Hypothyroidism and Weight Management

Hypothyroidism and Weight Management

I wrote this to address misinformation/disinformation regarding what hypothyroidism is and what it is not. What is important and what is not. Be wary folks as there are a disturbing number of charlatans looking to make a profit without offering any meaningful benefit.

I had a total thyroidectomy in 2000 due to thyroid cancer. I bought into much of the bad information out there and ended up putting on ~70 lbs over the next 14 years. Despite all thoughts to the contrary - none of this was due to my thyroid, but everything to do with my transitioning from a high active military career to a cushy life in academia. I started tracking my caloric intake and output in MFP in 2014 and lost 60 lbs the first year gradually decreasing my intake and increasing my activity. I’ve been in maintenance ever since and compete in several obstacle course races and multisport races throughout the year.

Starting in 2006 I managed the pharmacovigilance profile of Synthroid (levothyroxine sodium tablets, USP). Having access to this information forced me to realize the impact thyroid has on weight management, what this influences and more importantly does not influence.

Thyroid and Hormonal Impact:

The thyroid gland is part of the endocrine system works in conjunction with the pituitary gland. The pituitary gland releases Thyroid Stimulating Hormone (TSH). The hypothalamus releases TSH Releasing Hormone (TRH).
The thyroid gland produces two primary hormones:

Triiodothyronine (T3)

Thyroxine (T4)

Symptoms of Hypothyroidism (low T3/T4):
• Sleeping disorders
• Tiredness / fatigue
• Difficulty concentrating (brain fog)
• Dry skin and hair
• Depression
• Sensitivity to cold temperature
• Frequent, heavy periods
• Joint and muscle pain

Resting Energy Expenditure (REE): the amount of energy expended by a person at rest. Basal metabolic rate (BMR) is more precisely defined as the REE measured just after awakening in the morning. In practice, REE and BMR differ by less than 10% so the terms can be used interchangeably. In testing the most extreme conditions – thyroidectomy patients off supplementation showed a similar variation to the control group ~5% shift from the mean.

What this amounts to in daily consumption is 80 kcals/day out of a 1600 kcal/day caloric budget.

Increased Cellular Uptake (Water Weight)

Any hormonal shift will result in an increase of cellular uptake – water weight. This was noted in early medicine as the increase weight noted with hypothyroidism. If hormones balance out this will trend back to normal weight after 5-7 days as long as sodium intake is fairly constant and hydration is maintained.

Note that hormones are free cycling – meaning your body mass has tremendous impact on hormonal balance. If you’re at a healthy BMI your endocrine system operates normally with little issue. If you are significantly under or overweight this causes a terminal cascade within the endocrine system – causing massive stress as glands attempt to respond to and produce hormones, continually struggling to keep up.

Testing:

When one begins to show symptoms or suspect they have a thyroid disorder the first step is a physical examination in conjunction with testing – initially TSH, but should always be followed up with a full thyroid panel.

Thyroid Panel

TSH 0.4-4.0 uU/ml (0.5-3.0 for supplemented patients) (0.2-2.0 for thyroid cancer patients)

fT3 230-619 pg/d

fT4 0.7-1.9 ng/dl

rT3 10-24 ng/dL

TRH stimulates TSH, which stimulates production of T4 and T3. T4 converts to T3 to specifically target tissues. Knowing how this works helps you identify what is going wrong in this cycle. Note that analysis takes multiple readings over time, so don’t get overly concerned with one reading. Lab errors are frequent, body changes are continual, and hormones are notoriously difficult to track and trend.

I need to add clarification on TSH and how this is often misinterpreted. The established ranges are stated above and pretty accurate (updated in 2002). What may be confusing is what feels normal to you. This is established during your adolescence and early adulthood, so whatever that number is feels “normal”. Looking back at my life I was very likely at the lower end and hyperthyroid, so this feels normal to me. I’m usually in the 0.2 currently with a dosage of 175/200 mcg alternating daily. Don’t get overly concerned with one test result out of this range though. Medical protocol should still be followed, but one high or low result should be taken in context with a full range of results.

Medication:

Hormones are incredibly powerful actors on the body – something you can see from the dosage – these are measured in micrograms and incredibly challenging to manufacture in pill form (even in pill form consistency and potency remains one of the most challenging issues). So these tablets are mostly filler.

TSH - Synthroid is the brand name of levothyroxine sodium tablets, USP – the generic version.

T3 – Cytomel (liothyronine sodium)

Generics must follow the precise formulation in regards to the active ingredient there may be a difference in the inactive ingredients, so take notes of your reaction when beginning any long term medication.

Synthetic vs. glandular – there isn’t much evidence supporting a difference, but I caution the use of any hormone supplementation due to the level of risk associated. Always discuss usage with your endocrinologist.

Hormones also take a long time to act, so you won’t be able to feel or detect any difference for weeks after beginning or changing dosages.

Diet:

There isn’t much that angers me, but this is a big one. There are several woo peddlers out there using their credentials (letters behind your name) to promote books/diets/services. You cannot “heal” your endocrine system with diet. You can only treat this with medicine.

While there is no “thyroid diet”. There are specific foods you want to avoid taking at the same time as your supplement:

• Walnuts
• Soybean flour
• Cottonseed meal
• Iron supplements or multivitamins containing iron
• Calcium supplements
• Antacids containing aluminum, magnesium, or calcium
• sucralfate (Carafate)
• cholestyramine (Prevalite) and colestipol (Colestid)

Many simply avoid taking food when taking your supplement. I recommend at least 60 mins before eating anything following taking thyroid medication.

Treatment:

Calories

If you have a thyroid disorder your struggle is pretty much identical to that of anyone else. There is no measurable impact to basal metabolism. There may be an impact to appetite due to a hormonal imbalance or shift, so it makes it critical to understand the difference between hunger and appetite.

Hunger is your body’s physiological need for food. The urge comes slowly over time and builds up. It is satiated with any food.

Appetite is your desire for food. These urges are more sudden and specific – driven hormonally. This results in these cravings of salty, sweet, crunchy, chocolate, etc.

There are several methods of managing this – if you have the urge to eat drink water and wait 30 mins. Establish a routine around eating and meal times.

Another important element is satiation. This is a very personal issue and something you need to experiment with your diet. Many find higher fiber foods more satiating. Spicing up foods is another common practice as the taste lingers in your mouth; people tend to feel the urge to eat diminish if taste is present.

Exercise

This is where I think many people sabotage themselves. When the majority of people make the decision to do something about their weight, they turn to a search engine – find “The Fastest Way to Lose Weight – Guaranteed!” and implement some drastic change. When you already have a problem regulating hormones this can be disastrous. You start out strong, but over time motivation fails and your body cannot keep up with the stress you’re putting it under. Pain increases as tissue repair begins to fall behind and eventually you miss a workout, then another, then depression. If coupled with a very low/low calorie diet this increases the chance of failure as your caloric deficit is too great.

The key to success is slow and gradual progress with a condition like this. Elite athletes with hypothyroidism still compete and are successful, but they plan ahead and gradually increase challenges. Note that thyroid disorders are increasingly common within endurance athletes as we tend to put our bodies through incredible endocrine stress. Warm up/cool down times should be increased. Hydration becomes all the more critical. Recovery times should be strictly adhered to.

Medical professional

Never attempt to diagnose or treat yourself and stay away from over the counter supplements. Without proper diagnosis you risk making things worse.

Finding a good physician may be the most challenging issue, although it is getting much better in the US. Talk to people who have succeeded. Research profiles on search engines. Specifically look for endocrinologists specializing in thyroid disorders. When you find a good one never let them go and let them know – spread the word! When you find a bad one let them know and fire them promptly if you can.

Dr. Jeffrey Brown revolutionized much of the treatment for elite level athletes and his methods are carrying over through the specialty. I cannot stress how much of a difference having a sound relationship with your primary physical and endocrinologist means to your life.

Bring data to every discussion. Document in MFP or a diary and share this with your doctor.

What Does Not Matter:

Pretty much everything else. It doesn’t matter much how you developed this or what variation of disorder you have – the treatment is all the same.

There are a multitude of primary causes for hypothyroidism, none of which matter in weight management. Regardless of how you came to a non-functioning thyroid gland there is nothing preventing you from maintaining a healthy weight.

What to focus on:

Prioritization

Prioritize what matters – Medical treatment > Caloric Intake > Exercise

The Pareto Principle

“80% of the effects come from 20% of the causes.”

Known as the 80/20 rule this remains a factor that continually presents throughout disciplines. What this means for you is to focus on the 20% of your life that matters and disregard the 80%. Now this is going to change over time and there will be competing priorities throughout your life. Keep this principle in mind when you feel out of control and thinking you need to control it all – you only need to be concerned with 20% of it.

168 Hours

When I first entered into the military I was thrown into one of the highest operational tempo fields and found myself continually struggling for time. My Chief saw this and sat me down explaining “Listen – there are 168 hours in the week. There’s always time to do what needs to be done.” If you’re struggling thinking I don’t have time – first review if it’s even worth the energy following the 80/20 rule, then budget it into your 168 hours/week.

Fatigue

All hormonal shifts result in fatigue so coping mechanisms against this are critical. Caffeine helps, but don't overuse. What helped me was to force myself to be 100% focused and excited about whatever was in front of me and to consider every opportunity as if it were the greatest opportunity in the history of the universe. Not going to say I was always successful at this, but it certainly helped. You have to remember that the hormonal imbalance will trend back to normal and focus on the future. Meditate. Pray. Do whatever it takes to get yourself through the low troughs.

Perspective & Attitude

I save this for last as I believe this to be the most important. When I was first diagnosed with cancer I spent a great deal of time researching survivors and found a common link – they went into this realizing that holding a positive attitude was going to be critical to success. I also noticed a disproportionate percentage of elite level athletes, academics, professionals in all areas. A majority reported similar epiphanies that could be summed up as “Life is incredibly short and we have a limited amount of time on this Earth to do good, so get to it.”

You can look at this from two perspectives - two stories:

1. “Crud. I have to take this stupid pill for the rest of my life”
2. “Incredible! All I have to do is take this little pill to live my life”

Both stories are true, but which would you rather be in.