In this What the Health episode, our guest, Dr. Kotwal, discusses the complexities of thyroid conditions and autoimmune diseases. Delving into personalized treatment approaches, long-term management, and common misconceptions, the episode provides valuable insights for listeners. Dr. Kotwal dispels myths, emphasizes individualized care, and shares proactive measures for maintaining thyroid health. Tune in to unravel the intricacies of thyroid well-being with expert guidance from the American Thyroid Association.

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Chapter Summaries:

00:30 Introduction to Thyroid and its Importance

00:51 Understanding Thyroid Conditions and Autoimmune Diseases

01:50 Interview with Dr. Anupam Kotwal on Thyroid Conditions

02:29 Understanding the Thyroid Gland and its Relation to Autoimmune Diseases

04:36 Exploring the Causes and Dangers of Thyroid Conditions

11:55 Demographics and Thyroid Conditions

20:21 Treatment and Management of Thyroid Conditions

30:09 Misconceptions and Myths about Thyroid Conditions

32:41 Preventive Measures and Lifestyle Changes for Thyroid Health

35:14 Conclusion, Final Thoughts, and Health Hacks

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Connect with Anupam Kotwal, MD:

• Bio: https://www.unmc.edu/intmed/divisions/dem/faculty/kotwal.html 
• X: https://twitter.com/DrAKotwal 

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Uncovering Thyroid Autoimmune Diseases

John Salak: It would be pretty hard to find someone who hasn't heard of the thyroid, which is reassuring since [00:00:36] everyone is born with one of these glands. Of course, if you start asking people exactly what a thyroid is, what it does, why it is important to maintain healthy thyroids, you'd probably get a lot of blank stares.

That's pretty sad. And also potentially dangerous. Millions of people suffer from either overactive or underactive thyroids. Both conditions can trigger autoimmune diseases that can have severe health consequences. Think heart disease, mental health issues, sexual and reproductive problems, and goiters.

Of course, even with these gains, there's a lot of uncertainty and misconception when it comes to thyroid issues. What are the symptoms, dangers, tests, and treatments? And are there any ways for high risk groups to lower their chance of contracting one of these diseases? Our next guest is an expert on all these questions, [00:01:48] and he's here to provide some answers.

Welcome everybody to this podcast and our interview today on What the Health. We're grateful to have Dr. Anupam Kotwal. Am I pronouncing that doctor? Okay. I got that right.

So, Doctor, what is the thyroid and how is it related to autoimmune diseases?

Dr. Kotwa: The thyroid gland is a small gland. It's located at the lower part of the neck in the middle. And it produces a thyroid hormone. It uses iodine in the blood to produce thyroid hormone. That's its main function. In terms of autoimmune conditions, so it is very commonly involved in autoimmunity.

Again, based on the name of the person, not to suggest how severe the condition is, it's called Graves hyperthyroidism. So that's an overactive thyroid gland. And then sometimes there can be like temporary or transient issues. So mild autoimmunity or inflammation of the thyroid gland can occur as well.

Dr. Kotwa: Yeah, so the prevalence or how frequently this occurs has been increasing over the years. Now in North America and kind of western world, about one in eight to one in 10 individuals will have Hashimoto. So actually quite common. Not all of them will have a low or underactive thyroid though.

So, what we call middle age.

John Salak: They're obviously different if not strains, types of thyroid conditions that are affecting your autoimmune system . What's causing these different strains? Are each condition different or caused by a different thing? And exactly how dangerous are they?

And then there is this question which is raised about, just does general stress or a poor lifestyle or significant stressors that are felt like an illness that happens, injury that happens, could that increase autoimmunity? We don't know that for sure. So as of now, it's predominantly a mix of a family history and then some either a deficiency or excess of iodine.

John Salak: How dangerous are these conditions, whether it's Hashimoto's or Graves or one of the other conditions related to this.

mild things but can affect quality of life. And then if it continues more than a few months and is not treated, it can lead to slowed heart rate can affect the blood pressure, can affect concentration and memory. And if it's very severe, which is what we call like mixed edema, which people are kind of, about to almost go into a coma state.

So everything is a little bit fast, a fast heart rate, feeling too hot, too sweaty some tremors or shakiness. But again, if it's severe and not treated initially it can lead to irregular heart rhythm or things like atrial fibrillation increase the risk of stroke. increased blood pressure[00:07:48] and can also lead to kind of a severe emergency like scenario in that case.

So both under or over active thyroid, I would say if they are not timely diagnosed and managed, start with some mild issues and then can become fairly severe in that case.

John Salak: It sounds like a lot of people may have a thyroid condition and they're unaware of it.

Is that fair to say? I mean, is it obvious if you have a condition short of going to a doctor and maybe them spotting it, how,

And that's why we say, keep at least your annual appointments with your primary care, even if you think you're the healthiest person and are doing everything else perfectly. Because [00:09:00] those visits will include these questions. If there is concern for tiredness or symptoms like this, then a healthcare provider would usually check thyroid function test and do that evaluation.

The other question comes, yeah, go ahead.

John Salak: No. Go ahead. The other question. Go ahead.

Dr. Kotwa: Just, and in terms of, I get asked, like, can patients feel something? Is there going to be a lump or an enlargement? Usually, The lump comes way later. So like an enlargement of a thyroid which we call goiter in colloquial terms

It can happen with Hashimoto. It's more common with iodine deficiency.

And. Need to be evaluated for that.

John Salak: Earlier, you had mentioned the fact that these conditions seem to be rising. What's the reason for the rise in these conditions?

Some of it is just better detection and better diagnosis and better healthcare. Right. So we are more, there's more awareness both from the medical community as well as. General non medical community about these conditions. [00:10:48] So people will be more likely to ask for testing or be aware of their symptoms. There has been some rise in autoimmune conditions in general. So, for example, rheumatoid arthritis or autoimmune Kind of joint or skin issues has been a link with lifestyle So we do know that poor diets and kind of more sedentary and poor lifestyle May increase generalized autoimmunity.

John Salak: What's clear is at least the number of people being identified with these diseases is on the rise for probably a combination of reasons, both better diagnosis and early detection and probably some societal or personal reasons. Women are more impacted than men by these diseases, and I [00:12:00] think it's a rate of three to one. Is that correct? And why do we think it's so?

Dr. Kotwa: Yes, absolutely. So three to five to one, depending on what condition we talk about. So the autoimmune both over and under active again, about three to five times more in women. Then men and again, this discrepancy increases as the age goes up to fifties or sixties.

or autoimmune skin issues and things like that.

And then the third possibility. Is linked with body habitus. In general, it's easier to feel the thyroid gland in women than in men kind of, muscles and tissue will more likely overlap the thyroid. So women are more likely to have thyroid enlargement that is felt which again, increases the chance that they'll get a hormone test or evaluation as compared to [00:13:48] men. So as of now, these are the reasons that we know of.

John Salak: Are there other demographic groups that are disproportionately at risk.

Dr. Kotwa: We talk about inequities and disparities in thyroid diseases. So , the autoimmunity affects Caucasians most commonly not only thyroid, but other autoimmune conditions as well. How much of that is an actual connection and how much of that is better healthcare utilization we think there is a link there.

And some of it is linked to just how they are interacting with the healthcare system. The data kind of gets affected by those factors. It's hard to say if there is a actual increased risk in a certain population, or is it just that some have better access to health care, but it has been shown that poor access to health care, delayed access to health care, whether it's from location or income is linked with, delayed diagnosis [00:15:00] and right now they may show some lower rates of these conditions

John Salak: And that would be true for so many other conditions as well. If you have poor access to health care you're going to be at greater risk of. more serious consequences for any disease that you're facing. It seems to be an older person's disease, and you mentioned that you see a higher level of these conditions in older people.

Can children and young adults also suffer from these sort of diseases? Do we see that happening? Is that increasing in any way, if it is happening?

John Salak: Yeah.

Dr. Kotwa: It can affect adolescents and children.

John Salak: And do you see that

Dr. Kotwa: Adolescent time, or early adulthood which again, it's tough because that's the group which may not be as involved in their health because they have so many other

things

Dr. Kotwa: Can go undiagnosed. And for example, if we don't start thyroid hormone appropriately, they can have all the issues that we discussed earlier along with growth retardation or so delayed or decreased attainment of height and appropriate weight if this condition is not.

So, so definitely can happen across all age spectrum. Even though it's most common in a specific age group.

John Salak: Is that how you got into this field specifically because of your own condition or exposure to the situation?

John Salak: You referenced some relation to weight earlier. Is that a correct perception that thyroid condition can lead to someone having weight issues.

Dr. Kotwa: I get asked this from patients pretty much every day. So under active thyroid hypothyroidism, if not treated for a few months can lead to decrease metabolism. So slowed metabolism, which will lead to increased weight also lead to fatigue. So people are less likely to be active and things like

So if someone presents with unclear weight loss, we do the thyroid function test to make sure whether they are under or overactive. But keeping in mind that we don't want to hang our hats just on the thyroid and not miss other issues. Sleep issues, other metabolic, there's actually some other hormone [00:19:12] conditions, for example, too much cortisol, which can lead to excess weight, and things like that. So we look at some other hormone and other issues.

John Salak: it.

Dr. Kotwa: severe increase in weight it's hard to explain only from the thyroid that we have the benefit of checking the hormone levels.

And if they're off, we can confirm them and treat the patient. Once we normalize the thyroid if there was some weight gain from it, it usually improves.

Dr. Kotwa: That is correct. And we do know that significant overweight or obesity is associated with temporary alteration in thyroid function. And if people lose weight, say from other way, like healthy ways, the thyroid hormone actually starts becoming normal. So I've had a situation with patients where we were unclear, we started some thyroid hormone and the patient actually lost weight.

And it looked like, they didn't really need to be on the thyroid hormone anymore. It would harm them if we give it because their levels became normal.

Dr. Kotwa:

Treatment for underactive thyroid is giving the patient thyroid hormone. It comes as a pill. The most common formulation is called levothyroxine. There's different brands of it. It's taken as a once a day pill in the morning, ideally on an empty stomach. And usually that treatment works for most people.

And again, most people do well with either of these formulations. There is a subset where for example, especially patients who've had their whole thyroid taken out from surgery or have significant hypothyroidism, that we've been giving them levothyroxine for a few months and even with normal levels, they feel poorly.

And that's when we question are they getting adequate treatment just with levothyroxine?

That's the group where we try and add on T3. So that's another hormone that thyroid produces in a very small amount.

Most of the T3 in our body comes from, the levothyroxine or T4 that gets converted to T3 in tissues. But there is a subset of individuals that are not converting that in the best manner.

John Salak: we

8 months. If patients feel much better with this and their hormones are well controlled, then we say, well, you probably were one of those people who had some issue with this conversion.

The frequency of that is anywhere from 5 to 15 percent.

So most people will not need this combination, but we do it on a case by case basis for some patients.

Dr. Kotwa: That is absolutely correct. Yes,

John Salak: And how long would the treatment go on for those people? You mentioned pills and gel tablets. Is it months? Is it years? Indefinite?

Sometimes there are temporary changes from inflammation of thyroid gland. So. Some of those issues, and usually in those cases, we may just watch, but, if someone gets started on thyroid hormone and they're on a very tiny dose, we can consider taking them off. The typical Hashimoto's thyroiditis, once someone becomes deficient in the hormone, they either will stay this way or they will progress.

And sometimes if we are struggling to deal with it, we may actually consider removing or destroying the thyroid gland so we can actually treat the patient with a steady dose. But most people, if they had clear diagnosis of Hashimoto, clearly low thyroid hormone, we say it's usually a lifelong replacement.

Dr. Kotwa: fairly straightforward. We recommend getting it done in the morning and ideally in a fasting state like overnight fast. So it's a blood test and that's pretty straightforward.

John Salak: Are there precautions individuals can take to sort of lower their risk of developing these conditions?

So right, it's not been found that excess taking more selenium will prevent it. But if someone's kind of on some weird diet that they cut out a lot of foods, maybe they should go to a more regular diet or have some macadamia nuts here and there. Again, that's a rare deficiency in the US.

So they probably will need more involvement of their medical care team to make sure they are being tested appropriately. Outside of that, we also get asked of diets. There's this substance called goitrogen, which can decrease the thyroid hormone production. Now, for example, if we eat uncooked cabbage or bok choy, tremendous amounts, [00:27:00] we really have to go out of our way to be able to do that. That can lead to decreased thyroid hormone production. Fortunately, the cooked form and the amounts that people would usually eat in their diet do not do that. . So that's just one thing I do inform patients.

Now once someone does have thyroid autoimmunity and is taking thyroid hormone there are things they can probably do to make sure their absorption is good of the pill

And those things. So that's where gluten or celiac

John Salak: to get. Um, I've heard

I've heard from patients as well as kind of just in talking to people in the community that sometimes decreasing gluten will make them feel better. Or cutting it out may, will make them feel better if it [00:28:12] does, I think that's great. Right now there is no clear evidence to say that, cutting gluten out in someone who doesn't have celiac will, will help

the

John Salak: help them.

Dr. Kotwa: but

it may make us feel better in general.

So I, I'm not against that. I think, I see my role as making sure that. patient. The general community is aware of,

John Salak: community is

Dr. Kotwa: what are the risk and benefit? You don't want to miss undiagnosed condition. For example, if you clearly have low thyroid hormone and autoimmunity.

John Salak: low thyroid

Dr. Kotwa: And if you're you need thyroid hormone in that

scenario.

John Salak: It's obviously complex. It's much more widespread than I think most people realize. But there are treatments and it seems like the treatments are easy to, relatively easy to deal with. I'm sure people would prefer not to deal with them.

Dr. Kotwa: Just one addition going back to the treatment. So I mentioned the hormone replacement for underactive, which is the most common autoimmune

issue. overactive Thyroid is more complex. It's not as

common. Usually

Can be treated with a medicine to make the thyroid hormone normal, but it doesn't work in all cases.

So that's the treatment there.

Now to your point,

John Salak: assess iodine.

Dr. Kotwa: of misconceptions. So, there's a few I think the major one which I've kind of experienced or heard of is that well, one is the, Thyroid support or iodine supplements will help so if someone has normal thyroid functions, either they have no symptoms or they've had the testing done, it's normal, we should not really need to take excess iodine.

Excess iodine, like in kelp supplements just iodine supplements, some of those have also thyroid hormone in them. So we know that excess iodine can actually precipitate thyroid autoimmunity, as I said earlier.

And that's not good. And with time, it can start affecting our heart. just like overactive thyroid would. So those are the reasons to

John Salak: you

Dr. Kotwa: take a kind of a thyroid support or iodine

supplement without talking to your medical

John Salak: that,

John Salak: change in

Dr. Kotwa: by kind of supplements, lifestyle changes? And the answer is to a certain extent. So this again, if depending on the hormone issue, someone has clearly over or underactive thyroid gland, which needs treatment then I would say just doing the change in your lifestyle supplements is not going to cut it.

So, that's what I kind of counsel my patients as that we, we can kind of work together.

Making sure you ruled out gluten issues and vitamin D

issues and

things like that. so those are, I think I think the two main ones that I've kind of experienced and

talked to patients with, and I've, I've been a thyroid focused endocrinologist in practice for about five years now.

so.

I think a lot of the misconceptions stem from like, just not having enough information or maybe a health provider kind of dismissing the concerns without actually having a discussion.

Supplements or anything that the patient is taking or could be taking.

be taking

autoimmune diseases, what people can do themselves to lower their risk of developing one of these diseases. And in the event they do develop disease, what can be done? How do they work with their physicians to limit the impact and become healthy and get themselves on a path towards health.

So again, Dr. Kotwal, thanks so much. Dr. Kotwal of the American Thyroid Association for spending some time with us here on What the Health.

Dr. Kotwa: Thank you so much. It was my absolute pleasure.

Signing up is easy and free. Just visit us at WellWellUSA. com, go to Milton's discounts in the top menu bar, and the sign up form will appear. Signing up will take just seconds, but the benefits can last for years. Okay. Thyroid related autoimmune diseases may not get a lot of play when it comes to everyday health issues.

tenderness and stiffness, joint pain and stiffness, irregular or excessive menstrual bleeding, hair loss, and enlarged tongues. And these are just some of the symptoms. The challenge here, of course, [00:36:00] is that these symptoms can indicate other problems as well. So if you're experiencing any or all of these, please make an appointment to see your doctor and get tested.

If there is an issue, Your medical professional is in the best position to prescribe a treatment. There is some uncertainty over how effective proactive measures can be at lowering the risk of getting one of these diseases. But certainly, reducing or quitting smoking will help, along with diagnosing and treating celiac disease, exploring selenium supplements, and easing up on soy.

org. That's thyroid. org. That's really easy. The group's website is loaded with essential information on these diseases and their treatments. Well, that's it for this episode of What the Health. We hope you enjoyed it. And we hope you'll come back and listen [00:37:12] in again. Thanks.