THYROIDECTOMY INCREASES THE

PREOPERATIVE BMI ( BODY MASS INDEX ) IN

HYPERTHYROID PATIENT IN RSUP DR.
KARIADI SEMARANG

SCIENTIFIC ARTICLES

Arranged to fulfill some requirements to achieve

a Bachelor of Medicine degree

REYHAN ZUHDI GOFITA WIDYAWIGATA

22010115120098

MEDICAL STUDY PROGRAM

FACULTY OF MEDICINE
DIPONEGORO UNIVERSITY
2018
 THYROIDECTOMY INCREASES THE
PREOPERATIVE BMI ( BODY MASS INDEX ) IN
HYPERTHYROID PATIENT IN RSUP DR.
KARIADI SEMARANG

Arranged by :
REYHAN ZUHDI GOFITA WIDYAWIGATA
22010115120098

Has been approved

Semarang, December 14, 2018

Adviser 1 Adviser 2

Dr. dr. Yan Wisnu Prajoko, Sp.B (K) Onk, dr. Endang Mahati, M.Sc,
M.Kes. Ph.D
197501242008011006
198310032008122003

Prober

dr. Albertus Ari Adrianto, Sp.B, Sp.BD

NIP. 196904222003121001

Knowing,
a. Dean
Chair of the Medical Education Program

Dr. dr. Neni Susilaningsih, M.Si, Med

NIP.196301281989022001
 THYROIDECTOMY INCREASES THE
PREOPERATIVE BMI ( BODY MASS INDEX ) IN
HYPERTHYROID PATIENT IN RSUP DR.
KARIADI SEMARANG
Reyhan Zuhdi Gofita Widyawigata , Albertus Ari , Yan Wisnu , Endang Mahati
1 2 2 3

1
Student from the Medical Faculty of Diponegoro University
2
Division of Surgery, Faculty of Medicine, Diponegoro University
3
Division of Pharmacology, Faculty of Medicine, Diponegoro University
 THYROIDECTOMY INCREASES THE
PREOPERATIVE BMI ( BODY MASS INDEX ) IN
HYPERTHYROID PATIENT IN RSUP DR.
KARIADI SEMARANG
Reyhan Zuhdi Gofita Widyawigata 1, Albertus Ari2, Yan Wisnu2, Endang
Mahati3
1
Student from the Medical Faculty of Diponegoro University
2
Division of Surgery, Faculty of Medicine, Diponegoro University
3
Division of Pharmacology, Faculty of Medicine, Diponegoro University

ABSTRACT

Background:
A condition of excess levels of free thyroid hormone in the bloodstream is
called hyperthyroidism, itcan cause an increase in metabolic rate which
ultimately leads to weight loss. This condition is still common in Indonesia.
Thyroidectomy is a form of hyperthyroid therapy. Previous study found that
patients treated with thyroidectomy had increased body weight compared to
patients treated with other antithyroid medications.
Objective:
Knowing the difference in BMI status in hyperthyroid patients in the pre- and
postoperative period of thyroidectomy.
Methods:
The type of this study is a retrospective observational analytic with
Crossectional approach. Data were obtained from medical records of patients
with a diagnosis of laboratory hyperthyroidism treated with thyroidectomy at
RSUP Dr. Kariadi January 1st 2015 - December 31st 2017 with a total of 62
patients in consecutive sampling. Data were analyzed using Wilcoxon, Mann
Whitney and Kruskal Wallis statistical tests.
Results:
The mean preoperative BMI status of thyroidectomy patients is 23.01 and the
mean postoperative BMI status of thyroidectomy patients is 24.46. There is a
significant increase in postoperative and gender significantly influences the
increase of postoperative BMI. Preoperative BMI and age did not affect the
increase of postoperative BMI.
Conclusion:
Thyroidectomy increases the preoperative BMI in hyperthyroid patient, and this
increase is influenced by age as well.
Keywords: Hyperthyroidism, Thyroidectomy, BMI
INTRODUCTION
Hyperthyroidism is an excessive levels of free thyroid hormone circulating
in the body's circulation due to hyperactivity of the thyroid gland characterized by
an increase in free Thyroxine (fT4), Thyroxine (T4), free Triiodothyronine (fT3) or
Triiodothyronine (T3) and a decrease in Thyroid Stimulating Hormone (TSH).1
Hyperthyroidism in Indonesia is still common, because hyperthyroidism
can be caused by several causes including: Graves' disease (75%), multinodular
toxic goitre, toxic adenoma, Hashimoto's thyroiditis, postpartum thyroiditis,
viruses, drugs such as amiodarone, gravidarum hyperemia, pituitary adenoma , and
others. Hyperthyroidism occured in endemic areas as well as enough iodine, so
people who experience hyperthyroidism need good care and treatment.2
Data from Riskesdas 2007 found 12.8% of men and 14.7% of women had
low TSH levels which indicated a suspicion of hyperthyroidism. However,
according to Riskesdas 2013, only 0.4% of Indonesia's population aged 15 years
and over who were interviewed admitted to being diagnosed as hyperthyroidism.
Even though it is a small percentage, the quantity is quite large. In 2013 there were
176,689,336 people aged ≥15 years, and more than 700,000 people diagnosed with
hyperthyroidism.3
Hyperthyroid affects almost all organs of the body with symptoms of
sweating, tachycardia, hypertension, hyperdefecation, bone reabsorption, tremor,
agitation, and insomnia. Excessive levels of thyroid hormone causes an increase in
metabolic rate which ultimately leads to weight loss even though appetite increases.
In addition, weight loss was also associated with increased intestinal motility and
malabsorption that occurred in hyperdefecation.4,5
The initial step in treating hyperthyroidism is to make the patients become
euthyroid through antithyroid drugs. After that there are three definitive treatment
options, namely by continuing antithyroid treatment, radioactive iodine (RAI) and
thyroidectomy.4 However, Dale et al. found that patients treated with thyroidectomy
had increased body weight compared to patients treated with other antithyroid
medications.6
 Based on this, a study of the comparison of BMI (body mass index) in
hyperthyroid patients performed pre and postoperative thyroidectomy needs to be
done to determine the difference in BMI status in hyperthyroid patients in the pre-
and postoperative thyroidectomy period so that it can be considered in determining
the type of definitive therapy according to the patient's condition.
MATERIALS AND METHODS
Subject of study
This study involved 62 subjects including patients diagnosed as hyperthyroidism
by laboratory examinations who underwent thyroidectomy and meet the inclusion
and exclusion criteria. The inclusion criteria were patients with age ≥18 years, with
FT4 levels of 7.8 - 20.2 and TSH <0.4. While the exclusion criteria are hyperthyroid
patients with comorbid diseases such as diabetes mellitus, chronic renal failure
(clinical and laboratory data), with nodules, have undergone definitive therapy such
as previous chemotherapy and radiotherapy then re-occurs, and incomplete data in
medical records (RM) such as weight and height.
Data Analysis
The data obtained is processed with computer software. All data obtained are
univariate analysis and presented in table form. The difference in BMI was carried
out by bivariate analysis using paired t test if the data were normally distributed. If
the data is not normal then the Wilcoxon statistical test is carried out. After that to
assess the relationship of sex risk factors the data were analyzed again using the
Mann Whitney test, then to assess the relationship between age risk factors and
preoperative BMI, the Kruskal Wallis statistical test was performed.
Ethical Clearance
This study has obtained an ethical clearance (EC) from the Medical and Health
Research Ethics Commission of the Faculty of Medicine, Diponegoro University
and RSUP Dr. Kariadi Semarang with Number 339 / EC / FK-RSDK / V / 2018.
RESULTS
Characteristic of Subject
Table 1. Baseline Characteristics of Samples
Variable F %
Gender
Women 12 67,7
Men 20 32,3
Age
25 – 34 3 4,8
35 – 44 16 25,8
45 – 55 22 35,5
>55 21 33,9
Preoperative BMI
Underweight 5 8,1
Normal 45 72,6
Overweight 9 14,5
Obese 3 4,8
Postoperative BMI
Underweight 4 6,5
Normal 32 51,6
Overweight 20 32,9
Obese 6 9,7

From 62 subjects, the youngest age was 33 years and the oldest was 78
years. In this study, age was divided into four groups, age 25-34 years, 35-44 years,
45-55 years and > 55 years. There were 4.8% (3 samples) with ages 25-34 years,
25.8% (16 samples) with ages 35-44 years, 35.5% (22 samples) with ages 45-55
years and 33.9% (21 samples) with age > 55 years.
Sex distribution in the sample was 32.3% (20 samples) of men and 67.7%
(42 samples) of women.
In this study, preoperative BMI and postoperative BMI were classified into
four groups: <18.5 (Underweight), 18.5 - 24.99 (Normal), 25.0 - 29.99
(Overweight) and > 30.0 (Obese).
In preoperative BMI, from 62 samples there were 8.1% (5 samples)
Underweight, 72.6% (45 samples) Normal, 14.5% (9 samples) Overweight and
4.8% (3 samples) Obese. In postoperative BMI there were 6.5% (4 samples)
Underweight, 51.6% (32 samples) Normal, 32.3% (20 samples) Overweight and
9.7% (6 samples) Obese.
Association Between BMI And Thyroidectomy
Table 2. Table of differences in pre-postoperative BMI
Variable Mean ( ± sd ) p
Preoperative BMI 23,01 ± 4,05
<0,01*
Postoperative BMI 24,46 ± 4,76

*significant
From a total of 62 samples, there were 47 BMI increases, there are no
changes for 6 samples and 9 samples decreased. The mean postoperative BMI was
found to increase (24.46) when compared with the mean of preoperative BMI
(23.0). So, there was an increase in BMI status of hyperthyroid patients in the
postoperative period with a significant difference in BMI (p <0.001).
Association Between ΔBMI and Preoperative BMI, Gender and Age
Preoperative BMI
Table 3. Comparison of ΔBMI based on preoperative BMI
IMT praoperasi N Δ Mean ( ± sd ) p
Underweight 5 1.2880 ± .85992
Normal 45 1.5116 ± 2.58484
0,995
Overweight 9 2.6289 ± 3.98502
Obese7 3 -2.8467 ± 9.69487
There were differences in the average ΔBMI based on preoperative BMI,
where the highest mean ΔBMI was in the overweight category (2.6289), followed
by the normal category (1.5116), then the underweight category (1.288), and the
lowest in the obese category (-2.8467), but statistically not significant (p> 0.05).
Gender
Table 4. Comparison of ΔBMI based on Gender
Gender Δ Mean ( ± sd ) p
Women 2.1314 ± 3.04451
0,007 *
Men 3.54481 ± .7800
* significant
The mean of ΔBMI in female was 2.1314 and in male was 3.54481. So there
are differences in BMI based on sex where men are higher than women and
statistically this is significant (p <0.05).
Age
Table 5. Comparison of ΔBMI based on Age
Age N Δ Mean ( ± sd ) p
25 – 34 3 1.62 ± 1.47336
35 – 44 16 2.3069 ± 2.00039
0,064
45 – 55 22 1.8373 ± 4.81824
> 55 21 0.3519 ± 2.09536
There was a difference in the mean of Δ BMI based on age, the highest at
age 35-44 years (2.3069), followed by ages 45-55 years (1.8373), age 25-34 (1.62),
and the lowest at age> 55 years (0.3519), but the differences are statistically not
significant (p> 0.05).
DISCUSSION
Characteristics of Subject
This study was conducted to determine differences in BMI status in
hyperthyroid patients in the pre- and postoperative period of thyroidectomy and to
analyze preoperative BMI risk factors, gender, and age for changes in postoperative
BMI. Confounding factors such as the type of antithyroid medication, nutritional
intake, stress conditions, lifestyle and other factors are considered as non-existent.
The study was conducted on 62 samples at the medical record installation of Dr.
RSUP Kariadi Semarang, Central Java. Preoperative data was taken before patients
received antithyroid therapy in preparation for surgery, while postoperative data
was taken within 3 months after surgery.
The frequency of gender of subject was men 20 (32.3%) and women 42
(67.7%).
This proportion of gender is in accordance with the theory that the risk
factors for hyperthyroidism are higher for women than men and similar to the
previous studies which stated the prevalence of hyperthyroidism in women tends to
be higher than men.8,9
Hormonal factors play a role in the high incidence of thyroid dysfunction in
women compared to men. Hormonal changes in pregnancy can affect the function
of the thyroid. Disorders of thyroid function after childbirth occured in some
women and most will improve on their own. However, around 20% will develop
into an autoimmune condition in the thyroid within a few years. Hansen et al also
suggested that genetically, the production of thyroid auto antibodies is more prone
to occur in women than in men.10,11
The age distribution of subjects was highest in groups of 45-55 years with a
number of 22 (35.5%) and ages> 55 years with a population of 21 (33.9%). Adults
(average age 30-50 years), where the age above 40 years is the most risky.1 This is
because hyperthyroidism has a tendency to appear at an age of extreme stress and
also during reproductive period, which usually occurs in the adult group.10
Differences of Hyperthyroid Patients BMI Status in the Pre-and Postoperative
Period of Thyroidectomy
This study showed a significant increase (p <0.001) from the BMI status of
hyperthyroid patients in the postoperative period (24.46) when compared with the
preoperative period (23.01). A total of 47 subjects (75.8%) experienced an increase
in postoperative nutritional status. This is in accordance with the previous studies
from Jonklaas and Nsouli-Maktabi stating that patients gain weight after
thyroidectomy and in accordance with the study from Dale et al, who found that
patients treated with thyroidectomy gained weight compared to patients treated with
RAI or antithyroid drugs even though this study only examined patients treated with
only thyroidectomy.6,12
 The first step in treating hyperthyroidism is to make the patient euthyroid
through antithyroid treatment. After that, there are three definitive therapy options
including continuing antithyroid drug therapy, radioactive iodine, and
thyroidectomy.13,14,15,16
Thyroidectomy is a surgical procedure that has been carried out because this
procedure has a low mortality rate.17 Thyroidectomy in hyperthyroid patients will
increase serum TSH, and along with that, the patient's BMI will also increase
according to the results of the study of Amrita Solanki et al.18
Effect of Preoperative BMI, Gender and Age with an increase in Postoperative
BMI
There was a difference in mean ΔBMI based on preoperative BMI, even though it
was not statistically significant (p = 0.995). The highest increase in BMI was in
overweight (2.62) and normal (1.51) patients. The distribution of BMI subjects have
changed, which found a decrease in the number of subjects with underweight and
normal BMI and an increase in the number of subjects with overweight and obese
BMI after surgery. This is in accordance with the previous study which stated that
there was a decrease in the percentage of underweight patients after surgery and
about 39.4% of patients experienced an increase in BMI towards unhealthy
category (overweight or obese).14
In this study there was a significant effect (p = 0.007) of sex risk factors on
changes in patient’s BMI who had thyroidectomy. From 42 female subjects, the
mean BMI increase was 2.13 while in 20 men the average BMI increase was 3.54.
this is suitable with the previous study which stated that the average BMI in men
was higher than in the women.19 Overweight and obese body fat accumulation
occurs mostly in visceral fat, where fat storage in the visceral area is greater in men
than women because of hormonal differences.20
There was a difference in mean ΔBMI based on age, even though it was not
statistically significant (p = 0.064). Subjects with age 25-34 experienced the highest
increase in BMI of 1.98, followed by ages 45-55 of 1.93, then age 35-44 of 1.61
and age> 55 of 0.78. this is different from the previous study which stated that age
and BMI increase along with increasing TSH.19
 This study has several limitation, such as not recording the results of
laboratory TSH and thyroid hormone patients after surgery, taking body mass index
data based only from medical records without measuring directly on the subjects,
and not including the type of antithyroid treatment used by patients as variables in
research.
From the results of the study, it is expected to monitor the nutritional status
and BMI of hyperthyroid patients with thyroidectomy to remain normal, so as not
to increase the risk of diseases caused by overweight and obesity, which are proven
to occur in many patients after thyroidectomy. 14
CONCLUSION
The conclusion of this study is that there is a significant increase in BMI of
hyperthyroid patients in the postoperative period. The difference in mean BMI
status was due to the patient's BMI increasing along with the increase of serum TSH
after thyroidectomy. Gender influences the increase in postoperative BMI in
hyperthyroid patients with thyroidectomy. This is because there are hormonal
differences in men and women that cause differences in fat storage during the
buildup of body fat. There was no effect of the preoperative BMI condition and the
age of the patient on the increase in postoperative IMT thyroidectomy.
In further study, identification of confounding variables is needed to reduce
the bias. Then further study is needed regarding the association of increasing BMI
with the type of antithyroid drug used in the preoperative period, regarding the
comparison of BMI in hyperthyroid patients who performed pre and postoperative
thyroidectomy using the case control research method to make the data more valid,
and regarding the association of TSH and thyroid hormone with increase in BMI of
patients postoperatively thyroidectomy.
ACKNOWLEDGMENTS
We thank all patients for the support and participation in this study. We also
thank the supervisors, nurses, staff and colleagues of Faculty of Medicine
Diponegoro University Semarang and the medical record section of Dr. Kariadi
hospital who helped in completing this study.
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