HYPOTHYROIDISM

INTRODUCTION: Hypothyroidism is a condition characterized by abnormally low thyroid hormone production. There are many disorders that result in hypothyroidism. These disorders may directly or indirectly involve the thyroid gland. Because thyroid hormone affects growth, development, and many cellular processes, inadequate thyroid hormone has widespread consequences for the body. Thyroid hormones are produced by the thyroid gland. This gland is located in the lower part of the neck, below the Adam's apple. The gland wraps around the windpipe (trachea) and has a shape that is similar to a butterfly formed by two wings (lobes) and attached by a middle part (isthmus). The thyroid gland uses iodine (mostly available from the diet in foods such as seafood, bread, and salt) to produce thyroid hormones. The two most important thyroid hormones are thyroxine (T4) and triiodothyronine (T3), which account for 99% and 1% of thyroid hormones present in the blood respectively. However, the hormone with the most biological activity is T3. Once released from the thyroid gland into the blood, a large amount of T4 is converted into T3 - the active hormone that affects the metabolism of cells. DEFINITION: Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone. Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn't produce enough of certain important hormones. INCIDENCE: Hypothyroidism, or underactive thyroid, is more common in women and people over age 50 .Women, especially those older than age 60, are more likely to have hypothyroidism. Hypothyroidism upsets the normal balance of chemical reactions in your body. It seldom causes symptoms in the early stages, but, over time, untreated hypothyroidism can cause a number of health problems, such as obesity, joint pain, infertility and heart disease.

CLASSIFICATION: Hypothyroidism is often classified by association with the indicated organ dysfunction Type Origin The most common forms include Hashimoto's Thyroid gland thyroiditis (an autoimmune disease) and radioiodine therapy for hyperthyroidism.

Primary

Secondary

Pituitary gland

Occurs if the pituitary gland does not create enough thyroid-stimulating hormone (TSH) to induce the thyroid gland to produce enough thyroxine and triiodothyronine. Although not every case of secondary hypothyroidism has a clear-cut cause, it is usually caused by damage to the pituitary gland, as by a tumor, radiation, or surgery. Secondary hypothyroidism accounts for less than 5% or 10% of hypothyroidism cases.

Tertiary

Results when the hypothalamus fails to produce sufficient thyrotropin-releasing hormone (TRH). TRH prompts the pituitary gland to produce thyroidHypothalamus stimulating hormone (TSH). Hence may also be termed hypothalamic-pituitary-axis hypothyroidism. It accounts for less than 5% of hypothyroidism cases.

CAUSES & RISK FACTORS: The thyroid gland is located in the front of the neck just below the voice box (larynx). It releases hormones that control metabolism. Hypothyroidism, or underactive thyroid, is more common in women and people over age 50. The most common cause of hypothyroidism is thyroiditis. Swelling and inflammation damage the thyroid glands cells. Causes of this problem include:

An attack of the thyroid gland by the immune system Cold or other respiratory infection Pregnancy (often called "postpartum thyroiditis")

Other causes of hypothyroidism include:

Certain drugs, such as lithium and amiodarone Congenital (birth) defects Radiation treatments to the neck or brain to treat different cancers Radioactive iodine used to treat an overactive thyroid gland Surgical removal of part or all of the thyroid gland Sheehan syndrome, a condition that may occur in a woman who bleeds severely during pregnancy or childbirth and causes the destruction of the pituitary gland

PATHOPHYSIOLOGY

The hypothalamic-pituitary-thyroid axis governs thyroid hormone secretion (see the image below).

The hypothalamic-pituitary-thyroid axis. Levels of circulating thyroid hormones are regulated by a complex feedback system involving the hypothalamus and pituitary gland. Although hypothalamic or pituitary disorders can affect thyroid function, localized disease of the thyroid gland that results in decreased thyroid hormone production is the most common cause of hypothyroidism. Under normal circumstances, the thyroid releases 100-125 nmol of T4 daily and only small amounts of T3. The half-life of T4 is approximately 7-10 days. T4, a prohormone, is converted to T3, the active form of thyroid hormone, in the peripheral tissues by 5-deiodination. Early in the disease process, compensatory mechanisms maintain T3 levels. Decreased production of T4 causes an increase in the secretion of TSH by the pituitary gland. TSH stimulates hypertrophy and hyperplasia of the thyroid gland and 5-deiodinase activity, thereby increasing T3 production. Deficiency of thyroid hormone has a wide range of effects. Systemic effects are the result of either derangements in metabolic processes or direct effects by myxedematous infiltration (ie, accumulation of glucosaminoglycans in the tissues). The hypothyroid changes in the heart result in decreased contractility, cardiac enlargement, pericardial effusion, decreased pulse, and decreased cardiac output. In the gastrointestinal (GI) tract, achlorhydria and prolonged intestinal transit time with gastric stasis can occur. Delayed puberty, anovulation, menstrual irregularities, and infertility are common. TSH screening should be a routine part of any investigation into menstrual irregularities or infertility. Decreased thyroid hormone effect can cause increased levels of total cholesterol and low-density lipoprotein (LDL) cholesterol and a possible change in high-density lipoprotein (HDL) cholesterol because of a change in metabolic clearance. In addition, hypothyroidism may result in an increase in insulin resistance. CLINICAL MANIFESTATIONS: Early hypothyroidism is often asymptomatic and can have very mild symptoms. Subclinical hypothyroidism is a state of normal thyroid hormone levels, thyroxine (T4) and triiodothyronine (T3), with mild elevation of thyrotropin, thyroid-stimulating hormone (TSH). With higher TSH levels and low free T4 levels, symptoms become more readily apparent in clinical (or overt) hypothyroidism.

Hypothyroidism can be associated with the following symptoms:[7][8][9] Early Cold intolerance, increased sensitivity to cold Constipation Weight gain and water retention Bradycardia (low heart rate fewer than sixty beats per minute) Fatigue Decreased sweating Muscle cramps and joint pain Dry, itchy skin Thin, brittle fingernails Rapid thoughts Depression Poor muscle tone (muscle hypotonia) Female infertility; any kind of problems with menstrual cycles Hyperprolactinemia and galactorrhea Elevated serum cholesterol Late

Goitre Slow speech and a hoarse, breaking voice deepening of the voice can also be noticed, caused by Reinke's Edema. Dry puffy skin, especially on the face Thinning of the outer third of the eyebrows (sign of Hertoghe) Abnormal menstrual cycles Low basal body temperature Thyroid-related depression Infertility in both men and women Mood swings Acute fatigue syndrome Stress Decreased libido in men Hypertension; Hypothyroidism increased peripheral vascular resistance, increase diastolic pressure, increased mean arterial pressure Carpal tunnel syndrome and bilateral paresthesias

Uncommon Impaired memory Impaired cognitive function (brain fog) and inattentiveness. A slow heart rate with ECG changes including low voltage signals. Diminished cardiac output and decreased contractility Reactive (or post-prandial) hypoglycemia Sluggish reflexes Hair loss Anemia caused by impaired haemoglobin synthesis (decreased erythropoietin levels), impaired intestinal iron and folate absorption or B12 deficiency from pernicious anemia Difficulty swallowing Shortness of breath with a shallow and slow respiratory pattern Increased need for sleep Irritability and mood instability Yellowing of the skin due to impaired conversion of beta-carotene to vitamin A (carotoderma) Impaired renal function with decreased glomerular filtration rate Acute psychosis (myxedema madness) (a rare presentation of hypothyroidism) [19] Decreased libido in men due to impairment of testicular testosterone synthesis Decreased sense of taste and smell (anosmia) Puffy face, hands and feet (late, less common symptoms) Gynecomastia Deafness Enlarged tongue Subclinical hypothyroidism Subclinical hypothyroidism occurs when thyroid stimulating hormone(TSH) levels are elevated but thyroxine (T4) and triiodothyronine (T3) levels are normal. In primary hypothyroidism, TSH levels are high and T4 and T3 levels are low. TSH usually increases when T4 and T3 levels drop. TSH prompts the thyroid gland to make more hormone. In subclinical hypothyroidism, TSH is elevated but below the limit representing overt

hypothyroidism. The levels of the active hormones will be within the laboratory reference ranges. DIAGNOSTIC EVALUATIONS: A physical examination may reveal a smaller-than-normal thyroid gland, although sometimes the gland is normal size or even enlarged (goiter). The examination may also reveal:

Brittle nails Coarse features of the face Pale or dry skin, which may be cool to the touch Swelling of the arms and legs Thin and brittle hair

Lab tests to determine thyroid function include:

TSH test T4 test

Other tests that may be done:

Cholesterol levels Complete blood count (CBC) Liver enzymes Prolactin Sodium

The only validated test to diagnose primary hypothyroidism, is to measure thyroid-stimulating hormone (TSH) and free thyroxine (T4). However, these levels can be affected by non-thyroidal illnesses. High levels of TSH indicate that the thyroid is not producing sufficient levels of thyroid hormone (mainly as thyroxine (T4) and smaller amounts of triiodothyronine (T3)). However, measuring just TSH fails to diagnose secondary and tertiary hypothyroidism, thus leading to the following suggested blood testing if the TSH is normal and hypothyroidism is still suspected:

Free triiodothyronine (fT3) Free thyroxine (fT4) Total T3

Total T4

Additionally, the following measurements may be needed:

Free T3 from 24-hour urine catch Antithyroid antibodies for evidence of autoimmune diseases that may be damaging the thyroid gland Serum cholesterol which may be elevated in hypothyroidism Prolactin as a widely available test of pituitary function Testing for anemia, including ferritin Basal body temperature

TREATMENT: Hypothyroidism is treated with the levorotatory forms of thyroxine (levothyroxine) (L-T4) and triiodothyronine (liothyronine) (LT3). Synthroid, produced by Abbott Laboratories, is the brand name counterpart to the generic Levothyroxine. Synthroid is also the most common pill prescribed by doctors that has the synthetic thyroid hormone in it, and it is taken by over 40% of people with hypothyroidism. This medicine can improve symptoms of thyroid deficiency such as slow speech, lack of energy, weight gain, hair loss, dry skin, and feeling cold. It also helps to treat goiter. It is also used to treat some kinds of thyroid cancer along with surgery and other medicines. Both synthetic and animal-derived thyroid tablets are available and can be prescribed for patients in need of additional thyroid hormone. Thyroid hormone is taken daily, and doctors can monitor blood levels to help assure proper dosing. Levothyroxine, the generic form of synthroid, is best taken 30 60 minutes before breakfast, as some food can diminish absorption. Calcium can inhibit the absorption of levothryoxine.

 Compared to water, coffee reduces absorption of levothyroxine by about 30 percent. Some patients might appear to be resistant to levothyroxine, when in fact they do not properly absorb the tablets a problem which is solved by pulverizing the medication. There are several different treatment protocols in thyroid-replacement therapy: T4 only This treatment involves supplementation of levothyroxine alone, in a synthetic form. It is currently the standard treatment in mainstream medicine. T4 and T3 in combination This treatment protocol involves administering both synthetic L-T4 and L-T3 simultaneously in combination. Desiccated thyroid extract Desiccated thyroid extract is an animal-based thyroid extract, most commonly from a porcine source. It is also a combination therapy, containing natural forms of L-T4 and L-T3 Treatment controversy The potential benefit from substituting some T3 for T4 has been investigated, but no conclusive benefit for combination therapy has been shown. The 2002 Laboratory Medicine Practice Guidelines of the National Academy of Clinical Biochemistry state that during pregnancy, "The L-T4 dose should be increased (usually by 50 mcg/day) to maintain a serum TSH between 0.5 and 2.0 mIU/L and a serum FT4 in the upper third of the normal reference interval." Doctors however often assume that if your TSH is in the "normal range", sometimes defined as high as 5.5 mIu/L, it has no effect on fertility. Healthy pregnant women however have a TSH level of around 1.0 mIU/L. Subclinical hypothyroidism There is a range of opinion on the biochemical and symptomatic point at which to treat with levothyroxine, the typical treatment for overt hypothyroidism. Reference ranges have been debated as well. As of 2003, the American Association of Clinical Endocrinologists (ACEE) considers 0.3 3.0 mIU/L within normal range. There is always the risk of overtreatment and hyperthyroidism. Some studies have suggested that subclinical hypothyroidism does not need to be

treated. A 2007 meta-analysis by the Cochrane Collaboration found no benefit of thyroid-hormone replacement except "some parameters of lipid profiles and left-ventricular function." A 2002 meta-analysis looking into whether subclinical hypothyroidism may increase the risk of cardiovascular disease, as has been previously suggested, found a possible modest increase and suggested further studies be undertaken with coronary-heart disease as an end point "before current recommendations are updated." Alternative treatments Compounded slow-release T3 has been suggested for use in combination with T4, which proponents argue will mitigate many of the symptoms of functional hypothyroidism and improve quality of life. This is still controversial and is rejected by the conventional medical establishment. Non-human presentation Hypothyroidism is also a relatively common disease in domestic dogs, with some specific breeds having a definite predisposition The purpose of treatment is to replace the thyroid hormone that is lacking. Levothyroxine is the most commonly used medication.

Doctors will prescribe the lowest dose possible that relieves your symptoms and brings your blood hormone levels back to normal. If you have heart disease or you are older, your doctor may start you on a very small dose. Most people with an underactive thyroid will need lifelong therapy.

When starting your medication, your doctor may check your hormone levels every 2 - 3 months. After that, your thyroid hormone levels should be monitored at least every year. Important things to remember when you are taking thyroid hormone:

Do NOT stop taking the medication when you feel better. Continue taking them exactly as your doctor prescribed. If you change brands of thyroid medicine, let your doctor know. Your levels may need to be checked. What you eat can change the way your body absorbs the thyroid medicine. Talk with your doctor if you are eating a lot of soy products or are on a high-fiber diet.

Thyroid medicine works best on an empty stomach and when taken 1 hour before any other medications. Do NOT take thyroid hormone with fiber supplements, calcium, iron, multivitamins, aluminum hydroxide antacids, colestipol, or medicines that bind bile acids.

While you are taking thyroid replacement therapy, tell your doctor if you have any symptoms that suggest your dose is too high, such as:

Palpitations Rapid weight loss Restlessness or shakiness Sweating

Myxedema coma is a medical emergency that occurs when the body's level of thyroid hormones becomes very low. It is treated with intravenous thyroid hormone replacement and steroid medications. Some patients may need supportive therapy (oxygen, breathing assistance, fluid replacement) and intensive-care nursing. Outlook (Prognosis) In most cases, thyroid levels return to normal with proper treatment. However, you must take thyroid hormone replacement for the rest of your life. Myxedema coma can result in death. Possible Complications Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an infection, illness, exposure to cold, or certain medications in people with untreated hypothyroidism. Symptoms and signs of myxedema coma include:

Below normal temperature Decreased breathing Low blood pressure Low blood sugar Unresponsiveness

Other complications are:

Heart disease Increased risk of infection Infertility Miscarriage

People with untreated hypothyroidism are at increased risk for:

Giving birth to a baby with birth defects Heart disease because of higher levels of LDL ("bad") cholesterol Heart failure

People treated with too much thyroid hormone are at risk for angina or heart attack, as well as osteoporosis (thinning of the bones). Medical Professional Call your health care provider if you have symptoms of hypothyroidism (or myxedema). If you are being treated for hypothyroidism, call your doctor if:

You develop chest pain or rapid heartbeat You have an infection Your symptoms get worse or do not improve with treatment You develop new symptoms

DIET FOR HYPOTHYROIDISM WITH DIABETES MELLITUS

Quick Thyroid Facts The two most common thyroid disorders, hypothyroidism and hyperthyroidism. But as a quick summary, here are some key points about diabetes and thyroid disease: Thyroid disorders are more common in people with diabetes than in people without diabetes. About one-third of people with Type 1 diabetes have a thyroid disorder, and thyroid disorders are also common in people with Type 2 diabetes. Too little thyroid hormone leads to hypothyroidism, the most common type. Symptoms of hypothyroidism, or a sluggish thyroid, include feeling tired, feeling cold, weight gain, depression, dry hair and skin, and constipation. Too much thyroid hormone causes hyperthyroidism, which isnt as common as hypothyroidism. Symptoms include weight loss, rapid heartbeat, shortness of breath, sweating, muscle weakness, and diarrhea. Hypothyroidism, if not treated, may lead to increased levels of cholesterol and triglycerides (blood fats), possibly raising the risk of heart disease. Hyperthyroidism can affect blood glucose control and increase the risk of osteoporosis. Make sure your levels of two thyroid-related hormones, thyroxine (T4) and thyroid-stimulating hormone (TSH) are measured at least once a year. Food and Hypothyroidism Food is more likely to play a role in the treatment of hypothyroidism than in the treatment of hyperthyroidism, or an overactive thyroid. If you do a search on the Internet, youll find literally millions of Web sites focused on what to eat for your thyroid, along with plenty of diets for a healthy thyroid. Most of this information is geared for someone with hypothyroidism and is based on the premise that an underactive thyroid, which slows your metabolism, is responsible for your weight gain jump-start your thyroid and youll soon be burning calories left and right, if these sources are to be believed. The reality is that while you may gain some weight due to a sluggish thyroid, the real treatment is to take the right type and amount of thyroid replacement, along with following a healthful eating plan and getting regular physical activity.

There are some tips for eating and hypothyroidism that you might keep in mind, however:

This sounds like a no-brainer, but take your thyroid medicine as directed by your physician. Skipping doses or taking it at different times of the day can prevent it from working as it should. Remember, too, that you might need to take thyroid medicine for the rest of your life, so get into the habit of making it part of your daily routine. Take your thyroid medicines on an empty stomach. Food can decrease the absorption of this medicine, especially foods high in fiber (bran cereal, wholegrain toast, fruits, vegetables, beans, etc.). Dont stop eating high -fiber foods; just eat them several hours apart from taking your thyroid medicines. Also, avoid taking calcium supplements or supplements that contain iron (such as a multivitamin/mineral) along with your thyroid medicine. These too can block absorption of the medicine. Iron deficiency is a cause of hypothyroidism. Women of childbearing age are more likely to be iron deficient. Ask your health-care provider to check your iron status if you have hypothyroidism. Certain foods, while good for you, can affect the production of thyroid hormone. These include broccoli, cauliflower, Brussels sprouts, cabbage, and collard greens. You dont have to avoid them, but dont eat them at the same time that you take your medicine. Cooking these vegetables seems to lessen this effect. Go easy with soy foods such as soy milk, tofu, miso, and tempeh. Soy contains a substance called genistein, which can decrease thyroid hormone production. Again, its not that you cant eat soy foods, but limit them to a few times per week. Eat foods that can help your body boost its production of thyroid hormone. These foods contain nutrients such as B vitamins, selenium, zinc, tyrosine, and iodine. Poultry, seafood, lean meat, whole grains, onions, beans, almonds, avocados, seeds, and low-fat dairy foods may be helpful. Go easy on fatty and sugary foods (this will help your diabetes management, too!). Dont take dietary supplements, such as iodine supplements, geared towards treating thyroid problems without first discussing this with your health-care provider. Also, dont stop taking your thyroid medicine in the hopes of treating hypothyroidism by diet alone.

Watch your portion sizes. This seems like a no-brainer, but if you need to lose weight, cut back on how much you eat. A dietitian can help you work out a weight-loss meal plan. Hypothyroidism diet The thyroid gland secretes a hormone that helps activate the cells in your body and enables them to carry out their normal function. If the levels of this hormone are deficient it causes the cells to become sluggish with their regular functions. If your cells are not in their best form it can cause you a number of complications with your health. Your immune system may fail, your metabolism slows down and your blood circulation becomes sluggish. When your thyroid fails to secrete the required amount of thyroid hormone you begin to show signs of hypothyroidism wherein you put on more weight, have an irritated disposition, are lethargic and so on. A hypothyroidism diet can help you lose weight and reduce the symptoms. Make sure that the following foods are a part of your hypothyroidism diet.

Iodine-rich foods: Iodine is required for the production of thyroid hormone in your body. A hypothyroidism diet should always include food that is rich in iodine content such as bananas, parsley, saltwater fish, seaweed and sushi. Using iodized salt instead of plain rock salt while cooking is beneficial. Water: Ensure that you increase your intake of water. Drink at least eight glasses every day. Your body stores more fat when you are dehydrated and can make you gain more fat. Fiber: A high fiber diet can be extremely beneficial for those who have hypothyroidism. A high fiber diet will regularize your bowel movement and also bring down your cholesterol levels. Fiber also helps lessen your hunger levels and make you burn additional calories. Fruits and vegetables are generally high in fiber. Coconut oil: Consuming coconut oil helps stimulate the production of thyroid hormone. It increases your metabolism and helps boost your energy. This should however be consumed in moderate levels depending on your body structure and age. Green tea: Drink a cup of green tea everyday. It increases your metabolism and also helps in the oxidation of fat. Tyrosine-rich foods: Tyrosine helps in the production of thyroid hormone. This is found in fish, lentils, lean meats, fish and low-fat milk.

Selenium-rich foods: Selenium is needed for the production of thyroid hormone. Increase your intake of foods such as brown rice, Brazil nuts, salmon and tuna Weight gain is something you can expect if suffering from thyroid issues. If you have hypothyroidism, diet plansshould be paid attention to and chosen carefully as they can help you avoid any further complications. DIET FOR DIABETIC WITH HYPOTHYROIDSM You can maintain good health by paying attention to key points that can trigger problems in your body. Exercise helps you will lose weight and strengthen your heart and lungs. A low-salt diet helps with normal blood pressure, the American Heart Association reports. If you suffer from diabetes and hypothyroidism, eat healthy foods that assist in normal blood sugar and metabolism stability. Develop a proper diet with your doctor and take your medicines. Include monitoring your blood sugars and thyroid stimulating hormone. The laboratory blood test TSH, or thyroid stimulating hormone, indicates the functioning of your thyroid. MEDICATION AND DIET Hypothyroidism may require you to take a synthetic thyroid stimulating medication, MayoClinic.com reports. Medications used to stimulate your thyroid include Levothyroxine, synthroid and levothyroid. The absorption of thyroid stimulating medication is affected by certain foods. A high fiber diet and soy products may affect how your body absorbs thyroid medication. Talk to your doctor about your diet and medications before starting your thyroid medicine. LOW-SALT FOODS Getting nutrients from foods low in salt guarantees a healthy diet. Water retention remains common in hypothyroidism. Low-salt foods such as fresh green vegetables and fruits are filled with nutrients and contain the vitamins you need for proper digestion, the National Kidney Foundation reports. Vitamin B helps your body to break down fats and helps to provide you with energy from foods you eat, MedlinePlus reports. Fresh fruit and vegetables add roughage to your diet and help your body rid itself of toxins. These foods also promote healthy bowel movements. You will feel less bloated and your abdomen will become flat.

FOOD CHOICES Your diabetic diet should follow an exchange diet filled with healthy choices, such as those suggested by the U.S. Department of Agriculture Food Pyramid. Foods within these dietary recommended sources give you the nutrients you require on your diabetic diet, MayoClinic.com reports. Remember to focus on foods that promote the intake of vitamins and minerals. Fish, chicken and turkey are healthful protein sources that have vitamins and minerals that help each organ of your body to function normally and better. The blood glucose levels you monitor will reflect the effects of the foods you eat. Keep a food journal for you and your doctor to discuss. WATER Drinking sufficient amounts of fluids, especially water, should be part of your hypothyroid and diabetic diet. Drink at least eight to 10 glasses of water daily, MedlinePlus states. You need water to maintain a healthy body that is hydrated and has fewer toxins. Remember to exercise as a part of your diet plans. This is an effective way to reach your goal of a healthy lifestyle. Healthy Diet For Diabetes And Thyroid Diabetes is associated with thyroid problems. Insulin resistance is related to thyroid diseases. High protein and low carbohydrate diet is generally recommended. A balance in the intake of fiber, carbohydrate, fat and protein is provided by such kind of meals. This in turn results in a moderate rise in the blood glucose level, due to a gradual entry of glucose in the bloodstream. This process regulates the quantity of insulin release, which causes a decrease in the calorie storage. The calories, which are taken in are put to use. Decrease the intake of certain foods, such as bagels, white bread, refined foods, rolls, beets, corn, parsnips, peas, carrots, potatoes, turnips, oranges, grapes, pineapple, papaya, bananas and watermelon. White rice, sugar, semolina and baked goods are a complete no-no, in case of thyroid disease and diabetes. Diabetic condition calls for the intake of several small meals, instead of the regular three meal pattern. About five to six small meals help in the prevention of sudden rise in the blood glucose levels. It also protects the individual form sudden hypoglycemic shocks. Lean protein in the form of white meat poultry, lean cuts of beef and fish are preferred. Hair loss, a common problem associated with thyroid disease is decreased with protein intake. About 25 grams of dietary fiber is recommended on a daily basis. Fiber is a complex carbohydrate, which

helps in the required insulin production. Certain foods, which are rich in fiber, such as apples, lentils, cauliflower, whole grains, almonds, green leafy vegetables, broccoli, kidney beans and pears are beneficial. A multi vitamin supplement, especially with selenium and zinc proves effective. BIBLIOGRAPHY: http://www.livestrong.com/article/487102-diet-for-diabetic-withhypothyroidism/#ixzz2RKpsTAQt http://www.nlm.nih.gov/medlineplus/ency/article/000353.htm http://www.ehow.com/way_5313133_diet-diabetes-hypothyroidism.html http://www.diabetesselfmanagement.com/Blog/Amy-Campbell/eating-for-ahealthy-thyroid/ http://www.diethealthclub.com/blog/diet-for-illness/diet-for-thyroid-anddiabetes.html http://www.diethealthclub.com/explore/hypothyroidism-diet.html http://www.livestrong.com/article/487102-diet-for-diabetic-withhypothyroidism/ http://hypothyroidismtalk.com/ http://www.nlm.nih.gov/medlineplus/ency/article/000353.htm