Nutrition Collaboration - Park County Chiropractic

Nutrition Collaboration
A collective of health practitioners
mentoring one another in topics related to
nutrition.
Who, When, Why
Anyone who wishes to join –
You select yourself
Second Monday each Month 1 - 2pm
To share and build understanding of the
common and uncommon knowledge of
the practice of nutrition in the care and
treatment of ourselves and the patients
under our care.
Rules
Share your knowledge with each other.
Competition and knowledge hording
only supports lost knowledge. This
group endeavors to share knowledge
and clinical experience to serve not only
ourselves, but all people.
It is asked that we as a group
consider:
“If you want to learn something
read about it. If you want to
understand something, write
about it. If you want to Master
something, teach it.”
Yogi Bhajan
What does this mean?
At some point we ask you to present a topic for
presentation to the group. This presentation need
only be 30-35 minutes in length with a power
point or notes available in Word for the group.
You should be able to do a Q&A with the group to
follow.
Everyone will be encouraged to participate in the
Q&A and it is asked that this become a roundtable
type Q&A.
If you chose not to present, that is your decision
and you will not be ousted from the group.
Please Help This Run Smoothly
 Push * now to mute your line
When the speaker is finished, if you have a
question or wish to add to the discussion,
press * to be put in the queue.
Thyroid
Thyroid and Who?
• 27 million Americans have overactive or underactive
thyroid glands. More than half remain undiagnosed.
• More than 8 out of 10 patients with thyroid disease are
women.
• Women are 5 to 8 times more likely than men to suffer
from hypothyroidism (underactive thyroid).
• 15 to 20% of people with diabetes and their siblings or
parents are likely to develop thyroid disease (compared
to 4.5 percent of the general population).
© 2005 American Association of Clinical Endocrinologists
Thyroid & Pregnancy
• Nearly 1 out of 50 women in the United States is
diagnosed with hypothyroidism during pregnancy.
• 6 out of every 100 miscarriages are associated with
thyroid hormone deficiencies during pregnancy.
• 5 to 18% of women are diagnosed with postpartum
thyroiditis.
• Approximately 25% women will develop permanent
hypothyroidism.
© 2005 American Association of Clinical Endocrinologists
Thyroid & Children
• 1 out of 5 thousand babies born in the United
States has hypothyroidism.
• Undiagnosed hypothyroid children may
experience slowed growth rate.
• Additional symptoms include sluggishness,
forgetfulness, mood swings, pallor, dry and
itchy scalp, increased sensitivity to cold and
constipation.
© 2005 American Association of Clinical Endocrinologists
Thyroid & Aging
• Incidence of hypothyroidism (underactive
thyroid) increases with age.
• By age 60, as many as 17% of women and 9%
of men have an underactive thyroid.
• Found in the neck
inferior to the thyroid
cartilage (also known as
the Adam's apple in
men) and at
approximately the same
level as the cricoid
cartilage.
Hormones associated
with Thyroid Function
• Thyroid
–
–
–
–
T4 (Thyroxin)
T3 (Triiodothyronine)
rT3 (Reverse Triiodothyronine)
Calcitonin
• Pituitary
– TSH (Thyroid-stimulating hormone)
• Hypothalamus
– TRH (Thyrotropin-releasing
hormone)
• Adrenal
– Cortisone
The thyroid produces several hormones, chief of
which is thyroxine (T4) and triiodothyronine (T3).
However, the thyroid also produces T1, T2, and
rT3 (reverse T3)
These hormones regulate the rate of oxygen use and basal metabolism rate,
cellular metabolism and growth and development. Thyroid hormones also
stimulate the use of cellular oxygen to produce ATP. They also stimulate the
synthesis of sodium-potassium pumps, which use the ATP for energy to eject
excess sodium ions (Na+) from the cell. In fact Thyroid hormones participate in
most all functions of the body.
Enzymes associated with Thyroid Function
DEIODINASES
• Iodothyronine
deiodinase - is an
enzyme important in the
action of thyroid
hormones. Deiodinases
are unusual in that the
enzyme contains
selenium, in the form of
an otherwise rare amino
acid selenocysteine
• Iodotyrosine deiodinase facilitates iodide salvage
in thyroid by catalyzing
deiodination of monoand diiodotyrosine, the
halogenated byproducts
of thyroid hormone
production
Thyroglobulin
AKA Colloid or Tg
•
Thyroglobulin (Tg) is a dimeric protein produced by and used entirely within the thyroid gland. In
earlier literature, Tg was referred to as "colloid".
Function
• Tg is used by the thyroid gland to produce the thyroid hormones thyroxine (T4) and
triiodothyronine (T3). The active form of triiodothyronine, 3, 5, 3' triiodothyronine, is produced
both within the thyroid gland and periphery by 5'-deiodinase (which has been referred to as
tetraiodothyronine 5' deiodinase.) Tg is produced by the thyroid epithelial cells, called thyrocytes,
which form spherical follicles. Tg is secreted and stored in the follicular lumen.
• Via a reaction with the enzyme thyroperoxidase, iodine is covalently bound to tyrosine residues in
thyroglobulin molecules, forming monoiodotyrosine (MIT) and diiodotyrosine (DIT).
• Thyroxine is produced by combining two moieties of DIT.
• Triiodothyronine is produced by combining one molecule of MIT and one molecule of DIT.
• Proteases in lysosomes digest iodinated thyroglobulin, releasing T3 and T4.
Clinical significance
• Patients with Hashimoto's thyroiditis or Graves' disease, frequently develop antibodies against Tg.
Tg-specific antibodies help in the diagnosis of these diseases, but they also may be present in
apparently healthy euthyroid individuals.
• Thyroglobulin levels in the blood can be used as a tumor marker for certain kinds of thyroid cancer.
Thyroglobulin levels in the blood can also be elevated in cases of Graves' disease.
Thyroid hormone biosynthesis
(1) iodide (I-) trapping by the thyroid follicular cells; (2) diffusion of iodide to the apex of the cells; (3) transport of
iodide into the colloid; (4) oxidation of inorganic iodide to iodine (via TPO) and incorporation of iodine into
tyrosine residues within thyroglobulin molecules in the colloid; (5) combination of two diiodotyrosine (DIT)
molecules to form tetraiodothyronine (thyroxine, T4) or of monoiodotyrosine (MIT) with DIT to form
triiodothyronine (T3); (6) uptake of thyroglobulin from the colloid into the follicular cell by endocytosis, fusion
of the thyroglobulin with a lysosome, and proteolysis and release of T4, T3, DIT, and MIT; (7) release of T4 and
T3 into the circulation; and (8) deiodination of DIT and MIT to yield tyrosine. T3 is also formed from
monodeiodination of T4 in the thyroid and in peripheral tissues.
Modified from Scientific American Medicine, Scientific American, New York, 1995.
Measurable Thyroid Blood Labs
•
•
•
•
•
•
•
•
TSH
Free T4 (fT4)
Free T3 (fT3)
T4 (sometimes called Total T4)
T3 (sometimes called Total T3)
Reverse T3 (rT3)
TPO Antibodies
Anti TG antibodies
Laboratory Findings in common Thyroid Disorders
Thyroid Disorder
T4
T3
rT3
T3 resin
uptake
Free T4
index
Free T4
TSH
TRH
test
Thyroglobulin
TR Ab
Hypothyroidism
Primary
L
L
L
L
L
L
H
H
N
-
Secondary (pituitary)
L
L
L
L
L
L
N,L
N
N
-
Hyperthyroidism
H
H
H
H
H
H
L
N
N,H
-
Grave’s disease
(thyrotoxic phase)
H
H
H
H
H
H
L
N
N,H
+
Hashimoto’s
thyroiditis
V
V
V
V
V
V
V
V
V
Euthyroid sick
syndrome, conversion
disorders,
peripheral receptor
resistance
N,H
N,L
N,H
N,L
N,L
N,L
N,L
N,L
N
T4, Thyroxine; T3, triiodothyronine; rT3, reverse triiodothyronine; TSH, thyroid-stimulating hormone; TRH,
thyroid-releasing hormone; TRAb, thyrotropin-receptor antibodies; H, high; L, low; N, normal; V, variable;
–, negative; +, positive; ++, markedly positive.
David M. Brady, DC Michael J. Schneider, DC
Fibromyalgia Syndrome: A New Paradigm for Differential Diagnosis and Treatment
JMPT Volume 24 • Number 8 • October 2001
++
-
Signs & Symptoms
Hypothyroid
Hyperthyroid
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Weight gain
Puffy face
Cold intolerance
Low sex drive
Depression
Abdominal bloating
Cold hands or feet
Dry or thinning hair
Joint or muscle pain
Slow healing
Thickening of the skin
Thin, brittle fingernails
Thinning of eyebrows esp. outer 1/3
Myxedema
Husky voice
Numbness of the arms and legs
Hearing loss
Mental confusion or memory problems
Cholesterol increase
Palpitations
Heat intolerance
Nervousness
Insomnia
Breathlessness
Increased bowel movements
Light or absent menstrual periods
Fatigue
Fast heart rate
Trembling hands
Weight loss
Muscle weakness
Warm moist skin
Hair loss
Staring gaze
Exophthalmia
Puffy Face
Loss of Sex Drive
Thinning Hair & Eyebrows
Weight Gain
Exophthalmia
Goiter
Dwarfism, Cretinism, Myxedema
Thyroid Cancer
• According to new data from the National
Cancer Institute (NCI), thyroid cancer
diagnoses have increased at a rate of 6.5
percent a year from 1997 to 2006.
• Thyroid cancers are typically not picked up on
lab tests, but by palpation, biopsy, and
advanced imaging. Calcium is sometimes
elevated.
Gluten & Thyroid
• Researchers have found autoimmune thyroid diseases
to be more common in people with CD than in the
general population
• Some patients with CD have reported a lowered need
for thyroid hormone replacement after being on the GF
diet for a period of time.
• What is the reason for this? One reason is that the GF
diet allows the small intestine to heal, and therefore
thyroid medication may be better absorbed.
• The GF diet may also cause a lower inflammatory
response and reduce the inflammation of the thyroid
gland.
Gluten Intolerance Group (GIG) of North America®
TPO
• Thyroid peroxidase or thyroperoxidase (TPO) is an enzyme
mainly expressed in the thyroid that liberates iodine for
addition onto tyrosine residues on thyroglobulin for the
production of thyroxine (T4) or triiodothyronine (T3)
(thyroid hormones). In humans, thyroperoxidase is encoded
by the TPO gene.
• Stimulation and inhibition
• TPO is stimulated by TSH, which upregulates gene
expression. It is inhibited by the thioamide drugs, such as
propylthiouracil and methimazole.
• Clinical significance
• It is a frequent epitope of autoantibodies in autoimmune
thyroid disease (most commonly, Hashimoto's thyroiditis)
so the antibody titer can be used to assess disease activity
in patients who have developed such antibodies.
TSH
• TSH is not a measure of metabolic rate it is a measure of the anterior pituitary
response to T3 to TR 2 (thyroid receptor beta 2)
• The biological effects of thyroid hormones at the peripheral tissue and not TSH
concentrations reflect the clinical severity of hypothyroidism. A judicious initiation
of thyroid hormone treatment should be guided by clinical and metabolic
presentation ad thyroid hormone concentrations and not by serum TSH
concentrations – BMJ 2003; 326:311-312.
• TSH was designed as a screening tool only!
• When it was initially described we did not have the knowledge of the different
thyroid receptor sites and the different forms of de-iodinase enzymes.
• It was not designed as a diagnostic test to determine the efficacy of prescription
therapy.
• It was not until 1993 that the knowledge of the different T3 receptor isoforms and
different de-iodinase enzymes were made available.
TSH
The normal laboratory values for TSH range from .5
to 5.0. Recently endocrinologist have suggested a
tighter range of .3 to 3.0.
The current medical standard suggests levels beyond
5.0 require intervention and or further testing.
Often further testing is not performed and the
patient is place on a synthetic T4 preparation
(Synthroid / Levoxyl)
The further the level of TSH beyond 10 the less likely
to be successfully treated with nutritional support
alone.
2.25
1.125
.5
3.0
3.375
TSH RANGE 5.0
T3 Receptor types
•
•
•
•
TR
TR
TR
TR
2
1
1
2
Pituitary
Liver & Kidney
Skeletal muscle, Heart, Brown fat
Brain & Hypothalamus
TR 2 represents less than 1% of all the T3
receptors in the entire body!
Does it make sense that less than 1% of total
receptor sites control the function of the other
99%?
Total T4
Total T4 is a measure of all available T4 both
bound and unbound. A chemical is placed in the
sample that unbinds all the protein bound T4 and
then all T4 is then measured.
8.45
6.425
4.4
10.475
Total T4
12.5
Free T4
1.34
Free T4 is the non protein bound (more
potentially active) form of the T4 molecule as
measured before any unbinding chemical is
added.
1.035
.73
1.645
Free T4
1.95
Excessive Binding
8.45
• If T4 is binding to protein
excessively the position of the clock
face on Total T4 will exceed that of
the position on the Free T4. The
same is true of TT3 and FT3.
Circumstances that create excessive binding:
1. Hyper-estrogenic states
2. Pregnancy – neonatal state
3. Tamoxifen
4. Oral contraceptives
5. Hepatitis (chronic and active)
6. Genetic factors
7. HIV
6.425
10.475
11.0
4.4
Total T4
12.5
1.34
1.15
1.035
.73
1.645
Free T4
1.95
Total T3
145
172.5
117.5
• T3 is carried in the blood bound to plasma
proteins. This has the effect of increasing the
half life of the hormone and decreasing the
rate at which it is taken up by peripheral
tissues. There are three main proteins that
bind this hormone. Thyronine binding
globulin (TBG) is a glycoprotein that has a
slight affinity for T3 (preferring T4). The
second plasma protein to which the hormone
binds is transthyretin (which has a higher
affinity for T3 than for T4). Both hormones
bind with a low affinity to serum albumin, but
due to the large availability of albumin it has a
high capacity.
90
Total T3 200
Free T3
Free T3 is named such because it is unbound
to a carrier protein like Thyronine Binding
Globulin (TBG), albumin or transthyretin (by
the way that got its name because it
transports thyroxin and retinol)
3.25
2.775
2.3
3.725
Free T3
4.2
Decreased Conversion
• If there is proper conversion of FT4
to FT3, both FT4 and FT3 should be 1.035
at about the same position on the
clock.
• This example represents a
.73
conversion problem. Now you must
find the etiology and treat
accordingly.
2.8
1.34
1.645
1.7
Free T4
3.25
2.775
2.3
1.95
3.725
Free T3
4.2
Decreased Conversion Cont.
T4 to T3 Inhibitors
Nutrient Deficiencies
• Iodine
• Iron
• Selenium
• Chromium
• Zinc
• Vit. A
• Vit. B2
• Vit. B6
• Vit. B12
Others:
Fluoride
Chlorine
Bromine
Lead
Mercury
Stress
Medications
• Beta Blockers
• Birth Control Pills
• Estrogen
• Iodinated
Contrast Agents
• Lithium
• Phenytoin
• Theophylline
Pesticides
Aging
Diabetes
Surgery
Cigarette Smoking
Radiation
Alcohol
Soy
Cruciferous Vegies
Fasting
Low Adrenal State
Growth Hormone
Alpha Lipoic Acid
Hemochromatosis
1.34
1.035
.73
1.645
1.7
Free T4
1.95
3.25
2.8
2.775
2.3
3.725
Free T3
4.2
220
Reverse T3
285
155
90
Reverse T3 350
• Reverse triiodothyronine (reverse T3, or rT3) is a molecule which is
an isomer of triiodothyronine (T3). It is derived from thyroxine (T4)
through the use of deiodinase.
• rT3, unlike T3, does not stimulate thyroid hormone receptors.
However, rT3 nonetheless binds to these receptors, thereby
blocking the action of T3. Under stress conditions, the adrenal
glands produce excess amounts of cortisol. Cortisol inhibits the
conversion of T4 to T3, thus shunting T4 conversion from T3
towards rT3. Consequently, there is a widespread shutdown in T3
binding across the body. This condition is termed Reverse T3
Dominance. It results in reduced body temperature, which slows
the action of many enzymes, leading to a clinical syndrome,
Multiple Enzyme Dysfunction, which produces the effects seen in
hypothyroidism. Effects include: fatigue, headache, migraine, PMS,
irritability, fluid retention, anxiety and panic.
Free T3 and rT3
1.34
 If the conversion of T4 to FT3 and rT3 is
normal, FT3 and rT3 should have about the
same position on the clock.
 Even though rT3 is within the normal range
for the laboratory value, it is in excess of FT3
indicating excessive T3
 Since FT3 and rT3 occupy the same receptor
site and since rT3 will not activate the
receptor a patient with a relatively elevated
rT3 will exhibit symptoms of tissue
hypometabolism despite the normal
laboratory values.
220
155
90
1.035
.73
1.645
1.7
Free T4
1.95
3.25
2.8
2.775
2.3
285
290
Reverse T3 350
3.725
Free T3
4.2
Etiology and Correction of Excess
rT3
• Excess Cortisol blocks T4 to T3 conversion and
increases T4 to rT3 conversion.
• Check salivary cortisol levels, and address
appropriately.
• Since rT3 is derived from T4 you must lower
T4 levels.
– If patient is on a T4 medication (Synthroid),
consider switching from the T4 medication to a T3
medication (Cytomel).
Thyroid Dashboard
8.45
1.34
6.425
4.4
10.475
10.6
Total T4
1.035
12.5
1.645
1.7
.73
Free T4
130 145
3.25
2.8
2.775
172.5
117.5
90
1.95
220
Total T3 200
155
90
2.3
285
290
Reverse T3 350
3.725
Free T3
4.2
Ideal Thyroid Dashboard
8.45
1.34
6.425
10.475
4.4
Total T4
1.035
12.5
1.645
.73
Free T4
145
3.25
172.5
117.5
90
1.95
2.775
220
Total T3 200
155
90
2.3
285
Reverse T3 350
3.725
Free T3
4.2
Blank Thyroid Dashboard
8.45
1.34
6.425
10.475
4.4
Total T4
1.035
12.5
1.645
.73
Free T4
145
3.25
172.5
117.5
90
1.95
2.775
220
Total T3 200
155
90
2.3
285
Reverse T3 350
3.725
Free T3
4.2
Other Measurable Considerations
•
•
•
•
•
•
Basal Body Temperature Testing
Iodine Patch Testing
Urinary Iodine testing (with and w/o loading)
Saliva Testing of TSH/T4/T3 and TPO
Salivary Cortisol Testing
Hyporeflexia and Hypereflexia
Basal Body Temperature Test
This test was developed by Dr. Broda Barnes, M.D. and is a measurement of the underarm temperature to determine hypo and
hyperthyroid states.
1. Shake down the thermometer to below 95º Fahrenheit and place it by the bed before going to sleep at night.
2. Upon waking, place the thermometer in your armpit for a full TEN minutes. Do not move. Try to lay still with your eyes closed
if possible. Do not get out of bed or move around until the ten-minute test is completed.
3. Read and Record the Date and Temperature.
4. Record the temperature for at least five mornings and if possible at the same time of day.
Menstruating women must perform the test on the Second, Third, and Fourth days of menstruation or any five (5) days in a row.
Men and Postmenopausal women can perform the test at any time.
Morning 1:
Date____________
Temperature_________________
Morning 2:
Date____________
Temperature_________________
Morning 3:
Date____________
Temperature_________________
Morning 4:
Date____________
Temperature_________________
Morning 5:
Date____________
Temperature_________________
Normal Basal Temperature is between 97.8 and 98.2
Iodine Patch Test
Patient Name ____________________Date________________
1.
Begin this test in the morning (after showering).
2. Use Tincture of Iodine to paint a “2 X 2” square on the inner arm.
▪ Tincture of Iodine is available from any drugstore or pharmacy. Be sure
it’s the original orange colored solution and not the clear solution.
APPROXIMATE
SIZE OF THE
IODINE PATCH
SHOULD
FILL THIS BOX
3. Write down your starting time: ______ : ______ am
4. Observe the coloration of the patch over the next 24 hours.
5. Record the hour of time for the following:
▪ Hour patch began to lighten: _______ : _______ am / pm
▪ Hour patch disappeared completely: _______ : ________ am / pm
6. Describe patch site after 24 hours
_____________________________________________________________
_____________________________________________________________
7. Any other observations or comments:
_____________________________________________________________
_____________________________________________________________
Iodine Patch Test
INTERPRETING IODINE PATCH TEST RESULTS
The faster the body draws in the iodine, the greater
the iodine need is likely to be.
1. Patch begins to slightly lighten after 24 hours-NORMAL
2. Patch disappears, or almost disappears in under 24
hours:
▪ Consider adding Iodomere—2-3 or more
tablets/day
OR
▪ Consider adding Prolamine Iodine—1-2 or
more tablets/day
3. Patch disappears, or almost disappears in under 10
hours:
▪ Consider adding Prolamine Iodine—1-2 or
more tablets/day
NOTE: According to Dr. Guy Abraham, a researcher
and an authority on the safe use of iodine, the
daily dose of iodine should be 12.5mg to 37.5mg
per day.
REPEAT TESTING - Repeat the Iodine Patch Test every 1-2 weeks
to carefully monitor the need for iodine. When the patch
no longer fades or disappears within 24 hours, lower the
iodine dose appropriately.
Amounts of iodine in some SP & MH supplements
Prolamine Iodine—3mg
Thyroid Complex (MH)—600mcg
Iodomere—200mcg
Trace Minerals B12—145mcg
Organically Bound Minerals—250mcg
Min Chex—300mcg
Min Tran—200mcg
Cataplex F (tablets)—95mcg
One simple, inexpensive way to check the health of your thyroid
is to do an iodine skin patch test. It should last 24 hours
when painted on your wrist/ forearm. If it’s less than 10
hours then it’s a very tired and malnourished thyroid and
time to give it sufficient iodine.
Remember, when dosing single trace minerals however, it’s
important to keep it in balance with all the other trace
minerals.
So when we prescribe an organic source of iodine we always add
to that adequate doses of trace minerals. It’s also good to
add a good quality Celtic sea salt or kelp to your diet as
well.
Thyroid Pharmaceuticals
HYPOTHYROID MEDICATIONS
Levothyroxine sodium
– Levothyroxine
– Synthroid
– Levoxyl
– Levothroid
– Euthyrox
– Levo-T
– Unithroid
Liothyronine (synthetic form of the T3 thyroid
hormone)
– Cytomel
Liotrix (synthetic drug combining both levothyroxine
and liothyronine (T4 and T3).
– Thyrolar
“Natural” Thyroid
– Amour
– Westhroid
– Naturethroid
– Bio-Throid
HYPERTHYROID MEDICATIONS
Thioamide (rarely, thionamide)
Thioamides are also a class of drugs which are used to
control thyrotoxicosis.
–
–
–
Propylthiouracil (PTU) or 6-N-Propylthiouracil
(PROP)
Methimazole (Tapezole)
Carbimazole (converted to the active form,
methimazole)
Thyrotrophin Alfa
– Thryrogen (use in cancer screen to keep pt from
having to go off thyroid med prior to scan)
Beta-blockers are used to control cardiac symptoms
Nutritional Strategies
• Hypothyroid Patient
• Hyperthyroid Patient
– Primary Products
– Thytrophin PMG
– Antronex
– Bugleweed
•
•
•
•
•
Symplex F/M
Thytrophin PMG
Thyroid Complex
Cataplex E (selenium)
Prolamine Iodine or
Iodomere.
– Secondary Products
•
•
•
•
Trace Minerals B12
Organically Bound Minerals
Cataplex G
Drenamin or the vast array
of adrenal adaptogens.
Thanks for joining us today!