One of those myth’s are on how Coconut oil can benefit those with hypothyroidism.  Unfortunately, there is not much evidence to support that claim. Here are some further details on that debate including two articles I have written, and one rebuttal from Bruce Fife.

http://thyroid.about.com/od/coconutoildebate/Coconut_Oil_and_the_Thyroid.htm

Thyroid conditions such as hypothyroidism typically require patient-specific advice on their issues and related complications, and I encourage anyone who is suffering from a Thyroid related disorder to reach out to my office for an appointment.

“I spend over 80 minutes with each new patient, so I have to limit the number of new patients I see each week; otherwise, there wouldn’t be any time to take care of my established patients.”

“Dr. Woliner, I understand completely.  I just want to get better.”

“Tell me more.”

“Ever since high school, I’ve been on one diet or another.  Up until the last five years or so, I was always able to drop 20-30 pounds no problem [1].”

“But?”

“But I’d always gain it back, and now, even when I starve myself, I can’t lose an ounce!”

“Yo-yo dieting messes up your metabolism.  65% of the weight lost is just water and muscle [2].  Not only do crash dieters lose their hair, get gallstones, and gain their weight back within a year, they increase their cortisol levels so much that makes it hard to ever lose weight again [3].”  I continued, “So what diets have you done?”

“What haven’t I done, you mean!  Weight Watchers and Jenny Craig, of course.  Diet clinics prescribed appetite suppressants, laxatives and diuretics [4].  I even did over a dozen of the fad diets that are touted in Women’s World Weekly.  Sprinkling Sensa on my food, hCG shots, and diet cookies you buy from the kiosk at the mall.  I hate to admit it, but I’m one of the ones that fell for that Kimkins scam.”

“Heidi Diaz, a.k.a. Kimberly Drake, had a lot of people fooled with her “after pictures” which were lifted of off ‘Russian Bride’ websites [5].  The trick all these diets use is that starvation itself causes a lack of appetite [6].  ‘SNATT’ is what they call it. Slightly Nauseous All The Time.”

“Nausea was only part of my troubles.  At 37, my periods stopped early, and my GYN is convinced that all these fad diets had something to do with it.  My heart even started skipping a beat – my doc said ‘QT-something …”

“Prolonged QT interval.  That’s serious; some people have died from that [7].  Ironically, the most dangerous time is when you start eating again after prolonged dieting.”

“Dr. Woliner, I’m through with all those pill-mill diet clinics.  So many of them wouldn’t let me use my drug plan, instead, they forced me to buy overpriced drugs right from their office.  I’m coming here because I know how important it is to see a board-certified doctor, one that still goes to the hospital in case I need you.”

I finished my exam.  “In addition to measuring your metabolic rate, I also want to send a note to your primary care physician, to coordinate care.”

Wendy’s metabolic rate was “minus 16%”, indicative of a slow metabolism [8].  Blood tests confirmed CENTRAL HYPOTHYROIDISM (suppressed TSH) INSULIN RESISTANCE (elevated HOMA-IR), and ADRENAL FATIGUE (high cortisol) [9].  I then prescribed a comprehensive plan of behavior changes, diet modification, exercise, supplements, and even some medications [10].  Three months later, she came back to check her progress.

“Dr. Woliner, I’m no longer shedding hair in the shower, but better yet, the scale is starting to move.  Just this last month, I lost another six pounds!”

REFERENCES:
[1] Roberts DC. Quick weight loss: sorting fad from fact. Med J Aust. 2001 Dec 3-17;175(11-12):637-40.

[10] Kolasa KM, et al. Weight loss strategies that really work. J Fam Pract. 2010 Jul;59(7):378-85.

“Perhaps if we turned off the fluorescent lights, you’d be more comfortable.  I can see well enough with the light coming through my window treatments.”

“Thank you Dr. Woliner.  Bright lights definitely make my migraines worse.  If you could only fix my IBS with a flip of a switch …”

“Tell me more.”

“Some weeks I’m constipated, not having a BM for five days or more, even with laxatives.  Lately it’s been the opposite; I’m in the bathroom at least ten times a day.  My bum is so irritated that I now see blood on the toilet paper each time I go.  And the bloating!  I can go from being normal to 5 months pregnant in the span of a few hours.”

I empathized, “I can see how frustrating that can be.  What have your doctors told you?”

“The GI looked at me from top to bottom, literally.  He said I had acid reflux, so he put me on Nexium.  I don’t have Crohn’s, just hemorrhoids that bleed pretty bad.”

“Anything else?”

“I had ‘sludge’ in my gallbladder, so they took that out.  Didn’t help.  The ER thought I had appendicitis, so they removed that too.”

“Have you ever been tested for food allergies?”

“Like peanuts?  I had a skin test that came out normal.”

“There are many types of adverse reactions to food, and swelling up due to a nut allergy is only one of them.  I was actually thinking about the other things: lactose intolerance, gluten allergy, and intolerances to food and food additives, such as MSG [1].”

“Dr. Woliner, I brought you all my old records.  If it isn’t in there, then I guess not.”

I moved onto my physical exam, “Say Ahhhh.”  As I looked into her mouth, I saw this white/yellow coating all over Heidi’s tongue, as well as two canker sores on the inside of her cheek.  Heidi’s breath didn’t smell too good either …

“I think we have our answer.  You’re not digesting your food, you’re fermenting it!”

“I don’t understand.”

“In addition to our teeth (and a fork and knife), we digest our food chemically, with stomach acid, digestive enzymes, and good bacteria (Lactobacillus acidophillus, etc).  Acid blocking drugs such as Nexium interfere with that process, allowing bad bacteria to grow and putrefy your food [2].  The byproducts irritate your gut, causing canker sores, dyspepsia, and diarrhea [3].  Proteins you’d normally break down, are absorbed intact, leading to food allergy symptoms of migraines, arthritis, and depression [4].”

“How do we find out what I’m allergic to?”

“I start with a blood test for 150 different foods and additives to see which ones are most likely to be a problem, but the gold standard is a ‘Double-Blind, Placebo-Controlled, Food Challenge’ [5].  I want to know for sure you have a bad reaction, so I don’t restrict your diet unnecessarily.”

“So I’ll have to avoid some foods the rest of my life?”

“Perhaps not.  That bad bacteria, ‘Small Intestine Bacteria Overgrowth (SIBO)’ is what they call it, causes a ruckus inside your gut [6].  Eliminating the bad bugs, and replacing them with friendly probiotics helps reduce food allergy symptoms [7].  After your GI tract is cleaned up, you may be able to tolerate foods you were previously sensitive to.”

In addition to having an overgrowth of Pseudomonas, which happened to be resistant to several antibiotics; Heidi’s tests showed responses to egg white, pork, onion, chicken, milk and coffee [8].  Challenge testing proved that coffee was a false positive, for which Heidi was extremely thankful.  A short course of treatment, combined with a pharmacologic dose of probiotics improved Heidi’s bowel movements to two “Class 4-5 Stools” per day [9].

Upon Heidi’s follow-up visit three months later, “Dr. Woliner, you can keep the lights on; I don’t get headaches anymore [10].”

 

REFERENCES:

[10] Arroyave Hernández CM, et al. Food allergy mediated by IgG antibodies associated with migraine in adults. Rev Alerg Mex. 2007 Sep-Oct;54(5):162-8.

Alyson continued to tell me her story.  “For example, this past summer, my best friend flew me to their home inSonomafor an entire month.  We ate nothing but organic everything, lean protein, I drank 150 ounce-plus of water a day and did a high intensity workout every morning mixing up interval training with boot camp at her gym.  In exactly 30 days – I lost a grand total of THREE pounds.  I didn’t even lose the initial ‘water weight’ everyone else loses.”

I empathized, “It’s hard to stay motivated with minimal results.”

“I’m willing to starve myself, if that would work.  I even did two rounds of hCG.  My wallet’s lighter, but that’s about it.”

“The FDA recently published a website, www.fda.gov/hcgdiet, detailing how hCG diet products are illegal, and how restrictive diets such as that one can cause electrolyte disturbances, an irregular heartbeat and are potentially fatal.”  I continued, “But looking at your diet history, I don’t think the problem is one of eating too much.”

“Dr. Woliner, what else could it be?  I have a friend that blew up taking Abilify for her depression, and another while on Actos for diabetes, but I’m not on any medications.”

“It’s true that many drugs have weight gain as a common side effect [1].  But there are other causes of weight gain.  With your other symptoms of cold intolerance, fatigue, and constipation, I’m thinking that you have an untreated thyroid condition [2].”

“I begged my other doctors to treat me for that, but they all said no.”

“Some doctors focus too much on lab tests without considering the patient’s history and physical exam findings [3].  Thyroid hormone resistance is more common than people realize.”

Alyson sat with a puzzled look on her face.  “So, even if these doctors said my tests were normal, I might still have a thyroid problem? [4]”

“The word ‘normal’ has many meanings.  There is a difference between ‘common’ and ‘optimal’ [5].  Rather than using a range that includes people who are overweight and being treated for high cholesterol and other conditions, perhaps it would be better to use narrower ranges of persons who feel ‘dandy’ [6].”

“Does anyone even use that word anymore?”

“My practice is built on patient-to-patient referrals.  Just liking my bedside manner is not enough to convince your friends to see me.  You have to glow.  So yes, I do plan on making you feel dandy.”

After finishing Alyson’s physical exam, my staff used our Korr indirect calorimetry machine to measure her metabolic rate [7].  “You’re at ‘minus 20%’.  That’s one of slowest metabolism’s I’ve ever seen!”

“How do we fix that?”

“I use a holistic approach that combines behavior changes, diet, exercise, supplements, and of course medications [8,9].  I prefer to use T3 based drugs as they have been shown to cause significantly more weight loss than T4 drugs such as Synthroid alone [#].”

As I ramped up Alyson’s dose of thyroid medication, her fatigue and other symptoms began to resolve.  To be on the safe side, I periodically rechecked her EKG and bone density, which remained normal [10].

“Dr. Woliner, your scale says I only lost 49 pounds, but at home, naked, I’m down 51!”

References:
[1] Singh T. Aripiprazole-induced weight gain. Psychiatry (Edgmont). 2005 Jun;2(6):19.
[2] de Moura Souza A, Sichieri R. Association between serum TSH concentration within the normal range and adiposity. Eur J Endocrinol. 2011 Jul;165(1):11-5.
[3] Kalra S, Khandelwal SK. Why are our hypothyroid patients unhappy? Is tissue hypothyroidism the answer? Indian J Endocrinol Metab. 2011 Jul;15(Suppl 2):S95-8.
[4] Dickey RA, Wartofsky L, Feld S. Optimal thyrotropin level: normal ranges and reference intervals are not equivalent. Thyroid. 2005 Sep;15(9):1035-9.
[5] Gurnell M, Halsall DJ, Chatterjee VK. What should be done when thyroid function tests do not make sense? Clin Endocrinol (Oxf). 2011 Jun;74(6):673-8.
[6} Shomon M. The Optimal Treatment for Hypothyroidism – Interview with Dr. Ken Woliner. http://thyroid.about.com. January 10, 2011.
[7] Kim B. Thyroid hormone as a determinant of energy expenditure and the basal metabolic rate. Thyroid. 2008 Feb;18(2):141-4.
[8] Singh P, et al. The impact of yoga upon female patients suffering from hypothyroidism. Complement Ther Clin Pract. 2011 Aug;17(3):132-4.
[9] Schomburg L. Treating Hashimoto’s thyroiditis with selenium: no risks, just benefits? Thyroid. 2011 May;21(5):563-4.
[10] Ricken R, et al. Long-term treatment with supraphysiological doses of thyroid hormone in affective disorders – effects on bone mineral density. J Affect Disord. 2012 Jan;136(1-2):e89-94.

“I’ve been depressed pretty much my whole life. It’s just that it’s gotten worse lately.” Annette continued, “My doctor changed my meds last December to a combination of Lexapro and Abilify but I still feel down.”

“Two out of three people treated for depression still have depressive symptoms. They call it treatment-resistant depression, and drugs such Abilify are often added, to augment the effects of antidepressants. Unfortunately, they have side effects.”

“You’re telling me! Before this I was on Symbyax and I gained nine pounds in three weeks! Despite dieting for forever, I still haven’t lost that weight.”1

“Abilify and Symbyax both can cause weight gain and diabetes. And since you aren’t getting that great of a response from them, perhaps we should look elsewhere. Perhaps we can fix your depression and help you lose weight at the same time.”

“My psychiatrist sent me here because she wants you to look at my thyroid. Do you think that could be it?”

“Though it is possible to ‘just be depressed’, I tend to think there is some specific cause. Hypothyroidism is one classic cause of depression, and thyroid medicines have been used quite effectively to improve mood and energy.”2

“I really hope it is my thyroid. That would fix a lot of my problems, even my weight.”

“Your thyroid isn’t the only thing I want to look at though. The way you wobbled down the hallway makes me wonder if you are low in vitamin D. Deficiencies of that vitamin lead to poor coordination and balance.”
“But we live in Florida. Don’t I get enough vitamin D from the sun?”

“Unfortunately, no. Even in Boca Raton, I’ve seen many patients with insufficient vitamin D, and vitamin D deficiency is yet another cause of treatment-resistant depression and weight gain.”3

I finished my physical exam. “Within a few weeks, your blood tests for thyroid and vitamin D will be back. Until that happens, however, I think we should try some high-dose vitamin D supplements. Though we are going to use doses far higher than a multivitamin, it is extremely safe with no side effects.”

Annette’s vitamin D level was indeed low, and at her follow up visit, she was already feeling significantly better. “As your psychiatrist suspected, your test for thyroid antibodies was positive. You also have Hashimoto’s Thyroiditis.”

“So what does that mean?”

“Thyroid antibodies interfere with the ability of other thyroid lab tests to detect which patients will respond to thyroid medication. Even though your TSH test was within the normal range, you probably would respond well to thyroid medication.”4

The combination of vitamin D and thyroid hormone seemed to do the trick. Annette’s mood improved to the point where she had desire to do things again. And no longer on the Abilify, the weight was far easier to lose.

“I’m playing tennis again, and honestly, I think that extra vitamin D is helping my tennis serve too!”

REFERENCES:
1. Callan JA. Weight gain with atypical antipsychotic drugs in bipolar disorder. J Psychosoc Nurs Ment Health Serv. 2009 Sep; 47(9):11-2.
2. Kelly T, Lieberman DZ. The use of triiodothyronine as an augmentation agent in treatment-resistant bipolar II and bipolar disorder NOS. J Affect Disord. 2009 Aug; 116(3):222-6.
3. Jorde R. Effects of vitamin D supplementation on symptoms of depression in overweight and obese subjects: randomized double blind trial. J Intern Med. 2008 Dec; 264(6):599-609.
4. Lojko D. L-thyroxine augmentation of serotonergic antidepressants in female patients with refractory depression. J Affect Disord. 2007 Nov;103(1-3):253-6.

I’ve seen it before. I first treat the wife’s thyroid problem, but then she realizes that I could help her husband with his medical concerns. When he sees how much energy his wife now has under my care, it isn’t too hard a sell to get him to make an appointment.

Still, Ed was skeptical. “I’ve been with the same internist for years, but all he seems to want to do is to push drugs on me.”

“Hmmmm. How so?”

“A few years back, my blood pressure was high and he said that hypertension could cause a stroke and kill me. He said, ‘Try diet and exercise for 3 months’, but when I came back, it was still high, so he put me on meds.”

Fran chimed in. “Those drugs had so many side effects. One made him hack and cough. Another made him tired and depressed. It took four tries before Ed found one he could tolerate.”

“I’ve written articles about how serious hypertension is [1]. By subscribing to unbiased sources of information such as The Medical Letter [2], I prescribe the most effective and least toxic medications first, rather than the most expensive (and potentially dangerous) drugs that pharmaceutical reps like to advertise.”

Ed continued, “That doctor also said my cholesterol was high and he said that atherosclerosis can cause a heart attack and kill me. He said, ‘Try diet and exercise for 3 months’, but when I came back, it was still high, so he put me on more meds.”

“I thought the blood pressure drugs were bad, but these were so much worse. Not only did Crestor cause Eddie to get the worst muscle cramps, it was also damaging his liver [3]! I wonder if the treatments are worse than the disease!”

“Statin drugs prevent the body from making too much cholesterol, but they also deplete the body of Coenzyme Q10, and that causes muscle aches, fatigue, and elevated liver enzymes [4]. I routinely check CoQ10 levels and use supplements to prevent those side effects.”

“Anyhow, my last set of blood tests showed my sugar is high and that he warned that diabetes could kill me. Do you know what he said next?”

“Let me guess, ‘Try diet and exercise for 3 months?’”

Fran interrupted, “Eddie needs more than lip service. It would be one thing if he taught us how to eat better, but all he had time for was to write prescriptions.”

“In addition to being a board-certified family physician, I also have a bachelor’s in Nutrition from Cornell, so I know how important diet and exercise is. You can’t teach 11 years of education in a 5-minute office visit, so I schedule 60 to 80 minutes with new patients, and at least 40 minutes for each follow up appointment. We’ll have plenty of time to teach you how to eat better.”

“Dr. Woliner, you don’t understand. I know what to do, I just don’t do it. I guess I just love bread too much.”

“No, I do understand. Eating too much isn’t just a cause of your weight gain, hypertension, and high cholesterol. It’ a symptom of the underlying condition which causes your sugar cravings. It’s called the METABOLIC SYNDROME, and when I fix your metabolism, you won’t crave bread excessively anymore [5].”

Ed wasn’t convinced. “You’re going to get an Italian to stop eating carbs? Good luck with that!”

“Let me make an analogy to help explain it. When a car is brand new, it doesn’t matter what type of gas you put into it, it runs fine. Even if the manufacturer says use Premium, if you use the regular 87 octane gas, you probably won’t notice any difference [6]. But when a car becomes a 55-year-old clunker,” Fran poked Ed’s arm as she realized I just called him a clunker, “you need more octane in the gasoline, otherwise the engine will start to knock. One of the problems with factory farms is that the soil quality is not there [7]. Our food doesn’t have all the vitamins and minerals in it as it would if we ate locally grown organic produce. Because I studied nutrition biochemistry and practice Functional Medicine, I know what vitamins and minerals we have to replace [8].”

I started Ed on a few pharmaceutical grade supplements, and as his appetite and weight came down, I was eventually able to taper him off his blood pressure medications.

At one of Ed’s follow up visits, he brought lunch in for my office. “Ever since I found this Organic Co-Op [9], my cooking has gotten so much better! You’ve got to taste the Purple Bell Pepper! It zings right off your tongue!”

REFERENCES:
[1] Woliner KN. Dealing with Hypertension. The Parklander. April 2011. Coral Springs, FL. p. 96.
[2] www.medicalletter.org
[3] Foody J. Statin use associated with increased risk of cataract, myopathy, liver dysfunction and acute renal failure with varying numbers needed to harm. Evid Based Med. 2010 Dec; 15(6):187-8.
[4] Komaroff AL. By the way, doctor. I take a statin. Should I be taking coenzyme Q10 to protect myself against the muscle pain that statins can cause? Harv Health Lett. 2010 Feb;35(4):8.
[5] Volek JS, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids. 2009 Apri;44(4):297-309.
[6] Wallinga D. Agricultural policy and childhood obesity: a food systems and public health commentary. Health Aff (Millwood). 2010 Mar-Apr;29(3):405-10.
[7] Reganold JP, et al. Fruit and soil quality of organic and conventional strawberry agroecosystems. PLoS One. 2010 Sep 1;5(9). e12346.
[8] Song Y, et al. Multivitamins, individual vitamin and mineral supplements, and risk of diabetes among older U.S. adults. Diabetes Care. 2011 Jan;34(1):108-14.
[9] www.coopdirectory.org

I nodded empathetically, realizing that Jennifer couldn’t believe what happened to her body, and she worried that no one else would believe it either.

“You looked pretty athletic. Let me guess, tennis?”

“I was varsity at Radcliffe. I still play six days a week.”

Jennifer continued, “Anyhow, you wouldn’t know it from looking at me. Ever since I had David eleven years ago, I’ve been gaining almost ten pounds every year.”

“Hmmm, your symptoms sound a lot like POSTPARTUM HASHIMOTO’S THYROIDITIS, where something related to pregnancy causes women to need more thyroid hormones than they can make on their own [1]”.

“They actually tested me for that. My doctors always told me my tests were normal.”

“There is a difference in having labs ‘in the reference range’ and having an ‘optimal thyroid state’. Dr. Leslie DeGroot, of Brown’s Alpert Medical School, described the ‘Dangerous Dogmas in Medicine’ as they relate to treatment of thyroid disorders [2]. Unfortunately, there are quite a few doctors out there that rely highly upon the gospel they were taught twenty years ago, without paying enough attention to new data, or their patient’s clinical symptoms.”

I continued taking my history. “So what have you tried to lose weight?”

“My diet was always pretty clean, so even when I tried going ‘low-carb’ or ‘low-fat’, it didn’t seem to make any difference. One health spa in Brazil cut me down to 300 Calories a day and had me exercise all day. I didn’t lose a pound!” Jennifer blushed a bit, “I’m ashamed to admit it, but I fall for whatever the latest diet fad that promises ’30 pounds in 30 days!’ [3]”

“I’m glad you’ve realized that these bogus diet clinics should really say, ‘I lost $350 in two weeks! Ask me how!’ [4]”

“It was worse than that. One diet clinic sold me ‘vitamin supplements’ from their office pharmacy, but they really contained amphetamines, diuretics, laxatives, and other stuff I still don’t know what was in them. I had the worst palpitations, headaches and I couldn’t sleep through the night [5]. My primary had to put me on anti-depressants for six months to handle the withdrawal symptoms after I stopped them.”

“I’m glad you survived that ordeal, but honestly, you got off lucky. Crash diets are known to cause hair loss (sometimes permanent), muscle weakness, and potentially fatal heart arrhythmias [6]. The latest diet craze, the ‘HCG Diet’, is nothing new; it was debunked back in the 1970’s as a fraudulent scheme by doctors to exploit their patients for financial gain [7]. Just last October, the Texas Attorney General forced hCG clinics in that state to stop defrauding patients with their unethical marketing tactics [8].”

“Well, I’ve finally decided to make my health a priority. I checked you out on www.vitals.com, so I know you are board-certified and legit. So what are you going to do for me?”

“I scheduled 80-minutes with you today, so I have plenty of time to do a complete history and physical exam. There are some tests I would like done to pin down exactly what is going on with your metabolism. Untreated thyroid disorders can lead to pre-diabetes, and that can also lead to weight gain [9].”

Jennifer did test positive for hypothyroidism and insulin resistance, as well as a low metabolic rate measured by indirect calorimetry [10]. After being put on a regimen of behavior changes, diet, exercise, OTC supplements, and prescription medications, steadily, but surely, her weight decreased an average of two pounds per week until she lost the 60 pounds she put on over the last ten years.

“Dr. Woliner, ever since you fixed my metabolism, I’m not hungry anymore. Really, I don’t even feel like I’m on a diet. I just eat normally.”

REFERENCES:
1. Galofré JC, et al. Increased postpartum thyroxine replacement in Hashimoto’s thyroiditis. Thyroid. 2010 Aug;20(8):901-8.
2. De Groot LJ. Dangerous dogmas in medicine: the nonthyroidal illness syndrome. J Clin Endocrinol Metab. 1999 Jan;84(1):151-64.
3. I’m confused by the numbers of fad diets available that tout great weight loss. Are there any basic, simple weight loss strategies I can follow? Duke Med Health News. 2011 Jul;17(7):8.
4. Federal Trade Commission. “Red Flag Bogus Weight Loss Claims” Washington DC. 2003. http://www.ahpa.org/Portals/0/pdfs/03_FTC_Media%20Guide_redflag.pdf
5. Smith BR, Cohen PA. Dependence on the Brazilian diet pill: a case report. Am J Addict. 2010 May-Jun;19(3):291-2.
6. Goette DK, Odom RB. Alopecia in crash dieters. JAMA. 1976 Jun 14;235(24):2622-3.
7. Robb-Nicholson C. By the way, doctor. I’ve been trying to lose weight for a long time and nothing seems to work. What do you know about the HCG diet? Harv Womens Health Watch. 2010 May;17(9):8.
8. Texas Attorney General. Multiple Texas Weight-Loss Clinics Agree To Stop Marketing Prescription Drugs Improperly. October 27, 2011. https://www.oag.state.tx.us/oagnews/release.php?id=3883
9. Liu C, Scherbaum WA, Schott M, Schinner S. Subclinical hypothyroidism and the prevalence of the metabolic syndrome. Horm Metab Res. 2011 Jun;43(6):417-21.
10. Perseghin G. Pathogenesis of obesity and diabetes mellitus: insights provided by indirect calorimetry in humans. Acta Diabetol. 2001;38(1):7-21.

“Your name is all over the Internet; and not with Google Ads, but with real articles and interviews! [1]” Shelly continued, “Dr. Woliner, I’ve checked you out on vitals.com and you’re well known for treating difficult-to-treat cases, especially thyroid.”

“I’ve gotten a reputation of looking at patients and their symptoms, not just their lab values. Various types of Thyroid Hormone Resistance such as Hashimoto’s Thyroiditis and the Reverse T3 Syndrome don’t show up well on standardized thyroid testing. [2]”

“Anyhow, my thyroid is only one of my problems. My world changed when I went into menopause. Hot flashes and night sweats were only part of it. I thought I’d lose my mind when I gained all that weight and lost half my hair.”
I listened intently as I was reviewing the 30-page stack of old records Shelly brought with her to this first appointment. “So what did you do?”

“I clicked on one of those Google Ads I talked about before. After watching Oprah’s show about bio-identical hormone replacement therapy (bHRT), I did a Google search and there they were. I should have seen the warning signs …”
“What do you mean?”

“Even before seeing me, knowing me at all, they ordered lab tests that I was forced to pay a lot of money for. I told them that I had tests just done by my Ob/Gyn, but they wanted to do their own.”

“Ordering the same tests or therapies on every patient is a sure sign of assembly line medicine. I tend to think of my office as a Michelin-rated restaurant, rather than a fast-food joint such as McDonalds.” Pulling out one of the lab reports, “As I review the data your brought with you, there are a few tests, such as your recent EKG, that I don’t have to repeat, but these ‘saliva tests’ are essentially useless. [3,4,5]”

“Why do you say that? The other doctor had me repeat them every three months.”

“This lab has different reference ranges for estradiol, progesterone, and other hormones whether you are pre-menopausal, post-menopausal, on one therapy or another, or the method of drug delivery (creams, patches, or capsules), as well as the timing from the last dose of medication – a sure sign of lack of reliability of the test [6]. It is totally inaccurate for those that take their hormones as a lozenge (a.k.a. troches). The peer-reviewed journal Clinical Chemistry states, ‘When presenting these data to their physician, patients are surprised to learn that the results are practically worthless for a clinical interpretation … physicians should therefore inform their patients of the lack of reliability of these non-approved services [7].’ Instead of giving useful data, I believe this test’s main use is as a ‘dog-and-pony show’ to provide a revenue-stream for the doctor [8].”

“He was real good at that. When I did my taxes, I realized I spent over $16,000 with him last year.”

I choked. Shocked, “I know I’m out-of-network, but even my most challenging cases don’t spend a quarter of that on my services! How’d it get to be so much?”

“In addition to all the lab testing they had me do, they prescribed hormones, all sorts of them. Bi-Est, Progesterone, Testosterone …”

“Bio-identical hormones are usually less expensive than those from Walgreen’s and CVS. I know of several high quality compounding pharmacies in the area that cost less than $50/month for these drugs.”

“Oh, I wanted to go to the same pharmacy my Great Dane gets her medications from, but they forced me to pay them for my hormones, and then had their compounding pharmacy ship it to me.”

“That type of split-fee relationship is considered ‘patient brokering’ and punishable as a third degree felony in the state of Florida [9]. Not only could a doctor lose his license, he could go to jail for that! But I don’t see how you could have ended up with bills so high.”

“Human Growth Hormone (hGH). Though I was there for my menopausal symptoms, the doctor convinced me these injections would help me lose weight. At over $1000 per month, it adds up.”

“These practices are best characterized as ‘deceptive, untrue, or fraudulent representations in or related to the practice of a profession or employing a trick or scheme in or related to the practice of a profession,’ and ‘exercising influence on the patient in such a manner as to exploit the patient for the purpose of financial gain.’ The “Florida Comprehensive Drug Abuse Prevention and Control Act,” reclassifies them as a felony of the second degree, ranked in level 4 of the Criminal Punishment Code! [10]”

“Oh my goodness!”

“My sister is the lawyer in the family; perhaps I should go back to the medicine and just get you better. Let me reassure you, however, I don’t dispense prescription drugs in this office and I’ll always allow you to use the pharmacy of your own choice for your medications, supplements, or whatever. I want you to be on medications you need, not ones that I need to get a mark-up on.”

“That makes me feel better. I would rather be treated like a patient needing help than a junkie that wants refills from a pill mill. [11]”

As I finished up my 80-minute new patient history and physical exam, I put together a plan for further testing (Shelly recently had a pap smear, but was due for a bone density scan), as well as therapies that ranged from behavior changes to pharmaceutical-grade supplements and bio-identical hormones.

“My staff will give you a list of quality compounding pharmacies in the area to choose from. I have a feeling your dog’s pharmacist is on the list. [12]”

REFERENCES:
[1] Shomon, Mary. The Optimal Treatment for Hypothyroidism: Interview with Ken Woliner, MD. Updated December 22, 2010. http://thyroid.about.com/od/hypothyroidismhashimotos/a/Optimal-Treatment-Hypothyroidism-Ken-Woliner.htm
[2] Yoshida K, Sakurada T, Kaise K, Kaise N, Nomura T, Itagaki Y, Yamamoto M, Saito S, Yoshinaga K. Relationship between serum free thyroid hormone concentrations and target organ responsiveness in thyroid disease patients before and after treatment. Tohoku J Exp Med. 1989 Dec;159(4):323-31. PubMed PMID: 2633409.
[3] Hagen J, Gott N, Miller DR. Reliability of saliva hormone tests. J Am Pharm Assoc (2003). 2003 Nov-Dec;43(6):724-6. PubMed PMID: 14717270.
[4] Davison S. Salivary testing opens a Pandora’s box of issues surrounding accurate measurement of testosterone in women. Menopause. 2009 Jul-Aug;16(4):630-1.
[5] Flyckt RL, Liu J, Frasure H, Wekselman K, Buch A, Kingsberg SA. Comparison of salivary versus serum testosterone levels in postmenopausal women receiving transdermal testosterone supplementation versus placebo. Menopause. 2009 Jul-Aug;16(4):680-8.
[6] www.zrtlab.com “ObservedSalivarySupplementationRanges.pdf” and “ZRT SalivaObservedReferenceRanges.pdf”.
[7] Gröschl M. Current status of salivary hormone analysis. Clin Chem. 2008 Nov;54(11):1759-69. Review. PubMed PMID: 18757583.
[8] Torrey, Trisha. Why Does My Doctor Send Me for So Many Medical Tests? Updated November 14, 2008. http://patients.about.com/od/followthemoney/f/FAQdoctortests.htm
[9] Florida Statutes, 458.331(1)(o), 456.054, and 817.505. www.leg.state.fl.us/Statutes
[10] Florida Statutes, 893.13(8). www.leg.state.fl.us/Statutes
[11] Vanguard. The Oxycontin Express. Winner of 2009 Peabody Award. www.hulu.com/watch/100279/vanguard-the-oxycontin-express
[12] International Academy of Compounding Pharmacists www.iacprx.org

Too often I hear stories of desperation, of patients who feel ignored while their doctor adjusts medication solely to get the lab test into the normal range, irregardless of how the patient’s symptoms are doing.  “Don’t worry.  I scheduled over 60 minutes for this new patient consultation, and in the future, I usually schedule 40 minutes for each follow-up visit.  You won’t be rushed today.”

“Thank you Dr. Woliner.  But I really want to know if you can help me.  I’ve actually seen four different endocrinologists in the last year, but they all say the same thing; my TSH is too low and they want to lower my dose.”

“Unlike other types of medical conditions, hypothyroidism is treated rather uniformly by most doctors.  There are many types of cholesterol drugs, anti-depressants, etc.  But with thyroid, most people are given one choice only, Synthroid.  ‘One-test, one-pill’ is how hypothyroidism is described in medical school lectures.”

“My therapist referred me to you, and she said you had an alternative approach to diagnosing thyroid disorders.”

“My approach isn’t that different, it’s just that it is more encompassing than what you’ve gone through before.  I spend more time with patients to gather a comprehensive history and physical exam.  In addition to the TSH, I test for T3 and T4, the actual thyroid hormones within your body.  I also look for other things such as thyroid antibodies that can throw off those tests, making them less reliable.”

I continued gathering my history.  “So you felt better when you were on a higher dose of medicine?  Were you having any side effects?  Palpitations?  Anything?”

“That’s what I don’t get.  I was feeling fine before they started reducing my dose.  Even my bone density scan came back with my bones being thicker than a 25 year old!”

Ronnie’s physical exam revealed signs of being under-medicated.  “Losing hair, especially on the outside of your eyebrows is one sign.  Your tongue is swollen so bad I can see indentations from your teeth; doctors call that myxedema.  What is more striking is that you have hardly any reflexes, not just at your knees, but at your forearms and ankles.

“Both your history and physical exam suggest you need more thyroid medication, not less.  I think we should draw a more extensive panel of blood tests to look for other medical conditions that could make that TSH test less reliable.”

Two weeks later when Ronnie returned to go over her results, my suspicions were confirmed.  “You tested positive for both thyroid antibodies and low levels of T3, the most active type of thyroid hormone.”

“So what does that mean?”

“You have Hashimoto’s Thyroiditis, a condition in which antibodies interfere with the thyroid’s normal functioning.  It also means that we do not know what the ideal normal range for the TSH should be for you.  When they standardized the TSH test, they kicked everyone with antibodies out of the study.”

“So how do we know what dose I should be on?”

“I’ll still use lab tests as a guide, but I’ll listen to your symptoms too.  You were low in T3, so I will substitute some of your Synthroid with a T3 medication called Cytomel.  In the New England Journal of Medicine they showed that this change alone resulted in improvements in mood, memory, and energy.”

On her new regimen, Ronnie’s depression lifted and she was no longer fatigued.  “I’m not sure if the thyroid medication helped me lose weight, or that because I’m no longer as depressed that I’m eating better and exercise more.  Either way, I’m just happy I can fit into my old clothes.”

You’ve just suffered a stroke, or what doctors medically call a cerebrovascular accident (CVA). The blood supply to your brain has been cut off, and now it’s an emergency. Your spouse calls 911, and gets you to the hospital right away. If you’re lucky, your symptoms will resolve spontaneously, or the doctors will be able to do treatments to restore the function of your limbs. What would you do if you couldn’t use your hand to write? Your leg to walk? Your mouth to speak?

Sudden paralysis is so devastating; it was originally described by Hippocrates as “Apolexy”, or to be “struck down by God with violence”. One of the most modifiable risk factors for stroke is hypertension, also known as high blood pressure. If you’ve ever been to a doctor’s office, you’ve probably had your blood pressure taken with an arm cuff. Your blood pressure is measured with two numbers, with 120 over 80 (written 120/80) considered to be normal (optimal). If your numbers are consistently over 140/90, your doctor will want to figure out why it is high and work with you to get it down. Treating hypertension adequately not only prevents strokes, it also can protect you from getting a heart attack, heart failure, arterial aneurysms, kidney failure, and blindness.

Although there are unusual causes of high blood pressure (adrenal tumors, etc.), 90-95% of all cases are classified as “essential hypertension”, with no one specific cause. Age is one risk factor. Just like a garden hose left sitting in the sun, with time, your arteries get stiffer. Being overweight means that you have not just more fat, but more arteries, veins, and capillaries too; all those extra blood vessels increases the resistance your heart has to pump against causing blood pressure to rise. A sedentary lifestyle, smoking, and stress all are risk factors for hypertension, as are deficiencies of potassium, magnesium, and vitamin D. Perhaps the most worrisome thing is that high blood pressure is often a precursor to diabetes, as insulin resistance causes both high blood pressure and sugar intolerance.

In addition to treating the causes of hypertension, you and your doctor will work to get your blood pressure in control. Taking 30 minutes of “un-responsible time” each day is good way to decrease your stress. A “DASH Diet” that is rich in vegetables and fruits, low-fat dairy, lean meat, fish, poultry, nuts and beans, but limited in sugar-sweetened foods and beverages has been shown to drop blood pressure. Only dead things don’t move, so regular exercise, even if it is just walking briskly around the block each day, will also help.

Sometimes medications are needed. Although newer drugs such as Bystolic, Caduet, Diovan, Exforge, and Takturna are advertised heavily, other safe and effective medications such as HCTZ, Lisinopril, Losartan, Verapamil ER, and Metroprolol work just as well (or better). Why pay over $100 per month for a drug when there is an equally good medicine that only costs $4 to $10 per month?

Treating hypertension has contributed to the 50% decline in stroke and heart disease over the last 40 years. Being consistent with your treatment is easy to do when you know how important it is.