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Editorial: Controversy Over Diagnosing Hypothyroidism

Wall Street Journal Highlights Unconventional Doctor Working With Runners

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Updated April 16, 2013

Editorial: Controversy Over Diagnosing Hypothyroidism

Endocrinologists disagree whether elite runners may have difficult-to-diagnose hypothyroidism.

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An article in the April 10, 2013 issue of the Wall Street Journal -- U.S. Track's Unconventional Physician, by Sara Germano and Kevin Clark -- highlights the work of endocrinologist Jeffrey S. Brown, MD, implying that his diagnosis and treatment of hypothyroidism among elite and Olympic runners may be an unnecessary or even unethical way to enhance the athletes' performance, or even a legal form of "doping." (Note: Thyroid medication is not on the list of substance banned by the World Anti-Doping Agency.)

According to the article, Jeffrey S. Brown, MD, an endocrinologist, has worked with nine-time Olympic gold medalist Carl Lewis, and number of other elite and Olympic runners, in whom he's diagnosed and treated hypothyroidism. He's also a paid consultant to Nike, whose top running coach, who calls Brown "the best sports endocrinologist in the world."

Brown, according to the Wall Street Journal, Brown "argues that the diagnosis of hypothyroid in endurance athletes is consistent with research showing that extreme stress is often a trigger for the condition." Brown's argument seems to be that even a slight diminishment in performance -- due to mild hypothyroidism -- counts for an elite athlete, who may benefit from treatment to optimize thyroid function.

Bringing out the usual cast of traditional endocrinologists to comment -- such as Jeffrey Garber, MD -- the authors claim that hypothyroidism typically strikes middle-aged or older women, not younger, male athletes. They state that Garber has said that "hypothyroidism increasingly is being diagnosed in people who don't have it, by endocrinologists whom Garber labeled as 'alternative.'" A Mayo Clinic endocrinologist, Ian Hay, referred to Brown's approach as "...unusual, if not a bit suspicious."

I was surprised to see such a poorly researched, innuendo-filled article in a newspaper like the Wall Street Journal and the disdain that the endocrinologists -- and the authors -- clearly had for Dr. Brown. But then, I shouldn't be surprised, because the authors are just repeating what they heard from mainstream endocrinologists, who stubbornly cling to the outdated ideas that hypothyroidism is easy to diagnose, that the Thyroid Stimulating Hormone (TSH) test is the sole gold standard for diagnosis, that hypothyroidism is an easily-treated problem mainly affecting middle-aged women, and that stress and adrenal function have no impact on thyroid function.

I thought it would be helpful to ask several nationally-known practitioners with expertise in thyroid and hormone balance to share their thoughts regarding this story.

According to Richard Shames, MD, who has been treating thyroid patients for more than 35 years, "Dr. Jeffrey S. Brown has gotten it right. Young endurance athletes can indeed suffer from hypothyroidism, just like anyone else at any age or any walk of life. Hypothyroidism is such a common illness, that it would not be at all surprising to find it affecting some young athletes. The condition might not become evident until the intense training demands on the body exceed the thyroid gland's ability to make sufficient hormone."

According to Dr. Shames, it's well known that intense physical training can affect hormones. "Endurance training often results in a young female athletes losing their normal menstrual cycles -- it's an understandable hormonal change. Men can have exercised-induced hormonal changes as well. There needs to be more study, but perhaps this hypothyroidism manifests in male athletes who have some genetic predisposition for thyroid problems, or autoimmune issues in general. That would still translate to many men."

Kent Holtorf, MD - founder of the Holtorf Medical Clinics -- says he regularly sees athletes with physiologic stresses, which, when combined with intense exercise and dieting, can cause hypothyroidism, and make it more difficult to detect. Says Dr. Holtorf: "It is usually not detected because the TSH does not increase, but rather the Free T3 is low, the Reverse T3 goes up and the T4 can increase due to reduced transport into the cell or decrease due to lack of secretion. Basal Metabolic Rate (BMR) declines and the relaxation phase of reflex increases, both of which can affect athletic performance."

Manhattan-based physician, David Borenstein, MD -- who works with hundreds of thyroid patients -- feels like Dr. Brown's approach makes sense. Says Dr. Borenstein: "The physical exertion involved in being an elite athlete is a chronic stress, and we know that chronic stress can be physically dangerous. Endurance training can cause adrenal depletion and weaken adrenal function, and this in turn can inhibit thyroid function. And these athletes are not only under stress from athletic performance, but mental and emotional stress as well. A lot of money is on the table as a result of their performance -- they are being paid millions to perform well. For many of these athletes, their future is going to come down to how they run the next race, so even a slight reduction in energy or strength, due to a thyroid imbalance, can have a serious impact. If the typical person with undiagnosed hypothyroidism takes an few extra minutes to walk to the store, that's no big deal. But if a runner takes even an extra tenth of a second, that can mean the difference between winning and losing a crucial race."

Dr. Borenstein disagrees with the characterization that Dr. Brown's diagnosing and treating hypothyroidism in the runners is some form of "thyroid doping." Says Dr. Borenstein: "When one dopes, one is using supraphysiologic levels of a controlled or banned substance to increase performance. That is not what's happening here. We're not overmedicating. We're replacing something natural to the body that's missing, and something that is essential for basic functioning."

Dr. Shames agrees. "The idea that thyroid treatment could be s performance-enhancing may make someone with normal thyroid function become slightly hyperthyroid is nonsense. The opposite is true. Performance is impaired unless the person is in fact hypothyroid. It's similar to the controversial idea that some patients are only trying to lose weight by taking thyroid medication. The only people to really find thyroid medication helpful in losing weight are those whose weight problem was partially caused by hypothyroidism in the first place."

Dr. Borenstein says that the story also points out the challenges that all thyroid patients -- not just top runners -- face. "Whether we're talking about an athlete or the average person, we all need to get through the day and accomplish what we need to do. While most of us aren't star athletes, but we need to work effectively and have energy and you can't do that when you have fatigue, muscle weakness, and brain fog due to undiagnosed and untreated hypothyroidism."

According to Dr. Shames, a big part of the problem is the craziness surrounding TSH testing for diagnosis of low thyroid. Says Dr. Shames: "An athlete with a TSH of 3.0 would be considered quite normal by most American endocrinologists, but would be deemed hypothyroid by others. Keep in mind that it's not just high-performance athletes who can't get a decent diagnosis from a standard endocrinologist. A great many more non-athletes are in the exact same boat. I am convinced that Dr. Brown is providing two very useful and important services. He is helping athletes who indeed have a low thyroid condition, but because of the tyranny of one overrated blood test - the TSH test -- are being denied proper treatment. Another important service is his spotlighting the need for better thyroid care for all the rest of us."

* * *

Thanks to Drs. Holtorf, Shames and Borenstein, who obviously -- like Dr. Brown -- understand that we don't know everything we need to know about thyroid function by slavishly focusing only on TSH test results.

Meanwhile, over at the Wall Street Journal's comments page, you'll find disdain for Dr. Brown and the athletes, and more conventional "easy to diagnose, easy to treat" dogma from physicians.

In my opinion, Dr. Brown deserves applause, not derision, from his colleagues.

Source: Sara Germano and Kevin Clark, U.S. Track's Unconventional Physician, Wall Street Journal, April 10, 2013, Editorial: Wall Street Journal Article Highlights Controversy Over Diagnosing Hypothyroidism

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