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Ketogenesis occurs predominantly within the hepatic mitochondria, with carnitine palmitoyl transferase I (CPT-1) acting as the critical rate-limiting enzyme for mitochondrial fatty acid import (Figure 1)

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Musshoff, F., Schwarz, G., Sachs, H., Skopp, G

P., Lionetti, L., Crezcenzo, R., Botta, M., Barletta, A., & Liverini, G

Based on this assumption, many physicians and endocrinologists believe that the normalization of TSH with a T4 preparation demonstrates adequate tissue levels of thyroid, perpetuated by practice guidelines indicating T4 monotherapy as the standard of care

Moreover, synbiotics have been reported to improve gut integrity via SCFA production, by which inhibiting the TLR4LPS complex-triggered proinflammatory cascade, hampering proinflammatory cytokine signaling pathways, such as nuclear factor kappa B (NF-B), thereby decreasing insulin resistance (31, 34)