Thyroid disorders are common and treatable

Thyroid disorders are common in the United States. The thyroid gland produces hormones that regulate metabolism.

If your thyroid is overactive (hyperthyroidism), you might feel anxious or weak. You might experience tremors, palpitations, increased perspiration and weight loss despite normal or increased appetite. Hyperthyroidism also can cause increased heart rate or an abnormal heart rhythm (atrial fibrillation), osteoporosis, elevated calcium levels and shortness of breath.

You also might notice hyperactivity; abnormal stare (eyelid retraction) and lid lag; warm and moist skin; and thin, fine hair. Hyperthyroidism is diagnosed with a blood test showing a decreased level of thyroid-stimulating hormone, or TSH, and elevated free levels of thyroid hormones (T3 and T4).

Typically in nonpregnant patients, a radioactive iodine uptake scan is performed to verify the overactive thyroid gland. Once diagnosed, this condition is usually treated by a specialist with oral medication, radioiodine or surgery.

If your thyroid is underactive (hypothyroidism), you might feel tired and sluggish. You Might suffer cold intolerance, weight gain, constipation, dry skin, muscle aches and menstrual irregularities.

Hypothyroidism can cause decreased heart rate, elevated blood pressure and increased cholesterol levels. You might notice impaired memory and concentration and slowing of movement and speech, dry skin, hoarseness, swelling, puffiness in the face, loss of eyebrows, depression and joint pain. Hypothyroidism is five to eight times more common in women than men.

A physical exam might reveal enlargement of the thyroid gland (goiter) and delayed reflexes. Because the typical symptoms are nonspecific, the diagnosis of hypothyroidism relies heavily on laboratory tests. It is typically confirmed with blood tests showing an elevated level of TSH and decreased levels of free T4.

Once diagnosed, this condition is easily treated with levothyroxine, an oral medication that is a synthetic replacement for T4. When the right dose of medication is determined, TSH returns to normal and symptoms improve.

It is important that hypothyroidism be detected in any woman who wants to become or is pregnant because low thyroid hormone might decrease fertility or impair fetal brain development.

Also, it is important that thyroid function studies be monitored periodically to ensure the correct dose of levothyroxine. Dosage of this medication might change with weight gain, weight loss or pregnancy.

Therapy for hypothyroidism is almost always lifelong. Levothyroxine is safe and generally effective over many years. Patients with thyroid disorders can live long and healthy lives if adequately treated.

Dr Emily Furlow White is an internal medicine specialist with Baptist Health Medical Group Family Medicine London.

Thyroid disorders are common and treatable

Health Report: Digestive disorders and inflammatory bowel disease

From the moment food is swallowed, the digestive system sets off an intricate process that involves the esophagus, stomach, small and large intestines, liver, gallbladder and pancreas.

In most cases, digestion happens without thought or effort. However, that’s not the case for an estimated 1.6 million people who are living with an inflammatory bowel disease such as Crohn’s disease and ulcerative colitis.

“The goals of therapy for inflammatory bowel disease include endoscopic and clinical remission — ensuring that our patients’ symptoms are controlled, they are off steroids, and they have a good quality of life,” said Gauree Konijeti, MD, a gastroenterologist at Scripps Clinic.

Crohn’s Disease

While the exact cause of Crohn’s disease is unknown, it is a complex autoimmune disorder that occurs when your body’s immune system becomes persistently activated, and results in inflammation of portions of the digestive tract. Crohn’s disease most commonly affects the terminal ileum (the end part of the small intestine), colon or both.

Factors that may play a role in Crohn’s disease include:

• Genetics and family history


• Environmental factors


• Tendency of the body to over-react to normal bacteria (gut microbiome) in the intestines


• Smoking


• Infections


• Medications

Crohn’s disease may occur at any age, but symptoms most often hit between the ages of 15 and 35, and depend on which part of the digestive tract is involved. Symptoms range from mild to severe, and can come and go with periods of flare-ups.

The main symptoms of Crohn’s disease are:

• Cramps and pain in the abdomen


• Fever


• Fatigue


• Loss of appetite


• Feeling the need to pass stools, even though the bowels are already empty. It may involve straining, pain and cramping.


• Watery diarrhea, which may be bloody


• Weight loss

Although Crohn’s disease cannot be cured, treatment can offer significant help to most patients. In addition to medications and surgery, patients can also find relief from Crohn’s by eating a well-balanced, healthy diet.

Ulcerative Colitis

The cause of ulcerative colitis is also unknown, but is thought to be similar to  Crohn’s disease. Unlike Crohn’s disease, however, ulcerative colitis only affects the colon rather than other parts of the gastrointestinal tract.

Ulcerative colitis may affect any age group, most commonly people between the ages of 15 and30, and 50 and 70.

The symptoms of ulcerative colitis are often less severe than with Crohn’s. They may start slowly or suddenly and can include:

• Pain in the abdomen (belly area) and cramping


• A gurgling or splashing sound heard over the intestine


• Blood and pus in the stools


• Diarrhea, from only a few episodes to very often


• Fever


• Feeling the need to pass stools, even though the bowels are already empty. It may involve straining, pain and cramping (tenesmus).


• Weight loss

Treatments for ulcerative colitis also include diet modification, stress management, medications and surgery.

For more information, visit scripps.org/KUSI or call 858-240-5075.

Health Report: Digestive disorders and inflammatory bowel disease

Pelvic Floor Disorders (Part 2): Barriers to Effective Treatment

Patients face many obstacles to effective treatment for pelvic floor disorders.

Pelvic Floor Recap

In my last blog post, I talked about pelvic floor disorders (PFDs), a fairly common problem affecting mostly women but also some men. These disorders can vary in cause and expression, though common symptoms include urinary incontinence, pelvic floor pain, and sexual dysfunction. Often the dysfunction arises because of a muscle spasm, or failure of the pelvic floor muscles to relax as needed. Confusion about PFD is widespread among patients and providers alike, which likely stems from the fact that reasons for dysfunction in pelvic floor muscles “can be urologic, gynecologic, gastrointestinal, musculoskeletal, neurologic, or psychologic in nature.” In other words, this is just the type of acute, straightforward problem our healthcare system is designed to handle! (Cue sarcasm.)

Sarcasm aside, we should care about PFDs because of its including addiction. Other providers may not know quite where to send patients for further consultation, which is reflected in reports that patients may have to see between 5 to 10 doctors before receiving their diagnosis of PFD.

Thought Experiment

Let’s just think about what visiting 5 to 10 doctors before a diagnosis might mean for a patient. First, there’s the investment of time: assuming a patient sees 1 doctor every 2 weeks (which few of us could manage)—this could mean 2.5 to 5 months before she gets a diagnosis that points to effective treatment options, while simultaneously suffering from confusing symptoms which are likely affecting her daily activities and closest relationships. She probably needed to spend a conservative 2 hours on each visit, including travel time, so she’s just lost between 10 and 20 hours of productivity or take-home pay as well. This is likely over and above other expenses such as transportation and childcare. And if her copay per visit is $20, like the copay with my employer’s plan, she’ll have spent between $100 to $200 on out-of-pocket expenses alone. If she’s employed and her work hours are not flexible, I can only imagine the difficulty of getting an accurate diagnosis, and how many patients might give up early.

Challenges to Receiving an Optimal Treatment

Each case of PFD can be quite unique depending on patient history, which is why  current opinion dictates that the most effective evaluation and management of PFD patients likely requires a team-based approach. Commonly used treatments can be broadly summarized in 3 categories: limited effectiveness in the long run and might have side effects. Physical therapy, which carries little to no side effects, can be an effective (albeit time-consuming) treatment. Pelvic floor muscle training, similar to that performed in physical therapy, has also proven effective in preventing urinary incontinence, prior to and after delivery, in pregnant women.

A peeve though is that a typical round of physical therapy requires time and patience, possibly 2 months to a year. And the effects of such treatments don’t always persist in the absence of religious self-care. So PFD could be categorized as a chronic condition, one which may require routine follow ups to manage effectively.

The Role of Insurance

While physical therapy has wide applications for many conditions, it requires time with specialized providers, and coverage for physical therapy benefits varies based on a patient’s health insurer. Some insurers consider physical therapy medically necessary with a provider referral (and often on the condition that a patient is showing improvement). Other insurers place a cap on the number of visits they will cover per year, though this varies by state; in Maryland, for example, 30 visits per year must be covered if these visits are deemed medically necessary. Still other insurers place annual caps on the dollar amount spent on physical therapy per year: for Medicare patients in 2015 this cap for physical therapy and speech-language pathology is $1900 and includes a 20% coinsurance.

Physical therapy is resource-intense, and these caps on visits and spending (particularly for public programs like Medicare) are commendably designed to preserve resources for those who need them most. But for those with PFD, insurance benefit design may present a barrier to receiving effective treatment. Given that roughly 40% of women ages 60 to 79 years, and 50% of those over 80 years of age are estimated to have a PFD, many women in Medicare’s age group may need physical therapy for PFDs and therefore be sensitive to physical insurance coverage caps. Women in this age group are also more likely to need physical therapy for a host of other reasons, such as recovery from surgery or falls.  

The diagnosis of PFD itself (which may manifest in a claim as a range of different ICD-9 codes) is not singular, and presents a challenge for insurers on which condition may require which “medically necessary” treatment. Additionally, physical therapy includes a range of specific treatment strategies, and as newer and often more effective methods emerge, insurance benefits may need time to catch up. This is the case with biofeedback for example, which shows symptom improvement in 75% of patients. The technique is effectively “covered” by many insurers, including Medicare, but sometimes in a convoluted fashion: by first denying the claim, and then covering it if sufficient paperwork is submitted to document clinical need.

The Problem With Convoluted Processes Is Simple: They Are Convoluted

If a physical therapy clinic forgets to submit paperwork, the patient may be denied coverage and receive a bill. Some of these oversights are rectified with phone calls from the patient (and perhaps the medical bill bargaining advice laid out in The New York Times), but coverage for physical therapy in particular can be so tricky that some urology clinics suggest patients write letters to their insurers to increase likelihood of reimbursement. This seems like an unnecessary burden to place on patients, especially given the intimate and often embarrassing symptoms associated with PFD.  

Patients With Pelvic Floor Disorder Have a Long Road Ahead of Them

Getting the correct diagnosis can take time and persistence. While the research around effective treatments is gaining momentum, treatment itself can take months of repeated visits to specialized physical therapists and insurance benefit design can sometimes add an additional obstacle for patients. Low rates of awareness and high stigma associated with PFDs complicate this entire process. As providers and researchers interested in improving care, we should be the ones spreading the word on PFDs, identifying ways to pinpoint effective treatments, and aligning insurance benefits to ensure patients receive these treatments with minimal embarrassment and difficulty.  

In the next post, we’ll leverage several anecdotal experiences by both patients with PFD and providers to better understand how these problems are perceived by some of our most valuable stakeholders.

Pelvic Floor Disorders (Part 2): Barriers to Effective Treatment

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How social media is fuelling the worrying rise in eating disorders

The number of teenagers being admitted to hospital with eating disorders has nearly doubled in just three years Photo: Alamy

A quick internet search, a few clicks, and the screen flashes up an image of a young woman, tall, fully made-up – and frighteningly emaciated. Around me I hear take a sharp intake of breath. I was filming a recent episode of the Channel 4 documentary Supersize vs Superskinny, in which we asked a group of parents to look at “thinspiration” websites – so-called because they are dedicated to encouraging young women with eating disorders to maintain their life-threatening illnesses.

Such pro-anorexia and pro-bulimia websites offer tips on how to avoid food (drink ice-cold water or black coffee, chew ice cubes, brush your teeth, go for a run, look at yourself naked and pinch your fat, or clean something dirty until you lose your appetite…). They suggest starting a “Fasting Journal”, and posting online “inspirational” images of your ribcage, shoulder blades or thigh gap. They offer advice on how to hide your eating disorder from your family, even on how to “purge” silently.

Little wonder, then, that the NHS has revealed that the number of teenagers being admitted to hospital with eating disorders has nearly doubled in just three years. The Royal College of Psychiatrists has laid the blame for this unprecedented rise firmly at the door of social media.

^{The number of teenagers being admitted to hospital with eating disorders has nearly doubled in three years (Alamy)}

While some “pro-ana” [pro-anorexia] sites claim to provide a neutral forum for suffers to discuss their problems and support each other in recovery, others brazenly assert that anorexia is a lifestyle choice, not a medical condition – and the individual’s choice not to eat should be respected. (A sample post from a young girl: “I convinced my parents to let me go vegan so now all I eat during dinner is vegetables if I even eat at all Stay f—— strong and skinny! Starve on.”)

• I’m lucky social media was in its infancy when I was anorexic

Looking at the skeletal selfies posted on these websites, and the messages of encouragement accompanying them, the parents in my focus group were visibly upset. As a former sufferer myself, even as someone who used to look that way, I too was shocked. I had never come across such honest discussions of how to starve yourself.

I recently interviewed a 17-year-old girl whose anorexia had been sparked by one of these websites. She showed me a thin red bracelet sent to her “by some guy in America when I joined the pro-ana movement. When the hunger gets too much, when I think I’m going to give in, I touch the bracelet and remind myself it’s stronger to starve.”

^{Emma Woolf, a former sufferer}

Who is running these sites, and what their motivation might be, is anyone’s guess. The very fact that they exist, entirely unregulated, and accessible to any teenage girl (or boy) in the privacy of their bedroom, is a scandal. In July 2013, David Cameron pledged to take action against the “corroding influence” of internet pornography, particularly child sexual abuse.

The Prime Minister promised that children would be protected by the automatic filtering of adult material, that illegal image searches would be blocked, and that sites such as Twitter would be forced to monitor the images posted by their users. If we can do this for pornography, why not for images of emaciated young girls?

Go online yourself, have a look. Every parent and teacher needs to know that “thinspiration” sites are dangerous. They glamorise anorexia, they promote photogenic waif-like models and starvation, and ignore the breadth and misery of eating disorders. Anorexia is not photogenic or glamorous, not from the inside. I was anorexic for more than ten years. When I started at Oxford University aged 19, I weighed around nine stone and was happy, healthy and well-adjusted.

When I left, aged 21, I weighed around five stone. None of the myths around anorexia applied: I did not dislike my body, and never had done. I did not think I looked fat, or wear skimpy clothes, or even look in the mirror much. I had declared war on myself.

^{Some ‘pro-ana’ sites suggest the individual’s choice not to eat should be respected (Rex Features)}

Even if you’re not actively looking for encouragement with an eating disorder, even if you avoid the internet altogether, you can’t avoid the overwhelming message of our age, that weight loss is good, weight gain is bad, that thinner (harder, leaner, greener) is better. We live in a hypervisual age, with most of us – especially the young – confronting thousands of images every day. The focus on women’s bodies is intense, in every magazine, website or TV advert, on every billboard and celebrity shot, and in the conversations of friends, mothers and sisters around us.

The effect can be profound, and yet still eating disorders are misunderstood. They are dismissed as a teenage, female condition (although male eating disorders are on the increase) or misrepresented as faddy dieting, body hang-ups, a phase they’ll “grow out of”. In fact, the opposite is true: eating disorders are highly addictive, and self-starvation becomes involuntary.

Anorexia has the highest mortality rate of all mental illnesses, more deadly than schizophrenia. One in five anorexics will die, either from physical complications or suicide.

In looking at the danger of media influences, we need to recognise the long-term health consequences. With anorexia, these include infertility, amenorrhoea (cessation of periods), loneliness and depression; bulimia can lead to kidney and heart problems as well as electrolyte imbalance. Osteoporosis (low bone density) is an invisible but growing problem among young women who avoid calcium-rich dairy products such as milk and cheese – and up to 90 per cent of anorexics show some degree of bone loss.

Secretly Starving: Inside the world of anorexia blogging

Meanwhile, a form of disordered eating known as orthorexia is becoming increasingly mainstream, fuelled by the mania for healthy eating and our growing anxiety around obesity. Orthorexia is somewhere on the blurred boundary between being health-conscious and a health obsessive.

It is defined as a “fixation with righteous or correct eating” – but what begins as an attempt to improve one’s lifestyle can morph into an unhealthy fixation. It can lead to self loathing, low self-esteem, social isolation and even malnourishment. In their search for the perfectly balanced lifestyle, orthorexics combine restrictive diets with punishing exercise regimes, are fanatical about calorie-counting, green juicing and honing their gym-bodies. Orthorexia thrives in a society in which we’re urged to count calories and “eat clean”, to avoid artificial additives and preservatives, to beware plastic packaging and hidden toxins and, above all, never to get fat.

^{Orthorexia is becoming increasingly mainstream (Getty)}

Disordered eating invariably goes hand in hand with excessive levels of physical activity. When I was at my sickest with anorexia, I would get up at dawn and run five miles a day, no matter how cold or exhausted I felt. But, again, there are those blurred lines. Hardcore workouts have surged in popularity among middle-class women, who go for the burn at their “skinny-bitch collective” classes and then Instagram the results. An 18-year-old student I know says she “feels bad” when she sees the post-workout selfies of her role models Ellie Goulding, Kylie Jenner and Miley Cyrus on Tumblr.

The situation for parents, especially mothers, is complicated. Do you encourage your daughter to exercise regularly, eat her five-a-day and drink her green juice, or will this trigger something more obsessive? Will she pick up on your own dietary habits? Will your body dissatisfaction damage her for life?

Now in my 30s, I have a healthy BMI and am physically “recovered”. But it has taken more than a decade to get to this point: gaining weight was the hardest fight of my life. I wonder if I was in my teens now, desperately trying to beat an eating disorder in today’s febrile online environment, how I would have coped. Goaded or triggered or simply surrounded by these images of super-healthiness, fitness, thinness, other anorexics chewing ice cubes, and my role models existing on wheatgrass shots: would I ever have recovered? I’m not sure.

• Emma Woolf is the author of An Apple a Day and The Ministry of Thin. Her latest book, Letting Go, is published by Summersdale, priced £8.99. To order your copy, call 0844 871 1514 or visit books.telegraph.co.uk

How social media is fuelling the worrying rise in eating disorders