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- [00:00]
A
Hello, I'm Aaron Lohr, and this is the Endocrine News Podcast. When I'm at the grocery store, I'll often look at the back of the product package to see the ingredients. And I'll confess, sometimes I have no idea what some of those ingredients are. And in the United States, the FDA doesn't regulate supplements for safety and efficacy, so manufacturers don't have to disclose their ingredients. We can't always know for certain what's in those. We all want to know what we're putting in our body. Some ingredients are good for us and some aren't. Today we'll be talking about a case where a patient was unknowingly ingesting an ingredient that was having a significant endocrine impact. Joining me today is Dr. Meghana Patty Patti, an endocrine specialist at Lafayette General Medical center in Louisiana. She's she recently presented a study at Endo 2025 entitled Beware the hidden ingredients and supplement use in your patients with elevated testosterone. Thank you for being here today, Dr.
- [01:15]
B
Patty Patty, thank you so much for inviting me to the podcast. Excited to share what I know.
- [01:21]
A
Wonderful. Now, before we dive into your case study, which I think is fascinating, one term that's going to come up is hidden ingredients. What does that mean exactly?
- [01:32]
B
I'm glad you asked about that and you already mentioned about it. So when we go to purchase food in the stores, we don't usually read through the food labels thoroughly. So by hidden ingredients, we mean substances that are either not explicitly named in ways consumers easily recognize, or they're present in small amounts but can still impact health food. For example, they are hidden under the umbrella terms or code names, or they have a vague labeling. It would either say natural or artificial flavors, but they contain dozens of chemicals, spices or seasonings, which are legally allowed to be vague to protect the recipes. But they can contain preservatives, allergens, and sometimes they also are named as scientific or trade names or some code numbers.
- [02:23]
A
I imagine that creates a bit of a puzzle for the consumer to solve, and this is important to your case study. What do we know about the relationship between testosterone and insulin sensitivity and hypoglycemia?
- [02:37]
B
Testosterone can contribute to hypoglycemia indirectly because it can increase your body's insulin sensitivity, meaning your cells become better at using glucose. So as a result, insulin works more effectively, causing more glucose to move from bloodstream into your cells and can lower your sugars. And if somebody is on anti diabetic medications, it can lead to hypoglycemia now.
- [03:05]
A
Let'S jump into your wonderful case study. Can you tell us more about the patient and how they presented?
- [03:11]
B
We have this young gentleman who is 26 year old who came into our endocrine clinic for frequent hypoglycemia episodes and he was initially referred to rule out insulinoma. So he started having these episodes of low blood sugars, mostly post pradvial, after eating and at times fasting where his sugars usually dropped below 70 and there were episodes where it dropped below 55 and it led to hospitalization and he had classic hypoglycemia symptoms. So that led us to explore more into his case. He also had like fatigue and we did some labs later on.
- [03:52]
A
Can you tell us about some of the initial tests that you ran and what you found from those?
- [03:57]
B
So we did like a complete blood count which showed elevated hemoglobin and hematocrit. His glucose was in the low normal range around like 60s on the BMP. And we also did a testosterone levels because of the elevated hemoglobin and the hematocrit and it was found to be elevated. The total testosterone was elevated. Rest of the labs were pretty unremarkable. He had a hemoglobin A1C of 5.2. And we did some aggressive workup because I was trained in a cancer hospital and the oncology did a thorough evaluation for his elevated hemoglobin and hematocrit and his symptoms and there was no tumor that was found. We also did an ultrasound of the testes and there was no testicular lesion. We did a mixed meal test to see why his sugars were dropping postprandially and the lowest blood sugar that was recorded on that test was 63, but his C peptide level was elevated at 4.9 and then it wasn't feasible to do a 72 hour fast in our hospital at that time. So we did a endoscopic ultrasound and selective arterial calcium stimulation test to rule out insulinoma and nothing was was remarkable. We did that because the CT with adrenal protocol showed some indeterminate findings and they couldn't rule out in serenoma all other than elevated testosterone and his frequent hypoglycemia like symptoms and low sugars, nothing remarkable. Also we used a CGM to see at what time of the day his sugars are dropping and how low and it dropped as low as 54 on the CGM. However he did not check it with a point of care when it dropped to 54.
- [05:46]
A
So you found the elevated testosterone Levels like you said, you didn't really find anything remarkable in some of the other tests. So what did you do next and where did that take you?
- [05:55]
B
This is a young man with an elevated testosterone. So we started questioning why this young man could have elevated testosterone. So the first thing that usually comes to our mind is exogenous testosterone or androgen use which is most common in young population. And sometimes they take over the counter supplements that are contaminated with androgens. So we did a thorough history taking following visit and asked in detail about his diet and any possible supplements that he might be using. And after excluding everything, patient stated that he was drinking a vitamin drink. And we looked at the label and it showed that it has various multivitamins and some electrolytes in it. And in the bottom in a fine te, it states that it contains caffeine from this guarana seed extract.
- [06:46]
A
I definitely want to ask about that guarana pretty soon so we get a better idea what that is. But first it sounds like you told the patient, hey, let's stop using that energy drink in some of the supplements. So what happened after they discontinued those?
- [07:01]
B
So we had a follow up visit a couple of months later. We told the patient that this could possibly contribute to his elevated testosterone and low sugars. So he stopped all the supplements and we repeated his labs and reassessed his symptoms and surprisingly the testosterone levels normalized the following and he did have improvement in the hypoglycemia episodes as well.
- [07:26]
A
That is very interesting. And, and so you mentioned one of those ingredients that you found was something called guarana. Can you tell us a little bit more about what that is and, and where does it usually show up?
- [07:36]
B
I read a little bit about this and apparently this is like a native fruit from the Amazonian basin and it has been used as a traditional medicine for centuries by these indigenous population. It is mainly used as a stimulant because of its high caffeine content. And in Brazil they use this as an ingredient in energy drinks to boost the sexual function.
- [08:02]
A
So the amount of hidden ingredients like guarana that we're likely exposed to as a public is concerning. When should healthcare providers, like you all did, when should healthcare providers look into their patient's diet and supplement use?
- [08:17]
B
I believe every visit, like every new patient that walks into your office, should be made aware of the food choices and should be educated about reading the labels before purchasing. And for healthcare providers, especially if you have an otherwise healthy individual and if there are any concerning symptoms or some atypical lab results that should be interpreted with caution, taking into account potential confounding variables, especially in today's world of increasingly complex and diverse food choices.
- [08:53]
A
Now, is there anything that patients can do to be more aware of the hidden ingredients in their products?
- [09:01]
B
I think we should take some time to read the food labels and pay attention to the ingredients that sound unfamiliar and read through the fine text. If you come across some ingredient that you never read about before or heard about before, you should look deeper into the ingredients. They could be processed foods, additives that might otherwise go unnoticed. This would empower our society to make more informed choices and know more about what we are eating.
- [09:32]
A
Well, thank you so much for taking the time to share your case study with us. I'm sure we're all going to be reading the back of those labels so much more carefully than maybe we used to. But thank you so much for being a guest today.
- [09:43]
B
Thank you for having me.
- [09:46]
A
That's all for this episode. I hope you enjoyed listening to Dr. Patty Patty discuss her case study. If you love exploring case studies, be sure to check out the Endocrine Society's journal, JCEM Case Reports. JCEM Case Reports is a peer reviewed, open access journal that publishes original clinical cases covering the entire spectrum of endocrinology worldwide. The journal welcomes the submission of case reports describing rare or unusual endocrine conditions or an unusual presentation or treatment of common endocrine disorders. We'll leave a link to it in today's episode description. We'll be back soon with another fantastic dive into the world of endocrinology. Until then, thanks for listening. Endocrine News Podcasts are a free service of the Endocrine Society. To learn more or to become a member, visit the society's website at www.endocrine.org.