Shivani Agarwal, M.D., assistant professor of medicine in the division of endocrinology, is an achiever, a doer, a motivator, and a lightning rod for change. She is among the next generation of clinicians who are changing the face of medicine.
Dr. Agarwal has received national and international recognition, grants, and awards— including a $1 million grant from the National Institutes of Health to support the use of diabetes technologies among at-risk young adults—and the department of medicine’s 2022 Rising Star Award. We spoke to her about some aspects of her work.
What inspired you to go into endocrinology?
I have a family history of diabetes. I saw how much it affects not just the person who has the disease but their entire family. And that interested me because the whole health care model was just clinician to patient. But there is so much more that the patient must manage that was not being addressed. Also, I went to public health school in between my third and fourth years of medical school where I learned how to look at problems from the view of the healthcare system. And it really resonated with me that if we improve the way that we deliver care, we can improve individual health. Treating people living with diabetes is a catalyst for that.
What spurred your focus on at-risk young adults with type 1 diabetes?
Preventing and managing diabetes in at-risk and underrepresented communities presents several challenges, including financial, a lack of access to healthy food and safe places to engage in physical activity, a lack of access to medical care (or consistent care), generational trauma, and racism. It’s multi-layered from a medical and public health perspective.
During my endocrine fellowship, I trained under an attending who was treating a lot of young adults seeking care for type 1 diabetes. They were coming from pediatrics, or alarmingly, returning after years of no medical care with kidney and eye diseases – conditions that we should not have been seeing in such a young population.
There was a lot more attention to type 2 diabetes – especially the burgeoning rates in children, which of course is very important, but few people were focusing on young adults with type 1 diabetes. It was disproportionate to the number of people affected. And type 1 diabetes is on the rise and more common in young adults. We don’t entirely know why. We are looking not just at genetics (because some patients have no family history) but whether environmental factors play a role.
The young adult stage is a very critical time to intervene and help establish lifetime habits for success in disease self-management. But we need to address societal barriers young adults face. The price of insulin, if they aren’t covered by Medicaid, is enormous. If they are covered by Medicaid, the paperwork to renew is cumbersome; long waits at a Medicaid office is impossible while holding down a job.
This is also a time of change: many are entering the workforce, changing jobs and geographical settings (and needing to find new clinicians) and moving out of their homes. So, you have a perfect storm of factors that can result in uncontrolled diabetes.
You created a pilot program during COVID for continuous glucose monitoring in critically ill patients. How did that come about?
Managing patients’ diabetes while in the hospital is difficult under any circumstances but especially during COVID when so many critically ill patients with diabetes were arriving at hospitals. Staff were stretched beyond capacity. It was very difficult to frequently monitor patients’ blood sugar levels when hospitals were overrun and staff were moving from crisis to crisis.
Continuous glucose monitors (CGMs) are not FDA-approved for inpatients, but the FDA waived this during the pandemic. So, we took this as an opportunity to talk to hospital leadership, recognizing the critical need and the ability of CGMs to offload our nursing burden and provide care for patients in the best way possible.
Hospital leadership was really open to it, which I thank them for.
We placed the devices on a few patients in the ICU who needed intensive monitoring. And it was amazing. We were able to see their blood sugars in real time. Fluctuations that, in current COVID circumstances, would be difficult to monitor were immediately treated. We found that CGMs were quite accurate in comparison to finger sticks and outpatient use.
With the positive results in the initial three patients, we increased the number receiving CGMs (20 in total). Other ICUs have taken notice and would like to implement our protocol in their institutions.
Our next steps are to implement the program on a larger scale in our hospital systems with input about how to best disseminate the practice among nursing and inpatient providers.
Ones to Watch
The department of medicine wishes to acknowledge all the rising stars throughout our divisions, including Drs. Yorg Al-Azzi; Krystal Cleven; Inessa Gendlina; Sahan Hapangama; Tiffany Lu; Shereen Mahmood; Ari Moskowitz; Jessica Pacifico; Shani Scott; Kristine Torres-Lockhart; and Lili Zhang.
Posted on: Friday, April 29, 2022