ABC of Diabetes - Role of Lifestyle

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Role of Lifestyle:

R ole of L ifestyle Dr. S. Aswini Kumar. MD, Professor of Medicine Govt Medical College Hospital, Thiruvananthapuram A ttitude & B ehavioral C hanges of D iabetes 1 in draswinikumars@gmail.com....9447799984

New Concepts in Type 2 DM:

New Concepts in Type 2 DM 2 DM2 - a disease of the young DM2 - a disease of liver Diabetes is curable Diabetes is preventable

Case Study 1: Ms. Aparna:

Case Study 1: Ms. Aparna 15 year old Girl Weight: 95kg FBS: 325 PPBS: 450 Family doctor referred her after starting on OHA When ever she is not eating , she only taking rest THE NEW YOUNG INDIAN DIABETIC 3

Case Study 2: Ms. Aswathy:

Case Study 2: Ms. Aswathy 12 year old Girl Weight: 65kg FBS: 110 PPBS: 140 Presented with complaints of Abdominal distension USS - 12cm of thickness fat of anterior abdominal wall THE NEW INDIAN PREDIABETIC 4

Natural History of Diabetes:

Natural History of Diabetes Insulin secretion Type 2 diabetes Years from diagnosis 0 5 -10 -5 10 15 Pre-diabetes Onset Diagnosis Insulin resistance Postprandial glucose Macrovascular complications Fasting glucose Microvascular complications 5

Micro & Macrovascular Complications :

Micro & Macrovascular Complications Heart Attack Sudden Blindness Stroke Autonomic Neuropathy Chronic Kidney Disease Type 2 Diabetes Peripheral Neuropathy It’s a Nightmare! Peripheral Occlusive Vascular Disease 6 6

Why is the prevalence of DM2 increasing?:

Why is the prevalence of DM2 increasing? Aging of population Universal urbanization More sedentary lifestyle Food consumption patterns More foods with high fat content More refined carbohydrates 7

Lifestyle change – root of the problem:

Lifestyle change – root of the problem 8 “In older days a lot of energy was spent for ‘ procuring simple food’ , conscious efforts were not needed to maintain body weight , as daily activity did most of energy balancing work”

Lifestyle change – root of the problem:

Lifestyle change – root of the problem 9 In modern days, in our successful efforts to make life more ‘easier’ and more ‘comfortable’ we have become ‘energy conserving’ rather than ‘energy expending’ species Hill Jo et al, Obesity and the environment; Where do we go from here? Science 299, (5608): 853, 2003

Defect in ‘calorie balance’:

Defect in ‘calorie balance’ 10 ‘ Obesogenic ’ ‘ Diabetogenic ’ Balance

Awareness, (the lack of):

Awareness, (the lack of) 30% of overweight men and 10% of over weight women believe themselves to be having a healthy weight Gorynski P, Kryzizanowski M, A study of self perception of being over weight in adult inhabitants in Cracow; J Clin Epidemiology 1989; 42: 1149-54 10% 30% 11

Weight gain - reason:

Weight gain - reason 12 Mere 5% positive energy balance results in again of 5kg per year Severe obesity will result if this persists for years Jequier E, Wyatt HR, Reed GW et al: Adiposity. Leptin signalling and energy balance, Ann N Y Acad Sci967. 379-88. 2002

Create awareness:

Create awareness Lifestyle aberrations - the cause for obesity (and diabetes) Most cases are due to persistent positive energy balance over years And ……… Lifestyle modification is the treatment 13

Challenges in adopting a Healthy Eating Habit:

Challenges in adopting a Healthy Eating Habit 14

Lack of awareness/interest:

Lack of awareness/interest Wrong choice of food Washing cut vegetables Harmful overcooking Buying unhealthy food 15

Lack of time for cooking?:

Lack of time for cooking? The excuse for eating out or buying processed foods Home delivery or eating luxury items 16

What change occurred to the capital?:

What change occurred to the capital? 17 East Fort in 1960s East Fort today Number of Bakerys ==== Number of Medicals

How to meet these challenges?:

How to meet these challenges? 18

Regular planned Eating:

Regular planned Eating 19 Sitting at a table at specified times Avoid eating from any where

Distraction – leads to over eating:

Distraction – leads to over eating 20 Television viewing Working at computers

Change in general attitude:

Change in general attitude Social get ( not eat) togethers Too many sponsored dinners 21

Change in general attitude:

Change in general attitude Include active indoor games Include healthy food 22

Dietary Recommendations:

Dietary Recommendations 23

The Indian Food Pyramid:

The Indian Food Pyramid 24 Donad JO Gorman, Exercise and treatment of Diabetes and obesity, Endocrino metabol Clin A Am 2008. 887-903

The ATKINS Diet:

The ATKINS Diet 25 St Jeor et al; Dietary protein and weight reduction, a statement for health care professionals, Circulation 2001; 104; 1869-74 The Atkins Diet High protein low CHO diet Protein content as high as 25-35% Derived from animal proteins Lacks vitamins and minerals May be harmful (nephropathy)

Glycemic Index of Food items:

Glycemic Index of Food items 26 The average calculated from data collected in 10 human subjects Cauliflower < 15 Parboiled rice 47 White bread 70 Cucumber < 15 Green peas 48 Watermelon 72 Green beans < 15 Banana 53 Honey 73 Peanuts < 15 White rice 56 French fries 76 Tomatoes 15 Ice cream 61 Total cereal 76 Fat-free milk 32 Oatmeal 65 Vanilla wafers 77 Apple 36 Table sugar 65 Cornflakes 84 Grapes 43 Pineapple 66 Potato 85 Orange 43 Wheat bread 69 Dates 103 Measure of the effects of carbohydrates on blood glucose levels

Dietary recommendations - 1:

Dietary recommendations - 1 27 Consume whole grain products Eat fruits and vegetables

Dietary recommendations - 2:

Dietary recommendations - 2 28 Count calories Reduce portion sizes

Dietary recommendations - 3:

Dietary recommendations - 3 29 Avoid all fried foods

Dietary recommendations - 4:

Dietary recommendations - 4 30 Oil to choose from

Patho-physiology– Liver plays major role:

Patho -physiology– Liver plays major role 31 Gluconeogenesis Glycogenolysis

Dietary recommendations - 5:

Dietary recommendations - 5 32 Limitation of salt intake Taking of low fat milk Moderation of alcohol Cessation of smoking Low fat milk

Lifestyle modifications on an individual basis:

Lifestyle modifications on an individual basis 33

Weight Management:

Weight Management 34 Measure the height and weight

Read against readymade charts:

Read against readymade charts 35

Medical Nutrition Therapy:

Medical Nutrition Therapy 36 Diet prescription Main stay of treatment Shall be individualized, Realistic flexible suitable to patients life style preferably Indian diet Patient educated and at regular intervals compliance judged

Weight Management:

Weight Management 37 . Under weight  Normal weight S Over weight s Increase food intake to optimize weight Continue same amount of food intake Gradually decrease the amount of food High calorie diet 500kcal/increase/day Isocaloric Weight maintenance diet Low calories diet 500kcal deficit/day

Loose weight by cutting down 75 Kcal:

Loose weight by cutting down 75 Kcal 2 teaspoons of sugar 2 glucose biscuit 1 cream biscuit half teaspoon butter four chips half a vada half a laddu one half of a samosa half a cold drink one pakkoda one tsp of oily chicken curry one fourth of a gulab jamun 38

Eating less easier than working more:

Eating less easier than working more 39 A 500 kcal/day reduction in calorie intake is much easier than to increase similar amount of calorie expenditure Gal Dubnov-Raz , Elliot M, Berry: The dietary treatment of obesity

Benefits of 10% Weight Loss:

Benefits of 10% Weight Loss STOP INSULIN REDUCE OHA ENSURE GOOD QOL 20% fall in Systolic BP 10% fall in Total Cholesterol 15% fall in LDL 8% increase in HDL 30% fall in Triglyceride 50% fall Fasting Glucose 10% fall in Diastolic BP 40

What to eat and what not to eat?:

What to eat and what not to eat? 41

Diabetes – What not to eat?:

Diabetes – What not to eat? Sugar Sweets Tubers Pastry Mutton curry Beef fry Chips Colas 42

Diet and Diabetes – A days menu:

Diet and Diabetes – A days menu 06.30 am Tea without 08.30am Break fast 10.30am Snack 01.30pm Lunch 02.30pm Fruits 04.30pm Tea without 06.30pm Green salad 08.30pm Dinner 43

Challenges in adhering to Physical Activities:

Challenges in adhering to Physical Activities 44

Lack of awareness/inspiration:

Lack of awareness/inspiration 45 Lack of time Increased work load

Lack of space:

Lack of space 46 Lack of space Poor infra-structure

What prevents one from walking:

What prevents one from walking Fear of theifs Barking dogs 47

What prevents one from walking:

What prevents one from walking 48 Traffic excess Flooded street

What is – the solution?:

What is – the solution? Vellayambalam Paved walkway or Museum Compound Gandhi Park Circle at East fort or Arrange for one 49

How to increase physical activity:

How to increase physical activity Decrease the amount of time being inactive Doing work for self and family 50

How to be more active :

How to be more active Taking walk breaks at the office and Using stairs instead of elevators 51

Slide 52:

52 Parking cars at the far end and Having some office recreation

Energy expenditure during exercise:

Energy expenditure during exercise Calories spent per minute Lying down, sleeping, sitting 1 Standing, desk work, driving 2 Level walking, level bicycling 3 Social doubles badminton 4 Social singles badminton 5 Gardening , swimming 6 Competitive badminton 7 Jogging 8 Basketball 9 Running 1km in 10min 10 53

Calories Spent in Various Activities :

Calories Spent in Various Activities Walking, 3.0 miles/hr 275/hr Walking 5 miles/hr 420/hr Cycling, 8 miles/hour 325/hr Mopping, vacuuming 240/hr Scrubbing floors 300/hr Gardening 220/hr Vigorous dancing 500/hr 54

Regular and Planned Exercise:

Regular and Planned Exercise 55 Regular e xercise daily At least 5 days/week

Our poor children:

Our poor children 56

Our poor children:

Our poor children 57 Tuition all the way

When they are 45 !!!:

When they are 45 !!! 58

Exercise - How it should be?:

Exercise - How it should be? Regular - Isotonic and aerobic Not isometric or resistance exercises 59

Table Tennis is ideal:

Table Tennis is ideal 60 Initial investment is high – follow up expenditure low

Shuttle Badminton is fine:

Shuttle Badminton is fine 61

How it should be:

How it should be Patient should be able to carry out a normal conversation while exercising without getting breathless 62

Exercise – Pros and Cons:

Exercise – Pros and Cons Advantages Benefits glycemic control Improves insulin sensitivity Builds physical fitness Optimizes body weight Gives psychological well being 63

Disadvantages:

Disadvantages 64 Carry some risk also Strains the compromised CVS Injuries to musculoskeletal system Predisposes to hypoglycemia May exacerbate complications

Precautions:

Precautions 65 Correct foot wear Comfortable loose clothes Close inspection of feet every day Carry snacks as protection from hypoglycemia

Special precautions of patients with co-morbidities:

Special precautions of patients with co-morbidities 66

Individuals with arthritis:

Individuals with arthritis 67 Regular physical activity i ndicated and not contra-indicated Exercise under supervision Physiatrist or qualified instructors

Individuals with Cardiovascular disease:

Individuals with Cardiovascular disease Clinically stable - 30’moderate intensity activity out door or indoor Those with advanced CVD - less intense shorter bouts after check up 68

Individuals with Neuropathy:

Individuals with Neuropathy Walk only on safe surfaces Using appropriate foot wear 69

Individuals with Neuropathy:

Individuals with Neuropathy 70 Non weight bearing chair exercise Or try arm ergonomics

Individuals with Retinopathy:

Individuals with Retinopathy Avoid strenuous exercise Better still 71

Individuals with Retinopathy:

Individuals with Retinopathy 72 Swimming Rowing

Examples of socio-cultural barriers::

Examples of socio-cultural barriers: 73

Tackling socio-cultural barriers::

Tackling socio-cultural barriers: 74

Take Home Messages:

Take Home Messages DM2 - a major challenge to human health Type 2 diabetes can be abolished or prevented Diabetes can be managed with life style alone No need for Insulin or OHA if weight reduced by 10% lifestyle interventions are effective in prevention Barriers for life style changes should be addressed Healthy eating and regular exercise are needed 75

A word of caution:

A word of caution 76

Slide 77:

77

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