1 st time in India To keep the members of 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 American Association of Diabetes Educators (AADE) i.e., healthy eating, being active, monitoring, taking medication, problem-solving, healthy coping and reducing risks.

This issue cover story gives insights on the importance of exercise for people with diabetes. People with diabetes can achieve their targets by various ways; however, it is important for them to take precautions while exercising so as to not injure themselves while achieving result-focused goals. This issue also covers a section on diabetes and women’s health – A double challenge for women with menopause.

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 , 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. S. Sridhar Dr. Ramesh Omprakash Goyal MD, DM (Endo – PGI, Chandigarh) MD (General Medicine & Therapeutics), DM (Endocrinology) Assistant Professor, Department of Endocrinology and Metabolism, Consultant in Diabetology & Endocrinology, Madurai Medical College; Consultant Apollo Hospitals, Ahmedabad, Gujarat. Endocrinologist, Vadamalayan Hospital, Madurai, Tamil Nadu.

Dr. Ajay Vasant Rotte Dr. Jamal Ahmad MBBS, PGDHHM, DFID, IDC, MBA MD (General Medicine), DM (Endocrinology), (Hospital Management) FCCP, FRCP, PhD (Medicine), DSc (Endocrinology) CEO and Senior Diabetologist, United CIIGMA Hospital, Aurangabad, Maharashtra. Physician and Endocrinologist, Diabetes and Endocrinology Super Speciality Centre, Aligarh, Uttar Pradesh.

Dr. (Wg. Cdr.) Arun Kumar Dr. Milind Katta MD (Medicine), DM (Endocrinology) MBBS, Diabetology (CPS), CCGDM, CCEBDM, CCD, FICM, DPHARM Senior Consultant Endocrinologist, Arunosha Labs Pvt. Ltd., Delhi. Consultant Critical Care Specialist and Diabetologist, Balaji Hospital and Sugun Hospital, Andheri, Mumbai.

Dr. Banshi Saboo Dr. Samir Dasgupta MD, PhD MD Chief Diabetologist and Chairman, Diabetes Consultant Diabetologist and Endocrinologist, Care and Hormone Clinic, Ahmedabad, Rabindranath Tagore Surgical Centre, Kolkata, Gujarat. West Bengal.

Dr. Lavanya Katakam Dr. Parimal Swamy MD (General Medicine), MD, Dip. (Preventive Health Care) DM (Endocrinology) Apollo, Sugar Balance Centre, Asthama-Allergy Consultant Diabetologist and Endocrinologist, Care Centre, Jabalpur, Madhya Pradesh. Aswini Endocrine Center, Guntur, Andhra Pradesh.

Dr. Gurpreet Singh Ms. Umasakthy G. MBBS MSc, RD, PGDDE Consultant and Head, Minerva Medica Senior Executive Dietician and Diabetes Diabetes and Endocrine Clinic, Ludhiana, Educator, Dr. Mohan’s Diabetes Specialities Punjab. Centre, Gopalapuram, Tamil Nadu. Table of Content

Cover Story: Healthy Coping: Exercise Prescription for Diabetes 01 Pursuit for A Healthier Tomorrow 21 Dr. S. Sridhar Dr. Ramesh Omprakash Goyal

Being Active: Special Concerns for Assess and Address the Women with Diabetes 06 Risk of 23 Dr. Jamal Ahmad Dr. Ajay Vasant Rotte

Taking Medications: Six Protective Herbs to Your Diabetes Report Card 09 Include in Your Diet! 27 Dr. Arun Kumar Dr. Milind Katta

Monitoring: Diabetes by the Number Why Settle For Normal When 13 You Can Reach Optimal? 29 Dr. Banshi Saboo Dr. Sameer Dasgupta

Problem Solving: Diabetes and Menopause: Coping with Uncertainty of Diabetes A Double Challenge 15 32 Dr. Parimal Swamy Dr. Lavanya Katakam

Reduce Your Risk: Neutralise the Role of Medical Effects of High Blood Sugar Naturally 18 Therapy in 34 Dr. Gurpreet Singh Ms. Umasakthy G. Table of Content

Tools in Diabetes: Eat Out, Be Wise! Livongo for Diabetes 40 49

Future Trends: “Ouchless” Patch Promises Needle-Free 42 Shopping Smart 50 Diabetic Monitoring

Diabetes Educator of the Month 43 Diet-Related Behavioural Tips 51

Busting the Myth: : Beans (Lente carbs)/फिलयां Egg Yolk Must be Discarded 44 53

Get Active! 45 Recipe 54

National Diabetes Educator Program (NDEP) Best Practices 47 References 55 Dr. Shachin Kumar Gupta Cover Story: Exercise Prescription for Diabetes

Benefits of exercise in the prevention of (T2DM) Expert Opinion 'If exercise was a pill it would be prescribed to every patient' was noted among some of Australia’s leading experts and 1 Dr. S. Sridhar was published in the journal ‘The Guardian’. Globally, T2DM has reached epidemic proportions and is associated with an MD, DM (Endo – PGI, Chandigarh) Assistant Professor, Department of increased risk for (CVD) and 2 Endocrinology and Metabolism, premature mortality. A sense of change in people’s lifestyle Madurai Medical College; Consultant must be implemented for this reason. Endocrinologist, Vadamalayan Hospital, Madurai, Tamil Nadu.

A dual strategy of aerobic activity and strength training makes sense: 3 ¢ Aerobic activity, like walking or swimming, strengthens the heart, lungs and muscles. It helps control blood pressure and blood sugar. It keeps arteries flexible. It is also essential for maintaining or losing weight and excess body fat. All of these are key strategies for many people with diabetes. ¢ Strength training helps muscles respond better to , the hormone that ushers blood sugar into cells. A single bout of it can make muscle cells "listen" to insulin better for 12 hours or more. It also improves muscle mass, muscle strength, blood pressure and body composition.

Table 1: Strategies to stay active for people with diabetes Aerobic activity Muscle strengthening activity

Activity Walking, jogging, cycling or group fitness classes Walking uphill, weight lifting or other muscle strengthening resistance exercises

Duration At least 30 minutes per day At least 30 minutes or less per day

Intensity Moderate-intensity activity; means that the person should feel If using weight for example dumbbells; try to do at least warm, mildly out of breath and mildly sweaty 1 set of 8–12 repetitions per activity

Frequency If the person aims to do 30 minutes per day then he/she should do At least 2 days a week this at least 5 times per week so that he/she can reach a total of 150 minutes a week

1 Miscellaneous benefits of exercise ¢ Helps people achieve and maintain a healthy weight and prevents ¢ Reduces feelings of stress, anxiety and depression ¢ Builds and maintains healthy bones, muscles and joints ¢ Boosts energy level ¢ Improves quality of sleep

Muscle strengthening exercises/Resistance exercises

Flexibility exercise Flexibility exercise increases the ability to bend joints and stretch muscles through a full range of motion. Some activities include: ¢ Stretching (sit and reach) ¢ Warm-up and cool-down

Exercising caution4

People with diabetes need to be a bit more careful about exercise than other people. Here are some tips for exercising safely with diabetes: ¢ Start slowly: If the patient is new to exercise, start with a low-impact activity like walking, swimming or bicycling and then gradually increase the intensity. ¢ Time it right: The best time to exercise is an hour or so after eating when your blood sugar is likely to be a bit higher.

2 ¢ Know your limits: Ask the patient to check their blood sugar before and after exercise to see how their body responds to exertion, particularly in elderly and brittle diabetic individuals and people with (T1DM). ¢ Protect your feet and eyes: – Make sure that the patient uses appropriate footwear with supportive midsoles and socks to avoid blisters so as to avoid skin ulcers. – If the patient has nerve pain or loss of sensation, ask him/her to avoid activities that could cause pressure ulcers or stress fractures. – If the patient has developed blood-vessel abnormalities in one or both eyes (), ask them to not lift heavy weights or perform other activities that cause a sudden increase in blood pressure that can trigger bleeding in the eye. ¢ Be prepared: People with diabetes must always have water and snacks handy when they exercise. Especially, -rich snacks are very important as that can quickly boost blood sugar if it gets too low.

Exercise prescription

The DE should develop an exercise prescription around the person’s goal for activity, taking into account his/her exercise history, diabetes history including control and complications, medical history, co-morbid conditions, CVD status and motivation/psychosocial issues. Household chores, recreational activities and activities at work should be considered when designing the activity plan. The first step in developing the exercise prescription is to conduct an exercise assessment that addresses:

Personal goals for exercise ¢ Improved blood glucose control ¢ Weight loss ¢ Increased strength and endurance ¢ Begin competitive athletics ¢ Reduce CVD risk

Exercise history ¢ Type of exercise that is currently performed or has been performed in the past ¢ Effect of exercise on health and diabetes control ¢ Enjoyment of activity

3 Diabetes and medical history ¢ Type and duration of diabetes ¢ Current level of blood glucose control [glycated haemoglobin (HbA1c)] ¢ Presence of complications ¢ Current diabetes treatment regimen ¢ May range from planning and oral agents to intensive insulin therapy or some combination of each ¢ Adjustments may need to be made to meal plan or medication to accommodate exercise and prevent hypoglycaemia ¢ Frequency of self-monitoring of blood glucose (SMBG) SMBG may need to be more frequent to determine the effects of exercise and prevent hypoglycaemia. Continuous glucose monitoring system (CGMS) may also be considered to see the impact of exercise on blood glucose levels (immediate post activity and after a few hours). ¢ Frequency and severity of hypoglycaemia especially in relation to exercise will indicate the types of adjustments that need to be made so that the risk is minimised ¢ Co-morbid conditions should also be assessed in order to develop a safe plan that will minimise risks

Motivational/ Psychosocial issues ¢ Social support: Exercise buddy and emotional support from family members and friends Interest, past successes and challenges with exercise ¢ Selection of time of day and frequency of exercise that be consistent and convenient taking in to account the lifestyle of the individual

4 Realistic plan for the individual A realistic short-term plan should be developed to ensure success. The plan should be adjusted after the person achieves success, to reach more long-term goals. ¢ The plan should fit in the daily routine of the individual in terms of frequency (number of times a week), duration and time of the day ¢ Type, ease and intensity of exercise ¢ Should be fun and enjoyable ¢ Should include daily activities such as housework, walking to and fro from the bus, marketing, and expanding the same to 30 minutes of exercise a day

¢ The American Diabetes Association (ADA) recommends that individuals with T2DM should perform at least 150 minutes of moderate-intensity aerobic exercise training or at least 75 minutes of Important vigorous aerobic exercise training per week. pointers for ¢ People with diabetes should avoid exercising alone DEs and going into remote areas. ¢ Good foot care should be practiced by wearing well-fitted shoes and cotton socks and inspecting feet every time after exercise. Advice patients to keep feet dry.

People with diabetes are encouraged to exercise regularly for better blood sugar control and to reduce the risk of CVDs as well as have a healthier heart, better weight control and stress management.

5 Being Active: Special Concerns for Women with Diabetes

Introduction

Expert Although diabetes presents with mostly similar symptoms in Opinion both men and women, there are some symptoms and complications which are unique to women like gestational Dr. Jamal Ahmad diabetes, polycystic ovary syndrome, vaginal infections and monthly hormonal changes which affect insulin action. The MD (General Medicine), DM physiological monthly menstrual cycle and blood sugar levels (Endocrinology), FCCP, FRCP, PhD (Medicine), DSc (Endocrinology) in women with diabetes can affect each other to varying Physician and Endocrinologist, Diabetes degrees. and Endocrinology Super Speciality Centre, Aligarh, Uttar Pradesh.

Menstrual cycle and hormones – effect on diabetes

¢ Studies have shown that glucose control differ in follicular and luteal phase of menstrual cycle due to hormonal changes.5 ¢ Oestrogen and progesterone hormones interact with insulin hormone and may increase the body’s resistance to own or injected insulin. These effects differ between individuals. ¢ Due to these interactions, diabetic women may experience a surge in blood glucose levels which may occur for three to five days either before, after or during menstruation. ¢ These effects may be consistent or may vary from one month to another making it more difficult to monitor and predict blood glucose levels. ¢ Increased progesterone levels may trigger food cravings making management of diabetes more difficult.

Effect of diabetes on menstrual cycle

¢ Research indicates that menstruation starts, on an average, a year later in women with T1DM and they are more prone to have menstrual problems before age of 30 as compared to women without diabetes. ¢ Diabetes in women have also been associated with increased chances of having longer menstrual cycles and periods, heavier periods and earlier onset of menopause.6

6 Monitoring blood glucose levels and menstrual cycle changes6

Look out for increased Monitor mood changes, Compare cycle with sugar symptoms of premenstrual bloated or tender Use a period tracker app levels and note monthly trends syndrome which may indicate feeling before, during and or pattern poor blood sugar control after your periods

Simultaneously monitor and record blood glucose levels

‘Careful monitoring of menstrual cycle changes and blood sugar levels along with suitable lifestyle modifications involving physical activity, nutrition and development of healthy habits play a significant role in proper diabetes management’

Being pregnant, diabetic, and active: The ultimate challenge for women with diabetes!

Pregnancy in women with diabetes requires planning, stringent monitoring and proper diabetes management to ensure healthy baby and healthy mother. The DE plays an important role in conveying these important points:7,8 ¢ Pre-conception counselling and planned pregnancy are critical to improving maternal and foetal outcomes. Pre-conception glycaemic control and preventive health services enable successful pregnancy outcome. ¢ All women and adolescents of reproductive age with diabetes should be educated about risks of unplanned pregnancies. They should also be educated about family planning options.

¢ Diabetes treatment in pregnancy is a combination of medical nutrition therapy, physical activity and weight management. ¢ If prescribed, insulin is preferred medication during pregnancy. Timely follow-up and monitoring are essential. ¢ There is a concern about the safety of exercise in pregnancy. Pregnant women with diabetes should be advised to monitor foetal activity and blood glucose levels before and after exercise. Physical activity should be limited to 15–30 minutes. ¢ Women who have been physically active prior to pregnancy are encouraged to continue an active lifestyle.

7 In summary, a balanced diet, adequate exercise as suitable along with insulin if indicated enables to achieve glycaemic targets and healthy pregnancy.

¢ Menstrual cycle and hormonal changes have an impact on diabetes and vice versa in women with diabetes. ¢ Pre-conception counselling, lifestyle modification and close monitoring of blood glucose levels during pregnancy are critical for healthy pregnancy. Important pointers for DEs

The key for women with diabetes is to know how their menstrual cycle affects their diabetes and vice versa by careful monitoring it. They should compare their cycle with their blood glucose levels and note any trends that they see so that they can be prepared for diabetes management changes in future months.

8 Taking Medications: Your Diabetes Report Card

Introduction

Expert Diabetes being a complex, chronic illness requires Opinion continuous medical care with multi-factorial risk-reduction strategies beyond glycaemic control. Continuous patient self- Dr. (Wg. Cdr.) Arun Kumar management education, monitoring and support are critical to prevent acute complications and decrease the risk of MD (Medicine), DM (Endocrinology) development of long term-complications.8 Senior Consultant Endocrinologist, Arunosha Labs Pvt. Ltd., Delhi.

Many medical institutions use the toolkit of a diabetic report card to monitor and update patient progress

¢ The report card aids in the chronic care model implementation and has all essential patient data along with the important parameters related to diabetes check-up in an easily accessible format. ¢ It may also include information about risk factors, target goals, meaning and importance of each quality measure, lists of previous self-management goals set by the patient and a space to input new goals.9 ¢ The format for diabetic report card is not fixed and different diabetic care centres can create a format tailored to their needs. A common and essential detail is related to the ABCs of diabetes.10,11,12,

A is for A1c A1c/HbA1c can also be reported as estimated average glucose (eAG). It gives a picture of the average blood glucose control for the past 2 to 3 months and is an indication of how well the diabetes management plan is working. Suggested target: Below 7% How often? At least twice a year

B is for blood pressure Blood pressure is the force of blood flow inside the vessels. When blood moves with too much force through the vessels (termed high blood pressure or hypertension), the heart has to work harder and the risk for heart attack, stroke, eye problems and kidney diseases increases. Suggested target: Below 140/90 mmHg or lower in some cases How often? At every visit

9 C is for Cholesterol is a waxy substance found in blood and the cholesterol numbers can give information about the amount of fat in the blood. There are different types of cholesterol. High-density lipoprotein (HDL) cholesterol helps protect the heart and low-density lipoprotein (LDL) cholesterol can clog the arteries. Hence, LDL is often called the "bad cholesterol" or "lousy cholesterol". High triglycerides increase the risk of heart attack or stroke. Suggested LDL target: Below 100 mg/dL How often? At least once a year

Apart from above parameters, the expanded ABCs of diabetes can also be incorporated in the diabetic report card. These include the following: 9, 12–14

A is also for albuminuria It means the presence of protein in the urine. Screening for these levels can detect early kidney damage which can be stopped from progressing to kidney failure and prevent requirement for dialysis or kidney transplantation later on. Suggested target: Below 30 mg of protein How often? At least once a year

A is also for aspirin After consultation with the doctor, low-dose aspirin therapy in suitable patients can help prevent heart attacks and strokes. How often? At each medical visit, people with diabetes should be evaluated to determine the appropriateness of aspirin use. If prescribed, aspirin should be taken on a daily basis.

D is for diabetes education Both patients and care providers should be made aware of the need for ongoing medical nutrition therapy and diabetes self-management education to enable the achievement of diabetic management goals and prevent diabetes-related complications. Suggested resources: Dieticians, diabetes educators How often? Ongoing, emphasis is on it being a continuous process

10 E is for an eye exam Regular eye check-ups can catch diabetic eye disease early providing the opportunity to intervene with effective treatment and thus help to preserve vision. How often? At least once a year

F is for foot care Regular foot examination and proper foot care are of utmost importance to prevent serious infection and amputation later on. The loss of sensation due to makes it difficult to feel and realise when something is wrong with the feet. Hence, it is vital to examine visually. How often? Check feet daily. Remind doctor to check them at every visit. Get an extensive foot examination performed once a year.

G is for glucose (sugar) monitoring Monitoring of glycaemic status by patient/healthcare provider is considered a cornerstone of diabetic care in achieving glycaemic control and preventing diabetes-related complications. SMBG allows patients to assess response to therapy and SMBG data can aid health professionals to guide treatment and management plan. How often? Frequency and timing of SMBG should be determined by the particular needs and goals of each patient and decided by discussing with the doctor.

H is for health maintenance Patients with diabetes are at high risk for complications, hospitalisation and death from influenza and pneumococcal disease. This can be avoided by timely immunisation with safe and effective vaccines which are available readily. How often? Flu vaccine, every year; pneumococcal vaccine, at least once

I is for identifying special medical needs Voicing health concerns at every visit can help the doctor identify possible problems and refer for speciality care if needed. How often? When needed Other parameters like kidney function screening, smoking status, stool occult blood examination can also be added as necessary in the diabetic report card.

11 ¢ Use of diabetic report card can help in easy access to diabetes management related information and assessment of the same. ¢ Evaluation of records can help to change management plan to suit the people with diabetes better and achieve targets/goals for each parameter. Important pointers for DEs

A diabetes report card can help ensure patients to keep a track of important facts thereby, maintaining control on diabetes and prevent complications related to diabetes in future.

12 Monitoring: Diabetes by the Number

Introduction

Expert Diabetes is a major disease burden in India and we are home Opinion to the second largest number of diabetes cases in the world. In 2017, there were over 72 million cases of diabetes in 15 Dr. Banshi Saboo India.

MD, PhD Chief Diabetologist and Chairman, Diabetes Care and Hormone Clinic, Ahmedabad, Gujarat.

Glycaemic control is a cornerstone of diabetes management. Blood glucose targets are individualised based on:16 ¢ Duration of diabetes ¢ Age/life expectancy ¢ Co-morbid conditions ¢ CVD or advanced microvascular complications ¢ Hypoglycaemia unawareness ¢ Individual patient considerations

The following numbers are defined for optimally targeting glycaemic control:

¢ HbA1c: Less than 7% ¢ HbA1c may also be reported as eAG: Less than 154 mg/dL ¢ Before a meal (preprandial plasma glucose): 80 – 130 mg/dL ¢ One or two hours after a meal (postprandial plasma glucose): Less than 180 mg/dL

Make it count – number of steps to make a difference15,17,18

Structured exercise in the form of aerobic and resistance training have been found to be beneficial in diabetes management.16 With the growth of paedometry, the physical activity recommendations have focused on the number of steps to be taken per day (i.e., 10,000 steps/day).

13 Although walking is also a great place to start, studies have shown that persons with T2DM naturally walk at a speed (intensity) that is slower than that associated with minimal intensity (i.e., moderate) required to harness the health benefits, despite increasing their number of steps taken per day.17 Hence to make the steps count, ‘Pick Up Pace’ program prescribed increased walking speed (thus, intensity of walking) during 30 minutes bouts, to a level that elicited significant improvements in cardio-respiratory fitness over 12 weeks in a group already walking >10,000 steps/day.

Accumulate

Exercise at  100 steps/min 3,000 steps/day Another strategy suggested to preventing T2DM is ‘walk more, sit less and exercise’ as Sit less depicted in the alongside figure.18

Avoid taking <5,000 steps/day and limit prolonged sitting bouts Take 7,500 steps/day Walk More

There are various activities which can be done in a short time and help burn significant calories.

Here are few ways to burn approximately 100 calories: ¢ Jump rope continuously for 10 minutes ¢ Walk briskly through the mall for 20 minutes ¢ Enjoy a short aerobics class for 15 minutes ¢ Swim laps without stopping for 10 minutes ¢ Push your child in a stroller or take the dog for a walk for 30 minutes

¢ Optimal glycaemic levels should be targeted Important based on individual patient considerations. pointers for ¢ Physical activity should be performed at the DEs required intensity to obtain the health benefits associated with it.

In order to maintain good health, every diabetic should know a number of different figures relating to their bodies. These include height, weight, blood pressure and cholesterol levels.

14 Problem Solving: Coping with Uncertainty of Diabetes

Introduction

Expert Diabetes as a health problem has reached epidemic Opinion proportions and it is only natural that every individual feels at risk to a more or less extent. So what can be done to alleviate Dr. Parimal Swamy this uncertainty?

MD, Dip. (Preventive Health Care) Screening for and risk to develop diabetes in Apollo, Sugar Balance Centre, Asthama- future should be assessed either informally by identifying risk Allergy Care Centre, Jabalpur, Madhya factors or through validated tools in asymptomatic Pradesh. individuals.8

Testing should be considered in or obese individuals with other risk factors like hypertension, dyslipidaemia, CVD, physical inactivity, etc. For other persons without any risk factors, testing every three years should begin at the age of 45 years.

Prediabetes: A risk factor for increased diabetes and CVDs8

¢ ‘Prediabetes’ is the term used for persons whose body glucose levels are too high to be considered normal but it does not meet the diagnostic criteria of diabetes. ¢ Prediabetes is associated with obesity (especially abdominal or visceral obesity), high blood pressure and dyslipidaemia with high triglycerides and/or low HDL cholesterol.

Defining prediabetes Fasting plasma glucose 100 – 125 mg/dL () Or 2 hours plasma glucose during 75 g oral 140 mg/dL to 199 mg/dL (Impaired glucose tolerance) Or HbA1c 5.7 to 6.4%

15 What can be done to stay healthy?8,19

Progression to diabetes can be delayed and may even be prevented if healthy interventions are done at this stage. These include: ¢ Eating well: A rich in fruits vegetables, fruits and whole grains with lean proteins and certain kind of fat. ¢ Getting active: Increase physical activity and avoid prolonged sedentary periods. Accumulation of small steps like taking the stairs or walking an extra block can contribute to staying fit. ¢ Weight loss: Changing eating patterns and regular exercise can aid in weight loss which makes a big difference in prediabetes. ¢ Medications: Along with lifestyle modifications, some patients may be prescribed medication like metformin to help lower blood glucose levels. ¢ Regular testing: Yearly testing should be done in patients with prediabetes to catch and recognize the progression to diabetes early.

Psychological and behavioural support

¢ Along with the above changes, interventions to increase emotional and behavioral health support are equally important. ¢ DSME forms an integral part of optimal diabetes management. ¢ Patients should be encouraged to seek help and open up regarding their emotional status and concerns. ¢ Caregivers, family members, friends or support groups can contribute to ensuring psychological well-being. ¢ If needed, professional medical help from psychologists and psychiatrists should also be sought.

16 ¢ Prediabetes should be considered a risk factor for development of diabetes and CVD. Important ¢ Early intervention in the form of life style modification can help delay or prevent the pointers for development of diabetes mellitus. DEs ¢ Psychological well-being is also an important component of successful diabetes management.

There are several uncertainties in diabetes; however, uncertainty is important because it relates to self-management behaviours among those with diabetes. Eating well and getting active are the starting points to eradicate uncertainty in diabetes.

17 Reduce Your Risk: Neutralise the Effects of High Blood Sugar Naturally

Introduction

Expert The role of healthy dietary habits and exercise cannot be Opinion stressed enough for the successful and effective management of diabetes. These are natural ways to Dr. Gurpreet Singh neutralise the effects of high blood sugar and prevent the development of related complications. MBBS Consultant and Head, Minerva Medica Diabetes and Endocrine Clinic, Ludhiana, Punjab.

The king of – breakfast

Studies have proven that skipping breakfast adversely affects the body’s mechanisms for glucose homeostasis and related gene expressions. Skipping breakfast is correlated with increased postprandial glycaemic response in both healthy individuals and individuals with diabetes.20 Different studies have demonstrated increased blood sugar levels throughout the day and increased HbA1c levels as a result of skipped breakfast.21

Other advantages of a nutritious breakfast in regular breakfast eaters: ¢ Aids in weight reduction and keeping it off ¢ Have lower LDL cholesterol levels ¢ Have overall healthier eating habits ¢ Are more likely to meet their daily fibre goal ¢ Feel better, have improved attention span and are able to concentrate better

A Champion’s breakfast The key to a healthy ideal breakfast is to choose a variety of food so that there is a balance of carbohydrate, protein and fat. These can be: ¢ Whole grains: Oatmeal, whole wheat or whole kernel corn using recipes ¢ Lean protein: Eggs, Greek yoghurt, low-fat cottage cheese and ¢ Healthy fat: Nuts, light butter, seeds and avocados ¢ Fruits and vegetable (but skip or limit juice) ¢ Lower fat dairy: Non-fat or low-fat milk, rice, almond, coconut or soy milk

18 The benefits of dietary fibres22

¢ The viscous and gel-forming properties of soluble dietary fibres decreases macronutrient absorption, reduces postprandial glucose response and decrease total and LDL cholesterol. ¢ Insoluble cereal dietary fibres and whole grains are associated with reduced diabetes risk. ¢ Dietary fibres contribute to the improvement of insulin sensitivity, modulation of gut hormone secretion and reduction of various metabolic and inflammatory markers associated with metabolic syndrome.

Along with these healthy choices in diet, incorporation of regular physical exercise will also boost the beneficial effect.23,8

¢ Moderate intensity physical activity has been shown to improve insulin sensitivity. ¢ Both aerobic exercise and resistance training have a beneficial effect. ¢ Gentle stretching for 5 to 10 minutes helps body warm up and get ready for aerobic activities. It also helps keep joints flexible, prevent stiffness, and may help reduce the chance of injury during other activities such as walking or swimming.

The ‘Diabetes Prevention Program’ (DPP) study administered as structured curriculum with sections on lowering calories, increasing physical activity, self-monitoring, maintaining healthy lifestyle behaviours and psychological, social and motivational challenges was successful in significantly reducing the incidence of diabetes. The two major goals of DPP intensive, behavioural, lifestyle intervention were to achieve and maintain a minimum of 7% weight loss and 150 minutes of physical activity per week similar in intensity to brisk walking. The goals were the same but the method was individualised.8

19 ¢ Morning meal has many health benefits for all people and especially for a person Important with diabetes. Hence, it should not be skipped. pointers for ¢ Incorporation of dietary fibres has a positive effect on glycaemic control. DEs ¢ Participating in regular moderate-intensity physical activity also has beneficial effects in the management of diabetes.

For a successful and effective management of diabetes, the trick is to keep the metabolism going all day long at a steady rate. The simple solution for this is to eat a good breakfast: don’t forget fibre – try oatmeal with fresh fruit or fat-free yoghurt, stay away from large coffee drinks with whipped cream, sweetened cereals, and breakfast pastries.

20 Healthy Coping: Pursuit for A Healthier Tomorrow

Introduction

Expert Diabetes, particularly T2DM is categorised under the term Opinion ‘lifestyle diseases’. As the name suggests, diabetes is not an acute medical condition which can be managed by just Dr. Ramesh Omprakash Goyal popping a pill. Diabetes is a chronic complex health condition requiring continuous medical care with ‘multifactorial risk MD (General Medicine & 8 Therapeutics), DM (Endocrinology) reduction strategies beyond glycaemic control.’ Consultant in Diabetology & Endocrinology, Apollo Hospitals, Ahmedabad, Gujarat.

¢ Too much dependence on medication is a change required in people with diabetes. ¢ Significant evidence exists that support the multifactorial approach to diabetes management in which lifestyle modifications like regular exercise, healthy diet, smoking cessation, focus on mental well-being along with ongoing patient self-management education and support play a huge role in prevention, delay and modification of diabetes disease course to a more favourable outcome. ¢ Furthermore, relying on only medication without other interventions can cause unnecessary increased dosage and number of anti-diabetic medication potentially exposing the patient to more side-effects. Also, development of associated mental and physical complications cannot be prevented or managed efficiently by intake of medicines alone. However, the requirement for constant effort and monitoring of various parameters to ensure good diabetic management can cause a person with diabetes to feel overwhelmed. These diabetes self- management demands and continuous endeavour to maintain ideal parameters can eventually lead to a state of frustration, disillusion and somewhat submission to the condition of diabetes that they no longer care. This is termed as ‘diabetes burnout’.24, 25 It can manifest as subtle negative changes in attitude towards diabetes management to full blown destructive behaviour and associated psychological changes.

Signs of diabetes burnout

¢ Having negative feelings about diabetes and its management. ¢ Experiencing thoughts of giving up and seeking ‘freedom’ from this confining and often frustrating condition.

21 ¢ Decreasing efforts in diabetes management and participating in self-destructive behaviour e.g., eating whatever one want despite knowing its adverse effects on blood sugar levels, estimating quantities of insulin required rather than checking blood sugar levels and injecting precise amounts, etc. ¢ Avoiding medical appointments or discussions about diabetes. ¢ Denying their diagnosis of diabetes, often giving excuses. ¢ Psychological changes like stress, anxiety, depression, emotional states like anger, resentment, shame, guilt and helplessness. ¢ A person resorting to self-destructive behaviour while experiencing burnout may subsequently suffer from fatigue and/or hyperglycaemic episodes which in severe cases can lead to coma.

Tips to deal with diabetes burnout ¢ Seek support: Support can be from a spouse, family member, friend, support groups or professional counsellor. Even a little help from others can help ease the burden the person may be experiencing. ¢ Acceptance: It is what it is. Think of positive things that have happened because of the timely diagnosis of diabetes. Early diagnosis gives the chance to intercede, avoid development of complications and make a positive difference in the quality of life. ¢ Take small steps: Once the healthy lifestyle changes are made into ‘habits’, it becomes second nature and daily routine to a person. Take one day at a time rather than thinking of it as a whole pending list of to-dos. ¢ No judgements: Be kind to yourself. Engage in activities you like. Experiment new recipes and bring variety to the diet.

¢ Depending too much on medication without changes Important in lifestyle and diet is detrimental to proper diabetes pointers for management. DEs ¢ Look out for signs of diabetes burnout in people with diabetes and support them in overcoming it.

Diabetes burnout is the state of frustration and somewhat submission to the condition of diabetes. Helping understand, address and overcome the mental and emotional impact of having diabetes can help people with diabetes.

22 Assess and Address the Risk of Diabetic Foot

Introduction

Expert Diabetic neuropathy along with peripheral arterial disease Opinion (PAD) leads to foot ulcers and amputation in people with diabetes. Diabetic foot complications are a major cause of Dr. Ajay Vasant Rotte morbidity and mortality in people with diabetes. Early identification, assessment and treatment of patients with MBBS, PGDHHM, DFID, IDC, MBA (Hospital Management) diabetes and feet at risk for ulcers or amputations can delay CEO and Senior Diabetologist, United or prevent negative outcomes. CIIGMA Hospital, Aurangabad, Maharashtra.

Risk of ulcers or amputations is increased in individuals with the following risk factors:8

Peripheral neuropathy with Poor glycaemic control Cigarette smoking Foot deformities loss of protective sensation

Pre-ulcerative callus or corn Peripheral arterial disease History of foot ulcer Amputation

Diabetic kidney disease Visual impairment (especially patients on dialysis

Preventive measures

¢ Patients at risk should be made aware of the implications of foot deformities, loss of protective sensation (LOPS) and PAD; the proper care of foot, nail and skin; the importance of using appropriate footwear and performing foot examination on a daily basis. ¢ Patients with LOPS should be advised to palpate or visually inspect the foot using an unbreakable mirror for early recognition of foot problems. ¢ Patients’ understanding and their physical capability to conduct proper foot surveillance should be assessed. Where necessary, the patients’ caregiver or family members should also be educated on the same to assist with their care. ¢ A comprehensive foot examination should be performed at least annually by health care provider and the foot should be inspected at every visit.

23 Key components of comprehensive foot examination:26 ¢ When examining the feet of a person with diabetes, remove their shoes, socks, bandages and dressings and examine both feet meticulously. ¢ The examination should include inspection of the skin (colour, thickness, dryness, cracking) for infection, sweating, ulceration, calluses and blistering. ¢ Neurological assessment should be performed (10 g monofilament testing with at least one other assessment: pinprick, temperature, vibration). ¢ Vascular assessment of pulses in the legs and feet is another component of comprehensive foot examination.

Management of diabetic foot8

Risk stratification should be done based on history and foot examination findings and preventive/ treatment measures should be instituted accordingly. ¢ Well-fitted walking shoes or athletic shoes that cushion the feet and redistribute pressure can be used to manage people with neuropathy or evidence of increased plantar pressures (e.g., redness, warmth or calluses). ¢ People with bony deformities (e.g. Hammertoe, prominent metatarsal heads, Charcot foot) may need extra wide/deep shoes or may even require custom moulded shoes. ¢ Thorough workup and immediate treatment should be given to patients with neuropathy presenting with acute onset of red, hot, swollen foot or ankle and Charcot neuropathy should be excluded.

¢ General footwear recommendations include broad and square toe box, padded tongue, quality lightweight material and sufficient size to accommodate a cushioned insole. ¢ Screen for infection. If present, appropriate empirical antibiotic therapy should be given. ¢ Foot ulcers and wound care may require care and intervention by a podiatrist, orthopaedic or rehabilitation specialist experienced in management of individuals with diabetes. ¢ Hyperbaric oxygen therapy may be considered for selected people with diabetic foot ulcers.

24 ¢ Diabetes related foot problems are a significant problem in people with diabetic neuropathy. ¢ Risk assessment and early initiation of preventive measures in the form of patient education and daily Important foot examination along with a comprehensive foot pointers for examination at least once a year can help reduce DEs adverse outcomes. ¢ Thorough work up and appropriate treatment measures in the form of medical or surgical interventions should be instituted without delay whenever indicated.

Inform patients regarding the risk factors that precede a and also advise them on weight management, monitoring blood glucose levels and good maintenance practices such as keeping feet clean and moisturised.

25 Six Protective Herbs to Include in Your Diet!

Introduction

Expert Herbs and spices are an integral part of Indian cooking. They Opinion are excellent flavour enhancers and can be a health- conscious cook’s best aide. Apart from providing exciting Dr. Milind Katta flavours to your taste buds, they also have a variety of health benefits. In this article, we shall be discussing the benefits of MBBS, Diabetology (CPS), CCGDM, six such herbs that can boost the health factor and also the CCEBDM, CCD, FICM, DPHARM taste factor especially when incorporated into a diabetic Consultant Critical Care Specialist and Diabetologist, Balaji Hospital and Sugun person’s diet. Hospital, Andheri, Mumbai.

Momordica charantia (Bitter gourd)27–29

¢ Bitter gourd also known as bitter melon or karela is a unique, intensely bitter fruit rich in vital and minerals. It is commonly used in Indian cooking and has long been used as a natural remedy for treating diabetes. ¢ Apart from its blood glucose lowering effect, bitter melon has been traditionally known for its other medicinal properties such as anti-cancer, anti-inflammatory, anti-viral and cholesterol lowering effects. ¢ The presence of phenolic compounds makes it a potential antioxidant and anti- mutagen.

Withania somnifera (Ashwagandha)27

¢ Ashwagandha is an ayurvedic herb also known as Indian ginseng or winter cherry. ¢ It has been associated with hypoglycaemic, diuretic and hypocholestrolaemic effect. ¢ It is marketed in powder form by various brands in India and it can be incorporated in small amounts into various recipes.

26 Gymnema sylvestre (Gurmar)27,30

¢ Gurmar is a perennial shrub found over top of woody trees in the tropical forest of India is also known as Merasingi. ¢ It is a reputed herb in ayurvedic medicine and is associated with anti-hyperglycaemic effect and hypolipidaemic effect. ¢ Literature also associates this herbal plant with anti-obesity, anti-inflammatory, anti- microbial, hypolipideamic and anti-arthritic activity.

Pterocarpus marsupium (Malabar kino)31

¢ Malabar kino, also known as Indian kino tree, has long been believed to have medicinal properties in Ayurveda. ¢ Studies have shown this plant has effective blood glucose lowering effect and its glycaemic effect can be comparable to add-on therapy in patients with T2DM.

Murraya koenigii (Curry leaves)32

¢ Curry leaves, also known as kadi patta, are extensively used in Indian cooking as flavouring agents in curries like dal, sambar, rasam and chutneys. ¢ Its health benefits include anti-diabetic effects along with antioxidant and anti- hypertensive effect.

Rosmarinus officinalis (Rosemary)33

¢ Rosemary, also known as mehndi, is a popular herb used in Italian and French . ¢ Studies have shown it improves hyperglycaemia and dyslipidaemia and aids in increasing antioxidant levels thus reducing the risk of chronic diseases such as CVDs.

27 Thus, addition of the above herbs to diet can aid in management of diabetes along with providing dietary variety. However, it is important to understand that they are not a substitute for anti-diabetic medications and it is always advised to make major dietary modifications only in consultation with a doctor and dietician.

¢ Various herbs and spices can be incorporated into diet of a person with diabetes to Important harness its medicinal properties and anti-diabetic effect. pointers for ¢ It is important to convey that these measures do not substitute treatment and are DEs used only in addition to medication and other management measures for controlling blood sugar levels.

People must be encouraged to use herbs in their diet for diabetes as it can play an important role in improving and managing their symptoms of diabetes.

28 Why Settle For Normal When You Can Reach Optimal?

Introduction

Expert The diagnosis of diabetes comes with a huge challenge of Opinion convincing the patient to consciously adopt a healthier, active and responsible lifestyle. Dr. Samir Dasgupta The term ‘responsible’ implies making a conscious decision

MD to manage diabetes in the most suitable way which will Consultant Diabetologist and improve and sustain better quality of life. Endocrinologist, Rabindranath Tagore Surgical Centre, Kolkata, West Bengal.

Apart from constant self-monitoring and assessment of glycaemic levels and lifestyle modifications, it also includes being responsible enough to follow healthcare professionals’ prescriptions and have regular check-ups as advised to assess risk factors. Ideal diabetes management treats the person with a holistic approach and a diabetic management team include medical and healthcare professionals in various specialities, e.g., physicians, nurses, dieticians, pharmacists, mental health professionals and DEs.34

Tips to overcome obstacles and navigate the way to optimal health in diabetes8,34

Catch it early: Screening for diagnosis of diabetes ¢ Testing should be done in overweight or obese adults who have other risk factors like family history, hypertension, high triglyceride levels, physical inactivity, women with polycystic ovary syndrome, etc. ¢ People with prediabetes (HbA1c levels ≥5.7%, impaired glucose tolerance, or impaired fasting glucose should be tested yearly). ¢ Women diagnosed with should have lifelong testing every 3 years ¢ For all other adults, screening should begin at age of 45 years and if results are normal, repeat testing done every 3 years or earlier if needed.

29 Comprehensive medical assessment and diabetic care plan ¢ Confirm diagnosis, characterise and classify diabetes, record past medical and family history. ¢ Assess lifestyle and behaviour patterns; tobacco, alcohol or substance use. Record medication taking behaviour and immunisation history. ¢ Screen for psychosocial conditions, barriers to diabetes self-management, episodes of hypoglycaemia and pregnancy in women. Assess co- morbidities. ¢ Perform physical examination and record height, weight, body mass index and blood pressure. Eyes, thyroid, skin and foot should also be examined. ¢ Perform required laboratory investigations like HbA1c levels, lipid profile, liver function tests, renal function tests, etc. ¢ Set a management plan with goals for different parameters, including therapeutic treatment plan with anti-diabetic medications, referrals to specialists including dietician and DE, lifestyle modifications, and use of glucose monitoring devices. ¢ CV risk assessment and staging of chronic kidney disease if present.

Monitor and maintain blood glucose levels in desired range ¢ SMBG is an integral part of effective therapy. ¢ Perform HbA1c levels at least twice a year in persons having stable glycaemic control and quarterly in patients whose therapy has changed or who are not meeting glycaemic goals. ¢ HbA1c <7%, preprandial capillary plasma glucose 80–130 mg/dL, peak postprandial capillary plasma glucose <180 mg/dL is the recommended glycaemic targets for many non-pregnant adults. More or less stringent glycaemic goals may be appropriate as per patient characteristics.

Appropriate pharmacological and lifestyle intervention ¢ Nutrition: Encourage healthy low calorie eating pattern. Individualised medical nutrition therapy is recommended. ¢ Physical activity: Regular moderate to intense physical activity improves diabetes related parameters. Aerobic training along with resistance training should be considered in appropriate individuals. Breaking up prolonged sedentary time may also be encouraged. ¢ Medication: Use of insulin or oral hypoglycemic agents as appropriate. ¢ Mental healthcare: Ensure emotional well-being and convey to not feel hesitant to ask for help if they are having trouble coping.

30 Immunisation ¢ Make sure people with diabetes are appropriately immunized against influenza and pneumonia.

DSME and support ¢ Take part in diabetes education forums in group or individual sessions: Awareness regarding diabetes and related complications is important in self- management. ¢ Have a sick day plan: stress or illness requires more frequent monitoring of blood glucose, ketones in urine or blood, and ongoing communication with physician. ¢ Have a hypoglycaemia plan: Learn to identify related signs and symptoms, know how to manage it.

Preventing CVDs and other complications ¢ Ensure controlled blood pressure and lipid levels. ¢ Quit smoking, incorporate healthy dietary habits, and consider aspirin therapy. ¢ Have regular screening for neuropathy, eye and kidney disease.

¢ Optimal health parameters can be achieved only when people with diabetes are educated and made aware of Important diabetes, its implications and preventive measures. pointers for ¢ Healthcare professionals’ team based approach, DEs DSME, SMBG, healthy lifestyle interventions, comprehensive and regular medical assessment are all important steps in ideal diabetes management.

If diabetes is uncontrolled, it can damage the heart, blood vessels, eyes, kidneys, and nerves. This is why it is so important to get screened for diabetes and take steps to prevent it way earlier in order to avoid complications.

31 Diabetes and Menopause: A Double Challenge

Introduction

Expert Menopause is the general term used to describe the phase of Opinion a woman’s life after the cessation of menstrual cycle – usually around the age of 50. Menopause can also occur when Dr. Lavanya Katakam ovaries are removed during surgery for other medical reasons. MD (General Medicine), DM (Endocrinology) For some women, the end of menstruation can be sudden. For Consultant Diabetologist and most, the menstrual cycle comes to a gradual halt becoming Endocrinologist, Aswini Endocrine less frequent with longer intervals before finally stopping Center, Guntur, Andhra Pradesh. altogether.

Menopause can cause various physical and emotional symptoms in women. It presents a twin challenge in women with diabetes due to the combined effects each condition has on the body.35

Menopause and diabetes: What to expect?36,37

Blood glucose Weight gain Infections Sleep problems Sexual dysfunction level fluctuations

¢ Changes in ¢ Menopause and ¢ High blood glucose ¢ Hot flushes and ¢ High blood glucose oestrogen and aging is associated levels along with leads levels can damage progesterone levels with increase in drop in oestrogen to sleep deprivation the nerves of the affect body's total body fat, level creates ideal which in turn vagina causing sensitivity to insulin decline in muscle condition in urinary makes control of thinning and causing variable mass and tract/vagina for blood glucose levels inflammation of and unpredictable abdominal bacteria/yeast to tougher. vaginal walls blood glucose redistribution of thrive in and thus (vaginal atrophy) levels. fat. increase the chance ¢ Vaginal dryness in ¢ Weight gain can of aquiring urinary menopausal phase increase the need tract and vaginal can cause pain for oral diabetic infections. during intercourse. medicine or insulin

32 How to tackle this twin challenge? 35,37

Though menopause can make it harder to keep blood sugar levels under check, there are plenty of simple steps which can be taken to better manage diabetes and menopause. Tips for diabetes management during menopause ¢ Healthy lifestyle changes: Eat healthy, avoid smoking, reduce alcohol intake, and exercise regularly.

¢ Monitor blood glucose levels more frequently: Check more often during the day and occasionally during the night too. Keep a log of blood sugar reading and symptoms and adjust diabetes medications accordingly in consultation with the doctor. Test HbA1C regularly.

¢ Seek help for menopausal symptoms: Expert advice can be sought from dietician for weight gain issues. Vaginal lubricant may be recommended by the doctor to restore vaginal moisture or vaginal oestrogen therapy to correct vaginal atrophy. Option of hormone replacement therapy (HRT) can be discussed in women whose quality of life is significantly affected by menopausal symptoms.

¢ Get assessed for heart disease risk: Undergo blood pressure and cholesterol screening. ¢ Protect bone health: Assess bone density. Take calcium and D supplements as needed.

¢ Menopause in women with diabetes presents a dual challenge due to the impact of both conditions on the Important body causing significant physical and emotional impact. pointers for ¢ Women with diabetes in the menopausal phase must DEs be made aware of what to expect and how to manage the associated symptoms for improving the quality of life.

For women with diabetes going through menopause, it's more important than ever to monitor the blood sugar to prevent health issues.

33 Role of Medical Nutrition Therapy in Diabetes Management

Introduction

Expert Medical nutrition therapy is an essential key to people living Opinion with diabetes and who want to prevent diabetes. Medical nutrition therapy plays a major role in the following Ms. Umasakthy G. levels: MSc, RD, PGDDE ¢ Primary prevention Senior Executive Dietician & Diabetes ¢ Educator, Dr. Mohan’s Diabetes Secondary prevention Specialities centre, Gopalapuram, ¢ Tertiary prevention Tamil Nadu.

Primary prevention: Includes the guidelines to delay or prevent the onset of diabetes. Secondary prevention: Includes the guidelines to control and manage the existing diabetes status. Tertiary prevention: Includes the guidelines to prevent or delay the progression of diabetes and its complications.

Aims of medical nutrition therapy

¢ Reduce blood sugars as close to the normal range ¢ Reduce blood lipid levels to decrease the risk of CVD ¢ Reduce blood pressure as close to normal range ¢ Prevent or slow down the progression of chronic complications by changing lifestyle and nutrition intake ¢ Assess the nutritional needs considering personal and cultural preferences and willingness to change ¢ Achieve and maintain a reasonable weight ¢ Achieve normal growth and development in children and adolescents ¢ Maintain a balance between diet, medications and physical activity Diabetes control depends to a great extent on following the right diet. Knowing what to eat and what not to eat is very important. Diet has long been linked to the development of obesity, diabetes and CVD, and dietary modification is one of the cornerstones of chronic disease prevention.38

34 Nutrition forms an important pillar in managing diabetes and diet becomes the baseline of the treatment. Following and adhering to the nutrition principle and meal planning is the most challenging aspect of managing diabetes. Hence education plays a major role in translating the nutritional principles into practice. DEs are the prime person in mediating these dietary guidelines and to make them adhere. Nutritional requirements are almost same for people with diabetes as for people who do not have diabetes. A nutritional approach has to be individualised and tailor-made. Dietary guidelines can be formulated according to the type of diabetes. But, diet need not be a complete deviation from the normal diet. Special dietary advice is needed in people who have or cardiomyopathy. Following are the basic dietary guidelines that are necessary to achieve the aims of medical nutrition therapy. Let us start with the macro and micronutrients:39 ¢ ¢ Protein ¢ Fats ¢ Fibre ¢ Fluids ¢ Vitamins and minerals

Calories

Calorie requirements are calculated based on Ideal body weight, body mass index and waist-hip ratio. How to calculate these parameters: Ideal body weight = Height (cm) – 100) * 0.9 Body mass index = Weight in kg/ height in m2 Waist-hip ratio = Waist (cm)/ hip (cm)

Table 2: Recommended calorie intake based on BMI

Body mass index Classification Recommended calories <18 Underweight 40 kcal/kg 18 to 24.9 Normal weight 30 kcal/kg 25 – 29.9 Overweight 25 kcal/kg 30 – 34.9 Obese 20 kcal/kg >35 Morbid obesity 20 kcal/kg Source: Raghuram et al; Diet and Diabetes, NIN, Hyderabad, 1997.

35 A female person is considered to have central obesity if her waist-hip ratio is more than 0.85 and a male person has central obesity if his waist hip ratio is more than 0.9. Calories are derived from major nutrients such as carbohydrates, fats and protein.

Carbohydrates

People with diabetes need not restrict carbohydrates but they can change the type of carbohydrate they take. Carbohydrates are converted to blood glucose quickly within an hour or so after a meal. The level of glucose in the blood is directly related to the amount of carbohydrate taken. Both the quantity and quality of carbohydrates influence the metabolic response to the ingestion of carbohydrate (FAO/WHO, 1998). Cereals and pulses contain complex carbohydrates which are broken down into simple sugars before they get absorbed. But sugars, honey, jaggery and jam contain simple sugars which are directly absorbed into the blood. These are the refined carbohydrates that cause a rapid rise in blood sugars, hence are not recommended for a person with diabetes. Approximately, 60–65% of the total calories can be obtained from carbohydrates. It is recommended to choose whole grain cereals like brown rice, wheat, ragi, jowar, bajra, barley, and oats than maida, rava, vermicelli and pasta. Sweets and desserts are often high in sugars and fat and tend to be in low in other essential nutrients. As cereals continue to be the main staple 40 and provide the bulk (60% – 70%) of total energy intake in Asian Indian diets, data on the health impact of cereals are of great significance. Cereal-based diets consumed in the past were rich not only in fibre but also in other micronutrients and have been associated with a lower risk of CVD andT2DM.41 However, because of changing food processing technology and the modern milling process, the refining destroys the structure of the grain kernel and removes dietary fibre and other essential micronutrients in grains.42 Intake of many refined grains including commonly used types of white rice can also induce high glycaemic responses. Long-term consumption of refined grains has been associated with a higher risk of T2DM and CVD. 43, 44

Protein

Protein is a nutrient that is necessary for bodybuilding and many essential functions in our body. 0.8 g of good quality protein is the daily recommended allowance. 15–20% of the total calories are derived from proteins. Vegetarian sources of protein are whole grams and pulses and contain fibre. Animal protein sources like chicken, egg, fish, beef, pork, mutton, lamb, sausages, organ meats, prawns, crab, milk and milk products are rich in protein as well as fat. One must always choose chicken, fish, egg white, pulses, milk and milk products. It is better to restrict the intake of beef, pork, mutton, sausages, organ meats, prawns and crabs. Protein may be restricted when the kidney function is affected in an individual with diabetic nephropathy.

36 Fats

20-25% of the total calories can be derived from fats. There are two kinds of fats, visible and invisible fats. Butter, ghee, vanaspati and cooking oils are visible fats. Egg, meat, nuts and oil seeds contain invisible fats. People with diabetes must be cautious with the fat intake as people with diabetes are more prone to heart diseases. Butter, ghee, vanaspati, coconut and palm oil are rich in saturated fats and are better to be avoided as they tend to increase the cholesterol levels in the blood. Canola oil, groundnut oil, gingelly oil, mustard oil, nuts, cereals, pulses and milk products contain monounsaturated fatty acid and polyunsaturated fatty acid. These oils can be used in moderation and in combination.

Vitamins and minerals

Requirement of vitamins and minerals are same as normal individuals. But as people with diabetes are more prone to infections and other complication, they may require a litter higher quantity. Daily intake of greens, vegetables, fruits, cereals, pulses, milk and milk products can provide adequate vitamins and minerals.

Fibres

Dietary fibre is the indigestible part of the food and has unavailable carbohydrates. Fibre is found in plant foods like vegetables, fruits, pulses, whole grains. 25 g of fibre per day is the recommended fibre allowances. Diets containing high dietary fibre can reduce blood sugar, cholesterol and blood pressure. High fibre foods like vegetables and greens are low in calories and glycaemic index, hence they are recommended in the daily diet. In addition, dietary fibres can relieve constipation and are helpful to treat patients with CVD.

Fluids

Adequate intake of fluids is recommended. 2 – 3 litres of water per day is recommended. It can be included as buttermilk, lemon juice, tomato juice and soups. Fruit juices are not advised as the fibre is broken while making juices. Porridges are better to be avoided as they have a high glycaemic index.

37 Alcoholic beverages

Avoiding alcohol is better for a person with diabetes. 1 or 1 ½ pegs per day may be allowed. Alcohol beverages are high in calorie and low in other nutritive value. When consumed in higher amounts, alcohol weakens the heart muscles, nerves and increases blood pressure and cholesterol levels. Diabetes patients are prone to hypoglycaemia when consumed in excess.

A note on glycaemic index

Glycaemic index is a way to classify carbohydrates according to how quickly they are absorbed and raise the blood glucose levels. Foods like white rice, white bread, sugars, jaggery, maida are high glycaemic foods and can raise the blood glucose level. Foods like whole wheat, wheat bread, brown rice, and pulses have a moderate glycaemic index and can be used in moderation. Green vegetables and green leafy vegetables are low glycaemic index foods and are recommended in plentiful amounts. A study from the Chennai Urban Rural Epidemiology Study (CURES) quotes that it would be advisable to substitute foods with a lower glycaemic index as this could substantially reduce the glycaemic load and therefore possibly the risk of diabetes and CVD in the future.45

Have a healthy plate

One must fill half their plate with vegetables and greens. One-fourth of the plate must be filled with whole grains, whole grams or pulses, non-vegetarian foods, curd and the remaining one-fourth needs to be filled with cereals like brown rice, wheat or ragi. Portion sizes must always be taken care of.

Vegetables and fruits

The beneficial effect of diets rich in fruits and vegetables has been well recognised for the prevention of chronic diseases, especially CVD, as they contain substantial amounts of nutrients such as folate, antioxidant, and dietary fibre.46–49 Vegetables like potato, yam, colocasia, tapioca and sweet potato are starchy in nature. They can increase the blood sugars when consumed with the rice or wheat. Hence, it is better to restrict them. Root vegetables such as carrot and beetroot are high in calories, can be used in moderation or in combination with low-calorie vegetables. Vegetables that can be consumed in plenty amounts are: beans, gourd vegetables, brinjal, broad beans, broccoli, cauliflower,

38 cabbage, chow-chow, knoll khol, kovakai, ladies finger, mint, onion, papaya, tinda, plantain flower, plantain stem, spinach, lettuce, onion, tomato, pumpkin, etc. Fruits like banana, mango, jackfruit, chikku, custard apple and grapes are better to avoid. Fruits like apple, guava, orange, papaya, musk melon, sweet lime, watermelon, pears, peach, kiwi, jamun are recommended in allowed quantity. Eating whole fruit is advisable.

Few dietary tips

¢ Biscuits and bakery products except brown bread need to be avoided as they contain trans fats too other than sugars ¢ Any cereal like gruel or porridge form is not advised ¢ Always choose wholesome vegetables, cereals and pulses ¢ Choose fat wisely ¢ Combination of 2 or 3 oils are recommended ¢ Restrict salt intake. Papad, pickle and salted foods may be avoided ¢ Clear soup, buttermilk, unsweetened lemon or tomato juice, salads are low in calories and can be consumed whenever one feels like In conclusion, the best nutrition advice is to follow an individualised meal plan that is designed to meet the goals of diabetes management. Best diet will always meet the physical, metabolic and lifestyle requirement of an individual with diabetes. DEs are the core person who can plan a well-balanced diet that can control blood sugars and prevent complications. These educators can make a patient understand his or her nutritional needs and educate regarding lifestyle modification. By making few behavioural and lifestyle changes with effective planning, putting them into action and anticipating inevitable occasional setback are the ways to succeed despite having diabetes. It is essential to assess the readiness to change and set realistic short- and long-term goals. Self- tracking the eating and activity patterns, and weighing regularly help to track for success in diabetes control. As the journey continues, keep revising and changing goals.

Individuals who have pre-diabetes or diabetes should receive individualised medical nutrition therapy in order to achieve their treatment goals.

39 Tools in Diabetes: Livongo for Diabetes

The Livongo app is designed to help people manage with diabetes by giving them easy access to their Livongo blood glucose readings and trends, providing them with fresh ideas and enabling them to learn from other people with the same condition.

Here’s what Livongo can do!50

Actionable pattern analyses Most meters only provide a single blood sugar value and no feedback on ways to change behaviours. However, Livongo uses artificial intelligence; their reinforcement learning algorithms deliver trends and actionable, customised insights to members.

One-click free strip – always Test strips are expensive and a hassle to get from the pharmacy. These are critical barriers to frequent missing. Livongo gives their members as many test strips as and when needed, delivered right to their door.

Over-the-meter air updates By keeping members equipped with advanced interactive meter technology, we keep them on the cutting edge to support success.

Livongo creates a community to support members!

Real-time support Hypoglycaemia (severe low blood glucose readings) and hyperglycaemia (severe high blood glucose readings) without immediate support can lead to significant health consequences and emergency room visits. Livongo’s Diabetes Response Specialists call or text in minutes providing 24/7 support when readings are out of range.

40 Convenient coaching The annual time spent in a healthcare setting is 0.1%. The other 99.9% of that time is spent without a readily available clinician that knows you and has access to your data. Livongo has their own Certified DEs that are standing by to advice on nutrition, lifestyle and diabetes management.

Data sharing keeps others in the loop Loved ones and clinician team are important as a social support system to keep a person with diabetes safe. Livongo members can share blood sugar readings in real time with family, friends and physicians to alert when they’re out of range.

A Livongo-connected community Lack of social support leads to depression, anxiety and reduced mental health. Studies show the positive health impact on HbA1c of peer-to-peer support – anonymous and private community peer support provides motivation for success.

41 Future Trends: “Ouchless” Patch Promises Needle-Free Diabetic Monitoring

A new microneedle patch, filled with dozens of tiny polymeric needles just 0.6 millimetres long, could provide pain-free injections. Researchers have shown that the microneedle patch could deliver lidocaine, a common painkiller, within five minutes of application.51 In contrast, the drug in a commercial transdermal patch took 45 minutes to penetrate into the skin. This new way to administer painkillers quickly is good news for people who squirm at the sight of needles. Given the innovative technique for administering drug non-invasively, the patch can also be used in home-care settings.52 This non-invasive adhesive patch can measure blood glucose levels directly through the skin without the need to draw blood by finger-prick sampling for calibration. The patch, based on a miniaturised pixel array platform, pulls glucose out from fluid between cells across hair follicles and can monitor blood glucose levels over several hours.53 It has been suggested that the patch technology lends itself to low-cost, high-volume production, which could address the need to develop a non-invasive, patient-friendly and affordable glucose monitoring platform for the growing global population of patients with T1DM and T2DM.53 This technology could then be developed as an affordable, wearable sensor that sends clinically relevant glucose measurements to the diabetes patient's phone or smartwatch, wirelessly.53

42 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. Minal Gada

CDE, MSc A 36-year-old woman, mother of one, was diagnosed with Nurture Health Solutions. prediabetes. She had read so many different ways to lose weight to attain an optimal glucose level and so she believed there is no point in getting active when there are so many easier shortcuts. To clear her misconceptions related to diet and weight reduction and promote a healthy and active lifestyle in her she was referred to a DE by her doctor.

Intervention by DE

DE took a detailed history of her and found that she had a history of gestational diabetes mellitus. She checked her sugar levels and found that she is having prediabetes. DE advised her to lose weight and control her blood sugar levels by following a proper healthy diet and engaging in some physical activity. She told the DE that she has read many quick and easy ways online for losing weight and controlling sugar levels such as soup diet, juice diet, etc. So she doesn’t wish to work-out or stay active. The DE explained to her that these diets are not nutritionally adequate. She will gain back her weight after switching to her normal routine diet. The DE explained her that healthy eating is an important part of lifestyle modification. DE also explained to her that prediabetes is a warning sign and this can be completely reversed with proper diet and exercise. If not controlled at this stage it will progress to T2DM which is a systemic disorder that affects all the parts of your body mostly eyes, nerves, heart, kidneys etc. DE explained her importance of physical activity and weight loss in controlling blood sugar levels. She understood the importance of her being diagnosed as having prediabetes. She was motivated to start with healthy eating habits and exercise to control her blood sugar levels.

43 Busting the Myth: Egg Yolk Must be Discarded

Fact: Egg is a good source of protein. Egg yolk is a good source of vitamins like , and . Egg yolk contains choline which is required for brain development, muscle and nerve function. Recent studies have shown that egg consumption is not associated with the risk of CVD and cardiac mortality in the general population. Hence 1 egg/day can be consumed by healthy individuals. In another recent study published in American Journal of Clinical Nutrition, it was found that people with prediabetes or T2DM who consumed a 3-months high-egg (>12 eggs/week) weight-loss diet with a 6-months follow-up exhibited no adverse changes in cardiometabolic markers compared with those who consumed a low-egg (<2eggs/week) weight-loss diet. An egg is a no carbohydrate and high protein option. Hence whole eggs can be advised to people having diabetes provided they restrict or eliminate saturated and trans fat from their diet.

44 Get Active!

Physical activity to reduce the risk of diabetes

Vigorous physical activity, exercise and fast walking are negatively associated with the incidence of T2DM, whereas leisure, sedentary activities are positively correlated with T2DM. Overweight and obesity increase the risk of developing diabetes. Hence it is important to keep the weight in control in order to prevent diabetes. Exercising has many positive effects in reducing weight and preventing the risk of diabetes.

Benefits of regular exercising

¢ Helps to reduce and increase insulin sensitivity. ¢ Helps to lower blood glucose, blood pressure, HDL cholesterol and triglycerides. ¢ Helps to reduce the risk of prediabetes and T2DM and also other complications like heart diseases and stroke. ¢ Strengthens your heart, muscles and bones. ¢ Improves blood circulation to the muscles and helps to keep your body flexible. Exercises can be aerobic, resistance and flexibility exercise. Aerobic exercises such as brisk walking, dancing, swimming, cycling, etc. makes the heart and bones stronger, helps to reduce the risk of prediabetes and T2DM by maintaining the blood glucose levels. Exercise helps to improve glucose transporter type 4 (GLUT-4) mediated uptakes of glucose into the muscles.

45 Points to remember while exercising

¢ It is important to choose an exercise which you will like to do. ¢ The best rule of thumb of safe workout is to listen to your body. If you feel tired, have too much fatigue, pain, injury or shortness of breath, you need to slow down. You can change the workout or go for lower intensity activities. ¢ It is important to start the exercise with warm up and some stretching exercises.

¢ This should be followed with at least 20 to 30 minutes of aerobic activity. It should not be so intense that it causes shortness of breath or intense pain. ¢ The aerobic exercise should be followed by 5 to 10 minutes of cool down exercises or stretching. ¢ Moderate intensity physical activity for 2–3hours/week is recommended.

46 National Diabetes Educator Program (NDEP) Best Practices

NDEP – National Diabetes Educator Program has been ongoing since last 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/

47 NDEP is the backbone of diabetes care and works with DEs to reduce the burden of diabetes by facilitating the implementation of proven approaches to prevent or delay the Contributed onset of T2DM and the complications of diabetes. Diabetes is by the only condition that can be managed majorly by patients upon educating them with DSME. By working together, Dr. Shachin Kumar Gupta educators and patients can optimise the healthcare team to Diabetologist successfully manage diabetes over the long-term. We thank NDEP Trainer, Bhopal. USV for undertaking this noble work of disseminating knowledge and preventing diabetes progression among individuals in our community.

48 Eat Out, Be Wise!

West Indian cuisine

West India includes the states of Goa, Gujarat, and Maharashtra. The cuisine of Western India is diverse. Gujarat is worldwide known for food, the Maharashtrian cuisine is diverse and ranges from bland to fiery hot. Goan cuisine is dominated by the use of rice, coconut, seafood, Kokum, cashew-nuts.

Healthy options

Gujarati cuisine Khandvi is made of gram flour and buttermilk which are good source of proteins and is a good snack option, steamed Patra, methi thepla, moong dal dhokla/khaman (made of gram flour), handwa (made with a mix of buttermilk, flour, coriander, chillies, lentils and rice) dal dhokli (good source of complete proteins) and muthiya are other healthy options.

Maharashtrian cuisine Steamed/Baked kothimbirvadi made of gram flour, buttermilk and coriander make a healthy evening snack option. Usal or dahi usal, methi pitla with jowar bhakri, aamti, dalimbi usal, varan bhaat, roasted thalipeeth are other healthy options.

Goan cuisine Steamed fish, grilled chicken, solkadhi, stir-fried vegetables, grilled mushrooms, fish recheado are other healthy options.

49 Shopping Smart

Fat-free cereals

In today’s world, due to the paucity of time and busy lifestyles, breakfast cereals are gaining immense popularity. Manufacturers are marketing them as low fat meal replacers and are asking us to replace two of our traditional home cooked meals with these highly processed cereals loaded with additives. Usually products marked as low fat or fat free can be misleading as they may be high in sugar content. In order for the fat-free food to maintain its taste, the fat has to be replaced by either sodium, sugar or something else that will give it a similar flavour and texture. For example, if you have a look at the list of ingredients mentioned on a cereal packet, it has honey, malt extract and sugar (8.4 g in 30 g cereal) making the product high in simple carbs/sugar. This means you are consuming sugar coated cereal, which can induce increased appetite and be detrimental to your sugar levels. Studies have shown that the body utilises more energy metabolising a meal from less-processed foods than highly processed foods, which means lesser calories leftover for the body to store as fat.

50 Diet-Related Behavioural tips

Control at home environment

¢ Eat meals with family members instead of eating while watching TV or using the computer or phones. ¢ Have healthy snacks at your disposal like fruits, vegetables, protein bars and sprouted pulses. ¢ Keep tempting food out of sight as well as prevent buying them.

Control at your work environment

¢ Do not skip meals because you may end up eating more in the next meal instead plan what you will be carrying in advance. ¢ After meal take a 5 minute walk before you go back to your desk.

Control your mealtime environment

¢ Fill half your plate with vegetables, quarter with lean protein and the other quarter with starch. ¢ Use smaller plates, bowls, and glasses while eating so that the portion size is reduced. ¢ Politely refuse second servings.

Daily food management

¢ Drink large glass of water before eating. ¢ Avoid high-calorie add-ons such as cream with your coffee, butter, mayonnaise and salad dressings. ¢ Read foods labels to ensure that you are making a healthier choice. ¢ Don’t snack while cooking meals. ¢ Use a quarter spoon if you want to taste your product.

51 ¢ Take small bites and chew your food well. ¢ Don’t consume food rich in salt like processed, packaged foods and bakery products.

Eating out and social eating

¢ Order à la carte rather than buffet style. ¢ Order some vegetables or a salad for an appetiser instead of eating bread to prevent overeating. ¢ Limit alcohol intake. ¢ If you are going to a friend place then offer to carry some low calories dishes.

Exercise well

¢ Make exercise a priority and a planned activity in the day. ¢ If possible, walk the entire or part of the distance to work. ¢ Park at the end of the parking lot and walk to the store or office entrance. ¢ Always take the stairs all of the way or at least part of the way to your floor. ¢ If you have a desk job, walk around the office frequently. ¢ Do leg lifts while sitting at your desk.

Have a healthy attitude by focusing on a healthy lifestyle rather than concentrating on .

52 Superfood: Beans (Lente carbs) / Qfy;ka

The most commonly consumed beans are kidney beans, black beans, adzuki beans, yellow/green peas, chickpeas, soybeans, etc.

Health benefits

¢ Good source of protein, fibre and minerals like magnesium, copper, etc. ¢ Controls appetite ¢ Prevents constipation, improves gut health ¢ Helps control blood sugar levels ¢ Reduces blood pressure and cholesterol levels

How to consume?

¢ It can be added in salads and vegetables ¢ It can be consumed as beans curry ¢ It can be used for making tikkis ¢ Combination of beans and rice makes it a complete protein

Dosage

30 g–60 g three days a week

53 Recipe

Spanish omelette

Serves: 1

Ingredients Amounts Method for preparing dressing: Egg 1 whole , 2 whites ¢ Heat olive oil in a frying pan Oil 2 tsp. ¢ Sauté the onion, capsicum, tomato and carrot. Onion (finely chopped) 1 no. Close the lid and allow cooking until soft Capsicum (chopped) 1 no. ¢ Spread the mixture evenly Tomato (finely chopped) 1 no. ¢ Break the eggs on the vegetables Carrot (grated) 1 no. ¢ Add black pepper powder and salt Coriander leaves Few ¢ Cook until done Black pepper and salt To taste ¢ Serve hot with one slice of multigrain bread/whole *1 tsp.= 5 g wheat chapatti

54 References

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57 50. Livongo. Empowering all people with chronic conditions to live better and healthier lives. Available at: https://www.livongo.com/ 51. Kochhar JS, Lim WXS, Zou S, et al. Microneedle integrated transdermal patch for fast onset and sustained delivery of lidocaine. Molecular Pharmaceutics. 2013; 10 (11):4272–4280. 52. National University of Singapore. Ouchless patches deliver painkiller faster. Available at: https://www.futurity.org/ microneedle-patch-injections-762282/ 53. GEN news highlights. “Ouchless” Patch Promises Needle-Free Diabetic Monitoring. Available at: https://www.genengnews.com/

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