How do thyroid hormones affect weight? Thyroid gland and excess weight Hyperthyroidism is gaining weight, this could be the case

With pathologies of this system.

Due to disturbances in the functioning of this organ, a person may face the problem of excess body weight. Only complex therapy with medications and a review of lifestyle will help improve the clinical picture.

The thyroid gland oversees the production of 2 hormones: T3, or triiodothyronine, and, or thyroxine. These substances are responsible for regulating many functions in the body, including metabolism.

Metabolism largely determines what changes will occur with a person’s weight: gaining or losing kilograms.

If the thyroid gland cannot produce, then all processes in the body slow down: brain activity decreases, pulse and metabolism slow down. Metabolism becomes sluggish, a person is inactive, as a result of which weight gain occurs.

Many women, when they notice weight gain, begin to adhere to special diets. Restrictions in food negatively affect the functioning of the thyroid gland, as the body begins to receive insufficient amounts of nutrients, micro- and macroelements.

Because of this, he tries to stock up on the necessary amount of energy, which is why weight gain occurs. Because of this, a person with thyroid problems not only does not lose weight, but also gains weight.

Hormones T3 and T4

In addition, the following pathologies can provoke excess weight gain:

  1. – a genetic disease that occurs as a result of the negative effects of infections, poisons or radioactive iodine.
  2. – in this case, metabolic processes are disrupted.

Thyroid disorders that can lead to weight gain can be recognized by the following signs:

  • Swelling and jaundice of the face.
  • Hoarse voice and difficulty speaking.
  • Dry skin and...
  • Brittle nail plates.
  • Decreased memory and attention.
  • Low activity, drowsiness during the day and insomnia at night.
  • Metabolic disorders.
  • Numerous rashes on the body.

Thyroid pathologies that cause weight gain can also be recognized by cycle disruption, decreased sexual desire, and infertility.

If you notice several symptoms of abnormal thyroid function, you should immediately consult a doctor and undergo a diagnostic examination.

How to lose weight if you have thyroid disease?

To normalize body weight, you will first need to normalize your hormone levels. For this purpose, special medications are prescribed - synthetic hormone substitutes: L-thyroxine, Eutirox.

It is also necessary to approach the issue of nutrition responsibly. Your diet should include as many fatty fish, seafood and seaweed as possible. There is also a sufficient amount of iodine in coconut oil, eggs and beef.

When the level of biologically active substances in the body returns to normal, a person’s weight returns to normal. It also gets rid of lethargy, chronic fatigue and acne on the skin.

To ensure that your weight is always within normal limits, try to undergo regular examinations and visit your doctor. Follow all his recommendations to prevent any complications from occurring.

How to diagnose abnormalities in hormone levels?

Thyroid pathologies that affect body weight can be recognized by the following clinical manifestations:

  • The level of endocrine hormones exceeds the norm.
  • The thyroid gland begins to secrete too much.
  • Cholesterol levels are higher than normal.
  • Liver enzyme levels are elevated.

The appearance of excess body weight requires a mandatory comprehensive medical examination. If tests show that your body is normal, you need to undergo a more extensive examination.

In life, there is often evidence that hormonal imbalance causes serious fluctuations in body weight. The sex glands and, oddly enough, the thyroid gland are especially “sinful” of influencing metabolism.

So what is the connection between the thyroid gland and excess weight? Current medical data and videos in this article will answer the main questions - “who is to blame?” and “what to do?” if the scale arrow inexorably creeps up.

Before you understand how the thyroid gland affects weight, you need to find out what biological role it plays in the body. The thyroid gland is a small endocrine organ consisting of two lobes connected by an isthmus.

Its follicular cells secrete the hormones thyroxine and triiodothyronine, which perform the following functions in the body:

  • stimulation of growth and development;
  • acceleration of metabolism;
  • increased excretion of metabolic products and ballast substances from the body;
  • lowering blood cholesterol levels;
  • stimulation of the nervous system by accelerating the transmission of electrochemical impulses between neurons of the brain and spinal cord;
  • increased synthesis of protein compounds;
  • increasing the rate of cell division.

Thus, thyroid hormones - and triiodothyronine - are activators of metabolism and trigger processes in the body that help get rid of extra pounds and slimness.

When hormonal imbalances can cause weight gain

How can the thyroid gland and excess weight be connected if thyroxine, which is secreted by the endocrine gland, is called by doctors the slimming hormone? The fact is that there are diseases associated with impaired organ function and decreased production of thyroxine. The most popular of them are presented in the table below.

Table: Classification of hypothyroidism:

Primary hypothyroidism Secondary hypothyroidism Tertiary hypothyroidism
Peculiarities Hormonal disorders are associated with the pathology of the thyroid gland itself Thyroxine deficiency is associated with a decrease in the production of thyrotropin (a hormone that stimulates thyroid activity) in the pituitary gland and hypothalamus Postglandular hypothyroidism associated with inactivation of thyroid hormones in the blood
Diseases
  • hypo-/aplasia of the thyroid gland – congenital underdevelopment of the organ;
  • thyroiditis – inflammatory changes in the thyroid gland;
  • endemic goiter associated with a lack of iodine in food;
  • , caused by medical manipulations (removal of the thyroid gland, radioiodine therapy, long-term use of thyreostatics).
  • hypopituitarism – congenital atrophy of the pituitary gland;
  • defect in the synthesis and transport of thyroid hormone-releasing hormone by the hypothalamus.
  • sepsis;
  • states of shock;
  • acute pancreatitis.

Any of these diseases causes a decrease in the production of thyroid hormones and provokes:

  • slowing down metabolism;
  • retention of ballast in the body;
  • violation of fat metabolism, increased cholesterol levels in the blood.

All this causes extra pounds, which are very difficult to fight.

Thus, weight problems can arise with thyroid pathology, which is caused by primary, secondary or tertiary hypothyroidism. – increased production of thyroid hormones, on the contrary, is accompanied by accelerated metabolism and sudden weight loss, despite increased immunity.

Diseases of the thyroid gland, in which the functional activity of the organ remains normal, also do not affect weight gain.

Note! Excess weight is not always a sign of hormonal disorders. Often we simply justify ourselves by eating sweets and fast food every day, but at the same time attributing weight gain to problems with the thyroid gland.

Principles of weight correction in patients with hypothyroidism

It is known that excess weight due to pathologies of the thyroid gland is difficult to correct and is difficult to lose. To combat it, an integrated approach is required and, above all, treatment of hormonal disorders. If you have hypothyroidism, obesity will not disappear so easily: get ready for a long struggle.

Balanced diet

All patients with hypothyroidism who are trying to lose weight should follow the principles of a healthy diet and follow these rules:

  1. Carbohydrates should be limited to fast foods - sweets, confectionery, baked goods, including those prepared with your own hands. Slow carbohydrates - cereals, whole grain pasta - should be consumed in sufficient quantities.
  2. The basis of the diet should be vegetables and unsweetened fruits.
  3. Fiber, bran, and other indigestible fibers are important for patients with hypothyroidism to stimulate digestion.
  4. Protein needs should be met with high-quality nutrients (lean meat, lean fish, dairy products).
  5. It is necessary to drink clean, non-carbonated water and decoctions of dried fruits in sufficient quantities.
  6. It is recommended to consume 1600-2000 kcal per day. There is no need to go hungry: due to the variety of foods and a large number of vegetables and fruits in the diet, the need for all nutrients is met.

In the summer season, the price of vegetables and fruits is very small, but the benefits are enormous

Important! Do not forget about the need for sufficient microelements in the diet that have a positive effect on the functioning of the thyroid gland: zinc, selenium, iodine. The diet of a patient with hypothyroidism should contain seaweed, fish, seafood, buckwheat and oatmeal, dried apricots, and figs.

Physical activity

Increased fatigue and decreased overall activity literally chain patients with hypothyroidism, whose only desire is to sleep, to the sofa.

Lifestyle should not be dictated by a sick thyroid gland: weight loss will only occur when a person begins to lead an active lifestyle:

  • take a walk in the fresh air every day;
  • play sports - swimming, running or race walking, aerobics or gymnastics;
  • travel and enjoy outdoor recreation;
  • learn something new every day.

Techniques to speed up your metabolism

There are several rules that will help in the fight for a slim figure.

By following them, you will speed up your metabolism and lose a few extra pounds:

  1. Eat small portions, but often - 5-6 times a day.
  2. Do not forget about healthy sleep: 7-8 hours of night rest in a calm environment not only helps to restore strength, but also promotes weight loss.
  3. Train your muscles. For the same volume, muscle tissue burns three times more calories than fat tissue.
  4. Be sure to have breakfast. In the first 30 minutes after waking up, the body starts metabolic processes and urgently needs amino acids and glucose.
  5. Drink water.
  6. Eat fat-burning foods. Pineapple, grapefruit, kiwi and ginger are not only delicious, but also a healthy way to lose a few extra pounds.

Drug therapy for the disease

And yet, the main method remains taking synthetic analogues of the hormone thyroxine (Euthyrox, L-thyroxine). Replacement therapy shows good results even in the absence of a diet.

The dose of the drug is selected individually by the doctor (the instructions recommend starting with a standard dosage of 50 mcg/day). Hormonal treatment, as a rule, is long-term and allows for the elimination of all pathological symptoms of hypothyroidism, including excess weight.

Note! Taking thyroxine medications with intact thyroid function in order to lose weight is not only ineffective, but also dangerous. It can lead to the development of acquired thyrotoxicosis, accompanied by symptoms such as tremors in the limbs, insomnia, irritability, exophthalmos, palpitations, diarrhea, etc.

As we have found out, the cause of excess weight is not always the thyroid gland: obesity occurs for a number of different reasons that are not related to each other. If weight gain is associated with hypothyroidism, weight loss using general methods is ineffective for a long time. Therefore, the main way to lose weight is to eliminate hormonal imbalances.

More than once we have heard from overweight women the phrase “I don’t eat anything at all, but the weight doesn’t come off!” In fact, “I don’t eat anything” turns out to be not entirely true - a woman eats less than before, but the calorie content of the food that enters the body is enough to maintain fat deposits in the same amount.

But sometimes all the conditions are actually met, the amount of carbohydrates and fats consumed is reduced, and the arrow on the scale stubbornly remains in place.
This means it’s time to contact an endocrinologist to check how your thyroid gland is connected.

Functions of the thyroid gland

Place your hand on the front of your neck. Pinch your fingers slightly and you will easily feel a small seal in the front. This is the “thyroid” - a small gland that has a huge impact on the functioning of the entire body. It produces hormones that regulate basic metabolic processes - the absorption of carbohydrates, the breakdown of proteins and fats. All this happens with one goal - from any resources to give us the energy needed for the operation of each cell, like fuel for a car.

This energy is provided primarily by carbohydrates. When there are few of them, the body takes on the processing of fats. Low-carb diets are based on this principle of involving fat burning.

What happens when all supplies are used up? Energy needs to be taken somewhere, and the “digestion” of muscle tissue begins. This is exactly what happens to those who, either by choice or by force, are constantly seriously undernourished. “Skin and Bones” is about them.

Excess weight and thyroid gland

Malfunctions of the thyroid gland can be caused by various reasons. In this article we will look at something else - what kind of failures there are and how they affect weight.

The first type is low activity of hormone production, otherwise hypothyroidism. Its first signs:

  • constant fatigue
  • laziness,
  • dulling of emotions,
  • vague anxiety,
  • irritability.

The fact is that the production of dopamine (the hormone of joy) and serotonin decreases; to compensate for them, the production of adrenaline and cortisol, which are responsible for tension and stress, increases. And now you are exhausted and alarmed at the same time. With hypothyroidism, the metabolic rate decreases, proteins and fats are processed more slowly, and carbohydrates are less absorbed. Plus a decrease in vitality. And the kilograms begin to grow even without increasing the volume of food.

The second type is increased activity, hyperthyroidism. In short, your body’s gas pedal is constantly pressed, all processes are accelerated. Heart, blood flow, digestion, metabolism - everything works faster than necessary. The balance in the body is disturbed. A person experiences insomnia, inability to concentrate, irritability, rapid pulse, and shortness of breath. And all this against the backdrop of weight loss, no matter how much food you eat.
The list of diseases in both cases is huge. But it cannot be otherwise when the basis of life activity is disrupted - the metabolic processes that unite the thyroid gland.

Excess weight due to thyroid gland

Low activity of hormone production and metabolism physiologically directly leads to weight gain. In addition, for example, with hypothyroidism, body temperature drops below 36.6 degrees. When we have a chill, we try to drink something hot, warm ourselves under a blanket, and eat something while switching TV channels. That is, excess weight due to the thyroid gland is aggravated by a decrease in overall tone and poor nutrition.

What to do? First of all, contact an endocrinologist and donate blood. Nowadays, there are a number of tests that provide an accurate assessment of the malfunction of the thyroid gland. Hypothyroidism is treated with hormone replacement therapy, which is designed to very gently “wake up” the thyroid gland and stimulate metabolism.

Don't be afraid to gain even more weight from hormones. In this case, they are designed to speed up metabolism, that is, they directly contribute to the processing of fat!

Normalization of nutrition is the second important aspect of treatment. Vegetables, unsweetened fruits, fiber, bran, white fish, lean meats, cottage cheese. You need buckwheat, oats, seafood and seaweed, figs and dried apricots. And drink water!

Remember that with hypothyroidism it takes 3-4 times longer to “lose” weight than a healthy person. It is important to restore vigor and vitality - start with walks, gradually increase physical activity, try to experience more positive emotions. And then the body will begin to restore the metabolic rate more and more actively.

In life, there is often evidence that hormonal imbalance causes serious fluctuations in body weight. The sex glands and, oddly enough, the thyroid gland are especially “sinful” of influencing metabolism.

So what is the connection between the thyroid gland and excess weight? Current medical data and videos in this article will answer the main questions - “who is to blame?” and “what to do?” if the scale arrow inexorably creeps up.

Before you understand how the thyroid gland affects weight, you need to find out what biological role it plays in the body. The thyroid gland is a small endocrine organ consisting of two lobes connected by an isthmus.

Its follicular cells secrete the hormones thyroxine and triiodothyronine, which perform the following functions in the body:

  • stimulation of growth and development;
  • acceleration of metabolism;
  • increased excretion of metabolic products and ballast substances from the body;
  • lowering blood cholesterol levels;
  • stimulation of the nervous system by accelerating the transmission of electrochemical impulses between neurons of the brain and spinal cord;
  • increased synthesis of protein compounds;
  • increasing the rate of cell division.

Thus, thyroid hormones - and triiodothyronine - are activators of metabolism and trigger processes in the body that help get rid of extra pounds and slimness.

When hormonal imbalances can cause weight gain

How can the thyroid gland and excess weight be connected if thyroxine, which is secreted by the endocrine gland, is called by doctors the slimming hormone? The fact is that there are diseases associated with impaired organ function and decreased production of thyroxine. The most popular of them are presented in the table below.

Table: Classification of hypothyroidism:

Primary hypothyroidism Secondary hypothyroidism Tertiary hypothyroidism
Peculiarities Hormonal disorders are associated with the pathology of the thyroid gland itself Thyroxine deficiency is associated with a decrease in the production of thyrotropin (a hormone that stimulates thyroid activity) in the pituitary gland and hypothalamus Postglandular hypothyroidism associated with inactivation of thyroid hormones in the blood
Diseases
  • hypo-/aplasia of the thyroid gland – congenital underdevelopment of the organ;
  • thyroiditis – inflammatory changes in the thyroid gland;
  • endemic goiter associated with a lack of iodine in food;
  • , caused by medical manipulations (removal of the thyroid gland, radioiodine therapy, long-term use of thyreostatics).
  • hypopituitarism – congenital atrophy of the pituitary gland;
  • defect in the synthesis and transport of thyroid hormone-releasing hormone by the hypothalamus.
  • sepsis;
  • states of shock;
  • acute pancreatitis.

Any of these diseases causes a decrease in the production of thyroid hormones and provokes:

  • slowing down metabolism;
  • retention of ballast in the body;
  • violation of fat metabolism, increased cholesterol levels in the blood.

All this causes extra pounds, which are very difficult to fight.

Thus, weight problems can arise with thyroid pathology, which is caused by primary, secondary or tertiary hypothyroidism. – increased production of thyroid hormones, on the contrary, is accompanied by accelerated metabolism and sudden weight loss, despite increased immunity.

Diseases of the thyroid gland, in which the functional activity of the organ remains normal, also do not affect weight gain.

Note! Excess weight is not always a sign of hormonal disorders. Often we simply justify ourselves by eating sweets and fast food every day, but at the same time attributing weight gain to problems with the thyroid gland.

Principles of weight correction in patients with hypothyroidism

It is known that excess weight due to pathologies of the thyroid gland is difficult to correct and is difficult to lose. To combat it, an integrated approach is required and, above all, treatment of hormonal disorders. If you have hypothyroidism, obesity will not disappear so easily: get ready for a long struggle.

Balanced diet

All patients with hypothyroidism who are trying to lose weight should follow the principles of a healthy diet and follow these rules:

  1. Carbohydrates should be limited to fast foods - sweets, confectionery, baked goods, including those prepared with your own hands. Slow carbohydrates - cereals, whole grain pasta - should be consumed in sufficient quantities.
  2. The basis of the diet should be vegetables and unsweetened fruits.
  3. Fiber, bran, and other indigestible fibers are important for patients with hypothyroidism to stimulate digestion.
  4. Protein needs should be met with high-quality nutrients (lean meat, lean fish, dairy products).
  5. It is necessary to drink clean, non-carbonated water and decoctions of dried fruits in sufficient quantities.
  6. It is recommended to consume 1600-2000 kcal per day. There is no need to go hungry: due to the variety of foods and a large number of vegetables and fruits in the diet, the need for all nutrients is met.

In the summer season, the price of vegetables and fruits is very small, but the benefits are enormous

Important! Do not forget about the need for sufficient microelements in the diet that have a positive effect on the functioning of the thyroid gland: zinc, selenium, iodine. The diet of a patient with hypothyroidism should contain seaweed, fish, seafood, buckwheat and oatmeal, dried apricots, and figs.

Physical activity

Increased fatigue and decreased overall activity literally chain patients with hypothyroidism, whose only desire is to sleep, to the sofa.

Lifestyle should not be dictated by a sick thyroid gland: weight loss will only occur when a person begins to lead an active lifestyle:

  • take a walk in the fresh air every day;
  • play sports - swimming, running or race walking, aerobics or gymnastics;
  • travel and enjoy outdoor recreation;
  • learn something new every day.

Techniques to speed up your metabolism

There are several rules that will help in the fight for a slim figure.

By following them, you will speed up your metabolism and lose a few extra pounds:

  1. Eat small portions, but often - 5-6 times a day.
  2. Do not forget about healthy sleep: 7-8 hours of night rest in a calm environment not only helps to restore strength, but also promotes weight loss.
  3. Train your muscles. For the same volume, muscle tissue burns three times more calories than fat tissue.
  4. Be sure to have breakfast. In the first 30 minutes after waking up, the body starts metabolic processes and urgently needs amino acids and glucose.
  5. Drink water.
  6. Eat fat-burning foods. Pineapple, grapefruit, kiwi and ginger are not only delicious, but also a healthy way to lose a few extra pounds.

Drug therapy for the disease

And yet, the main method remains taking synthetic analogues of the hormone thyroxine (Euthyrox, L-thyroxine). Replacement therapy shows good results even in the absence of a diet.

The dose of the drug is selected individually by the doctor (the instructions recommend starting with a standard dosage of 50 mcg/day). Hormonal treatment, as a rule, is long-term and allows for the elimination of all pathological symptoms of hypothyroidism, including excess weight.

Note! Taking thyroxine medications with intact thyroid function in order to lose weight is not only ineffective, but also dangerous. It can lead to the development of acquired thyrotoxicosis, accompanied by symptoms such as tremors in the limbs, insomnia, irritability, exophthalmos, palpitations, diarrhea, etc.

As we have found out, the cause of excess weight is not always the thyroid gland: obesity occurs for a number of different reasons that are not related to each other. If weight gain is associated with hypothyroidism, weight loss using general methods is ineffective for a long time. Therefore, the main way to lose weight is to eliminate hormonal imbalances.

The influence of hormones on the vital functions of the human body is in no way comparable to the size and weight of the endocrine gland. The main gland that regulates metabolic processes in the body, the thyroid, is a very small organ in volume. The weight of the thyroid gland ranges from 5 grams in newborns to 25-30 grams in adults. Moreover, in women the thyroid gland is always larger in volume and heavier than in men. Despite such a modest size of the weight of the thyroid gland, the substances it produces can radically change a person’s fate, ruining not only the figure, but also significantly reducing the quality of life.

How does the thyroid gland affect a person’s weight?

The thyroid gland produces three types of hormones:

  • T 3 – triiodothyronine;
  • T 4 – thyroxine;
  • Calcitonin;
  • Somatostatin and serotonin are produced in smaller quantities, which also affect metabolic processes in the body.

T3 and T4 are considered the most essential among all thyroid hormones, since they act as catalysts for the breakdown of nutrients entering the body and are responsible for their absorption by the body.

Of all thyroid diseases, three main groups are known:

  • Normal;
  • Low (hypothyroidism);
  • Increased (hyperthyroidism).

With normal production excess weight not caused by the thyroid gland, but from completely different factors. First of all, increased consumption of carbohydrates (passion for overeating) and a passive sedentary lifestyle. But pathologies that directly affect changes in blood levels have the most direct impact on body composition.

Hypothyroidism – causing weight problems

How does the thyroid gland affect weight?? If excess thyroid function accelerates metabolism - metabolism. All carbohydrates, proteins and fats that enter the body are quickly broken down, absorbed and excreted from the body, but if T3 and T4 are insufficient, the opposite picture is observed - the metabolic process in the body slows down sharply. The first symptoms of hypothyroidism are retention of excess fluid in the body - swelling of the face, limbs, and excess weight gain unprovoked by excess food intake.

The main source of energy is carbohydrates. During normal metabolism, they are broken down and used to ensure the functioning of the body. The excess turns into fats, which are stored as a reserve. An imbalance between the body's energy needs and the rate of absorption of nutrients leads to the fact that even a small amount of food taken by the patient is not spent on maintaining life processes, but turns into useless fats. In addition to the patient’s wishes, his body weight begins to increase.

How to fight weight with thyroid diseases

Independent general preventive measures:

  • Diets;
  • Reducing the amount of food consumed;
  • Increased physical activity for hypothyroidism.

They not only do not achieve an effect, but can be harmful, since as a result of self-medication, a person fights not with the cause that generates the increase in excess volumes, but with the consequence of much deeper processes in the body. At this time, the progression of a dangerous disease is possible, the gradual manifestation of symptoms that affect vital systems, such as the central nervous system or the genital area.

The most effective way to combat excess body weight is a timely visit to an endocrinologist. This is especially true for women who have crossed the forty-year mark in life. It is this category that accounts for up to 75% of patients with hypothyroidism. Having passed a blood test for the content of T3 and T4, the patient immediately receives an answer to the main question - about their level in the blood. What happens next is determined by the doctor. Usually it is enough to adjust the level thyroid hormones that affect weight, how body weight is normalized and overall well-being is improved. In approximately 2/3 of the population, thyroid problems are caused by a deficiency of the microelement iodine in food and water. For preventive purposes, iodine-containing drugs, foods rich in this element and artificially iodized and fluoridated table salt are prescribed.

Age after 40 years almost always entails a decrease in a person’s physical activity. Physiological mechanisms are activated that promote the deposition of fatty tissue, and the person becomes fatter. If these age-related changes are superimposed on pathology, weight gain with sick thyroid gland happens much faster. To neutralize the effects of age-related and pathological factors, it is necessary to follow a diet that maximally limits the intake of carbohydrates into the body.

The basis of this diet is protein and plant foods. The abundance of low-calorie fiber, vitamins, and microelements contained in fresh plant foods - vegetables and fruits - helps speed up metabolic processes. The work of the gastrointestinal tract is stimulated - intestinal motility increases, and excess difficult-to-digest food is removed from the body. Vitamins act as catalysts. Their effects on metabolism may be comparable to those of the thyroid gland, but do not replace them.

Independent choice of diet to reduce excess weight due to the thyroid gland during treatment of hypothyroidism is harmful and dangerous. This should be done by a nutritionist. Many vegetables and fruits contain increased amounts of trace elements and organic acids and salts, which can cause side effects if consumed in excess - gout, calcification and stone formation in the gall and bladder, allergic reactions.

“Mono-diets” are especially harmful - when excessive consumption of any one product is offered as a panacea:

  • Kefir;
  • Apples;
  • Nut kernels;
  • Raw food.

Any diet should be balanced, reasonable, monitored by periodic analyzes of the content of hormones and microelements in the blood and urine. It is almost impossible to achieve this at home.

Cure of hypothyroidism usually entails normalization of the patient's well-being. When the endocrinologist is satisfied with the condition of the gland, maintaining the optimal level no longer depends on him, but on the patient.