Impaired Sensitivity to Thyroid Hormones Is Associated With Diabetes and Metabolic Syndrome

Diabetes Care. 2019 Feb;42(2):303-310. doi: 10.2337/dc18-1410. Epub 2018 Dec 14.


Objective: Diabetes prevalence and incidence increase among individuals with hypothyroidism but also among those with hyperthyroxinemia, which seems contradictory. Both high free thyroxine (fT4) and high thyroid-stimulating hormone (TSH) are present in the resistance to thyroid hormone syndrome. A mild acquired resistance to thyroid hormone might occur in the general population and be associated with diabetes. We aimed to analyze the association of resistance to thyroid hormone indices (the Thyroid Feedback Quantile-based Index [TFQI], proposed in this work, and the previously used Thyrotroph T4 Resistance Index and TSH Index) with diabetes.

Research design and methods: We calculated the aforementioned resistance to thyroid hormone indices based on a U.S. representative sample of 5,129 individuals ≥20 years of age participating in the 2007-2008 National Health and Nutrition Examination Survey (NHANES). Also, to approximate TFQI, a U.S.-referenced Parametric TFQI (PTFQI) can be calculated with the spreadsheet formula =NORM.DIST(fT4_cell_in_pmol_per_L,10.075,2.155,TRUE)+NORM.DIST(LN(TSH_cell_in_mIU_per_L),0.4654,0.7744,TRUE)-1. Outcomes of interest were glycohemoglobin ≥6.5%, diabetes medication, diabetes-related deaths (diabetes as contributing cause of death), and additionally, in a fasting subsample, diabetes and metabolic syndrome. Logistic and Poisson regressions were adjusted for sex, age, and race/ethnicity.

Results: Odd ratios for the fourth versus the first quartile of TFQI were 1.73 (95% CI 1.32, 2.27) (P trend = 0.002) for positive glycohemoglobin and 1.66 (95% CI 1.31, 2.10) (P trend = 0.001) for medication. Diabetes-related death rate ratio for TFQI being above versus below the median was 4.81 (95% CI 1.01, 22.94) (P trend = 0.015). Further adjustment for BMI and restriction to normothyroid individuals yielded similar results. Per 1 SD in TFQI, odds increased 1.13 (95% CI 1.02, 1.25) for diabetes and 1.16 (95% CI 1.02, 1.31) for metabolic syndrome. The other resistance to thyroid hormone indices showed similar associations for diabetes-related deaths and metabolic syndrome.

Conclusions: Higher values in resistance to thyroid hormone indices are associated with obesity, metabolic syndrome, diabetes, and diabetes-related mortality. Resistance to thyroid hormone may reflect energy balance problems driving type 2 diabetes. These indices may facilitate monitoring treatments focused on energy balance.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Diabetes Mellitus, Type 2 / blood
  • Diabetes Mellitus, Type 2 / complications
  • Diabetes Mellitus, Type 2 / epidemiology*
  • Female
  • Humans
  • Hyperthyroidism / complications
  • Hyperthyroidism / epidemiology
  • Hypothyroidism / blood
  • Hypothyroidism / complications
  • Hypothyroidism / epidemiology
  • Incidence
  • Male
  • Metabolic Syndrome / blood
  • Metabolic Syndrome / complications
  • Metabolic Syndrome / epidemiology*
  • Middle Aged
  • Mortality
  • Nutrition Surveys
  • Obesity / blood
  • Obesity / complications
  • Obesity / epidemiology
  • Prevalence
  • Thyroid Hormone Resistance Syndrome / blood
  • Thyroid Hormone Resistance Syndrome / complications
  • Thyroid Hormone Resistance Syndrome / diagnosis
  • Thyroid Hormone Resistance Syndrome / epidemiology*
  • Thyroid Hormones / blood
  • Thyrotropin / blood
  • United States / epidemiology
  • Young Adult


  • Thyroid Hormones
  • Thyrotropin