Dual Diagnosis: Managing Hypothyroidism and Type 2 Diabetes

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Managing hypothyroidism or type 2 diabetes often feels like running a marathon uphill. Now, imagine tackling both at once. The sluggish metabolism, relentless fatigue, unpredictable blood sugar spikes, constant cravings, and weight gain can feel like a never-ending battle. But here’s the good news: you’re not doomed to struggle with this double diagnosis. New science and strategies show us how to manage these two conditions together—and thrive.

In this article, we’ll uncover the secrets to syncing your thyroid health with blood sugar control, explore the surprising connections between these two conditions, and share actionable steps to help you reclaim your energy, stabilize your weight, and finally feel like yourself again. 

Hypothyroidism and type 2 diabetes are both endocrine disorders that can significantly impact your overall health and quality of life. While they are distinct conditions, there is often an interplay between the two. 

Hypothyroidism occurs when your thyroid gland – the master gland of metabolism -- doesn’t produce enough thyroid hormones. The lack of thyroid hormone leads to a slowdown in your metabolism and body functions and can cause many related symptoms. The most common cause of hypothyroidism in the United States is Hashimoto’s thyroiditis, an autoimmune disorder. 

In patients with type 2 diabetes, the body can’t use insulin effectively, resulting in high blood sugar levels effectively.

The prevalence of thyroid disorders in diabetes patients ranges up to 46.5%, with studies demonstrating that thyroid dysfunction is more common in type 2 diabetes patients compared to the general population. Notably, the risk for thyroid disease nearly doubles in people with diabetes, with approximately 30% of people with thyroid disease diagnosed with diabetes.

Both conditions share several common risk factors, such as:

• Obesity and metabolic syndrome
• A sedentary lifestyle
• Personal or family history of autoimmune conditions 

Thyroid function and glucose metabolism

Thyroid function affects insulin sensitivity and glucose metabolism. Research has shown that higher thyroid-stimulating hormone (TSH) levels are associated with a higher diabetes risk. 

Studies have identified TSH as an independent predictor for type 2 diabetes. One study found that the best cut-off value of TSH was 4 mIU/L for predicting type 2 diabetes in patients with autoimmune thyroid disease like Hashimoto’s. This suggests that monitoring TSH levels in patients with type 2 diabetes is crucial for identifying those at risk of developing a thyroid condition. 

Bidirectional relationship

The relationship between thyroid dysfunction and diabetes appears to be bidirectional. Hypothyroidism can slow your metabolism, slow glucose absorption, and make your body more insulin-resistant. This can complicate blood sugar control, potentially worsening or contributing to the development of type 2 diabetes. 

At the same time, poor blood sugar control in type 2 diabetes patients may be associated with an increased risk of thyroid dysfunction. High blood sugar levels may affect thyroid hormone production and worsen hypothyroidism symptoms like fatigue and weight gain.

Clinical implications

Understanding the connection between these conditions has important clinical implications. Patients with type 2 diabetes should be regularly screened for thyroid dysfunction, especially when TSH levels exceed 4 mIU/L. Similarly, hypothyroid patients should be monitored for signs of impaired glucose metabolism and type 2 diabetes.

Hypothyroidism and type 2 diabetes require different sets of blood test panels.

Diagnosing hypothyroidism

Hypothyroidism is typically diagnosed through a combination of clinical evaluation and laboratory testing. Doctors assess symptoms like fatigue, weight gain, cold intolerance, and depression, alongside physical findings such as dry skin or hair loss. Laboratory tests play a critical role and include: 

• TSH (thyroid-stimulating hormone) – the primary marker. Elevated TSH above the reference range generally indicates an underactive thyroid
• Free thyroxine (Free T4) – the inactive thyroid hormone, and low or low-normal levels in the reference range are common in hypothyroidism
• Free triiodothyronine (Free T3) – the active thyroid hormone, which is usually low or low-normal in hypothyroidism
• Thyroid peroxidase antibodies (TPOAb) --  when positive (elevated above the reference range), TPOAb can indicate autoimmune Hashimoto’s thyroiditis 

You can have this blood testing with a conventional blood draw at your doctor’s office or a lab. A convenient and painless alternative is the Paloma Thyroid Test Kit. This home test kit makes it easy to collect a small blood sample via finger prick and quickly get certified lab results, all from the comfort of your home. 

Diagnosing type 2 diabetes 

Type 2 diabetes is diagnosed through a combination of clinical evaluation and blood tests to measure glucose levels. Common symptoms such as frequent urination, excessive thirst, fatigue, and blurred vision may prompt testing. The primary diagnostic tests include:

• Fasting plasma glucose (FPG) –  which measures your blood sugar after an overnight fast 
• Hemoglobin A1C (HbA1c) – reflects average blood sugar levels over the past two to three months. 

A fasting glucose level of 126 mg/dL or higher or an HbA1c level of 6.5% or above typically indicates diabetes. Alternatively, the oral glucose tolerance test (OGTT) may be used, especially in cases where other tests are inconclusive. 

Random plasma glucose levels of 200 mg/dL or higher in the presence of symptoms can also confirm the diagnosis. Early diagnosis through these tests is critical for managing the condition and preventing complications.

Hypothyroidism treatment

The primary treatment for hypothyroidism is thyroid hormone replacement therapy. There are four types of thyroid medication: 

• Brand name and generic synthetic thyroxine (T4), known as levothyroxine. Some of the better-known brands include Synthroid, Levoxyl, and Tirosint
• A combination of levothyroxine and liothyronine (synthetic triiodothyronine T3). The brand name of this medication is Cytomel
• Natural desiccated thyroid (NDT), a porcine-derived thyroid drug that includes natural forms of both the T4 and T3 hormone. The best-known brand names are Armour Thyroid and NP Thyroid 
• Compounded T4, T3, or NDT in personalized combinations – specially formulated for each patient

These medications help restore normal thyroid hormone levels in your body.

Key points for thyroid hormone replacement use: 

• Your thyroid medication is usually taken 60 minutes before your first meal and/or coffee of the day
• Avoid taking it with other medications or supplements, especially those that contain iron or calcium. 
• Regular follow-ups with your doctor are essential to adjust the dosage as needed

You’ll find more guidance on how to take your medication in this article on the Paloma blog.

Type 2 diabetes treatment

Type 2 diabetes is a chronic condition that requires comprehensive management to control blood glucose levels and prevent complications. The foundation of type 2 diabetes treatment involves diet, exercise, and weight management. A balanced diet low in refined carbohydrates, regular physical activity, and maintaining a healthy weight can significantly improve blood glucose control.

Depending on the severity of your diabetes, your doctor may prescribe various medications to help manage your blood sugar levels. These may include:

• Metformin: Metformin is often the first-line medication for type 2 diabetes. It works by reducing glucose production in the liver and improving insulin sensitivity. Some brand names of metformin include Glucophage and Glumetza.
• Sulfonylureas: Sulfonylureas stimulate the pancreas to produce more insulin, lowering blood glucose levels. Some of the generic drugs in this category include glipizide, glimepiride, and glyburide, and brand names include Glucotrol, Amaryl, and DiaBeta.
• DPP-4 inhibitors: DPP-4 inhibitors help the body produce more insulin when blood sugar is high and reduce glucose production. Generic drugs include sitagliptin, saxagliptin, linagliptin, and alogliptin. Some better-known brand names include Januvia, Onglyza, and Tradjenta.
• GLP-1 receptor agonists: These injectable medications slow digestion, increase insulin production, and reduce glucose production. Generic names include dulaglutide, exenatide, liraglutide, and semaglutide. Brand names include Ozempic, Trulicity, Byetta, and Victoza, among others. 
• SGLT2 inhibitors:  SGLT2 inhibitors help the kidneys remove excess glucose through urine. Generic names include canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. Brand names include Invokana, Farxiga, and Jardiance.
• Insulin: For some people with type 2 diabetes, insulin therapy may be necessary to control blood glucose levels. Types of insulin include rapid-acting, short-acting, intermediate-acting, and long-acting (insulin glargine). Brand names include Humalog, Novolog, Lantus, and Toujeo, among others. 

A combination of these medications is often used to achieve optimal blood glucose control. For example, metformin may be combined with a sulfonylurea or an SGLT2 inhibitor. 

Blood sugar monitoring

When you have type 2 diabetes, regular blood sugar monitoring is also an essential part of treatment. It helps you understand how food, exercise, and medications affect your glucose levels. Here are some tips for monitoring:

• Use a glucose meter (glucometer) as recommended by your health care provider
• Keep a log of your readings
• Learn to recognize and respond to high and low blood sugar symptoms
• Consider using a continuous glucose monitor (CGM) for more detailed insights

Two categories of medication – metformin and GLP-1s – have been shown to help not only type 2 diabetes but hypothyroidism. 

For hypothyroidism, metformin has demonstrated promising results in several studies. Patients treated with metformin have been found to have a smaller thyroid volume and a lower risk of goiter, thyroid nodules, and thyroid cancer. Metformin has also been shown to reduce TSH levels in both overt and subclinical hypothyroidism, potentially improving thyroid function. 

For type 2 diabetes, metformin has been a cornerstone treatment for over 60 years due to its outstanding ability to decrease plasma glucose levels. It reduces glucose production in the liver, which improves insulin sensitivity and increases glucose uptake in skeletal muscles. Metformin also stimulates GLP-1 release, enhancing insulin secretion and lowering plasma glucose levels. Additionally, recent research suggests that metformin may positively affect gut microbiota composition, which could contribute to its anti-diabetic effects.

GLP-1s have also shown potential benefits for individuals with hypothyroidism. While the direct effects on thyroid function are still being studied, these medications have demonstrated significant improvements in managing common side effects of hypothyroidism, such as weight gain and fatigue. A recent study found that patients with hypothyroidism who lost more than 5 pounds while taking GLP-1 medications experienced a reduction in their TSH levels.

GLP-1s have revolutionized type 2 diabetes treatment by promoting insulin secretion, suppressing glucagon release, and delaying gastric emptying. These medications improve glycemic control and contribute to weight loss and blood pressure reduction. The combination of improved metabolic parameters and weight loss can be particularly beneficial for individuals with both type 2 diabetes and hypothyroidism, as these conditions often coexist and can exacerbate each other.

For patients with both hypothyroidism and T2D, GLP-1s offer several advantages:

• Weight management: Hypothyroidism often leads to weight gain, which can exacerbate type 2 diabetes. The weight loss effects of GLP-1 agonists can be particularly beneficial for these patients.
• Cardiovascular protection: Some GLP-1 agonists have shown heart and vascular health benefits. Hypothyroidism and type 2 diabetes are both associated with an increased risk of cardiovascular disease.
• Thyroid effects: According to research, patients with hypothyroidism who lose more than five pounds after starting a GLP-1 medication experience, on average, a 0.36 mU/L to 0.55 mU/L reduction of their thyroid-stimulating hormone (TSH) levels.
• Simplified treatment: GLP-1 agonists can reduce the need for multiple medications, simplifying the treatment regimen for patients managing both conditions.

Research is also exploring the potential of combining GLP-1 agonists with other medications for enhanced efficacy. Both metformin and GLP-1s appear to have synergistic effects when used in combination. According to research, metformin has been shown to increase GLP-1 circulating levels, which could enhance the effectiveness of GLP-1s. This combination therapy could offer more comprehensive management of diabetes and thyroid function.

If you are planning to get pregnant, or you’re already pregnant and are hypothyroid with type 2 diabetes, keep in mind that special considerations are necessary:

• Work closely with your thyroid care provider and obstetrician, and make sure they are informed about your treatment plans
• Be aware that you’ll need more frequent thyroid and blood sugar monitoring 
• Medication adjustments may be necessary, especially in the first trimester of pregnancy, when your thyroid dosage will likely need to be increased

Complementary and alternative medicine offers potential benefits for people who have both hypothyroidism and type 2 diabetes. Some possible approaches include the following. 

Nutritional supplements

Vitamin D supplementation has demonstrated positive effects in patients with both type 2 diabetes and hypothyroidism. Studies have shown that vitamin D can improve thyroid function, reduce autoantibody levels, and enhance blood glucose control. Selenium, another vital nutrient, has been found to upregulate activated regulatory T cells and partially reduce thyroid autoantibodies. When added to conventional hypoglycemic agents, the combination of vitamin D and selenium has shown therapeutic effects in patients with both conditions.

Herbal remedies

Several herbal remedies have shown potential in managing type 2 diabetes, which may indirectly benefit thyroid function. Cinnamon, fenugreek, and bitter melon have demonstrated promise in glycemic control. These herbs may help reduce insulin resistance, a common factor linking thyroid dysfunction and type 2 diabetes.

Mind-body practices

Mind-body practices such as yoga, tai chi, and meditation have been associated with improved hemoglobin A1c and fasting blood glucose levels in type 2 diabetes patients. These practices may also help manage stress, which can affect both thyroid function and blood sugar levels.

Combination therapies

Research has shown that combining CAM therapies with conventional treatments can enhance clinical efficacy and potentially reduce the economic burden of managing these conditions. For instance, combining vitamin D, selenium, and hypoglycemic agents has significantly improved thyroid function, autoantibody levels, and blood glucose and lipid profiles.  

A balanced diet is fundamental in managing both hypothyroidism and type 2 diabetes. Here are some dietary guidelines to consider.

Focus on low-glycemic foods

• Focus on foods with a low glycemic index
• Incorporate foods that have a minimal impact on blood sugar, such as non-starchy vegetables, legumes, nuts, seeds, and whole grains.

• Avoid refined sugars and processed carbohydrates.
• Choose lean proteins and healthy fats

Prioritize anti-inflammatory foods

• Eat plenty of omega-3-rich foods (e.g., fatty fish and chia seeds) and antioxidants from fruits and vegetables to reduce inflammation linked to both conditions.
• Consider incorporating probiotic-rich foods like yogurt and fermented vegetables, which have anti-inflammatory properties.

Support thyroid health with essential nutrients

• Iodine: Iodine, found in seaweed, iodized salt, and eggs, is critical for thyroid hormone production.

• Selenium: Brazil nuts, turkey, fish, and organ meats are excellent sources. Selenium helps convert thyroid hormones to their active form.

• Zinc: Found in shellfish, nuts, and seeds, zinc supports healthy thyroid function.

Avoid potential food triggers

• Limit raw goitrogens (found in cruciferous vegetables) 
• Monitor for gluten sensitivity, as it can worsen hypothyroidism.

Other recommendations 

• Establish consistent eating patterns with moderate portions to help stabilize blood sugar levels and support metabolism.

• Include plenty of fiber-rich foods, which help lower blood sugar and resolve hypothyroidism-related constipation. 

Regular exercise is beneficial for both hypothyroidism and type 2 diabetes management. Physical activity can help:

• Boosts metabolism and alleviates hypothyroidism symptoms like weight gain and fatigue.
• Improve insulin sensitivity and stabilize blood sugar levels
• Manage weight
• Enhance overall well-being

Physical activity should include different types of exercise, including: 

• Aerobic exercise: Walking, cycling, or swimming can help manage blood sugar.

• Strength training: Builds muscle mass, which enhances insulin sensitivity and supports metabolism.
• Yoga and stretching: Reduces stress, improves flexibility, and supports thyroid function.

Here are some recommendations regarding exercise: 

• Start slow if fatigue from hypothyroidism is a concern, and gradually increase intensity.
• Aim for at least 150 minutes of moderate-intensity aerobic activity per week
• Include strength training exercises 2-3 times a week
• Start slowly and gradually increase intensity and duration
• Choose activities you enjoy, such as walking, swimming, or cycling

Always consult your health care provider before starting a new exercise regimen, especially if you’re taking insulin or other diabetes medications that can affect blood sugar levels.

Stress can significantly impact both thyroid function and blood sugar levels. Implementing stress-reduction techniques can be beneficial:

• Practice mindfulness meditation or another stress management technique
• Try breathwork or breathing exercises
• Engage in regular physical activity
• Consider yoga, tai chi, or qi gong
• Seek support from friends, family, or a mental health professional

Getting 7 to 9 hours of sleep every night is crucial for individuals with both hypothyroidism and type 2 diabetes. For hypothyroid patients, adequate sleep is essential as it helps regulate thyroid hormone production and release. Poor sleep quality or insufficient sleep can worsen the symptoms of hypothyroidism, such as fatigue and cognitive difficulties.

In type 2 diabetes, sleep is vital in maintaining proper blood sugar control. Studies have shown that both short sleep duration (less than 6 hours) and long sleep duration (more than 9 hours) are associated with an increased risk of developing type 2 diabetes and insulin resistance[6]. Sleep deprivation can lead to higher circulating insulin levels, fasting glucose, and insulin resistance. It also affects hormones that regulate hunger and fullness, potentially leading to poor dietary choices and an increased risk of obesity, a significant risk factor for diabetes.

Furthermore, getting adequate sleep is essential for overall health and well-being. It helps improve mood, cognitive function, and energy levels, which are particularly important for managing the symptoms of both hypothyroidism and type 2 diabetes. Proper sleep hygiene – including maintaining a consistent sleep schedule and creating a conducive sleep environment – can significantly improve sleep quality and duration. 

Consistent medical follow-ups are crucial for managing both conditions effectively.

Recommended check-ups and tests for hypothyroid patients and people with type 2 diabetes include: 

• Thyroid function tests (TSH, Free T4, Free T3) every 6 to 12 months at minimum
• A hemoglobin A1C (HbA1c) test every 3 to 6 months
• Annual comprehensive metabolic panel
• Regular blood pressure checks
• Annual eye exam
• Foot examinations (for diabetes-related complications)

Implementing and maintaining healthy lifestyle habits is key to managing both conditions:

• Quit smoking if you currently smoke
• Limit your alcohol consumption
• Maintain a healthy weight
• Stay well-hydrated
• Avoid extreme diets or fasting without medical supervision

It’s also important to address the emotional aspects of living with chronic conditions. Prioritize your mental health with practical actions, including the following:

• Join support groups for individuals with hypothyroidism and/or diabetes. (Note: Paloma’s free online community offers support from others with thyroid conditions.) 
• Consider counseling or therapy if you’re struggling with the emotional aspects of your conditions
• Practice self-compassion and celebrate small victories in your health journey
• Engage in hobbies and activities that bring you joy and relaxation

You can leverage technology to help manage your conditions. For example:

• Use smartphone apps to track medication, diet, and exercise. (Note: Paloma’s free smartphone app can help.) 
• Set reminders for medication and check-ups
• Utilize wearable devices to monitor blood sugar -- i.e., a continuous glucose monitor   (CGM) – and to track your activity levels and heart rate.

Keep an eye out for symptoms that may signal worsening of either condition. These include: 

• Uncontrolled blood sugar levels, with frequent highs or lows.
• Persistent fatigue or weight changes despite treatment.
• Symptoms of diabetic complications, such as nerve pain, vision problems, or delayed wound healing.
• Worsening hypothyroid symptoms, such as depression, cold intolerance, or hair thinning.

Be sure to promptly report these symptoms to your health care provider for evaluation and adjustments to your treatment plan.

Managing hypothyroidism and type 2 diabetes simultaneously requires dedication, patience, and a comprehensive approach. By incorporating personalized care and resources like those offered with a Paloma Health membership, you can gain tailored insights into your thyroid health while effectively managing your overall well-being. Paloma Health specializes in comprehensive thyroid care, providing access to experienced clinicians, at-home testing, and personalized treatment plans that can help you better understand and manage hypothyroidism in conjunction with type 2 diabetes.

Remember, everyone’s journey is unique, and finding the right balance may take time. Stay persistent, be kind to yourself, and celebrate each step forward. Paloma Health empowers you with tools and support to navigate your health journey more effectively, ensuring that your treatment aligns with your unique needs and goals.

Always consult with your health care providers or a dedicated thyroid specialist like those at Paloma Health before making significant changes to your treatment plan. Personalized care and a thoughtful approach can make all the difference in successfully managing both hypothyroidism and type 2 diabetes, allowing you to lead a healthy, fulfilling life.

• Hypothyroidism and type 2 diabetes are interconnected endocrine disorders, with up to 46.5% of diabetic patients experiencing thyroid dysfunction.
• Hypothyroidism slows metabolism and glucose absorption, complicating blood sugar control, while poor blood sugar management can worsen symptoms of hypothyroidism like fatigue and weight gain.
• Diagnosing an underactive thyroid involves tests for TSH, Free T4, and Free T3 levels, while type 2 diabetes is diagnosed through fasting plasma glucose and HbA1c tests.
• Treatment for hypothyroidism typically includes thyroid hormone replacement therapy, whereas type 2 diabetes management focuses on lifestyle factors and medications such as metformin and GLP-1 receptor agonists.
• Metformin has shown potential benefits for thyroid health by reducing TSH levels and reducing blood sugar. GLP-1 medications can aid in weight loss and improve metabolic parameters for patients with both conditions.
• Nutritional supplements like vitamin D and selenium, along with mind-body and stress management practices, may enhance treatment outcomes for individuals managing both hypothyroidism and type 2 diabetes.

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