Please be advised that numerous lots of natural thyroid formulations (including Armour, NP thyroid, and Westhroid) have been recalled for subpotency. If you’re on one of these medications, check with your endocrinologist ASAP.

https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/rlc-labs-inc-issues-voluntary-nationwide-recall-all-lots-nature-throidr-and-wp-thyroidr-current?fbclid=IwAR1ZWQ_Y0FLajEgoS1MnPFYik_UOvaAlf-_NAfYLB5TJDthGN_7EOdmRQkc

By Meghana Kumar, MD

Vitamin D: The Sunshine Vitamin | Chronicles in Health

Vitamin D has been a buzzword of sorts lately during the COVID-19 pandemic. It’s a vitamin that acts more like a hormone and has been implicated in all sorts of processes in the human body. Read on to find out why you should make sure to maintain normal levels of vitamin D and how to do so.

Vitamin D comes from two primary sources: food/supplements and sunlight (hence why it’s nicknamed the “sunshine vitamin”). This is activated by enzymes in the body, and activated vitamin D then helps to regulate calcium and phosphorus levels. So inadequate Vitamin D means that we lack some of the key building blocks for healthy bones.

A deficiency of vitamin D can lead to fatigue, weakness, poor balance, increased fall risk, bone pains, and, if prolonged and severe, can affect bone strength and even lead to bone fractures. As we get older and osteoporosis risk increases, it is especially crucial to maintain adequate vitamin D levels. It has also been linked to the body’s protection against infections, wound healing, and mood.

Fortunately, vitamin D deficiency, which can be checked by bloodwork, is typically easy to fix. Most experts recommend that adults get at least 600 IU of vitamin D per day. As you can imagine, vitamin D deficiency is particularly common in the wintertime when people spend less time outdoors in the sun. Here are some foods that are excellent sources of vitamin D:

-fish

-egg yolks

-mushrooms

-cheese, yogurt, milk

-fortified orange juice

-fortified cereals

However, for some people, dietary intake and sunlight exposure still are not enough. Before starting a vitamin D supplement, check with your doctor about what the appropriate dose, type, and route is. For example, people with kidney or liver impairment may need special formulations of vitamin D that are already activated. Someone with gastrointestinal problems may need a higher dose to achieve adequate absorption of the vitamin D. Vitamin D toxicity is possible, so you want to make sure not to overdo the supplements.

When you go to the pharmacy aisle, you will notice that vitamin D comes in two forms: D2 (ergocalciferol) and D3 (cholecalciferol). D2 comes from plant-sources while D3 comes from animal sources. Most studies show that D2 and D3 are equally effective, though the source may be important to consider if you practice a vegan diet.  

Like any supplement, it’s important to discuss the details with your doctor. Though mineral and vitamin supplements are easy to obtain over the counter, the minutiae of dosing and formulation can have significant impacts on your body if not carefully supervised. So next time you’re in the pharmacy, take a good look at the supplement aisle and do your research before investing in a bottle!

by Meghana Kumar, MD

Sugar Free Assortment, 17.75 oz bag | Russell Stover

You’ve seen the aisles of enticing desserts aimed for people with diabetes in the grocery store – puddings, chocolate bars, cookies. Can you really indulge in these products guilt free?

These sweets tend to be sweetened with artificial sweeteners, like Splenda, Stevia, and aspartame. Artificial sweeteners have been linked with obesity, appetite stimulation, and glucose intolerance as well, though not nearly to the same extend as regular sugar. They can also cause bloating, diarrhea, and abdominal pain, especially when consumed in excess.

Remember that sugar-free doesn’t necessarily mean carbohydrate-free – it often simply means that the product contains no added sugar. In other words, carbohydrates come in more forms than refined white sugar. A sugar-free vanilla pudding (Jello single-serve cup) still has 10 grams of carbs, stemming from the dairy contents. While better than the 25 grams in a regular pudding, it may still impact your blood sugar and certainly is not a license to eat without inhibition. One Voortman’s sugar-free chocolate chip cookie contains 14 grams of carbohydrates (coming from flour), but no added sugars. This distinction is especially important for people who need to count and dose insulin for carbohydrates precisely.

Calorie and saturated fat content often do not differ significantly between sugar-free chocolate and regular desserts. For example, a chocolate bar still has fat and calories from milk and cocoa butter. So keep in mind that, carbs aside, there are usually healthier choices than highly processed sugar-free snacks – fresh fruits, a scoop of cottage cheese, carrot sticks and hummus, etc.

Some people may find moderation with regular desserts to be a more satisfying and equally healthy choice. For instance, 2 pieces of Hershey’s Dark Chocolate Nuggets with almonds have 10 grams of carbs, whereas 3 pieces of Hershey’s sugar-free Special Dark chocolates have 13 grams of carbs. If you can stop yourself at one or two pieces, then the former may be a preferable option.  

In short, don’t just rely on advertising (the people who design food packaging are savvy!) – look at the nutritional labels and make the decision for yourself about whether a food item is a healthy choice or not.

Meghana Kumar, MD

What Should I Look for When Buying Whole Grains? - The New York Times
Photo c/o: https://www.nytimes.com/2020/03/16/well/eat/what-should-i-look-for-when-buying-whole-grains.html

In many cuisines, white rice is a staple of the dinner table – but one cup of cooked white rice has almost 50 grams of carbohydrates! This can put someone with diabetes in a tough position when it comes to reconciling sitting down to a family meal with their health needs. Here are some healthy alternatives to white rice that won’t force you to compromise on flavor.

First some terminology:

A carbohydrate (carb for short) is a molecule that is broken down to sugar for use as energy in the body.

Net carbs represent the total carbs in a food item minus fiber (which is not digested and therefore does not impact blood glucose). Net carbs are comprised of simple and complex carbs. Simple carbs are quick to digest whereas complex carbs (which are made of longer chains of molecules) take longer to digest. Complex carbs do not spike blood sugar as dramatically or rapidly and provide energy for a longer duration. Therefore, complex carbs are considered a superior option for diabetics.

Low carb substitutes:

  1. Vegetable rice – You can make this yourself in seconds using a food processor or buy it ready-made. Any vegetable can be riced if you get creative – sweet potatoes, cabbage, cauliflower, broccoli, etc.  1 cup of cauliflower rice = 4 grams of total carbs, 2 grams of net carbs.
  2. Shirataki rice – Made from konnyaku flour, this rice can have a distinct odor and texture but is a great addition to a ketogenic diet. Look online for tips to make shirataki rice palatable. 1 cup = 5 grams of carbs, 0 grams of net carbs.

Moderate to high carb substitutes:

Brown rice, quinoa, couscous, barley, bulghur, buckwheat, farro, freekeh, and other grains are all still relatively high in starch, containing 30-50 grams of total carbohydrates per cup. But don’t write these options off completely! They also contain higher amounts of fiber and protein than white rice. They have varying amounts of important minerals like iron, selenium, and calcium. Most importantly, the carbohydrates they do contain are complex. These characteristics help carbohydrates to be absorbed and digested more slowly, allow you to stay full for longer with a smaller quantity of food, and are ultimately far better than white rice for your blood sugars.

Next time you go to the grocery store, we encourage you to step out of your comfort zone and try something new. The varieties are endless – if you don’t like brown rice, try brown jasmine or basmati rice. If not white quinoa, see if red quinoa is more up your alley. Happy eating!

Meghana Kumar, MD

Image courtesy of https://blog.drseeds.com/thyroid-hormone-overview/

Thyroid hormone replacement is the mainstay of treatment for hypothyroidism, whether the hypothyroidism is caused by radiation, surgery, or Hashimoto’s disease (autoimmune destruction of the thyroid gland). The goal is to replace the body’s production of thyroid hormone in the most physiologic way possible. However, a quick internet search will reveal an overwhelming number of options for thyroid hormone replacement. In this article, we will break down the different brands of thyroid hormone available in the US and things to consider before selecting a formulation.

A normal thyroid gland produces 80% T4 (inactive thyroid hormone) and 20% T3 (active thyroid hormone). Various organs have enzymes which convert T4 to T3, which then mediates all the functions of thyroid hormone, from sleep to digestion to temperature regulation.

T4-only formulations:

Generic – Levothyroxine

Brand name – Synthroid, Levoxyl, Euthyrox, Unithroid, Tirosint

These medications are usually the first-line treatment offered. It is important to stay on the same brand or advise your doctor if you are prescribed a different brand than before. Different brands even at the same dose may have slightly different contents.

All these medications are comparable in effectiveness. Tirosint is notable because it comes in a gel capsule or solution form, which can help with medication absorption. Some patients may experience more stable thyroid levels upon switching from generic to brand name hormone.

T3 and T4 combination formulations:

Thyroid extract medications: Armour, NP Thyroid, Nature-Thyroid, WP Thyroid, Westhroid

Synthetic: Cytomel/Liothyronine (T3) plus one of the T4 medications listed above.

Most doctors are reluctant to prescribe thyroid extract medications (which are made from dried and powdered pig thyroid glands) because they do not simulate the normal human thyroid production closely. They tend to contain high concentrations of T3 which can cause highly variable levels and symptoms.  Prescribing T3 and T4 as separate pills allows the doctor to control the ratios of each.

A T3-only medication regimen is generally not prescribed.

There are a number of factors that go into selection of a thyroid hormone replacement. Your endocrinologist can talk to you further about which medication is the best choice for you, and why.

Meghana Kumar, MD

Glucometers have revolutionized the management of diabetes. Early glucometers were clunky, slow, and required large drops of blood. The oldest ones simply displayed a color that had to be correlated to a numeric chart. On the other hand, the sleek, pocket-sized devices of today are lightning-fast and accurate.

So it’s no wonder that self-monitoring of blood glucose has become the standard of care. At its best, it lights our path in achieving glycemic control. At its worst, it’s an influx of confusing data, a constant reminder of this condition. So how do we make sure the glucometer is an asset rather than a nuisance?   

5 things you should know about using a glucometer:  

  1. Timing matters. It’s not enough to merely check glucoses – your provider also needs a context for these glucose values. Make sure the date and time settings on the meter are correct, and if you keep a log, write the times alongside the values. Even better, make note of the relationship of the readings to meals. Checking pre-meal glucoses is a good place to start, and your doctor may want you to check 1-2 hours after a meal or overnight too.
  2. Clean hands, accurate readings. Wash your hands with soap and water – and dry thoroughly! Residue of certain substances (like fruit) can artificially raise your glucose reading. Water can make the glucose look lower than it really is. Alcohol swabs or hand sanitizer will work too in a pinch, but keep in mind that applying alcohol excessively may dry out your skin.
  3. Fingersticks don’t have to be a pain. Pricking on the side of the finger rather than the finger pad can help, since that region contains less sensory nerve endings, as can changing the lancet type or size. Alternate site testing (AST) refers to testing glucose from sites other than fingers – ie. Palm, forearm, thigh, abdomen. Ask your provider if your meter is approved for AST. Values from alternate sites tend to lag behind your actual blood glucose level, so the readings must be interpreted with caution.
  4. What to do when numbers don’t make sense. Each finger is giving you a different reading, or you’re getting vastly different readings only minutes apart – how frustrating! First, ensure that your test strips aren’t expired, the test strips were properly stored, and your hands are clean. Make sure you’re giving an adequate blood sample. Then give the control solution a try. This is the small bottle that comes with every new meter. Apply a drop of this solution on the test strip to verify the accuracy of the glucometer. Your endocrinologist can send a prescription of the control solution to your pharmacy (and remember, it has an expiration date, too).
  5. You can identify patterns too. Whykeep a log if the meter records all the glucoses? For one thing, it saves time at your appointment if the provider has a log to look through, leaving more time for us to discuss important management issues. But more importantly, a log helps you to recognize trends – like what that mid-afternoon vending machine treat does to your blood sugar.

Novo Nordisk is offering a free 90-day supply of insulin to those who have lost health insurance due to the COVID-19 pandemic AND has expanded their patient assistance program for discounted insulin. Ask your endocrinologist for more information to see if you may qualify.

Letal Garber, MS, RD, LD

Diabetes and Covid-19: What you need to know and tips on management

During a time of uncertainty, it’s easy to get stressed or panicked. Our practice stands by our philosophy that knowledge is power; the more informed you are, the better chances of a good outcome. Our goal is to propagate safety and minimize fear during this difficult time.

Here’s what we know about the connection of Covid-19 and Diabetes:

  1. People may be infected with the virus up to two weeks before developing symptoms.
  2. The most common symptoms are fever, fatigue, and cough.
  3. Most people recover from the virus, but the disease can be more dangerous to those who have chronic conditions such as Diabetes.
  4. This is especially true with pre-existing complications secondary to uncontrolled Diabetes, which could mean increased risk of infection and difficulty with healing due to poor circulation.
  5. If Diabetes is well managed, your risk of getting severely sick from Covid-19 is about the same as the general population.

Here’s what you can do to reduce your risk:

  1. General:
    1. Follow government and state guidelines for dealing with Covid-19.
    1. Do your part by staying home, wash hands, avoid touching your face, sneeze in tissues or your elbow, and sanitize commonly used surfaces.
    1. Practice social distancing and minimize contact with others.
      1. Keep your appointments by scheduling virtual visits! We are now offering telemedicine appointments with a simple click of a button. You can join the virtual appointment by clicking on the link sent to you via email or text. For those of you with upcoming appointments, if you don’t hear from us first, give us a call to change the visit to a virtual meeting.
  2. Medication Management:
    1. Make sure you maintain a stockpile of oral medications and/or insulin and keep these properly stored.
    1. Also keep enough inventory of testing supplies (test strips, lancets), ketone strips, alcohol wipes, glucose tablets and/or sugar-containing fluids such as juice for low blood sugars.
    1. You may want to ask for 90-day prescriptions with refills versus the typical 30-day prescription.
    1. Ask your insurance if they contract with mail order pharmacies to reduce need to leave the house.
    1. If you’re having difficulty affording your medication, investigate patient assistance programs and resources such as InsulinHelp.org. If you’re running low on insulin and/or can’t afford insulin, don’t go without it. Wal-Mart has mealtime and 24-hour insulin that doesn’t require a prescription, just ask your provider.
    1. Keep a stock of broth, jello, electrolyte drinks, canned or frozen foods in the event of acute illness.
  3. Lifestyle Management:
    1. Monitor your blood sugars regularly and send in your blood sugar data to your provider for adjustment of your medications.
    1. Aim for 3 balanced meals per day with lean protein such as beans, chicken, fish, nuts/seeds, complex carbs (whole wheat pasta, baked potato, peas), and many vegetables. Stay hydrated with water.
    1. Limit high carb snacks, chips, dessert and beverages and fried foods.
    1. Engage in “joyful movement” most days of the week (30 minutes of moderate activity 5 times per week at minimum). Think about what activities you enjoy: walking, aerobics, biking and stick to it!
    1. Practice self-care in order to manage stress and improve mental health. Be intentional about finding ways to relax whether it’s reading a new book, practicing a new skill, or simply listening to calming music.

We can’t change the fact that this pandemic has impacted the world. What we can change is the extent to which we inform ourselves and make choices that improve our wellbeing. Stay informed, calm, safe, and healthy and we hope to hear from you soon!

In light of the COVID-19 pandemic and recommendations for physical distancing by the CDC, we have created the option for virtual or electronic appointments for our patients. This may particularly be of interest for patients who are at high risk for contraction of the virus (people who are over the age of 60, have diabetes, are immunosuppressed, etc.)

If you would like to arrange a virtual appointment with any of our providers, please call our front desk. We will assess the need for labs and in-person visits on a case-by-case basis.

We wish you good mental and physical health during this difficult time. We are here to help you!