Diabetes And You

Diabetes Education for You : 

Diabetes Education for You Dr. Girish Vaswani (DNB Med) Bhatia hospital, Dalvi hospital, Kothari Hospital

What is Diabetes mellitus? : 

What is Diabetes mellitus? Diabetes mellitus refers to a group of common metabolic disorders that share the phenotype of hyperglycemia (high blood sugar level). Various distinct types of DM exist and are caused by a complex interaction of genetic and environmental factors.

Who is this presentation intended for ? : 

Who is this presentation intended for ? This presentation is intended for giving you a basic knowledge about DM. I would not like to discuss and use complicated medical terminology but be brief and simple about this common metabolic disorder, which is on the rise all over the world. It is estimated that India is projected to become the “Diabetes Capital” of the world by 2020.

No room for pessimism : 

No room for pessimism I would like to state that “once a diabetic, always a diabetic” holds true. Though I may sound pessimistic, what is important to note is DM is predominantly a life-style disease. Adequate control of your disease is hence in your hands and can be easily achieved with a mix of diet, exercise, oral tablets and insulin.

Be Active, Be Optimistic : 

Be Active, Be Optimistic Hence in the true sense, DM should not be considered as a disease but as an opportunity to adopt a healthy lifestyle and diet. It is recommended to actively involve yourself with your healthcare provider to manage this metabolic disorder. Remember, your co-operation is needed to improve your health and to enable you to lead a healthy, wealthy and prosperous way of life.

What are the symptoms of DM? : 

What are the symptoms of DM? Well, many people having a high blood sugar would pass a lot of urine. This in medical language is called “polyuria”. As a result of polyuria, they would feel excessively thirsty and hence drink a lot of water, a term called “polydipsia”. As sugar is lost in the urine, there is a loss of calories that results in “weight loss” and a feeling of excessive hunger, a term called “polyphagia”.

Are there any other pointers besides the above? : 

Are there any other pointers besides the above? Yes, of course. You may feel tired easily. Wounds heal slowly and various skin and soft tissue infections like furuncles (boils), carbuncles and fungal skin infections occur more frequently in diabetic patients than in a normal person.

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In addition, a diabetic patient may have symptoms related to complications of the disease rather than the disease per se, some of which I would discuss later on.

What are the different types of DM? : 

What are the different types of DM? In order to make it easy for you to understand, I would simply say that DM is of two main types: T1DM and T2DM.

In T1DM : 

In T1DM There is a destruction of the beta cells in the pancreas that results in the absolute insulin deficiency. This destruction is generally immune mediated, but rarely, may be non immunological. This type of DM occurs in less than 1- 5 % of the population.

“Other type” of DM – T2DM : 

“Other type” of DM – T2DM Is commoner and has been increasing rapidly all over the world due to industrialization and urbanization, physical inactivity (desk jobs), lack of exercise and obesity, long work hours and stress, and, inappropriate eating habits with a shift to the cola-burger-pizza or the vada-pav-pav-bhaji-sandwich culture.

T2DM : 

T2DM In this type of DM, the hallmark is insulin resistance (most probably the result of obesity) superimposed on which is abnormal insulin secretion and declining beta cell function. Initially there is excessive insulin that does not work, and, as the disease progresses the insulin producing cells (the beta cells of the pancreas) eventually get exhausted and are destroyed.

T2DM : 

T2DM Thus in the early stages of T2DM, your blood sugar can be controlled by diet and exercise with or without oral tablets. In the later stages, insulin secretion reduces and stops and the patient requires insulin injections.

Are there other types of DM? : 

Are there other types of DM? Besides these, of course there are other causes of DM that I would not be discussing about as it would only complicate your understanding of the disease.

How is DM diagnosed? : 

How is DM diagnosed? As per the American Diabetic Association (ADA) criteria for the diagnosis of DM are: Normal FPG < 100 Fasting plasma glucose > 126 mg/dl (minimum 8 hrs fasting) or Random Plasma glucose > 200 mg/dl with symptoms suggestive of DM

What is pre-diabetes? : 

What is pre-diabetes? IFG is defined as a FPG level between 101-125 mg/dl IGT is defined as a plasma glucose level between 140-199 mg/dl at the end of 2 hrs of an oral GTT using 75 Gms of anhydrous glucose. These categories are classified as pre-diabetes.

Is pre-diabetes dangerous? : 

Is pre-diabetes dangerous? Yes. Around 40-50 % of pre-diabetics eventually progress to develop DM at the end of 5 yrs. Hence it is recommended to act at this stage itself in order to prevent DM. Pre-diabetes may also be associated with ongoing vascular damage and hence increased risk of micro/macro-vascular complications of DM even before the setting in of high blood sugars.

Which groups of people have been shown to ultimately develop T2DM? : 

Which groups of people have been shown to ultimately develop T2DM? Race and ethnicity (Asians, Pima indians, etc) Family History of DM (parent/sibling with T2DM) Obesity-BMI >25 kg/m2 & physical inactivity Previously identified IFG/IGT, PCOD & acanthosis nigricans History of GDM or delivery of baby > 4 Kg Hypertension >140/90 mmHg & history of vascular disease & abnormal lipids HDL cholesterol < 35 and/or TG > 250 mg/dl

What are the acute complications of DM? : 

What are the acute complications of DM? DM is a metabolic disorder affecting not only the carbohydrate but also the protein and fat metabolisms and has far reaching deleterious effects on nearly all the body systems. It is associated with a lot of complications that may acute or chronic. The acute complications to count a few of them are DKA, Lactic acidosis and HONK, which are life-threatening and require immediate medical attention. These can be treated more easily than in the past.

What are the chronic complications of DM? : 

What are the chronic complications of DM? The chronic complications of DM are of two types: macro vascular and micro vascular. The macro vascular complications include cerebro and cardiovascular disease as well as peripheral vascular disease with or without the dreaded diabetic foot gangrene. Once these complications occur, various studies have shown that they progress despite good sugar control. Nonetheless complacency in achieving targets of diabetic control as suggested by the ADA is highly deplorable.

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The micro vascular complications like nephropathy, retinopathy and neuropathy are more closely relate to the blood sugar and HbA1c levels. Aggressive DM control may retard their progress.

Does the course of DM vary from patient to patient? : 

Does the course of DM vary from patient to patient? Yes. Some patients may have an aggressive course with retinopathy, nephropathy and neuropathy complications whereas others may never develop any. Also cardiac and vascular complications may develop in some. Thus the course of DM varies from patient to patient sparing some a debilitating life but kinder to others.

What is meant by good diabetic control? : 

What is meant by good diabetic control? FPG between 70-100 mg/dl; PPG < 140 mg/dl HbA1c < 6.5 % Total cholesterol < 150 mg/dl; LDL < 100 mg/dl or <70 mg/dl (if cardiac/vascular disease) HDL> 35 mg/dl; TG <150 mg/dl Blood pressure <130/85 or < 120/80 (if DKD) Achieve optimal weight/Control cardiovascular risk factors aggressively/Detect and treat eye complications early

What are the various modes of treatment? : 

What are the various modes of treatment? 1      Life-style modifications 2      Obesity management 3      Oral hypoglycemic agents 4      Insulin

What is life-style modification? : 

What is life-style modification? DM is a disease in which lifestyle plays an important role, hence it is possible to control the blood sugars, at least, in the initial phase of the disease solely using this modality of treatment. I would say that throughout your lifetime, whether you are a diabetic, a potential diabetic or a normal person, these life-style modifications would help you to lead a good quality of life. The suggestion that I am making in this is that they are the golden rules of a “way of life” rather than a modality of treatment.

Lifestyle modifications include: : 

Lifestyle modifications include: 1      Diet 2      Exercise 3      Weight loss 4      Avoidance of tobacco consumption Stress management

Diabetes Prevention : 

Diabetes Prevention Hence it now becomes very clear to you that you can not only participate in management of your DM but also be actively involved in its prevention in your family and friends by helping each other to understand that lifestyle modifications is not only for a diabetic, hypertensive or heart patient but for the society as a whole.

Dietary Modifications: A healthy Diet for ALL : 

Dietary Modifications: A healthy Diet for ALL These dietary guidelines may be adopted by anyone who is health and weight conscious. These guidelines help you to control blood sugars, reduce weight and lead a healthy life as most of us already know that “ As you eat, So you become” so is said in the Bhagwat Gita and the Bible.

Fats and Frieds : 

Fats and Frieds Ghee and oil are to be avoided. If at all, only 2 teaspoons of oil or ghee are to be consumed per person in the whole day. Preferably to avoid coconut and groundnut oils as they contain “bad fats” and instead to substitute with soya, olive, sunflower oils. Do not deep fry repeatedly as the oil becomes rancid and more harmful. It is preferable to bake in the microwave than to fry.

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A simple way to limit oil consumption is not to take extra oil or ghee on the top of the rotis or in the rice and to avoid fried foods (like samosas, kachori, farsan, etc) in the diet at home.

When eating out : 

When eating out In a hotel or at a party I would recommend filling your plate with more of vegetable salads and greens before the main course and having soups instead of bites is a sure way to fill your stomach with “low energy food” instead of “energy-dense food”. This will help you limit the calories consumed.

Animal and dairy foods : 

Animal and dairy foods Milk and milk products like butter, cheese, malai are energy dense. Substitute with skimmed milk and margarine. Avoid egg yellow. Egg white is healthy. Red meats like mutton, lamb, beef, pork, salami, and bacon contain a high content of “bad fats”. It is advisable to stick to chicken without the skin and fish.

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Prawns, lobsters, squids and other shellfish are to be avoided and bangda, surmai, rawas, pompfret can be cooked in a curry with less or no oil at all. Do not fry the fish. Consuming cooked fish as mentioned above is beneficial as they contain “good fats” that may prevent atherosclerosis.

Dry fruits : 

Dry fruits Badam is a rich source of omega 3 fatty acids. Hence benefits and 5-6 pcs can be eaten daily.

Fruits and vegetables : 

Fruits and vegetables Avoid fruits like bananas, chikoos, mango, grapes and sitaphal. You could choose from orange, sweet lime, peru, apple, papaya, and watermelons. Having one whole fruit a day is recommended.  Potatoes and beet are to consumed limitedly as are onion and carrot. Add lots of other vegetables especially greens in your diet.

Moderately consume grains and cereals : 

Moderately consume grains and cereals Whole wheat, whole wheat bread rather than ordinary maida bread can be taken. Jowar, bajra can be used. Include sprouts of masoor, beans and soybean in your diet.

Sweets : 

Sweets Ice creams, cakes, pastries, mithais, jalebis, and other sweets and chocolates, sherbets, cold drinks, fruit juices are to be avoided or consumed sparingly. Substitute sugar with artificial sweetners like equal or sugar-free. Home made lime juice with sugar-free instead of sugar is very refreshing when served chilled, low in calories and a good substitute to colas.You could bake yourself an eggless cake using sugar-free.

Biscuits and bakery items : 

Biscuits and bakery items Marie, cream crackers and digestive biscuits may be had with the evening tea. Glucose biscuits, cream biscuits and khari, butter khari and other bakery items are to avoided. Whole wheat brown bread can be substituted for bread and pav. These products contain salt (baking soda) and are harmful for patients having hypertension and heart disease.

Fast foods and snacks : 

Fast foods and snacks Pizzas, colas, burgers, sandwiches with white breads, pao-bhaji, samosas, wafers, low fat foods and farsan are to be avoided. Frequent snacking while watching TV and in- between- meals leads to weight gain and increases blood sugar. Modify this habit and snack on vegetable salads and boiled foods if hungry.

Tobacco Use : 

Tobacco Use Most dangerous. All patients and normal persons also should quit immediately or undergo de-addiction if finding it difficult to quit. Remember smoking increases the risk of heart attacks, stroke, lung diseases and cancers. So if you want to enjoy life to the fullest, kick the habit at double speed.

Alcohol Use : 

Alcohol Use It is not taboo in diabetic patients and should be restricted to less than 2 small pegs a day. What have to be borne in mind are the various interactions of oral hypoglycemic drugs and alcohol and its effect on the overall diabetic control. Personally, I recommend all persons to quit alcohol.

Weight reduction and Exercise : 

Weight reduction and Exercise In T2DM, insulin resistance and decreased insulin sensitivity along with insulin secretion defect play a pivotal role in the disease mechanisms. Of course, beta cell failure is ongoing and starts earlier and hence the disease passes through the various phases ranging from IFG, IGT, a combination of both, and finally overt DM.

Weight reduction and exercise : 

Weight reduction and exercise In the initial phase the blood sugar can be controlled with only lifestyle modifications but as it progresses would, in addition to lifestyle modifications, require oral hypoglycemic agents and finally insulin.

Weight reduction and exercise : 

Weight reduction and exercise One of the limbs of the pathogenesis, is the increase in the resistance to insulin in the peripheral tissues particularly the adipose tissue, skeletal muscle and liver.   Weight reduction and exercise hence play an important role in control of the blood sugar. All diabetics should be convinced to lose weight and start moving their limbs-Exercise

Benefits - Exercise : 

Benefits - Exercise The benefits are: improved sense of well being, better control of blood sugar, increase in “good lipids”, reduction of blood pressure, reduced chances of heart attacks and strokes.

Exercise : 

Exercise A daily brisk walk for 45 mints to an hour would be enough for achieving the above benefits.  However, a light jog, short outdoor game, playing table tennis or badminton or swimming or gardening or any other physical activity is more helpful if done on a regular basis.  Involving friends in such physical activity increases compliance.

What is hypoglycemia? : 

What is hypoglycemia? The occurrence of a very low level of blood sugar (< 55mg/dl) with the presence of symptoms suggestive of hypoglycemia and prompt relief (of symptoms) after the correction of blood sugar by consuming sugar, glucose powder, fruit juices, sweet foods or sweet drinks

Does every diabetic suffer from it? : 

Does every diabetic suffer from it? Most of the diabetic patients will suffer from a low blood sugar during their lifetime of treatment. Utmost care is taken by your caregiver to ensure that such an episode is avoided.

How do I prevent myself from getting hypoglycemia? : 

How do I prevent myself from getting hypoglycemia? Hypoglycemia may occur as there are many predisposing factors such as starvation, religious fasting, skipping a meal, skipping a snack, eating less due to illness or intentional weight loss, alcohol consumption and also severe exercise.  Ill-timed insulin dosages, excessive insulin administration and wrong type of insulin contribute to its occurrence.  Remember “NO MEAL, NO INSULIN” and “NO MEAL, NO TABLETS”.

Is hypoglycemia fatal? : 

Is hypoglycemia fatal? Unfortunately, Yes.   If untreated and prolonged it may result in brain damage and also death. Hence it requires to be identified and treated as early as possible.   Persons with underlying coronary artery disease may suffer myocardial ischemia or get a heart attack. Similarly, a stroke and paralysis may result.

Hypoglcemia unawareness : 

Hypoglcemia unawareness Repeated episodes of hypoglycemia result in the phenomenon of hypoglycemia unawareness and hypoglycemia related autonomic failure. It is in such patients that most of the damaging potential is unleashed. Luckily, avoidance of hypoglycemia reverses this phenomenon.

What are the symptoms of low blood sugar? : 

What are the symptoms of low blood sugar? Tremors, tachycardia ( a fast pulse rate ), palpitations, sweating, excessive hunger and early morning headache and nightmares ( night time Hypoglycemia ). The blood pressure may be high or low or remain unchanged. Besides these, giddiness, light-headedness, vertigo, blurred vision and abnormal behavior with drowsiness, unawareness, stupor, coma and fits may also occur.

What should I or my relatives or friends do if I suffer from an episode of low blood sugar? : 

What should I or my relatives or friends do if I suffer from an episode of low blood sugar? If a glucometer is available, the capillary blood glucose may be recorded immediately by the by-standers and if you are conscious enough, you may ask anyone to provide you sugar, glucose sticks, glucose powder or sugarcane juice or any fruit juice or sweet item that is immediately available. You may be rushed to your diabetic caregiver or nearby hospital in case of an emergency.