Aging is associated with changes in body composition, including both fat gain and muscle loss, and is associated with increased risk of type 2 diabetes. Moreover, changes in fat distribution take place in adults as they age and may contribute to the increased risk of type 2 diabetes. Recent literature has shown differences in the age-related changes in body composition by diabetes status; suggesting that some of these changes might not only be a risk factor of the development of diabetes but could also be a consequence of the disease. In this article, we review the current evidence on body composition changes that take place in adults after the diagnosis of type 2 diabetes and compare them to those observed in adults without diabetes as they age. We also review the effect of various lifestyle, pharmacological, and surgical glucose-lowering treatments on body composition in adults with type 2 diabetes.
Background : Post bariatric hypoglycemia (PBH) is an increasingly recognized complication of bariatric surgery. Onset typically occurs more than 1-year post-op with episodes typically occurring postprandially. In contrast, insulinoma causes fasting and postprandial hypoglycemia and has been described after bariatric surgery, with 9 reported cases. Case : A 69-year-old woman presented to the emergency department after syncope in the setting of hypoglycemia to 39 mg/dL. Medical history was notable for Roux-en-Y gastric bypass 9 years ago. She had been experiencing fatigue in the 8 months prior with episodes of diaphoresis, hunger and mental fogginess that occurred randomly throughout the day and resolved with hard candy. An inpatient supervised fast resulted in Whipple triad with blood glucose 32 mg/dL and insulin 28 uU/mL (N 2.6-24.4) within 3 hrs of starting the test, thus making it difficult to exclude PBH. Therefore, a repeat fast was performed after minimal carbohydrate intake. This test yielded similar results with hypoglycemia occurring within 2.5 hrs. Based on this, medical treatment with octreotide and diazoxide was initiated. CT abdomen showed atrophic pancreas with no mass and an enhancing liver mass suggestive of a hemangioma. However, MRI abdomen revealed a 2.9 cm pancreatic tail mass and 3 hypervascular liver lesions concerning for metastasis. Subsequently, biochemical results from the supervised fast confirmed hyperinsulinemic hypoglycemia likely due to metastatic insulinoma based on imaging studies: C-peptide 4.67 ng/mL (N 0.8-3.85), proinsulin >800 pmol/L (N <=18.8), ß hydroxy butyrate 0.04 mmol/L (N <= 0.28). Pancreatic mass FNA via endoscopic ultrasound was suspicious for neuroendocrine tumor (NET). Liver mass biopsy showed metastatic NET. Hypoglycemia worsened despite continuous IV dextrose infusion and medical therapy necessitating distal pancreatectomy, splenectomy and partial hepatectomy for tumor debulking. Pathology revealed a 1.4 cm grade 2 well- differentiated NET in the pancreatic tail (mitotic rate 1 per 10 hpfs, Ki67 5%) and 2 foci of metastasis in the liver (8 and 0.9 cm). Unfortunately, the patient developed unexplained refractory shock with multiorgan failure post-operatively and passed away after 7 days. Conclusion :To our knowledge, this is the first case reported of malignant insulinoma after bariatric surgery. Malignant metastatic insulinoma is very rare. It causes severe hypoglycemia that can occur in the very early PP period similar to PBH, which could delay diagnosis. Inconclusive initial imaging should not preclude comprehensive workup in severe persistent hypoglycemia. Reference : Mulla, CM et al. Insulinoma After Bariatric Surgery: Diagnostic Dilemma and Therapeutic Approaches. Obes Surg . 2016. 26:874-881 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the a...
Introduction Since its introduction 80 years ago, the therapeutic I-131 dosage has usually been tailored to individual patient requirements based on the uptake of a tracer radio-iodine(RAI) dose. Estimated exposure has typically been extrapolated from the results of activity measurements at one or two time points, e.g., at 4 and 24 hours. We now know that treatment of hyperthyroid Graves disease with these methods lead to a 13–25% rate of failure to cure hyperthyroidism and a 46–80% rate of long-term hypothyroidism in cured patients. There is a need for a much more personalized approach to RAI dosing based on individual RAI tissue uptake, kinetics. This can be achieved only after including multiple data points during the evaluation of tissue uptake. The Collar Therapy Indicator (CoTI), a device placed in cloth collar around the neck resembling a turtle neck sweater collar with a connecting wire and recording box, has been shown in small feasibility studies to provide data regarding radioiodine exposure that correlates with conventional methods of measuring I-123 and I-131 uptakes after diagnostic dose administration and/or therapy for thyroid disorders Methods; We hypothesized that the device’s continuous measurement capability will permit more accurate estimates of radiation exposure to thyroid tissue than conventionally employed methods assessing fractional uptake at one or a few time points. It may also provide information about the extent of variability in the absorbed radiation dose among patients with hyperthyroidism. We performed a feasibility study in a patient with graves’ disease to see the difference between tradition methods of I-123 uptake and the CoTI; (1) We compared the conventional quantitative uptake-derived thyroid time activity curve (TAC) as well as the Area Under the Curve (AUC)(based on percent uptake at 6 hour and 24 hour time points) to that obtained using the CoTI.(2) We evaluated the uptake and clearance kinetics of diagnostic I-123 administered.(3) We also evaluated patient experience in using the CoTI device with a survey instrument. Results; The CoTI plotted TAC and AUC offered a different approach from the conventional methods of calculation (6 hr and 24 hr % uptake) of I-123 TAC and AUC. The patient reported no difficulty in using the device and the device itself was not inconvenient. Conclusions; The calculation of % uptake as well as rate of uptake within the thyroid by CoTI might help us, in achieving a more personalized approach to I-131 RAI dose calculation for treatment of Graves’ disease. The preliminary research findings that we have generated will help us investigate different aspects of RAI uptake within the thyroid and will hopefully lead to solutions, for some of the common issues and problems arising out of random dosing of RAI.
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