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    Understanding Ailments

    Diabetes

    When we use the term diabetes, we almost always mean diabetes mellitus. There is another, rare form of diabetes, known as diabetes insipidus, which has nothing to do with blood sugar and is a completely different disease. Diabetes insipidus is usually due to a tumor in the hypothalamic region in the brain. Blood glucose is normal in these patients.

    On the other hand, diabetes mellitus is due to a disease of the pancreas, which results in a high blood glucose level. Markedly elevated blood glucose levels then lead to excessive thirst and excessive urination.

    Diabetes mellitus is a progressive disease with horrendous complications, which include heart attack, stroke, memory loss, dementia, impotence, leg amputation, kidney failure and blindness. Unfortunately, diabetes remains undiagnosed in a large number of patients because it does not cause any symptoms for many years. By the time diabetes is diagnosed, most patients have developed complications of this disease.

    According to some conservative estimates, at least 17 million Americans have diabetes. Unfortunately, almost half don’t even know they have it .The number of cases of diagnosed diabetes in the U.S. has increased 33% from 1990 to 1998. The greatest increase has occurred in the young age group of 30-39 years of age.

    In general, people are very concerned about cancer, heart disease and cholesterol, but don’t think much about the consequences of diabetes. The advanced complications of diabetes, quite frankly, make for a miserable quality of life.

    Patients with advanced complications (such as kidney failure, leg amputation and blindness) often ask why no one warned them diabetes could lead to such a hellish existence.

    What are the different types of diabetes?

    For a practical standpoint, there are three types of diabetes:

    Type 1, Type 2 and gestational diabetes.

    Type 2 diabetes is the most common form of diabetes, accounting for about 95% of diabetic patients. If properly managed, it usually does not require insulin therapy. On the other hand, Type 1 diabetes, which requires insulin therapy, accounts for less than 5% of cases.

    In Type 1 diabetes, there is complete destruction of insulin producing cells (beta cells) in the pancreas and consequently, insulin production stops. Therefore, these patients have to take insulin on a regular basis in order to sustain their life. If they stop taking insulin, these patients can rapidly lapse into a coma and die if treatment is not instituted in time. On the other hand, in Type 2 diabetes, the body is able to produce insulin, but there is resistance to the action of insulin at the cellular level. Type 2 diabetes is part of Insulin Resistance Syndrome and we will focus on this type of diabetes in the remainder of this chapter. In the past, Type 2 diabetes was also called NIDDM (non insulin dependent diabetes mellitus) or Adult Onset Diabetes.

    Type 2 diabetes was called IDDM (insulin dependent diabetes mellitus) or Juvenile Onset Diabetes. We have stopped using these older terms because they can be inaccurate and misleading. For example, some Type 2 diabetic patients end up on insulin and many physicians mistakenly classify these patients as IDDM (Type 1). Although Type 1 diabetes typically develops at a young age,it can develop in an adult. In the past, most young people with diabetes were classified as Type 1. However, sometimes Type 2 diabetes develops in teenagers.

    Actually, Type 2 diabetes in teenagers is on an alarming rise, primarily due to our "fast food culture" and a lack of physical activity in the teenage population.

    Gestational diabetes refers to development of diabetes during pregnancy. After pregnancy ends, most of these women return to “normal” blood glucose ranges. However, within 10 years, more than 50% of women with gestational diabetes will develop Type 2 diabetes.

    What are the Symptoms of Diabetes?

    Type 2 diabetes is a silent killer. It develops slowly over a period of years. Usually there are no symptoms for a long time. Patients often have vague, non-specific symptoms such as fatigue and usually blame it on getting old. Unfortunately, during this time, complications of diabetes are usually developing and the patient may ultimately have any of the following symptoms:

    • Tingling, numbness, burning sensation or pain in feet, fingers or both.
    • Memory loss
    • Stroke
    • Transient loss of vision
    • Chest pain/heart attack
    • Impotence
    • Excessive thirst
    • Frequent urination
    • Blurry vision
    • Drowsiness, coma

      Excessive thirst and urination, blurry vision, drowsiness and coma are usually symptoms of severe diabetes. Type 1 diabetes usually has more dramatic symptoms such as

    • Weight loss
    • Excessive thirst.
    • Frequent urination especially waking up several times at night to urinate.
    • A life-threatening condition known as Diabetic Keto-Acidosis (DKA). In this condition, a patient may experience nausea, vomiting, abdominal pain, mental confusion, drowsiness and can even lapse into coma. These patients usually have a fruity smell to their breath. Patients with DKA are usually Type 1 diabetics, although it can occur in Type 2 diabetics, too.

    What is the link between diabetes and Insulin Resistance Syndrome?

    Insulin Resistance Syndrome consists of obesity, low HDL cholesterol, high triglycerides, high blood pressure and impaired glucose tolerance or diabetes. Insulin resistance is present in almost all Type 2 diabetic patients. Insulin resistance means that your body becomes less sensitive to the action of your own insulin. In order to compensate for this insulin resistance, the pancreas is able to produce large quantities of insulin and therefore, blood glucose remains normal for many years. Ultimately, after several years, your body is unable to keep up with this mounting insulin resistance. Your blood glucose start rising, but only after meals. This condition is called Impaired Glucose Tolerance.

    This condition can be diagnosed only if you have an oral glucose tolerance test. In this test, if your blood glucose is between 140 mg/dl and 200 mg/dl at two hours after a 75 grams glucose drink, then you have Impaired Glucose Tolerance. Eventually, several years later, your blood glucose starts rising even in the fasting state. If your fasting blood glucose elevates in the range of 100 mg/dl. to 125 mg/dl, it is called

    Impaired Fasting Glucose.


    Impaired Glucose Tolerance and Impaired Fasting Glucose are early stages of diabetes (also known as Pre-diabetes), but are frequently ignored by many physicians. Ultimately, a diagnosis of diabetes is made when a fasting blood glucose is more than 125 mg/dl orwhen after a two hour oral glucose tolerance test, your blood glucose is more than 200 mg/dl.

    The capacity of the pancreas to produce insulin varies from person to person. Some people have a limited capacity to produce insulin and they develop diabetes only after a few years of mild insulin resistance. Others have a tremendous reserve for insulin production and do not develop diabetes for many years despite severe insulin resistance. On an average, 10-20 years of insulin resistance go by before a diagnosis of diabetes is made. During that time, many people experience complications of diabetes such as heart attack, stroke, dementia, neuropathy in feet and hands and gangrene of the legs. They may even die before they are diagnosed with diabetes.

    OBESITY

    Obesity has reached epidemic proportions in the U.S. and other parts of the industrialized world. Even in developing countries, obesity is escalating rapidly. More than 60% of adults in the US are now overweight or obese. What is even more alarming is the rapid increase in the prevalence of obesity among children and adolescents. The rate of overweight children and adolescents has more than doubled in the U.S. since the 1970s. Approximately 14% of U.S children and adolescents are now seriously overweight.

    Obesity is now a well known risk factor for diabetes, high blood pressure, heart attacks, stroke, gall stones, degenerative arthritis and certain cancers such as breast, colon, uterus, ovary, kidney and prostate cancer. In 2003, the American Cancer Society published its analysis of sixteen years of follow-up of 900,000 U.S. adults who were free of cancer at enrollment in the study in 1982. There were 57,145 deaths from cancer during this period.
    Obesity was significantly associated with a higher rate of death due to cancer of the breast, uterus, cervix, ovary, esophagus, liver, gallbladder, pancreas, kidney, and prostate. This study was published in 2003 in the New England Journal of Medicine.

    There are two types of obesity:


    1. Generalized obesity

    2. Abdominal obesity

    You have abdominal obesity if your waist-line is more than 35 inches for females or more than 38 inches for males. Slang words, such as “spare tire” or “love handles” are often used to describe abdominal obesity. Most individuals with generalized obesity also have abdominal obesity. However, some individuals, especially Asians, may have abdominal obesity without generalized obesity. Therefore, the current WHO definition of obesity may underestimate obesity in the Asian population. This issue was emphasized in a recently published study from Singapore, in which many Chinese, Malaysians and Indians, who were non-obese according to WHO definition, were found to have excess fat accumulation and increased risk factors for cardiovascular disease.


    Cholesterol

    HDL cholesterol removes cholesterol from the blood vessel wall and delivers it to the liver for final disposal. In this way, it serves to keep the walls of the blood vessels free of cholesterol deposits. That's why it’s known as the good cholesterol. Think of it as a roto-rooter for your blood vessels!

    LDL cholesterol gets deposited into the blood vessel wall and subsequently leads to narrowing of the blood vessels. That is why it’s known as the bad cholesterol. Think of it as the growing clog in your pipes!

    Triglycerides are a form of fat circulating in the blood. High triglycerides cause deposition of cholesterol in the blood vessel walls which leads to narrowing of the blood vessels.


    What kind of cholesterol disorder is seen in patients with Insulin Resistance Syndrome?

    Patients with Insulin Resistance Syndrome typically have: Low HDL cholesterol (less than 45 mg/dl in males, less than 55 mg/dl in females) High triglycerides (more than 150 mg/dl). Their LDL cholesterol level may be normal, but the particle size of their LDL is small (Pattern B) which is more dangerous than the large sized LDL particles.

    Therefore, cholesterol gets deposited easily in the blood vessels of these patients and the build-up of cholesterol cannot be cleansed out efficiently due to low level of HDL cholesterol. Consequently these patients are at very high risk for narrowing of the blood vessels. HDL cholesterol and triglyceride level serves as an extremely useful test to diagnose Insulin Resistance Syndrome. If your HDL is low and/or your triglyceride level is high, you have Insulin Resistance Syndrome. A low HDL cholesterol has been known to be a strong risk factor for coronary artery disease for a long time. In 1977, the results of the famous Framingham Heart Study were published in the American Journal of Medicine. In this study HDL cholesterol was found to be the most potent lipid predictor of coronary heart disease. Several other studies including the Coronary Primary Prevention Trial (CPPT), the Multiple Risk Factor Intervention Trial (MRFIT), and the Lipid Research Clinics Follow-up Study (LRCF) further confirmed the strong relationship between low HDL cholesterol and coronary artery disease.

    Raising HDL cholesterol reduces the risk for heart attack.

    A 1% increase in HDL cholesterol is associated with a 3% decrease in risk of heart disease. This impressive role of HDL cholesterol in preventing heart attack was shown in the famous Veterans Affairs HDL Intervention Trial (VA-HIT). The results of this study were published in the New England Journal of Medicine in 1999. In the U.S., the National Cholesterol Education Program (NCEP) published new guidelines for cholesterol detection and treatment in 2001.

    This national panel of experts strongly emphasize the importance of HDL cholesterol and Insulin Resistance Syndrome (also known as Metabolic Syndrome). According to the new guidelines, cholesterol testing should include LDL cholesterol, HDL cholesterol and triglycerides???


    What is the relationship between insulin resistance and coronary heart disease?

    Coronary heart disease develops due to narrowing of the blood vessels, a process known as atherosclerosis. This process of atherosclerosis develops slowly over a number of years. Then, one day a clot forms at the site of the narrowed blood vessel and acutely shuts down the blood flow to a portion of the heart.

    This is what causes an acute heart attack or technically speaking, angina (minor episode without any damage to heart muscle) or acute myocardial infarction (prolonged episode with damage to the heart muscle). A person who has coronary heart disease frequently also has low HDL cholesterol, high triglycerides, high blood pressure, abdominal obesity and pre-diabetes or diabetes.

    A number of excellent medical studies have clearly shown these metabolic disorders to be the major risk factors for coronary heart disease. Intense medical research in the last decade has shown that all of these medical disorders have a common thread. This common thread is insulin resistance. Therefore, collectively, these disorders are known as Insulin Resistance Syndrome, also known as Syndrome X or Metabolic Syndrome. Insulin Resistance Syndrome has, therefore, emerged as the root cause for coronary heart disease in a majority of patients.


    Insulin resistance causes narrowing of the blood vessels and puts you at high risk for a heart attack due to the following.

    1. High level of insulin

    Insulin resistance means that your body becomes less sensitive to certain actions of your own insulin. One of these actions is to drive glucose from blood into the cells. In order to compensate for this insulin resistance, your pancreas is able to produce large quantities of insulin, which keeps blood glucose normal for a long time.

    This compensatory high level of insulin, however, is not good for the body. A high insulin level in the blood due to insulin resistance is now a well-established risk factor for heart disease . A high level of insulin stimulates smooth muscle cell proliferation in the arterial wall and causes thickening and stiffness of the arterial wall , which, in turn contributes to narrowing of the coronary blood vessels. Several, large, excellent clinical studies have clearly shown high insulin level to be a major risk factor for coronary heart disease.

    In the Helsinki Policemen Study, investigators measured blood insulin level in 982 healthy men aged 35-64 during an Oral Glucose Tolerance Test. A nine and a half year follow-up of these individuals showed that the insulin level was clearly associated with the risk for coronary heart disease.

    In another study from Finland, 909 diabetic and 1,373 non-diabetic individuals were studied. Blood insulin level was found to have a correlation with coronary heart disease in these individuals . In the Paris Prospective Study, 7,164 working men aged 43-54 were studied for the risks for heart disease. After a mean follow-up of 11.2 years, blood insulin level was found to be a strong predictor of heart disease.

    In a Danish Study, 504 men and 548 women were followed for 17 years. Blood insulin level was found to a strong predictor of heart disease. In Quebec, Canada, researchers studied 797 men and 322 women and found a strong correlation between blood insulin level and coronary heart disease.

    2. High blood pressure

    High blood pressure is known to cause narrowing of the arterial blood vessels,including coronary arteries of the heart. Blood pressure higher than 115/80 increases your risk for a heart attack.

    Blood pressure above 130/80 is called hypertension. A healthy blood pressure is less than 110/70 in most individuals. Insulin resistance is present in the majority of patients with hypertension. This association between insulin resistance and hypertension has been shown in several excellent studies . Several studies have found high insulin level to be associated with the risk for hypertension. High insulin level causes high blood pressure by the following mechanisms :

    It causes thickening of arterial walls, which then become stiff. There is increased resistance to blood flow through these stiff blood vessels, which leads to increase in blood pressure. It causes retention of sodium and water from the kidneys, which then leads to high blood pressure. It contributes to sympathetic nervous system over-activity, which causes constriction of blood vessels, which then leads to high blood pressure.

    3. High Triglycerides and Low HDL cholesterol.

    Individuals with Insulin Resistance Syndrome typically have high triglycerides and low HDL cholesterol. In normal individuals, one of the functions of insulin is to suppress the breakdown of fat from the fat cells into the blood stream. This action of insulin is hampered in individuals with insulin resistance. As a result there is an exaggerated breakdown of fat from the fat cells. The product of this fat breakdown is called free fatty acids.

    Thus, in individuals with insulin resistance, there is a high level of free fatty acids in the blood. The liver takes up these free fatty acids and converts them into VLDL cholesterol (Very Low Density Lipoproteins)

    These cholesterol particles are rich in triglycerides and therefore, individuals with insulin resistance have a high level of triglycerides on their cholesterol blood test. VLDL particles interact with HDL particles and exchange their triglycerides for the cholesterol of HDL particles. This results in a decrease in HDL cholesterol. The more VLDL (triglycerides) you have, the more triglycerides transfer to HDL cholesterol in exchange for cholesterol and more lowering of HDL cholesterol takes place. These triglycerides-enriched HDL particles also break down easily which further lowers HDL level . This is exactly what happens in patients with Insulin Resistance Syndrome who have high level of VLDL (triglycerides rich particles.

    HDL works as a scavenger. It cleans out cholesterol particles that build up in the walls of blood vessels. Low HDL cholesterol means less cleansing of the cholesterol build-up in the vessel wall. That’s why low HDL is a major risk factor for narrowing of coronary blood vessels.

    VLDL particles also give rise to the formation of another cholesterol particle, known as IDL (Intermediate Density Lipoprotein), which then converts to LDL (Low Density Lipoproteins).

    VLDL, IDL and LDL particles deposit in the arterial wall, which causes narrowing of the vessel wall.

    4. Increase in the small dense LDL cholesterol particles

    LDL (bad cholesterol) consists of two subpopulations: small, dense particles and large, fluffy particles. Small, dense particles deposit more easily inside the blood vessel wall as compared to the large, fluffy particles. In patients with Insulin Resistance Syndrome, there is a preponderance of these harmful small, dense LDL particles, which more easily deposit into the arterial wall and leads to narrowing of the coronary blood vessels .

    Now you should understand why individuals with Insulin Resistance Syndrome have such a build-up of bad cholesterol (LDL, VLDL and IDL) in their blood vessels. Due to low HDL cholesterol, they cannot clean out this build-up of gunk. The net result is narrowing of the blood vessels, including coronary arteries, setting up the stage for heart attacks

    5. Increased tendency for clot formation and decreased ability to break the clot

    In patients with Insulin Resistance Syndrome, there is a high level of several clotting factors including fibrinogen level in the blood, which increases the risk for clot formation.

    In addition, these patients also have a decreased ability to break the clot due to a high level of a substance known as PAI-1, short for Plasminogen Activator Inhibitor. Consequently, individuals with Insulin Resistance Syndrome are at high risk for clot formation and have decreased ability to break these clots. When such clots form in the already narrowed coronary blood vessels, a person suffers an acute heart attack.

    6. High CRP (C-reactive Protein) level

    CRP is an easily available blood test in most laboratories. Recently there has been tremendous interest in CRP among researchers in the field of atherosclerosis (or narrowing of the blood vessels). CRP indicates ongoing inflammation. Inflammatory cells are present in the atherosclerotic plaque and can make it susceptible to rupture. A clot forms at the ruptured plaque leading to an acute heart attack. A high level of CRP has been found to be associated with significantly higher risk for heart attack. Individuals with insulin resistance have a high level of CRP and therefore are at high risk for heart attack.

    7. Endothelial Dysfunction

    The endothelium is the lining of the blood vessel wall. The endothelium produces a number of substances, a balance of which is important for its own healthy functioning. A number of these substances can cause constriction of the vessel wall (vasoconstriction) whereas the others cause a dilatation of the vessel wall (vasodilatation). In normal individuals, there is a fine balance between these two processes. Patients with insulin resistance have disruption in this balance in such a way that there is more vasoconstriction and less vasodilatation. This endothelial dysfunction causes further narrowing of the blood vessels. The association between endothelial dysfunction and insulin resistance has been well documented in several studies in diabetic as well as non-diabetic patients.

    8. High blood glucose level (pre-diabetes, Diabetes)

    Diabetes is a rather late event in the progression of insulin resistance. Many patients die of a heart attack before they are even diagnosed with diabetes. Diabetics usually have high blood pressure, low HDL cholesterol, high triglycerides level, high fibrinogen level, high PAI-1 level and endothelial dysfunction. It is no surprise that most diabetics have developed significant narrowing of the blood vessels by the time they are diagnosed with diabetes.

    Diabetics have about four fold higher risk for heart disease than non-diabetics. Pre-diabetes is also associated with a high risk for heart attack. This condition is diagnosed using a two hour Oral Glucose Tolerance Test. In the famous Honolulu Heart Study, a direct relationship was found between the one hour blood glucose (in a glucose tolerance test) and risk for heart disease in pre-diabetic as well as diabetic individuals .

    In a twenty years follow-up of three famous European studies, the Whitehall Study, the Paris Prospective Study and the Helsinki Policemen Study, a direct relationship was again found between the two hour glucose (in a glucose tolerance test) and risk of death from heart disease

    High Blood Pressure (Hypertension)

    Many patients as well as some physicians do not fully comprehend the serious consequences of high blood pressure. Quite often patients don’t accept the diagnosis of high blood pressure and try to blame it on “being in physician’s office.” Even some physicians tend to agree with these patients and ignore this serious disease. This is basically due to an old, incorrect concept.

    If your blood pressure is high in a physician's office, just imagine what happens to your blood pressure when some driver cuts you off on the freeway. The fact is that life is full of stresses. If your blood pressure rises abnormally high during stress, eventually you will end up with high blood pressure all the time. According to the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood pressure in the U.S., 31% of hypertensive Americans were not even aware that they had hypertension.

    Those who were aware of their hypertension, only 69% were receiving treatment for it and only 31% had achieved the target control of blood pressure. Sadly, these numbers have not changed between 1988 and 2000. Many patients remain in denial about their high blood pressure. They think that as long as they aren’t taking medications for high blood pressure, they don’t have it.

    They want to treat their blood pressure by losing weight, (as if that is so easy to do). I tell them that they need to go on blood pressure medicine right away. In the meantime, they should try to lose weight. Then if their blood pressure gets too low, we will back off on the medicine. Often, weight reduction may decrease the dose of your blood pressure medicine, but most patients still need medicine to control their high blood pressure.

    High blood pressure causes hardening of the arteries.

    It’s a fantasy to think that your high blood pressure won’t harm your body while you try to work on your weight. The reality is that high blood pressure can cause a stroke that can leave you in a wheelchair for the rest of your life. I have seen it happen. Why take that kind of chance? Blood pressure is not like a flu that you can get rid of. Once you have high blood pressure, you have it for the rest of your life and often you have to take medicine to control it for the rest of your life.

    The earlier you start controlling blood pressure effectively with medicine, the less damage it will have on your body and the better off you will be. Quite often a family history of high blood pressure is present, but sometimes it may be lacking, as older family members may not have been properly diagnosed. Many patients think that high blood pressure causes headache and fatigue, so if they’re feeling fine, then their blood pressure must be fine, too.

    The fact is that blood pressure, like cholesterol disorder, is a silent killer and most often does not cause any symptoms by itself. Its symptoms are those of it’s complications, such as heart attack or stroke. These complications can be prevented with proper drug treatment. Unfortunately, many patients don’t take high blood pressure seriously until some complications occur.

    In the past, some physicians mistakenly treated high blood pressure gingerly in older patients, but now we know that high blood pressure must be treated aggressively at all ages. Older people in particular are more prone to devastating complications such as stroke, heart attack, memory loss and kidney failure. Proper treatment of high blood pressure can reduce the risk of these complications. An excellent, large clinical trial was carried out investigating this question of treating high blood pressure in the elderly. This study was called the SHEP (Systolic Hypertension in the Elderly Program) trial and was published in the Journal of the American Medical Association in 1991. In this clinical study, 4,736 elderly individuals with systolic blood pressure between 160 and 219 mm Hg and diastolic blood pressure below 90 mm Hg were randomized to placebo or active drug treatment. The risk for stroke was reduced by 36% in patients receiving drug treatment. This study clearly established the benefits of treating high blood pressure in older patients.


    What is high blood pressure?

    The ideal blood pressure is about 100/70mm Hg.

    The upper number is called systolic and the lower number is called diastolic.

    Both of these blood pressures are equally important.

    In the past, there used to be some misconception that diastolic blood pressure was more important than systolic blood pressure, but this turned out to be incorrect.

    Any blood pressure value above 115/80 is high and is known to cause damage to the heart and other organs in the body.

    Unfortunately, the current definition of high blood pressure is more than 140/90.
    Now you can understand why many patients develop many complications of high blood pressure by the time they are diagnosed with this deadly condition. Any blood pressure above 115/80 should be taken seriously. Any blood pressure above 130/80 is too high and should be treated effectively. Older people in particular are more prone to devastating complications such as stroke, heart attack, memory loss and kidney failure. Proper treatment of high blood pressure can reduce the risk of these complications.

    An excellent, large clinical trial was carried out investigating this question of treating high blood pressure in the elderly. This study was called the SHEP (Systolic Hypertension in the Elderly Program) trial and was published in the Journal of the American Medical Association in 1991. In this clinical study, 4,736 elderly individuals with systolic blood pressure between 160 and 219 mm Hg and diastolic blood pressure below 90 mm Hg were randomized to placebo or active drug treatment. The risk for stroke was reduced by 36% in patients receiving drug treatment. This study clearly established the benefits of treating high blood pressure in older patients.

    Hypothyroidism (Underactive Thyroid)

    Hypothyroidism is a very common disorder, especially in women.

    The two most common symptoms of hypothyroidism:

    • Weight gain (or difficulty losing weight)
    • Fatigue.

    The other common symptoms of hypothyroidism:

    • Decrease in concentrating ability
    • Forgetfulness
    • Muscle cramps
    • Puffy eyes
    • Hair loss
    • Intolerance to cold
    • Constipation
    • Menstrual irregularities
    • Frequent miscarriages.
    • Sometimes an enlarged thyroid gland (known as a goiter) is also present.

    Hypothyroidism can also cause a high cholesterol level, high blood pressure and slowing of heart rate. It is quite common to mistakenly attribute these symptoms to "just getting old." Hypothyroidism can be easily diagnosed with a blood test.

    Hashimoto's thyroiditis

    pHashimoto's thyroiditis is an autoimmune disease of the thyroid gland and is the most common cause of hypothyroidism (underactive thyroid). It affects women much more frequently than men. A family history of thyroid disorder is usually present. An enlarged thyroid gland, known as a goiter, is also usually present. Sometimes, thyroid nodules are present. Diagnosis of Hashimoto's thyroiditis can be easily made by a blood test.

    Symptoms of hyperthyroidism:

    • Weight loss
    • Shakiness
    • Anxiety
    • Irritability
    • Palpitations
    • Tiredness
    • Feeling hot all the time when other people are feeling comfortable
    • Thinning of hair
    • In women, hyperthyroidism can also lead to irregular menses and sometimes lack of menses.

    Symptoms of hyperthyroidism:

    The common causes of hyperthyroidism are:

    • Too large of a dose of thyroid hormone
    • Graves' disease
    • Toxic multinodular goiter
    • Subacute Thyroiditis
    • Postpartum Thyroiditis
    • Painless Thyroiditis

    Treatment of Hypothyroidism Hypothyroid patients are treated by replacing thyroid hormone. Most of these patients are hypothyroid due to Hashimoto's thyroiditis. Some are hypothyroid as result of radioactive iodine treatment for Graves disease. Others become hypothyroid as a result of thyroid surgery, usually done for the treatment of thyroid cancer. Some rare cases of hypothyroidism include congenital hypothyroidism, juvenile hypothyroidism and thyroiditis, as a result of post-delivery. The dose of thyroid hormone must be individualized and is adjusted according to the thyroid function test results. Requirement of thyroid hormone generally increases during pregnancy. A normal thyroid gland produces two types of thyroid hormones, Levothyroxine (or T4) and triiodothyronine (or T3). For replacement purposes, traditionally only T4 ( Synthroid, Levoxyl or Levothroid) was used because some of this T4 gets converted into T3 inside the body. However, a number of patients continue to have symptoms of hypothyroidism despite having a normal thyroid function test. These patients benefit from the addition of T3 ( Cytomel ) In the past, only a handful of endocrinologists were adding T3 (Cytomel) to T4 (Levoxyl, Synthroid or Levothroid) to replace thyroid hormone, but recently more and more endocrinologists are using combination therapy in many hypothyroid patients. An article published in the February 11, 1999 issue of the New England Journal of Medicine clearly indicated that combination therapy with T4 and T3 was superior to T4 therapy alone in controlling the patient's symptoms of hypothyroidism.

    In the past, doctors have used to hypothyroid patients with T4 (Levoxyl, Synthroid or Levothroid) alone. However, since the publication of the New England Journal of Medicine article, doctors have been combining Cytomel to Levoxyl or Synthroid in treating most of their hypothyroid patients. Research findings indicates that the combination of Cytomel and Levoxyl or Synthroid are more effective in controlling the patient's symptoms than Levoxyl or Synthroid used alone.

    Graves disease

    Graves disease is an autoimmune disease of the thyroid gland. For some obscure reasons, the body starts producing antibodies which are directed at the thyroid gland. These antibodies are stimulatory in nature and thus force the thyroid gland to produce more and more thyroid hormone. Large quantities of thyroid hormone produce symptoms of hyperthyroidism (overactive thyroid). Sometimes, eye symptoms may be pronounced. These include bulging of the eyes, feeling of a foreign body in the eyes, excessive dryness of the eyes, blurry vision and double vision. Sometimes, eyesight may be in danger and requires immediate medical attention.

    Vitamin B 12

    Vitamin B12 is one of the most important vitamins in our body. It helps in the repair of DNA in every cell of the body and is important in maintaining the integrity of our genome. It is particularly important for the health of the brain, nerves, blood cells, fatty acids metabolism, gastrointestinal tract and heart.

    What are effects of low Vitamin B12?

    Low vitamin B 12 can cause:

    • Lack of energy.
    • Tingling and numbness in the feet and hands due to peripheral neuropathy.
    • Memory loss, dementia and depression.
    • Abnormal gait and lack of balance
    • Anemia
    • Burning of the tongue, poor appetite, constipation alternating with diarrhea, vague abdominal pain.
    • Increase in the level of Homocysteine which is a risk factor for heart disease. Low folic acid is the other contributory factor for raising Homocysteine level.

    Who is at risk for low Vitamin B12?

    • Anyone on a strict vegetarian diet, because vegetables are devoid of Vitamin B12.
    • Anyone on Metformin (Glucophage)
    • Anyone on stomach medicines such as Prilosec, Prevacid, Protonix, Aciphex, Pepcid, Zantac, Tagamet etc.
    • Antibiotics can lower Vitamin B12 by interfering with the normal intestinal bacterial flora.
    • Anyone who has undergone stomach surgery.
    • Gastrointestinal disorders such as chronic pancreatitis, atrophic gastritis, small intestinal resection or bypass, gluten enteropathy, Crohn's disease and malignancy.

    How do I know if I am low in Vitamin B12?

    Vitamin B12 deficiency often remains undiagnosed because physicians generally don't think of it as a possibility. For example, when a diabetic patient complains of tingling in their feet, physicians do all the work-up to diagnose diabetic peripheral neuropathy. They then start you on drug treatment without checking your Vitamin B12 level, even if you are on metformin. In reality, peripheral neuropathy in diabetic patients on metformin is often due to two factors: diabetes itself and vitamin B12 deficiency.Vitamin B 12 deficiency can be diagnosed by a blood test. A blood level less than 400 pg/ml indicates Vitamin B12 deficiency. In my clinical experience, patients do much better when their Vitamin B12 level is close to 1000 pg/ml.

    What are natural sources of Vitamin B12?

    Animal products are the main natural sources of Vitamin B12. Plant derived food is devoid of Vitamin B12. Good dietary sources include egg yolk, salmon, crabs, oysters, clams, sardines, liver, brain and kidney. Smaller amounts of Vitamin B 12 are also found in beef, lamb, chicken, pork, milk and cheese.

    Is there danger of Vitamin B12 overdose?

    To my knowledge, there are no reported cases of Vitamin B12 overdose in medical literature. Vitamin B12 in high doses along with folic acid and Vitamin B6 helps to lower homocysteine level. High level of homocysteine is a known risk factor for cardiovascular disease. Lowering of homocysteine level helps to lower cardiovascular risk.

    What are different forms of Vitamin B12 supplements?

    Vitamin B12 supplements are available as oral pills and pills for sublingual absorption. I prefer the sublingual absorption route because the absorption of vitamin B12 from the oral cavity (dissolving in the mouth) is excellent, better than from the stomach and intestines. Vitamin B12 is also available in the form of an injection. You need a prescription from a physician for a vitamin B12 injection.

    Vitamin D

    Why should I care about Vitamin D?

    Vitamin D is one of the most important vitamins for our health.

    • Vitamin D is important for the absorption of ingested calcium. If you don't have enough Vitamin D, you don't appropriately absorb calcium.
    • Vitamin D is important for the health of our bones and muscles. If you are low in Vitamin D, you are at risk for osteoporosis. You also develop muscle aches and pains, which often gets misdiagnosed as Fibromyalgia or Chronic Fatigue Syndrome
    • Vitamin D is important for the normal functioning of our immune system.
    • Vitamin D also has anti-cancer properties and is beneficial for our heart.

    Myths about Vitamin D

    Unfortunately, there are a number of myths about Vitamin D. Here is list of myths that patients tell doctors:

    • I can not be low in Vitamin D, because I drink milk.
    • I can not be low in Vitamin D, because I take a multivitamin and calcium tablet that also contains Vitamin D
    • I can not be low in Vitamin D because I live in sunny southern California.
    • I read there is a high risk of Vitamin D toxicity if I take Vitamin D.

    So why is Vitamin D deficiency so common?

    The sun is the main source of Vitamin D and accounts for 90% of Vitamin D in our body. Upon exposure to the sun, our skin manufactures Vitamin D, which then finds its way into the blood stream. Cholesterol is the raw material for the synthesis of Vitamin D. Most of us do not get enough sun exposure. Often our jobs and lifestyle forces us to stay indoors. Even when we go out in the sun, we make sure to put a healthy layer of sun screen which blocks the synthesis of vitamin D in our skin. We have been told that the sun may cause skin cancer.

    Unfortunately we are not told that the sun is beneficial as well. The truth about the sun is that it is both good and bad for us. It provides us with Vitamin D but may also zap us with an occasional skin cancer.

    How do I know If I am low in Vitamin D?


    Get your vitamin D level checked. It is a simple blood test. it is important to get the correct test for Vitamin D. There are two tests for vitamin D level: 25 OH Vitamin D and 1,25 OH Vitamin D. 25 OH Vitamin D (and NOT the 1,25 OH Vitamin D) is the correct test for diagnosing Vitamin D deficiency. Another common problem is the normal range printed on the lab form. In my experience, most normal ranges printed on the lab forms are incorrect. A 25 OH vitamin D level less than 30 ng/ml is considered low by most endocrinologists. If this level is less than 20 ng/ml, you have severe deficiency of Vitamin D.

    What's the treatment of Vitamin D deficiency?


    For mild Vitamin D deficiency, Vitamin D3 (also known as cholecalciferol) 1000-2000 I.U. per day is usually adequate. For severe Vitamin D deficiency, you may need Vitamin D3 (cholecalciferol) in a mega dose of 50,000 I.U. per week for 12 weeks and even longer. This dose of Vitamin D requires a prescription by a physician who should also monitor your serum calcium level to prevent Vitamin D toxicity.

    What is Vitamin D toxicity?


    If you take too much Vitamin D, your serum calcium level may get elevated, which if mild usually does not cause any symptoms. However, if serum calcium is too high, you may develop heart problems, drowsiness and in extreme cases, even coma and death. So it is important that you let your physician know about your vitamin D dose. Your physician should monitor your serum calcium level which is often included in a routine chemistry panel.

    Osteoporosis

    The most common form of osteoporosis in women is postmenopausal osteoporosis which occurs as a result of loss of ovarian function at the time of menopause.However, if a woman has surgical removal of her ovaries at a young age, she is susceptible to osteoporosis at a young age. Some women experience premature ovarian failure in their twenties or thirties. Consequently, these women are also at a high risk for the development of osteoporosis at a younger age.

    Causes of Osteoporosis:

    • Menopause
    • Vitamin D deficiency
    • Overactive thyroid gland
    • Overactive parathyroid glands (4 glands lying just posterior to the thyroid gland in the neck)
    • Certain gastrointestinal disorders
    • Certain drugs such as Prednisone, Dilantin and thyroid hormone in excessive doses.

    Do I have osteoporosis?

    The best way to find out whether you have osteoporosis is by doing special testing, called bone density testing. Most frequently, bone density testing is done by using a technique called DEXA (dual energy x-rays absorptiometry) scanning.

    Fatigue

    Fatigue is a common symptom. It is often quite debilitating. Fatigue has many different causes. Unfortunately physicians often do not diagnose the root cause of fatigue.They often write it off by saying, things like "It's all in your head", "You must be depressed", "Oh, you have Chronic Fatigue Syndrome", or "You're just getting older."It takes an experienced endocrinologist to sort out the various causes of fatigue.

    The common causes of fatigue include:

    • Under-active thyroid
    • Over-active thyroid
    • Uncontrolled Diabetes
    • Pre-diabetes
    • Post-prandial hypoglycemia
    • Side-effect of drugs
    • Vitamin D deficiency
    • Sleep apnea
    • Low testosterone in men
    • Low growth hormone
    • Anemia
    • Depression
    • Adrenal insufficiency
    • Cancer
    • Weak heart
    • Emphysema and scarring of lungs
    • Chronic infections such as tuberculosis, valley fever

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