Medical Nutrition Therapy for Thyroid,

Adrenal, and Other Endocrine

Disorders
•Thyroid-related diseases often are poorly
diagnosed, and much about their treatment
requires greater clarification and study.
•Each of these disorders has stages beginning
with genetic susceptibility, environmental
triggers, and active autoimmunity, followed by
metabolic derangements with overt symptoms
of disease
•Research is needed to clarify how nutrients
interact with genetics, especially in these
autoimmune thyroid disorders (AITDs)
THYROID PHYSIOLOGY
• The thyroid gland is a small,
butterfly-shaped gland
• found just below the Adam’s
apple.
• weighs less than an ounce,
• it produces hormones that
influence essentially every
organ, tissue, and cell in the
body.
Thyroid gland hormones
• Controlled by hypothalamus and pituitary glands
• Produces 2 main hormones:
• Thyroxine (T4) – 4-molecules of iodine
• Triiodothyronine (T3) – 3 molecules of iodine
• (most predominant/active form)
• T4 is converted to T3 by peripheral organs such as kidney, liver and spleen
• Functions include regulates many processes:
• Fat & CHO metabolism
• Body temperature
• Heart rate
• Other hormones produced:
• Calcitonin – regulated amount of calcium in blood
• Reverse T3 (rT3) , isomer of T3 derived from T4 through deiodinase but the body
can’t use it.
Thyroid hormones production
• The synthesis of these hormones requires:
• Tyrosine – amino acid
• Iodine – trace mineral
• Iodide is oxidized to iodine by hydrogen peroxide “Organification”
• 2 additional molecules of iodine bind to the Tyrosyl ring involving
Thyroid Peroxidase (TPO) – responsible for hormone production .
• Hormones are released into circulation but metabolic effects results
when they occupy specific thyroid receptors.
• Cells need 5-7 times more T4 than T3 to bind to the nuclear receptors to have
physiologic effect.
• Generation of thyroid hormones within the
thyroid gland are controlled by feedback
mechanisms within the hypothalamic-
pituitary thyroid axis (HPT axis).
• Thyroid hormones on pituitary
• ↑T3 & T4 … ↓TSH
• ↓ T3 & T4 ... ↑ TSH

• Although T4, T3, and rT3 are generated

within the thyroid gland, T4 is quantitatively
the major secretory product.
• All T4 found in circulation is generated in
the thyroid unless exogenously
administered.
• Production of T3 and rT3 within the thyroid
is relegated to very small quantities and is
not considered significant compared with
their peripheral production.
Within the liver and
kidney, the enzyme
responsible for production
of T3 is a selenium-
dependent enzyme called
5-deiodinase, an enzyme
that removes one
molecule of iodine from T4
to form either T3 or rT3
 Assessment in thyroid disorders
• Evaluation of thyroid status based on laboratory data such as a full
thyroid panel.
• In the absence of a full thyroid panel, a serum thyrotropin (also known
as
• TSH) is the single best screening test for primary thyroid dysfunction,
(when it does not include thyroid associated autoimmune conditions),
for the vast majority of outpatient clinical situations .
• diet history to evaluate micronutrients pertaining to thyroid health
• calorie and carbohydrate intake.
• Dietary intake of goitrogenic foods
 Lab norms
• TSH values greater than 2 mIU/L have an increased risk of
developing overt hypothyroidism during the next 20 years.
• Subclinical autoimmune thyroid disease is so common in the
population that laboratory reference ranges derived from
testing apparently healthy subjects easily could be
misconstrued for those with disease.
• Importantly, several studies have detected an increase in TPO
antibody positivity with TSH concentrations outside the
narrow range of 0.2 to 1.9 mIU/L
• This fact provides evidence that TSH in the upper reference
range often is associated with abnormal pathologic findings
Mitochondrial dysfunction and morphologic skeletal muscle
alterations including myalgia, muscle cramps, and weakness
• decreased TSH levels combined with normal to high T4 or T3
levels may be suggestive of hyperthyroidism.

• In the course of chronic liver disease such as hepatic cirrhosis,

alterations in hepatic deiodination resulting in increased rT3
and a simultaneous decrease in T3 levels also have been
observed
 Hypothyrodism
• Underactive thyroid.
• More than 50% due to an autoimmune disorder ‘Hashimoto’s thyroiditis’
attacks thyroid gland tissue.
• Women are five to eight times more likely than men to suffer from
hypothyroidism.
• individuals who have celiac disease may be at risk.
• The enlarged, chronically inflamed thyroid gland becomes nonfunctional,
with reactive parts of the gland deteriorating after several years.
• Thyroid autoantibodies indicate the body’s immune system is attacking
itself and whether an autoimmune thyroid condition is present, be it
hypothyroidism or hyperthyroidism.
 Hypothyrodism
• Specific antibody tests identify Hashimoto’s thyroiditis:
• Thyroid peroxidase antibodies (TPO Ab)
• are immune cells that indicate the immune system is attacking TPO in the thyroid gland.
• The TPO Ab test is the most important, because TPO is the enzyme responsible for the production of thyroid hormones,
and the most frequent target of attack in Hashimoto’s.
• Thyroglobulin antibodies (TGB Ab)
• immune cells that indicate the immune system is attacking thyroglobulin in the thyroid gland.
• Sometimes this test is necessary as well because it is the second most common target for Hashimoto’s disease.
• Schmidt syndrome refers to hypothyroidism with other endocrine disorders, including Addison’s
disease (adrenal insufficiency), hypoparathyroidism, and diabetes mellitus, all of which may be
autoimmune in nature.
• Euthyroid sick syndrome is hypothyroidism, associated with a severe systemic illness that
causes decreased peripheral conversion of T4 to T3, an increased conversion of T3 to the
inactive rT3, and decrease binding of thyroid hormones.
• Conditions commonly associated with this syndrome include protein-calorie malnutrition, surgical trauma, myocardial
infarction, chronic renal failure, diabetic ketoacidosis, anorexia nervosa, cirrhosis, thermal injury, and sepsis
• Once the underlying cause is treated, the condition usually is resolved
 Adrenal /
oxidative
stress

environmental
aging
factors

Triggers

pregnancy Menopause
Medical management
• When the thyroid is underactive (hypothyroidism) because of
autoimmune disease (Hashimoto’s disease):
• radioactive iodine treatment
• surgical removal (thyroidectomy)
• the conventional pharmacologic approach
• thyroid hormone replacement medication.
• New research on genetics as a new adjunct therapy
 Medical Nutrition Therapy
• Several nutrients are involved in thyroid health:
• Iodine for hormone synthesis
• Other deficiencies of micronutrients such as iron, selenium, vitamin A,
and possibly zinc may interact with iodine nuriture and thyroid function
Medical Nutrition Therapy –
Fasting/restrictive diets
• Calorie and CHO restriction may reduce substantially thyroid hormone
activity
• Varies between individuals
• Genetics, obesity, gender macronutrient content of diet influence outcome
• Nutritional status and energy expenditure influence thyroid function
centrally at the level of TSH secretion, deiodination, and possibly
elsewhere.
• 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. However, when caloric restriction
is longer than 3 weeks, T4 and rT3 levels return to normal values
• Fasting also exerts a powerful influence on the metabolism of thyroid
hormones to save energy and limit catabolism. Mild elevations in
endogenous cortisol levels may be partly responsible.
• Fasting decreases serum T3 and T4 concentrations, whereas
intrahepatic thyroid hormone concentrations remain unchanged.
• However, ketones generated from calorie deprivation do not appear to
suppress T3 generation and hepatic 5-deiodinase activity.
• 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
 MNT - Goitrogens
• cruciferous veg. e.g broccoli, cauliflower, cabbage , release compound ”goitrin” when
hydrolyzed interferes with synthesis of thyroid hormones .
• Concerned when coupled with iodine deficiency
• Heating will solve the problem
• Soy can lower thyroid hormone synthesis “moderation consumption”
• Soybean, an important source of protein in many developing countries, also
has goitrogenic properties when iodine intake is limited.
• The isoflavones, genistein and daidzein, inhibit the activity of TPO and can lower
thyroid hormone synthesis.
• soybean interrupts the enterohepatic cycle of thyroid hormone metabolism.

• However, high intakes of soy isoflavones do not appear to increase the risk of
hypothyroidism when iodine consumption is adequate.
Iodine
• As a trace element, iodine is present in the human body in amounts of 10
to 15 mg, and 70% to 80% of it is located in the thyroid gland.
• Ninety percent 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.
• The thyroid gland must capture an estimated minimum of 60 mcg of iodide
(the ionic form of iodine) daily to ensure an adequate supply for the
production of thyroid hormone … results in a spectrum of disorders.
• providing iron along with iodine results in greater improvements in thyroid
function and volume than providing iodine alone .
• It is also vital to thyroid function, as it is a major cofactor and stimulator for
the enzyme TPO.
Iodine
• In autoimmune Hashimoto’s, supplementing with iodine may
exacerbate the condition.
• Because iodine stimulates production of TPO, this in turn increases the levels
of TPO antibodies (TPO Abs) dramatically, indicating an autoimmune flare-up.
• Some people develop symptoms of an overactive thyroid, whereas
others have no symptoms despite tests showing an elevated level of
TPO Abs. Therefore one must be cautious regarding the use of iodine.
• Furthermore, although iodine deficiency is the most common cause
of hypothyroidism for most of the world’s population, in the United
States and other westernized countries, Hashimoto’s accounts for the
majority of cases
Iodine def. in pregnancy
• Increase the risk of stillbirths, spontaneous abortions, and congenital
abnormalities.
• The most severe is cretinism, a state of mental retardation mostly in
combination with dwarfism, deaf-mutism, and spasticity
 Iron
• it has been thought that low thyroid function may cause anemia. Recent
studies suggest that low thyroid function may be secondary to low iron
status or anemia.
• because TPO is a glycosylated heme enzyme that is iron-dependent.
• A full assessment of iron status could likely help to identify the cause of
many cases of thyroid malfunction
Selenium
• a cofactor for 5-deiodinase. If selenium is deficient, the deiodinase activity is impaired, resulting in a
decreased ability to deiodinate T4 to T3.
• Evidence suggests a strong linear association between lower T3/T4 ratios and reduced selenium status.
• This association is particularly strong in older adults, possibly as the result of impaired peripheral conversion.
• An inverse relationship between T3 and breast cancer is associated with decreased selenium status, even
when plasma T4 and TSH concentrations may be similar. This combination of factors strongly suggests that
low T3 may be due to faulty conversion of T4 to T3 expected in selenium deficiency.
• Selenium participates in the antioxidant network. Several studies reported on the benefit of selenium
treatment in Hashimoto’s thyroiditis and Graves’ disease.
• Evidence also suggests that high intakes of selenium may exert a detrimental influence on thyroid hormone
metabolism.
• Although individuals exposed to high dietary levels of selenium typically have normal levels of T4, T3, and
TSH, a significant inverse correlation has been found between T3 and selenium.
• Some researchers have hypothesized the activity of 5-deiodinase may become depressed after a high dietary
intake of selenium, suggesting a safe level of dietary selenium at or below 500 mcg daily
Polycystic ovary syndrome
• is a common endocrine disorder of unknown cause that affects an
estimated 3% to 12% of women of reproductive age in Western societies
• The condition is characterized by reproductive issues such as amenorrhea
or other menstrual irregularities, anovulation, enlarged ovaries with
multiple cysts, and infertility.
• More generalized symptoms include acne, hirsutism (excessive or abnormal
distribution of hair growth), malepattern baldness, obesity, and sleep
apnea
• The insulin resistance seen in 50% to 70% of women with PCOS is unique in
that it occurs independent of body weight to some extent and is not always
corrected by weight loss
• Hypothyrodism occurs in some cases of PCOS.
High carbohydrate diet has CHO approximately 60% of total
calories), whereas others respond better to a low-carbohydrate
diet (#40% of total calories).
HYPERTHYROIDISM
• Graves’ disease is an autoimmune disease in which the thyroid is diffusely
enlarged (goiter) and overactive, producing an excessive amount of thyroid
hormones.
• It is the most common cause of hyperthyroidism (overactive thyroid).
• Physical symptoms frequently include red, dry, swollen, puffy, and bulging
eyes (exophthalmos), heat intolerance, difficulty sleeping, and anxiety.
• the most common sign of Graves’ disease is goiter or thyroid enlargement
• The excessive thyroid hormones may cause a serious metabolic imbalance,
thyrotoxicosis.
Pathophysiology
• Graves’ disease, the TRH receptor itself is the primary autoantigen and is
responsible for the manifestation of hyperthyroidism.
• The thyroid gland is under continuous stimulation by circulating
autoantibodies against the TRH receptor, and pituitary TSH secretion is
suppressed because of the increased production of thyroid hormones.
• These thyroid-stimulating antibodies cause release of thyroid hormone and
thyroglobulin (Tg) and they also stimulate iodine uptake, protein synthesis,
and thyroid gland growth.
• A TSH antibody—typically referred to as thyroid-stimulating
immunoglobulin—test is used to identify hyperthyroidism, or Graves’
disease.
Triggers
• influenced by a combination of environmental and genetic factors.
• Genetic factors contribute to approximately 20% to 30% of overall
susceptibility.
• Other factors include infection, excessive iodide intake, stress (stress-
induced immunosuppression), female gender (pospartum), steroids,
and toxins.
• Smoking has been implicated in the worsening of Graves’
ophthalmopathy.
• Graves’ disease also has been associated with infectious agents
Medical management – Hyperthyrodism
• antithyroid medications can be used to prevent the thyroid from
producing hormones
• The effects of immunotherapy are also being evaluated
Vitamin D & C
• critically important for establishing immune balance and preventing the
production of autoantibodies
• a prohormone with antiproliferative, differentiating, and
immunosuppressive activities.
• a vitamin D deficiency is associated with numerous autoimmune
conditions, including Hashimoto’s.
• More than 90% of people with autoimmune thyroid disease have a genetic defect
affecting their ability to metabolize vitamin D .
• Vitamin D also appears to work with other nutritional factors to help regulate
immune sensitivity and may protect against development of autoantibodies.

• Ascorbic acid has been shown to be effective in preventing cadmium

induced decreases in T3 and hepatic 5-deiodination.
 ADRENAL DISORDERS
The adrenals are the two triangular-shaped
glands located at the top of each kidney and are responsible
primarily for governing the body’s adaptations to stress of any
kind.
Cushing’s Syndrome
• In Cushing’s syndrome, too much cortisol remains in the bloodstream
over a long period.
• 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.
• Weight gain, easy bruising, depression, muscle loss, and weakness are
common symptoms.
• A weight management protocol may be needed.
Addison’s Disease
• Primary adrenal insufficiency/ HYPERCORTISOLISM also known as
Addison’s disease, is rare.
• insufficient steroid hormones are produced.
• Regulation of blood glucose levels and stress management are affected.
Loss of appetite, fatigue, low blood pressure, nausea and vomiting, and
darkening of skin on the face and neck may occur.
• 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.
Adrenal Fatigue
(subclinical adrenal insufficiency, adrenal stress, adrenal exhaustion, adrenal
burnout, and adrenal imbalance)

• collection of signs and symptoms caused by the decreased ability of

the adrenal glands to respond adequately to stress.
• can occur whether the source of stress, physical, emotional or
psychologic, is chronic and continues to persist causing a cumulative
effect, or is a very intense single event stressor. the adrenal glands are
unable to keep pace with the demands of perpetual fight-or-flight
arousal, resulting in subclinical adrenal dysfunction.
• excessive fatigue and exhaustion, hair loss, hormone imbalance, poor
digestion, low immune function, slow recovery from illness, inability
to concentrate, and inability to cope with stressors.
 Chronic adrenal stress causes the following:
• Affects communication between the brain and hormone secreting glands
directly affect thyroid function.
• The hypothalamus and pituitary gland direct hormone production, including
that of the thyroid.
• When the hypothalamus and pituitary weaken because of chronic adrenal
stress, they are not able to communicate well with the thyroid gland
• Increases thyroid-binding protein activity, so that thyroid hormones cannot get into
cells to do their job
• Hampers the conversion of T4 to active forms of T3 that the body can use
• Interferes with the detoxification pathways through which unnecessary thyroid
hormones exit the body, leading to thyroid hormone resistance
• Causes cells to lose sensitivity to thyroid hormones
• Weakens the immune barriers of the digestive tract, lungs, and brain; promotes poor
immune regulation
• These factors increase the risk for triggering Hashimoto’s or exacerbating it
 Chronic adrenal stress causes the following:
• Chronic adrenal stress affects other systems of the body, which in turn, decrease thyroid function.
• For example, the adrenal hormone cortisol plays a large role in thyroid health. Cortisol “stress hormone”
because it influences, regulates, or modulates many of the changes that occur in the body in response to
stress, including but not limited to the following:
• Antiinflammatory actions
• Blood glucose levels
• Blood pressure
• Central nervous system activation
• Fat, protein, and carbohydrate metabolism to maintain lood glucose
• Heart and blood vessel tone and contraction
• Immune responses
• Cortisol levels follow a circadian rhythm and normally fluctuate throughout the day and night, peaking at about
8:00 am and reaching a low at about 4:00 pm (Allen, 2013).
• It is very important that bodily functions and cortisol levels return to normal after a stressful event. In chronic
adrenal stress it exhausts the adrenal and thyroid glands, as well as the hypothalamus and the pituitary gland.
Over time, this exhaustion leads to functional hypothyroidism. In addition, constant cortisol production
weakens the gastrointestinal (GI) tract, making one more susceptible to inflammation, dysbiosis (poor gut
health), and infection. Thus a vicious cycle weakens the thyroid.
Some of the conventional approaches in the
treatment of adrenal fatigue
• With proper care, most people who experience adrenal fatigue can
expect to regain their normal status
• B-complex vitamins
• Exercise in moderation
• DHEA (dehydroepiandosterone)
• Proper diet
• Relaxation
• Sleep
• Stress relief and management l