C ASE DISCUSSION

Dr. Al k a
M.D. 2ND Year Nutrition and Dietetics
 Preliminary Data
 Name- Mrs.Vijay Lakshmi Anand
 Age- 56 Years
 Gender- Female
 Marital status: Married
 Address- Ghaziabad
 Occupation-Housewife
 k/c/o -Diabetes since 1 years and Hypertension since 9 months.
 Chief complaint/present illness:
Swelling in front of neck, Rapid hair fall, fatigue , hoarseness of voice and increased
tiredness since 3 months.
History of Chief Complaint: Patient was apparently well until 2 years back suddenly her
weight increased rapidly, before 1 year her blood glucose level is also increased and
before 3 months she was complaint of increased tiredness , hair fall, muscle weakness
and lethargy.
.
 History of Past illness: Not a case of Asthma, Epilepsy.
 History of Past treatment: Pt. was on allopathy medications before 2 months
 Drug History: Telma-H 80mg 1 tablet HS
Glimipride 1mg OD
Thyroxe 25mg OD
 Family History: Father was Diabetic.
 Gynecological and Obs. History- Menopause at 49 Years of age and G2P0A0L2
 Personal History

• Bowel – I r r e g u l a r and C o n s t i p a t e d
• Diet : Mixed Diet
• Appetite – Increase
• Micturition – Normal In frequency
• Tongue- Coated
• Color of Tongue-Whitish pink
• Sleep – Disturbed
• Thirst – Adequate ( 2-3 Litres of water/day)
• Addiction- None
• Habit: Tea; 3 times in a day
Vital signs:
Height – 5.5 inch
Weight – 99Kg
BMI – 36.3Kg/m 2 (Obese Cl a ss 2 )
B.P – 130/90mmHg
Pulse – 82bpm
RR – 14cycles/min

7
General Physical Examination:

Appearance – Puffiness over the face.

Expression – Dull expression
Mouth- Hygienic
Built: Obese
Tongue- Coated
Icterus – absent Lips: Blackish
Pallor- absent Hairs- Greying of hairs and Alopecia
Cyanosis- absent Skin- Dryness over the skin
Eyes- Puffiness over the eyes
Clubbing- absent
Nose- No DNS
Oedema- Absent Ear- Normal
 BMI:
 BMI = calculated as weight (kg)/height (m)2
 Helps to classify weight status & risk
of disease
 BMI provides an estimate of body fat and is
related to disease risk.
 Lower BMI thresholds for overweight and
obesity have been proposed for the Asia-
Pacific region since this population appears
to be at risk for glucose and lipid
abnormalities at lower body weights.
Classification of obesity on the basis of BMI
Underweight: less than 18.5 kg/m2

Normal range: 18.5 kg/m2 to 24.9 kg/m2

Overweight: 25 kg/m2 to 29.9 kg/m2

Obese, Class I: 30 kg/m2 to 34.9 kg/m2

Obese, Class II: 35 kg/m2 to 39.9 kg/m2

Obese, Class III: more than 40 kg/m2

Classification of weight status & disease risk (WHO)
Laboratory
Investigation:
HYPOTHYROIDISM
 Introduction
 The development, structure and functions of
human body are governed and maintained by 2
mutually interlinked systems— the endocrine
system and the nervous system; a third system
combining features of both these systems is
appropriately called neuroendocrine system.
 The Endocrine System anatomically, the
endocrine system consists of 6 distinct organs:
pituitary, adrenals, thyroid, parathyroids,
gonads, and pancreatic islets; the last one is
included in neuroendocrine system .
 Anatomy of Thyroid Gland
 The thyroid gland is a butterfly-shaped organ composed of bulbous right and left lobes connected
in the midline by a thin structure called the isthmus.
 It is located in the neck, the thyroid wraps around the anterior trachea directly inferior to the
larynx, at the level of the C5 through T1 vertebrae.
 Height-5 cm
Width- 5 cm
Weight 20-30 g in adults, with slightly heavier thyroids seen in women
 The thyroid functions as an endocrine gland and is responsible for producing thyroid hormone
and calcitonin.
 The thyroid receives its blood supply predominantly from two sources- The superior thyroid
artery, which is the first branch of the external carotid artery, supplies the upper half of the thyroid
in over 95% of people. The lower portion of the thyroid is most commonly supplied by the
inferior thyroid artery
Allen E, Fingeret A. Anatomy, Head and Neck, Thyroid. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470452
 Physiology
• Endocrine gland
• The thyroid secretes hormone belonging to the amine group of hormones,
derived from the amino acid Tyrosine-
 Thyroxin (T4)
 Tri-iodothyronine (T3)
• Thyroid secretions are under influence of TSH (thyroid stimulation hormone)
from pituitary gland.
 Physical Examination
 The examination consists of two components-

1. Inspection
2. Palpation
1. Inspection
A) Anterior Approach- The patient should be seated or standing in a
comfortable position with the neck in slightly extended position.
 Cross-lighting increases shadows, improving the detection of masses.
 To enhance visualization of the thyroid, you can:
 Extending the neck, which stretches overlying tissues
 Have the patient swallow a sip of water, watching for the upward movement
of the thyroid gland.
B) Lateral Approach-After completing anterior inspection of the thyroid,
observe the neck from the side.
 Estimate the smooth, straight contour on the cricoid cartilage.
 Measure any prominence beyond this imagined contour, using a ruler placed in
the area of prominence.
2. Palpation:
A) Anterior Approach-
 The patient is examined in the seated or standing
position.
 Attempt to locate the thyroid isthmus by palpating
between the cricoid cartilage and the suprasternal
notch.
 Use one hand to slightly retract the
sternocleidomastoid muscle while using the other to
palpate the thyroid.
 Have the patient swallow a sip of water as you palpate,
feeling for the upward movement of the thyroid gland.
B) Posterior Approach
 The patient is examined in the seated or
standing position.
 Standing behind the patient, attempt to locate
the thyroid isthmus by palpating between the
cricoid cartilage and the suprasternal notch.
 Move your hands laterally to try to feel under
the sternocleidomstoids for the fullness of the
thyroid.
 Have the patient swallow a sip of water as you
palpate, feeling for the upward movement of
the thyroid gland.
 Epidemiology
 Hypothyroidism affects up to 5% of the general population, with a further
estimated 5% being undiagnosed. Over 99% of affected patients suffer from
primary hypothyroidism.
 Primary hypothyroidism is up to 8–9 times more common in women than in
men, and the prevalence increases with age, with a peak incidence between
the ages of 30 and 50 years . In the US, hypothyroidism affects an
estimated 4% of women aged 18–24 years and 21% of women older than
74 years.
 A UK survey determined that approximately 7.5% of women and 2.8% of
men have elevated serum levels of TSH , while a Danish population study
found that the lifetime risk of overt hypothyroidism was 4.1% in women
and 1.3% in men.
Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. Lancet (London, England), 390(10101),
1550–1562. https://doi.org/10.1016/S0140-6736(17)30703-1
 Etiology:
 Hypothyroidism is majorly divided into two categories, primary and
secondary (central) hypothyroidism. Hypothyroidism is termed primary
when the thyroid gland itself is not able to produce adequate amounts of
thyroid hormone.
 The less common, secondary, or central hypothyroidism is labeled when the
thyroid gland itself is normal, and the pathology is related to the pituitary
gland or hypothalamus.
 The most prevalent etiology of primary hypothyroidism is an iodine
deficiency in iodine-deficient geographic areas worldwide.
Kostoglou-Athanassiou, I., & Ntalles, K. (2010). Hypothyroidism - new aspects of an old disease. Hippokratia, 14(2), 82–
87.
Clinical Features Or
Symptoms:
H-P-T Axis
 Pathophysiology
 The most common cause of hypothyroidism is the
inability of the thyroid gland to produce a sufficient
amount of thyroid hormone,
 The hypothalamus secretes thyrotropin-releasing
hormone (TRH) that stimulates the pituitary gland
to produce thyroid-stimulating hormone (TSH).
 Thyroid-stimulating hormone stimulates the thyroid
gland to produce and secrete mainly T4 and smaller
quantities of T3.
 Levels of T3 majorly and T4, to some extent, in
turn, exert negative feedback on the production of
TRH and TSH. Alteration in the structure and
function of any of these organs or pathways can
result in hypothyroidism.
Risk Factors of Hypothyroidism:
Correlation of Obesity with Hypothyroidism :

Sanyal, D., & Raychaudhuri,

M. (2016). Hypothyroidism
and obesity: An intriguing
link. Indian journal of
endocrinology and
metabolism, 20(4), 554–557.
https://doi.org/10.4103/2230-
8210.183454

Figure 1: Interrelationship between obesity and thyroid dysfunction. REE: Resting energy expenditure, AITD: Autoimmune
thyroid disease, NIS: Sodium iodide symporter, TRH: Thyrotropin ‑releasing hormone, TSH: Thyroid stimulating hormone
Correlation of Obesity with CVD
MANAGEMENT
 Aim:

 Reduce the weight with naturopathic, yogic and intervention.

 To reduce the mental and physical fatigue.
 Improve the sensitivity of body or maintain body temperature
 Relives the constipation
 To regulate the bowel movement
 To improve the physical strength.
Title and Author Journal & Year Intervention Conclusion

Effect of short-term International Journal 30 subjects of the study The improvement in the
naturopathy and yoga of Basic & Clinical P group underwent 10 body weight, BMI, lipid
intervention on harmacology days of naturopathic profile and thyroid
anthropometric 2020 and yogic interventions. profile of the obese
variables, lipid profile Naturopathic hypothyroid patients
and thyroid profile in treatments included following yogic and
obese hypothyroid hydrotherapy, mud naturopathic
patients: a randomised therapy, fasting therapy interventions suggest
controlled trial. and diet modification. that it may be
Geeta B shetty et al . The yogic intervention considered as an
was adjuvant therapy for the
a 50 minutes yoga better management of
session per day for 10 patients suffering from
days which hypothyroidism.
included asanas,
pranayama and
relaxation techniques.
Title and Author Journal and Year Intervention Conclussion

Integrated Yoga and Journal of Ayurveda A 6 week IYN protocol The case report shows
Naturopathy module and Integrative was given to a 50-year- remarkable changes in
in management of Medicine. old male participant with MetS status after
metabolic following a 6 week IYN
Metabolic Syndrome:
syndrome( obesity, intervention.
A case report. hypertension and The results showed
Apar Saoji et al. hypothyroidism) . reduction in weight (97.9
kgs to74.6 kgs), total
cholesterol (192 mg% to
145 mg%), triglycerides
(153 mg% to 90 mg%),
TSH (6.90 mIU/ ml to
3.052 mIU/ml)
Title and Author Journal and Year Intervention Conclusion

Effect of Ice Massage International journal Ice (1°C–2°C) was Results suggest that
to Head and Spine on of therapeutic filled in a rubber bag 20 min of ice massage
Blood Pressure and massage & bodywork (ice bag)Ice bag was to head and spine may
Heart Rate Variability 2021 applied to each reduce blood pressure
in Patients with participant’s head (3–5 and heart rate in
Hypertension: a Pilot s each on the crown, patients with
Study back, right and left hypertension.
A Mooventhan et al. sides) followed by
spine (3–5 s in the
cervical, 6–10 s in the
thoracic, and 3–5 s
each in the lumbar and
sacral regions) by
continuous
displacements. The
same procedure was
repeated for a period
Title and Author Journal and Year Intervention Conclusion

Effect of Yoga on Journal of clinical all the participants The results of the
Blood Glucose Levels and diagnostic were trained by yoga present study
in Patients with Type 2 research experts and subjected demonstrated that the
Diabetes Mellitus. 2015 to regular practice yoga is effective in
Subhash Manikappa under supervision for reducing the blood
Chimkodeet al. six months. The yoga glucose levels in
was practiced daily in patients with T2DM.
overnight fasting state
at 6 AM
Title and Author Journal and Year Intervention Conclusion

YOGIC International Journal IAYT which includes This IAYT

MANAGEMENT FOR of Ayurveda and loosening (integrated approach
HYPOTHYROIDISM: Pharma Research exercises ,asanas and to yoga therapy) was
A CASE STUDY. 2018 pranayama. helpful in treating the
Sahana Murthy et al. Yoga poses like patient of
Saravangasana,Halasa hypothyroidism.
na
Matsyasana,Ustrasana
Bhujangasana,
Sethubandhasana,
Dhanurasana, Ujjayi
pranayama help to
Balance and regulate
the functioning
of the thyroid gland.
Title and Author Journal and Year Intervention Conclusion

Effect of 6 months All the subjects 6 months practice

intense Yoga practice Journal of Compleme underwent 6 months of yoga may help in
on lipid profile, ntary and Integrative of yoga practice 1 h improving cholesterol
thyroxine medication Medicine daily for 4 days a level, serum TSH,
and serum TSH level 2016 week. Lipid profile, may also help in
in women suffering thyroxine dosage and reducing the thyroxine
from hypothyroidism: serum TSH level were requirement in female
A pilot study assessed before and patients suffering from
Savitri Nilakanthan et after intervention hypothyroidism
al.
Title and Author Journal and Year Intervention Conclusion

Effects of Swedish Evidence-Based The massage protocol This study has shown
Massage Therapy on Complementary and is an hour of Swedish that Swedish Massage
Blood Pressure, Heart Alternative Medicine. Massage Therapy to Therapy for one hour
Rate, and 2013 the whole body, once weekly significantly
Inflammatory Markers a week for four weeks. reduced BP and HR.
in Hypertensive
Women.
Izreen Supa et al.
Title and Author Journal and Year Intervention Conclusion

Pineapple juice Hypothyroid rats In conclusion,

supplementation International Journal orally administrated supplementation of the
activates thyroid gland of Biosciences with pineapple juice whole
and attenuates 2017 (0.75 ml/100g body pineapple juice has
hyperlipidemia in rats weight) for 8 shown a strong
Magda Ezz et al. consecutive weeks antioxidant
activity, which plays a
central role in
activating the thyroid
hormones synthesis in
hypothyroid rats, as
well as anticipating
the hyperlipidemia
associated
with hypothyroidism,
which is a risk factor
for
Title and Author Journal and Year Intervention Conclusion

Flaxseed (Linum Nutrients, 2020 Flaxseed was Flaxseed

Usitatissimum L.) administered for 10 supplementation was
Supplementation in weeks at a dose of 28 well-tolerated and
resulted in a consistent
Patients Undergoing g/d.
and significant decrease
Lipoprotein Apheresis in total cholesterol and
for Severe low-density lipoprotein
Hyperlipidemia—A (LDL) levels. The
Pilot Study median (and range)
percentage decrease was
Kanikowska D et al. 11.5% and 7.3% for
cholesterol and LDL-C
Title and Author Journal and Year Intervention Conclussion

Chia induces clinically Nutricion Hospitalaria Consumption of 35g of Consumption of chia for
discrete weight loss , 2015 chia flour/day for 12 12 weeks promotes
and improves lipid weeks. significant reduction in
weight and waist
profile only in altered
circumference. And
previous values. observed a reduction in
Luciana Tavares total cholesterol and
Toscano et al. VLDL-c and an increase
in HDL-c.
Title and Author Journal and Year Intervention Conclusion

Efficacy of Ginger Evidence based The participants The daily consumption

Supplementation in complementary received one 500 mg of 1000 mg of ginger
Relieving Persistent Alternative Medicine. capsule containing powder led to a
significant reduction in
Hypothyroid 2022 ginger powder in the
hypothyroid symptoms.
Symptoms in Patients intervention group and The most responsive
with Controlled one starch-containing symptoms to ginger
Primary capsule in the placebo supplementation were
Hypothyroidism: A group 30 min before weight gain, cold
Pilot Randomized, lunch and dinner intolerance, constipation,
Double-Blind, (twice daily) for 30 dry skin, decreased
Placebo-Controlled days. appetite, memory loss
Clinical Trial and anthropometric
outcomes i.e. weight,
Hamide Ashraf et al. BMI, and waist
circumference & lab
investigation FBS, TG,
and total cholesterol also
improved with ginger
supplementation
Title and Author Journal and Year Intervention Conclusion

Diet and thyroid - Journal of medical Dietary micronutrients

myths and facts. nutrition & play an important role in
(Review) nutraceuticals,2014 the synthesis of thyroid
hormones. Iodine
Sharma R et al.
remains the cornerstone
with increasing focus on
other nutrients like
selenium and zinc. The
best advice for all
patients is to consume a
healthy balanced diet,
meet the daily iodine
requirement and
eliminate the most potent
goitrogenic substances
from the diet