By Gary M. Pepper, M.D. (This article is for educational purposes only and is not intended as medical advice or treatment) During the Covid-19 pandemic my medical practice has been operating as normally as possible. The other day a young woman arrived wearing a surgical mask with a stack of medical records in hand, for a new patient appointment. Her difficulties began 6 weeks prior with intense tenderness in the right side of her neck just above the clavicle (collarbone) which varied in intensity over the course of about 10 days. Evaluation by her primary care physician uncovered newly elevated thyroid hormone levels. During our discussion she recalled a respiratory tract infection starting a week before the neck pain developed. Still complaining of lung congestion she denied fever or shortness of breath. Sitting comfortably, the thyroid was no longer tender but was slightly enlarged and unusually firm. Reading on it will become clear why my preliminary diagnosis is sub-acute thyroiditis, an inflammation of the thyroid following a viral respiratory tract infection, possibly Covid-19.
The nature of interaction between the thyroid and coronavirus is unknown but we are on the verge of finding out as we investigate cases like this. Until then, our understanding of how other viral infections affect the thyroid can provide grounds for speculation. A good place to start is with Hashimoto’s thyroiditis, also known as chronic lymphocytic thyroiditis. This is a common thyroid disease most often diagnosed in middle-aged women although it can occur in both sexes and all ages. As an autoimmune disease Hashimoto’s results when immune cells and the antibodies they produce attack the thyroid gland. Normally immune cells, known as lymphocytes, with their antibodies are protective against viral and bacterial infection. In autoimmune thyroid disease a population of the affected individuals immune cells begin to destroy thyroid cells instead. Technically this is an inflammatory reaction but unlike many inflammations, Hashimoto’s is generally painless. Being painless, Hashimoto’s can exist for many years before it is detected by routine blood tests for thyroid levels or is discovered on physical exam presenting as an enlarged and lumpy (nodular) thyroid gland.
The development of Hashimoto’s is thought to involve inherited (genetic) factors but also likely requires an environmental trigger such as a virus to initiate clinical disease. The genetic nature of Hashimoto’s is manifest in the occurrence of the disease in multiple members within a family. The type of viral infection promoting this disease is unclear. Some studies point to Epstein Barr virus, commonly called EB virus as a potential trigger for Hashimoto’s activation. EB virus is extremely wide spread found in over 95% of the world’s population. In humans, it generally exists in an asymptomatic state from childhood to old age. In certain individuals, EB virus can create serious illnesses such as mononucleosis or cancers of the lymphoma type. Evidence that EB virus plays a significant role in autoimmune thyroid disease includes finding of the EB viral genetic material (RNA) in the thyroid tissue of 80% of those with Hashimoto’s and 62% of those with Grave’s (hyperthyroidism). 90% of all lymphomas involving the thyroid occur in those with Hashimoto’s, and as just mentioned lymphoma is a characteristic cancer related to EB viral infection.
Why do some people and not others develop the more severe form of EB disease such as lymphoma or autoimmune thyroid disease? The likely explanation is that as mentioned above, genetic factors result in susceptibility to more aggressive complications of the viral infection. Many infectious disease experts are speculating similar genetic factors account for the extreme variability between individuals of complications of Covid-19.
Another form of thyroid inflammation that unlike Hashimoto’s is often painful, is sub-acute or DeQuervain’s thyroiditis. This thyroid disorder tends to occur days to weeks after an upper respiratory illness. The onset is often accompanied by fatigue, generalized muscle pain, low-grade fever and throat pain, which can radiate upward to the ears. At the onset of this disorder thyroid hormone levels are elevated due to destruction of thyroid cells releasing hormone into the blood. Many of the presenting symptoms of sub-acute thyroiditis are those of elevated thyroid levels such as rapid heart rate, sweating, and weight loss. These symptoms usually resolve in a few weeks and in 15-30% of patients due to thyroid tissue destruction permanently under active thyroid function (hypothyroidism) results.
Substantial evidence exists for involvement of viral infection in the development of sub-acute thyroiditis. For example, the occurrence of sub-acute thyroiditis is more frequent in summer when Coxsackievirus infection is most common. Virus particles similar to mumps and flu have also been found in the thyroid of people with sub-acute thyroiditis and outbreaks of this thyroid disease have occurred during mumps epidemics. Some experts believe that sub-acute thyroiditis is a post-viral illness, meaning the body’s immune response persists even after cleansing the body of the virus but in a misdirected manner, attacking molecular targets on the thyroid cells that bear similarities with the virus structure. Interestingly, the occurrence of sub-acute thyroiditis is more common in those with Hashimoto’s.
The presence of HTLV-1 viruses has also been associated with development of autoimmune thyroid disease including both Hashimoto’s thyroiditis and Grave’s disease (hyperthyroidism). Evidence for this involves finding antibodies to HTLV-1 virus in Hashimoto’s and Grave’s patients. About 6% of those with Grave’s and 7% of Hashimoto’s having these antibodies. Since 95% of people with antibodies to HTLV-1 never develop any symptoms, screening people for this infection is currently not being done.
A common question in my medical practice is whether those with Hashimoto’s have increased vulnerability to Covid-19 infection? There have been no formal studies of this as yet but in a poll of the 10 endocrinologists in my group none felt that Hashimoto’s was a risk factor for suppression of the immune system which could result in more severe viral complications. Also, there is no compelling evidence that those with Hashimoto’s have impaired ability to fight infections. Of great interest, a study published in 2022 reports that several cases of Grave’s disease or overactive thyroid function have resulted after SARS-CoV-2 vaccination
Studies indicate that low levels of thyroid hormone can result in impaired immune function without any link to underlying Hashimoto’s. This relationship should motivate those with hypothyroidism to check that their thyroid hormone levels are optimized to help maintain immune function. There is disagreement in the medical community regarding what exactly constitutes best thyroid hormone levels and how to achieve those levels when medication is required. Concerned individuals should discuss this matter with a qualified health care provider and valuable information on this topic can be found at www.metabolism.com.
Another question in the wake of the coronavirus pandemic is whether the virus induces pathological changes in the thyroid such as seen with Hashimoto’s thyroiditis, Grave’s disease or sub-acute thyroiditis. If infection by this virus does affect the thyroid the clinical signs and symptoms could take weeks after recovery from Covid-19 to become apparent. As detailed by the case reported at the beginning of this article, initial symptoms of sub-acute thyroiditis include pain in the throat often radiating upward to the ears, swelling in the lower neck, and tenderness in this area. During the early phase of sub-acute thyroiditis symptoms of elevated thyroid levels can also occur including excessive sweating, persistently feeling hot, rapid heartbeat, shakiness, and unexplained weight loss. Similarly, Grave’s disease can cause these symptoms but without the accompanying tenderness in the thyroid area. If enough damage is done to the thyroid by the inflammation within a few more weeks symptoms of low (hypo) thyroid levels may develop such as feeling unusually cold, muscle cramps, unexplained weight gain, fatigue, constipation and facial puffiness. Individuals are encouraged to consult with their health care professional if experiencing these or other unusual symptoms to determine if they represent a medical disorder.
This article is the first in a series at metabolism.com; “Overweight Kids….Trouble in Paradise”.
In the opener, we touch on many aspects of what can be a toxic tangle. In coming articles we plan to break out and do a deeper dive into each of the aspects presented. Subscribe to metabolism.com below to avoid missing the next article, “ Are Overweight Kids Destined for Diabetes?”
By Gary M Pepper, M.D.
Childhood obesity presents one of the most urgent public health issues in the United States today. The intimate interaction between parents and their children further complicates the problem. Parents shape the eating habits their children develop — but that also means parents can serve as important partners helping their children to make healthier nutritional choices.
About one in three children in the United States are classified as overweight or obese, as Kumar and Kelly note in their review published in Mayo Clinic Proceedings in 2017. These authors point out the prevalence of obesity increases as children get older. A 2014 study published in The New England Journal of Medicine, following children from entry into kindergarten through the end of eighth grade, also found that the prevalence of obesity increased by the time kids reached eighth grade. This research showed more children who were overweight when they entered kindergarten became obese by age 14 years old as compared to their normal-weight kindergarten classmates, with the biggest increase in obesity occurring between first and third grades.
Technically speaking, obesity is defined as a body mass index (BMI) of 30 or greater https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm. Childhood obesity comes with other health issues that affect physical and mental health. As the prevalence of childhood obesity has increased, so too has the prevalence of health complications in childhood typically thought to afflict mostly adults. Unfortunately, childhood obesity also tracks into later years: A high percentage of adolescents with obesity continue to remain obese as adults.
The Rise of Childhood Obesity: Complex Causes, Dangerous Combinations
While endocrine and genetic disorders can lead to obesity, most kids don’t have an underlying endocrine or single genetic cause for weight gain. The 2017 review published in Mayo Clinic Proceedings pinpoints a positive energy balance combined with genetic predisposition for weight gain as the most common cause of obesity for children. In other words, kids are taking in more calories through food than they are expending with physical activity.
Childhood obesity results from complex interactions of factors related to a child’s genetics, epigenetics, and environment along with ecological effects such as family, community, and school. The environmental factors that can lead to weight gain are also quite complex and include:
Adverse life experiences.
Depression.
Parental and general culinary culture conditioning.
Perinatal factors (such as birth size, catch-up growth, antibiotic use).
Psychosocial and emotional distress.
Stress.
Increased caloric consumption, aggravated when specific food intake is resulting in a high sugar burden.
Decreased caloric expenditure.
The last two factors form a dangerous intersection. Sweet snacks and beverages, fast foods, big portions, and high-glycemic foods all contribute to increased caloric consumption. Decreased caloric expenditure due to reduced physical activity and a trend toward sedentary activities (think: computers, phones, tablets, and televisions) is also on the rise. Together, more calories taken in and less caloric expenditure creates the positive energy balance spurring weight gain.
The current pandemic paints a dire picture. With fewer opportunities for activity and a marked increase in negative emotional triggers, today’s kids are facing a unique challenge. Children need support and guidance to make healthy choices perhaps more than ever before.
Health Issues Associated With Childhood Obesity
Childhood obesity can have serious health implications, with complications manifesting both during adolescence and later in life. Related health issues include:
Diabetes
Children with obesity run an increased risk of developing diabetes. Along with the challenges of managing diabetes itself comes the risk of additional acute and chronic complications.
Abundant research has shown an association between weight in adolescents and the development of diabetes in adulthood. In the past 20 years the incidence of obesity in children and the incidence of diabetes in adulthood has increased hand-in-hand.
A 2017 study by Meyers-Davis et al in The New England Journal of Medicine found the incidence of both type 1 and type 2 diabetes increased significantly among youths between 2002 and 2012. Type 1 diabetes — which usually develops before the age of 35 years and requires insulin treatment — is not necessarily associated with being overweight. Type 2 diabetes, on the other hand, is typically associated with onset after the age of 35 years and almost always has overweight as the major factor.
Despite the common assumption that type 1 diabetes is the “worse” of the two types of diabetes, a study by Constantino et al published in Diabetes Care in 2013found that early-onset type 2 diabetes came with greater mortality, more complications, and more unfavorable cardiovascular disease risk factors than type 1. Early-onset type 2 diabetes can also create metabolic challenges that last a lifetime.
Cardiovascular Complications
Weight in childhood can play into cardiovascular health later in life. Twig et al examined the association between body-mass index (BMI) in late adolescence and death from cardiovascular causes as adults, In 2016, their research paper in The New England Journal of Medicine, concludes that overweight and obesity at a young age was strongly associated with increased cardiovascular deaths in adulthood. A 2013 study in Diabetes Care also noted cardiovascular deaths drove the increased death rate associated with type 2 diabetes, with many deaths occurring right in the prime of life.
All in all, childhood obesity can lead to various cardiovascular complications, including:
Heart disease.
High blood pressure.
Stroke.
Sudden death
Cancer
Diabetes and being overweight have been associated with an increased risk of several cancers, both as individual causes and as intertwined factors. Pearson-Stuttard et al looked at the incidence of cancers (such as liver and endometrial cancers) that could be attributed to diabetes and high BMI in a 2018 study in The Lancet Diabetes & Endocrinology. The study found many cancer cases linked to the prevalence of both. Though the combined effects are striking, the research also indicated that high BMI alone was responsible for twice the number of cancer cases caused by diabetes itself.
Other Health Issues in Childhood and Beyond
Kids (and even parents) might think about many of the above risks as “adult” problems. However, childhood obesity is not just about a risk of death many years in the future. Kids can start experiencing the effects of obesity as young adults — or even earlier.
For example, a study by He et al in Fertility and Sterility published in 2018 investigated the association between childhood obesity and infertility in women. The research noted that childhood obesity appeared to increase the risk of infertility for women of reproductive age.
The 2017 review in Mayo Clinic Proceedings also listed a range of systems in the body that can be impacted by obesity during childhood, including:
Dermatological.
Endocrine.
Gastrointestinal.
Musculoskeletal.
Neurologic.
Pulmonary.
As noted in that review, childhood obesity can have psychosocial consequences as well. Children with obesity are more likely than their peers to experience bullying and discrimination, and they may contend with anxiety, depression, and poor self-esteem.
What Can Parents Do Today?
The 2017 review from the Mayo Clinic underscores family-based lifestyle interventions as a cornerstone of weight management for kids. This approach is twofold, incorporating dietary modifications and increased physical activity.
Parents can guide kids learning to make healthier choices for their meals and snacks while encouraging unstructured physical activity (like playing outdoors) for younger kids and more structured physical activity (such as after-school sports) for older kids. At the same time, parents should limit screen time for tasks other than schoolwork — the Mayo Clinic recommends less than two hours of screen time per day for kids older than 2 years old and avoiding screen time altogether for kids younger than 2.
That’s easier said than done, of course. In the current pandemic reality, finding opportunities to turn off the screens and get outside are harder to come by than ever before. Even in the best of times, financial and cultural barriers to healthy eating and physical activity still exist. We’ll explore how parents can empower kids to change their dietary and activity habits later in this series.
Obesity can impact just about every part of the body, and obesity in childhood can have serious implications for years to come. Parents can play a big role in getting their kids motivated to change their eating habits. By offering a compassionate, nonjudgmental source of support, parents can give their kids the tools they need to make healthy and sustainable changes.
Metabolism.com and Dr. Gary Pepper wish to acknowledge and thank Farryl Last for her expert assistance in the preparation of this article,
Elizabeth J. Mayer-Davis, Ph.D., Jean M. Lawrence, Sc.D., M.P.H., M.S.S.A., Dana Dabelea, M.D., Ph.D., Jasmin Divers, Ph.D., Scott Isom, M.S., Lawrence Dolan, M.D, Giuseppina Imperatore, M.D., Ph.D., Barbara Linder, M.D., Ph.D., Santica Marcovina, Ph.D., Sc.D., David J. Pettitt, M.D., Catherine Pihoker, M.D., Sharon Saydah, Ph.D., M.H.S., Lynne Wagenknecht, Dr.P.H. Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002–2012. The New England Journal of Medicine 2017; 376:1419-1429.
Maria I. Constantino, Lynda Molyneaux, R.N, Franziska Limacher-Gisler, Abdulghani Al-Saeed, M.D., Connie Luo, R.N., Ted Wu, M.D., Ph.D., Stephen M. Twigg, M.D., Ph.D., Dennis K. Yue, M.D., Ph.D., Jencia Wong, M.D., Ph.D. Long-Term Complications and Mortality in Young-Onset Diabetes. Diabetes Care 2013; 36(12): 3863-3869.
Gilad Twig, M.D., Ph.D., Gal Yaniv, M.D., Ph.D., Hagai Levine, M.D., M.P.H., Adi Leiba, M.D., M.H.A., Nehama Goldberger, M.Sc., Estela Derazne, M.Sc., Dana Ben-Ami Shor, M.D., Dorit Tzur, M.B.A., Arnon Afek, M.D., M.H.A., Ari Shamiss, M.D., M.P.H., Ziona Haklai, M.A., Jeremy D. Kark, M.D., Ph.D. Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in Adulthood. The New England Journal of Medicine 2016; 374:2430-2440.
By Gary M. Pepper, M.D.
(This article is for educational purposes only and is not intended as medical advice or treatment)
During the Covid-19 pandemic my medical practice has been operating as normally as possible. The other day a young woman arrived wearing a surgical mask with a stack of medical records in hand, for a new patient appointment. Her difficulties began 6 weeks prior with intense tenderness in the right side of her neck just above the clavicle (collarbone) which varied in intensity over the course of about 10 days. Evaluation by her primary care physician uncovered newly elevated thyroid hormone levels. During our discussion she recalled a respiratory tract infection starting a week before the neck pain developed. Still complaining of lung congestion she denied fever or shortness of breath. Sitting comfortably, the thyroid was no longer tender but was slightly enlarged and unusually firm. Reading on it will become clear why my preliminary diagnosis is sub-acute thyroiditis, an inflammation of the thyroid following a viral respiratory tract infection, possibly Covid-19.(more…)
Suzi has hypothyroidism and high blood pressure. She sends the following story describing how t3 treatment appeared to help normalize her blood pressure. This is the first time I have come across this effect and thought it would be helpful to share her story on the main blog. Does anyone else have a similar (or contradictory) experience?
I was diagnosed hypothyroid 2 years ago and given levothyroxine. On diagnosis I had lots of symptoms and my BP was 175/115 despite my whole family having low BP. After some months on T4 I did feel an improvement in a lot of ways and my BP got better. Then after a year, things started going wrong, as if my body didn’t like T4.
I tried reducing my dose of T4 back down to 75µg but went hypo. But each time I increased above 75µg my BP increased again, then on 112µg it became a serious problem, especially the diastolic. I still had fatigue, constipation, red eyes, swollen legs and so on.
About 3 weeks ago I started on 10µg T3 and reduced my T4 from 112 to 75µg and pretty much immediately felt clearer headed and more energy, the constipation went etc….. My BP has gone down by an average of 20, which I know because I check it regularly myself. I’m doing a 24-hour BP monitor this week too, because my doctor put me on Amlopidine 6 weeks ago after being shocked by the monitor results from then while on 112µg T4 (only took Amlopidine for 2 weeks after terrible side-effects incl. overwhelming fatigue and massively swollen legs).
So, it looks as though my body goes weird on T4 tablets when the dose is above 75µg, but if I stuck to that dose I’d be really hypothyroid. The T3 has changed my life completely!!
Now I’m wondering what the ideal balance T4 / T3 tablets would be? Is that possible to say or does it depend on each individual body and genetics? My typical BP now is around 120/ 95; it goes down after eating, and gets worse when I’m hungry or tired. The T3 reduced my BP so much more than the Amlopidine did, and on T3 I feel great whereas on Amlopidine I felt half dead. I’d like to get my BP back to before I got hypo, so that’d be 110/70.
All I need to do now is find my ideal dose of T4 and T3, could you possibly advise me on that? If I started 20µg T3 instead of 10µg, would you advise a reduction in T4 from 75µg? ( I’ll be doing a TSH, fT3 and fT4 test in about 5 weeks’ time, maybe I should wait till then?).
A few years ago the book, Eat Right for Your (Blood) Type, was published by Dr. Peter D’Adamo with the premise that our present day nutritional needs are dependent on the types of food available to our genetic ancestors. For example, if your ancient ancestors evolved in a region of the world where protein was plentiful, then your body now requires a protein rich diet to stay healthy. According to the author your blood “type” is the clue to determining your nutritional heritage and your ideal diet type. I was never convinced of the usefulness of this blood type theory but agree that genetics strongly influences the way an individual stores fat and what constitutes their optimal nutritional requirements.
Along these lines recent research points to a connection between success with various weight loss diets and genetic differences between individuals. This was the conclusion of a study known as the A to Z Weight Loss Study. This study compared the results of 300 women who followed one of four possible diets ranging from those low in carbs (Adkins diet) to those low in fats (Ornish diet) to those high in protein (Zone diet). The women were then screened for genetic differences in specific genes that control fat metabolism.
Found was that some participants needed low carbs to lose weight while others required a diet low in fat to achieve weight loss. Analysis of the fat metabolizing genes showed that a specific favorable genetic profile was associated with up to a 6 fold increase in the amount of weight loss achieved with a particular diet. A participant was much more likely to lose weight if they were on the diet that harmonized with their particular genetic type.
How can you tell in advance if you are a carb sensitive or a fat sensitive dieter? For those with access to these experimental genetic tests (conducted by Interleukin Genetics) you could conceivable get the information you need. For the rest of us, starting with one type of diet and switching to the other type if weight loss isn’t achieved seems like a common sense approach.
The mission of the The Thyroid Project is to encourage sharing of information and experience between the public and the medical community about the treatment of hypothyroidism (low thyroid function). For at least the past few decades there is a growing awareness of “something missing†in the way suffers of hypothyroidism are treated for their disease.
Too many patients, as documented in an on-line study of 12,000 individuals conducted by the American Thyroid Association published in June 2018, (https://doi.org/10.1089/thy.2017.0681) , complain of persistent symptoms of hypothyroidism despite what their doctors believe is successful treatment with levothyroxine (brands include Synthroid, Unithroid, Tirosent, Levoxl). We believe something needs to be done to resolve this conflict between patients and their doctors.
Without effective intervention the early stage of type 2 diabetes known as prediabetes carries a high risk of progressing to outright diabetes. Metabolism.com provides an up-to-date summary of recommendations from national authorities, for preventing and possibly reversing this life long affliction
Diabetes can be defined simply as elevated blood sugar levels. What exactly is high blood sugar and when should someone be concerned about their level? Does having prediabetes mean diabetes is around the corner? Metabolism.com tackles this tricky but important topic in this comprehensive review.
By Gary M. Pepper, M.D. Ozempic, Rybelsus, Trulicity, Wegovy, Saxenda are the central players in the weight loss craze sweeping across the globe. Metabolisim.com has been monitoring this phenomenon from its beginnings in 2008 with its report “Lizard Spit Reduces Blood Sugar and Appetite”, regarding the first drug in this class, Byetta (exenatide). Caught In the middle of the current chaos are the medical experts who treat diabetes and have been prescribing these medications for more than a decade. Here is a brief commentary from one such board certified endocrinologist; “I started treating Type 2 diabetics with GLP-1 agonists more than 10 years ago. In some respects, these medications have revolutionized the treatment of diabetes by lowering blood sugar effectively and promoting weight loss at the same time, a unique combination of benefits. Not everyone benefits from these drugs to the same degree unfortunately, and I have seen lots of patients experience unacceptable side effects from them. Nothing though, has prepared me for what is happening now. Too often, I find myself confronting someone who expects me to prescribe one of these drugs just so they can lose weight. Sadly, one extreme example was someone who, despite battling a life threatening medical condition, was insistent on getting a prescription. At the same time my diabetic patients are scrambling to find a place to buy their medications if they can even afford it. It is disheartening, to say the least, and I dread the negative interactions with some of my patients I now face almost daily.”
Off- Label Use
The FDA is the U.S. government’s department tasked with evaluating and approving drugs for specific medical conditions. When a new medication is approved for treating a medical condition by the FDA the agency will, at the same time, set strict guidelines for exactly which patients may use the newly approved drug. When a medication is used “off-label” it means that these limitations are being overridden by the provider for a potential benefit which outweighs the drugs risks. It is a general misconception that off-label means illegal; it does not. This practice has been going on for ages and more than 20% of prescriptions in the United States are prescribed off-label. A common example is the use of beta-blockers (approved for heart problems) for the treatment of performance anxiety.
GLP-1 agonist drugs, as discussed recently by metabolism.com. were originally approved for the treatment of Type 2 diabetes in adults. In the past few years most of these same medications have gained unprecedented popularity for their “off-label” weight loss benefit. Of the 5 GLP-1 agents presently in U.S. pharmacies only Wegovy (semaglutide) and Saxenda (liraglutide) are FDA approved for treating obesity. Of these two, Wegovy is the newer and had been much more popular that its sister drug Saxenda, probably due to being dosed only once weekly compared to daily for Saxenda and less likely to cause side effects. Due to Wegovy’s soaring popularity, its manufacturer, Novo Nordisk, increased the price of Wegovy two times since its initial release.
