By Dr. Tira Chaicha-Brom

Osteoporosis is a condition of weak bones and carries a high fracture risk and in turn increased mortality. Unfortunately, this condition typically goes undiagnosed because it is typically asymptomatic, unless someone was to have a fracture. 10.2 million Americans have osteoporosis and 43.4 million have the precursor osteopenia. Often, people will assume that having a “hunchback” is a sign of osteoporosis, but that is not always the case. If someone were to have lost some height, this could indicate a vertebral fracture which would be diagnostic for osteoporosis.  Sometimes people will assume that because they are old and have hip or back pain, that they have osteoporosis. However, osteoporosis does not hurt and the pain that patients complain about is more likely related to arthritis which is due to joint pain. Osteoporosis typically affects women more than men due to menopause but it is often underdiagnosed in men since they are not usually screened for the disease.

How is osteoporosis diagnosed if it is asymptomatic?  We typically order a bone density. A bone mineral density (BMD) is a painless procedure where one is laying on his/her back and x-rays are taken of the spine and hip and sometimes, the wrist.  A BMD can help predict the risk of fractures but it is not used to diagnose fractures, which would require a different imaging study such as a plain film X-rays.  For post- menopausal women and men above the age of 70 a T-score of -2.5 or lower on a BMD is diagnostic for osteoporosis.  Interestingly, though, most fractures occur in the osteopenia range since more patients will be in this category.  Another way a patient could be diagnosed with osteoporosis is to have an osteoporotic, or fragility, fracture. This type of fracture occurs from a fall from a standing position and results in a fracture of a large bone such as the hip, spine, or arm and often excludes fractures of the feet or fingers.

Our bones are the strongest when we are in our 30s and after that we start to lose bone density.  Some people will lose bone density at a faster rate than others due to changes in sex hormones (estrogen and testosterone) among other factors such as weight, medications (especially long term steroid use), or smoking. Other risk factors for bone loss include being thin, diabetes, inflammatory bowel disease, and a family history of osteoporosis.  If you are diagnosed with osteoporosis, typically your doctor or endocrinologist will evaluate your blood or urine to look for causes to explain the bone loss, but oftentimes there are no underlying reasons.

The United States Task Force recommends starting to screen women at the age of 65 years old for osteoporosis with a bone density. Even though they do not recommend screening for men, the National Osteoporosis Foundation recommends for men to be screened starting at years old.  Patients with certain risk factors may be screened before these ages.

There are several treatments available for osteoporosis which are offered based on a patients risk for fracture.  Typically, if a patient is of high risk for fracture then oral medications can be used but for those who are very high risk, it oftentimes requires medications that are injected. Most of the options will help prevent further loss of bone (bisphosphonates and denosumab). One class of medications will help develop new bone (PTH analogs) and another class can do both – increase bone and also stop it from declining (romosumab).  Each of these medications has its own side effect profile and your doctor can help you determine which treatment is appropriate for you. 

            Oftentimes, patients will be scared to start a medication due to the potential side effects. One of the more commonly prescribed medications for osteoporosis is the bisphosphonates (e.g. Fosamax/alendronate, Boniva/ibandronate, Actonel/risedronate). This class of medication has been around since 1990 and is very effective.  The two main side effects are osteonecrosis of the jaw (ONJ) and atypical femur fractures (AFF).  ONJ refers to exposed jaw bone that does not heal within 8 weeks.  AFF is a mid-thigh fracture after low or no trauma.  Both of these side effects are very rare and can be seen in <0.01% of patients.  Typically the bisphosphonates are used for 3-5 years before considering stopping the medication. The time limit on these medications is in order to prevent these side effects from happening. If the BMD shows it is improving after a certain amount time on the medication, then the medication may be held for 1-2 years (drug holiday) and if the BMD declines again, then the medication can be resumed.

            Some patients wonder if osteoporosis can be prevented. Weight bearing exercise and an adequate intake of calcium and vit D can help, but these may not be enough.  The recommended amount of calcium is 1200mg daily, in combination of diet and supplements, for all adults over the age of 50, as per American Association of Clinical Endocrinology (AACE 2020) guidelines.  The recommended vit D for adults over 50yo is 1000-4000 I.U. daily.  There are currently no guidelines for recommending vit K although many supplements on the market already sell vit D with vit K.  Limiting caffeine and alcohol consumption and smoking cessation can also prevent further bone loss.  There are no over the counter treatments that have been shown to be adequate to treat osteoporosis.

            Another very important factor that is often overlooked is to consider fall risks.  As we age, our eye sight, hearing, and proprioception may not be as good as they were when we were younger so we are more likely to fall. We need to look around the house and consider rugs, poor lighting, pets, and certain shoes as trip/fall hazards.

Osteoporosis is a very serious condition that is associated with a high fracture and mortality risk. It affects men, women, and every ethnicity/race and advancing age is a risk factor. A BMD is a simple tool that can be used to screen for this disease and very effective treatment options are available to prevent fractures.  

Dr. Singh has announced Her departure from TD&E effective 8/17/21

Dear Patients,

It is with a heavy heart that I am announcing my departure from Texas Diabetes & Endocrinology, P.A. on August 17, 2021. I will greatly miss my patients and the relationships that we have built over the last several years.

It has been a great pleasure helping you with your health care needs, and I want to thank you for trusting me to participate in your medical journey. My number one priority in this transition is for you to continue to receive excellent personalized medical care, and I know that you will be in exceptional hands with all of the Physicians and Advanced Practice Providers at Texas Diabetes & Endocrinology, P.A.

Texas Diabetes has two new physicians starting at the end of summer and I have personally helped in recruiting them. I know that they will make excellent additions to this wonderful practice.  I am very pleased to leave my patients in their capable hands.

Your medical records will remain with Texas Diabetes & Endocrinology, P.A. If you require a copy of your records, you may contact the office at (512) 458-8400, option 5 or email medicalrecords@texasdiabetes.com.

I have greatly valued our relationship over the years, and I wish you continued good health and happiness.

All my best,

Kim Singh, M.D.

Thyroid Conditions

Thyroid.  For many of us, the word conjures up a sense of curiosity, wonderment, even awe!  What is the thyroid gland and what exactly does it do?  How do you know if you’ve got a thyroid problem? 

Let’s start with the basics. The thyroid gland is a small, butterfly shaped gland that sits in the base of your neck.  It makes thyroid hormones (thyroxine and triiodothyronine) which regulate your metabolism.  Metabolism is a series of processes that control how your body creates and uses energy.  So…why do we hear so much about thyroid and thyroid dysfunction?  Well, it turns out that there are some pretty common illnesses that can affect thyroid health.   

A thyroid hormone deficiency is a state called HYPOTHYROIDISM.  You may have this if your thyroid gland is the target of an autoimmune attack (this is called Hashimoto’s disease) or if you’ve had your thyroid gland irradiated or surgically removed.  Since thyroid hormone is your source of metabolism, untreated hypothyroidism can cause a multitude of symptoms: fatigue, lethargy, weight gain, dry skin, depression,  constipation, hair loss, cold intolerance, irregular menstrual cycles in women-these are all symptoms of slowed metabolism. The solution is simple-take thyroid hormone replacement which comes as an oral supplement.

A thyroid hormone excess is a state called HYPERTHYROIDISM. You may have this if your gland is the target of an autoimmune attack (this is called Graves disease) or if you thyroid gland grows renegade chunks of thyroid tissue that lose the ability to regulate the amount of thyroid hormone they produce.  These so called “hot nodules” manufacture extra thyroid hormone without your body’s permission.  Finally, you can develop hyperthyroidism if your thyroid gland becomes acutely injured – an injured thyroid gland sheds pre-formed thyroid hormone.   This is called a thyroiditis. Medications, autoimmune attacks, viruses and pregnancy can cause thyroiditis.   Hyperthyroidism can also cause of multitude of symptoms: rapid heart rate, weight loss, tremors, palpitations, frequent and loose stools, anxiety, irregular menstrual cycles in women-these are all symptoms of accelerated metabolism.  The solution is not quite as straightforward as it is for a hypothyroid state but a hyperthyroid state can certainly be treated. Depending on the underlying cause, a hyperthyroid state can be treated with surgery (removal of the thyroid gland), medications, or irradiation. In some cases of thyroiditis, the thyroid gland heals on its own.

The thyroid gland is also prone to structural illnesses. Thyroid glands often grow NODULES – a thyroid nodule is an abnormal growth of thyroid cells that forms a lump within the thyroid gland.  While the  vast majority of nodules (probably more than 95%) are benign, some nodules do contain cancers within them so timely evaluation is important.  Thyroid ultrasound is an important tool used to assess nodule size and characteristics.  If necessary, a thyroid fine needle aspiration biopsy can be done to assess the potential for malignancy.  This is a relatively easy and straightforward procedure that can done in the physician’s office with the aid of an ultrasound machine.

Finally…a word about thyroid hormone replacement.  Oral thyroid hormone supplementation comes in various forms:

One synthetic version of thyroid hormone is called Levothyroxine-this is synthetic thyroxine also known as T4. There are several branded versions of Levothyroxine: Synthroid, Levoxyl, Unithroid, Tirosint are some common ones.  Generally speaking, branded levothyroxine preparations are usually consistent in terms of potency from batch to batch. Generic formulations may not be as consistent so your provider may specify a branded version.

Another synthetic version of thyroid hormone is called Liothyronine.  This is synthetic triiodothyronine also known as T3. The most common branded version of Liothyronine is called Cytomel.  Liothyronine is absorbed in a more rapid fashion and some patients report an increased sense of well-being when it is used in combination with Levothyroxine.  Although the guidelines published by the ATA (American Thyroid Association) conclude that Levothyroxine should remain the standard of treatment for hypothyroidism, many physicians do prescribe combination therapy with Levothyroxine and Liothyronine in patients who may not feel as well on Levothyroxine monotherapy.

The nonsynthetic version of thyroid hormone is dessicated animal thyroid extract.  This is exactly what it sounds like-it’s thyroid hormone extracted from the thyroid glands of animals-most commonly, pigs. Animal thyroid extracts were first used to treat hypothyroidism in the late 19th century but became largely replaced by synthetic versions.  One concern: animal thyroid extracts have more T3 in relation to T4 compared to the ratio produced by a healthy human gland.  T3 may place a more potent metabolic demand on the heart and in some individuals can precipitate dangerous heart rhythms. For this reason, your provider may be reluctant to prescribe this type of thyroid hormone if you are older and/or have an underlying heart condition.

In addition to thyroid health, there are numerous factors that contribute to a person’s physical and mental sense of well-being, or lack thereof.  Among these factors: diet and sleep patterns, coexisting disease states, relationships with other human beings, the quality of the surrounding environment, the ability to navigate stress, etc…. When we feel unwell, we are best served to step back and take a look at the big picture.  Because while the thyroid gland is indeed a powerful factory of thyroid hormone production and thyroid hormone itself is an incredibly capable hormone, the thyroid is only one small part of a much more complex and sophisticated piece of machinery we call the human body. 

If you have been thinking of having your thyroid levels checked out the endocrinologists at Texas Diabetes can help walk you through the process. When you trust Texas Diabetes & Endocrinology with your thyroid condition, you are assigned your own, personal team of carers who will get to know you and tailor a treatment plan that fits your individual needs.

Schedule your appointment with us today.

Dr. Ozer has announced his departure from TD&E effective 6/16/21

Dear Patients:

It is with mixed emotions that I am announcing my departure from Texas Diabetes & Endocrinology, P.A. on June 16th, 2021. I will be moving to Boston, MA to pursue a new career in diabetes technology research. This was an unexpected opportunity and one that I could not pass up. In this new position I will be able to apply my clinical experience to further developments in the field, hopefully benefitting millions of people and maybe even you!

 It has been a great pleasure helping you with your health care needs over the years, and I want to thank you for trusting me to participate in your medical journey. My number one priority in this transition is for you to continue to receive excellent personalized medical care, and I know that you will be in exceptional hands with all of the Physicians and Advanced Practice Providers at Texas Diabetes & Endocrinology, P.A.

Your medical records will remain with Texas Diabetes & Endocrinology, P.A. If you require a copy of your records, you may contact the office at (512) 458-8400, option 5 or email medicalrecords@texasdiabetes.com.

I have greatly valued our relationship over the years, and I wish you continued good health and happiness.

All my best,

Kerem Ozer

NextStepMD with Muscle Wise

At Texas Diabetes & Endocrinology, the doctors, advanced practice providers and staff are committed to helping our patients lose weight, maintain weight loss and gain better control of their health. Obesity and carrying excess weight are increasingly common, which can lead to high blood pressure, elevated cholesterol and diabetes as well as other health conditions. People with and without diabetes struggle to lose weight and may have to take multiple medications for medical problems related to the excess weight. Take the Next Step with Texas Diabetes & Endocrinology!

If you have struggled with weight maintenance for a long time, or if you haven’t been able to lose weight through personal efforts, lifestyle changes, or through a structured weight loss program, our new offering is for you!

The NextStep program incorporates weekly visits with one of our experienced coaches into a medically managed program where monthly meetings with one of our healthcare providers supplements the program through the use of expert advice, guidance, and –if indicated- medications.

We have evaluated and tested a number of different weight loss solutions and work closely with our patients to recommend the methods that offer the greatest opportunities for success. We focus not only on weight loss, but work with our patients to maintain that weight loss long-term. People with diabetes frequently can reduce their blood-sugar-lowering medication, including insulin, by losing weight.

Our programs are medically supervised for our patients with diabetes, but are also open to people who have pre-diabetes or don’t have diabetes at all. As your health and wellness coaches, we offer one-on-one sessions. Our goal is to educate, motivate and support you through your weight loss journey. Our programs are medically designed with two components – sensible weight loss and sustainable, stable weight maintenance. Our weight loss strategies include the use of nutrition education, diet and exercise plans as well as FDA-approved weight loss medications if necessary.

One of the exclusive weight loss methods that we work with is Muscle Wise. The Muscle Wise protocol offers structured weight loss while supporting muscle mass and understanding of how food affects and is utilized by the body, including what causes fat storage, utilization of stored fat for energy, improved energy, appetite control and reduced cravings. It is proven that losing weight can improve blood sugar, cholesterol levels and reduce blood pressure. While following the Muscle Wise protocol, your pancreas will get a well-deserved break by limiting simple and complex carbs until your weight loss goal is achieved. The emphasis here again is weight maintenance once a healthy balance is achieved.

MuscleWise is differentiated from other similar programs by the ability to maintain an exercise regimen, the ability to maintain greater flexibility and much more.

Through the one-on-one coaching sessions, we will help you navigate the world of contradictory nutrition advice. We will help you determine what changes are necessary while on the Muscle Wise program in order to establish new eating habits and form long term success. Each coach brings vast nutrition knowledge and experience to the table ensuring you are receiving the best support a

New Private Pay Policy

To Our Patients: 

We have implemented a policy requiring a credit card on file for all Self-Pay (Private Pay) patients. Effective July 15, 2020, we now kindly require a credit card to be on file with our office so that your payment can be automatically drafted the day of or after your appointment. If you decline to place a credit card on file, you may pre-pay your visit in full prior to the appointment date. Please call our billing office to receive your estimate for services at (512)458-8400, option 6.

When do I give you my credit card?
We prefer that you enter your credit card information while confirming/pre-registering for your appointment through our secure platform, Phreesia. Please pay close attention to your appointment reminders sent via text & email to complete pre-registration.You can also deliver your credit card information over the phone, by mail, or in person, but the most secure way is online during pre-registration. 

But wait, I’m nervous about leaving you my credit card information. 
Phreesia’s secure PCI-DSS compliant system never stores sensitive credit card information in our office system or Phreesia’s, it is stored with the merchant. 

What is PCI-DSS compliant?
Payment Card Industry (PCI) Security Standards Council offers robust and comprehensive standards to enhance payment card data security and reduce exposure to credit card fraud. PCI Data Security Standard (DSS) provides an actionable framework for developing a robust payment card data security process, including prevention, detection, and appropriate reaction to security incidents. 

How will I know how much you are going to charge me?
Upon storing your credit card information in Phreesia, you will sign the card-on-file policy, including the maximum amount we can charge to your card. You will never be charged more than the agreed-upon maximum amount. On the day of or after your appointment, your card will be automatically drafted for the amount due and a receipt will be emailed to you. 

What if I have more questions?
Our staff is happy to speak with you about your account at any time. Please call our billing department at (512)458-8400, option 6. 

Texas Diabetes & Endocrinology, P.A. 

Update on Diabetes and Covid-19 Studies show the impact of diabetes control on Covid 19 outcomes

Two studies, one from China and one from England, offer similar messages to people with diabetes.

The first study, from Hubei Province, China, evaluated nearly 1000 patients with Covid 19 and pre-existing diabetes (published in Cell Metabolism). The patients who were better controlled upon entry to the hospital (average A1c 7.3%) had a significantly higher survival rate than those who had an average A1c of 8.1%.

The second study, from England, noted that one in four people who have died of Covid 19 also had diabetes. Weight and higher A1c correlated to a higher death rate.

Overall, the data shows that people who go to the hospital for Coronavirus and also have poorly managed diabetes, have a higher risk of dying.

What does this mean for people with diabetes?

First, there is no evidence that people with diabetes have a higher risk of contracting Coronavirus, and most people with the infection will not need hospital care at all.

Secondly, the best approach to reducing the risk of complications due to Coronavirus is to manage diabetes carefully and keep blood sugars controlled.

Prevention of Coronavirus by wearing masks and social distancing is the best approach for everyone.

If you have diabetes, be sure to monitor your blood sugars and keep all medical appointments. If your blood sugars are not well controlled, please seek medical care. Our endocrinologists and mid-level practitioners are here to help.

This update is brought to you by the doctors and mid levels at Texas Diabetes and Endocrinology, where helping you be successful in managing your diabetes is our priority.