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Thyroid Disease and Diet — Nutrition Plays a Part in Maintaining Thyroid HealthBy Cheryl Harris, MPH, RDSuggested CDR Learning Codes: 3000, 3020, 3090, 4000, 4040, 4050, 5000, 5110, 5120,5160, 5190, 5290; Level 2“I have a tough time losing weight because of my thyroid.”You’ve probably heard this complaint time and again from clients who have thyroid disease—and with good reason. To the great frustration of many of the 27 million Americans with thyroidgland issues, the thyroid has a profound impact on metabolism. Unintended weight gain andweight loss are common, and both can be a daunting challenge to rectify. Although weight maybe the most common complaint, clients are at an increased risk of cardiovascular disease anddiabetes, underscoring the need to eat a balanced diet and adopt a healthful lifestyle. Butsince one-half of all people with thyroid disease are undiagnosed and weight changes are acommon symptom,1 RDs are in a prime position to spot potential thyroid conditions, makeappropriate referrals, and help clients get a timely diagnosis and the treatment they need.This continuing education activity will provide an overview of thyroid disease, its relationshipwith cardiovascular disease and diabetes, and the role nutrition plays in maintaining thyroidhealth.Thyroid 101The thyroid gland is a 2-inch butterfly-shaped organ located at the front of the neck. Thoughthe thyroid is small, it’s a major gland in the endocrine system and affects nearly every organin the body. It regulates fat and carbohydrate metabolism, respiration, body temperature, braindevelopment, cholesterol levels, the heart and nervous system, blood calcium levels,menstrual cycles, skin integrity, and more.1The most common thyroid condition is hypothyroidism, or underactive thyroid. In the UnitedStates, hypothyroidism usually is caused by an autoimmune response known as Hashimoto’sdisease or autoimmune thyroiditis. As with all autoimmune diseases, the body mistakenlyidentifies its own tissues as an invader and attacks them until the organ is destroyed. Thischronic attack eventually prevents the thyroid from releasing adequate levels of the hormonesT3 and T4, which are necessary to keep the body functioning properly. The lack of thesehormones can slow down metabolism and cause weight gain, fatigue, dry skin and hair, anddifficulty concentrating (see table below).2 Hashimoto’s affects approximately 5% of the USpopulation, is seven times more prevalent in women than men, and generally occurs duringmiddle age.3

Hyperthyroidism, or overactive thyroid gland, is another common thyroid condition. The mostprevalent form is Graves’ disease in which the body’s autoimmune response causes thethyroid gland to produce too much T3 and T4. Symptoms of hyperthyroidism can includeweight loss, high blood pressure, diarrhea, and a rapid heartbeat. Graves’ disease alsodisproportionately affects women and typically presents before the age of 40. 4Hashimoto’s is more common than Graves’ disease, but both are referred to as autoimmunethyroid disease (ATD), which has a strong genetic link and is associated with otherautoimmune disorders, such as type 1 diabetes, rheumatoid arthritis, lupus, and celiacdisease.2A goiter, or enlargement of the thyroid gland, can be caused by hypothyroidism,hyperthyroidism, excessive or inadequate intake of iodine in the diet, or thyroid cancer—themost common endocrine cancer whose incidence studies indicate is increasing. 5TreatmentThe disease process for Hashimoto’s is a spectrum, and not all patients require treatment.Some patients have autoimmune antibodies but retain enough thyroid function without theneed for intervention for years. Generally, once the body can no longer produce an adequateamount of thyroid hormone for necessary physiological functions, thyroid replacementmedication is necessary to correct the hormonal imbalances associated with hypothyroidism.Hyperthyroidism usually is treated with medications, surgery, or oral radioactive iodine.However, these treatments are imprecise and may cause the thyroid to secrete inadequateamounts of T3 and T4 and function insufficiently after treatment. Seventy percent to 90% ofpatients with Graves’ or thyroid cancer eventually need treatment for hypothyroidism as aresult of treatment.6Cardiovascular Risk and DiabetesPatients with hypothyroidism have a greater risk of cardiovascular disease than the risksassociated with weight gain alone. Low levels of thyroid hormones lead to a higher blood lipidprofile, increased blood pressure, and elevated levels of the amino acid homocysteine and theinflammatory marker C-reactive protein.6Thyroid hormones regulate cholesterol synthesis, cholesterol receptors, and the rate ofcholesterol degradation. Hypothyroidism increases LDL levels, and increased cholesterollevels have been shown to induce hypothyroidism, leading to a harmful feedback loop that hasbeen illustrated most clearly in animal models. In humans, normalization of thyroid hormonelevels has a beneficial effect on cholesterol, which may be worth noting especially for clientswho choose not to take prescribed thyroid medications.7Moreover, a strong relationship exists between thyroid disorders, impaired glucose control, anddiabetes. Thirty percent of people with type 1 diabetes have ATD, and 12.5% of those withtype 2 diabetes have thyroid disease compared with a 6.6% prevalence of thyroid disease inthe general public. Both hypothyroidism and hyperthyroidism affect carbohydrate metabolism

and have a profound effect on glucose control, making close coordination with anendocrinologist vital.8WeightIt’s imperative dietitians have a good understanding of the metabolic changes associated withthyroid disease so they can set realistic goals and expectations for clients. Most people withhypothyroidism tend to experience abnormal weight gain and difficulty losing weight untilhormone levels stabilize. Moreover, it’s common for patients with Graves’ disease toexperience periods of high and low thyroid hormone levels, so it may take several months toachieve a balance. During this time, it’s essential clients focus on healthful behaviors such aseating nutritious foods, exercising regularly, managing stress, and sleeping adequately ratherthan focus on the numbers on the scale.Clara Schneider, MS, RD, RN, CDE, LDN, of Outer Banks Nutrition and author of numerousbooks, including The Everything Thyroid Diet Book, says, “The No. 1 priority is to get thethyroid disease under control. Clients need to have labs and medications addressed first.Weight changes are just not going to happen before all of that is under control.” She notes thatHashimoto’s typically occurs around menopause, which compounds the weight gain issue thatmany women experience during that time.“The biggest factors that help with weight loss are calorie- and carbohydrate-controlled mealplans,” says Sheila Dean, DSc, RD, LD, CCN, CDE, of the Palm Harbor Center for Health &Healing in Florida. “Naturally I try to ensure [clients are] eating a whole foods-based, minimallyprocessed diet with at least 2 L of water daily.” Schneider agrees that a heart-healthy eatingplan is fundamental. “The diet should emphasize more vegetables, leaner meats, more beans,fiber, and fluids. We need to look at intake of sugars, added fats, fast food, and meals out.”Emphasizing lean proteins, vegetables, fruits, heart-healthy fats and omega 3s, high-fiberfoods, and appropriate portions can help manage or prevent illnesses associated with thyroiddisease. As Schneider notes, “It’s eating for prevention of all these diseases that accompanythyroid disease: heart disease, diabetes, cancer, and more.” As an added bonus, fiber canrelieve constipation that people with hypothyroidism often experience.Key NutrientsMany nutritional factors play a role in optimizing thyroid function. However, both nutrientdeficiencies and excesses can trigger or exacerbate symptoms. Working in collaboration with aphysician is ideal to determine nutritional status for optimal thyroid health.Iodine: Iodine is a vital nutrient in the body and essential to thyroid function; thyroid hormonesare comprised of iodine. While autoimmune disease is the primary cause of thyroid dysfunctionin the United States, iodine deficiency is the main cause worldwide. 9Iodine deficiency has been considered rare in the United States since the 1920s, largely due tothe widespread use of iodized salt. This, along with fish, dairy, and grains, is a major source ofiodine in the standard American diet.

However, iodine intake has dropped during the past few decades. Americans getapproximately 70% of their salt intake from processed foods that, in the United States andCanada, generally don’t contain iodine. A 2012 Centers for Disease Control and Preventionreport indicates that, on average, Americans are getting adequate amounts of iodine, with thepotential exception of women of childbearing age10 (see “Thyroid Disease and Pregnancy”sidebar below).Both iodine deficiency and excess have significant risks; therefore, supplementation should beapproached with caution. Supplemental iodine may cause symptom flare-ups in people withHashimoto’s disease because it stimulates autoimmune antibodies. 11Iodine intake often isn’t readily apparent on a dietary recall since the amount in foods is largelydependent on levels in the soil and added salt. However, Schneider says, “Clients takingiodine tablets are a red flag. Frequent intake of foods such as seaweed, which is high in iodine,or an avoidance of all iodized salt may serve as signs that further exploration is needed.”Vitamin D: Vitamin D deficiency is linked to Hashimoto’s, according to one study showing thatmore than 90% of patients studied were deficient. However, it’s unclear whether the lowvitamin D levels were the direct cause of Hashimoto’s or the result of the disease processitself.12Hyperthyroidism, particularly Graves’ disease, is known to cause bone loss, which iscompounded by the vitamin D deficiency commonly found in people with hyperthyroidism. Thisbone mass can be regained with treatment for hyperthyroidism, and experts suggest thatadequate bone-building nutrients, such as vitamin D, are particularly important during and aftertreatment.13Foods that contain some vitamin D include fatty fish, milk, dairy, eggs, and mushrooms.Sunlight also is a potential source, but the amount of vitamin production depends on theseason and latitude. If clients have low vitamin D levels, supplemental D3 may be necessary,and the client’s physician should monitor progress to ensure the individual’s levels stay withinan appropriate range.Selenium: The highest concentration of selenium is found in the thyroid gland, and it’s beenshown to be a necessary component of enzymes integral to thyroid function.14 Selenium is anessential trace mineral and has been shown to have a profound effect on the immune system,cognitive function, fertility in both men and women, and mortality rate.A meta-analysis of randomized, placebo-controlled studies has shown benefits of selenium onboth thyroid antibody titers and mood in patients with Hashimoto’s, but this effect seems morepronounced in people with a selenium deficiency or insufficiency at the outset.15 Conversely,an excessive intake of selenium can cause gastrointestinal distress or even raise the risk oftype 2 diabetes and cancer. So clients will benefit from having their selenium levels tested andincorporating healthful, selenium-rich foods in to their diets, such as Brazil nuts, tuna, crab,and lobster.15

Vitamin B12: Studies have shown that about 30% of people with ATD experience a vitaminB12 deficiency. Food sources of B12 include mollusks, sardines, salmon, organ meats such asliver, muscle meat, and dairy. Vegan sources include fortified cereals and nutritional yeast.Severe B12 deficiency can be irreversible, so it’s important for dietitians to suggest clients withthyroid disease have their levels tested.16GoitrogensCruciferous vegetables such as broccoli, cauliflower, and cabbage naturally release acompound called goitrin when they’re hydrolyzed, or broken down. Goitrin can interfere withthe synthesis of thyroid hormones. However, this is usually a concern only when coupled withan iodine deficiency.17 Heating cruciferous vegetables denatures much or all of this potentialgoitrogenic effect.18 “If you’re eating three to four servings per week of cooked or even lightlysteamed crucifers, generally it shouldn’t have a negative effect on thyroid health andparticularly if iodine consumption and tissue levels are adequate,” Dean says.Soy is another potential goitrogen. The isoflavones in soy can lower thyroid hormonesynthesis, but numerous studies have found that consuming soy doesn’t cause hypothyroidismin people with adequate iodine stores.19 While moderate soy intake (ie, levels found in food)gets a green light, concern remains for high-dose soy supplementation, specifically in peoplewith preexisting compromised thyroid function. In addition to biological plausibility for thyroidsuppression with soy consumption, a randomized, double-blinded study showed a threefoldincrease in the development of clinical hypothyroidism among women with subclinicalhypothyroid levels when supplemented with high doses of soy. Iodine levels did not appear tobe a factor.20Clearly, given the prevalence of subclinical and overt thyroid disease and frequentsupplemental soy intake, especially among postmenopausal women, more research isneeded, However, Dean cautions clients to eat soy in moderation: “Certainly, I'm notencouraging soy-based supplements.”While a typical intake of cooked crucifers and soy are generally considered safe in people withadequate iodine, the potential exception is millet, a nutritious gluten-free grain, which maysuppress thyroid function even in people with adequate iodine intake. 21 If a dietary recallindicates frequent millet consumption in patients with hypothyroidism, it may be wise tosuggest they choose a different grain.What About a Gluten-Free Diet?Gluten sensitivity and gluten intolerance continue to be topics of discussion in the dieteticscommunity, with speculation that a gluten-free diet may help relieve symptoms of variousautoimmune conditions, including ATD. The two aspects of this theory involve the relationshipbetween ATD and a gluten-free diet in people with celiac disease and the effect of a glutenfree diet in people with ATD without celiac disease.The rate of celiac disease is significantly higher among people with ATD than the generalpopulation. Studies have shown that 2% to 4.8% of US adults with ATD have celiac diseaseand 7.8% of children with ATD have celiac disease vs. 1% of the general population.22 Celiac

disease testing is recommended for anyone who has ATD and celiac disease symptoms.However, appropriate and timely identification is often delayed because the typical symptomsof ATD overlap greatly with the symptoms for celiac disease, such as diarrhea, constipation,weight changes, fatigue, anemia, and infertility.Studies have found that people with undiagnosed celiac disease commonly have antithyroidantibodies and show reductions in thyroid antibody titers, indicating a lesser autoimmuneresponse, after six months of consuming a gluten-free diet.23,24 Moreover, when people withceliac disease and hypothyroidism go on a gluten-free diet and start experiencing increasedabsorption of both food and medications due to intestinal healing, often they need lower dosesof thyroid medication.25 So a gluten-free diet may benefit both conditions in those with ATDand celiac disease.To date, no studies have evaluated the effects of a gluten-free diet in people who have ATDbut not celiac disease. This remains an area of controversy, although some experts reportobserving benefits in clients.So what should RDs do in practice? If clients are interested and motivated to try a gluten-freediet, they should be tested for celiac disease first before going gluten free, even in the absenceof gastrointestinal symptoms. Once someone with celiac disease adopts a gluten-free diet, theautoimmune markers for the disease disappear, so it is critical that the testing precedes dietarychanges to insure accuracy. If the test is negative, a trial gluten-free diet emphasizing naturallygluten-free foods (eg, fruits, vegetables, beans, nuts, seeds, fish, poultry) for several monthswill allow clients and RDs to observe any potential effects.Foods, Supplements, and Medication InteractionsWhen it comes to thyroid medications, it’s important for RDs to know which medications caninteract with common nutritional supplements. Calcium supplements have the potential tointerfere with proper absorption of thyroid medications, so patients must consider the timingwhen taking both. Studies recommend spacing calcium supplements and thyroid medicationsby at least four hours.26 Coffee and fiber supplements lower the absorption of thyroidmedication, so patients should take them one hour apart.27 Dietitians should confirm whetherclients have received and are adhering to these guidelines for optimal health.Chromium picolinate, which is marketed for blood sugar control and weight loss, also impairsthe absorption of thyroid medications. If clients decide to take chromium picolinate, they shouldtake it three to four hours apart from thyroid medications.28 Flavonoids in fruits, vegetables,and tea have been shown to have potential cardiovascular benefits. However, high-doseflavonoid supplements may suppress thyroid function.29 The Natural Standards Databaseprovides an extensive list of supplements that have a potential impact on thyroid function, sotaking precautions and coordinating patient care with a knowledgeable practitioner is prudent.ExerciseA discussion on thyroid disease and good health isn’t complete without stressing theimportance of physical activity. Lisa Lilienfield, MD, a thyroid disease specialist at the KaplanCenter for Integrative Medicine in McLean, Virginia, and a certified yoga instructor, is a firm

believer in the importance of exercise, particularly for clients with a thyroid disorder. “Withhypothyroid patients, certainly exercise can help with weight gain, fatigue, and depression.With hyperthyroidism, anxiety and sleep disturbances are so common, and exercise can helpregulate both.”In addition to the obvious impact exercise has on weight and metabolism, a study of patientswith Graves’ disease found that a structured exercise program showed dramatic improvementsin fatigue levels, and significantly more patients were able to successfully stop takingantithyroid medications without a relapse.30Since fatigue can be a barrier to exercise, starting off slowly and gently is paramount.Lilienfield and Schneider recommend patients use a pedometer as a tool for a tangible sourceof structure and motivation. Lilienfield also suggests clients attend a gentle yoga class as aplace to get started.Tying It AltogetherThyroid disease presents unique challenges due to undesired weight changes, significantcardiovascular risks, and symptoms such as fatigue, mood changes, and gastrointestinalupset, which can hinder the development of healthful behaviors. It’s vital that dietitians focuson setting realistic goals for heart-healthy changes and regular exercise when counselingclients. With so many potential nutrient deficiencies and interactions with medications andsupplements, it will be important for dietitians to coordinate with the rest of the clients’healthcare team for optimal health outcomes.— Written by Cheryl Harris, MPH, RD, a dietitian in private practice in Fairfax and Alexandria,Virginia. She’s also a speaker, writer, and health coach.HypothyroidismWeight gainConstipationFatigueHair lossDepression, “brain fog,” or difficultyconcentratingJoint painInfertility, missed periodsMiscarriageHyperthyroidismWeight lossDiarrheaFatigueN/AAnxiety, difficulty concentrating,nervousnessMuscle weaknessInfertility, missed periodsMiscarriage— Author compiled table from several sources.

Thyroid Disease and PregnancyAccording to the American Thyroid Association, “Pregnancy is a stress test for the thyroid.”Thyroid disorders often first become apparent during this time and are quite common duringthe postpartum period. They have a huge impact on mom and baby. Hypothyroidism andhyperthyroidism can cause preeclampsia, low birth weight, miscarriage, and a variety of otherserious complications, even at subclinical levels.Many clients seek RDs when experiencing infertility, planning for a baby, or early in theirpregnancy. Those who have other autoimmune diseases, a goiter, a family history of thyroiddisease, thyroid antibodies, or a history of miscarriage or preterm birth are considered high riskof developing thyroid complications during or after pregnancy. Confirming whether or not theseclients have had thyroid screening will lessen the risk of preventable complications. 1Pregnant women with existing thyroid disease should be proactive about their health, as thefirst six weeks of pregnancy are particularly critical. “Getting good control before conception iskey, and women should have their thyroid function tested monthly during pregnancy becauserequirements are increased,” says Lisa Lilienfield, MD, a thyroid disease specialist at theKaplan Center for Integrative Medicine in McLean, Virginia.Pregnant clients need up to 50% more iodine than nonpregnant patients. Iodine deficiency inpregnancy can cause severe consequences in the developing fetus, such as mentalretardation and stunted growth.2 However, there also are dangers with excess intake, withsymptoms similar to those seen in iodine deficiency. The American Thyroid Associationrecommends pregnant women take a prenatal vitamin containing 150 mcg of potassium iodide,which more than one-half of prenatal vitamins don’t contain.Postpartum thyroiditis is a form of Hashimoto’s and affects 4% to 10% of women in the yearfollowing childbirth. Symptoms may be subtle but diagnosis is important for the health ofsubsequent pregnancies. Women who have experienced postpartum thyroiditis are atincreased risk for developing hypothyroidism later in life.1References1. Ogunyemi DA. Autoimmune thyroid disease and pregnancy. eMedicine 261913-overview. Updated March 8, 2012.2. Dietary supplement fact sheet: iodine. Office of Dietary Supplements ickFacts. Reviewed June 24, 2011. AccessedJanuary 17, 2012.Recommended ReadingFor Professionals “Medical Nutrition Therapy for Thyroid and Related Disorders” in Krause’s Food, Nutrition,& Diet Therapy, 13th edition

For Clients The Everything Thyroid Diet Book by Clara Schneider The Thyroid Diet Revolution by Mary ShomanTake-Home Pearls Thyroid disease is common, particularly among women and people with other autoimmunediseases. Weight loss is particularly challenging for thyroid disease patients unless hormone levels arestabilized. The initial focus should be on healthful eating, physical activity, and adequate sleep. Many people with thyroid disease are at higher risk of cardiovascular disease and diabetes. A heart-healthy diet that includes vegetables, fruits, lean proteins, fiber, and omega-3s isparamount. Both nutrient deficiencies and excesses worsen thyroid function and symptoms.Communication and coordination with the client’s healthcare team is vital. Supplements can affect thyroid function and interfere with the efficacy of thyroid medication. Physical exercise is crucial. Encourage clients to start with walking and beginner’s yoga.References (for main article)1. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalencestudy. Arch Intern Med. 2000;160(4):526-534.2. Hypothyroidism. Bethesda, MD: National Endocrine and Metabolic Diseases InformationService, US Dept of Health and Human Services; 2012. NIH Publication No. 12-6180.3. Golden SH, Robinson KA, Saldanha I, Anton B, Ladenson PW. Clinical review: prevalenceand incidence of endocrine and metabolic disorders in the United States: a comprehensivereview. J Clin Endocr Metab. 2009;94(6):1853-1878.4. Graves’ Disease. Bethesda, MD: National Endocrine and Metabolic Diseases InformationService, US Dept of Health and Human Services; 2008. NIH Publication No. 08-6217.5. Aschebrook-Kilfoy B, Ward MH, Sabra MM, Devesa SS. Thyroid cancer incidence patternsin the United States by histologic type, 1992-2006. Thyroid. 2011:21(2):125-134.

6. Biondi B, Klein I. Hypothyroidism as a risk factor for cardiovascular disease. Endocrine.2004;24(1):1-13.7. Duntas LH, Brenta G. The effect of thyroid disorders on lipid levels and metabolism. MedClin North Am. 2012;96(2):269-281.8. Johnson JL. Diabetes control in thyroid disease. Diabetes Spectrum. 2006;19(3):148-153.9. Dietary supplement fact sheet: iodine. Office of Dietary Supplements ickFacts. Reviewed June 24, 2011. AccessedJanuary 17, 2012.10. Centers for Disease Control and Prevention. Second National Report on BiochemicalIndicators of Diet and Nutrition in the U.S. Population. Atlanta, GA: Centers for DiseaseControl and Prevention, US Dept of Health and Human Services; 2012.11. Dean S. Medical nutrition therapy for thyroid and related disorders. In: Mahan KL, EscottStump S, eds. Krause’s Food, Nutrition, & Diet Therapy. 13th ed. Philadelphia, PA:Saunders; 2008: 711-724.12. Tamer G, Arik S, Tamer I, Coksert D. Relative vitamin D insufficiency in Hashimoto'sthyroiditis. Thyroid. 2011;21(8):891-896.13. Jyotsna VP, Sahoo A, Ksh SA, Sreenivas V, Gupta N. Bone mineral density in patients ofGraves disease pre- & post-treatment in a predominantly vitamin D deficient population. IndianJ Med Res. 2012;135(1):36-41.14. Rayman MP. Selenium and human health. Lancet. 2012;379(9822):1256-1268.15. Toulis KA, Anastasilakis AD, Tzellos TG, Goulis DG, Kouvelas D. Seleniumsupplementation in the treatment of Hashimoto’s thyroiditis: a systematic review and a metaanalysis. Thyroid. 2010;2010:1163-1173.16. Sworczak K, Wisniewski P. The role of vitamins in the prevention and treatment of thyroiddisorders. Endokrynol Pol. 2011;62(4):340-344.17. Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes for Vitamin A,Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum,Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academies Press; 2001.18. Rungapamestry V, Duncan AJ, Fuller Z, Ratcliffe B. Effect of cooking brassica vegetableson the subsequent hydrolysis and metabolic fate of glucosinolates. Proc Nutr Soc.2007;66(1):69-81.

19. Messina M, Redmond G. Effects of soy protein and soybean isoflavones on thyroidfunction in healthy adults and hypothyroid patients: a review of the relevant literature. Thyroid.2006;16(3):249-258.20. Sathyapalan T, Manuchehri AM, Thatcher NJ, et al. The effect of soy phytoestrogensupplementation on thyroid status and cardiovascular risk markers in patients with subclinicalhypothyroidism: a randomized, double-blind, crossover study. J Clin Endocrinol Metab.2011;96(5):1442-1449.21. Elnour A, Hambraeus L, Eltom M, Dramaix M, Bourdoux P. Endemic goiter with iodinesufficiency: a possible role for the consumption of pearl millet in the etiology of endemic goiter.Am J Clin Nutr. 2000;71(1):59-66.22. Ch’ng CL, Jones MK, Kingham JG. Celiac disease and autoimmune thyroid disease. ClinMed Res. 2007;5(3):184-192.23. Ventura A, Neri E, Ughi C, Leopaldi A, Citta A, Not T. Gluten-dependent diabetes-relatedand thyroid-related autoantibodies in patients with celiac disease. J Pediatr. 2000;137(2):263265.24. Naiyer AJ, Shah J, Hernandez L, et al. Tissue transglutaminase antibodies in individualswith celiac disease bind to thyroid follicles and extracellular matrix and may contribute tothyroid dysfunction. Thyroid. 2008;18(11):1171-1178.25. Jiskra J, Limanova Z, Vanickova Z, Kocna P. IgA and IgG antigliadin, IgA anti-tissuetransglutaminase and antiendomysial antibodies in patients with autoimmune thyroid diseasesand their relationship to thyroidal replacement therapy. Physiol Res. 2003;52(1):79-88.26. Mazokopakis EE, Giannakopoulos TG, Starakis IK. Interaction between levothyroxine andcalcium carbonate. Can Fam Physician. 2008;54(1):39.27. Benvenga S, Bartolone L, Pappalardo MA, et al. Altered intestinal absorption of L-thyroxinecaused by coffee. Thyroid. 2008;18(3):293-301.28. John-Kalarickal J, Pearlman G, Carlson HE. New medications which decreaselevothyroxine absorption. Thyroid. 2007;17(8):763-765.29. Egert S, Rimbach G. Which sources of flavonoids: complex diets or dietary supplements?Adv Nutr. 2011;2(1):8-14.30. Cutovic M, Konstantinovic L, Stankovic Z, Vesovic-Potic V. Structured exercise programimproves functional capacity and delays relapse in euthyroid patients with Graves' disease.Disabil Rehabil. 2012;Epub ahead of print.

Examination1. Which of the following are symptoms of thyroid disease?A. Weight gainB. Weight lossC. Heart palpitationsD. Symptoms depend on the type of thyroid disease an individual has.2. Which of the following statements regarding thyroid disease in the United States istrue?A. It is predominantly found in women.B. It is predominantly an autoimmune condition.C. It is predominantly related to a lack of iodine.D. A and B3. Why do clients with untreated hypothyroidism have an increased risk ofcardiovascular issues?A. Effects of the weight gain typically associated with hypothyroidismB. Increased C-reactive protein levelsC. Change in lipid metabolismD. All of the above4. Which of the following statements about iodine is false?A. Iodine is necessary for thyroid function.B. Iodine is found in table salt but rarely in processed foods.C. Iodine deficiency is the main cause of thyroid disease in the United States.D. Iodine deficiency and excess causes harm.5. Which of the foll