Thyroid disease is common and treatment is highly effective. Dr Louise Johnson tells us more.

What is the thyroid?

The thyroid is a small gland, measuring about 5cm, that lies under the Adam’s apple in the neck. The two halves (lobes) of the gland are connected in the middle (called the isthmus), giving it the shape of a bow tie. Normally the thyroid gland can’t be seen and can barely be felt.

The thyroid gland secretes thyroid hormones, which control the speed at which the body’s chemical functions proceed (metabolic rate). The thyroid hormone influences the metabolic rate in two ways:

• By stimulating almost every tissue in the body to produce proteins.
• By increasing the amount of oxygen that cells use.

Thyroid hormones affect many vital body functions, such as the heart rate, the rate at which calories are burned, skin maintenance, growth, heat production, fertility and digestion.

Thyroid hormones

There are two thyroid hormones:

• T4 (Thyroxine)
• T3 (Triiodothyronine)

T4, the major hormone produced by the thyroid gland, has only a slight effect, if any, on speeding up the body’s metabolic rate. Instead T4 is converted into T3, the more active hormone.

The conversion of T4 to T3 occurs in the liver and other tissues. Most of T4 and T3 in the bloodstream is carried bound to a protein called thyroxine-binding globulin. Only a little of T4 and T3 is circulating in the blood. However, it’s the free hormone that is active.

To produce the thyroid hormones, the thyroid gland needs iodine, an element contained in food and water. The thyroid gland traps the iodine and processes it into thyroid hormones. As the thyroid hormones are used, some of the iodine contained in the hormones is released, returns to the thyroid gland, and is recycled to produce more thyroid hormones.

The body has a complex mechanism for adjusting the level of thyroid hormones. First the hypothalamus, located above the pituitary gland in the brain, secretes thyrotropin-releasing hormone, which causes the pituitary gland to produce thyroid-stimulating hormone (TSH).

TSH stimulates the thyroid to produce hormones. The pituitary gland slows or speeds the release of TSH, depending on whether the level of thyroid hormones circulating in the blood are too low or too high.

Diagnostic tests for thyroid disease

1. The neck of a person is examined to feel whether the thyroid gland is palpable.
2. Blood tests are done measuring T4, T3 and TSH. Usually, the level of TSH in the blood is the best predictor of thyroid function.

• If the TSH levels are high, the thyroid is underactive. It’s called hypothyroidism.
• If the TSH is very low, the thyroid is overactive. It’s called hyperthyroidism.

Hypothyroidism

Simply put, this is an underactive thyroid gland and leads to inadequate production of the thyroid hormones and a slowing of vital bodily functions.

Clinical picture

• Facial expressions become dull
• Voice is hoarse
• Speech is slow
• Eyelids droop
• Eyes and face become puffy (myxoedema)
• Hair becomes sparse, coarse and dry
• Skin becomes coarse, dry, scaly and thick
• Fatigue is common
• Weight gain
• Constipation
• Muscle cramps
• Unable to tolerate cold
• Older people may become forgetful; can easily be mistaken for Alzheimer’s disease
• People with hypothyroidism have high levels of cholesterol

Causes of hypothyroidism

Primary hypothyroidism is due to a disorder of the thyroid gland. The most common causes are:

• Hashimoto thyroiditis is an autoimmune disease where antibodies are formed against the thyroid gland and eventually destroy it.
• Thyroid inflammation (thyroiditis) is caused by a viral infection and is usually temporary.
• Treatment of thyroid cancer or hyperthyroidism treatment.
• Lack of iodine in the diet is common in many developing countries. South Africa’s iodine is added to salt to prevent this.
• Radiation of the head and neck due to the treatment of cancers.

Diagnosis of hypothyroidism

Measurement of the TSH levels in blood. If this value is high, then a second test of T4 can be done to confirm that it is low.

Treatment

Replacement of the thyroid hormone using oral preparations. The preferred form of hormone replacement is synthetic T4 (levothyroxine).

Hyperthyroidism

Simply put, this is an overactive thyroid gland and leads to high levels of thyroid hormones and speeding up of vital body functions.

Clinical picture

• Heart rate and blood pressure increases
• Heart rhythm may be abnormal
• Excessive sweating
• Feeling of anxiousness
• Difficulty in sleeping
• Weight loss without trying
• Increased bowel movements
• Hand tremors
• Increased activity level despite fatigue and weakness
• Change in menstrual periods in women
• Changing in the eyes with a look of one that is staring

Causes of hyperthyroidism

The most common causes are:

• Graves’ disease is an autoimmune disorder. In this disorder the antibodies that are produced against the thyroid, stimulate it to produce more thyroid hormones. This leads to enlargement of the thyroid called a goitre. The eye symptoms are very pronounced with puffiness around the eyes, increased tear formation, irritation and sensitivity to light. This is sometimes called thyroid eye disease. Two distinctive signs are: bulging eyes (proptosis) and double vision (diplopia).
• Toxic multinodular goitre is a disease where there are multiple nodules (small lumps) in the thyroid. One or more produce excessive thyroid hormones. This is more common with ageing.
• Thyroiditis is inflammation of the thyroid that at first causes an overactive thyroid due to viral disease or auto antibodies (Hashimoto’s). The thyroid stores become depleted in time and this will lead to hypothyroidism.
• Single toxic nodule.

Diagnosis of hyperthyroidism

Measurement of TSH level in the blood. TSH level will be suppressed and T4 will be very high.

Antibodies against the thyroid can also be done to establish a cause.

Treatment

1. Treatment of the cause.
2. Betablockers to block the effect of the thyroid hormone and relieve the symptoms of palpitations, sweating, tremors and anxiety.
3. Sometimes medication (carbimazole) to block the production of the thyroid hormone.
4. Radioactive iodine to destroy the thyroid gland. This is the most common treatment of hyperthyroidism since it’s easy to administer a radioactive dosage of iodine that will destroy only the thyroid in a three-to-six-month period without surgery.
5. Surgery (thyroidectomy) to remove the thyroid or part of it. Sometimes eye surgery is needed in Graves’ disease.

Thyroid disease is a very common disease and should always be suspected. Treatment is highly effective, and any person can live a full life with the correct medical treatment.

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We learn eight tips to help make life transitions more bearable and positive experiences.

There is no escaping change or life transitions and its potential to impact your life. Change can often be stressful and may require adjustment time. Various types of change can seem overwhelming but may also present valuable opportunities for personal growth.

Whether you have been actively seeking change or it has been imposed upon you, there are unique challenges that come with different forms of change.

Typical life changes may include pivotal transitions in work or studies, relationships, or family dynamics, moving home or relocating, loss of a loved one or significant health diagnoses. Change and the uncertainty it brings are part of life and resisting change will not make it any easier.

Change is normal and adjusting to it comes naturally to most people, however, major transitions may mean letting go of the life you are accustomed to and embracing a new one. If a transition is intensely challenging, it can destabilise your thoughts and emotions, leaving you feeling overwhelmed and distressed.

Knowing how to cope with the curveballs life throws at you, is therefore a crucial life skill. Embracing change in a positive way helps you to become stronger and more resilient. Managing change in life is key to personal growth and enables you to live a life where you are thriving, rather than just surviving.

8 tips to cope with life transitions

1. Understand and accept the limits of what you can control and what is beyond your control. Focus your energy and efforts constructively rather than becoming stuck in anger and denial.
2. Practise good self-care. Get plenty of sleep, eat a balanced diet, and feel the benefits of physical exercise.
3. Embrace healthy coping skills. Fun activities such as listening to music, spending time in nature, reading a good book or playing with a pet are good for your well-being and can reduce your stress levels.
4. Cut out unhealthy coping skills. If you have been turning to activities or habits that do more harm than good, make a conscious effort to cut back.
5. Seek meaningful connections and support. Spend time with family and friends who are good for you.
6. Let go of your regrets. Regrets can hold you back in life. Looking back at the past may cause you to miss the opportunities change presents for the future.
7. Practise self-compassion. Treat yourself with the same kindness and compassion as you would a loved one going through a challenging time in their life.
8. The gift of gratitude. With reflection you may discover a greater appreciation for what you do have and what remains constant in your life during a period of change.

A life worth living

To create a life that you do not feel you need to escape from, a life worth living, you need to be proactive about how you manage the changes you face in your life. However, sometimes, adjusting can be so daunting and overwhelming that it leads to an adjustment disorder.

This may happen when the stress associated with change exceeds your resources for coping, and your reaction becomes disproportionate to the event. Consider seeking professional mental health support if you are struggling to cope with change.

While the personal experience of adjustment to any change is unique, and may be expected to be uncomfortable initially, it may be cause for concern if you still feel overwhelmed three months later, or your suffering is disproportionate in response to the situation.

If you are not coping in your day-to-day life, social relationships, at home, work, or school, talking to a mental health professional can be helpful in providing emotional support and learning to identify healthy coping mechanisms and stress management strategies.

Seek proper treatment from a therapist or psychiatrist who can help you to manage the condition and learn the skills you need to cope with change and future life transitions.

If you are having a difficult time coming to terms with change or experiencing emotional distress, Netcare Akeso’s 24-hour crisis line is always here for you on 0861 435 787. Trained counsellors are available to listen and can guide you on the various options for assistance, whether for yourself or a loved one.

Kate Bristow expands on food and feelings: what food improves mood and knowing the difference between emotional eating and real hunger.

Happiness is something that we are all looking for. Generally, things like exercise, meditation and therapy are top of the list of recommendations. But did you know that the food you eat can play a role in your feelings?

There have been studies done on food and mental well-being and certain foods can be linked to increased serotonin levels in the brain. Serotonin is a chemical, also known as the happy hormone, which plays a big role in regulating your mood. Serotonin levels which are low can cause low mood.

Which foods lift mood and how to manage in diabetes

1. Dark chocolate – There are components in dark chocolate which have been shown to produce serotonin and have anti-depressant properties. Dark chocolate isn’t a complete no in diabetes; in moderation it can be used to take away that craving for something sweet, and now to bring on a better mood.
2. Bananas – Although not recommended in large quantities in diabetes, bananas contain vitamin B6 and the body needs vitamin B6 to create serotonin.
3. Coconut – More research is needed here, but animal studies have found that coconut milk can possibly reduce anxiety.
4. Coffee – Research shows that coffee consumption has been significantly associated with a decreased risk of depression, including the decaffeinated version.
5. Avocado – This fruit is packed with good stuff, including choline which the body uses to regulate the nervous system and mood. Studies have shown decreased anxiety in women when they eat avocados. Avos are also rich in vitamin B which is good to decrease stress levels.
6. Berries – Higher fruit and vegetable intake has been linked to better mental health. Berries are rich in antioxidants, which may reduce symptoms of depression.
7. Foods which are fermented – Sauerkraut, kimchi, kefir, kombucha and yoghurt help with a healthy gut and may improve your mood. Up to 90% of serotonin is made in the gut, so eating these products will promote the production of serotonin.
8. Mushrooms – These are packed with vitamin D which has been linked to antidepressant properties and mood enhancement. It’s also easily absorbed in this form by the body. For the best benefit, expose your mushrooms to the sun for a couple of hours before you cook them.

The good news is that the above, eaten in the right proportions are healthy choices and can be included as part of an eating plan in diabetes.

Emotional and comfort eating

We all have a relationship with food, just as we have a relationship with family and friends. And without even thinking about it, you could be an emotional or mindless eater. Add diabetes into the mix with a whole lot of strangers, as in the healthcare team and your family and friends taking extra interest in what you are eating, and it can get complicated.

Food is not just fuel for the body; it can be soothing and nurturing as in a baby receiving breast milk to settle and sooth. It’s not surprising then that you reach for food to help you cope with feelings (stress, conflict, anxiety, relationship challenges), we all need comforting from time to time.

However, even though eating does make you feel better and help settle emotions of distress, it may be beneficial to recognise the cause of the emotion and manage this rather than dull everything with food.

Diabetes itself can be a cause of stress and depression. Having to pay close attention to what you eat and learning on the job can be tough and possibly a cause of emotional eating.

Express your emotions in a safe way

Here’s one example of a conversation with yourself, “I’m eating because I’m frustrated for not being as productive as I would have liked today.”

It’s important to recognise behaviours like this and figure out your triggers and ways to express your emotions in a safe way. For example:

• Talk to a friend or family member
• Allow yourself to show emotion e.g. cry
• Journal
• Exercise
• Do something fun to distract yourself

What can you do differently next time?

Dr Jen Nash, a psychologist who is living with diabetes, says that food challenges are real. But she also says that food should be pleasurable and a diagnosis of diabetes shouldn’t mean the end of this. Hunger is only one of 30+ reasons why you eat.

She suggests setting goals which are achievable. Strive to do the right thing 90% of the time and don’t feel guilty when things don’t go according to plan. She suggests an Oh-well attitude and to use the experience as a learning tool – What can I do differently next time?

• Try not to feel that you’re being watched by everyone and equip yourself to face the challenges that food may give you in the journey ahead.
• Try practical ideas such as experimenting with new recipes but planning a weekly shopping list and menu is a good idea.
• Phone a friend who is there to support you and that you can be accountable to. This isn’t stalking, but rather support for choices that you make. Keep in touch with family and friends and reach out if you’re struggling. You are not alone.
• Look after your body – make healthy choices with regards to food, get enough sleep and exercise regularly.

Mindful eating and how it helps in your meal plan choices

As a person with diabetes, you’re required to pay attention to what you’re eating constantly. Feeling stressed or depressed can be a cause of emotional eating. If you find yourself eating as a form of comfort, substitute this behaviour with an alternative treat: have your nails done, go to a movie or visit a friend.

You should enjoy food but eating mindlessly for the sake of eating means that you’re not taking time out to really savour what you’re eating. Before reaching out for a tasty treat, ask yourself “Why am I eating, am I actually hungry?” This is a more mindful approach.

Mindful eating means that you use all your emotional and physical senses to enjoy the food you’re eating. It encourages better choices for food, which are satisfying and nourishing.

Mindless eating or distracted eating can be associated with anxiety and stress, overeating and the associated weight gain.

How unhealthy eating patterns cause mayhem

Unhealthy eating patterns have been known to lead to mood swings, fluctuations in blood glucose levels and nutritional imbalances. With this lack of stability, your mind and body doesn’t function well.

Examples include:

• Skipping meals leads to low blood glucose levels which can leave you feeling weak and tired.
• Cutting out food groups can lead to not getting all the essential nutrients in your diet, which can also lead to mood swings and decreased energy.
• Too many refined carbohydrates can cause erratic blood glucose levels, low energy and irritability.

Health eating habits

Evidence suggests that a healthy eating plan is both physically and mentally protective. Some general guidelines include:

• Eat at regular set intervals during the day.
• Choose less refined sugars and eat more whole grains.
• Make sure you have protein at every meal.
• Keep a variety of food in your eating plan.
• Try to reach and maintain a healthy weight.
• Drink enough fluid, particularly water.
• Exercise regularly.

Pause mindfully

Pause mindfully when you eat, intentionally create time between each bite.

P    Present – Stop multi-tasking when you eat, and just eat.

A   Awareness – Be aware of the feeling of hunger, how does it make you feel physically?

U   Understand – Your feelings and how they may influence the food choices you make.

S    Savour – Take a mindful bite – smell, taste, touch, listen.

E    Enjoy – How much are you enjoying this bite?

Mindful eating becomes a strategy to encourage meals with fewer distractions, as well as better eating habits. Taking the time to enjoy the flavour of your food, atmosphere and company has been shown to lead to better psychological well-being, increased pleasure when eating and satisfaction.

So, go out there and enjoy mindful meals with your loved ones and in doing so create better health for yourself and fewer emotional eating habits.

Physical hunger vs. emotional hunger

PHYSICAL

Stomach growling

Thinking/considering choices

Low energy levels

Hunger grows slowly

How much time since the last meal?

Is food satisfying?

EMOTIONAL

What am I feeling? (anger, bored, stress)

How strong were the emotions?

When did you start feeling like this?

How did you hope food may help? (soothe or help you escape feelings)

References

https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/food-psychology/the-eating-journey

https://www.cnet.com/health/mental/8-mood-foods-that-will-make-you-happy/

www.eatingmindfully.com

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Dr Louise Johnson expands on polycystic ovarian syndrome and the risk of it leading to Type 2 diabetes.

Polycystic ovarian syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. It was described in 1935 by Stein and Leventhal.

Systematic screening of women according to the National Institute of Health diagnostic criteria estimate that 4 to 10% of women of reproductive age suffer from PCOS.¹

Understanding PCOS

PCOS is a hormonal imbalance when the ovaries create excess androgen hormones.

The diagnosis of PCOS can follow one of three guidelines:

National Institute of Health criteria:

1. Hyperandrogenism (high male hormone)
2. Menstrual irregularity

Androgen Excess PCOS Society criteria:

1. Hyperandrogenism
2. Menstrual irregularity or polycystic ovaries on ultrasound

Rotterdam criteria (2 of 3):

1. Hyperandrogenism
2. Menstrual irregularity
3. Polycystic ovaries on ultrasound

In polycystic ovaries there are small follicle cysts (fluid filled sacs with immature eggs) visible on your ovaries on ultrasound due to lack of ovulation (anovulation). This is one of the most common causes of infertility in women.

Signs of PCOS

• Irregular periods which include missing menstruation or heavy bleeding.
• Abnormal hair growth on arms, chest and abdomen. This is called hirsutism and affects up to 70% of women with PCOS.
• Acne especially on face, chest and back. This may continue past teenage years and is difficult to treat.
• Obesity is common in 40 to 80% of women with PCOS and they have trouble maintaining a healthy weight.
• Darkening of skin in the folds of the neck, armpits and groin and under breasts. This is called acanthosis nigricans.
• Cysts on ovaries that appear larger or with many follicles (egg sac cysts) on ultrasound.
• Skin tags in armpits or on the neck.
• Thinning hair or patches of hair loss.
• Infertility is caused by PCOS.

What are the main causes of PCOS?

The exact cause is unknown. Genetics may play a role. Several other factors, most importantly obesity, also play a role. Other factors that play a role are:

1. Higher levels of androgens (male hormones)
2. Insulin resistance
3. Low grade inflammation

How is PCOS diagnosed?

Clinical history of abnormal menstrual cycle.

Signs and symptoms as discussed above.

High levels of testosterone and luteinizing hormone (LH).

On ultrasound more than 12 follicles in each ovary.

Follicle size between 2 and 9mm.

Morbidities associated with PCOS

Obesity

This is one of the most common features of PCOS and varies between 61 and 76%. Childhood obesity is a well-documented risk factor for PCOS.

Insulin resistance

This is considered the main pathogenic factor in the background of increased metabolic disturbances in women with PCOS which can explain high androgen levels, menstrual irregularity and abnormal blood lipid levels.³

Type 2 diabetes

PCOS confers a substantially increased risk for Type 2 diabetes and gestational diabetes from early ages. About 1 in 5 women with PCOS will develop Type 2 diabetes.

Cardiovascular disease

In 1992 Dalhgren et al² identified a 7 times higher risk of heart attack in women with PCOS compared to healthy people. More recent data shows higher burden of atherosclerosis and early onset cardiovascular dysfunction and heart vessel calcifications.

Infertility

In a 2015 study it was shown that infertility is 10-times more common in women with PCOS than in healthy controls. Women who conceive with PCOS might suffer from pregnancy-related complications, such as gestational diabetes and pregnancy-induced hypertension. Concerning the effects of the foetus, women with PCOS are 2.5 times at a higher risk of giving birth to a small for gestational age child.

Cancer

Females suffering from PCOS are at risk for endometrial cancer. Studies show a three-fold increase risk to develop endometrial cancer.

Psychological well-being

Women with PCOS are more prone to suffer from depression, anxiety, disordered eating and psychosexual dysfunction. It’s worth noting that obesity, acne, hirsutism and irregular menstrual cycles, all associated with PCOS, are major contributors to the psychological stress that the patients experience due to the challenging of the female identity and her body image.

Treatment

The management of PCOS targets the symptomatology for which patients usually present: anovulation, infertility, hirsutism and acne.

Lifestyle

Lifestyle modifications, such as exercise and a calorie-restricted diet, are considered as a cost-effective first-line treatment. Excessive weight is associated with adverse metabolic and reproductive health outcome. For instance, female fertility significantly decreases with body mass index (BMI) more than 30.

Multiple studies show that weight decrease as little as 5% regulates menstrual cycle, improves fertility, reduces insulin and testosterone levels, decreases acne and hirsutism and benefits psychological well-being.

Medical treatment

1. Oral contraceptive pills

Oral contraceptive pills are the most used medication for the long-term treatment of women with PCOS. It’s recommended for regulating of menstrual cycle and decrease of testosterone levels as first-line treatment. A minimum of six months on oral contraceptives is usually required to obtain satisfactory results against acne and hirsutism.

2. Metformin

Metformin is an oral antidiabetic biguanide drug that acts on suppressing glucose production from the liver and increasing peripheral insulin sensitivity. The use of metformin in women with PCOS decreases insulin resistance, reduces testosterone levels and improves glucose managing in the body.⁴

Screening recommendations

Screening for Type 2 diabetes

Women with PCOS should be routinely screened for Type 2 diabetes. Studies have shown that measuring only fasting glucose in patients with PCOS miss up to 80% of prediabetics and 50% of diabetics.

Current guidelines suggest screening women with PCOS using an oral glucose tolerance test every three years. Risk factors that require screening more often are:

• Family history of diabetes
• Hypertension medication use
• Smoking
• Increased waist circumference more than 80cm in females
• Physical inactivity

Screening for cardiovascular disease

Women with PCOS should be screened regularly for risk factors such as:

• Increased waist circumference
• Smoking
• Blood pressure
• Abnormal cholesterol profile (increase triglycerides and low HDL)

 Screening for psychological well-being

Screening women with PCOS for depression, anxiety, negative body image and eating disorders is important.

PCOS is a complex disease and should be managed by a team of medical practitioners from a dietitian, psychologist, gynaecologist, dermatologist and specialist physician. Team work can lead to a successful outcome.

References

1. Azzizz R, Woods K et.al. (2004)’The prevalence and features of the polycystic ovary syndrome in an unselected population.’ J Clin Endocrinol Metab. 89,2745-2749
2. Dahlgren E, Janson P et.al. (1992) ‘Polycystic ovary syndrome and risk for myocardial infarction.’ Acta Obstet Gynecol Scand. 71,599-604
3. Diamanti -Kandarakis E, Dunaif A (2012) ‘Insulin resistance and the polycystic ovarian syndrome revisited: an update on mechanisms and implications.’ Endocr Rev, 33 981-1030
4. Hayek S.E., Bitar L et. al. (2015) ‘Polycystic ovarian syndrome: an updated overview’ Physiol, 7:124

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