1 st time in India To keep the members of diabetes care team abreast with DSME and DSMS concepts

USV as your reliable healthcare partner believes in supporting your endeavour to make India a Diabetes Care Capital of the World.

Indian Diabetes Educator Journal (IDEJ) is a first-of-its-kind initiative in India developed to strengthen the concepts of Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS) among the members of diabetes care team, especially the diabetes educators (DEs).

IDEJ content is developed based on seven self-care behaviours of the American Association of Diabetes Educators (AADE) i.e., healthy eating, being active, monitoring, taking medication, problem-solving, healthy coping and reducing risks.

Can diabetes be cured? A major thought in every persons mind. This issue’s cover story is dedicated to being free from diabetes. This is a long process which requires dedication, compliance of medications and acceptance of consequences that occur while treating diabetes. The current issue focuses on minute details that people with diabetes deal with during this phase. This issue also covers a section on the crucial role of DEs in the management of people with diabetes, and pointers to help improve the personalised care and maintain patient-provider relationship.

We sincerely thank our contributors for making this issue delightful reading for our readers.

We dedicate this journal to all the healthcare professionals who are working relentlessly towards making “India a Diabetes Care Capital of the World”.

Sincere Regards,

Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of diabetes patients. This Journal intends to empower your clinic support staffs for basic counselling of diabetes patients. This journal has been made in good faith with the literature available on this subject. The views and opinions expressed in this journal of selected sections are solely those of the original contributors. Every effort is made to ensure the accuracy of information but Hansa Medcell or USV Private Limited will not be held responsible for any inadvertent error(s). Professional are requested to use and apply their own professional judgement, experience and training and should not rely solely on the information contained in this publication before prescribing any diet, exercise and medication. Hansa Medcell or USV Private Limited assumes no responsibility or liability for personal or the injury, loss or damage that may result from suggestions or information in this book.

You can contribute your articles, opinion, cases, recipes, experiences or write to us to if you want to subscribe to soft copy of IDEJ every month by sending an e-mail to:

[email protected] or [email protected] or [email protected]

*DSME:*DSME: DiabetesDiabetes Self-ManagementSelf-Management Education,Education, DSMS:DSMS: DiabetesDiabetes Self-ManagementSelf-Management SupporSupportt Expert Contributors of the Month

Dr. Pramod Gandhi Dr. Rajiv Awasthi MD (Medicine), DM (Endocrinology) MD (Medicine) Consultant Endocrinologist, Nagpur, Lucknow, Uttar Pradesh. Maharashtra.

Dr. Manoj Indurkar Dr. P. Ravi Kumar MD (Medicine) MD (Paediatrics), DM (Endocrinology) Professor and Head, Department of Medicine, Assistant Professor, MKCG Medical College, SS Medical College, Berhampur, Odisha. Rewa, Madhya Pradesh.

Dr. Navneet Shah Dr. Praveenkumar Devarbhavi MD (Medicine), FICA MD (General Medicine), DM (Endocrinology and Metabolism) Diabetologist, Endocrinologist and Consultant Physician, Director, Department of Diabetes Consultant Endocrinologist, Maax and Endocrinology at Sterling Hospital, Superspeciality Hospital, Karnataka, Ahmedabad, Gujarat. Bangalore.

Dr. B. Vijay Kumar Dr. Partha Roy MD (Medicine) MBBS, F. Diab (MDRF) Senior Consultant Physician, Yoshoda Consultant Diabetologist Hospital, Secunderabad, Telangana.

Dr. Kiranmai Alla Dr. Ajish T. P. MD, DM (Endocrinology) MD, DM Dr. Kiran’s Endocure, Cure Hospital, Consultant Endocrinologist, Kollam, Kerala. Vijayawada, Andhra Pradesh.

Dr. Satyam Chakraborty Ms. Ariba Zuhair MD (Internal Medicine), MSc DM (Endocrinology) Dietician, Dr. Mohan’s Diabetes Specialties Consultant Endocrinologist, Institute of Centre, Lucknow, Uttar Pradesh. Neurosciences, Kolkata, West Bengal. Table of Content

Problem Solving: Dealing with Diabetes Burnout and Diabetes Distress Diabetes Educators Speak! 01 16 Dr. Satyam Chakraborty

Cover Story: Freedom from Diabetes Reducing Risk: A Sudden Drop in Weight may Sometimes Not be Linked 02 to Patient’s Healthier Habits 19 Dr. Pramod Gandhi Dr. Rajiv Awasthi

Healthy Eating: A Guide to Choose the Healthy Coping: Does Fasting Help Perfect Diet for People with Diabetes 04 Prevent Diabetes? 22 Dr. P. Ravi Kumar Dr. Manoj Indurkar

Being Active: The Impact of T2DM on Diabetes in Control: Cultural Issues People with Osteoporosis 07 When Treating Diabetes 25 Dr. Navneet Shah Dr. Praveenkumar Devarbhavi

Monitoring: Transform your Health – Monsoon Highs and Lows! Compliance to SMBG among People with T2DM 10 30 Dr. B. Vijay Kumar Dr. Partha Roy

Taking Medication: The Harmful Family and Diabetes Corner: Living Consequence of Aggressive Glycaemic with Diabetes is a Family Affair Control in Adults with Diabetes 13 33 Dr. Ajish T. P. Dr. Kiranmai Alla Table of Content

Importance of Patient-Centered Therapy in Diabetes Mellitus 36 Get Active! 49 Ms. Ariba Zuhair

Multiple Feathers on the Cap 41 National Diabetes Educator 50 Program (NDEP) Best Practices

Eat Out, Be Wise Conference Highlights 43 52

Tools: Pregnant with Diabetes 44 Shopping Smart 53

Future Trend: Smart Health IT - A New Model of Healthcare for 45 Superfood: Whole Grains (साबतु अनाज) 54 Rural India

Diabetes Educator of the Month 46 Recipe 55

Patients’ Corner 47 References 57 Diabetes Educators Speak!

Can diabetes be reversed? Yes, it is possible. How? Here is an example:

Ms. Anju Paul had unhealthy eating habits and a sedentary lifestyle. She had a sweet tooth and used to skip meals for having sweets. Her sleep routine was irregular. She was detected with diabetes, with glycated haemoglobin level (HbA1c) of 7.5%, which scared her and she soon visited an NDEP certified DE, Ms. Natasha Kapre Vora to seek help. Ms. Natasha Kapre Vora taught her discipline of eating and importance of staying physically active. She followed her advice with determination and was focused towards achieving her goal even during the festive season and or while going for outings or fun tours. The DE, Ms. Natasha Kapre Vora was constantly in touch with her during the festive season and when she was travelling. Under her guidance, Ms. Anju increased her protein and fibre intake, included exercise in her daily routine, started sleeping on time and increased her fluid intake. With time she lost weight and her visceral fat levels which were high significantly reduced. Her HbA1c levels came down and diabetes medicines were stopped by the doctor. She was on cloud 9 to say she used to have diabetes, and losing weight had helped her boost her confidence. Her diet plan was also followed by her husband who also lost weight. Her son liked the healthy recipes shared by Natasha. The whole family started eating healthy. Even after losing weight and reversing diabetes, Ms. Anju is still motivated and focused on maintaining her weight and continuing the lifestyle modifications for the rest of her life. Kudos to Ms. Anju Paul and her certified DE Ms. Natasha Kapre Vora!

1 Cover Story: Freedom from Diabetes

The diabetes burden

Expert According to the Centres for Disease Control and Prevention, Opinion in 2012, 1.7 million adults were newly diagnosed with diabetes and currently, more than 29 million adults are living 1 Dr. Pramod Gandhi with diabetes. People with diabetes are at risk for numerous complications, therefore, they must participate in many MD (Medicine), DM (Endocrinology) facets of self-care including home glucose monitoring, Consultant Endocrinologist, Nagpur, 2 Maharashtra. healthy eating and exercising.

Importance of family in diabetes self-care

DSME is a critical component of care for all individuals with diabetes.2 For adults with diabetes, engaging in diabetes self-care activities helps in improving glycaemic control as well as preventing complications. Quite a bit of diabetes management happen within family and social environment.3 Thereby, addressing to the family members of adults with diabetes is critical, since the majority of disease management happens at home.

Family members can actively support and care for people with diabetes. Here are some tips/ways they can help their kin with diabetes: ¢ Sharing responsibilities: Support can be provided in many in many forms, such as instrumental support in driving them to appointments or helping inject insulin and social and emotional support in helping them cope with their disease.4 ¢ Impact of attitude: The family member’s communication and attitude often seem to have a significant impact on a patients psychological well-being of a, his/her decision to follow recommendations for medical treatment and ability to initiate and maintain changes in diet and exercise. ¢ Lifestyle changes: There may be a need for changing, the types of food prepared and consumed at home, making time away from work to attend medical visits with the person and reprioritisation of family finances.

2 ¢ Update yourself: The family members should educate themselves about diabetes- care needs so that they know answers to certain questions such as why lifestyle changes are necessary? How these changes can best be implemented? Where to find additional information, such as healthy recipes or exercise routines? 5 ¢ Be sympathetic: About the condition, particularly for those people who have been newly diagnosed with diabetes.

Path to improved health

Apart from being emotionally supportive, family members should encourage their relative with diabetes to make healthy changes. This will help their relative manage his/her diabetes in a better way. 6,7

Table 1: Do’s and Don'ts while managing diabetes Do’s Don'ts

When eating together, eat the same meal Avoid buying foods that are not allowed

Include foods that are low in fat, cholesterol, salt and added sugar Don’t bring up other people’s horror stories who had diabetes

Include a variety of fresh fruits, vegetables, whole grains, lean meats and fish Do not be rude when the person with diabetes does not obey

Encourage exercise and do it together. E.g., walking, jogging, bicycling, swimming and dancing

¢ According to the behavioural research – the better the support from the people around you, the easier it is to manage diabetes. Important ¢ Any diagnosis presents a learning curve, therefore the first and best step in becoming an ally for your pointers for loved one is to arm yourself with education. DEs ¢ Going stepwise is the key to permanent lifestyle changes, therefore just doing small things, such as taking a walk after dinner can improve blood glucose and overall diabetes management.

A major portion of diabetes cases are preventable. Simple lifestyle changes have been effective in preventing or delaying the onset of type 2 diabetes (T2DM). Maintaining normal body weight, engaging in regular physical activity and eating a healthy diet can reduce the risk of diabetes.

3 Healthy Eating: A Guide to Choose the Perfect Diet for People with Diabetes

Introduction

Expert Eating well is important irrespective of whether you are living Opinion with diabetes or not. Having diabetes does not mean you need to surrender your most loved foods or quit eating in eateries. Dr. P. Ravi Kumar Actually, there is nothing you cannot eat. But, you need to know how certain foods affect your blood sugar. You need to MD (Paediatrics), DM (Endocrinology) eat regular, qualitative meals and make food choices to help Assistant Professor, MKCG Medical College, Berhampur, Odisha. control your diabetes better and prevent other health problems.

A healthy meal plan should include:

Protein Complex Fish, chicken or carbohydrates turkey (without skin), Whole grain bread, eggs or egg whites. oatmeal, potatoes, Select or choose brown or wild rice grades of beef trimmed of fat

Limited amounts of Fibre Lots of heart-healthy fats Beans, vegetables whole grains, Especially Olive, peanut or fruit and the green, canola oil, walnuts, vegetables leafy ones almonds and flax seed

Understanding the effect of food on blood glucose levels

Food has three main nutrients - carbohydrates, proteins and fats and a balance of these three things are needed to stay healthy. Here are a few points that can help you learn how to: 8 ¢ Count carbohydrates: It is found in all kinds of foods, such as bread, pasta, fruits, dairy products and sugary foods such as desserts. “Complex” carbohydrates, such as whole grain bread, provide more nutrition than others.

4 ¢ Read food labels: Reading the food labels can give you a clue to just how healthy (or unhealthy) a food is. Look for foods with three or more grams of fibre per serving and avoid saturated and trans-fats.

¢ Measure each serving: Measure your food and do not overeat. For e.g., a serving of protein (such as chicken or fish) should be the size of a deck of cards. ¢ Develop an eating plan: Find a meal plan that works best for you. ¢ Prevent high or low blood sugar: Monitor your blood glucose levels regularly. ¢ Set goals for healthy eating: Set simple goals and a realistic plan that fits into your lifestyle.

A sample menu

Always keep into account your size and activity level while planning meals.

Table 2: 1,200 to 1,600 calories meal plan

Breakfast 1 medium slice - whole-wheat bread with 2 teaspoons jelly, ½ cup shredded wheat cereal with a cup of 1% low-fat milk, a piece of fruit and coffee Lunch Cheese and veggie pita, medium apple with 2 tablespoons almond butter and water Dinner 1½ teaspoons vegetable oil, small baked potato, ½ cup carrots, side salad (1½ cups spinach, ½ of a tomato, ¼ cup chopped bell pepper, 2 teaspoons olive oil, 1½ teaspoons red wine vinegar), unsweetened iced tea Snack 2½ cups popcorn or an orange with ½ cup 1% low-fat cottage cheese

Estimating the food portion sizes

The choice of food and the amount you eat is relative to your blood glucose level. If you eat more than you need, your blood glucose will rise. Therefore, having a good sense of portion control is an important skill and luckily, you already have the tools – your hands. The Canadian Diabetes Association suggests using this portion size as a guide:9

5 Estimation of food portion sizes Your hands can be very useful in estimating portions. They are always with you, and they are always the same size! When planning a meal, the Canadian Diabetes Association suggests using these portion sizes as a guide:

How many vegetables? Choose as much as you How much milk? can hold in both hands Drink up to 1 cup or 250 mL of low-fat milk with a meal.

How much grains How much meat and starches? and alternatives? How much fruit? Choose an amount up to Choose an amount the Choose an amount up the size of your fist size of your palm and the to the size of your fist thickness of your little finger

¢ Uncontrolled diabetes increases your risk of several Important serious diseases. ¢ But, if you eat foods that help keep blood sugar, pointers for insulin and inflammation under control, it can DEs dramatically reduce your risk of developing complications.

Taking steps to prevent or control diabetes does not mean living in deprivation; it means eating a tasty, balanced diet that will also boost your energy and improve your mood.

6 Being Active: The Impact of T2DM on People with Osteoporosis

Introduction

Expert Evidence suggests a strong link for reduced bone mineral Opinion density (BMD) in children, adolescents and adults with type 1 diabetes mellitus (T1DM),10 which increases the risk of 11 Dr. Navneet Shah osteoporosis and its related complications in later life.

MD (Medicine), FICA Diabetologist, Endocrinologist and Consultant Physician, Director, Department of Diabetes and Endocrinology at Sterling Hospital, Ahmedabad, Gujarat.

There may be several mechanisms through which diabetes could influence bone and some of which may have contradictory effects: ¢ Obesity which is widespread in T2DM is strongly associated with higher BMD.12 ¢ Hyperinsulinaemia may promote bone formation.13 Thereby, causing reductions in BMD. ¢ Higher glucose levels in the blood may reduce bone strength.14

Preserving bone health

Osteoporosis, a condition that leads to thinning of bones, is the first link to bone health and diabetes. Both osteoporosis and diabetes are common and the risk of developing both increases with age. With age, almost everyone loses bone density and muscle mass, thereby becoming more prone to bone fractures. Thus, staying physically active is important as you age — it not only helps keep diabetes complications at bay, but also helps maintain strong bones.

“According to a review of diabetes and bone health published in the journal Diabetes/Metabolism Research and Reviews, T1 and T2DM are also associated with an increased risk of osteoporosis, as well as bone fractures. The review found that fractures of the hip, arm, foot and spine are all more common in people with diabetes.”15

7 How to maintain strong bones with diabetes?

Diet and exercise, specifically weight-bearing exercises, are the two key ways to preserve bone health. Bones are living tissue just like muscles, and to remain strong they need to work against gravity or bear weight. ¢ Weight-bearing exercises are important for helping slow down bone loss; examples include walking, jogging, hiking, yard work, weight training and tennis.

¢ In terms of diet, calcium and vitamins D and K are good for bones. Keep your bones healthy by consuming a nutritious diet with calcium-rich food, while also ensuring that your vitamin D levels are adequate, and taking a supplement if needed or prescribed by the doctor.

¢ Good sources of calcium include low-fat dairy products and leafy green vegetables. Although very few foods contain vitamin D naturally, it can be obtained from sun exposure and some foods are fortified with calcium and vitamin D such as orange juice and yoghurt.

With diabetes, aim for at least 1,200 milligrams of calcium and 800 to 1,000 international units of vitamin D every day.

¢ Along with calcium, vitamin K is another nutrient that has been shown to improve bone health, it can be found in dark leafy green vegetable. ¢ In addition to a healthy diet, avoid smoking completely and limit alcoholic beverages. Smoking is bad for bone health, as is heavy drinking. Women who smoke go through earlier menopause, which also increases the risk for osteoporosis.

8 ¢ According to scientific evidence, people with coexisting T2DM and osteoporosis should be managed in an optimal way. ¢ Maintaining strong bones is an important part of managing diabetes. Important ¢ Identifying and evaluating populations at increased risk of developing pointers for osteoporosis is critical to disease prevention and management. DEs ¢ Having either T1 or T2DM increases a persons risk of developing an osteoporosis- related fracture. ¢ All diabetes-related factors should be considered in assessing osteoporosis and fracture risk reduction should be recommended to people with diabetes.

Through a healthy lifestyle, one can not only reduce the risk of diabetes complications, but also maintain strong bones and lower the chances of developing osteoporosis.

9 Monitoring: Transform your Health – Compliance to SMBG among People with T2DM

Introduction

Expert The UK Prospective Diabetes Study (UKPDS) and the Diabetes Opinion Control and Complications Trial (DCCT) have confirmed that good blood sugar control could effectively reduce the risk of 16,17 Dr. B. Vijay Kumar diabetic complications. Therefore, blood glucose monitoring has become essential for evaluating people with MD (Medicine) diabetes, developing a reasonable hypoglycaemic regimen, Senior Consultant Physician, Yoshoda Hospital, Secunderabad, Telangana. reflecting the effectiveness of hypoglycaemic treatment and guiding treatment adjustment.

International Diabetes Federation (IDF), American Diabetes Association (ADA) and many other organisations have released guidelines recommending – self-monitoring of blood glucose (SMBG) for all people with diabetes.18,19 Patients’ SMBG compliance is an important factor in determining the performance of SMBG. Thus, it is particularly important to identify the patients’ SMBG compliance and its influential factors.

Factors affecting SMBG compliance of people with diabetes

¢ Studies have shown that age, sex, body mass index (BMI), history of hypertension, history of cardiovascular disease, education background, income status, employment and insulin treatment are not associated with SMBG compliance. ¢ Only the duration of diabetes mellitus and use of oral hypoglycaemic agents are correlated with patients’ SMBG compliance.20 ¢ Among people with T2DM, longer duration of diabetes is associated with poorer SMBG compliance. ¢ Also, people with diabetes who use oral anti-diabetic drugs tend to have poorer SMBG compliance.20

10 Numerous studies have identified factors which affect adherence; these are further grouped into the five dimensions described below:21 ¢ Socioeconomic-related factors ¢ Healthcare team/health system-related factors ¢ Condition-related factors ¢ Treatment-related factors ¢ Patient-related factors

Using Telehealth to improve outcomes in diabetes

Recently, remote monitoring using Telehealth devices has garnered a lot of attention by enabling physiological information, including blood glucose, to be sent on a regular basis to healthcare professionals working remotely.22

Why Telehealth? Telehealth might be more effective at improving glycaemic control than ‘usual care’ including standard self-monitoring due to following benefits: ¢ It involves goal setting and transmission of blood glucose information ¢ Immediate feedback from a healthcare professional ¢ Fewer, expensive and unplanned hospital admissions ¢ Over time fewer long-term complications ¢ Lower HbA1c levels than usual care ¢ It has a unique use to deliver an interdisciplinary team approach for rural diabetes care ¢ Sustainable

Food diaries: Monitor food items and glucose levels

It's well known that food diaries can track basic information such as portion sizes and the number of food people eat. Additionally, they can track medication use; physical activity; nutrition information; levels of ketones, blood glucose and insulin; calorie counts and percentage of recommended daily intake.

11 There are many different online trackers and iPhone apps available, like Everyday Health’s Calorie Counter, which allows you to add meals and snacks and automatically keeps track of your daily nutrition and calorie levels. But remember, you can also just use an old-fashioned notebook and pencil.

¢ For patients with a longer course of a disease and/or under oral anti-diabetic medication, interventions such as patient education should be adopted to increase the SMBG compliance. Important ¢ Telehealth modestly improves glycaemic control in people with T2DM over pointers for 12 months. Mean HbA1c can be improved with Telehealth DSME/S services in an DEs underserved, free clinic population. ¢ People with diabetes may prefer a specific method for keeping a diary, such as a handwritten form, a computer spreadsheet or an app, but it's sometimes best for dieticians to initially hand their clients and patients a diary.

SMBG should be part of a regular management plan for people with diabetes.

12 Taking Medication: The Harmful Consequence of Aggressive Glycaemic Control in Adults with Diabetes

Introduction

Expert “Tight control” is a method of intensive diabetes self- Opinion management that involves keeping blood glucose levels as close as possible to normal without causing severe or Dr. Ajish T. P. frequent episodes of hypoglycaemia (low blood sugar), in the aim of preventing complications of diabetes. MD, DM Consultant Endocrinologist, Kollam, Kerala.

The ADA has defined tight control in terms of numeric values and urged most people with diabetes to strive for these more stringent goals. To reach the target HbA1c of less than 7%, the ADA recommends aiming for the following blood glucose levels:23 ¢ Average blood glucose levels before meals should be 70–130 mg/dL ¢ Blood glucose levels after meals should be less than 180 mg/dL

Improving diabetes medication adherence

Medication non-adherence is common and is one of the leading public health challenges faced today. Within one year, over 50% of people with diabetes prematurely discontinue their medications.24,25 This widespread non-adherence has serious consequences to individual and the healthcare systems that serve them. Non-adherence has been linked with poorer treatment outcomes and progression of disease symptoms and complications.

Strategies to improve medication adherence are as follows: ¢ Correct and complete instruction regarding medication should be given to the patient. Both verbal and written instructions should be given. ¢ Simple and affordable treatment regimen should be prescribed as far as possible. ¢ Patient perception about medication use should be assessed.

13 ¢ Patient should be encouraged to correlate drug intake with daily events/habits and maintain required modifications. In case of chronic disease, family members should motivate them to adhere to the medication. ¢ Counselling involves providing verbal information onto patients about their illness and its treatment and lifestyle modification. ¢ Clarify the patient’s expectations for treatment and answer their questions. ¢ Explain how each medication works to control or prevent symptoms. ¢ Patient may benefit from the use of reminder devices such as calendars, etc.

Guidelines for improving the care of the older person with diabetes mellitus

Older persons with diabetes mellitus have higher rates of premature death, functional disability and coexisting illnesses such as hypertension, coronary heart disease and stroke than those without diabetes mellitus.26 Older adults with diabetes mellitus are also at greater risk than other older persons for several common geriatric syndromes, such as depression, cognitive impairment, urinary incontinence, injurious falls and persistent pain.26

¢ Clinicians should establish, in collaboration with patients or caregivers, specific goals of care or target outcomes for persons with diabetes. ¢ The clinician should review the feasibility of medication dosing and costs. ¢ Efforts should be made to keep care, simple and inexpensive, through practices such as single daily dosing of drugs (or when this is not feasible, twice daily dosing). ¢ The older adult who have diabetes (and is not on other anticoagulant therapy and does not have any contraindications to aspirin) should be offered daily aspirin therapy. ¢ The older adults who have diabetes and smokes should be assessed for willingness to quit and should be offered counselling and pharmacological interventions to assist with smoking cessation. ¢ The older adult with diabetes who is on an angiotensin-converting enzyme (ACE) inhibitor or angiontensin receptor blockers (ARB) should have renal function and serum potassium levels monitored within 1 to 2 weeks of initiation of therapy, with each dose increase and at least yearly.

14 ¢ Specific barriers to medication adherence in T2DM, especially those that are potentially Important modifiable, need to be more clearly identified. pointers for ¢ Strategies that target poor adherence should DEs focus on reducing medication burden and addressing negative medication beliefs of people with diabetes.

For people having long-term diabetes, trying to manage a tight glycaemic control in their day-to-day life can be frustrating. They should be taught the importance of medication adherence to avoid the burden of any kind of consequence.

15 Problem Solving: Dealing with Diabetes Burnout and Diabetes Distress

Introduction

Expert Diabetes burnout, sometimes also called as diabetes distress, Opinion happens to be a natural and rational response to living with a long-term condition called diabetes. What makes the disease Dr. Satyam Chakraborty all the more frustrating is the unpredictability in blood sugar and daily schedules. MD (Internal Medicine), DM ( Endocrinology) Consultant Endocrinologist, Institute of Neurosciences, Kolkata, West Bengal.

Who is affected? People with long-term diabetes are more prone to diabetes burnout, but it can happen at any age as a result of the demands of living with a long-term condition. Parents and caregivers of those with diabetes can also be affected.27 It can be triggered by lots of things, including: ¢ As a natural reaction to having managed their diabetes over a long period of time - without a single day off. ¢ A particularly demanding time e.g., relationship difficulties, family stress or bereavement. As during these events, diabetes may naturally be seen as a low priority. ¢ Developing diabetes-related complications.

5 ways to cope with diabetes burnout28

¢ Intake of vitamins: Vitamin B12 helps to boost energy and stay motivated. Vitamin D, on the other hand, can improve ones mood. Vitamins can help our bodies where we have a deficiency.

¢ Exercising and staying active: Exercising helps to lose weight and increases serotonin in the brain. Serotonin helps enhance mood, which helps to makes you feel good.

16 ¢ Getting involved: Participating in support groups, volunteer events, fundraisers, charities and diabetes advocacy are all great ways to support the cause. By being involved helps you stay focused and determined to make a difference. Not only are you making a difference in your life, but in others as well.

¢ Setting a goal: When setting goals, it is important to be realistic. Making small changes can help you achieve those goals, rather than setting expectations too high in a short amount of time. Whether it be lowering your HbA1c, losing weight or making certain lifestyle changes.

¢ Starting from square one: The best thing to do is start from where you began. It is a task to break bad habits and develop new ones. But it can be revitalising to start fresh. By re-evaluating how to manage diabetes, re-educating yourself and essentially gaining a new perspective.

The “3R” approach Dealing with burnout means:29 ¢ Recognise (watching for the warning signs of burnout) ¢ Reverse (undo the damage by managing stress and seeking support) ¢ Resilience (build resilience to stress by taking care of physical and emotional health).

17 ¢ Help the person with diabetes to avoid seeing crises as insurmountable problems. ¢ Ask the person to try looking beyond the present to how future circumstances may be a little better. ¢ Take note of any subtle ways in which he/she might already feel somewhat Important better as he/she deals with difficult pointers for situations. DEs ¢ Establish a collaborative relationship with patients. ¢ Relieve the stress of “trying to achieve perfection”. ¢ Pay attention to strong negative feelings about diabetes. ¢ Take time to review all self-care behaviours. ¢ Identify the errors and reinforce therapeutic information.

Diabetes is a tricky thing. It will always have the capacity to frustrate us, irritate us, scare us, and make us mad, but if we know how to work with our feelings we can avoid serious burnout or at least catch it early and reverse it.

18 Reducing Risk: A Sudden Drop in Weight may Sometimes Not be Linked to Patient’s Healthier Habits

Introduction

Expert We as a society are obsessed with weight. According to Opinion government statistics, more than 85% of people with T2DM are overweight. So it stands to reason that much of the focus Dr. Rajiv Awasthi of managing T2DM is based on reaching and staying at a healthy weight. But, staying at a healthy weight does not MD (Medicine) indicate sudden or drastic weight loss. Lucknow, Uttar Pradesh.

It is important to note that thin people can get diabetes too and not just T1DM. In a 2008 study published in the journal Diabetes Care, adults age 60 to 79 years old with a BMI of less than 18.5 (which is considered to be underweight) were 30% more likely to get T2DM than adults with a “normal” BMI of 18.5 to 24.9.30

Forget weight loss: Focus more on healthy habits

Experts believe that focusing on weight loss as the ultimate goal gets it back-to-front, and rather promoting a consistent set of healthy behaviours would see the whole population healthier in the long run. It has been observed that when people follow healthy habits for enjoyment and well-being rather than focussing and stressing on weight loss, they are more likely to stick to the lifestyle changes, staving off weight gain later. A 2012 study observed that people who consistently had the following behaviours had a lower risk of mortality over the course of the study – Regular exercise (more than 12 times a month), diet rich in vegetables and fruit (at least five serves a day), modera te alcohol intake and avoiding or quitting smoking. In this study, people who kept up with all four behaviours had similarly low risk of dying, regardless of whether they were classed as normal weight, overweight or obese.

19 Steps to healthy weight loss ¢ Get physical: Exercise can help keep off the weight and keep you active. ¢ Eat breakfast: The most effective diabetes diet includes breakfast. Do not ever skip it. ¢ Cut calories: The exact number of calories that people on a diabetes diet should consume depends on a number of factors, including age, gender, current weight, activity level and body type. A reasonable goal for people with T2DM is between 1,200 and 1,800 calories per day for women and between 1,400 and 2,000 calories per day for men.31

¢ Feast on fibre: Generous amounts of fibre may help to lower blood sugar levels and speed up weight loss. According to 2015–2020, Dietary Guidelines, women between ages 31 and 50 should aim to eat at least 25 grams of fibre daily, while men in that same age range should eat about 31 grams.31

¢ Eat mini-meals: A diabetes diet structured with three or more small meals daily is better than a diet plan that includes only one or two big meals. ¢ Set small goals: Small goals help in achieving the target and keeps one motivated and consistent on the journey of healthy weight loss.

Unexplained weight loss could be an early sign of diabetes32

If you have not tightened the belt on your diet or ramped up your exercise routine and your weight is still dropping, talk to your doctor. While weight loss of just a pound or two is not a reason for concern, unexplained weight loss of 10 pounds or more may mean something is wrong. It could be an early sign of diabetes. This weight loss can occur relatively quickly — over a few weeks to a couple of months. Unexplained weight loss can occur in people who have T2DM, but it is more commonly found in people with T1DM. It is important to remember that unexplained weight loss is not normal. It is a sign not only of diabetes but also may point to other issues such as cancer or problems with your gastrointestinal tract, metabolism or thyroid. If you are dropping weight and you do not know why, see your physician as soon as possible.

20 ¢ Weight loss is clinically relevant if more than 5% of body weight is lost over 6–12 months, although smaller losses may be important in frail elderly people. ¢ Causes can be classified as organic (malignant and non-malignant), Important psychological, social or unknown. pointers for ¢ Drugs should be reviewed because side-effects often contribute to weight loss. DEs ¢ All people with diabetes should be assessed and screened for depression and cognitive impairment. ¢ If initial history, examination and investigations are normal, three months of “watchful waiting” are preferable to further blind investigations.

Maintaining a healthy weight is important for everyone, but if you have diabetes, excess weight may make it harder to control your blood sugar levels and may increase your risk for some complications.

21 Healthy Coping: Does Fasting Help Prevent Diabetes?

Introduction

Expert It is well known that weight loss and exercise regimes can Opinion both prevent the onset of T2DM and improve metabolic control.33 According to most national diabetes associations Dr. Manoj Indurkar and clinical practice, dietary interventions are considered essential in the treatment and prevention of diabetes-related MD (Medicine) complications.34 Professor and Head, Department of Medicine, SS Medical College, Rewa, Madhya Pradesh.

There are many types of dietary interventions people may use; one of which is intermittent fasting. This is a dietary intervention that time-restricts feeding to 4–6 hours and extends the overnight fast from 12 hours towards 18 or 20 hours. This may be a beneficial additional dietary strategy used in T2DM management. Researchers at the 2014 ADA Scientific Sessions in San Francisco, CA, presented a new finding on how diabetes risk in people with pre-diabetes may be combated by periodic fasting.

Body 'feasts' on bad cholesterol in fat cells, negating insulin resistance effects The researchers found that during fasting days, the participants' cholesterol went up slightly, as it had done in the previous study of healthy people. However, over a 6-week period, the cholesterol levels of the people with pre-diabetes actually decreased by about 12%.35 After 10–12 hours of fasting, the body begins to scavenge other sources of energy throughout the body in order to sustain itself. The benefit to people with prediabetes is that because the body feasts on the low density lipoprotein (LDL) or "bad" cholesterol in fat cells, it negates the effect of insulin resistance. They concluded that fasting has the potential to become an important diabetes intervention.

There are many ways to practice intermittent fasting. Here are just a few: ¢ The 16:8 plan has you fasting for 16 hours each day and eating only during an 8-hour window of your choice. Tip: Incorporate the hours you sleep as part of the 16-hour fast. ¢ The 5:2 plan describes a 24-hour fast. Eat supper on day one, then fast until supper the following day. You do this twice (or once) a week. ¢ The 36-hour plan is a 36-hour fast in which you simply refrain from eating for more than a day. You could follow this plan once a week or less frequently. (E.g., you eat supper on day one, on day two you do not eat at all and on day three you eat again).

22 6 ways intermittent fasting helps reverse T2DM

While some of the reasons for intermittent fasting effectiveness are rooted in complex science, other reasons are simply common sense. Consider the following:36 ¢ Lowers blood sugar: Every time you eat, your blood sugar rises. That’s simple science. So, when you are not eating your blood sugar is lower.

¢ Increases insulin receptivity: Because your cells are no longer overloaded with sugar, insulin can do its job and move the sugar out of your blood. ¢ Decreases insulin levels: Due to the fact that cells are now receptive to insulin, your pancreas produces less insulin.

¢ Regenerates your pancreas: Researchers have discovered that intermittent fasting effectively reboot the pancreas, regenerating  cells. ¢ Helps you lose weight: Often, simply losing weight can reverse T2DM. Intermittent fasting has been shown to help people lose between 3 and 8% of body weight in three to 24 weeks. ¢ Increases your metabolic rate: This translates into more calories burned, helping facilitate some of the above benefits of intermittent fasting.

Benefits of early time-restricted feeding (eTRF) eTRF is a form of intermittent fasting that involves eating early in the day to be in alignment with circadian rhythms in metabolism. It improves some aspects of cardiometabolic health and offers following benefits:37 ¢ eTRF reduces insulin levels and improves insulin sensitivity and â cell responsiveness. ¢ eTRF lowers blood pressure but does not affect arterial stiffness, LDL cholesterol or high density lipoprotein (HDL) cholesterol. ¢ eTRF reduces oxidative stress but does not affect inflammatory markers. ¢ eTRF reduces appetite in the evening. ¢ eTRF is feasible and acceptable.

23 Table 3: Do’s and Don'ts while fasting Do’s Don‘ts

Be sure to fit your fast into your lifestyle Avoid fasting during high-stress times

Eat a meal including a lean protein, healthy fat and plenty of vegetables, the night before Avoid gorging yourself the previous night

Take your vitamins Stop if you feel you are pushing too hard or too far

Prepare your mind, body and home Avoid high-intensity cardiovascular workouts

¢ eTRF increases insulin sensitivity. Important ¢ eTRF also improves  cell function and lowers blood pressure and oxidative stress. pointers for ¢ eTRF lowers the desire to eat in the evening which may facilitate weight loss. DEs ¢ Intermittent fasting can improve health even in the absence of weight loss.

eTRF - by virtue of combining daily intermittent fasting and eating in alignment with circadian rhythms in metabolism - will prove to be a particularly efficacious form of intermittent fasting.

24 Diabetes in Control: Cultural Issues When Treating Diabetes

Introduction

Expert The chronic nature of diabetes underscores the importance of Opinion self-management education that promotes behaviour skills that are necessary to optimise the quality of life. DEs Dr. Praveenkumar Devarbhavi recognise that the most effective approach to patient education is individualised to the needs of each person with MD (General Medicine), 38 DM (Endocrinology and Metabolism) diabetes. Educators likewise recognise that the way a Consultant Endocrinologist, Maax person learns and how information is utilised depends heavily Superspeciality Hospital, Karnataka, on prior life experiences and support networks; and that each Bangalore. of these elements is shaped by culture.39

Awareness of the cultural background and its impact on health

Awareness of the need for cultural sensitivity is the first step toward providing sensitive and competent diabetes education. ¢ It is more than a finite knowledge of cultural values, beliefs, customs, language, thoughts, and actions. ¢ The need to gain relevant insight necessitates the need to develop a certain amount of cultural humility. ¢ This will help develop a mutually respectful and positive relationship among patients and healthcare providers. ¢ The more engaged individuals with diabetes and their support members are involved in their healthcare, the more likely they are to achieve desired outcomes and improve their quality of life.

Eating habits in the Indian culture

Whenever Indian families gather, nutritious food, bursting with flavour, spices up the meal time. Avoid missteps by understanding how the eating habits in the Indian culture are largely based on religion and tradition. A high-vegetable diet with no beef and generally no pork comes from the Hindu religion. Tasty vegetables Eating habits of the Indian culture are based on culinary traditions. ¢ Most dishes feature meat or vegetables mixed with sauce and rice. ¢ For vegetarians, the menu for everyday meals is based mostly upon a diet without meat.

25 ¢ When meat is incorporated in dishes, it is most commonly in the form of chicken or lamb and sometimes seafood such as prawns. ¢ The majority of the Indian population is Hindu, so beef and pork are often excluded from Indian dishes due to religious requirements.

Daily meals There are three main meals in the Indian culture, so the meal timing is similar to western cultures. ¢ In India, most people eat a morning meal, a mid-day meal and an evening meal with occasional indulgences of healthy snacks. ¢ The evening meal is generally the biggest meal of the day, followed by the mid-day meal. ¢ Green tea is more apt to be served with evening meals than alcohol, which is not heavily consumed in India.

Diabetes diet plan for Indians40

North

Table 4: Food choices for North Indian people with diabetes Food groups Eat more often Avoid or Eat less often

Starches ¢ Roti, phulka, chapatti ¢ Paratha, puri, kachori, naan ¢ Brown basmati rice ¢ Pulao, biriyani ¢ Potatoes-prepared with minimal oil ¢ Fried potatoes

Fruits ¢ All fresh fruits ¢ Regular canned fruit ¢ Monitor portion size of the fruit ¢ Light canned fruit

Vegetables ¢ All vegetables cooked with minimal oil ¢ Creamed or fried vegetables

Meat and meat ¢ Dal cooked in minimal oil ¢ Fried or creamed dal alternatives ¢ Chicken (without skin) and fish cooked in minimal oil ¢ Chicken, fish or red meat cooked with cream ¢ Eat lean lamb, goat, pork or beef less often and in small quantity ¢ High-fat cuts of lamb, goat, pork or beef ¢ Low-fat cheese and paneer, part-skim Ricotta cheese, tofu ¢ Regular cheese and paneer, regular Ricotta cheese

Dairy ¢ Skim milk, fat-free yohgurt and buttermilk ¢ 2% or whole milk and its products

Fats ¢ Canola, vegetable or olive oil ¢ Butter, ghee, cream, half-and- half ¢ Nuts such as almonds, peanuts, walnuts ¢ Coconut, coconut oil, coconut milk ¢ Seeds such as sunflower seeds

Tip: Avoid too much of fatty items like ghee and butter.

26 South People having diabetes need to be more cautious with their diet plan especially South Indians because rice is the staple food for them. Tips ¢ Do not wash rice several times before cooking. ¢ Avoid excess portions of white rice and if possible replace it with brown rice which is rich in fibre content and hence helps in controlling blood sugar. ¢ You can also replace rice with a variety of grains such as cracked wheat, oats, barley, quinoa, ragi and other millets. ¢ Use a minimum amount of oil while cooking and it is healthy to use oils like olive, canola or peanut oils, as they are high in monounsaturated fats. ¢ Replace starchy vegetables like potato, green plantain with green vegetables. ¢ Use fat-free, skim or 1% milk instead of whole milk. ¢ Avoid deep fried snacks and prefer dry roasted and baked foods which are made with less or no oil. ¢ Limit taking high salty foods like pickles, chutneys, papadams, etc. And for people with diabetes and high blood pressure, it is better to avoid those things. ¢ Desserts must be made only with the recommended quantities of fresh fruits. Artificially sweetened low-fat desserts or desserts with a minimal amount of real sugars may be used but in control. ¢ Drink plenty of water; at least 6–8 cups a day. ¢ Learn to read the nutrition labels of the packaged foods and take them according to the recommended intake.

27 East People here are sweet lovers and it is very rare to see meals without sweets. Rice is the staple food in these regions. List of healthy and not so healthy foods for East Indian people with diabetes:

Table 5: Food choices for East Indian people with diabetes

Healthy foods (use often) Not so healthy foods (use less often) Starches Roti Parata fried with oil Plain brown/basmati rice (cooked) Pulao or fried rice with >1 tsp oil Roasted mudhi or chuda (puffed rice) Chuda upama with oil and vegetables Meat or meat alternatives Dhal (mung, toor or masoor) Dhal with lots of oil or ghee Baked fish or chicken Fried chicken or fish Pan-fried fish with masala (cooked with oil and spices) Fried fish in tomato gravy Vegetable dishes Stir-fried vegetables Vegetable curry with lots of oil and spices Dalma (mixed vegetable with dal) Dalma with coconut and ghee Dairy Yoghurt and buttermilk made with skim milk or 2% milk Yoghurt and buttermilk whole Raita made with low-fat milk Raita with fried boondi Rasgolla and other steamed desserts Desserts made with whole milk and or fried Fruit dishes Plain fresh fruit Fruit salad with jaggery and nuts

28 West In Western India the focus in more on two major states – Maharashtra and Gujarat. Gujarati diet is for people from different regions of Gujarat like South and North Gujarat, Kathiavad and Kutch. Gujarati’s normally have sweet tooth and hence, people with diabetes from this region need to control more on their food habits.

Overcoming cultural barriers

Some ways to work within cultural traditions to improve nutrition and eating habits thereby improving diabetes management include: ¢ Use of effective communication in populations with low literacy, limited English proficiency and non-English speakers. ¢ Use of trained and properly integrated professional interpreters when communicating with non-English speaking patients. ¢ The ability to communicate cross-culturally is essential in providing education to a diverse population, as it enables the use of proper verbal and non-verbal communication style across cultures. ¢ The provided patient education should include culturally sensitive information that may be distributed to enhance patient understanding of diabetes management.

¢ Adapt communication/interaction patterns. Use appropriate strategies to demonstrate respect and use indirect communication when necessary. ¢ Perform targeted cultural assessments (for defining problems, modifying/ constructing interventions and establishing participating outcome goals). ¢ Determine patients’ preferred learning style: visual, Important auditory, experiential and use appropriate teaching pointers for modality (talking circles, one-on-one, didactic, lay DEs model). ¢ Determine applicability of a strategy demonstrated effective with one particular population to a particular individual within that population or to a different population. ¢ Work in partnership with ethnic communities.

DEs should be mindful of the cultural traditions and customs among all cultural and ethnic groups to recognise socio-economic challenges that may exist.

29 Monsoon Highs and Lows!

Introduction

Expert When it starts pouring, none of us can resist the temptation to Opinion savour piping hot pakodas, vada pav, dabeli and hot masala tea! However, for people who are living with diabetes, the Dr. Partha Roy monsoon is the season, in which they have to take utmost care and sometimes people with diabetes may feel bogged MBBS, F. Diab (MDRF) down by monsoon blues. Consultant Diabetologist

Despite the fact that individuals living with diabetes require all-round care, the rundown of care amid monsoons is much more. Since the humidity, sweat and moisture during monsoons is conducive for the growth of fungi and other microorganisms. Those with diabetes ought to be extra cautious in this climate and follow an appropriate eating pattern and personal hygiene. Diabetes lowers a person’s immunity and in this way, it is important to keep an eye out for any associated complications during monsoons.

How seasonal changes affect blood sugar levels?41

Apart from stress, illness and infections, seasonal changes are also known to cause significant fluctuations in the blood sugar levels. The values also change as per the climate the individual lives in. Monsoon and diabetes India has a monsoon that tends to wreak havoc and damage roads. For people with diabetes, waterborne infections, foot infections and blood sugar fluctuations can pose difficulties during the rainy season. Some people with diabetes might be prone to respiratory infections like bronchitis due to a weakened immune system. People who have had waterborne infections might have dehydration and so it is important to keep hydrated.

Winter and diabetes Indian winters are generally not harsh, but the northern regions experience lower temperatures and people with diabetes have to regularly monitor changes in their blood sugar levels during the winter season.

30 With the arrival of winter, there is an increase in the incidence of cold and flu among people. In people with diabetes, infections cause high blood sugar levels. In the winter seasons, the blood vessels of the hands and the feet tend to constrict. This leads to lack of (or slower) blood supply to those parts and the condition is characterised by abnormally low blood sugar symptoms and causes numbness in the toes and fingers. Summer and diabetes The typical summer season for Indians means scorching heat, water shortage and air conditioners. But for people with diabetes, summer with sizzling temperatures might be dangerous if proper precautions are not taken. Firstly, the heat and high temperature affect the metabolism of the body. Due to the perspiration in the summer months, the body tends to lose fluids and this leads to dehydration. This can cause high blood sugar levels. Additionally, when there is a lesser amount of fluid in the body, the kidneys get lesser amounts of blood flow and in turn, they work less effectively. Hyperglycaemia leads to dry mouth, weakness, confusion, abdominal pain and shortness of breath. If left untreated, it can even result in a diabetic coma. Higher temperatures cause dilation of blood vessels and in some people with diabetes, this leads to enhanced or quicker absorption of insulin leading to low blood sugar symptoms.

Monsoon health tips for people with diabetes

During monsoon, people with diabetes need to take extra care to prevent illnesses. Here are a few ways through which they can boost immunity:42

Have home-cooked or freshly cooked food as much as possible ¢ Drink plenty of water. Stay hydrated. Avoid bottled beverages and opt for coconut water instead. Stick to warm food and beverages. Soups, ginger tea, etc. are easy to make and help build immunity. ¢ If you feel that you will be out for long on a rainy day, carry some snacks because people with diabetes tends to feel hungry more often than people without diabetes. Wash fruits and vegetables thoroughly. During monsoons, these are more likely to be infested by worms. ¢ Make sure your rainy footwear is one size bigger than your actual shoe size. Doing so reduces the chances of shoe bites. Change wet socks immediately. At first available chance, dry the feet and legs with soft cloth. ¢ Check feet and the spaces in between toes regularly for injuries and infections. Do not use hard plastic footwear commonly used for monsoon in India. ¢ If closed shoes are a must for office, try to keep a pair at work and use another pair for commuting.

31 Special care for the elderly person with diabetes Special care for the elderly person with diabetes is warranted especially during monsoon. ¢ Due to the slippery floor, monsoon falls are very common amongst senior citizens. ¢ Hypoglycaemia is a common adverse effect associated with anti-diabetes medications. ¢ Certain medications also may trigger low blood pressure in elderly person with diabetes.

¢ Important For elderly person with diabetes, keep an eye on the low blood sugar levels, low blood pressure etc. to avoid untoward incidences. pointers for ¢ Be familiar with the different types of existing drugs for the treatment of diabetes and DEs select the most effective, safe and better tolerated by patients.

With a little bit of extra care and precaution, people living with diabetes can also enjoy the monsoon as much as people without diabetes can. So what are you waiting for – Take out that colourful umbrella, wear your gumboots and get ready to enjoy the monsoon!

32 Family and Diabetes’s Corner: Living with Diabetes is a Family Affair

Introduction

Expert The involvement of family is crucial to diabetes control. For Opinion people diagnosed with T2DM, it’s like their world completely changing. It means big changes for their families, too. How Dr. Kiranmai Alla well families cope with these changes can mean the difference between rapidly worsening disease and a MD, DM (Endocrinology) relatively healthy life. It is an opportunity for families to Dr. Kiran’s Endocure, Cure Hospital, Vijayawada, Andhra Pradesh. strengthen their relationships with each other and to improve every member's overall health.

Diabetes: A family illness

Three main things make T2DM a family illness:43 ¢ Genetics: There is clearly a genetic component to diabetes and family members share the genes that predispose a person to diabetes.

¢ Food: When the family is living in the same household, everyone usually eats the same kinds of food at the same table. High-fat, high-calorie diets increase the risks of obesity which put people at risk for T2DM.

¢ Exercise: Sometimes one family member gets plenty of exercises while everyone else sits on the sofa and watches TV. But when everybody else is a couch potato, it is hard for a person with diabetes to get the exercise, he or she now desperately needs.

Diabetes means a change for everybody to a healthier lifestyle. Interventions that target the family are usually more effective than those targeted to an individual. Avoiding diabetes education to just the individual with T2DM could limit its impact on patients, since

33 family may play such a large role in disease management. Including family members in educational interventions offers following benefits:44

Helps to develop healthy family behaviours

It may It provide promotes support to diabetes people with self-management diabetes

8 ways to get your family on board when you have diabetes

Supportive family members can help you manage your T2DM and may even see their own health benefit as they help you make positive lifestyle changes. Luckily, many of the changes you need to make — especially around food and exercise — can make your family healthier, too. Some ways you and your loved ones can work together to manage T2DM as a team are listed below: ¢ Help your family understand factors that contribute to diabetes and how it’s managed and treated. ¢ Take them to meet your doctor or DE. ¢ Explain the signs and symptoms of low blood sugar as well as how they can help if you experience it. ¢ Describe how your eating schedule may be different and share what you are learning about proper portion sizes and better eating. ¢ If you need to test your blood sugar often or take medication or insulin on a regular basis, help them get familiar with the process and your schedule. ¢ Tell your family members about how their encouragement and support motivates you and is more helpful than their nitpicking on your diet and exercise choices. ¢ Try new healthy foods or recipes together. ¢ Find activities you can enjoy together that get you moving.

34 ¢ Involving families in diabetes self-care interventions may be a key mechanism for improving diabetes outcomes for patients. ¢ Important Involving families in diabetes education interventions may enable them to be more supportive of the patient and improve the patient’s feeling of being supported in their pointers for diabetes self-care. DEs ¢ Through participating in interventions, family members may also experience improvements in their own knowledge about diabetes, skills in supporting loved ones with diabetes and changes in their own health behaviours and health outcomes.

Among adults with diabetes, interventions including family or household members may be more effective than usual care in improving diabetes-related knowledge and glycaemic control.

35 Importance of Patient-Centered Therapy in Diabetes Mellitus

Introduction

Expert Diabetes mellitus is a disorder of carbohydrate metabolism Opinion characterised by the impaired ability of the body to produce or respond to insulin leading to improper levels of sugar Ms. Ariba Zuhair (glucose) in the blood. Diabetes is defined as one of the metabolic disorder characterised by hyperglycaemia, MSc resulting from defects in insulin secretion, insulin action or Dietician, Dr. Mohan’s Diabetes 45 Specialties Centre, Lucknow, both according to ADA. Uttar Pradesh.

Patient-centred care

In ADA, the National Institute for Health and Care Excellence (NICE) and the Institute of Medicine, a patient-centred approach to care has increasingly become both a parameter of quality assessment and a widely acknowledged core value. In T2DM, patient-centred care is associated with increased patient satisfaction, improved patient-provider communication and enhanced patient well being. Patient-centred care is a way to help promote meaning and purpose in daily life. Patient-centred care allows the patient to have autonomy while directing their care and services.46 The patient-centred care approach is designed to be responsive to the changing needs of people with diabetes.

Obesity and diabetes

Obesity is a medical condition in which excess body fats accumulates to the extent that it may have an adverse effect on health. It is defined by BMI and further evaluated in terms of fat distribution via the waist-hip ratio and total cardiovascular risk factors. Obesity and diabetes are interrelated, being overweight or obese increases the chances of developing the T2DM particularly; the visceral obesity (excess weight around the abdomen) is a strong risk for T2DM. Increased deposits of visceral adipose tissue lead to increased delivery of free fatty acid to the liver, which can lead to the development of insulin resistance in this organ. In contrast to subcutaneous fat, visceral fat is a metabolically active tissue which releases a variety of adipocytokines and inflammatory mediators which can cause further reduction in insulin sensitivity. High levels of free fatty acids can also act on the pancreas and inhibit insulin secretion, the process called “lipotoxicity”

36 Need for dual or triple therapy for an obese person with T2DM

For people with T2DM, oral monotherapy may be initially effective for controlling blood glucose, but it is associated with a high secondary failure rate. The different classes of oral agents used to treat T2DM have complementary mechanisms of action. While treating obesity with diabetes, first preference should be weight friendly drugs.

Initial therapy

Metformin monotherapy should be started at diagnosis of T2DM unless there are contradictions. Metformin is effective, safe and inexpensive and may reduce the risk of cardiovascular events and death.47 Metformin may be safely used in patients with estimated glomerular filtration rate (GFR) as low as 30 mL/in-patient and should be advised to stop the medication in cases of nausea, vomiting and dehydration. Metformin is associated with vitamin B 12 deficiency, with a recent report from the Diabetes Prevention Program Outcomes Study (DPPOS).48 In patients with metformin intolerance, consider an initial drug from dual therapy and proceed accordingly. When HbA1c is >8.9% consider dual combination therapy initially to more expeditiously achieve the target HbA1c level. Insulin has an advantage of being effective over agents and should be considered as a part of any combination regimen.

Combination therapy – do we need this?

A comparative effective meta-analysis49 suggest that each new class of non-insulin agents added to initial therapy generally lowers the HbA1c by 0.9–1.1%. If the HbA1c target is not achieved after 3 months, consider a combination of metformin and one of the six available treatment option: sulphonylurea, thiazolidinedione, dipeptidyl peptidase-4 (DPP-4) inhibitor, sodium-glucose cotransporter-2 (SGLT-2) inhibitor, glucagon-like peptide 1 (GLP-1) receptor agonist. If the HbA1c target is still not achieved after 3 months of dual therapy proceed to triple therapy. Drug choices are based on patients preferences,50 as well as various patients diseases and drug characteristics with the goal of reducing blood glucose level, while minimising side-effects, especially, hypoglycaemia.

37 Effect of oral hypoglycaemic agents Table 6: Monotherapy metformin + Lifestyle management Efficacy High Start with monotherapy unless: Hypo risk Low risk ¢ HbA1c is greater than or equal to 9% – consider dual therapy. Weight Neutral/Loss ¢ HbA1c is greater than or equal to 10%, blood glucose is Side-effects Gastrointestinal/Lactic acidosis greater than or equal to 300 mg/dL or patient is markedly Costs Low symptomatic – consider combination injectable therapy.

If HbA1c target not achieved after approximately 3 months of monotherapy – proceed to two- drug combination (order not meant to denote any specific preference, choice depends on a variety of patient and disease-specific factors).

Table 7: Dual therapy metformin + Lifestyle management Sulphonylurea Thiazolidinedione DPP-4 inhibitor SGLT-2 inhibitor GLP-1 receptor Insulin (basal) (Glipizide, (Pioglitazone, (Sitagliptin, (Empagliflozin, agonist Gliclazide, Rosiglitazone) Linaglyptin, Canagliflozin) (liraglutide) Glimepiride) Vildaglyptin)

Efficacy High High Intermediate Intermediate High Highest Hypo risk Moderate risk Low-risk Low-risk Low-risk Low-risk High-risk

Weight Gain Gain Neutral Loss Loss Gain Side-effect Hypoglycaemia Oedema Rare Genitourinary Gastrointestinal Hypoglycaemia Heart failure infection, Dehydration, Vaginal infection, Ketosis

DPP-4: Dipeptidyl peptidase-4; SGLT-2: Sodium-glucose co-transporter-2; GLP-1: Glucagon-like peptide-1

If HbA1c target not achieved after approximately 3 months of dual therapy proceed to three- drug combination (order not meant to denote any specific preference – the choice dependent on a variety of patient and disease-specific factors).

38 loss loss, Side- Weight Weight Neutral effects Gastroi- ntestinal infection lurea edione GLP-1 SGLT-2 agonist inhibitor receptor Sulphony- Thiazolidin- Neutral, gastroi* ntestinal infection infection, Weight loss Weight gain Weight loss, Side-effects Genitourinary GLP-1 DPP-4 edione agonist SGLT-2 receptor inhibitor inhibitor Thiazolidin- Sulphonylurea emia gain, Weight Weight Hypoglyca- X syndrome Side-effect Dehydration gain, Fragile Weight loss, edione DPP-4 SGLT-2 inhibitor Inhibitor Thiazolidin- Sulphonylurea gain gain, Weight Weight Neutral Neutral Oedema Side-effects Table 8: Triple therapy metformin + Lifestyle management GLP-1 agonist receptor Sulphonylurea DPP-4 inhibitor SGLT-2 inhibitor Thiazolidinedione loss loss, loss, Weight Weight Weight ntestinal infection Gastroi- dehydration Weight gain, Side-effects hypoglycaemia Sulphonylurea Thiazolidinedione DPP-4 inhibitor SGLT-2 inhibitor GLP-1 receptor agonist DPP-4: dipeptidyl peptidase-4; SGLT-2: Sodium-glucose co-transporter-2; GLP-1: Glucagon-like peptide 1

39 If HbA1c target not achieved after approximately 3 months of triple therapy: ¢ If the patient is on oral combination move to GLP-1 receptor agonist. ¢ If the patient is on GLP-1 receptor agonist, add basal insulin or vice versa. ¢ Metformin therapy should be maintained, while other oral agents may be discontinued on an individual basis to avoid unnecessarily complex or costly regimens.

Apart from medication treatment and lifestyle changes, there are certain important points to be considered: ¢ Do not skip any medications: DE should ensure that patient take regular medication to control their blood glucose levels. They should educate the patient regarding the dosage adjustments according to their blood sugar levels. This has to be taught as the patient may increase their consumption of diet or change the levels of physical activity. ¢ SMBG: The blood glucose levels should be monitored regularly Important as there are chances of blood glucose fluctuations. SMBG helps pointers for in flexibility in dosage, diet and physical activity adjustments. DEs ¢ Nutritional aspect: Intake of fluids should be increased; a low calorie, high protein high fibre diet should be included, minimum oil consumption should be encouraged. Patients should be explained about economical oil allowances. Complex carbohydrates should be given preference over simple carbohydrates in the diet. Patients should completely eliminate fast foods from the diet. ¢ Exercise: A minimum of 45 minutes of exercise is necessary to control blood sugar as well as to maintain ideal body weight. Brisk walking should be included in the normal routine.

It is important to understand a patient’s co-morbidities along with diabetes in order to develop a personalised approach to treat diabetes. For example, if the patient is obese and is given sulphonylurea/thiazolidinedione/insulin, the probably increased food intake due to the drug’s compensatory mechanism is not going to help the patient’s condition and co-morbidities. A personalised approach is a way!

40 Multiple Feathers on the Cap

The different hats worn by DEs – The crucial role of DE for inpatient diabetes management

Continuity of care by DEs

Continuity of care is one of the most valued experiences for a people with diabetes by a DE. Management continuity is relevant whenever a person is receiving care from more than one clinician or provider. It concerns the processes involved in coordinating, integrating and personalising care in order to deliver a high-quality service. This ensures that the practice team and the systems supporting it work effectively and efficiently.51 In a study, it was observed that the diabetes education teams integrated into primary care exhibited many of the principles of person-centred care, as evidenced by the 2 overarching themes: 52

¢ The first is personalised care, with the subthemes caring environment, shared decision making and patient preference for one-on-one care. Participants described feeling included in partnerships with their healthcare providers, as they collaborated with physicians and DEs to develop knowledge and set goals in the convenience and comfort of their usual primary care settings. Many participants also expressed a preference for one- on-one sessions. ¢ The second theme is the patient-provider relationship, with the subthemes respect, supportive interaction and facilitating patient engagement. Supportive environments created by the educators built trusting relationships, where patients expressed enhanced motivation to improve their self-care.

Take-home messages ¢ While receiving the patient at the reception, the DE must acknowledge the patient and ensure to welcome him/her in the room. ¢ If there is a waiting period and this causes the patient to wait for his/her scheduled appointment, the DE must apologise for the delay and ask the patient for any requirements, if needed. ¢ During the examination, the DEs must make the patients comfortable by asking them about their religious reforms and considerations and explain to them in detail about the procedure, working and outcome. ¢ DEs must be as transparent as possible to the patients so as to let them know more about their conditions. Patients may have various frequently asked questions (FAQs), it is the DEs role to answer them systematically.

41 Some of the most common questions encountered by DEs are:

¢ What I can and cannot eat in this condition? ¢ Will my diabetes go away? ¢ Can I have a normal life with diabetes? ¢ Will my children be affected by this condition?

Here are some sample questions to guide a patient-centred assessment:53

¢ How is diabetes affecting your daily life and that of your family? ¢ What questions do you have? ¢ What is the hardest part right now about your diabetes, causing you the most concern and worry? ¢ How can we best help you? ¢ What is one thing you are doing or can do to better manage your diabetes?

¢ Specialised DEs in primary care can provide customised education and support to Important meet patients’ individualised needs and goals and they can provide primary care pointers for physicians with key information to improve overall clinical care. ¢ Person-centred care is the next evolution of healthcare and DEs must embrace this DEs change.

42 Conference Highlights

54th Annual meeting of the European Association for the Study of Diabetes (EASD) 2018

¢ Dates to remember: 1 – 5 October 2018 ¢ Location: Berlin, Germany EASD holds its annual meeting in a different European city each year with more than 15,000 delegates from over 130 countries attending. The scientific program includes more than 1,200 talks and presentations on the latest results in diabetes research by leading experts in the field. The aims of the association are to encourage and support research in the field of diabetes, the rapid diffusion of acquired knowledge and to facilitate its application.

Interesting topics that will be covered54

¢ Diabetes prevention on demand: What strategies? - The role of microbiota in T2DM ¢ EASD/JDRF symposium : Looking into the future – developing new interventions for T1DM - Prevention trials for T1DM: The TrialNet experience and looking into the future ¢ SGLT-2 and DPP-4 inhibitors: New avenues to protect the kidney - SGLT-2 and DPP-4 inhibition: Extending from glycaemic control to kidney protection ¢ New approaches to diabetes risk in urban areas - A novel toolkit for action research on urban diabetes ¢ Digital diabetes health: From now to the future - Use of digital health to increase adherence to treatments

43 Tools: Pregnant with Diabetes

This app is intended for those women with diabetes who are pregnant or who have gestational diabetes. It is tedious to keep a track of all the information the doctors and nurses advise pregnant women, hence, the help is right at their hand or to be more precise, their smartphones. The app contains easy to understand information and advice on how to have an unproblematic pregnancy for both mom and baby. The app is also intended for women with diabetes who wish to become pregnant.

Key questions that are answered in the app55,56

¢ Diet and carbohydrates - Why is it important to count carbohydrates when you have T1DM, T2DM or gestational diabetes? - What is special for pregnant women with T1DM, and why is it important that they count carbohydrates? ¢ The foetus - How does the mother’s diabetes influence the foetus? - What are the statistics that the child will get diabetes? ¢ After birth - Why is it often necessary that the mother and child have to stay in the hospital for a few days after delivery? - What are the special needs of a baby with a mother having diabetes? - How does the insulin dose change for a mother with T1DM after delivery? - What happens when you have had gestational diabetes during pregnancy?

This app is available for iOS and Android.

44 Future Trend: Smart Health IT – A New Model of Healthcare for Rural India

SMART Health IT is an open, standards-based technology platform that enables innovators to create apps that seamlessly and securely run across the healthcare system. 57 The SMART platform is composed of open standards, open source tools for developers building apps and a publicly accessible app gallery. To date, dozens of clinical applications have been built on this platform, and SMART applications are being used to provide clinical care at healthcare institutions, including Boston Children’s Hospital and Duke Medicine. 57 This new healthcare app could help people in India determine their risk of developing diabetes.58 According to the project rationale, the program is training healthcare workers due to a lack of doctors in rural India — in some parts of the country, one doctor is expected to provide comprehensive primary healthcare for up to 30,000 residents in comparison to Australian rural areas, are estimated to have58 doctors per 100,000 people in rural areas and in the US, rural areas have approximately 68 doctors per 100,000 people. 58

IMPACT Diabetes will help people living in rural areas to access timely, affordable and guideline-based healthcare in the community, reduce the risk of developing life-threatening complications and ultimately save lives" - Vivek Jha, executive director of The George Institute for Global Health, India.

Why a focus on diabetes for the project?58

There were over 72 million cases of diabetes in India in 2017, and lack of access to health and medical services in India is significant — there are approximately 600 million people with little or no access to healthcare. This project intends to open up this availability by equipping healthcare workers with technology. Dubbed IMPACT Diabetes, the program will train women in the community health sector to use a new tablet app. Healthcare workers, known as accredited social health activists (ASHAs), will be able to screen people in Indian communities to identify those with diabetes or at high risk of the disease. The process: 58 ¢ Patients will have their case history recorded by ASHAs, be tested for blood sugar levels and blood pressure levels and have their weight and height recorded. ¢ The patient's risk score is then calculated. ¢ Based on the above, healthcare workers can offer patients appropriate diet and lifestyle advice — or, if they are at high risk for the disease, refer them to a doctor for treatment. ¢ The app will allow ASHAs to schedule follow-ups with patients, to ensure their condition is being managed.

45 Diabetes Educator of the Month

Following sections are contributed by Nurture Health Solutions

Contributed Nurture Health Solutions is a true health and well-being by company offering niche comprehensive health and wellness solutions to corporates and individuals. Ms. Khushboo Pathak

RD, CDE Nurture Health Solutions.

A 32-year-old woman often gets headaches during the day and after lunch. She is aware that low blood glucose levels or hypoglycaemia can cause headaches. She checks her blood glucose levels on a daily basis and more often even when she is having a headache. However, her blood glucose levels are within target range. To seek guidance and understand the root cause of her problem she visited a DE.

Intervention by DE

The DE took a detailed history of her and noticed that her water intake was low and she was having biscuits and chips every day. She was on medicines for hypertension and was stressed due to her work. She was also not having proper sleep. The DE explained to her that headache can also be due to high blood pressure. Hence, asked her to check her blood pressure levels. The DE counselled her that all processed, bakery products are high in salt and hence she should avoid consumption of these foods. The DE also advised her to have adequate amounts of fluids throughout the day. The DE asked her to do meditation or yoga to de-stress herself. She was advised to have a good sound sleep for at least 6-7 hours. She started meditation to de-stress herself, increased her fluid intake and soon the frequency of her headaches decreased. She was thankful to the DE for guiding her.

46 Patients’ Corner

Frequently asked questions

Query: I am a 54-year-old man recently diagnosed with diabetes and hypertension. Does a diagnosis of T2DM mean I will have to go on insulin? DE: Most people with T2DM do not need to take insulin injections at diagnosis. For a newly diagnosed patient with T2DM, lifestyle modification like dietary modification, increasing physical activity and oral medications are usually enough to bring the blood glucose to a normal level. If the blood glucose levels remain uncontrolled, it means the oral medications are not working effectively and insulin needs to be initiated. Query: My husband is 48 years old and has diabetes for the past couple of years. His HbA1c level has increased by 1.6%. Can he get rid of T2DM if he stops eating carbs and/or lose a lot of weight? DE: T2DM is a progressive disorder often preceded by years of elevated blood glucose levels high enough to be diagnosed as pre-diabetes. When most people with T2DM are finally diagnosed, they've been on this path for five to six years and have lost more than half of their natural insulin-making capability in the â cells of their pancreas. Losing even a few kilos during early stage when blood glucose begins to rise can dramatically improve blood pressure, cholesterol, triglycerides and blood glucose levels. One should not stop carbs completely, moderation is key. Reducing carbohydrate intake will definitely help improve blood glucose levels. Quality and quantity of carbohydrate is very important. Choose good carbs over bad carbs. Eat healthy, exercise regularly, monitor blood glucose levels and maintain regularity in medications. Diabetes cannot be cured but controlled. Query: Is it okay to eat a bowl of fruits everyday post meals for people with diabetes? If yes, which fruits are the safest to eat? DE: Eating fruit right after meals is not advised as it adds to the carb load of the meal and increases the fat stores. For people with diabetes, a gap of two hours after the meal and one hour before the meal is advisable. Eating fruits between your meals or on empty stomach is a good habit to have your plateful of nutrition, as it is the time where digestion is quick and also different enzymes are secreted and used by the system to digest the fruits. All fruits are safe to consume but the key is moderation. Always eat fruits that are fresh, local and in season. Eat fruits with some nuts to balance the glycaemic load. You may also sprinkle fruits with cinnamon which is very helpful in balancing blood sugar levels.

47 Query: I am a 52-year-old woman, been diagnosed with T2DM for 7 years, however, it has always been in control. Of late, since I’m reaching menopause, my glucose levels have been fluctuating a lot. I was advised by a friend to use a glucose monitoring device. How often should I check my glucose levels and replace my glucometer? DE: SMBG is an important component for management of diabetes. You can do staggered blood glucose testing, in which you have to perform pre- and postprandial blood glucose testing for meals over the course of a week (fasting, post breakfast, pre-lunch, post-lunch, pre-dinner, post-dinner). This will help you to analyse factors (food/stress/physical activity) which are causing fluctuations in blood glucose levels. You do not need to replace your glucometer, you can calibrate it and check the accuracy by doing the blood test on the glucometer and the lab at fasting. The accuracy of SMBG meters available has been recommended to produce results within a 20% margin of error. Query: I am a 46-year-old man, I know several friends of mine who have T2DM and I'm concerned about my own risk. Should I get tested for the condition? DE: Diabetes is a common disorder that is associated with significant morbidity and mortality. It has an asymptomatic stage that may be present for up to seven years before diagnosis. According to the ADA, all patients should be screened for diabetes at three-year intervals beginning at age 45, especially people who are overweight or obese, have a wider waist circumference and waist to height ratio. If multiple risk factors (family history, blood pressure, high cholesterol levels, etc.) are present, screening should be done at an earlier age and more frequently. You can take the Indian Diabetes Risk score to check if you are at risk.

Busting the myth: Lite butter is better than normal butter

Fact: Lite butter is made from vegetable oil whereas regular butter is made from cow’s milk. Even though lite butter is cholesterol- free, it is not fat-free. It has saturated fat and sodium which the increases risk of heart disease, if consumed in large amount. Moreover, some margarines available have trans-fats which are harmful.

48 Get Active!

Exercise with diabetes: Tips for working-out safely

Walking may be one of the most basic forms of exercise but it's also a very effective form of activity for helping to reduce blood glucose levels.

Precautions to be taken before you get moving: ¢ Get your doctor’s consent before starting an exercise program. Make sure your doctor reviews your diabetes drugs. ¢ Carry at least 15 grams of a fast-acting carbohydrate in case of low blood sugar. It might be a half-cup of fruit juice or glucose tablets or sugar that equal 15 grams.

¢ Wear well-fitting shoes for the activity you’re doing and choose athletic polyester socks. They dry quicker and cause less friction than all-cotton socks. ¢ Inspect your feet before and after exercise. Check for blisters or sores.

¢ Drink plenty of fluid before, during and after exercise. ¢ Wear a medical ID bracelet or carry a medical ID in your pocket. ¢ Check your blood sugar level before and after exercise to make sure it’s in your target range. Your DE can tell you what it should be before you start exercising. This is very important if you take insulin. After an intense workout or exercising for a long time, you may want to eat something with at least 15 grams of carbohydrates within 2 hours. This will help you avoid low blood sugar.

¢ If you become shaky, anxious or more sweaty than usual or feel a change in your heartbeat, stop exercising right away and check your blood sugar. If it is low, follow your DE’s advice about how to treat it. ¢ Always warm up for 5 to 10 minutes at the start of your workout. For instance, walk or bike slowly. Do 5 to 10 minutes of cool-down and gentle stretching at the end.

49 National Diabetes Educator Program (NDEP) Best Practices

NDEP – National Diabetes Educator Program has been ongoing since 7 years. It has been developed with the objective of creating DEs. A DE is a healthcare professional who is specialised and certified to teach people with diabetes how to manage their condition. This program is under the auspices of the Indian Association of Diabetes Educators (IADE) and Dr. Mohan’s Diabetes Education Academy (DMDEA), a unit of Dr. Mohan’s Specialties Centre, and is promoted by USV. The program is being conducted in 150 NDEP centres across India.

Join NDEP Facebook page to know more about it!

For more information, follow us on: https://www.facebook.com/NDEPCOURSE/

50 I still remember that day when one of the USV guys visited my clinic and mentioned, “We are planning some patient education related activity”. Contributed As usual, I thought it must be some camp or investigation or by some patient flyer distribution and I was not moved much. I then asked him, what is it like and he narrated the work Dr. Manoj Sharadrao Chitale module and I was intrigued to know more and then came the MD Medicine stalwarts’ session of the trainers, it included Padmashree Consultant Physician, Shree Clinic, Dr. Shashank Joshi, Dr. Shilpa Joshi, Dr. Contractor and Nashik, Maharashtra. Dr. V. Mohan.

I realised that, I will be receiving a very rare opportunity of imparting knowledge from the top to the grass root level in the most simplified and practical manner. Since 8 years, I have been associated with this program and it is immensely helpful not only to the student who has participated but also to its main target patient, society and the needy ones. We as doctors hardly communicate in our busy OPD to the patients; we give them best possible healthcare with the least possible time. For a patient with diabetes as a disease and its diagnosis is like a major catastrophe, because of the taboo, its ill publicity, adverse health impact and organ damage, and especially when they don’t know how to handle it and start feeling low frustrated and helpless. Needless to say, it also puts a great economic burden on the already precarious situation of most of the folks in a developing country like ours. The main success of this program is that it bridges the big gap between the patient and doctor; disease and prevention; knowledge and applicability; knowing and execution. It imparts knowledge in the most easy and understandable language, filling in the lacuna between reading the material on social media or print media and understanding it; It aids in applying knowledge, feeling as the executor and gratifying the results. The feedback I received from my patients is really overwhelming but the universal tagline is confidence, increased self-esteem and freedom. Freedom from many things like dependence, fear, worry and social stigma. Finally, last but not least, we have been successful in making our patient to one peer group where they can freely interact, share, improve and become self-reliable and more independent For me, NDEP is a new dimension in creating and refining DEs.

51 Eat Out, Be Wise!

North

Sattu ka paratha Sattu ka paratha recipe is made out of sattu which is roasted chana dal flour. A most common way to use sattu is in parathas. Sattu atta is spiced with herbs and stuffed into the whole wheat dough, cooked on tawa and served with curd and a vegetable.

East

Xaak aru bhaji Different types of xaak (leafy vegetables) are always a part of authentic Assamese cuisine. Dhekia xaak, the edible fiddlehead fern is not only popular in Assam but also in the entire region of our beautiful North-East. People love to cook this xaak in different ways. For e.g., dhekia xaak stir fry with chickpeas/potatoes, fish sour curry with dhekia xaak and ou tenga (elephant apple), pork stew with dhekia etc.

South

Bisi bele bhaat This is a traditional dish from Karnataka. Bisi means hot, bele means lentils and bhaat means rice. This is a healthy one pot meal which consists of rice, lentils and vegetables. The combination of cereal (rice) and pulse (lentils) improves the quality of protein and makes it a complete protein dish.

West

Zunka bhakar A traditional Maharashtrian dish, zunka bhakri has a chickpea flour base and a tempering of sautéed onions, mustard seeds and ginger-garlic. This side dish is eaten with jowar or bajra rotis. Including a bowl of vegetable which makes it a complete meal, as zunka gives protein, roti gives carbohydrates and vegetables give fibre, vitamin and minerals.

52 Shopping Smart

On a lazy monsoon morning, a warm bowl of oatmeal is a delicious way to start the day. But deciding which kind of oatmeal to make — steel-cut, rolled, quick cook or instant can be tricky. All oats begin as groats or kernels of grain that are later processed into different varieties. The variations in processing determine the different type of oats. Whole oat groats are the result of simply harvesting oats, cleaning them and removing their inedible hulls. They take the longest to cook.

Steel cut oats

If you cut groats into two or three pieces with a sharp metal blade, you get steel cut oats. They cook quicker than oat groats because water can more easily penetrate the smaller pieces. Steel cut oats are also sometimes called Irish oatmeal. They take about 20–30 minutes to cook and are chewier than rolled and instant oats; they should be soaked before cooking.

Rolled oats – Regular (old fashioned)

Rolled oats (sometimes called old fashioned oats) are created when oat groats are steamed and then rolled into flakes. This process stabilises the healthy oils in the oats, so they stay fresh longer and helps the oats cook faster by creating a greater surface area. They absorb more water and cook faster than steel-cut oats — usually in about 5 minutes — and are the oat of choice for granola bars, cookies and muffins. They do not require soaking.

Quick or instant oats

If you roll the oat flakes thinner, and/or steam them longer, you create quick oats and ultimately instant oats. They get cooked very fast. Steel cut oats and rolled oats are healthier options as compared to instant oats because they are less processed. Instant oats cause a spike in blood glucose levels. Check the food label before buying oats to see the type of oats present in it.

53 Superfood: Whole Grains / साबतु अनाज

Whole grains are important sources of many nutrients, including fibre, vitamins (thiamine, riboflavin, niacin and folate) and minerals (iron, magnesium and selenium). United States Department of Agriculture (USDA's) MyPlate recommends making half of your daily grain choices whole grain for healthy eating. Brown rice, whole oats, whole wheat, bulgur, millets, quinoa and sorghum are examples of types of whole grains in cereals. Dietary fibre from whole grains, as part of an overall healthy diet, helps reduce blood cholesterol levels and may lower risk of heart disease. Fibre is important for healthy bowel function and helps reduce constipation. Whole grains being high in fibre help provide a feeling of fullness with fewer calories. Selecting whole grains for at least half your daily servings may help maintain your weight. Vitamin B found in whole grains helps the body release energy from protein, fat and carbohydrates. Iron is used to carry oxygen in the blood. Magnesium is a mineral used in building bones and releasing energy from muscles. Selenium is important for a healthy immune system.

How to consume?

Consume it in the form of pulao or khichadi (barley pulav, bajra moong dal khichdi etc) make chillas or add a handful of whole grains to salads, etc.

Recommended dosage

3–4 bowls a week

54 Recipe

Corn fritters

Serves: 1

Ingredients Amounts Method Corn (boiled) 1 cup ¢ Coarsely grind the boiled corn Onion (finely chopped) 1 no ¢ Add the remaining ingredients Carrots (grated) ¼ cup ¢ Add required amount of water to make a thick batter Green chillies (chopped) 2 no of pouring consistency Ginger (grated) A small piece ¢ Heat a paniyaram pan, add 2–3 drops of oil in each Garlic clove (chopped) 2–3 cloves hole and pour a tbsp of batter in each hole ¢ Cumin powder 2 tsp Keep the heat on medium to low flame and close the pan. Once the edges turn golden brown, flip over the Turmeric powder 1 tsp fritters to the other side using a stainless steel rod or Besan flour 2 tbsp spoon Coriander leaves (chopped) 3 strands ¢ Cook the other side also until golden brown. Salt To taste Remove from pan using a rod or spoon and serve hot Oil 2 tsp 1 cup = 30 grams 1tsp = 5 grams

55 Secret behind grandma’s recipes

Jamun seed powder Jamun is an effective grandma’s remedy for curing diabetes. Jamun seeds and pulp not only helps in lowering blood glucose levels but also helps to delay diabetes-related complications. Sun-dried jamun seed powder Once the fleshy part of the fruit is consumed, wash the seeds and dry in sun for a week. After a week the seed is really dry, the outer skin will peel off and inside berry would be more like a pistachio. Pound the seeds along with the outer skin and make into a fine powder. Consume 1 tsp of this jamun seed powder on an empty stomach early morning with a glass of water.

56 References

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59 51. Freeman G and Hughes J. Continuity of care and the patient experience. The King’s Fund. Available at: https://www.kingsfund.org.uk/sites/default/files/field/field_document/continuity-care-patient-experience-gp- inquiry-research-paper-mar11.pdf 52. Grohmann B, Espin S and Gucciardi E. Patients’ experiences of diabetes education teams integrated into primary care. Canadian Family Physician. 2017;63(2):e128–e136. 53. Powers MA, Bardsley J, Cypress M, et al. Diabetes Self-management Education and Support in Type 2 Diabetes. A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators and the Academy of Nutrition and Dietetics. Diabetes Care. 2015;38(7):1372–1382. 54. European Association for the Study of Diabetes. Available at: https://www.easd.org/ 55. Pregnant with diabetes. Available at: https://play.google.com/store/apps/details?id=com.heyworld. pregnantwithdiabetes&hl=en_IN 56. Rasmussen S. Pregnant with diabetes. Available at: https://itunes.apple.com/in/app/pregnant-with-diabetes/ id797791382?mt=8 57. SMART. SMART—An App Platform for Healthcare. Available at: https://smarthealthit.org/an-app-platform-for- healthcare/about/ 58. Connelian S. This app can help determine the risk of diabetes for people in rural India. 2018. Available at: https://mashable.com/2018/04/19/diabetes-app-india-australia/#FLWrP32ebuq3

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