GOITER & Dietary Management)

GUIDE :
Submitted by:
Mrs.JYOTHSNA DEVI KUCHIPUDI
B.SC(CN&D),M.Sc(FS&QC),NET,M.Phil(F&N POOrnima.M
),(Ph.D) M.Sc 1st Year (Food Nutrition and
ASSISTANT PROFESSOR Dietetics)
Dept of Food Nutrition & Dietetics School of Allied Healthcare & sciences
School of Allied Healthcare & Sciences Jain University
Jain University Bengaluru
Bengaluru
 Endocrine System
The glands and organs that make hormones and release them directly into the
blood so they can travel to tissues and organs all over the body. The hormones
released by the endocrine system control many important functions in the body,
including growth and development, metabolism, and reproduction. The
endocrine system includes the hypothalamus, pineal gland, pituitary gland,
thyroid gland, parathyroid glands, thymus, adrenal glands, and pancreas. It also
includes the testes in males and the ovaries and placenta (during pregnancy) in
females.
The endocrine system includes the hypothalamus, pineal
gland, pituitary gland, thyroid gland, parathyroid glands,
thymus, adrenal glands, and pancreas. It also includes the
testes in males and the ovaries and placenta (during
pregnancy) in females.
 THYROID HORMONE
• Thyroid is a small, butterfly-shaped gland located at the front of the neck under the
skin. It’s a part of the endocrine system and controls many of the body’s important
functions by producing and releasing (secreting) certain hormones.
• Thyroid’s main function is to control the speed of the metabolism (metabolic rate),
which is the process of how the body transforms the food we consume into energy, the
gland produces hormones that regulate the body’s metabolic rate, growth and
development. All of the cells in our body need energy to functioning.
FUNCTIONS
•Thyroid hormones (THs) play critical roles in growth, differentiation and metabolism. They are
important for optimal functioning of almost all tissues with major effects on metabolic rate and
oxygen consumption.

•The thyroid gland secretes two biologically active thyroid hormones: thyroxine (T4) and 3,5,3'-
triiodothyronine (T3). TH synthesis and secretion is regulated by a negative-feedback system that
involves the hypothalamus, pituitary, and thyroid gland (the HPT axis). Only 0.03% and 0.3% of
total serum T4 and T3 respectively is free (unbound).
Some of the important functions of the thyroid hormones include- neural growth and
differentiation, myocardial contractility, regulation of bone formation and resorption,
development and function of brown and white adipose tissue, cholesterol
metabolism and synthesis, and in-utero they are important for fetal growth and
differentiation. Thus, given their pleotropic effects, thyroid hormones are critical for
survival and optimal functioning of the human body.
DISORDERS OF THYROID GLAND
•Thyroid disorders are conditions that affect the thyroid gland and its normal functioning. Different
types of thyroid disorders affect either its structure or function.

•The function of the thyroid gland is regulated by a feedback mechanism involving the brain.

•They are specific kinds of thyroid disorders : Various pathophysiological processes affect the
organ. One of the major clinical manifestations of this is enlargement of the gland .

• In general abnormal enlargement of thyroid gland is defined as goiter by American thyroid

association.
GOITER
A simple goiter is an enlargement
of the thyroid gland. It is usually
not a tumor or cancer.
A goiter is the irregular growth of the thyroid gland. A goiter may
be an overall enlargement of the thyroid, or it may be the result of
irregular cell growth that forms one or more lumps (nodules) in the
thyroid. The presence of goiter can be determined by inspection,
palpation, or by an imaging study.
HISTORY

•During 1600 BC Chinese used to treat the condition with the sea weed , but
the exact benefit was not known .

•Historically goiter was mentioned in literature of various languages around

the world. Ancient Indian physicians have described the condition called as
Galaganda in detail in Ayurveda books between 14 Th century BC and
400A.D.

•But the pharmacological basis behind this treatment was understood only
after the discovery of Iodine by Bernerd Courtois in 1811
EPIDEMOLOGY
The most common cause of goiters worldwide is iodine deficiency that
affects an estimated 2.2 billion people. The prevalence and incidence of
goiter are based on the degree of iodine deficiency.

With mild iodine deficiency, the incidence of goiter is 5% to 20%. With a

moderate deficiency, the prevalence increases to 20% to 30%, and with
severe iodine deficiency, the incidence increases to greater than 30%. Even
with the use of iodine, there has been an increase in the incidence of thyroid
nodules.
• Ultrasonography can detect even the smallest of nodules, causing the
incidence of nodules to be 60% to 70% in adults. However, imaging and
screening are not the sole causes of the increase in incidence. It has been
thought that obesity, insulin resistance, and metabolic syndrome may be
factors that have caused an increased incidence of goiter.
• Females are approximately four times more likely to develop goiter as
compared to males. There is no racial difference in goiter prevalence.
•Association of iodine deficiency with goiter was first discovered during 19 th
century by various researchers like Lugol and Coindet.

•Thyroid hormone in pure form was extracted by Edward Kendeall in 1914 at

Mayo clinic . 21st century was marked with development of safer surgical
practices and in depth understanding of the goiter pathology leading to better
management of the condition.
•Normal thyroid gland measures 4 to 4.8 cm in sagittal, 1 to 1.8 cm in transverse, and 0.8 to 1.6
cm in anteroposterior dimensions and 10-20 grams in weight.

•Thyroid size increases with age and body size. It is larger in males as opposed to females. The
size decreases with higher iodine intake.

•The thyroid gland can enlarge due to a variety of physiological or pathological stimuli. Goiter
during adolescence and pregnancy are two causes of a physiological goiter. Goiter can be
associated with euthyroidism, hypothyroidism, or hyperthyroidism.
 ETIOLOGY
Several pathogenic mechanism underactive thyroid gland (such
as in Hashimoto’s disease)

Overactive thyroid gland ( as in Graves’ disease)

Hormonal changes (as during puberty or in pregnancy)

Iodine deficiency, which is the most common cause worldwide

Thyroiditis

Intake of goitrogens such as soy, peanuts, cabbage or broccoli

Pituitary disease

Radiotherapy

Nodules or cysts

Thyroid cancer

Certain medications
 PATHOPHYSIOLOGY
•Enlargement of thyroid, i.e. goiter is an adaptive reaction of thyroid follicular
cells to any process that blocks thyroid hormone production. The most
common cause of goiter is iodine deficiency.

•In countries that use iodized salt and in others where iodine deficiency is not a
problem, Hashimoto thyroiditis is an important cause of goiter. However,
iodine deficiency still remains the most common cause worldwide.
Goiters have various morphological, hormonal, and clinical presentations and not all causes of
goiter can be attributed to iodine deficiency. Genetic, demographic, and environmental factors
are also responsible for the development of goiter.

◦ Other causes include Graves disease, inborn errors of thyroid hormone synthesis, congenital

hypothyroidism, inflammatory thyroid diseases like postpartum thyroiditis, infiltrative

diseases of thyroid like sarcoidosis, and amyloidosis, TSH secreting pituitary adenomas, and
others
 The pathophysiological consequences of goiter results from the following

◦ Thyroid hormone dysfunction

◦ Enlarges thyroid gland

◦ The effect of primary disease causing goiter

 SYMPTOMS
The main symptom is an enlarged thyroid gland . The size may range from
a single small nodule to a large mass at the front of the neck. Some people
with a simple goiter may have symptoms of an underactive thyroid gland .

In rare cases , an enlarged thyroid can put pressure on the windpipe
( trachea) and food tube ( esophagus). This can lead to :

Breathing difficulties ( with very large goiters), especially when lying flat
on the back or when reaching up with your arms
 The pathophysiological consequences of goiter results from the following

◦ Thyroid hormone dysfunction

◦ Enlarges thyroid gland

◦ The effect of primary disease causing goiter

DIAGNOSIS
Urinary iodine (UI) is a more sensitive indicator of
changes in iodine intake and is, therefore, the preferred
indicator for assessing iodine nutrition in the population
and monitoring iodine interventions.

A goiter is often discovered during a routine physical

exam. By touching the neck, the health care provider
may detect an enlargement of the thyroid, an individual
nodule or multiple nodules. Sometimes a goiter is found
when undergoing an imaging test for another condition.
Measure the size of the thyroid

Detect any nodules

Assess whether the thyroid may be overactive or underactive

Determine the cause of the goiter

Thyroid function test

Antibody test

Ultrasonography

Radioactive iodine uptake

 TYPES OF GOITER
1. Toxic goiter

In this, the amount of thyroid hormones produced by the

enlarged thyroid gland increases.

2. Non toxic goiter

In this, the thyroid gland is enlarged without an increase in

the level of thyroid hormones. Non toxic goiter is associated
with the absence of hypothyroidism or hyperthyroidism.
Classification based on the cause

3.Endemic goiter
It occurs due to deficiency of iodine in a community. More than 10% of the people of the
community are affected.

4.Sporadic goiter
In this a lesser number of individuals from the community are affected. It can affect people with
possible factors such as family history, iodine deficiency, age (over 40 years) and female gender.
5.Simple (diffuse) goiter
In this, the whole thyroid gland swells and it feels smooth to touch .

6.Nodular goiter
In this, thyroid nodules develop in the thyroid gland. Nodules are

solid or fluid filled lumps in the thyroid gland. They can be:

•Uninodular (with one nodule)

•Multinodular (with more than one nodule)

Relation between iodine deficiency and
goiter
Iodine is an essential trace element in the human body and is a crucial
component of both thyroxin and triiodothyronine, key hormones of
thyroid gland.

 Iodine exerts its physiological function through these hormones,

promoting material and energy metabolism and allowing growth and
development. Insufficient iodine intake can lead to an iodine deficiency,
which will manifest itself as specific health problems such as goiter
 Iodine intake must be kept in balance; excessive iodine levels will lead to adverse effects
just as insufficient iodine levels will.

Iodine has biological effects only when it contributes towards the synthesis of thyroid
hormones within the body. However, not all iodine obtained from the diet can be utilized for
thyroid hormone synthesis in the human body and some of it is excreted through the kidneys.

 In people who have a low protein intake, such as vegetarians, the bioavailability of iodine is
limited
Basic Characteristics of 4 Patients With Iodine
Deficiency–Induced Goiter
RECOMMENDED DIETARY INTAKE
PER DAY
Infants aged 0–6 months* 90 µg
Infants aged 7–12 months* 110 µg
Girls and boys aged 1–3 years 90 µg
Girls and boys aged 4–8 years 90 µg
Girls and boys aged 9–13 years 120 µg
Girls and boys aged 14–18 years 150 µg
Women and men aged 19 years 150 µg
and over
Pregnant women 220 µg
Lactating women 270 µg
Iodine is found naturally in a range of foods such as:

dairy products

seafood

seaweed (kelp)

eggs

green leafy vegetables.

The amount of iodine available in these foods depends on where the food was grown and how it was
made.
Universal salt iodization is the most widely used strategy to control iodine deficiency. In India,
the essential iodization of all table salts was introduced in 1983

Have 2 to 3 seafood meals per week. This will provide most adults with enough iodine to fulfil
their average iodine requirement, and provide beneficial fish oils.

Beef , fish , shell fish , cod

 DIETARY REQUIREMENTS
Calories: The calorie requirement for a goiter patient can vary
depending on their age, gender, weight, and activity level. Generally, a
balanced diet with an appropriate calorie intake to maintain a healthy
weight is recommended. Adults may need 30-40Kcal/kg BW and
children about 100 Kcal/kg BW.

Carbohydrates: Liberal amount of carbohydrates are recommended

as they are the major colorie contributers’. Opt for complex
carbohydrates such as whole grains, fruits, and vegetables. Limit
Iodine: Iodine is crucial for thyroid function. Include iodine-rich foods in the diet such as iodized
salt, seafood, dairy products, and seaweed. For children 120mcg for adults150mcg. Also depend
on the kind of thyroid disorder the individual has

Proteins: Proteins are essential for tissue repair and maintenance. Good sources of protein
include lean meats, poultry, fish, eggs, dairy products, legumes, nuts, and seeds. It is
recommended that adults consume about 0.8gm of protein /kg of BW per day( 60% of foods with
high biological value recommended )
Fats: Healthy fats are important for overall
health. Focus on sources of unsaturated fats
such as avocados, nuts, seeds, and olive oil.
Limit saturated fats found in fatty meats, full-fat
dairy, and processed foods.
TREATMENT
•Thyroid hormone replacement pills prescribed if the goiter is due to an
underactive thyroid

•Small doses of Lugol’s iodine or potassium iodine solution if the goiter is

due to a lack of iodine

•Radioactive iodine to shrink the gland if the thyroid is producing too

much thyroid hormone

•Surgery ( thyroidectomy) to remove all or part of the gland

MEDICATION

Levothyroxine is a thyroid hormone replacement therapy. It is likely prescribed if the cause of

the goiter is an underactive thyroid ( hypothyroidism) .Other medications are prescribed if the
cause of the goiter is an overactive thyroid (hyperthyroidism). These drugs include methimazole
and propylthiouracil.

Prescription of aspirin or a corticosteroid medication if the goiter is caused by inflammation

 FOODS TO BE AVOIDED
There are a class of foods described as goitrogenic . According to a
report published in Journal of Clinical and Diagnostic Research in
January 2016 , goitrogenic foods are certain types of foods that can
reduce the absorption of the T4 thyroid hormone and negatively
interfere with the way the thyroid hormone works. Goitrogenic foods
may be especially problematic for those with Hashimotos thyroiditis,
since they’re known to increase the mechanism of autoimmune
diseases.


Cabbage

Cauliflower

Brussels sprouts

Broccoli

Turnips

Mustard greens

Kale

Cassava root

Lima beans
Sweet potato

Millet

Soy and soy products

Green tea

You don't have to completely eliminate goitrogenic foods, which offer other health benefits, from your
diet, but it's best to avoid eating them raw. According to the report in the Journal of Clinical and
Diagnostic Research, washing, cooking and boiling can reduce the amount of goitrogens present in these
foods and make them safer for you to eat if you have a goiter.
FOODS TO PREVENT GOITER
Consuming adequate iodine is the most critical dietary factor for preventing goiter. It’s easy to
add iodine to your diet through these simple strategies:

Use iodized table salt which provides a moderate amount of iodine. Sea salt does not contain
added iodine.

Eat seafood like cod, tuna, shrimp, and seaweed a couple of times a week.

Have yogurt, cheese, and milk daily as part of balanced meals.

If you avoid dairy, try enriched soy milk as a plant-based source of iodine.

Eating seaweed regularly helps meet iodine needs on vegan and vegetarian diets.

SPECIAL CONSIDERATION-- Pregnant and breastfeeding women need a higher intake of

iodine and other nutrients to support both maternal health and infant development. The iodine
RDA increases to 220 mcg during pregnancy and 290 mcg when breastfeeding.

A prenatal iodine supplement should be RECOMMENDED.

 REFERENCE
https://www.researchgate.net/figure/Urinary-iodine-excretion-UIE-classifications-in-school-children_
tbl2_315904720
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10402791/
https://www.sciencedirect.com/science/article/pii/S2376060520303643#t0010
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094504/
Goiter causes and treatment N K Agarwal
https://academic.oup.com/edrv/article/24/1/102/2424321?login=false