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How Do Athletes Manage Graves' Disease

When physically active individuals cannot keep up with their usual workouts, a diagnosis of Graves' disease should be considered, especially in men for whom this condition is less common.

With Minisha Sood, MD, and Mario Skugor, MD

Larry Turkheimer was in the best shape of his life, doing triathlons and feeling fit when he became so exhausted he could barely get out of bed in the morning. After feeling tired for about six months, he visited his internist who told him to rest. "I did that but nothing seemed to help for the next year," he said, so the Los Angeles-based advertising executive, 62 years young, went from one doctor to another in search of a diagnosis.

When you find yourself unable to keep up with your usual athletic routine, listen to your body.  While there are many reasons that you may not be able to maintain your usual performance level, it is important to seek medical attention to identify what’s behind this change.

From his internist, he was sent to a rheumatologist, an infectious disease specialist, and a gastroenterologist before he met with an endocrinologist; this search lasted nearly a year before he learned that his symptoms were related to Graves’ disease.  To this Mr. Turkheimer says, "I would say to athletes and non-athletes, be patient and ask a lot of questions."

When someone who is highly fit starts to feel fatigue, a thyroid check may be in order.When athletes can't maintain their usual level of fitness, it may be a sign of Graves' disease. Photo: 123RF.

When You Can No Longer Keep Up with  Your Regular Workouts

A hallmark sign of hyperthyroidism is unexplained fatigue.1,2 And a diagnosis can be particularly challenging since differences in laboratory blood values may not match with presenting complaints.3

At the time of his diagnosis, Mr. Turkheimer was prescribed medication that did little to improve his symptoms or make him feel any better. After consulting with his doctor about other options to treat Graves' disease, Mr. Turkheimer decided to go with radioactive iodine (RAI) treatment to get the disease under control. It has been slow going for this highly active man, and understandably, extremely frustrating.

“I am a triathlete—a two-time IRONMAN finisher,” he says. “How do athletes like myself stay competitive with all the fatigue and the dietary challenges that come with Graves’ disease?”

Graves disease is an autoimmune thyroid condition that leads to hyperthyroidism, or an overactive thyroid. Left untreated, Graves’ thyroiditis can have serious adverse effects on multiple organs, including the heart, muscles, and bones as well as fertility in men.1,2

Diagnosis of Graves' Disease Is More Complicated In Athletes 

When an athlete, particularly someone over age 40, struggles to maintain his usual training, competition, or recovery, an overactive thyroid gland may explain the changes. Symptoms such as fatigue, shortness of breath, or palpitations, can be telltale signs of Graves’ disease.3

This is the most common form of hyperthyroidism in the United States, affecting 1 in every 200 adults but because it is seven to eight times more common in women than men,4 Graves’ isn’t usually considered a problem in men.2 Typically, medication is used to normalize thyroid function and if that proves insufficient, treatment with either radioactive iodine or surgery is used to protect the patient against continued exposure to excess thyroid hormones.

Arriving at a diagnosis is made more challenging given differences in laboratory blood values that don’t match with presenting complaints and symptoms.3 The ability to properly diagnose a thyroid condition may be further complicated in individuals undergoing significant physical stress or who taking anabolic steroids or exogenous thyroid hormone.

Since medication didn’t make Mr. Turkheimer feel better, he was treated with radioactive iodine to alleviate his symptoms and restore his energy. Feeling somewhat better, he now takes the synthetic thyroid hormone and is trying to start exercising again by walking a mile or so, a few days a week to build up his strength.

Recovery Is Often Slow, and Can't Be Rushed  

Bouncing back after treatment for Graves' disease takes time, and an athletes ability to return to training will depend upon individual responsiveness to treatment.

 “It’s been frustrating,” Mr. Turkheimer concedes. “I had been doing triathlons for 20 years, training all the time and now I can hardly walk a mile or two without feeling exhausted. And I’ve had insomnia, anxiety, and depression as well. I just don’t know whether I should push myself to exercise more.”

When it comes to Graves’ disease, patients should be wary of doing too much too soon, experts say. If you push yourself, unpleasant physical symptoms can develop due to inflammation, a common occurrence in autoimmune diseases.

Treatment for Graves’ thyroiditis does not result in an immediate improvement of symptoms, says Minisha Sood, MD, an endocrinologist at Lenox Hill Hospital in New York City. The treatment with radioactive iodine can take several weeks or a few months to work, once the dose is given. “Everyone has a different trajectory,” Dr. Sood says. “But it could take anywhere from three to six months for a patient to feel better.”

One factor that will impact the management of Graves’ disease is ophthalmopathy.1,5 About 20%, and up to 50%, of people with Graves’ disease, experience this eye condition.4  Graves' eye disease typically causes swelling and inflammation in the tissue behind the eye, as well as redness, dryness, puffy eyelids, and a gritty sensation like having sand or dirt in the eyes as the chief symptoms.5Some patients may develop a bulging of the eyes that is caused by inflammation of tissues behind the eyeball.

“It’s a complicated condition, best comanaged between the ophthalmologist and the endocrinologist,” Dr. Sood says. “But if you have eye disease due to Graves’, you can have worse outcomes if your condition is not managed right.”

“As for dealing with diet during the time my hyperthyroidism was in full swing, I cut out sugar and bread, and ate protein all day long but still was losing weight,” said Mr. Turkheimer. “Also, I cut out all caffeine. Managing my diet with hyperthyroidism has been tough because most doctors are not well versed in addressing dietary needs.” He suggests seeking that expertise from other athletes or nutrition specialists.

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Returning to Your Former Fitness Level

For Mr. Turkheimer, walking a mile and trying to work up to two is how he is trying to get back into shape. He also is trying to get more sleep to fight back his fatigue. “I used to get by on five or six hours of sleep,” he says. “Now I try for a minimum of eight or nine hours of sleep so I aim to get into bed around 9 pm.”

According to the experts, returning to training, and ultimately to competition, will depend upon an individual's responsiveness to treatment. 3 This can only be determined by monitoring a person's lab values and physiological improvements, and it takes time. Not something that comes easily to any athlete but by taking the time to recover, you will gradually return to your desired level of fitness. If you push too hard, too soon, you will simply set your progress back.

Here are four tips that Drs. Sood and Skugor recommend for athletes trying to get back into shape:

Don’t push yourself. It’s tempting to fight fatigue by pushing forward but it is not recommended. “Listen to your body because if you don’t, you can further stress your system, slowing your recovery,” says Dr. Sood, MD

“If you’re an athlete and your thyroid levels are not well-controlled, you’ll be at heightened risk for a rapid heart rate and shortness of breath.”

With Graves’ disease that has not yet been treated, there is a diminished strength as well as a high heart rate, explains Mario Skugor, MD, an endocrinologist at the Cleveland Clinic in Ohio. “If you exercise the symptoms will get worse,” he says.

Start slowly and build up. “Remember that it takes time to recondition yourself,” Dr. Sood says. Don’t jump right back in an attempt to do everything you were doing before all at once.

Mr. Turkheimer has heeded this advice, and says he is still “a work in progress.” “I want to exercise because it will help me get my energy back,” he says. “However, I’m realizing that I have to get myself back in shape more gradually. It’s been a slow build back.”

Keep your physician in the loop. “Work out in conjunction with your physician so you know your thyroid levels are well controlled,” Dr. Sood says. “If you work out and you are feeling really tired, it could mean that your hormone levels are off and you may need your medication adjusted.” Keeping your doctor in the loop ensures that your condition is properly monitored, and the correct blood tests are ordered in a timely fashion so irregularities can be caught and corrected.

Be patient. While it's not what you want to hear, in the long run, you will get back to feeling yourself but the results of Graves’ treatment doesn’t happen overnight. “Once your Graves’ disease is well managed and your body has adjusted, you should be able to accomplish everything you achieved before,” Dr. Skugor says. “It’s important to understand that you can fix this and be as good as you’ve ever been,” so long as you seek treatment and maintain regular follow-up visits so your progress is monitored. 

EndocrineWeb would like to thank Larry Turkheimer for sharing his story so that others might learn from his medical journey, and be better prepared to address unexpected symptoms.

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