Status of Bone Mineral Density in Patients with Hyperthyroidism

Vitamin D deficiency is widely prevalent in patients with hyperthyroidism along with lower bone mineral density. Against this background, the present study aims to analyze the status of bone mineral density in patients with hyperthyroidism along with age and sex matched controls. 70 consecutive patients and controls were analyzed for thyroid function test, BMD parameters and DEXA scan. The values of BMD parameters were analyzed at the baseline in both patients & control group. The baseline values of vitamin D and PTH of both the groups were 19.24±10.15 Vs 28.38±14.56 and 69.81±57.41Vs 58.53±46.49 respectively. BMD at spine and Hip were -1.38±1.31 Vs -0.26±0.80 and -1.02±1.11 Vs -0.22±0.93 respectively. The BMD of total body was 1.044±0.10 Vs 1.160±0.08. Vitamin D deficiency was found to be prevalent in patients with hyperthyroidism along with significantly reduced BMD compared to controls. The occurrence of osteopenia was higher than osteoporosis in the patient group at both lumbar spine and hip region

Metabolic Profile of Young Onset Type 2 Diabetes Mellitus Patients and Their First Degree Relatives

Objective: There is a paucity of data on the metabolic profile of the first degree relatives of young onset type 2 diabetes mellitus especially from India. Therefore, this study was done to evaluate the metabolic profile of young- onset type 2 diabetic patients and their first degree relatives. Material and method: Thirty young- onset type 2 diabetic patients of age < 30 yrs and 89 first degree relatives (28 parents and 61 siblings) were assessed for anthropometric parameters such as BMI, waist circumference, waist hip ratio and body mass index. Various biochemical tests were done which included fasting and 2 hours post 75 gm glucose load, glycated haemoglobin (HbA1c), lipid profile and renal function test. Metabolic syndrome was diagnosed as per National Cholesterol Education Program- Third Adult Treatment Panel III (NCEP- ATP III) criteria and IDF criteria.Results: Mean age of the patients was 27.53 years whereas mean age of the first degree relatives was 36.53 years. Mean BMI of the patients and first degree relatives were 26.46 and 25.46 kg/m2 respectively. 60% of patients and their first degree relatives separately fulfilled the IDF criteria for central obesity. 51 (57.3%) first degree relatives fulfilled the WHO criteria for abdominal obesity. Family history of diabetes was seen in 60% of these young diabetics. Out of 89 first degree relatives, 32 relatives (35.9%) were found to have diabetes and additional 13(14.6%) relatives had either impaired fasting glucose or impaired glucose tolerance test results. 18 (60%) patients and 48 (54%) first degree relatives fulfilled the IDF criteria for metabolic syndrome. According to NCEP ATP III criteria, 73.3% of these young onset diabetic patients and 50% of their first degree relatives fulfilled the criteria for metabolic syndrome.Conclusion: More than 50% of the first degree relatives of the young onset type 2 DM patients fulfill the criteria of metabolic syndrome and 50% of these FDRs have diabetes or prediabetes. Hence, our study clearly reinforces the importance of screening the first degree relatives for metabolic parameters, as it will detect metabolic syndrome or diabetes early in this high risk group so that appropriate treatment can be started in time to prevent the complications

VITAMIN D; AN EVIDENCE BASED MEDICINE

Vitamin D [25OHD] is both a nutrient and hormone which provides wide variety of health benefits to human health; hence makes it unique. Vitamin D deficiency prevails all over Indian subcontinent including both urban and rural population with a prevalence rate 70%–100% in general Indian population [1]. Vitamin D deficiency leads to rickets, osteomalacia and osteoporosis.  Vitamin D also plays an important role in cardiovascular diseases, diabetes, cancer and infectious disease such as tuberculosis.  The health benefits of vitamin D are beyond bone metabolism confirmed from various studies. vitamin D not only regulate calcium metabolism but also regulates insulin production, reduces the risk of diabetes and cancer, rennin production, helps in destruction of infectious agents, regulates cell growth, enhances immunity, maintenance of vascular tone of the body, myocardial function and helps in many more complex diseases [2]. Recently, Vitamin D has received enormous attention worldwide and referred as drug of the decade. The advocacy for vitamin D supplementation would not have been done only for populations who are at risk for developing vitamin D deficiency; sensible sun exposure is an inexpensive and enjoyable way to maintain vitamin D stores. Unfortunately, it seems a paradox where majority of population is vitamin D deficient living in sunny country. Reasons to this problem are many including higher melanin content, environmental (latitude &amp; altitude), clothing pattern, food habits and genetic factors [3].  Although, Randomized controlled trials provide some low-quality evidence to support vitamin D supplementation for the reduction of asthma exacerbations in children is either limited or inconclusive with limitations such as high degree of clinical diversity (interventions and outcomes) and methodological heterogeneity (sample size and risk of bias) in included trials are challenges  [4]. Results of recent trials assessing the effect of vitamin D supplementation on the prevention of childhood acute respiratory infections (ARI) have been also inconsistent [5] and have no beneficial effect of vitamin D in improving insulin resistance was identified as well [6].  In addition vitamin D supplementation (1400 IU/ week) to low birth weight infants did not decrease the incidence of severe morbidity and mortality. (7)   On the other hand results of various studies supports the vitamin D supplementation including improvement in handgrip strength [8] increased newborn's length [9] reduces risk of maternal co-morbidities and helps improve neonatal outcomes [10]. Vitamin D requirements are probably greater in pregnancy, as evidenced by physiologically higher 1,25-dihydroxy vitamin D levels seen in the second and third trimesters. Studies recommended that vitamin D should continue to supplement in all pregnant women from the 12th week of gestation onwards [11]. Whether Vitamin D supplementation in prediabetes subjects prevents the development of diabetes is a matter of debate, and the results are inconsistent from available studies. Short-term vitamin D supplementation was found helpful in the decline of residual beta cell function (RBCF) in children with type 1 diabetes [12]. A study in subjects with pre-diabetes evaluated the effect of 12 months of Vitamin D supplementation on glycemic parameters and progression of pre-diabetes to diabetes in an ethnically homogeneous Kashmiri population, found that vitamin D supplementation helps significantly in  lowering FPG, 2-h plasma glucose and A1C levels [13]. On the other hand vitamin D supplementation (200 IU/day) did not affect plasma CRP and whole blood cytokine production of low birth weight infants (14). Study on healthy subjects also shown beneficial effect that were supplemented with cholecalciferol at a dose of 60,000 IU/week for 12 weeks resulted in improvement in the skeletal muscle energy metabolism[15].  Oral dose of vitamin D can be easily distributed among populations. However, 1000 IU of vitamin D/day has shown better results than 60, 000 IU/week in populations but it will be difficult to feed 1000 IU/Day to populations due to logistics issues. So, 60,000 IU/ week up to 8 weeks then once a month may be chosen as a dose schedule in populations [16]. Moreover, the usual calcium pill contains 200 IU of vitamin D and 2 pills a day equals 400 IU/day which is grossly inadequate. To achieve optimal serum 25 (OH) D levels i.e. 30 ng/ml in population; 2000 IU of vitamin D/day is required [17] thus at present it may be safest to adhere to 2000 IU/day as a standard practice in India. Indian studies regarding vitamin D supplementation including pregnant women [18], Young women [19] and asian Indians [20] already shown beneficial effect. Studies in animal models show plausible evidence in favour of vitamin D as an anti-inflammatory agent and a viable option for treatment of anti- inflammatory disease i.e crohn's disease (CD). Epidemiological and cross sectional studies indicate that vitamin D may have a potential of treating CD in humans [21]. Recent findings from various studies provide evidence of a possible beneficial effect of vitamin D supplementation in patients with early Parkinson's disease [22], respiratory tract infections [23] chronic heart disease (CHD) [24] and also helps in strengthening femoral neck (FN) in a dose-dependent manner, especially in women [25]. In a recent study we have shown improvement in bone health after vitamin D supplementation in patients with hyperthyroidism [26].  Hence, we propose that vitamin D may be used as evidence based medicine in clinical practice. This will also helpful in mitigating the growing burden of communicable and non-communicable diseases in India. The health benefits of vitamin D are beyond bone metabolism confirmed from various studies. vitamin D not only regulate calcium metabolism but also regulates insulin production, reduces the risk of diabetes and cancer, rennin production, helps in destruction of infectious agents, regulates cell growth, enhances immunity, maintenance of vascular tone of the body, myocardial function and helps in many more complex diseases [2]. Recently, Vitamin D has received enormous attention worldwide and referred as drug of the decade. The advocacy for vitamin D supplementation would not have been done only for populations who are at risk for developing vitamin D deficiency; sensible sun exposure is an inexpensive and enjoyable way to maintain vitamin D stores. Unfortunately, it seems a paradox where majority of population is vitamin D deficient living in sunny country. Reasons to this problem are many including higher melanin content, environmental (latitude &amp; altitude), clothing pattern, food habits and genetic factors [3].  Although, Randomized controlled trials provide some low-quality evidence to support vitamin D supplementation for the reduction of asthma exacerbations in children is either limited or inconclusive with limitations such as high degree of clinical diversity (interventions and outcomes) and methodological heterogeneity (sample size and risk of bias) in included trials are challenges  [4]. Results of recent trials assessing the effect of vitamin D supplementation on the prevention of childhood acute respiratory infections (ARI) have been also inconsistent [5] and have no beneficial effect of vitamin D in improving insulin resistance was identified as well [6].  In addition vitamin D supplementation (1400 IU/ week) to low birth weight infants did not decrease the incidence of severe morbidity and mortality. (7)   On the other hand results of various studies supports the vitamin D supplementation including improvement in handgrip strength [8] increased newborn's length [9] reduces risk of maternal co-morbidities and helps improve neonatal outcomes [10]. Vitamin D requirements are probably greater in pregnancy, as evidenced by physiologically higher 1,25-dihydroxy vitamin D levels seen in the second and third trimesters. Studies recommended that vitamin D should continue to supplement in all pregnant women from the 12th week of gestation onwards [11]. Whether Vitamin D supplementation in prediabetes subjects prevents the development of diabetes is a matter of debate, and the results are inconsistent from available studies. Short-term vitamin D supplementation was found helpful in the decline of residual beta cell function (RBCF) in children with type 1 diabetes [12]. A study in subjects with pre-diabetes evaluated the effect of 12 months of Vitamin D supplementation on glycemic parameters and progression of pre-diabetes to diabetes in an ethnically homogeneous Kashmiri population, found that vitamin D supplementation helps significantly in  lowering FPG, 2-h plasma glucose and A1C levels [13]. On the other hand vitamin D supplementation (200 IU/day) did not affect plasma CRP and whole blood cytokine production of low birth weight infants (14). Study on healthy subjects also shown beneficial effect that were supplemented with cholecalciferol at a dose of 60,000 IU/week for 12 weeks resulted in improvement in the skeletal muscle energy metabolism[15].  Oral dose of vitamin D can be easily distributed among populations. However, 1000 IU of vitamin D/day has shown better results than 60, 000 IU/week in populations but it will be difficult to feed 1000 IU/Day to populations due to logistics issues. So, 60,000 IU/ week up to 8 weeks then once a month may be chosen as a dose schedule in populations [16]. Moreover, the usual calcium pill contains 200 IU of vitamin D and 2 pills a day equals 400 IU/day which is grossly inadequate. To achieve optimal serum 25 (OH) D levels i.e. 30 ng/ml in population; 2000 IU of vitamin D/day is required [17] thus at present it may be safest to adhere to 2000 IU/day as a standard practice in India. Indian studies regarding vitamin D supplementation including pregnant women [18], Young women [19] and asian Indians [20] already shown beneficial effect. Studies in animal models show plausible evidence in favour of vitamin D as an anti-inflammatory agent and a viable option for treatment of anti- inflammatory disease i.e crohn's disease (CD). Epidemiological and cross sectional studies indicate that vitamin D may have a potential of treating CD in humans [21]. Recent findings from various studies provide evidence of a possible beneficial effect of vitamin D supplementation in patients with early Parkinson's disease [22], respiratory tract infections [23] chronic heart disease (CHD) [24] and also helps in strengthening femoral neck (FN) in a dose-dependent manner, especially in women [25]. In a recent study we have shown improvement in bone health after vitamin D supplementation in patients with hyperthyroidism [26]. Hence, we propose that vitamin D may be used as evidence based medicine in clinical practice. This will also helpful in mitigating the growing burden of communicable and non-communicable diseases in India

Complete Remission in Newly Diagnosed Type 1 Diabetes Mellitus Patient

Type 1 diabetes mellitus is a chronic disease affects pancreatic beta cells. Usually it has a life long duration, however, in few cases, it can be transient. We reported a 20 year old male patient who visited the diabetic clinic of Lok Nayak Hospital with classical symptoms of type 1 diabetes mellitus. He was diagnosed with type 1 diabetes on the basis of lab parameters. He was found to be positive for ICA512 and GAD antibodies. Measurement of C-peptide was also done by mixed meal tolerance test. Initially, Insulin was advised to control hyperglycemia. After 2 weeks, he was given 14 infusions of Teplizumab injection, one infusion per day and the same has been repeated after six months. As per clinical judgment, it was assumed that he was not on placebo arm and probably received Teplizumab as investigational product. Teplizumab injection drastically reduces the insulin doses and after some time, his insulin was completely waived off. Complete remission was seen in this patient after treatment with Teplizumab injection. During the 4 years follow-up, this remission is still ongoing in this patient. He had normal fasting and home blood glucose concentration with normal HbA1c without insulin therapy from last 4 years. To keep his blood sugar values under control, patient was also advised regular exercise and a diabetic diet

Vitamin D Supplementation improves Bone Mineral Density in Patients with Hyperthyroidism

Background: Diseases of the thyroid gland are a common occurrence in India. Thyrotoxicosis causes acceleration of bone remodeling and even though it is one of the known risk factors for osteoporosis, the metabolic effects of thyroxine on bone is a little- discussed subject.Materials & Methods: 70 consecutive patients with hyperthyroidism attending endocrine clinic of Maulana Azad Medical College. Serum total calcium, phosphorous, urinary creatinine and alkaline phosphatase were measured by standard methods. Serum T4, serum 25(OH)D estimations were done by radioimmunoassay assay. Serum intact PTH and TSH concentration was measured by immune-radiometric assay using commercial kits. Bone mineral density was measured using Hologic DR 4500A densitometer. Bone mineral density was measured at both hips, and lumbar spine (L2-L4) using anteroposterior view. 50% of the patients were randomized for vitamin D supplementation.Results: The mean age of the patients was 39±10.01 years. The baseline vitamin D of the patients was 19.24±10.15 ng/ml. The values of vitamin D in randomized and non-randomized patients were 27.82±16.43 vs 11.82±6.58 ng/ml (p>0.0001) respectively. Patients who received vitamin D had acquired optimum level of vitamin significantly, whereas, BMD at lumbar spine was also found increased after post treatment of vitamin D. However, it was not significantly raised when compared with the pre treatment. BMD at hip region was found elevated after post-treatment. There was an improvement noticed in total body BMD as well.Conclusion: Patients with active thyrotoxicosis, acquired optimum vitamin D levels, elevated lumbar spine and hip BMD after one year of vitamin D supplementation. Vitamin D supplementation is necessary to be advocated in patients with hyperthyroidism