A Fresh Take On Hypothyroidism
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The Three Rs To Boost Thyroid-Related Energy Levels
This is Dr. Izabella Wentz. She’s a doctor of pharmacology, and after her own diagnosis with Hashimoto’s thyroiditis, she has taken it up as her personal goal to educate others on managing hypothyroidism.
Dr. Wentz is also trained in functional medicine through The Institute for Functional Medicine, Kalish Functional Medicine, and the American Academy of Anti-Aging Medicine. She is a Fellow of the American Society of Consultant Pharmacists, and holds certifications in Medication Therapy Management as well as Advanced Diabetes Care through the American Pharmacists Association. In 2013, she received the Excellence in Innovation Award from the Illinois Pharmacists Association.
Dr. Wentz’s mission
Dr. Wentz was disenchanted by the general medical response to hypothyroidism in three main ways. She tells us:
- Thyroid patients are not diagnosed appropriately.
- For this, she criticises over-reliance on TSH tests that aren’t a reliable marker of thyroid function, especially if you have Hashimoto’s.
- Patients should be better optimized on their medications.
- For this, she criticizes many prescribed drugs that are actually pro-drugs*, that don’t get converted adequately if you have an underactive thyroid.
- Lifestyle interventions are often ignored by mainstream medicine.
- Medicines are great; they truly are. But medicating without adjusting lifestyle can be like painting over the cracks in a crumbling building.
*a “pro-drug” is what it’s called when the drug we take is not the actual drug the body needs, but is a precursor that will get converted to that actual drug we need, inside our body—usually by the liver, but not always. An example in this case is T4, which by definition is a pro-drug and won’t always get correctly converted to the T3 that a thyroid patient needs.
Well that does indeed sound worthy of criticism. But what does she advise instead?
First, she recommends a different diagnostic tool
Instead of (or at least, in addition to) TSH tests, she advises to ask for TPO tests (thyroid peroxidase), and a test for Tg antibodies (thyroglobulin). She says these are elevated for many years before a change in TSH is seen.
Next, identify the root cause and triggers
These can differ from person to person, but in countries that add iodine to salt, that’s often a big factor. And while gluten may or may not be a factor, there’s a strong correlation between celiac disease and Hashimoto’s disease, so it is worth checking too. Same goes for lactose.
By “checking”, here we mean testing eliminating it and seeing whether it makes a difference to energy levels—this can be slow, though, so give it time! It is best to do this under the guidance of a specialist if you can, of course.
Next, get to work on repairing your insides.
Remember we said “this can be slow”? It’s because your insides won’t necessarily bounce back immediately from whatever they’ve been suffering from for what’s likely many years. But, better late than never, and the time will pass anyway, so might as well get going on it.
For this, she recommends a gut-healthy diet with specific dietary interventions for hypothyroidism. Rather than repeat ourselves unduly here, we’ll link to a couple of previous articles of ours, as her recommendations match these:
She also recommends regular blood testing to see if you need supplementary TSH, TPO antibodies, and T3 and T4 hormones—as well as vitamin B12.
Short version
After diagnosis, she recommends the three Rs:
- Remove the causes and triggers of your hypothyroidism, so far as possible
- Repair the damage caused to your body, especially your gut
- Replace the thyroid hormones and related things in which your body has become deficient
Learn more
If you’d like to learn more about this, she offers a resource page, with resources ranging from on-screen information, to books you can get, to links to hook you up with blood tests if you need them, as well as recommended supplements to consider.
She also has a blog, which has an interesting relevant article added weekly.
Enjoy, and take care of yourself!
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When Doctors Make House Calls, Modern-Style!
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In Tuesday’s newsletter, we asked you foryour opinion of telehealth for primary care consultations*, and got the above-depicted, below-described, set of responses:
- About 46% said “It is no substitute for an in-person meeting with a doctor; let’s keep the human touch”
- About 29% said “It means less waiting and more accessibility, while avoiding transmission of diseases”
- And 25 % said “I find that the pros and cons of telehealth vs in-person balance out, so: no preference”
*We specified that by “primary care” we mean the initial consultation with a non-specialist doctor, before receiving treatment or being referred to a specialist. By “telehealth” we mean by videocall or phonecall.
So, what does the science say?
A quick note first
Because telehealth was barely a thing (statistically speaking) before the first stages of the COVID pandemic, compared to how it is now, most of the science for this is young, and a lot of the science simply hasn’t been done yet, and/or has not been published yet, because the process can take years.
Because of this, some studies we do have aren’t specifically about primary care, and are sometimes about specialists. We think this should not affect the results much, but it bears highlighting.
Nevertheless, we’ll do what we can with the science we have!
Telehealth is more accessible than in-person consultations: True or False?
True, for most people. For example…
❝Data was found from a variety of emergency and non-emergency departments of primary, secondary, and specialised healthcare.
Satisfaction was high among recipients of healthcare, scoring 9-10 on a scale of 0-10 or ranging from 73.3% to 100%.
Convenience was rated high in every specialty examined. Satisfaction of clinicians was high throughout the specialities despite connection failure and concerns about confidentiality of information.❞
whereas…
❝Nonetheless, studies reported perception of increased barriers to accessing care and inequalities for vulnerable patients especially in older people❞
~ Ibid.
Source: Satisfaction with telemedicine use during COVID-19 pandemic in the UK: a systematic review
Now, perception of those things does necessarily equate to an actual increased barrier, but it is reasonable that someone who thinks something is inaccessible will be less inclined to try to access it.
The quality of care provided via telehealth is as good as in-person: True or False?
True, ostensibly, with caveats. The caveats are:
- We’re going offreported patient satisfaction, not objective patient health outcomes (we found little* science as yet for the relative incidence of misdiagnosis, for example—which kind of thing will take time to be revealed).
- We’re also therefore speaking (as statistics do) for the significant majority of people. However, if we happen to be (statistically speaking) an insignificant minority, well, that just sucks for us personally.
*we did find some, but it wasn’t very helpful yet. For example:
An electronic trigger to detect telemedicine-related diagnostic errors
this one does look at the incidence of diagnostic errors, but provides no control group (i.e. otherwise-comparable in-person consultations) for comparison.
While most oft-considered demographic groups reported comparable patient satisfaction (per race, gender, and socioeconomic status, for example), there was one outlier variable, which was age (as we quoted from that first study above).
However!
Looking under the hood of these stats, it seems that age is not the real culprit, so much as technological illiteracy, which is heavily correlated with age:
❝Lower eHealth literacy is associated with more negative attitudes towards I/C technology in healthcare. This trend is consistent across diverse demographics and regions. ❞
Source: Meta-analysis: eHealth literacy and attitudes towards internet/computer technology
There are things that can be done at an in-person consultation that can’t be done by telehealth: True or False?
True, of course. It is incredibly rare that we will cite “common sense”, (as sometimes “common sense” is actually “common mistakes” and is simply and verifiably wrong), but in this case, as one 10almonds subscriber put it:
❝The doctor uses his five senses to assess. This cannot be attained over the phone❞
~ 10almonds subscriber
A quick note first: if your doctor is using their sense of taste to diagnose you, please get a different doctor, because they should definitely not be doing that!
Not in this century, anyway… Once upon a time, diabetes was diagnosed by urine-tasting (and yes, that was a fairly reliable method).
However, nowadays indeed a doctor will use sight, sound, touch, and sometimes even smell.
In a videocall we’re down to two of those senses (sight and sound), and in a phonecall, down to one (sound) and even that is hampered. Your doctor cannot, for example, use a stethoscope over the phone.
With this in mind, it really comes down to what you need from your doctor in that consultation.
- If you’re 99% sure that what you need is to be prescribed an antidepressant, that probably doesn’t need a full physical.
- If you’re 99% sure that what you need is a referral, chances are that’ll be fine by telehealth too.
- If your doctor is 99% sure that what you need is a verbal check-up (e.g. “How’s it been going for you, with the medication that I prescribed for you a month ago?”, then again, a call is probably fine.
If you have a worrying lump, or an unhappy bodily discharge, or an unexplained mysterious pain? These things, more likely an in-person check-up is in order.
Take care!
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How To Survive A Heart Attack When You’re Alone
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Dr. Alan Mandel emphasizes the importance of staying calm and following these steps to improve survival chances:
Simple is best
Here’s how you will survive a heart attack alone: briefly.
So, you will need to get help as quickly as possible. 90% of people who make it to a hospital alive, go on to survive their heart attack, so that’s your top priority.
Call emergency services as soon as you suspect you are having a heart attack. Stay on the line, and stay calm.
While having a heart attack is not an experience that’s very conducive to relaxation, heightened emotions will exacerbate things, so focus on breathing calmly. One of the commonly reported symptoms of heart attack that doesn’t often make it to official lists is “a strong sense of impending doom”, and that is actually helpful as it helps separate it from “is this indigestion?” or such, but once you have acknowledged “yes, this is probably a heart attack”, you need to put those feelings aside for later.
If you have aspirin available, Dr. Mandel says that the time to take it is once you have called an ambulance. However, if aspirin is not readily available, do not exert yourself trying to find some; indeed, don’t move more than necessary.
Do not drive yourself to hospital; it will increase the risk of fainting, and you may crash.
While you are waiting, your main job is to remain calm; he recommends deep breathing, and lying with knees elevated or feet on a chair; this latter is to minimize the strain on your heart.
For more on all this, plus the key symptoms and risk factors, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
Heart Attack: His & Hers (Be Prepared!)
Take care!
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Five Supplements That Actually Work Vs Arthritis
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This is Dr. Diana Girnita, a double board-certified physician (internal medicine & rheumatology) who, in addition to her MD, also has a PhD in immunology—bearing in mind that rheumatoid arthritis is an autoimmune condition.
Her mission is to help people with any form of arthritis (rheumatoid or otherwise) and those with many non-arthritic autoimmune conditions (ranging from tendonitis to lupus) to live better.
Today, we’ll be looking at her recommendations of 5 supplements that actually help alleviate arthritis:
Collagen
Collagen famously supports skin, nails, bones, and joint cartilage; Dr. Girnita advises that it’s particularly beneficial for osteoarthritis.
Specifically, she recommends either collagen peptides or hydrolyzed collagen, as they are most absorbable. However, collagen can also be sourced from foods like bone broth, fish with skin and bones, and gelatin-based foods.
If you’re vegetarian/vegan, then it becomes important to simply consume the ingredients for collagen, because like most animals, we can synthesize it ourselves provided we get the necessary nutrients. For more on that, see:
We Are Such Stuff As Fish Are Made Of
Glucosamine & chondroitin
Technically two things, but almost always sold/taken together. Naturally found in joint cartilage, it can slow cartilage breakdown and reduce pain in osteoarthritis.
Studies show pain relief, especially in moderate-to-severe cases; best taken long-term. Additionally, it’s a better option than NSAIDs for patients with heart or gastrointestinal issues.
10almonds tip: something that’s tricker to find as a supplement than glucosamine and chondroitin, but you might want to check it out:
Cucumber Extract Beats Glucosamine & Chondroitin… At 1/135th Of The Dose?!
Omega-3 fatty acids
Dr. Girnita recommends this one because unlike the above recommendations that mainly help reduce/reverse the joint damage itself, omega-3 reduces inflammation, pain, and stiffness, and can decrease or eliminate the need for NSAIDs in rheumatoid arthritis and psoriatic arthritis.
She recommends 2-4g EPA/DHA daily; ideally taken with a meal for better absorption.
She also recommends to look for mercury-free options—algae-derived are usually better than fish-derived, but check for certification either way! See also:
What Omega-3 Fatty Acids Really Do For Us
Boswellia serrata (frankincense)
Popularly enjoyed as an incense but also available in supplement form, it contains boswellic acid, which reduces inflammation and cartilage damage.
Dr. Girnita recommends 100 mg daily, but advises that it may interact with some antidepressants, anti-anxiety medications, and NSAIDs—so speak with your pharmacist/doctor if unsure.
We also wrote about this one here:
Science-Based Alternative Pain Relief
Curcumin (turmeric)
Well-known for its potent anti-inflammatory properties, it’s comparable to NSAIDs in pain relief for most common forms of arthritis.
Dr. Girnita recommends 1–1.5g of curcumin daily, ideally combined with black pepper for better absorption:
Why Curcumin (Turmeric) Is Worth Its Weight In Gold
Lastly…
Dr. Girnita advises to not blindly trust supplements, but rather, to test them for 2–3 months while keeping a journal of your symptoms. If it improves things for you, keep it up, if not, discontinue. Humans can be complicated and not everything will work exactly the same way for everyone!
For more on dealing with chronic pain specifically, by the way, check out:
Managing Chronic Pain (Realistically!)
Take care!
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When BMI Doesn’t Measure Up
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When BMI Doesn’t Quite Measure Up
Last month, we did a “Friday Mythbusters” edition of 10almonds, tackling many of the misconceptions surrounding obesity. Amongst them, we took a brief look at the usefulness (or lack thereof) of the Body Mass Index (BMI) scale of weight-related health for individuals. By popular subscriber request, we’re now going to dive a little deeper into that today!
The wrong tool for the job
BMI was developed as a tool to look at large-scale demographic trends, stemming from a population study of white European men, who were for the purpose of the study (the widescale health of the working class in that geographic area in that era), considered a reasonable default demographic.
In other words: as a system, it’s now being used in a way it was never made for, and the results of that misappropriation of an epidemiological tool for individual health are predictably unhelpful.
If you want to know yours…
Here’s the magic formula for calculating your BMI:
- Metric: divide your weight in kilograms by your height in square meters
- Imperial: divide your weight in pounds by your height in square inches and then multiply by 703
“What if my height doesn’t come in square meters or square inches, because it’s a height, not an area?”
We know. Take your height and square it anyway. If this seems convoluted and arbitrary, yes, it is.
But!
While on the one hand it’s convoluted and arbitrary… On the other hand, it’s also a gross oversimplification. So, yay for the worst of both worlds?
If you don’t want to grab a calculator, here’s a quick online tool to calculate it for you.
So, how did you score?
According to the CDC, a BMI score…
- Under 18.5 is underweight
- 18.5 to 24.9 is normal
- 25 to 29.9 is overweight
- 30 and over is obese
And, if we’re looking at a representative sample of the population, where the representation is average white European men of working age, that’s not a bad general rule of thumb.
For the rest of us, not so representative
BMI is a great and accurate tool as a rule of thumb, except for…
Women
An easily forgotten demographic, due to being a mere 51% of the world’s population, women generally have a higher percentage of body fat than men, and this throws out BMI’s usefulness.
If pregnant or nursing
A much higher body weight and body fat percentage—note that these are two things, not one. Some of the extra weight will be fat to nourish the baby; some will be water weight, and if pregnant, some will be the baby (or babies!). BMI neither knows nor cares about any of these things. And, this is a big deal, because BMI gets used by healthcare providers to judge health risks and guide medical advice.
People under the age of 16 or over the age of 65
Not only do people below and above those ages (respectively) tend to be shorter—which throws out the calculations and mean health risks may increase before the BMI qualifies as overweight—but also:
- BMI under 23 in people over the age of 65 is associated with a higher health risk
- A meta-analysis showed that a BMI of 27 was the best in terms of decreased mortality risk for the over-65 age group
This obviously flies in the face of conventional standards regards BMI—as you’ll recall from the BMI brackets we listed above.
Read the science: BMI and all-cause mortality in older adults: a meta-analysis
Athletic people
A demographic often described in scientific literature as “athletes”, but that can be misleading. When we say “athletes”, what comes to mind? Probably Olympians, or other professional sportspeople.
But also athletic, when it comes to body composition, are such people as fitness enthusiasts and manual laborers. Which makes for a lot more people affected by this!
Athletic people tend to have more lean muscle mass (muscle weighs more than fat), and heavier bones (can’t build strong muscles on weak bones, so the bones get stronger too, which means denser)… But that lean muscle mass can actually increase metabolism and help ward off many of the very same things that BMI is used as a risk indicator for (e.g. heart disease, and diabetes). So people in this category will actually be at lower risk, while (by BMI) getting told they are at higher risk.
If not white
Physical characteristics of race can vary by more than skin color, relevant considerations in this case include, for example:
- Black people, on average, not only have more lean muscle mass and less fat than white people, but also, have completely different risk factors for diseases such as diabetes.
- Asian people, on average, are shorter than white people, and as such may see increased health risks before BMI qualifies as overweight.
- Hispanic people, on average, again have different physical characteristics that throw out the results, in a manner that would need lower cutoffs to be even as “useful” as it is for white people.
Further reading on this: BMI and the BIPOC Community
In summary:
If you’re an average white European working-age man, BMI can sometimes be a useful general guide. If however you fall into one or more of the above categories, it is likely to be inaccurate at best, if not outright telling the opposite of the truth.
What’s more useful, then?
For heart disease risk and diabetes risk both, waist circumference is a much more universally reliable indicator. And since those two things tend to affect a lot of other health risks, it becomes an excellent starting point for being aware of many aspects of health.
Pregnancy will still throw off waist circumference a little (measure below the bump, not around it!), but it will nevertheless be more helpful than BMI even then, as it becomes necessary to just increase the numbers a little, according to gestational month and any confounding factors e.g. twins, triplets, etc. Ask your obstetrician about this, as it’s beyond the scope of today’s newsletter!
As to what’s considered a risk:
- Waist circumference of more than 35 inches for women
- Waist circumference of more than 40 inches for men
These numbers are considered applicable across demographics of age, sex, ethnicity, and lifestyle.
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The Checklist Manifesto – by Dr. Atul Gawande
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Dr. Gawande, himself a general surgeon, uses checklists a lot. He is, unequivocally, an expert in his field. He “shouldn’t” need a checklist to tell him to do such things as “Check you have the correct patient”. But checklists are there as a safety net. And, famously, “safety regulations are written in blood”, after all.
And, who amongst us has never made such a “silly” error? From forgetting to turn the oven on, to forgetting to take the handbrake off, it takes only a momentary distraction to think we’ve done something we haven’t.
You may be wondering: why a whole book on this? Is it just many examples of the usefulness of checklists? Because I’m already sold on that, so, what else am I going to get out of it?
Dr. Gawande also explains in clear terms:
- How to optimize “all necessary steps” with “as few steps as possible”
- The important difference between read-do checklists and do-confirm checklists
- To what extent we should try to account for the unexpected
- How to improve compliance (i.e., making sure you actually use it, no matter how tempting it will be to go “yeah this is automatic for me now” and gloss over it)
- The role of checklists in teams, and in passing on knowledge
…and more.
Bottom line: if you’ve ever tried to make tea without putting the tea-leaves in the pot, this is the book that will help you avoid making more costly mistakes—whatever your area of activity or interest.
Click here to check out the Checklist Manifesto, and make fewer mistakes!
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Willpower: A Muscle To Flex, Or Spoons To Conserve?
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Willpower: A Muscle To Flex, Or Spoons To Conserve?
We have previously written about motivation; this one’s not about that.
Rather, it’s about willpower itself, and especially, the maintenance of such. Which prompts the question…
Is willpower something that can be built up through practice, or something that is a finite resource that can be expended?
That depends on you—and your experiences.
- Some people believe willpower is a metaphorical “muscle” that must be exercised to be built up
- Some people believe willpower is a matter of metaphorical “spoons” that can be used up
A quick note on spoon theory: this traces its roots to Christine Miserandino’s 2003 essay about chronic illness and the management of limited energy. She details how she explained this to a friend in a practical fashion, she gave her a bunch of spoons from her kitchen, as an arbitrary unit of energy currency. These spoons would then need to be used to “pay” for tasks done; soon her friend realised that if she wanted to make it through the day, she was going to have to give more forethought to how she would “spend” her spoons, or she’d run out and be helpless (and perhaps hungry and far from home) before the day’s end. So, the kind of forethought and planning that a lot of people with chronic illnesses have to give to every day’s activities.
You can read it here: But You Don’t Look Sick? The Spoon Theory
So, why do some people believe one way, and some believe the other? It comes down to our experiences of our own willpower being built or expended. Researchers (Dr. Vanda Siber et al.) studied this, and concluded:
❝The studies support the idea that what people believe about willpower depends, at least in part, on recent experiences with tasks as being energizing or draining.❞
Source: Autonomous Goal Striving Promotes a Nonlimited Theory About Willpower
In other words, there’s a difference between going out running each morning while healthy, and doing so with (for example) lupus.
On a practical level, this translates to practicable advice:
- If something requires willpower but is energizing, this is the muscle kind! Build it.
- If something requires willpower and is draining, this is the spoons kind! Conserve it.
Read the above two bullet-points as many times as necessary to cement them into your hippocampus, because they are the most important message of today’s newsletter.
Do you tend towards the “nonlimited” belief, despite getting tired? If so, here’s why…
There is something that can continue to empower us even when we get physically fatigued, and that’s the extent to which we truly get a choice about what we’re doing. In other words, that “Autonomous” at the front of the title of the previous study, isn’t just word salad.
- If we perceive ourselves as choosing to do what we are doing, with free will and autonomy (i.e., no externally created punitive consequences), we will feel much more empowered, and that goes for our willpower too.
- If we perceive ourselves as doing what we have to (or suffer the consequences), we’ll probably do it, but we’ll find it draining, and that goes for our willpower too.
Until such a time as age-related physical and mental decline truly take us, we as humans tend to gradually accumulate autonomy in our lives. We start as literal babies, then are children with all important decisions made for us, then adolescents building our own identity and ways of doing things, then young adults launching ourselves into the world of adulthood (with mixed results), to a usually more settled middle-age that still has a lot of external stressors and responsibilities, to old age, where we’ve often most things in order, and just ourselves and perhaps our partner to consider.
Consequently…
Age differences in implicit theories about willpower: why older people endorse a nonlimited theory
…which explains why the 30-year-old middle-manager might break down and burn out and stop going to work, while an octogenarian is busy training for a marathon daily before getting back to their daily book-writing session, without fail.
One final thing…
If you need a willpower boost, have a snack*. If you need to willpower boost to avoid snacking, then plan for this in advance by finding a way to keep your blood sugars stable. Because…
The physiology of willpower: linking blood glucose to self-control
*Something that will keep your blood sugars stable, not spike them. Nuts are a great example, unless you’re allergic to such, because they have a nice balance of carbohydrates, protein, and healthy fats.
Want more on that? Read: 10 Ways To Balance Blood Sugars
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