What Is Graves’ Disease? Symptoms and Dietary Notes for Graves’ Disease

Graves’ disease is an autoimmune disorder causing overproduction of thyroid hormones, leading to hyperthyroidism. It is characterized by diffuse goiter, weight loss, palpitations, and heat intolerance.

Symptoms of Graves’ disease include anxiety, tremors, excessive sweating, and eye problems such as exophthalmos. Women are affected more frequently, and family history increases susceptibility.

Dietary notes for Graves’ disease management emphasize limiting iodine-rich foods, caffeine, and highly processed meals. Balanced nutrition with sufficient calcium and vitamin D supports bone and metabolic health.

Treatment options include antithyroid drugs, radioactive iodine therapy, and surgery. Long-term follow-up is essential to monitor thyroid function and prevent complications.

Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology

Prof. Dr. Kılıçkesmez holds the Turkish Radiology Competency Certificate, the Turkish Interventional Radiology Competency Certificate, Stroke Treatment Certification, and the European Board of Interventional Radiology (EBIR). In his academic career, he won the Siemens Radiology First Prize in 2008.

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What Is Graves Disease?

Graves disease is an autoimmune disease in which the immune system attacks the thyroid gland, leading to excessive hormone production. In this disease, antibodies are produced that overstimulate the thyroid gland, resulting in a hormonal imbalance known as hyperthyroidism. The patient’s metabolism speeds up, leading to weight loss, rapid heartbeat, and excessive sweating. At the same time, goiter, or thyroid gland enlargement, may also develop. Graves disease can also affect eye health, causing pronounced bulging of the eyes, dryness, and sometimes visual disturbances. Although the exact cause is unknown, both genetic predisposition and environmental factors play significant roles.

What Are the Causes of Graves Disease?

Both genetic and environmental factors play significant roles in the development of Graves disease. The fundamental cause is autoantibodies that attack the thyroid gland due to an immune system malfunction. Thyroid-stimulating immunoglobulins (TSIs) bind to TSH receptors on thyroid cells, triggering excessive production of thyroid hormones, resulting in hyperthyroidism.

Genetic predisposition is a primary cause of Graves disease. Certain genes have been found to play a key role in disease development. These genes regulate the immune system and increase susceptibility to autoimmune diseases.

• CTLA-4
• PTPN22
• CD40
• TSHR

Apart from these genes, variants in the major histocompatibility complex (MHC) region also contribute to the disease by affecting the immune response. In addition, some non-coding variants in the TSHR gene trigger the disease by creating an immune response targeting the thyroid gland.
Environmental factors can trigger the disease in genetically predisposed individuals. Stress, infections, and iodine intake are key factors that can accelerate this process.

• Stress
• Infections
• High iodine intake

Additionally, smoking is an important risk factor for Graves disease and can especially worsen Graves ophthalmopathy. Epigenetic changes, particularly those related to DNA methylation disorders, can also play a role in the development of the disease by affecting gene expression.

How Common Is Graves Disease?

Graves disease is a commonly seen autoimmune disorder worldwide, with an estimated global prevalence of 1–2%. It is one of the most frequent causes of hyperthyroidism. Although incidence rates vary by region, 20–50 new cases are reported each year per 100,000 people. Graves disease affects women more frequently than men, with a female-to-male ratio ranging from 5:1 to 10:1. About 3% of women and 0.5% of men are at risk of developing this disease during their lifetime.
Women aged 30–60 make up the highest risk group for Graves disease. However, the disease can occur at any age. It is known to have a genetic predisposition, with clustering observed within families and associations with certain genes, particularly CTLA4 and PTPN22. There are also differences among ethnic groups.

• Graves disease is more common among people of European descent,
• lower incidence rates have been reported in people of African and Asian descent,
• but rising cases have been detected in urban African populations in recent years.

Environmental factors also play a key role in the development of Graves disease. Smoking and stressful life events are risk factors that can increase the incidence of the disease, particularly in women.

What Is the Pathogenesis of Graves Disease?

The pathogenesis of Graves disease is a complex autoimmune process triggered by a combination of genetic and environmental factors. This disease begins when the immune system mistakenly attacks the thyroid gland, leading to thyroid dysfunction.
First, an autoimmune trigger is activated, and the immune system produces autoantibodies that attack thyroid-stimulating hormone receptors. These antibodies excessively stimulate the thyroid gland, increasing hormone production and resulting in hyperthyroidism.

Dysfunction of regulatory T cells that control thyroid function further destabilizes the immune system. The abnormal function of these cells helps B cells that increase autoantibody production. Overactivation of T cells also worsens the condition.

Genetic predispositions play a significant role in the development of Graves disease. Certain gene polymorphisms can cause the immune system to develop an aggressive response against the thyroid gland.

In addition, environmental factors are effective in triggering the disease. These factors include:

• Stress
• Infections
• Excessive iodine intake
• Smoking

What Are the Symptoms of Graves Disease?

Graves disease is a complex disorder with many different symptoms, mostly resulting from the overproduction of thyroid hormones. Patients’ metabolism speeds up, resulting in weight loss, excessive sweating, and extreme sensitivity to heat. Cardiovascular effects include rapid or irregular heartbeat, palpitations, and high blood pressure. The nervous system is also affected, leading to tremors, irritability, anxiety, and sleep problems. In addition, patients may feel fatigued even at rest.
One of the distinguishing features of Graves disease is goiter. This causes swelling at the base of the neck due to thyroid gland enlargement. Graves ophthalmopathy, a condition involving the eyes, is also common and may cause eye irritation, redness, and a gritty sensation.

• Metabolic symptoms: Weight loss, excessive sweating, heat sensitivity.
• Cardiovascular symptoms: Rapid or irregular heartbeat, high blood pressure.
• Nervous system symptoms: Tremor, irritability, sleep problems.
• Goiter: Swelling at the base of the neck due to thyroid enlargement.

Other complications of Graves disease include muscle weakness, menstrual irregularities, and osteoporosis. Irregular menstrual periods are common in women, while untreated cases increase the risk of bone thinning and fractures.

How Is Graves Disease Diagnosed?

The diagnosis of Graves disease requires a combination of clinical, serological, and imaging methods. First, the patient’s clinical symptoms are evaluated. Hyperthyroidism in this disease is commonly manifested by symptoms such as rapid heartbeat, weight loss, and intolerance to heat. Extrathyroidal findings such as eye involvement and skin changes also play an important role in the diagnostic process.
Serological tests are critical for diagnosis. The first tests performed to confirm hyperthyroidism are:

• TSH (Thyroid-Stimulating Hormone): Low levels are considered an early indicator of hyperthyroidism.
• Free Thyroxine (FT4) and Triiodothyronine (FT3): High levels of these hormones support the diagnosis.
• TSH receptor antibodies (TRAb): The presence of TRAb is the most specific test for diagnosing Graves disease.

Imaging techniques also play a complementary role in the diagnostic process. Ultrasound assesses the size and structure of the thyroid gland and reveals the increased vascularity characteristic of Graves disease. The radioactive iodine uptake test measures the thyroid gland’s capacity to retain iodine, which helps differentiate Graves disease from other causes of hyperthyroidism.
Finally, Graves disease should be distinguished from other thyroid disorders, such as thyroiditis. When making a differential diagnosis with Hashimoto’s thyroiditis, different antibodies (TRAb, TPOAb, TGAb) are evaluated. In this way, a correct diagnosis can be made and an appropriate treatment process can be started.

How Is Graves Disease Treated?

Various treatment options are used in Graves disease, depending on the severity of the disease and the patient’s general health status. These treatments aim to control hyperthyroidism, improve the patient’s quality of life, and alleviate symptoms.
First, antithyroid drugs reduce the production of thyroid hormones, alleviating symptoms. These drugs include substances such as methimazole and propylthiouracil and often require long-term use.

Radioactive iodine therapy is used to shrink thyroid tissue and reduce hormone production. This treatment directly affects the thyroid gland and halts the progression of the disease.

Surgical intervention generally involves removal of all or part of the thyroid gland. Surgery is preferred in patients who do not respond to other treatments. However, surgery carries a risk of complications and should be carefully evaluated.

In some cases, beta blockers are used to lower heart rate and control symptoms such as irritability. These drugs do not directly affect thyroid hormones but alleviate symptoms caused by the disease.

With technological advances, attacks of the disease can be controlled by embolization and ablation, allowing for reduced doses of thyroid-suppressive medications. This reduces patients’ dependence on medication and avoids parathyroid injury or hoarseness, which can occur after surgery.

What Are the Risk Factors for Graves Disease?

The risk factors for Graves disease are associated with many different elements, including genetic, hormonal, and environmental factors. Genetic predisposition is one of the strongest risk factors. Individuals with a family history of Graves disease have a higher risk. Certain genetic variations, especially changes in the CTLA4, PTPN22, and TSHR genes, increase this susceptibility.
Gender is also a significant risk factor. Women are much more likely to develop Graves disease than men, with a female-to-male ratio of 5:1 to 10:1. The hormone estrogen is thought to increase this sensitivity. Pregnancy is also considered a risk factor due to changes in the immune system.

Environmental factors make up a significant part of the risk.

• High iodine intake: Iodine-containing drugs or supplements can trigger the disease in genetically predisposed individuals.
• Smoking: Smoking is a major risk factor for the development of Graves ophthalmopathy.
• Stress and trauma: Severe psychological stress and physical trauma may increase disease severity.
• Infections: Viral infections can trigger disease development by altering the immune system.
• Microbiota changes: Imbalances in the gut microbiota may play a role in the onset of the disease.

When Can Graves Disease Be Treated?

The timing of Graves disease treatment varies according to the patient’s condition and symptom severity. Treatment is usually planned when conventional methods are insufficient or not preferred by the patient. Alternative treatment options can be considered, especially for patients unsuitable for antithyroid drugs, radioactive iodine therapy, or surgery.
The main indications for thyroid artery embolization (TAE) are:

• Failure of conventional treatments: Embolization may be considered in patients who do not respond adequately to medications or experience severe side effects.
• Patients unwilling to undergo surgery or radioactive iodine therapy: Patients who do not accept surgery or radioiodine treatment and seek a less invasive method may prefer embolization.
• Preoperative preparation: In cases where surgery must be delayed or in patients with a large hypervascular thyroid gland, embolization may be performed to facilitate surgery.
• Alleviation of severe hyperthyroid symptoms: In patients with severe symptoms such as thyrotoxicosis, thyroid artery embolization can quickly reduce hormone production and control symptoms.

Submaximal thyroid ablation:

• This method has been applied in a few centers worldwide and in our center in Turkey and has been found to be highly effective. It is more effective than the embolization method, and the treatment indications are similar.

When Is Graves Disease Treatment Not Possible?

In some cases, interventional radiology techniques cannot be used in the treatment of Graves disease. These situations are determined by considering the patient’s general health and thyroid function. Uncontrolled hyperthyroidism is a significant obstacle to interventional procedures, mainly because iodinated contrast agents may trigger a thyroid crisis (Jod-Basedow phenomenon), posing a life-threatening risk. Additionally, treatments involving radiation, such as radiofrequency ablation, cannot be performed during pregnancy due to the risk to the fetus.
Certain thyroid conditions also prevent the use of interventional radiology techniques. Particularly in patients with multinodular goiter or thyroid autonomy, the risk of iodine-induced thyrotoxicosis is high. Iodine-containing procedures should be avoided or approached with caution in these cases. Any procedure involving iodinated contrast agents is contraindicated in patients at risk for thyroid storm, such as those with thyrotoxicosis or severe hyperthyroidism.

Finally, if thyroid nodules are close to critical structures, interventional radiology is also contraindicated. Large or complex thyroid nodules in contact with structures such as the trachea or recurrent laryngeal nerve may pose a risk for serious complications during ablation procedures.

What Is the Recovery Process After Graves Disease Treatment?

The recovery process after arterial embolization for Graves disease involves several stages. Patients usually have a short hospital stay, mainly for monitoring purposes. Temporary hoarseness and pain in the thyroid area are commonly observed. Anti-inflammatory drugs and analgesics are used for patient comfort.
Monitoring and follow-up are crucial during recovery. Thyroid function must be carefully monitored, and thyroid hormone levels should be checked regularly. This follow-up is vital for detecting the development of hypothyroidism or persistent hyperthyroidism. In some cases, additional treatment may be required.

Long-term outcomes vary among patients. Some experience a significant decrease in thyroid hormone levels, while others may require further intervention. The results of embolization should be evaluated after the procedure and repeated if necessary. Risks and complications, such as unintended embolization and potential nerve injury, should also be considered, although they are rare with experienced operators.

How Can Graves Disease Be Prevented?

Prevention of Graves disease revolves around managing risk factors and making lifestyle changes. This disease results from the interaction of genetic and environmental factors, but certain strategies can be effective in reducing the risk. Applying these strategies is an important step in preventing the development of the disease. Below are some key methods that may help prevent Graves disease:

• Avoid Smoking: Smoking increases the risk of Graves disease, especially the development of Graves ophthalmopathy. Therefore, quitting smoking is of great importance.
• Control Iodine Intake: Excessive iodine intake can trigger Graves disease in some individuals. Limiting foods high in iodine and avoiding unnecessary iodine supplements is beneficial.
• Stress Management: Stress is a trigger for autoimmune diseases. Yoga, meditation, and cognitive behavioral therapy can help reduce stress.
• Monitor Thyroid Function: Individuals with a family history of autoimmune thyroid disease should regularly monitor their thyroid function for early detection of abnormalities.
• Prevent Infections: Viral infections can trigger autoimmune responses. Vaccinations and maintaining general health can help reduce this risk.

Frequently Asked Questions

Is Graves disease dangerous?

Graves disease is an autoimmune disorder that causes the thyroid gland to overwork and can lead to serious problems if left untreated. Cardiac arrhythmias, heart failure, osteoporosis, and, in rare cases, a life-threatening condition known as “thyroid storm” can occur. Graves ophthalmopathy may also develop, leading to vision problems. During pregnancy, there is an increased risk of miscarriage, preterm birth, and thyroid problems in the baby. Therefore, early diagnosis and treatment are vital in preventing these risks.

Is Graves disease cancer?

Graves disease is an autoimmune disorder that causes the thyroid gland to produce excess hormones and should not be confused with cancer. In other words, Graves disease is not cancer. However, research has shown that people with Graves disease, especially those with thyroid nodules, may have a slightly increased risk of thyroid cancer. For example, the incidence of thyroid cancer is higher in people with Graves disease and thyroid nodules compared to those without nodules. Nevertheless, Graves disease and thyroid cancer are different conditions; one is autoimmune, and the other is cancer.

Can Graves disease be completely cured?

Graves disease cannot be completely cured, but symptoms can be effectively controlled. Treatment options include antithyroid drugs, radioactive iodine therapy, and surgical intervention—all of which aim to balance thyroid hormone production. However, these treatments do not eliminate the autoimmune cause of the disease, so there is a possibility of recurrence. Regular follow-up is important, and if symptoms return, treatment can be readjusted. Preoperative ablation or embolization methods are highly effective minimally invasive treatments.

What should Graves disease patients avoid eating?

Individuals with Graves disease should avoid foods high in iodine. Seafood, seaweed, iodized salt, and dairy products can increase iodine levels and further stimulate the thyroid gland, worsening symptoms. Reducing the intake of soy products such as soy milk and tofu may also be helpful, as these foods contain substances that can affect thyroid function. Caffeine can increase palpitations and anxiety, so it is recommended to avoid sources like coffee, tea, and chocolate as much as possible. If the person has gluten sensitivity or celiac disease, avoiding gluten-containing foods can also be beneficial.

Is surgery necessary for Graves disease?

No! Ablation or embolization methods are highly effective minimally invasive treatments before surgery.

Surgical intervention is generally not required for Graves disease but may be considered in specific cases. Surgery may be chosen when a large goiter causes compression symptoms such as difficulty breathing or swallowing, when there is suspicion of cancer, severe eye symptoms, or when the patient does not want to wait for the long-term effects of medication. Surgery is also considered if antithyroid drugs are ineffective or cause side effects, and if radioactive iodine therapy is unsuitable. Ultimately, the decision for surgery should be personalized according to each patient’s situation and preferences.

Does Graves disease cause fatigue?

Yes, Graves disease can cause fatigue. This autoimmune disorder causes excessive production of thyroid hormones, which speeds up metabolism and leads to problems such as insomnia, anxiety, and sleep disturbances, resulting in persistent fatigue. Overactivity of the body may also lead to muscle weakness and exhaustion. Proper treatment and balancing of thyroid hormone levels can help reduce this feeling of fatigue.

Is Graves disease the same as toxic goiter?

Graves disease and toxic goiter are not exactly the same. Graves disease is an autoimmune disorder in which the immune system overstimulates the thyroid gland, causing it to enlarge and produce excessive hormones. In contrast, toxic goiter (such as toxic multinodular goiter or toxic adenoma) is caused by one or more nodules in the thyroid producing hormones uncontrollably. Both conditions result in high thyroid hormone levels, but their underlying mechanisms and clinical features are different.

Can Graves disease patients smoke?

People with Graves disease are strongly advised not to smoke, as smoking worsens the disease and increases the risk of complications. In particular, smokers are twice as likely to develop thyroid eye disease (TED) and heavy smokers have an eightfold higher risk. Smoking also weakens the response to treatment and increases the risk of recurrence. For this reason, quitting smoking is strongly recommended to protect your health if you have Graves disease.

Can Hashimoto’s disease turn into Graves disease?

Yes, Hashimoto’s thyroiditis can rarely turn into Graves disease. Both are autoimmune thyroid diseases; however, Hashimoto’s is usually associated with hypothyroidism (underactive thyroid), while Graves leads to hyperthyroidism (overactive thyroid). In some cases, thyroid-stimulating antibodies characteristic of Graves may appear in patients with Hashimoto’s, causing hyperthyroidism. This rare transition highlights the complex interaction between these two diseases.

Is Graves disease genetic?

Graves disease is a closely related autoimmune disease with genetic predisposition. Genetic factors play a role in 75–80% of cases. Differences in certain tissue group genes such as HLA-DR3 and genes like CTLA-4 and PTPN22, which regulate the immune system, increase the risk of disease development. Although genetic predisposition is the main factor, environmental factors can trigger the onset of the disease. We can say that Graves disease occurs as a result of the combination of these genetic and environmental factors.

What are the symptoms of Graves disease?

Graves disease is an autoimmune disorder that causes the thyroid gland to become overactive and leads to various symptoms. The most common symptoms are enlarged thyroid gland (goiter), palpitations, tremor, weight loss despite increased appetite, intolerance to heat, excessive sweating, irritability, sleep problems, fatigue, muscle weakness, frequent urination, and irregular menstrual cycles. Graves ophthalmopathy develops in about 30% of patients, with symptoms such as eye protrusion, pain, redness, or tearing. Rarely, Graves dermopathy may occur, causing thick, red skin lesions especially on the legs or the tops of the feet. The severity and combination of symptoms can vary from person to person.

What are the effects of this disease on the thyroid gland?

Graves disease is an autoimmune disorder in which the immune system produces antibodies that overstimulate the thyroid gland to produce excessive hormones, resulting in hyperthyroidism. This causes symptoms such as rapid heartbeat, weight loss, and excessive sweating. It is seen in about 1% of the US population and is the most common cause of hyperthyroidism in the country. Women are affected five times more than men, and it typically appears in people over the age of 30. If left untreated, it can lead to serious complications such as heart failure, osteoporosis, and, rarely, thyroid storm. Treatment options include antithyroid drugs, radioactive iodine therapy, and surgical intervention.

What medications are used in the treatment of Graves disease?

Graves disease is generally treated with antithyroid medications such as methimazole and propylthiouracil, which inhibit the production of thyroid hormones. Methimazole is usually preferred because of its better safety profile. About 50% of patients achieve remission after 12 to 18 months of treatment, but recurrence rates can be as high as 50–60%. When medication is insufficient or intolerable, radioactive iodine therapy or thyroid surgery is considered. Beta blockers are also used to alleviate the symptoms of hyperthyroidism.

How effective is radioactive iodine therapy in Graves disease?

Radioactive iodine (RAI) therapy is highly effective in the treatment of Graves disease, with cure rates ranging from 66.4% to 93% with a single dose, depending on the treatment dose and use of antithyroid drugs. Higher RAI doses (e.g., 20 mCi) are associated with faster recovery and higher cure rates. Use of antithyroid drugs (e.g., carbimazole) during treatment significantly reduces success rates: up to 93% in patients not using the drugs, but only 49% in those using them. In addition, patients with high levels of TSH receptor antibodies have a lower chance of cure with a single RAI dose. The most common complication of RAI therapy is the development or worsening of Graves ophthalmopathy in 15–20% of patients. Overall, RAI therapy provides a safe and effective option depending on the patient’s individual characteristics and treatment protocols.

What is the risk of eye problems if Graves disease is untreated?

If Graves disease is untreated, about 25% of patients develop Graves eye disease (TED). Symptoms include dryness and burning, light sensitivity, excessive tearing, blurred or double vision, redness, swollen or tight eyelids, and protrusion of the eyes. In severe cases, untreated TED can lead to optic nerve compression and vision loss. In addition, about 70% of patients without overt eye symptoms show extraocular muscle enlargement on imaging, indicating subclinical eye involvement. Thus, it is very important to treat Graves disease to minimize the risk of eye complications.

How is new-generation ablation therapy applied in Graves disease?

New-generation ablation therapy is a minimally invasive option in Graves disease, using thermal ablation techniques such as radiofrequency ablation (RFA) and microwave ablation (MWA) under ultrasound guidance. This procedure applies heat to thyroid tissue to reduce its volume and restore normal thyroid function. In one study, the median volume reduction rate at 12 months post-procedure was 39.8%, with 96% of patients reaching euthyroid status. In another pilot study, single-session RFA therapy achieved a 73.3% remission rate at 12 months. The procedure is generally well tolerated, with transient side effects (e.g., tachycardia, hoarseness), and long-term complications (such as recurrent laryngeal nerve injury) have not been reported.

How effective is embolization in Graves disease?

Thyroid artery embolization (TAE) has shown promising results in the treatment of Graves disease. In a study of 41 patients, 70.7% achieved normal thyroid function one year after embolization, with a recurrence rate of 19.5%. In another study, 63.6% of 22 patients became euthyroid, and all patients experienced a 33% to 50% reduction in thyroid gland volume. Histological analyses show that TAE promotes the expression of pro-apoptotic genes, leading to increased apoptosis of thyroid cells and restoration of normal thyroid function. However, TAE carries a risk of off-target embolization that can lead to complications such as cerebral infarction. Therefore, while TAE may be highly effective for some patients, proper patient selection and management are necessary.

Prof. Dr. Özgür KILIÇKESMEZ

Girişimsel Radyoloji ve Nöroradyoloji Uzmanı Prof. Dr. Özgür Kılıçkesmez, 1997 yılında Cerrahpaşa Tıp Fakültesi’nden mezun oldu. Uzmanlık eğitimini İstanbul Eğitim ve Araştırma Hastanesi’nde tamamladı. Londra’da girişimsel radyoloji ve onkoloji alanında eğitim aldı. İstanbul Çam ve Sakura Şehir Hastanesi’nde girişimsel radyoloji bölümünü kurdu ve 2020 yılında profesör oldu. Çok sayıda uluslararası ödül ve sertifikaya sahip olan Kılıçkesmez’in 150’den fazla bilimsel yayını bulunmakta ve 1500’den fazla atıf almıştır. Halen Medicana Ataköy Hastanesi’nde görev yapmaktadır.