• Dr. Teresa Rispoli

Poor Fat Digestion Linked to Thyroid & Gallbladder Issues


The Link Between Fat Malabsorption, Gallstone Disease and Hashimoto’s While you may think that the body’s inability to absorb fat sounds like a good thing weight-wise, it isn’t. We all need healthy fats in order to absorb vital fatty acids and other nutrients that our body needs. If our body isn’t able to absorb these nutrients, we should take that as a sign that there are other issues going on that are impacting us negatively as well.

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.

So let’s talk about fat malabsorption, the role of the liver and gallbladder in digesting fats and eliminating toxins, and how Hashimoto’s increases your risk of having these issues.

In this article, you will learn:

  • How the liver and gallbladder affect one’s digestion of fats

  • The link between fat malabsorption, gallstone disease and Hashimoto’s

  • Symptoms of fat malabsorption and gallbladder issues

  • What to do if you don’t have a gallbladder

  • The Root Cause Approach to addressing fat malabsorption, and liver and gallbladder problems

  • How Your Gallbladder Affects Hashimoto’s and Fat Digestion

The Liver and Gallbladder’s Role in Healthy Fat Digestion First, let’s talk about how the liver and gallbladder work together (along with the pancreas) to break down fats for healthy digestion, absorption, and elimination. We know that whatever we eat eventually makes it down into the small intestine, but some people have trouble digesting the fats that we consume from the foods we eat. Fats are not water soluble, and our small intestine is a very watery environment. So how does the fat get broken down? To do this, our liver produces a substance called bile. Bile from the liver is sent to the gallbladder via a passageway called the common bile duct, and then it is concentrated and stored there. When we eat a fatty meal, the concentrated bile is released from the gallbladder through the common bile duct, then heads to the initial part of the small intestine (called the duodenum). There, the bile begins to break down the fats into tiny globules. At the same time, the neighboring pancreas organ releases its own pancreatic juices (containing digestive enzymes such as lipase and bicarbonate ions), mixing with the bile and tiny globules of fat. The pancreatic juices neutralize the digesting food (which is very acidic) and also help with protein and carbohydrate digestion. Both bile and pancreatic secretions, in sufficient amounts, are required to emulsify the fats (or lipids) so that they can be digested in the watery part of small intestine. Bile acts like dish soap and works to dissolve the globs of fat (picture fats that are sometimes left in a pan soaking in your sink). In the small intestine, this allows nutrients to be more readily absorbed. More importantly, bile helps us absorb fatty acids and fat soluble vitamins such as A, D, E, and K, as they cannot be absorbed without adequate bile. Without adequate bile, these essential nutrients can be lost and excreted with other wastes in the stool – leading to nutrient deficiencies. This is one reason why nutrient depletions are so common in people with Hashimoto’s!

Bile is then recycled from the intestines, back to the liver, for reuse after breaking down fats. This offloads the workload of the liver by recycling about 95 percent of the body’s bile. (This way, the liver doesn’t have to continually produce new bile.)

The entire process – and your bile’s health – ultimately comes down to your liver’s health.If the gallbladder is dysfunctional, it is likely that the liver is also dysfunctional and producing unhealthy bile. (This is why I focus on liver support as an initial step with any new client I work with!)

Now you know how important bile is in breaking down and emulsifying fats. Without bile our ability to digest – and absorb key nutrients from – anything fatty would be hindered. This includes healthy fats, too, like fish oil or avocados.

If you’ve had your gallbladder removed, or if your gallbladder is not functioning optimally, you are not going to have the concentration of bile that you need, nor will you get some of the additional benefits you would get from a healthy bile flow. Additional Benefits of Bile

  1. Bile is thought to be antimicrobial, although the exact mechanism as to how it provides this benefit isn’t certain. It appears to stimulate the immune system in the intestines. In fact, it has been known to help prevent the bacterial overgrowth that is seen in small intestinal bacterial overgrowth (SIBO), a common root cause of Hashimoto’s. (Thus, I always recommend testing for SIBO if you have issues with fat malabsorption.)

  2. Bile is key to supporting the liver in excreting hormones and excess toxins, including cholesterol, the body’s waste products, environmental toxins, heavy metals, and other harmful substances. Since it helps remove excess estrogen, bile plays a key role in female sex hormone balance (and I’ll discuss this more in a minute).

  3. Bile may also have a role in blood sugar metabolism. Along with fat metabolism, bile may act as a signaling molecule relating to glucose (blood sugar) metabolism, and insulin levels have been correlated with bile cholesterol saturation. Thus, bile may play an important role in maintaining blood sugar balance. There have also been a lot of studies pointing to clear associations between insulin resistance and gallstones, which can form as a result of bile issues. (I found this particularly interesting, as blood sugar issues and type 2 diabetes often co-occur with Hashimoto’s, along with gallbladder issues!)

The Link Between Fat Malabsorption, Gallstone Disease and Hashimoto’s People with Hashimoto’s and hypothyroidism often experience fat malabsorption issues and have an increased risk for gallbladder problems, as the thyroid can affect the composition of bile and its ability to flow.

The lack of thyroxine (free T4), as seen in hypothyroidism, decreases liver cholesterol metabolism. This results in changes to the bile composition itself, which then leads to what is called a state of bile cholesterol supersaturation. This thickens the bile and impairs it by slowing its rate of flow.

Decreased bile flow impacts an important process called peristalsis, which involves wave-like muscle contractions that push food and bile through the intestines. As peristalsis is reduced, many people experience constipation, with up to 15 percent of hypothyroid patients reporting to have fewer than three bowel movements weekly.

As digestion slows down, there can also be increased bacterial growth, which can then result in diarrhea.

Furthermore, the change in bile composition and delayed flow can cause the liver’s cholesterol to crystallize, forming gallbladder stones, or gallstones (solid particles that block the common bile duct and pancreatic duct, and cause inflammation of the gallbladder).

The lack of thyroxine associated with hypothyroidism can also affect the sphincter of Oddi (layers of muscle that regulate the flow of bile into the small intestine/duodenum, which close between meals, preventing bile from continuing to flow into the small intestine when it isn’t needed). The sphincter may experience increased tension, which can prevent normal bile flow.

This has been thought to contribute to the formation of common bile duct stones, as well as gallstones.

Thus, it’s not surprising that there is an increased prevalence of hypothyroidism found in patients with common bile duct stones. In fact, patients with common bile duct stones and gallstones have, respectively, 7-fold and 3-fold increases in the frequency of hypothyroidism.

There are also indirect effects relating to bile production in those with thyroid disease.

Remember that when you have issues with bile production, you can have deficiencies in essential fat soluble vitamins such as vitamins A, E, D, and K, as well as fatty acids. Vitamin D deficiency is commonly found in people with Hashimoto’s. Some 68 percent of my readers have reported having a diagnosed vitamin D deficiency. In fact, when I know someone has been supplementing with vitamin D, but still tests as deficient, I view that as an important clue that they may have fat malabsorption issues. The lack of key vitamins and fatty acid deficiencies can cause a whole host of additional symptoms, and can further impact thyroid hormone conversion (T4 to the active T3 hormone). Furthermore, poor bile flow can lead to a recirculation of toxins such as heavy metals and excess hormones.

As you may know, nutrient depletions and impaired detoxification pathways are often the root causes of Hashimoto’s symptoms, so it’s important to address the gallbladder and bile issues that may be at the root of these issues. Symptoms of Fat Malabsorption Issues and Gallbladder Problems

Since gallbladder and bile impairment can contribute to fat malabsorption issues and have been linked to hypothyroidism, it is no surprise that fat malabsorption issues are relatively common with Hashimoto’s. Unfortunately, they are often overlooked by practitioners or viewed as symptoms of other common conditions. Let’s review the common signs and symptoms of fat malabsorption and gallbladder issues:

  • Digestive symptoms include greasy, smelly, floating, or light-colored stools; gas or belching after eating, diarrhea, stomach pain, gallbladder pain (located on the right side, under the ribs), gallstones, nausea, and weight loss. If you are not properly digesting and absorbing fats from food, you may start to experience low energy levels and increased cravings for carbs, since fats are an incredible slow-burning source of energy. People attempting a ketogenic (high fat) diet may experience nausea or any of the above symptoms, and find that they are unable to comply with the high fat dietary requirements.

  • Non-digestive symptoms include dry hair, eczema, depression, dry itchy/flaky skin or scalp, oily scalp, dandruff, and rashes. Hormonal imbalances (including estrogen dominance) and adrenal issues may also be seen.

  • Symptoms related to vitamin and fatty acid deficiencies: As I already mentioned, if you’ve had fat malabsorption occurring for a while, you may start to develop symptoms of fatty acid deficiency, as well as depletions in the fat-soluble vitamins A, D, E, and K. Fatty acid deficiency symptoms may present as pain, inflammation, dry skin, oily hair, acne, or eczema. Deficiencies in the fat-soluble nutrients can lead to numerous additional symptoms, including vision problems, immune system imbalance, fragile bones, poor wound healing, easy bruising, bleeding gums, nosebleeds, dull hair, depression, skin disorders, eczema, dry and itchy/flaky skin or scalp, dandruff, oily scalp, rashes, and many other seemingly unrelated symptoms.

How to Determine Gallbladder Issues There are a number of simple diagnostic tools that I use with clients. The first is just evaluating your symptoms. Your stools can tell you a lot, too! Greasy, smelly, floating, or light-colored stools can be a sign of bile issues.

I have found that many people with fat malabsorption issues also often experience low stomach acid (another common issue associated with Hashimoto’s), which makes it more difficult to digest proteins. The proteins that are often most difficult are gluten, dairy, and soy. Those who have symptoms of low stomach acid and see improvement after eliminating these proteins from their diet, may have a fat malabsorption issue.

Furthermore, if you have the MTHFR gene variation or difficulties with methylation, you may already have challenges with clearing toxins from your body, and may suffer from symptoms related to impaired methylation (like brain fog, anxiety, irritability, and chemical sensitivities). An impaired ability to detoxify may also contribute to gallbladder issues.

Your practitioner can run some labs, such as liver function tests and/or a complete blood count (CBC) test, to check for gallbladder issues. Markers for impaired gallbladder functioning may include high bilirubin, AST, ALT, LDH, GGT, ALP, and 5’-nucleotidase. However, I find that oftentimes, gallbladder dysfunction can be missed.

As mentioned earlier, if a person has been supplementing with vitamin D but their labs still show a deficiency in it, I always suspect fat malabsorption, so testing one’s vitamin D levels can also help with diagnosis.

A low fecal elastase test result and/or high fecal fats/steatocrit, such as on the GI-MAP test in functional-medicine stool testing, can also indicate fat malabsorption. While a “low” result for fecal elastase is reported as being under 200 μg/g, an optimal level is above 500 μg/g, and people may be symptomatic, even with fecal elastase between 200-500 μg/g. Low fecal elastase can be an indication of exocrine pancreatic insufficiency, which can have more root causes, such as celiac disease, mold toxicity, SIBO, and many others.

If you are experiencing pain, or if your practitioner suspects gallbladder issues such as gallstones or common bile duct stones, they may use ultrasound testing or an abdominal X-ray to look for stones or other problems. However stones may not show up is they are fatty in nature and not calcified!

Other Risk Factors That May Point the Way to Gallstone Issues

If you are experiencing some of the above symptoms, there are other risk factors that may point to the presence of gallstones. Known risk factors for gallstone formation include:

  • Obesity

  • Genetic susceptibility (can dramatically increase risk, by nearly five times)

  • High homocysteine levels

  • Insulin resistance

  • Metabolic syndrome (three or more symptoms of: high blood pressure, high fasting glucose, abdominal obesity, reduced HDL levels, and increased triglyceride levels)

  • Advanced cirrhosis, chronic hepatitis C or nonalcoholic fatty liver disease

Furthermore, female sex hormone (estrogen) changes can lead to gallbladder issues. (This is the reason why women who have not yet reached menopause are three times more likely to be at risk of having gallstones.)

Interestingly, oral contraceptive use and estrogen hormone replacement therapy have both been tied to changes in bile composition, specifically increases in cholesterol levels, which thickens the bile. This composition change is thought to contribute to the formation of gallstones. (I’ve heard of increases in incidents of estrogen dominance seen after gallbladder removals, which would make sense given that the increased levels of estrogen would not be getting eliminated without sufficient amounts of bile.)

Some women also experience cholestasis, a reduction in bile flow, in late pregnancy. This is thought to be related to changes in estrogen and progesterone hormone levels. There can be a reduction in both the normal flow of bile (along with greater cholesterol saturation), as well as in the body’s ability to clear out hormones. This sometimes results in reduced gallbladder function, as well as the formation of gallstones, although gallstones may clear during the postpartum period. Conventional Treatments

Many people are not aware that they may have a fat malabsorption or gallbladder issue, as common symptoms may mirror other conditions. Gallstones themselves may often go completely undetected. It is estimated that about 15 percent of adults in the U.S. have gallstones, with only a very small percentage (1-3 percent) experiencing gallbladder-related symptoms.

It’s important, however, to be aware of severe gallbladder issues.

A gallbladder attack (acute cholecystitis), which happens when a gallstone passes into the small intestine or becomes stuck in a bile duct, can cause a good deal of continuous pain (in the upper right side of the abdomen) and is associated with nausea and vomiting, as well as fevers. Infections may also occur. This blockage is often what inspires someone to contact their physician or visit the ER. Gallstone issues are a leading cause for hospital admissions related to gastrointestinal problems.

The conventional treatment for a gallbladder attack is often gallstone surgery.

In my opinion, (and many medical professionals agree), you should not have your gallbladder removed unless the symptoms warrant it. True, a cholecystectomy (the complete removal of the gallbladder) can sometimes be unavoidable – especially if someone has been dealing with gallbladder disease for a lengthy time. However, unfortunately, the surgery is overused today, and is often called for even when a patient is experiencing only minimal – and correctable – symptoms. It is one of the most common elective abdominal surgeries performed in the U.S. today!

After this surgery, bile flows directly from the liver to the small intestine via the common bile duct, but it does not get stored and concentrated, so you can experience all of the symptoms we’ve already talked about. Having the bile flow directly into the small intestine may also affect the gut microbiome and gut function. Additionally, this surgery doesn’t necessarily stop the patient from producing another gallstone in the bile duct or liver!

If you are thinking of having gallbladder surgery (in a nonemergency situation), I highly recommend the book Save Your Gallbladder Naturally by Sandra Cabot, as well as consulting with a functional medicine practitioner, for guidance. The Functional Root Approach to Supporting Liver, Gallbladder, and Fat Digestion

If you are experiencing symptoms associated with fat malabsorption, if you know you have a gallbladder condition such as gallstones, or if you are at an increased risk for gallbladder disease, my Functional Root Approach recommends several goals to focus on:

  • Supporting your liver and gallbladder health

  • Stimulating bile flow (quantity and motility) to support fat digestion

  • Dissolving gallstones or common bile duct stones

  • Supporting your body’s overall detoxification system

There are a number of supplements that I recommend, as well as supportive foods that you can incorporate into your diet, to help you reach these goals:

1. Hepatiben can help support liver and gallbladder health, while also supporting fat

digestion, in five different ways:

  • TOP LIVER DETOX INGREDIENTS – milk thistle is well known as the top herb for liver detoxification. But few know that the active ingredient is silybin, which only 5-10% concentration in milk thistle. We have a very strong dose of silybin at 200mg. Combined with phosphatidylcholine, this increases its effectiveness 2-3 times for a very effective cleanse.

  • SUPPORTS LIVER FUNCTION – contains 5 ingredients for promoting phase II detox in the liver. Removal of toxins take place in this stage increases liver health and reduces harmful oxidation that damages human tissue.

  • OPTIMIZES WEIGHT LOSS – the most resistant weight to lose are fat cells created to store toxins collected from the body. By reducing stored toxins, the body reduces these fats cells and weight loss is achievable.

  • SUPPORTS GUT REPAIR – the main entry point for toxins is the gut lining. Over time the lining becomes pitted. Hepatiben has 4 trusted ingredients to support inflammation reduction and help rebuild the epithelial gut wall lining.

  • MTHFR Gene Mutation – this genetic mutation impacts an estimated 60-70% of people to some degree and depletes the body of methionine, glutathione and cysteine. All are found in high doses in Hepatiben, which will allow for more efficient detoxification cycles in the liver.I routinely recommend taking one capsule of this supplement with each meal, as a key component of my Liver Support Protocol!

2. Remember that chronic fat malabsorption may result in a deficiency of essential fatty acids. If you have signs of fatty acid deficiency such as pain, inflammation, dry skin, oily hair, acne, or eczema, you may benefit from one to four grams of fish oil per day. 3. For those who have had fat malabsorption issues for some time, supplementing with fat-soluble vitamins A, D, E, and K can help to improve symptoms and resolve deficiencies resulting from fat malabsorption. Designs for Health makes a vitamin that contains A, D, E and K, that I’ve recommended for those with fat malabsorption, called Vitamin D Complex (note, it does contain the retinyl palmitate version of vitamin A, which can be controversial, though there is one study that showed this form can lower TSH in hypothyroid women).

4. Also, as mentioned earlier, consider supporting any issues related to low stomach acid with betaine and pepsin, to help promote the proper digestion of proteins.

5. Some people with fat malabsorption issues may also have exocrine pancreatic insufficiency, or a deficiency in pancreatic enzymes. This condition may result from chronic stress, mold toxicity, SIBO, alcohol use, H. pylori, low stomach acid, Giardia, celiac disease, or damaged microvilli in the gut.

I’ve found supplementing with pancreatic enzymes as well as Lipase Enzymes to be very helpful in the breaking down and digesting of fats. In fact, about 50 percent of people who have tried pancreatic enzymes have reported seeing benefits after using them for a few weeks to a few months. In some cases, people may need to take pancreatic enzymes long-term and try other things to completely resolve their symptoms. 6. Many people are deficient in magnesium, and it is an important nutrient required for the liver’s detoxification pathways. (As an added bonus, it also helps with sleep.) Either magnesium citrate or magnesium glycinate can be helpful, but note that magnesium citrate has a stool-softening effect.

7. I recommend liver-supporting foods, including hot lemon water (my favorite morning drink), cruciferous veggies (note: some people may have a sulfur sensitivity and may be sensitive to crucifers), sprouts and seedlings, green juices and chlorophyll, fermented foods, turmeric, and berries. Cilantro is another great supportive food to help detox heavy metals. Beets are also wonderful, as they are rich in betaine and folate, which help to break down homocysteine and can aid your body in eliminating toxins. (Beets are especially good for those with methylation issues as well.)

8. Lastly, I recommend avoiding foods that may exacerbate gallbladder issues or contribute to the formation of gallstones. Gallstones have been associated with the Standard American Diet (S.A.D.), which is high in sugar and processed foods, and low in fiber. Research has shown that the intake of high energy simple sugars, and saturated fats, favor gallstone formation.

One study found that men who ate a diet high in polyunsaturated or monounsaturated fats (think olive and plant oils) were 18 percent less likely to develop gallstones than those on a diet consisting of the least of these types of fat (ie. diets that were higher in saturated fat).

For this reason, I highly recommend increasing your intake of healthy fats, and lowering your intake of sugar and carbs. Increasing the amount of fiber and ascorbic acid (vitamin C) may also reduce your risk of developing gallstones. In 1968, Dr. James Breneman described the ”gallbladder diet.” He believed that gallbladder attacks were the result of food sensitivities, and he recommended people use an elimination diet to identify their own triggers. In his research, he found that there were a handful of top food offenders, including: eggs (the biggest offender), pork, onion, milk, poultry, coffee, oranges, nuts, corn, and tomatoes. He also found that about 20 percent of his study’s participants were sensitive to the prescription drugs they were using!

We know that food sensitivities can also be a trigger for Hashimoto’s. I always recommend people remove gluten and dairy as an initial step when evaluating any food sensitivities they might have. This is especially important, as gluten has been linked to an increased prevalence of gastric and gallbladder motility issues. Removing triggering food sensitivities can really make a difference in how you feel, and pretty quickly, too – so I recommend considering doing an elimination diet to identify your trigger foods! Also, please note, what I’ve learned about in my extensive research on food sensitivities is that we are often sensitive to the foods we eat most often… so use the “gallbladder diet” foods as a guide, but keep in mind that your food triggers may be different.

Tips for Those Without a Gallbladder

Along with the natural solutions discussed above, I’d also add a few recommendations specifically for those who no longer have a gallbladder:

  • Supplement with ox bile. This can be found in combination products like Digestion GB by Pure encapsulations, or as a standalone supplement, like Ox Bile by Allergy Research Group. I recommend working with a practitioner to determine your ideal dose.

  • Avoid trans fats and fried foods.

  • Test for food sensitivities.

  • Add fiber to your diet.

  • Take vitamin C.

  • Consider beetroot juice.

  • Ensure you are getting adequate – and filtered – water to support a healthy detoxification system.


Get Started Today


Remember, “You are what your body can digest, absorb and eliminate.” Optimal liver and gallbladder health is essential to all three of these important bodily functions. Remember too, how important bile is to your body’s ability to breakdown and gain the nutritional benefits of fats.

The good news? There is a lot you can do to ensure you are supporting these systems, as well as to address symptoms you may already be experiencing.

Eliminating food sensitivities is a great initial step, and if you are still experiencing fat malabsorption symptoms, consider some of my recommended digestive enzymes and supplements, like Hepataben Digestion GB by Pure Encapsulations, fish oil, Pancreatic Enzymes , and magnesium. I also recommend identifying the food sensitivities that may be contributing to gallbladder impairment. Set up a Functional Nutrition Consultation to get to the root of you health concern References

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Dr. Teresa Rispoli

Tel: 818.707.3126

28247 Agoura Road

Agoura HIlls, CA 91301

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BY Teresa Rispoli