Thyroid Disease

Emily Culvern Jocelyn Reddy Sarah Fecco Colin Fuqua Karly Childress

Types of Thyroid Disease

There are two different types of Thyroid disease: Hyperthyroidism & Hypothyroidism
Hypothyroidism: thyroid is under-productive

Often caused by Hashimotos thyroiditis

Hyperthyroidism: thyroid is overactive

Often caused by Graves disease

Hashimotos Disease
Hypothyroidism It is an autoimmune disease that is caused by inflammation of the thyroid gland Symptoms include difficulty concentrating, fatigue frequent bowel movements, goiter, heat intolerance, increased appetite, and sweating among others It tends to occur in families and is associated with other autoimmune condition such as type 1 diabetes and celiac disease

Graves Disease
Hyperthyroidism Graves disease is an autoimmune disease caused by thyroid autoantibodies that activate the TSH receptor It usually presents itself in early adolescence and affects 2% of the female population Symptoms include constipation, depression, fatigue, heavier menstrual periods, joint and muscle pain, weakness, and weight gain among others

Hashimotos Disease
http://www.thyroidscience.com/cases/huang .3.3.11/huang.3.3.11.htm

Graves Disease
http://nileherb.blogspot.com/2009/03/enlar ged-thyroid-gland-and.html

Who is at risk?
Females Pregnant women and neonates

Ages 50 and over pose the highest risk of thyroid disease

Family history of thyroid/autoimmune disease Removal of thyroid or radioactive treatment Current or former smoker Iodine or herbal supplements containing iodine

Over-consumption of soy foods

Prevalence
can be close to 20 million cases of global thyroid conditions over 1.5 million adults & more than 200,000 children in USA had Hashimotos thyroiditis in the year 1996 alone over 3 million people in USA in 1996 had Graves disease 4 out of 100 women have some type of autoimmune thyroid disease 1 per 3,000-4,000 newborns are affected by congenital hypothyroidism

Methods of Treatment
Treatment depends on the type and the severity of the disease

Treatment of Hashimotos disease/hypothyroidism:

no definitive cure hormone replacement by medication replacing one or more can alleviate the symptoms

Treatment of Graves disease/hyperthyroidism:

3 treatments:
1. Anti-thyroid medication 2. Beta blockers 3. Surgery

Nutritional Interactions
Over the past thirty years, research has been conducted to find new preventions or reverse of various types of diseases. Many tests have been focused on the identification of bioactive food components, which is why vitamins and minerals showed particular promising results
We have decided to talk about vitamin D and Iodine and their interaction with Thyroid Disease

Why Vitamin D?

Vitamin D has been shown to prevent bone loss associated with hyperthyroidism

The Objective of the Study on Vitamin D

The objective of this study was to investigate the association of hyperthyroidism and bone loss and its correlation with Vitamin D

Materials & Methods

80 consecutive patients (62 female an 18 males) with Graves disease were tested for biochemical, thyroid functions, serum vitamin D levels, and BMD (bone mass density). They were treated and rendered euthyroid. Diagnosis was based on clinical features of thyrotoxicosis, serum T4, and TSH levels in hyperthyroid range, readio-iodine uptake, and diffuse thyromegaly Healthy controls were used that composed mainly of hospital employees, students, and nurses where a low vitamin D status has been reported. Extensive questioning with a detailed history and clinical examinations were used

Materials & Methods continued...

Statistical methods such as mean, standard deviation were applied to summarize the variables. Proportions and percentages were used to summarize the categorical variables For comparison of baseline continuous variables between groups was done by applying independent T-test For comparison of categorical variables, chi square or fishers exact test was applied

Results
The mean radioactive uptake at 2 hours was 38.56 and at 24 hours was 65.89% Serum creatine, BMI, and TSH were lower in Graves patients compared to healthy controls Serum T4, ALP, duration of sun exposure and serum calcium were higher in people with hyperthyroid Graves patients compared to healthy euthyroid controls those patients were treated with carbimazole and all became euthyroid In 2-4 months those patients began having a normal T4 range Mean serum T4 levels at baseline were 20.94 Mean levels increased as months progressed. The TSH levels at baseline increased from .08 to 1.67 at the end BMI was shown to increase with therapy

Discussion
Hyperthyroid state is associated with an increase in bone turnover with a possibly direct effect of T4 on osteoclast, resulting in hypercalcemia with suppressed PTH both patients and controls were vitamin D deficient The high levels of PTH could be due to vitamin D deficiency associated with secondary hyperthyroidism overwhelming T4 mediated PTH suppression In a study of 34 untreated hyperthyroid patients, a mean 25(OH)D level of 23.4ng/ml was compared the to normal control level of 28ng/ml In another study of 208 Graves patients, serum 25(OH)D value of less the 10ng/dl was found in 40% of female and 18% of male patients no healthy control was taken and thus cannot determine if the high vitamin D deficiency was due to the high prevalence in general population or due to hyperthyroidism itself

Discussion continued...
A strong positive correlation between BMI and BMD at all sites was found Lack of substantial increase in BMD after 2 years of treatment with attainment of euthyroid state could occur because the bone turnover may not be normalized for a sufficient length of time Limitations to study: area of sunlight exposure has not been recorded making it difficult to correlate sun exposure and vitamin D status clinical scoring was not done nor was history of menopause recorded dietary calcium intakes of subjects and their socioeconomic status was not recorded

urinary creatine ratio or phosphate excretion index could not be derived

Why Iodine?
Iodine has been shown to be positively linked to the thyroid Iodine is valuable in maintaining a proper thyroid function

3 iodine is added to make T3 and 4 iodine to make T4, which are the two main hormones that the thyroid procuces
Deficiency has been shown to cause hypothyroidism

One particular study suggests a connection between iodine deficiency in old age and the increase of thyroid autoantibodies
In other words, an adequate intake of iodine can reduce the presence of thyroid autoantibodies in the consumer

The Objective

Thyroid disease - a common autoimmune disorder, which can be detected by the presence of thyroid antibodies
To asses thyroid autoimmunity among elderly people in a town with low iodine intake in comparison to a town with sustained recommended iodine intake from a natural sources

Materials & Methods

The study was carried out in the towns of Randers and Skagen in Denmark
the study was conducted on mostly elders as a representation of

long term iodine deficiency

Population, both men and women born in 1920 living in Randers, and population both men and women born in 1918 through 1923 living in Skagen took part in the study

Questionnaire regarding treatment for thyroid disease use iodine continuing vitamin and mineral preparations, duration of residence, smoking habits, and alcohol use
Iodine Deficiency - Randers

Iodine Replete (showing recommended levels) - Skagen

Materials & Methods continued...

A blood sample was drawn using minimal tourniquet and non fasting spot urine sample was collected in iodine free polyethylene containers Dynotest RIA with functional sensitivity of 30 u/: used to measure thyroid antibodies A functional sensitivity of 20 u/L used to measure thyroglobulin antibodies The iodine content is urine was examined via Sandell - Kolthoff reaction modified Urinary creatine was determined by kinetic Jaffe Method and used to estimate age and gender specific iodine/creatine ratio The stats of each group and town recorded along with possible interfering variables: gender, smoking, alcohol, intake, and location or town

Results
Participation rate was 47%

More women then men took part in the study

75% of participants had been residents of one of the two towns for over 40 years

The difference among towns was apparent in duration of residence as well as those abstaining from alcohol. Smoking frequencies were similar

Results continued...
Elders with a deficient Iodine intake - thyroid antibodies shown to be

more prevalent
Elders within recommended Iodine intake - thyroid antibodies not as

common
Those with moderate iodine deficiency (measured by urinary iodine

excretion below 50 u/24 hrs) had increased risk of harboring thyroid antibodies
With Randers being an iodine deficient zone, the increase in

occurrence of thyroid antibodies directly coincided with length of time as a resident

Skagen (iodine replete) did not have as strong of a correlation

between time as a resident and number of thyroid antibodies

Iodine Intake Level

Hosting a thyroid antibody was more common in elders from iodine deficient zone compared to those from iodine replete zone Thyroid antibodies were common in 75-80 year old men and women from both iodine deficient and iodine replete levels

In short - more iodine deficient than iodine replete elders harbored a thyroid autoantibody and differences increased with duration of residence

Variables to Consider
As age increases, immune system function is compromised.

Older age in some participants could play as much of a role on thyroid disease as being iodine deficient
Alcohol consumption and smoking can play a contradicting

role against minerals and should be considered when assessing iodine levels
The location of the iodine experiment degrades some

relevance to us

Aging & Thyroid

The aging process affects the immune system that becomes less responsive to antigenic challenges and the incidence and morbidity of infections increase with age Immune system is activated in elderly with increased concentration of inflammatory cytokines causing a pro-inflammatory environment and complicates degenerative disease and increases incidence of autoimmune disorders Age influences the prevalence of TGAb and TPOAb These antibodies increased with age from 7-9% in the young to 2220% for TGAb and TPOAb respectively in the 60-65 year old women A higher prevalence rates of both TGAb and TPOAb of 37% and 28% in women irrespective of iodine intake level Results suggest a peak in thyroid autoimmunity between age of 65 and 100 years

Aging continued...
Iodine intake did not influence the occurrence of thyroid autoantibody in those under age of 45 years in a large population based survey
The findings that thyroid autoantibodies occurred more frequently with iodine deficiency was dominated by a difference in TGAb. Iodine deficiency associated with a rise in frequency especially among men who rose almost to the level of women Suggests that iodine deficiency may increase proinflammatory environment in men in old age as thyroglobulin levels were elevated with iodine deficiency in both men and women

Conclusion
In Hyperthyroid Graves patients, BMD was found to be significantly lower at hip, spine, and forearm compared to healthy, euthyroid controls When treated for hyperthyroidism, the absolute BMD improved, but BMD corrected for BMI showed a decrease Damage in BMD caused by thyroid hormone ecess is not made up even after two years of patent being euthyroid The impact of aging on the immune system is modified by iodine Data suggests a peak in thyroid autoimmunity between the age of 65 and 100 years

References
1. Andersen, Stig, Finn Iversen, Steen Terpling, Klaus M. Pedersen, Peter Gustenhoff, and Peter Laurberg. "Iodine Deficiency Influences Thyroid Autoimmunity in Old Age - A Comparative Population-based Study. Thesis. Aalborg University Hospital, Denmark, 9 November 2011. Iodine Deficiency Influences Thyroid Autoimmunity in Old Age A Comparative Population. Science Direct, 9 Nov. 2011. Web. 5 Apr. 2012. <http:// www.sciencedirect.com.proxy.lib.utk.edu:90/science/article/pii/ S0378512211003343> 2. Dar, Rayees A., Nisar A. Chowdri, Fazl Q. Parray, and Sabiya H. Wani. "An Unusual Case of Hashimoto's Thyroiditis with Four Lobed Thyroid Gland. PubMed. North American Journal of Medical Sciences, 4 Mar. 2012. Web. 2 Apr. 2012. <http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3309625/?tool=pubmed> 3. Godbole, Madan M., Geeta Rao, By N. Paul, Vishwa Mohan, Preeti Singh, Drirh Khare, Satish Babu, Alok Nath, P. K. Singh, and Swasti Tiwari. "Prenatal Iodine Deficiency Results in Structurally and Functionally Immature Lungs in Neonatal Rats." Thesis. Sanjay Gandhi Postgraduate Institute of Medical Sciences, 2011. American Physiological Society. American Journal of Physiology, 12 Mar. 2012. Web. 2 Apr. 2012. <http://ajplung.physiology.org/content/early/2012/03/10/ajplung.00191.2011.abstract> 4. Jyotsna, Viveka P., Abhay Sahoo, Achouba Singh, V. Sreenivas, and Nandita Gupta. "Bone Mineral Density in Patients of Graves Disease Pre- & Post-treatment in a Predominantly Vitamin D Deficient Population." Thesis. Department of Endocrinology & Metabolism, All India Institute of Medical Sciences, 2009. Bone Mineral Density in Patients of Graves Disease Pre- & Post-treatment in a Predominantly Vitamin D Deficient Population. Indian Journal of Medical of Research, 4 Nov. 2009. Web. 2 Mar. 2012. <http://easybib.com/cite/form/thesis/pubtab/pubonline?data

Questions?