The complications of uncontrolled diabetes
What other problems can people with diabetes have?
What are the complications of diabetes and what complications can diabetes lead to?
Hypoglycemia, Ketoacidosis (DKA), Kidney Disease (nephropathy), Cardiovascular Disease, Diabetic Foot Ulcers that lead to lower limb amputation, Heart Disease and Stroke, Nerve disease (diabetic neuropathy), and Eye disease (diabetic retinopathy) are some of the complications uncontrolled diabetes can lead to.
The long-term effects of diabetes impact every organ in the body.
Complications of diabetes | Diabetes-Related Complications
In this article, we will cover:
- What can be done to slow the complications of diabetes?
- What are the acute microvascular complications of diabetes?
- What other health problems can people with diabetes develop?
- What does uncontrolled diabetes do to your body?
One of the questions I am frequently asked is, “Does diabetes raise my risk for other health problems?”
Unfortunately, the answer is yes. People with diabetes are considered immunosuppressed because of how much raised sugar levels affect the immune system. Diabetes can affect the entire body because of how important the blood and vascular systems are to the body’s ability to function.
How many people in the U.S. have diabetes and how common is diabetes?
- Diabetes affects over 29 million people in the United States.
- One in two adults in the U.S. has been diagnosed with diabetes, whether they know it or not because despite the common belief, diabetics oftentimes don’t even realize that they have diabetes.
- According to the Centers for Disease Control and Prevention (CDC), more than 1 in 10 Americans have diabetes, and approximately a third are prediabetic, meaning they are at a high risk of developing it.
How diabetes works video: Microvascular Complications of Diabetes: Eye, Kidney, and Nerve Damage
Vascular & Microvascular Complications of Diabetes
Diabetes comes with a wide variety of symptoms.
Diabetes is an incredible catalyst. In medicine, I always say that two times two is not for two times, two is 22. It’s perfectly true when it comes to diabetes, so your risk of heart circulation problems and eye problems are two times more when you are diabetic and two times more when you have hypertension. But when you have both, the risk is not four times more. The risk is 22 times greater. So that’s why if you or a loved one has diabetes and hypertension, you need to see an ophthalmologist once a year. You need to make sure your doctor is checking your urine for microalbumin and you need to get your feet examined because poor blood circulation is a huge problem for diabetics. I can’t emphasize that enough.
What are the vascular complications of diabetes mellitus?
Microvascular organs are the eyes, kidneys, and nerves. Unfortunately, there are a lot of microvascular complications that result from diabetes.
What organs does diabetes affect?
- Lower Extremities
What are the 5 most common leading complications of diabetes?
- Cardiovascular disease
- Nerve damage (neuropathy)
- Kidney damage (nephropathy)
- Eye damage (retinopathy)
- Foot damage / lower extremity blockages
Diabetes Risk Factors:
- Kidney disease
- Glucose level
- Blood sugar level
Signs of uncontrolled diabetes
When do diabetes complications start?
Microvascular and Vascular complications of Diabetes
How does diabetes affect the vascular system?
Diabetes is a disease that affects almost every organ. One of the predominant ways it affects different organs is by causing microvascular problems. When we talk about vascular issues and vascular disease, we are referring to blood vessels. We typically define this into macro and microvascular, meaning bigger blood vessels that are more than two and a half to three millimeters in diameter, which are blood vessels in the heart, blood vessels in the brain, carotid arteries that feed the brain, and the larger blood vessels. The way diabetes impacts the body and circulation and different organs is by causing microvascular coronary complications, which means small blood vessels at the capillary level.
Diabetes is a systemic disease, whether it’s type one or type two. Type one and type two diabetes have consequences on the body on every organ system.
The underlying main mechanism is the type of fuel the body needs is different. That’s why sugar control is extremely vital for diabetes control as well as making sure other risk factors like cholesterol control and lipid control and blood pressure control is very important. In fact, it is more important in diabetics than non-diabetics because diabetics have heightened sugar levels to begin with.
How diabetes can affect all various organs from head to toe (literally and figuratively).
Can diabetes cause blocked arteries?
Every organ gets affected by diabetes, but to what degree? We know that diabetes can affect the eyes, circulation, and nerves. But why is that? Most importantly, what do we need to keep in mind?
Apart from prevention, screening for diabetes is important.
What are some of the screening techniques for diabetics to make sure that we are not suffering from any microvascular complications or consequences of diabetes?
Diabetes can lead to anthogenesis, which is plaque formation. Where does this plaque form? Anywhere! This is a blockage. Plaque is the process of fatty deposits that accumulate and harden within the body. Do you know how you can have plaque between two teeth inside the blood vessel wall? We have a blockage formation process that starts along with calcium. So where do these blockages go? Any blood vessels. You have blood vessels in every organ in the body. That is why diabetics can have trouble from head to toe. If you’re diabetic, you are also at a high risk of stroke.
When that happens, it can start causing compromise of different organs. Diabetes causes retinopathy, which is the number one reason for blindness in The United States and it does that by something called nonproliferation, which is the early part of retinopathy and then proliferative retinopathy.
Microvascular complications are when the heart arteries get clogged and blockages lead to standing bypass surgeries and heart attacks. Other microvascular complications are when blockages in the carotid artery that causes stroke and then other microvascular issues. It’s a lower extremity blockage.
Once you get those macrovascular blockages, you should be on blood thinners like baby aspirin, which has a protective role because that’s been in a very low dose and a baby dose works as a blood thinner. It’s a blood-thinning medication that prevents people from getting a heart attack or stroke. For diabetics, it’s very important to pay attention to that.
Microvascular means small blood vessels. The big one is retinopathy, which is in the eye. The second one is the kidneys. Diabetics will often develop kidney problems by the same factor and common pathophysiology mechanism that causes this problem to begin with. The third one is diabetic neuropathy, which is when the nerves and nerve ending gets impacted by diabetes. The same mechanism of what we call vascular growth factors, too, because diabetes is a condition where type one means your body doesn’t form enough insulin or type two, meaning your body forms enough insulin, but it doesn’t create resistance.
It doesn’t allow the impact of insulin the way it should. When people have diabetes, that pathophysiology is very similar to somebody who is starving because your body is resisting insulin. Now, you have sugar that stays in your bloodstream but cannot go from your bloodstream to your intracellular. All of your vital organs will not get the sugar, which is the fuel and the energy we need. That’s why the sugar is high in the blood and low inside the cells.
But every cell, every tissue and every organ in the body needs fuel. It needs the energy to function.
When the sugar and glucose can go there, it starts utilizing fat and the unhealthy way of metabolism. When that happens, you get secretion of bad chemicals because anytime you’re using bad fuel instead of good fuel, you start having all these chemicals and they are called three fatty acids. These chemicals will now go and cause a plethora of problems, one of which is the vascular growth factor. There are different growth factors that can go at a capillary level and start building this extra piece of tissue, which in turn will start causing some of the problems in the retina.
It will cause the formation of a microaneurysm, which means the blood vessels will get this microaneurysm, meaning enlargement of the blood vessel or bulging at a microscopic level. But your blood vessels are getting enlarged. The first change that happens with more capillaries. These are not necessarily a good thing and eventually, it would lead to a lack of blood flow because of this access that goes. It can then go from non-proliferative retinopathy to proliferate retinopathy. This is why people with diabetes will end up having blindness and loss of vision.
It’s very important that if somebody is diabetic that they go and get their eyes checked by an ophthalmologist who will check the retina. They will put a special camera and make sure that it doesn’t already have those changes which are started in the retina as those changes started. It’s a sign that you need better diabetes control.
How does diabetes affect your heart, eyes, feet, nerves and kidneys?
Can diabetes cause blindness? How diabetic retinopathy develops
We all know that November is Diabetic Eye Disease Month, but very few people really understand the underlying mechanism of how diabetic retinopathy develops in the first place. Diabetics should pay attention to this not only in November, but every month of the year, too.
Microvascular is eye-based, proliferative retinopathy and nonproliferative diabetic retinopathy needs to be picked up early as possible. Get checked for any otherwise routine exam. If you have type one diabetes and are young. You can wait a few years if you are a type two diabetic and a little bit older and have hypertension and some other risk factors or have any symptoms, definitely see an eye specialist right away.
Are you seeing floaters in the eyes due to diabetes?
Diabetic eye problems can cause every kind of event, even a cataract, which is a lens problem.
Floaters in the eye are typically a vitreous problem, which means vitreous is the fluid outside the retina in the front. If you look at the eyeball that is recognized in the back, which is the curtain, but in the front that is vitreous. In the vitreous, that is the small blood vessels, in the rupture, those little red blood cells. You can see floaters in front of you. That is one of the most common reasons for floaters. Vitreous problems can be from diabetes. are seeing floaters in the eyes due to diabetes? It’s difficult to say one hundred percent of the time for one hundred percent of vision, but that could be a correlation. I would strongly recommend that anyone who is diabetic see an eye specialist including an ophthalmologist or optometrist.
What You Need to Know About Diabetic Retinopathy
Early detection is critical
Why you need to get evaluated for diabetic retinopathy on a regular basis
DIABETIC EYE EXAMS. If you’re diabetic, pay attention to your eyes. You need an annual diabetic eye exam. Most people don’t realize that diabetics have a two times higher risk of stroke than non-diabetics. it goes to the eye. eyes being number one. Why are eye exams so important in diabetic patients? Because eyes have small blood vessels. Anywhere blood vessels are small to begin with and now you get inside lining with plaque formation and blockage, you’re going to start having trouble. So that’s why the eyes are very prone to getting diabetic-related complications and they get trouble in pathology at multiple levels within the eyes and they can get retinopathy, macular degeneration or glaucoma.
That is the fungus, which is the very back of the eye. When we look under an ophthalmoscope, we can see how long people have had diabetes. And there are silver linings that are there just like hypertension. So that’s why an eye exam is very important.
When should diabetics get an eye exam?
Diabetics should get an eye exam at least once a year. Find a great eye doctor and make sure that you are on their roster and get your eyes examined at least once a year. This applies for people who have diabetes for more than ten years. But if you did get type two diabetes later in life, then even earlier to start getting your eye exams. Diabetes can affect every part of the eye, the retina being the most serious and more common.
Diabetics: When to see an Eye Doctor?
How frequently should you see an eye specialist after developing diabetes?
You should see an eye specialist frequently if you’re a diabetic. You need to see an eye specialist once a year. Then, depending on the finding, you can decide how quickly you want to see them again.
Within a year you should see an eye specialist. It depends if you have other risk factors like hypertension in your cholesterol. If you’re symptomatic, then immediately, if you’re completely asymptomatic and you have perfect vision, you could wait a few years. But overall, the microvascular impact of diabetes happens with glycemic control. If you’re diabetic and have a poor glycemic index, that is also a factor.
It also depends on the other aspects of your symptoms. If you have hypertension and any vision problem, see the ophthalmologist right away if you are completely asymptomatic with perfect vision, even then, if your sugar control is not very good, you’ve got to see an eye specialist right away. If you are type one diabetic and you just got diagnosed at a young age, maybe four or five years, you can wait, and then you can see that the recommendation is to wait up to five years.
If you are a type two diabetic, you’re more likely to be older, in which case you have to see an eye specialist pretty soon within the first year of being diagnosed. Once it’s established, you should keep seeing the ophthalmologist once a year.
Nephropathy means the kidneys. The kidneys will act in a couple of different ways. There are several mechanisms by which the nephropathy under the kidney problem happens, but they are all because of microvascular complications. The very small blood vessels once again play a major role in this.
Chronic Kidney Disease (CKD) & Diabetes
Nephropathy is an issue with kidneys. Once you have diabetes, you have to get your kidneys checked. The way to check a kidney is actually by doing blood work, which would tell a lot of kidney function.
Even more important in the early stages is a urine test, checking urine for microalbumin, making sure that people are not losing protein in the microalbumin, which is a very small molecule of protein because that’s the earliest change we see. The reason it’s important is that there are some incredible medications that we can know, that somebody can start and those medications can protect people from getting kidney problems.
Kidney disease and diabetic nephropathy.
The way diabetic nephropathy starts is the job of the kidney that is something called membrane in the kidney. The kidney is a filter. The job of the kidney is to make sure that the protein doesn’t leak. Kidneys are supposed to preserve protein from getting out of the body by protecting it. Unfortunately, when people have diabetes, some of the small molecules of protein, what we call microalbumin, start leaking first.
How bad is stage one Chronic Kidney Disease (CKD)?
Stage one kidney disease means certainly it’s an awareness that the kidneys are having some impact on the way we decide CKD means chronic kidney disease, and it is from one to six-stage stages. The first stage is when your kidney function goes less than 10 percent than it is off. The way we determine that is my blood work, something called GFR, which is a glomerular filtration rate that tells us what people’s kidney function is.
Once your kidney function goes, you’re going to stage one. That means it’s just the beginning and there’s no need to panic. All that means is to make sure you take control. This means better control of not only diabetes and blood sugar, but blood pressure, diabetes, and hypertension together are ten times worse than either one alone. The reason why is because diabetes worsens and the impact of hypertension and hypertension worsens the impact of diabetes.
I always say in medicine two times two is not four, it’s two times two is twenty-two. It’s perfectly true for diabetes and hypertension. If you’re a diabetic, your risk is two times more than nondiabetics for kidney problems, heart problems, circulation problems, and stroke.
If you are hypertensive, your risk is two times more than if you were non-hypertensive. But when you combine these factors together, your risk is not four times your risk was twenty-two times more. This is why everything augments in diabetic patients. There is a multiplication relationship here.
How does diabetes affect urine color?
What does it mean if test results show I have protein in my urine?
Pay attention to your urine. Your doctor should be checking your urine for microalbumin. They need to make sure that they check for this really low-level protein and make sure that there is no protein going out. I always tell my patient that when you go to the bathroom and if you see foam when you are urinating, make sure you get your kidneys checked. It’s a very simple urine test.
The reason is that your microalbumin, which is a part of the membrane, gets that proliferation, which is another major microvascular problem that can result from diabetes. Once you start leaking protein and albumin, or microalbumin in your urine, it’s a big problem because your kidney function will start deteriorating and you will start losing protein from the bloodstream.
What are the other organs where we have small blood vessels?
Your kidney arteries are relatively small. Diabetes, along with a combination of hypertension, will cause plaque inflammation and kidney arteries. The kidney is very important.
The number one thing that happens is diabetics start losing protein and microbian, which is a very micro protein in the kidney and in the urine. The kidney’s job is to protect the body from losing this protein. With diabetes, with this kind of plaque formation and nephropathy, people will start losing protein. So that’s why monitoring your kidneys is very important. Unfortunately, diabetes in combination with hypertension is the number one reason for people requiring dialysis.
ACTION ITEM: Get your kidneys checked and get a urine test to make sure you are not losing protein in your urine. There are medications that can reverse the damage of diabetes on the kidneys. This is one of those things that we have a tool in our hands. We can attempt to reverse the damage to the kidneys and reverse the neuropathy.
The third organ that diabetics have to worry about is the nerves. Diabetes will affect nerves and cause neuropathy. There are all kinds of nerves in the body and diabetes affects all of those nerves. Because nerves also have a lining and that gets immediately affected by diabetes, along with the rest of the circulation in the lower extremities. The lower extremity arteries are small, especially below-the-knee, what we call the tibial vessels. These blood vessels are extremely small and delicate. When a diabetic has diabetes that is not very well controlled for more than ten years, it is guaranteed they will eventually have a below-the-knee blockage formation at some point.
Neuropathy. Within neuropathy (nerves), there are motor-sensory and autonomic nerves and diabetes potentially can impact all of that. are the microscale complications. Microvascular was the heart, stroke, lower extremities, preventing amputation. Finally, a couple of simple strategies to get amazing glycemic control to have that awareness that this is very important for several reasons.
DIABETIC FOOT ULCERS & AMPUTATION
Non-healing wounds and diabetic foot ulcers lead to inevitable amputation.
People don’t realize that diabetic foot ulcers are the number one reason why people go for amputation and it’s a huge burden on people’s lives because people who get diabetic foot ulcers will get toe amputation and they are the same people who are at risk of much higher levels of amputation.
Diabetic Foot Ulcers (DFU) and non-healing wounds
How does diabetes lead to amputation?
Unfortunately, many diabetics will get diabetic foot ulcers (DFUs). When diabetics get ulcers, the diabetic foot doesn’t heal that easily. This remains the number one reason for amputation that people end up going and amputation itself is a big problem.
This leads to the problem of non-healing wounds and non-healing diabetic foot ulcers, or what we call DFU, which is a diabetic foot ulcer. Once somebody develops a diabetic foot ulcer, they have a significantly higher risk of not only losing the toe or the entire foot or an entire limb but also not surviving. We always talk about heart attacks, which is when your arteries in the heart shut down, people get a heart attack. Everyone understands when you say the word heart attack, it’s very clear in people’s minds that it’s a major problem. It happens abruptly and it can completely change the course of your life. It can either kill someone or even if you survive, you can still have a very different life.
Amputation is a very impactful event that should not be taken lightly. That is why we must do everything we can to prevent it from occurring in the first place. People don’t realize that there’s an event called a diabetic foot attack when your feet should be getting blood but they are not. The arteries shut down and don’t feed blood to the foot and now in combination with neuropathy and with infection, people can get wounds, nonhealing ulcers in the diabetic foot and they can eventually develop gangrene.
This leads to amputation and amputation is a downward spiral because once people have amputations, these wounds may not heal which eventually leads to more problems for the rest of the body. Twenty-five percent of people who end up with major amputations will not survive. That’s why the diabetic foot attack has been unrecognized.
This is important to know and the reason I’m bringing this up in this conversation is that microvascular complications like neuropathy in diabetics will eventually play a role in leading to this.
LOWER EXTREMITY FOOT CHECK.
When you are at the doctor’s office, they should take your shoes and socks off and check the pulse. Diabetics should get their feet examined twice a year. Unfortunately, most diabetics get neuropathy so they don’t feel the symptoms unlike other people.
If they have a small cut between two toes or when they are cutting their toenails and they have a little injury, they may not even realize they have a wound or an ulcer. Sometimes, there is even gangrene with a foul smell.
The first time they realize something is there is when they actually smell but they don’t feel that pain. So that’s why a foot exam is so important that the people get their health care providers to examine the feet and check the pulses. If you are an advanced diabetic, which means diabetes has been there at least ten years and longer. If you’re in your twenties, it is not time to worry.
But if you have had diabetes for more than ten years, then your actual physical-biological age doesn’t matter. At that point, diabetes has had a chance to create trouble and wreak havoc on your body. Make sure trouble is not already created. How do you do that? It’s a very simple test.
We check circulation with blood pressure testing. So how do we check arm blood pressure? The same way you can check blood pressure at the ankle level, you can also check the blood pressure of each toe individually.
We check ankle-brachial index (ABI), the same way we would for blood pressure. We also check toe brachial index (TBI). This can tell us the circulation at the feet and that actually helps a lot in preventing amputation and in diagnosing ischemia.
What is ischemia? Lack of blood flow where the feet don’t get blood flow. When that happens, I assume that somebody has diabetes and assume that they have peripheral neuropathy.
They are not feeling these wounds or ulcers and they have a little cut. Now, this cut will not heal. This is what we call a diabetic foot ulcer. The diabetic foot ulcer will sometimes take months, and in some people, it may take years before it heals because there is not enough blood flowing there. What happens on top of that is it can get an infection. Because in diabetics, the virtue of high blood sugar means it attracts bacteria because the sugar-high bacteria love it.
There are much higher tendons in their local immunity because the circulation is bad. So now people get diabetic foot ulcers which get infected or the other word is gangrene. And this is the number one reason why people end up losing their limbs. I can’t tell you how many times I see people who are completely fine, no problem whatsoever, living their lives perfectly normal and they get a small infection of the toe or a wound and the entire trajectory of their life changes.
I coined a term called a diabetic foot attack. When we use the word heart attack, everyone knows it’s a blockage formation in the heart that causes crushing chest pain. People will end up needing emergent procedures to fix the blockages in the heart. Otherwise, they can potentially die or have other consequences. What most people don’t realize is diabetics often suffer from a foot attack, which is when you’re fine until you’re not.
At least from the outside, things feel okay to the diabetic because you don’t feel any symptoms. You’re completely asymptomatic. You have a little tingling, numbness, but nothing else and then you get one infection or you get one wound that’s not healing. And then you have underlying PAD, which is poor circulation, and then bam, this ulcer will never heal, requiring amputation.
When people get amputation at one level, these are the same people who need a higher level of amputation. If you get amputation of the toe, you may need amputation at the ankle level, which is called transmetatarsal amputation (TMA). These are the same people who end up losing their entire limb. I have seen this story one too many times. When people are a longstanding diabetic, they feel fine and then they end up losing their lower extremities.
In the United States, we’re still doing more than 150,000 amputations, 80 percent of which are in diabetics because of diabetic foot ulcers and peripheral vascular disease-related complications.
Annually, more than 20 million individuals in the U.S. have PAD and one million of them get limb ischemia. A large majority of them have diabetes. If you are diabetic with a diabetic foot ulcer, the complication rate goes three times higher. Now, the treatment of foot ulcers will cause more complications and consequences. That’s why I always tell people not to ignore symptoms.
Early detection is key. It is essential that you can detect it early on. Screening is the key to preventing diabetic foot ulcers is key. If you develop a diabetic foot ulcer, make sure you don’t have peripheral vascular disease and limb ischemia. The good news is limb ischemia used to be a very difficult disease to treat or even pick up. Now it has gotten much easier. We can detect and prevent limb ischemia by doing all the things I mentioned and which is what I hope everyone does but God forbid somebody has limb ischemia and poor circulation, it’s very easy to detect by examining the blood pressure of the ankle and blood pressure of the toe. We also have sensors that we can put on your toes and the sensors can tell us if someone has a limb ischemia and poor perfusion at the skin level or not.
What kind of situation requires amputation?
People with peripheral vascular disease or critical limb ischemia should be concerned about amputation.
The good news is that the treatment has gotten easier. Back in the day, this would require amputation because that was the only therapy. Now, international cardiologists take pride in providing something called limb salvage angioplasty, which means we have different tools and techniques that we learn from fixing people’s coronary arteries in the heart. We apply those in the lower extremity arteries and we can open all these blockages and still prevent people from having to go for amputation.
Amputation Prevention: Save limbs and save lives.
I have dedicated my career to saving lives and preventing amputations and in turn that translates into people living longer and healthier lives.
Not every center and not every physician has this level of expertise. So that’s why it’s important that anyone who has to go through this gets the right kind of diabetes testing. Sometimes it requires educating the doctors and providers because you would be surprised at how many people who were trained twenty years ago and they don’t even know all the advances in peripheral vascular disease that’s going on. Even the medical therapy of the disease entity has grown tremendously.
Why hasn’t my endocrinologist hasn’t mentioned microvascular diabetic complications at all?
The younger you are, the less likely you’re going to develop these complications. But again, the actual physical age doesn’t matter. The number of years with diabetes is what matters.
How You Can Avoid Diabetes Complications
Have questions about managing diabetes? Ask your healthcare provider for a referral to Apex Heart and Vascular in Passaic, New Jersey. We offer diabetes management services throughout New Jersey and can help with amputation prevention for diabetic patients. Diabetes is a very aggressive disease and has many atherosclerotic factors. So long as the diabetes is higher, the risk that you can develop all these complications is greater. Take control of your health today before it is too late.
What types of healthcare professionals might be part of my diabetes treatment team?
Ideally, you should see a podiatrist, an endocrinologist, an eye doctor, a kidney doctor, a cardiologist and a vascular specialist to manage your diabetes.
Board Certified Interventional Cardiologist | Passaic, New Jersey
Make sure you get routine care which includes diabetes control, annual diabetic eye exams, making sure your urine gets checked for microalbumin, your feet examined by a podiatrist and your pulse checked in your lower extremities by a vascular surgeon. If you have any symptoms, get your circulation tested. If you are over fifty years old, get your circulation tested. If you have any cardiac symptoms, don’t ignore them. Make sure you have routine EKGs. We are available for virtual consults if somebody needs to get more one-on-one attention.
Apex Heart and Vascular in Passaic, New Jersey, provides the latest interventional techniques for PAD, PVD, and diabetes management.
Our New Jersey Cardiologists have technical expertise in minimally invasive and non-surgical treatment options for Peripheral Artery Disease (PAD), Peripheral Vascular Disease (PVD), and diabetic foot ulcers.
The premier Passaic New Jersey cardiologists restore blood flow to the legs and feet to get their patients back on track for a healthier life. Apex Heart and Vascular cardiologists have a proven record of success saving limbs and preventing amputation.
To schedule an appointment, contact Apex Heart and Vascular today.
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ABOUT DR. ANUJ SHAH MD
Dr. Shah is an interventional cardiologist and an endovascular specialist originally trained at Mt. Sinai. He has been in practice for 11 years and is passionate about the improvement of leg circulation and peripheral arterial disease. He is currently the Director of Apex Heart and Vascular and still has privileges at Mount Sinai as an assistant professor. He is a regional authority on peripheral arterial disease and critical limb ischemia and frequently is featured in the media and podcasts on diabetes management.