Hypothyroid-like symptoms, energy balance, and diet quality

Symptoms: fatigue, cold-intolerance, hair loss, decreased libido, constipation… sound familiar?

 

thyroid

Hypothyroid-like symptoms occur relatively frequently during times of rapid fat loss, and this may be at least partially dependent on diet quality.  Another component is the fact of being in an energy deficit, but this is difficult to evade on a weight loss diet.

Tl;dr: large energy deficit = hypothyroid-like symptoms.

Food choices and diet quality is important, too.

The negative impact of low calorie diet-induced weight loss on thyroid biology and energy metabolism is well established, but this figure from Agnihothri and colleagues sums it up rather nicely (2014):Agnihothri

Rapid fat loss causes a decline in TSH and T3.

And in this study on long-term calorie restriction (3-15 years), a similar phenomenon occurred (Fontana et al., 2006).  However, TSH was normal (unlike in Agnihothri’s study), possibly because they were not actively losing weight:

Fontana

Fontana diet

Note: calorie restricted diet had adequate protein…  low T3 because they’re weight-reduced and hypoleptinemic, and normal TSH because they’re not actively losing weight.

But then there’s this study, which shows active weight loss does not necessarily cause reduced TSH levels, if the diet is ketogenic (Yancy et al., 2005):

Yancy

Yancy diet

Also, this study showed reduced T3 after 11 days on a ketogenic diet, but it didn’t impact TSH or resting energy expenditure , suggesting no hypothyroid-like symptoms (Bisschop et al., 2001):Bisschop REE

Bisschop TSH

And lastly, from the [notorious] Ebbeling study:

Ebbeling

Low TSH and low T3, but highest energy expenditure in weight-reduced patients on very low-carbohydrate diet.

Summary

Agnihothri: Low calorie diet-induced active weight loss: low T3 and low TSH; probably low energy expenditure and hypothyroid-like symptoms.

Yancy: Ketogenic diet, active weight loss: normal TSH.

Fontana: Weight-reduced, weight-stable (CR): low T3, normal TSH.

Bisschop: Ketogenic diet, weight-stable (11 days): low T3, normal TSH, and normal energy expenditure (indicative of no hypothyroid-like symptoms)

Ebbeling: Very low-carbohydrate diet, weight-stable (4 weeks): low T3, low TSH, normal energy expenditure (indicative of no hypothyroid-like symptoms).

 

In all of the above studies, leptin mirrored body fat.  And all of the old Rosenbaum & Leibel studies showed the reduction in thyroid function after low calorie diet-induced weight loss could be repaired with leptin treatment.  Their 2002 paper had it all (Rosenbaum et al., 2002)… replacing leptin levels to pre-weight loss levels, which required roughly 3 mg/d, completely restored thyroid levels and energy expenditure:

Leibel

Carbohydrate restriction appears to throw a wrench in the gears.

We also know from rodent studies that excess carbohydrates, particularly fructose, can induce leptin resistance.  Perhaps by improving leptin sensitivity, carbohydrate restriction attenuates some of the hypothyroid-like symptoms associated with an energy deficit.  This would explain the findings of Bisschop’s and Ebbeling’s studies, and would be in line with the known impact of carbohydrate restriction on lowering plasma triacylglycerols, and the theorized (and somewhat controversial) association between high triacylglycerols and low leptin sensitivity.

If you’re on a weight loss diet and are experiencing cold intolerance, fatigue, low libido, or any other hypothyroid-like symptoms, consider either upping the calories or lowering the carbs (or this?).

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Ketoacidosis

Nutritional ketosis is a normal, physiological response to carbohydrate and energy restriction.  A ketogenic diet is an effective weight loss strategy for many.  Ketoacidosis, on the other hand, is a pathological condition caused by insulin deficiency.  The common theme is low insulin; however, in ketoacidosis, blood glucose levels are very high.  Ketone levels are elevated in both states, although are 10-20x higher in ketoacidosis (~0.5-2 vs. > 20 mM).  Nutritional ketosis and ketoacidosis should not be confused with one another, and a ketogenic diet doesn’t cause ketoacidosis.

In ketoacidosis, gluconeogenesis occurs at a very high rate and the lack of insulin prevents glucose disposal in peripheral tissues.  Skeletal muscle protein breakdown contributes gluconeogenic substrates, exacerbating the problem.  This can cause blood glucose to reach pathological levels, exceeding 250 mg/dL.

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Gut microbiome & short-chain fatty acids: resistant starch vs. prebiotics

Bifidobacteria undoubtedly like resistant starch (RS).  They bind and hold on tight, an effect mediated by cell surface proteins.  Big thanks to Tim Steele for passing along many of the studies cited here.  One of said studies showed that treatment of bifidobacteria with proteases abolished the RS binding; but even dead critters would bind if their cell surface proteins were intact (Crittenden et al., 2007).  

I suspect fermented foods have this all figured out.  The microbes in sauerkraut are going to be embedded in & all around the cabbage polysaccharides; likely protected from digestive enzymes (to a degree) and holding on tight.

Something similar has been shown for galactooligosaccharides (GOS) (Shoaf et al., 2006).  In this study, GOS, but not a variety of other fibres, inhibited the binding of pathogenic gut microbes to intestinal epithelial cells.

These mechanisms are likely not mutually exclusive, and both seem like they could benefit the host (us).

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On resistant starch and blood glucose control

For overall health and well-being, fermented foods like sauerkraut and kefir are great.  Especially when following a low carbohydrate diet which is generally low in the types of foods which feed the gut microbiome.

For those with gastrointestinal problems, the gut microbiota is probably involved.  Whether it is bacterial overgrowth or dysbiosis, gut bugs are usually the culprit.  Treatment options vary widely, ranging from global extermination with vinegar & a low fibre diet (as per Jane Plain), or remodeling the microbiome with a prebiotic like galactooligosaccharides.   Probiotics like bifidobacteria can help, too, if they’re administered with either prebiotics or fermented foods (they need something to nourish them in transit).  Dark chocolate is also an excellent vessel.  Resistant starch is another option, although the question remains as to whether or not this is compatible with a low carbohydrate diet.

Resistant starch has been around for a while, and when I was in school it received about 10 minutes of attention during the fibre lecture.  But Jimmy Moore and Richard Nikolay have been talking about it a lot lately so I decided to freshen up on the topic.  In brief, it can be therapeutic for GI issues, but some studies have shown mixed effects on glucose & insulin metabolism.  The former is virtually unarguable, but I found the latter interesting.  And the impact of resistant starch on ketosis is included as well.

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Impact of a low-carbohydrate, high-fat diet on gut microbiota.

NPR recently reported on a study where the participants ate either a meat-based, fiber-free ketogenic diet or a vegetarian diet and had their gut microflora analyzed.  The low carb diet was much higher in fat, and as such, increased the prevalence of a microbe involved in fat digestion.  “Bilophila.”  The article focused on this one and cited a 2012 study where Bilophila was associated with intestinal inflammation… however, the ketogenic diet increased the levels of Bacteroides and decreased Firmicutes.  These are the two that brought the whole gut microbe-obesity connection into the spotlight.  The microbiome in obese mice is characterized by low Bacteriodetes and high Firmicutes. Fecal transplants from obese mice to lean mice causes them to gain weight.  Little is known about Bilophila relative to Bacteriodetes & Firmicutes, and I suspect the focus was on Bilophila because the authors wanted something negative to say about a meat-based, fiber-free ketogenic diet, and that 2012 mouse study suggested Bilophila could be their answer.

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Dietary protein, ketosis, and appetite control.

Dietary protein has a purpose, and that purpose is not carbs.”  Nor is it to break ketosis or stall weight loss.  

Drastically increasing protein intake may reduce the degree of ketosis in the context of a large energy surplus, but this is likely due more specifically to the large energy surplus than the protein.  This would explain why Warrior dieters (1 meal meal per day) often report reduced ketones if they eat too much protein.  It’s more likely that the 2000 kcal bolus is exerting it’s anti-ketotic effect by being a large energy surplus, such that anything other than 90% fat would blunt ketosis.  It’s not the proteins… Want proof?  Here’s an n=1 to try: give up Warrior dieting for a few days and try 3 squares.  My bet is that you’ll be able to increase protein intake and still register ketones as high or higher than before.  There are data to support this and reasons why it may not matter (below).

disclaimer: I don’t think “deep ketosis” is necessary to reap the benefits of carbohydrate-restriction.  But if you love high ketone meter readings, then this might be a better strategy to maintain deep ketosis while getting adequate protein. win-win.

if I hear: “oh no, I was kicked out of ketosis!” one more time… 

All of the studies below are confounded one way or another, but so are we humans.

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Dietary protein does not negatively impact blood glucose control.

“Dietary protein-derived amino acids have a purpose, and that purpose is not carbs.”

At a reasonable level of dietary intake, protein is used for the maintenance of organs & tissues.  Lean body mass.  It’s functional.  Protein isn’t stored in any appreciable capacity, and most excess is either oxidized or stored as glycogen.  Theoretically, about 50-60% of protein-derived amino acids can be converted into glucose, mathematically, but it’s not what you think…

“At a reasonable level of dietary intake.”  A recent publication took a look at this (Fromentin et al., 2013).   They set out to determine how much protein is converted to glucose under “optimal gluconeogenic conditions.”  That is, the subjects were 12 hours fasted, which is a physiologically relevant, optimal gluconeogenic condition.  They were then given 4 eggs (~23 g protein) that were labeled with two stable isotopes (15N & 13C, derived from hens fed isotope-enriched diets!).  Throughout the entire study duration, the subjects were infused with a third isotope, 2H-glucose.  By collecting and analyzing the enrichment of isotopically-labeled metabolites like expired CO2, urea, and glucose, the researchers were able to determine the fate of those 23 grams of protein.

Some of the dietary protein-derived amino acids were used for protein synthesis, others were oxidized.  But blood glucose levels did not change.  Nor did the rate of gluconeogenesis.

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Implications of the circadian nature of ketones.

Ketosis.  Happens during starvation and also by restricting carbohydrates (and protein, to a lesser degree)… might be important for epilepsy and bipolar disorder, too.

ketogenesis

Ketostix measure urinary acetoacetate (AcAc) and reflect the degree of ketosis in the blood probably about 2-4 hours ago.  Blood ketone meters measure beta-hydroxybutyrate (bHB) right now.  bHB fluctuates to a greater degree, eg, it plummets after a meal whereas AcAc takes longer to decline.  AcAc/bHB is usually around 1, but increases after a meal (Mori et al., 1990):Ketone body ratio

Conversely, when glucose levels decline and fatty acid oxidation increases, liver redox potential drops which reduces AcAc/bHB.

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Low carbohydrate diets favorably impact testosterone levels.

It is known.  Carbohydrate restriction improves (lowers) testosterone in women with PCOS.  It works for men, too… but by “works” I mean “increases.”

Decrease of serum total and free testosterone during a low-fat high fibre diet (Hamalainen et al., 1982) 

Intervention pseudo-crossover study: 30 healthy Finnish men in their 40’s were studied on their habitual high fat diet (40%  fat), then put on a low-fat (25%) high fibre diet for 6 weeks, then switched back to high fat.  The high fat diet was also higher in saturates, P:S ratio 0.15 vs. 1.25.

free T

 

Free testosterone levels declined on the low fat diet, but they recovered after 6 weeks of going back to their high [saturated] fat dieting (p < 0.01).

Some observational data: Testosterone and cortisol in relationship to dietary nutrients and resistance exercise (Volek et al., 1997)

…fat, and in particular saturated fat, is associated with increased testosterone levels [in men]:

observational

 

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Protein Leverage Hypothesis

Inverse Carb Leverage HypothesisTM

Protein Leverage Hypothesis: Dude eats 15% protein on a 2000 kcal diet (75 g protein).  Exchange 25 grams of protein with carb, and he’s now eating 10% protein on a 2000 kcal diet (50 g protein).  Theory states Dude will increase total food intake to get back those 25 grams.

Ergo, Protein Leverage Hypothesis:

protein leverage hypothesis

Disclaimer: I don’t care much for the Protein Leverage Hypothesis.  It might be true, but that doesn’t mean it matters.  It works well in rodents, but obese patients eat tons of protein.  The rebuttal to this is that the protein in their diet is too diluted with other [empty] calories.  They’re overeating because of low protein %.

The flipside, confirmed ad nauseam in rodent studies, is that frank protein deficiency increases food intake.  Frank protein deficiency means negative nitrogen balance & tissue loss… not just skeletal muscle; organs, too.  Incompatible with survival.

Feed someone a low protein low fat diet, they get hungry.  If it’s ad libitum, they eat more.

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