Hyperthyroidism: Overactivity of the Thyroid Gland

Part 1: Introduction to hyperthyroidism
Written by James Norman MD, FACS, FACE Hyperthyroidism is a large topic, so we have split it into four manageable sized portions. This page introduces hyperthyroidism. Subsequent pages are listed at the bottom which address more specific details of making the diagnosis of hyperthyroidism, the causes of hyperthyroidism, and different treatment options available for hyperthyroidism. In healthy people, the thyroid makes just the right amounts of two hormones, T4 and T3, which have important actions throughout the body. These hormones regulate many aspects of our metabolism, eventually affecting how many calories we burn, how warm we feel, and how much we weigh. In short, the thyroid "runs" our metabolism. These hormones also have direct effects on most organs, including the heart, which beats faster and harder under the influence of thyroid hormones. Essentially, all cells in the body will respond to increases in thyroid hormone with an increase in the rate at which they conduct their business. Hyperthyroidism is the medical term to describe the signs and symptoms associated with an over production of thyroid hormone. For an overview of how thyroid hormone is produced and how
its production is regulated, check out our thyroid hormone production page.

Hyperthyroidism is a condition caused by the effects of too much thyroid hormone on tissues of the body. Although there are several causes of hyperthyroidism, most of the symptoms patients experience are the same regardless of the cause (see the list of symptoms below). Because the body's metabolism is increased, patients often feel hotter than those around them and can slowly lose weight even though they may be eating more. The weight issue is confusing sometimes since some patients actually gain weight because of an increase in their appetite. Patients with hyperthyroidism usually experience fatigue at the end of the day, but have trouble sleeping. Trembling of the hands and a hard or irregular heartbeat (called palpitations) may develop. These individuals may become irritable and easily upset. When hyperthyroidism is severe, patients can suffer shortness of breath, chest pain, and muscle weakness. Usually the symptoms of hyperthyroidism are so gradual in their onset that patients don't realize the symptoms until they become more severe. This means the symptoms may continue for weeks or months before patients fully realize that they are sick. In older people, some or all of the typical symptoms of hyperthyroidism may be absent, and the patient may just lose weight or become depressed.

Common symptoms and signs of hyperthyroidism
• • • • • • • • • • • • • • •

Palpitations Heat intolerance Nervousness Insomnia Breathlessness Increased bowel movements Light or absent menstrual periods Fatigue Fast heart rate Trembling hands Weight loss Muscle weakness Warm moist skin Hair loss Staring gaze

Remember, the words "signs" and "symptoms" have different medical meanings. Symptoms are those problems that a patient notices or feels. Signs are those things that a physician can objectively detect or measure. For instance, a patient will feel hot, this is a symptom. The physician will touch the patient's skin and note that it is warm and moist, this is a sign.

Hyperthyroidism: Overactivity of the Thyroid Gland
Part 2: Causes of hyperthyroidism
Written by James Norman MD, FACS, FACE

There are several causes of hyperthyroidism. Most often, the entire gland is overproducing thyroid hormone. This is called Graves' disease. Less commonly, a single nodule is responsible for the excess hormone secretion. We call this a "hot" nodule. Thyroiditis (inflammation of the thyroid) can also cause hyperthyroidism. The most common underlying cause of hyperthyroidism is Graves' disease, a condition named for an Irish doctor who first described the condition. This condition can be summarized by noting that an enlarged thyroid (enlarged thyroids are called goiters) is producing way too much thyroid hormone. (Remember that only a small percentage of goiters produce too much thyroid hormone; the majority of thyroid goiters actually become large because they are not producing enough thyroid hormone.) Graves' disease is classified as an autoimmune disease, a condition caused by the patient's own immune system turning against the patient's own thyroid gland. The hyperthyroidism of Graves' disease, therefore, is caused by antibodies that the patient's immune system makes. The antibodies attach to specific activating sites on the thyroid gland, and that in turn causes the thyroid to make more hormone.

There are actually three distinct parts of Graves' disease: 1. 2. 3. overactivity of the thyroid gland (hyperthyroidism) inflammation of the tissues around the eyes, causing swelling thickening of the skin over the lower legs (pretibial myxedema).

Most patients with Graves' disease, however, have no obvious eye involvement. Their eyes may feel irritated or they may look like they are staring. About one out of 20 people with Graves' disease will suffer more severe eye problems, which can include bulging of the eyes, severe inflammation, double vision, or blurred vision. If these serious problems are not recognized and treated, they can permanently damage the eyes and even cause blindness. Thyroid and eye involvement in Graves' disease generally run a parallel course, with eye problems resolving slowly after hyperthyroidism is controlled.

Characteristics of Graves' Disease
• • •
40s) Graves' disease affects women much more often than men (about 8:1 ratio, thus 8

women get Graves' disease for every man that gets it). Graves' disease is often called diffuse toxic goiter because the entire thyroid gland

is enlarged, usually moderately enlarged, sometimes quite big. Graves' disease is uncommon over the age of 50 (more common in the 30s and

Graves' disease tends to run in families (not known why)

Other Less Common Causes of Hyperthyroidism
Hyperthyroidism can also be caused by a single nodule within the thyroid instead of the entire thyroid. As outlined in detail on our nodules page, thyroid nodules usually represent benign (non-cancerous) lumps or tumors in the gland. These nodules sometimes produce excessive amounts of thyroid hormones. This condition is called "toxic nodular goiter." The picture on the right is an iodine scan (also simply called a thyroid scan) which shows a normal sized thyroid gland (shaped like a butterfly). This scan is abnormal because a solitary "hot" nodule is located in the lobe on the left. This single nodule is comprised of thyroid cells which have lost their regulatory mechanism that dictates how much hormone to produce. Without this regulatory control, the cells in this nodule produce thyroid hormone at a dramatically increased rate causing the symptoms of hyperthyroidism. (As a point of reference, some nodules are "cold" since they don't produce any hormone at all. There is a picture of a cold nodule on the nodule page.)

Inflammation of the thyroid gland, called thyroiditis, can lead to the release of excess amounts of thyroid hormones that are normally stored in the gland. In subacute thyroiditis, the painful inflammation of the gland is believed to be caused by a virus, and the hyperthyroidism lasts a few weeks. A more common painless form of thyroiditis occurs in one out of 20 women, a few months after delivering a baby and is, therefore, known as postpartum thyroiditis. Although hyperthyroidism caused by thyroiditis causes the typical symptoms listed on our introduction to hyperthyroidism page, they generally last only a few weeks until the thyroid hormone stored in the gland has been exhausted. For more about thyroiditis, see our article on this topic.

Hyperthyroidism can also occur in patients who take excessive doses of any of the available forms of thyroid hormone. This is a particular problem in patients who take forms of thyroid medication that contains T3, which is normally produced in relatively small amounts by the human thyroid gland. Other forms of hyperthyroidism are even rarer. It is important for your doctor to determine which form of hyperthyroidism you may have since the best treatment options will change depending on the underlying cause

Diagnosing Hyperthyroidism: Overactivity of the Thyroid Gland
Part 3: Making the diagnosis of hyperthyroidism
Written by James Norman MD, FACS, FACE

The actual diagnosis of hyperthyroidism is easy to make once its possibility is entertained. Accurate and widely available blood tests can confirm or rule out the diagnosis quite easily within a day or two. Levels of the thyroid hormones themselves, T4 and T3, are measured in blood, and one or both must be high for this diagnosis to be made. It is also useful to measure the level of thyroid-stimulating hormone (TSH). This hormone is secreted from the pituitary gland (shown in orange) with the purpose of stimulating the thyroid to produce thyroid hormone. The pituitary constantly monitors our thyroid hormone levels, and if it senses the slightest excess of thyroid hormone in blood, it stops producing TSH. Consequently, a low blood TSH strongly suggests that the thyroid is overproducing hormone on its own. Other special tests are occasionally use to distinguish among the various causes of hyperthyroidism. Because the thyroid gland normally takes up iodine in order to make thyroid hormones, measuring how much radioactive iodine or

technetium is captured by the gland can be a very useful way to measure its function. The dose of radiation with these tests is very small and has no side effects. Such radioactive thyroid scan and uptake tests are often essential to know what treatment should be used in a patient with hyperthyroidism, and it's especially important if your doctor thinks your hyperthyroidism is caused by Graves' disease.

Common tests used to diagnose hyperthyroidism

Thyroid-stimulating hormone (TSH) produced by the pituitary will be decreased in hyperthyroidism. Thus,

the diagnosis of hyperthyroidism is nearly always associated with a low (suppressed) TSH level. If the TSH levels are not low, then other tests must be run.

Thyroid hormones themselves (T3, T4) will be increased. For a patient to have hyperthyroidism, they must

have high thyroid hormone levels. Sometimes all of the different thyroid hormones are not high and only one or two of the different thyroid hormone measurements are high. This is not too common, as most people with hyperthyroidism will have all of their thyroid hormone measurements high (except TSH).

• •

Iodine thyroid scan will show if the cause is a single nodule or the whole gland We have a page that examines in detail all the laboratory and x-ray tests used to diagnose thyroid diseases,

including a description of these tests and what they mean

Thyroid Gland Function
Common Tests to Examine
Written by James Norman MD, FACS, FACE

Some information on this page is a little more advanced. If you have trouble understanding the process of normal thyroid function, please go to our page describing this process first. As we have seen from our overview of normal thyroid physiology, the thyroid gland produces T4 and T3. But this production is not possible without stimulation from the pituitary gland (TSH) which in turn is also regulated by the hypothalamus's TSH Releasing Hormone. Now, with radioimmunoassay techniques it is possible to measure circulating hormones in the blood very accurately. Knowledge of this thyroid physiology is important in knowing what thyroid test or tests are needed to diagnose different diseases. No one single laboratory test is 100% accurate in diagnosing all types of thyroid disease; however, a combination of two or more tests can usually detect even the slightest abnormality of thyroid function.

For example, a low T4 level could mean a diseased thyroid gland ~ OR ~ a non-functioning pituitary gland which is not stimulating the thyroid to produce T4. Since the pituitary gland would normally release TSH if the T4 is low, a high TSH level would confirm that the thyroid gland (not the pituitary gland) is responsible for the hypothyroidism.

If the T4 level is low and TSH is not elevated, the pituitary gland is more likely to be the cause for the hypothyroidism. Of course, this would drastically effect the treatment since the pituitary gland also regulates the body's other glands (adrenals, ovaries, and testicles) as well as controlling growth in children and normal kidney function. Pituitary gland failure means that the other glands may also be failing and other treatment than just thyroid may be necessary. The most common cause for the pituitary gland failure is a tumor of the pituitary and this might also require surgery to remove.

Modern measurement of thyroid hormones is done by a new technique, radioimmunoassay (RIA),

discovered by Dr. Solomon Berson and Dr. Rosalyn Yallow. They were awarded the 1977 Nobel Prize in Medicine for this discovery which revolutionized the study of thyroid disease as well as the entire field of endocrinology.

The following are commonly used thyroid tests

Measurement of Serum Thyroid Hormones: T4 by RIA T4 by RIA (radioimmunoassay) is the most used thyroid test of all. It is frequently referred to as a T7 which means that a resin T3 uptake (RT3u) has been done to correct for certain medications such as birth control pills, other hormones, seizure medication, cardiac drugs, or even aspirin that may alter the routine T4 test. The T4 reflects the amount of thyroxine in the blood. If the patient does not take any type of thyroid medication, this test is usually a good measure of thyroid function.

Measurement of Serum Thyroid Hormones: T3 by RIA As stated on our thyroid hormone production page, thyroxine (T4) represents 80% of the thyroid hormone produced by the normal gland and generally represents the overall function of the gland. The other 20% is triiodothyronine measured as T3 by RIA. Sometimes the diseased thyroid gland will start producing very high levels of T3 but still produce normal levels of T4. Therefore measurement of both hormones provides an even more accurate evaluation of thyroid function.

Thyroid Binding Globulin Most of the thyroid hormones in the blood are attached to a protein called thyroid binding globulin (TBG). If there is an excess or deficiency of this protein it alters the T4 or T3 measurement but does not affect the action of the hormone. If a patient appears to have normal thyroid function, but an unexplained high or low T4, or T3, it may be due to an increase or decrease of TBG. Direct measurement of TBG can be done and will explain the abnormal value. Excess TBG or low levels of TBG are found in some families as an hereditary trait. It causes no problem except falsely elevating or lowering the T4 level. These people are frequently misdiagnosed as being hyperthyroid or hypothyroid, but they have no thyroid problem and need no treatment.

Measurement of Pituitary Production of TSH Pituitary production of TSH is measured by a method referred to as IRMA (immunoradiometric assay). Normally, low levels (less than 5 units) of TSH are sufficient to keep the normal thyroid gland functioning properly. When the thyroid gland becomes inefficient such as in early hypothyroidism, the TSH becomes elevated even though the T4 and T3 may still be within the "normal" range. This rise in TSH represents the pituitary gland's response to a drop in circulating thyroid hormone; it is usually the first indication of thyroid gland failure. Since TSH is normally low when the thyroid gland is functioning properly, the failure of TSH to rise when circulating thyroid hormones are low is an indication of impaired pituitary function. The new "sensitive" TSH test will show very low levels of TSH when the thyroid is overactive (as a normal response of the pituitary to try to decrease thyroid stimulation). Interpretations of the TSH level depends upon the level of thyroid hormone; therefore, the TSH is usually used in combination with other thyroid tests such as the T4 RIA and T3 RIA.

TRH Test In normal people TSH secretion from the pituitary can be increased by giving a shot containing TSH Releasing Hormone (TRH...the hormone released by the hypothalamus which tells the pituitary to produce TSH). A baseline TSH of 5 or less usually goes up to 10-20 after giving an injection of TRH. Patients with too much thyroid hormone (thyroxine or triiodothyronine) will not show a rise in TSH when given TRH. This "TRH test" is presently the most sensitive test in detecting early hyperthyroidism. Patients who show too much response to TRH (TSH rises greater than 40) may be hypothyroid. This test is also used in cancer patients who are taking thyroid replacement to see if they are on sufficient medication. It is sometimes used to measure if the pituitary gland is functioning. The new "sensitive" TSH test (above) has eliminated the necessity of performing a TRH test in most clinical situations.

Iodine Uptake Scan A means of measuring thyroid function is to measure how much iodine is taken up by the thyroid gland (RAI uptake). Remember, cells of the thyroid normally absorb iodine from our blood stream (obtained from foods we eat) and use it to make thyroid hormone (described on our thyroid function page). Hypothyroid patients usually take up too little iodine and hyperthyroid patients take up too much iodine. The test is performed by giving a dose of radioactive iodine on an empty stomach. The iodine is concentrated in the thyroid gland or excreted in the urine over the next few hours. The amount of iodine that goes into the thyroid gland can be measured by a "Thyroid Uptake". Of course, patients who are taking thyroid medication will not take up as much iodine in their thyroid gland because their own thyroid gland is turned off and is not functioning. At other times the gland will concentrate iodine normally but will be unable to convert the iodine into thyroid hormone; therefore, interpretation of the iodine uptake is usually done in conjunction with blood tests.

Thyroid Scan Taking a "picture" of how well the thyroid gland is functioning requires giving a radioisotope to the patient and letting the thyroid gland concentrate the isotope (just like the iodine uptake scan

above). Therefore, it is usually done at the same time that the iodine uptake test is performed. Although other isotopes, such as technetium, will be concentrated by the thyroid gland; these isotopes will not measure iodine uptake which is what we really want to know because the production of thyroid hormone is dependent upon absorbing iodine. It has also been found that thyroid nodules that concentrate iodine are rarely cancerous; this is not true if the scan is done with technetium. Therefore, all scans are now done with radioactive iodine. Both of the scans above show normal sized thyroid glands, but the one on the left has a "HOT" nodule in the lower aspect of the right lobe, while the scan on the right has a "COLD" nodule in the lower aspect of the left lobe (outlined in red and yellow). Pregnant women should not have thyroid scans performed because the iodine can cause development troubles within the baby's thyroid gland.

Two types of thyroid scans are available. A camera scan is performed most commonly which uses a gamma camera operating in a fixed position viewing the entire thyroid gland at once. This type of scan takes only five to ten minutes. In the 1990's, a new scanner called a Computerized Rectilinear Thyroid (CRT) scanner was introduced. The CRT scanner utilizes computer technology to improve the clarity of thyroid scans and enhance thyroid nodules. It measures both thyroid function and thyroid size. A life-sized 1:1 color scan of the thyroid is obtained giving the size in square centimeters and the weight in grams. The precise size and activity of nodules in relation to the rest of the gland is also measured. CTS of the normal thyroid gland In addition to making thyroid diagnosis more accurate, the CRT scanner improves the results of thyroid biopsy. The accurate sizing of the thyroid gland aids in the follow-up of nodules to see if they are growing or getting smaller in size. Knowing the weight of the thyroid gland allows more accurate radioactive treatment in patients who have Graves' disease.

Thyroid Scans are used for the following reasons:
• • • •
Identifying nodules and determining if they are "hot" or "cold". Measuring the size of the goiter prior to treatment. Follow-up of thyroid cancer patients after surgery. Locating thyroid tissue outside the neck, i.e. base of the tongue or in the chest.

Thyroid Ultrasound Thyroid ultrasound refers to the use of high frequency sound waves to obtain an image of the thyroid gland and identify nodules. It tells if a nodule is "solid" or a fluid-filled cyst, but it will not tell if a nodule is benign or malignant. Ultrasound allows accurate measurement of a nodule's size and can determine if a nodule is getting smaller or is growing larger during treatment. Ultrasound aids in performing thyroid needle biopsy by improving accuracy if the nodule cannot be felt easily on examination. Several more pages are dedicated to the use of ultrasound in evaluating thyroid nodules.

Thyroid Antibodies The body normally produces antibodies to foreign substances such as bacteria; however, some people are found to

have antibodies against their own thyroid tissue. A condition known as Hashimoto's Thyroiditis is associated with a high level of these thyroid antibodies in the blood. Whether the antibodies cause the disease or whether the disease causes the antibodies is not known; however, the finding of a high level of thyroid antibodies is strong evidence of this disease. Occasionally, low levels of thyroid antibodies are found with other types of thyroid disease. When Hashimoto's thyroiditis presents as a thyroid nodule rather than a diffuse goiter, the thyroid antibodies may not be present.

Thyroid Needle Biopsy This has become the most reliable test to differentiate the "cold" nodule that is cancer from the "cold" nodule that is benign ("hot" nodules are rarely cancerous). It provides information that no other thyroid test will provide. While not perfect, it will provide definitive information in 75% of the nodules biopsied. A very extensive discussion of Thyroid Needle Biopsy is found on another page.

Do I need to stop taking my thyroid pills for these tests?
Since Euthyrox or Synthroid (and most other thyroid pills) behave exactly as normal human thyroid hormone, they are not rapidly cleared from the body as other medications are. Most thyroid pills have a half life of 6.7 days which means they must be stopped for four to five weeks (five half lives) before accurate thyroid testing is possible. An exception to the long half life of thyroid medication is Cytomel - a thyroid pill with a half life of only forty-eight hours. Therefore it is possible to change a person's thyroid replacement to Cytomel for one month to allow time for his regular pills to clear the body. Cytomel is then stopped for ten days (five half lives) and the appropriate test can then be done. Usually patients, even those who have no remaining thyroid function, tolerate being off thyroid replacement only ten days quite well

Hyperthyroidism: Overactivity of the Thyroid Gland
Part 4: Treatment Options for Hyperthyroidism
Written by James Norman MD, FACS, FACE

There are readily available and effective treatments for all common types of hyperthyroidism. Some of the symptoms of hyperthyroidism (such as tremor and palpitations, which are caused by excess thyroid hormone acting on the cardiac and nervous system) can be improved within a number of hours by medications called beta-blockers (eg, propranolol; Inderal). These drugs block the effect of the thyroid hormone but don't have an effect on the thyroid itself, thus beta blockers do not cure the hyperthyroidism and do not decrease the amount of thyroid hormone being produced; they just prevent some of the symptoms. For patients with temporary forms of hyperthyroidism (thyroiditis or taking excess thyroid medications), beta blockers may be the only treatment required. Once the thyroiditis (inflammation of the thyroid gland) resolves and goes away, the patient can be taken off these drugs.

Anti-thyroid Drugs
For patients with sustained forms of hyperthyroidism, such as Graves' disease or toxic nodular goiter, anti-thyroid medications are often used. The goal with this form of drug therapy is to prevent the thyroid from producing hormones. Two common drugs in this category are methimazole and propylthiouracil (PTU), both of which actually interfere with the thyroid gland's ability to make its hormones. The illustration shows that some hormone is made, but the thyroid becomes much less efficient. When taken faithfully, these drugs are usually very effective in controlling hyperthyroidism within a few weeks. Anti-thyroid drugs can have side effects such as rash, itching, or fever, but these are uncommon. Very rarely, patients treated with these medications can develop liver inflammation or a deficiency of white blood cells therefore, patients taking antithyroid drugs should be aware that they must stop their medication and call their doctor promptly if they develop yellowing of the skin, a high fever, or severe sore throat. The main shortcoming of antithyroid drugs is that the underlying hyperthyroidism often comes back after they are discontinued. For this reason, many patients with hyperthyroidism are advised to consider a treatment that permanently prevents the thyroid gland from producing too much thyroid hormone.

Radioactive Iodine Treatment
Radioactive iodine is the most widely-recommended permanent treatment of hyperthyroidism. This treatment takes advantage of the fact that thyroid cells are the only cells in the body which have the ability to absorb iodine. In fact, thyroid hormones are experts at doing just that. By giving a radioactive form of iodine, the thyroid cells which absorb it will be damaged or killed. Because iodine is not absorbed by any other cells in the body, there is very little radiation exposure (or side effects) for the rest of the body. Radioiodine can be taken by mouth without the need to be hospitalized. This form of therapy often takes one to two months before the thyroid has been killed, but the radioactivity medicine is completely gone from the body within a few days. The majority of patients are cured with a single dose of radioactive iodine. The only common side effect of radioactive iodine treatment is underactivity of the thyroid gland. The problem here is that the amount of radioactive iodine given kills too many of the thyroid cells so that the remaining thyroid does not produce enough hormone, a condition called hypothyroidism.There is no evidence that radioactive iodine treatment of hyperthyroidism causes cancer of the thyroid gland or other parts of the body, or that it interferes with a woman's chances of becoming pregnant and delivering a healthy baby in the future. It is also important to realize that there are different types of radioactive iodine (isotopes). The type used for thyroid scans (iodine scans) as shown in the picture below give up a much milder type of radioactivity which does not kill thyroid cells.

Surgical Removal of the Gland or Nodule
Another permanent cure for hyperthyroidism is to surgically remove all or part. Surgery is not used as frequently as the other treatments for this disease. The biggest reason for this is that the most common forms of hyperthyroidism are a result of overproduction from the entire gland (Graves' disease) and the methods described above work quite well in the vast majority of cases. Although there are some Graves' disease patients who will need to have surgical removal of their thyroid (cannot tolerate medicines for one reason or another, or who refuse radioactive iodine), other causes of hyperthyroidism are better suited for surgical treatment earlier in the disease. One such case is illustrated here where a patient has hyperthyroidism due to a hot nodule in the lower aspect of the right thyroid lobe. Depending on the location of the nodule, the surgeon can remove the lower portion of the lobe as illustrated on the left, or he/she may need to remove the entire lobe which contains the hot nodule as shown in the second picture. This should provide a long term cure.

Concerns about long hospitalizations following thyroid surgery have been all but alleviated over the past few years since many surgeons are now sending their patients home the morning following surgery (23 hour stay). This, of course, depends on the underlying health of the patient and their age, among other factors. Some are even treating partial thyroidectomy as an out-patient procedure where healthy patients can be sent home a few hours after the surgery. Although most surgeons require that the patient be put to sleep for operations on the thyroid gland, a some are even removing one side of the gland under local anesthesia with the aid of IV sedation. These smaller operations tend to be associated with fewer complaints.

A potential down side of the surgical approach is that there is a small risk of injury to structures near the thyroid gland in the neck including the nerve to the voice box (the recurrent laryngeal nerve). The incidence of this is about 1%. Like radioactive iodine treatment, surgery often results in hypothyroidism. This fact is obvious when the entire gland is removed, but it may occur following a lobectomy as well. Whenever hypothyroidism occurs after treatment of an overactive thyroid gland, it can be easily diagnosed and effectively treated with levothyroxine. Levothyroxine fully replaces thyroid hormones deficiency and, when used in the correct dose , can be safely taken for the remainder of a patient's life without side effects or complications. Just one small pill per day.

Thyroid Problems and Pregnancy

Headaches, Anxiety, Nervousness, and High Blood Pressure
Written by James Norman MD, FACS, FACE

The most common thyroid disorder occurring around or during pregnancy is thyroid hormone deficiency, or hypothyroidism. The details of hypothyroidism are covered on several other pages on our site, so only those factors pertaining to pregnancy are discussed here. Hypothyroidism can cause a variety of changes in a woman's menstrual periods: irregularity, heavy periods, or loss of periods. When hypothyroidism is severe, it can reduce a woman's chances of becoming pregnant. Checking thyroid gland function with a simple blood test is an important part of evaluating a woman who has trouble becoming pregnant. If detected, an underactive thyroid gland can be easily treated with thyroid hormone replacement therapy. If thyroid blood tests are normal, however, treating an infertile woman with thyroid hormones will not help at all, and may cause other problems. Because some of the symptoms of hypothyroidism such as tiredness and weight gain are already quite common in pregnant women, it is often overlooked and not considered as a possible cause of these symptoms. Blood tests, particularly measuring the TSH level, can determine whether a pregnant woman's problems are due to hypothyroidism or not. Since thyroid medications (particularly Levothyroxine) are essentially identical to the thyroid hormone made by the normal thyroid gland, a woman with an underactive thyroid gland can feel confident that it is perfectly safe to take thyroid hormone medication during pregnancy. There are no side effects for the mother or the baby as long as the proper dose is used. In the case where hypothyroidism in the mother is NOT detected, the thyroid will still develop normally in the baby. Women with previously treated hypothyroidism should be aware that their dose of medication may have to be increased during pregnancy. They should contact their doctor, who should check their blood level of TSH periodically throughout pregnancy to see if their medication dose needs adjustment. Thyroid function tests should continue to be reviewed every 2-3 months throughout the pregnancy. After delivery, the thyroxine dose should be returned to the pre-pregnancy dose and thyroid function tests reviewed two months later.

Hyperthyroidism and Pregnancy
Hyperthyroidism refers to the signs and symptoms which are due to the production of too much thyroid hormone. [Hyperthyroidism is covered in great deal on other pages on

this site (about 8 in all), so only that part of hyperthyroidism which pertains to the pregnant mother will be discussed here]. An overactive thyroid gland (hyperthyroidism)
often has its onset in younger women. Because a woman may think that feeling warm, having a hard or fast heartbeats, nervousness, trouble sleeping, or nausea with weight loss are just parts of being pregnant, the symptoms and signs of this condition may be

overlooked during pregnancy.

In women who are not pregnant, hyperthyroidism can affect menstrual periods, making them irregular, lighter, or disappear altogether. It may be harder for hyperthyroid women to become pregnant, and they are more likely to have miscarriages. If a woman with infertility or repeated miscarriages has symptoms of hyperthyroidism, it is important to rule out this condition with thyroid blood tests. It is very important that hyperthyroidism be controlled in pregnant women since the risks of miscarriage or birth defects are much higher without therapy. Fortunately, there are effective treatments available. Antithyroid medications cut down the thyroid gland's overproduction of hormones and are reviewed on another page on this site. When taken faithfully, they control hyperthyroidism within a few weeks. In pregnant women thyroid experts consider propylthiouracil (PTU) the safest drug. Because PTU can also affect the baby's thyroid gland, it is very important that pregnant women be monitored closely with examinations and blood tests so that the PTU dose can be adjusted. In rare cases when a pregnant woman cannot take PTU for some reason (allergy or other side effects), surgery to remove the thyroid gland is the only alternative and should be undertaken prior to or even during the pregnancy if necessary. Although radioactive iodine is a very effective treatment for other patients with hyperthyroidism, it should never be given during pregnancy because the baby's thyroid gland could be damaged.

Because treating hyperthyroidism during pregnancy can be a bit tricky, it is usually best for women who plan to have children in the near future to have their thyroid condition permanently cured. Antithyroid medications alone may not be the best approach in these cases because hyperthyroidism often returns when medications is stopped. Radioactive iodine is the most widely recommended permanent treatment with surgical removal being the second (but widely used) choice. It is concentrated by thyroid cells and damages them with little radiation to the rest of the body. This is why it cannot be given to a pregnant woman, since the radioactive iodine could cross the placenta and destroy normal thyroid cells in the baby. The only common side effect of radioactive iodine treatment is underactivity of the thyroid gland, which occurs because too many thyroid cells were destroyed. This can be easily and safely treated with levothyroxine. There is no evidence that radioactive iodine treatment of hyperthyroidism interferes with a woman's future chances of becoming pregnant and delivering a healthy baby. For more information on the treatment options of hyperthyroidism see our page on this topic.

Thyroid Problems After Pregnancy
One of every twenty women develop thyroid inflammation within a few months after delivery of their baby, a condition called postpartum thyroiditis. This form of thyroid inflammation is painless and causes little or no gland enlargement. However, the condition interferes with the gland's production of thyroid hormones. Thyroid hormone may leak out of the inflamed gland in large amounts, causing hyperthyroidism that lasts for several weeks. Later on, the injured gland may not be able to make enough thyroid hormone, resulting in temporary hypothyroidism. Symptoms of hyperthyroidism and hypothyroidism may not be recognized when they occur in a new mother. They may be simply attributed to lack of sleep, nervousness, or depression.

Thyroid Symptoms Occasionally Overlooked in New Mothers

• • • •

Fatigue Insomnia Nervousness Irritability


• • • •

Fatigue Depression Easily upset Trouble losing weight

Postpartum thyroiditis goes away on its own after one to four months. While it is active, however, women often benefit from treatment for their thyroid hormone excess or deficiency. Some of the symptoms caused by too much thyroid hormone, such as tremor or palpitations, can be improved promptly by medications called beta-blockers(e.g., propranolol). Antithyroid drugs, radioactive iodine, and surgery do not need to be considered because this form of hyperthyroidism is only temporary. If thyroid hormone deficiency develops, it can be treated for one to six months with levothyroxine. Women who have had an episode of postpartum thyroiditis are very likely to develop the problem again after future pregnancies. Although each episode usually resolves completely, one out of four women with postpartum thyroiditis goes on to develop a permanently underactive thyroid gland in future. Of course, levothyroxine fully corrects their thyroid hormone deficiency, and when used in the correct dose, can be safely taken without side effects or complications.

Thyroid Problems in the Baby
Rarely, a baby may be born without a thyroid gland. This birth defect is not caused by thyroid problems in the mother. If an infant's hypothyroidism is not recognized and treated promptly, he/she will not develop normally. Therefore, all newborn babies in the United States routinely have a blood test to be sure that hypothyroidism is diagnosed and treated. Most thyroid medications will have no effect on the baby. The exception to this generality is the administration of radioactive iodine to the mother during pregnancy. Radioactive iodine can cross the placenta and it can destroy thyroid cells in the fetus.

Your Thyroid Gland
Written by James Norman MD, FACS, FACE

The thyroid gland is the biggest gland in the neck. It is situated in the anterior (front) neck below the skin and muscle layers. The thyroid gland takes the shape of a butterfly with the two wings being represented by the left and right thyroid lobes which wrap around the trachea. The sole function of the thyroid is to make thyroid hormone. This hormone has an effect on nearly all tissues of the body where it increases cellular activity. The function of the thyroid, therefore, is to regulate the body's metabolism.

Common Thyroid Problems
The thyroid gland is prone to several very distinct problems, some of which are extremely common. These problems can be broken down into [1] those concerning the production of hormone (too much, or too little), [2] those due to increased growth of the thyroid, causing compression of important neck structures or simply appearing as a mass in the neck, [3] the formation of nodules or lumps within the thyroid which are worrisome for the presence of thyroid cancer, and [4] those which are cancerous. Each thyroid topic is addressed separately and illustrated with actual patient x-rays and pictures to make them easier to understand. The information on this web site is arranged to give you more detailed and complex information as you read further.

Goiters ~ A thyroid goiter is a dramatic enlargement of the thyroid gland. Goiters are often removed

because of cosmetic reasons or, more commonly, because they compress other vital structures of the neck including the trachea and the esophagus making breathing and swallowing difficult. Sometimes goiters will actually grow into the chest where they can cause trouble as well. Several nice x-rays will help explain all types of thyroid goiter problems.

Thyroid Cancer ~ Thyroid cancer is a fairly common malignancy, however, the vast majority have excellent

long term survival. We now include a separate page on the characteristics of each type of thyroid cancer and its typical treatment, follow-up, and prognosis. Over 30 pages thyroid cancer.

Solitary Thyroid Nodules ~ There are several characteristics of solitary nodules of the thyroid which make

them suspicious for malignancy. Although as many as 50% of the population will have a nodule somewhere in their thyroid, the overwhelming majority of these are benign. Occasionally, thyroid nodules can take on characteristics of malignancy and require either a needle biopsy or surgical excision. Now includes risks of radiation exposure and the role of Needle Biopsy for evaluating a thyroid nodule. Also a new page on the role of ultrasound in diagnosing thyroid nodules and masses.

Hyperthyroidism ~ Hyperthyroidism means too much thyroid hormone. Current methods used for treating a

hyperthyroid patient are radioactive iodine, anti-thyroid drugs, or surgery. Each method has advantages and disadvantages and is selected for individual patients. Many times the situation will suggest that all three methods are appropriate, while other circumstances will dictate a single best therapeutic option. Surgery is the least common treatment selected for hyperthyroidism. The different causes of hyperthyroidism are covered in detail.

Hypothyroidism ~ Hypothyroidism means too little thyroid hormone and is a common problem. In fact,

hypothyroidism is often present for a number of years before it is recognized and treated. There are several common

causes, each of which are covered in detail. Hypothyroidism can even be associated with pregnancy. Treatment for all types of hypothyroidism is usually straightforward.

Thyroiditis ~ Thyroiditis is an inflammatory process ongoing within the thyroid gland. Thyroiditis can present

with a number of symptoms such as fever and pain, but it can also present as subtle findings of hypo or hyperthyroidism. There are a number of causes, some more common than others. Each is covered on this site

How Your Thyroid Works
"A delicate Feedback Mechanism"
Your thyroid gland is a small gland, normally weighing less than one ounce, located in the front of the neck. It is made up of two halves, called lobes, that lie along the windpipe (trachea) and are joined together by a narrow band of thyroid tissue, known as the isthmus. The thyroid is situated just below your "Adams apple" or larynx. During development (inside the womb) the thyroid gland originates in the back of the tongue, but it normally migrates to the front of the neck before birth. Sometimes it fails to migrate properly and is located high in the neck or even in the back of the tongue (lingual thyroid) This is very rare. At other times it may migrate too far and ends up in the chest (this is also rare). The function of the thyroid gland is to take iodine, found in many foods, and convert it into thyroid hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid cells are the only cells in the body which can absorb iodine. These cells combine iodine and the amino acid tyrosine to make T3 and T4. T3 and T4 are then released into the blood stream and are transported throughout the body where they control metabolism (conversion of oxygen and calories to energy). Every cell in the body depends upon thyroid hormones for regulation of their metabolism. The normal thyroid gland produces about 80% T4 and about 20% T3, however, T3 possesses about four times the hormone "strength" as T4.

The thyroid gland is under the control of the pituitary gland, a small gland the size of a peanut at the base of the brain (shown here in orange). When the level of thyroid hormones (T3 & T4) drops too low, the pituitary gland produces Thyroid Stimulating Hormone (TSH) which stimulates the thyroid gland to produce more hormones. Under the influence of TSH, the thyroid will manufacture and secrete T3 and T4 thereby raising their blood levels. The pituitary senses this and

responds by decreasing its TSH production. One can imagine the thyroid gland as a furnace and the pituitary gland as the thermostat. Thyroid hormones are like heat. When the heat gets back to the thermostat, it turns the thermostat off. As the room cools (the thyroid hormone levels drop), the thermostat turns back on (TSH increases) and the furnace produces more heat (thyroid hormones).

The pituitary gland itself is regulated by another gland, known as the hypothalamus (shown in our picture in light blue). The hypothalamus is part of the brain and produces TSH Releasing Hormone (TRH) which tells the pituitary gland to stimulate the thyroid gland (release TSH). One might imagine the hypothalamus as the person who regulates the thermostat since it tells the pituitary gland at what level the thyroid should be set.

Thyroid Function Tests
Normal Laboratory Values
A b b re vi at io n T 4 F T 4 F F T 4 T H B R F T 4I T 3 F T 3 F T 3I R AI U T S H T B


Typical Ranges

Serum thyroxine Free thyroxine fraction

4.6-12 ug/dl 0.030.005% 0.7-1.9 ng/dl

Free Thyroxine

Thyroid hormone binding ratio Free Thyroxine index Serum Triiodothyronine Free Triiodothyronine l Free T3 Index Radioactive iodine uptake Serum thyrotropin Thyroxinebinding globulin


4-11 80-180 ng/dl 230-619 pg/d 80-180

10-30% 0.5-6 uU/ml 12-20 ug/dl T4

TRH stimulation test Peak Serum thyroglobulin l Thyroid microsomal antibody titer Thyroglobulin antibody titer

G T S H T g T M A b T g A b
Last updated on 05/21/09

+1.8 ugm 9-30 uIU/ml at 20-30 min 0-30 ng/m Varies with method Varies with method

n Overview of the Thyroid
A major player in regulating your metabolism
Written by Kelly M. Rehan Reviewed by Robert M. Sargis MD, PhD

Thyroid Essentials

• • •

The thyroid regulates your metabolism. The two main thyroid hormones are T3 and T4. Thyroid disorders are common, and they include goiters, hyperthyroidism, and hypothyroidism.

The thyroid’s main role in the endocrine system is to regulate your metabolism, which is your body’s ability to break down food and convert it to energy. Food essentially fuels our bodies, and our bodies each “burn” that fuel at different rates. This is why you often hear about some people having “fast” metabolism and others having “slow” metabolism.

The thyroid keeps your metabolism under control through the action of thyroid hormone, which it makes by extracting iodine from the blood and incorporating it into thyroid hormones. Thyroid cells are unique in that they are highly specialized to absorb and use iodine. Every other cell depends on the thyroid to manage its metabolism.

The pituitary gland and hypothalamus both control the thyroid. When thyroid hormone levels drop too low, the hypothalamus secretes TSH Releasing Hormone (TRH), which alerts the pituitary to produce thyroid stimulating hormone (TSH). The thyroid responds to this chain of events by producing more hormones. To learn more, read our article about how the thyroid works.

Anatomy of the Thyroid Derived from the Greek word meaning shield, the thyroid is a butterfly-shaped gland located in front of the windpipe (called the trachea) and just below the larynx or Adam’s apple in the neck. It is comprised of two halves, known as lobes, which are attached by a band of thyroid tissue called the isthmus.

During development, the thyroid is actually located in the back of the tongue and has to migrate to the front of the neck before birth. There are rare instances when the thyroid migrates too far or too little. There are even cases when the thyroid remains in the back of the tongue—this is known as lingual thyroid.

Hormones of the Thyroid The two main hormones the thyroid produces and releases are T3(tri-iodothyronine) and T4 (thyroxine). A thyroid that is functioning normally produces approximately 80% T4 and about 20% T3, though T3 is the stronger of the pair.

To a lesser extent, the thyroid also produces calcitonin, which helps control blood calcium levels.

Diseases and Disorders of the Thyroid There are many diseases and disorders associated with the thyroid. They can develop at any age and can result from a variety of causes—injury, disease, or dietary deficiency, for instance. But in most cases, they can be traced to the following problems:

• • • •

Too much or too little thyroid hormone (hyperthyroidism and hypothyroidism, respectively). Abnormal thyroid growth Nodules or lumps within the thyroid Thyroid cancer

Below are some of the most common thyroid disorders. To learn more, read our article about common thyroid problems.

• •

Goiters: A goiter is a bulge in the neck. A toxic goiter is associated with hyperthyroidism, and a non-toxic

goiter, also known as a simple or endemic goiter, is caused by iodine deficiency. Hyperthyroidism: Hyperthyroidism is caused by too much thyroid hormone. People with hyperthyroidism

are often sensitive to heat, hyperactive, and eat excessively. Goiter is sometimes a side effect of hyperthyroidism. This is due to an over-stimulated thyroid and inflamed tissues, respectively.

Hypothyroidism: Hypothyroidism is a common condition characterized by too little thyroid hormone. In

infants, the condition is known as cretinism. Cretinism has very serious side effects, including abnormal bone

formation and mental retardation. If you have hypothyroidism as an adult, you may experience sensitivity to cold, little appetite, and an overall sluggishness. Hypothyroidism often goes unnoticed, sometimes for years, before being diagnosed.

Solitary thyroid nodules: Solitary nodules, or lumps, in the thyroid are actually quite common—in fact, it’s

estimated that more than half the population will have a nodule in their thyroid. The great majority of nodules are benign. Usually a fine needle aspiration biopsy (FNA) will determine if the nodule is cancerous.

Thyroid cancer: Thyroid cancer is fairly common, though the long-term survival rates are excellent.

Occasionally, symptoms such as hoarseness, neck pain, and enlarged lymph nodes occur in people with thyroid cancer. Thyroid cancer can affect anyone at any age, though women and people over thirty are most likely to develop the condition.

Thyroiditis: Thyroiditis is an inflammation of the thyroid that may be associated with abnormal thyroid

function (particularly hyperthyroidism). Inflammation can cause the thyroid’s cells to die, making the thyroid unable to produce enough hormones to maintain the body's normal metabolism. There are five types of thyroiditis, and the treatment is specific to each

Hypothyroidism: Too Little Thyroid Hormone
Part 1: Introduction, causes, and symptoms of hypothyroidism
Written by James Norman MD, FACS, FACE

Hypothyroidism is a condition in which the body lacks sufficient thyroid hormone. Since the main purpose of thyroid hormone is to "run the body's metabolism," it is understandable that people with this condition will have symptoms associated with a slow metabolism. The estimates vary, but approximately 10 million Americans have this common medical condition. In fact, as many as 10% of women may have some degree of thyroid hormone deficiency. Hypothyroidism is more common than you would believe, and millions of people are currently hypothyroid and don't know it. For an overview of how thyroid hormone is produced and how its production is regulated, check out our thyroid hormone production page. Causes of Hypothyroidism There are two fairly common causes of hypothyroidism. The first is a result of previous (or currently ongoing) inflammation of the thyroid gland, which leaves a large percentage of the cells of the thyroid damaged (or dead) and incapable of producing sufficient hormone. The most common cause of thyroid gland failure is called autoimmune thyroiditis (also called Hashimoto's thyroiditis), a form of thyroid inflammation caused by the patient's own immune system. The second major cause is the broad category of "medical treatments." The treatment of many thyroid conditions warrants surgical removal of a portion or all of the thyroid gland. If the total mass of thyroid producing cells left within the body are not enough to meet the needs of the body, the patient will develop hypothyroidism. Remember, this is often the goal of the surgery for thyroid cancer.

But at other times, the surgery will be to remove a worrisome nodule, leaving half of the thyroid in the neck undisturbed. Sometimes, this remaining thyroid lobe and isthmus will produce enough hormone to meet the demands of the body. For other patients, however, it may become apparent years later that the remaining thyroid just can't quite keep up with demand. Similarly, goiters and some other thyroid conditions can be treated with radioactive iodine therapy. The aim of the radioactive iodine therapy (for benign conditions) is to kill a portion of the thyroid to prevent goiters from growing larger or producing too much hormone (hyperthyroidism). Occasionally, the result of radioactive iodine treatment will be that too many cells are damaged so the patient often becomes hypothyroid within a year or two. However, this is usually greatly preferred over the original problem. There are several other rare causes of hypothyroidism, one of them being a completely "normal" thyroid gland that is not making enough hormone because of a problem in the pituitary gland. If the pituitary does not produce enough thyroid stimulating hormone (TSH) then the thyroid simply does not have the "signal" to make hormone. So it doesn't. Symptoms of Hypothyroidism

• • • • • • • • • • • • • •

Fatigue Weakness Weight gain or increased difficulty losing weight Coarse, dry hair Dry, rough pale skin Hair loss Cold intolerance (you can't tolerate cold temperatures like those around you) Muscle cramps and frequent muscle aches Constipation Depression Irritability Memory loss Abnormal menstrual cycles Decreased libido

Each individual patient may have any number of these symptoms, and they will vary with the severity of the thyroid hormone deficiency and the length of time the body has been deprived of the proper amount of hormone. You may have one of these symptoms as your main complaint, while another will not have that problem at all and will be suffering from an entirely different symptom. Most people will have a combination of these symptoms.

Occasionally, some patients with hypothyroidism have no symptoms at all, or they are just so subtle that they go unnoticed. If you have these symptoms, you need to discuss them with your doctor. Additionally, you may need to seek the skills of an endocrinologist. If you have already been diagnosed and treated for hypothyroidism and continue to have any or all of these symptoms, you need to discuss it with your physician. Potential Dangers of Hypothyroidism Because the body is expecting a certain amount of thyroid hormone the pituitary will make additional thyroid stimulating hormone (TSH) in an attempt to entice the thyroid to produce more hormone. This constant bombardment with high levels of TSH may cause the thyroid gland to become enlarged and form a goiter (termed a "compensatory goiter"). Left untreated, the symptoms of hypothyroidism will usually progress. Rarely, complications can result in severe lifethreatening depression, heart failure, or coma. Hypothyroidism can often be diagnosed with a simple blood test. In some persons, however, it's not so simple and more detailed tests are needed. Most importantly, a good relationship with a good endocrinologist will almost surely be needed. Hypothyroidism is completely treatable in many patients simply by taking a small pill once a day. However, this is a simplified statement, and it's not always so easy. There are several types of thyroid hormone preparations and one type of medicine will not be the best therapy for all patients. Many factors will go into the treatment of hypothyroidism and it is different for everybody

Inflammation of the thyroid gland
Written by James Norman MD, FACS, FACE

Thyroiditis is an inflammation (not an infection) of the thyroid gland. Several types of thyroiditis exist and the treatment is different for each. Hashimoto's Thyroiditis Hashimoto's thyroiditis, also called autoimmune or chronic lymphocytic thyroiditis, is the most common type of thyroiditis. It is named after the Japanese physician, Hakaru Hashimoto, who first described it in 1912. The thyroid gland is always enlarged, although only one side may be enlarged enough to feel. During the course of this disease, the cells of the thyroid becomes inefficient in converting iodine into thyroid hormone and "compensates" by enlarging (for a review of this process see our function page).

The radioactive iodine uptake may be paradoxically high while the patient is hypothyroid because the gland retains the ability to take-up or "trap" iodine even after it has lost its ability to produce thyroid hormone. As the disease progresses, the TSH increases since the pituitary is trying to induce the thyroid to make more hormone, the T4 falls since the thyroid can't make it, and the patient becomes hypothyroid. This sequence of events can occur over a relatively short span of a few weeks or may take several years.

• • • •

Treatment should begin with thyroid hormone replacement. This prevents or corrects the hypothyroidism,

and it also generally keeps the gland from getting larger. In most cases, the thyroid gland will decrease in size once thyroid hormone replacement is started. Thyroid antibodies are present in 95% of patients with Hashimoto's Thyroiditis and serve as a useful

"marker" in identifying the disease without thyroid biopsy or surgery. Thyroid antibodies may remain for years after the disease has been adequately treated and the patient is on

thyroid hormone replacement. De Quervain's Thyroiditis De Quervain's thyroiditis (also called subacute or granulomatous thyroiditis) was first described in 1904 and is much less common than Hashimoto's thyroiditis. The thyroid gland generally swells rapidly and is very painful and tender. The gland discharges thyroid hormone into the blood and the patients become hyperthyroid; however, the gland quits taking up iodine (radioactive iodine uptake is very low), and the hyperthyroidism generally resolves over the next several weeks.

• • • • • • • •

Patients frequently become ill with fever and prefer to be in bed. Thyroid antibodies are not present in the blood, but the sedimentation rate (which measures inflammation)

is very high. Although this type of thyroiditis resembles an infection within the thyroid gland, no infectious agent has ever

been identified, and antibiotics are of no use. Treatment is usually bed rest and aspirin to reduce inflammation. Occasionally cortisone (steroids, which reduce inflammation) and thyroid hormone (to "rest" the thyroid

gland) may be used in prolonged cases. Nearly all patients recover, and the thyroid gland returns to normal after several weeks or months. A few patients will become hypothyroid once the inflammation settles down and therefore will need to stay

on thyroid hormone replacement indefinitely. Recurrences are uncommon.

Silent Thyroiditis Silent thyroiditis is the third and least common type of thyroiditis. It was not recognized until the 1970s, although it probably existed and was treated as Graves' disease before that. This type of thyroiditis resembles in part Hashimoto's thyroiditis and in part De Quervain's thyroiditis. The blood thyroid test is high and the radioactive iodine uptake is low (like De Quervain's thyroiditis), but there is no pain and needle biopsy resembles Hashimoto's

thyroiditis. The majority of patients have been young women following pregnancy. The disease usually needs no treatment, and 80% of patients show complete recovery and return of the thyroid gland to normal after three months. Symptoms are similar to Graves' disease except milder. The thyroid gland is only slightly enlarged and exophthalmos (development of "bug eyes") does not occur. Treatment is usually bed rest with beta blockers to control palpitations (drugs to prevent rapid heart rates). Radioactive iodine, surgery, or antithyroid medication is never needed. A few patients have become permanently hypothyroid and needed to be placed on thyroid hormone

Hypothyroidism: Too little thyroid hormone
Part 2: Diagnosis and Treatments of Hypothyroidism.
Since hypothyroidism is caused by too little thyroid hormone secreted by the thyroid, the diagnosis of hypothyroidism is based almost exclusively upon measuring the amount of thyroid hormone in the blood. There are normal ranges for all thyroid hormones which have been calculated by computers which measured these hormones in tens of thousands of people. If your thyroid hormone levels fall below the normal range, that is consistent with hypothyroidism These tests are very accurate and reliable and are so routine that they are available to everybody. More about these tests on another page. reading. REMEMBER hypo = too little thyroidism = disease of the thyroid Thus, hypo-thyroidism = a disease of too little thyroid activity. However, its not always so simple...keep

The idea is to measure blood levels of T4 and TSH. In the typical person with an under-active thyroid gland, the blood level of T4 (the main thyroid hormone) will be low, while the TSH level will be high. This means that the thyroid is not making enough hormone and the pituitary recognizes it and is responding appropriately by making more Thyroid Stimulating Hormone (TSH) in an attempt to force more hormone production out of the thyroid. In the more rare case of hypothyroidism due to pituitary failure, the thyroid hormone T4 will be low, but the TSH level will also be low. The thyroid is behaving "appropriately" under these conditions because it can only make hormone in response to TSH signals from the pituitary. Since the pituitary is not making enough TSH, then the thyroid will never make enough T4. The real question in this situation is what is wrong with the pituitary? But in the typical and most common form of hypothyroidism, the main thyroid hormone T4 is low, and the TSH level is high.

The next question is: When is low too low, and when is high too high? Blood levels have "normal" ranges, but other factors need to be taken into account as well, such as the presence or absence of symptoms. You should discuss your levels with your doctor so you can interpret how they are helping (or not?) fix your problems.

Oh, if only it were this simple all the time! Although the majority of individuals with hypothyroidism will be easy to diagnose with these simple blood tests, many millions will have this disease in mild to moderate forms which are more difficult to diagnose. The solution for these people is more complex and this is due to several factors. First we must realize that not all patients with hypothyroidism are the same. There are many degrees of this disease from very severe to very mild. Additionally, and very importantly, we cannot always predict just how bad (or good) an individual patient will feel just by examining his/her thyroid hormone levels. In other words, some patients with very "mild" deviations in their thyroid laboratory test results will feel just fine while others will be quite symptomatic. The degree of thyroid hormone abnormalities often, but NOT ALWAYS will correlate with the degree of symptoms. It is important for both you and your physician to keep this in mind since the goal is not necessarily to make the lab tests go into the normal range, but to make you feel better as well! We must also keep in mind that even the "normal" thyroid hormone levels in the blood have a fairly large range, so even if a patient is in the "normal" range, it may not be the normal level for them. For the majority of patients with hypothyroidism, taking some form of thyroid hormone replacement (synthetic or natural, pill or liquid, etc) will make the "thyroid function tests" return to the normal range, AND, this is accompanied by a general improvement in symptoms making the patient feel better. This does not happen to all individuals, however, and for these patients it is very important to find an endocrinologist who will listen and be sympathetic. (We
aim to help you find this type of doctor.)

Because most patients will be improved (or made completely better) when

sufficient thyroid hormone is provided on a daily basis to make the hormone levels in the blood come into the normal range, physicians will often will rely on test results to determine when a patient is on the appropriate dose and therefore doing well. Remember, these tests have a wide normal range. Find a doctor who helps make you FEEL better, not just make your labs better because once given this diagnosis, you are likely to carry it for a long, long time. There is more than one drug, there is more than one lab test, and there is a "just right" doctor for everybody.

Treatment of Hypothyroidism
Hypothyroidism is usually quite easy to treat (for most people)! The easiest and most effective treatment is simply taking a thyroid hormone pill (Levothyroxine) once a day, preferably in the morning. This medication is a pure synthetic form of T4 which is made in a laboratory to be an exact replacement for the T4 that the human thyroid gland normally secretes. It comes in multiple strengths, which means that an appropriate dosage can almost always be found for each patient. The dosage should be re-evaluated and possibly adjusted monthly until the proper level is established. The dose should then be re-evaluated at least annually. If you are on this medication, make sure your physician knows it so he/she can check the levels at least yearly. Note: Just like we discussed above, however, this simple approach does not hold true for everybody. Occasionally the correct dosage is a bit difficult to pin-point and

therefore you may need an exam and blood tests more frequently. Also, some patients just don't do well on some thyroid medications and will be quite happy on another. For these reasons you should not be shy in discussing with your doctor your blood hormone tests, symptoms, how you feel, and the type of medicine you are taking. The goal is to make you feel better, make your body last longer, slow the risk of heart disease and osteoporosis...in addition to making your blood levels normal! Sometimes that's easy, when its not, you need a physician who is willing to spend the time with you that you deserve while you explore different dosages other types of medications (or alternative diagnoses).

Some patients will notice a slight reduction in symptoms within 1 to 2 weeks, but the full metabolic response to thyroid hormone therapy is often delayed for a month or two before the patient feels completely normal. It is important that the correct amount of thyroid hormone is used. Not enough and the patient may have continued fatigue or some of the other symptoms of hypothyroidism. Too high a dose could cause symptoms of nervousness, palpitations or insomnia typical of hyperthyroidism. Some recent studies have suggested that too much thyroid hormone may cause increased calcium loss from bone increasing the patient's risk for osteoporosis. For patients with heart conditions or diseases, an optimal thyroid dose is particularly important. Even a slight excess may increase the patient's risk for heart attack or worsen angina. Some physicians feel that more frequent dose checks and blood hormone levels are appropriate in these patients.

After about one month of treatment, hormone levels are measured in the blood to establish whether the dose of thyroid hormone which the patient is taking is appropriate. We don't want too much given or subtle symptoms of hyperthyroidism could ensue, and too little would not alleviate the symptoms completely. Often blood samples are also checked to see if there are antibodies against the thyroid, a sign of autoimmune thyroiditis. Remember, this is the most common cause of hypothyroidism. Once treatment for hypothyroidism has been started, it typically will continue for the patient's life. Therefore, it is of great importance that the diagnosis be firmly established and you have a good relationship with a physician you like and trust.

Synthetic T4 can be safely taken with most other medications. Patients taking cholestyramine (a compound used to lower blood cholesterol) or certain medications for seizures should check with their physician about potential interactions. Women taking T4 who become pregnant should feel confident that the medication is exactly what their own thyroid gland would otherwise make. However, they should check with their physician since the T4 dose may have to be adjusted during pregnancy (usually more hormone is needed to meet the increased demands of the mother's new increased metabolism). There are other potential problems with other drugs including ironcontaining vitamins. Once again, pregnant women (and all women and men for that matter)

taking iron supplements should discuss this with your physician. There are three brand name Levothyroxine tablets now available. You may want to consult with your physician or pharmacist on the most cost effective brand since recent studies suggest that none is better than the other.

Thyroid Goiter
Enlargement of the Thyroid
Written by James Norman MD, FACS, FACE

The term nontoxic goiter refers to enlargement of the thyroid which is not associated with overproduction of thyroid hormone or malignancy. The thyroid can become very large so that it can easily be seen as a mass in the neck. This picture depicts the outline of a normal size thyroid in black and the greatly enlarged goiter in pink. There are a number of factors which may cause the thyroid to become enlarged. A diet deficient in iodine can cause a goiter but this is rarely the cause because of the readily available iodine in our diets. A more common cause of goiter in America is an increase in thyroid stimulating hormone (TSH) in response to a defect in normal hormone synthesis within the thyroid gland. The thyroid stimulating hormone comes from the pituitary and causes the thyroid to enlarge. This enlargement usually takes many years to become manifest.

This picture depicts the typical appearance of a goiter in a middle aged woman. Note how her entire neck looks swollen because of the large thyroid. This mass will compress the trachea (windpipe) and esophagus (swallowing tube) leading to symptoms such as coughing, waking up from sleep feeling like you can't breath, and the sensation that food is getting stuck in the upper throat. Once a goiter gets this big, surgical removal is the only means to relieve the symptoms. Yes, sometimes they can get a lot bigger than this!

Indications for Treatment
Most small to moderate sized goiters can be treated by providing thyroid hormone in the form of a pill. By supplying thyroid hormone in this fashion, the pituitary will make less TSH which should result in stabilization in size of the gland. This technique often will not cause the size of the goiter to decrease but will usually keep it from growing any larger. Patients who do not respond to thyroid hormone therapy are often referred for surgery if it continues to grow.

A more common indication for surgical removal of an enlarged thyroid [goiter] is to

remove those glands which are enlarged enough to cause compression on other structures in the neck such as the trachea and esophagus. These patients will typically complain of a cough, a slight change in voice, or nighttime choking episodes because of the way that the gland compresses the trachea while sleeping. This X-ray shows how an enlarged right lobe of the thyroid has moved the trachea to the patient's left. The trachea (outlined in light yellow) should be straight from the mouth down to the lungs, but in this patient it is compressed and displaced far to the left. The enlarged gland can even compress the blood vessels of the neck which are also an indication for its removal. More about this on our page examining sub-sternal thyroids.

As always, suspicion of malignancy in an enlarged thyroid is an indication for removal of the thyroid. There is often a dominant nodule within a multinodular goiter which can cause concern for cancer. It should be remembered that the incidence of malignancy within a multinodular goiter is usually significantly less than 5%. If the nodule is cold on thyroid scanning, then it may be slightly higher than this. For the vast majority of patients, surgical removal of a goiter for fear of cancer is not warranted.

Another reason (although not a very common one) to remove a goiter is for cosmetic reasons. Often a goiter gets large enough that it can be seen as a mass in the neck. When other people begin to notice the mass, it is usually big enough to begin causing compression of other vital neck structures...but not always. Sometimes the large goiter causes no symptoms other than being a cosmetic problem. Realizing of course, if its big enough to be seen by your neighbors, something needs to be done...medications or surgery or it will most likely continue to get bigger.

The Diabetes Center
Introduction to Diabetes
Written by James Norman MD, FACS, FACE

Diabetes is a very big topic! To make the diagnosis, complications and treatment of diabetes more understandable, we have broken "diabetes" into several dozen diabetes topic pages which go into more and more detail. Our search engine will help you find specific diabetes information, or you can come back to this introduction page to see each of the diabetes topic pages listed. Diabetes is a disorder characterized by hyperglycemia or elevated blood glucose (blood sugar). Our bodies function best at a certain level of sugar in the bloodstream. If the amount of sugar in our blood runs too high or too low, then we typically feel bad. Diabetes is the name of the condition where the blood sugar level consistently runs too high. Diabetes is the most common endocrine disorder. Sixteen million Americans have diabetes, yet many are not aware of it. African-Americans, Hispanics, and Native Americans have a higher rate of developing diabetes during their lifetime. Diabetes has potential long term complications that can affect the kidneys, eyes, heart, blood vessels, and nerves. A number of pages on this website are devoted to the prevention and treatment of the complications of diabetes. Types of Diabetes Although doctors and patients alike tend to group all patients with diabetes together, the truth is that there are two different types of diabetes which are similar in their elevated blood sugar, but different in many other ways. Throughout the remainder of these web pages we will be referring to the different types of diabetes when appropriate, but when the topic pertains to both types of diabetes we will use the general term "diabetes". Diabetes is correctly divided into two major subgroups: type 1 diabetes and type 2 diabetes. This division is based upon whether the blood sugar problem is caused by insulin deficiency (type 1) or insulin resistance (type 2).

Insulin deficiency means there is not enough insulin being made by the pancreas due to a malfunction of their insulin producing cells. Insulin resistance occurs when there is plenty of insulin made by the pancreas (it is functioning normally and making plenty of insulin), but the cells of the body are resistant to its action which results in the blood sugar being too high.

The Diabetic Exchange List (Exchange Diet)
*The Exchange Lists are the basis of a meal planning system designed by a committee of the American Diabetes Association and the American Dietetic Association. While designed primarily for people with diabetes and others who must follow special diets, the Exchange Lists are based on principles of good nutrition that apply to everyone. The Exchange Lists The reason for dividing food into six different groups is that foods vary in their carbohydrate, protein, fat, and calorie content. Each exchange list contains foods that are alike; each food choice on a list contains about the same amount of carbohydrate, protein, fat, and calories as the other choices on that list. The following chart shows the amounts of nutrients in one serving from each exchange list. As you read the exchange lists, you will notice that one choice is often a larger amount of food than another choice from the same list. Because foods are so different, each food is measured or weighed so that the amounts of carbohydrate, protein, fat, and calories are the same in each choice. Carbohydrate (grams) 15 . . . . 5 15 Protein (grams) 3 7 7 7 7 2 . Fat (grams) trace 0-1 3 5 8 . . Calories 80 35 55 75 100 25 60

I. Starch/Bread II. Meat Very Lean Lean Medium-Fat High-Fat III. Vegetable IV. Fruit V. Milk

Skim Low-fat Whole VI. Fat

12 12 12 .

8 8 8 .

0-3 5 8 5

90 120 150 45

You will notice symbols on some foods in the exchange groups. Foods that are high in fiber (three grams or more per normal serving) have the symbol *. High-fiber foods are good for you, and it is important to eat more of these foods. Foods that are high in sodium (400 milligrams or more of sodium per normal serving) have the symbol #. As noted, it's a good idea to limit your intake of high-salt foods, especially if you have high blood pressure. If you have a favorite food that is not included in any of these groups, ask your dietitian about it. That food can probably be worked into your meal plan, at least now and then. I. Starch/Bread List Each item in this list contains approximately fifteen grams of carbohydrate, three grams of protein, a trace of fat, and eighty calories. Whole-grain products average about two grams of fiber per serving. Some foods are higher in fiber. Those foods that contain three or more grams of fiber per serving are identified with the symbol *. You can choose your starch exchanges from any of the items on this list. If you want to eat a starch food that is not on the list, the general rule is this: 1/2 cup of cereal, grain, or pasta = one serving 1 ounce of a bread product = one serving Your dietitian can help you to be more exact. CEREALS/GRAINS/PASTA *Bran cereals, concentrated (such as Bran Buds, All Bran) *Bran cereals, flaked Bulgur (cooked) Cooked cereals Cornmeal (dry) Grape Nuts Grits (cooked) Other ready-to-eat, unsweetened (plain) cereals Pasta (cooked) Puffed cereal Rice, white or brown (cooked) Shredded wheat *Wheat germ

1/3 cup 1/2 cup 1/2 cup 1/2 cup 2 1/2 tbsp 3 tbsp 1/2 cup 3/4 cup 1/2 cup 1 1/2 cups 1/3 cup 1/2 cup 3 tbsp

DRIED BEANS/PEAS/LENTILS *Beans and peas (cooked) (such as kidney, white, split, blackeye) *Lentils (cooked) *Baked beans STARCHY VEGETABLES *Corn *Corn on the cob, 6 in. *Lima beans *Peas, green (canned or frozen) *Plaintain Potato, baked 1 small Potato, mashed Squash, winter (acorn, butternut) Yam, sweet potato BREAD Bagel 1/2 Bread sticks, crisp, 4 in. long x 1/2 in. Croutons low fat English muffin Frankfurter or hamburger bun Pita, 6 in. across Plain roll, small Raisin, unfrosted *Rye, pumpernickel White (including French, Italian) Whole wheat CRACKERS/SNACKS Animal crackers Graham crackers, 2 1/2 in. square Matzoh Melba toast Oyster crackers Popcorn (popped, no fat added) Pretzels Rye crisp (2 in. x 3 1/2 in.) Saltine-type crackers Whole-wheat crackers, no fat added (crisp breads such as Finn, Kavli,

1/3 cup 1/3 cup 1/4 cup 1/2 cup 1 long 1/2 cup 1/2 cup 1/2 cup (3 oz) 1/2 cup 3/4 cup 1/3 cup (1 oz) 2 (2/3 oz) 1 cup 1/2 1/2 (1 oz) 1/2 1 (1 oz) 1 slice 1 slice (1 oz) 1 slice (1 oz) 1 slice 8 3 3/4 oz 5 slices 24 3 cups 3/4 oz 4 6 2-4 slices

Wasa) STARCHY FOODS PREPARED WITH FAT (count as 1 starch/bread serving, plus 1 fat serving) Biscuit, 2 1/2 in. across Chow mein noodles Corn bread, 2-in. cube Cracker, round butter type French-fried potatoes (2 in. to 3 1/2 in. long) Muffin, plain, small Pancake, 4 in. across Stuffing, bread (prepared) Taco shell, 6 in. across Waffle, 4 1/2 in. square Whole-wheat crackers, fat added (such as Triscuits)

(3/4 oz)

1 1/2 cup 1 (2 oz) 6 10 (1 1/2 oz) 1 2 1/4 cup 2 1 4-6 (1 oz)

II. Meat List Each serving of meat and substitutes on this list contains about seven grams of protein. The amount of fat and number of calories vary, depending on what kind of meat or substitute is chosen. The list is divided into four parts, based on the amount of fat and calories: very lean meat, lean meat, medium-fat meat, and high-fat meat. One ounce (one meat exchange) of each of these includes the following nutrient amounts: Carbohydrate (grams) . . . . Protein (grams) 7 7 7 7 Fat (grams) 0-1 3 5 8 Calories 35 55 75 100

Very Lean Lean Medium-Fat High-Fat

You are encouraged to use more lean and medium-fat meat, poultry, and fish in your meal plan. This will help you to decrease your fat intake, which may help decrease your risk for heart disease. The items from the high-fat group are high in saturated fat, cholesterol, and calories. You should limit your choices from the high-fat group to three times per week. Meat and substitutes do not contribute any fiber to your meal plan. Meats and meat substitutes that have 400 milligrams or more of sodium per exchange are indicated with the symbol #. Tips 1. Bake, roast, broil, grill, or boil these foods rather than frying them with added fat. 2. Use a nonstick pan spray or a nonstick pan to brown or fry these foods.

3. Trim off visible fat before and after cooking. 4. Do not add flour, bread crumbs, coating mixes, or fat to these foods when preparing them. 5. Weigh meat after removing bones and fat and again after cooking. Three ounces of cooked meat are equal to about four ounces of raw meat. Some examples of meat portions are: 2 ounces meat (2 meat exchanges) = 1 small chicken leg or thigh, 1/2 cup cottage cheese or tuna; 3 ounces meat (3 meat exchanges) = 1 medium pork chop, 1 small hamburger, 1/2 of a whole chicken breast, 1 unbreaded fish fillet, cooked meat, about the size of a deck of cards. 6. Restaurants usually serve prime cuts of meat, which are high in fat and calories.

Beef Pork Veal Poultry Fish

Lean Meat and Substitutes One exchange is equal to any one of the following items: USDA Good or Choice grades of lean beef, such as round, sirloin, and flank steak; tenderloin; and chipped beef# Lean pork, such as fresh ham; canned, cured, or boiled ham#, Canadian bacon#, tenderloin All cuts are lean except for veal cutlets (ground or cubed) Chicken, turkey, Cornish hen (without skin) All fresh and frozen fish Crab, lobster, scallops, shrimp, clams (fresh or canned in water#) Oysters Tuna# (canned in water)

1 oz 1 oz 1 oz 1 oz 1 oz 2 oz 6 med 1/4 cup 1 oz 2 med 1 oz 1 oz 1/4 cup 2 tbsp 1 oz 1 oz 3 1/4 cup

Herring (uncreamed or smoked) Sardines (canned) Wild Game Venison, rabbit, squirrel Pheasant, duck, goose (without skin) Cheese Any cottage cheese Grated parmesan Diet cheese# (with fewer than 55 calories per ounce) 95% fat-free luncheon meat Egg whites Egg substitutes (with fewer than 55 calories per 1/4 cup) Medium-Fat and Meat Substitutes One exchange is equal to any one of the following items: Most beef products fall into this category. Examples are: all ground beef, roast (rib, chuck, rump), steak (cubed, Porterhouse, T-bone),



1 oz

Pork Lamb Veal Poultry Fish

and meat loaf. Most pork products fall into this category. (Examples: chops, loin roast, Boston butt, cutlets) Most lamb products fall into this category (examples: chops, leg, roast) Cutlet (ground or cubed, unbreaded) Chicken (with skin), domestic duck or goose (well drained of fat), ground turkey Tuna# (canned in oil and drained) Salmon# (canned)

1 oz 1 oz 1 oz 1 oz 1/4 cup 1/4 cup 1/4 cup 1 oz 1 oz 1 oz 1 1/4 cup 4 oz 1 oz


Skim or part-skim milk cheeses, such as: Ricotta Mozzarella


Diet cheeses# (with 56-80 calories per ounce) 86% fat-free luncheon meat# Egg (high in cholesterol, so limit to 3 per week) Egg substitutes (with 56-80 calories per 1/4 cup) Tofu (2 1/2 in. x 2 3/4 in. x 1 in.)

Liver, heart, kidney, sweetbreads (high in cholesterol) High-Fat Meat and Substitutes Remember, these items are high in saturated fat, cholesterol, and calories, and should be eaten only three times per week. One exchange is equal to any one of the following items: Beef Most USDA Prime cuts of beef, such as ribs, corned beef# 1 oz Pork Spareribs, ground pork, pork sausage! (patty or link) 1 oz Lamb Patties (ground lamb) 1 oz Fish Any fried fish product 1 oz All regular cheese#, such as American, Blue, Cheddar, Monterey, Cheese 1 oz Swiss Other Luncheon meat#, such as bologna, salami, pimiento loaf 1 oz Sausage#, such as Polish, Italian 1 oz Knockwurst, smoked 1 oz Bratwurst#! 1 oz 1 Frankfurter# (turkey or chicken) (10/lb) frank

Peanut butter (contains unsaturated fat) Count as one high-fat meat plus one fat exchange: (beef, pork, or combination) (400 mg or more of sodium per Frankfurter# exchange) (10/lb) III. Vegetable List

1 tbsp. 1 frank

Each vegetable serving on this list contains about five grams of carbohydrate, two grams of protein, and twenty-five calories. Vegetables contain two to three grams of dietary fiber. Vegetables that contain 400 mg of sodium per serving are identified with a # symbol. Vegetables are a good source of vitamins and minerals. Fresh and frozen vegetables have more vitamins and less added salt. Rinsing canned vegetables will remove much of the salt. Unless otherwise noted, the serving size for vegetables (one vegetable exchange) is: 1/2 cup of cooked vegetables or vegetable juice 1 cup of raw vegetables Artichoke (1/2 medium) Eggplant Asparagus Greens (collard, mustard, turnip) Beans (green, wax, Italian) Kohlrabi Bean sprouts Leeks Beets Mushrooms, cooked Broccoli Okra Brussels sprouts Onions Cabbage, cooked Pea pods Carrots Peppers (green) Cauliflower Tomato (one large) Rutabaga Tomato/vegetable juice Sauerkraut Turnips Spinach, cooked Water chestnuts Summer squash (crookneck) Zucchini, cooked Starchy vegetables such as corn, peas, and potatoes are found on the Starch/Bread List. For "free" vegetables (i.e., fewer than ten calories per serving), see the Free Food List. # = 400 mg or more of sodium per serving. IV. Fruit List Each item on this list contains about fifteen grams of carbohydrate and sixty calories. Fresh, frozen, and dry fruits have about two grams of fiber per serving. Fruits that have

three or more grams of fiber per serving have a * symbol. Fruit juices contain very little dietary fiber. The carbohydrate and calorie contents for a fruit serving are based on the usual serving of the most commonly eaten fruits. Use fresh fruits or frozen or canned fruits with no sugar added. Whole fruit is more filling than fruit juice and may be a better choice for those who are trying to lose weight. Unless otherwise noted, the serving size for one fruit serving is: 1/2 cup of fresh fruit or fruit juice 1/4 cup dried fruit Fresh, Frozen, and Unsweetened Canned Fruit Apples (raw, 2 in. across) 1 Applesauce (unsweetened) 1/2 cup Apricots (canned) (4 halves) 1/2 cup Banana (9 in. long) 1/2 Blackberries (raw) 3/4 cup *Blueberries (raw) 3/4 cup Cantaloupe (5 in. across) 1/3 Cantaloupe (cubes) 1 cup Cherries (large, raw) 12 whole Cherries (canned) 1/2 cup Figs (raw, 2 in. across) 2 Fruit cocktail (canned) 1/2 cup Grapefruit (medium) 1/2 Grapefruit (segments) 3/4 cup Grapes (small) 15 Honeydew melon (medium) 1/8 Honeydew melon (cubes) 1 cup Kiwi (large) 1 Mandarin oranges 3/4 cup Mango (small) 1/2 Nectarines (2 1/2 in. across) 1 Orange (2 1/2 in. across) 1 Papaya 1 cup Peach (2 3/4 in. across) 1 Peaches (canned) (2 halves) 1 cup Pear (1/2 large) 1 small Pears (canned) (2 halves 1/2 cup Persimmon (medium, native) 2 Pineapple (raw) 3/4 cup

Pineapple (canned) Plum (raw, 2 in. across) *Pomegranate *Raspberries (raw) *Strawberries (raw, whole) Tangerine (2 1/2 in. across) Watermelon (cubes) *Dried Fruit *Apples *Apricots Dates (medium) *Figs *Prunes (medium) Raisins Fruit Juice Apple juice/cider Cranberry juice cocktail Grapefruit juice Grape juice Orange juice Pineapple juice Prune juice * = 3 grams or more of fiber per serving V. Milk List

1/3 cup 2 1/2 1 cup 1 1/4 cup 2 1 1/4 cup 4 rings 7 halves 2 1/2 1 1/2 3 2 tbsp 1/2 cup 1/3 cup 1/2 cup 1/3 cup 1/2 cup 1/2 cup 1/3 cup

Each serving of milk or milk products on this list contains about twelve grams of carbohydrate and eight grams of protein. The amount of fat in milk is measured in percent of butterfat. The calories vary depending on the kind of milk chosen. The list is divided into three parts, based on the amount of fat and calories: skim/very low-fat milk, low-fat milk, and whole milk. One serving (one milk exchange) of each of these includes: Carbohydrate Protein Fat Calories (grams) (grams) (grams) Skim 12 8 trace 90 Low-fat 12 8 5 120 Whole 12 8 8 150 Milk

Milk is the body's main source of calcium, the mineral needed for growth and repair of bones. Yogurt is also a good source of calcium. Yogurt and many dry or powdered milk products have different amounts of fat. If you have questions about a particular item, read the label to find out the fat and calorie content. Milk can be drunk or added to cereal or other foods. Many tasty dishes, such as sugarfree pudding, are made with milk (see the Combination Foods list). Add life to plain yogurt by adding one of your fruit servings to it. Skim and Very Low-Fat Milk Skim milk 1 cup 1/2% milk 1 cup 1% milk 1 cup Low-fat buttermilk 1 cup Evaporated skim milk 1/2 cup Dry nonfat milk 1/3 cup Plain nonfat yogurt 8 oz Low-Fat Milk 2% milk 1 cup Plain low-fat yogurt (with added nonfat milk 8 oz solids) Whole Milk The whole-milk group has much more fat per serving than the skim and low-fat groups. Whole milk has more than 3 1/4% butterfat. Try to limit your choices from the whole-milk group as much as possible. Whole milk 1 cup Evaporated whole milk 1/2 cup Whole milk plain yogurt 8 oz VI. Fat List Each serving on the fat list contains about five grams of fat and forty-five calories. The foods on the fat list contain mostly fat, although some items may also contain a small amount of protein. All fats are high in calories and should be carefully measured. Everyone should modify fat intake by eating unsaturated fats instead of saturated fats. The sodium content of these foods varies widely. Check the label for sodium information. Unsaturated Fats Avocado Margarine 1/8 medium 1 tsp

#Margarine, diet Mayonnaise #Mayonnaise (reduced-calorie) Nuts and Seeds: Almonds, dry roasted Cashews, dry roasted Pecans Peanuts (small) Peanuts (large) Walnuts Other nuts Seeds (except pumpkin), pine nuts, sunflower (without shells) Pumpkin seeds Oil (corn, cottonseed, safflower, soybean, sunflower, olive, peanut) #Olives (small) #Olives (large) Salad dressing, mayonnaise-type, regular Salad dressing, mayonnaise-type reduced-calorie Salad dressing, all varieties, regular #Salad dressing, reduced-calorie (2 tbsp of low-calorie dressing is a free food) Saturated Fats

1 tbsp 1 tsp 1 tbsp 6 1 tbsp 2 20 10 2 whole 1 tbsp 1 tbsp 2 tsp 1 tsp 10 5 2 tsp 1 tbsp 1 tbsp 2 tbsp

Butter 1 tsp #Bacon 1 slice Chitterlings 1/2 oz Coconut, shredded 2 tbsp Coffee whitener, liquid 2 tbsp Coffee whitener, powder 4 tsp Cream (light, coffee, table) 2 tbsp Cream, sour 2 tbsp Cream (heavy, whipping) 1 tbsp Cream cheese 1 tbsp #Salt pork 1/4 oz # = 400 mg or more of sodium if more than one or two servings are eaten.

Free Foods A free food is any food or drink that contains fewer than twenty calories per serving. You can eat as much as you want of items that have no serving size specified. You may eat two or three servings per day of those items that have a specific serving size. Be sure to spread them out through the day. Drinks #Bouillon or broth without fat Bouillon, low-sodium Carbonated drinks, sugar-free Carbonated water Club soda Cocoa powder, unsweetened Coffee/tea Drink mixes, sugar-free Tonic water, sugar-free Fruit Cranberries, unsweetened Rhubarb, unsweetened Vegetables (raw, 1 cup) Cabbage Celery #Chinese cabbage Cucumber Green onion Hot peppers Mushrooms Radishes #Zucchini Salad Greens Endive Escarole Lettuce Romaine Spinach Sweets Candy, hard, sugar-free (1/2 cup) (1/2 cup)

(1 tbsp)

Gelatin, sugar-free Gum, sugar-free Jam/jelly, sugar-free Pancake syrup, sugar-free Sugar substitutes (saccharin, aspartame) Whipped topping Condiments Catsup Horseradish Mustard #Pickles, dill, unsweetened Salad dressing, low-calorie Taco sauce Vinegar Nonstick pan spray

(2 tsp) (1-2 tbsp) (2 tbsp) (1 tbsp)

(2 tbsp) (1 tbsp)

Seasonings Seasonings can be very helpful in making foods taste better. Be careful of how much sodium you use. Read labels to help you choose seasonings that do not contain sodium or salt. Basil (fresh) Lemon pepper Celery Seeds Lime Cinnamon Lime Juice Chili powder Mint Chives Onion powder Curry Oregano Dill Paprika Flavoring extracts (vanilla, almond, walnut, butter, Pepper peppermint, lemon, etc.) Garlic Pimento Garlic powder Spices Herbs #Soy sauce Soy sauce, low Hot pepper sauce sodium ("lite") Wine, used in Lemon cooking (1/4 cup)

Lemon juice

Worcestershire sauce

Combination Foods Much of the food we eat is mixed together in various combinations. These combination foods do not fit into only one exchange list. It can be quite hard to tell what is in a certain casserole dish or baked food item. Following is a list of average values for some typical combination foods to help you fit these foods into your meal plan. Ask your dietitian for information about any other foods you'd like to eat. The American Diabetes Association/American Dietetic Association Family Cookbooks and the American Diabetes Association Holiday Cookbook have many recipes and further information about many foods, including combination foods. Check your library or local bookstore. Food Exchanges 2 medium-fat meat, 2 Casserole, homemade 1 cup (8 oz) starches, 1 fat 1/4 of a 15-oz size pizza or 1 medium-fat meat, 2 #Cheese pizza, thin crust a 10" pizza starches, 1 fat 2 medium-fat meat, 2 *#Chili with beans (commercial)1 cup (8 oz) starches, 2 fats *#Chow mein (without noodles 2 lean meat, 1 starch, 2 2 cups (16 oz) or rice) vegetable #Macaroni and cheese Soup *#Bean #Chunky, all varieties 1 cup (8 oz) 10 3/4-oz can 1 lean meat, 1 starch, 1 vegetable 1 medium-fat meat, 1 starch, 1 vegetable 1 starch, 1 fat 1 starch 1 medium-fat meat, 1 fat, 2 starches 1 starch 1 cup (8 oz) 1 medium-fat meat, 2 starches, 2 fats Amount

#Cream (made with water) 1 cup (8 oz) #Vegetable or broth 1 cup (8 oz) #Spaghetti and meatballs 1 cup (8 oz) (canned) Sugar-free pudding (made with 1/2 cup skim milk) If beans are used as a meat substitute: *Dried beans, *peas, *lentils 1 cup (cooked)

1 lean meat, 2 starches

Foods for Occasional Use

Moderate amounts of some foods can be used in your meal plan, in spite of their sugar or fat content, as long as you can maintain blood-glucose control. The following list includes average exchange values for some of these foods. Because they are concentrated sources of carbohydrate, you will notice that the portion sizes are very small. Check with your dietitian for advice on how often and when you can eat them. Food Angel-food cake Cake, no icing Cookies Frozen fruit yogurt Gingersnaps Granola Granola bars Ice cream, any flavor Ice milk, any flavor Sherbet, any flavor #Snack chips, all varieties Vanilla wafers Amount 1/12 cake 1/12 cake (3-in. square) 2 small (1 3/4 in. across) 1/3 cup 3 1/4 cup 1 small 1/2 cup 1/2 cup 1/4 cup 1 oz 6 small Exchanges 2 starches 2 starches, 2 fats 2 starches, 1 fat 1 starch 1 starch 1 starch, 1 fat 1 starch, 1 fat 1 starch, 2 fats 1 starch, 1 fat 1 starch 1 starch, 2 fats 1 starch, 2 fats

# = If more than one serving is eaten, these foods have 400mg or more of sodium.

Management Tips Here are some tips that can help you to change the way you eat. Make Changes Gradually Don't try to do everything all at once. it may take longer to accomplish your goals, but the changes you make will be permanent. Set Short-term, Realistic Goals If weight loss is your goal, try to lose two pounds in two weeks, not twenty pounds in one week. Walk two blocks at firest, not two miles. Success will come more easily, and you'll feel good about yourself. Reward Yourself When you achieve your short-term goal, do something special for yourselfµgo to a movie, buy a new shirt, read a book, visit a friend. Measure Foods It is important to eat the right serving sizes of food. You will need to learn how to estimate the amount of food you are served. You can do this by measuring all the food

you eat for a week or so. Measure liquids with a measuring cup. Some solid foods (such as tuna, cottage cheese, and canned fruits) can also be measured with a measuring cup. Measuring spoons are used for measuring smaller amounts of other foods (such as oil, salad dressing, and peanut butter). A scale can be very useful for measuring almost anything, especially meat, poultry, and fish. All food should be measured or weighed after cooking. Some food you buy uncooked will weigh less after you cook it. This is true of most meats. Starches often swell in cooking, so a small amount of uncooked starch will become a much larger amount of cooked food. The following table shows some of the changes: Starch Group Uncooked Cooked Oatmeal 3 level tbsp 1/2 cup Cream of wheat 2 level tbsp 1/2 cup Grits 3 level tbsp 1/2 cup Rice 2 level tbsp 1/2 cup Spaghetti 1/4 cup 1/2 cup Noodles 1/3 cup 1/2 cup Macaroni 1/4 cup 1/2 cup Dried beans 3 tbsp 1/3 cup Dried peas 3 tbsp 1/3 cup Lentils 2 tbsp 1/3 cup Meat Group Hamburger 4 oz 3 oz Chicken 1 small drumstick 1 oz 1/2 of a whole chicken breast 3 oz

Read Food Labels Remember, dietetic does not mean diabetic! When you see the word "dietetic" on a food label, it means that something has been changed or replaced. It may have less salt, less fat, or less sugar. It does not mean that the food is sugar-free or calorie-free. Some dietetic foods may be useful. Those that contain twenty calories or less per serving may be eaten up to three times a day as free foods. Know Your Sweeteners Two types of sweeteners are on the market: those with calories and those without calories. Sweeteners with calories (such as fructose, sorbitol, and mannitol) may cause cramping and diarrhea when used in large amounts. Remember, these sweeteners do have calories, which can add up. Sweeteners without calories include saccharin and aspartame (Equal, Nutrasweet) and may be used in moderation Plan for Exercise You may need to make some changes in your meal plan or insulin dose when you begin an exercise program. Check with your dietitian or doctor about this. Be sure to carry

some form of carbohydrate with you to treat low blood glucose (for example, dried fruit or glucose tablets). Additional information on these topics is available from your dietitian or doctor. Asparagus and Fresh Mozzarella Ingredients: 1 lb asparagus spears 2 oz fresh mozzarella cheese, cut or torn into pieces 1 tsp snipped fresh lemon verbena or 1/4 tsp. finely shredded lemon peel Directions: Snap off and discard woody bases from asparagus. Using a sharp knife, carefully split asparagus stalks lengthwise. Place a steamer basket in a large skillet. Add water to just below the bottom of the steamer basket. Bring water to boiling. Add asparagus to steamer basket. Cover and steam for 1 minute. Transfer asparagus to a broiler-proof serving dish; top with mozzarella cheese. Broil asparagus 4 inches from heat about 2 minutes or until cheese bubbles slightly. Just before serving, sprinkle with lemon verbena. Makes 4 to 6 servings. Nutrients Per Serving: 56 Calories 3 g Total Fat 2 g Saturated Fat 2 g Carbohydrates 5 g Proteins 11 mg Cholesterol 134 mg Sodium 1 g Fiber ******************************************* Oven-Roasted Broccoli Ingredients: 2 tbsp olive oil 4 cups broccoli florets 1 cup thinly sliced leek 1/2 tsp salt 1/4 tsp black pepper Directions:

Add oil to a shallow baking pan. Heat in a 450 degree oven for 1 minute. Stir broccoli into hot oil. Bake, covered, for 15 minutes. Stir leek, salt, and pepper into baking pan. Roast, covered, for 5 to 7 minutes more or until broccoli is crisp-tender. Makes 4 to 6 servings. Nutrients Per Serving: 98 Calories 7 g Total Fat 1 g Saturated Fat 8 g Carbohydrate 3 g Protein 0 mg Cholesterol 319 mg Sodium 3 g Fiber ******************************************* Garlicky Green Beans Ingredients: 1 lb green beans 2 tbsp butter 1/2 tsp black pepper 2 cloves garlic, minced Directions: In a Dutch oven or larger saucepan cook green beans, covered, in a small amount of boiling salted water for 10 to 15 minutes or until crisp-tender. Drain; set beans aside. Melt butter in the same pan over medium heat. Add pepper and garlic; cook and stir for 1 minute. Stir in green beans. Makes 6 servings. Nutrients Per Serving: 61 Calories 4 g Total Fat 3 g Saturated Fat 6 g Carbohydrate 2 g Protein 11 mg Cholesterol 143 mg Sodium 3 g Fiber

******************************************* Curried Cauliflower Ingredients: 4 cups cauliflower florets 2 tbsp butter 2 tbsp sliced green onion (1) 1 tsp curry powder 1/8 tsp crushed red pepper salt Directions: In a medium saucepan cook cauliflower, covered, in a small amount of boiling salted water for 8 to 10 minutes or just until crisp-tender. Drain; set aside. Melt butter in the same saucepan over medium heat. Add green onion; cook and stir for 30 seconds. Stir in curry powder and crushed red pepper. Stir in cauliflower. Season to taste with salt. Makes 4 servings. Nutrients Per Serving: 82 Calories 6 g Total Fat 4 g Saturated Fat, 6 g Carbohydrate 2 g Protein 16 mg Cholesterol 128 mg Sodium 3 g Fiber Chicken with Garlic Galore Ingredients: 1 - 3 to 3 1/2 lb whole broiler-fryer chicken 3 heads garlic (about 40 cloves) 2 tbsp olive oil 1 tbsp snipped fresh lemon thyme or thyme 1 tsp cracked black pepper 1/4 tsp salt 1 medium onion, cut into wedges 2 c fat-free half and half 2 tbsp all-purpose flour

1 tsp snipped fresh lemon thyme or thyme 1/4 tsp salt 1/8 tsp ground black pepper Directions: Preheat oven to 375 degrees F. Rinse chicken: pat dry. Skewer neck skin to back; set aside. Peel away outer layers from garlic heads, leaving skins and cloves intact. Separate cloves. Peel and mince four of the cloves. In bowl, combine minced garlic, 1 tablespoon of the oil, 1 tablespoon thyme, cracked pepper, and 1/4 teaspoon salt. Sprinkle over chicken: rub in with your fingers. Place six of the garlic cloves in cavity of chicken. Tie legs to tail. Twist wing tips under back. Place onion and remaining garlic in shallow roasting pan. Drizzle with remaining oil. Place chicken, breast side up, on onion mixture in pan. Roast for 1 1/4 to 1 1/2 hours or until drumsticks move easily in sockets and chicken is no longer pink (180 degrees F). Remove from oven. Cover chicken loosely with foil: let stand for 15 minutes. For sauce: Using slotted spoon, remove onion mixture from pan. Squeeze 10 of the garlic cloves froms skins into blender. Add onion and 1/4 cup of the half and half. Cover and blend until smooth. Transfer to saucepan. Stir in flour. Add remaining half and half, 1 teaspoon thyme, 1/4 teaspoon salt, and ground pepper. Cook and stir until bubbly. Cook and stir for 1 minute more. Serve chicken with sauce and remaining garlic cloves. Makes 6 Servings. Dietary Exchanges: 1 Carbohydrate, 4 Lean Meat Nutrients Per Serving: 282 Calories 10 g Total Fat 2 g Saturated Fat 67 mg Cholesterol 343 mg Sodium 16 g Carbohydrates 1 g Fiber 25 g Protein *************************************************************** Creamy Mushroom Chicken Ingredients: nonstick cooking spray 4 skinless, boneless chicken breast halves (about 1 1/4 lb total) 1 tsp olive oil 2 c sliced fresh mushrooms

1 medium red sweet pepper, cut into 3/4 inch pieces 1/2 tsp bottled minced garlic (1 clove) 1/2 c reduced-sodium chicken broth 1/2 c fat-free dairy sour cream 1 tbsp all-purpose flour 1/8 tsp ground black pepper 1 tbsp dry sherry (optional) Directions: Lightly coat large nonstick skillet with cooking spray: heat over medium heat. Add chicken; cook about 4 minutes or until browned, turning once. Remove chicken from skillet. Carefully add oil to hot skillet. Add mushrooms, sweet pepper, and garlic; cook until vegetables; cover and keep warm. Carefully add broth to hot skillet; return chicken. Sprinkle lightly with salt and ground black pepper. Bring to boiling; reduce heat. Cover and simmer for 5 to 7 minutes or until chicken is tender and no longer pink (170 degrees F). Remove chicken; cover and keep warm. For sauce: In small bowl, combine sour cream, flour, and 1/8 teaspoon pepper. If desired, stir in sherry. Add to skillet. Cook and stir until thickened and bubbly. Return chicken and vegetables; heat through. Makes 4 Servings. Dietary Exchanges:1 Vegetable, 4.5 Very Lean Meat, 1 Fat Nutrients Per Serving: 232 Calories 4 g Total Fat 1 g Saturated Fat 82 mg Cholesterol 190 mg Sodium 10 g Carbohydrates 1 g Fiber 37 g Protein *************************************************************** Salmon with Mango Salsa Ingredients: 4 - 6 to 8-oz fresh or frozen salmon fillets (with skin), about 1 inch thick 2 tbsp sugar 1 1/2 tsp finely shredded lime peel 3/4 tsp salt

1/4 tsp cayenne pepper 1 large ripe mango, seeded, peeled and cut into thin bite-size strips 1/2 of a medium cucumber, seeded and cut into thin bite-size strips 2 green onions, sliced 3 tbsp lime juice 1 tbsp snipped fresh cilantro 1 small fresh jalapeño, chile pepper, seeded and chopped 1/2 tsp bottled minced garlic Directions: Thaw fish, if frozen. Rinse fish: pat dry with paper towels. Place fish fillets, skin sides down, in shallow dish. For rub: In small bowl, stir together sugar, lime peel, 1/2 tsp of the salt, and the cayenne pepper. Sprinkle mixture evenly over fish; rub in with your fingers. Cover and marinate in refrigerator for 4 to 24 hours. Meanwhile, for salsa: In bowl, combine mango, cucumber, green onions, lime juice, cilantro, jalapeño pepper, garlic, and remaining salt. Cover and chill until ready to serve. Prepare grill for indirect grilling. Test for medium heat about drip pan. Place fish fillets, skin sides down, on greases grill rack over drip pan, tucking under any thin edges. Cover and grill about 20 minutes or until fish flakes easily with fork. If desired, remove skin from fish. Serve fish with salsa. Makes 4 Servings. Dietary Exchanges: 1 Fruit, 5 Lean Meat Nutrients Per Serving: 852 Calories 15 g Total Fat 3 g Saturated Fat 105 mg Cholesterol 520 mg Sodium 18 g Carbohydrates 2 g Fiber 37 g Protein *************************************************************** Beef Satay with Peanut Sauce Ingredients: 1 - 1 to 1 1/4 lb beef flank steak 1/3 cup light teriyaki sauce 1/2 tps bottled hot pepper sauce 1 medium red sweet pepper, cut into 3/4 inch pieces

4 green onions, cut into 1 inch pieces 3 tbsp reduced-fat or regular peanut butter 3 tbsp water 2 tbsp light teriyaki sauce Directions: Trim fat from meat. Thinly slice meat across grain into bite-size strips. For marinade: In medium bowl, combine 1/3 cup teriyaki sauce and 1/4 teaspoon of the hot pepper sauce. Add meat: toss gently to coat. Cover and marinate in refrigerator for 30 minutes. Drain meat, reserving marinade. On metal skewers, thread meat accordian-style, alternating with sweet pepper and green onion pieces. Brush with marinade. Place kabobs on rack of uncovered grill directly over medium coals. Grill for 3 to 4 minutes or until meat is slightly pink in center, turning once. (Or broiler pan 4 to 5 inches from heat about 4 minutes, turning once.) For sauce: In small saucepan, combine peanut butter, the water, 2 tablespoons teriyaki sauce, and remaining hot pepper sauce. Cook and stir over medium heat just until smooth and heated through. Serve kabobs with sauce. Makes 5 Servings. Dietary Exchanges: 1.5 Lean Meat, 1 Fat Nutrients Per Serving: 217 Calories 10 g Total Fat 3 g Saturated Fat 43 mg Cholesterol 567 mg Sodium 10 g Carbohydrates 1 g Fiber 21 g Protein Barbecued Chicken Ingredients: 6 chicken breasts, 6 ounces each, bone in, fat and skin removed olive oil cooking spray Barbecue Sauce 1 10 3/4-oz can tomato puree 1/2 onion, chopped fine 3 tbsp French style whole-grain mustard 3 tbsp fresh lemon juice sugar substitute equivalent of 2 tbsp sugar, or to taste

1 tabsp Worcestershire sauce 1 to 2 tsp hot sauce (optional) 1/4 tsp ground allspice 1/4 tsp ground ginger 1/3 c water freshly ground pepper Directions: Prepare the coals in the barbecue or light the grill. To make the sauce: place the tomato puree in a deep sauce pan. Add the onion and simmer slowly, covered, for 5 minutes. Uncover and add the mustard, lemon juice, sugar substitute, Worcestershire sauce, pepper sauce, (if using), allspice, ginger, and water. Simmer slowly for about 10 minutes until the sauce thickens. Add the pepper. Makes about 2 cups which can be frozen, refrigerated for up to 4 days, or served warm immediately. When ready to grill, lightly coat the chicken breasts with cooking spray. Pat with freshly ground pepper and them place on the grill, bone side up. Grill, turning frequently, for 20 to 25 minutes. After 20-25 minutes brush both sides with barbecue sauce. Continue to grill until the chicken is no longer pink when cut with a knife. To serve, return the barbecue sauce to the stove and bring to a rapid boil for at least 2 minutes. Transfer sauce to a serving dish and pass to spoon over chicken breasts. Makes 6 Servings (2 tablespoons sauce with each serving). Dietary Exchanges: 4 Very Lean Protein Nutrients Per Serving: 170 Calories 10% Calories from Fat 2 g Total Fat 0.5 g Saturated Fat 3 g Carbohydrates 33 g Protein 82 mg Cholesterol 246 mg Sodium 1 g Dietary Fiber ********************************************** Brunswick Stew Ingredients: 1 3 1/2-lb frying chicken or 2 boneless skinless breasts and 2 hindquarters 1 tsp non-aromatic olive oil, divided 1 large sweet onion, cut in 1" dice

3 ribs celery cut in 1/4" slices 3-oz Canadian bacon cut the same size as the celery 1 red bell pepper cut the same 2 c canned, crushed tomatoes 1 c low sodium chicken stock 1 tbsp Worcestershire sauce1 1/4 tsp cayenne pepper 1 c frozen corn kernels 1 c frozen baby lima beans 1 tbsp arrowroot mixed with 2 tbsp stock or water (slurry) 1/4 c chopped fresh parsley 1/4 c chopped fresh basil Directions: If you are using a whole chicken, cut off the legs with the thighs and the breasts. Use the carcass and wings for stock. Remove the skin from all the pieces. Separate the legs from the thighs and bone the thigh, leaving the bone in the leg. Remove the skin and bone from the breast pieces. Bones, fat and skin will all help to make a flavorful stock. Cut the meat into 1½ " chunks. Heat ½ teaspoon of the oil in a 10½ " chef's pan on medium high. Sauté the onion 3 minutes or until it starts to turn translucent. Add the celery, Canadian bacon, and red bell pepper and cook 3 more minutes. Remove to a plate and without washing the pan, add the remaining ½ teaspoon oil and heat. When the pan is nice and hot, toss in the thigh meat and legs to brown 2 minutes. Add the breast meat and brown 1 to 2 minutes more. Pour in the tomatoes, stock, and Worcestershire sauce. Add the cooked vegetables and cayenne. Bring to a boil, reduce the heat, cover and simmer 35 minutes or until the chicken is tender. Add the lima beans and corn and cook 12 minutes more or until the beans are tender. Stir in the slurry and heat to thicken. Add the parsley and basil and you are ready to serve. Makes 6 Servings. Nutrients Per Serving: 260 Calories 6 g Fat 2 g Saturated Fat 7% Calories from Saturated Fat 21 g Carbohydrates 3 g Fiber 362 mg Sodium ********************************************** Spinach Lasagna Ingredients:

1/4 cup skim milk 1 container (15 oz) light ricotta cheese 1 jar (about 32 oz) meatless spaghetti sauce 7 lasagna noodles, cooked and drained 1 bunch (1 lb) fresh spinach, washed, dried, and torn into pieces 1/2 c grated Parmesan cheese 1/2 c sliced almonds 2 c shredded reduced-fat mozzarella cheese Directions: Preheat oven to 350°F. Mix the milk and ricotta cheese in a small bowl; set aside. Lasagna is made by building alternating layers of noodles, cheese, sauce, and other ingredients. First, cover the bottom of a 9"x13" baking pan with about half of the sauce. Follow with layers of half the noodles, half the spinach pieces, half the ricotta mixture, half the Parmesan cheese, half the almonds, and half the mozzarella cheese. Again starting with the sauce, repeat the layers, reserving a little sauce and some almonds to sprinkle on top. Bake for 30 minutes; let sit 10 minutes before cutting into 8 squares. Serve warm. Makes 8 Servings: Dietary Exchanges: 2 starch, 2 meat Carbohydrate Choices: 2 Nutrients Per Serving: 384 Calories 18 g Fat 7 g Saturated Fat 37 g Carbohydrate 21 g Protein 860 mg Sodium 6 g Fiber ********************************************* Beef Stroganoff Ingredients: 1 lb steak, sirloin or tenderloin 2 tbsp flour, all purpose 2 oz sour cream. 2 oz cottage cheese, creamed 1/2 c water 2 tbsp margarine

2 tsp beef bouillon granules 1 1/2 c mushrooms, fresh sliced 1/4 tsp salt 1/4 tsp. 1 tsp garlic, minced 1 tsp black pepper 1/2 c hot noodles or rice Directions: Partly freeze beef. Thinly slice across grain into bite-size strips. Combine flour, pureed cottage cheese and 5 ounces of water. Stir in bouillon, sour cream, 1/2 cup water, salt and pepper. Set aside. In a large skillet, stir half of meat in margarine on high heat until done. Remove. Add rest of meat, mushrooms, onions and garlic. Cook and stir till meat is done and onions are tender. Return all meat to skillet. Add sour cream-cottage cheese mixture. Cook and stir over medium heat until bubbly. Cook on reduced heat with stirring for 5 minutes more. Serve over rice or noodles. Dietary Exchanges: 1 1/2 diabetic servings would consist of 1 Meat and 1/2 of a mixed serving of Dairy and Vegetable. A half cup of rice would add a third serving, this one of Grain. Lemon Pepper Steaks Ingredients: 2 boneless beef top loin steaks, cut 1 inch thick 1 tbsp snipped fresh oregano or 1 tsp dried oregano, crushed 1 tsp bottled minced garlic 1 tsp finely shredded lemon peel 1 tsp olive oil or cooking oil 1/4 tsp coarsely ground black pepper Directions: Trim fat from steaks. In a small bowl stir together oregano, garlic, lemon peel, oil and pepper. Using your fingers, rub mixture onto both sides of steaks. For a charcoal grill, grill steaks on rack of an uncovered grill directly over medium coals until desired doneness, turning meat once halfway through grilling. Allow 11 to 15 minutes for medium rare (145 degrees F) and 14 to 18 minutes for medium (160 degrees F). (For a gas grill, preheat grill. Reduce heat to medium. Place steak on grill rack over heat. Cover and grill as above.) To serve, thinly slice steak diagonally across the grain into thin strips.

Broiling Directions: Preheat broiler. Place steaks on the unheated rack of a broiler pan. Broil 3 to 4 inches from heat until desired doneness, turning once halfway through broiling. Allow 12 to 14 minutes for medium rare and 15 to 18 minutes for medium. Makes 4 Servings. Nutrients Per Serving: 154 Calories 5 g Total Fat 2 g Saturated Fat 1 g Carbohydrate 24 g Protein 54 mg Cholesterol 61 mg Sodium 0 g Fiber ******************************************* Chicken Medallions with Mustard Sauce Ingredients: 4 skinless, boneless chicken breast halves salt and black pepper 2 tbsp olive oil or cooking oil 1/4 c dry white wine 2 tbsp creme fraiche 2 tbsp tarragon mustard or dill mustard Directions: Place each chicken breast half between 2 pieces of plastic wrap. Pound lightly with the flat side of a meat mallet to 1/2-inch thickness. Remove plastic wrap. Sprinkle chicken with salt and pepper. In a 12-inch skillet cook chicken breasts, 2 at a time, in hot oil over medium-high heat for 2 to 3 minutes or until golden, turning once. Transfer chicken to a serving platter; keep warm. For sauce, carefully add wine to hot skillet. Cook and stir until bubbly to loosen any brown bits in bottom of skillet. Add creme fraiche and mustard to skillet; stir with a wire whisk until combined. Spoon sauce over chicken. Makes 4 Servings. Nutrients Per Serving: 255 Calories 11g Total Fat 3 g Saturated Fat 1 g Carbohydrate

33 g Protein 92 mg Cholesterol 306 mg Sodium 0 g Fiber ******************************************* Spicy Orange-Glazed Pork Chops Ingredients: 1/4 c sugar-free or low-sugar orange marmalade 2 tsp Dijon-style mustard 1 tsp lemon juice 1/8 to 1/4 tsp cayenne pepper 4 boneless pork loin chops, cut 3/4 inch thick salt and black pepper Directions: For glaze, in a small bowl stir together orange marmalade, mustard, lemon juice, and cayenne pepper. Set glaze aside. Trim fat from chops.Sprinkles chops with salt and black pepper. For a charcoal grill, grill chops on the greased rack of an uncovered grill directly over medium coals for 12 to 15 minutes or until done (160 degrees F), turning once and brushing frequently with glaze during the last few minutes of grilling. (For a gas grill, preheat grill. Reduce heat to medium. Place chops on greased grill rack over heat. Cover and grill as above.) Makes 4 Servings. Nutrients Per Serving: 263 Calories 10 g Total Fat 3 g Saturated Fat 5 g Carbohydrate 37 g Protein 92 mg Cholesterol 126 mg Sodium 0 g Fiber ******************************************* Teriyaki Beef Spirals

Ingredients: 1 c loosely packed fresh spinach leaves 1/2 c finely chopped water chestnuts 1/4 c chopped green onions (2) 1/4 c reduced-sodium teriyaki sauce 3/4 to 1 lb beef flank steak salt and black pepper Directions: Remove stems from spinach leaves. Layer leaves on top of each other; slice crosswise into thin strips. In a medium bowl combine spinach strips, water chestnuts, green onions, and 2 tablespoons of the teriyaki sauce. Trim fat from steak. Score steak on both sides by making shallow cuts at 1-inch intervals in a diamond pattern. Place meat between 2 pieces of plastic wrap. Pound lightly with flat side of meat mallet into a 10x8inch rectangle. Remove plastic wrap. Sprinkle steak with salt and pepper. Spread spinach mixture over steak. Starting from a short side, roll steak up. Secure with wooden toothpicks at 1-inch intervals, starting 1/2 inch from one end. Slice between toothpicks into eight 1-inch slices. Thread 2 slices onto each of 4 long metal skewers. Brush slices with teriyaki sauce. For a charcoal grill, grill slices on the rack of an uncovered grill directly over medium coals for 12 to 14 minutes for medium doneness, turning once and brushing with teriyaki sauce halfway through grilling. (For a gas grill, preheat grill. Reduce heat to medium. Place slices on grill rack over heat. Cover and grill as above.) Makes 4 Servings. Nutrients Per Serving: 135 Calories 6 g Total Fat 2 g Saturated Fat 2 g Carbohydrate 18 g Protein 42 mg Cholesterol 135 mg Sodium 1 g Fiber Eggs Benedict Con Queso Ingredients: 5 large eggs 5 slices (1 oz each) Canadian bacon or lean ham

5 whole-wheat or oat-bran English muffin halves, toasted 3 tbsp chopped fresh cilantro or thinly sliced scallions Sauce: 1 tbsp unbleached flour 3/4 c nonfat or low-fat milk 3/4 diced reduced-fat process cheese (like Velveeta Light) 1/4 c chunky-style salsa Directions: To poach the eggs, fill a large nonstick skillet with 3 inches of water and bring the water to a boil over high heat. Reduce the heat to low to keep the water gently simmering. Break the eggs, one at a time, into a custard cup. Holding the cup at the water's surface, slip the eggs, one at a time, into the water, spacing them evenly apart. Cover the skillet and cook for several minutes, or until the whites are completely set and the yolks thicken. Lift the eggs out of the water with slotted spoon, set aside, and keep warm. To make the sauce, combine the flour and a couple tablespoons of the milk in a 1 1/2 quart microwave-safe bowl and whisk until smooth. Whisk in the remaining milk. Microwave at high power for 1 minute, stir, and cook for another minute or until thick and bubbly. Stir in the cheese and cook in the microwave for another minute to melt the cheese and then stir in the salsa and heat for about 30 seconds. Set aside. Coat a large nonstick skillet with nonstick cooking spray and preheat over medium-high heat. Add the Canadian bacon or ham to the skillet and cook for about 1 minute on each side, or until lightly browned. To assemble the dish, place one English muffin half on each of 5 serving plates. Top each muffin half with 1 slice of Canadian bacon and 1 egg. Spoon one-fifty of the sauce over each serving and sprinkle with some of the cilantro or scallions. Serve hot. Makes 5 Servings. Dietary Exchanges: 2 1/2 Lean Meat, 1 Starch Nutrients Per Serving: 225 Calories 19 g Carbohydrates 224 mg Cholesterol 7.5 g Fat 2.3 g Saturated Fat 2.5 g Fiber 20 g Protein 804 mg Sodium 302 mg Calcium

************************************** Southwestern Egg Scramble Ingredients: 3/4 c canned (drained) hominy 2 tbsp chopped green chilies 2 c fat-free egg substitute 1/2 c shredded, reduced-fat Monterey Jack (plain or with hot peppers) or Mexican cheese blend Directions: Coat a large nonstick skillet with cooking spray and preheat over medium heat. Add the hominy to the skillet and cook for about 1 minute, until heated through. Stir the chilies into the egg substitute and pour over the hominy. Reduce the heat to medium-low and cook without stirring for several minutes, until the eggs are set around the edges. Stirring gently to scramble, continue to cook for another minute, until the eggs are almost set. Sprinkle the cheese over the eggs and cook just until the eggs are set but not dry and the cheese is melted. Serve hot. Makes 4 Servings. Dietary Exchanges: 2 1/2 Very Lean Meat, 1/2 Starch Nutrients Per Serving: 125 Calories 7 g Carbohydrates 1 mg Cholesterol 2.3 g Fat 1 g Saturated Fat 1 g Fiber 17 g Protein 414 mg Sodium 169 mg Calcium ************************************** Primavera Omelette Ingredients: 2 tbsp chopped onion 2 tbsp chopped red bell pepper

1/4 c sliced mushrooms 1/8 tsp dried oregano 1/3 c (packed) chopped fresh spinach 1/2 c fat-free egg substitute 2 tsp grated Parmesan cheese 1/4 tsp dried parsley, finely crumbled Directions: Coat an 8-inch nonstick skillet with nonstick cooking spray and preheat over medium heat. Add onion, bell pepper, mushrooms, and oregano. Cover and cook for about 2 minutes, stirring a couple of times, until the vegetables are tender. Add the spinach and cook for another minute, until the spinach is wilted. Remove the vegetable mixture to small dish and cover to keep warm. Re-spray the skillet and place over medium-low heat. Add the egg substitute and cook without stirring for 2 minutes, until set around the edges. Use spatula to lift the edges of the omelette, and allow the uncooked egg to flow below the cooked portion. Cook for another minute or two, until the eggs are almost set. Arrange the vegetable mixture over half of the omelette and sprinkle with the cheese. Fold the other half over the filling and cook for another minute or two, until the eggs are completely set. Slide the omelette onto a plate, top with parsley, and serve hot. Makes 1 Serving. Dietary Exchanges: 2 Very Lean Meat, 1 Vegetable Nutrients Per Serving: 96 Calories 6 g Carbohydrates 3 mg Cholesterol 1.4 g Fat 0.8 g Saturated Fat 1 g Fiber 15 g Protein 337 mg Sodium 113 mg Calcium ************************************** Ham and Pepper Frittata Ingredients: 1 tbsp extra virgin olive oil or canola oil 1/2 c diced yellow bell pepper 1/2 c diced green bell pepper

1/2 c diced red bell pepper 1 c diced, lean, reduced-sodium ham 2 tsp dried parsley 1/4 tsp coarsely ground black pepper 2 c fat-free egg substitute 1 c shredded, reduced-fat, white cheddar or Swiss cheese Directions: Coat a large ovenproof skillet with the olive oil and preheat over medium-high heat. Add the peppers, ham, parsley, and black pepper and saute for several minutes, until the vegetables are crisp-tender and the ham is beginning to brown. Spread the mixture evenly over the bottom of the skillet. Pour the egg substitute over the skillet mixture and reduce the heat to medium-low. Cover and cook without stirring for about 6 minutes, until the eggs are almost set (the edges will be cooked but the top will still be runny). Remove the lid from the skillet and wrap the handle in aluminum foil (to prevent it from becoming damaged under the broiler. Place the skillet under a preheated broiler and broil for a couple of minutes, until the eggs are set but not dry. Sprinkle the cheese over the top and broil for another minute to melt the cheese. Cut the frittata into 4 wedges and serve hot. Makes 4 Servings. Dietary Exchanges: 4 Lean Meat, 1 Vegetable, 1/2 Fat Nutrients Per Serving: 222 Calories 7 g Carbohydrate 32 mg Cholesterol 8.3 g Fat 2.9 g Saturated Fat 1.1 g Fiber 28 g Protein 690 mg Sodium 299 mg Calcium Grilled Chicken and Rice Salad Ingredients: 12 oz skinless, boneless chicken breasts halves or thighs 1/3 c bottled Parmesan Italian salad dressing 1 c loose-pack frozen French-cut green beans 2 c cooked brown rice and wild rice blended, chilled 1 c canned artichoke hearts, drained and quartered 1 c shredded red cabbage

1/2 c shredded carrot 1 green onion, sliced Lettuce leaves (optional) Directions: Brush chicken with 2 tablespoons of the dressing. Place chicken on the grill rack directly over medium coals. Grill, uncovered, for 12 to 15 minutes or until chicken is tender and no longer pink, turning once halfway through grilling. (Or broil on the unheated rack of a broiler pan 4 to 5 inches from the heat for 12 to 15 minutes, turning onch halfway through broiling.) Cut chicken into bite-size pieces. Meanwhile, rinse green beans with cool water for 30 seconds; drain well. In a large bowl, toss together beans, cooked rice, artichoke hearts, cabbage, carrot, and green onion. Pour the remaining dressing over rice mixture; toss to gently coat. If desired, arrange lettuce leaves on four dinner plates. Top with the rice mixture and chicken. Makes 4 Servings. Nutrients Per Serving: 285 Calories 8 g Total Fat 1 g Saturated Fat 53 mg Cholesterol 490 mg Sodium 30 g Carbohydrates 4 g Fiber ************************************************ Grilled Bass with Strawberry Salsa Ingredients: 4 4-5 oz fresh or frozen sea bass or halibut steaks, 1 inch thick 1 small lime 1/4 tsp salt 1/4 cayenne pepper 1 c chopped fresh strawberries 1/4 c finely chopped seeded fresh poblano chile pepper (half of a small) 2 tbsp snipped fresh cilantro 1/2 tsp cumin seeds toasted 1/8 tsp salt Directions:

Thaw fish, if frozen. Rinse fish; pat dry with paper towels. Finely shred lime peel. Peel, section, and chop lime; set aside. In a small bowl, combine lime peel, the 1/4 teaspoon salt, and the cayenne pepper. Sprinkle evenly over both sides of each fish steak; rub in with your fingers. Arrange medium-hot coals around a drip pan. Cover and grill for 7 to 9 minutes per 1/2-inch thickness or until fish flakes easily when tested with a fork, gently turning once halfway through grilling time. Meanwhile, in a medium bowl combine chopped lime, strawberries, chile pepper, cilantro, cumin seeds, and the 1/8 tsp salt. Serve with grilled fish. Makes 4 Servings Nutrients Per Serving: 129 Calories 2 g Total Fat 1 g Saturated Fat 46 mg Cholesterol 298 mg Sodium 5 g Carbohydrate 1 g Fiber ************************************************ Bull's-Eye Onion Burgers Ingredients: 1 large sweet onion 1 lb 95% lean ground beef 1 1/2 tsp garlic powder 1/8 tsp salt 1/4 tsp ground black pepper 4 slices low-fat Swiss cheese (3 oz) 8 red and/or green kale leaves, stems removed 2 tsp olive oil 4 3/4-inch-thick slices hearty bread or Texas toast, toasted Directions: Peel onion. Cut four 1/4-inch-thick onion slices; refrigerate remaining onion for another use. Loosely shape meat into four 1/2-inch-thick patties; sprinkle with garlic powder, salt, and pepper. Press an onion slice into each patty and shape meat around onion until onion is flush with the surface of the meat patty. For a charcoal grill, place meat patties onion sides up, on the grill rack directly over medium coals. Grill, uncovered, for 10 to 13 minutes or until meat is done (160 degrees F), turning once halfway through grilling. Lightly brush kale leaves with oil, top kale with a cheese slice for each patty,

and add to the grill the last 1 to 1 1/2 minutes of grilling. To serve, top each bread slice with two kale leaves and cheese, then add burger onion side up. Makes 4 Servings. Nutrients Per Serving: 321 Calories 10 g Fat 4 g Saturated Fat 22 g Carbohydrates 78 mg Cholesterol 337 mg Sodium 2 g Fiber Blueberry Pancakes Ingredients: 1 c plain nonfat yogurt 1 carton egg substitute 1/2 tsp vanilla 1 c whole wheat flour 1 tbsp sugar 1 tsp baking powder 1/2 tsp baking soda 1 c frozen blueberries, thawed, washed and drained Directions: In a large bowl, combine yogurt, egg substitute and vanilla. In a separate bowl, combine remaining dry ingredients. Mix dry and liquid ingredients. Fold in blueberries. Pour ¼ cup of batter onto a nonstick skillet lightly coated with cooking spray. When bubbles start to appear, flip the pancake and cook until golden brown. Makes 10 Large Pancakes. Dietary Exchanges: 1/2 Starch, 1/2 Fruit Nutrients Per Serving: 78 Calories 14 gCarbohydrates 5 gProtein 10 mg Cholesterol 131 mg Sodium 29 mg Dietary Fiber

******************************************* Old-Fashioned Potato Salad Ingredients: 2-1/4 pounds red boiling potatoes, cooked, cooled, skinned 3/4 cup celery, small dice 1 cup Vidalia or other sweet onion, finely diced 1 cup Best Foods/Hellman's Light Mayonnaise 4 large eggs, hard boiled 1 large clove garlic, halved 2 to 3 Tbsp red wine vinegar 1-1/2 tsp salt, or to taste 1-1/2 tsp freshly ground black pepper, or to taste Directions: Put whole potatoes in a 5-quart pot; cover with water to about 2-inches above potatoes, lightly sprinkle with salt and bring to a boil. When potatoes come to a full boil, reduce heat to medium, cover and adjust lid to let steam escape. Cook about 20 to 25 minutes; test for tenderness with a meat fork. DO NOT OVERCOOK. When potatoes are done, drain and set aside until cool enough to peel. Cut a large garlic clove in half and rub the sides and bottom of the serving bowl with each half of the garlic clove. After rubbing the bowl, mince the garlic clove halves and set aside. Prepare remaining ingredients, beginning by cutting the potatoes into the serving bowl, including the minced garlic. Add fat-reduced mayonnaise and about 2 Tbsp of the red wine vinegar. Mix all ingredients thoroughly, adding more vinegar a few drops at a time, if needed, until desired consistency and taste is reached. Salt and pepper to taste. Chill at least 2 to 3 hours before serving. Makes 8 One-Cup Servings. Dietary Exchanges: 1 1/2 Starch, 1 Fat Nutrients Per Serving: 92 Calories 8 g Total Fat 2 g Saturated Fat 23 g Carbohydrate 7 g Protein 111 mg Cholesterol 596 mg Sodium 3 g Fiber *******************************************

Stuffed Portabella Mushrooms Ingredients: 4 large portabella mushrooms 1 tsp olive oil 1/2 c chopped onion 1/2 c chopped red and green bell pepper 2 cloves chopped garlic 1 c 2% cottage cheese 2 tsp Worcestershire sauce 1/4 c whole wheat bread crumbs non-stick cooking spray 1/2 tsp paprika 2 tbsp parmesan cheese Directions: Preheat oven to 350 degrees. Clean mushrooms and remove the stems. Heat olive oil in a non-stick skillet over medium-heat and add onion, bell pepper and garlic and sauté for 5 minutes until veggies are tender. Remove from heat and stir in cottage cheese and Worcestershire sauce and breadcrumbs. Divide mixture evenly among mushroom caps. Coat a glass baking dish with cooking spray and place filled mushroom caps in dish. Sprinkle with paprika. Bake uncovered for 20 minutes. Sprinkle with parmesan cheese before eating. This can be made ahead and eaten as a snack, or used as a meal and eat more than one with a salad or grilled chicken or steak. Makes 4 Servings. Nutrients Per Serving: 101 Calories 3g Fat 7g Carbohydrates 10g Protein ******************************************* South of the Border Pizza Ingredients: 1/3 c frozen mixed pepper and onion stir-fry 1/4 c mild or medium salsa 1/4 c shredded reduced-fat Cheddar cheese 1 whole-wheat English muffin

Directions: In a medium non-stick skillet coated with non-stick spray coating, cook the onion and pepper mixture over medium heat, stirring frequently, until the onion is tender, about 4 to 6 minutes. Meanwhile, divide the salsa evenly between the English muffin halves, and spread it evenly over each half. Sprinkle the cheese evenly over the two halves. Toast the muffin halves in a toaster oven until the cheese melts. When the onion and pepper mixture is done, top the pizza halves with the pepper mixture, dividing it evenly. Makes 2 Servings. Dietary Exchanges: 1 Starch, 1 Medium Fat Meat Nutrients Per Serving: 165 Calories 7 g Fat 15 g Carbohydrate 4 g Sugars 12 g Protein 20 mg Cholesterol 426 mg Sodium 2 g Dietary Fiber ******************************************* Salsa Chicken Ingredients: 8 c finely shredded iceberg lettuce 3 tbsp chili powder 1 tsp ground cumin 1 lb boneless, skinless chicken breast, cut into 1" pieces 2 large egg whites 2 tbsp extra-virgin olive oil 8 oz chunky tomato salsa 1/2 c fat-free sour cream Cilantro sprigs (optional) Directions: Divide the lettuce among 4 individual plates, cover and set aside. In a large bowl, combine the chili powder and cumin. Add the chicken, turning to coat. Lift the chicken from the bowl, shaking off the excess coating. Dip the chicken into the egg whites, then coat again with the remaining dry mixture. Heat the oil in a wide nonstick frying pan or wok over medium heat. When the oil is hot, add the chicken and stir-fry gently until no

longer pink in the center. Cut to test (5-7 minutes). Remove the chicken from the pan and keep warm. Pour the salsa into the pan; reduce the heat to medium and cook, stirring, until the salsa is heated through and slightly thickened. Arrange the chicken over the lettuce; top with the salsa and sour cream. Garnish with cilantro sprigs, if using. Makes 4 Servings. Nutrients Per Serving: 266 Calories 10 g Fat 2 g Saturated Fat 12 g Carbohydrates 32 g Protein 66 mg Cholesterol 457 mg Sodium 5 g Fiber

Salmon Dip Source: Healthy-Diabetic-Recipes.co.uk Ingredients: 1 can (7 3/4 oz) salmon 2 tbsp minced green onions 1/4 c plain lowfat yogurt 1/4 c mayonnaise or salad dress. 1/2 tsp ground ginger 2 tbsp toasted sesame seeds Directions: Drain and flake the salmon. Combine all the ingredients in a bowl. Cover and refrigerate at least 1 hour. Serve with raw vegetable dippers, such as zucchini, carrots, pea pods, cherry tomatoes, cauliflowerets, broccoli florets, etc. Makes 16 (1 Tablespoon) Servings. Dietary Exchanges: 1 T Free, 3 T - 1 Fat Nutrients Per Serving: 17 Calories 1.5 g Fat 0 g Carbohydrates

0 g Protein 106 mg Sodium 16 mg Potassium 1 g Cholesterol ******************************************************************* Black Bean Dip Source: DiabeticGourmet.com Ingredients: 1 can (15 ounces) black beans, undrained 1 tsp chili powder 1/4 tsp each salt, black pepper and ground cumin 2 drops hot pepper sauce 3/4 c minced white onion 2 cloves garlic 1 can (4 ounces) chopped green chilies, drained Directions: Drain beans, reserving 2 tablespoons liquid. Combine beans, reserved liquid, chili powder, salt, black pepper, cumin and hot pepper sauce in blender. Process until smooth. Combine onion and garlic in nonstick skillet. Cover and cook over low heat until onion is soft. Uncover and cook until slightly browned. Add chilies. Cook 3 minutes more. Add bean mixture. Mix well. Serve hot or cold with melba toasts or jicama. Garnish with pepper strips, if desired. Makes 24 Appetizers. Dietary Exchanges: 1/2 Starch/Bread Nutrients Per Serving: 18 Calories 1 g Fat 4 g Carbohydrates 2 g Protein 134 mg Sodium 0 mg Cholesterol ******************************************************************* Ambrosia Fruit Dip

Source: Diabetes.About.com Ingredients: 1 package (8 ounces) reduced-fat cream cheese, softened 1 c plain nonfat yogurt 1 tsp vanilla extract 1 tsp grated lemon rind 3-1/2 tsp Equal® for Recipes* or 12 packets Equal® sweetener* or 1/2 c Equal® Spoonful*
*Equal® is a registered trademark of the Merisant Company.

Directions: Blend cream cheese and yogurt until smooth. Stir in remaining ingredients. Chill. Serve with fresh fruit. Makes 2 Cups. Dietary Exchanges: 1/2 Milk, 1 Fat Nutrients Per Serving: 90 Calories 5 g Fat 6 g Carbohydrate 5 g Protein 16 mg Cholesterol 107 mg Sodium ******************************************************************* Guacamole Ingredients: 1 ripe medium avocado, peeled, pitted, and cut into chunks 1/4 c fat-free sour cream 2 small plum tomatoes, diced 1/4 c diced seedless cucumber 1/4 medium red onion, finely chopped 2 tbsp chopped cilantro 2 tbsp freshly squeezed lime juice 1-2 small jalapeno peppers, seeded and finely chopped 1/4 tsp seasoned salt

Directions: In a medium bowl with a fork, mash the avocado with the sour cream (there should be small chunks remaining). Add the tomatoes, cucumber, onion, cilantro, lime juice, jalapenos, and salt; stir lightly until well blended. Makes 16 (2 Tablespoon) Servings. Dietary Exchanges: 1/2 Fat Nutrients Per Serving: 28 Calories 2 g Fat 3 g Carbohydrate 1 g Sugar 1 g Protein 0 mg Cholesterol 31 mg Sodium 1 g Dietary Fiber ******************************************************************* Creamy Spinach Dip Ingredients: 1 (10 ounce) package frozen chopped spinach, thawed and drained very well 1-1/2 c low-fat sour cream 2 tbsp red wine vinegar 2 tbsp minced mint 2 garlic cloves, minced 1/2 c minced water chestnuts 1/4 tsp cayenne pepper Salt and pepper to taste Directions: Prepare the spinach and set aside. In a medium bowl, combine the sour cream, vinegar, mint, garlic, water chestnuts, cayenne pepper, salt and pepper. Add the spinach and mix well. Cover and refrigerate for 1 hour before serving. Makes 16 (2 Tablespoon) Servings. Diabetic Exchanges: 1/2 Carbohydrate

Nutrients Per Serving: 33 Calories 2 g Fat 3 g Carbohydrate 1 g Sugars 2 g Protein 7 mg Cholesterol 27 mg Sodium 1 g Dietary Fiber Turkey Salad with Apples and Almonds Ingredients: 2 tbsp sliced almonds 3 tbsp fat-free sour cream 1 tbsp reduced-fat mayonnaise dash ground celery seed dash ground cardamom 1/8 tsp salt or a taste (optional) 1 c (5 oz) roasted turkey or chicken breast cubes 1 c cubed tart or sweet apple, peeled or unpeeled 1 small celery stalk, diced Directions: Spray a medium nonstick skillet with nonstick spray. Add the almonds. Over medium heat, cook the almonds, stirring until they brown and smell toasted, about 4 or 5 minutes. If the almonds begin to burn, lower the heat slightly. Immediately remove to a small plate and set aside. In a medium bowl, stir together the sour cream, mayonnaise, celery seed, cardamom, and salt (if desired). Stir in the turkey, apple, celery, and reserved almonds. Serve at once or cover and refrigerate several hours or up to 24 hours. Leftover salad will keep in the refrigerator for 2 to 3 days. Makes 4 Servings. Dietary Exchanges: 1/2 Carbohydrate, 1 Lean Meat Nutrients per Serving: 111 Calories 3 g Total Fat 0 g Saturated Fat 30 Calories from Fat 8 g Carbohydrate 6 g Sugar 12 g Protein

30 mg Cholesterol 78 mg Sodium 2 g Dietary Fiber ***************************************** Cabbage and Carrot Slaw Ingredients: 2 tbsp cider vinegar 2 tbsp reduced-fat mayonnaise 2 tsp sugar 1/4 tsp dry mustard 1/4 tsp salt, or to taste (optional) 1/8 tsp black pepper 4 c very thinly sliced cabbage 1 large carrot, grated or shredded 1/2 red bell pepper, seeded and diced Directions: In a large bowl, combine the vinegar, mayonnaise, sugar, mustard, salt (if desired), and black pepper. Whisk until well combined. Add the cabbage, carrot and pepper. Stir to coat the vegetables with dressing. Serve immediately or cover and refrigerate. Leftover slaw will keep in the refrigerator 3 to 4 days. Makes 5 Servings. Dietary Exchanges: 1 Vegetable, 1/2 Polyunsaturated Fat Nutrients per Serving: 51 Calories 2 g Total Fat 0 g Saturated Fat 18 Calories from Fat 8 g Carbohydrate 5 g Sugars 1 g Protein 2 mg Cholesterol 51 mg Sodium 2 g Dietary Fiber ***************************************** Broccoli-Rice Salad

Ingredients: 4 c small broccoli florets 3 tbsp reduced-fat mayonnaise 1/4 c low-fat buttermilk 2 tsp cider vinegar 1 tsp sugar 1/8 tsp white pepper 1/8 tsp salt, or to taste (optional) 1 c cooked brown rice 2 tbsp chopped red onion Directions: To bring out the bright green color of the broccoli, place it in a medium saucepan with 1/4 cup water. Bring to a boil and boil 1 minute. Remove from heat and cool in a colander under cold running water. Drain. Place the mayonnaise in a large serving bowl. Slowly add the buttermilk, whisking until smooth. Whisk in the vinegar, sugar, celery seed, pepper, and salt (if desired). Stir in the rice, reserved brocolli, and onion. Serve at room temperature or cover and refrigerate several hours. Leftover salad will keep in the refrigerator 2 to 3 days. Stir before serving. Makes 7 Servings. Dietary Exchanges: 1/2 Starch, 1 Vegetable, 1/2 Polyunsaturated Fat Nutrients per Serving: 71 Calories 2 g Total Fat 0 g Saturated Fat 22 Calories from Fat 11 g Carbohydrate 3 g Sugars 2 g Protein 3 mg Cholesterol 60 mg Sodium 2 g Dietary Fiber ***************************************** Pasta-Vegetable Salad Ingredients: 2 tbsp cider vinegar 2 tbsp tomato sauce

2 tsp sugar 2 tbsp olive oil 1 garlic clove, minced 1/4 tsp dried marjoram leaves 1/4 tsp basil 1/4 tsp salt, or to taste (optional) 1 c uncooked penne or similarly shaped pasta 1 large tomato, cubed 1 small zucchini, cubed 1 medium red or yellow pepper, seeded and chopped 1 c broccoli or cauliflower florets Directions: In a serving bowl combine the vinegar and tomato sauce. Stir to mix well. Stir in the sugar, oil, garlic, marjoram, basil, and salt (if desired). Set aside. Cook the pasta according to package directions. Transfer to a colander and rinse under cold running water. Drain. Meanwhile, add the tomatoes, zucchini, pepper, and broccoli to the bowl with the dressing. Stir to mix well. Stir in pasta. Serve immediately or cover and refrigerate 1 hour or up to 36 hours before serving. Stir before serving. Makes 16 Servings. Dietary Exchanges: 1/2 Starch Nutrients per Serving: 44 Calories 2 g Total Fat 0 g Saturated Fat 17 Calories from Fat 6 g Carbohydrate 2 g Sugar 1 g Protein 0 mg Cholesterol 14 mg Sodium 1 g Dietary Fiber Pork Tenders In Gravy Ingredients: 2 lbs pork tenderloin, cut into 1/2 to 1 inch cubes 1/2 c flour non-fat nonstick cooking spray 1 medium onion, chopped 1 green bell pepper, chopped

3 c water 1 c white cooking wine 1/4 c soy sauce 1/4 c worcestershire sauce 1 tsp garlic powder 2 tsp seasoned salt salt and pepper Directions: Coat pork cubes with flour. Spray dutch oven well with cooking spray and place over medium heat. Saute onion and green pepper 5 to 10 minutes or until tender. Remove and set aside. Again spray bottom of pan and place over medium-high heat. Add pork cubes, stirring to brown. Return onions and green pepper to pot and add water, wine, soy sauce, worcestershire sauce, garlic powder and seasoned salt. Add salt and pepper to taste. Cover dutch oven and simmer over low heat for 30 minutes. Uncover and simmer about 15 minutes longer. Makes 8 Servings. Dietary Exchanges: 3 Lean Protein, 2 Vegetable Nutrients Per Serving: 202 Calories 4.2 g Fat 1.43 g Saturated Fat 25.9 g Protein 8.9 g Carbohydrate 79 mg Cholesterol ********************************************** Pepper Steak Ingredients: 1 lb sirloin or round steak non-fat nonstick cooking spray 1 green bell pepper, sliced 1 red bell pepper, sliced 1 medium onion, sliced 2 tbsp soy sauce 1/2 c cooking wine (any kind) 1 tsp minced garlic 1 can (10.5 ounces) beef broth 2 tbsp cornstarch

1/4 c water Directions: Slice steak into thin strips, across grain. Spray large skillet with cooking spray and place over medium-high heat. Saute green and red pepper and onion slices, stirring often, for 3 to 4 minutes. Remove from skillet and set aside. Quickly brown steak strips in hot skillet, stirring and turning as they cook. Lower heat and add soy sauce, cooking wine, and garlic to skillet. Simmer 10 minutes, then add beef broth and return vegetables to skillet. Simmer 5 minutes. Mix cornstarch and water together, add to skillet, stirring to thicken. Makes 6 Servings. Dietary Exchanges: 2 Lean Protein, 2 Vegetable Nutrients Per Serving: 168 Calories 3.2 g Fat 1.12 g Saturated Fat 19.6 g Protein 9.3 g Carbohydrate 44 mg Cholesterol ********************************************** Paprika Chicken Ingredients: 1/3 c plus 2 tbsp flour 1 tbsp paprika 1/2 tsp salt 1/8 tsp pepper non-fat nonstick cooking spray 4 boneless, skinless chicken breasts (3 ounces each) 1 large onion, chipped 2 1/2 c fat-free chicken broth 1 chicken bouillon cube, dissolved in 1/2 c hot water 1/2 c light sour cream 2 tbsp flour Directions: In large bowl, mix 1/3 c flour, paprika, salt, and pepper. Spray large skillet well with cooking spray heat over medium-high heat. Dredge chicken breasts in flour mixture,

and brown on both sides in heated skillet. Cover chicken breasts with chopped onion. Pour 1 cup chicken broth and the bouillon over chicken and onions. Cover skillet and reduce heat to low. Simmer until chicken is done, 20 to 30 minutes. Makes 4 Servings. Dietary Exchanges: 4 Lean Meat, 3/4 Starch Nutrients Per Serving: 272 Calories 7.2 g Fat 3.19 g Saturated Fat 31.4 g Protein 19.1 g Carbohydrate 85 mg Cholesterol ********************************************** Chicken Breasts with Lemon Sauce Ingredients: 4 boneless, skinless chicken breasts (3 oz each) garlic salt to taste black pepper to taste non-fat nonstick cooking spray 1 c fat-free chicken broth 1 1/2 tbsp fresh lemon juice 1/2 tsp grated lemon peel 1/4 c fat-free parmesan cheese 1/3 c fat-free sour cream 1 tbsp all-purpose flour Directions: Season chicken breasts with garlic salt and black pepper. Spray skillet with nonstick cooking spray. Add chicken breasts and brown and cook over medium heat until done, about 4 to 5 minutes on each side. In medium saucepan, combine chicken broth, lemon juice, lemon peel, parmesan cheese, and sour cream. Use flour to make a thin paste. Stir paste back into sauce and stir over medium heat until thickened. Pour over cooked chicken breasts and serve. Makes 4 Servings. Dietary Exchanges: 1/8 Starch, 2 1/3 Lean Meat

Nutrients Per Serving: 139 Calories 1.1 g Fat 0.28 Saturated Fat 22.7 g Protein 7.3 g Carbohydrate 52 mg Cholesterol Tangy Broiled Chicken Ingredients: 6 skinless, boneless chicken breast halves (about 1 1/2 lb) 1 c refrigerated Marie's Zesty Fat Free Red Wine Vinaigrette 3/4 c Light N Tangy V8 Vegetable Juice or V8 Picante Vegetable Juice 1 tbsp cornstarch Directions: Place large plastic bag in deep bowl. Add chicken. In 2-cup measure, combine vinaigrette and "V8" juice. Pour over chicken. Close bag. Refrigerate at least 4 hours or overnight, turning chicken occasionally. Remove chicken from marinade and arrange on rack in broiler pan, reserve marinade. In 1-quart saucepan, stir together cornstarch and reserved marinade until smooth. Cook over medium heat until sauce boils and thickens, stirring constantly. Brush chicken with sauce. Broil 4 inches from heat 15 minutes or until chicken is no longer pink, turning once and brushing often with sauce during cooking. If desired, serve with orange-onion salad and parslied noodles. Makes 6 Servings. Dietary Exchanges: 1/2 Carbohydrate, 3 Very Lean Meat Pyramid Servings: 1/2 Sweet, 1 Meat Nutrients Per Serving: 166 Calories 26 Calories from Fat 3 g Fat 1 g Saturated Fat 69 mg Cholesterol 281 mg Sodium 8 g Carbohydrate 0 g Dietary Fiber 5 g Sugars 25 g Protein

************************************************ Beef and Pasta Ingredients: 3/4 lb lean ground beef (85% lean) 1 can (14.5 oz) Swanson Vegetable Broth 1 tbsp Worcestershire sauce 1/2 tsp dried oregano leaves, crushed 1/2 tsp garlic powder 1 can (about 8 oz) stewed tomatoes 1 1/2 c dry medium tube-shaped or corkscrew macaroni Directions: In medium skillet over medium-high heat, cook beef until browned, stirring to separate meat. Pour off fat. Add broth, Worcestershire, oregano, garlic powder and tomatoes. Heat to a boil. Stir in macaroni. Reduce heat to low. Cover and cook 10 minutes, stirring often. Uncover and cook 5 minutes more or until macaroni is done and most of liquid is absorbed. If desired, garnish with parmesan cheese. Makes 4 Servings. Dietary Exchanges: 2 Starch, 2 Lean Meat, 1/2 Fat Pyramid Servings: 1 1/2 Starch, 1 Vegetable, 1 Meat Nutrients Per Serving: 287 Calories 101 Calories from Fat 11 g Fat 4 g Saturated Fat 53 mg Cholesterol 654 mg Sodium 27 g Carbohydrate 1 g Dietary Fiber 4 g Sugars 20 g Protein ************************************************ Baked Onion Chicken Ingredients:

1 pouch Campbell's Dry Onion Soup Mix with Chicken Broth 2/3 c dry bread crumbs 1/8 tsp pepper 1 egg or 2 egg whites 2 tbsp water 12 skinless, boneless chicken thighs or 6 skinless, boneless chicken breast halves (about 1 1/2 lb 2 tbsp margarine or butter, melted (optional) Directions: With rolling pin, crush soup mix in pouch. On waxed paper, combine soup mix bread crumbs, and pepper. In shallow dish, beat together egg and water. Dip chicken into egg mixture and coat with crumb mixture. On baking sheet, arrange chicken. Drizzle with margarine. Bake at 400 degrees for 20 minutes or until chicken is no longer pink. Makes 6 Servings. Dietary Exchanges: 1 Starch, 4 Very Lean Meat Pyramid Servings: 1 Starch, 1 Meat Nutrients Per Serving: 215 Calories 43 Calories from Fat 5 g Fat 1 g Saturated Fat 108 mg Cholesterol 628 mg Sodium 11g Carbohydrate 1 g Dietary Fiber 3 g Sugars 29 g Protein ************************************************ Pasta with Broccoli and Shrimp Ingredients: 1/4 lb Rotelle pasta 1 1/2 tsp Estee Salt-It, divided 1 tbsp + 1 tsp lemon juice, divided 1 lb fresh broccoli, trimmed, cut into bite-sized pieces (4 cups) or 4 cups frozen broccoli florets from a 16- to 20-oz bag 3/4 lb large fresh shrimp, peeled and deveined or 1/2 lb pre-peeled and deveined frozen

shrimp 1/2 c Estee Creamy Italian Salad Dressing 1/3 c chopped fresh dill or 1/2 tbsp dried dill 1/2 tsp Estee Fructose black pepper (to taste) Directions: Cook pasta according to package directions, using 1 tsp Salt-It instead of salt. Drain and place in large bowl. In large saucepan, bring 4 inches water and 1 tbsp lemon juice to a boil. Add broccoli and shrimp and cook just until shrimp turn pink and broccoli is fork tender. Drain and add to pasta. Add onion and toss. In small bowl, stir together salad dressing, dill, fructose, remaining lemon juice, and Salt-It. Add black pepper to taste. Pour over pasta mixture and toss to coat. Serve warm or cold. Makes 4 Servings. Dietary Exchanges: 1 Starch, 1 Vegetable, 2 Very Lean Meat Pyramid Servings: 1 Starch, 1 Vegetable, 1 Meat Nutrients Per Serving: 186 Calories 17 Calories from Fat 2 g Fat 0 g Saturated Fat 119 mg Cholesterol 245 mg Sodium 24 g Carbohydrate 4 g Dietary Fiber 6 g Sugars 18 g Protein

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