Diabetes has reached “a crisis level over the last several decades,” according to Dr. Rashmi Mullur, an endocrinologist with UCLA Health. A common link appears to be the primary culprit.
“We are still experiencing what we consider our obesity epidemic that has been in motion since the early 80s,” said Mullur. “This in turn has fueled an increase in [Type 2] diabetes.”
Although a slight plateau in obesity was noted in 2010, Mullur said it has “started to climb up again.” This is a global problem, not a localized one.
According to reports from the Centers for Disease Control (CDC), in 2018 it was estimated that the staggering number of diabetics (diagnosed and undiagnosed) equated to “34.2 million people of all ages – or 10.5% of the U.S. population.”
On both a global level and within the U.S., Mullur explained that “in the prevalence we are seeing, we are seeing not only diabetes rising, we are seeing it affecting our BIPOC (Black, Indigenous, and people of color) communities.” Diabetes knows no boundaries when it comes to the wide-ranging numbers, regardless of ethnicity.
“In 2017, diabetes was the seventh leading cause of death in the United States.”*
From a treatment standpoint, Mullur said that “the use of race-based medicine is inappropriate in our communities of color and our black indigenous populations are experiencing higher levels of diabetes and morbidity from diabetes due to inequitable healthcare.”
I’ve understood its common with many health conditions that have reached a state of emergency to incorporate a multi-level approach to implement changes and make a positive impact on people’s health. First and foremost, Mullur said the most important thing “is just access to care.”
It’s not uncommon for individuals to be diagnosed with diabetes in their “late 50s or -60s age and some of those patients might have been diagnosed earlier if they had access to care,” she said. “I think access to care is going to be the most important as the first step. As we add access to care, you get preventive medicine.” Preventive medicine can add many years to a diabetic’s life.
Structural inequity is a large component of access to care and management of health conditions. Mullur explained that doctors can “tell people all day and all night to [integrate] what we call ‘healthy lifestyle’ choices.” It’s not that simple though.
“If they are in an area where they don’t have access to food, because it’s a food desert, or they can’t go exercise outside because it’s not a safe area or the climate prevents it, or if they live in an area where they have increased air pollution, they are at higher risk for developing diabetes and other chronic conditions,” Mullur said.
As we’ve learned through the pandemic, access to digital health care can, at times, be extremely beneficial for patients – that is patients who can access it. It can lessen the burden when one lives with chronic illness, is disabled, has caregiver issues, and in many more scenarios. But not everyone has access to it at this time.
Mullur also holds the position of Chief of Telehealth at the Greater Los Angeles Veteran’s Administration (VA) and magnified the lack of digital health care access among the population. She said that it “[will be] a huge benefit once we get it working.” Most importantly, she stressed how imperative it is “to make sure we reach our patients that live in remote areas.”
Getting to that point is not an easy path as investment-wise and structurally there’s much progress to still be made. “That infrastructure is going to take real public policy and change,” said Mullur.
Living with diabetes tends not to be exclusive. In her practice, Mullur said it’s quite common to treat an individual with diabetes and a secondary condition. “Most of my population doesn’t just have diabetes. They have diabetes and…” she said.
“The large cohort has diabetes plus the diabetes-related chronic conditions – hypertension, heart disease, high cholesterol, etc.,” she clarified.
It’s not limited to just those secondary conditions, Mullur said, as there are many conditions that are comorbid, such as “diabetes and thyroid disorders, diabetes and migraine…”
When a diabetic patient presents with a headache and/or migraine, Mullur said “In my practice as an integrative doctor, it’s all together. I can’t treat one condition separate from another.”
Patients often tell her “they can feel when their sugar is off. Many times, patients will report they have a headache.”
High and low blood sugar are likely culprits. She suggests her patients check their blood sugar level and sometimes, but not all times, it’s been reported to be high when experiencing headache symptoms.
“The classic symptoms of low blood sugar are shaking, sweating, trembling, palpitations, and feeling on edge,” she said. “But as patients [experience] more low blood sugar episodes, their bodies get used to it. It’s called Hypoglycemia Unawareness and sometimes they don’t get symptoms.” That can be dangerous territory.
When one experiences Hypoglycemia Unawareness “sometimes the only thing they’ll notice is perhaps confusion or a headache,” Mullur said. She immediately asks patients these questions: “Have you ever had a low blood sugar reading? Do you wake up in the morning with a headache?”
She explained that, “if they are asleep at night and they have slept through their low blood sugar level, sometimes they can wake up with a low level and it’ll feel like a headache. Those are the ways I’ve really seen diabetic headache.” This would be different than a person with diabetes experiencing a true migraine.
Education and communication are at the forefront of Mullur’s outstanding doctor-patient approach, both which garner immense respect.
Education insofar as “help[ing] the patient understand the symptoms of high and low blood sugar that contribute to feeling not right (whether it’s a migraine or a tension headache) and really teasing out if this is blood sugar- related, is this exercise related, is this something related to my diabetes or is this something else [is important],” she explained.
And this isn’t easy. In successfully managing diabetes or any other chronic condition, trying to identify the ‘why’ behind a symptom can be a full-time job, stressful, confusing, and uncertain.
Mullur said, “That tends to be hard for not only doctors, but patients. It’s really challenging.”
In addition to her positions with UCLA Health and the Greater Los Angeles VA, Dr. Mullur has pioneered several clinical programs using integrative medicine techniques for the management of chronic disease and is a national leader on the use of integrative medicine for patients with diabetes.
Watch for more from Dr. Mullur on November 11, 2021
Coming next: Surgery for chronic sinus infection was rough, but successful