Endocrinology and Metabolic Diseases Department

Endocrinology and Metabolic Diseases

At the Endocrinology and Metabolic Diseases Department of Anadolu Medical Center we diagnose and treat problems related to endocrine glands such as the thyroid, pancreas, adrenal glands, ovaries and testicles, and pituitary glands.

Which health problems do we diagnose and treat at our department?

• Diabetes
• Obesity
• Thyroid diseases
• Metabolic problems
• Growth hormone problems
• Disease of the adrenal gland
• Hereditary diseases
• Osteoporosis

Risk Factors for Diabetes

What is Type 1 Diabetes?

Scientists are still trying to find the underlying cause of type 1 diabetes and the risk factors that cause susceptibility in the individual. However, a progress has been made in researches about its mechanism of development. Several researches show that type 1 diabetes may be triggered in childhood or adolescence, and even by a certain viral infection in utero. Scientists think that this virus may have caused a change in the child's immune system and produced antibodies that have the capability to attack beta cells. It is argued that when the child encounters a similar viral infection later in life, this infection may activate antibodies to attack beta cells.

Is Type 1 Diabetes genetic?

Family history has a minor role in diabetes. A majority of patients with this type of diabetes do not have family members having the same disease. However, if any of your parents or grandparents, particularly your father or grandfather has had type 1 diabetes, your risk to develop the same disease will be higher. Therefore, researches demonstrate that there has to be a certain genetic disposition to type 1 diabetes in order to develop this disease. There are some genetic variations seen with type 1 diabetes (HLA – haplotype).

What is Type 2 Diabetes?

Unlike type 1 diabetes, family history has a major role in type 2 diabetes.

Is Type 2 Diabetes genetic?

In a study carried out with 200 adults with type 2 diabetes, it is reported that at least one close relative of two-third of the test subjects and at least two close relatives of about 50% of the test subjects had diabetes. In particular, it is observed that the possibility to develop diabetes was twice in people whose mother had diabetes than in people whose father had diabetes – 17 percent versus 33 percent. Minimum 1 child of 11% of the women with type 2 diabetes had diabetes, whereas only one child of 4% of the men had type 2 diabetes.

Genes

Researchers found variations in minimum 18 genes that could increase the risk of diabetes. All these genetic variations have 2-20 percent effect on the possibility of development of the disease. Researchers hope that methods to prevent or delay the disease can be developed for persons who are at risk of diabetes. However, no reliable test has yet been developed to determine whether these genetic variations significantly increase the risk to develop diabetes in time.

Racial and ethnic origin

Racial and ethnical origin also affects risk of diabetes. For examples, black people, people of Hispanic origin, Asians and native Americans have a higher risk of type 2 diabetes compared with white people. However, scientists do not have reliable information about the reasons of this situation.

Correlation of diabetes and obesity

The most important factor in type 2 diabetes is fatness. About 80% of the people with type 2 diabetes are either fat or obese. As weight increases, the risk of type 2 diabetes increases, too. Researches show that when fat cells increase, insulin resistance of all body cells somehow increases.

Role of excessive fat in diabetes

The site where fats are concentrated is also important. In people with abdominal obesity (excessive fat in the abdomen) the risk to develop type 2 diabetes is higher than people with excessive weight in the hips and thighs. Recent researches show that waist circumference measurement is a better risk indicator than general body weight in terms of diabetes.

Diabetic metabolism

Abdominal obesity is often accompanied by insulin resistance, high blood glucose, high blood pressure (hypertension), low high-density lipoprotein (HDL) cholesterol (i.e. "good" cholesterol") and high triglyceride (another type of fat found in blood). This set of anomalies which is called the metabolic syndrome is a major risk factor not only for diabetes but also heart diseases and stroke. Doctors are increasingly showing greater interest in the metabolic syndrome as it often indicates onset of diabetes. If your waist circumference is wide, your HDL and triglyceride levels are in unhealthy dimensions, your doctor may recommend you to have your blood glucose level measured after fasting for minimum eight hours.

Prediabetes

About 79 million Americans have prediabetes. If your fasting blood glucose measurement is 100-125 mg/dL (i.e. blood glucose amount is above normal, but not high enough to diagnose diabetes), then you have prediabetes. Also a hemoglobin A1c (A1c) level between 5.7 and 6.4 percent shows that you are in the high risk category in terms of diabetes. Several people with diabetes who do not change their lifestyles or use drugs are candidates for having type 2 diabetes in 10 years.

Diabetes and physical inactivity

An inactive lifestyle is another risk factor for type 2 diabetes. We consume glucose through physical activity, and hence less glucose builds up in our blood. Exercise grows muscles and muscle cells draw and use high amount of glucose. However, if you do less exercise, your muscle tissues will be reduced, you will consume less glucose, and your blood glucose level will rise.

Diabetes in old age

Ageing is another risk factor of diabetes, however, getting old, in its own right, does not pose a problem. The factors that make a difference especially after 45 are level of activity and foods consumed. When people get older, they do less exercise, and consume fatty and carbohydrate foods more and put on weight (particularly in the middle part of your body). In a 12-year-long research performed among 4200 men and women aged 65 and above, it was shown that people who were found to have high body fat at the age of 50 were 4 times more likely to develop diabetes than those who had lower body fat.

Diabetes in pregnancy

Some women develop type 2 diabetes during pregnancy, which is called gestational diabetes. Although it disappears after birth, researches show that 50% of these women have a higher risk to develop diabetes in the subsequent stages of their lives. Therefore, it will be true to call gestational diabetes a warning sign. Women with this type of diabetes must take care to lead a healthy life.

Other factors that increase the risk of diabetes

A low number of people who have diseases that cause permanent damage in the pancreas such as hemochromatosis (absorption and accumulation of excessive iron), chronic pancreatitis (inflammation of the pancreas), though rarely, pancreas cancer are also under risk of diabetes. There are also tumors which increase the risk of diabetes as they induce excessive hormone production hindering insulin effect. The growth hormone produced by pituitary gland tumors, epinephrine or cortisol secreted by adrenal tumors and glucagon secreted by pancreatic tumors also increase blood glucose level.

Ways of Protection Against Diabetes

If there are one or more persons in your family who have Type 1 or Type 2 diabetes, you probably have concerns about developing the same disease and are interested in measures to reduce your risk.

Is there any way to prevent type 1 diabetes?

To protect yourself against diabetes, it is important that you understand whether there is any concrete reason or any life style preference "to blame". For example, there are many people who blame themselves, believing that they developed diabetes as they were fed with too much sugar in childhood. However, this is not true, because developing type 1 diabetes has no connection with sugar consumption. Although there is no way to prevent type 1 diabetes, there are proven methods to reduce risk of type 2 diabetes.

What are the ways of protection against type 2 diabetes?

Type 2 diabetes is so directly related to excessive weight and inactivity that your starting point to protect yourself should be excessive weight and inactivity. Diet and exercise are the milestones for protection against type 2 diabetes. These measures are especially important for those who have a risk factor, for example, prediabetes, obesity, family history, having diabetes while pregnant (gestational diabetes), ethnicity (African Americans, Hispanics, Asians, American Natives).

1- Diet and exercise

Researches conducted worldwide show that type 2 diabetes can be prevented by some weight loss and regular physical activity. The largest and the most famous one among these researches is called Diabetes Prevention Program conducted in the United State. At the end of three years, among the participants of the study, those who had a diet low in fat and calorie, those who exercised 30 minutes a day, and those who lost 6.5 kg on average developed type 2 diabetes at a rate of 60 percent less than those who did not apply these lifestyle changes. It was established that changing lifestyle a short time ago could delay development of diabetes for 10 years or more. A diet rich in fibrous food is a factor that reduces type 2 diabetes risk. In a study conducted among approximately 36,000 women, the risk of development of type 2 diabetes was 36 percent lower in women who consumed the highest amount of fiber-rich grains than those who consumed the lowest amount of fiber-rich grains. In a recent research conducted in Finland, a similar result was found among men. Fiber found in brown rice or whole-grain products like whole wheat bread can affect insulin sensitivity of our body positively. In a Harvard research performed among 84,000 female nurses, it was found that risk of type 2 diabetes was decreased 1/3 in women who added minimum 1200 mg calcium and 800 IU vitamin D to their diet. However, the effect of vitamin D on risk of diabetes is a subject which is still being investigated.

2 – Give up smoking

Giving up smoking can reduce the risk of type 2 diabetes. In a research conducted among 21,000 American male doctors, the possibility of those who consumed 20 or more cigarettes a day to develop diabetes was 70% higher than those who never smoked or gave up smoking.

3- Diabetes Medications

Numerous researches show that oral medications used in the treatment of type 2 diabetes have a protective effect against the disease. For example, those among the participants of the Diabetes Prevention Program who used metphormin, a diabetes medication, for a period of three years, had a 30 percent lower risk to develop type 2 diabetes than those who took placebo. Only in a small group, people with obesity between 24-44 years of age (with an excessive weight of 22 to 40 kilograms), it was seen that metphormin was as effective as change of lifestyle. The mediation was slightly more effective only in people aged 60 and above, with a very low excessive weight. American Diabetes Association (ADA) which evaluated these findings does not recommend the use of oral medications in place of or in addition to lifestyle changes such as diet and exercise for prevention of diabetes. In another study named Heart Outcomes Prevention Evaluation (HOPE), test subjects who received ACE inhibitor ramipril had a 30 percent lower possibility to develop diabetes than those who received placebo. However, because this outcome has not been verified with subsequent researches, ACE inhibitor cannot be recommended for prevention of diabetes for the moment.

What are diabetic and bone-joint problems?

Diabetes may be related to some lesser known bone and joint problems. For example, the Charcot joint. Also called neuropathic arthropathy, this bone-joint problem occurs in one of the joints due to nerve damage. Tingling, lethargy, swelling and deformation are observed in the affected joint. Generally, the proposed treatment is to support this joint with orthotic devices and to avoid load imposing activities.

What is diabetic stiff hand syndrome (DSHS)?

Diabetic stiff hand syndrome, also known as diabetic cheiroarthropathy, is a disorder in which finger movement becomes limited as the hands become waxy and thickened. The cause of the diabetic hand syndrome is unknown, but it is generally observed in persons who have diabetes for a long-term. Progress can be prevented by proper blood sugar control, accompanied by physical therapy. Also known as diffuse idiopathic skeletal hyperostosis (DISH), this disorder is characterized by calcification and hardening of the tendons and ligaments (mostly of the spine). It may be seen in persons with diabetes as insulin and insulin-like growth factors may trigger bone reformations. DISH may cause pain, stiffness and movement restrictions in the affected region. It is often treated with acetaminophen (Tylenol) to mitigate pain and prevent the progress of calcification. If a bone spur occurs, it has to be removed by surgery.

What is Dupuytren’s disease (contracture)?

This disease is characterized by one or more fingers bending towards the palm. It occurs more frequently in people with long-term diabetes, and the connective tissues of the palm and the fingers become hardened and lesions occur. Although the pain may be relieved with corticosteroid injection, severe cases may require surgery as the ability to hold objects is lost. Frozen shoulder, as its name implies, is a painful condition that generally restricts shoulder movement at one side of the body. Although diabetes is a frequent risk factor, the nature of the tie between them is unknown. It is tried to be treated often using intensive physical therapy.

Measures you have to take to protect your health

1- Exercise

Excessive weight and obesity are risk factors for both diabetes and knee and hip osteoarthritis. For this reason, you can prevent both by regular exercise. Persons who are diagnosed with diabetes should exercise to treat diabetes and relieve pain caused by osteoarthritis. Researches showed that 30% of the people who had both diabetes and arthritis did very little exercise or no exercise at all. However, even loss of 7 kilograms reduces knee pain by a half. Even without losing weight, it is possible to increase the movement ability of the joint and lessening pain just by doing regular exercise. Consult your doctor and find an exercise program that will not put much stress on your damaged joints. In osteoporosis, excessive weight and obesity are generally listed among the protective factors, and the fact that your body has to carry excessive weight has a strengthening effect on your bones. However, it is interesting that this protective effect is not seen in persons with excessive weight if they have also diabetes. For this reason, exercises imposing a load are very important for bone formation and protecting strong bone. Running, walking, aerobic are all load-imposing exercises, cycling and swimming are different. Exercises that increase flexibility, strength and balance also protect your bones against possibility of fractures.

2- Diet

You have to take sufficient amount of calcium and vitamin D to protect your bones. Anybody who is over 50 years of age should take 1200 mg calcium and minimum 800 IU vitamin D. The best foods for calcium are low-fat milk products, dark green vegetables like spinach, and foods-drinks with calcium supplement (orange juice or grain breakfasts) . Human body produces vitamin D by absorbing sunlight. However, many people do not go out to sun, and do not include vitamin D in their diet. There are many evidences showing that vitamin D helps to regulate your blood sugar, besides protecting your bones. Consult your doctor to learn whether you need Vitamin D supplement, calcium support or both. There is no special diet that can prevent or improve arthritis, however there are evidences that food rich in omega-3 fatty acid (sardine, mackerel, salmon, Atlantic sea bass, trout and tinned white tuna fish) help to prevent inflammation which plays part in arthritis and other joint disorders.

3- Bone density scan

Osteoporosis is identified by bone mineral density test that measures bone density of the hip and spine. Persons who have a broken bone after 50 years of age should have a bone mineral density test performed. No special rule has been reported until now in relation to osteoporosis screening for persons with diabetes.

4- Drugs

Osteoporosis is treated with drugs that delay, reduce bone loss or promote bone reformation. In osteoarthritis, however, drugs for relieving pain, stiffness and inflammation are used. Tell about all your drugs to your family doctor as these may affect your diabetes treatment. For example, when you take a high dose acetominophen, blood sugar measurements that you perform at home using some devices may be erroneous, and taking high dose aspirin may drop your blood sugar.

What are the types of nerve damage in diabetes?

Nerve damage is one of the heaviest consequences of diabetes. The most effective method to prevent it is to keep your blood sugar under strict control. Researches show that a strict blood glucose control reduces the risk of diabetic nerve damage by 60 percent. However, when nerve damage occurs, blood even very good sugar control shall not be beneficial. 60-70 percent of persons with diabetes experience nerve damages, however, no signs may be noticed initially. Diabetes may result in three types of nerve damage: Peripheral, mononeuropathy and autonomic neuropathy.

Peripheral neuropathy

Peripheral neuropathy is a damage that occurs in peripheral nerves, i.e. nerves that connect the spinal cord to the rest of the body. The most common type, peripheral neuropathy is characterized by gradual dysfunction of the sensory nerves in the arms and legs due to lack of oxygen and nutrition, pressure and inflammation. The degree of severity changes subject to which nerves suffer the damage, and it becomes worse at night. Severe nerve damage may give rise to complete loss of sense in the affected region. It may also have effects such as loss of reflex and muscle control, loss of muscular structure and strength, foot ulcers and foot lesions prone to infection, loss of coordination and balance, loss of hair in damaged regions.

Mononeuropathy

Mononeuropathy is loss of blood flow to a single nerve or a group of nerves. A sudden pain or weakness occurs in the region where the affected nerve functions. This may sometimes cause the eyelid to loosen. Mononeuropathy heals by itself in 2 to 6 months without treatment.

Autonomic neuropathy

Autonomic neuropathy occurs when diabetes causes damage to the autonomic nerve system that controls involuntary bodily functions. The digestive system, heartbeat and blood pressure are the best examples. The most common type of autonomic neuropathy is erectile dysfunction in men. Other symptoms of autonomic neuropathy include gastric emptying, weakened gall control, fast or irregular heartbeats, and excessive sweating. Most people with autonomic neuropathy also have peripheral neuropathy.

What are the treatment methods of nerve damage (neuropathy)?

Proper blood sugar control is the first step in the treatment of neuropathy, though it does not provide much benefit. Therefore, medication is necessary.

How is peripheral neuropathy treated?

The most widely used drug to treat symptoms of peripheral neuropathy is gabapentin although it has not been approved by FDA. It has been very effective, but it has to be taken in high doses (1200 mg a day, sometimes up to 3600 mg). If side effects are seen, these may be treated by decreasing the dose. Another neurontin-like drug that is used as a pain reliever in patients with diabetic neuropathy is FDA approved pregabalin. Amitriptyline, an antidepressant which has been used for a long time, is also effective from time to time. Another antidepressant used in the treatment of peripheral neuropathy is desipramine. A new drug, duloxetin is an FDA approved antidepressant recommended as a pain killer for diabetes.

How is autonomic neuropathy treated?

Autonomic neuropathy that affects the nerves in the digestive system is called diabetic gastroparesis. In this condition, it is recommended that frequent and small portions of low-fat meals are eaten throughout the day instead of large meals in order to prevent nausea and vomiting caused by slow emptying of the stomach. Using metaclopramide or antibiotic erythromycin may improve gastric emptying. In the treatment of diarrhea, antibiotics like tetracycline (which prevents proliferation of intestinal bacteria that may aggravate diarrhea) or classic anti-diarrhea medications can be effective. In men with autonomic neuropathy, damage may occur in nerves that control erection. Reduction in blood sugar supplied to these nerves may exacerbate the problem. In a research it was found that in men with A1c level above 8 percent, erectile dysfunction risk is very high. In half of these disorders, sildenafil and similar drugs can be effective. Also there are injectable drugs and vacuum devices. It will be useful to consult an urologist for these problems.

Microvascular Diseases in Diabetes

The capillary vessels in the bodies of persons with diabetes may be congested and damaged. This is called microvascular ("micro" means small) disease and may frequently result in damage in kidneys and eyes.

• Nephropathy
• Retinopathy

Nephropathy (renal damage)

In 30-40 percent of patients with type 1 diabetes, and in 20% of patients with type 2 diabetes renal damage will eventually occur, however, renal insufficiency does not develop in all of them. The damage occurs in the capillary vessels in the entire kidneys that function as a filter which clears the waste materials in blood. The risk of heart attack and stroke rises due to the damage in the kidneys. The first sign that indicates the damage in the kidneys is presence of small amount of a protein called albumin in urine (microalbuminuria); this condition is generally encountered in persons who have diabetes for 5-10 years. In 8-10 years after this stage, with the aggravation of the renal damage, large amounts of protein may be present in urine (proteinuria), waste materials may accumulate in blood (azotemia), and in the end, renal insufficiency that requires dialysis or kidney transplant may occur.

Retinopathy

Affecting more than four million Americans at the age of 40 and over, diabetic retinopathy is the most common diabetic complication. Virtually in all persons with type 1 diabetes and in more than 70% of persons with type 2 diabetes, signs of retinopathy – often not leading to vision loss - are eventually seen. However, diabetic neuropathy may result in blindness, and is the most frequent cause of acquired blindness in adults between 20-74 years of age.