Chapter 3/ Thyroid and related disorders

How much the thyroid gland weigh, where is located, what is the shape of it and what is its role in the body?
The thyroid gland is a small, butterfly-shaped gland found just below the Adam’s apple. Although it weighs
less than an ounce it produces hormones that influence essentially every organ, tissue, and cell in the body,
thus, having an enormous effect on health.

What is the physiology of the thyroid gland hormones production??

From the ipad
Abbreviations:
(TSH) thyroid stimulating hormone
(T4) thyroxine, a thyroid hormone named for its four molecules of iodine
(T3) triiodothyronine, a thyroid hormone named for its three molecules of iodine.

Which hormone is the most predominant form of the thyroid hormones?

T3 is the most predominant and active form of thyroid hormone that the body can use.

Which processes does the thyroid gland regulate in the body?

fat and carbohydrate metabolism, body temperature, and heart rate.

List the 3 hormones that the thyroid produces?

T3, T4 and calcitonin
What is the role of calcitonin in the body?
a hormone that helps regulate the amount of blood calcium

What are the requirements of these hormones?

The synthesis of these hormones requires tyrosine, a key amino acid involved in the production of thyroid
hormone, and the trace mineral iodine.

Is HPT axis a part of endocrine or exocrine system?

The HPT axis is part of the endocrine system responsible for the regulation of metabolism.

How the body controls the production of the thyroid hormones, not too much or too less? By which
product?
The biosynthetic processes resulting in generation of thyroid hormones within the thyroid gland are
controlled by feedback mechanisms within the HPT axis.

What is TBG?
thyroid-binding globulin, a protein that transports thyroid hormones through the bloodstream,
In which form the thyroid hormone, T4, is in the blood?
When T4 is released from the thyroid, 1. it is primarily in a bound form with thyroid-binding globulin (TBG),
2. lesser amounts bound to T4-binding pre-albumin.
3. Only 0.03% to 0.05% of T4 within the circulatory system is in a free or unbound form and it is called free T4
4. In peripheral tissues, approximately 70% of T4 produced is either de-iodinated and converted to T3 or rT3,
or eliminated.
What about T3?
T3 is the most metabolically active thyroid hormone.
80% to 85% is generated outside the thyroid gland, primarily by conversion of T4 in the liver and kidneys.
The pituitary and nervous system are also capable of converting T4 to T3 so are not reliant on T3 produced in
the liver or kidney.

Pituitary gland and nervous system uses the T3 that is converted by the liver and kidney, right or false
statement?
False statements.
Which one is the predominant the
T4 since most of the produced is T4
or T3 since it is the active form?
‫سؤال للدكتورة‬

What each one of the following values reflect in the physical signs?
What are the conditions that causes the inhibition of 5-deiodinase?

What does hypothyroidism/ under active thyroid mean?

the thyroid gland doesn't make enough thyroid hormones to meet your body's needs.

What is the most common cause for hypothyroidism? What is the name of the disease?
More than half are due to an autoimmune disorder called Hashimoto’s thyroiditis
What does Hashimoto’s thyroiditis do?
It is an auto immune disorder in which the immune system attacks and destroys thyroid gland tissue.

What are the typical symptoms for hypothyroidism?

Low energy. Hypercholesterolemia.
- Cold hands and feet. - Muscle pain.
- Fatigue. - Depression, and cognitive deficits.

What/ how hypothyroidism start? What are the triggers?

1. Adrenal Stress and Oxidative Stress:
Low thyroid function is almost always secondary to some other condition, often adrenal fatigue.
2. Aging:
The incidence of hypothyroidism increases with age. By age 60, 9% to 17% of men and women have an under-
active thyroid.
3. Menopause:
The relationship between thyroid hormone and the gonadal axis is well established; however, there are few
studies on the relationship between thyroid function and menopause specifically.
4. Pregnancy:
Thyroid dysfunction has been related to obstetric complications such as premature delivery, gestational
hypertension, preeclampsia, and placental abruption.

What is the new recommendation for iodine intake during pregnancy?

The World Health Organization (WHO) recently increased the recommended iodine intake during pregnancy
from 200 to 250 mcg/day
What a hallmark for healthy aging?
Maintaining thyroid hormone function throughout the aging

What are the medical management options for hypothyroidism?

1. Radioactive iodine treatment,
2. congenital defects
3. surgical removal (thyroidectomy),
 4. the conventional pharmacologic approach for treatment is prescription thyroid hormone replacement
medication.
What is the name of the thyroid surgical removal operation?
Thyroidectomy

What are your main recommendations regarding nutrition therapy in hypothyroidism cases?
1. Fasting or Restrictive Diets:
2. Goitrogens:
3. Iodine:
4. Iron
5. Selenium:
Explain each one of the recommendations above?

How fasting or restrictive diet affect thyroid gland function?

1. Calorie and carbohydrate restriction may reduce substantially thyroid hormone activity.
2. Nutritional status and energy expenditure influence thyroid function centrally at the level of TSH
secretion, de-iodination, and possibly elsewhere.
3. This varies widely between individuals. Genetics, obesity, gender, and the macronutrient content of the
hypo-caloric diet influence the response.
4. Because an increase of rT3 is found at the expense of T3 during caloric restriction, it is possible that the
hepatic pathways play a substantial role in metabolic control during energy balance. )‫(مش فاهمتها‬
5. Overall during fasting, there is a down regulation of the hypothalamus-pituitary-thyroid axis, which is
assumed to represent an energy-saving mechanism, instrumental in times of food shortage.
What are goitrogens and how they may lead to hypothyroidism?
They are cyanogenic plant foods from the cruciferous vegetables that exert antithyroid activity HOW????
Through inhibition to TPO.
Two mechanisms
1. The hydrolysis of some glucosinolates found in cruciferous vegetables may yield goitrin,
What is goitrin? a compound known to interfere with thyroid hormone synthesis.
2. The hydrolysis of indole glucosinolates results in the release of thiocyanate ions, which can compete
with iodine for uptake by the thyroid gland.
It is important to know that the increased exposure to thiocyanate ions from cruciferous vegetables does
not increase the risk of hypothyroidism unless accompanied by iodine deficiency.
(cauliflower, broccoli, cabbage, Brussels sprouts, mustard seed, turnip, radish, bamboo shoot, and cassava)

Other important source for protein is soybean which is used in many developing countries which also has
goitro-genic properties when iodine intake is limited.

The isoflavones, genistein and daidzein, inhibit the activity of TPO and can lower thyroid hormone synthesis.
‫(من وين بيجوا)؟‬
How much iodine is in the human body?
As a trace element, iodine is present in the human body in amounts of 10 to 15 mg.
Where most of it is located?
70% to 80% of it is located in the thyroid gland.
In which form it is available?
90% of it is organically bound to thyroglobulin (Tg).

Iodide is actively absorbed in the thyroid gland to help produce the biochemically active thyroid hormones T4
and T3. How much iodine must the thyroid capture to do its activities?
Minimum of 60 mcg of iodide (the ionic form of iodine?) daily.
Why iron is important in the MNT in Hypothyroidism?
Because TPO is a glycosylated heme enzyme that is iron-dependent and the insertion of heme iron into TPO is
necessary for the enzyme to translocate to the thyroid epithelial cells, thus assisting TPO to catalyze the two
initial steps of thyroid hormone synthesis. What are they?
Why selenium is important in the MNT in hypothyroidism?
Because selenium, as selenocysteine, is a cofactor for 5-deiodinase and if selenium is deficient, the deiodinase
activity is impaired, resulting in a decreased ability to de-iodinate T4 to T3.

What is the most common cause for hyperthyroidism? And what is it?
Graves’ disease: is an autoimmune disease in which the thyroid is diffusely enlarged (goiter) and overactive,
producing an excessive amount of thyroid hormones.
What is the name of enlarged thyroid?

What are the common symptoms?

− Red, dry, swollen, puffy, and bulging eyes − Difficulty sleeping.
(exophthalmos). − Anxiety.
− Heat intolerance

What is the pathophysiology of hyperthyroidism? Explain the state of hormones in such a case?
1. The TRH receptor itself is the primary auto-antigen and is responsible for the manifestation of
hyperthyroidism.
2. The thyroid gland is under continuous stimulation by circulating autoantibodies against the TRH
receptor
3. and pituitary TSH secretion is suppressed why???because of the increased production of thyroid
hormones
what causes the onset of hyperthyroidism or what are the triggers?
1.Genetic factors:
contribute to approximately 20% to 30% of overall susceptibility.
2. Stress: how!!?
1. Stress can be a factor for thyroid autoimmunity. Acute stress-induced immunosuppression may be
followed by immune system hyperactivity, which could precipitate autoimmune thyroid disease.
2. This may occur during the postpartum period, in which Graves’ disease may occur 3 to 9 months after
delivery. Estrogen may influence the immune system, particularly the beta-cells.
3. Trauma to the thyroid also has been reported to be associated with Graves’ disease. This may include
surgery of the thyroid gland, percutaneous injection of ethanol, and infarction of a thyroid adenoma.
3. Other factors include infection, excessive iodide intake, stress, female gender, steroids, and toxins.
NOTE: hyperthyroidism only has medical management. What is it?

Is surgical removal of the thyroid common? NO

What is PCPS/ define it?

It is a condition characterized by reproductive issues such as amenorrhea or other menstrual irregularities,
anovulation: lack or absence of ovulation, enlarged ovaries with multiple cysts, and infertility. Generalized
symptoms:
acne
hirsutism
male-pattern baldness
obesity
sleep apnea.

What are the biochemical and endocrine abnormalities in PCOS patient?

1. hyperandrogenic state means? a higher concentration of free androgens (dehydroepiandrosterone,
testosterone, and androstenedione)
2. decreased hepatic production of sex hormone binding globulin.
3. hyper-insulinemia
4. impaired glucose tolerance
5. hyperlipidemia

What is your nutritional advice for a PCOS girl?

My nutritional intervention is focusing on enhancing insulin sensitivity and this is accomplished by
1. restricting refined carbohydrates and total calories
2. consuming high-fiber foods
3. eat small frequent meals.
Not for everyone but according to tolerance Some patients with insulin resistance feel better on a diet high in
complex carbohydrates (approximately 60% of total calories), whereas others respond better to a low-
carbohydrate diet (40% of total calories)
4. supplementation with vitamin D3 (up to 10,000 IU/day),
5. and chromium picolinate (200 to 1000 mcg/day)
has been reported to improve glucose tolerance, insulin secretion, and insulin sensitivity in human
subjects.
So when you see chromium supplement what you should remember?
How to manage the imbalances in HPT axis?
1. Provide adequate precursors for the formation of T4
Iodide is a limiting nutrient in many individuals for the production of T4. Adequate levels of organic iodide
from which sources? are important in T4 production.
Adequate dietary protein intake is important in establishing proper protein calorie nutrition.
Supplementation with tyrosine does not appear to have a beneficial effect on elevating thyroid hormones.
 2. Reduce anti-thyroidal antibodies
A variety of food antigens could induce antibodies that cross react with the thyroid gland. A food elimination
diet using gluten-free grains and possible elimination of casein, the predominant milk protein, may be
considered for hypothyroidism of unexplained origin.
It also has been suggested that environmental toxins may play a role in inducing autoimmune thyroiditis and
thyroid dysfunction.
Implementing nutritional support and providing adequate levels of vitamin D to support the immune system
may be beneficial.
3. Improve the conversion of T4 to T3
Nutritional agents that help support proper de-iodination by the type 1 5-deiodinase enzyme include
selenium (as L-selenomethionine) and
zinc (as zinc glycinate or zinc citrate).
(Human studies repeatedly have demonstrated consequent reduced concentrations of thyroid hormones
when a zinc deficiency is present.)
In children with Down syndrome, zinc sulfate may reduce thyroidal antibodies, improve thyroid function,
and reduce the incidence of subclinical hypothyroidism.

4. Enhance T3 influence on mitochondrial bioenergetics

Selenium supplementation in animals can
1. improve the production of T3 and
2. lower autoantibodies to thyroid hormones,
3. while improving energy production.
Supplementation with selenomethionine results in
4. improved deiodination of T4, which may improve adenosine triphosphate formation by supporting
improved mitochondrial activity.

5. Use caution with supplements

Lipoic acid reduces the conversion of T4 to T3. Because it is usually not a therapeutic advantage to decrease
peripheral activation of T3 subsequent to T4 therapy, use of lipoic acid supplements in hypothyroid patients
receiving exogenous hormone therapy should be approached with caution.

Which sources are for iodine?

sea vegetables, iodized salt, and seafood
A patient is taking tyrosine supplementation, what is your advice?
What is your advice for down syndrome patient with HPT imbalances?
Give sources for dietary selenium?
Food sources of selenium include the Brazil nut, cod, halibut, yellow fin tuna, salmon, sardines, shrimp,
mushrooms, and barley.
What is the role of selenium in the body regarding thyroid?
If my thyroid patient is taking lipoic acid what I should advise him?

Cushing’s syndrome/ why it occurs?

Too much cortisol remains in the bloodstream over a long period. (endogenous)
The exogenous form occurs when individuals take steroids or other similar medications and ceases when the
medication is stopped.
Endogenous Cushing’s syndrome is rare and occurs as the result of a tumor on the adrenal or pituitary gland.
What are the symptoms of Cushing syndrome?
Weight gain, easy bruising, depression, muscle loss, and weakness are common symptoms. A weight
management protocol may be needed.

* Addison’s Disease/ why it occurs?

Primary adrenal insufficiency, is rare.
insufficient steroid hormones are produced in spite of adequate levels of the hormone ACTH.
Regulation of blood glucose levels and stress management are affected.
Symptoms?
Loss of appetite
Fatigue
low blood pressure
nausea and vomiting
darkening of skin on the face and neck
what is my main nutritional advise for patients with Addison’s disease?
Patients with Addison’s disease should not restrict their salt intake unless they have concurrent hypertension.
Those patients who live in warm climates and therefore have increased losses through perspiration may need
to increase salt intake. ‫بس هدول بكل العالم منحكيلهم يرفعوا من استهالك الصوديوم‬