Shadowing a Diabetes Doctor, or, You are what your hormones decide you are – May 24, 2012

I had the opportunity to shadow a veteran endocrinologist for 4.5 hours Thursday morning.  It was a fascinating experience to see the treatment of actual diabetic patients instead of staring at diabetes data trends on a CRT computer screen.

The physician, who has been an endocrinologist for nearly 30 years, estimated that his practice consisted of 60:40 diabetes / thyroid patients.

Most diabetic patients we saw were older (>50) and had excess belly fat (possibly an indication of metabolic syndrome, i.e. insulin resistance).  And the greater the age and body fat, the greater the complications of their diabetes (which makes me quake with fear at the future health of children and adolescents with type II diabetes).  Most appeared to have circulation issues that led to swelling in the feet, discoloration, and/or dry skin around the ankles.  Circulation issues can disturb immune function which can lead to amputation: this latter problem was very scarily portrayed in HBO’s “Weight of the Nation” in which an older man required a leg amputation due to his uncontrolled diabetes.  The physician informed me that uncontrolled diabetes is the leading cause of amputation in the nation.  One very obese patient had venous insufficiency (which I assume is related to long-term, possibly poorly controlled diabetes but I cannot be certain).

Ultimately, the complications resulting from long-term diabetes are vast and severe and one causative factor appears to be the long-term accumulation of AGEs in the vascular system (advanced glycated end products, i.e. proteins and other molecules with bound glucose, due to chronically abnormally elevated blood glucose and high fructose consumption).  These glycated molecules bind together and clog/disrupt blood flow and, for capilaries, can cause hemorrhaging (which can lead to blindness in severe diabetic retinopathy, now the leading cause of blindness in working age Americans).

The accumulated damage to the vascular system can impede blood flow, oxygen distribution, and lead to nerve damage (diabetic neuropathy), which is why many diabetic patients we saw Thursday had their feet tested for nerve sensation with what is basically a 10 gauge fishing line.

All in all, diabetes is a frightening disease and prevalence, especially of type II diabetes, is reaching tremendous levels (~25 million adults, ~8.3% of population, with another 79 million people estimated to have prediabetes).  The US population prevalence has increased hugely over the past 50 years in conjunction with increases in obesity (most diabetes being type II, likely due to the effects of insulin resistance).

We also saw a handful of patients with thyroid issues, including 3 women with low thyroid levels related to thyroid surgery and 2 men for low testosterone levels.  Both of these conditions appeared to cause weight gain which supports the hypothesis that obesity may be a hormonal disorder.

One women complained of being unable to lose weight after significant dieting for three months despite subsisting primarily on yogurt, carrots, and eggs and minimizing calories.  Another man stopped his testosterone therapy and reported substantial weight regain (similar to Vince Vaughn and cigarettes, suggesting that hormones are driving weight loss/gain in various ways).  I am unsure how thyroid hormones affect weight other than affecting metabolic rate (which might simply be a downstream effect of hormonal action) but sex hormones are known to reduce fat levels by acting on enzymes on the fat tissue (estrogen and testosterone downregulate LPL enzymes on fat tissue which should limit triglyceride stores in fat cells).  Testosterone pellets are now gaining greater acceptance as positive results emerge and FDA approval has occurred.  One patient was offered this therapy and said he preferred it as the testosterone gel was ineffective and risky around children as the hormone can be transferred between patient and child and absorbed through the skin.

All in all, the day was a fascinating glimpse of the massive effect that hormones have upon the human body and mind.  Most individuals would claim that they have control over the state of their health.   They can control their weight, their mood, their energy levels, etc. etc. by simply acting from free will.  However, the fact that hormones have such a strong hold over the biological processes of our body severely weakens this belief.  If your hormones drive you to fatten, become hyperactive, stay awake, etc., then that is what you will do.

Therefore, because human health and even  behavior are driven by hormones than the understanding and control of our hormonal system, through the field of endocrinology, is all the more important.

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