Power of Prevention Vol. 3 Issue 1 by AACE

Vol. 3, Issue 1

BACK ON TRACK 3 Time olympic Gold Medalist

Gail Dever’s sTorY Page 2

The KiDNeY–DiabeTes liNK: Progress in Saving Kidney Function! Page 18

New Year, New You! Page 10

The SloPeS

To SucceSS US Olympic Cross-Country Skier Kris Freeman’s Story Page 12

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January is Thyroid Awareness Month!

S p E c i a l

S E c T i o N

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• When You Should Know Your TSH • Thyroid Eye Disease: What’s New?

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10 New Year, New You! It’s a new year! Learn how you can stay on track to reach your goals.

Ta b l e o f C o n t e n t s 2 Back on Track: 3 Time Olympic Gold Medalist Gail Dever’s Story

9 Thyroid Eye Disease What is thyroid eye disease? Find out more about how to prevent, control and treat it.

20 How to Read a Food Label: Focus on Trans Fat

Important things you need to know about reading food labels.

Read about how “the fastest woman in the world” overcame thyroid disease.

12 The Slopes to Success:

4 Thyroid gland – Too Slow

A US Olympic Cross-Country skier finds success on and off the slopes.

Vitamin D is essential. But what does it mean to be vitamin D deficient? Learn more here.

Hypothyroidism or Hyperthyroidism? What’s the difference? Find out here!

15 Diabulemia – A Life-

24 The Type 2 Talk: Changing

Threatening Approach to Thinness

the Type 2 Diabetes Conversation

Learn more about a struggle facing type 1 diabetes patients.

Read about an exciting campaign that will change the type 2 diabetes conversation.

18 The Kidney-Diabetes

26 Want to Learn More

or Too Fast? Which Is It, Doc?

6 When You Should

Know Your TSH Level Learn more about when you should know your TSH

7 Thyroid Disease:

A Post Web Exclusive Learn more about thyroid disease from this article published by the Saturday Evening Post.

Skier Kris Freeman’s Story

Link: Progress in Saving Kidney Function Find out more about the link between diabetes and kidney function!

22 Low Vitamin D Levels in Adults

About Thyroid Disorders?

Find out where you can read and download patient handouts about a variety of topics.

26 Letters from Readers

THE Magazine

Power of Prevention, published by the American College of Endocrinology (ACE), the educational and scientific arm of the American Association of Clinical Endocrinologists (AACE), is dedicated to promoting the art and science of clinical

AMERICAN COLLEGE OF ENDOCRINOLOGY Bill Law, Jr., MD, FACP, FACE President, ACE Daniel S. Duick, MD, FACP, FACE President Elect, ACE

endocrinology for the improvement of patient care and public health. Designed as an aid to patients, Power of Prevention includes current information and opinions on subjects related to endocrine health. The information in this publication does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS Daniel Einhorn, MD, FACP, FACE President, AACE Yehuda Handelsman, MD, FACP, FACE President Elect, AACE DONALD C. JONES Chief Executive Officer, AACE

acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

The ideas and opinions expressed in Power of Prevention do not necessarily reflect those of the Publisher. ACE is not responsible for statements and opinions of authors or the claims made by advertisers in the publication. ACE will not assume responsibility for damages, loss, or claims of any kind

Power of Prevention Editors Donald A. Bergman, MD, MACE Executive Editor Etie S. Moghissi, MD, FACP, FACE Editor Dace L. Trence, MD, FACE Co-Editor

arising from or related to the information contained in this publication, including any claims related to products, drugs, or services mentioned herein.

Material printed in Power of Prevention is protected by copyright. No part of this publication may be reproduced or transmitted in any form without prior written permission from Power of Prevention, except under circumstances within “fair

AACE PUBLIC & MEDIA RELATIONS Bryan Campbell Director of Public & Media Relations and CAP Representative Sarah Senn Public & Media Relations Coordinator for Power of Prevention Casey Jones Public & Media Relations Coordinator

Power of Prevention is published by the American College of Endocrinology, 245 Riverside Avenue, Suite 200; Jacksonville, FL 32202 • 904-353-7878 • Fax 904-353-8185 • E-mail info@aace.com, Web site www.aace.com.

AACE is a professional medical organization with more than 6,000 members in the United States and 91 other countries. Founded in 1991, AACE is dedicated to the optimal care of

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patients with endocrine problems. AACE initiatives inform

TRAVIS CHEATHAM Director of Graphic Design

the public about endocrine disorders. AACE also conducts

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physicians whose advanced, specialized training enables

AMY OGLESBY Graphic Designer

as diabetes, thyroid disorders, growth hormone deficiency,

Contributing Editors Nathalie A. Turner, MS, ELS Medical Literacy Editor Power of Prevention Magazine

continuing education programs for clinical endocrinologists,

them to be experts in the care of endocrine diseases, such

osteoporosis, cholesterol disorders, hypertension and obesity.

ACE is a scientific and charitable medical organization dedicated to promoting the art and science of clinical endocrinology for the improvement of patient care and public health.

A Note from the Editors:

January is thyroid Awa r e n e s s M o n t h

Dear Reader, Thank you for reading this issue of Power of Prevention Magazine. This magazine is being distributed in offices of endocrinologists throughout the nation who belong to the American Association of Clinical Endocrinologists (AACE). AACE is a professional medical organization with more than 6,000 members in the United States and 91 other countries. Founded in 1991, AACE is dedicated to the optimal care of patients with endocrine problems. Clinical endocrinologists specialize in diagnosing and treating thyroid disease, diabetes and osteoporosis, which have reached epidemic proportions in the United States. Power of Prevention Magazine is published by the American College of Endocrinology (ACE), the scientific and educational arm of AACE.

This issue of the magazine features a special section on thyroid health and is just one component of our 17-year-old campaign, “Thyroid Awareness Month.” Through the years, we have worked diligently with a single charge: Educate the millions of Americans with diagnosed or yet to be diagnosed thyroid condition about the signs and symptoms of thyroid disease. As many as 20 to 30 million Americans may suffer from a thyroid condition. Of that number, approximately half still remain undiagnosed. If you don’t suffer from some type of thyroid disorder, there is a good chance that someone you know does (a close relative, your neighbor, or a friend). This issue covers many important topics relating to thyroid health. You will read the story of a woman who overcame her thyroid disorder to become the “fastest woman in the world.” You will also learn about the very latest in treatment guidelines for thyroid conditions. But there’s more to the Power of Prevention Magazine than just thyroid disorders. You will read about the Olympic Cross-Country Skier who proves type 1 diabetes can’t slow him down. You’ll also learn about the importance of vitamin D for your overall health, as well as the relationship between diabetes and chronic kidney disease. These are just a few of the many stories you will find inside. In addition to the magazine, we encourage you to check out our website, www.powerofprevention.com. You can also follow AACE and Power of Prevention via Facebook (www.facebook.com/theaace) and Twitter (@theaace, @pwrofprevention) to learn more about endocrine-related topics throughout the year. Thanks again for checking out a copy of the Power of Prevention Magazine. I hope that you will find it useful and informative, and I encourage you to share this information with your family and friends. I would like to leave you with a key message that we’ve repeated every year since “Thyroid Awareness Month” started, 17 years ago: If your thyroid isn’t working properly, neither are you!

Sincerely,

Jeffrey R. Garber, MD, FACP, FACE Guest Editor, Power of Prevention Magazine

Dr. Jeffrey R. Garber is presently Chief of Endocrinology at Harvard Vanguard Medical Associates and a member of the Beth Israel Deaconess Medical Center and Brigham and Women’s Hospitals endocrine divisions. He is an Associate Professor of Medicine at Harvard Medical School, where he played a substantive role in the clinical training of more than 35 endocrine fellows. Dr. Garber currently serves as Immediate Past President of the American Association of Clinical Endocrinologists (AACE). His book, The Harvard Medical School Guide to Overcoming Thyroid Problems, was written for members of the lay public interested in learning about thyroid disorders.

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Back on Track 3 Time Olympic Gold Medalist Gail Dever’s Story

B y B rya n C a m p b e l l

link and you just might miss the fastest woman in the world. But you’ll never forget her champion’s smile, and her signature fingernails.

Gail Devers became a household name during the Barcelona Olympics of 1992. The young American sprinter raced into our hearts with one of the greatest finishes in Olympic history—a photo finish in the 100-meter sprint finals. Five women finished within 0.06 seconds of each other. Gail won the gold medal and the title “Fastest Woman in the World.” People around the world instantly recognized her for her huge smile and her even bigger fingernails. But just two years before that race, it seemed like Gail’s racing days were over. Gail Devers was a rising star in the track and field community. After a successful college career, she set her

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sights on the 1988 Seoul Olympics. But as she prepared for the games, she noticed that something wasn’t right with her body. She often felt run-down, like she had been “running in neutral” all day long. She experienced other problems, too. She was losing weight fast. “At first, I thought this was cute, but after a while, it went beyond being cute,” says Devers. She competed in the 1988 Olympics but did not win a medal. After the games, her health continued to get worse. At one point, she thought about giving up racing altogether. “I went to several doctors, and none of them could tell me what was wrong,” says Devers. “At some point it stopped being about competing, and it started being about getting my life back.”

Finally, after three years of unanswered questions, Gail got a simple test called a TSH. The test checks the function of the thyroid. As it turns out, she had a condition called Graves’ disease.

you are experiencing weight gain or weight loss that you can’t explain, or if you are feeling any of the other symptoms of thyroid dysfunction (see pp. 4-5), then you should think about getting your thyroid checked.

Graves’ disease is a form of overactive thyroid disease. It is an autoimmune disorder, which means that the body’s immune system is actually attacking the thyroid, prompting it to produce more thyroid hormone than is normal.

Today, Gail is running a new race. She’s no longer competing in track competitions. But she is still chasing young ladies around. Today, Gail is living in Atlanta, site of her 1996 Olympic victories, with her husband and two young daughters.

Thyroid hormone acts as a kind of regulator for metabolism. If your body doesn’t have enough thyroid hormone, you can feel sluggish and weak. In Gail’s case, with too much thyroid hormone in her system, her body was running on overdrive all the time.

“I haven’t slowed down at all.”

She received radioiodine [RAY-dee-o-EYE-uh-dine] treatment, which slowed down her thyroid. Because her thyroid now cannot make enough thyroid hormone, she is on a daily thyroid hormone replacement regimen. She takes one pill every day to keep her thyroid levels in check. And she makes sure to see her endocrinologist [en-doh-kri-NAH-low-jist] every six months to make sure that her levels are good.

And that’s the message that Gail still takes with her wherever she goes. She’s passionate about making sure people understand the signs and symptoms of thyroid disease, and that they understand proper treatment. “I get my thyroid hormone levels checked every six months, and I make sure my levels are right,” says Devers. “I don’t plan on slowing down again for a long time.” To hear more from Gail Devers about the importance of thyroid health, visit http://www.powerofprevention.com/gaildeversvideo. P

The treatment got Gail back in the race. “It was like I got my life back,” says Devers. “I was back to battling my opponents, not my own body.” And with careful monitoring from her doctor, she started training again. And less than two years later, she was standing on the podium, accepting her first gold medal. Yes, first. Four years later, at the Olympic Games in Atlanta, she took home not one, but two more gold medals, one for the 100 meter sprint, and one for the 4×100 meter relay. Again, Gail was a household name. Those fingernails became known around the world! But just what was it that led the fastest woman in the world to grow those fingernails? The answer provides a key to understanding her personal struggle. “I grow my fingernails for three years, because that’s how long I went undiagnosed,” says Devers. “Every three years I cut them and start growing them again.” Gail’s signature fingernails are a message to people everywhere that they don’t have to live with a thyroid disorder. If you are feeling sluggish or run down, if

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Thyroid gland

Too Slow or Too Fast? B y D i a n n e S . C h e u n g , M D , MPH

Hypothyroidism [hye-po-THIGH-roi-diz-uhm] (underactive thyroid gland) “Doctor, I’m gaining weight. Is it my thyroid’s fault?” This is perhaps the most common question to endocrinologists [en-doh-krih-NOL-uh-jists] in the office. Sometimes the answer isn’t what most patients would like to hear. Hypothyroidism is a condition when the body does not produce enough thyroid hormone. The thyroid, a butterflyshaped gland located in the middle of the neck, is responsible for regulating the body’s metabolism. When this gland doesn’t make enough thyroid hormone (T3 and T4), the ability for the body to use and store energy slows down. In turn, production of T3 and T4 is regulated by a gland in the brain called the pituitary [pi-TOO-i-ter-ee] gland, which produces thyroid-stimulating hormone (TSH). TSH stimulates the thyroid gland to produce T3 and T4. In hypothyroidism, TSH is higher than normal, and T3 and T4 are low. There are 2 common causes of hypothyroidism. Autoimmune hypothyroidism, also called Hashimoto’s thyroiditis, is caused by the body destroying the thyroid gland (an “autoimmune” process). Over 90% of patients with chronic autoimmune thyroiditis have anti-thyroid antibodies. The condition can easily be treated with thyroid hormone replacement. Thyroid disorders can also occur with the use of certain medications. Hypothyroidism is more common in women, and many but not all patients have a goiter (an enlarged thyroid gland causing a swollen neck). Diagnosis of hypothyroidism is mainly made with blood tests, since the symptoms of low thyroid production are not specific to the condition. These symptoms include • Weight gain

• Fatigue • Forgetfulness • Constipation • Dry skin • Hair loss

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• Cold intolerance • Irregular menses Having these symptoms does not necessarily mean you have hypothyroidism. Testing the blood for TSH is part of the medical evaluation for thyroid problems. Elevated TSH levels establishes a diagnosis of hypothyroidism. The more severe, the higher the TSH level and lower the T4 levels will be. Seeing your primary care doctor or an endocrinologist is the first step if you suspect hypothyroidism. A simple blood test for TSH can be done, and if it is high, it can be confirmed with a repeat TSH with a free T4 level. Hashimoto’s thyroiditis tends to run in families, so if Grandma had a goiter and took thyroid medication, and you have weight gain and fatigue, definitely get a blood test to check your thyroid. As the thyroid loses its function, patients may develop a goiter (enlarged thyroid gland). Other than looking odd, it can cause symptoms in the neck such as hoarseness, choking, and persistent coughing. Treatment of hypothyroidism involves replacing thyroid hormone. The most common thyroid replacement used is levothyroxine [lee-voh-thigh-ROX-een], a synthetic T4 replacement. T4 stays in the body for many days and is converted to active T3 as needed.

t h y r o i d Levothyroxine should be taken on an empty stomach in the morning, an hour before breakfast, and it is best to wait at least four hours before taking medicines such as oral calcium or iron replacement, bile acid-binding resins, and proton pump inhibitors, as well as soy and fiber products. Patients can find relief of many of their symptoms within a few weeks of initiating thyroid replacement, but it may take up to a few months to reach a normal thyroid state.

Hyperthyroidism [hye-per-THIGH-roi-diz-uhm] (overactive thyroid) “Doctor, I can’t sleep and I’m anxious all the time.” The flip side of hypothyroidism is hyperthyroidism. Graves’ disease is the most common form of hyperthyroidism. This condition makes the immune system produce an antibody that makes the thyroid gland produce more thyroid hormone. As a consequence, the pituitary gland slows down or shuts off production of TSH, while T4 and T3 levels are higher than the normal range in the blood. The added thyroid hormone affects the body by “speeding up” many of the processes, causing some or all of the following symptoms:

• Rapid or irregular heartbeats • Weight loss • Anxiety and nervousness • Tremor (shaking) • Insomnia • Diarrhea or frequent bowel movements • Heat intolerance • Fatigue • Irregular menses in some women • Erectile dysfunction (impotence) in some men Graves’ disease is more common in women. A goiter often occurs along with excessive thyroid hormone production. Some patients develop an eye problem known as Graves’ orbitopathy [or-bit-AH-pah-thee], which causes dry irritated eyes, double vision (diplopia) and eyes that stick out due to swelling of the eye muscles. (To read more about Graves’ orbitopathy, see page 9.) Hyperthyroidism can also occur due to a toxic nodular goiter. Another cause can be a viral infection called subacute or granulomatous [gran-yuh-LOH-muh-tus] thyroiditis, in which the thyroid gland becomes inflamed and painful. Fortunately, when the viral infection resolves, so does the thyroiditis. There is also painless thyroiditis that can occur when the thyroid gland becomes inflamed temporarily, such as after giving birth.

a w a r e n e s s The first step in diagnosis is to measure the amount of TSH, which should be low, and T3 and T4 levels should be high. Since there are several causes of hyperthyroidism in which the thyroid gland goes back to normal by itself (painless thyroiditis and subacute thyroiditis), it is important to determine the cause. This may require a radioiodine [ray-deeoh-EYE-oh-dyne] uptake and scan. Treatment for hyperthyroidism includes medication, radioactive iodine, and surgery. Anti-thyroid drugs such as methimazole [me-THIM-uh-zohl] and propylthiouracil [proh-pil-thigh-oh-YOOR-uh-sil] (PTU), decreases the amount of thyroid hormone made. Both drugs work well, but due to recent reports of liver failure in patients on PTU, methimazole is now preferred. Methimazole and PTU may cause rash, hives, and stomach upset. Rarely, a condition called agranulocytosis [uh-gran-yuh-loh-sahy-TOH-sis] (low white blood cells) can occur. Beta blockers, such as propranolol [pro-PRAN-oh-lawl], are also prescribed to control symptoms such as tremor (shaking), irregular heart beat, and anxiety. Medication may need to be taken for several months or up to a few years before the thyroid returns to normal. Hyperthyroidism can come back and require repeat treatment with medication, radioactive iodine, or surgery. Some patients who do not respond to medications or who cannot handle the side effects of the medications may decide to receive radioactive iodine. Radioactive iodine is taken in capsule or liquid form and destroys part or a majority of the thyroid gland. Patients may need to go on thyroid replacement therapy after treatment. A few patients will need surgery. Reasons for surgery include a large goiter that is causing pressure symptoms, unable to handle the side effects of antithyroid drugs, unable to receive radioactive iodine, or possibly have thyroid cancer (rare). There are patients with Graves’ orbitopathy whose eye disease worsens once they receive radioactive iodine treatment, so surgery could be an option if hyperthyroidism is not controlled on antithyroid drugs. Whichever thyroid condition you may have, there is an effective treatment available. If you suspect that you may have either hypothyroidism or hyperthyroidism, please go see your primary care doctor or endocrinologist, because there is a remedy waiting for you. P

Dr. Dianne S. Cheung is board-certified in Endocrinology, Diabetes and Metabolism having completed her fellowship training at the UCLA Ronald Reagan Medical Center. Dr. Cheung is currently in private practice with South Bay Endocrine Associates in Torrance, California. She is active member of the Inpatient Diabetes Committee at Torrance Memorial Medical Center. She has presented abstracts and posters on diabetes and thyroid cancer at national conferences, including The Endocrine Society and the American College of Physicians. Dr. Cheung has published in peer-reviewed medical journals, and her research interests are in diabetes and thyroid disease.

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When You Should Know Your TSH Level Though experts don’t agree about population screening for hypothyroidism [hie-po-THIGH-roid-is-m], evidence supports checking your TSH if you 1. have autoimmune disease, such as type 1 diabetes,

B y J e f f r e y R . G a r b e r , M D , FA C P, FA C E

Screening

or pernicious [per-NISH-ous] anemia

Why screen people for a medical condition when they have no symptoms, risk factors, or a finding on a physical exam? Screening is done because

2. have a first-degree relative with autoimmune thyroid disease 3. have a history of neck radiation of the thyroid gland, including radioactive iodine therapy for hyperthyroidism [hie-per-THIGH-roid-is-m] and external beam radiotherapy for head and neck malignancies

1. The condition is common 2. The condition is important 3. The condition is hard to diagnose, at least in its early stages

4. have a prior history of thyroid surgery or dysfunction 5. have an abnormal thyroid examination

4. The diagnosis is easy to make

6. have psychiatric disorders

5. The diagnosis is accurate

7. are taking medicines that may affect the function of your thyroid, such as amiodarone [A-MEE-oh-duh-rone] or lithium

6. Treatment for the condition is effective and safe

8. have an elevated cholesterol level

Despite this seemingly clear guidance, experts disagree about screening for thyroid-stimulating hormone (TSH) in the general population. The attached table shows the range of screening recommendations.

Studies are exploring whether or not universal TSH screening should be done in all women planning pregnancy or who are pregnant. P

Screening Recommendations of Eight Organizations for Screening Adults Without Symptoms for Thyroid Dysfunction American Thyroid Association

Women and men >35 years of age should be screened every 5 years.

American Association of Clinical Endocrinologists

Older patients, especially women, should be screened.

College of American Pathologists

Women ≥50 years of age should be screened “if they seek medical care;” all geriatric patients should be screened on admission to the hospital and at least every 5 years.

American Academy of Family Physicians

Patients ≥60 years of age should be screened.

American College of Obstetrics and Gynecology

Women in “high-risk groups” (those with autoimmune disease or a strong family history of thyroid disease) should be screened starting at 19 years of age.

American College of Physicians

Women ≥50 years of age with an incidental finding suggestive of symptomatic thyroid disease should be evaluated.

U.S. Preventive Services Task Force

Insufficient evidence for or against screening.

Royal College of Physicians

Screening of the healthy adult population is unjustified.

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Thyroid Disease: A Post Web Exclusive By Patrick Perry, MPH & Wendy Braun, RN

What You Need to Know About Your Body’s “Thermostat” Millions of Americans are living with an overactive or underactive thyroid, according to the American Association of Clinical Endocrinologists (AACE). Unfortunately, many go undiagnosed until something goes terrible awry, at times wreaking havoc on one’s quality of life. In this Web exclusive interview, we offer information about diagnosing and treating thyroid disease from Dr. Jeffrey R. Garber, Immediate Past President of AACE, Chief of Endocrinology at Harvard Vanguard Medical Associates, and Associate Professor of Medicine at Harvard Medical School to accompany the Jul/Aug 2010 Post Investigates feature: “Thyroid: A Secret Culprit,” by Dr. Mehmet Oz. Post: Who should be tested? Should it be part of a routine annual physical? Dr. Garber: Thyroid testing was not part of President Bush Sr.’s annual physical. If you remember, his hyperthyroidism was diagnosed after he had problems breathing while jogging. Today, the American Thyroid Association recommends screening every five years, starting at age 35. Universal screening is not felt to be cost effective, but most experts would recommend testing women over 60, those with symptoms, and then targeted subgroups such as smokers or those with a personal or family history that includes autoimmune conditions. Having symptoms of thyroid disease does not mean one has it. Making a diagnosis solely based on symptoms can be inordinately difficult. However, the diagnosis becomes straightforward by testing for it. People should target themselves based on symptoms. If you are aware of thyroid conditions

and believe you are experiencing enough symptoms, it is easy for a doctor to justify testing. In addition, doctors should target patients on the basis of other risk factors. For example, I would check someone who comes to my office saying “I feel perfectly well” if I felt a lump in their thyroid or there was a compelling history. Thyroid disease is very easy to overlook. Post: Hypothyroidism seems to be frequently in the headlines. Any reason why? Dr. Garber: I think we live in an era in which people are seeking holistic approaches—sometimes in a good sense, and sometimes in a way that they can get exploited, in my view. Thyroid disease lends itself to an approach by some practitioners that is generally symptom-based. The idea that a constellation of symptoms dictates a diagnosis, despite the lack of conventional proof, is where the tension comes in. “What Your Doctor Won’t Tell You” is a great headline. What people don’t read about is the downside of taking thyroid hormone products. It is not a free ride. My major concern is the risk of over-treatment. Continued on page 8

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Continued from page 7

The second concern is that by treating symptoms without a certain diagnosis, a doctor will overlook another important fact or condition. For example, hypothyroidism can masquerade as depression, but depression can masquerade as hypothyroidism. Then there is the cost of medicine and the cost of testing. I would never argue with someone who says they feel a certain way, but the data doesn’t support that treating marginal disease necessarily leads to benefit. If a person has borderline thyroid stimulating hormone (TSH) levels and no symptoms or compelling medical reason, such as planning a pregnancy, treatment may not be called for. If people are borderline and symptomatic, of course, try to treat it. But give it a limited time. Don’t just commit people to medicine and put them at risk for being over-medicated or being subject to costs and missing other possible reasons for what they are feeling. Fatigue is the 21st century complaint. We’ve got a lot of reasons to be tired besides our thyroid. Thyroid drug analogs, or copies of thyroid hormone, are also being mentioned in the press. As recently as March 11, 2010, the New England Journal of Medicine featured a follow-up article on the subject. The concept is to design a thyroid hormone analog that has the benefits of, say, inducing weight loss or lowering cholesterol, but not the drawback of stimulating the heart. Post: How far away is this concept from actual reality? Dr. Garber: It was pretty far away until March 11. These researchers demonstrated that one particular analog did not affect the heart, and did lower cholesterol. Another drug analog was studied in heart disease patients. Many lost weight, but 60 percent to 70 percent of the patients dropped out of the study because they felt lousy. Since the study was not designed to analyze weight loss, researchers couldn’t do a good job of finding

out whether people ate less because they had a lousy appetite, which is a terrible way to lose weight, as opposed to eating less because their appetite isn’t as high. Post: Is there a better test for thyroid hormone levels on the horizon? Dr. Garber: Not at present. The current discussion is whether we need to take a new look at what is considered the normal range for TSH levels, depending on the situation. Data show that some TSH levels we now consider elevated—in the elderly—may not represent hypothyroidism. And, on the other hand, new guidelines are definitely going to set a lower TSH of approximately 2.5 as the upper normal in the first trimester of pregnancy. Post: What is the link between thyroid hormone and heart attack and heart disease? Dr. Garber: If you are profoundly hypothyroid, you often become hypertensive and hypercholesterolemic. As a result, your vessels become constricted as well. Hyperthyroidism affects the heart mostly through rhythm disturbances characterized by fast heart rates, including atrial fibrillation and sinus tachycardia. Post: Are there other new developments you would like to mention? Dr. Garber: A recent discovery suggests there is a subgroup of people with a certain genotype that are more likely to feel better on a T3-T4 combination therapy. We are not at the point that we are going to start doing genetic testing on people, but the study found that certain people with a certain genotype were more likely to feel better on combination therapy. From a hot, new, and conceptual point of view, the discovery may provide yet another role for genetic testing. P

Article reprinted with permission from the Saturday Evening Post. For more information, visit www.saturdayeveningpost.com.

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Thyroid Eye

DISEASE: What’s New? B Y R e b e cc a S . B a h n , M D Graves’ disease is the most common cause of an overactive thyroid in the US. It is an autoimmune condition, which means the body creates antibodies against its own tissues or organs. In this case, antibodies attack the thyroid. This makes the thyroid produce too much thyroid hormone. This condition is called hyperthyroidism [hie-per-THIGH-roid-is-m]. About 25% to 50% of those with Graves’ disease develop thyroid eye disease (TED). In people with TED, antibodies attack the thyroid and tissues behind the eyes. Since TED is only seen in patients with Graves’ disease, it is also called Graves’ ophthalmopathy [ahfthal-MOP-a-thee] or Graves’ orbitopathy [or-bit-OP-a-thee].

Preventing and Controlling Thyroid Eye Disease Smoking is the most important risk factor for TED. It can make you get the disease, or it can make it worse. Second-hand smoke has a similar effect. All smokers with Graves’ hyperthyroidism should be referred to a medical program to help them stop smoking. All patients with TED, regardless of whether or not they are smokers, should also avoid secondhand smoke as much as possible. People with hyperthyroidism due to Graves’ disease usually have three treatment options: the antithyroid drug methimazole [meh-THIM-uh-zole], surgery, or radioactive iodine. Surgery and radioactive iodine result in an underactive thyroid (hypothyroidism [hie-po-THIGH-roid-is-m]). However, radioactive iodine may worsen TED. Therefore, according to recent guidelines produced by the American Association of Clinical Endocrinologists and the American Thyroid Association, smokers who already have symptoms of mild TED and who choose to receive radioactive iodine instead of methimazole or surgery should take steroids— such as prednisone—with the radioactive iodine. This will keep the eye disease from getting worse. If patients already have severe TED, they should not undergo radioactive iodine therapy at all, but should instead be treated with either thyroid surgery or methimazole. In addition, since low thyroid hormone levels following any of these treatments puts a patient at risk for TED developing or worsening, the guidelines indicate that normal levels of thyroid hormone should be achieved and maintained no matter which treatment is chosen.

Treatment of Thyroid Eye Disease Most patients with TED experience only mild eye redness or discomfort. However, about 20% of patients with TED develop more serious symptoms, including bulging eyes (known as proptosis [prop-TOH-sis]), double vision, swelling around the eyes, or eye pain.

Illustration Provided by Scott Leighton

Most patients can be treated by controlling TSH levels, using eye drops, and going to their doctor for periodic check-ups. TED tends to get better on its own over several years. However, about 3% to 5% of TED patients get intense pain and swelling or even loss of vision. Depending on the degree of inflammation, abnormal eye muscles, eyelid problems, and visual loss, steroids such as prednisone with or without radiation (directed at the part of the skull housing the eye), eye muscle and lid surgery, or more extensive surgery called orbital decompression may be necessary.

A New Approach: Rituximab Treatment of TED For those who do develop severe disease, there is a study at Mayo Clinic in Rochester, Minnesota, to find out whether a medication called rituximab [ri-TUK-sih-mab] might be an effective and safe treatment for patients with TED. Though rituximab does not have FDA approval as a treatment for TED, and is considered investigational for this purpose, it is currently approved and used in the treatment of other medical conditions, including the autoimmune condition rheumatoid arthritis. Because patients with rheumatoid arthritis and those with TED have similar immune system issues, researchers at Mayo Clinic are studying whether rituximab will reverse abnormalities in TED patients and improve the disease. The rituximab study is open only to patients who have moderate to severe symptoms of TED because the medication sometimes causes serious side effects, including infections and severe skin rash. Any patient with TED interested in discussing becoming part of this study or getting treatment for TED in general is encouraged to either call or email Dr. Rebecca Bahn (507-284-2462; bahn.rebecca@mayo. edu) or Dr. Marius Stan (507-284-2463; stan.marius@mayo.edu). P Dr. Rebecca Bahn is Professor of Medicine, Consultant in Endocrinology and Metabolism and Associate Dean of Research for Career Development at Mayo Clinic. She served as President of the American Thyroid Association in 2007-2008. Dr. Bahn obtained her medical degree from Mayo Clinic College of Medicine and completed postgraduate clinical training and a research fellowship in immunology at the same institution. Her clinical practice focuses on treating patients with Graves’ hyperthyroidism and ophthalmopathy and her NIHfunded research program centers on the cause and new treatments for these conditions.

POWER OF PREVENTION • Vol. 3, Issue 1

New Year,

NEW YOU BY Barbara Quinn, MS, RD, CDE It’s the new year. Time to turn the page and start fresh. Never mind that half the people who make new year’s resolutions abandon them within six months. Make this the year you reach your goals by looking at RESOLUTIONS in a new way:

Reflect on the changes you will need to make to reach the goals you have for this NEW YEAR. It is true that “if nothing changes, nothing changes.” So, as you turn the page on this calendar year, set your mind on one or two lifestyle habits that you may want to approach differently for the next 365 days. Expect

progress, not perfection. Go ahead. Try that low-fat milk. Take an apple to work for an afternoon snack instead of grabbing a candy bar. Order a salad instead of cream soup at a restaurant. Each step along the way will get you closer to your preferred destination.

Specify what you will do. Educators say we are more likely to accomplish goals that are SMART---specific, measurable, appropriate, realistic, and timely. For example, instead of vowing to “get more exercise,” a SMART goal is to “walk for 20 minutes on Monday, Wednesday, and Saturday this week.” This approach makes it easier to track your progress as well. Organize your calendar. We schedule appointments and

lunch dates; why not set aside time to accomplish the goals that are important to us? Taking some “me” time is not only smart, it’s essential for long-term health and well-being. Like the old adage says, “If you don’t take time to be well, you will have to take time to be sick.”

Let go of “all or nothing” thinking. I only set myself up for failure if I vow to “never eat sugar” or “always exercise an hour a day.” Set goals to be achievable, not impossible. Understand how your diet, exercise, and medications

work together to improve your health and well-being. When it comes to understanding complex medical issues that affect our day-to-day functioning, it’s true that we “don’t know what we don’t know.” For example, if it’s been awhile since you had an update in how to manage

Barbara Quinn, MS, RD, CDE is a registered dietitian and certified diabetes educator in Carmel Valley, California. Ms. Quinn writes a weekly column ON NUTRITION for the Monterey County Herald. She is the author of The Diabetes DTOUR Diet, Rodale, 2009.

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your diabetes, this would be a good year to schedule an appointment with your doctor and/or diabetes educator.

Take time. Life happens. Not every day of every week will

go as perfectly as you plan. Changing habits takes time and patience. Aristotle said: “We are what we repeatedly do. Excellence, therefore, is not an act, but a habit.”

Invest in a pedometer. It is one of the simplest---and

cheapest---ways to track your physical activity goals. Think you need to accomplish 10,000 steps a day, as many health experts suggest? Use a step counter to see where you are on a typical day. Then you can set weekly goals and track your progress over time.

Offer yourself rewards along the way. Behavior that is rewarded is more likely to continue, say experts. Improvement in A1c values (a measure of our average blood sugar levels), weight, cholesterol lab values, or energy levels are all reason to celebrate the progress we are making. “Never, never, never give up,” said British statesman Winston Churchill. Each day is a new opportunity to practice what and how we want to be. With practice, we can learn to respond in new and better ways to the challenges of life. Finally, as we start this New Year, be encouraged by this lesson on life in five chapters, adapted from a short essay by Portia Nelson: Chapter I I walk down the street. There is a deep hole in the sidewalk. I fall in. I am lost... It isn’t my fault. It takes a long time to find my way out. Chapter II I walk down the same street. There is a deep hole in the sidewalk. I pretend I don’t see it. I fall in again. I can’t believe I am in this same place. But it isn’t my fault. It still takes a long time to get out.

Chapter III I walk down the same street. There is a deep hole in the sidewalk. I see it this time. I still fall in... I know where I am. It is my fault. I get out immediately. Chapter IV I walk down the same street. There is a deep hole in the sidewalk. I walk around it. Chapter V I walk down another street.

Whatâ&#x20AC;&#x2122;s one of the best things for kids with diabetes? A healthy dose of fun.

For a child with diabetes, attending diabetes camp is about having fun and learning. But bringing children with diabetes together in a supportive, medically supervised environment also allows them to share experiences, support one another, build self-confidence, and learn about managing their diabetes. For years, Lilly has provided insulin to diabetes camps across the country. And through the Lilly Camp Care Package, we also offer a variety of resources to camps affiliated with the American Diabetes Association or the Diabetes Education and Camping Association.

HI67073

0910 PRINTED IN USA

The Slopes to S uccess By Sarah Senn

“It always seems impossible until it’s done.” Nelson Mandela

t’s a clear winter morning and Olympic cross-country skier Kris Freeman is ready to hit the slopes. The 2011 Skiing World Championships are just months away, and he is determined to ski his very best at this event. Kris waxes his skis and checks all of his equipment to make sure he’s ready before starting his run. He has his helmet, goggles, and ski poles ready, and for most skiers, that’s the last stage. However, Kris has one extra step. He has to check his insulin pump. Although Kris trains as a cross-country skier every day, 365 days a year, he also has to manage his type 1 diabetes every day, 365 days a year.

Cross-country skiing is a rigorous sport, but it can be even more challenging when you have diabetes. A skier since the age of two, Kris has learned to overcome the obstacles of skiing. It is an intense physical and technical sport that requires an extreme amount of endurance and dedication. For Kris, skiing is a full-time career.

The News Every skier dreams of one day making it to the big stage – the Olympics. Kris is no exception. He was invited to join the 2002 US Olympic team as a cross-country skier at the age of 19. Kris was on top of the world and eagerly moved to Park City, Utah, in 2000 to prepare for the Olympics. But he noticed that something was different. His vision was blurry, he was urinating more frequently, and he was tired. Skiers often experience these symptoms during intense training, so Kris figured that these conditions were because of his tough training schedule. He continued to train for the Olympics but found it to be much more difficult than he expected. During routine blood tests required to train for the Olympics, the doctor discovered that Kris’ blood sugar (glucose) was very elevated at 260 mg/dL. “The doctor told me I had to see an endocrinologist [endoh-kri-NA-low-jist], and I said, ‘Endo what?’” Kris went to the endocrinologist and was promptly diagnosed with type 1 diabetes. During his initial visit, the doctor was somewhat hesitant about Kris’ ability to participate in cross-country skiing.

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“Basically, all I heard at that first meeting was ‘diabetes’ and ‘career over.’”

But why should it? Why should that stop Kris from pursuing his dream? He told his coach about his condition and received support from the vice president of the US Olympic team to carry on. He continued to train for the Olympics and started learning about new treatments and other athletes that have type 1 diabetes, including Olympic swimmer, Gary Hall, Jr. “The way I confront something is to learn the most that I can about it.” Kris found an endocrinologist who believed in his dream and he worked with the Olympic team’s doctors to manage his training schedule and diet. “The biggest change I made was really overhauling my diet.” Kris started studying the glycemic index food chart. He memorized the carbohydrate levels from the chart, evaluating all of the food he ate. He learned to figure out the amount of carbs in a meal just by looking at the plate. Kris also started focusing on better protein intake and higher fiber intake. As his diet became more balanced, Kris was able to use less insulin to control his diabetes. “By eating food as close to its natural form as possible, it was easy to manage my sugar along with insulin.”

From the Course to the Camps Kris has a story to tell and he likes to share his experiences with others. In 2002, Kris teamed up with Eli Lilly and Company to participate in diabetes summer camps for children. These camps help children with diabetes learn to manage the condition and allow them to connect with others who are facing similar challenges. For many kids, these camps provide a break from an often harsher environment, where schools often do not understand how hard it is to manage diabetes as a child. There is a good ratio of medical staff to campers, which allows everyone to receive the attention and care that they need.

Limitless Although it’s been 10 years since Kris was diagnosed with type 1 diabetes, he still faces new challenges every day. He wears a special insulin pump 24 hours a day that does not have any exposed tubing so that the insulin will not freeze when he is skiing. Kris has practiced using the pump during training races to find the best basal insulin rate to control his levels. But for Kris, diabetes hasn’t limited his abilities. It has given him the motivation to work harder and stay healthier. “I really don’t think diabetes has hindered me very much,” Kris says. “The more energy you put into treating yourself, the more you’re going to get back in your life.” Just two years after being diagnosed, Kris won the Under-23 World Championships, which was the proudest moment of his career. He was a member of the 2002, 2006, and 2010 US Olympic Ski Teams and has placed fourth in the Open World Championships twice. When he first heard that he had diabetes, Kris admits, “My first thought was ‘How can I keep skiing,’ not ‘This is serious and could hurt me.’ These thoughts showed me how important skiing really was to me.” Kris isn’t giving up on his dream. He continues to inspire people of all ages with his story. “I don’t think of myself as a diabetic first. I think of myself as a cross-country skier.” P

Kris sets aside two to three weeks each year to travel to different diabetes camps to share his story with the campers, their families, and staff. He talks about managing his condition and the challenges he’s faced along the way. Kris encourages the kids to take care of themselves and know that although diabetes can be a scary thing, it is treatable. “There is really almost nothing you can’t do if you put the effort into it.” Kris says that he thinks most kids are most successful when they are told what they can do and how they can achieve it as opposed to what they can’t do because of diabetes. He also talks about the chances they have to improve their diabetes because of new technology and treatments that were not available when he was diagnosed. The campers often ask questions and he is happy to provide insight, but Kris says, “It is amazing what the kids are able to teach me. They inspire me.”

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Go to cornerstones4care.com/cookbook1 *Available while supplies last

Cornerstones4CareTM is a trademark of Novo Nordisk A/S. The photographs used in this ad are for illustration only. The models in the photographs do not necessarily have diabetes or other ailments. © 2010 Novo Nordisk Printed in the U.S.A. 142298 October 2010

DiabulimiaA Life-Threatening Approach to

T h inness

B Y K a t h r y n E . Ac k e r m a n , M D , MPH a n d Ta r i n E . J a c k s o n

eople living with type 1 diabetes mellitus (DM) are taught to be conscious of the foods they eat. They decide their dose of insulin shots based on how many carbs they eat. This focus on food can become obsessive. People who have type 1 DM and are fixated on their body image are at risk for eating disorders similar to anorexia nervosa and bulimia. “Diabulimia” [dye-a-byoo-LEE-mee-uh], an unofficial, non-medical term that combines “diabetes” and “bulimia,” describes the condition that results from omitting or reducing insulin doses to lose weight.

Insulin is a hormone that the body needs to metabolize food, specifically sugar (glucose). People with type 1 DM do not make insulin. As a result, their cells cannot use glucose and will “starve” unless insulin is injected. When the body cannot use glucose for energy, it begins to break down fat. This causes acid byproducts called ketones [KEEtones]. Glucose is lost in the urine and fat is burned, leading to rapid weight loss. However, if the ketones and blood sugar levels continue to increase, the person’s life will be in danger from extreme dehydration and acidosis, known as diabetic ketoacidosis [KEE-toh-ass-i-DOH-sis] (DKA). Diabulimics often try a dangerous balancing act. They purposely skip some insulin doses to lose weight, while trying to avoid DKA. They may lie about their blood sugar levels, skip A1c checks, and use other means to hide their high blood sugars. Diabulimics often feel weak, cannot concentrate, and become thirsty. But even if diabulimics don’t develop DKA or the symptoms of poor blood sugar control, over time they will be at high risk for diabetic complications. These complications include kidney damage, blindness, and heart disease, and the person could even die a premature death. Patients with type I DM are often diagnosed as children or adolescents. The diagnosis might be made after they have lost a lot of weight and been sick for a while. Once the patient has better insulin control, he/she might gain weight while adjusting to a new diet and insulin regimen. No matter when diabetes starts, learning how to manage it is a lifelong process that continues throughout adulthood. It is especially hard to be diagnosed with diabetes as a teenager, when one wants to be accepted by their peers and are trying to “fit in.” Girls, in particular, often have body image issues at this age. People living with type 1 DM often feel burdened

by their chronic illness and perceive themselves as being “different”. However, unlike most teens, those with type 1 DM have a dangerous weight loss tool: insulin. Many patients who omit/restrict their insulin are even at a healthy weight, but they see themselves as overweight. Others may be overweight and feel that the only way to lose pounds is by not taking or restricting their insulin. This is an extremely dangerous way to lose weight and can be harmful to one’s health and well-being.

Prevalence and Consequences of Diabulimia In a study by Ann Goebel-Fabbri, PhD, 30% of women with type 1 DM reported restricting their insulin to lose weight at some point in their lives. These patients had higher rates of kidney disease and foot problems than patients who didn’t restrict their insulin, and they were 3.2 times more likely to die over the 11-year study period. Girls with Type 1 DM are twice as likely to develop an eating disorder compared with their non-diabetic peers. Getting young people with DM to meet others with the disease through organizations and camps can be helpful to gain disease acceptance and coping strategies. But parents and counselors need to be aware of teens sharing bad information and glorifying the perceived “benefits” of diabulimia with one another, an unfortunate trend in some group settings. Continued on page 16 Dr. Kathryn E. Ackerman is a Harvard Medical School Instructor of Medicine, a clinician at Children’s Hospital Sports Medicine and researcher at Massachusetts General Hospital in the Neuroendocrine Unit. Trained in internal medicine, sports medicine, and endocrinology, she’s a team physician for US Rowing and serves on the Board of Directors of the Diabetes Exercise and Sports Association (DESA).

Ms. Tarin E. Jackson is a Pharmaceutical Sales Representative and Founder of www.sugapak.com. She has had type 1 diabetes for 18 years and is a member of the Diabetes Exercise and Sports Association (DESA).

POWER OF PREVENTION • Vol. 3, Issue 1

Continued from page 15

Symptoms of Diabulimia: Below is a list of some of the warning signs of diabulimia: • Elevated A1c levels • Blood sugar records that do not match A1c results • Unexplained DKA episodes • High blood sugar levels • Excessive thirst or frequent urination • Yeast/bladder infections • Unexplained weight loss or weight gain • Depression, low self-esteem, low energy, fatigue, anxiety, or irritability • Discomfort with eating or taking insulin in front of others • Preoccupation with body image, weight, or food intake • Cancelling of medical appointments

Exercise as a Better Strategy for Weight Management: According to Dr. Goebel-Fabbri, “Insulin restriction = calorie purge, which is a symptom of an eating disorder.” There are several ways to maintain a healthy weight and/or lose weight when living with type 1 DM. The key tools in maintaining a healthy weight or losing weight as a patient with diabetes is diet, exercise, and most importantly, control of blood sugar. Exercise has many benefits for the body and helps improve one’s sense of well-being. Maintaining or achieving control of blood sugar while exercising can be tough. Each patient with diabetes should speak with his/her endocrinologist [en-dohkri-NAH-low-jist] about exercise and find out which activities are safe to do. The patient should be aware that complications such as eye, nerve, foot, heart, artery, and joint problems, and not monitoring blood sugar will have a bearing on what exercise is safe. It might be helpful for people with type 1 diabetes to see a nutritionist and/or exercise physiologist [fiz-ee-OL-oh-jist]. The

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more varied the exercise program is, and the more challenging exercise goals are, the more difficult it can be to manage sugar levels during exercise. The impact of exercise on blood sugar levels depends on several things: fitness level, food intake prior to activity, the intensity and duration of exercise, recent blood sugar(s), and how long, how much, and what type of insulin was taken before exercise. Finally, sustained regular exercise often reduces overall insulin requirements, allowing motivated people with type 1 DM and a good exercise regimen to decrease insulin in a healthy way.

Treatment Plans for Diabulimia Often patients require inpatient treatment if they have signs of DKA. Inpatient and outpatient treatments are most effective with a team approach. The team should be comprised of an endocrinologist, psychiatrist/psychologist, exercise physiologist, and registered dietician. A program promoting healthy eating habits, an improved body image, and exercise can then be tailored to the specific needs of each patient with type 1 DM. The goal is to shift the focus away from weight and toward a healthy body with controlled blood sugars. As with any individual living with diabetes and any person without diabetes who has suffered from an eating disorder, a “diabulimic” requires continued education, resources, and emotional support to help with his/her disease. Friends, family, and medical providers need to be aware of the struggles of diabulimia and recognize the signs and symptoms. Diabetes, eating disorder, and addiction support groups can be of use, as well. Resources:

www.diabetes-exercise.com www.joslin.org www.centerforhopeofthesierras.com www.nationaleatingdisorders.org www.sugapak.com

HEALTHSEEKER™ is a unique online experience that combines a supportive social networking environment with important information on managing diabetes. The game utilizes the player’s own Facebook® friends as sources of inspiration and support along the road to better health. HEALTHSEEKER™ is fun and very easy to play. Go to Facebook® and log on to

www.healthseekergame.org and take simple steps towards health & nutrition

HealthSeeker™ and the HealthSeeker logo are trademarks of the Diabetes Hands Foundation. Neither Diabetes Hands Foundation nor Joslin Diabetes Center endorses products or services. HealthSeeker™ is made possible through support provided by Boehringer Ingelheim Pharmaceuticals, Inc. Facebook® is a registered trademark of Facebook, Inc. Copyright © 2010, Boehringer Ingelheim Pharmaceuticals, Inc. All rights reserved. (11/10) DI84301CONS

The Kidney-Diabetes Link: Progress in Saving Kidney Function!

B y D a c e T r e n c e , M D , FA C E

emember feeling thirsty all the time? All those nights getting up to use the bathroom? And how that stopped as your blood sugars began to come down after you started treatment for your diabetes? The kidneys play a large role in diabetes- it is the only way the body can eliminate excess sugar (glucose). How well the kidneys can work over time can in turn be affected by high glucoses, as well as uncontrolled blood pressure and uncontrolled cholesterol, all part of having type 2 diabetes mellitus. To keep the kidneys working as well as possible, kidney function needs to be monitored. Screening tests are typically recommended yearly from the time the diagnosis of Type 2 diabetes mellitus is made, usually started yearly after 5-10 years of type 1 diabetes

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mellitus. What is not well known is that if there are no kidney effects from diabetes in those with Type 1 diabetes after 25 years of the diabetes, then the risk of developing kidney complications decreases significantly. Unfortunately, this does not hold for those with the more common form of diabetes- Type 2- these individuals remain at risk for life. Risk factors for developing diabetic kidney disease, include a family history of kidney function loss in those with diabetes (genetics), smoking, obesity, in addition to untreated high blood pressure and high cholesterol. Screening tests for diabetic kidney disease usually start with checking for abnormal amount of protein in the urine. Healthy kidneys take wastes out of the blood, along

with a small amount of protein that is eliminated in the urine. When kidneys start to work less well, increasing amounts of a protein called albumin may leak into the urine, a condition known as microalbuminuria. This can be checked for by a small urine sample obtained at any time of the day. Although this test is easy to do, it can frequently be falsely positive, so you should not panic if told that you have positive microalbuminuria or a positive microalbumin to creatinine ratio. Having a large steak dinner the night before, being on your feet for a prolonged period of time, having a urinary infection- these along with many other reasons, can give a positive microalbumin to creatinine test. You will usually be asked to confirm abnormal test resultseither through another small urine sample or possibly a 24 hour urine collection. As kidney function worsens, the amount of albumin and other proteins in the urine increases, and the condition is called proteinuria. These are all measurements of the “leakiness” of the kidney.

needs, including limiting sodium (salt) which can raise the blood pressure, also limiting potassium as diseased kidneys may not be able to efficiently excrete excess potassium. High potassium levels can affect the heart rhythm. Smoking not only increases the risk of kidney disease, but it also contributes to deaths from strokes and heart attacks in those with kidney disease- so if you smoke, this is the time to quit! The good news is that the incidence of kidney disease in people with diabetes is decreasing. This is thought to be related to increasing use of all the steps listed above, as soon as screening tests suggest that the kidneys are not working as well as they should. Talk to your diabetes specialist about your kidney tests and whether additional evaluation from a kidney specialist may be helpful, as people with diabetes can also have kidney disease from other causes than diabetes. Be involved in your health care and ask questions if any information is unclear! P

The kidney also acts as an active filter of body wastes. GFR (glomerular filtration rate) is a calculation of how efficiently the kidneys are filtering wastes from the blood. The traditional GFR calculation required an injection into the bloodstream of a substance that was later measured in a 24-hour urine collection. We now calculate eGFR (estimated GFR) without an injection or urine collection, using only a blood measurement of creatinine and the person’s age, sex, and race. Many laboratories automatically calculate the eGFR when a creatinine value is measured and report it on the lab report. The National Kidney Foundation has determined different stages of chronic kidney disease based on the value of the eGFR. An eGFR of 90 or above is considered normal. Dialysis or transplantation is needed when the eGFR is less than 15. Many steps can be taken if it is determined that you have diabetic kidney disease, to help protect remaining kidney function, even reverse early disease. High blood sugars should be brought under control. High blood pressure should be treated, starting with medications in the ACE (angiotensin converting enzyme) inhibitor or ARB (angiotensin receptor blocker) groups. High cholesterol should be treated, usually requiring a statin class drug. Some doctors tell their kidney patients to limit the amount of protein they eat so the kidneys have less work to do. But a person should not avoid protein entirely. You should work with a dietitian to create the right food plan for your

Dr. Dace Trence is Director of the Diabetes Care Center and Associate Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the Board of Trustees for the American College of Endocrinology, chairs the AACE CME committee and is co-editor of Power of Prevention Magazine.

POWER OF PREVENTION • Vol. 3, Issue 1

How to Read a Food Label: Focus on trans fat B y M . M o l l y McM a h o n , M D , FA C E

Nutrition can play a critical role in your personal program to prevent medical problems. It can also improve many common medical conditions you might already be struggling with. Endocrinologists [en-doh-krih-NOL-uh-jists] have always had a strong interest in nutrition. Learning how to use nutrition facts labels while shopping at the grocery store is important. These labels are required by the Food and Drug Administration (FDA) on most food products and beverages. Recently, attention has focused on the importance of minimizing (and ultimately eliminating) trans fat, a component of foods that can lead to blood vessel problems. The FDA also recommends decreasing the amount of added sugar in the foods we eat, which is suspected to add to problems with managing our weight. So, let’s focus on how to get the most from reading the food label.

Serving Size 1 oz. (28.4g about 20 chips) Servings Per container 1 160 8g

70 13% 4%

Trans Fat 0g 130mg

5% 6%

19g

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20%

A copy of the nutrition facts label for a small bag of potato chips is shown on the bottom of this page. As you can see, information provided on the top half provides facts about the potato chips, including serving size, calories, and nutrient information. The bottom part provides daily recommended values for 2,000- and 2,500-calorie diets. The label footnote recommends important nutrients, including fats, sodium, and fiber. However, there is no recommended daily amount listed for trans fat or sugar. Trans fat gets a lot of attention because of its bad effects on health. Trans fats are used to make liquid vegetable oils more solid (like margarine). This keeps foods fresher longer, makes shelf-life longer, and leads to a less greasy feeling when eating. Trans fat is found in many products, including some shortenings and margarines, deep-fried foods, baked goods, and crackers. The bad thing about trans fats is what they do to blood fats. They can increase levels of LDL (unhealthy) cholesterol and decrease levels of HDL (healthy) cholesterol. Also, trans fat intake can increase markers of inflammation. This is a process by which your body responds to injury. Inflammation plays a key role in heart disease. Most doctors and scientists believe that trans fat is worse than saturated fat. Food labels are confusing. A product label can say no trans fat if the amount of trans fat in one serving size of that item contains less than 0.5 grams of trans fat. It may seem like eating 0.4 grams of trans fat does not matter, yet that is not true. Many experts advise intake of trans fat that is less than 1% of your total daily calorie intake. So if you are following a 2,000-calorie diet, your intake of trans fat should be less than 2 grams a day or about 20 calories. Small amounts can add up quickly. So how can the food item packaging information help you know if any trans fat is present in that food item? You must read the ingredient list. Trans fat is present if the ingredient list includes the words “partially hydrogenated [hahyDROJ-uh-neyt-ed]” oils. Try to eat less of or none of foods that contain these words on the ingredient list. Choosing fruits, vegetables, whole grains, and lean sources of protein (like meat and dairy products) will help you eat less or no trans fat trans fat (and saturated fat) and will also offer many other health benefits.

Now let’s talk about the sugar content of foods. Recently, the American Heart Association suggested guidelines for upper limits of added sugar to our foods. What is added sugar? Added sugar is sugar added during processing, preparation, or at the table. By contrast, natural sugar is part of fruits, vegetables, and milk products. Unfortunately, nutrition facts labels do not detail the difference between added or naturally occurring sugars. High intake of sugar increases levels of triglycerides [try-GLIS-uh-rides] and decreases levels of HDL cholesterol. High intake is associated with diabetes and high blood pressure but does not cause diabetes or high blood pressure. And now we know that our preferences in taste can keep us from feeling full and make us eat more calories. High levels of stress can also make us eat more sugared foods.

Nutrition can play a critical role in your personal program to prevent medical problems. The American Heart Association suggests that the average woman eat less than 100 (~6 teaspoons) calories from added sugar and men no more than 150 (~9 teaspoons) calories per day. One teaspoon of sugar has about 16 calories. Most Americans get more than 22 teaspoons of sugar per day! Sugars are part of the make-up of fruit juice (choose 100% fruit juice when available or better yet, a piece of fruit), sweetened beverages, many sports drinks, desserts, breads, and sugared cereal. So it pays to keep your intake of sugar-sweetened drinks, sugared cereals, sugared dried fruits, and other sugary foods low. It can be fun to read labels for hidden sources of sugar, like some salad

dressings, barbecue sauces, and fruit breads. Remember that natural sugars are present in fruits and vegetables, so not all sugar listed on the nutrition facts label is something to avoid in your diet. For example, fructose is a form of sugar found in fruits, honey, and vegetables. Lactose is a form of sugar found in dairy products. Just think that a 20-ounce soda contains about 17 teaspoons of sugar! High intake of sugar-sweetened beverages by children is associated with weight gain, so try to have your children drink more water and less juice and sweetened beverages. Many beverage companies are now offering smaller sizes of sugar-sweetened drinks. Also, sugar-sweetened soda contains high-fructose corn syrup. High-fructose corn syrup has adverse effects on blood fats like triglyceride levels, and it adversely affects where fat is deposited in the body. Once again, eating a diet rich in fruits, vegetables, whole grains, and lean sources of protein is great for your health while limiting your intake of added sugar.

Summary Points: • Remember, there are health risks from eating trans fat and high amounts of added sugars. • Food item ingredient lists that include partially hydrogenated oil lets you know that trans fat is present in that food item even if the nutrition facts label states that no trans fat is present. Begin to read ingredient lists looking for sources of added sugars. • Eating a diet rich in fruits, vegetables, whole grains, legumes, and lean protein is great for your health, is tasty, and will limit your intake of trans fat and added sugar. P

Dr. M. Molly McMahon is a consultant in the Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic in Rochester, MN. She is Professor of Medicine at Mayo Medical School. Dr. McMahon serves as the Practice Chair for Nutrition and the medical director of the clinical dietitians and the Nutrition Support Service allied health members. She also has a focus on wellness and healthy nutrition on campus and serves on the Wellness Executive Committee at Mayo Clinic.

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Low Vitamin D

LEVELS IN ADULTS B Y D a n i e l L . H u r l e y , M D , FA C E

Where does vitamin D come from? Vitamin D has two basic forms. Vitamin D2 is found in vegetables and supplements. Vitamin D3 is mainly formed from your skin being exposed to ultraviolet B (UVB) radiation with sunlight or tanning beds. It also comes from foods such as fatty fish and dairy foods with added vitamin D, and from vitamins containing D3. Both vitamin D2 and D3 do not become active until they pass through the liver. Calcitriol [KAL-si-TRYE-ole] is then produced in the kidney and is the most active form of vitamin D in the body.

Why is vitamin D important? Vitamin D is needed to build healthy bones and to help prevent bone loss. Vitamin D helps calcium get from the intestines to the bone. Calcium is a mineral needed to make new bone and replace new or aging bone. Not getting enough calcium can lead to bone loss, or less dense bones. This is called “osteopenia” [os-tee-oh-PEEN-eeah] if the condition is mild, or “osteoporosis” [os-tee-ohpuh-RO-sis] if the bone is much less dense than normal. Vitamin D is also needed to harden new bone, just like wet cement becomes concrete. Thus, vitamin D keeps bone from being soft, thin, or osteoporotic [os-tee-ohpuh-ROT-ik] by giving the bone adequate calcium. Taking vitamin D can also make muscles stronger in people who don’t have enough of the vitamin, and help reduce the number of falls by about 50%. This is important because most broken bones in patients with bone loss occur after a fall.

How common is a low vitamin D level? Having too little vitamin D is more common than once thought. Up to 50% of adults who see their doctor have it. Not enough adults have optimal vitamin D levels, which should be over 25 ng/mL (nanograms per milliliter). Up to 70% of adult whites and 95% of adult African Americans in the US have a vitamin D level under 30 ng/mL. Having a level of 10 ng/mL or lower of vitamin D is considered very low. People in the northern United States and in less sunny climates are likely to have low vitamin D levels.

POWER OF PREVENTION • Vol. 3, Issue 1

Who is at risk for low vitamin D levels? It is now well known that many people have vitamin D levels that are too low for good health. Vitamin D is made mainly when skin is exposed to UVB from the sun. But many factors limit the sun exposure to the skin. Clothing, sunscreen, time of day, season, regions with less sun, low altitudes, skin pigment, and age all affect the skin’s ability to produce vitamin D. Not many foods contain vitamin D, and vitamin D added to foods is not well regulated. In addition, even eating foods with added vitamin D may not give you enough of the vitamin for optimum health. The two most common causes of low vitamin D levels are lack of sun and not enough intake of vitamin D by mouth. Other causes of low vitamin D levels include the body’s inability to absorb enough vitamin D (intestines made shorter by surgery, gastric bypass, and intestinal diseases), chronic kidney disease, and liver failure (Table 1).

TABLE 1: Clinical Risk Factors for Low Vitamin D Levels • Lower intake o Not enough intake by mouth • Not enough sun exposure • Gastrointestinal o Malabsorption [mal-ab-SORP-shun] - short bowel syndrome, pancreatitis [pan-kree-ah-TITE-is] (inflamed pancreas), inflammatory [in-FLAH-mah-tor-ree] bowel disease (bowel disease that alters food absorption, celiac sprue [SEE-lee-ac sprue], bariatric [BAH-ree-AH-trik] surgery) • Liver o Severe liver disease or failure • drugs o Anti-seizure drugs • Kidney o Aging o Renal insufficiency [in-suh-FISH-en-cee] (decreased kidney function not related to age)

Who should be tested for low vitamin D levels? Because it is expensive, checking blood for vitamin D levels is not recommended for everyone. But if you’re at risk for low vitamin D levels (see Table 1), you should get tested. The best form of vitamin D in the blood to check is that produced by the liver – 25 hydroxycholecalciferol [hyeDROK-see-ko-leh-kal-SIF-er-ol]. A healthy range is anywhere between 25 and 80 ng/mL. But even levels that are somewhat low can cause bone loss and osteoporosis. Table 2 lists vitamin D levels found in health and disease states.

TABLE 2: Vitamin D Levelsa <10 ng/mL

severe deficiencyb

10-24 ng/mL

mild to moderate deficiencyc

25 to 80 ng/mL

optimal levels

>80 ng/mL

toxicity possible

How Can We Prevent and Treat Low Vitamin D Levels? It is safe and does not cost much to add vitamin D to your diet. However, many people with low vitamin D levels don’t know they have the condition or don’t get the right treatment. You can get vitamin D through what you eat. However, except for fatty fish, vitamin D in most foods, including dairy products with added vitamin D (“fortified”), is low to none. For instance, one cup of fortified milk provides 300 mg calcium and 100 international units (IU) of vitamin D. Drinking four cups of milk (or a dairy equivalent) provides a total of 1200 mg calcium but only 400 IU of vitamin D. The current Food and Nutrition Board guidelines for adequate intake (AI) of 400-600 IU of vitamin D can be met by diet and a daily multivitamin. However, this may still not be enough for many people. New recommendations by the Institute of Medicine were published in late 2010. Reading food labels can help you figure out how much vitamin D you’re getting, but the only way to be sure how much you’re getting is to get your blood tested.

Mayo Medical Laboratories, Mayo Clinic.

Could be associated with osteomalacia [os-tee-oh-ma-LASS-ee-ah] (adults) or rickets (children).

May be associated with bone loss or osteoporosis.

to once daily. In people with extreme malabsorption, UVB from sunlight or tanning beds can help. Obtaining a blood level is the only way to be sure vitamin D intake is adequate for any given person. P

Which vitamin D is best, and how much is enough? Vitamin D2 and vitamin D3 are safe dietary supplements. Which one is better is not clear, but both seem to be good choices as long as an “optimal” vitamin D blood level is reached. Both can be taken once daily from 400 IU to up to 2000 IU or in larger doses available by prescription only (up to 50,000 IU) taken less often such as once a week or even once a month. Both vitamin D2 and D3 are best absorbed in the gut if taken with a meal containing some fat. There are many ways to take vitamin D if your blood levels are low. A common mistake in treatment is to stop taking vitamin D when the blood level reaches the “optimal” level. No matter what dose you start with, and if you haven’t changed your sun exposure levels or diet, a total intake of at least 1000 to 2000 IU daily will likely be needed on a regular basis to be healthy. People with malabsorption often need larger amounts of vitamin D. For example, patients after gastric bypass may require 50,000 IU of vitamin D2 or D3 from once weekly

Dr. Daniel L. Hurley is a consultant in the Department of Medicine and Division of Endocrinology, Diabetes, Metabolism, and Nutrition at Mayo Clinic. Dr. Hurley received his Internal Medicine and Endocrinology training at Mayo Graduate School of Medicine. He was awarded the Randall G. Sprague Award for Outstanding Achievement as an Endocrine fellow, the Department of Medicine Teacher of the Year Award, and the Henry S. Plummer Distinguished Physician Award for the Department of Medicine. His clinical interests include metabolic bone disease, nutritional health, and mentoring endocrine fellows and staff physicians new to Mayo Foundation.

POWER OF PREVENTION • Vol. 3, Issue 1

The Type 2 Talk:

Changing the Type 2 Diabetes Conversation B y J e f f r e y I . M e c h a n i c k , M D , FA C P, FA C E , FA C N , E C NU , a n d B r y a n C a m p b e l l

ou are sitting in the waiting room waiting to speak with your doctor about your diabetes. Questions race through your head.

“Would my doctor be upset if I say I had to eat out every night last week?” “Is it really important to check my blood sugar frequently?” “What do these medications I am on actually do?” The medical assistant calls out your name. It’s time. You step through the door. Step on the scale. “How did I gain two pounds? I have been trying my best and taking my medication.” Then it’s into the examination room. As minutes fly by you start to read the information on the walls, check your phone for messages, flip through a few magazines, and then the doctor appears. In the flurry of activity the doctor asks you how you’ve been feeling. Have you been taking your medication? Any unusual pains? During this time, you completely forget your own questions. And before you know it, your time is up. You are leaving with a new prescription and more questions than you started with. Maybe you’ll ask them next time. If any of these scenarios sounds familiar, you are not alone. More than 21 million Americans have type 2 diabetes. Every day patients struggle to understand the disease and their

Dr. Jeffrey I. Mechanick is Clinical Professor of Medicine and Director of Metabolic Support in the Division of Endocrinology, Diabetes and Bone Disease, Mount Sinai School of Medicine. He is Secretary and a member of the Board of Directors of the American Association of Clinical Endocrinologists and Chairs the AACE Publication Committee. Dr. Mechanick co-edited Nutritional Strategies for the Diabetic and Prediabetic Patient, The Complete Guide to Lifelong Nutrition, and Thyroid Cancer: From Emergent Biotechnology to Clinical Practice Guidelines to be published in 2011. Dr. Mechanick is in private practice in endocrinology and metabolic support in New York City.

POWER OF PREVENTION • Vol. 3, Issue 1

management plan. Virtually every month there is a new product or medication on the market. It’s nearly impossible to keep up. Doctors have limited time to spend with each of those 21 million patients. It’s important for them to understand just how your treatment is going so they can ensure you are receiving the best care possible. In fact, there are many times that doctors wish they had asked other questions to provide the best care for their patients. Patients and doctors want the same outcome. But unfortunately, they aren’t always communicating well with each other. That’s why the American Association of Clinical Endocrinologists [en-doh-cri-NA-lo-jists] and the American College of Endocrinology have partnered with AstraZeneca and Bristol-Myers Squibb to create The Type 2 Talk: Changing the Type 2 Diabetes Conversation. The Type 2 Talk is a unique program and web site (www. thetype2talk.com) that we hope will help you change the conversation you have with your doctor about your diabetes. The web site is filled with tools to help you make the most of your time with your doctor. The site takes common conversations that you might have with your doctor and shows you some ways to ask the questions that will help get you the answers you need. Some examples of these topics include motivation, slips in self-management, and treatment goals. In addition to providing a framework for these conversations, the web site also provides tips for both doctors and patients to ensure successful conversations. The web site, www.thetype2talk.com, also includes worksheets that you can use to manage goals before, during, and after your visit with the doctor. To learn more about ways to improve your type 2 talk, visit www.thetype2talk.com today. P

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Want to Learn More About

thyroid disorders? B Y J e f f r e y R . G a r b e r , M D , FA C P, FA C E

HANDOUTS Visit our Power of Prevention website (www.powerofprevention.com). There you can read and download our patient handouts, previously published in our Thyroid Awareness Month issues of Power of Prevention Magazine (Volume 2, Issue 1 and our very first issue Volume 1, Issue 1). These handouts address the following topics: • Hypothyroidism • Hyperthyroidism • The Thyroid, Pregnancy, and Infancy • Hashimoto’s Thyroiditis • Thyroid Cancer • Radioiodine Therapy • Thyroid Nodules • Thyroid Neck Check The handouts contain some notable updates. Hyperthyroidism: Points out the limited role that the drug propylthiouracil, which can cause fatal liver damage, has in the treatment of hyperthyroidism. Thyroid Cancer: Points out that in many cases surgery followed by thyroid hormone therapy without radioiodine therapy is sufficient treatment for thyroid cancer. Radioiodine therapy is radiation treatment employing radioactive iodine to destroy thyroid tissue or thyroid cancer.

CLINICAL PRACTICE GUIDELINES Want the latest scientific literature and technical expert opinion on various thyroid disorders? Though geared to professionals, clinical practice guidelines also serve as a rich resource for those who want a more detailed and scientific description about thyroid disorders, as well as many other endocrine diseases. Guidelines are available for free through the AACE website (http://www.aace.com/pub/guidelines/index.php). Our most recently published guideline on thyroid disorders is Thyroid Nodules (http://www.aace.com/pub/pdf/guidelines/ThyroidGuidelines.pdf). Upcoming guidelines will cover hyperthyroidism and hypothyroidism. Please visit our website periodically to check them out along with other publications which may be of interest to you. P

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Letters

from Readers Question: My physician keeps telling me to exercise, but I have arthritis and it’s often difficult for me to move around. Are there any exercises I can do at home that will not create additional strain on my body? Answer: Exercising isn’t just about the amount of weight you lift or the time you spend on the treadmill. It’s about doing what you can to stay moving. That could mean taking a stroll to the mailbox instead of driving your car to it or just walking around your living room a few times a day. Question: My primary care physician diagnosed me with diabetes a few years ago and my condition has been under control until recently. During my last visit he said that I might have a thyroid issue too. He says that I need to see an endocrinologist. What does an endocrinologist treat? Will he/she be able to treat my diabetes and possible thyroid dysfunction? Answer: An endocrinologist is a specially-trained physician who treats endocrine conditions, including diabetes, thyroid dysfunction, osteoporosis and many other conditions related to hormones and glands. If you need help finding an endocrinologist in your area, simply visit www.aace.com and click on resources and go to “Find an Endocrinologist.” This tool will allow you to search for an endocrinologist by location (either City/ State or ZIP code) and/or by specialty (such as “diabetes mellitus” or “thyroid dysfunction”). Question: I am 52 years old, and I am looking for comprehensive information about nutrition that is written specifically for the patient. Do you have any resources you could recommend? Answer: Check out The Complete Guide to Lifelong Nutrition, the American College of Endocrinology’s comprehensive manual on nutrition. It is available for purchase at amazon.com. Question: I found your magazine in my endocrinologist’s office, and I think this would be a great resource to share with my family members and friends. Is the magazine available online and how can I access it? Answer: Yes! The magazine is available online at www.powerofprevention.com. When you visit this site, you’ll be able to access previous issues of the magazine and share the links with your family and friends.

Thank You

The American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) would like to thank Abbott Laboratories, Inc., Amgen Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Lilly Diabetes and Novo Nordisk Inc. for their support of the Power of Prevention initiative.