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 GlandPart 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. overactivity of the thyroid gland (hyperthyroidism)

2. inflammation of the tissues around the eyes, causing swelling

3. 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

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

40s)

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 GlandPart 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 FunctionCommon 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 GlandPart 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

Hyperthyroidism

Fatigue

Insomnia

Nervousness

Irritability

Hypothyroidism

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 GlandWritten 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 hyper-

thyroidism. 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

Test

Abbreviation

Typical Ranges

Serum thyroxine T4

4.6-12 ug/dl

Free thyroxine fraction

FT4F

0.03-0.005%

Free Thyroxine  FT4

0.7-1.9 ng/dl

Thyroid hormone binding ratio 

THBR

0.9-1.1

Free Thyroxine index

FT4I

4-11

Serum Triiodothyronine

T3

80-180 ng/dl

Free Triiodothyronine l

FT3

230-619 pg/d

Free T3 Index FT3I

80-180

Radioactive iodine uptake

RAIU

10-30%

Serum thyrotropin

TSH

0.5-6 uU/ml

Thyroxine-binding globulin

TBG

12-20 ug/dl T4

+1.8 ugm

TRH stimulation test Peak

TSH

9-30 uIU/ml at 20-30 min

Serum thyroglobulin l

Tg

0-30 ng/m

Thyroid microsomal

antibody titer  

TMAb

Varies with

method

Thyroglobulin antibody titer

TgAb 

Varies with

method

Last updated on 05/21/09

n Overview of the ThyroidA 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 HormonePart 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 life-

threatening 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 hormonePart 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. However, its not always so simple...keep

reading.

REMEMBER

hypo = too little

thyroidism = disease of the thyroid

Thus, hypo-thyroidism = a disease of too little thyroid activity.

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 hyp er thyroidism 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 iron-

containing 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 GoiterEnlargement 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 CenterIntroduction 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)Protein(grams)

Fat(grams)

Calories

I. Starch/Bread 15 3 trace 80

II. Meat

Very Lean . 7 0-1 35

Lean . 7 3 55

Medium-Fat . 7 5 75

High-Fat . 7 8 100

III. Vegetable 5 2 . 25

IV. Fruit 15 . . 60

V. Milk

Skim 12 8 0-3 90

Low-fat 12 8 5 120

Whole 12 8 8 150

VI. Fat . . 5 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 serving1 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) 1/3 cup

*Bran cereals, flaked 1/2 cup

Bulgur (cooked) 1/2 cup

Cooked cereals 1/2 cup

Cornmeal (dry) 2 1/2 tbsp

Grape Nuts 3 tbsp

Grits (cooked) 1/2 cup

Other ready-to-eat, unsweetened (plain) cereals 3/4 cup

Pasta (cooked) 1/2 cup

Puffed cereal 1 1/2 cups

Rice, white or brown (cooked) 1/3 cup

Shredded wheat 1/2 cup

*Wheat germ 3 tbsp

DRIED BEANS/PEAS/LENTILS

*Beans and peas (cooked) (such as kidney, white, split, blackeye) 1/3 cup

*Lentils (cooked) 1/3 cup

*Baked beans 1/4 cup

STARCHY VEGETABLES

*Corn 1/2 cup

*Corn on the cob, 6 in. 1 long

*Lima beans 1/2 cup

*Peas, green (canned or frozen) 1/2 cup

*Plaintain 1/2 cup

Potato, baked 1 small (3 oz)

Potato, mashed 1/2 cup

Squash, winter (acorn, butternut) 3/4 cup

Yam, sweet potato 1/3 cup

BREAD

Bagel 1/2 (1 oz)

Bread sticks, crisp, 4 in. long x 1/2 in. 2 (2/3 oz)

Croutons low fat 1 cup

English muffin 1/2

Frankfurter or hamburger bun 1/2 (1 oz)

Pita, 6 in. across 1/2

Plain roll, small 1 (1 oz)

Raisin, unfrosted 1 slice

*Rye, pumpernickel 1 slice

(1 oz)

White (including French, Italian)1 slice(1 oz)

Whole wheat 1 slice

CRACKERS/SNACKS

Animal crackers 8 

Graham crackers, 2 1/2 in. square 3

Matzoh 3/4 oz

Melba toast 5 slices

Oyster crackers 24

Popcorn (popped, no fat added) 3 cups

Pretzels 3/4 oz

Rye crisp (2 in. x 3 1/2 in.) 4

Saltine-type crackers 6

Whole-wheat crackers, no fat added (crisp breads such as Finn, Kavli, Wasa)

2-4 slices (3/4 oz)

STARCHY FOODS PREPARED WITH FAT(count as 1 starch/bread serving, plus 1 fat serving)

Biscuit, 2 1/2 in. across 1

Chow mein noodles 1/2 cup

Corn bread, 2-in. cube 1 (2 oz)

Cracker, round butter type 6

French-fried potatoes (2 in. to 3 1/2 in. long)10 (1 1/2

oz)

Muffin, plain, small 1

Pancake, 4 in. across 2

Stuffing, bread (prepared) 1/4 cup

Taco shell, 6 in. across 2

Waffle, 4 1/2 in. square 1

Whole-wheat crackers, fat added (such as Triscuits) 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)

Fat(grams)

Calories

Very Lean . 7 0-1 35

Lean . 7 3 55

Medium-Fat . 7 5 75

High-Fat . 7 8 100

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.

Lean Meat and SubstitutesOne exchange is equal to any one of the following items:

BeefUSDA Good or Choice grades of lean beef, such as round, sirloin, and flank steak; tenderloin; and chipped beef#

1 oz

PorkLean pork, such as fresh ham; canned, cured, or boiled ham#, Canadian bacon#, tenderloin

1 oz

Veal All cuts are lean except for veal cutlets (ground or cubed) 1 oz

Poultry Chicken, turkey, Cornish hen (without skin) 1 oz

Fish All fresh and frozen fish 1 oz

  Crab, lobster, scallops, shrimp, clams (fresh or canned in water#) 2 oz

  Oysters 6 med

  Tuna# (canned in water) 1/4 cup

  Herring (uncreamed or smoked) 1 oz

  Sardines (canned) 2 med

Wild Game Venison, rabbit, squirrel 1 oz

  Pheasant, duck, goose (without skin) 1 oz

Cheese Any cottage cheese 1/4

cup

  Grated parmesan 2 tbsp

  Diet cheese# (with fewer than 55 calories per ounce) 1 oz

Other 95% fat-free luncheon meat 1 oz

  Egg whites 3

  Egg substitutes (with fewer than 55 calories per 1/4 cup)1/4 cup

Medium-Fat and Meat SubstitutesOne exchange is equal to any one of the following items:

BeefMost beef products fall into this category. Examples are: all ground beef, roast (rib, chuck, rump), steak (cubed, Porterhouse, T-bone), and meat loaf.

1 oz

PorkMost pork products fall into this category. (Examples: chops, loin roast, Boston butt, cutlets)

1 oz

LambMost lamb products fall into this category (examples: chops, leg, roast)

1 oz

Veal Cutlet (ground or cubed, unbreaded) 1 oz

Poultry Chicken (with skin), domestic duck or goose (well drained of fat), ground turkey

1 oz

Fish Tuna# (canned in oil and drained)1/4 cup

  Salmon# (canned)1/4 cup

Cheese Skim or part-skim milk cheeses, such as:  

  Ricotta 1/4 cup

  Mozzarella1 oz

  Diet cheeses# (with 56-80 calories per ounce) 1 oz

Other 86% fat-free luncheon meat# 1 oz

  Egg (high in cholesterol, so limit to 3 per week) 1

  Egg substitutes (with 56-80 calories per 1/4 cup)1/4 cup

  Tofu (2 1/2 in. x 2 3/4 in. x 1 in.)4 oz

  Liver, heart, kidney, sweetbreads (high in cholesterol) 1 oz

High-Fat Meat and SubstitutesRemember, 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

CheeseAll regular cheese#, such as American, Blue, Cheddar, Monterey, Swiss

1 oz

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

  Frankfurter# (turkey or chicken) (10/lb)1

frank

  Peanut butter (contains unsaturated fat)1

tbsp.

Count as one high-fat meat plus one fat exchange:

Frankfurter# (beef, pork, or combination) (400 mg or more of sodium per exchange) (10/lb)

1 frank

III. Vegetable List

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 juice1 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 juice1/4 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) 1/3 cup

Plum (raw, 2 in. across) 2

*Pomegranate 1/2

*Raspberries (raw) 1 cup

*Strawberries (raw, whole) 1 1/4 cup

Tangerine (2 1/2 in. across) 2

Watermelon (cubes) 1 1/4 cup

*Dried Fruit

*Apples 4 rings

*Apricots 7 halves

Dates (medium) 2 1/2

*Figs 1 1/2

*Prunes (medium) 3

Raisins 2 tbsp

Fruit Juice

Apple juice/cider 1/2 cup

Cranberry juice cocktail 1/3 cup

Grapefruit juice 1/2 cup

Grape juice 1/3 cup

Orange juice 1/2 cup

Pineapple juice 1/2 cup

Prune juice 1/3 cup

* = 3 grams or more of fiber per serving  

V. Milk List

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:

MilkCarbohydrate

(grams)Protein(grams)

Fat(grams)

Calories

Skim 12 8 trace 90

Low-fat 12 8 5 120

Whole 12 8 8 150

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 sugar-free 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 solids)

8 oz

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 1/8

medium

Margarine 1 tsp

#Margarine, diet 1 tbsp

Mayonnaise 1 tsp

#Mayonnaise (reduced-calorie) 1 tbsp

Nuts and Seeds:

Almonds, dry roasted 6

Cashews, dry roasted 1 tbsp

Pecans 2

Peanuts (small) 20

Peanuts (large) 10

Walnuts 2 whole

Other nuts 1 tbsp

Seeds (except pumpkin), pine nuts, sunflower (without shells)

1 tbsp

Pumpkin seeds 2 tsp

Oil (corn, cottonseed, safflower, soybean, sunflower, olive, peanut)

1 tsp

#Olives (small) 10

#Olives (large) 5

Salad dressing, mayonnaise-type, regular 2 tsp

Salad dressing, mayonnaise-type reduced-calorie

1 tbsp

Salad dressing, all varieties, regular 1 tbsp

#Salad dressing, reduced-calorie(2 tbsp of low-calorie dressing is a free food)

2 tbsp

Saturated Fats

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 (1 tbsp)

Coffee/tea  

Drink mixes, sugar-free  

Tonic water, sugar-free  

Fruit

Cranberries, unsweetened (1/2 cup)

Rhubarb, unsweetened (1/2 cup)

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  

Gelatin, sugar-free  

Gum, sugar-free  

Jam/jelly, sugar-free (2 tsp)

Pancake syrup, sugar-free (1-2 tbsp)

Sugar substitutes (saccharin, aspartame)  

Whipped topping (2 tbsp)

Condiments

Catsup (1 tbsp)

Horseradish  

Mustard  

#Pickles, dill, unsweetened  

Salad dressing, low-calorie (2 tbsp)

Taco sauce (1 tbsp)

Vinegar  

Nonstick pan spray  

SeasoningsSeasonings 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, peppermint, lemon, etc.)

Pepper

Garlic Pimento

Garlic powder Spices

Herbs #Soy sauce

Hot pepper sauceSoy sauce, low sodium ("lite")

LemonWine, used in cooking (1/4 cup)

Lemon juiceWorcestershire 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 Amount Exchanges

Casserole, homemade 1 cup (8 oz)2 medium-fat meat, 2 starches, 1 fat

#Cheese pizza, thin crust 1/4 of a 15-oz size pizza or a 10" pizza

1 medium-fat meat, 2 starches, 1 fat

*#Chili with beans (commercial) 1 cup (8 oz) 2 medium-fat meat, 2 starches, 2 fats

*#Chow mein (without noodles or rice)

2 cups (16 oz)2 lean meat, 1 starch, 2 vegetable

#Macaroni and cheese 1 cup (8 oz) 1 medium-fat meat, 2 starches, 2 fats

Soup

*#Bean 1 cup (8 oz) 1 lean meat, 1 starch, 1 vegetable

#Chunky, all varieties 10 3/4-oz can1 medium-fat meat, 1 starch,1 vegetable

#Cream (made with water) 1 cup (8 oz) 1 starch, 1 fat

#Vegetable or broth 1 cup (8 oz) 1 starch

#Spaghetti and meatballs (canned)

1 cup (8 oz) 1 medium-fat meat, 1 fat, 2 starches

Sugar-free pudding (made with skim milk)

1/2 cup 1 starch

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 Amount Exchanges

Angel-food cake 1/12 cake 2 starches

Cake, no icing 1/12 cake (3-in. square) 2 starches, 2 fats

Cookies 2 small (1 3/4 in. across) 2 starches, 1 fat

Frozen fruit yogurt 1/3 cup 1 starch

Gingersnaps 3 1 starch

Granola 1/4 cup 1 starch, 1 fat

Granola bars 1 small 1 starch, 1 fat

Ice cream, any flavor 1/2 cup 1 starch, 2 fats

Ice milk, any flavor 1/2 cup 1 starch, 1 fat

Sherbet, any flavor 1/4 cup 1 starch

#Snack chips, all varieties 1 oz 1 starch, 2 fats

Vanilla wafers 6 small 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 wheat2 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 breast3 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 spears2 oz fresh mozzarella cheese, cut or torn into pieces1 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 Fat2 g Saturated Fat2 g Carbohydrates5 g Proteins11 mg Cholesterol134 mg Sodium1 g Fiber

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Oven-Roasted Broccoli

Ingredients:

2 tbsp olive oil 4 cups broccoli florets1 cup thinly sliced leek1/2 tsp salt1/4 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 Calories7 g Total Fat1 g Saturated Fat8 g Carbohydrate3 g Protein0 mg Cholesterol319 mg Sodium3 g Fiber

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Garlicky Green Beans

Ingredients:

1 lb green beans2 tbsp butter

1/2 tsp black pepper2 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 Calories4 g Total Fat3 g Saturated Fat6 g Carbohydrate2 g Protein11 mg Cholesterol143 mg Sodium3 g Fiber

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Curried Cauliflower

Ingredients:

4 cups cauliflower florets2 tbsp butter2 tbsp sliced green onion (1)1 tsp curry powder1/8 tsp crushed red peppersalt

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 Calories6 g Total Fat4 g Saturated Fat,6 g Carbohydrate2 g Protein16 mg Cholesterol128 mg Sodium3 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 oil1 tbsp snipped fresh lemon thyme or thyme1 tsp cracked black pepper1/4 tsp salt1 medium onion, cut into wedges2 c fat-free half and half2 tbsp all-purpose flour1 tsp snipped fresh lemon thyme or thyme1/4 tsp salt1/8 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 Calories10 g Total Fat2 g Saturated Fat67 mg Cholesterol343 mg Sodium16 g Carbohydrates1 g Fiber25 g Protein

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Creamy Mushroom Chicken

Ingredients:

nonstick cooking spray4 skinless, boneless chicken breast halves (about 1 1/4 lb total)1 tsp olive oil2 c sliced fresh mushrooms1 medium red sweet pepper, cut into 3/4 inch pieces1/2 tsp bottled minced garlic (1 clove)1/2 c reduced-sodium chicken broth1/2 c fat-free dairy sour cream1 tbsp all-purpose flour1/8 tsp ground black pepper1 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. Addmushrooms, 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 Calories4 g Total Fat1 g Saturated Fat82 mg Cholesterol190 mg Sodium10 g Carbohydrates1 g Fiber37 g Protein

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Salmon with Mango Salsa

Ingredients:

4 - 6 to 8-oz fresh or frozen salmon fillets (with skin), about 1 inch thick2 tbsp sugar1 1/2 tsp finely shredded lime peel3/4 tsp salt1/4 tsp cayenne pepper1 large ripe mango, seeded, peeled and cut into thin bite-size strips1/2 of a medium cucumber, seeded and cut into thin bite-size strips2 green onions, sliced3 tbsp lime juice1 tbsp snipped fresh cilantro1 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 Calories15 g Total Fat3 g Saturated Fat105 mg Cholesterol520 mg Sodium18 g Carbohydrates2 g Fiber37 g Protein

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Beef Satay with Peanut Sauce

Ingredients:

1 - 1 to 1 1/4 lb beef flank steak1/3 cup light teriyaki sauce1/2 tps bottled hot pepper sauce1 medium red sweet pepper, cut into 3/4 inch pieces4 green onions, cut into 1 inch pieces3 tbsp reduced-fat or regular peanut butter3 tbsp water2 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 Calories10 g Total Fat3 g Saturated Fat

43 mg Cholesterol567 mg Sodium10 g Carbohydrates1 g Fiber21 g Protein

Barbecued Chicken

Ingredients:

6 chicken breasts, 6 ounces each, bone in, fat and skin removedolive 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 Fat2 g Total Fat0.5 g Saturated Fat3 g Carbohydrates33 g Protein82 mg Cholesterol246 mg Sodium 1 g Dietary Fiber

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Brunswick Stew

Ingredients:

1 3 1/2-lb frying chicken or 2 boneless skinless breasts and 2 hindquarters1 tsp non-aromatic olive oil, divided1 large sweet onion, cut in 1" dice3 ribs celery cut in 1/4" slices3-oz Canadian bacon cut the same size as the celery1 red bell pepper cut the same2 c canned, crushed tomatoes1 c low sodium chicken stock 1 tbsp Worcestershire sauce11/4 tsp cayenne pepper1 c frozen corn kernels1 c frozen baby lima beans1 tbsp arrowroot mixed with 2 tbsp stock or water (slurry)1/4 c chopped fresh parsley1/4 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 Calories6 g Fat2 g Saturated Fat7% Calories from Saturated Fat21 g Carbohydrates3 g Fiber362 mg Sodium

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Spinach Lasagna

Ingredients:

1/4 cup skim milk1 container (15 oz) light ricotta cheese1 jar (about 32 oz) meatless spaghetti sauce7 lasagna noodles, cooked and drained1 bunch (1 lb) fresh spinach, washed, dried, and torn into pieces1/2 c grated Parmesan cheese1/2 c sliced almonds2 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 Calories18 g Fat7 g  Saturated Fat37 g Carbohydrate21 g Protein860 mg Sodium6 g Fiber

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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 thick1 tbsp snipped fresh oregano or 1 tsp dried oregano, crushed1 tsp bottled minced garlic1 tsp finely shredded lemon peel1 tsp olive oil or cooking oil1/4 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 Calories5 g Total Fat2 g Saturated Fat1 g Carbohydrate24 g Protein54 mg Cholesterol61 mg Sodium0 g Fiber

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Chicken Medallions with Mustard Sauce

Ingredients:

4 skinless, boneless chicken breast halvessalt and black pepper2 tbsp olive oil or cooking oil1/4 c dry white wine

2 tbsp creme fraiche2 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 Calories11g Total Fat3 g Saturated Fat1 g Carbohydrate33 g Protein92 mg Cholesterol306 mg Sodium0 g Fiber

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Spicy Orange-Glazed Pork Chops

Ingredients:

1/4 c sugar-free or low-sugar orange marmalade2 tsp Dijon-style mustard1 tsp lemon juice1/8 to 1/4 tsp cayenne pepper4 boneless pork loin chops, cut 3/4 inch thicksalt 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 Calories10 g Total Fat3 g Saturated Fat5 g Carbohydrate37 g Protein92 mg Cholesterol126 mg Sodium0 g Fiber

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Teriyaki Beef Spirals

Ingredients:

1 c loosely packed fresh spinach leaves1/2 c finely chopped water chestnuts1/4 c chopped green onions (2)1/4 c reduced-sodium teriyaki sauce3/4 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 10x8-inch 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 Calories6 g Total Fat2 g Saturated Fat2 g Carbohydrate18 g Protein42 mg Cholesterol135 mg Sodium1 g Fiber

Eggs Benedict Con Queso

Ingredients:

5 large eggs5 slices (1 oz each) Canadian bacon or lean ham5 whole-wheat or oat-bran English muffin halves, toasted3 tbsp chopped fresh cilantro or thinly sliced scallions

Sauce:1 tbsp unbleached flour3/4 c nonfat or low-fat milk3/4 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 Calories19 g Carbohydrates224 mg Cholesterol7.5 g Fat2.3 g Saturated Fat2.5 g Fiber20 g Protein804 mg Sodium302 mg Calcium

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Southwestern Egg Scramble

Ingredients:

3/4 c canned (drained) hominy2 tbsp chopped green chilies2 c fat-free egg substitute1/2 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 Calories7 g Carbohydrates1 mg Cholesterol2.3 g Fat1 g Saturated Fat1 g Fiber17 g Protein414 mg Sodium169 mg Calcium

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Primavera Omelette

Ingredients:

2 tbsp chopped onion2 tbsp chopped red bell pepper1/4 c sliced mushrooms1/8 tsp dried oregano1/3 c (packed) chopped fresh spinach1/2 c fat-free egg substitute2 tsp grated Parmesan cheese1/4 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 Calories6 g Carbohydrates3 mg Cholesterol1.4 g Fat0.8 g Saturated Fat1 g Fiber15 g Protein337 mg Sodium113 mg Calcium

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Ham and Pepper Frittata

Ingredients:

1 tbsp extra virgin olive oil or canola oil1/2 c diced yellow bell pepper1/2 c diced green bell pepper1/2 c diced red bell pepper1 c diced, lean, reduced-sodium ham2 tsp dried parsley1/4 tsp coarsely ground black pepper2 c fat-free egg substitute1 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 Calories7 g Carbohydrate32 mg Cholesterol8.3 g Fat2.9 g Saturated Fat1.1 g Fiber28 g Protein690 mg Sodium299 mg Calcium

Grilled Chicken and Rice Salad

Ingredients:

12 oz skinless, boneless chicken breasts halves or thighs 1/3 c bottled Parmesan Italian salad dressing1 c loose-pack frozen French-cut green beans2 c cooked brown rice and wild rice blended, chilled1 c canned artichoke hearts, drained and quartered 1 c shredded red cabbage1/2 c shredded carrot1 green onion, slicedLettuce 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 Calories8 g Total Fat1 g Saturated Fat53 mg Cholesterol490 mg Sodium

30 g Carbohydrates4 g Fiber

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Grilled Bass with Strawberry Salsa

Ingredients:

4 4-5 oz fresh or frozen sea bass or halibut steaks, 1 inch thick1 small lime1/4 tsp salt1/4 cayenne pepper1 c chopped fresh strawberries1/4 c finely chopped seeded fresh poblano chile pepper (half of a small) 2 tbsp snipped fresh cilantro 1/2 tsp cumin seeds toasted1/8 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 Calories2 g Total Fat 1 g Saturated Fat46 mg Cholesterol298 mg Sodium5 g Carbohydrate1 g Fiber

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Bull's-Eye Onion Burgers

Ingredients:

1 large sweet onion1 lb 95% lean ground beef1 1/2 tsp garlic powder1/8 tsp salt1/4 tsp ground black pepper4 slices low-fat Swiss cheese (3 oz)8 red and/or green kale leaves, stems removed2 tsp olive oil4 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 Calories10 g Fat4 g Saturated Fat22 g Carbohydrates78 mg Cholesterol337 mg Sodium2 g Fiber

Blueberry Pancakes

Ingredients:

1 c plain nonfat yogurt 1 carton egg substitute 1/2  tsp vanilla1 c whole wheat flour 1 tbsp sugar1 tsp baking powder 1/2 tsp baking soda1 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 Calories14 gCarbohydrates5 gProtein10 mg Cholesterol131 mg Sodium29 mg Dietary Fiber

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Old-Fashioned Potato Salad

Ingredients:

2-1/4 pounds red boiling potatoes, cooked, cooled, skinned 3/4 cup celery, small dice1 cup Vidalia or other sweet onion, finely diced1 cup Best Foods/Hellman's Light Mayonnaise4 large eggs, hard boiled1 large clove garlic, halved2 to 3 Tbsp red wine vinegar1-1/2 tsp salt, or to taste1-1/2 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 Calories8 g Total Fat2 g Saturated Fat23 g Carbohydrate7 g Protein111 mg Cholesterol596 mg Sodium3 g Fiber

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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 Calories3g Fat 7g Carbohydrates10g Protein

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South of the Border Pizza

Ingredients:

1/3 c frozen mixed pepper and onion stir-fry1/4 c mild or medium salsa1/4 c shredded reduced-fat Cheddar cheese1 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 Calories7 g Fat15 g Carbohydrate4 g Sugars12 g Protein20 mg Cholesterol426 mg Sodium2 g Dietary Fiber

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Salsa Chicken

Ingredients:

8 c finely shredded iceberg lettuce3 tbsp chili powder1 tsp ground cumin1 lb boneless, skinless chicken breast, cut into 1" pieces 2 large egg whites2 tbsp extra-virgin olive oil8 oz chunky tomato salsa1/2 c fat-free sour creamCilantro 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 Calories10 g Fat2 g Saturated Fat12 g Carbohydrates32 g Protein66 mg Cholesterol457 mg Sodium5 g Fiber

 

Salmon Dip

Source:  Healthy-Diabetic-Recipes.co.uk

Ingredients:

1 can (7 3/4 oz) salmon2 tbsp minced green onions

1/4 c plain lowfat yogurt1/4 c mayonnaise or salad dress.1/2 tsp ground ginger2 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 Calories1.5 g Fat0 g Carbohydrates0 g Protein106 mg Sodium16 mg Potassium1 g Cholesterol

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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 Calories1 g Fat4 g Carbohydrates2 g Protein134 mg Sodium0 mg Cholesterol

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Ambrosia Fruit Dip

Source:  Diabetes.About.com

Ingredients:

1 package (8 ounces) reduced-fat cream cheese, softened1 c plain nonfat yogurt1 tsp vanilla extract1 tsp grated lemon rind3-1/2 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 Calories5 g Fat6 g Carbohydrate5 g Protein

16 mg Cholesterol107 mg Sodium

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Guacamole

Ingredients:

1 ripe medium avocado, peeled, pitted, and cut into chunks1/4 c fat-free sour cream2 small plum tomatoes, diced1/4 c diced seedless cucumber1/4 medium red onion, finely chopped2 tbsp chopped cilantro2 tbsp freshly squeezed lime juice1-2 small jalapeno peppers, seeded and finely chopped1/4 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 Calories2 g Fat3 g Carbohydrate1 g Sugar1 g Protein0 mg Cholesterol31 mg Sodium1 g Dietary Fiber

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Creamy Spinach Dip

Ingredients:

1 (10 ounce) package frozen chopped spinach, thawed and drained very well1-1/2 c low-fat sour cream2 tbsp red wine vinegar2 tbsp minced mint2 garlic cloves, minced1/2 c minced water chestnuts1/4 tsp cayenne pepperSalt 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 Calories2 g Fat3 g Carbohydrate1 g Sugars2 g Protein7 mg Cholesterol27 mg Sodium1 g Dietary Fiber

Turkey Salad with Apples and Almonds

Ingredients:

2 tbsp sliced almonds3 tbsp fat-free sour cream1 tbsp reduced-fat mayonnaisedash ground celery seeddash ground cardamom1/8 tsp salt or a taste (optional)1 c (5 oz) roasted turkey or chicken breast cubes1 c cubed tart or sweet apple, peeled or unpeeled1 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 Calories3 g Total Fat0 g Saturated Fat30 Calories from Fat8 g Carbohydrate6 g Sugar12 g Protein30 mg Cholesterol78 mg Sodium2 g Dietary Fiber

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Cabbage and Carrot Slaw

Ingredients:

2 tbsp cider vinegar2 tbsp reduced-fat mayonnaise2 tsp sugar1/4 tsp dry mustard1/4 tsp salt, or to taste (optional)1/8 tsp black pepper4 c very thinly sliced cabbage1 large carrot, grated or shredded1/2 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 Calories2 g Total Fat0 g Saturated Fat18 Calories from Fat8 g Carbohydrate5 g Sugars1 g Protein2 mg Cholesterol51 mg Sodium2 g Dietary Fiber

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Broccoli-Rice Salad

Ingredients:

4 c small broccoli florets3 tbsp reduced-fat mayonnaise1/4 c low-fat buttermilk2 tsp cider vinegar1 tsp sugar1/8 tsp white pepper1/8 tsp salt, or to taste (optional)1 c cooked brown rice2 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 Calories2 g Total Fat0 g Saturated Fat22 Calories from Fat11 g Carbohydrate3 g Sugars2 g Protein3 mg Cholesterol60 mg Sodium2 g Dietary Fiber

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Pasta-Vegetable Salad

Ingredients:

2 tbsp cider vinegar2 tbsp tomato sauce2 tsp sugar2 tbsp olive oil1 garlic clove, minced1/4 tsp dried marjoram leaves1/4 tsp basil1/4 tsp salt, or to taste (optional)1 c uncooked penne or similarly shaped pasta1 large tomato, cubed1 small zucchini, cubed1 medium red or yellow pepper, seeded and chopped1 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 Calories2 g Total Fat0 g Saturated Fat17 Calories from Fat6 g Carbohydrate2 g Sugar1 g Protein0 mg Cholesterol14 mg Sodium1 g Dietary Fiber

Pork Tenders In Gravy

Ingredients:

2 lbs pork tenderloin, cut into 1/2 to 1 inch cubes1/2 c flournon-fat nonstick cooking spray1 medium onion, chopped1 green bell pepper, chopped3 c water1 c white cooking wine1/4 c soy sauce1/4 c worcestershire sauce1 tsp garlic powder2 tsp seasoned saltsalt 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 Calories4.2 g Fat

1.43 g Saturated Fat25.9 g Protein8.9 g Carbohydrate79 mg Cholesterol

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Pepper Steak

Ingredients:

1 lb sirloin or round steaknon-fat nonstick cooking spray1 green bell pepper, sliced1 red bell pepper, sliced1 medium onion, sliced2 tbsp soy sauce1/2 c cooking wine (any kind)1 tsp minced garlic1 can (10.5 ounces) beef broth2 tbsp cornstarch1/4 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 Calories3.2 g Fat1.12 g Saturated Fat19.6 g Protein9.3 g Carbohydrate44 mg Cholesterol

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Paprika Chicken

Ingredients:

1/3 c plus 2 tbsp flour1 tbsp paprika1/2 tsp salt1/8 tsp peppernon-fat nonstick cooking spray4 boneless, skinless chicken breasts (3 ounces each)1 large onion, chipped2 1/2 c fat-free chicken broth1 chicken bouillon cube, dissolved in 1/2 c hot water1/2 c light sour cream2 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 Calories7.2 g Fat3.19 g Saturated Fat31.4 g Protein19.1 g Carbohydrate85 mg Cholesterol

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Chicken Breasts with Lemon Sauce

Ingredients:

4 boneless, skinless chicken breasts (3 oz each)garlic salt to tasteblack pepper to tastenon-fat nonstick cooking spray

1 c fat-free chicken broth1 1/2 tbsp fresh lemon juice1/2 tsp grated lemon peel1/4 c fat-free parmesan cheese1/3 c fat-free sour cream1 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 Calories1.1 g Fat0.28 Saturated Fat22.7 g Protein7.3 g Carbohydrate52 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 Vinaigrette3/4 c Light N Tangy V8 Vegetable Juice or V8 Picante Vegetable Juice1 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 Calories26 Calories from Fat3 g Fat1 g Saturated Fat69 mg Cholesterol281 mg Sodium8 g Carbohydrate0 g Dietary Fiber5 g Sugars25 g Protein

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Beef and Pasta

Ingredients:

3/4 lb lean ground beef (85% lean)1 can (14.5 oz) Swanson Vegetable Broth1 tbsp Worcestershire sauce1/2 tsp dried oregano leaves, crushed1/2 tsp garlic powder1 can (about 8 oz) stewed tomatoes1 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 Calories101 Calories from Fat11 g Fat4 g Saturated Fat53 mg Cholesterol654 mg Sodium27 g Carbohydrate1 g Dietary Fiber4 g Sugars20 g Protein

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Baked Onion Chicken

Ingredients:

1 pouch Campbell's Dry Onion Soup Mix with Chicken Broth2/3 c dry bread crumbs1/8 tsp pepper1 egg or 2 egg whites2 tbsp water12 skinless, boneless chicken thighs or 6 skinless, boneless chicken breast halves (about 1 1/2 lb2 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 Calories43 Calories from Fat5 g Fat

1 g Saturated Fat108 mg Cholesterol628 mg Sodium11g Carbohydrate1 g Dietary Fiber3 g Sugars29 g Protein

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Pasta with Broccoli and Shrimp

Ingredients:

1/4 lb Rotelle pasta1 1/2 tsp Estee Salt-It, divided1 tbsp + 1 tsp lemon juice, divided1 lb fresh broccoli, trimmed, cut into bite-sized pieces (4 cups) or 4 cups frozen broccoli florets from a 16- to 20-oz bag3/4 lb large fresh shrimp, peeled and deveined or 1/2 lb pre-peeled and deveined frozen shrimp1/2 c Estee Creamy Italian Salad Dressing1/3 c chopped fresh dill or 1/2 tbsp dried dill1/2 tsp Estee Fructoseblack 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 Calories17 Calories from Fat2 g Fat0 g Saturated Fat

119 mg Cholesterol245 mg Sodium24 g Carbohydrate4 g Dietary Fiber6 g Sugars18 g Protein