“When I speak of the [care] team, our patients are an essential part of that team management.” - Dr. Richard Siegel
What is uncontrolled diabetes? Dr. Richard Siegel joins Shireen on this episode of the Yumlish Podcast to answer that question. Dr. Seigel defines steps on how to manage diabetes and examines what diabetes management and care looks like for inpatients, taking into account the special considerations patients with diabetes might need to take if they are admitted to the hospital. He also touches on how COVID-19 has impacted medical innovation, regarding diabetes care and new access methods.
Dr. Richard Siegel graduated from Albany Medical College and did internal medicine training with chief residency at Boston University Medical Center. Dr. Richard Siegel trained in internal medicine and he did his endocrine fellowship over 3 years at Tufts Medical Center and subsequently joined the faculty in 1997. After completing his endocrine fellowship, he helped to create an early version of the inpatient diabetes management program by collaborating with general and transplant surgery. At Tufts Medical Center, he is currently the co-director of the Diabetes and Lipid Center and is the consulting endocrinologist and bariatrician at the Weight and Wellness Center.
Question of the Week: How has COVID-19 impacted your or a loved one’s diabetes?
Shireen: Dr. Richard Siegel trained in internal medicine, and he did his endocrine fellowship over three years at Tufts medical center and subsequently joined the faculty in 1997. At Tufts medical center, he is currently the co-director of the diabetes and lipid center and is the consulting endocrinologist and bariatrician at the weight and wellness center.
In this episode, endocrinologist Dr. Richard Siegel explains the dangers of unmanaged diabetes and what steps you can take to effectively manage your diabetes. He discusses how diabetes management differs between inpatients and outpatients and equips you with some key things to know before you were admitted to the hospital.
Dr. Siegel also shares how COVID-19 has improved medical innovation and access to diabetes care. Podcasting from Dallas, Texas, I’m Shireen, and this is the Yumlish Podcast.
Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions with you each week. Welcome Dr. Siegel.
Richard Siegel: Thanks so much for having me.
Shireen: A pleasure having you on. Diving right in, Dr. Siegel, how did you become passionate about clinical nutrition and diabetes management as an endocrinologist?
Richard Siegel: So I think this started in medical school and really a lot of this is about mentorship and I think it’s always important to have good, good mentors.
I recall during the fourth year of my medical school in Albany, New York, uh, the chief of the endocrine division, there was Dr. A. David Goodman who has since passed away, but he really was passionate about, uh, diabetes. He also, I think, had trained in, uh, nephrology. There’s a lot of cross between endocrinology and nephrology, which is kidney disease.
Uh, and I recall on, on rounds, we would be going around, and, uh, he would be calculating out exactly what the change in the blood sugar might be based on how much fluid a particular person might get if they came in with high sugars. And so really he was, uh, he was a thinking man and endocrinology is very cognitive, uh, specialty.
I also had an excellent mentor when I was in my internal medicine residency, uh, as well. Uh, and this doctor, doctor Dr. Stewardship, and is still still practicing, uh, in addition to, uh, doing diabetes and endocrinology. He teaches in the area of kinesiology, which is related to exercise. So, um, really sort of, I think those couple of mentors stick out in, in, in my mind, um, bringing me to interest in, uh, endocrinology, nutrition, uh, exercise counseling, which I, I also tend, tend, tend to do as well.
Shireen: And then let’s talk about the diabetes side a little bit and help us really understand what is unmanaged diabetes and why is it so bad?
Richard Siegel: So, um, unmanaged diabetes really can wreak havoc on the body. Uh, it’s what I might call a catabolic state. Um, uh, catabolism is where the body breaks down and this can happen.
In most cases when, when, when blood sugars, uh, when are over 180 to 200 milligrams per deciliter, to remind you a normal blood sugar is generally between 70 to 140 milligrams per deciliter. But when the blood sugar, yeah. Yeah, above 180 to 200 and stays there over days, weeks, sometimes, even months. Um, this is what can bring on for many people, the symptoms of decompensated diabetes, which can include polyuria. So that’s frequent urination. And polydipsia that’s frequent thirst. Um, even polyphagia, as people are losing calories and sugar in their urine, they are, uh, they’re tending to eat more. Because they’re losing sugar in the urine, they’re often losing weight. And with all this they’re feeling fatigued. You know, the really the most common symptom of anyone coming into an outpatient clinic is feeling tired. And this is definitely one reason why people can feel tired. When blood sugars are in this range, uh, the immune system does not work as well.
So people certainly could be prone towards, uh, infections, um, per se. So, uh, with uncontrolled unmanaged diabetes, there’s slow damage over time that can occur. And this really puts risks to the entire body as blood sugar is really, you know, traveling to all the organs. And this is where we think about the, for the long term, the microvascular and macrovascular complications, that’s small blood vessels and large blood vessels. We can also think about diabetes distress, uh, which is a term that’s, uh, that goes along with, uh, mental health, and really the, the, the vicious cycle that, that can occur between, um, depression and other, uh, behavioral disorders and, and, uh, and diabetes.
And, um, as I said earlier, with infection now, really, uh, immune dysfunction, the cells that normally are fighting off, uh, infection are just not working, uh, as well.
Shireen: And what I find interesting here is that it’s not something that you feel right away, right? This is something that’s slowly creeping up, showing itself in symptoms like fatigue, um, and it’s not, it’s not something that happens overnight and yet there’s all this stuff happening. Um, and there’s very, very little in terms of symptoms that you can really pick up on there to understand exactly what is going on.
Richard Siegel: That’s that’s right. Really. I mean, for when it comes on, very suddenly people may notice the symptoms, but when it’s more subtle over weeks or months, sometimes only in, in retrospect, when I ask, have you been very thirsty?
Have you been losing weight? Have you been, uh, drinking a lot, a lot of fluids to what will people realize that? So, um, I have Many patients who may come in and their blood sugars have been 200, 300 for, for weeks or months. And they, you know, they, the, to some extent they’re really used to it. Uh, and, um, yeah, they are, they’re often very, very tired, but they’ve, they’ve, they’ve compensated.
Um, it’s the people who are de-compensated, especially when it’s happening more acutely, which may have happened in the setting of another event, such as an infection. Um, those are the people that we may end up, uh, seeing in the hospital in terms of diabetes consultation. Um, whether they’re coming in specifically for diabetes or for, for another reason.
Shireen: And so for, for such folks, um, should they, what are the different things that they should do essentially to make sure that they don’t have unmanaged diabetes?
Richard Siegel: So thinking about, uh, this really involves a team approach for one really, I think the basis for all of this is, is education. And as patients are coming into my outpatient clinic, uh, at Tufts medical center for, for the first time I emphasize uh, that really, we want to teach you about what diabetes is and, uh, I do emphasize our, our team approach. Um, and really, I, you know, I guess sort of thinking about there are our outpatient clinic, patients may come to us on their own, so that could be self-referrals, uh, or it could be provider initiated through a primary care clinic, um, or otherwise, sometimes it’s through, through, through a specialist.
And you know, what we’re talking about really at that first visit is a little bit of, you know, about their, well, what they, what they know about diabetes and emphasizing the education programs that we have. Um, sometimes that’s one-on-one and sometimes those are in groups, um, self management education programs, uh, with a, uh, with a diabetes educator.
Shireen: And so how does diabetes management care look and feel differently? Inpatient versus outpatient?
Richard Siegel: So with, uh, thinking about, uh, inpatient, once again, we’re part of a team that’s helping to manage, manage the patients. Um, you know, some of the patients are, again, coming in through the emergency room for, uh, another reason.
Uh, and we are consulted because their blood sugars are elevated when they, when they come in. So. Yeah, inpatient really, we have a more specific focus and very often that’s really just related to, uh, avoiding extremes of blood sugars. So, uh, we’ll generally say if you’re admitted to the hospital, uh, if you’re in the intensive care units, you know, we’re actually looking to get blood sugars a little bit lower than, than we might be if you’re, if you’re on the regular, uh, regular hospital floor. So that range in the intensive care unit at our hospital is usually a hundred to 150 milligrams per deciliter, whereas on the regular hospital floor that may be, uh, upwards of about 180 milligrams per deciliter, but still we want to avoid both hypoglycemia and severe hyperglycemia, um, uh, as both of those, uh, can cause, uh, uh, problems when, when people are, are in the hospital. The management for patients in the hospital may differ depending on what type of diabetes, uh, they, they have, um, for patients with type 1 diabetes where they’re, uh, exclusively on, on insulin, uh, that insulin may need to be, uh, adjusted when they come in the hospital. Um, very often the doses that are used as an outpatient, uh, are going to be very different than what’s going to be used in the hospital because people are eating very differently or perhaps they, they may not be eating, uh, and at all. So, um, for people who are on insulin, uh, we are often, uh, readjusting those, those doses.
When people come into the hospital, they should prepare for the idea that their, their blood sugar is going to be checked by, by glucometer, and depending on what the situation is, if they’re not eating that blood sugar may be checked every six hours, um, if they are eating, it may be get checked, uh, before the meal times, uh, and at bedtime.
Now, some patients wear a continuous glucose monitor such as for our freestyle Libra or Dexcom. Uh, and generally that can be continued while it’s in the hospital. And that is information that may be very helpful. For both patients, as well as, as, as the care team. Uh, and that could be supplemental, uh, to what what’s, what’s checked in terms of the, uh, glucometer really we’re using this information about the blood sugar patterns to help, uh, decide on the orders, and the orders may need to be adjusted, day to day, because things can change very, very quickly in the hospital. Um, I do recommend that patients, uh, engage their care team. Really, you should have a good sense of what’s going on. You know, how often your, your, your sugars are going to get monitored, why they’re getting monitored, what the blood sugar goals are, and if changes are being made, why they’re being made.
Sometimes when, when people are in the hospital, uh, and, uh, they may only be getting insulin if their blood sugar is high, and that can lead to blood sugars, staying high, if they’re, uh, if they’re, if they’re eating. So, uh, really when I, when I speak of the team, um, our patients are an essential part of that, uh, team management.
Shireen: Can you walk us through what special considerations individuals with diabetes might need to take. If they’re admitted to the hospital?
Richard Siegel: So when patients are coming into the hospital, they need to be a, really have a full sense of their, their medication list as, uh, we are asking what oral medications they’re on, we’re asking what insulins they’re on.
Uh, it’s important that the care team really have a sense of any dietary considerations. Um, as specific diets will be written when they’re in the hospital. And, uh, if there are certainly any food allergies that are involved, the care team needs to be aware of that.
Shireen: Has COVID-19 in particular impacted those with diabetes and then just even overall medical innovation and new access methods for diabetes care?
Richard Siegel: So with the COVID pandemic, we went, at Tufts medical center, exclusively to televisits for, for, for three months. So the first three months I was at home, uh, and doing televisits for all my patients. And we were really just starting to discover, uh, some of the barriers and really finding our way. Now we really learned how to use telemedicine.
Yeah, in a better way. Uh, currently I’m doing one afternoon session of televisits per week. Um, very powerful thing for patients with diabetes, uh, through the pandemic and with telemedicine is the use of really the cloud-based technology and software. So, this has allowed us to, uh, get a sense of what patient’s blood sugars are as well as how they may be taking particular medications. Different, uh, software programs and apps include, um, gluco, which can allow patients either in our office or from home, uh, upload to the cloud, different glucometers, continuous glucose monitors, uh, and two of the, the three major pumps. And then there were other, uh, websites, uh, that are cloud-based including Tidepool, um, Dexcom Clarity, LibreView for the, the FreeStyle, Libre, uh, and CareLink for the Medtronic products. Patients were using, selectively, the patient portal to send us information and portal certainly may vary as to whether they can accept documents or not.
So some patients we’re also using my regular email to, to get me information as well. Um, we, definitely with the use of televisits, increased our use of education, uh, as well as, uh, between our clinical pharmacist and our nurse practitioners invent diabetes educators. Uh, we were using televisits for, for teaching on pens and, uh, injection technique.
Uh, and I know that some of the companies were doing, uh, even pump starts, uh, using, using televisits. And so even now as the, uh, the pandemic lessons, uh, we continue to use these, uh, these resources and I think, uh, will continue to be helpful. You know, I think, you know, the, the, the cloud-based technology is really extremely, uh, useful, uh, especially for analyzing blood sugar patterns, uh, between visits and making, making recommendations.
Shireen: Just from your observation, Dr. Siegel, how have you seen COVID-19 impact those with diabetes?
Richard Siegel: So we realized, uh, as patients were getting admitted to the hospital with COVID-19 that, uh, it is a very powerful infection for some more than others. So for patients with fairly well controlled diabetes, they were coming in, uh, and if they, especially, if they’re getting admitted to the ICU, even if they were not on insulin, they were going on insulin. And their insulin needs were very, very high. So, uh, patients were becoming very insulin resistant, uh, related to, to the, to the infection requiring, uh, insulin drips. Um, and it’s thought that, you know, related to the virus, uh. That’s some of the so called cytokines, uh, chemicals that are, uh, brought out by the immune cells related to the virus, uh, were affecting the liver and fat tissue and, and the pancreas, uh, affecting both how the body makes insulin and how it responds to insulin. For others there, there certainly has been suspicion whether the COVID-19 virus actually can get into those beta cells of the pancreas that make insulin, uh, to actually bring on diabetes.
Um, so, you know, patients who were not known to have diabetes prior to coming into the hospital, uh, may have developed new onset, uh, diabetes, and it’s possible that some of these patients might have had slightly high blood sugars, you know, prior to this, uh, and the stress of the, the situation, uh, ended up bringing this out.
Um, as the virus gets better, insulin requirements come down and, um, uh, occasionally patients who are on insulin, uh, as we tell patients in the hospital, even if you’re on insulin, it doesn’t always mean that you’ll always be on insulin. So, um, thinking about inpatient, uh, diabetes, it can really, again, be a very changeable sort of situation as patients transition back out, uh, to, to the clinic.
Um, so some of those patients on insulin, uh, with COVID-19 may go back to oral medication or potentially back to just a lifestyle management alone.
Shireen: Because folks will sometimes resist getting on insulin just for that sheer reason. But there is a path back from there.
Richard Siegel: Sure. Yeah. Uh, and really, you know, that, you know, this is where again, the, the education comes in, whether it’s, uh, in the hospital or outside of the hospital, teaching people really that insulin maybe, maybe needed during times of, of stress because of the various stress hormones that the body tends make.
Shireen: All right. So with that, Dr. Siegel, we’re toward the end of the episode. At this point, I’d love for our listeners to learn more about how they can connect with you and learn more about your work.
Richard Siegel: So, uh, listeners can connect, uh, with me through the various social media sites at Tufts Medical Center, including Instagram and Twitter.
Uh, you can find me on the Division of Endocrinology websites through tuftsmedicalcenter.org and, uh, certainly I’m, I’m taking new patients. Uh, again, I, as was mentioned earlier, I, I see patients both in the Diabetes Lipid Clinic, as well as in the, uh, the Weight and Wellness Center, where we work with patients who need it for, uh, helping to get weight down, and, uh, certainly, uh, weight management and diabetes, uh, maybe frequently go, go together, so happy to, to respond if there are inquiries, uh, through, through the hospital.
Shireen: Thank you so much for your time and to our listeners. If you want to head over to our social media, our question of the week for you is to understand how has COVID-19 impacted either yours or a loved one’s diabetes?
Head over to our social media on Facebook and on Instagram to answer that question. With that, Dr. Siegel, thank you so very much for your time today with us.
Richard Siegel: My pleasure. Thanks for having me.
Shireen: Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media @Yumlish_ on Instagram and Twitter and at @Yumlish on Facebook and LinkedIn for tips about managing your diabetes or other chronic conditions. You can also visit our website Yumlish.Com for even more information, and to get involved with all of the exciting opportunities Yumlish has to offer.
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