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Diabetes

Diabetes mellitus has become a major menace in India. Every fourth or fifth household in urban areas has a diabetic patient. The incidence of diabetes has increased dramatically over the years. A few decades ago, approximately 2% of the adult population suffered from diabetes. In the last two to three decades there has been a sharp rise to approximately 8 – 10%. According to the World Health Organization (WHO), India will have 57 million diabetic patients by 2025. Although there is no known cure for diabetes, with modern treatment one can hope to lead as normal, as active, and as useful a life as any other person.

Diabetes is a condition in which there is too much glucose (sugar) in the blood due to defective insulin action or deficiency in its secretion. Insulin is required for glucose to enter the cells of the body, where it is utilised. It is as if insulin is a key which opens the doors of the cells to allow glucose to enter. When insulin is absent or is less efficient, glucose in the blood cannot enter the cells and remains in the blood in high amounts.

When glucose does not enter the body cells due to lack of insulin, it accumulates in the blood. After it reaches a certain limit, it starts appearing in the urine. Normal urine does not contain glucose. When glucose appears in the urine, it draws out more water with it and hence there is excessive urination. Because of excess urination (loss of water) there is excessive thirst. Although there is excess glucose in the blood, there is not enough in the cells due to lack of insulin. The cells are starved of glucose. This causes an increase in appetite. Hence a diabetic eats more, but the body’s cells do not get enough glucose. In a desperate effort to get energy, the “starved cells” begin using body fat and protein. This can eventually cause loss of weight and tiredness, but usually only in Type I diabetes.Because of high levels of glucose in the blood, some people become irritable. Sometimes very high blood glucose can lead to coma. Also there is a greater risk of developing infections. Symptoms may not be present.

Two main factors are responsible for causing diabetes:

1. Inherited factors: Some genetic factors are inherited from parents. That is why it is more common in some families. If one parent has diabetes, there is a 20% chance of diabetes in the children, whereas if both parents are diabetics, chances increase to 20 – 50%.

2. Environmental factors such as:
   • Obesity
   • Physical inactivity
   • Lack of exercise
   • Poor food choices, especially high-sugar, high-fat, low-fibre fast foods.

These factors precipitate diabetes in those who have inherited the trait.

No, all diabetics are not alike. Diabetics can be classified into two main groups.

• Develops at an early age – usually in childhood
• Patients are young, lean and thin
• Illness develops rapidly
• Patients are dependent on insulin for life

• Develops later in life (40+)
• Patients are often overweight or have a potbelly
• Illness progresses slowly
• Patients are not necessarily dependent on insulin, but often require it for good control

1. Primary prevention of diabetes is targeted in individuals who are at a high risk of developing diabetes. You are at high risk if you:
   • Have a blood relative who is a diabetic
   • Are overweight (BMI >25)
   • Delivered a big baby (birth weight was 4 kg or more)
   • Had diabetes or even a mild elevation of blood sugar during pregnancy
   • Are physically inactive, meaning you exercise less than three times a week
   • Have high blood pressure
   • Are pre-diabetic: fasting blood glucose of 110 – 126 mg%, postprandial (after eating) glucose of 140 – 200 mg%
   • Have triglycerides or cholesterol levels higher than normal
   Success in preventing diabetes depends upon:
   • Maintaining an ideal body weight or losing about 5 – 7% of your body weight (if your body weight is more than desired). Even 2 – 3 kg of weight loss can make a difference.
   • Diet should be of foods which have a low glycemic index, such as whole wheat, whole grains, beans, fruits, vegetables, etc. Fats should be only of an unsaturated type like liquid vegetable oils.
   • Undertaking a brisk walk or other forms of physical activity for 30 minutes, 5 times a week.
2. Secondary Prevention: If you keep good control of your diabetic state (blood sugar, lipid profile, blood pressure) and take other measures such as a small daily dose of aspirin, statins and ACE inhibitors (if needed and under the guidance of your doctor), you can prevent the complications of diabetes.
3. Tertiary Prevention: Even when complications such as eye, kidney, heart, vascular, or nerve problems have started, it is possible too prevent further damage and preserve the function of these organs if these problems are detected in the earlier stages.

• Are over the age of 25 years
• Are overweight
• Don’t exercise
• Suffer from repeated infections
• Have high blood pressure
• Have a history of angina or heart attack
• Have high blood cholesterol
• Have a bad obstetric (childbirth) history

Get blood sugar tested two hours after a meal (postprandial). If blood sugar is greater than 140 mg%, re-check while fasting and two hours after 75 gms of glucose have been taken orally.

Even if your fasting blood sugar is normal but, after the Impaired Glucose Tolerance (IGT) test your blood sugar levels are above normal, you should repeat the IGT every year. The IGT should not be ignored. Lifestyle modification can help in preventing diabetes.

Diabetes, if not well controlled, affects other organs of the body and can lead to serious acute and long-term complications. It is possible to delay or prevent some of these complications if diabetes is controlled properly.

Patients with diabetes who neglect to control high blood sugar may lose excessive amounts of water and salt in their urine. This can lead to dehydration, which can sometimes be fatal.

The diabetic who knows the most
will live the longest.

Burning of fats can be inefficient as a way of producing energy and the process results in products called ketone bodies which make the blood acidic. This condition, called ketoacidosis, is more common amongpatients who require insulin to control the diabetes. It occurs if the patient stops taking insulin or the insulin requirement increases (due to illness or fever). The patient suffers vomiting, abdominal pain, dehydration (excessive loss of salt and water), breathlessness, and a characteristic fruity smell like acetone on the breath. Unconsciousness and even death may occur.

What are the symptoms of hypoglycaemia?

Mild hypoglycaemia is self-limiting and is corrected by the body’s natural mechanism, whereas severe hypoglycaemia, if not treated properly, may result in coma.

Proper care about diet, exercise and medication can help to avoid hypoglycemia. Always carry something sweet and eat it the moment you observe the symptoms. Keep your relatives informed about hypoglyacemia. Always carry your identity card showing that you are a diabetic. Contact a doctor immediately if you are in severe hypoglycaemia.

The common long-term complications are as follows:

Many diabetics complain of not being able to get proper glasses due to fluctuating vision. It is because of fluctuating blood sugar levels. To obtain new glasses while the blood sugar is uncontrolled serves no purpose. Therefore, it is advisable to control blood sugar for at least two to three weeks before obtaining new glasses and then maintain good control.

A change in the number of glasses prescriptions may be a sign of diabetic retinopathy, a condition which leads to blindness if due care is not exercised.

Diabetic retinopathy is the most frequent cause of blindness in diabetics. Early detection and appropriate therapy may prevent blindness due to diabetic retinopathy. Diabetic retinopathy occurs when vessels in the retina are ruptured or produce a new growth (neo-vascularization), which leads to impaired vision and blindness.

The diabetic who knows the most
will live the longest.

• Eye check-up by an eye specialist twice a year or whenever you think there is even a slight loss of vision.
• Optimal control of glucose and blood pressure.
• If the condition continues to develop, photocoagulation can be undergone, which seals the blood vessels leaking into the retina.
• In some cases when loss of vision is great, a surgical procedure called vitrectomy may be considered.

Heart attacks are about three times more common in persons with diabetes, and diabetics are prone to develop high blood pressure.

• They occur in a comparatively younger age group, at least a decade earlier.
• Classical chest pain may not be felt.
• The coronary arteries are blocked at multiple places; hence bypass surgery becomes more difficult.
• Recurrence is more common.

• Heredity
• Aging
• Physical inactivity
• Uncontrolled blood sugar
• High blood pressure
• Microalbuminuria – loss of protein in the urine because of damage to the blood vessels in the kidneys
• High circulating fats (cholesterol, LDL, triglycerides)
• Altered coagulation factors (in blood)

• Normal weight
• Regular exercise
• Blood pressure <130/85
• Blood sugar:
• Fasting 110 – 120 mg%
• Postprandial up to 140 mgs
• Glycated Haemoglobin (HbA₁c) <7%
• Cholesterol <150 mg%
• HDL > 50 mg%
• LDL < 70 mg%
• TGS < 130 mg%
• Urine albumin < 30 mg% per day

Uncontrolled diabetes damages the kidneys, often leading to kidney failure. One third of all new cases of renal (kidney) failure seen today are the result of uncontrolled diabetes.

• Keeping blood pressure (BP) within the normal range (130/85) through diet, exercise and drugs
• Controlling the blood glucose level
• Restricting protein intake to about 40 g/day
• Monitoring of albumin in urine periodically

The arteries may develop fat deposits, hindering the flow of blood. This can lead to stroke and gangrene of limbs at times.

Your attitude decides your success
in looking after your diabetes.

Uncontrolled diabetes affects the nerves, which can lead to loss of sensation. Because of loss of sensation, minor cuts and wounds go unnoticed. The wound can get infected, and when this happens in association with poor circulation, it can lead to gangrene or a need for amputation.

Show your doctor your feet at each visit
and ask your doctor if your feet are at risk.

• Control your blood sugar, blood pressure and lipids.
• Check your feet every day for cuts, sores, red spots, swellings and infected toe nails. Find time to do this.
• Wear shoes at all times of the day especially when you are out. Wear socks at night if your feet are cold.
• Wash your feet daily, dry them properly; use warm, not hot water.
• Dry your feet well, especially between your toes.

Each and every test has some significance and offers important but limited information. Some parameters like blood sugar change minute to minute, others like cholesterol may not change for months. Hence, the tests are repeated according to this pattern of change and stability so that monitoring becomes effective and economical.

• Weight
• Height
• BMI – weight in kilograms/[height in metres]² (Underweight <19, Normal 19 – 25, Overweight 25 – 30, Obese >30)
• Blood sugar – fasting and postprandial (after eating); repeat more frequently till it becomes normal.
• Blood pressure (BP)
• Haemoglobin, and other blood tests
• Lipid profile (cholesterol,HDL-cholesterol, LDL-cholesterol, triglycerides)
• Serum creatinine, blood urea, and uric acid
• Urine for routine test including microalbumin
• Liver function test – repeat after one year
• Fundus examination (internal examination of the dilated pupil of the eye) – repeat after one year
• ECG
• X-ray chest – repeat after 5 years

• State of control of diabetes
• Early detection of complications
• Reversal of complications
• Further deterioration

Self care is more effective and
practical with best results.

• Weight
• Blood sugar
• HbA₁c (Glycated haemoglobin – this is a measure of how well controlled your blood glucose is over a span of time)
• BP assessment
• Urine for albumin
• Reassessment of treatment

• Lipid profile
• Cardiovascular system – ECG
• Modification of treatment if required

1. Comprehensive check-up of all systems
2. Fundus (eye) examination
3. Complete heart check-up
4. Renal function test, liver function test

Merely having the knowledge is not enough,
you have to achieve its implementation.

Management of diabetes

• Control of the symptoms of diabetes
• Control of blood sugar level
• Control of Hb A₁C (Glycated haemoglobin)
• Control of the complications of diabetes. While to the patient with diabetes, control of symptoms and blood sugar may seem adequate, the doctor may want to ensure that associated problems (blood fats, blood pressure, etc.) are also kept in check.

• Diet
• Exercise
• Medication

When we eat any food, whether consisting of carbohydrates, proteins, fats or mixed in different ratios, the blood sugar rises. The blood sugar rise depends on the glycemic index (GI) of the particular food.

The GI is the ratio of blood sugar level after taking any food item to that after taking equal calories of glucose. The GI of glucose is very high. If we do not want our blood sugar to rise very quickly, our food should be of low GI.

• Low GI means a smaller rise in blood glucose levels after meals.
• Low GI diets can help people lose weight.
• Low GI diets can improve the body’s sensitivity to insulin.
• Low GI can improve diabetes control.
• Low GI foods keep you full for longer.
• Low GI can prolong physical endurance.

Glycemic Index of Some Food Items

• The GI of whole-wheat atta or whole dal is lower than an equal amount of maida, suji, or washed dal.
• Coarse cereals, green vegetables, and some fruits have a lower GI because of greater fibre content.
• Fibre slows the digestion, hence blood sugar rises slowly.
• Some low GI snacks are dhokla, sprouts, atta biscuits, roasted channa, popcorn, besan, chila or baked items.
• The GI of starchy vegetables can be reduced by adding curd.
• Reduce the GI of dal (sambar) by adding green vegetables.
• Split major meals into small, frequent meals to reduce the GI.

• In a typical day, a normal-weight diabetic should have 1500 calories from meals and snacks although this will vary by age, gender, and amount of physical activity.
• Eat a variety of items of food every day. Do not skip meals.
• Increase the amount of dietary fibre in your diet.
• Use less oil in cooking.
• Avoid fried foods, milk-cream, or food cooked in coconut oil.
• Avoid ready-to-eat foods, sweets, and sugary drinks.
• Restrict protein consumption if you have kidney damage.
• Keep a regular check on your weight and try to maintain it.
• Match your meal time to the insulin injection schedule.

What are the main adjustments in a diabetic diet?

1. Weight should not exceed your expected ideal weight.
2. Do not starve yourself. Take the free foods from the list below.
3. Divide your whole day’s ration into 5 to 6 meals of equal quantity and nutrients, rather than eating 2 to 3 major meals.
4. Exercise is good and should be a part of the daily routine.
5. Feasts and fasts should be avoided.
6. Cereals are the principal source of carbohydrates and should be consumed in prescribed amounts; use of mixed or whole grain cereals is desirable.

Plain tea and coffee, nimbu pani, clear soup, plain aerated soda, vinegar, diluted khatti lassi, kheera, kakkri, tomato, muli, karela, sag, and leafy vegetables.

Ice cream, pudding, mango, banana, sitaphal, kishmish, grapes, chikoo, khajur, dry fruits, nuts, alu, shakarkandi, kachalu, chukander, fried foods, pickles in oil, cakes, pastry, maida articles, and pineapple.

Meals by Caloric Content

1. 1 katori of dal is 150 mL or 25 g
2. 1 cup of milk is 150 mL
3. Use only skimmed milk for drinking and for preparation of tea and curd
4. 1 katori of curd is 25 g

Meals (continued)

Nutritive Value of Commonly Used Portions of Indian Foods

Merely having the knowledge is not enough,
you have to achieve its implementation.

1. Composition of food:

   Carbohydrates	65% of total calories
   Proteins	15 – 30% of total calories
   Fat	20% of total calories

2. Distribution of meals:

   Bed tea	5 – 10% of total calories
   Breakfast	20% of total calories
   Lunch	30% of total calories
   Evening tea	10% of total calories
   Dinner	30% of total calories

Low-GI Recipes

• Exercise is an essential component of diabetes management. It is useful for everyone, whether or not you have diabetes. Regular exercise, even walking just 3 – 4 km a day, has a tremendous benefit. Exercise:Keeps weight within the normal range
• Improves sense of well-being
• Preserves insulin sensitivity
• Keeps the blood sugar within the normal range, even if there is no weight loss
• Corrects lipid (fat) disorders
• Helps prevent blood clots
• Offers better digestion of food
• Keeps mobility of the joints intact
• Decreases the risk to the heart by reducing blood pressure and correcting the lipids
• Improves bone and muscle strength

Exercise helps to reduce the long term complications of diabetes.

• Shortage of time
• Over-busy schedule
• Bad weather
• Pollution outside
• More important engagements to keep
• Risk of getting exposed to allergens
• Better to enjoy good sleep rather than walk in a park

• If you have excessive blood glucose – particularly if glucose level is > 400 mg%
• If you have ketones in your urine
• When you have an illness or infection
• On the first sign of pain or vision change
• On the first sign of feeling dizzy or shortness of breath – it could be the sign of a heart problem
• In extreme weather

Many of you have felt that you are taking too many tablets; it may be inconvenient and expensive, and may be having some side effects too. You may not be convinced about the usefulness of these drugs, as there are no immediate results. The doctors, on the other hand, are responsible not only for immediate benefit but also for prevention of long-term complications.

Both are right, the patients and the doctors. The doctors ought to explain, and patients have to understand, why a particular drug is given and for how long. Always ask if you do not understand what has been said or advised.

1. Drugs which are essential for normalizing blood sugar levels for:
   Type I diabetes: Insulin is essential and has to be taken lifelong.
   Type II diabetes: One can take tablets which:
   
   1. Reduce insulin resistance, like biguanides and thiazolidinediones
   2. Increase insulin secretion, like sulphonylureas
   3. Reduce digestion of carbohydrates, like alpha-glucosidase inhibitors
   One may need only one or two of these drugs, or sometimes three, and insulin as well.
2. Drugs to keep the blood pressure below 130/85. The first choice is an ACE inhibitor. It also prevents kidney and heart damage.
3. Drugs that correct the lipid profile – like statins.
4. A small dose of aspirin, 75 – 150 mg. a day, is effective in preventing blood-clotting disorders responsible for heart attack and cerebral stroke.

These drugs are important and most diabetics need them.

Discuss with your doctor
before taking any medicine.

Determining the basic calorie requirement for your weight and height is an essential component of treatment strategy. Follow these steps to determine the basic calorie requirement that is right for you.

1. Determine the ideal body weight for your height:

   	Men	Women
   Height	152 cm	152 cm
   Weight	48 kg	45 kg
   Add for each additional cm	1.1 kg	0.9 kg

2. Multiply your ideal weight by 22 Kcal per kg to get the daily basic calorie requirement.
3. Add: For a sedentary life style: 25% of basic calories
       For moderate exercise: 50% of basic calories
       For strenuous exercise: 75% of basic calories
4. Add or subtract 500 Kcal if you are underweight or overweight respectively.

1. Determine ideal body weight: For 152 cm, the ideal body weight is 48 kg. To add 1.1 kg for each additional cm, subtract 152 from 170, which equals 18. Then multiply by 1.1, which equals 19.8. The ideal weight is 48 + 19.8 = 67.8 rounded to 68 kg.
2. Determine basic calorie requirement for a weight of 68 kg: 22 Kcal/kg is the formula. For a 68 kg person, the basic calorie requirement is 68 x 22 = 1496 (approximately 1500) Kcal.
3. Add calories for lifestyle: Add 25% of basic calories for a sedentary lifestyle. 25% of 1500 = 375 Kcal; 375 +1500 = 1875.
4. Add or subtract calories for weight: Since the man is over-weight (his ideal weight is 68 kg, but he is 80 kg), subtract 500 from 1875 Kcal, for a calorie requirement of 1375 Kcal per day.

Therefore, a male adult weighing 80 kg with a height of 170 cm with a sedentary lifestyle requires 1375 Kcal per day.

A walk a day keeps diabetes away.

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