Page 1

Institute of

Endocrinology Specializing in Diabetes, Health & Hormones

May 2017 Volume 1 | Issue 1

See us at our convenient Panama City or Destin location Meet the Team Chronic Fatigue Men’s Health Osteoporosis

Hormone Replacement Understanding Diabetes INSIDE - Special Offers!

Thyroid & Metabolism


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Dear Readers,

6 9 10 12 13 14 16 18

It is with my great happiness and enthusiasm, that I introduce the first edition of our quarterly magazine to you .

Weight Gain Management Testosterone Replacement Diabetic Eye Disease Chronic Fatigue Bio-identical Hormone Replacement What is Diabetes? Thyroid & Metabolism Osteoporosis

Special Offers 4, 5 &11

Contents 3 4 5 11 19

Welcome Meet the Panama City Office Meet the Destin Office Office Information Health Tracker


Since I established my endocrine practice in the beautiful Panhandle area, I have always thought about a way to directly communicate with the community. I wanted to directly speak to every one of you and update you with what is new in our exciting medical field of endocrinology. Endocrinology is that wonderful field of medicine that deals with many critical and very important aspects of your health. Hormone replacement, thyroid disorders, diabetes management and weight control are just a few of a long list of disorders that are perfectly handled and managed by a board certified endocrine team.

I have had the pleasant opportunity to work with Dr. Kamel since I graduated from Florida State University in 2008. Following Dr. Kamel’s leadership we started a small endocrine practice that literally grew overnight. We have built a solid reputation within our community by being personable, patient and experts in our field. At our Institute, every patients’ issues are taken seriously and treated with the utmost respect and care.

We, at the Institute of Endocrinology, treat our patients with an individualized yet evidence based and scientific approach specific to every case.

We welcome you to our practice. Let us help improve the quality of your life! God bless.

Sherief Kamel



I am blessed with a wonderful team that works with me diligently to improve the health and wellbeing of our patients. I would like to thank everyone of them for their contribution to making this magazine possible. I hope that you find the information in this magazine useful and thank you for taking the time to learn more about us.


Sherief Kamel, MD

Ashli Brooks Ashli Brooks

FNP-BC, COO and co-founder of the Institute of Endocrinology, clinical experience since 2008 The information and opinions in this magazine are for general information only and are not tailored for the needs of individual cases. Please consult with your healthcare provider before changing any of your medications or following any medical advice.



Dr. Sherief Kamel

Ashli A. Brooks


Dr. Kamel is board-certified for exceptional expertise in the fields of Endocrinology, Diabetes, Metabolism and Internal Medicine. He graduated with honors (MB.CH.B) at Alexandria University, Faculty of Medicine, in Alexandria, Egypt and completed his internal medicine residency at St. Luke’s Roosevelt Hospital, a Columbia University College of Physicians and Surgeons Hospital, in New York, New York.


Education: Master’s Degree from FSU ‘08 Bachelor’s Degree from University of West Georgia ‘05 Certifications and Associations: Board Certified as a Family Nurse Practitioner Certified in Medtronic Insulin Pump Therapy Certified in Botox, Fillers and Aesthetics

Dr. Kamel is certified by the American College of Endocrinology to perform biopsies of the thyroid, parathyroid, and lymph nodes and neck ultrasonography. He is experienced in treating the most difficult cases implementing evidence based clinical care customized to the individual patient. Utilizing the most current practices, therapies, nutritional and pharmacological treatments, Dr. Kamel is committed to providing the best care in the region. Dr. Kamel is the founder of the Institute of Endocrinology with more than 15 years of clinical experience since 2002. He is a member of the Endocrine Society, American Association of Clinical Endocrinology, American Thyroid Association and American Medical Association.

Left to Right: Mayra, Krishna, Lorie, Amy, Amanda, Dr. Kamel, Ashli, Dr. Ergin, Jessica, Ashlyn, Cory, Nikki

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Both locations. Exipres 8/31/17


Dr. Ahmet Ergin MD, CCD, ECNU

Dr. Ergin is an endocrinologist at Institute of Endocrinology at the Panama City and Destin offices. He graduated with honors at Marmara University School of Medicine in Istanbul, Turkey, and completed his internal medicine residency and endocrinology fellowship at Cleveland Clinic in Cleveland, Ohio. Dr. Ergin is board-certified in Internal Medicine and in Endocrinology and holds specialty certifications for Clinical Bone Densitometry as well as endocrine neck ultrasound and biopsies. His special interests are diabetes and thyroid disorders, hormone replacement for men and women. He is a member of the Endocrine Society and The American Association of Clinical Endocrinologists. Dr. Ergin is the main co-author of the book “The Cleveland Clinic Manual of Dynamic Endocrine Testing” and has co-authored many articles in peer-reviewed journals. with this coupon

Jamie Williams

MSN, ARNP, NP-C Jamie Williams provides specialized endocrinology services to patients of all ages, including assessment, diagnosis, and management of all endocrine conditions including diabetes, hypothyroidism, hyperthyroidism, osteoporosis, hypogonadism, polycystic ovarian syndrome, and weight management. She has special interest in overall health, diabetes, chronic fatigue, and osteoporosis. She has been trained and is licensed to order and interpret laboratory and diagnostic tests as well as prescribe appropriate pharmacologic and non-pharmacologic therapies. Mrs. Williams works in collaboration with physicians to provide optimum care to patients. Mrs. Williams graduated Cum Laude with a Master’s Degree in Nursing (MSN) from the University of Alabama at Birmingham (UAB). She is board certified as a Family Nurse Practitioner (FNP-C) by the American Academy of Nurse Practitioners.


Dermal Filler TREATMENT

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Left to Right Michelle, Andi, Rae, Ponchie, Dr. Ergin, Dacia, Lisa, Melinda, Jamie, Jamie



Are You Gaining Weight No Matter What Diet You Try?


f your answer to that question is yes, you are at the right place. Please read this entire article to the end! The medical rationale for weight loss in obese and overweight individuals is that it is associated with a significant increase in risk of early death and many health risks, including type 2 diabetes mellitus, hypertension, cholesterol elevation, and heart disease. The higher the body mass index (BMI), the greater the risk of sickness and dying from obesity related complications. BMI is defined as the body mass divided by the square of the body height. The relationship between BMI and mortality is likely to be similar for all races and ethnicities. If your BMI is between 25 and 29.9, you are overweight, if more than 30 you are medically obese. Many types of diets produce modest weight loss. Options include balanced low-calorie, low-fat lowcalorie, moderate-fat low-calorie, low-carbohydrate diets, and the Mediterranean diet. Dietary adherence is an important predictor of weight loss, regardless of the type of diet. So cheating is not allowed in reality if you want to lose weight. Studies have compared different diets such as the Atkins diet, the Zone diet, and the Weight Watchers diet. No single diet turns out to be better than any other. Any diet that reduces the number of calories you eat can help you lose weight – as long as you stick with it. Physical activity works the same way. You can walk, dance, garden, or even just move your arms while sitting. What’s important is that you increase the number of calories you burn by


moving more. And you have to keep doing the extra activity. If you go on a diet for a short time, or increase your activity for a while, you might lose weight. But you will regain the weight if you go back to your old habits. Weight loss is about changing your habits for good.

Thus, we at Institute of Endocrinology suggest tailoring a diet that reduces energy intake below energy expenditure to individual patient preferences, rather than focusing on the macronutrient composition of the diet. The addition of dietary counseling on regular intervals may facilitate weight loss, particularly during the first year. Although less potent than dietary restriction in promoting weight loss, increasing energy expenditure through physical activity is a strong predictor of weight loss maintenance. Physical activity should be performed for approximately 30 minutes or more, five to seven days a week, to prevent weight gain and to improve cardiovascular health. There appears to be a dose effect for physical activity and weight loss, and much greater amounts of exercise are necessary to produce significant weight loss in the absence of a calorically-restricted diet. Therefore, when weight loss is the desired goal, a diet should be combined with physical activity and the activity should be gradually increased over time as tolerated by the patient. A multicomponent program

by Dr. Sherief Kamel, MD FACE ECNU & Ashli Brooks, FNP-BC

that includes aerobic and resistance training is preferred. Existing medical conditions, age, and preferences for types of exercise should all be considered in the decisions. In our wellness clinic at Institute of Endocrinology we individualize treatment plans. Each person goes through certain tests to understand their caloric needs and we set a goal for daily calories allowed in order to lose weight. Dietary/nutrition coaching comes into play in order to apply this in patient’s daily routine and diet preferences. Behavior modification or behavior therapy is one cornerstone in the treatment. The goal of behavioral therapy is to help patients make longterm changes in their eating behavior by modifying and monitoring their food intake, modifying their physical activity, and controlling cues and stimuli in the environment that trigger eating. Our highly skilled dietitians walk you through and support you during this ‘not so pleasant’ weight loss experience. Understanding that there isn’t an easy or miracle way to weight loss is the key. We also prescribe weight loss medicines for patients who can’t achieve their goals through diet and exercise alone. All those medicines do is to suppress appetite and make it easier to resist temptations. We will also prescribe and motivate and keep our patients accountable for their diet and exercise regimens. It is a life-long effort to stay fit and healthy and we are here to help because we know it is not easy when you try to do it alone. Call Institute of Endocrinology at our Destin or Panama City location to schedule a wellness clinic appointment. 


Men’s Health.

Testosterone Replacement Today!

by Dr. Ahmet Ergin, MD, CCE, ECNU

Male Testosterone Production with Age

20 30 40 50 60 70 80 Testosterone Level

Testosterone Deficiency


ndrogens and testosterone are a type of hormone the body makes naturally. Hormones are chemical messengers that turn different body processes on and off. Androgens are often called “male hormones.” That’s because they are the main hormones that make men different from women. People often think that only men have androgens and only women have female hormones called “estrogens.” But the fact is, men and women both have androgens and estrogens. The difference is that men normally have much higher levels of androgen and testosterone than estrogen. And women normally have much higher levels of estrogen than androgen. A man might need androgen replacement if he has low levels of an androgen called “testosterone.” There are a few different androgens, but testosterone is the main one. Anabolic effects of testosterone include growth of muscle mass and strength, increased bone density and strength, increased sex drive. Symptoms of low testosterone in men can include: • Little or no interest in sex – We call this “low libido.” • Feeling depressed

• In a boy, being slow to go through puberty: fDo f not get bigger muscles, even with lots of exercise fDo f not get a beard, body hair, or deeper voice

If you think you have these symptoms, please schedule an appointment with Institute of Endocrinology.

We will provide a complete evolution to diagnose low testosterone and to uncover the possible root cause of the problem. If treatment is indicated there are several different forms of testosterone replacement. Testosterone can be given in an injection (shot), patch, gel etc. Some men who have androgen replacement with testosterone have side effects. These can include: high amounts of red blood cells, blood clots (but this is rare), elevated prostate specific antigen, etc. It is very important that you are treated under expert supervision by an endocrinologist specializing in hormone replacement. Call Institute of Endocrinology for a complete evolution. 

• Feeling tired, especially at the end of the day • Developing breasts, called “gynecomastia.”



Diabetic Eye Disease I f you have diabetes, your vision and your eyes can be negatively affected. Because the eyes have some of the smallest blood vessels in the body, these vessels are a good indication of how well your diabetes is being controlled, and how it is affecting the rest of your body. The eyes are truly a window into how advanced diabetes is because, when dilating the eyes, we can directly look at the tiny blood vessels in the back. It is recommended that people managing diabetes get annual dilated eye exams, and follow up more often if there already is diabetic eye disease. Diabetes can cause a range of eye problems. Because diabetes can affect nerves, the cornea can become less sensitive, leading to dry eye. Foreign body sensation, grittiness to the eyes, and intermittent blurring of vision that clears with blinking are also early signs of dry eye. Cataracts often happen sooner, and develop more rapidly in people with diabetes, particularly when their blood sugar is not well controlled. Constant blurred vision, glare issues in bright light, and starbursting patterns of lights are signs of developing cataracts, or possibly something more serious.

by Dr. Nathaniel Ruttig, MD

The blood vessels in the back of the eye are very small and can get blocked off, or bleed, creating new floaters, foggy vision, or loss of vision completely. Glaucoma, a deterioration of the optic nerve in the back of the eye, is also more common in people with diabetes.

The best things a diabetic can do for their eyes and to protect their vision is to control their blood sugar and blood pressure. Maintaining a wellbalanced nutritional diet is extremely advantageous. If blood sugar is not controlled, high levels can damage blood vessels in the eye leading to diabetic retinopathy. Untreated diabetic retinopathy can also lead to abnormal blood vessels developing on the retina causing vision loss. In addition, wearing ultraviolet protecting sunglasses whenever outdoors and while driving is important for protecting the retina. If you are a diabetic, it is essential to get yearly dilated eye exams. Have any changes in vision, eye pain, redness, eye discharge, or eyelid problems looked at before things get worse. ďƒ‚





Protect your vision from DIABETES Have a dilated eye exam every year, and follow these steps to keep your health on TRACK


Take your medications as prescribed



Reach and maintain a healthy weight


Add more physical activity to your daily routine


Control your ABC’s : A1C, blood pressure, cholesterol levels


Kick the smoking habit


We specialize in Diabetes

| Health | Hormones | Weight Loss

CLINIC HOURS: Monday - Friday 7 am to 4 pm

Panama City Office


Destin Office

633 E Baldwin Road Panama City, FL 32405

1241 Airport Road, Suite M, 2nd Floor Destin, FL 32451

Phone 850.522.5490

Phone 850.460.7090

Fax 850.522.5491

Fax 850.460.7093

Thyroid | Adrenal | Pituitary | Osteoporosis | Parathyroid | Hormone Replacement | Polysistic Ovarian Syndrome Nutrition | Obesity | Hair Loss | Hypertension | Lipid Disorder | Thyroid Biopsies | Nuclear Medicine Ultrasound | Ankle Brachial Index Testing | Neuropathy Testing | Bone Densities

Both centers are supported by teams of specialty trained nurse practitioners and professional support staff, providing patients with the benefits of full service endocrine centers.

We also specialize in Medical

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Why Am I So Tired All the Time? by Dr. Ahmet Ergin, MD, CCE, ECNU


atigue (chronic tiredness) is a common complaint. A crosssectional survey of United States workers found the two-week period prevalence of fatigue to be 38%, with an estimated annual cost to employers exceeding $136 billion in lost productive work time. So, it is a big deal. It is common! You are not alone! Everyone feels tiredness in the afternoon and after work to a degree but if fatigue is preventing you functioning normally or reduce your performance at work you will need to talk to your primary care doctor or a specialist such as endocrinologists. At institute of Endocrinology we evaluate our patients for fatigue for the following possible causes. There are many hormonal (endocrine) causes of fatigue including low or high thyroid hormone levels, low vitamin D, high parathyroid hormone, diabetes, low testosterone levels, adrenal insufficiency, metabolic syndrome, etc. Yet, common non-hormonal factors that cause fatigue are listed below. At Institute of Endocrinology we test possible hormonal causes of fatigue yet also analyze the possible nonhormonal reasons listed below. Some non-hormonal medical causes of fatigue include depression,

fibromyalgia, anemia and chronic disease states (of any kind- such as chronic lung or kidney disease or heart failure, inflammatory diseases, etc.). Most of the time, fatigue can also be traced to one or more of your habits or routines, particularly lack of exercise. It’s also commonly related to depression whether the individual accepts being depressed or not. On occasion, fatigue is a symptom of other underlying physical or mental conditions that require medical treatment. Taking an honest inventory of things that might be responsible for your fatigue is often the first step toward relief. Fatigue may be related to: • Use of alcohol or drugs • Excess physical activity • Jet lag • Lack of physical activity • Lack of sleep • Medications, such as antihistamines or cough medicines • Unhealthy eating habits Of course, what is too much or too little regarding the inventory list above is a subject of debate. For example, people who try to eat healthy most of the time yet still cheat on their diet

CFS Symptoms Severe Headache


Joint Pain

Impaired Memory

Profound Exhaustion

Unexplained Muscle Pain

with comfort foods or processed foods, even occasionally, can still suffer from fatigue especially when there is some allergy component within that specific diet itself, such as gluten sensitivity or lactose intolerance. Physical activity should be at least 150 minutes per week with moderate intensity. Yet most people spend time in the gym 3 days- 30 min each time with low intensity activity and as a result their fatigue persists. Required sleep duration depends on the individual and changes anywhere from 6 to 8 hours from individual to individual. Everyone knows how many hours they are comfortable with. Sleep quality is also very important. For example, someone with sleep apnea will not feel refreshed even after 10 hours of sleep. There are clinical risk factors your doctors at Institute of Endocrinology determine in order to test you for sleep apnea when you are presented with fatigue. At Institute of Endocrinology we will do a thorough investigation to rule out medical reasons related to your fatigue symptoms. We will also review possible life style changes to improve your life and help you feel better. 


Unrefreshing Sleep

Sore Throat


Bio-identical Hormone Replacement.

Are You Ready Yet? T

he term “bioidentical hormone� technically refers to a hormone with the same molecular structure as a hormone that is endogenously produced (17-beta estradiol). However, in popular culture, the term refers to the use of custom-compounded, multi-hormone regimens with dose adjustments based upon serial hormone monitoring. Many postmenopausal women are turning to this approach because of safety concerns about conventional hormone preparations. We, however, agree with a number of expert groups including the North American Menopause Society and the Endocrine Society, both of whom advise against the use of custom-compounded hormones. The quality of the compounded products may be substandard in some cases. In one study, potencies ranged from 67.5 to 268 percent of the amount specified on the labeling of compounded drugs.

by Dr. Sherief Kamel, MD FACE ECNU & Ashli Brooks, FNP-BC

At Institute of Endocrinology we follow the highest, best evidence practice guidelines and we prefer to treat our patients with bio-identical hormone therapy that are FDA approved. We sometimes use compounded drugs if conventional treatment fails to achieve desired results. The goal of menopausal hormone therapy is to relieve menopausal symptoms, most importantly hot flashes (vasomotor symptoms). Other symptoms associated with perimenopause and menopause that respond to estrogen therapy include mood lability/depression, sadness, losing interest in activities, genitourinary symptoms of menopause such as dry skin and dry vagina, urinary tract infections and sleep disturbances (when related to hot flashes). Healthy symptomatic women in their 50s should know that the absolute risk of complications for healthy, postmenopausal women taking menopausal hormone therapy for five years is very low. The hormone bioidentical estrogen is the most effective treatment for menopause symptoms. Women who no longer have a uterus can take estrogen by itself. Women with a uterus must take estrogen with another hormone, called progesterone.

effective treatment

If you want to take hormones, ask your endocrinologist at Institute of Endocrinology if it is an option. You should not take hormones if you have had breast cancer, a heart attack, a stroke, or a blood clot. Family history of these conditions are not a contraindication for treatment. ďƒ‚ 13


What Is Diabetes And How Does iabetes is a disease state where the body’s D blood glucose control mechanisms fail in one or multiple ways. First, let’s understand the defective mechanisms behind development of diabetes. When the pancreas is under attack by its’ own immune system, insulin deficiency develops. When more than 90% of the pancreas is non-functional, diabetes type 1 occurs. The patient will have minimal or no insulin

of fat accumulation in fat cells. When cells are so enlarged, it creates stress within the cell and fat cells start secreting inflammatory signals and fatty acids. Inflammatory signals, as well as fatty acids, create a resistance to insulin action by interfering insulin receptors. As-a-result, insulin resistant individuals will need to secrete more insulin to overcome the resistance which also causes fatigue in insulin resistant patients. Moreover, insulin Type 1 Diabetes production decreases due to inflammation Symptoms may include: affecting the pancreas ¥¥ Frequent urination directly. All of these ¥¥ Increased thirst factors create a ¥¥ Extreme hunger syndrome called ¥¥ Marked weight loss metabolic syndrome. ¥¥ Extreme fatigue The stage after ¥¥ Irritability metabolic syndrome, is diabetes. At Institute of Endocrinology we highly recommend overweight individuals to go through a screening for metabolic syndrome and start a treatment process to prevent progression to diabetes. In fact, most large vessel complications such as heart attacks and strokes happen in metabolic syndrome stage, before diabetes develops. Once diabetes develops patients are then at risk of small vessel damage which can lead to blindness, kidney failure and neuropathy.

produced in their body. Whereas, type 2 diabetes is much different. There are eight different defects that occur in the process of developing diabetes. Type 2 diabetes begins with insulin resistance. Insulin resistance can start in a variety of ways, but the most common reason for insulin resistance is excessive weight gain. Weight gain occurs as a result 14

There are multiple defects in the development of diabetes. They are like a domino effect, one triggers the next. The first two as already discussed, include insulin resistance in the liver, muscle and fat along with lack of adequate insulin production to meet the demand from these tissues. Metformin and pioglitazone are drugs that are designed to improve insulin resistance in type 2 diabetic patients. continued on next page 


It Affect Our Lives? What other defects are there? One of the most important regulators of insulin are intestinal hormones which are secreted from the intestinal system to alert the pancreas about the presence of food and carbs. The pancreas immediately responds to these intestinal hormones and creates a big bolus of insulin to help glucose enter cells. In type 2 diabetics, intestinal hormones are produced less and they also become resistant to what is available. At Institute of Endocrinology we commonly treat our patients with intestinal hormone analogs to help overcome this defect so the pancreas can secrete the insulin needed after eating. The next important defect in diabetes is that kidneys reabsorb glucose after being filtered. Normal kidneys cannot handle blood glucose that exceeds 180 mg/dl resulting in excess unabsorbed glucose to be dumped into the urine. This is a protective mechanism of the body to prevent blood sugar from increasing to more than 180 mg/ dl in the blood. In diabetics however, this system is broken. Type 2 diabetics do not excrete glucose until blood glucose reaches 220. As a result they maintain constant high glucose levels in blood. There is a class of diabetes drugs which will block the receptors that reabsorb the glucose in kidney, asa-result patients excrete up to 70 gr of sugar in their urine daily. Of course, one of the best ways to control blood sugar is insulin which is what diabetics are deficient of. Today insulin drugs on the market are almost duplicate of human insulin, that’s why they are called biologics. They create the same affect as our own insulin. For example, basal insulin helps control the liver’s glucose production when metformin alone is not enough.


by Ahmet Ergin, MD, CCE, ECNU

Early insulin treatment, contrary to common belief, is beneficial. The delay in insulin administration can cause uncontrolled diabetes and complications. We have type 1 diabetics who have been using insulin for decades, and these patients as-long-as their blood glucose is under control never develop complications of diabetes. There are many different types of insulin however and this will be subject of another article.

We empower our patients to take control of their diabetes through education, selection of appropriate drugs individualized for each patient, and timely follow-up on the results of actions taken. Please visit us at Institute of Endocrinology for a complete evaluation and treatment of your diabetes. Take charge and say “no” to the complications of diabetes! 

Type 2 Diabetes Symptoms may include: ¥¥Any of the Type 1 symptoms ¥¥Recurring infections ¥¥Blurred vision ¥¥Cuts or bruises slow to heal ¥¥Numbness or tingling in the hands/feet ¥¥Frequent skin, gum, or bladder infections




What Does My Thyroid Do For My Metabolism? Thyroid hormones are critical for brain and organ development in infants and for metabolic activity in adults; they also affect the function of virtually every organ system. Thyroid hormones must be constantly available to perform these functions. To maintain their availability there are large stores of thyroid hormone in the circulation and in the thyroid gland. Furthermore, thyroid hormone biosynthesis and secretion are maintained within narrow limits by a regulatory mechanism that is very sensitive to small changes in circulating hormone concentrations. We have thyroid tests such as TSH, T4 and T3 levels to understand complex regulation of thyroid hormones at Institute of Endocrinology.

by Ahmet Ergin, MD, CCE, ECNU

Metabolism: Thyroid hormones stimulate diverse metabolic activities of most tissues, leading to an increase in basal metabolic rate. One consequence of this activity is to increase body heat production. A few examples of specific metabolic effects of thyroid hormones include:  Lipid metabolism: Increased thyroid hormone

levels stimulate fat mobilization, leading to increased concentrations of fatty acids in plasma.

 Carbohydrate metabolism: Thyroid hormones

stimulate almost all aspects of carbohydrate metabolism, including enhancement of glucose entry into cells.

Hypothyroidism or underactive thyroid means your thyroid isn’t producing enough thyroid hormones. And in many cases, the cause can be genetic or, you could be severely iodine deficient, since thyroid hormones need iodine to be produced. Or it can be caused by pituitary gland disorder which is the master gland for the body, or a traumatic physical injury to your neck and head, or from the removal or radiation of your thyroid gland and the list goes on and on. Yet, almost 90% of Americans who have hypothyroidism have chronic autoimmune thyroiditis (Hashimoto’s thyroiditis).

It is known that almost all cells in the body are targets for thyroid hormones. While not strictly necessary for life, thyroid hormones have profound effects on many “big time” physiologic processes, such as development, growth and metabolism. Deficiency in thyroid hormones is not compatible with normal health.

Hashimoto’s thyroiditis is an autoimmune problem, meaning your gland is being attacked by your own confused immune system. Either the protein in your thyroid called “thyroglobulin” is being attacked, or the thyroid enzyme “peroxidase” is being attacked. Both can result in thyroid cells being destroyed over time, and can create symptoms such as fatigue, depression, sluggishness, weight gain, hair loss and fluid accumulation. continued on next page 



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IMPORTANT SAFETY INFORMATION: MINIMED 670G SYSTEM The Medtronic MiniMed 670G system is intended for continuous delivery of basal insulin (at user selectable rates) and administration of insulin boluses (in user selectable amounts) for the management of type 1 diabetes mellitus in persons, fourteen years of age and older, requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin. The MiniMed 670G system includes SmartGuard technology, which can be programmed to automatically adjust delivery of basal insulin based on continuous glucose monitor sensor glucose values, and can suspend delivery of insulin when the sensor glucose value falls below or is predicted to fall below predefined threshold values. The system requires a prescription. The Guardian Sensor (3) glucose values are not intended to be used directly for making therapy adjustments, but rather to provide an indication of when a fingerstick may be required. A confirmatory finger stick test via the CONTOUR®NEXT LINK 2.4 blood glucose meter is required prior to making adjustments to diabetes therapy. All therapy adjustments should be based on measurements obtained using the CONTOUR®NEXT LINK 2.4 blood glucose meter and not on values provided by the Guardian Sensor (3). Always check the pump display to ensure the glucose result shown agrees with the glucose results shown on the CONTOUR®NEXT LINK 2.4 blood glucose meter. Do not calibrate your CGM device or calculate a bolus using a blood glucose meter result taken from an alternative site (palm) or from a control solution test. Do not calibrate your CGM device when sensor or blood glucose values are changing rapidly, e.g., following a meal or physical exercise. If a control solution test is out of range, please note that the result may be transmitted to your pump when in the “Always” send mode. WARNING: Medtronic performed an evaluation of the MiniMed 670G system and determined that it may not be safe for use in children under the age of 7 because of the way that the system is designed and the daily insulin requirements. Therefore, this device should not be used in anyone under the age of 7 years old. This device should also not be used in patients who require less than a total daily insulin dose of 8 units per day, because the device requires a minimum of 8 units per day to operate safely. Only use rapid acting U100 insulin with this system. Pump therapy is not recommended for people whose vision or hearing does not allow recognition of pump signals and alarms. Pump therapy is not recommended for people who are unwilling or unable to maintain contact with their healthcare professional. The safety of the MiniMed 670G system has not been studied in pregnant women. For complete details, including product and important safety information concerning the system and its components, please consult http://www.medtronicdiabetes.com/important-safety-information#minimed-670g and the appropriate user guide at http://www.medtronicdiabetes.com/ download-library * Refers to SmartGuard Auto Mode feature; The MiniMed® 670G system can automatically increase or decrease insulin delivery based on continuous glucose monitoring (CGM) values; however, the user must still administer meal boluses. 940M16849-011 20170420 © 2017 Medtronic MiniMed, Inc. All rights reserved.

Having enlarged, non-cancerous thyroid nodules are common, as experienced by many Hashimoto’s thyroiditis patients.

At Institute of Endocrinology we provide superb care which includes a very detailed thyroid biochemical work up along with a thyroid ultrasound to rule out thyroid nodules that can be cancerous. The term hyperthyroidism (overactive thyroid) refers to any condition in which there is too much thyroid hormone present in the body. In other words, the thyroid gland is overactive. Another term that you might hear for this problem is thyrotoxicosis, which refers to high thyroid hormone levels in the blood stream, irrespective of their source. If there is too much thyroid hormone, every function of the body tends to speed up. It is not surprising then that some of the symptoms of hyperthyroidism are

nervousness, irritability, increased perspiration, heart racing, hand tremors, anxiety, difficulty sleeping, thinning of your skin, fine brittle hair and weakness in your muscles—especially in the upper arms and thighs. Hyperthyroidism occurs as a result of Grave’s disease, a disease process similar to Hashimoto’s however, too much thyroid hormone is produced and is caused by the confused immune system attacking thyroid cells. Some patients will have thyroid nodules which will autonomously produce thyroid hormones. Occasionally an acute thyroiditis can occur as a result of an upper respiratory infection affecting the thyroid. Thyroid hormones initially rise then lower, and in the final stage either recover or stay low. As a result, at Institute of Endocrinology we pay very close attention to making the correct diagnosis and treat our patients accordingly. 

live healthy



May is Osteoporosis Awareness Month Defining Incidence

Roughly 54 million Americans suffer from osteoporosis or low bone mass placing them at increased risk for fracture. Studies suggest that after age of 50, approximately one in two women and one in four men will break a bone due to osteoporosis6. Additionally, twenty percent of seniors who have a hip fracture die within one year of surgery, or require long-term nursing home care.

Defining Osteoporosis

Osteoporosis is the breakdown of bone architecture or decreased bone production, causing the bones to become thin, weak, and easily broken (fractured).4

Why is identifying Osteoporosis important?

Osteoporosis is often referred to as a "silent disease" because you do not feel the degenerative process as it occurs. All too often, the first sign of osteoporosis is the breaking of a bone or decreased height. Osteoporosis is responsible for millions of broken bones and billions in related costs every year, with projected costs to be more than 18 billion by 20256. Osteoporosis can have many adverse effects such as, limiting a person’s mobility or causing chronic pain. Our goal is to screen at-risk individuals, determine their risk for fracture, and initiate preventive measures and treat bones early to avoid any degeneration complications.

1. Schousboe, J. T., Shepherd, J. A., Bilezikian, J. P., & Baim, S. (2013). Executive Summary of the 2013 International Society for Clinical Densitometry Position Development Conference on Bone Densitometry. Journal of Clinical Densitometry, 16(4), 455-466. doi:10.1016/j. jocd.2013.08.004 2. Cummings, S. R., Bates, D., & Black, D. M. (2002). Clinical Use of Bone Densitometry. Jama, 288(15), 1889. doi:10.1001/jama.288.15.1889 3. Eastell, R. (2012). Update on the Endocrine Society osteoporosis in men guideline. Bone, 50. doi:10.1016/j.bone.2012.02.044 4. Cosman, F., de Beur, S.J., LeBoff, M.S. et al.(2015). Osteoporosis International, 26(S2), 487-490.doi:10.1007/s00198-015-3362-0


Diagnosing Osteoporosis

For those affected by low bone mineral density (BMD) or Osteoporosis, prompt measurement of bone loss and calculation of fracture risk are essential in determining all treatment options. We have many tools for measurement of bone mineral density such as a dualenergy x-ray absorptiometry (DXA)2 and the Fracture Risk Assessment Tool (FRAX).5 DXA scan is an imaging tool that measures bone mineral density at common fracture sites such as hips, spine, or wrist. The DXA report gives a T-score, which compares the individuals bone mineral density to a 30-year-old female bone mineral density. The World Health Organization divides T-scores into different categories: Normal (-1.0 or higher), Osteopenia (-1.0 to -2.5), or Osteoporosis (-2.5 or lower), or Severe Osteoporosis (-2.5 or lower and fracture)10. We use the FRAX for calculating specific fracture risk over the next 10 years.5

Risk Factors for Osteoporosis • • • • • • • •


History of fracture of parent Personal history of fracture Certain races (Caucasian, Asian) Low body weight Alcohol or Tobacco Use Decreased physical activity Low intake of calcium Recurrent fall

Chronic Conditions and Medications Associated with Causing Bone Loss • Late onset Puberty or early loss of menses • Estrogen/Testosterone deficiency

5. Welcome to FRAX®. (n.d.). Retrieved May 14, 2017, from https://www. sheffield.ac.uk/FRAX/ 6. Singer, A., Exuzides, A., Spangler, L., O’Malley, C., Colby, C., Johnston, K., . . . Kagan, R. (2015). Burden of Illness for Osteoporotic Fractures Compared With Other Serious Diseases Among Postmenopausal Women in the United States. Mayo Clinic Proceedings, 90(1), 53-62. doi:10.1016/j.mayocp.2014.09.011 7. Stuart L, Hazem A, Undavalli C, Berima T, Prasad C, Erwin PJ, Montori VM (2012) Risk factors of osteoporosis related fractures in men: a systematic review and meta-analysis. J Clin Endocrinol Metab doi: 10.1210/jc.2011–3058

by Jamie Williams, MSN, ARNP, NP-C

• • • • • • • • • •

Hyperthyroidism Parathyroid disorders Vitamin deficiencies Gastrointestinal disorders Chronic lung disease Rheumatology disorders Antiseizure medications Long-term antidepressants (SSRI) Thyroid medication in excess Steroid use of over 2 months

Who needs to be screened? 3,9

According to the National Osteoporosis Foundation (NOF) and the Endocrine Society, screening is recommended for: All women age 65+ and men age 70+ regardless of risk factors or history of fracture. All age 50+ with risk factors, or a history of fracture after age 50. All with chronic conditions or that are on medications associated with bone degeneration. Younger postmenopausal women, women in the menopausal transition.

Good news-Treating Osteoporosis

We at Institute of Endocrinology can help you to preserve and restore your bone density. We work to minimize or eliminate risk factors and minimize or correct any underlying causes of the bone density breakdown8. For those already affected by osteoporosis, prevention measures and medication therapies can slow further loss of bone or even increase bone density. Each treatment plan is individualized for optimal results and providing convenience. There are many options for treatments, some offered to be administered in a quick medical visit at Institute of Endocrinology.  8. National Institutes of Health Consensus Development Program: Osteoporosis Prevention, Diagnosis, and Therapy. (n.d.). Retrieved May 14, 2017, from https://consensus.nih. gov/2000/2000Osteoporosis111html.htm 9. Are You At Risk? (n.d.). Retrieved May 14, 2017, from https://www.nof. org/preventing-fractures/general-facts/bone-basics/are-you-at-risk/ 10. World Health Organization – WHO Criteria for Diagnosis of Osteoporosis. (n.d.). Retrieved May 14, 2017, from http:// www.4bonehealth.org/education/world-health-organization-criteriadiagnosis-osteoporosis/


Medical tests Medical test

My target



e.g. 53 mmol/ mol (or 7%)

e.g. Every 6 months

(glycated hemoglobin)

Blood pressure

e.g. Less than 130/80 mm Hg

Total cholesterol

e.g. Less than 4 mmol/L

Date of test

My test results

Health Tracker Questions to ask your health professional about medical tests and health checks: ¥¥ What does the test/health check


¥¥ What are my targets for each

medical test?


¥¥ How often should I have each

e.g. Less than 2 mmol/L

test/health check?

¥¥ What will the test result/health

check tell me?

¥¥ How can I reach my targets?

Health checks Health check Feet

Eye M.D. How often to check

Date of appointment

of Niceville

You’ll See the Difference.

Action plan

Exams and Procedures Include:

• Annual Exams • Acute Appointments Eyes • Dry Eye • Macular Degeneration Kidneys • Glaucoma Teeth • Cataracts Questions to ask your health professional about medical tests and health checks • Diabetic Retinopathy 1. What does the test/health check involve?• Diabetic Plaquenil 2. What are my targets for each medical test? • Blepharoptosis 3. How often should I have each test/health check? • Excision of Skin Cancer 4. What will the test result/health check tell me? • Eyelid Surgery Weight


How can I reach my targets?

Dr. Nathaniel J. Ruttig Board Certified Comprehensive Ophthalmologist

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1480 Hickory Street | Suite 104 | Niceville, Florida

office 850.760.0500 | toll free 866.786.7773 | www.eyemdofniceville.com 19

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Institute of Endocrinology  

Specializing in Diabetes, Health & Hormones at our two office locations in Panama City Beach and Destin, Florida.

Institute of Endocrinology  

Specializing in Diabetes, Health & Hormones at our two office locations in Panama City Beach and Destin, Florida.