What if TSH levels were like shoe sizes, thyroid meds like mobility aids

Seeing things visually might help clarify what thyroid therapy is like.

Our thyroid hides in our neck and our hormones hide in every inch of our body. Nobody sees our thyroid gland distort, die, or shrivel. Nobody sees what fatigue feels like.

Nobody sees organs suffering from lack of T3. Nobody sees how our pills manipulate our TSH. Nobody sees hormone molecules converting and binding to receptors.

Maybe that’s partly why nobody is held accountable for illogical or unjust therapy decisions. Nobody is driven to act to correct it.

In a series of posts, a science fiction analogy of an imaginary disease illustrates the logic of thyroid disease diagnosis, thyroid hormone testing, and the three basic thyroid therapy types.

Let’s imagine another world.

A) What if thyroid disease was like a crippling foot disease?

B) What if TSH levels were like shoe sizes?

C) What if thyroid medications were like a powerful pill combined with a mobility aid like a cane, a walker or a wheelchair?

What would go wrong if you applied thyroid therapeutic absurdity to a fictional foot disease? It’s a thought experiment.

I hope the fantasy gives enough distance to help us laugh a little, not just feel frustrated.

THE SCENARIO

Let’s say that in this alien humanoid world, 95% of healthy people’s shoe sizes, male or female, ranged from size 5 to size 9.  This is the normal healthy reference range for shoe size.

Let’s imagine that in this fictional world, you could always count on abnormal shoe size being associated with one another type of an embarrassing, shocking and disabling “crippling foot disease.”

In this world, a larger shoe size, you see, was almost always the sign of a type of “bigfoot” disease with inflammation and tumours in its early stages.

On the other end of the spectrum, the “smallfoot” subtype of this disease compacted the foot, strengthened its muscles, and caused loss of control over foot movements.

You could say that a person either had hypo-foot or hyper-foot, and they could also have tumours expanding the size the foot.

The vast majority of sufferers had the inflammatory type that made them sluggish as they walked around like their feet were heavy bricks. Fewer people had the smallfoot variety that made their foot jerk and jump involuntarily, so it was less understood and more feared.

Both ends of the foot disease spectrum caused progressively crippling permanent deformity and damage. While the disease was either inflating or shrinking the foot, damage occurred in a random pattern: Loss of one or more toes! Bone chunks could disintegrate! An isolated tendon or a muscle could suffer degeneration!

However, this disease rarely harmed anything above the mid-calf, and it never reduced your legs’ total vertical height. It always left at least part of a mass of bony, muscly flesh called a “foot” at the end of your leg.

You could end up with a foot that was abnormally large in one dimension but small in another dimension. In one person, feet could be very wide due to bony growths on one side, but without one or more toes. Another person could have long feet with a tumour on the heel, but extremely thin feet because of missing bone and tendon on one or both sides of the foot. Each person had their own deformity and degree of deformity.

Because of this, it was common for sufferers to wear a size 8 shoe that fit their feet in one dimension but not the other dimension. It always resulted in a poor fitting shoe, but you could still get a shoe that fit to the largest dimension. That was your shoe size.

In this culture, nobody made shoes to adapt to foot shape deformities. They hadn’t progressed enough yet to accommodate and respect this disability. Their culture had a long history of exalting the aesthetic beauty of a normal looking foot. They kind of had a “foot fetish,” which then led to a shoe fetish. It was socially necessary to make your foot look normal on the outside by wearing a normal-looking shoe, even if it didn’t fit exactly.

In this strange world, as long as you took a powerful and mysterious medicine every day, your foot’s overall size would adjust to the dosage, whatever its shape deformity was. The alien biology just responded this way to the contents of this pill. The pill contained a naturally occurring substance found in their feet already. The larger the medicine dose, the smaller both your feet’s overall volume would become. The medicine basically shrinks feet in all directions. A lack of this substance will expand them, and a larger amount will contract them. Zoom in, zoom out.

This is how giving a person in this world this special medicine could actually normalize the shoe size they wore to cover up their deformed foot in public. But their medicine could not reverse the permanent damage that made it hard to walk without support.

The person with this awful foot condition would be unable to walk normally and would need to rely on a mobility aid, like a cane or a walker. That’s why it was a “crippling” foot disease.

In this world it would take a bunch of different tests to see what was really going on inside the foot. Many complex factors affected how the shape of the foot was changing, its effects on muscle versus bone or tendon, or why these factors and overall shoe size was responding more to the dose or less than expected to the same dose the next year. It would also take special medical expertise (costly to the individual) to hire a physiotherapist to adapt the mobility aid to their body and help train them in using it.

Their medical system decided that those tests and experts were too expensive and unnecessary. In fact, the tests were pretty cheap at first, but then they were declared unnecessary, and eventually they they became expensive tests because they were so rare. The patient would be charged for these “extra” tests because the medical system would not pay for anything but a shoe size test. As for the physio experts, they were hard to find, because most foot disease patients didn’t know any further support was available, even at a cost. Patients were routinely assured that it would always be “enough” just to take the meds and use the standard mobility aid.

In the history of this medical system, shoe size quickly rose to become the overarching test. This body part already had high respect in the culture and medical system. It soon became a marker that was easy to measure, and it was the judge of everything related to foot disease.

Despite the uniqueness of each person’s deformed foot, they believed that shoe size represented the sum total of all factors of foot health. They believed it integrated all the relevant data from the internal and external state of health of your feet and expressed it externally in a single size. Few people were interested in explaining just how exactly the loss of a toe would impact a change from foot size 7 to foot size 6, because sometimes the loss made no change of shoe size at all, especially when the person’s larger foot width was the dimension that determined shoe size.

Most importantly, shoe size was the easiest way to dose the medicine that made it almost doctor-proof and easy to meet the criteria of success. The medicine’s most dramatic effect was on shoe size, so it was believed that this number amplified and integrated all relevant data. No matter what happened to the health of the foot, you could always shrink it or grow it with alteration of medicine dose. So the medicine and the index of its effectiveness went hand in hand (or as their saying went, “foot in shoe”).  

Shoe size became the only test that diagnosed the disease, and it set a target for therapy, and finally, shoe size alone even determined whether the therapy was a complete success, even if the foot was horribly deformed and dysfunctional at the same time that it had a given size.

Doctors became less and less interested in monitoring or enhancing the functional use of the foot, slowing down the progression of bone loss, or optimizing the pill’s function to build muscle strength or ankle joint function over time, or understanding how this disease and its therapy affected the person’s overall health or function.

Now let’s listen to a fictional foot doctor talk to their younger trainee about their imaginary patient.

THE DOCTOR’S EXPLANATION

“We have diagnosed a woman with foot disease that was manifested as a very big shoe size of 10. We have now initiated therapy that reduces her big shoe size, and we’ve fitted her with a mobility aid.”

“Of course, we use canes that come with the red pill. Walking canes are cheap and convenient, and standardized by mass production. They come in many sizes, and they require no complex adjustments to the user or additional tests to see if they are working optimally. Canes also come with the strongest recommendations from the foot disease therapy guideline writers. We have a very good relationship with the cane + medicine seller, who also sells our shoe size test kits to our testing laboratories.”

“Aha, you’ve asked about the historical ‘cane vs. walker’ controversy that just won’t die. The cane is all we have given people for decades, so for all most people know, canes are the only type of therapy there ever was, is, or ever will be, and that’s a good thing, because walkers should be buried in history.”

“Why do we always choose a cane as mobility aid? We’ll tell you why.”

“We used to give all people with foot disease walkers and a slightly different medicine back in the 1970s and earlier. That’s before we learned that canes and the red pill were all that were necessary even though they only provide one point of support from one stick rather than two wheels and two sticks.”

“The walker is such a bulky support for the body that it is too easy to overdose. Its medication includes an extra substance, “blue substance,” that we’ve completely removed from our pills. Blue substance directly strengthens muscles and tendons. We’ve found that the blue substance is a natural derivative of our “red substance” medication anyway, so you don’t have to provide it in the medicine.”

“We also took away blue substance from our medication because it comes with a well known side effect of reducing shoe size while enhancing foot muscle strength, which when overdosed, may lead to the jumping and jerking we see in smallfoot disease. It’s true that using blue substance and the walker even with size zero feet does not always cause the jumping foot syndrome, but it goes without question that it’s not healthy to have a low shoe size. Low shoe size is always associated with poor foot health before therapy, and statistics also show risk associations in therapy at foot sizes below range.”

“I’ll tell you a secret — we didn’t actually bother to conduct any detailed comparative studies between cane + medication on the one hand and walker + medication while our therapy overtook the market in the 1970s. Instead, the cane gained popularity based on its own merits. We know today if we tried to make the same transition from walker to cane, we’d have to go through very carefully randomized controlled comparative studies.

But thank goodness it was unnecessary for our better cane-therapy to rise to dominance without all that wasted research money.  We don’t need to do deep research to confirm what everyone should take for granted. Cane+meds is, without any doubt, the best standard of therapy, as confirmed by its long history and widespread safe use.

We can prevent the return of walker-therapy by discouraging prescriptions to keep its market share small, avoiding studying it in our research, and generally not talking about it except now and then to drive home its risks of inducing smallfoot disease.

We also know by our many studies of our therapy versus no therapy at all, that normalizing shoe size with our cane + medicine therapy model is effective at resolving crippling foot disease because it normalizes shoe size and reduces many of its symptoms. It is, without question, better than no therapy at all.

“Our studies show that if you have crippling foot disease and no other problems with your legs from any other disease, you will still be able to hold a cane and position it, push down on it, move a leg forward, and so on. You can count on the human body learning new movement skills and adapting to the loss of support. It’s healthy exercise anyway to have less support.”

“If you do need more than one point of support, all you need to do is upgrade to a higher dose. Larger doses always come with two longer canes with handles like crutches.”

However, there’s a downside to upgrading. According to the medicine-shoe size axis theory, emphasizing the medicine and its cane support will have the effect of reducing your shoe size. Therefore, we have to be very, very careful not to emphasize your therapy too much and cross that shoe-size lower boundary.”

“Oh, it’s so satisfying to see shoe size normalize and achieve a size in the range of health! Our therapy is virtually guaranteed to normalize shoe size in about 90% of patients. If or when it can’t do so, they have something else wrong with them that it’s not our job to fix, or else they must be taking the medicine incorrectly or using their cane improperly and it’s their fault.”

The fact is, now almost everyone with this disease uses cane+meds, and hardly anybody still uses the old-fashioned, potentially dangerous walker+meds. It’s genuinely puzzling and troubling that any foot doctors still prescribe that old therapy because of its shoe-size-lowering risks.

ADJUSTING THERAPY

“So here’s how we dose our therapy to target shoe size. In this woman’s therapy, we test every few months at first, then every six months, to check on the size of her foot. We can  never permit her foot stay a shoe size larger than 9 or become smaller than 5.”

We also know that any shoe size whatsoever within the shoe size range of 5 to 9 is statistically associated with health in people without the disease.

Therefore, even if our therapy can’t reverse all the permanent damage or enable them to walk very fast with their cane, any shoe size within the reference range of 5 to 9 will bring an acceptable enough level of foot health. So let’s target her therapy at a size 9. It makes us feel good to be as far away from the danger zone of low shoe size, and the guidelines say that’s good enough. ”

WHAT’S REALLY GOING ON HERE?

Hi, I’m the Eye in the Sky narrator who knows more about the woman’s health and needs than the doctors and this patient do, so I’ll let you in on some facts they would know if they did more testing that they didn’t do.

This particular woman’s foot disease is unique. She was born with a condition that made her susceptible to tendon and muscle atrophy long before she had foot disease, and now that she has been weakened by the disease, her tendon and muscle atrophy is showing up. As a young adult, she had attained a shoe size of 5.  It took her a long time to get to shoe size 10, and long before that time, even while the foot was at size 8 or 9, the damage was already being done and she was already being crippled and having trouble walking.

If you were to give her a test of foot muscle strength in addition to foot bone strength and quality, you’d see clear signs of muscle and tendon weakness show up in that data. It means she would do better with a walker and its medicine, which contains muscle-strengthening “blue substance.”

But that old therapy option isn’t available from the doctors in her city anymore because the coalition of foot doctors have officially banned the sale of blue substance and have forbidden doctors to prescribe it. The doctors in the region fear prescribing it. They might suffer intense peer ridicule, or worse, be sent to foot disease professional redeveloment sessions and moved to a small town far away from their families. They’ve heard rumors that prescribing walkers + meds or even just adding blue substance by itself to the red pill can basically be career suicide.

Since that better option has been placed off limits by her society, let’s talk about what it would take to optimize her individual therapy to her cane, the only therapy on offer.

She would have to dose enough foot medicine and cane size to bring her down to a shoe size of 4, even though her original healthy adult shoe size was 5. This is because the therapy in the context of advanced foot-disease damage have changed so many variables. Of course, this is where she will meet with difficulty. That shoe size of 4 would be below the system’s shoe size normal-range target, so it would be very hard to find a doctor willing or able to break the policy about not going below the shoe size range.

She’d still hobble around with muscle atrophy, as well, even with a shoe size of 4, and that would still cause pain and lower her mobility for the rest of her life.  But at least being permitted a shoe size of 4 would bring a greater level of mobility than being forced to maintain a higher shoe size on a smaller dose of medicine.

It’s unfortunate, but the foot disease scientists don’t seem to be researching this issue of low foot size in therapy very well. The fears of risk at a lower shoe size are based on faulty reasoning and incomplete research methods. They keep doing limited studies that never measure blue substance, and they don’t consider how much blue and red substance is found in the foot when the size is below range during therapy, compared to people who aren’t on therapy.

They are very afraid of jumping foot disease, the manifestation of small foot disease that can cause accidents, even fatalities. But it is hard for them to distinguish the causes of jumping disease as a separate thing from the lower shoe size, because everything is defined by shoe size, not by red and blue substance. It’s hard for them to justify why most people have to keep a normal shoe size when they have to suppress shoe size to zero in people who have “hip disease” in addition to foot disease. If they didn’t suppress those people’s shoe size, their treated hip disease could flare up, and they would risk not walking at all, and hip disease can be more fatal.

Overall, it is very hard for them to understand why so many people treated for foot disease and hip disease at a shoe size of zero are healthy and do not have jumping foot disease.

~~ Back to the foot doctor’s point of view :

THE DOCTOR EVALUATES THE OUTCOME

“It’s been a year since we put this woman on what we lovingly call “caneotherapy” now, and we’re so proud to say that our patient has maintained a normalized foot size of 9. Her testers report that she has been using her cane daily and taking her meds daily. She’s a good, compliant patient. We have achieved success!”

“Once again, we’ve proven that our modern foot disease caneotherapy works. Oh, how satisfying it is to serve as a foot disease doctor. In fact, it’s so easy. Anyone can be a good and effective cane doctor.”

You have heard some of our mumbling detractors saying that adding a bit of blue substance into her caneotherapy red pill might help her with mobility by strengthening her foot. But we know that blue substance is derived from the red, so that’s just nonsense. Plus, allowing too many patients to go in that direction of supplementing with blue substance is a slippery slope back toward the old walkertherapy! Those people who like to prescribe blue substance are taking unnecessary risks with their patients’ health and it’s a poorly recommended therapeutic model.”

“Oh, and by the way, she reported having a sore left foot and trouble getting around with her cane, but that’s probably a different health problem, as the guidelines say. She might not be grabbing the cane properly. It might even be imaginary pain. Or she might be one of the 15% of patients for whom caneotherapy mysteriously fails to resolve the effects of the disease. So we gave her some pain meds and tips on proper cane usage.  She’ll be fine. ”

No, of course this isn’t right.

How logical is this medical approach?

The next post examines this analogy to thyroid therapy and reveals some of its major fallacies.