Issue No. 8, November 2015

In this issue: • World Diabetes Day • Sugar Consumption and Diabetes

To keep the members of diabetes care team abreast with Diabetes Self-Management Education (DSME) concepts To download PDF of current and previous issues, please scan the code Indian Diabetes

JOURNAL Preface

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 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. Traditionally, any occasion in India is celebrated with intake of sweets. Also, it is customary to "sweeten the mouth" post every meal and any celebration. There is an undesirable link between sugar and diabetes which are well documented. Also, evidences support the association between consumption of sugar sweetened beverages and type 2 diabetes mellitus. On occasion of World Diabetes Day – 2015, this issue of IDEJ gives more insights on the link between sugar intake and diabetes. 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 USV 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. USV 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 by sending an email to: [email protected] or [email protected] Indian World Diabetes Day World Diabetes Day (WDD) is held on the 14th of November every year since this day marks the birthday of the person who co-discovered insulin, Sir Frederick Banting. WDD is the world’s largest Diabetes diabetes awareness campaign reaching a global audience of over 1 billion people in more than 160 countries. JOURNAL TABLE OF CONTENT The WDD campaign is represented by a blue circle logo as a symbol for diabetes awareness. It signifies the unity SR. NO. TOPIC PAGE NO. of the global diabetes community in response to the diabetes epidemic.1 1. World Diabetes Day 1 Need for such awareness campaigns 2. Expert Opinion 4 Diabetes is a huge and growing burden with 387 million adults having diabetes according to 3. KOL Speak – Link Between Sugar Intake and Diabetes 8 available data in 2014.This number is soon expected to increase to up to 600 millions by 2015 worldwide. Most of the patients with diabetes suffer from at least one complication by the time 4. Sugar Sweetened Beverages and Rising Tide of Diabetes 12 they are diagnosed with diabetes. Therefore, to raise the awareness of diabetes, its prevention and complications becomes the need of the hour. 5. World Diabetes Day Celebration 14 Governments and private organisations are encouraged to increase awareness of the 4. Indian Sugar Consumption Pattern 15 disease, particularly among the high risk general population. 5. Indian Sugar Guide 17 Looking back – WDD campaigns 6. Various Apps for Measuring Sugar Intake in Diabetes 18 Thematic flow of World Diabetes Day from origin till date 7. Counselling Tips 21 WDD is a campaign that features a new theme chosen by IDF each year to address the issues 8. Busting the Myth 22 faced by the global diabetes community.

9. Patient Voice 23 The major areas covered since year 2000 are: 10. Case of the Month 24 2000: Diabetes and lifestyle in the new millennium 11. Frequently Asked Questions on Sugar Consumption 25 2001: Reducing the burden: Diabetes and cardiovascular WDD is centred on a theme disease related to diabetes and covers 12. Diabetes Self Management Education (DSME) discussion on diabetes and 2002: Your eyes and diabetes: Don't lose sight of the risks Approach To Tailoring Indian Scenario 27 human rights, diabetes and 2003: Diabetes could cost you your kidneys: Act Now! lifestyle, diabetes and obesity, diabetes in the disadvantaged 13. Superfood 30 2004: Fight obesity, prevent diabetes and the vulnerable, and also 14. Recipe 31 2005: Diabetes and foot care diabetes in children and adolescents 15. References 32 2006: Diabetes in the disadvantaged and the vulnerable

1 2007–2008: Diabetes in children and adolescents2 Key messages of WDD – 2015 campaign

2009–2013: Diabetes education and prevention • Act to change your life today – Healthy eating is an important part of managing all types of 2014–2016: Healthy living and diabetes3 diabetes • Act to change the world tomorrow – Access to affordable healthy food is essential for Current year theme of WDD – 2015) reducing the global burden of diabetes and ensuring globally sustainable development

What diabetes educators can do this WDD?

• Identify patients at high risk of developing diabetes through a simple questionnaire to assess risk factors such as age, waist circumference, family history, cardiovascular history and gestational history

• Promote measures to reduce risk factors of type 2 diabetes

• Encourage healthy eating practices among paediatric population to halt the rise in diabetes epidemic Benefits of healthy eating • Help people understand the risks and set realistic goals to improve health • It helps to prevent the onset of type 2 diabetes • Raise awareness of the warning symptoms of diabetes and encouraging early diagnosis • It is an important part for the effective management of all types of among people diabetes to help avoid complications • Highlight the importance of evidence-based education in the prevention and treatment of • WDD – 2015 campaign shall address the importance of healthy eating diabetes and its complications pattern in diabetics as well access to healthy foods. It also stresses • Promote measures to prevent or hold back complications of diabetes3 upon the foods which help to prevent onset or effectively manage type 2 diabetes • Educate people about health risks associated with excess sugar intake based on current year theme

Meats and sweets: Less often Poultry, eggs, cheese and Wine: In moderation yoghurt: Moderate portions, daily to weekly Fish and seafood: Often, at least 2 times Drink water per week Fruits, vegetables and grains: (mostly whole)

Olive oil, beans, nuts, legumes and seeds, herbs and spices Base every meal on these foods Daily physical activity

2 3 Expert Opinion the importance of sugar not only as a food item, but it is also intrinsic to the Indian way of life. Nutritionally, sugar provides only “empty” calories (1 g of sugar gives 4 kcal and lacks the natural minerals). Sugar consumption and diabetes Consumption of Indian sweets varies from region to Contributed by: region depending on the climate, agriculture and tradition. For example, sweets commonly consumed in

Dr. V. Mohan North India are different from those consumed in South MD, FRCP (London, Edinburgh, Glasgow, Ireland), PhD., DSc. FNASc, DSc (Hon. Causa), FNA, India. Other local practices also increase sugar FACP, FACE, FTWAS, Chairman & Chief Diabetologist, Dr. Mohan’s Diabetes Specialities Centre & consumption in meals, for example in the state of Gujarat Madras Diabetes Research Foundation, Who Collaborating Centre for Non-Communicable Diseases (mid-west India), there is a practice of adding sugar to all Prevention And Control & IDF Centre Of Education. gravies, breads, curd, aamras (mango pulp), etc. There is a strong relationship between calorie intake and Ms. S. S. Jaishree obesity. In India, the prevalence of obesity is increasing at a MSc., PGCDE rapid pace due to an increase in energy intake owing to increased purchasing power and Assistant Manager in N&D Dr. Mohan's Diabetes Specialities Centre & Gopalapuram, Chennai. availability of high fat, energy-dense foods, along with reduction in the energy expenditure consequent to urbanisation and mechanisation.4,5

Common sweets during festive season in India Sugar and sweet consumption have been popular and In India, during different festivals, there is a wide range of Though sugar is of considerable intrinsic to Indian culture, traditions and religions since sweets available. The amount of sugar present in different cultural and hedonic relevance in India, nutritionally it provides ancient times. Indian festivals portray a rich cultural types of Indian sweets varies considerable across the only “empty” calories heritage and significance of our country. Food is an nation, for example, (medium size) contains integral part of Indian festivals. Indian sweets contain 224 calories whereas kajukatli (medium size) has 101 6 high amount of sugar as well high saturated and trans fats calories per piece approximately. Similarly juices are also (prepared using partially hydrogenated vegetable oils). as bad as sweetened drinks and beverages like Coca-Cola and Pepsi as they have Decreasing physical activity and increasing trend of per added sugar. capita sugar consumption assumes significance in view of the high tendency for Indians to develop insulin resistance, abdominal adiposity and hepatic Table 1: Common sweet items with their calorie values7 steatosis, along with increasing “epidemic” of type 2 diabetes mellitus and cardiovascular Sr .no Sweet (100 g) Energy (kcal) Fat (g) Carbohydrate (g) Protein (g) diseases. 1 Adhirasam 498 15 86 4 Sugar consumption during festive seasons in India 2 Badhusha 436 25 50 4 The most popular sweetener in the world, sugar, was discovered in India. Traditionally, any 3 Burfi 392 18 48 11 occasion in India is celebrated with intake of sweets. 4 505 32 52 2 Also, it is customary to “sweeten the mouth” after every 5 Jangiri 426 23 51 5 meal, any joyous occasion, religious festival, social 6 Gulab Jamun 448 20 56 13 gathering, etc. It is considered mandatory to offer sweets to the gods on every religious occasion (e.g., it is believed 7 404 18 49 8 Lord Ganesha, who is worshiped first in all religious 8 Ladoo 404 18 56 6 occasions, is fond of ladoos). Indian religious offerings 9 Sonpapdi 445 23 50 9 mostly contain five amrits (elixirs) which are milk, curd, 10 Rasagulla 208 2.5 11 11 ghee (clarified butter), honey and sugar; these indicate

4 5 Though fruit juices contain vitamins, minerals and antioxidants, they lack vitamin C and fibre. Proposed strategies for control of excess sugar intake They are loaded with sugar and are nutritionally poor compared to whole oranges and other Government plant foods like vegetables. 1. Strict guidelines regarding sugar intake should be formulated. 8 Relationship between sugar, obesity and diabetes 2. Spread awareness among consumers and the medical establishment regarding the ill- • Consumption of sugar sweetened beverages cause a rapid increase in blood glucose and effects of high sugar intake. insulin levels leading to high glycaemic load (GL). High GL diets stimulate appetite, induce 3. Increasing taxation could be one of the strategies to weight gain and are associated with development of both glucose intolerance and insulin curb increasing consumption of sugar sweetened resistance beverages.

• Limiting the intake of sugar sweetened beverages is a simple change, which if 4. Sale of sugar sweetened beverages should be implemented could have a measurable impact on weight control and risk of type 2 banned in school premises. Healthy alternative diabetes as well as other metabolic diseases in the general population drinks should be made available to children. Recommendations of American Heart Association (AHA) 5. Warning labels such as “drinking beverages with on sugar intake added sugar(s) contributes to obesity, diabetes, and tooth decay” could be mandatory for sugar sweetened beverages. • About 6 teaspoons or 24 grams of sugar for females 6. Increase access to free, safe drinking water in public places, schools and offices to (<100 calories/day) and about 9 teaspoons or 36 American encourage water consumption instead of sugar sweetened beverages. grams of sugar ( <150 calories/day) for males Diabetes ® Association ® 7. Restriction of advertisements for commercial foods on television (during prime time and • Avoid products containing added sugars as there is children’s programmes). no nutritional benefit derived from them 8. Decrease taxes on and prices of fruits, vegetables, nuts and other healthy food items. • Soft drinks are a prime source of extra calories that can contribute to weight gain and provide no nutritional Consumers benefits 1. Inculcate healthy eating habits in children from early • The average can of sugar sweetened soda or fruit punch provides about 150 calories. childhood. This is equivalent to 10 teaspoons of table sugar 2. Instead of sugar and fat-loaded sweets, opt for fresh • As a part of healthy diet, an adult consuming 2,000 calories daily should aim for not more fruits for . Raisins and dates can also be than 450 calories (1064 mL) a week from sugar sweetened beverages9 consumed to “sweeten the mouth” post meals.

Strategies to reduce excess intake of sugar consumptions 3. Avoid gifting sweets; instead go for nuts and fresh fruits, etc. For an optimal and effective reduction in sugar intake, approaches from various sides 4. Cut down sugar in coffee and tea. including policy makers, governments, consumers, food manufacturers and other agencies involved in food production (food and sugar swwtened beverages) is required. 5. Avoid intake of processed and packaged foods as much as possible.

The most important among these is a firm political will that should specifically focus on curbing 6. Cut down on intake of sugar sweetened beverages, instead opt for natural drinks the rising prevalence of obesity, type 2 diabetes and cardiovascular diseases in India. These proposed strategies not only help in reducing sugar intake but also have a meaningful impact in reducing the incidence of obesity and type 2 diabetes in India.10

6 7 KOL Speak – Link Between Sugar Intake and Diabetes They found that diets with a high GL and a low cereal fibre content increased the risk of diabetes in women.3 A host of additional studies demonstrate that sucrose added to a diet of laboratory animals or increased in the diet of healthy volunteers is associated with impaired Contributed by: glucose tolerance, retinopathy and nephropathy, and reduced insulin sensitivity of the 12–18 Dr. Vijay Viswanathan tissues. Head & Chief Diabetologist, M.V. Hospital for Diabetes & Prof. M. Viswanathan, At present, there is an increase in adult-onset diabetes Diabetes Research Centre, Royapuram, Chennai, India. among children. One in four extremely obese children under the age of 10 and one in five obese adolescents under the age of 18 in the US have impaired glucose tolerance – a precursor to type 2 or adult-onset diabetes, which increases the risk of heart disease, kidney failure, Sugar and sweet consumption blindness and limb amputations. Adult- onset diabetes is Sugar and sweet consumption have been popular and intrinsic to Indian culture, traditions, a chronic degenerative disease that is typically seen in and religion from ancient times. Sugar consumption in India is increasing including traditional people past the age of 60.19 The fact that children are now sources like and sugar sweetened beverages. Along with decreasing physical suffering from this debilitative disease would have shocked health professionals a generation activity, this increasing trend of per capita sugar consumption assumes significance in view of ago. the high tendency for Indians to develop insulin Obesity and diabetes are also causing birth defects that resistance, abdominal adiposity, and hepatic steatosis, destroy a child’s chance of leading a normal life. along with increasing “epidemic” of type 2 diabetes and Researchers studied 23,000 pregnant women and found cardiovascular diseases.10 that obese women who also have type 2 diabetes are 3 Traditionally, any occasion in India is celebrated with times more likely than non-obese non-diabetic women to intake of sweets. Also, it is customary to “sweeten the have a baby with a birth defect, and 7 times more likely of mouth” after every meal, any joyous occasion, religious giving birth to a child with a cranio-facial defect such as festival, social gathering, etc. It is considered mandatory to cleft palate or abnormal limb development. Nearly 6% of 10 offer sweets to the gods on every religious occasion. all women with type 2 diabetes had babies with major 20 Evidence-based association between sugar intake and diabetes defects compared with 1.34% of women without diabetes.

Various anthropological studies have demonstrated that upon the Safe level of sugar as per various guidelines introduction of refined sugar to a culture, the incidence of diabetes There have been numerous recommendations regarding sugar intake in adult and pediatric increases after a latent period of about 20 years. According to T. L. population by different health organisation bodies across the world. Cleave, author of The Saccharine Disease, the “virtual absence of 21 diabetes in primitive communities who live on complex WHO recommendations carbohydrates such as various grains and tubers compared with populations eating carbohydrates which are refined is an • Reducing the intake of free sugars throughout the life course anthropological proof that sugar is a leading cause of diabetes”.11 (strong recommendation) • Reducing the intake of free sugars to less than 10% of total Studies reporting an undeniable link between sugar consumption energy intake (strong recommendation) and diabetes are well documented. Salmeron et al., at the Harvard School of Public Health examined the relationship between glycaemic • Reducing the intake of free sugars to below 5% of total energy (i.e., sugar) diets, low fibre intake and the risk of non-insulin-dependent diabetes mellitus. intake (conditional recommendation)

8 9 22 American Academy of Paediatrics recommendations • Sucrose is a disaccharide made of glucose and fructose • Reducing the intake of sugar sweetened beverages and foods • Commonly known as table sugar or white sugar, it is • Sweetened beverages and naturally sweet beverages such as found naturally in sugar cane and in sugar beets fruit juice should be limited to: • Research demonstrates that substitution of sucrose - 118–177 mL per day for children 1–6 years old for starch for up to 35% of calories may not affect - 236–354 mL per day for children 7–18 years old glycaemia or lipid levels. However, because foods high in sucrose are generally high in calories, Quality of carbohydrates substitution should be made in the context of an overall healthy eating pattern with caution Glycaemic index and glycaemic load not to increase calorie intake

• Substituting low glycaemic load foods for higher • Additionally, as with all people, selection of foods containing sucrose or starch should 24 glycemic load foods may modestly improve emphasise more on nutrient-dense foods for an overall healthy eating pattern glycaemic control Fructose

• It is recommended to use low glycaemic index diets • Fructose consumed as “free fructose” (i.e., naturally like millets and other complex carbohydrates occurring in foods such as fruit) may result in better Dietary fibre and whole grains glycaemic control compared with isocaloric intake of sucrose or starch • People with diabetes should consume at least the amount of fibre and whole grains recommended for • Free fructose is not likely to have detrimental effects the general public or more on triglycerides as long as intake is not excessive (>12% energy) • Intake of dietary fibre is associated with lower all- cause mortality in people with diabetes23 • People with diabetes should limit or avoid intake of sugar sweetened beverages (from any caloric sweetener including high-fructose corn syrup and sucrose) to reduce risk of weight • Fibre intake to improve glycaemic control, based on gain and worsening of cardio-metabolic risk profile existing research, are also unrealistic, requiring fibre intake of > 50 g/day • Many foods marketed to people with diabetes may contain large amounts of fructose (such as agave nectar); these foods should not be consumed in large amounts to avoid • Total fibre intake, especially from natural food sources (vs. supplements) seems to have a excess caloric intake and to avoid excessive fructose intake beneficial effect on serum cholesterol levels and other cardiovascular disease risk factors such as blood pressure • Evidence suggests that consuming high levels of fructose-containing beverages may have particularly adverse effects on selective deposition of ectopic and visceral fat, lipid • Owing the general health benefits of fibres, recommendations for the general public to metabolism, blood pressure, insulin sensitivity and de novo lipogenesis, compared with increase intake to 14 g/1,000 kcals daily or about 25 g/day for adult women and 38 g/day glucose-sweetened beverages for adult men are encouraged for individuals with diabetes • In terms of specific effects of fructose, concern has been raised regarding elevations in Substitution of sucrose for starch 25 serum triglycerides • While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates • Such studies are not available among individuals with diabetes; however, there is little may have similar blood glucose effects, consumption should be minimised to avoid reason to suspect that the diabetic state would mitigate the adverse effects of sugar displacing nutrient-dense food choices sweetened beverages

10 11 Non-nutritive sweeteners and hypocaloric sweeteners • Data on sugar availability from 175 countries in last 10 years also showed that high sugar levels in a population’s food supply were linked to a high diabetes rate • Use of non-nutritive sweeteners (NNSs) has the potential to reduce overall calorie and carbohydrate • The prevalence of diabetes in the population increased by 1% for every 150 calorie intake if substituted for caloric sweeteners without increase from sugars, per person, per day compensation by intake of additional calories from other food sources

• Research supports that NNSs do not produce a glycaemic effect; however, foods containing NNSs may affect glycaemia based on other ingredients in the product

Guidelines for the future

• Parents should inculcate healthy eating habits and food choices in children from early childhood

• Give fresh fruits for instead of sugar and fat- laden sweets

• Give fruits and nuts as gifts rather than sweets

• Avoid fast foods, packaged foods, sugar sweetened beverages like fanta, coca-cola. etc.

• Encourage children into athletic/games/dancing, etc. Role of sugar sweetened beverages and obesity in type 2 diabetes Sugar Sweetened Beverages and Rising Tide of Diabetes • Sugar sweetened soft drinks contribute 7.1% of total energy intake and represent the largest single food source of calories in the diet

• These beverages contain large amounts of high-fructose corn syrup which may contribute Contributed by: to weight gain and an increased risk of type 2 diabetes Dr. Manmohan Sharma • These beverages are leading source of added sugars

MD (Med.)., DM (Endocrinology) and each serving represents a considerable amount of The prevailing mechanisms Consultant Diabetologist and Endocrinologist, Meerut. glycaemic load that may increase the risk of diabetes linking sugar sweetened • Also cola-based soft drinks contain caramel colouring, beverage intake to weight gain are decreased satiety and which is rich in advanced glycation end products that incomplete compensatory might increase insulin resistance and inflammation reduction in energy intake at • The odds ratio of becoming obese increased 1.6 times s u b s e q u e n t m e a l s a f t e r • Various studies conducted showed the likelihood of genetic linkage between consumption consumption of liquid calories for each additional sugar sweetened drink consumed of sugar and type 2 diabetes every day • Recently a large epidemiological study at San Francisco suggested sugar as an independent risk factor for diabetes by promoting weight gain

12 13 World Diabetes Day Celebration Indian Sugar Consumption Pattern

Contributed by: Palm sugar Dr. A. K. Das He is currently practicing as Consulting Physician and Diabetologist at Muzaffarpur, Bihar. He has White sugar Khandasari been honoured with diabetes awareness initiative award for creating awareness about diabetes among patients and general public by Diabetes India in the year 2015. Honey Jaggery His major awareness programmes for World Diabetes Day (WDD) 2015 are:

• Organising “RUN FOR HEALTH” mass level programme involving super specialty and Brown sugar senior doctors at Muzaffarpur, Bihar on 14th November, 2015

Indian food items not only differ in composition and nutrient values across the country but also in terms of added sugar content.

Table 2: Commonly consumed food articles in India containing natural or added sugars Main meals Snacks Beverages Additional Rice, wheat, oats, millets, Indian sweets; halwa, Sugar cane juice, Sweet chutneys, pickles, barley, breads, , , chikki, sweetened , sharbat, aamras, murabbas, sugar/jaggery, stuffed Indian puddings, fruit cakes, aam panna, milkshakes, honey, khandsari with bread, yoghurt, vegetables, cookies, ice creams, etc. fruit juices, sugar ghee, jams, tomato etc. sweetened beverages, etc. ketchup

• Organising various interactive sessions like quiz competitions, debates, yoga and meditation programmes for public regarding diabetes

• Organising various camps covering diabetic complications such as diabetic neuropathy, retinopathy, microalbuminuria, lipid, bone mineral • It is important to note that the intake of "traditional sugars" (honey, jaggery) has declined density and Hb1AC testing camps whereas the intake of sugar from sugar sweetened beverages has increased

• Providing free medicine and blood testing to poor • In addition, it has been noted that when the consumption from jaggery/khandasari and diabetes patients sugar sweetened beverages are added to that of white sugar, the total sugar intake in • Using electronic and print media to create awareness on a larger scale regarding care Indians exceeds the average global per capita consumption required in diabetes and management • It is seen that consumption of sugar and honey has shown slight reduction in rural and • Blood screening camps in Muzaffarpur urban areas whereas there is a substantial increase in sugar-containing food items (miscellaneous foods), particularly in the urban areas10 • Organising CMEs focussing particularly on diabetes mellitus

14 15 Sugar sweetened beverages – Biggest threat for Indian Sugar Guide developing diabetes

• The risk of type 2 diabetes mellitus is increased by the consumption of sugar sweetened beverages because of the high glycaemic load, which causes insulin resistance, inflammation and impaired beta-cell function

• There is an increased risk of type 2 diabetes mellitus and metabolic syndrome because of sugar sweetened beverages as evidenced by various studies done mentioned below:

- The Framingham Offspring study showed that those who consumed ≥ 1 soft drink per day had a 37% higher risk of developing obesity compared to non-consumers Common sweets items with their caloric values and amount of different ingredients - The NHS II cohort demonstrated that those who consumed ≥1 SSB/day had a 83% greater risk of developing type 2 diabetes mellitus

- Another study showed that those who consumed ≥ Sugar sweetened beverages 2 SSBs/day had a 24% greater risk of developing may increase the risk of diabetes type 2 diabetes mellitus compared to those who a n d c a r d i o v a s c u l a r r i s k consumed <1 SSB/month independently of obesity as a potential contributor to a high - Dhingra et al. showed that those who consumed ≥1 dietary glycaemic load and SSB/day (diet or regular) had a 39% greater risk of increased fructose metabolism developing metabolic syndrome over the course of 4 years

- Positive association of both (the risk of diabetes mellitus and weight gain) with the intake of sugar sweetened beverages, independent of known risk factors have also been shown26,27

16 17 2. Food-o-meter29 • Food Calorie Calculator helps to find nutritional facts, including calories, fat, carbohydrates, protein, sugar, fibre • More than 37,000 foods and beverages have been covered in this app 3. Sugar counter app30 • Contains a comprehensive database of over 1400 types of food with their sugar stats broken down in a clear and explanatory way • Records and monitors sugar intake and creates daily food planners too • Offers a valuable insight into the products that one never expects to yield unexpectedly high quantities of sugar

4. Show me the sugar app31 Apps which are used for Various Apps for Measuring Sugar Intake in Diabetes • This app exposes hidden sugar in food items and gives measuring sugar intake are valuable information about daily sugar consumption simple and comprehensive and play an important role in The diabetes patients should be aware of sugar content of foods they consume in daily life. In • It compares brands and visualises the progress over monitoring the blood glucose the current era android and iphones, various apps have solved this problem effectively and time levels, providing feedback, have made control of sugar intake easier and convenient. support as well as motivation to the patient to maintain target 28 1. Calorie Counter Pro glucose values • Calorie Counter PRO provides a database of nearly a million foods and provides helpful information on hundreds of exercises • Provides daily nutritional summary of all major nutrients

18 19 28 5. Fooducate app Counselling tips • It involves grading system of 10 grades ranging from A, B+, B, B-, C+, C, C, D+ and D Childhood and pregnancy are two important periods in • Grades are calculated based on the product life wherein cravings are common and most of the time its package information, nutrition label and sugar craving. When diabetes develops in this phase of ingredient list life it is very important to educate and counsel this population to modify their sugar consumption for better • The application also offers “daily tips” which health and to avoid future complications. cover topics regarding food safety, kid’s nutrition, nutrition label analysis or general Some ways to modify and curb the sugar food and diet news consumption are:

6. Calorie Counter – MyFitnessPal32 • Ask them to reach for a fruit whenever they are craving to eat something sweet. They will get fibre and nutrients along with some • This is world’s most popular health and fitness app natural sweetness • It has the largest food database • Advise them to eat regularly throughout the day. When meals are • It covers over 5,000,000 food items skipped, blood sugar levels drop and as a result, the body craves • It has comprehensive features to create individual custom foods and exercises for sugar and refined carbohydrates. Eating within an hour of waking up and every 2 to 3 hours thereafter will help to keep the • It tracks all major nutrients, progress reports, customised goals based on profile, recipe blood sugar levels steady and curb the cravings calculator • They should be told to stock up foods like nuts, seeds and dry fruits • It gains insights into individual calories and nutrients and keep them handy instead of reaching for a high calorie sugary • It helps to make healthier choices dessert

• Sugar cravings could also be a result of dehydration and so proper hydration must be emphasised upon. They should be advised to carry around a bottle of water to sip. Herbal teas/lemon teas are beneficial too

• Foods containing natural sugars can be included in the diet like date with almond/walnut/pista/channa or figs (anjeer)

• Dark chocolate can be chosen over a regular chocolate bar. Cravings usually lasts for 10–20 minutes. So engaging in physical activity or sports will help to distract from the urge to eat sweets as well as help to burn calories

• Spices such as cinnamon (dalchini), cardamom (elaichi) give a sweet taste to food. They can be added to foods like fruits, oatmeal, porridges for a sweet taste

•

20 21 Busting the Myth Patient Voice

Myth: People with diabetes should not drink alcohol as it Narrated by: Mrs. Vaidya, mother of Esha Vaidya raises their blood sugar level Case presentation Fact: There is no need for people with diabetes to give up A month back, I noticed that my 10-year-old daughter had been waking up in the night alcohol completely because of their diabetes. Although frequently for urination. She later developed itchiness in her groin for which I took her to my alcohol does have an effect on blood sugar levels, with a family physician who diagnosed it as urinary tract infection (UTI) and gave her medication for few precautions and careful management, people with the same. UTI relapsed after a week for which my doctor advised to get her urine routine test diabetes can also enjoy a drink. done along with a fasting blood sugar test. Since we have a family history of diabetes and also Research indicates that the alcohol recommendations for I had developed diabetes during my pregnancy, the doctor suspected that she might have people with diabetes are no different than recommendations for the general population, which developed diabetes. is currently 2 standard drinks per day for men and 1 standard drink per day for women and Test results people over 65 years of age [1 standard drink equals 300 mL of beer (5% alcohol) or 120 mL of wine (12% alcohol) or 30 mL of whiskey/gin/vodka/rum (40% alcohol)]. It is best to drink • Fasting plasma glucose (FBS): 380 mg/dL alcohol with a meal or some carbohydrate-containing food and to include alcohol-free days. • Postprandial plasma glucose (PPBS): 425 mg/dL Some people may need to consume less alcohol than these general recommendations due to • Urinary glucose: 4+ their age, medication or the need to lose weight. It is therefore important to discuss the amount of alcohol that can be consumed with the DE. If an individual is overweight, have has After going through the reports, my doctor referred me to a diabetologist. The diabetologist trouble managing blood glucose, has high blood pressure, high triglycerides or other advised immediate hospitalisation to normalise her blood glucose levels. The doctor started complications, he/she may be advised to drink less or not drink at all. Different alcoholic drinks her on insulin which brought down her glucose levels to the desired range. After the discharge, have varying effects on the blood sugar. It also depends how much is consumed. A single her glucose levels at home started fluctuating for which my diabetologist referred me to a DE. alcoholic drink (a 300 mL bottle of beer or medium glass of wine) may not have a huge effect Intervention by DE on the overall blood sugar. On taking a detailed history of her dietary habits, DE found that her diet was low in proteins and Most alcoholic drinks tend to initially raise the blood sugar. Typically, beers, lagers, wines, fibre and high in carbohydrates. The sources of carbohydrate were rice, chapattis, sugar, sherries and liqueurs have this effect. However, alcohol inhibits hepatic glucose output which sweets, chocolates, ice-creams, etc. The DE also informed me that she was consuming larger means the person is at a greater risk of hypoglycaemia once the blood sugars start dropping. If portion sizes as per her age. DE informed me that her craving for sugary foods could possibly the person has consumed a number of these drinks, one can expect to see a rise in blood be due to uncontrolled blood sugars. Being a 10-year-old child, to curb her sugar cravings sugar followed by a steady drop a number of hours later, often whilst asleep. People who take was a challenge for me. insulin or certain oral diabetes medications, such as a sulphonylurea (glipizide, glyburide) or DE designed a personalised meal plan with a balance of complex carbohydrates, fibre and meglitinide that stimulate the pancreas to produce more insulin, they need to be wary of enough proteins to support her growing phase. Instead of consuming sweets, the DE advised hypoglycaemia. me to give her foods containing natural sugar in between the main meals. The DE helped me If the diabetes is already well under control, a moderate amount of alcohol may be fine either out with a few sweet recipes which were a combination of natural sugars, proteins and fibre. before, during or soon after a meal. Avoid drinking on an empty stomach, as this will quickly DE educated us on the importance of portion control and occasionally allowed her to eat increase the amount of alcohol in the bloodstream. Also avoid binge-drinking or sustained sweets of her choice keeping a check on the portion size. drinking and never substitute alcohol for meals. All of this can increase the risk of hypoglycaemia.

22 23 Along with diet, DE also emphasised on how important physical portion control and was allowed to eat sweets of her choice on certain occasions, keeping a activity is for her. She advised me to engage her in outdoor check on the portion size. activities like cycling, swimming, skipping and other sports for at Also, she was advised to include some form of low-intensity physical activity like walking, least an hour in a day. yoga, cycling, etc. for at least 30–45 minutes in a day to bring her blood glucose levels within At present, my daughter has lost 2 kgs and her sugars are under the desired range. control. I am very thankful to my DE’s advice as because of her I Over a period of 3 months, patient’s blood investigations showed drastic improvement. Her can allow my daughter to enjoy having sweets without worrying repeat investigation report was as follows: about her sugars. • FBS: 98 mg/dl

• PPBS: 126 mg/dl Case of the Month • HbA1C: 7.2%

Case history Also, her weight dropped from 70.4 kg to 65.2 kg and hence, her insulin dosage reduced from 15-15-15 to 12-12-12. A 55-year-old, Type 2 diabetic having a sedentary lifestyle was referred to a DE for uncontrolled sugar level. The patient now practices portion control and enjoys her sweets without getting a spike in her blood glucose levels. Biochemical parameters

• FBS: 220 mg/dL This case is contributed by Ms. Siddhika Ghag • PPBS: 260 mg/dL RD, CDE- NDEP Batch 2012-2013 • HbA1C: 9% Registered Dietician and Certified Diabetes Educator Medications

• Metformin (1 g): 1-0-1

• Insulin: fast-acting: 15-15-15 Frequently Asked Questions on Sugar Consumption • Long-acting: 0-0-20

Intervention by DE Patient with fluctuating sugar levels

On taking a complete dietary recall, the DE found that the Patient: My sister (47-year-old) is having diabetes since reason for her uncontrolled blood glucose was faulty eating habits with severe sugar cravings last 3 years. She is on oral hypoglycaemic drugs. She post meals. She used to crave for sugary sweets like , gulab jamun, ice-cream, eats only food products labelled as 'sugar free or chocolates, ladoos, etc. and was not able to keep a check on the portion consumed. Also, her diabetic'. Still her blood sugar level on routine meals were high in carbohydrate and low in protein with negligible fibre. examination fluctuates every 2–3 months which requires A personalised meal plan with a balance of complex carbohydrates, proteins and fibre was frequent dose adjustments. What could be the possible reasons for the same? designed for her to prevent spike in post meal blood glucose levels. Instead of consuming sweets immediately post meals, she was recommended to have natural sugar containing DE: Products labelled as 'sugar free or diabetic' does not necessarily mean that they are free foods like dates in the form of date rolls, dry fruit rolls, figs, a piece of dark chocolate, etc. in of calories and carbohydrates. They may not contain added sugars but may be a rich source of controlled portions in between the main meals. She was educated on the importance of carbohydrate which in turn gets metabolised into glucose and raises the blood glucose levels. Sugar free packaged food products are usually high in fat content which can lead to insulin

24 25 resistance further impairing blood glucose control. Instead of consuming these products, Diabetes Self Management Education (DSME) focus should be on eating a regular balanced diet which is portion controlled with Approach To Tailoring Indian Scenario carbohydrate intake that matches her activity level and medication dosage.

Patient with prediabetes concerned about sugar intake The journey from bad to good in any field can only Patient: I am a 37-year-old male working in an MNC as a senior executive. On routine medical be covered by ''education'' examination, I was diagnosed to have prediabetes as my sugars were in borderline range. I am not having any Contributed by: symptoms of diabetes at present and I haven’t been prescribed any medications for diabetes. Do I have to Dr. Arun Vadavi take diabetic diet and cut down my sugar intake in coffee (M.B.B.S, M.D.) or tea?

DE: There is no such thing as a diabetic diet. You can prevent diabetes by adopting a healthy lifestyle which includes a balanced diet along with exercise. Diet should be rich in complex carbohydrates, fibre, moderate in protein and low in fat. Table sugar, honey, In last 25 years, diabetes has seen a revolution in every Diabetes education comprising jaggery and products which contain them are a form of simple carbohydrate which result in aspect. New in-sight into causation of hyperglycaemia is understanding of diabetes, spike in blood glucose levels. You don’t have to completely give up on sugar but the amount of revealed. Newer and different parameters and their exercise guidelines, self- sugar added should be accounted for in the total carbohydrate budget for the day. evaluations are introduced. Many oral hypoglycaemic management quizzes, etc. play You can include sugar in your diet if: agents and designer insulins are available for treatment. an important role along with medications and lifestyle • It is a part of a healthy eating plan These are all a part of a larger picture popularly known as modifications "technological advancement". But the big question here is – • You maintain good physical activity has all this advancement improved the sustained control of • You monitor your blood sugars frequently blood glucose level in the society at large? The answer is Patient with elevated sugar levels during fasting “NO”.

Patient: My father (52-year-old) is diabetic since last 12 years. He is on oral hypoglycaemic Technology can improve performance of an individual from “good” to “better”. But, it cannot drugs. During fasting in our religious functions (Navratri), his blood sugar shoots to make an ignorant (or a bad) performer to become an aware (or good) performer. The journey unexpected rise (more than 280–300 mg/dL). He doesn’t from bad to good in any field can only be covered by “education”. eat much during fasting period. So why does his blood Type 2 diabetes is a lifestyle disease. The genetic and lifestyle mismatch leads to endocrine sugar show such enormous results? disorder causing type 2 diabetes. Focussing on correcting the hormonal and metabolic DE: Ideally a person with diabetes should not fast as disturbance without correcting the treatable root cause will not give any lasting result. Persons fasting for long hours can lead to impaired blood glucose at risk of diabetes and those with established diabetes, all remain ignorant for the lack of right levels. If he chooses to do so, he should review his information at the right time in a right way, while medicines give a quick fix solution which lasts medication with the help of his healthcare provider. only as long as the yearly calendar without supportive learning support programme. Usually foods consumed during religious fasts are high in The message here is diabetes education is a more important and a bigger work in type 2 carbohydrates such as sago khichdi, sago wada, bananas, diabetes care than only prescribing medicines without giving any education. For facing the potato chips, faralichivda. These foods raise the blood glucose levels. These can be replaced challenge of type 2 diabetes to the mankind, timely and comprehensive education is the best with healthier options like buckwheat (kuttu) khichdi, roasted sweet potato, samo rice, fruit yoghurt, nuts, etc. and the only weapon.

26 27 Defining role of a certified diabetes educator The process of diabetes self-management education is defined as:35

• Performance of an individualised bio-psychosocial and cognitive assessment of the Contributed by: individual with diabetes and/or the caregivers Dr. Vinod K. Abichandani • Formulation of an education plan including collaboratively identified goals and objectives M.D Diabetologist, Ahmedabad based on a core body of knowledge in topics related to diabetes and self-care behaviours

• Implementation of the education plan based on established principles of teaching – learning theory and lifestyle counselling

Patient education is an evolving and expanding field. As it continues to grow, discussions • Evaluation(s) to assess the individual’s understanding and utilisation of diabetes about who should provide diabetes education is an area of particular interest in the global management skills and knowledge, including reassessment of needs; and community. The new questions surface, such as: • Proper documentation of all educational encounters

• How does one provide education with limited resources? Pharmacist trained by the NDEP like the DEs can provide services including medication • How do non-traditional care providers fit it? (e.g., anti-diabetics, anti-hypertensives and statins) management, compliance assessment, blood glucose monitoring, training skills on meters and injections, prospective and • Which healthcare disciplines should be responsible for the educational process? retrospective drug utilisation review, adverse drug reactions and toxicity screening and • What are the benefits of credentialling (undergoing a qualified diabetes educator pharmacokinetic dosing. programme/course)? Conclusion Many disciplines are involved in the care and education of people with diabetes. The role of The role of DE in clinical practice and in hospital teams is a new approach to improving the healthcare providers gets constantly expanded in diabetes and determines the development quality of patient education. The DE has specific responsibilities in the evaluation of every of newer clinical management credentials for nurses, dietitians and pharmacists. diabetes patient. An assessment is based not only on what that the individual knows about The "National Diabetes Educator Program (NDEP) , India" credential is available to members his/her illness and where his/her educational needs lie but also on his/her readiness to learn. of the healthcare professional disciplines that comprise the diabetes care team, including The physician's contact time with each diabetes patient is limited but a DE has the time to nurses, dietitians, pharmacists, physicians, health educators, behavioural therapists, spend with the patient and family. One must listen to what each individual has to say about his podiatrists and others. diabetes and other problems and to start the teaching-learning process. The nurse educator Certified diabetes educators (CDEs) are now must be skilled in this teaching-learning process and have a good background and recognised as experts in diabetes education and understanding of diabetes, including diabetes complications and problems. Very importantly, their role continues to expand as educators. This the educator must have the capability and the responsibility to evaluate the effectiveness of enhances their position in the diabetes team.34 the teaching and learning that are done. Today, many CDEs provide diabetes clinical Such evaluation provides proof that better education of the management as well as patient education. The diabetes patient does provide improvement in patient self- DEs are a necessary cost- Diabetes Control and Complications Trial (DCCT) effective addition to the care through a better understanding of his/her illness. conducted in the 1980s and early 1990s, helped to healthcare team whose efforts Proper care and management reduce the frequency of define this more advanced role and to establish the are directed towards the office visits, telephone calls and hospitalisation. Finally, the improvement of the total care value of the multidisciplinary team for intensive educator must remain adequately acquainted with current provided to a diabetes patient diabetes management.33,34 diabetes research relevant to his/her role.

28 29 Superfood Recipe

Cinnamon (Dalchini) Apple Oatmeal

Health benefits This is a healthy and delicious way to start your day. This breakfast recipe is a perfect combination of complex carbohydrates, proteins and fibre with goodness of cinnamon. • Has a blood sugar lowering effect, hence excellent in diabetes management

• Helps reduce belly fat

• Heart protective as it helps to lower blood pressure

• Helps improve good cholesterol levels

• Helps improve immunity due to its antioxidant property

How to consume

Cinnamon can be ground into a powder and can be added to tea or cut fruits or added as a spice during cooking.

Recommended dosage

One to six gram cinnamon per day (around 0.5–2 teaspoons).

Serves: 1

Ingredients Amounts Milk 1 cup Apple juliennes 1 no. Oats 2 tsp Cinnamon ½ tsp

Method:

• Cut half apple into long juliennes and toss it on a frying pan with 1/4th tsp. cinnamon powder for 2 mins

• In another vessel heat 1/2 cup of water, add 2 tsp. oats and bring it to boil

• Once oats gets cooked, add milk and remaining half apple cut into small pieces

• To this add remaining cinnamon powder

• Pour this oat meal in a bowl and top it up with apple cinnamon mixture

• Serve hot

30 31 References 15. Schusdziarra, et al. Effect of Solid and liquid carbohydrates upon postprandial pancreatic endocrine function. J Clin Endocrinol Metab. 1981;53:16–20.

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Content Contribution (certain sections) by Nurture Health Solutions Ms. Sheryl Salis RD, CDE, CPT, ND, M.D. (A.M.), MDHA Registered Nutritionist, Wellness Coach, Naturopath, Doctor of Alternative Medicine, Certified Diabetes Educator, Certified Insulin Pump Trainer and Health Writer. Founder and Director of Nurture Health Solutions, a proprietary firm providing Nutrition, Diabetes and Lifestyle Consultation Services.

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