ALSO IN THIS ISSUE - Empower...Dr. Vishnu Garla Dr. Vishnu Garla is an assistant professor at the University of Mississippi Medical Center, Jackson, Mississippi. He serves as the Associate

ALSO IN THIS ISSUE:Adrenal Fatigue – Truth or Myth

If It's Not My Thyroid, Then What Is It?

Mythbusters: Thyroid Edition

Dr. Ricardo CorreaRicardo Correa, MD, Es. D, FACP, CMQ is an Assistant Professor of Medicine and Program Director for the Endocrinology,

Diabetes and Metabolism of the University of Arizona College of Medicine-Phoenix. He is the vice-chair of the CME committee of the AACE. Also he is editor of Dynamed and outreach unit director of Endotext.org and Thyroid manager.

Dr. Melanie R. GoldfarbMelanie Goldfarb, MD, MS, FACS is a fellowship-trained endocrine surgeon and Director of the Center for Endocrine Tumors

and Disorders. Her expertise is minimally invasive surgery for thyroid cancer and disorders, hyperparathyroidism, and adrenal tumors, including pheochromocytoma, Cushings, Conns, and adrenal cancer.

Dr. Scott IsaacsScott Isaacs, MD, FACP, FACE is a board-certified endocrinologist and obesity medicine specialist in Atlanta, Georgia, and

Adjunct Assistant Professor of Medicine at Emory University School of Medicine. Dr. Isaacs currently serves on the national AACE board of directors and is on the editorial board for Empower Magazine. Dr. Isaacs is past president of the Atlanta Chapter of the Atlanta Diabetes Association.

Dr. Cheryl R. RosenfeldCheryl Rosenfeld, DO, FACE, FACP, ECNU practices endocrinology with North Jersey Endocrine Consultants, which she

founded in 2006, and is a Clinical Assistant Professor of Medicine at the Touro College of Osteopathic Medicine in Middletown, NY.

Greetings from the

Editors

Dear Reader,

We hope that you are enjoying the beginning of the fall season. Thank you for picking up EmPower® Magazine, the American Association of Clinical Endocrinologists’ and the American College of Endocrinology’s voice to you. It is dedicated to promoting the art and science of clinical endocrinology to improve patient care and public health. We want to empower you to take charge of your health and help provide you with resources to live healthy and fulfilling lives.

The articles in EmPower Magazine are written by a diverse group of experts in the field, focusing on a variety of timely endocrine topics. Through this magazine, we will help you stay up-to-date and informed on topics important to you.

This issue of EmPower Magazine is dedicated to busting myths and misconceptions in endocrinology. Here, you will read about bioidentical hormones and salivary hormone testing, supplements and nutraceuticals for diabetes and weight loss, and learn about the cholesterol-lowering medications called statins. You will also read about myths debunked regarding the adrenal and thyroid glands and learn about non-endocrine conditions that can have symptoms mimicking thyroid disease. In addition, we have included an article discussing whether hyperparathyroidism can exist with a normal calcium and/or parathyroid hormone level. Finally, featured in this issue is also a story of a patient who was treated for a diagnosis she ultimately didn’t have, that we hope inspires and empowers you!

We sincerely hope that as you read this issue, you will feel empowered to live a healthier lifestyle. As always, we welcome your feedback. Be healthy. EmPower!

Sincerely,

Editorial Board

Editor-In-Chief

Dr. Maria Papaleontiou

Maria Papaleontiou, MD, is an Assistant Professor of Internal Medicine in the Division of

Metabolism, Endocrinology and Diabetes at the University of Michigan. Her clinical practice

focuses on thyroid disorders and thyroid cancer, with a special interest in the treatment of

endocrine disorders in older adults. She conducts health services research in the field of

thyroidology and aging. She is active in the American Thyroid Association and AACE.

19 Mythbusters: Thyroid EditionThe purpose of this article is to shed evidence-based light on some of the more debated topics in thyroidology and separate fact from fiction.

24 A Delicate BalanceA patient’s persistence and an inquisitive endocrinologist help correct a misdiagnosis of Hashimoto’s thyroiditis.

3 This Issue’s Contributors

4 Bioidentical Hormone TherapyThe term “bioidentical hormones” essentially means hormones that are identical to and have the exact same chemical and molecular structure as hormones that are produced in the human body.

6 The Safety and Effectiveness of Supplements & NutraceuticalsOverall, most adults use some form of a dietary supplement with a broad variety ranging from multivitamins to those with alleged performance enhancement in sports.

10 The More You Know: StatinsStatins are a group of drugs prescribed by your doctor to lower the level of cholesterol in your blood.

12 Adrenal Fatigue – Truth or MythAdrenal insufficiency may not be initially recognized as the symptoms are vague and may overlap with many other disorders.

14 If It’s Not My Thyroid, Then What Is It?Fatigue, weight gain, mood swings, poor concentration, memory issues, sweating, heart palpitations – your internet search says these are all symptoms of thyroid disease…but what happens when thyroid blood tests are actually normal?

18 Can You have Hyperpara-thyroidism with a "Normal" Calcium and/or "Normal" Parathyroid Hormone Level?Primary Hyperparathyroidism (PHPT) is a condition of hormonal imbalance– too much calcium and/or parathyroid hormone (PTH) in the blood. It is an underdiagnosed and undertreated disease that is caused by a benign tumor in one or more parathyroid glands.

12

TA B L E O F C O N T E N T S

14 19

AMERICAN COLLEGE OF ENDOCRINOLOGYSandra L. Weber, MD, FACP, FACE PRESIDENT

Howard M. Lando, MD, FACP, FACE PRESIDENT ELECT

Felice A. Caldarella, MD, FACP, CDE, FACE VICE PRESIDENT

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTSSandra L. Weber, MD, FACP, FACE PRESIDENT

Howard M. Lando, MD, FACP, FACE PRESIDENT ELECT

Felice A. Caldarella, MD, FACP, CDE, FACE VICE PRESIDENT

Paul A. Markowski, CAE CHIEF EXECUTIVE OFFICER, AACE

EMPOWER EDITORSMaria Papaleontiou, MD EDITOR-IN-CHIEF

EDITORIAL BOARDRicardo Correa, MD, Es.D, FACPMelanie R. Goldfarb, MD, MS, FACSScott Isaacs, MD, FACP, FACECheryl R. Rosenfeld, DO, FACP, FACE

AACE STAFFGlenn Sebold DIRECTOR OF RELATIONSHIPS

Amy Price ASSISTANT DIRECTOR OF GRAPHIC DESIGN

®

EmPower® Magazine, published by the American College of

Endocrinology (ACE), the educational and scientific arm of

the American Association of Clinical Endocrinologists (AACE),

is dedicated to promoting the art and science of clinical

endocrinology for the improvement of patient care and public

health. Designed as an aid to patients, EmPower® Magazine includes current information and opinions on subjects related

to endocrine health. The information in this publication does

not dictate an exclusive course of treatment or procedure to

be followed and should not be construed as excluding other

acceptable methods of practice. Variations taking into account

the needs of the individual patient, resources, and limitations

unique to the institution or type of practice may be appropriate.

The ideas and opinions expressed in EmPower® Magazine do not necessarily reflect those of the Publisher. ACE is not

responsible for statements and opinions of authors or the

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Email [email protected].

AACE is a professional medical organization with more than

7,500 members in the United States and more than 90 other

countries. Founded in 1991, AACE is dedicated to the optimal

care of patients with endocrine problems. AACE initiatives inform

the public about endocrine disorders. AACE also conducts

continuing education programs for clinical endocrinologists,

physicians whose advanced, specialized training enables them

to be experts in the care of endocrine diseases such as diabetes,

thyroid disorders, growth hormone deficiency, osteoporosis,

cholesterol disorders, hypertension and obesity.

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For more information, visit us at www.empoweryourhealth.org

3EMPOWERYOURHEALTH.ORG

Dr. Adegbenga B. Ademolu

Dr. Adegbenga B. Ademolu is an international Fellow-in-Training of the American Association of Clinical Endocrinologist. He is also a member of the Endocrine Society where he functions as a reviewer for the Journal of Clinical Endocrinology and Metabolism (JCEM), Journal of the Endocrine Society (JES) and Endocrinology. He is on the editorial board of American Endocrine journal.

Dr. Irina Bancos

Dr. Irina Bancos is the Associate Professor of Medicine and works in the Pituitary-Adrenal-Gonadal subdivision of Endocrinology division at Mayo Clinic, Rochester. She also serves as Director of the Endocrine testing center and Associate Program Director for the Endocrine Fellowship. Dr. Bancos received her MD from the Iuliu Hatieganu Medical University in Cluj-Napoca, Romania.

Dr. David A. Cohen

David A. Cohen, MD, FACE, ECNU (@DavidACohen_MD) is an Assistant Professor and the Vice Chair of Education for the Department of Medicine at Robert Wood Johnson Medical School. He is a graduate of the Keck School of Medicine of USC, and completed a residency in Internal Medicine-Pediatrics at The Mount Sinai Hospital, a fellowship in Endocrinology, Diabetes, and Metabolism at the Keck School of Medicine of USC, and the Rabkin Fellowship in Medical Education through Beth Israel Deaconess Medical Center and Harvard Medical School.

Dr. Vishnu Garla

Dr. Vishnu Garla is an assistant professor at the University of Mississippi Medical Center, Jackson, Mississippi. He serves as the Associate program director for the Endocrinology fellowship program as well as the Director of the Pituitary clinic. He completed his residency in Internal Medicine-Pediatrics at Marshall University, West Virginia and Endocrinology fellowship at the University of Mississippi Medical Center.

Matthew Gironta

Matthew Gironta is a Pre-Med student at Drew University majoring in biology, with a minor in sociology. He coaches tennis, has served as a Team Captain for the American Cancer Society's Relay for Life, and is exploring non-verbal forms of communication by working with dogs. Matthew is hoping to become an oncological surgeon in the future.

Dr. Michael Irwig

Dr. Michael S. Irwig is a board certified endocrinologist with a special interest in andrology and transgender medicine. He completed medical school at Cornell University, an internal medicine residency at the University of Virginia and an endocrinology fellowship at the University of Washington. He currently practices at the Medical Faculty Associates/George Washington University where he is Professor of Medicine and Director of Andrology.

This Issue’s Contributors

Dr. Sina Jasim

Dr. Jasim is a faculty member at the Division of Endocrinology, Metabolism and Lipid Research at Washington University in St. Louis, School of Medicine. Her clinical research and practice focus on patients with thyroid and adrenal disorders. She is the Vice chair of the thyroid disease state network at AACE. She completed her residency in internal medicine at Saint Louis University School of Medicine and completed her Endocrinology fellowship training at the Mayo Clinic, Rochester, MN.

Dr. Ekta Kapoor

Dr. Ekta Kapoor is an endocrinologist and women’s health specialist at Mayo Clinic, Rochester, Minnesota. She is an assistant professor of medicine with a joint appointment in the divisions of Endocrinology, Metabolism and Nutrition and General Internal Medicine at Mayo Clinic Rochester. Dr. Kapoor specializes in management of menopause-related issues in women, including an expertise in menopausal hormone therapy.

Dr. Karl Nadolsky

Karl Nadolsky, DO, is a board-certified endocrinologist specializing in diabetes, metabolism and obesity. Dr. Nadolsky earned his degree in kinesiology from Michigan State University and medical degree from Nova Southeastern College of Osteopathic Medicine in Ft. Lauderdale, Florida. He completed his internal medicine residency at Naval Medical Center in Portsmouth, Virginia, and his endocrinology fellowship at Walter Reed National Military Medical Center in Bethesda, Maryland. Dr. Nadolsky is a diplomate of the American Board of Obesity Medicine and his clinical interests include obesity, metabolic syndrome/pre diabetes, lipidology and Type 2 diabetes.

Dr. Sahil Parikh

Sahil Parikh, MD, is currently a Fellow-in-Training at Rutgers Division of Endocrinology, Metabolism and Nutrition in New Brunswick, New Jersey. Dr. Parikh obtained his MD degree in 2014 from Rutgers New Jersey Medical School and completed his internal medicine residency training at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey.

Dr. Fred Singer

Dr. Singer specializes in metabolic bone disease and has a long-term experience in osteoporosis, primary hyperparathyroidism and skeletal complications of malignancy. His experience includes, Professor of Medicine at University of Southern California, Clinical Professor of Medicine at Geffen School of Medicine at UCLA and Attending Physician in Endocrine Clinic of Greater Los Angeles Veteran’s Administration Center and has been presented with the following honors and awards: President of the American Society for Bone and Mineral Research, Chairman of the Board of The Paget Foundation, and Member of the Board of Trustees of the National Osteoporosis Foundation. Dr. Singer received his premedical training at UCLA and attended UCSF School of Medicine.

4 EMPOWER MAGAZINE • FALL 2019

The term “bioidentical hormones” essentially means hormones that are identical to and have the exact same chemical and molecular structure as hormones that are produced in the human body. This includes commercially available hormones that are approved by the United States Food and Drug Administration (FDA) as well as custom compounded preparations made in pharmacies that are not regulated by the FDA. As it turns out, the term “bioidentical” is a marketing term, rather than a medical term, used to convey meanings such as “natural,” “organic” and “plant-derived.” However, it has not been proven that custom compounded bioidentical hormone therapy is more effective or safer than the FDA-approved hormone preparations.

There is a huge demand for custom compounded bioidentical hormones due to widespread marketing and a perception of better safety of these formulations. These products are often promoted as a remedy and preventive strategy for a number of conditions including sexual problems, aging, dementia,

and cancer, etc. Some of these products are also marketed as being safer in comparison to the long-term risks that may be associated with hormone replacement therapy, including breast cancer. However, there is no evidence to support these claims. In fact, these preparations are not regulated by the FDA, and there can be significant batch to batch variation in the amount of the active drug, which leads to the risk of receiving a lower dose, or worse still, higher than prescribed due to variance. There are also concerns regarding the purity of these formulations. As such, these preparations are potentially unsafe, and physicians should discourage the use of compounded bioidentical hormone therapy. It is therefore very important to counsel and educate patients in this regard.

FDA-approved bioidentical estrogen is available in a number of formulations, including pills and preparations to be used on the skin (patches, gels, etc.) Similarly, bioidentical progesterone is available in pill form. Custom-compound

By Ekta Kapoor, MD

Bioidentical Hormone Therapy


hormone preparations are available as capsules, troches, gels, creams, lotions, suppositories, or pellets. The use of pellets should be avoided since they often lead to concentrated doses of the hormone for the patient. Once the pellets have been placed, they cannot be removed, and the patient is left with high levels of hormones until the pellet wears off.

There are some situations where custom compounded hormone therapy is necessary, such as a patient allergy or sensitivity to the preservatives in FDA-approved estrogen products. In this situation, the estrogen can be compounded in a preservative-free base in a pharmacy. For example, a woman with a peanut allergy may be allergic to the FDA-approved micronized progesterone pill because it contains peanut oil, so a product without peanut oil may need to be compounded. Sometimes patients request a particular strength or route of the hormone formulation that is not FDA-approved. In this situation, a custom compounded preparation can also be considered; however, a pharmacy that specializes in custom compounded bioidentical hormone therapy should be used.

Providers who prescribe custom compounded bioidentical hor-mone therapy should include hormone level testing in the saliva or blood as part of routine care of these patients. Patients are often recommended to maintain a certain hormonal profile and make changes to their dosing based on these hormone levels; however, there is no evidence to support this. If a patient does not have the expected response to hormone therapy use and there are concerns regarding absorption of the medication, testing the levels of estrogen hormone in the blood is recommended. However for the most part, in routine care of patients on hormone therapy, there is no role for hormone level testing. The hormone dosing is adjusted based on the control of symptoms and not based on levels of the hormones. Moreover, salivary hormone testing is not reliable at all in this setting and is not recommended.

In general, we prefer to treat patients with the FDA-approved formulations. However, if the patient chooses to stay on custom compounded bioidentical hormone therapy, they should have regular follow-up with their provider, and they should be closely monitored for the adverse effects associated with conventional FDA-approved hormone

therapy, including venous thromboembolism and breast cancer. Women on custom compounded testosterone therapy need to be closely monitored for symptoms and signs of overdosing, including acne, voice changes and increased hair growth.

These preparations are not regulated by the FDA, and there can be significant batch to batch variation in the amount of the active drug, which leads to the risk of receiving a lower dose, or worse still, higher than prescribed due to variance... As such, these preparations are potentially unsafe.


IntroductionObesity is a complex disease of excess fat tissue accumulation and dysfunction that can predispose to other chronic conditions, like type 2 diabetes and high blood pressure. Obesity also results in a variety of disruptions to energy balance that may differ between individuals. Cutting calories (energy) in the diet and increasing energy expenditure (burning calories) are the key factors in losing fat and treating or preventing complications, such as type 2 diabetes. Dietary components, exercise and other lifestyle factors like sleep are also critical for health and fighting back against fat tissue-related diseases (also known as “adiposity-based chronic disease”). Unfortunately, making diet and other lifestyle changes is challenging as human biology and genetics along with environmental factors (including other medical conditions or medications) fight against those efforts. This is why medications, and even surgery, have been developed

to help patients battle the struggles. To learn about some of the new medications that treat type 2 diabetes and help with weight loss, visit http://bit.ly/2kUMCl8. With that in mind, many patients are leary of medications or surgery and prefer to try products marketed as “natural,” which are generally labeled as “supplements” or “nutraceuticals.” Overall, most adults use some form of a dietary supplement with a broad variety ranging from multivitamins to those with alleged performance enhancement in sports.

TermsLet’s first define these terms. “Supplement” technically refers to “a nutrient that may be added to the diet to increase the intake of that nutrient. Sometimes used to mean dietary supplement.” “Nutraceutical” is a more recently devised term that simply combines “pharmaceutical” with “nutrition” and applies to products ranging from

By Karl Nadolsky, DO, FACE


dietary supplements and herbal products to even foods. These include so-called “herbal remedies”, which applies to products made from plants/herbs used for medicinal purposes. Dietary supplements (vitamins, minerals, herbs, etc) do not require review or approval by the Food & Drug Administration (FDA) before being sold. The manufacturing companies are responsible for safety of their products and labelling claims truthfully without misleading. However, they do not have to be reviewed by the FDA before the product is marketed. Legislation in 1994, coined “Dietary Supplement Health Education Act” had good intentions of freedom but unintentionally opened up expansion and promotion of potentially harmful and often ineffective products, touting unproven health claims that cost consumers significant financial loss and perhaps undermine the development of legitimate weight loss medications.

Natural medicationsJust because something is mar-keted as “natural” doesn’t make it safe or effective. Any supplement or “nutraceutical” is technically a medicine based upon definition: “compound or preparation used for the treatment or prevention of disease.” By definition, a “drug” is a substance that has a physiological effect when ingested or otherwise introduced into the body - thus any supplement or nutraceutical that actually has any physiologic effect is a drug. Over-the-counter availability does not make something safe, and if not well-studied or regulated, may not have the desired efficacy or benefits. As an example, there was a very popular and reasonably effective supplement called ephedra or Ma Huang. Ephedra comes from a plant that seemed to have some fat burning and appetite suppression effects but ultimately was tied to very serious side effects, including death, which led to its banishment.

Additionally, as supplements and nutraceuticals are technically medicinal and may actually have drug-like effects, they also may have interactions with other medications that may or may not be well known so they must be cautiously considered for use.

Weight loss supplements are big businessWeight loss is one of the primary reasons people may seek out supplements and in the United States, over $2 billion are spent on weight-loss supplements. A plethora of supplements

have been developed and marketed for weight loss and diabetes over the years, far more than can be reviewed in a brief article. However, there are some resources to help guide those who are interested. The Cleveland Clinic has published a nice guidance tool for patients considering

supplements to help with glucose control and cholesterol levels based on their review of the evidence for benefits versus risks. To dig even deeper, the National Institutes of Health has a very in depth database of many available supplements to help consumers make informed decisions here:ods.od.nih.gov/factsheets/WeightLoss-Consumer

Examples of popular supplements for weight loss and/or diabetesA significant consideration when looking into using a less regulated medication (over-the-counter supplement) is the lack of data that may be either supporting its benefits or revealing its risks along with trusting the manufacters’ claims of ingredients and dosing instructions. Another caution is that many products marketed have combinations of several ingredients, causing confusion as to what those benefits and risks

may actually be along with potential drug interactions.

Orlistat – a lipase inhibitor, meaning it blocks an enzyme that helps with the digestion and absorption of some fats, is marketed over the counter as “Alli.” This is actually a pharmaceutical, but sold over-the-counter, and also comes in a higher dose that is prescription only. It does have fairly reasonable results in trials for weight loss and glycemic control, especially at the higher prescription strength, but must be taken with meals (preferably low fat meals due to expected side effects from not absorbing fat in diet). Additionally, its use is limited by the gastrointestinal side effects (flatulence, oily stool, diarrhea and abdominal cramping). Caution must also be paid to the potential of malabsorbing fat soluble vitamins like A, D, K and E.

Caffeine – a drug that has been utilized for a long time by humans, caffeine does have stimulant effect and some increase in energy expenditure with fat burning. Short-term studies show some benefits for weight loss while long-term trials and observational studies generally support the benefits of coffee and tea (perhaps due to the caffeine) for (Continued on page 8)

Just because something is marketed as “natural” doesn’t make it safe or effective.


fat loss or weight gain prevention and diabetes. Acutely, caffeine can cause reduced insulin sensitivity and higher sugars. Safety concerns are generally only with very high doses near 500 mg/day or 5-6 cups of coffee a day.

Chromium – chromium has been promoted for fat loss and improved glucose control as its deficiency may cause reduced response to glucose in the blood and increased risk of diabetes. The studies on supplementation show some minimal benefits or risks as most people should not be deficient in chromium, which is found in coffee, nuts, green beans and broccoli.

Conjugated Linoleic Acid – fatty acid produced in the digestive tract of ruminants such as cattle, goats and buffalo that may favorably influence lipid metabolism and body composition. This supplement had high expectations but results for fat loss and glucose control have been dissapointing and include adverse effects on cholesterol.

Creatine – known for its relatively well-established benefits for strength training (including increasing muscle mass in elderly), creatine monophosphate supplementation may actually modestly improve glycemic control in combination with exercise, with minimal adverse effects.

Green Tea – green tea obviously contains caffeine so it includes that potential benefit, though some studies have looked at green tea without caffeine and show modest benefit on weight. Minimal safety concerns, especially if consumed as a beverage without other calories added.

Green Coffee – green coffee extract has not lived up to hyped expectations in real life studies. It does seem to have some slight benefits for body composition and “cardiometabolic” health (blood pressure, cholesterol, glucose). Some of its effect may be attributed to the caffeine content.

Forskolin – marketed for fat burning and appetite reduction but the few clinical trials show minimal, if any, benefits, though without significant safety concerns.

Garcinia Cambodia (Hyroxycitric acid) – may slightly decrease appetite and increase fat breakdown but results from studies do not show much benefit for weight. There have been safety concerns reported, especially due to it being combined with other ingredients.

Hoodia Gordonii – initial evidence suggests it suppresses appetite by helping with reducing food intake, though the few human studies have been dissappointing. Minimal safety concerns, though there have been a few reports of heart rate and blood pressure increases along with headaches.

Bitter Orange (synephrine) – synephrine may increase energy expenditure and fat burning though overall benefits in the few studies conducted are unclear. There are safety concerns due to cardiac stimulation, which can be worse when combined with other stimulants.

Glucomannan – a type of water-soluble fiber supplement thought to help with satiety (feeling of fullness) but studies have shown dissapointing results for weight loss and body composition. Some studies show slightly improved glucose control but its use is limited by gastrointestinal side effects.

The Safety and Effectiveness of Supplements & Nutraceuticals (Continued from page 7)

Supplements to Help Lower Blood Sugar

Cinnamon

Alpha lipoic acid

Guar gum

Beta glucan (whole oats/barley)

Garlic

Pectin

Wheat dextrin

Chromium

Bitter Melon

Calcium polycarbophil

Not Recommended - Evidence: Our team does not recommend this product because clinical trials to date suggest little or no benefit.

Recommended with Caution: Preliminary studies suggest some benefit. Future trials are needed before we can make a stronger recommendation.

Supported by P&G

www.clevelandclinicwellness.com/suppreviewFor more detailed information, access full supplement reviews at:

Inulin

Ginseng

Methylcellulose

Alpha linolenic acid (flaxseed oil)

Not Recommended - High Risk: Our team recommends against using this product because clinical trials to date suggest substantial risk greater than the benefit.

Recommended: Several well-designed studies in humans have shown positive benefit. Our team is confident about its therapeutic potential.

Soluble corn fiber

Psyllium

Glucomannan

OTHER FIBERS

Magnesium


White Kidney Bean – touted as a “starch blocker” by interfering with the breakdown and thus absorption of carbohydrates. Some trials have shown a slight benefit for body fat and possibly glycemic control.

Berberine – a natural plant alkaloid historically used for its antibiotic properties found to have benefits for blood glucose and cholesterol, adopted for these uses in Asia. Several studies have shown slight weight loss but fairly good improvements of blood glucose, blood pressure and cholesterol limited by some gastrintestinal side effects. Larger and longer trials would help understand long-term benefits and risks.

Raspberry Ketone –has only been studied in combination with other ingredients and has been insufficiently studied to suggest benefit. Probably no concerning safety issues beyond the adverse effects on personal finances.

Yohimbe – relatively famous for its aphrodisiac lore, yohimbe has been thought to benefit fat loss due to its hyperadrenergic (adrenaline) effects. Despite some suggestion of improved fat loss in high level athletes, it has not been studied well enough in those with obesity or diabetes and has several safety concerns.

Probiotics – the gut microbiome has been found to be very important for health, including body weight and fat along with cardiometabolic health. Having good gut health is important, so probiotics have been marketed for weight loss but have only shown very slight benefits in the trials thus far. There may be some glycemic benefit in those with type 2 diabetes.

ConclusionMost supplements developed and marketed for weight loss and diabetes have not been shown to have great benefits and many are plagued by concerning and/or potential side effects, resulting in risks outweighing the benefits. Even though some supplements/nutraceuticals may have shown some marginal benefit and minimal risks, cost remains the primary concern. With that in mind, remember that these over-the-counter remedies act as medicine (drugs) if they have any benefit and may come with adverse effects. The focus should remain in utilizing the well-studied medications that have been FDA-approved due to benefits that generally outweigh risks. The risks and benefits of each supplement/nutraceutical should be carefully considered in order to make informed decisions with your physician. Improving dietary and exercise habits along with other lifestyle factors (like sleep hygiene and stress reduction) are certainly the most important items to focus on and tend

to be cheaper than most supplements. Remember that with weight and weight-related complications like type 2 diabetes, the combination of diet, exercise, other lifestyle measures plus medications or supplements is key to improving health.

Disclosure: Dr. Nadolsky has previously invested in development of a product which contains berberine, a bioactive compound mentioned in this article.

Supplements to help manage total cholesterol, LDL, and HDL

CoQ10 (as adjunct to statin therapy to lower LDL cholesterol)

Krill Oil

Beta glucan (whole oats/barley)

Garlic

Pectin

Wheat dextrin

Chia Seed

Calcium polycarbophil

Recommended with Caution: Preliminary studies suggest some benefit. Future trials are needed before we can make a stronger recommendation.

Supported by P&G

www.clevelandclinicwellness.com/suppreviewFor more detailed information, access full supplement reviews at:

Niacin

Ginseng

Alpha linolenic acid (flaxseed oil)

Recommended: Several well-designed studies in humans have shown positive benefit. Our team is confident about its therapeutic potential.

Soluble corn fiber

Psyllium

Guar gum

Omega-3 fatty acids (fish oil)

InulinMethylcellulose

Plant sterols and stanols

Flaxseed (ground)

Probiotics - Lactobacillus reuteri NCIMB 30242

Red yeast rice

Resveratrol (grape skin extract)

SoyVitamin D

Not Recommended - Evidence: Our team does not recommend this product because clinical trials to date suggest little or no benefit.

Not Recommended - High Risk: Our team recommends against using this product because clinical trials to date suggest substantial risk greater than the benefit.

Glucomannan

OTHER FIBERSMagnesium


Statins are a group of drugs prescribed by your doctor to lower the level of cholesterol in your blood. Cholesterol is a waxy, fat-like substance in your body’s cells that may be dangerous to your body’s system at high, unchecked levels in the blood. Examples of statins approved by the United States Food and Drug Administration (FDA) and their commonly known names in the pharmaceutical industry are atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor, Altoprev), pravastatin (Pravachol), rosuvastatin (Crestor, Ezallor), simvastatin (Zocor), and pitavastatin (Livalo, Zypitamag).

Your doctor may place you on statins to prevent damage to the arteries that circulate blood throughout your body and the development of heart disease, even if you don’t yet have evidence of such disease.

Among the conditions for which your doctor will place you on a statin is diabetes mellitus. Over time, diabetes is associated with abnormalities in your cholesterol levels that can hasten the rate of damage to your system. High cholesterol in your blood can block arteries by forming a substance called plaque that can stick to the walls of your arteries. Plaque can block the normal smooth transit of your blood along the arteries that convey blood to different parts of your body, thereby causing problems similar to the way that traffic jams do. The problems caused by this blood transit disturbance depend on the type of artery it blocks and the part of your body to which the artery transports blood. Cholesterol can cause a heart attack if it blocks an artery that supplies blood to the heart and can cause a stroke if it blocks an artery leading to the brain. The possibility of these dangers is increased if a heart attack had affected your sibling, father, or mother. Using statins to prevent such conditions is beneficial.

By Adegbenga B. Ademolu, MBBS

The More You Know: Statins



Hypertension (high blood pressure) together with high cholesterol can lead to diseases like heart attack and stroke more quickly than either hypertension or high cholesterol alone. To reduce this risk, statins are used to lower the cholesterol level, particularly in people with obesity and high cholesterol. However, al-though the prevalence of obesity has increased among Americans as well as in virtually all other ethnic groups throughout the world, the presence of obesity itself does not signal the use of statins. Obesity—whether in the trunk, abdominal area, throughout the body, or around major organs like the heart or liver—does not automatically indicate high cholesterol or statin use. If you are obese and your doctor did not place you on statins, discuss it with your doctor and ask whether you have normal cholesterol.

Metabolic syndrome is another reason for using statins, because metabolic syndrome increases the likelihood of developing heart disease, diabetes, and stroke. Also, some individuals are born with a condition (familial hyperlipidemia or hypercholesterolemia) that causes their blood lipids (blood fat) to be much higher than in the average American. Such disease conditions run in their family and, therefore, statin use is often common in their family as well.

Like most drugs, statins have some undesirable effects. Statins can cause muscle aches and joint pain, particularly in elderly patients. If these symptoms occur, discuss them with your doctor, because stopping the statins may ameliorate these complaints. Statins may also cause liver damage, although this is rare. Statins are also known to cause increases in your blood glucose level. Although accidentally taking an overdose of statins probably is not dangerous, it should be reported to your doctor.

If you are using other drugs with statins, there may be an interaction between the statins and the other drugs that increase or reduce the effects of the other drugs. Always let your doctor know the other drugs you are taking before starting statins, in case you need to substitute an alternative drug. Heavy alcohol consumption also affects the way statins work in the body and how they are excreted.

In most cases, the use of statins requires a lifelong commitment to control your cholesterol level. However, particularly if damage your liver nears a dangerous level, your doctor may advise you to stop the statin for a drug holiday so that your liver can recover from the undesirable effects of the statin.

Women are advised not to take statins while pregnant or when trying to conceive, as statins may be harmful to their unborn baby. Breastfeeding mothers are also advised against taking statins. People who have abnormal cholesterol as an inherited problem (familial hypercholesterolemia) who are breastfeeding should stop breastfeeding prior to statin use.

Statins are generally taken by mouth once a day and usually at night, when your body produces less cholesterol. When you use statins, avoid ingesting large quantities of grapefruit juice (ie, ≥1 quart/day). The good news about statins is that they are cost effective and have Medicare and Medicaid coverage.

Your doctor may place you on statins to prevent damage to the arteries that circulate blood throughout your body and the development of heart disease, even if you don’t yet have evidence of such disease.



The adrenal glands are small glands that sit on top of the kidneys and secrete steroid hormones such as cortisol. Adrenal insufficiency is a disorder characterized by low production of cortisol. Patients with untreated adrenal insufficiency complain of fatigue, weight loss, abdominal discomfort, dizziness, and other symptoms. Adrenal insufficiency may not be initially recognized as the symptoms are vague and may overlap with many other disorders.

"Adrenal fatigue" is an unrecognized condition said to be due to the relative deficiency of cortisol in response to chronic stress. A Google search for the term "adrenal fatigue" yielded close to 25 million results, indicating the widespread use of this term. This term has been used in various popular health books (including “Adrenal Fatigue for Dummies”), alternative medicine websites and patient forums. Variable supplements including micronutrients (magnesium, vitamin C) and herbs (basil, aswagandha, and

licorice) and “adrenal” supplements (frequently made from animal adrenal, pituitary, and gonadal glands) are available online for purchase and claim to cure adrenal fatigue. These supplements are expensive, have no proven benefits, and some have been shown to cause harm.

Adrenal Insufficiency versus “Adrenal Fatigue”

By Ricardo Correa, MD, Vishnu Garla, MD, Sina Jasim, MD, Michael Irwig, MD, and Irina Bancos, MD


Adrenal Fatigue - Truth or Myth

Adrenal insufficiency Adrenal fatigue

Deficiency of cortisol and other adrenal hormones. Etiology is au-toimmune, post-surgery, infiltra-tive disorders, pituitary mass.

Believed to be due to the inability of the adrenal gland to meet the increasing demand for cortisol induced by stress.

Clinical features include fatigue, weight loss, dizziness, and ab-dominal discomfort.

May have fatigue, difficulty sleeping or waking up, crave salt and need caffeine to get through the day.


A variety of unsubstantiated methods to diagnose adrenal fatigue have been put forward, predominantly consisting of questionnaires and unvalidated hormone assessments. Commonly used hormonal assessments to diagnose adrenal fatigue consist of testing salivary cortisol at different times of the day (cortisol awakening response, direct awakening cortisol, etc.). These tests have shown inconsistent results in patients with the same symptoms.

If it’s not adrenal fatigue, then what is it?Although adrenal fatigue is not an actual disorder, patients’ symptoms and concerns can be debilitating and need proper evaluation and management. Multiple disorders may present with similar symptoms, which can be misconstrued as adrenal fatigue. The initial evaluation should include a careful history of the symptoms’ origin, progression, history of concurrent chronic disorders and medications. Close attention should be taken to evaluate for psychiatric conditions which may present as fatigue. The most common conditions that can potentially be labelled as adrenal fatigue are:

Adrenal insufficiency: The adrenal glands are not capable of producing cortisol. It may be secondary to either adrenal or pituitary problems. It is characterized by fever, weight loss, abdominal pain, and dizziness and other symptoms.

Chronic fatigue syndrome is characterized by debilitating fatigue along with physical symptoms (at least four of the following: muscle pain, multi-joint pain, sore throat, tender lymph nodes, short term memory loss, headaches, or unrefreshing sleep). It is diagnosed only after ruling out other causes of fatigue.

Obstructive sleep apnea is a sleep-related breathing disorder characterized by complete or incomplete cessation of breath-ing, unrefreshed sleep, excessive daytime sleepiness, and fatigue. Diagnosis is made by performing a sleep study. Treatment involves lifestyle changes for weight loss and continuous positive airway pressure.

Fibromyalgia: Fibromyalgia is often accompanied by fatigue, memory problems, and sleep disturbances. The treatment includes non-pharmacological methods like cognitive behav-ioral therapy, exercise and pharmacological therapy with some drugs that have been approved by the Food and Drug Administration (FDA).

Depression: Depression can manifest as fatigue, loss of appetite, loss of interest and insomnia. The diagnosis can be made with a thorough clinical history and exam. Treatment includes use of behavioral therapy and antidepressants.

In conclusion, not every fatigue is adrenal in origin. It is crucial

that if you have some symptoms suggestive of adrenal insufficiency to visit a board-

certified endocrinologist so he/she can evaluate you and determine what is

the correct diagnosis and treatment if needed.


Multiple disorders may present with similar symptoms, which can be misconstrued as adrenal fatigue.


IntroductionFatigue, weight gain, mood swings, poor concentration, memory issues, sweating, heart palpitations – your internet search says these are all symptoms of thyroid disease…but what happens when thyroid blood tests are actually normal? Should the doctor prescribe thyroid hormone to improve symptoms despite lack of evidence of a thyroid disorder? The answer is no. Current thyroid laboratory testing is very sensitive and specific for thyroid disorders, so when the laboratory tests are normal, thyroid disease is highly unlikely and another cause of symptoms should be sought. Furthermore, taking thyroid hormone for symptom relief in the absence of thyroid disease may cause dangerous irregular heart rhythms and bone loss. It is important to recognize that there are many non-thyroid causes of thyroid-like symptoms and recognizing additional signs may help you and your doctor work together to make the correct diagnosis.

Heart DiseaseWhile no one would miss chest pain or shortness of breath as signs of coronary disease and heart failure, there are other subtler signs that mimic thyroid disease and should never be dismissed. Palpitations are often associated with an overactive thyroid; however, these fast and/or irregular heartbeats may also occur with heart failure or valve disorders. Fatigue is also a sign of coronary disease or heart failure, the latter causing weight gain due to accumulation of fluid in the tissues, which may be seen as swelling, also known as edema. Although pain in the neck or jaw may be seen with certain types of thyroiditis, those are worrisome symptoms for angina or heart attack, and may be accompanied by sweating or nausea. Prompt diagnosis of heart disease limits further damage to heart muscle and disability.

Sleep DisordersMany patients associate their fatigue with an underactive thyroid, but fatigue is a prominent symptom of sleep apnea,

By Cheryl Rosenfeld, DO, FACE, FACP, ECNU and Scott Isaacs, MD, FACP, FACE

If It’s Not My Thyroid, Then What Is It?



a common disorder that affects over 30% of men and over 15% of women in the United States. Recognition of clues like non-refreshing sleep, excessive sleepiness during the day, drowsy driving, irritability, depression, poor concentration, and memory loss may help you to bring this to your doctor’s attention. It is important to diagnose and treat sleep apnea – left untreated it may cause high blood pressure, stroke, coronary artery disease, heart failure and atrial fibrillation. Other sleep problems like narcolepsy, idiopathic hypersomnia, insomnia, shift work disorder, or even being awakened by light or noise may cause daytime fatigue. Prompt identification and resolution will help provide more restful sleep and improved energy.

Liver or Kidney DiseaseLiver and kidney problems can cause fatigue, dry skin, swelling in the legs and ankles and loss of appetite. Laboratory tests may show elevated creatinine for kidney disease or elevated liver enzymes (AST-aspartate aminotransferase, ALT-alanine aminotransferase). Overall, 75-100 million Americans have a common condition known as fatty liver disease which can be a cause of chronic fatigue. Fatty liver disease is caused by a buildup of fat in the liver and is related to increased body fat, genetics and the environment. The diagnosis of fatty liver disease is suspected with abnormal liver tests (although liver tests can be normal) and confirmed with an imaging study such as an ultrasound, CT or MRI scan.

Vitamin and Mineral DeficienciesVitamin and mineral deficiencies are a common cause of symptoms that can be similar to thyroid disease. These symptoms include fatigue, aches and pains, dry or flaking skin, cracks in the corners of the mouth and numbness in the extremities. Vitamin B12 and vitamin D are the most common vitamin deficiencies although there can be many others, especially with people who don’t eat enough vegetables and fruits. Vitamin B12 deficiency is more common in people who eat a vegetarian or vegan diet. Iron is the most common mineral deficiency. Iron deficiency is

caused by either blood loss (such as a bleeding ulcer, colon polyp, heavy menstruation) or malabsorption (caused by intestinal disorders). Vitamin and mineral deficiencies can be identified with blood tests done by a primary care physician or endocrinologist and adequately treated with

supplementation.

Blood DisordersDisorders of red or white blood cells can mimic thyroid disorders with symptoms like fatigue, weakness, feeling cold, excessive sweating, pale skin, easy bruising, shortness of breath, leg cramps, difficulty concentrating, dizziness and insomnia. Low red blood cell counts, also known as anemia, can be caused by iron deficiency or vitamin B12 deficiency, but there are many other causes. Leukemia is a type of bone marrow cancer that produces cancerous white blood cells and can come on slowly (chronic leukemia) or suddenly (acute leukemia). The diagnosis of blood disorders is made with a test called CBC for complete blood count.

Neurologic DisordersFatigue is one of the most common symptoms of neurologic disorders. These include multiple sclerosis, Parkinson’s disease, stroke, traumatic brain injury and myasthenia gravis. There may be accompanying symptoms such as muscle weakness, abnormal skin sensations, headache, constipation, tremor or slow movements. If you suspect that you could have a neurologic disorder, it’s a good idea to check in with your primary care physician or a neurologist.

DepressionIt’s a well-known fact that depression has physical symptoms, many of which are identical to thyroid disease. The most common symptoms of depression are vague aches and pains. Other symptoms include back pain, joint pain, gastrointestinal problems, sleep disturbances, fatigue, weight gain or weight loss. Some patients with depression only have physical symptoms, making diagnosis

(Continued on page 16)

Current thyroid laboratory testing is very sensitive and specific for thyroid disorders, so when the laboratory tests are normal, thyroid disease is highly unlikely and another cause of symptoms should be sought.



Non-traditional doctors and internet sites often tout undiagnosed thyroid disease as a source of a multitude of ailments. But there are many other conditions that can cause thyroid-like symptoms.

a challenge. If all other medical conditions have been ruled out, it’s helpful to consider your mental health as a possible source of symptoms.

Medication Side EffectsComplaints of weight gain and fatigue should always prompt a search for thyroid disease, but when the laboratory tests are normal, a search for the cause of those symptoms should include the medicine cabinet. Medications causing weight gain include steroids, antihistamines, blood pressure medications, antidepressants, and diabetes medications. Fatigue can be caused by antihistamines, antidepressants, supplements (like melatonin), as well as by medications for high blood pressure, anxiety, pain, and even antibiotics. One medication reference lists over 1,000 medications that have fatigue as a side effect. Substances like caffeine and nicotine may cause palpitations and tremors, typical symptoms of an overactive thyroid, but fatigue is seen when the effects wear off. While not all medications in each class cause weight gain and/or fatigue, if you are concerned about one of your medications, you must discuss this with your physician prior to stopping any medication. It is potentially dangerous to stop a medication without a substitute treatment in place.

Lifestyle Along with ruling out serious medical conditions that cause hypothyroid symptoms, consider your lifestyle. Are you living optimally to promote health and wellbeing? An unhealthy diet, lack of adequate physical activity, dehydration

or poor sleep can cause thyroid-type symptoms. A healthy lifestyle includes a nutritious meal plan that contains a lot of vegetables and fruits, daily physical activity, 1½-2 quarts of water a day and 7-9 hours of restful sleep every night. Over-the-counter sleep medications can worsen symptoms because of side effects like daytime sleepiness and weight gain. Instead of medication, try to have good sleep hygiene with consistent bedtimes, avoiding stimulating activities (like internet browsing or social media) before bedtime and have a dark, quiet bedroom.

Excessive stress from family, job or finances can have physical symptoms that mimic thyroid disease, so it’s always helpful to find ways to reduce stress in your life. Excess alcohol use (more than 1 per day for women, 2 per day for men) can mimic thyroid symptoms like fatigue and weight gain. Excessive caffeine can cause fatigue, racing heart and rebound headaches.

ConclusionNon-traditional doctors and internet sites often tout undiagnosed thyroid disease as a source of a multitude of ailments. But there are many other conditions that can cause thyroid-like symptoms. If thyroid blood tests are normal, a thyroid disorder is highly unlikely. Your doctor should monitor thyroid function tests periodically and refer you to an endocrinologist if necessary. Work with your physician to consider all the possibilities for your symptoms and focus on living a healthy lifestyle.

If It’s Not My Thyroid, Then What Is It? (Continued from page 15)


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Primary Hyperparathyroidism (PHPT) is a condition of hormonal imbalance– too much calcium and/or parathyroid hormone (PTH) in the blood. It is an underdiagnosed and undertreated disease that is caused by a benign tumor in one or more parathyroid glands. In PHPT, a parathyroid gland “‘goes rogue”, continuously producing parathyroid hormone (PTH) and ignoring signals from the body to stop. PHPT is usually sporadic (though about 5% of cases are genetic/familial) and the incidence is about 2% in middle-aged and older individuals but can occur at any age. The only cure, when deemed necessary, is an outpatient surgical procedure.

The parathyroid glands regulate the calcium levels in the body. There are generally four glands, which are very small (about the size of a grain of rice) that sit behind the thyroid gland. Calcium is the fuel, or energy source of all of the body’s cells, and therefore too much or too little can cause a wide range of symptoms. When PTH levels rise, the body thinks that it needs more calcium, so it steals calcium from the bones, which causes a decrease in bone mineral density - osteoporosis. It also steals calcium from the intestines, and sometimes deposits calcium in the kidneys, which causes kidney stones. Other more common symptoms of primary hyperparathyroidism can include fatigue, weakness, mental confusion, difficulty concentrating, depression, anxiety, waking up to go to the bathroom, itching, and sexual dysfunction. It also increases morbidity and mortality in patients who have underlying heart and vascular disease.

“Classic” primary hyperparathyroidism is when both the calcium and PTH levels are significantly elevated. Historically, clinicians did not recommend surgery unless someone had these specific lab values. However, over the past decade, the endocrine community has come to recognize that not all parathyroid disease is created equal, and that the disease manifests itself in different ways, which can still cause harm

and side effects. Calcium and PTH work like the scales of a pendulum – if one level goes up, the other is supposed to go down significantly; if it doesn’t, then the body’s normal regulation of calcium is not working as a result of PHPT.

Patients might have seemingly “normal” lab values, but still have primary hyperparathyroidism. This can come in the form of “normocalcemic” (i.e., calcium level is normal or mid-normal but PTH is high), “normohormonal” (i.e., calcium and PTH are in normal range, but usually on the higher end of normal, and patients have symptoms that cannot otherwise be explained), or “inappropriately high PTH” (i.e., calcium is slightly elevated and PTH is either slightly elevated or the high end of normal). Surgical outcomes are equally beneficial in normocalcemic and hypercalcemic patients according to recent studies, but a higher percentage of patients have multi-gland disease (i.e., more than one parathyroid gland will need to be removed).

Patients should be aware of the different presentations of primary hyperparathyroidism. Personalized and individualized treatment plans are necessary and many, but not all, diagnoses of hyperparathyroidism need treatment.

Can You Have Hyperparathyroidism with a "Normal" Calcium and/or "Normal" Parathyroid Hormone Level?

The parathyroid glands regulate the calcium levels in the body. There are generally four glands, which are very small (about the size of a grain of rice) that sit behind the thyroid gland.

By Melanie Goldfarb, MD, MS, FACS and Fred Singer, MD



here are countless myths and misconceptions associated with this silver dollar-sized tissue that have spread throughout the mainstream health and fitness culture... The purpose of this article is to shed evidence-based light on some of the more debated topics in thyroidology and separate fact from fiction.

By David A. Cohen, MD, FACE, ECNU and Sahil Parikh, MD

T


The thyroid gland is the small butterfly-shaped organ at the base of your neck that regulates your body’s metabolism. Every cell in the body counts on an appropriate amount of thyroid hormone. Too much

thyroid hormone (called hyperthyroidism) can be a problem, leading to damage to the heart, bones, muscles and so much more, while causing many symptoms, including weakness, anxiety, and insomnia. On the other hand, too little thyroid hormone (called hypothyroidism) can damage the same organs, and contribute to weight gain, “brain fog,” and infertility, just to name a few. However, there are countless myths and misconceptions associated with this silver dollar-sized tissue that have spread throughout the mainstream health and fitness culture. From mild cognitive impairment to intractable chronic pain to morbid obesity (and just about everything in between), almost any symptom can be attributed to being a “thyroid issue”. While abnormal thyroid function absolutely will lead to significant symptoms, we need to be careful not to wrongly attribute every symptom to the thyroid. There now exists a small but vocal community that advocates for unproven solutions regarding thyroid testing and treatments. The purpose of this article is to shed evidence-based light on some of the more debated topics in thyroidology and separate fact from fiction.

To rT3 or not to rT3?The thyroid gland makes thyroxine hormone, called T4, which is then converted into either triiodothyronine (T3) or reverse T3 (rT3). If there is not enough T4 or T3, the pituitary gland responds by releasing more Thyroid Stimulating Hormone (or TSH) in order to drive increased production of T4 and T3, maintaining hormone levels within the normal ranges. Therefore, the first lab finding that is seen in hypothyroidism is an elevated TSH. On the other hand, TSH decreases in hyperthyroidism. TSH goes in “the opposite direction” of the function.

While T3 is the active form of thyroid hormone, reverse T3 is simply a breakdown product and has no effect on the body. Though evidence-based guidelines advise measuring only TSH, T4, and/or T3 to understand thyroid function, many

continue to push for routine checking of rT3. We know from our understanding of physiology, extensive well-validated studies, and tremendous experience working together with our patients that a good clinical history of symptoms, a detailed physical exam, and measurement of the appropriate hormones are more than enough to diagnose a patient with thyroid disease. Evidence supporting routine rT3 checks is scant to say the least. Reverse T3 levels exist in the body for a very short time (compared to T3 and T4) and can be affected by many factors including illness and medications. Additionally, all medications used to treat hypothyroidism and hyperthyroidism will affect rT3 levels. For example, if a patient is taking T4 or T3 replacement, rT3 will rise for a very short time after taking the medicine; therefore, checking rT3 may make one think that the medicine is too much or too little. All of this makes rT3 level interpretations highly unreliable for

MythBusters: Thyroid Edition


thyroid evaluation and treatment, rendering routine testing unnecessary and costly. Therefore, most healthcare providers rightfully refrain from routine checking of rT3 levels.

The Thyroid Diet, Supplements, Vitamins, and MineralsIodine is the building substrate for thyroxine hormone. Iodine deficiency and its subsequent effects on thyroid gland are well known. Fortunately, in the United States, most people can obtain sufficient iodine (approximately 150 micrograms/day) through their daily dietary intake. In many individuals, excess iodine intake can actually cause hypothyroidism (called the Wolff-Chaikoff Effect) or hyperthyroidism (called the Jod-Basedow Phenomenon).

Selenium is another micronutrient that is needed for normal production and use of thyroid hormone. Selenium also appears to act as an antioxidant (protecting the thyroid from free radical damage) with anti-inflammatory properties. Evidence shows that selenium supplementation improves eye disease in patients with autoimmune hyperthyroidism (called Graves’ Disease), but this benefit is likely limited to individuals with selenium deficiency. If there is a concern for a lack of selenium (which is very rare in the United States), replacement with 50-100 micrograms per day may be beneficial.

Zinc helps convert T4 to T3. Its deficiency can lead to increased production of rT3, which, as stated above, is biologically inactive. Therefore, zinc replacement is unlikely to have any benefit.

Vitamin A and D deficiencies have been associated with hypothyroidism and autoimmunity. However, there is no evidence that their deficiencies actually cause thyroid disease. It is worthwhile to check vitamin D levels in patients with thyroid disease and to provide supplementation if there is a deficit, but this isn’t expected to improve thyroid function.

Iron is necessary for normal thyroid hormone production. Healthcare practitioners will often check for iron deficiency in patients who have thyroid disease, particularly given the increased risk of autoimmune gastrointestinal conditions (such as celiac disease and gastritis) in patients with thyroid disease.

Many advocate for various special diets, including gluten free, anti-inflammatory, paleo, and keto as cures for hypothyroidism. Unfortunately, while eating healthy is beneficial for maintenance of overall health, there are no clinical studies or scientific data to show that any particular diet can prevent or treat thyroid disease.

While eating healthy is beneficial for maintenance of overall health, there are no clinical studies or scientific data to show that any particular diet can prevent or treat thyroid disease.

(Continued on page 22)


Euthyroid Hashimoto’s & Subclinical Hypothyroidism: Where Do We Draw the Line in the Sand?Hypothyroidism can be caused by many different things. The cause can be as straightforward as surgical removal. Severe and prolonged iodine deficiency can also be a cause. In the Western world, autoimmune inflammation called Hashimoto’s thyroiditis, thought to be a combination of genetic susceptibility and environmental factors, is the most common cause of hypothyroidism. Hashimoto’s thyroiditis is highly suggested in the setting of certain blood tests (thyroglobulin antibodies or TPO antibodies) or evidence from a thyroid ultrasound (which isn’t typically recommended or necessary).

There are no symptoms related to Hashimoto’s thyroiditis, other than if the chronic autoimmune inflammation causes gland failure (hypothyroidism). This destructive process varies widely from patient to patient - it can be very rapid or can evolve slowly over many, many years.

“Euthyroid Hashimoto’s” is the term used when people have one or both of the antibodies to the thyroid gland, but their TSH and T4 levels are normal. There is no treatment of the Hashimoto’s thyroiditis, only thyroid hormone replacement if hypothyroidism occurs. Where genuine controversy does exist within the medical community is the precise point at

which thyroid replacement is warranted, considering that a mildly elevated TSH has been suggested to perhaps be a normal manifestation of aging. There are some conditions in which there are (or may be) adverse effects associated with mild hypothyroidism (termed subclinical hypothyroidism):

• Obesity and diabetes

• Cholesterol

• Increased risk of heart attack, heart disease, and death from heart disease

• Stroke

• Depression and bipolar disease

• Muscle weakness and exercise intolerance

• Hip fractures

• Pregnancy-related complications, including pre-eclampsia, infertility, postpartum hemorrhage, miscarriage, and preterm delivery

It is essential that we remember that “association does not mean causation,” so we shouldn’t jump to treating everyone who has subclinical hypothyroidism and falls into one of the above categories. Rather, this is best approached individually with each patient, deciding to treat based on what together the health care practitioner and the patient think is best for the patient.

Mythbusters: Thyroid Edition (Continued from page 21)

It is essential that we remember that “association does not mean causation.”

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”C.K.” 60, has worked as a life insurance and financial planner as well as a naturopathic doctor (ND) for almost 40 years. In her day to day life, she helps lots of agents and clients, but her work as an ND allows her to educate people so that they can make informed decisions regarding their health. C.K. relates that in her state, a naturopathic doctor cannot write prescriptions like a traditional doctor would, but she is able to “coach and educate people…and become a product resource for them,” and then those patients can decide whether or not to explore what she has suggested. She spoke about balancing her health, including naturopathic medicine and traditional medicine, “When you help somebody get better it’s just a wonderful thing, it makes their quality of life that much better.”

However, in 2016, C.K. began to exhibit some troubling symptoms of her own despite taking supplements to improve her health. When she would take a walk her “heart rate went

up and my feet swelled,” she was losing her hair and lost 20 lbs. without trying. Based on her symptoms and a negative cardiac work up, her doctor diagnosed her with Hashimoto’s thyroiditis and prescribed Armour thyroid. Unfortunately, she felt worse after starting the new medication - she could not get out of bed in the morning and would sit there and want to cry. She interpreted this as depression related to having to take medication, as she preferred not to take prescriptions per se, and returned to the physician three months later for reevaluation. Her doctor took her off the medication and her depression got better, “I felt like a normal human being the following day.”

She subsequently sought out a holistic doctor and a functional medicine specialist, who both continued to tell her she had Hashimoto’s thyroiditis and treated her with low dose naltrexone, other supplements (many that contained iodine) and an elimination diet. None of these measures

By Matthew Gironta


A Delicate Balance

25EMPOWERYOURHEALTH.ORG 25EMPOWERYOURHEALTH.ORG

improved her symptoms. It was at this time she related, “I was misdiagnosed for two years with Hashimoto’s thyroiditis.” Hashimoto’s thyroiditis is an autoimmune disease in which our own antibodies attack the thyroid, potentially causing it to become enlarged and malfunction. This can be diagnosed by a physician by testing for antibodies (such as thyroid peroxidase) in the blood stream. As the antibodies typically do not cause symptoms and not all patients with Hashimoto’s thyroiditis have abnormal thyroid function, thyroid medication should only be prescribed if the thyroid function tests, like thyroid stimulating hormone (TSH) and thyroxine (T4), are abnormal. Armour thyroid was not the correct treatment for her symptoms.

When the situation did not improve, C.K. went to see an endocrinologist, who discovered that she did not have Hashimoto’s thyroiditis. Instead, she had an overactive thyroid related to her iodine and other supplements. The endocrinologist recommended that she stop the iodine supplements because that was furthering the overproduction of thyroid hormone. She was placed on a low iodine diet, and advised on appropriate amounts of cofactors such as manganese and selenium. After this change, her thyroid tests improved and she felt significantly better.

Through the two years of doctors and testing, C.K. kept her upbeat spirit and attitude. Even before the diagnosis she was very health conscious, recommending food journaling, avoidance of over-processed foods and paying attention to symptoms. Her advice is that since herbs are food and medicine, be “aware of what you are taking and how you are using it.”

Overall, she says the most important thing for a patient to do is to work with someone “who is open to you and to ask questions. If you don’t give feedback to the person that’s trying to help you, they can’t modify what they are doing.” She credits her persistence with obtaining the correct diagnosis and treatment. Working with her endocrinologist, she is now on the right balance of supplements and is taking in an appropriate amount of iodine in her diet.


Through the two years of doctors and testing, C.K. kept her upbeat spirit and attitude. Even before the diagnosis she was very health conscious, recommending food journaling, avoidance of over-processed foods and paying attention to symptoms. Her advice is that since herbs are food and medicine, be “aware of what you are taking and how you are using it.”

Thank YouThe American College of Endocrinology (ACE) and the American Association of Clinical

Endocrinologists (AACE) would like to thank AbbVie and Lilly Diabetes for their support of the EmPower initiative.

Supported by a sponsorship from AbbVie.

ALSO IN THIS ISSUE - Empower...Dr. Vishnu Garla Dr. Vishnu Garla is an assistant professor at the University of Mississippi Medical Center, Jackson, Mississippi. He serves as the Associate

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