Recently diagnosed with Graves' and TED looking for info on Block&Replace/AddBackTherapy as my doctors are telling me nothing except "be patient" and it's not used much in Australia so not having much luck on facebook pages either.
Many thanks,
Casperina (not my real name 
lol)
Welcome to the forum casperina,
Can you share your thyroid blood tests (with ranges in brackets) and let us know what type/ dosage of thyroid medication you take? Key vitamins have a huge role in thyroid health; have you ever had tests for ferritin, folate, Vitamin D or Vitamin B12?
Most people who develop TED have an overactive thyroid and Grave’s Disease, whereas some have it with an under active thyroid/ Hashimotos (like myself) and a few have it who are euthyroid (no thyroid condition).
I recommend you take a Selenium supplement, 200ug daily, as this has showed to help in mild/ moderate TED when taken in the first 6 months. Many take a maintenance dose of 100ug daily when the active phase of the condition has passed. Preservative free lubricating eye drops are important, such as HycoSan or Hyloforte. For light sensitivity wear sunglasses (even indoors if needed). If you have any eye pain, my TED ophthalmologist said to take ibuprofen (with food to protect your stomach). Also worth doing is using 2 pillows at night, to elevate your head.
Above all, please don’t overdo it on Google images, as they show ‘worst case’ scenarios.
I received great advice and support from TEDct, so do get their information pack. They hold regular webinars and have a Facebook group.
tedct.org.uk
Please be reassured, my eyes now look nothing like they did 18 months ago, so try not to panic. For me, huge sunglasses and bright lipstick helped me have confidence to face the world. Please keep posting if you need any further advice or support.
I recommend you take ongoing photos of your eyes/ alignment and store in ‘hidden’ on your phone, as you don’t want to be looking at them all the time. Having this bank of photos over time is useful when I have both endocrinology and ophthalmology appointments.
Regarding medication for Graves, pennyannie and PurpleNails are far more knowledgeable than I, so i have alerted them to your post. I’ve not heard of ‘add back’ therapy.
Very best wishes to you 🦋
Hi Buddy195,
Thanks for posting!
Please forgive my slow response, I'm really having trouble thinking straight and trying to work out where to start.
I'll start with my labs as you suggested:
12 Jan 2022
TSH <0.01 L (0.5-4.5)
Free T4 33 H (10-20)
Free T3 13.6 H (3.1-5.4)
Thyroid Peroxidase Ab 12 (<=33)
Serum Folate 24.6 (6.0-45.0)
Vitamin B12 231 L (>=260) pmol/L
Active B12 52 (>=50) pmol/L (lab note - B12 deficiency is unlikely)
Iron 22 (8-30)
Ferritin 117 (30-250)
25-hydroxy Vitamin D3 92 (60-160)
26 Feb 2022
TSH <0.01 L
Free T4 22 H
Free T3 7.0 H
Started Carbimazole 15mg/day in am
8 April 2022
TSH <0.06 L
Free T4 12 H
Free T3 4.1 H
TSH Receptor IU/L 11.5 H (<=1.75)
Continue Carbimazole and add Levothyroxine 50mcg/day in am
13 July 2022
TSH 4.30
Free T4 15 H
Free T3 4.5 H
TSH Receptor IU/L Test not completed by Lab did TPO Ab instead.
Thyroid Peroxidase Ab 13 (<=33)
Continue Carbimazole and add Levothyroxine 50mcg/day Mon to Fri and 100mg Sat & Sun.
No further Vitamin/Mineral testing has been done since the initial tests in January.
I have booked to have these taken in two weeks with the Nurse Practitioner as I am experiencing increasing depression, fatigue, muscle aches and cog fog (I've had all but the depression since September last year but since adding in the Levo they are getting worse).
I have told the GP twice and now the Endo who explained that my thyroid function is "perfect". I asked "when do you think I might start feeling better" and he said that I have been "slam dunked" and that it would take time for the physical and mental symptoms to resolve" I told him that I was now struggling with the mental side effects and he asked if I had any other questions.
I then asked him about Selenium as I had read it is good for eyes and antibodies - he replied that it is of no use unless you are deficient in it and this can be related to a vitamin D deficiency but that I could try it if I wanted to. He did not offer any tests to determine if I was in fact deficient in Selenium, Vitamin D or anything else (hence my arranging to have bloods taken in two weeks).
I have not been able to ask him about my TSH being much higher than it was as the blood results are not made available to me until after the consults and I honestly printed them off and did not look at them given his response to me at the time.
I guess these ^^^ things are the things that are bugging me the most - Is feeling like this expected at this stage?
If it is to be expected, then I probably don't have an issue (I surely do not want a prescription for antidepressants) - I just wish I had been given some warning that this might occur so that I wouldn't worry and would be prepared for worst case scenario.
As for the eyes,
Unfortunately looking back, I have had eye symptoms for longer than two years and was diagnosed with allergies by an Ophthalmologist.
I went to a new Optometrist in December 2021 after three months of trial and error eye drops not working and continued upper eyelid swelling. He could not diagnose anything either - I asked if it could be Graves' as my symptoms matched Hyper at the time. He checked his book, took further measurements, said "yes" and wrote a referral to my GP for tests.
I do have Moderate TED confirmed by CT Orbit and Ophthalmologist in May this year.
I some lid retraction as well as the swelling above and below the eye.
My lower left eye muscle is inflamed but there is no optic nerve involvement at this stage.
I do have monocular and binocular double vision, which are variable given the time of day and activities of the previous day.
Thankyou for the recommendations, I have not heard of HycoSan or Hyloforte.
I have been using Refresh single use eye drops multiple times per day and I use PolyVisc ointment at night.
I've always worn wraparound sunnies but hats are a new thing for me and I've come to not be able to go outside without one.
I do elevate my head at night and was sleeping with a cooling mask/sleep mask and am now looking into disposable eye occlusion dressings that stick on instead.
I have also been taking photos when I feel a change in my face. I never thought to hide the photos though, so thanks again for that tip.
As for the Add Back Therapy, I came across this term used as an alternative for Block and Replace (because the Thyroxine is "added back" into the system) or sometimes used to mean basically the same thing but with lower dosages. Seems some Medico's don't like the term Block and Replace?
I really appreciate all your suggestions, even if I am already doing a lot of them - I've just been learning a heap from everyone except my doctors it seems.
Hopefully that will improve over time
🤞
(edit: correct dosage, edit spacing, edit underlining, add B12 measurement)
Have you had TSI or TRab antibody tests to confirm Graves? I have TED and Hashimotos not Graves, so it’s very important to get the right antibodies checked, as PurpleNails outlined.
Yes, have had:
TSH Receptor IU/L 11.5 H (<=1.75) This is the antibody test&
Thyroid Peroxidase Ab 13 (<=33) Endo said that antibodies did not show up in this test but it is likely I have them but they do not show up in the assay that is tested.
Welcome to forum
Was your Graves confirmed? Often medics treat all hyper as Graves. They often assume it must be Graves if TED involved too, but TED can occur outside Graves & the conditions severity rum separately, they are treated by different specialist.
Do you have an ophthalmologist TED monitoring your Eyes?
Are you currently on a antithyroid carbimazole or PTU?
Usually titration (using the least amount of antithyroid medication to bring your FT4 (Thyroxine) & FT3 (Triiodothyronine) into range is the approach used.
If you find you still fluctuate unexpectedly or for example FT3 is disproportionately high meaning your FT4 is too low before FT3 is in range. Block and replace is used.
Usually as maximum dose is taken eg 50-60mg carbimazole and the levothyroxine at full dose. Approximate replacement guide* is 1.6mcg of levo x per 1kg of body weight.
What are your current results do you have online access to result or collect printed copies?
For full thyroid you need
TSH
FT4
FT3
TPO, TG Antitbodies
TSI and or TRab Graves antibodies must be tested to confirm Graves.
Folate
Ferritin
B12
Vitamin D
Gluten intolerance often issue with Graves. have you had celiac screen which would show allergy, intolerance does not show on test. Do you have gut issues?
For TED have you been advised to take Selenium? - Take 200mcg at first but this should dose should only be taken for 6 months. Then reduce to 100mcg . Bear in mind selenium rich food can take you over the maximum requirement.
*Preservative* free eye drops & wipes. Rotating different brands seem to help. Liquid versions for daytime & gel versions at nighttime.
I found warm compresses (eg wheat bags, microwaveable gel masks) helped. Very gentle massage toward lash line. This “unclogs” the blocked Meibomian Gland & lipid oil layer protects eye and retains the water. Some find cold compresses more comfortung if swollen.
If you like to moisturise near your eye area use water based clear gels not oil / cream. I did this as developed milia white spots round eye. I found the puffiness & swelling reduced when I switched.
Serious complications are rare changes in appearance often improve greatly. Do not Google the condition and panic over worst case scenarios. Keep a photo record of eyes eg take a photo every 2 or 3 weeks.
Many report TED triggered or worsened when thyroid levels are low.
Hi PurpleNails,
Thanks for posting!
I hope you don't mind if I refer you to my reply to Buddy195, I hope that explains most of what you have asked.
Thankyou for your explanation of how and when Block and Replace is used. Here in Aus, it seems that B&R is mostly used if you have antibodies or for paediatric patients - but I am not a doctor and this has not been explained to me.
"Approximate replacement guide* is 1.6mcg of levo x per 1kg of body weight."
Oh interesting, I wonder if this explains my TSH jumping up to the higher side? I only weigh 60kg (normally 55) and am on 50mcg of Levo., though have just been prescribed double on the weekends.
"Gluten intolerance often issue with Graves. have you had celiac screen which would show allergy, intolerance does not show on test. Do you have gut issues?"
Not that I know of, I had issues a number of years ago but it turned out I had a large stone so my Gall Bladder was removed, so gut has changed since then but I have attributed it to not having the gall bladder.
I am looking into what tests I can and should get for the 11th August.
"*Preservative* free eye drops & wipes. Rotating different brands seem to help. Liquid versions for daytime & gel versions at nighttime."
I went looking in the next town over to get different drops last week - they all sell the same, lol.
I'll have to see if my chemist will order something different for me.
"If you like to moisturise near your eye area use water based clear gels not oil / cream. I did this as developed milia white spots round eye. I found the puffiness & swelling reduced when I switched."
I do like a good massage around the eye in the mornings and the moisturiser I've been using seems ok but I didn't think of using a gel, thankyou.
"Many report TED triggered or worsened when thyroid levels are low."
Oh, I didn't know that, my levels have just gone back up a bit. I can't say I've noticed either way at this stage though.
🤞we all get this sorted sooner rather than later.
(edit - underlining for clarity)
The more recent result is not high FT4 is 50% and FT3 is 60% so quite ideal.
The TSH looks quite high. It’s said 1 is healthy.
Was that serum iron tested or ferritin?
Please add measurement on B12 it looks different to the usual range others know more about B12.
Did you start on 15mg carbimazole (that’s a very low starting dose) and certainly not a blocking level.
To partly block but add back Levo of 50mcg & 100mcg on weekends on a low dose makes no sense.
It’s would practically cancel out the reduction & add and still fail to control autoimmune fluctuations.
TRab is positive. So that confirms Graves. TPO is not always elevated with Graves although often it is.
Was that serum iron tested or ferritin?
Lab note says "unless specified, testing has been performed on serum/plasma, general Haematology on whole blood"
Please add measurement on B12 it looks different to the usual range others know more about B12.
Vitamin B12 231 L (>=260) pmol/L
Active B12 52 (>=50) pmol/L (lab note - B12 deficiency is unlikely)
Did you start on 15mg carbimazole (that’s a very low starting dose) and certainly not a blocking level.
To partly block but add back Levo of 50mcg & 100mcg on weekends on a low dose makes no sense.
It’s would practically cancel out the reduction & add and still fail to control autoimmune fluctuations.
Yes 15mg the whole time so far, no reduction.
I appreciate your time but if you do not understand the treatment I am receiving I will follow it up more directly with the Endo as I am very confused by the whole process, lack of clarity and information provided by him and my doctor.
I am having a very hard time understanding anything at the moment as my cognition is so impaired. It has taken my five hours to answer all the questions yesterday and another three hours today.
I'm sorry I feel like I am wasting your time, I do appreciate that you have taken the time so far, it's more than I have gotten from anyone else.
Thankyou so much.
I think your medics have invented a new -Add back- method which differs slightly to block and replace.
I didn’t see the logic of incomplete blocking and adding back but perhaps there are benefits.
If the regimen is working and keeping you stable - eg your next blood tests are a similar and you haven’t had an alteration with FT4 or FT3 dropping or rising. The approach might be right for you.
It’s normal for a higher starting dose to bring down levels quickly then adjust but you have seemed to start on a moderate dose and as that has brought your levels into range medics had added Levo to stop you dropping too far.
I’ve not been on B&R I have a nodule causing elevated levels. It’s currently managed by 10mg / 5mg carbimazole alternating days. I started on 20mg after 2 months I was borderline hypo.
Starting doses tend to be much higher (50 - 60mg) but long term B&R is usually 20-40mg and levothyroxine replacement usually 50-150mcg daily. So your add back method is very near to low level B&R.
Not quite high enough for a completely true blocking dose (although not that far off). Adding back some levo will also help partly stabilise fluctuations as it means your thyroid doesn’t have to produce the hormone.
If it works stick with it. - even if using titration & block & replace adjustments would be necessary.
B12 is very low with B12 under range Active B12 only just within range.
I’m not very knowledgeable on B12. I suggest you do a specific post focusing on B12 results so it can be noticed by those who can advise.
I see your ferritin (iron stores) & iron have both been tested & both over 50% of range so they look ok, same with folate.
Hope I haven’t confuse you more. It can take a long time to get you head around understanding everything, the terms & their meaning & piecing together understanding results.
You certainly aren’t wasting our time.
I have seen several references to some sort of add back regimen. But I'm not convinced it has been properly assessed - ever. First few times I noticed had me searching and I could not find anything at the time.
Therefore, it seems to be entirely empirical.
Due to lack of information and (my) understanding, I try to stick to the sidelines!
In original post casperina describes medics being reluctant to use term block & replace.
Essentially the regimen is the similar principle. I suspect historical B&R is open to lack of monitoring.
Doctors dislike using high doses of carbimazole or for prolonged duration. So there is a logic to this approach.
It more “reduce & (partly) add back”
I also think if doctors are set on treatments to definitive reverse hyper introducing levo before such treatment is wise. Medic don’t really accept allergies to thyroxine but as we know people can have issues with fillers.
I'm a little bit late answering and can't see that there is much more to add.
You might like to dip into the Elaine Moore Graves Disease Foundation and there is World wide following on Elaine's open forum and you might just find someone else there from Australia who is in a similar boat to yourself. elaine-moore.com
Graves is an auto immune disease, said to be driven by stress and anxiety, for which there is no cure.
Everybody's journey with Graves is unique to them, and why it is a poorly understood and badly treated AI disease and quite why this has happened to you and what you can do about it are the 64 million $ questions and again, reading around on Graves on Elaine's website on the' why's ' and of the more holistic and alternative treatment options interesting.
Graves is considered life threatening because of the effect it has on the thyroid which is a major gland, the body's engine, and responsible for full body synchronisation including your physical, mental, emotional, psychological and spiritual well being, your inner central heating system and your metabolism.
All the AT drug does is block your thyroid hormones, T3 and T4 rising any higher and the continued use of the drug will see your T3 and T4 levels fall back down into range and hopefully your symptoms reduced.
The AT drug is usually titrated down as otherwise you risk your T3 and T4 levels falling too far through the ranges causing additional symptoms of hypothyroidism the extreme opposite end of the hyperactive phase you first experienced.
It takes time finding the right balance of AT drug as your Graves antibodies can still be raging and driving up your T3 and T4 - or your Graves antibodies could be blocking your T3 and T4 response to the AT drug - or your Graves may have burnt itself out and be dormant, but we don't know the activity after diagnosis and only have symptoms and blood tests results to go by.
It can be a roller coaster of symptoms and ' slam dunk ' works as well :
Most people are treated with just the AT drug and the T3 and T4 levels fall back down into range and a T3/ T4 balance restored.
The Block and Replace regime is not offered to all patients but when T3 dominant, in that your T3 and T4 don't respond together, in ratio, to the AT drug the thinking is too totally block with a larger dose of AT drug and add back in measured dose of T4 so you do not fall too far through the ranges and experience other debilitating symptoms.
When metabolism isn't running to your unique set point your body will struggle in many ways - you maybe eating for Australia but loosing weight, exhausted just sitting on the sofa but thinking you need to go on a run round the block and do so, , insomnia, tiredness, heat intolerance, fast bowel, constipation, and so it goes on - and on :
It is essential to keep your core strength strong and solid to support you through this and suggest you get your ferritin, folate, B12 and vitamin D levels run and post the results and ranges back on here for further advice :
The most recent research is suggesting the longer one is on the AT drug the better the outcome for the patient :
pubmed.ncbi.nlm.nih.gov/338...
Thankyou pennyannie, I will have another look at elaine-moore's site.
hello there, I have graves disease and TED too.I was diagnosrd in 2018.I was first put on carbimazole only (called titration) where over time they try to reduce the dose down gradually while still giving enough to control the overactive thyroid.I tried this for over a year but due to one thing and another it wasn't successful .I am in the UK and my appointments were never close enough together to fine tune it.I was always swinging from my T4 being too high , then too low.My TED kept flaring up so my opthamologist suggested block and replace to try and make things more stable.I was on a constant dose of 40mg per day of carbimazole and when my T4 got low in range then thyroxine was introduced gradually.I started at 25mcg per day and eventually ended up on 100mcg for 5 days and 50mcg for 2 days a week.You need to have regular blood tests, say every 6-8 weeks to check levels and see if any adjustments need making.This was more stable for me but appointments and testing were still not timely enough and Covid obviously had its part to play.My levels were difficult to stabilise sometimes changing when I had been steady on a dose for some time.I was on block and replace for about 3 years.Due to many reasons I decided to have a thyroidectomy in June this year.I have felt alot better since then.They found a nodule as well as my graves which I didn't know I had.Maybe that is why my levels were dificult to control.Block and replace may well be successful for you.I have had other issues alongside my thyroid which have made it more complicated for me .If you want to read my experience you could click on the picture at the side of my name and my profile should come up.I have kept it up to date.Please remember that everyone has their own unique thyroid experience and just because something doesn't work for one person doesn't mean it won't work for you.You are wise to research things for yourself and get as much information as you can so you can make the right decision for you.Best wishes in you journey and I hope I have helped in some way.
I’m so pleased you are continuing to do well after your operation Cavapoochonowner! 👍😊
Thankyou very much.
Hi Cavapoochonowner,Thankyou for posting and telling me your experience.
"You need to have regular blood tests, say every 6-8 weeks to check levels and see if any adjustments need making."
This is one thing that has frustrated me, initially my tests were closer together but since the bloods in April & Levo. added, then next test in July?
I really thought this was odd and I keep hearing 6-8 weeks so I will definitely chase this up with the Nurse Practitioner.
I went to the GP around the 6-8 weeks, no I didn't ask for a test but explained the change in my symptoms and was told to "be patient".
Oh I just read your profile:
"Had a funny episode in November when daughter had to phone 999 as she thought I was having a stroke.I was confused and couldn't get my words out.Tested for stroke in hospital but said it was migraine.I have migraine with aura but never had problems with confusion and speech."
I was diagnosed with nocturnal epilepsy (tonic clonic seizures in my sleep) 24 years ago.
Two years ago after being stable on meds for the majority of that time, I had an "episode" where I woke with slurry speech and lack of coordination which lasted for three days, well I went to the doctor after 3 days. I didn't think it was that bad, I had had a sore neck and thought I pinched a nerve. People at work said they thought I had a stroke, Dr said it was epilepsy - did they even check for anything else, or take the most obvious route?
I have had some issues ever since, thought it was the epilepsy meds I had been on for 24 years so tapered off them last year, all the hyper symptoms increased as I got lower on the dose. I finally got Graves' diagnosis in Jan this year. I asked Endo if hyper could have been the cause and he said that it can lower the seizure threshold in some people.
Things like this make me wonder.
I am happy to give things a shot but I understand your decision to have the op. You tried and if you're not happy and you can change something, then change it!
Well done, I'm glad you're healing well.
I can't wait for the day I feel like my old self.
🤞it will be sooner rather than later.
hello, I can definitely feel your frustration regarding blood tests and appointments and not getting them on time.Sorry about your experience with epilepsy.It always seems to make things more difficult when there are other issues to consider.Regarding my migraines I have to be careful not to let my T4 get too high in range or it seems to cause frequent migraines.It could be the increased heart rate or maybe the increased anxiety which sets them off.At the moment my T4 is 18 which seems to be good for me.They are right on this forum when they say everyone has their own "sweet spot" regarding levels.It's just trial and error trying to find it.Wishing you all the best.
Thankyou Cavapoochonowner, I wish you the best also.
Hello casperina
I'm guessing you must have learnt by now, either from your doctor, or your own research, that Grave's disease is one of very many autoimmune diseases. Dry eyes and dry mouth are clinical symptoms of Sjorgren's syndrome, which often co-exists with thyroid autoimmunity. (just google the two together). Yes, often autoimmune diseases come in pairs and multiples, as the underlying cause is "Chronic Inflammation". Experimenting with "diet and lifestyle changes" is key to healing. Medications are "bandaids", sometimes perhaps necessary to buy time and energy for the optimization process.
Going by your bio, I would recommend the following to start your research on your healing journey.
Dr. Brooke Goldner
See my recent posts (two) to PrincessAnnie here
healthunlocked.com/thyroidu...
which contains another link to Heloise
healthunlocked.com/thyroidu...
Her protocols are the simplest, accessible to everyone, and reproducible going by the testimony of followers.
Get her books, cruise through her youtube channels (Q&A sessions are helpful).
If you're already on FB, join the one set up by her husband Thomas (he's the one who "accidentally" started Dr Goldner's healing journey). "smoothieshred.com/", same site for the hyper-nourishing green smoothie recipes & "how to" video.
HTH, take very good care
Good advice, eiddew! Do you realize there have been two summits after Inflammation; one on the Lymph system which now makes me wonder if it is more important since it starts the immune reaction through messaging and one on Pain, now in a weekend rerun. Keeping the lymph flowing is vital. It can actually dispose of some bacteria very early. On the other hand certain foods can create inflammation. They gave an example of a young child who was very ill and found that blueberries caused severe inflammation. You never know.
painfree.byhealthmeans.com/...
Hi Heloise
Many thanks for pinging this series on my radar. Most speakers are new faces to me. I will check it out.
I didn't find TENS helpful when once I had a pinched nerve episode, with excruciating pain for weeks. A simple exercise I picked up "randomly" on Dr. John Bergman's youtube channel helped instead, dramatically. Simple, effective, and free. I was starting to clean up my diet by then, and that definitely helped to calm the inflammation.
Yes, I know our lymphatic system does not have a musculature, unlike our blood circulation system. So it needs to be "pumped" by our physical movements, such as exercise and /or massages (if we are too ill to move). A critical portion of our immune cells reside in the lymphatic nodes. They need to get in and out, so do nutrients & rubbish / metabolites / dead cells. Another reason why movement / exercise forms a critical part of any healing journey.
What I like about Dr Goldner's books and messages, is her holistic mind+body approach to health and healing. A lot of the times, what keeps us stuck in old/unhealthy mode is mental. Unlocking mental sabotage is a critical step towards full healing.
You may be interested in this book, "Cured", by Dr Jeff Rediger. He narrates the audible version himself. Very pleasant to listen to. The stories and messages on healing and hope are thought-provoking and powerful.
amazon.co.uk/s?k=cured+dr+j...
Hope you'll enjoy it, too, if you haven't read it.
best wishes
Hi eiddew,
Thanks for posting!
Unfortunately yes, I am aware (now) of the range of Autoimmune diseases and how they like to gang up on people!
The Endo said I have a genetic link to Graves' as my maternal grandmother had Type 1 Diabetes, I did not know that T1D was autoimmune, so it has been a steep leaning curve.
I also have a friend on another forum who has Sjorgren's syndrome, which she believes she acquired after years of prescribed benzodiazepine use. I don't know but I am not a doctor.
I too have many years of prescribed benzo use under my belt, I am hopeful that this will not contribute to another autoimmune condition but who knows?
I appreciate the links, I do agree that medications are band-aids and often the first port-of-call when lifestyle changes could possibly take precedence and with a better result - at the least with less side effects.
There are also some conditions that require medication also so it can be a fine balancing act of the two.
I will be sure to check out the links you have posted and consider the information for a later date when I am able to figure out what the **** I need to be doing!
😀😆
👍
Hi casperina
I'm glad you will be taking responsibility of your own health.
Sjorgren's syndrome is one of many autoimmune diseases Dr Goldner has helped her patients to overcome. The success cases are described in her book "Goodbye Autoimmune Disease".
amazon.co.uk/Goodbye-Autoim...
As for type I diabetes, if you worry about having it triggered, check out Cyrus & Bobby's work. They both have T1D, and have been teaching patients with all forms of diabetes to regain health and vitality. You would find that their approach is not too far from Dr Goldner's.
You can start by making Dr Goldner's green smoothie, sip while cruising through the information. You don't have to change your diet quite yet, simply ADD the green smoothie, made according to instruction from the links, to your daily routine. Start with 1L before you ramp up to 2L/day. People who are not yet on plant-based whole food often experience bloating, due to the gut microbiome not yet catching up with the amount of fibers in the smoothie. Ramping up is a good idea. Also drink adequate amount of water, recommendation by Dr Goldner is half your body weight (in lb) of water (in oz).
take care, have fun exploring.
Thankyou, I appreciate you taking the time.
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