Over-the-counter protein supplement resulting in impaired thyroxine absorption in a hypothyroid patient.

SUMMARY: Whey protein is a popular dietary supplement that is claimed to provide multiple health benefits. It has been shown to delay gastric emptying and impair ileal nutrient absorption. Additionally, some of the other additives like papain enzyme, soy lecithin in these protein supplements could interfere with L-thyroxine absorption. There is no evidence in the literature for the effects of protein supplements on L-thyroxine absorption. Herein, we describe a case of a 34-year-old lady who was on endocrinology follow up for primary hypothyroidism with stable thyroid-stimulating hormone (TSH) levels within the normal range while on L-thyroxine with a dose of 125 µg daily for the last 3 years, presenting with mild hypothyroid symptoms and elevated TSH level following a recent introduction of a protein supplement by her physical care adviser. Her treatment adherence and ingestion technique were good throughout, she was not on other medications or herbal remedies, there were no other changes in her food pattern or features suggestive of malabsorption, she was not pregnant, was taking the same L-thyroxine brand and TSH test was done from the routine lab. Since the only factor which could have contributed to the deranged TSH levels was the recent introduction of the whey protein supplement, we advised her to stop the protein supplement while continuing the same dose of L-thyroxine. Her TSH level was repeated in 6 weeks and was found to be normal (1.7 mIU/L). Our case report demonstrates that over-the-counter protein supplements could interfere with L-thyroxine absorption. Therefore, patients on L-thyroxine should be cautious when taking them. LEARNING POINTS: Over-the-counter protein supplements could interfere with oral L-thyroxine absorption. The underlying mechanism could be the effect of whey protein by delaying gastric emptying and reduced responsiveness of organic anion transporters in the ileum, and there may be a contribution from other additives like papain and soy lecithin present in these supplements. When there is an elevation of previously stable thyroid-stimulating hormone (TSH) value in a hypothyroid patient on oral L-thyroxine, the patient's assessment should include inquiring for a recent introduction of protein supplement, in the absence of other well-known risk factors. Discontinuation of protein supplement results in normalization of thyroid function tests. Patients on oral L-thyroxine should be cautious when taking over-the-counter protein supplementation.

High Prevalence of Overweight/Obesity in Urban Sri Lanka: Findings from the Colombo Urban Study.

BACKGROUND: South Asian countries face a double burden of malnutrition characterized by high prevalence of underweight, overweight, and obesity. Understanding the distribution of this public health problem is important to tailor targeted interventions for communities. The objective of the current study was to find out the prevalence of obesity in urban Sri Lanka and to identify sociodemographic factors associated with it. METHODS: Adult males and females residing in an urban government division of the Colombo District in Sri Lanka were included in this study (Colombo Urban Study). Stratified simple random sampling was used to select a sample of 463 from the total population. Sociodemographic data using an interviewer-administered questionnaire, anthropometric measurements, and serum samples were obtained for investigations. RESULTS: When the global BMI cutoffs were applied, the community prevalences of underweight, normal weight, overweight, and obesity were 7.7%, 39.6%, 37.0%, and 15.8%, respectively. When the Asian BMI cutoffs were applied, the respective prevalences were 7.7%, 26.8%, 34.3%, and 31.2%. The community prevalence for abdominal obesity was 58.1% when using Asian cutoffs. Females had a higher prevalence of both obesity and abdominal obesity. There was an ethnic difference in obesity rates with Moors having the highest rates (65.5%) followed by Sinhalese (52.3%) and Tamils (40.2%). The highest obesity prevalence was observed in the most educated group. Multiple regression analysis showed that high BMI was associated with female gender and family history of hypertension. Serum LDL negatively associated with BMI while the strength of this relationship was impacted by serum HBA1c levels. Finally, serum triglyceride level showed positive association with BMI, and the effect was more marked in Moors compared to Sinhalese. CONCLUSION: Two-thirds of adults in the studied urban population were overweight or obese. This highlights the urgent need for interventions to curb this epidemic. The gender, ethnic differences in obesity, its associations with educational status, and the interactions with metabolic comorbidities indicate that these interventions may need to be targeted towards different groups in the population.

Hypopituitarism following envenoming by Russell's vipers (Daboia siamensis and D. russelii) resembling Sheehan's syndrome: first case report from Sri Lanka, a review of the literature and recommendations for endocrine management.

Russell's vipers (Daboia russelii and D. siamensis) inhabit 10 South and South East Asian countries. People envenomed by these snakes suffer coagulopathy, bleeding, shock, neurotoxicity, acute kidney injury and local tissue damage leading to severe morbidity and mortality. An unusual complication of Russell's viper bite envenoming in Burma (D. siamensis) and southern India (D. russelii) is hypopituitarism but until now it has not been reported elsewhere. Here, we describe the first case of hypopituitarism following Russell's viper bite in Sri Lanka, review the literature on this subject and make recommendations for endocrine investigation and management. A 49-year-old man was bitten and seriously envenomed by D. russelii in 2005. He was treated with antivenom but although he recovered from the acute effects he remained feeling unwell. Hypopituitarism, with deficiencies of gonadal, steroid and thyroid axes, was diagnosed 3 years later. He showed marked improvement after replacement of anterior pituitary hormones. We attribute his hypopituitarism to D. russelii envenoming. Russell's viper bite is known to cause acute and chronic hypopituitarism and diabetes insipidus, perhaps through deposition of fibrin microthrombi and haemorrhage in the pituitary gland resulting from the action of venom procoagulant enzymes and haemorrhagins. Forty nine cases of hypopituitarism following Russell's viper bite have been described in the English language literature. Patients with acute hypopituitarism may present with hypoglycaemia and hypotension during the acute phase of envenoming. Those with chronic hypopituitarism seem to have recovered from envenoming but present later with features of hypopituitarism. Over 85% of these patients had suffered acute kidney injury immediately after the bite. Steroid replacement in acute hypopituitarism is life saving. All 11 patients with chronic hypopituitarism in whom the outcome of treatment was reported, showed marked improvement with hormone replacement. Unrecognized acute hypopituitarism is potentially fatal while chronic hypopituitarism can be debilitating. Physicians should therefore be aware of this complication of severe envenoming by Russell's vipers, especially in Burma and South India, so that the diagnosis may be made without delay and replacement started with essential hormones such as hydrocortisone and thyroxine.