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Hypothyroidism

Mar 23 | 2:00 PM

Endocrine disorders are common among Indian population out of which thyroid disorders represents an important subset of these endocrine disorders. The prevalence of these thyroid disorders varies widely according to geographical distribution, diet and nutrition and patient population. The occurrence of hypothyroidism in India is 11%, compared with only 2% in the UK and 4.6% in the USA. The prevalence of hypothyroidism increases with age, and the disorder is nearly 10 times more common in females than in males. Let's understand the increased risk and Mx of hypothyroidism pertaining to Indian population.

[Music] a very good evening to everyone i welcome you all to this session i'm dr simran khan man md internal medicine working as a consultant physician at patiala today we all have gathered here to discuss on a very important topic that risks an approach to management of hypothyroidism as we all know hypothyroidism is caused by either insufficient secretion of thyroid hormone or complete loss of function of thyroid gland and it is usually progressive and irreversible disease however if treatment done properly it is nearly always completely successful and allows patient to live a healthy life to discuss this topic we have none other than doctors martha thula consultant physician and dermatologist we welcome you all ma'am yes thank you so much mam offers a systemic scientific and individualized approach to prevention and treatment of various diseases as she believes that optimal health lies in fusion of precision and preventive medicine ma'am says my goal is to not not to just treat the symptoms but to identify analyze and address root cause of problem and holistically treat it through medicine nutrition and lifestyle modifications mam being an internal medicine also has done fellowship in diabetes mellitus she has also received certified training in bhrt and iv nutrition from society for regenerative anti-aging and aesthetic medicine india she has also received training in precision and anti-aging medicine from american academy of anti-aging medicine metabolic medical institute usa ma'am is currently working at unique plastic surgery and magna cold flame man specializes in precision medicine anti-aging medicine bioidentical hormone replacement therapy medical weight management diabetes management gut health iv nutrition hormonal health we welcome you all ma'am to netflix and thank you for joining us today thank you so much ma'am uh you can continue from here yes thank you so much thank you for your warm welcome i hope i'm audible to all of you if not please chat here and i would welcome questions at the end of the session and please take a note of what are we going to discuss today i think this may add value to the treatment protocols that you may be adopting in your patients and clients so let's start with it so the presentation keeps playing but let me uh start with thyroid physiology as you know thyroid formation is so important nutrients are so very important nowadays everybody talks about nutrients post corporate and during coverage there are four important neutrons that are essential for thyroid hormone synthesis iodine selenium zinc and iron in the absence of any of these mechanisms the thyroid fails to properly form the hormone and it's under working so the undergrowth of the thyroid and insufficient release of the thyroid hormone eventually presents with hypothyroidism and hence the homeostasis and the metabolic balance is lost in the body and presence within numerous symptoms that will go through so in this thyroid physiology i want to explain why iodine is particularly essential because it is very important for the component of t4 and t3 do you know that 30 percent of the world lives in an area where iodine is deficient that is the reason why iodine deficient hypothyroidisms are most common and most of these patients present with goiters or spelling in their thyroid gland as you all must have seen in your clinicals and there are um there are studies which show that supplementing these patients iodine deficiency coita patients with iodine has shown that there is reduction in the size of the goiter so that is the importance of iodine and also studio also shows that it inhibits the iodine inhibits and prevents the growth of thyroid nodules in nearly 66 percent of the patients so that important is the iodine now coming to selenium selenium is an important component of something called glutathione peroxidase it is an enzyme which decreases reactive oxygen species as you all know there is high oxidation process happening in the body and it releases hydrogen peroxidase free radicals so selenium is important component of glutathione peroxidase so supplementing with selenium has increased the selenium peroxidase levels by 21 percent and increased levels of selenium by 45 so studies show i can link all these uh study articles later once we finish uh the presentation the selenium supplementation has also shown to lower the levels of tpo thyroid peroxidase antibodies by 76 percent now coming to zinc zinc is again an important component for thyroid synthesis and is involved in the action of the thyroid hormone as well and in individuals specifically with nodular goiter zinc levels are greatly correlated with the size of the goiter that again there is a study which showed the relationship between the serum zinc levels the thyroid hormones and the thyroid volume following the successful um supplementation of the necessary uh zinc as i said and now coming to iron we in most of our clinicals i have seen so many hypothyroidism patients with iodine deficiency iron deficiency anemias these are the individuals needing more higher dosage of uh synthetic low thyroxin that is the thyroid replacement medication so again that is the reason why this is very basic suffered so hypothyroidism as it's not thyroid gland which is normally producing not normally producing the nf thyroid hormone why we are discussing hypothyroidism is one fifth of the burden of chronic diseases lies in hypothyroidism other major issues as you already know are the hypertension diabetes pcos and the gut amongst them the most important thing is being hypothyroidism and did you know that all of these five chronic condition have been reportedly having high inflammation and per gut health that will come on to it later so poor gut health and high inflammation has been the basis of all these chronic diseases that have been abundant to us in india so as i basically mentioned some of the physiologies that have been going through on the background here if you see you all know that hypothyroid hypothalamus releases thyroid trs then the tsh is released from the hypophysis then the action of tsh on thyroid will result in the formation of t4 and t3 where t4 has to be converted to t3 for it to be efficiently used in the body if these are sufficient enough t4 and t3 have got an inhibitory action in both trh and tsh so that whole body will maintain in a balance so at every step of process of formation of thyroid hormone everything is so very important if one step or some things go wrong somewhere we end up having some sort of symptoms or we end up having abnormal tsh levels or t3 levels so first box on the left hand side has already been explained amongst them or the nutrients that are important for the formation of thyroid hormones are mentioned out of the four important ones are iodine iron zinc and selenium next on the right hand side what are the factors that that inhibit proper production of thyroid hormones any stress trauma infections as you know uh in infections we come across with the condition that i'll explain explain you later uh that is the reason why we specifically do not start treating them during the infection but we have to find out what it is so the unseen toxins it could be as simple as the plastic products we use the plastic bottles we use um the over-the-counter [Music] unnecessary uh non-testified supplements it could be because in today's world if you see in pandemic as well there are numerous companies producing so many medications served as immunity pills but are they all heavy metal proofed are they clear for heavy metals are they cleared for gmos we do not know so these are examples of some of the areas where we can be burdened with heavy metals or toxins or unnecessary mercury cadmium inlet next coming to next thing what are the factors that are important for conversion of t4 to t3 selenium and zinc as i explained there are numerous studies which explain how these two play a role in conversion now next thing factors that improve cellular sensitivity once the thyroid hormone is released it should be as sensitive as possible so that will utilize the hormone so exercise exercise exercise is one of the important thing you must have seen so many clients with hypothyroidism end up saying i visited so many times and doctor every time increases the dose backhand what the client does at home is very important to the adherence of treatment what is the use if the patient the client or a patient is taking a pill once daily and is not following good diet and is abusing himself or is not exercising is sedentary the whole day there's no purpose of giving the medication if everything else do not fall in place so this thing happens most of the time when they take pill and go and take other things for granted and they do not make a lifestyle change now coming to the left side what are the fi now if you know there is a reverse t3 in the body what is the role of reverse t3 um it was t3 uh was designed in such a way that it will store the hormone whenever uh body for example if we are in stress uh if we are in starvation the body will realize that this hormone should be stored so whenever we are in a low calorie diet or something t4 instead of forming t3 will form reverse t3 so that it can store whatever food we are eating because when we are consuming so less calories so it can be a case with stress it can be a case with trauma or it could be a case with feminine or your severe infections toxins whatever the body will try to slow down the metabolism that is the reason of forming reverse t3 and then coming to the next one what are the root causes why so many clients or patients in today's day are presenting with hypothyroidism here comes the factors yes genetics have been blamed every time but not everybody who's hypothyroid today are because of the genitive defect coming to the next modifiable risk factors like impaired gut uh impaired immune response imbalance in the gut microbiome where the diversity of the gut microbiome is lost so if you know there are certain balances that we maintain there are certain ratios that we maintain in the gut for example bacteroides and form equities are maintained in the certain ratios uh proteobacter active into a bacteria made in certain ratios if they are out of balance uh suppose you have seen some of the studies with high inflammation insulin resistance under waste if you have studied their gut you see that their gut is overgrowing in formic it is it should not be the case formicutist should be little on the lesser side than bacteroids so things like this this is one example of how diverse a microbiome can be and how when the imbalance happens it can lead to numerous gut imbalances impaired gut and all these chronic diseases then it could be a toxic load toxic burden it could be depending on the water food and minerals where they're coming from where you're consuming from could be a disturbance in the immune system or it could be a stress or more importantly as i said a sedentary lifestyle as long as the normal metabolism is not maintained there is no need for the muscles to be more sensitive for thyroid hormone so this is where uh the exercise or more being more mobile can actually improve your thyroid levels now coming to the next slide how about chronic stress how um this chronic stress has an effect on hypothyroidism as well why am i talking about stress at all here see whenever we are in chronic stress where we are releasing high cortisol levels we are either in flight or fight mode occasionally it is fine once in a while because we are our body is designed in such a way that in hunter gatherer's time where lying is running after us or we are running after food we need to rush so the cortisol is a hormone where it will rush our blood vessels blood pressure boosts up and the muscles activate and we rush it is okay if we are activating this hormone once in a while but what happens when you're in chronic stress your cortisol is always high your body is always in a fight mode that is how body will show information and when there is inflammation the whole set of uh eating these eating disorders headaches migraines fibromyalgia everything land up in a later life and whenever you're in chronic stress we end up having bad eating behaviors and what do we go for sugars high carbs and what not everything caffeine coat and everything so that is how stress can simply affect it poor nutrition as i said any food that is deprived of the nutrients that are required for the activation of hypothyroidism it can be food allergies some people we do not even know how carry allergies and can have over-burdened immune system or over-active immune system then leaky gut syndrome what is this we often these days have been have been hearing about it what are these normally we have tight junctions between our epithelial cells in the gut so here if you see the tight junctions are lost there is a gap which is created and which can lead to inflammation because uh the gut lining absorbs all the toxic elements that are running flowing uh through otherwise have to be excreted to stools are absorbed back into the body what happens if these toxins are reabsorbed from the gut into your blood vessels body will obviously try to throw it out so body starts reacting that is the body's way of responding to certain foods this is uh the reason why certain people do not accept wheat certain people do not accept barley and dried that is gluten so some people can turn gluten intolerant and if you keep them off on gluten for some time they start to feel better the inflammation start to feel better the gastric symptoms come down so it can be as simple as this but how is this leaky gut associated with hypothyroidism you know hypothyroidism one of the most common presentations is hashimoto's disease will come to that but this hashimoto's disease is nothing but the presence of the antibodies like tpo and thyroid binding globulin if there are antibodies to this these we develop hashimoto's but why are these antibodies turning positive in the frost case first thing it could be genetics second thing it could be some autoimmune reaction happening in the body one of the most key triggers are leaky gut coming to the next thing dysbiosis as i said uh secondary to the microbes that are going growing on the cycle the highest number of microbes that grow are in our gut so gut is very rich with microbes like not just bacteria fungi and viruses as well but there need to be certain diversity and balance in today's world most of the guts that we are carrying now today we are less diverse gut is less diverse uh it's not flourishing with all kinds of microbes and there is imbalance in the kind of micro microbes so that is the link between the dispersers leaky gut and autoimmune conditions that is how we are linking this gut dysbiosis with hypothyroidism and what about the gas gut disruptors all the stress alcohol antibiotics acid blockers uh processed and junk food and so the synthetic compounds change the normal hormonal signals and can lead to this altered hormones the sources can be numerous of all these once you're evident is the medications that you're popping into your body like ammeron lithium and all all these things can cause an imbalance in your thyroid hormone formation and unseen are these heavy metals chemicals in the commercial cleaning of products the pesticides fungicides and herbicides everything the for basically the food identification have you studied about the structured water so there has been all this latest research growing on how the chronic dehydration has been linked to so many symptoms and so many diseases and how today's world we are depleted of the structured water because the water is polluted when the water is polluted the water loses its structure so this is what is happening why we are not receiving pure water or making water alkaline is other important thing now blue light toxicity how many of you are sitting in front of laptop today everybody who's seeing this right so what are we carrying uh behind this blue light our melatonin is not activated when the melatonin is not activated we are not sleeping when we are not sleeping our igf is not active and where igf is not active we are not uh rejuvenating our cells are not rejuvenating so all these things happen when the cells are not rejuvenating and the igf is not activated in the night we tend to put on weight do you know that this is how simply uh sleep not sleeping enough can affect us so blue light is very important and uh chronic exposure to blue light especially in the nights before your sleep can be very harmful this can lead to imbalance of your thyroid hormones again so all these are picturistically shown here how insomnia the trauma the hormonal changes the iodine deficiency and the pituitary disorders let me stop here pituitary disorders are the secondary disorders where thyroid is functioning well enough but it is not clearly stimulated by either trh or tsh if the thyroid is not stimulated enough then we end up with secondary hypothyroidism but ah the number of cases that we see just secondly now hypothyroid are less and we have discussed about environmental toxins yes there are certain subsets of medications here that can cause the loss of balance in thyroid hormones especially the amide around the lithium and these kind of medications and antidepressants as well and pregnancy do you know that pregnant women of if they are already hypothyroid they need 30 percent more dosage of thyroid hormone so that is how the pregnancy hormones can impact the thyroid hormone because if the person has not hypothyroid even before pregnancy but still the need for excess thyroid hormone is is there and the last thing is thyroiditis which can happen as an autoimmune process most of the time we have discussed about how h pylori or eb viruses or simply fungal mold can cause a trigger auto not just hypothyroidism all these three things can trigger many autoimmune diseases and hashimoto's yes definitely when the antibodies are high and most of the times what we see in india has been hashimoto's thyroiditis after iodine deficiency number one is iodine deficiency hypothyroidism and number two is hashimoto's thyroiditis and of course radiation and leaky gut have in the long run uh showed these things now coming to symptoms you all must be seeing symptoms starting from weight gain to irritability fatigue to enema in the body low heart rate to slow moment in the body morning slugginess morning stiffness or swollen eyelids or even a person is intolerant to cold or hypothyroid patients have little slower speech and elbows if you have seen there is a darkening or keratosis and the circulation is more they tend to retain more fluid they're trying to have federal edema and their menstrual liver gladiators are there and if you look at their nails if they're more brittle enriched all these you can come across when in the general examination of this particular patient now uh on the presentation on how that is what i've been explaining again you can see periorbital puffiness there can be hose voice there can be a quieter there can be a non-fitting edema in the feet and brittle nails and tiredness if you look at the weight they can increase in the weight and some people have a mixed edema when there is severe severe hypothyroidism and the skin can be dry and coarse and they can be macroglossy as well in few people so this is what a person can look like or we say there is hypothyroid faces of this person when labels um one third of the eyebrows are lost or thinning and there's a puffy dull face and the hair is dry and sparse and coarse now if you look at the right side this pseudo hypertrophy of the calf muscle which is again a problem with hypothyroidism and there is hoffmann syndrome now we have discussed various causes and how patient presence how can your symptom now how to take it forward first thing that we do anywhere is a tsh now the if the tsh has been normal then what is the problem if tsh is normally is it a pituitary disease if yes what is the free t4 is it normal so tsh is normal t4 is normal that means it is not related to thyroid at all no tsh is normal only t4 is low we should rule out all other effects is it a secure thyroid this is what i want to stop you must have seen many people who are sick on the bed and with or have drawn blood for dsht 3 d4 who might not be giving you a history of hypothyroid their life previously so these are the people presenting with low t4 and normal tsh and this is secure thyroid syndrome or it could be sometimes the effects of other drugs and then you evaluate them further now what about the people who are tsh high now you again look for free d4 uh look for them if it is normal or low if the deep free t4 or unbound t4 is normal how are the antibodies are they positive if the antibodies are positive t4 is a tsh is high no matter what the t4 is you might have to start them on the t4 treatment now the tsh has been high uh free t4 is normal and even the antibodies are negative do you treat them it depends on the tsh when the tsh is more than 10 you got to treat them if the tsh is between 5 and 10 if the patients have symptoms it depends on the physician but i would more likely in that case treat them and also i would like to find out what is the cause is it simply vitamin deficiencies or it is it the poor gut health we need to correct it so and now coming to elevated t3 and low t4 that is definitely definitely primary hypothyroidism check for the antibodies if the antibodies are negative find out what other causes have left to primary hypothyroidism but the treatment is again the same you have to uh treat them with liver thyroxine if tsh is high free t4 is low and the antibodies are positive that means the patient is having autoimmune hypothyroidism or hashimoto's thyroiditis and you give them ego thyroxine or t4 treatment this is how generally a flow pattern or flu chart will be now here i go to explain there are many lab values which are shown up everywhere in the labs they give a broad range of values now these are the ideal and optimum ranges that we need to look for you can take a screenshot or write it down these are the free t3 and free t4 values which are most narrow here but here i would like to correct it free t3 can be in the range between three to three point eight here it is wrongly mentioned it is not so tight it is between three to three point eight but free t4 the optimal range is one to one point five nano graph now um these are the values the same thing here mentioned again okay now you basically know how you got to treat when i talked about levothyroxine let me stop here what is the dose that you want to start usually we start anywhere between 1.5 to 1.8 microgram per kg per day so simply we say in most of the books 1.6 microgram per kg per day you start slow and go slow but what about people elderly who are more than 50 years we start them with the lowest doses like 12.5 to ah 25 mcg per day and how do you escalate the rules uh we escalate the dose every fourth to four to six weekly okay at the end of six weeks you have checked the tsh is being stable then what is the next uh follow-up test when should be the next follow-up test should be so it can be at the end of uh three months if it's beginning and now it's again stable what should be the next fall of time six months but people who have not been maintaining stability sh you have started somewhere with 25 you have raised tsh is way beyond check the body weight check for the other causes what is triggering it find out what are the deficiencies are you targeting the deficiencies or are you just simply increasing the dose of lipotyroxine remember you are giving levothyroxine which is a t4 t4 in the body should be converted to t3 so what are the factors that are important for this conversion selenium and zinc find out are the iron and selenium and zinc deficient number one find out are they have having bad gut health are they having poor eating habits are they using a lot of plastic what kind of water are they using are they using clean water so many things fall into this place uh when you think that you are giving the dose but they're not responding appropriately or adequately now [Music] many people talk about reversing these chronic diseases are they even reversible and can they be so lifestyle modification is important it can decrease or even sometimes reverse the autoimmune attack because there are so many people who have rece reversed uh their autoimmunity after falling certain lifestyles and improvising their lifestyles and keeping them away from toxic elements um can thyroid regenerate once this autoimmune attack ceases yes it can a thyroid releasing a hormone test can be done to determine if thyroid function has returned yes you can do it then um here again these are the different elements or vitamins how they affect in a way if you look at vitamin d everybody has been talking about vitamin d now how it is linked to autoimmune diseases how the deficiency is linked to cancers and et cetera et cetera so here you can take a screenshot and find out how each vitamin is acting in a way it has to be here are the lab values take a screenshot again um uh about anti-tpo antithyroid so these are the levels normal optimal ranges of the anti-tpo and anti-thyroglobulin antibodies make a note it's less than nine and less than four these are again the optimal ranges that i have been talking about in the previous slides you can take a screenshot if you like in pregnancy there is this one question always how much do you such a value should we maintain for the pregnant women it's the uh from the latest studies what we see is between 2 to 2.5 so make a note of it again so now these are the um this is the schematic we have you go through how the tests are done so you obviously when the patient has seen you for the first time you obviously test for tdsh you test for total t43 yes the unbound t43 is important as well in the later stages uh when the patient is not responding to teeth to the treatment to find out what is wrong you may need free t3 t4 as well and yes antibodies to find out if it is autoimmune or not and inflammatory markers to check out if they are harboring any inflammation so you have esr and liver enzymes to test for again second thing nutrition nowadays there are so many programs going around nutrition plant or reverse thyroid disease nutrition plant was pcos all these things so microbiome correction giving them anti-inflammatory diet and giving them seasonal diet is so very important and some people restrict certain things but it should not be the way it should be a very balanced diet between whole grains fats and proteins and a lot of fiber um there are in numerous ways that have been seen about detox functional liver detox nothing to worry functional liver detox here means only clean eating you need not do a special detox for that a clean eating oil cooling is nothing but there are numerous studies again i can share the articles later how the coconut oil pulling in the morning like gargling simple coconut oil how can it maintain oral bacterial hygiene it is so very important so gut detox is nothing but wherever needed the hydrocolon therapy or the medicated any mass that have worked in the other part of the world now coming to this golitogenic foods that now everybody talks about in previous days doctors endocrinologists used to restrict these foods but nowadays when the patient is having autoimmune thyroiditis we do not restrict them from these go uterogenic food so much because if we have broccoli the indian kind of eating is very different we do not have a big bowl of salad plate where we are filling with broccoli and eating so much of broccoli is needed for you to block the hormone so minimal um quantities of foods should not be restricted nowadays we are not asking people to restrict these foods but in fact they can cook them and have them in the minimal proportions they're not going to stop it um yeah so integrated lifestyle again uh levothyroxine is yes of course started at the dose of 1.5 to 1.8 microgram per kg per day and is escalated every 4 four to six weeks upon the doctor's visit to seeing how the patient is responding first thing we have to look at the symptoms second thing we should look for when the patient is reviewing with you is the tsh which is very very important if the tsh is still high it's still not stabilized your doctor or endocrinologist will need to uh hike up or increase the doses by 12.5 to 25 mcg depending on the age if a patient is aged more than 50 do not uh go for bigger increments than 12.5 mcg the start low and go slow for the adult individuals and um yes and all these measures work for the integrative lifestyle that like for example um yoga the breathing exercises breathing exercises here will calm you your vagus nerve or will activate your parasympathetic nervous system wherever whenever you are activating parasympathetic nervous system you are de-stressing yourself and that is how it will allow it you you to cool yourself and it can naturally maintain your cortisol levels so de-stressing yourself and activating parasympathetic nervous system is very very essential and sleep hygiene as i explained how an impaired improper unhygienic sleep can disturb your hormones so activate your melatonin turn off blue light blue screen devices that is all your gadgets one hour before sleeping and darkening your room can only activate your natural melatonin levels and only when you sleep after you sleep after two to three hours after you sleep igh will be stimulated so which is again very important and igh and insulin everything is so coordinated that you sleep well you maintain your weight well if you have a very bad or unhygienic sleep these are the people who end up with weight gain and groggy mornings and these are the people who have high resting metabolic rate and high resting heart rate so sleep is so very important so supplement support wherever whenever essential according to the testing please go ahead and what if the patient is vegan here remember i have seen many patients who are vegans especially are deficient in omega-3s i actually have a lab which can test for omega 6 to 3 ratio i have seen that their omega-6 is very high then omega-3 so these are all omega-3 deficient and most of the non-vegetarians also have seen surprisingly that omega-3 is deficient this is because of the lower rate of consumption of healthy fats flax seeds chia seeds fish certain legumes these are what are high in omega-3s fish is not a staple food in most of the places so mind it these and iron deficiency of course i have seen in many women and vitamin d every person is deficient in today's world and vitamin beet will again deficiency is seen in vegas vegans so these are the fourth category uh four important uh deficiencies that i have seen in my practice omega 3 iron b12 and vitamin d and endemic places of course you should look out for iodine yes herbal support some people believe in but i don't know there are no long term studies and there are no specific studies depending on a separate study material here now coming to foods these i have properly seen uh in every case scenarios how adding or deleting certain foods have de-stressed them have healed their leaky gut syndrome for example all these gut inflammation creating foods like gluten diary eggs sugars processed foods and junk foods and alcohol have caused dysbiosis of the gut and what you need to improve is uh addition of lot of fermented foods berries veggies fresh organic produces and coconut oil nowadays there are so many studies going on mct oil what is this mct oil it is component of coconut oil so western world spends slacks and grows of rupees on the research materials to study such a simple things that we have been known since so long that coconut is good for health and rainbow diet yes including vast range of vegetables different colors of vegetables and fruits villa naritia got microbiome which are very important and the whole world was taught about the anti-inflammatory foods during this pandemic about curcumin uh all the regularly used indian condiments like cinnamon cardamom have been explained now detoxing your body in the sense keeping yourself away from your gadgets uh earthing working more on your soil can increase your zeta potential and can decrease your inflammation and having clean water clean produce clean foods organic foods organic vegetables have been a lot of [Music] nutrient rich now we talk about nourished soil the vegetables where you are getting from is the soil nourished enough as this question yourself if you think that you're eating then enough nutrients from your vegetables if you think that you're getting enough nutrients from your vegetables you should find out how nutrient is your soil so that is how the safe soil movement is going on i think you have heard about it then um now what is the solution first thing we would always give them is levothyroxine t4 that is the modern uh method of treatment that we have learned yes we start off with the lower doses and depending on the body weight we start with ideally 1.5 to 1.8 mcg per kg per day start off with that but what else is happening you need to uh tell them what to introduce what to eliminate this is very important part of our counseling yes these have been additional factors there is no measured things that go on with this these are basically your uh natural uh cooking which is going on and supplements find out what you're deficient in and add the following and of course many hypothyroid patients how many of the patients that you have had asked what are the foods that we can eat what are the foods that we can avoid but let me tell you hypothyroid patients can accept most of the foods they tolerate most of the foods then they are not like diabetics where we can say you have to eliminate certain subsets of foods they can have a very balanced diet with legumes beans and indian foods fish nuts and eggs they can have a very more balanced diet so [Music] here when i talked about organic using urban organic food and water same thing comes with women as well women use lot of cosmetics we know that but are they clean are they organic find out and yes say no to plastic how many of you know that you are carrying uh bpas in your food bpas in your water because every product that we use some or the other thing that we use in our home is with uh dps yes these are studies if you want to take a screenshot these have shown for the uh yogic management of the thyroid i felt these are important to add here because you can add this to your client clients or patients as well so take screenshots if you like so take home message my message would be yes definitely addition of synthetic thyroid hormone has been a treatment mode but what we are missing out in our treatment journey is the modification of the lifestyle of the individual we need to find out the root cause treating just the symptom is not important find out the root cause yes symptoms should be treated they should feel better but find out the root cause and treat it that is important too so i would like to take questions from here somebody will just previously thank you thank you so much ma'am for sharing such an important topic hearing all our doubts yes uh so there are a few questions some are from my side some are from other people's sites yes so one question um uh we have mentioned many times we have to measure free t4 free t3 so many of uh us many people don't know what is the meaning of free tb3 and d4 in our in my practice also uh i have seen people don't know about this thing they come with the reports of a total t3 t4 so can you please tell me about more about so whenever the thyroid hormone is formed the most of it is not free it is bound to some carrier protein molecule like thyroid binding globulin when the free hormone is bound to thyroid binding globulin it becomes a total d4 or a total three t3 but most of the times when the patient is not showing improvement in symptoms after starting treatment that means something is wrong either the free hormone is not bound to the receptor molecule on the cell so that is the reason we prefer doing free t3 free t4 sometimes total t3 total t4 can be normal but when do you doubt and check them they are these are the candidates of people who are not improving with the treatment so what is going on find out the fdt4 so if you find out free t4 that means if it is low you found the culprit that means t4 is not leaving the thyroid binding globulin it is just bound like that it is not roaming free so yeah my many relation to albumin yes so uh have you seen um let's let's come the other way around have you seen hypoproteinemia patients who have become hypothyroid so have you seen nephrotic syndrome patients become hypothyroid so wha why is it happening there isn't enough protein so there is no no enough hormone they're losing the protein they're losing the bound hormone so bound hormone is lost with the protein because there is excess protein happening all the hormones which are bound to protein are lost one of the important one is thyroid so that is how the bound thyroid hormones are lost and these hypoproteinemia people these nephrotic syndrome people end up with thyroid hormone deficiency or they fall hypothyroid so as asked by someone just now so we should go with free t3 t4 levels first rather than totally yeah yeah so ma'am one more question um if there is a premium puzzle or menopausal woman with elevated tsh is there any particular difference between treatment or we should go with the same dose 1.6 um first thing what are the symptoms yes tsh is high how is the t4 is t4 normal if the tsh is high t4 normal no antibodies no symptoms and how much is the tsh within seven we need not treat them we can wait or if they started to develop symptoms tsh is same t4 is normal antibodies are negative they started symptoms start and see your thyroid supplement with a smaller dose like 12.5 mcg and then increment it find out after six weeks does her symptoms feel better if she says so continue no she says she is not feeling any better but the tsh also has not come down the sh is still high like some seven or eight symptoms are persisting increase the dose but increment only by shorter doses this thing also i wanted to i had a query when you said that it is uh if the patient is above 50 years of age we should start with the low lows is it related to age or if it is related to if the patient has some cardiac conditions or something then then we have to start with those it is with regard to when we talk about age that means by the time they are having either instance diabetes hypertension cardiac diseases it's all about when the elderly is mostly having a cardio metabolic disease i would say so when these are the risky patients who have cardio metabolic disease then you start out with smaller doses so my one more question is that if a patient is pregnant we start with 30 more dose but is there any difference in dosage in different trimesters as we can say in hyperthyroidism we can change the medication all over we can start with cardiovasol and then we can start with but the safer one what we use in pregnancies has been ptu right yeah yeah in hypothyroid uh [Music] we straight away uh start with the dosage according to their body weight then i mean body weight in the sense like pre-existing body weight in the first trimester nowadays no no uh antenatal visit is left without checking the tsh so first time is the first test that you want to check espin sugars and thyroid tsh so no pregnant woman can go missed so you start off with her body weight because she has only nine months you can't keep seeing starting low and checking on because it is going to develop fetal anomalies hypothyroid women if they are not treated sufficiently they end up with birth anomalies fetal anomalies we do not want that so we want to dose them sufficiently according to the body weight we do not want to wait and watch and we do not give a gap of six weeks in pregnant women we want to check every fourth week okay okay one more question which is being asked that is it necessary to check anti-tpo antibodies every time not every time the first time yes do check not every time is required and ma'am if patient is a case of hashimoto's disease what is the dose of thyroxine we usually give it again starts with the body weight only but what you look for is what is the trigger what is the trigger has it been recent viral infection or something has it been recent ibs we have seen this most of the autoimmune thyroiditis these are the typical subset of people who either have type 1 diabetes or rheumatoid arthritis certain set of other autoimmune diseases just find out what is the link yeah that is important too it's not just about treating one thing if they have autoimmune panel of other things we have to check out for that are they taking any other steroids any other medications for other autoimmune diseases it does so happen many times when the patient is diagnosed with autism and thyroiditis we should not miss out on other autoimmune conditions that they are harboring i have seen many ra patients with autoimmune thyroiditis so you need to be vigilant about this because i have read somewhere that we should start with the dose of 150 to 200 in uh in cases of autoimmune hypothyroidism let me put it here why these patients need higher dose not we i may not start off with 100 150 but why these patients require high dose is because most of the time this is the autoimmune thing that is happening thyroid hormone it's not deficient in forming it but that this autoimmune attack of it and since the cells are depleted so um there is an other offset inflammation going on in the body the autoimmune activity of the body is going on that's the reason they require more doses than required they may require more doses than the usual doses the physiological need for the dose increases in these people because of this autoimmunity and inflammation okay so mam there is one more question asked by someone that why the cutoff of psh is 10 in cases of subclinical hypothyroidism it is particularly 10 another association but i think that should be uh many uh endocrinologists debate here many endocrinologists do not want to wait till 10 as i said i do not wait till 10. i watch out for symptoms first general examination are they revealing pitting edema find out are they having uh bradycardia are they have this speech slowed down all these minimal hints on presentation can give you an idea where this patient might need so what if tsh is eight and they're starting to show minimal symptoms would i want to wait till ten this is a debatable thing between seven to ten uh some endocrine rules would like to start off here because they start to feel better and any role of a sodium and uric acid in cases of hypothyroidism do we need to check them before they are not required uric acid yeah uric acid may be required it is not very uh closely associated only not just to hypothyroidism otherwise as well and hyponatremia these are seen especially in elderly men their homeostasis for sodium goes low most of the men land up with hyponatremias later in their life after 50s because their natural sodium homeostasis is lost so these are the these aged men and women should be checked for electrolytes especially yes sodium is definitely an important part of it yes i forgot to add that slide in this good question though okay thank you so much and mom one more question uh from the audience best time to take thyroxine whether it is morning or bedtime fasting empty stomach avoid quiet trojans avoid anything uh before that so that that means literally you're putting onto empty stomach and after taking it avoid anything for one hour after that so because because this hormone is inhibited by a lot of food uh supplement a lot of nutrients in the food so these iodine is there are inhibited you know there is iodine is one iodine is two they act in multiple ways for the formation of thyroid hormone these mechanisms are inhibited so that's the reason why we have to take an empty stomach and leave it alone for other one hour so ideally yes morning so in day to day practice also i've seen that there are so many patients there who come to me that they are taking medications for hypothyroidism since last 20 years and currently the tsh is less than 0.01 so what should be done at that point of time if they have been on hypothyroid medication first thing we have to do is stop it if they are on medication stop it and watch immediately do not go with attacking anti-hyper with anti-hyper hypothyroid treatment you have to wait because the effect has to be weaned off you have to see how a person is acting without supplementation maybe the tsh can normalize you have to wait and watch you can't immediately stop it and start off with uh pto or carbon visual unless unless they're having grave syndrome they're having literally grave syndrome they're having all severe features tremors and everything of the hypothyroidism then it should be treated independently personalized we should uh stop it completely thyroxine uh once it is less than 0.1 or we should taper it off slowly and uh because it may affect heart rate as as i said if the patient is literally ultimately showing with severe hyperthyroid symptoms then i uh told to stop but if they have just come just they're behaving normally they have not realized there's any change but suddenly they got the test it's less it's less than 0.1 yes definitely have taper down if they have been 100 you have to reduce it to 75 and then 50 and 25 if they have been on 50 years to directly 25 they have you can stop and see so depends on the individual how he's presenting okay and there's a question ma'am what's your take on tsh in chronic diseases also what about tsa change during acute sepsis so that is secure thyroid is it secure thyroid that he's talking about uh maybe ma'am probably because in chronic diseases only yes yes secure thyroid do you give levothyroxine no sick you thyroid patients you have to wait and retest them how they're doing you have to retest them and um in case of pregnant females we tested them in first trimester their thyroid profile was completely normal and then again tested them in uh yeah so what should we start with treatment or uh what should be done this is a question you're saying in the second trimester they are detected that their psh has been high yeah you have to start you cannot take chance with pregnant women land up with anomalies okay so there was one uh question ma'am what is uh noticed uh to be done in cases of resistant hypothyroidism resistant hypothyroidism find out free t3 t4 this is what we miss sometimes find out what is the free t3d4 and is of t4 converting to t3 at all or not these are the two things which happen behind people not showing symptomatic improvement even though the doses have been escalated from 25 to 125. okay so maximum questions are repeated only ma'am almost all the questions have been taken ah one moment last question rule of spreading autoimmune hypothyroidism um yes initial autoimmune hypothyroidism there is a role of steroid ah but again this is very individualized and personalized yes we can start off with the lower steroid in very autoimmune patients with severe goiter they have shown improvement yes so first all the questions have been answered man so i think we are done with today's lecture thank you so much ma'am thank you for clearing specifically clearing all my doubts which i have okay thank you the session was useful to you thank you

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