (68%) at 4 hours (normal range: 3-16%) and (60%) 24 hours (normal range: 8-25%). The patient was prescribed anti-thyroid drug therapy through methimazole but elected not to take it due to concerns about side effects. She incorporated lifestyle interventions and, over a span of three months, was able to improve clinically and biochemically (TSH: 0.824 mcIU/mL, free T4: 0.77 ng/dL, total T3: 0.73 ng/mL, TRAb: 2.93 IU/L, TSI: 0.26 IU/L, and TPO antibody: undetectable). The lifestyle interventions she pursued included going dairy and gluten-free, ingestion of one to two Brazil nuts daily, regular exercise, mindfulness-based stress management, and cold-water immersion therapy. We review the evidence behind these interventions and discuss the utility of these measures in the management of Graves' disease.