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.
Home blood sugar (glucose) testing is an important part of controlling blood
sugar. One important goal of diabetes treatment is to keep the blood glucose
levels near the normal range of 70 to 120 mg/dl before meals and under 140 mg/dl
at two hours after eating. Blood glucose levels are usually tested before and
after meals, and at bedtime. The blood sugar level is typically determined by
pricking a fingertip with a lancing device and applying the blood to a glucose
meter, which reads the value. There are many meters on the market, for example,
Accu-Check Advantage, One Touch Ultra, Sure Step and Freestyle. Each meter has
its own advantages and disadvantages (some use less blood, some have a larger
digital readout, some take a shorter time to give you results, etc). The test
results are then used to help patients make adjustments in medications, diets,
and physical activities.
There are some interesting developments in blood glucose monitoring.
Currently, at least three continuous glucose sensors are approved in the United States (Dexcom, Medtronic and Navigator). The new
continuous glucose sensor systems involve an implantable cannula placed just
under the skin in the abdomen or in the arm. This cannula allows for frequent
sampling of blood glucose levels. Attached to this is a transmitter that sends
the data to a pager-like device. This device has a visual screen that allows the
wearer to see, not only the current glucose reading, but also the graphic
trends. In some devices, the rate of change of blood sugar is also shown. There
are alarms for low and high sugar levels. Certain models will alarm if the rate of
change indicates the wearer is at risk for dropping or rising blood glucose too
rapidly. The Medtronic version is specifically designed to interface with their
insulin pumps. However, at this time the patient still must manually approve any
insulin dose (the pump cannot blindly respond to the glucose information it
receives, it can only give a calculated suggestion as to whether the wearer
should give insulin, and if so, how much). All of these devices need to be
correlated to fingersticks for a few hours before they can function
independently. The devices can then provide readings for 3-5 days.
Diabetes experts feel that these blood glucose monitoring devices give
patients a significant amount of independence to manage their disease process;
and they are a great tool for education as well. It is also important to
remember that these devices can be used intermittently with fingersticks. For
example, a well-controlled patient with diabetes can rely on
fingerstick glucose
checks a few times a day and do well. If they become ill, if they decide to
embark on a new exercise regimen, if they change their diet and so on,
they can use the sensor to supplement their fingerstick regimen, providing more
information on how they are responding to new lifestyle changes or stressors.
This kind of system takes us one step closer to closing the loop, and to the
development of an artifical pancreas that senses insulin requirements based on
glucose levels and the body's needs and releases insulin accordingly - the
ultimate goal.
Hemoglobin A1c (A1c)
To explain what an hemoglobin A1c is, think in simple terms. Sugar sticks, and when it's
around for a long time, it's harder to get it off. In the body, sugar sticks
too, particularly to proteins. The red blood cells that circulate in the body
live for about three months before they die off. When sugar sticks to these cells,
it gives us an idea of how much sugar is around for the preceding three months. In
most labs, the normal range is 4%-5.9 %. In poorly controlled diabetes, its 8.0%
or above, and in well controlled patients it's less than 7.0% (optimal is
<6.5%). The benefits of measuring A1c is that is gives a more reasonable and
stable view of what's happening over the course of time (three months), and the
value does not bounce as much as finger stick blood sugar measurements. There is
a direct correlation between A1c levels and average blood sugar levels as
follows.
While there are no guidelines to use A1c as a screening tool, it gives a
physician a good idea that someone is diabetic if the value is elevated. Right
now, it is used as a standard tool to determine blood sugar control in patients
known to have diabetes.
A1c(%)
Mean blood sugar (mg/dl)
6
135
7
170
8
205
9
240
10
275
11
310
12
345
The American Diabetes Association currently recommends an A1c
goal of less than 7.0%. Other Groups such as the American Association of Clinical
Endocrinologists feel
that an A1c of <6.5% should be the goal.
Of interest, studies have shown that there is about a 10% decrease in
relative risk for microvascular disease for every 1% reduction in A1c. So, if a
patient starts off with an A1c of 10.7 and drops to 8.2, though there are not
yet at goal, they have managed to decrease their risk of microvascular
complications by about 20%. The closer to normal the A1c, the lower the absolute
risk for microvascular complications. Data also suggests that the risk of
macrovascular disease decreases by about 24% for every 1% reduction in A1c
values.
It should be mentioned here that there are a number of
conditions in which an A1c value may not be accurate. For example, with
significant anemia, the red
blood cell count is low, and thus the A1c is altered. This may also be the case
in sickle cell disease and
other hemoglobinopathies.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
The major goal in treating diabetes is controlling elevated blood sugar without causing abnormally low levels of blood sugar. Treatment for type 1 diabetes is with insulin, exercise, and a diabetic diet. Treatment for type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugar, oral medications are used. If oral medications are still insufficient, insulin medications are considered.
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.
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.
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.
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