Thyroid perspective update

10. October 2008 William Davis (18)
Since the publication of the extraordinary HUNT Study relating the entire spectrum of thyroid function and heart issues, I have been vigorously and systematically examining thyroid function in numerous patients.

While there's no news in relating flagrant low thyroid function with triggering heart disease in several forms, the cut-off between low thyroid and normal thyroid has been a matter of dispute for decades.

In the early 20th century, low thyroid function wasn't diagnosed until someone gained 40 lbs, displayed extravagant amounts of edema (water retention) in the legs and huge bags under the eyes, hair fell out in clumps, and often eventually proved fatal. At autopsy, these unfortunates also showed advanced and extensive quantities of coronary atherosclerotic plaque.

Low thyroid is usually diagnosed on the basis of the blood test, thyroid stimulating hormone, or TSH. TSH is a pituitary gland hormone responsible for stimulation of thyroid function. When thyroid function flags, the pituitary increases TSH release. Thus, a high TSH signals lower thyroid hormone levels.

The difficulty is in distinguishing normal thyroid function from low thyroid function judged by TSH levels. As the years have passed, in fact, the cut-off for "normal" TSH has drifted lower and lower.

The HUNT Study, I believe, clinches the argument: A TSH of 1.5 or lower, perhaps even 1.0 or lower, is desirable to eliminate the excess cardiovascular risk provided by an underactive thyroid, not to mention feel better: more energetic, clearer thinking, greater well-being.

Having now applied this renewed appreciation for thyroid, I have come to believe that:

--Low thyroid function, even subtle levels, are rampant and far more common than ever previously thought. In my office practice, the case could be made that several people per day are marginally or mildly hypothyroid (low in thyroid).
--Restoration of optimal thyroid levels facilitates correction of lipid measures, especially LDL cholesterol and, to a lesser degree, lipoprotein patterns dependent on the insulin axis such as triglycerides and small LDL. It's a lot happier way to correct lipids than statins.

I don't discount the value of feeling better. People who feel better--more energetic, more upbeat, clearer thinking--tend to do better in health overall. If thyroid restoration is a part of that equation, then greater attention should be paid to this facet of health on our way to optimal heart health.

Though I sometimes feel like an endocrinologist dispensing desiccated thyroid (rarely the synthetic T4), I believe that this has been a previously neglected and important part of our effort to achieve coronary plaque stabilization and reversal.
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Comments (18) -

  • Jeremy

    10/10/2008 2:33:00 PM |

    I have a TSH of 2, which the doctor told me was normal. What steps can I take to get my TSH to be lower, like 1.5 or 1?

  • Anna

    10/10/2008 5:58:00 PM |

    Great post, doc!  As I've mentioned in past comments, this is a subject near and dear to my heart.

  • Anonymous

    10/10/2008 8:02:00 PM |

    Doctor,
    I applaud your attention to the low thyroid issue but also would urge you to check Free T4 and Free T3 -- I spent several years gaining weight, depressed, exhausted, and suffering numerous symptoms (including high cholesterol) but being told I needed and anti-depressant, statins, etc because my TSH was normal.  When I finally found a doctor to test the Free T3 and 4, I was found to be low in both and I need both to function well.  I can track symptoms and cholesterol rises to the T3 and T4 blood levels. Thank goodness I've found a doctor who will test and adjust when I report the need for same.

    Keep up the good work.
    S

  • Anne

    10/11/2008 9:00:00 AM |

    My TSH is 2.6. What should I say to my doctor as on the lab report that comes out as normal.

  • gunther gatherer

    10/11/2008 10:52:00 AM |

    Hi Doctor and thanks for your informative blog. I'd like to echo Jeremy's comment and ask what one can do to lower TSH to below 1.5?

    Mine is currently 3.5, considered officially normal, but I have a very difficult time losing weight and would like more energy and better sleep. My diet is very good, but I think I may be missing something with TSH so high.

    Thanks, G

  • Nancy LC

    10/11/2008 6:19:00 PM |

    My doctors were happy to leave me around a TSH of 5.  I asked for, and got, a small increase in thyroid meds and got the TSH down to 3.  Felt better, but after reading about these latest studies I decided I wanted to be at 1 or lower.  So I talked to my doctor, told him I felt like I wasn't optimal yet and asked if I could go a little higher on the meds.  He agreed.

    This latest bump is making me feel really good, like I actually WANT to move around and exercise and get things done.  

    I tried the natural thyroid meds once and felt they were too high in T3 for me, I never adapted to them.

  • Dr. B G

    10/12/2008 7:28:00 PM |

    G,

    My TSH from 1997 until 2007 were always 1.3 to 1.9.  I lost 50 lbs over the last 5 yrs (and low carb the last 2yrs) but my TSH did not 'normalize' until my vitamin D normalized.

    Normal by DR. Davis and many experts and cancer epidemiologists is 25(OH)D 60-75 ng/ml.

    Good luck. You are grain-free right? Consider casein-free too (ie Paleo diet).

    -'G' too Smile

  • Dr. B G

    10/12/2008 7:28:00 PM |

    G,

    My TSH from 1997 until 2007 were always 1.3 to 1.9.  I lost 50 lbs over the last 5 yrs (and low carb the last 2yrs) but my TSH did not 'normalize' until my vitamin D normalized.

    Normal by DR. Davis and many experts and cancer epidemiologists is 25(OH)D 60-75 ng/ml.

    Good luck. You are grain-free right? Consider casein-free too (ie Paleo diet).

    -'G' too Smile

  • Lynn M.

    10/12/2008 9:46:00 PM |

    Nancy,

    An intolerance of natural thyroid meds often indicates adrenal insufficiency.  Also, natural thyroid such as Armour needs to be dosed differently than Synthroid.  Armour should be taken in small doses spaced through the day. T3 has a short half-life of 6-7 hours (the figure varies depending on the source), so you'll get too much jolt if taking the daily dose all at once.  T4 meds like Synthroid have a half life of 6-7 weeks, so once daily dosing is fine with them.

  • Anonymous

    10/13/2008 5:40:00 AM |

    I was recently diagnosed with Hashimoto's, due to elevated thyroid antibodies, yet my TSH was in the 3-3.5 range, which most doctors will state is 'normal'.

    So, it's proven very difficult to get treatment so far. I also have symptoms that match hypo, and an ultrasound that shows a mildly enlarged thyroid. I was also told that my thyroid felt 'lumpy' when it was palpated. Yet, two doctors so far won't even consider letting me try a low-dose trial of thyroid medication. The magic number for them is a TSH of 5.0 or higher.

    For those who haven't seen endocrinologists, many  tend to be... stubborn. Thyroid disease seems to be treated different than other diseases. Doctors pretty much ignore symptoms, they don't agree with a standard as to who is Hypothyroid, and who isn't, they don't use the same TSH marker to treat, and they don't even agree which blood tests to give. It's actually sort of insane.

    So for those of you with TSH levels in the high 2s or 3s, my only advice is to get your free values tested and your thyroid antibodies tested too. If they are positive, you potentially could find a doctor to treat you... eventually... maybe.  If you don't test positive for antibodies, and your free T3/T4 are normal, I think you'll have a real hard time finding a doctor to give you any thyroid meds.

  • donny

    10/13/2008 4:17:00 PM |

    I spent some time yesterday reading about vitamin a, iodine and thyroid.

    According to this http://jcem.endojournals.org/cgi/content/abstract/89/11/5441

    goiter becomes more likely in iodine deficient areas where vitamin a deficiency is also present. There also seems to be the suggestion that the goiters sometimes caused by a high, rather than a low, level of iodine intake might be guarded against by vitamin a sufficiency.

    quote "The data from the intervention indicate that VA status may also modify the response to iodine repletion. In the trial, there was a significant decrease in median TSH, Tvol, mean Tg, and goiter rate in the IS+VA group compared with the IS group. In areas of endemic goiter, the major determinant of serum Tg and Tvol is TSH stimulation of the thyroid (42, 45). Our findings suggest TSH hyperstimulation, indicated by increased TSH, Tg, and Tvol, was reduced by VA treatment.

    I've seen it stated all over the web that hypothyroid interferes with the ability of the body to convert beta carotene to vitamin a.  

    This study,

    http://www.ncbi.nlm.nih.gov/pubmed/3120391

    was in pregnant heifers, so grain of salt, but..

    They added synthetic beta carotene to these cattle's feed, and according to the abstract,

    "It is inferred from the results that beta-carotene interferes with the activity of the thyroid gland and the production of its hormones, and that the increases or decreases of the activity of this gland, caused by beta-carotene, influence the metabolism of cholesterol in the body."

    They don't mention what form the increase in cholesterol takes, but since thyroid function is described as 'interfered with' I suspect the change was not a beneficial one.

    These guys should know better, and never ever just say 'beta carotene' when what they really mean is 'synthetic beta carotene.' If these cattle had been fed green grass, their beta carotene intake would have been through the roof. I doubt this would have caused thyroid or cholesterol metabolism dysfunction. Reminds me of those studies on humans with synthetic beta carotene with not-so-good results.

  • Anna

    10/13/2008 6:27:00 PM |

    My advice to those with symptoms and a TSH over 2.0 or 2.5 (or any health issue that isn't being addressed well and helping the patient feel/function better) is to find another doctor who is more open minded about patients and health instead of settling for one way to look at things.   After all, our doctors are consultants who are supposed to work *for us* with their experience and expertise; not the other way around.  My teeth grind now when I hear someone say "my doctor won't let me...",  like the doc is a parent or boss.

    I never thought I'd become one of those "doctor-shoppers", because I always thought that was a negative, hypochondriac-sort of thing, especially for middle -aged women, the demographic I am now in (I have a new appreciation for the roots of the word "hysterical").  I can easily see how "doctor-shopping" can become a problem, but I've stopped seeing it as always a negative thing.  I pulled my exhausted, fuzzy-thinking self over that huge mental hurdle and pushed myself not to settle until I found docs who could also see me as a partner in my care, not as a subordinate in the relationship, because I saw that as the best way to achieve *all* my health goals, not just my thyroid care.  Ultimately, I think that can mean less visits to the doc over time and less tries at Rxing with a variety of meds in an attempt to manage symptoms.  For instance, nagging neck pain and stiffness on one side that persisted for many years (after a muscle injury), was diagnosed as osteoarthritis after an x-ray ordered by the doc I saw for a decade.  She said take NSAIDS and learn to bear it, part of getting older.  Great.  The next year, the new PCP osteopathic doc I saw said, want to try some PT -   often it helps.  I had 8 PT sessions (no that wasn't convenient or cheap) and initially I was unimpressed, but by the 4th session I saw real improvement, which increased until the last session.  The relief from the neck pain/stiffness has lasted several years (reccurances are usually easily dealt with by adjusting my sleep posture and resuming the PT exercises I learned).  No meds and much less pain and greatly improved mobility in my neck  or meds & bearing it - all a matter of perspective on how to treat/not treat.  

    I think most people are afraid or too weary to *really search* for an appropriate physician match, and they don't really want to take enough responsibility for understanding their needs; they'd rather just take a friends referral or be told what to do or wait until something urgent presents itself.  It's natural to crave familiarity, but that's a poor reason to stick with indifferent or adequate care or let Chance make the choice.  I know there can be other barriers, such as the expense and the difficulty scheduling around work or other obligations or even lack of local physician choice (especially in remote areas), but if there are significant health issues at stake (to treat or prevent), overcoming those barriers can really pay off in better care and reduced unproductive doc visits.  I'd say my unproductive office visits numbered 3:1 over the productive ones in the past 15 years or so - what a waste! - mostly because I stuck to the same doctor too long, one that just attributed everything I was experiencing to "getting old".  I'm not more bothered by aging than the next person, but frankly, most of her answers were cop-outs and I shouldn't have settled for lame responses for so long.

    I've seen some docs in the interim years that were definitely improvements, but I still felt I might be able to get better care within my network if I kept making inquiries.   For a brief time, we had very good PCP physician that both my husband and I liked very much, but I still saw my out of network doc for my thyroid and my PCP was ok with that.  

    But last year our PCP doc left our network and took a break from medical practice, just after my son's pediatrician suddenly passed away.  I suspect that ped-doc would have been a good candidate for TYP, btw, he lived near us and I often saw him in the grocery store with his cart full of AHA approved edible food-like substances).   So we were all left without an assigned PCP, though of course, if anything urgent came up we could see whoever was available.  And the travel to see the out of network thyroid doc was harder to do, so I started seeing an in-network endocrinologist, in the hopes that I could transition to him for all that stuff.  I had to switch to what he knew, Rxing only synthetic T4 and finally some added T3, instead of the 98/2% T4/timed release compounded natural T3 the other doctor gave me (which I liked better).

    I saw this as a good opportunity; I started looking for a new PCP for the whole family, someone in family medicine this time, also a bit closer to home than the other facility (which we chose when we were new to the area and lived closer).  I took my time, making short "get acquainted" appts with potential docs, which is allowed in my plan.  I asked a lot of questions about their approach to preventive care and how they promote good health, and especially with the health issues for our family.  

    I knew I'd probably found the right one when I saw the EBT coronary calcium score poster on the back of the door while I was waiting to meet the doc.  He said EBT CCS scans are a test worth paying out of pocket for even if insurance won't - you'll like that Dr. D!  He's familiar with BH, compounded Rx, has very good views of thyroid conditions, and tries to focus on lifestyle more than drugs and true prevention rather than just early screening and detection/treatment.  When I asked about thermography instead of mammography, he said a number of patients had asked about it and he was currently looking into it, so didn't have a recommendation yet; he was open to looking any info I could forward on thermography.  I think the persistent search will have been worth the effort, because I think we will make a good team; he's pretty close to a "Renaissance Doc", IMO.  Wish I'd known about him a long time ago, might have saved me and my family a lot of misery (rigid, unenlightened docs can forget that the loved ones can suffer when the patient isn't up to par, too).  I'd just about given up finding the right doc in our network; now I hope he doesn't bolt the system like the last one I felt great about.  

    It might take some time, effort, and expense, especially with limiting HMO networks and insurance restrictions/or lack of insurance, but the way I see it, it's really worth looking until you find better care, inside or outside your network network.   It's much easier to do this when the health care issues are more minor than when they get serious, too.  

    I don't know how all insurance plans work, but the last two plans we have had (through my husband's employer) allowed choosing a PCP at any time as many times as long as I stay within the network.  I'm told some PCPs don't bill for brief "new patient" visits (no exam), but don't quote me on that.  I'm in suburban area of a larger city, so there are literally hundreds of PCPs I can choose from within two networks (but I have to choose one or the other network, not a mix).  For too long I thought all the docs in a network would just think exactly the same, plus they all used the same lab, so that discouraged me from looking further.  Well, I was surprised to find out that wasn't necessarily true, but it took some continued and persistent digging to find the "free thinkers" and finally making a few of those "get acquainted appts" to ask questions.  That's much better than both of us being "on the spot" during an office visit for an acute health problem and learning there is a mismatch.

    "New patient" appts can quickly cover more topics than a regular exam visit, too, which is usually restricted to one health complaint or cramming in all the annual exam items.  I focussed on asking questions and learning how the doctor sees his/her role in our healthcare and where he/she did/didn't have experience and expertise, rather than debating my opinions or views that differed.  It was a much better way to narrow down my choices.  There's too much at stake to throw a dart at a name and then stick with the random result no matter what.

    Persistence is the key.  I've learned never to let my health become an auto-pilot sort of thing.

  • Anonymous

    10/16/2008 8:31:00 PM |

    TSH is only a good starting point, one absolutely has to also know their free T4 (and T3) so that a lower-normal TSH isn't masking a too low free T4 (and T3).  Combined the TSH and free T4 can identify central hypothyroidism, originating in the pituitary that comes with the same symptoms of hypothyroidism originating at the thyroid.

  • Anna

    10/18/2008 4:11:00 AM |

    Donny,

    Interesting about the Vit A and beta carotene connection to thyroid.  Before I took thyroid hormone I have very reddish-orange palms.  That went away after some time with thyroid treatment and hasn't returned.

  • Dr. B G

    10/19/2008 1:13:00 PM |

    Anna Donny,

    Those are amazing observations.

    I do think Vitamin A is important. Most supplements however have 'beta carotene' and as Donny mentioned they are probably Lurotin by BASF or some other SYNTHETIC vitamin. This un-natural vitamin did not fare well in any clinical trial.

    Natural vitamin A is crucial -- just as vitamin D is for the thyroid and every organ in the body for growth, reproduction and anti-proliferative effects.

    Cows may be entirely deficient when compared with grass fed cows. I came across one study where the beef industry made the lovely conclusion that more marbling of the meat was achieved when the cows were fed vitamin-A-deficient feed!

    -G

  • Dr. B G

    10/19/2008 1:13:00 PM |

    Anna Donny,

    Those are amazing observations.

    I do think Vitamin A is important. Most supplements however have 'beta carotene' and as Donny mentioned they are probably Lurotin by BASF or some other SYNTHETIC vitamin. This un-natural vitamin did not fare well in any clinical trial.

    Natural vitamin A is crucial -- just as vitamin D is for the thyroid and every organ in the body for growth, reproduction and anti-proliferative effects.

    Cows may be entirely deficient when compared with grass fed cows. I came across one study where the beef industry made the lovely conclusion that more marbling of the meat was achieved when the cows were fed vitamin-A-deficient feed!

    -G

  • dubyaemgee

    1/23/2009 4:11:00 PM |

    Honestly, this has to be one of the best blogs around!

    My levels are:
    Thyroid Panel with TSH
    TSH 4.326
    Thyroxine (T4) 5.2
    T3 uptake 38
    Free Thyroxine Index 2.0

    I see people referring to T3 and T4 levels, but not sure what "normal" is. My TSH seems high, and I feel as though I exhibit the symptoms of hypothyroidism. Any ideas?

  • Anonymous

    3/10/2009 8:58:00 PM |

    A wonderful endocrinologist in St. Louis named E.J. Cunningham told me that there is no blood test that tells you exactly how much T3 is inside the cells activating the mitochondria.  All of the tests are only approximations.  You must actually take a history and do a physical exam to diagnose hypothyroidism.  The only way to find out  if you are correct is the patients response to T3 or armour thyroid therapy.  If you have positive thyroid autoantibodies, you should be on therapy in most cases.

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