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The A1C, also known as a glycohemoglobin or hemoglobin A1C, provides a clear picture of your average glucose control for the past three months. The A1C measures the glucose that binds to hemoglobin in your red blood cells. The higher the glucose levels in your blood, the more glucose binds to the hemoglobin, and thus the higher your A1C level will be. Red blood cells are renewed every 120 days. By measuring the percentage of hemoglobin molecules that have glucose attached to them, you and your doctor can get an average of your glucose over three months.

The A1C test is done every three months. It does not require fasting, and can be done any time of day.

Why is the A1C test essential for diabetes management?
It gives you an overall picture of your diabetes, rather than a reflection of what is happening in one day, and helps you evaluate your diabetes care and make changes. An A1C test can help you manage your diabetes by:
It’s helpful to remember that the closer you get to your goal, the better you’ll feel today and tomorrow. According to Dr Noel Somasundaram ‘we recommend that patients aim for an A1C value of less than 7 percent’. This has to be done without increasing your risk for developing hypoglycemia ( low blood glucose).

The higher your A1C, the greater your risk for developing complications, such as heart attacks, strokes, kidney disease, and neuropathy, foot ulcers, and amputations. To help lower your risk for diabetes complications, keep your glucose levels in your target range by self-monitoring and making adjustments with medicine (insulin, tablets, or both), weight control, food control, and regular physical exercise.

What Do You Do if Your A1C Is above 7% or above Your Individual Target?
If your A1C is above target, it tells you that your diabetes treatment plan needs a change. This could mean that you need to develop a new plan to control your diabetes. By making an appointment to consult you can decide which medications best suit you as well as talk about your meal plan, and exercise. Most often you require new medications and change in diet and exercise. You may have to check your glucose at home. Set up an appointment to discuss the results with your doctor to ensure that you control your diabetes.

People who do not have diabetes usually have fasting plasma blood glucose levels that run under 90 mg/dl.

In diabetes patients controlling blood glucose values and keeping them close to normal as possible will help you safely achieve life without complications of diabetes. In general, high blood glucose, also called ‘hyperglycemia’, is considered “high” when it is 140 mg/dl. Ask your doctor what he thinks is a safe target for you for blood glucose before and after meals.

If your blood glucose runs high for long periods of time, this can cause significant problems for you long-term; you are at increased risk of complications, such as eye disease, kidney disease, heart attacks and strokes and amputations. High blood glucose can pose health problems in the short-term as well such as infections and coma in some patients. Your treatment plan may need adjustment if the blood glucose stays over 180 mg/dl for 3 days in a row. It is important to aim to keep your blood glucose under control and treat hyperglycemia when it occurs.

What are the symptoms of high blood glucose?

• Increased thirst
• Increased urination
• Dry mouth or skin
• Tiredness or fatigue
• Blurred vision
• More frequent infections
• Slow healing wounds
• Unexplained weight loss
• Lack of energy

What causes high blood glucose?

• Too much food
• Too little exercise or physical activity
• Not taking medications and insulin
• Not being regular with medications and insulun
• Insulin that has become ineffective after being exposed to extreme heat or freezing cold
• Stress, illness, infection, injury or surgery
• A blood glucose meter that is not reading accurately

What should you do for high blood glucose?

• Be sure to drink plenty of water. It is recommended to drink a minimum of 8 glasses each day.
• If your blood glucose is 250 or greater and you are on insulin, check your urine for ketones. If you have ketones, contact your doctor.
• Ask yourself what may have caused the high blood sugar, and take action to correct it. Ask your doctor if you are not sure what to do.
• Try to determine if there is a pattern to your blood glucose levels.
  • Check your blood glucose before meals 3 days in a row.
  • If greater than your target level for 3 days, a change in medication may be needed.
  • Contact your doctor or adjust your insulin dose.
  • Contact your doctor if you are currently using diabetes tablets only.

Determine why your blood glucose is high
Ask yourself the questions outlined below. The answers will give you the information you need to determine what to do about the hyperglycemia.

If your answers to the questions are yes, follow these suggestions.

High blood pressure (hypertension) is one of the principal causes of kidney disease and heart attack and stroke. When blood pressure is high, there is a large amount of tension inside the blood vessels that leads to damage. These vessels may constrict (“close off”), which can cause a heart attack, stroke, or kidney failure.

High glucose and high cholesterol can also damage blood vessels. Thus people with diabetes who also have hypertension are at especially high risk for blood vessel damage. It usually takes years for blood vessels to completely constrict, and damage to blood vessels can be slowed down or somewhat reversed with treatment.

The ABC of diabetes
By controlling you A- A1C, B- blood pressure and C-Cholesterol you can prevent complications of diabetes.

Diagnosis
Diagnosis of high blood pressure can only be done by having your blood pressure measured regularly. Usually, there are no obvious symptoms that indicate you have high blood pressure. If you have diabetes, the blood pressure is considered high if it is more than 130/80.
Your blood pressure should be measured on multiple occasions, as blood pressure can vary throughout the day and it is normal to have occasional readings greater than 130/80. Blood pressure generally peaks in the middle of the day, and is lowest at night while you are sleeping. It is best to take blood pressure from the left arm, if possible, and should be taken after you have rested for 5-10 minutes. Your left arm should rest comfortably at heart level.
Your doctor may ask you to check your blood pressure at home and record the readings as part of your blood pressure management.

Treatment
There are multiple ways to control your blood pressure. The first step is lifestyle changes.

Lifestyle Changes
Your diet and lifestyle can directly affect blood pressure. For example, too much sodium (salt), alcohol, or caffeine intake may increase your blood pressure. Your weight also affects your blood pressure. Increased weight leads to fluid retention, and the extra fat releases hormones that can make blood pressure rise. Excess weight also causes the heart to work harder. Routine exercises can speed-up weight loss.

Exercise can lower your systolic blood pressure – the top number in a blood pressure reading – by upto 4 to 9 mmHg. Some people can even reduce their need for blood pressure medication with exercise. Regular exercise also makes your heart stronger, making it able to pump more blood with less effort. Even if you do not have high blood pressure, regular exercise can help prevent it from rising as you age.

Weight loss, lowering sodium, alcohol and caffeine in your diet, in addition to decreasing stress, while increasing exercise are all an important parts of blood pressure control.

Medications
It is not uncommon for one to need one or several medications to achieve good blood pressure control. Many research studies have shown that you may need to take several medications to get your blood pressure to a goal of less than 130/80. You and your doctor can decide what are the best medications for you.

Imagine wanting to get pregnancy and bring discouraged from doing so. About 25 years ago, this was the case for many women with diabetes. However, with recent advances in diabetes management and careful planning, the chances of having a successful pregnancy are excellent! Talk to us about having a successful childbirth despite diabetes.

It’s all about planning
Preconception Planning
If you have diabetes and are thinking about becoming pregnant, it is recommended that you start preparing about 6 months prior to conception. The most important thing to do before conception is to have your diabetes in good control and to learn how to continue managing your diabetes during pregnancy.

Once you’ve decided you want to become pregnant, you should make an appointment with your endocrinologist (a diabetes physician specialist) to review your health status and pregnancy plans. If you don’t have an endocrinologist, your primary care provider can refer you to one.

In addition to an endocrinologist, there are other who can help you during your pregnancy: an obstetrician, of course; but other members of your healthcare team my include a dietitian who focus on the management of diabetes. You may be referred to other specialists by your endocrinologist. While you will be the one in charge of your pregnancy, it is still necessary to have a medical team as well as loved ones to support you during this time.

You will need to meet with your obstetrician more frequently than a woman without diabetes. These visits may include ultrasounds to determine fetal growth and development and other laboratory tests. It is important to know that you will be scheduling a number of visits with your team during your pregnancy.

Dr Noel Somasundaram recommends the following goals and medical assessments before pregnancy:

• Fasting and pre-meal blood glucose: 80-110 mg/dl
• Blood glucose one hour after meal: 100-130 mg/dl
• A1C, as close to 6% as possible without hypoglycemia
• Blood pressure below 130/80 mm Hg (if you are taking medication for your blood pressure, the medicine has
• to be reviewed to make sure that it is safe for use when pregnant)
• Review of diabetes and obstetrical history
• Eye evaluations to screen for and discuss risks of diabetic retinopathy
• Renal, thyroid, gynecological and sometimes cardiac evaluations

The critical stages of development for a baby begin within the first 4 weeks, which is often when a woman can’t even tell she is pregnant. Even so, during this time the baby’s spine and organs are formed. This is why it is important to keep your blood glucose levels in the target range prior to conception in order to help reduce the risk of harm to your baby. Checking your blood glucose three times daily and having an A1C test will help tell you if you’re staying on track. During your pregnancy, your A1C is checked every month. Chart your blood glucose values and send them periodically to your endocrinologist for review.

If You Are Already Pregnant
More than half of all pregnancies are unplanned. If you fall into this category and discover that you are pregnant, it’s important that you schedule an appointment with your endocrinologist and your obstetrician right way.

Glucose Management in Pregnancy
For the health of you and your baby, it’s important to achieve the best possible blood glucose control, while avoiding hypoglycemia. The table below lists the recommended glucose goals during pregnancy.

Taking Insulin
Women with type 1 diabetes must take insulin to manage their diabetes, and during pregnancy will find that the amount of insulin that they need will increase. Because diabetes pills have not been approved by the Food and Drug Administration (FDA) for use during pregnancy, woman with type 2 diabetes may also need to take insulin during their pregnancy, as well. As the pregnancy progresses, more insulin may be needed to compensate for the placental hormones that raise blood glucose. By the end of your pregnancy, you may need 2-3 times more insulin than you needed before pregnancy. Your healthcare team will work with you to find the insulin regimen that best meets your needs.

Nutrition
The food you eat during pregnancy not only helps your baby grow, but it also has an effect on your blood glucose levels and for this reason, a dietitian is an important member of your healthcare team. Part of a dietitian’s job is to provide you with a meal plan than takes into account you and your baby’s nutritional needs, your lifestyle, and the foods you like and dislike. A dietitian will also be able to tell you which foods are important to eat and which ones are best to omit during pregnancy in addition to helping you gain the appropriate amount of weight for each 3-month trimester of your pregnancy.

Activity
Exercise is an important part of managing diabetes, and is recommended as a safe therapy for managing diabetes in pregnancy. Women who are active for at least 5 days each week and who do aerobic and strength training exercises are more likely to have an easier pregnancy. Blood glucose is affected by exercise during pregnancy. Checking blood glucose around exercise is important to keep both you and your baby safe.
It’s okay to continue most activities during your pregnancy; however, it is best to check with your healthcare team, especially if the activity is strenuous such as skiing or hot yoga.

Gestational Diabetes
Gestational diabetesis the term used when diabetes is diagnosed during pregnancy. It usually develops between the 24th and 28th week of pregnancy and affects anywhere from 6-9 percent of all pregnancies. The treatment, blood glucose monitoring, scheduled office visits, meal planning, activity and medication are similar to the guidelines described above. Your healthcare team will help develop a specific care plan for you. It is very important that, once you deliver your baby, you schedule a follow-up appointment for laboratory testing and healthcare review with your team because women who have gestational diabetes are at risk for developing type 2 diabetes later on in life.

Postpartum (After Pregnancy)
With careful diabetes management, women can and do have successful pregnancies and healthy babies.
After your baby is born and you have seen your obstetrician for a follow-up visit, plan a healthcare check-up visit with your endocrinologist to review your blood glucose control, possible medication changes and weight management.

People with diabetes have been identified as one group that may face greater risks of complications when dealing with COVID-19. With that in mind, Dr Noel Somasundaram has prepared these guidelines for adults with diabetes who may find themselves dealing with any kind of viral symptoms.

 What to do if you are feeling sick and have diabetes?
On days when you are sick, your glucose levels can go high even if you are eating less than you usually do.

Having any of these conditions below can cause a “sick day” and may make your glucose levels go up.

Home Blood Glucose Monitoring, Hemoglobin A1c Testing, and Fructosamine Tests
There are many ways to monitor your diabetes and your diabetes control. Daily information is valuable to make decisions in the moment, while tests like A1c and Fructosamine provide an overall idea of control over a longer time period. Hemoglobin A1c tests tell you and your endocrinologist what your glucose control has been on average over the past three months. The fructosamine test is similar to an A1c but measures your average glucose over two weeks. Each type of test has its advantages and usefulness.

Home glucose monitoring
Home glucose monitoring provides a “snapshot” of how your glucose treatment program is doing at one moment in time. This information is particularly important to help you tailor your daily eating program and medication needs to keep glucose in a healthy range. Daily monitoring is vitally important to tell you if the symptoms you are experiencing – sweats, feeling faint, etc. – are the result of a low glucose value (hypoglycemia) so you can treat this problem quickly. Home glucose monitoring is also important when you are sick, or under stress, as it provides you with information you need to make immediate adjustments in your treatment program to keep your blood glucose level in range. By keeping track of glucose levels over a period of weeks, you can begin to see patterns and identify ways in which food, exercise or other factors influence your blood glucose levels. Daily glucose monitoring now comes in many forms by using either a blood glucose monitor or a continuous glucose monitor (CGM). Ask your endocrinologist which method is best suited for you.

Hemoglobin A1c test
While home glucose monitoring is like a snapshot, hemoglobin A1c testing is more like a full length movie – it provides an average view of your glucose level over a period of two to three months. These results will be reported the same day in the laboratory. For people who have not undergone any major changes in their lifestyle or diabetes treatment, hemoglobin A1c tests provide a good assessment of long-term glucose control.
Since A1c is an average, a normal hemoglobin A1c test does not always mean that your glucose has been under control continuously for the past 2-3 months. In fact, since A1c is an average value, sometimes people with swings in blood glucose levels — lots of highs and lows — would also have a normal hemoglobin A1c. This is why daily glucose readings are also important. Dr Noel Somasundaram recommends a target A1c level below 6.5%. If the A1c is above 7% you will need to discuss with your endocrinologist the changes that are required in the treatment plan as well as eating pattern and exercise.

Fructosamine test
The fructosamine test is another measure of glucose control, although it is not as commonly used. The main advantage of the test is that it can detect overall changes in blood glucose control within a few weeks, rather than months. Fructosamine levels indicate the level of glucose control over the past two or three weeks. When changes are being made in your diabetes treatment plan, the Fructosamine test can indicate your level of control over a time span of two weeks.

Heart disease and diabetes are like twins. A strong link exist between diabetes and heart disease. Those with diabetes have greater risk of heart attacks. Two thirds of the deaths in those with diabetes occurs from heart disease. In fact, cardiovascular disease leading to heart attack, stroke, or peripheral vascular disease leading to amputation are the biggest health risks for those with diabetes.

Insulin is the medication used to manage type 1 and, in some cases, type 2 diabetes.

Osteoporosis occurs when the body loses too much bone or when the bone formation is too little. As a result, bones become ‘porous’; weak and fragile and can easily break (fracture) from a fall or even from minor injury.

Osteoporosis means “porous bone.” When seen under a microscope, a healthy bone is similar to honeycomb. In osteoporosis, the holes and spaces in the honeycomb are much larger than in healthy bone. Osteoporotic bones have low bone density and are fragile. A DEXA scan is the diagnostic test for osteoporosis.

Osteoporosis is Common
With advancing age Osteoporosis becomes commoner. In women older than 60 years more than two thirds may have osteoporosis. One in two women and up to one in four men age 50 and older are likely to fracture a bone due to osteoporosis.

Osteoporosis is Serious
Bone Fracture is a serious complication of osteoporosis, especially with older patients. Osteoporotic bone fractures are most likely to occur in the hip, spine or wrist, but other bones can break too. The complications of fractures can be serious. In addition to causing permanent pain, osteoporosis causes some patients to lose height. When osteoporosis affects vertebrae,, it often leads to a stooped or hunched posture (scoliosis). Many patients become bed bound after a serious fracture and may develop complications such as pneumonia, embolism, and can even have a higher risk of death.

Osteoporosis Can be Silent!
Osteoporosis is often called a silent disease. Fracture (Breaking a bone) is often the first sign of osteoporosis.

Thyroid gland produces thyroid hormone, which controls many activities in your body, including how fast you burn calories and how fast your heart beats. Diseases of the thyroid cause it to make either too much or too little of the hormone. Depending on how much or how little hormone your thyroid makes, you may often feel restless or tired, or you may lose or gain weight. Women are more likely than men to have thyroid diseases, especially right after pregnancy and after menopause. Thyroiditis is also a common problem in women and it causes the thyroid to enlarge and develop nodules.

The following thyroid diseases may be encountered:
Hypothyroidism

• Hypothyroidism is when your thyroid does not make enough thyroid hormones. It is also called underactive thyroid. This slows down many of your body’s functions, mainly your metabolism.
• The most common cause of hypothyroidism is Hashimoto’s thyroiditis. The immune system mistakenly attacks the thyroid-resulting in damage of the thyroid so that it does not make enough hormones.
• Symptoms of hypothyroidism develop slowly, often over several years. At first, you may feel tired and sluggish. Later, you may develop other signs and symptoms of a slowed-down metabolism, including:

• • Feeling cold when other people do not
  • Constipation
  • Muscle weakness
  • Weight gain, even though you are not eating more food
  • Joint or muscle pain
  • Feeling sad or depressed
  • Feeling very tired
  • Pale, dry skin
  • Dry, thinning hair
  • Slow heart rate
  • Less sweating than usual
  • A puffy face
  • A hoarse voice
  • More than usual menstrual bleeding

• The treatment involves using replacement doses of thyroxine and correction of underlying factors.

Hyperthyroidism

• Hyperthyroidism, or overactive thyroid; it causes  thyroid to make too much thyroid hormone. This speeds up many of your body’s functions, like your metabolism and heart rate.
• The most common cause of hyperthyroidism is Graves’ disease. Graves’ disease is an auto-immune system disorder where antibodies stimulate the thyroid gland. 
• At first, you might not notice the signs or symptoms of hyperthyroidism. Symptoms usually begin slowly. But, over time, a faster metabolism can cause symptoms such as:
  • Weight loss, even if you eat the same or more food (most people lose weight)
  • Eating more than usual
  • Rapid or irregular heartbeat or pounding of your heart

• Feeling nervous or anxious
• Feeling irritable
• Trouble sleeping
• Trembling in your hands and fingers
• Increased sweating
• Feeling hot when other people do not
• Muscle weakness
• Diarrhea or more frequent bowel movements than normal
• Fewer and lighter menstrual periods than normal
• Changes in your eyes that can include bulging of the eyes, redness, or irritation
• Treatment of hyperthyroidism: At DHC we carefully evaluate your symptoms and the cause of your hyperthyroidism and develop a personalised choice along with you. Treatments include:
• Medicine.
  • Antithyroid medicines block your thyroid from making new thyroid hormone. These drugs do not cause lasting damage to the thyroid.
  • Beta-blockers block the effects of thyroid hormone on your body. These medicines can be helpful in slowing your heart rate and treating other symptoms until one of the other forms of treatment can take effect. Beta-blockers do not reduce the amount of thyroid hormones that are made.
• Radioiodine. This treatment kills the thyroid cells that make thyroid hormones. Often, this causes permanent hypothyroidism.
• Surgery. Thyroid surgery removes most or all of the thyroid. This may cause permanent hypothyroidism.

Thyroiditis

• Thyroiditis is inflammation of the thyroid. It happens when the body’s immune system makes antibodies that attack the thyroid.Causes of thyroiditis include:
  • Autoimmune diseases, like type 1 diabetes and rheumatoid arthritis
  • Genetics
  • Viral or bacterial infection
  • Certain types of medicines

  Two common types of thyroiditis are Hashimoto’s disease and postpartum thyroiditis.

Goiter (enlarged thyroid)

Thyroid nodules

Thyroid cancer

Getting some vitamin D by exposing your skin to the sun is something you hear regularly. Vitamin D is a prohormone- it is converted into activated hormone. Part of the vitamin D the body needs comes from food (such as dairy products and oily fish), and the rest has to be manufactured in the skin. When sunlight hits the skin a chemical reaction is triggered and this reaction produces cholecalciferol. The liver converts it to calcidiol. The kidneys then convert calcidiol to calcitriol, which is the active form of the hormone in the body.

However most people are now deficient in Vitamin D. The reasons for deficiency include inadequate manufacture of Vitamin D in skin and poor intake of vitamin D in food. It is known that those who have dark skin have poor ability to manufacture vitamin D even when exposed to long periods of Sunlight.

Vitamin D is a hormone the kidneys produce that controls blood calcium concentration and impacts the immune system. It is also known as calcitriol, ergocalciferol, calcidiol and cholecalciferol. Of those, calcidiol is the form doctors most commonly focus on when measuring vitamin D levels in the blood.

Vitamin D has its effects by binding to a protein (called the vitamin D receptor). This receptor is present in nearly every cell and affects many different body processes.

What does vitamin D do?
Vitamin D helps the body absorb calcium so that blood calcium levels are at the ideal point. This helps enable the mineralization of bone that is required for strong, healthy bones. Yet this is just one function of the hormone.

Vitamin D deficiency has been linked to a variety of health concerns, which points to a wide range of vitamin D functions, although research is still underway into why the hormone impacts other systems of the body. For instance, too little vitamin D makes an individual more prone to infections and illness, cardiovascular disease, and mental illnesses — including mood disorders like depression. Studies also show that people who have low vitamin D levels are more likely to be obese. Researchers have found that vitamin D helps regulate adrenaline, noradrenaline (also called norepinepherine), and dopamine production in the brain; as well as helping to protect from serotonin depletion. For this reason, low vitamin D levels increase an individual’s risk of depression significantly. A better understanding of vitamin D function is necessary to fully comprehend how it is linked to so many health concerns.