Ruchi Mathur, MD, FRCP(C) is an Attending Physician with the Division of Endocrinology, Diabetes and Metabolism and Associate Director of Clinical Research, Recruitment and Phenotyping with the Center for Androgen Related Disorders, Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
There are two major types of diabetes, called type 1 and
type 2. Type 1 diabetes was also called insulin dependent diabetes mellitus
(IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas
undergoes an autoimmune attack by the body itself, and is rendered incapable of
making insulin. Abnormal antibodies have been found in the majority of patients
with type 1 diabetes. Antibodies are proteins in the blood that are part of the
body's immune system. The patient with type 1 diabetes must rely on insulin
medication for survival.
In autoimmune diseases, such as type 1 diabetes, the
immune system mistakenly manufactures antibodies and inflammatory cells that are
directed against and cause damage to patients' own body tissues. In persons with
type 1 diabetes, the beta cells of the pancreas, which are responsible for
insulin production, are attacked by the misdirected immune system. It is
believed that the tendency to develop abnormal antibodies in type 1 diabetes is,
in part, genetically inherited, though the details are not fully understood.
Exposure to certain viral infections (mumps and
Coxsackie viruses) or other
environmental toxins may serve to trigger abnormal antibody responses that cause damage to the pancreas
cells where insulin is made. Some of the antibodies seen in type 1 diabetes include anti-islet cell antibodies, anti-insulin antibodies and anti-glutamic decarboxylase antibodies. These antibodies can be measured in the majority of
patients, and may help determine which individuals are at risk for developing
type 1 diabetes.
At present, the American Diabetes Association does not
recommend general screening of the population for type 1 diabetes, though
screening of high risk individuals, such as those with a first degree relative
(sibling or parent) with
type 1 diabetes should be encouraged. Type 1 diabetes tends to occur in young,
lean individuals, usually before 30 years of age, however, older patients do
present with this form of diabetes on occasion. This subgroup is referred to as
latent autoimmune diabetes in adults (LADA). LADA is a slow, progressive form of
type 1 diabetes. Of all the patients with diabetes, only approximately 10% of
the patients have type 1 diabetes and the remaining 90% have type 2 diabetes.
Type 2 diabetes was also referred to as non-insulin
dependent diabetes mellitus (NIDDM), or adult onset diabetes mellitus (AODM). In
type 2 diabetes, patients can still produce insulin, but do so relatively
inadequately for their body's needs, particularly in the face of insulin
resistance as discussed above. In many cases this actually means the pancreas
produces larger than normal quantities of insulin. A major feature of type 2
diabetes is a lack of sensitivity to insulin by the cells of the body (particularly fat and muscle
cells).
In addition to the problems with an increase in insulin resistance, the
release of insulin by the pancreas may also be defective and suboptimal. In
fact, there is a known steady decline in beta cell production
of insulin in type 2 diabetes that contributes to worsening glucose control.
(This is a major factor for many patients with type 2 diabetes who ultimately
require insulin therapy.) Finally, the liver in these patients continues to produce glucose
through a process called gluconeogenesis despite elevated glucose levels. The
control of gluconeogenesis becomes compromised.
While it is said that type 2 diabetes occurs mostly in
individuals over 30 years old and the incidence increases with age, we are
seeing an alarming number patients with type 2 diabetes who are barely in their
teen years. In fact, for the first time in the history of humans, type 2
diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor
eating habits, higher body weight, and lack of exercise.
While there is a strong genetic component to developing
this form of diabetes, there are other risk factors - the most significant of
which is obesity. There is a direct relationship between the degree of obesity and the
risk of developing type 2 diabetes, and this holds true in children as well as
adults. It is estimated that the chance to develop diabetes doubles for every
20% increase over desirable body weight.
Regarding age, data shows that for each decade after 40 years of age
regardless of weight there is an increase in incidence of diabetes. The
prevalence of diabetes
in persons 65 to 74 years of age is nearly 20%. Type 2 diabetes is also more
common in certain ethnic groups. Compared with a 6% prevalence in Caucasians,
the prevalence in African Americans and Asian Americans is estimated to be 10%,
in Hispanics 15%, and in certain Native American communities 20% to 50%.
Finally, diabetes occurs much more frequently in women with a prior history of
diabetes that develops during pregnancy (gestational diabetes - see below).
Diabetes can occur temporarily during pregnancy. Significant hormonal changes
during pregnancy can lead to blood sugar elevation in genetically predisposed
individuals. Blood sugar elevation during pregnancy is called
gestational
diabetes. Gestational diabetes usually resolves once the baby is born. However,
25%-50% of women with gestational diabetes will eventually develop type 2
diabetes later in life, especially in those who require insulin during pregnancy
and those who remain overweight after their
delivery. Patients with gestational diabetes are usually asked to undergo an
oral glucose tolerance test about
six weeks after giving birth to determine if
their diabetes has persisted beyond the pregnancy, or if any evidence (such as
impaired glucose tolerance) is present that may be a clue to the patient's
future risk for developing diabetes.
"Secondary" diabetes refers to elevated blood sugar
levels from another medical condition. Secondary diabetes may develop when the
pancreatic tissue
responsible for the production of insulin is destroyed by disease, such as
chronic pancreatitis
(inflammation of the pancreas by toxins like excessive alcohol), trauma, or surgical removal of the pancreas.
Diabetes can also result
from other hormonal disturbances, such as excessive growth hormone production
(acromegaly) and
Cushing's syndrome. In acromegaly, a pituitary gland tumor at the base of the
brain causes excessive production of growth hormone, leading to hyperglycemia.
In Cushing's syndrome, the adrenal glands produce an excess of cortisol, which promotes blood sugar elevation.
In addition, certain medications may worsen diabetes
control, or "unmask" latent diabetes. This is seen most commonly when steroid
medications (such as prednisone) are taken and also with medications used in the
treatment of HIV infection (AIDS).
Diabetes - Symptoms at Onset of DiseaseQuestion: The symptoms of diabetes can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
One in every 20 people develop a kidney stone at some point in their life. A kidney stone is a hard mineral and crystalline material formed within the kidney or urinary tract. Kidney stones symptoms and signs are, blood in the urine and pain in the abdomen, flank (lower back), or groin. A number of different conditions can lead to kidney stones including: gout, hypercalciuria, people with inflammatory bowel disease, kidney disease, and hypoparathyroidism. Some medications also increase the risk of kidney stones.
Liver cancer is the fifth most common cancer in the world and the majority of patients with liver cancer will die within one year as a result. Patients with associated cirrhosis caused by chronic hepatitis B or C infections, alcohol, and hemochromatosis are at the greatest risk of developing liver cancer. Many patients with liver cancer do not develop symptoms until the advanced stages of the tumor which usually makes prognosis poor. The combination of an imaging study (ultrasound, CT, or MRI scans) and an elevated blood level of alpha-fetoprotein will most effectively diagnose liver cancer, while a liver biopsy can make a definitive diagnosis. Medical treatments, including chemotherapy, chemoembolization, ablation, and proton beam therapy, are not very effective. Surgical removal of the tumor or a liver transplant may be most effective in certain cases.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
A sty (sometimes spelled stye) is a tender, painful red bump located at the base of an eyelash or on, inside, or under the eyelid, which is the result of an acute infection of the oil glands of the eyelid. Complications of a sty can be blepharitis and chalazion.
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Cellulitis is an acute spreading bacterial infection below the surface of the skin characterized by redness, warmth, inflammation, and pain. The most common cause of cellulitis is the bacteria Staph (Staphylococcus aureus).
Athlete's foot (tinea pedis) is a skin infection caused by the ringworm fungus. Symptoms include itching, burning, cracking, peeling, and bleeding feet. Treatment involves keeping the feet dry and clean, wearing shoes that can breathe, and using medicated powders to keep your feet dry.
Thrush is an infection of the mouth caused by the candida fungus. Symptoms of Thrush include pain or difficulty swallowing, a feeling that food gets stuck in the throat, and fever.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Hypoglycemia is a syndrome caused by low blood sugar. Symptoms of hypoglycemia include palpitations, trembling, intense hunger, sweating, nervousness, and weakness. Consuming lifesavers, table sugar, soda, and juice are good treatment options for hypoglycemia.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Retinal detachment is the separation of the retina from its attachments to the underlying eye tissue. Symptoms of retinal detachment include flashing lights and floaters. Highly nearsighted young adults and those who've had cataract surgery are at higher risk for retinal detachment.
Itching can be a common problem. Itches can be localized or generalized. There are many causes of itching to include: infection (jock itch, vaginal itch), disease (hyperthyroidism, liver or kidney), reactions to drugs, and skin infestations (pubic or body lice). Treatment for itching varies depending on the cause of the itch.
Carpal tunnel syndrome is a condition in which irritation of the wrist's median nerve causes tingling and numbness of the thumb, index, and the middle fingers. This condition is known as tarsal tunnel syndrome in the ankles and feet. Treatment of carpal tunnel syndrome depends on the severity of the symptoms and the nature of any disease that might be causing the symptoms.
A miscarriage is any pregnancy that ends spontaneously before the fetus can survive. Miscarriage usually occurs before the 13th week of pregnancy. The cause of a miscarriage cannot always be determined. The most common causes of a miscarriage in the first trimester are collagen vascular disease (lupus), hormonal problems, diabetes, chromosomal abnormalities, and congenital abnormalities of the uterus.
Restless leg syndrome (RLS or restless legs syndrome) is a common cause for painful legs that typically eases with motion, and becomes worse and more noticeable at rest. This characteristic nighttime worsening can frequently lead to insomnia. Treatment of the symptoms of restless leg syndrome is generally with medication as well as treating any underlying condition causing restless leg syndrome.
Impotence, also known as erectile dysfunction, is a common
problem among men characterized by the consistent inability to sustain an
erection sufficient for sexual intercourse or the inability to achieve
ejaculation, or both. Impotence can have emotional causes but most often it is
due to a physical problem.
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
Vancomycin-resistant enterococci (VRE) infection is the most common type of infection acquired by patients while hospitalized. Patients at risk for VRE are those who are already ill, and hospitalized, including individuals with diabetes, elderly, ICU patients, kidney failure patients, or patients requiring catheters. Enterococci can survive for months in the digestive tract and female genital tract. Other risk factors for acquiring VRE include those how have been previously treated with vancomycin and combinations of other antibiotics. Treatment of VRE is generally with other antibiotics other than vancomycin. Prevention of VRE can be achieved by proper hand hygiene.
Overactive bladder is a sudden involuntary contraction of the muscle wall of the bladder causing urinary urgency (an immediate unstoppable need to urinate). Overactive bladder is is a form of urinary incontinence. Treatment options may include Kegel exercises, biofeedback, vaginal weight training, pelvic floor electrical stimulation, behavioral therapy, and medications.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Encephalopathy means brain disease, damage, or malfunction. Causes of encephalopathy are varied and numerous. The main symptom of encephalopathy is an altered mental state. Other symptoms include lethargy, dementia, seizures, tremors, and coma. Treatment of encephalopathy depends on the type of encephalopathy (anoxia, diabetic, Hashimoto's, hepatic, hyper - hypotensive, infectious, metabolic, infections, uremic, or Wernicke's) are examples of types of encephalopathy.
Radiculopathy, a condition in which a nerve or nerves along the spine are compressed causing pain, numbness, weakenss, and tingling along the nerve(s). Some causes of radiculopathy include bone spurs, disc hernation, osteoarthritis, tumors, infection, and neuropathy. Treatment depends on the are of nerve compression. Surgery is generally not required.
Hyperglycemia is a serious health problem for diabetics. There are two types of hyperglycemia, 1) fasting, and 2)postprandial or after meal hyperglycemia. Hyperglycemia can also lead to ketoacidosis or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). There are a variety of causes of hyperglycemia in people with diabetes. Symptoms include increased thirst, headaches, blurred vision, frequent urination and more. Treatment can be achieved through lifestyle changes or medications changes. Carefully monitoring blood glucose levels is key to prevention.
The main features of metabolic syndrome include insulin resistance, hypertension (high blood pressure), cholesterol abnormalities, and an increased risk for clotting. Patients are most often overweight or obese. Lifestyle modification such as the Mediterranean diet, exercise, and quitting smoking are the preferred treatment of metabolic syndrome.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Hydronephrosis is a condition in which the kidney swells, due to a backup of urine. Hydronephrosis generally occurs with another disease.Symptoms of hydronephrosis include nausea, vomiting, urinary tract infection, fever, painful urination, increased urinary frequency and urgency, flank pain, and swelling of the abdomen. Treatment of hydronephrosis depends on the cause.
Neuropathic pain is chronic pain resulting from injury to the nervous system. The injury can be to the central nervous system (brain and spinal cord) or the peripheral nervous system (nerves outside the brain and spinal cord).
Diabetic Neuropathy is a complication of diabetes that causes damage to the nerves; this is related to the blood glucose of the body being too high for a long period of time. The four types of neuropathy include peripheral, autonomic, proximal and focal.
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