By Shannon Kelleher
BU News Service

When Amanda Zook gained forty pounds in three months the summer after graduating college, she knew that something wasn’t right. Bewildered, she went to see her doctor, who told the twenty-two year old “well, you’re getting older now,” gave her some medication for depression, and sent her on her way. Amanda didn’t trust the “diagnosis”, so a year later she went to see another doctor, who gave her a standard blood test and diagnosed her with hypothyroidism (underactive thyroid). It’s been twenty years since she started taking medication for the disorder, yet Amanda still suffers symptoms: aches and pains, insomnia, hair loss and lack of sex drive. She naps daily and forgets words. “I think it’s actually getting worse,” she says.

Hypothyroidism is riddled with controversy from diagnosis through treatment, and ultimately it’s the patients who bear the brunt of the confusion. There are as many as 27 million people in the United States diagnosed with hypothyroidism, most of them middle-aged women. While standard treatments are effective for some, others, like Amanda, are not getting the balance of hormones they need to feel normal. While some doctors remain relatively satisfied with the state of thyroidology, others contend that the field is in need of change.

The thyroid is a butterfly-shaped gland in the neck that produces the hormones that regulate metabolism. Two of those hormones, T3 and T4, are the most critical and best understood. “Thyroid hormone is kind of like the accelerator pedal or the thermostat,” says Dr. Henry Lindner, a specialist in endocrinology, diabetes and metabolism at the Hormone Restoration clinic in Tunkhannock, Pennsylvania. When thyroid hormone levels are healthy, the body’s metabolism runs smoothly. But if those levels are out of whack, the metabolism is too.

In mainstream endocrinology, the solution to this metabolic imbalance is wrapped up in two controversial elements: a TSH blood test for diagnosis and a synthetic T4-only medication for treatment (commonly a drug called levothyroxine). Thyroid-stimulating hormone, or TSH, is produced by the pituitary gland and stimulates the thyroid gland to produce T3 and T4. Unless the endocrinologist suspects that the patient has a problem with the pituitary gland (which accounts for about 5% of all hypothyroid patients), the doctor tests the concentration of TSH in the patient’s blood as a measure of how well her thyroid is functioning. The pituitary gland produces excess amounts of TSH in an effort to jump-start the sluggish thyroid, so if the TSH measurement is too high, the patient is diagnosed with hypothyroidism. The question is, what exactly is ‘too high’?

“There is considerable controversy about what the upper limit of normal for the range should be,” says Dr. Douglass Ross, Co-Director of the Thyroid Associates at Massachusetts General Hospital. Endocrinologists respond to the reference range uncertainty by simply using their best judgment. “I generally do not treat someone who feels ‘hypo’ but their TSH levels are normal and their antibodies are negative…but my definition of normal is much tighter than the normal range” says Dr. Stephanie Lee, an endocrinologist at Boston Medical Center. She also adjusts for age, treating young people for hypothyroidism if their TSH measures in the upper limit of the standard range.

Some argue that TSH reference ranges are too unreliable to be diagnostic. “When I was in medical school the TSH upper limit was 10,” says Dr. Ron Rothenberg,Vice President of the International Hormone Society in North and South America. “Now in most labs it’s like 5, 4.5. Most endocrine journals are saying 2.5. I think people feel the best when it’s less than 1.5. It’s a totally arbitrary number. But it’s set way too high. It lets a lot of people walk around hypothyroid.”

Within mainstream endocrinology, there is little debate when it comes time to write the prescription; a T4-only medication such as levothyroxine is almost always the choice. The idea is that when the T4 hormone enters the body, it converts to all the T3 the patient needs. “I prefer T4 because your body constantly, slowly converts T4 to T3 as needed, so the levels are very stable from minute to minute,” says Dr. Lee. “If you use T3 in addition to T4 or thyroid extract, the levels are very variable during the day.” While some occasionally prescribe T3 if T4 alone does not have the desired effect for the patient, few deviate often from synthetically-produced T4 medication.“(Levothyroxine) works beautifully…the biggest problem is they don’t take the pills regularly” says Dr. Lewis Braverman, a specialist in thyroid disorders and general endocrinology at Massachusetts General Hospital.

Some hormone therapists outside of mainstream endocrinology are less enthusiastic about T4-only medication being a catch-all hypothyroidism treatment. They say that patients feel best on a combination of T3 and T4, and some prescribe their patients desiccated thyroid (thyroid tissue extracted from pigs).“There has basically been a sort of assumption for the last 30, 40 years that all they need to do is get people T4 and their body will convert all of the T4 to T3 that they need and they’ll have perfect thyroid replacement. But that clearly does not work,” says Dr. Lindner. Some endocrinologists also acknowledge that not all patients’ bodies are equipped to convert T4 into the T3 that they need. “We know that certain people have genetic variance which make the conversion of T4 to T3 less efficient, and perhaps these are the patients who benefit from combination therapy,” says Dr. Kopp. However, endocrinologists tend to think of these patients as the exception, not the rule.

Endocrinologists continue to rely heavily on TSH tests for diagnosis despite a lack of consensus about the reference range. According to the 2014 “Guidelines for the Treatment of Hypothyroidism” published in the American Thyroid Association magazine Thyroid, levothyroxine is to remain the standard medication for treatment. But not even all mainstream endocrinologists think it’s a flawless system. “I think levothyroxine doesn’t mimic physiology perfectly,” says Dr. Ross. “People who take levothyroxine have slightly higher T4 and slightly lower T3 levels than normal.” Likewise, Dr. Kopp is skeptical that T4-only treatments are necessarily the best solution, believing that treatments with both T4 and T3 may have undiscovered potential. “As a clinician I can tell you that some people do feel better if they take combination therapy,” he says,“ but we don’t really know how to predict who benefits from combination therapy and who does not, and I think it is a part where we need more research to figure this out.”

With so much emphasis on blood tests, some non-mainstream thyroid doctors worry that endocrinologists are overlooking the most important source of information: the patient. “The old-time docs were clinicians and they would talk to the patients” says Dr. Jeffrey Dach, the founder of TrueMed MD. “We don’t have those guys any more.” But some endocrinologists hesitate when it comes to relying on vague symptoms such as fatigue and weight gain. “It’s really difficult to figure out whether their complaints are from their thyroid,” says Dr. Lee.

Amanda Zook understands firsthand that hypothyroidism is a complex condition. For the twenty years that she has been on medication, her TSH numbers have stayed in the normal range. Yet despite all the reassurances that nothing is wrong, Amanda knows better. “They don’t really have a way to test people when everybody is so different,” she says. [And] there’s no magic pill.”

By Shannon Kelleher
BU News Service

With marijuana now legalized for medical use in twenty-three states and for recreational use in two (Colorado and Washington), American interest in the leafy green drug is on the rise. In fact, according to the Pew Research Center, 48% of American adults report that they have tried marijuana, up from 40% only two years ago. However, despite its increasing popularity there appears to be a lack of both scientific knowledge and public awareness about the risks and possible benefits of marijuana.

Despite pre-clinical research explaining the drug’s mechanism and many case-control studies of people with a history of use, scientists have conducted few clinical marijuana studies. This is largely because it is considered a schedule 1 controlled substance, the most dangerous government drug listing. Heroin is also schedule 1, while cocaine and methamphetamines are schedule 2. Alcohol and tobacco are not listed. Marijuana is further restricted in that researchers must receive permission from a host of federal agencies in order to study it in clinical trials. Even then, they can only obtain it from the National Institute on Drug Abuse (NIDA).

There has scarcely been a point in American history when the government did not restrict marijuana research. According to Associate Professor of History Dr. David Herzberg at the University of Buffalo, as far back as the 19th century most states recognized marijuana as a poison and limited its sale. Restrictions have only tightened over the years, with the Marijuana Tax Act of 1937 requiring physicians to receive federal permission before prescribing the drug (although by that point most states had prohibited it). In 1970, marijuana was officially listed as a schedule 1 drug under federal law, resulting in the current series of hurdles that researchers must clear in order to obtain it. At the Center for Medicinal Cannabis Research, the largest facility of its kind in the United States, Dr. Atkinson acknowledges that it initially took his research team two and a half years to receive the marijuana they needed for clinical trials; the process has now been streamlined to about a year and a half.

While existing studies suggest that marijuana poses less severe health threats than legalized drugs like tobacco and alcohol, researchers nonetheless worry about two of its effects on frequent users: addiction and lowered IQ. NIDA states on its website that about 9% of users become addicted, although the number rises to 17% for those who start in adolescence. According to a 2014 study of marijuana use by college students published in the journal Addictive Behaviors, cannabis smokers performed worse on memory and cognition tests than non-smokers. McLean Hospital clinical researcher Dr. Kevin Hill, who treats marijuana addicts with gradually smaller doses of FDA-approved marijuana to combat withdrawal symptoms, says that “research is quite clear that regular use is going to catch up with you.” While it may be less addictive than some other drugs, marijuana poses a risk of dependency that can detract from a user’s quality of life.

Frequent marijuana use may also impair attention, executive function, and memory in adults—and it may weaken cognitive development in adolescents. A 2007 study published in the Journal of the International Neuropsychological Society found that 16-18 year-old marijuana users who quit for a month scored significantly lower on tests measuring their ability to sequence information than their peers who never used it. This suggests they might have a harder time learning, which could explain their lower GPAs; the users averaged a 3.0 whereas the controls averaged a 3.4.While it is difficult to definitively assess the effect of heavy marijuana use on IQ, Hill says that brain imaging studies at McClean show that users require more mental energy to carry out the same tasks as non-users. According to Dartmouth Professor of Psychiatry Dr. Alan Budney, even weeks after quitting long-term use, subsequent improvements in cognitive functioning cannot account for the level of mental aptitude a user would have had if he or she never started using.

Additionally, marijuana smoke has been shown to cause irritation in the lungs and excessive phlegm just like with tobacco smoke, although, as Budney notes, it has not been linked to cancer. The drug has not been directly correlated with psychosis, although researchers believe that it may cause psychosis to be expressed in those with a genetic predisposition.

On the other hand, the drug seems to have benefits. From the handful of clinical trials they have conducted and through observational and case study data, researchers have determined that marijuana can be effective in treating certain health conditions. Well-substantiated data suggests that it is an effective treatment for three ailments: chronic pain, neuropathy, and nausea. Dr. Atkinson’s research shows that marijuana works well with other pain treatments which are not sufficient by themselves. When doctors paired marijuana with these treatments, 30% of patients noticed decreased pain compared with a placebo sample. However, as Hill says, “Outside of [chronic pain, neuropathy, and nausea], the data’s not good. It’s not a yes/no, black/white thing.”

While marijuana may indeed have legitimate therapeutic benefits, it is extraordinarily difficult to standardize the dosage of smoked substances—and that’s where researchers have a problem with medical marijuana dispensaries. “With marijuana, what would you tell anybody?” Budney says. “You should take a 6% THC cigarette and you should puff on it 3 times a day for 6 weeks? We haven’t worked any of that out. That’s why we don’t have any smoked medicines right now.” For this reason, doctors don’t actually write prescriptions to dispensaries. These function more like herb stores: unregulated, offering varying concentrations and making sometimes unsubstantiated claims about cures.

It may be challenging at best to determine marijuana’s medicinal value, but scientists have found another way to tap into the drug’s silver lining. By designing compounds that mimic THC—the chemical kick behind marijuana’s intoxicating effect—rather than relying on the cannabis plant, researchers avoid a mess of clinical complexities and political inefficiencies. The National Institute of Health has funded research for these synthetic siblings of marijuana, like Dronabinol and Nabilone, to treat pain and nausea in chemotherapy and AIDS patients. But despite the government’s burgeoning interest in synthetic cannabinoids, there is no sign that federal roadblocks to researching the plant itself will be lifted anytime soon. And so the debate rages on.

“There’s only two types of people in the marijuana debate,” says Atkinson. “Those that are for it think it’s wonderful and there are no ills, and those that are against it think it’s the device of the devil and has no benefit.”

By Shannon Kelleher
BU News Service

As Robert A. Knox Professor at Boston University’s School of Public Health, Chair of International Health, and former director of the Center for Global Health and Development, Jonathon Simon is well versed in finagling with businesses and government agencies alike. But he also has an indelible soft spot for children—Simon often invites faculty members’ kids to play in the conference room during meetings.

Simon’s work centers around improving the health of populations in third world countries, with an emphasis on helping children. But he won’t describe it as pediatrics—his approach to health care is more integrative. “Often it’s not clinical things,” he explains. “Often it’s knowledge things. Moms know when their babes are sick. It’s their ability to act upon that knowledge, and that has to do with family dynamics.” He has found that issues of female empowerment often are central to a mother’s ability to care for her sick children. In cultures that operate under purdah, in which women cannot even leave the house for medical assistance without being accompanied by a man, health care systems must be structured differently to meet families’ needs.

By taking a holistic approach to health care, Simon works to target world health crises at their roots. All too often, the focus in targeting disease remains grounded in the drugs themselves, an approach that Simon believes misses the big picture. This has become clear to him with HIV treatment. When the South African government asked his group what it would cost to begin treating HIV at an earlier stage Simon knew there was more to look at than the cost of HIV therapy itself. He and his team measured costs associated with doctors, nurses, auxiliary training for health care workers, transportation, a working day missed to receive medical treatment— real world elements that are often overlooked. Only after three years of intensive research could they confidently approach the South African government with an answer that accounted for those various actors.

The structure of Simon’s team is crucial to uncovering the complexity behind each seemingly simple question. The Center consists of three groups: clinical sciences, applied economics, and evaluation sciences. The clinical group covers the medical side of things, performing standard trials for, say, antibiotics, while the applied economics group accounts for the complexity of cost. The evaluation sciences group sees if existing programs are working and tries to optimize them when they are not. “One of the interesting aspects of the center is that it’s quite a horizontal structure. It doesn’t feel like a hierarchical organization,” says Dr. Jacob Bor, who works in applied economics to answer questions about HIV treatment in southern Africa.

Dr. Nafisa Halim, a social demographer who researches women’s empowerment and gender equality in public health, admires Simon’s ability to bring people together. After earning her PhD in sociology, Halim knew that she needed to apply her skills to the real world in all its messiness. ““I am from Bangladesh. I saw poverty. I saw the illnesses and diseases firsthand.” When she learned about Simon and the culture he has created in the CGHD, Halim knew she had found a place where her work could have an impact. Halim now works with her colleague Emily Rothman, Associate Professor of the Committee of Health Sciences, to study an intervention in Bangladesh aimed at decreasing domestic violence. It’s a partnership that Halim says she owes to Simon’s skills as an “academic matchmaker,” saying: “I couldn’t make the connection of how a collaboration could take place.”

According to Simon, about 6 million kids under age five die every year, which is a vast improvement over the 18 million who died annually only a decade ago. Still, he believes most of the deaths are unnecessary. If the technologies we already have available were introduced into third world countries, he says, 80% of the children that died last year would still be alive.

“There is an absolutely criminal amount of avoidable mortality in children,” he says. “The ones that bother me the most are the malnutrition wards” he says. “I see some depressing shit, to be honest,” he says. “And I don’t get depressed…the key to staying in this industry long-run is to wake up every morning and delude yourself to believing that the professional work you’re going to do today is going to improve the life of a person in the world.” He smiles wryly. “And then just do that every day for forty-five years and then retire.”
at Boston University, Jon Simon is well versed in finagling with businesses and government agencies alike. But he also has an indelible soft spot for children—Simon often invites faculty members’ kids to play in the conference room during meetings.

Simon’s work centers around improving the health of populations in third world countries, with an emphasis on helping children. But he won’t describe it as pediatrics—his approach to health care is more integrative. “Often it’s not clinical things,” he explains. “Often it’s knowledge things. Moms know when their babes are sick. It’s their ability to act upon that knowledge, and that has to do with family dynamics.” He has found that issues of female empowerment often are central to a mother’s ability to care for her sick children. In cultures that operate under purdah, in which women cannot even leave the house for medical assistance without being accompanied by a man, health care systems must be structured differently to meet families’ needs.

By taking a holistic approach to health care, Simon works to target world health crises at their roots. All too often, the focus in targeting disease remains grounded in the drugs themselves, an approach that Simon believes misses the big picture. This has become clear to him with HIV treatment. When the South African government asked his group what it would cost to begin treating HIV at an earlier stage Simon knew there was more to look at than the cost of HIV therapy itself. He and his team measured costs associated with doctors, nurses, auxiliary training for health care workers, transportation, a working day missed to receive medical treatment— real world elements that are often overlooked. Only after three years of intensive research could they confidently approach the South African government with an answer that accounted for those various actors.

The structure of Simon’s team is crucial to uncovering the complexity behind each seemingly simple question. The Center consists of three groups: clinical sciences, applied economics, and evaluation sciences. The clinical group covers the medical side of things, performing standard trials for, say, antibiotics, while the applied economics group accounts for the complexity of cost. The evaluation sciences group sees if existing programs are working and tries to optimize them when they are not. “One of the interesting aspects of the center is that it’s quite a horizontal structure. It doesn’t feel like a hierarchical organization,” says Dr. Jacob Bor, who works in applied economics to answer questions about HIV treatment in southern Africa.

Dr. Nafisa Halim, a social demographer who researches women’s empowerment and gender equality in public health, admires Simon’s ability to bring people together. After earning her PhD in sociology, Halim knew that she needed to apply her skills to the real world in all its messiness. ““I am from Bangladesh. I saw poverty. I saw the illnesses and diseases firsthand.” When she learned about Simon and the culture he has created in the CGHD, Halim knew she had found a place where her work could have an impact. Halim now works with her colleague Emily Rothman, Associate Professor of the Committee of Health Sciences, to study an intervention in Bangladesh aimed at decreasing domestic violence. It’s a partnership that Halim says she owes to Simon’s skills as an “academic matchmaker,” saying: “I couldn’t make the connection of how a collaboration could take place.”

According to Simon, about 6 million kids under age five die every year, which is a vast improvement over the 18 million who died annually only a decade ago. Still, he believes most of the deaths are unnecessary. If the technologies we already have available were introduced into third world countries, he says, 80% of the children that died last year would still be alive.

“There is an absolutely criminal amount of avoidable mortality in children,” he says. “The ones that bother me the most are the malnutrition wards” he says. “I see some depressing shit, to be honest,” he says. “And I don’t get depressed…the key to staying in this industry long-run is to wake up every morning and delude yourself to believing that the professional work you’re going to do today is going to improve the life of a person in the world.” He smiles wryly. “And then just do that every day for forty-five years and then retire.”

By Shannon Kelleher
BU News Service

The first and last time I ate a bug intentionally I was ten. My family and I were at COSI, a science center in Columbus, Ohio for kids and lifelong nerds that’s essentially the lovechild of a museum and a playground. The gift shop at COSI is a repository for fun little nerd toys ranging from flubber to astronaut ice cream.  But did my brother want any of that? No. He wanted chocolate covered worms. Naturally I had to try them. They tasted a bit off: basically an unidentifiable crunchiness concealed in milk chocolate. After that I was through with consuming the creepy-crawlies.

But apparently some people are not.

According to cnbc.com, there’s actually a growing market for foods made from the very things that cause me, for one, to scream when I find them on my bedroom floor. Curiously, I don’t have that reaction when I see a cow or a chicken, two other sources of protein in my diet. Then again, cows and chickens have a million appendages or make gross scuttling sounds when they move.

Nonetheless, companies like Six Foods are in business, making chips from beans, rice, and cricket flour. They call these chips “chirps”, which is admittedly almost cute, but still….

Of course, the environmentalist in me perked up when I read that crickets are not only packed with protein (about 1.5 times as much per gram of beef), they are also a very Earth-friendly form of sustenance. Aside from the fact that factory farms are cruel (have you SEEN the documentary Earthlings??), they also use a tremendous amount of energy.  Every pound of beef we consume requires a gallon of gasoline to produce. And more CO2 is not what our atmosphere needs right now.

Are insect entrees the secret to saving the planet? I’ll admit I’m skeptical. While companies sporting foods with buggy ingredients are developing a small but present niche in the American economy, they’re still far from mainstream. It may take a while to acclimate the average American family to the idea of chowing down on a nice hot cricket casserole instead of Sloppy Joes.