To keep the members of DSME and DSMS conceptsAlthough it is all fun and fair, people with diabetes are always over the edge during such times. There is a need for pre-fast counselling

*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t

To keep the members ofdiabetes care team abreast with

DSME and DSMS concepts

st 1 time in India

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:

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Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of people with diabetes. This Journal intends to empower your clinic

support staffs for basic counselling of people with diabetes. This journal has been made in good faith with the literature available on this subject. The views and

opinions expressed in this journal of selected sections are solely those of the original contributors. Every effort is

made to ensure the accuracy of information but Hansa Medcell or USV Private Limited will not be held responsible for any inadvertent

error(s). Professional are requested to use and apply their own professional judgement, experience and training and should not

rely solely on the information contained in this publication before prescribing any diet, exercise and medication.

Hansa Medcell or USV Private Limited assumes no responsibility or liability for personal or the injury,

loss or damage that may result from suggestions or information in this book.

USV as your reliable healthcare partner believes in supporting your endeavour to make India a Diabetes Care

Capital of the World.

Indian Diabetes Educator Journal (IDEJ) is a first-of-its-kind initiative in India developed to strengthen the

concepts of Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS)

among the members of diabetes care team, especially the diabetes educators (DEs).

IDEJ content is developed based on seven self-care behaviours of the American Association of Diabetes

Educators (AADE), i.e., healthy eating, being active, monitoring, taking medication, problem-solving, healthy

coping and reducing risks.

This month’s issue focuses on diabetes management during fasting, feasting and festivities. Although it is all

fun and fair, people with diabetes are always over the edge during such times. There is a need for pre-fast

counselling due to increased chances of hypoglycaemia. This section covers pointers and tips for enjoying

festivals while being in moderation is the key. This current issue also encloses the role of family members to

help their loved ones manage diabetes during this season.

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,

Dr. Arun Vadavi

MD (Medicine), DLO

Director, “Sudha”– The Prevention Centre (Centre for Diabetes Care), Bangalore, Karnataka.

Dr. Manish Gutch

MD (Internal Medicine), DM (Endocrinology and Metabolism)

Asst. Prof., Department of Endocrinology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, U.P.

Dr. Tiven Marwah

MD, DIS, DISC

Practising Endocrinologist – Diabetologist; Hon. Associate Professor of Endocrinology, Ahmedabad, Gujarat.

Dr. Narayan Banerjee

MD (PGI) – General Medicine

Consultant Physician and Medicine Specialist, Kolkata, West Bengal.

Dr. Sushil Jindal

MD (Medicine), DM (Endocrinology)

Professor of Medicine, People’s College of Medical Sciences, Bhopal, Madhya Pradesh.

Expert Contributors of the MonthExpert Contributors of the Month

Dr. A. K. Gupta

MD (General Medicine)

Professor and Head, Dept. of Medicine, F. H. Medical College, Agra, Uttar Pradesh.

Dr. Ashok Venkatanarasu

MD (Internal Medicine), DM (Endocrinology)

Consultant Endocrinologist, Yashoda Hospital, Secunderabad, Telangana.

Dr. Manish Sachdev

D. Diab, CCEBDM, CCGDM, CCCA, MBBS

Advance Diabetes and Asthma Clinic, Mumbai, Maharashtra.

Dr. Yashpal Vikas Gogate

MD (General Medicine), DM (Endocrinology)

Harmony Health Hub, Nashik, Maharashtra.

Dr. Sarweswar Agarwal

MBBS, MDRC, PGC (MDRF-ADA), PG (Dip. in Diabetology)

Consultant Diabetologist, Shivam Superspeciality Clinic and Research Centre; Satyam Hospital and Research Centre, Assam.

Dr. K. Venugopala Reddy

MBBS, Dip. (Diabetology), PGC (Diabetes)

VGR Diabetes Specialities Hospital, Vijayawada, Andhra Pradesh.

Dr. Sanjay Gupta

MD (Medicine), DNB (Medicine),Dip. (Diabetology)

Senior Consultant Physician, Heart and Diabetes Specialist, SG Diabetes Centre, Delhi.

Dr. T. S. Ramaswamy


Chief Physician and Diabetologist,Sai Hospital, Palakkad, Kerala.

Dr. Sandeep Suri

MD, FIDM, MBBS

Consultant Medicine at Holy Help Hospital, Hisar, Haryana.

Dr. Kush Dev Singh Jarial

MD (Paediatrics), DM (Endocrinology)

Assistant Professor of Endocrinology, Indira Gandhi Medical College, Shimla, Himachal Pradesh.

Dr. Sandeep Kharb

MD (General Medicine),DNB (Endocrinology, Diabetes, Metabolism)

Sr. Consultant - Endocrinology, Asian Institute of Medical Sciences, Faridabad, Haryana.

Expert Contributors of the MonthExpert Contributors of the Month

Dr. Ankit Shrivastav

MD (Gen. Medicine), DM (Endocrinology and Metabolism), FACE

Consultant Endocrinologist and Diabetologist, Medanta ARAM Hospital and Aarogya Diabetes and Endocrine Centre, Ranchi, Jharkhand.

Ms. Sara Mushrifa

MSc.

Dietitian, Dr. Mohan’s Diabetes Specialities Centre, Domalguda, Hyderabad.

Keep Diabetes at Bay: Staying Active

Can Help Boost Health

Fast and Feast Safely in the

Festive Season


A False Sense of Hypoglycaemia


Enjoying Special Occasions with

Diabetes


Diabetes in Older People

Dr. Sanjay Gupta

Caring for People with Diabetes: Understanding the Cultural and Clinical Aspects

Dr. Sandeep Kharb



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30

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Focus on Breathing Difficulties and Diabetes in the Festive Season

Myths and Facts of

Weight Loss in T2DM

Dr. Arun Vadavi

Table of Content

16Enjoy A Guilt-Free Diwali!

Dr. Manish Gutch

A Guide to a Healthy Feast!

Diabetes Educators Speak!

Cover Story:

Fasting, Feasting and Festivities

Dr. Sushil Jindal

Moderation is the Key During Festivals!

Dr. A. K. Gupta

Get Outdoor and Get Active

Dr. Tiven Marwah

Importance of SMBG During Festivals


01

02

05

08

10

14Diabetic Ketoacidosis: An Area of Growing Concern During Long Hours of Fasting

Dr. Manish Sachdev


12

Table of ContentJuggling Between a Fast-Paced Life

and Diabetes

Do Not Ignore that Frozen Shoulder:It Could be a Sign of Diabetes

Understanding the Challenges, Strategies and Role of DiabetesEducation

Multiple Feathers on DEs Cap

Upcoming Diabetes Educator

Conferences

Tools: Smart Pen for People

with Diabetes

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36

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41

42

43

44

45

Future Trend: Watson Artificial

Intelligence Helping People

with Diabetes

Diabetes Educator of the Month

Family and Diabetes Corner

Get Active!

National Diabetes Educator Program

(NDEP) Best Practices

Eat Out, Be Wise!

Shopping Smart

Super Food: Makhana /मखाना

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49

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52

53

54

55

57

Recipe

References

Dr. Sandeep Suri

Dr. T. S. Ramaswamy

Ms. Sara Mushrifa

1

Can hypoglycaemia or hyperglycaemia be prevented? Yes, it is possible! Carbohydrate counting and guidance from a qualified person is a way to achieve blood glucose control.

Mr. Raj Thakkar, a 25-year-old man, is having type 1 diabetes mellitus (T1DM) for 15 years. He was not aware of carbohydrate

counting because of which he used to go into hypoglycaemia often and then used to correct it by taking excess sugar and

its products.

He was referred to a certified DE Ms. Sheryl Salis by his doctor.

When he came in for consultation, His total daily dose of insulin was 70 units. Carbohydrate counting was thought to him by the DE.

He used to eat a lot before workout due to the fear of hypoglycaemia. The DE counselled him, and pre and post workout guidelines

were explained to him in detail.

Ms. Sheryl Salis used to be in constant touch with him monitoring his meals and blood glucose readings. He used to update his pre-

workout and post-workout blood glucose readings to her as well. Within a few days, his total daily dose of insulin reduced from

70 units to 52 units.

A testimonial from Mr. Raj Thakkar

“Ma’am did a great job of understanding the way I work and providing insightful comments on ways of consuming food, preparation

and planning. It was extremely easy to open up with her as she was always there to solve my doubts along with her team. I really

enjoyed how we managed to change my habits, set my baseline with good food and control my sugar levels which ultimately

resulted in weight loss, reduction in insulin dosage and zero hypoglycaemic or hyperglycaemic episodes. I now feel that I have my

system in place and know how to manage my blood glucose levels. It was nice that she always advised keeping my wants in mind

and not just needs. Altogether, it was fun learning carbohydrate counting and eating right. Thanks a lot for your support ma’am.”

Kudos to Ms. Sheryl Salis and Mr. Raj Thakkar!

Diabetes Educators Speak!

2

ExpertOpinion

Introduction

Fasting and feasting are an integral part of every Indian household during festivals. While it seems like fun for everyone else, people with diabetes are mostly over the edge to be mindful of the sweets, food, functions, fasts, etc. It is even stressful for the family members to not let people with diabetes binge on the feast nor cut down on the feast as it would not be fair for the other family members, especially children.

Dr. Sushil Jindal

MD (Medicine), DM (Endocrinology)

Professor of Medicine, People’s College of Medical Sciences, Bhopal,Madhya Pradesh.

1Fasting, feasting and festivals around the year

India is well known as a country of cultural and traditional festivals as it has many cultures

and religions. One can enjoy the festival celebration in India every month. As it is a secular

country full of diversity in the religions, languages, cultures and castes, it is always crowded

with the people involved in the fairs and festivals celebration.

Some of the prevalent festivals and fast around the

year are Navaratri, Holi, Christian Lent/Easter, Gudi

Padwa, Ramadan, Onam, Buddist Lent, Raksha

Bandhan, Ganesh Chaturthi, Dussehra, Karva

Chauth, Dhanteras, Diwali, Bhai dooj, Christmas, etc.

The month-long Ramadan and Buddhist Lent fasts

are an example of religious observances practised by followers of Islam and Buddhism, respectively. These fasts are characterised by a well-documented impact on metabolic

2health, which can be minimised by well-known management strategies.

2Importance of pre-fast counselling

¢ People with diabetes should be informed of the potential discomforts and risks of fasting and suggested means of reducing them.

¢ People with diabetes should get a clear clarification with regards to their perspective of fasting; including duration of fast, allowance for liquids and snacks during the day, acceptance of sublingual foods and freedom to break the fast.

¢ Pre-fast assessment, comprises comprehensive history-taking, physical

examination and investigations aimed at identifying stigmata of target-organ

damage, so that strategies can be made to optimise health during fasts.

Cover Story: Fasting, Feasting and Festivities

3

2,3Importance of counselling during festivities

¢ DEs must advice people with diabetes to audit their self-monitoring of blood glucose

(SMBG) charting done during festivals, for assessment of the glycaemic variability

so that lessons learnt can be incorporated in next year's treatment plan.

¢ In infrequent fasts such as those held every year (Karva Chauth, Hoi, and Guru

Purnima), ad-hoc drug substitution or dose adjustment can be performed on the day

of the fast. For more frequent fasts (e.g., monthly Purnima, Ekadashi or Pradosha

fasts) and long-term fasts as in Navratri, the drug regimen should be crafted, so as

to allow fasting without necessitating frequent consultation with the DE.

¢ While fasting, the clinician can craft a prescription that suits the individual persons

needs, ensures safety and tolerability, and provides efficient glucose lowering.

¢ DEs must keep in mind for people with diabetes who intake drugs with a glucose-

independent action, which are more prone to to causing hypoglycaemia, such as

sulphonylureas and insulin, may need down-titration of dose.

2Diet and lifestyle recommendations

Fasting in itself is a lifestyle modification; If utilised properly, intermittent fasting can

provide multiple health-related benefits. The idea of a pre-fast meal should be such

that it provides enough "slow-release" calories to take care of the fasting period.

¢ Food items like unprocessed cereals, fruits, nuts and lentils reduce its glycaemic

index and allow energy availability for a longer period.

¢ Adequate water and fluids must be taken prior to the fast, especially; in cases

where fluid intake will be restricted throughout the day.

¢ During the fasting phase, it is recommended to restrict, physical activity.

¢ Stress management is an important component of non-pharmacological diabetes

care.

¢ Religious fasting offers an opportunity to practice meditation, reduce stress and facilitate better glycaemic control which helps improve the condition better.

4

A consistent check on blood sugar levels throughout the festival or fast keeps the risk of hypoglycaemia in

people with diabetes at bay.

Important pointers for DEs

¢ DEs have a responsibility to provide safe, effective, person-centred treatment, and should respect individual attitudes wishes and needs.

¢ DEs must assure people with diabetes that they can still enjoy their festivals provided certain simple measures are followed to keep the blood sugar levels under control.

¢ Pre-fast counselling should include an explanation of the symptoms of hypoglycaemia and hypoglycaemia awareness training (HAT).

¢ In situations where the risk of hypoglycaemia is high, it is recommended to avoid drugs acting independently of glucose.

For more frequent fasts (e.g., monthly Purnima, Ekadashi or Pradosha fasts, fortnightly and weekly fasts) the drug regimen should be crafted. The role of DEs is very important here.

All glucose-lowering drugs have a tendency to cause hypoglycaemia. These drugs can be classified as having a glucose-independent or a glucose-dependent mechanism of action.

¢ A drug with a glucose-dependent mechanism of action may need no change in dosage

or in the timing of administration during fasts.

¢ Drugs with a glucose-independent action are more prone of causing hypoglycaemia,

such as sulphonylureas and insulin, and may need down-titration of dose.

The safer alternative, if available within the same class, such as third-generation

sulphonylureas and insulin analogues, should be preferred.

2Oral Hypoglycaemic Agents (OHAs) medication adjustment

5

ExpertOpinion

Dr. A. K. Gupta


Professor and Head, Dept. of Medicine, F. H. Medical College, Agra, Uttar Pradesh.

Introduction

The festive season starts with a full swing, and people love being around good music, drinks, food, friends and good weather. It is difficult to have fun at a festival and stick to a healthy diet. Given below are some tips on maintaining a healthy and hearty celebration during festivals, while also

4being in a party mode!

Family members and caregivers can be of great help to ensure a healthy menu is set

apart for their loved ones with diabetes. Salads, fruit, smoothies and even protein

shakes should be encouraged instead of carbonated beverages. Similarly, oats and

mixed nuts ladoo should be eaten instead of motichoor or besan ladoo. Family 4members should ensure to add less oil and salt in all dishes.

It is important for people with diabetes to limit their portion and choose wisely. Ingesting carbs and desserts are harmful to their

body. It is essential to substitute these with healthy food items or cut back on carbs during the meal to leave some room for a healthy 4dessert.

Portion size

Eat healthy

Moderation is the Key During Festivals!

6

While being surrounded by deep-fried samosa, papads and puris, DEs should advise

people with diabetes to let their willpower take over and reach out for walnuts, cashew 4and hazelnuts to fight cravings.

During festivals, people with diabetes are advised to eat right and stay active. It is

important to not skip meals that day. Small meals at regular intervals are preferable

since erratic meal schedules result in erratic blood sugar levels. They should also 4definitely not embark on a strange new diet for diabetes, dull and devoid of pleasures.

Finally enjoy festivals

It is important for people with diabetes to not rob themselves of enjoyment. A secret trick to enjoying with friends and family is to eat

a few low carb foods at home before stepping out to visit friends or family to avoid indulging, and it is also advised to request one’s 4relatives to not force one with sugary drinks or fried foods.

Stay active

Snack attack

7


When it comes to food during festivals, it is important to stick to the basics. One should be thankful for the

food on their plate while not forgetting the true nature of a festival; is to provide to those who are less fortunate.


¢ DEs must advise people with diabetes and their family members to avoid packaged sweets. Instead, have home-made sweets.

¢ It is also nice to maybe break the monotony of heavy and multi-course meals with a touch of simple sophistication such as one home-made mithai, one freshly fried item, one sabzi, one dal, some roti and rice, accompanied by some chutney, pickle

5or papad, all of it served with love and attention to detail.

8

ExpertOpinion

Dr. Tiven Marwah

MD, DIS, DISC

Practising Endocrinologist – Diabetologist; Hon. Associate Professor of Endocrinology, Ahmedabad, Gujarat.

Get Outdoor and Get Active

During festive season, many people with diabetes throw caution to the wind and indulge in the gaiety of the festivals only to find them having high blood sugar levels. On the other hand, people who fast during Dussehra, Karva Chauth, Ramadan might experience low blood sugar levels (hypoglycaemia).

These days, people are more modernised than before and have left no time for leisure and recreational activities.

Celebrations are a good excuse to break the monotony of work and get

outdoors and stay active.

However, there are two types of behaviours in people with diabetes 6during festival times:

¢ One set of people tend to be reckless and celebrate the festival with

indulgence.

¢ Another set of people who, due to the fear of diabetes, have a bland

festival.

It is important to strike a balance between these two approaches and

lead a fulfilling life!

Introduction

6Tips for people with diabetes to enjoy their festivals

¢ People with diabetes should not skip their medications during festivals, especially while running around to complete the long list of chores.

¢ It is sometimes unrealistic to stay away from certain foods during the festivals; the best one can do is to reduce the portion sizes consumed. If sweets are prepared at home, it is advised to prepare them with skimmed milk instead of full-fat milk.

¢ The insulin dosage should be adjusted as per the carbohydrate intake.

9

7Encouraging physical activity and involvement during festivals

In Indian festivals sweets and dry fruits are usually overindulged; regular exercise burns off excess sugar in the bloodstream.

The primary benefit of exercise is that it increases the sensitivity of cells to insulin. Insulin allows any excess glucose that is present in the bloodstream to be pushed into the cells with the help of insulin. Thus making the glucose available to the body and provide it with energy.

Of course, exercise has additional benefits such as improving blood flow throughout the body, strengthening muscles and bones,

keeping the joints flexible, enhancing mood and most importantly reducing the risk of heart disease and stroke. One can perform

daily household chores and routine activities, but one should avoid any high-intensity exercise.

¢ Simple ways of staying active include going for a walk with the family, performing bending and stretching exercises regularly,

slow dancing, participating in social events and taking the stairs instead of an elevator more frequently.

¢ People with diabetes should even participate in festival related games, but they should make sure that these are not too

strenuous.

¢ Before starting any exercise, it is always a good idea to get one's blood sugar checked through a SMBG device.

Indian festivals are joyous occasions that are marked by the serving of sweets and savoury items. Those with diabetes

can still enjoy these festivals provided certain simple measures are followed to keep the blood sugar levels under control.


¢ DEs must advise people with diabetes that it is okay to perform regular activities but any excessive physical exertion must be avoided especially during fasting.

¢ People with diabetes should be advised by DE to avoid excessive indulgence in alcohol during festive seasons. Alcohol contains a large quantity of sugar in it and can increase blood sugar levels dramatically.

10

ExpertOpinion


MD (Internal Medicine),DM (Endocrinology)

Consultant Endocrinologist, Yashoda Hospital, Secunderabad, Telangana.

Importance of SMBG During Festivals

Why SMBG is considered essential for all 8people with diabetes?

SMBG should be part of a regular management plan for

people with diabetes. The information provided by it can help

with the appropriate scheduling of food, activity and

medication and understand the timing of blood glucose

variations. Lack of regular SMBG predicts hospitalisation for

diabetes-related complications. SMBG is an essential tool for

people with diabetes who are taking insulin or for those who

experience fluctuations in their blood glucose levels,

especially hypoglycaemia.

9Prevention of hypo/hyperglycaemia during festivals

From mouth-watering gulab jamun to the quintessential kaju katli, it is hard to let go of the sweets/desserts, especially when

festivities are in full swing. DEs should ensure people with diabetes that they can enjoy during festivals without putting themselves

at risk of hypoglycaemia or hyperglycaemia, here are some tips:

¢ Opt for food with natural sweeteners: Natural sweeteners like dates or figs (anjeer); instead of traditional sugar-loaded

sweets like cashew barfi (kaju katli) or boondi ka laddoo.

¢ Cook in a healthy manner: Making minor changes while cooking. For instance, instead of deeply frying chaklis, one can enjoy

baked (or air fried) chaklis.

¢ Choose food options wisely: Control the portion size and choose grilled, baked or barbequed snacks instead of fried ones. For

instance, when people with diabetes visit their friends or relatives, they should choose to eat a few dry fruits or nuts instead of

the calorie-laden sweets or deeply fried namkeens.

11

The American Diabetes Association (ADA) recommends using SMBG as a guide to successful therapy and to achieve postprandial

glucose targets. It can serve an important role in improving knowledge of glucose levels and the effects of different

behaviours on blood glucose outcomes in people with diabetes.


¢ People with diabetes should be made aware that there are increased risks of blood glucose variation in some circumstances during festivals and that they may require an increased testing frequency.

¢ DEs must encourage people with diabetes to not stock boxes of sweets or chocolates in their fridge as these may tempt one to gorge on it later. Instead, share those with the needy.

¢ People with diabetes should consider carrying a continuous glucose monitoring (CGM) device to decrease episodes of hypoglycaemia.

¢ Instead of the traditional sweets and namkeens, they should consider gifting fruits or healthy food hampers.

12

ExpertOpinion

The increasing prevalence of type 2 diabetes (T2DM)

presents a serious challenge to society. There is growing

evidence that the ‘glucocentric’ drug management approach

is misguided as it can cause drastic side-effects and co-

morbid conditions. While waiting for the evidence, it makes 10sense to focus efforts and resources on lifestyle measures.


MD (PGI) – General Medicine

Consultant Physician and Medicine Specialist, Kolkata, West Bengal.

A Guide to a Healthy Feast!

The personalisation of treatment targets is beneficial for people with diabetes who do not benefit from strict target values; whereas,

when a stricter target value is pursued they experience more adverse effects (e.g., hypoglycaemia, postural hypotension).

A personalised approach to the care of these individuals provides a unique management 11plan for each patient:

¢ In a study, of the 890 people with diabetes (54.7% men, mean age 62.7 years), 31.8%

were well-controlled according to the individualised approach and 24.8% according to 12the ‘one-size-fits-all’ approach.

¢ For specific subgroups personalising the treatment led to a 5.2%, 27.3% and 45.6%

increase of people with diabetes achieving low-density lipoprotein cholesterol (LDL-C),

glycated haemoglobin (HbA1c) and systolic blood pressure (SBP) goals respectively.

¢ This individualised approach may especially be beneficial for people with diabetes

aged 70 years on more than metformin monotherapy (HbA1c) and for people with

diabetes aged 80 years (SBP).

Introduction

Individualised approach is a way forward

13


¢ The presence of other medical conditions can directly affect the nature and degree of glycaemic control strategies implemented. In such situations, a realistic approach would be to target the HbA1c to a less intensive range than in otherwise healthy individuals.

¢ On the short term, individualising treatment targets may influence the prescription of medication and the number of adverse effects, which is important since many people with T2DM are overtreated, yet medication de-intensification rarely occurs.

¢ On the long-term, individualisation will lead to a better balance between harms and benefits, which may result in a better quality of life in general.

A clearly defined and relatively simple personalised approach leads to a higher proportion of people with T2DM

considered as cardio-metabolic well-controlled.

14

ExpertOpinion

DKA is an acute, major, life-threatening complication of

diabetes that mainly occurs in people with diabetes. This

condition is a complex disordered metabolic state

characterised by hyperglycaemia, ketoacidosis and

ketonuria. The most common early symptoms of DKA are the

insidious increase in polydipsia and polyuria.

Dr. Manish Sachdev

D. Diab, CCEBDM, CCGDM, CCCA, MBBS

Advance Diabetes and Asthma Clinic, Mumbai, Maharashtra.

Diabetic Ketoacidosis: An Area of GrowingConcern During Long Hours of Fasting

The following are other signs and symptoms of DKA:

¢ Malaise, generalised weakness and fatigability

¢ Nausea and vomiting; may be associated with diffuse abdominal pain, decreased

appetite and anorexia

¢ Decreased perspiration

13Diabetic ketoacidosis (DKA)

There are several challenges associated with blood glucose control in people with diabetes during

the festivals of Navratri and Durga Puja, which are associated with both culinary extravagances and

ritualistic fasting. Fasting alternating with binge eating can result in severe metabolic alterations,

increasing both morbidity and mortality in diabetes.

¢ Rebound hyperglycaemia is a result of prolonged fasting frequently followed by overeating and

binge eating.

¢ Dehydration, secondary to restricted fluid intake, often in the setting of stoppage of

medications and insulin, increases the risk of DKA.

¢ In fact, stoppage of insulin associated with religious fasting is one of the commonest causes of DKA in people with T1DM in India.

¢ Dehydration can result in postural hypotension and syncope in people with autonomic neuropathy along with increased risk of thrombosis and stroke secondary to

hyperviscosity.

¢ Osmotic diuresis secondary to rebound hyperglycaemia following overeating can result

in dyselectrolytaemia and altered sensorium, especially in the older people.

3Challenges associated with fasting for people with diabetes

15

3Recommendations for safe fasting

¢ During the fasting period, if blood glucose is <70 mg/dL, fast should be broken.

¢ Target blood glucose during fasting state is 100–200 mg/dL.

¢ It would be a good practice to audit the SMBG charting done by people with diabetes, during

festivals, for assessment of the glycaemic variability so that lessons learnt can be incorporated

in next year's treatment plan.

2,3Recommendations for short-term fasts:

• Any lunch-time therapy, e.g. metformin repaglinide, acarbose, voglibose or rapid action insulin will have to be discontinued on

the day of the fast. Dinner time therapy usually needs no change, though persons may prefer to take their drugs after breaking

the fast, instead of before.

• People with diabetes who take a single meal during the day of fasting, such as a brunch consumed on somvaar or mangalvaar

(Monday or Tuesday) fasts, may benefit from a single dose of a short-acting drug which targets post-prandial glycaemia.


¢ During festivals such as Navratri, Durga Pujas and Ramadan, DEs must highlight the need to enjoy festivals responsibly, and increase awareness on the role of healthy dietary habits and exercise in maintaining glycaemic control.

¢ DE must convey the importance of pre-fast counselling, and increase awareness regarding hypoglycaemic symptoms among people with diabetes.

¢ DEs must also understand and appreciate the religious and cultural needs of people with diabetes.

Ensuring good glycaemic control during festivals is a challenge both for the treating DE and the person with diabetes. Increasing

awareness among people with diabetes, highlighting the need to enjoy festivals responsibly, promoting healthy diet habits

and exercise, carbohydrate counting, adjustment of anti-diabetic medications and insulin doses accompanied by frequent

SMBG during fasting can go a long way in reducing diabetes morbidity.

1616

ExpertOpinion Festivals are special times, and most people can enjoy a small

serving of their favourite dessert now and then. It is important

to remember that most sweets have a lot of calories and

carbohydrate in a small portion so people with diabetes

should pay attention to their serving size.

Dr. Manish Gutch

MD (Internal Medicine), DM (Endocrinology and Metabolism)

Asst. Prof., Department of Endocrinology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, U.P.

Enjoy A Guilt-Free Diwali!

DEs must know that taste disorder is a common observation in diabetes with a

significant and somewhat specific impairment in sweet taste detection. The observed

correlation between the taste thresholds and the level of blood glucose concentration

suggests that there is a blunted sweet taste response in people with T2DM. This effect

the blood glucose levels directly.

14Abnormal taste sensitivity in people with diabetes

Glucose control in people with diabetes during Diwali – Not so sweet!

Hyperglycaemia is the technical term for high blood glucose (blood sugar). High blood

glucose happens when the body has too little insulin or when the body cannot use

insulin properly.

During Diwali, there are high chances of hyperglycaemia with the intake of sweets and the deadly combination of altered taste sensitivity. It is important for DEs to advise and let their people know more about hyperglycaemia.

15Hyperglycaemia

The signs and symptoms include the following:

¢ High blood glucose

¢ High levels of sugar in the urine

¢ Frequent urination

¢ Increased thirst

17

People with diabetes can manage hyperglycaemia by checking their blood glucose regularly

and by understanding which foods and variations cause this problem. They can treat

hyperglycaemia by exercising and reducing portion sizes.

DKA occurs when hyperglycaemia goes untreated. Hyperglycaemia develops when the body

does not have enough insulin; without insulin, the body cannot use glucose for fuel, so it

breaks down fats, for energy in the process waste products called ketones are produced.

The body cannot tolerate large amounts of ketones and tries to get rid of them through urine.

Unfortunately, the body cannot release all the ketones, and they build up in the blood which leads to DKA.

DKA is life-threatening and needs immediate treatment. The symptoms of DKA include:

¢ Shortness of breath

¢ Breath that smells fruity

¢ Nausea and vomiting

¢ Very dry mouth


¢ If a person’s blood sugar level is above 240 mg/dL, he/she should check for ketones in the urine. Exercising when ketones are present may make the blood glucose level go even higher. It is extremely important to be cautious while managing hyperglycaemia.

¢ DEs must advise people with diabetes to decide ahead of time on the quality and quantity of food will they eat and how will they handle social pressure?

The best bet to prevent hyperglycaemia is to practice good diabetes management and learn to detect it early so that one

can treat it – before one's condition gets worse.

18

ExpertOpinion

Introduction

For people with diabetes, exercise has the same effect on blood glucose as insulin. It lowers blood glucose, making the body more sensitive to insulin. However, this is a benefit of exercise that can also pose a problem if it lowers the blood glucose too much.

Festivals are a great way to stay active, helping around with the decoration, cooking meals, packaging gifts, cleaning the house is a great way to start.

Dr. Arun Vadavi

MD (Medicine), DLO

Director, “Sudha”– The Prevention Centre (Centre for Diabetes Care), Bangalore, Karnataka.

Keep Diabetes at Bay: Staying Active Can Help Boost Health

¢ It is always preferred to check glucose levels before and after the activity, as

sometimes glucose may drop below 70 mg/dL, but one may not feel like the

symptoms of low blood sugar.

¢ Longer more intense activities can cause blood glucose to drop faster. It is essential

to take some form of carbohydrate 20–30 minutes after some intense exercise.

¢ During this festive time, checking the foot is essential to avoid cuts, blisters or

sore feet.

Physical activity makes one healthier is many different ways:

¢ Gives one more energy and strength

¢ Lowers the cholesterol

¢ Improves the circulation

¢ Helps manage weight

¢ Strengthens the muscles, bones and joints

¢ Decreases stress

16Why physical activity helps diabetes and health?

16Things to consider before performing activities

19

Festivals bring so much joy and peace among friends and family, acknowledge the importance of festivals and work

to the best to enjoy with friends and family.

¢ Improves postures, balance and independent living

¢ Improves well-being

¢ Makes one sleep better

Other than the physical activity required during festivals, here are some exercises for the other days:

¢ Thirty minutes of moderate-intensity aerobic activity 5 days a week

¢ Walk briskly for 35 minutes

¢ Ride a bicycle for 20 minutes

¢ Swim for an hour

¢ Dance or pursue aerobics for an hour

¢ Take stairs instead of the elevator

¢ Get up from the desk during the day to stretch and walk around

¢ Take your pet for a long walk

¢ Reduce TV and computer time


¢ DEs must advise people with diabetes to have at least 15 grams of fast-acting carbohydrate with them to treat low blood glucose. Examples of 15 grams carbohydrates are 3–4 glucose tablets, snacks such as 200 mL juice, one small box of raisins, 200 mL regular soda.

¢ Family members of people with diabetes must accompany them for a walk to keep them motivated.

20

ExpertOpinion

Indian festivities

Festivals in India are often associated with fasting as well as feasting, whether it is Navratri followed by Dussehra and Diwali or Ramadan followed by Eid. During the festive seasons, markets are filled with sweets and foods rich in fat, sugar and salt. Also, during this time, there is not only an increase in newly detected cases of T2DM and other lifestyle disorders but also the worsening of sugar control in people

17with diabetes.


MD (General Medicine),DM (Endocrinology)

Harmony Health Hub, Nashik, Maharashtra.

People with diabetes want to indulge and enjoy themselves too, but the fear of high

blood sugar is constantly in their minds. Moderation is the key to enjoyment and

managing the condition.

Fast and Feast Safely in the Festive Season

¢ For individuals with hypertension, DEs should educate people with diabetes to avoid dehydration, to regularly monitor their blood pressure and to watch for

signs of hypotension such as dizziness and lightheadedness.

18,19Tips to enjoy festivities

¢ Diabetes is one of the most challenging conditions to manage during

Ramadan or Navratri, and people with diabetes require close monitoring.

- People with diabetes are unlikely to initiate the discussion. DEs

should mark Ramadan, Navratri and other such fasts on their office

calendar, to bring up the topic for discussion with them.

- DEs should ask about the person’s beliefs regarding fasting, his/her

illness, and the use of oral and injectable drugs when fasting.

21

- The DE should clearly communicate risks of medication changes, changes in

sleeping and eating schedules and withdrawal from substances.

- During the fast, give general preference to medications that will allow for the

easiest compliance e.g., slow-release preparations, longer elimination half-

lives and once daily dosing.

- The DE should encourage a moderate amount of physical activity; too much exertion may contribute to dehydration, but some activity is better than a completely sedentary month.

¢ It is essential to not stop the medication for any fast, the dosage and timing of the

medication will tend to change. DEs must take note of it.

¢ People with diabetes should be sure to check glucose levels regularly so that

medications can be adjusted as needed.


¢ Several studies have shown that people with diabetes arbitrarily change the intake time and dosing of drugs without taking medical advice. This behaviour could alter the pharmacokinetics and pharmacodynamics of drugs, especially those with a narrow therapeutic index, and consequently their efficacy and tolerance will

20also be affected.

¢ If people with diabetes show signs of low blood sugar (such as sweating, anxiety, shaking, weakness or confusion), then they should be advised to immediately break their fast with a sugary drink followed by carbohydrate-rich food.

People end up eating a lot more of fast-food after breaking their fast. Dishes like sabudana khichdi though are popular,

should be avoided as they are low in fibre. People with diabetes should opt for healthier options.

ExpertOpinion Hypoglycaemia is defined as a blood glucose level below

70 mg/dL. Symptoms of hypoglycaemia may include extreme

hunger, nervousness, excessive perspiration, rapid heartbeat

(tachycardia), headache, fatigue, mood changes, blurred

vision and difficulty in concentration and completing mental

tasks.


MBBS, MDRC, PGC (MDRF-ADA), PG (Dip. in Diabetology)

Consultant Diabetologist, Shivam Superspeciality Clinic and Research Centre; Satyam Hospital and Research Centre, Assam.

A False Sense of Hypoglycaemia

22

Do people suffer from hypoglycaemia or 21,22psuedohypoglycaemia?

However, pseudohypoglycaemia is an event when a person experiences typical

symptoms of hypoglycaemia but with a measured plasma glucose concentration

above 70 mg/dL (>3.9 mmol/L). Plasma glucose levels are within reference ranges in

all such people while they are symptomatic.

23Recommendations

Dr. Anne Whittington says, "After a 'spell of time', usually longer than a week of glucose

running high, the human body convinces itself, albeit wrongly, that 250 mg/dL, 350 mg/dL

or whatever, is 'normal.' That is why a reading of 100 mg/dL will then feel low to the body,

'used to' the higher figure, and perceives it as low sugar".

She also mentions that "There is a strong tendency

to overreact to this feeling low, and thus to consume

more carbohydrate than is necessary, to deal with

it”. If a person has a normal blood sugar reading but

feels low (because their body is still used to higher

blood sugar ranges), it is often not necessary to consume the 15 grams of carbohydrate one

would take for a 'real' low blood sugar.

Dr. Whittington recommends one or two 4-gram glucose tablets may be enough or ¹⁄�-cup of

juice or ¹⁄�-slice of bread. And, of course, in this situation, using less carbohydrate, just

enough to get rid of the uncomfortable sensation, is better than bringing the blood sugar

higher.

23


¢ It is important for DEs to recognise the difference between true and pseudohypoglycaemia to prevent unnecessary investigations or treatment for the same.

¢ The absence of symptoms with low glucose values should raise the suspicion of psuedohypoglycaemia. DEs must evaluate the potential drugs that may interfere with the testing

¢ DEs can suggest people with diabetes that someone who has blood sugar levels of 250 mg/dL and above, most of the t ime, should aim for 150/200 mg/dL the first week of reducing their blood glucose, 120–150 mg/dL the second week, and, the third week, about 100 mg/dL.

¢ DEs should keep close contact with such people during the process, and make phone calls to discuss special situations.

Emphasis must be given on correctly distinguish hypoglycaemia from psuedohypoglycaemia to be able to correct sugar

reduction in people with diabetes.

24

ExpertOpinion

24Family and diabetes

Living with diabetes can be an emotional roller-coaster ride, especially, because of the highs and lows that occur most of the time. Although, taking care and managing diabetes is the responsibility of the person with diabetes, family members can be an integral part of this management.

For family members, feelings vary every day; some days are full of worries and fears while some days are full of peace and confidence. To be afraid that something bad takes place is


MBBS, Dip. (Diabetology),

PGC (Diabetes)

VGR Diabetes Specialities Hospital, Vijayawada, Andhra Pradesh.

Enjoying Special Occasions with Diabetes

¢ Family members must consider giving small reminders to the one with diabetes about the risks they can encounter. For

example risk of hypoglycaemia, therefore, pay attention and plan things well.

¢ Family members must plan food items, exercise activities as well as execute them.

¢ There are lots of myths and wrong ideas associated with diabetes; family members of people with diabetes should take a step forward to learn more about the condition. For example, it is

not true that a major sweet tooth can lead to diabetes, or exercise is unsafe for people with diabetes. So that member with diabetes can be benefited, family members can learn the

mechanism of diabetes, ways to prevent emergencies or complications, and other information

associated with it.

24,25What can they do in such situations?

common among the family members. The fear of hypoglycaemia is the most described. The fear of

long-term complications is common as well, and family members even fear that the person with

diabetes may die. Fears associated with self-management behaviour; for example, the family

members may be afraid that the person with diabetes might forget

to take insulin.

Adherence to the self-management is a long process for the

person with diabetes and for the family members. There are many

barriers to optimal diabetes self-management faced by the person

with diabetes. Self-management is affected by several factors, such as feelings, attitudes, self-

efficacy knowledge and skills, and the motivation of the person with diabetes. In addition, the

support from the family members is important.

25

¢ They should also accompany the person with diabetes and tag along to a doctor’s

appointment.

¢ Everyone in the family should get onboard with nutritious meals and stay active.

¢ Family members should know that the person who has diabetes is responsible for managing it, not them. Therefore they should not second-guess the care plan or try to police meals or snacks. Living with diabetes is hard work, and encouragement and support are better than unwanted advice or worse, scolding.

¢ They should encourage one another to try activities like meditating, walking, gardening or watching a funny movie to ease the stress.

¢ They can offer emotional support, and encourage their loved ones to join a support group or talk about professional counselling

if they think that might help.

¢ Partners must be vocal about their thoughts. Women with diabetes are more likely to have vaginal and urinary tract infections,

while problems like nerve damage can cause vaginal dryness and make sex uncomfortable or even painful. Men who have

diabetes are more likely to have erectile dysfunction. Sometimes, having diabetes can affect self-esteem, which can make

someone less interested in sex.


¢ Family dynamics have been shown to have an impact on diabetes management and metabolic control in children and adolescents.

¢ Reaching out a hand to our loved ones can make a lot of difference; DEs should encourage family members to be prepared to face any emergency situation or challenges associated with people with diabetes.

Studies show that people are more likely to follow health regimens when they have a support network.

And research specific to people with diabetes found those who have support from family and friends have

healthier blood sugar levels during times of high stress.

26

ExpertOpinion Management of T2DM in older people is complicated, given

their clinical and functional diversity and the frequent

presence of geriatric syndromes, such as polypharmacy, 26depression and cognitive impairment. Older people need

access to a wide range of prescription drug options to safely 27meet their specific healthcare needs.

Dr. Sanjay Gupta

MD (Medicine), DNB (Medicine),Dip. (Diabetology)

Senior Consultant Physician, Heart and Diabetes Specialist, SG Diabetes Centre, Delhi.

Diabetes in Older People

Individualisation of therapeutic strategies due to co-morbidities

Selecting a pharmaceutical therapy for older people with diabetes can pose a

significant challenge and is determined by three primary factors unique to this group:

¢ The prevalence of multiple chronic diseases or co-morbidity is much higher in

older individuals.

¢ An older body reacts to drugs quite differently than a youthful one due to the

physiological changes that accompany ageing such as a change in metabolic

rate, decline in organ function and alteration of the sensitivity of some drugs can 27occur.

¢ There is generally a wider variation in pharmacological action of a drug across

older individuals compared with younger people with diabetes.

The DE should be clear about the blood sugar levels that have to be achieved in older

people with diabetes while discussing the treatment. For many years, the targets 28HbA1c has been 7% (53 mmol/mol) or lower for all people with diabetes.

In the light of recent studies, this 'one size fits all' approach is no longer tenable for

older people because they are exposed to unique health variables that are rare in

younger people. Individualised drug therapy is required when these factors interact in 26,28an older person.

There are studies that indicate that in those with new-onset diabetes each 1% further

reduction in HbA1c will translate in a further reduced risk of complications while other

studies indicate glycaemic targets of below 6.5% in those with diabetes or some 28duration had less favourable results.

Why is there a need for individualisation?

27

Renal function in the old people may be compromised, not only due to old age but also due to the coexistence of diabetes. Likewise,

chronic kidney disease (CKD) also limits treatment options for diabetes.

Diabetes is the main cause of CKD in developed countries. Furthermore, in

individuals with diabetes, CKD significantly increases cardiovascular morbidity and

mortality and it is the main reason for renal replacement therapy. The therapeutic

strategy for diabetes in old CKD people must be individualised in accordance with

the blood glucose control target previously established and agreed with them, their

family members and/or carers.

The DE should assess kidney disease progression in old person with diabetes to

decide whether or not to refer them to the nephrology specialist. Furthermore, other

cardiovascular risk factors (high blood pressure, hyperlipidaemia, CKD, etc.) should

be addressed in a comprehensive and individualised manner, in line with the recommendations of the main clinical guidelines.


¢ DEs must recommend diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes.

¢ Older people with diabetes need careful assessment, to establish glycaemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status.

¢ DEs must remember that an integral approach to assessing and addressing all modifiable cardiovascular risk factors is required and necessary.

Older people with diabetes require individually tailored pharmaceutical care.

29Diabetes and renal impairment in older people

28

Awareness of the impact of 30,31culture on health

In our country, there is an urgent need to address individual with diabetes health beliefs, cultural needs, current knowledge, physical limitations, emotional concerns, family support, financial status, medical history, health literacy, numeracy and other factors that influence each person’s ability to meet the challenges of self-management.

Caring for People with Diabetes: Understanding the Cultural and Clinical Aspects

In this section, we will focus on understanding the cultural aspects of festivals for

people with diabetes.

Awareness of the need for cultural sensitivity is the first step toward providing

sensitive and competent diabetes education. It is more than a finite knowledge of

cultural values, beliefs, customs, language, thoughts and actions. The need to gain

relevant insight necessitates the need to develop a certain amount of cultural humility.

This will help develop a mutually respectful and positive relationship among people

with diabetes and healthcare providers. The more engaged individuals with diabetes

and their support members are involved in their healthcare, the more likely they are to

achieve desired outcomes and improve their quality of life.

31Key points

¢ A key element to overcome cultural barriers during interactions at the clinic is the use of effective communication.

¢ When explaining the risks of festivals, fasts and diabetes to people with

diabetes, it is important to tailor the information as per the festival by letting them know that you too are aware of the festival, history of the festival, importance of traditions and the traditional foods that are

involved.

¢ By gaining their confidence in the conversation, seep in through the pros

and cons and risk factors that could lead to diabetes complication.

ExpertOpinion

Dr. Sandeep Kharb

MD (General Medicine),DNB (Endocrinology, Diabetes, Metabolism)

Sr. Consultant - Endocrinology, Asian Institute of Medical Sciences, Faridabad, Haryana.

29


¢ DEs need be mindful of the cultural traditions and customs among all cultural and ethnic groups, recognise socio-economic challenges that may exist, and should acknowledge that cultural perceptions of health can be unique for each individual.

¢ The DE should integrate the individual cultures within diabetes education and training as it is important for program effectiveness.

¢ The DE should utilise educational materials and resources appropriate for culture, age, literacy level, and learning readiness.

¢ The DE should incorporate sensitivity and respect when educating all people irrespective of ethnicity, race, age and socioeconomic status.

Understanding the motivational stimuli of people from diverse backgrounds will enable DEs to develop effective programs,

teaching strategies and individualised care plans to mitigate the impact of diabetes.

30

ExpertOpinion


MD (Gen. Medicine),DM (Endocrinology and Metabolism), FACE

Consultant Endocrinologist and Diabetologist, Medanta ARAM Hospital and Aarogya Diabetes and Endocrine Centre, Ranchi, Jharkhand.

¢ In many studies, genetic and lifestyle factors, such as obesity and lack of exercise, are

associated with T2DM.

¢ According to a study in 2016, air pollution, even at levels considered safe, caused one in

seven new cases of diabetes.

¢ A study also estimated that pollution contributed to 3.2 million new diabetes cases

globally in 2016.

¢ Pollution triggers inflammation which reduces the body’s insulin production. Indians

are more prone to inflammation than people in the West.

¢ A study mentions that particulate matter 2.5 microns size contains endocrine-disrupting chemicals. A recent study shows the increasing rate of diabetes across

North Indian cities that have a higher rate of air pollution.

¢ Merging this combo of air pollutants, especially during festivals - the risk becomes much higher.

Popular firecrackers burnt during festivals, such as fuljhadis

(sparklers), snake tablet, anar (flower-pot), pul pul (string

sparkler), ladi or laad (strings of 1,000 crackers) and chakri

(spinning firecracker) emit particulate matter 2.5 microns

size in levels 200 to 2,000 times the safety limit

recommended by the World Health Organisation (WHO).

The particulate matter 2.5 is particles 30 times finer than the

human hair; they accumulate in human organs and

bloodstream, increasing the risk of sicknessand death.

Focus on Breathing Difficulties and Diabetes in the Festive Season

Health hazard for people with diabetes 32,33,34during festive seasons in India


¢ DEs must advise people with T1DM to not stay outdoors for too long during festivals as the pollution can trigger the inflammation in the body.

¢ Family members must understand the side-effects for bursting crackers, especially if their loved ones have been living with diabetes.

31

Stay safe during festivals

¢ We cannot control firecrackers or pollution as much as we want to. There are concerns about growing air pollution. The source of particulate matter 2.5 microns size pollution is combustion, such as from coal and natural gas power plants, vehicles, forest fires and industrial processes that occur on a daily

33basis.

¢ While all this occurs in our day-to-day life, it is important to reduce the complications of diabetes by other means; i.e., eating healthy, staying active, avoiding food that causes hyperglycaemia, staying consistent with medications

and having strong willpower.

In children, breathing difficulties occur due to smoke from firecrackers. Diwali falls during the onset of winter, allergy and asthma

attacks increase and the pollution because of Diwali becomes an add-on factor that precipitates other conditions.

ExpertOpinion


MD (Paediatrics), DM (Endocrinology)

Assistant Professor of Endocrinology, Indira Gandhi Medical College, Shimla, Himachal Pradesh.

Diabetes occurs when the body does not produce enough

insulin or the cells are resistant to the effects of insulin. T2DM

is much more common than T1DM and being overweight is

one of the factors that increase the risk of developing this

condition. However, there are several myths surrounding the

T2DM and weight loss. Here are a few myths and facts along

with ideal strategies of losing weight with T2DM.

Myths and facts

35Myth: Diabetes will not improve unless you lose a lot of weight.

Fact: The focus should be on eating healthy and maintaining moderate

exercise regimen to help improve diabetes.

Introduction

35Myth: If you have T2DM, you can no longer have any carbohydrates.

Fact: While carbohydrate tolerance varies from one individual to other, carbohydrates

play an important role in the diet. DEs should monitor people with diabetes

carbohydrate intake and spread throughout the day for better outcomes.

35Myth: If you have diabetes, you can not enjoy food.

Fact: While one may have to adapt to an eating plan, there are many

delicious foods and recipes that a person with diabetes can enjoy!

Myths and Facts of Weight Loss in T2DM

32

33

Involvement of pancreatic cellsNon-insulin dependent diabetes mellitus or T2DM is a polygenic disorder leading to abnormalities in the carbohydrate and lipid metabolism.

The levels of glucose in the bloodstream rise after a meal, which triggers the release of insulin from the beta cells in the pancreas. However, in T2DM, beta cells lose their ability to produce insulin and this insulin resistance, along with a defect in insulin secretion by the pancreatic beta cells is characteristic of progression to hyperglycaemia.

Normalising of blood glucose due to weight loss

It is important to avoid foods that have a high glycaemic index score along with lowering/monitoring

carbohydrate and sugar content. Low glycaemic index foods are foods that have a score of 55 or less. 37This means these foods will not raise one’s blood sugar and may help avoid a blood sugar spike.

¢ Foods rich in omega-3 fatty acids; salmon, trout, tuna, avocados, garlic, black and blueberries,

chia seeds, apple cider vinegar, leafy greens, nuts, whole grains, and eggs aid in maintaining a low

glycaemic index.

¢ DEs must consult people with diabetes to identify a diet plan that may best suit to their needs.

¢ Exercise along with diet modification can help lower blood sugar and HbA1c levels, which will

help reduce complications.

¢ When a person with diabetes notices his/her improvement with regular exercise, DEs must

consider making changes in the insulin regimen as per their weight and dietary intake.

The most important way to control T2DM is to exercise and eat a balanced, whole foods diet. No single method, food, or workout will replace the long-term benefits of a healthy diet.


¢ Dietary modification leads to improvements in glycaemic control in patients with T2DM.

¢ Lifestyle modification using low carbohydrate interventions is effective for improving and reversing T2DM.

¢ In addition to choosing the right diet, regular exercise is crucial to the health of those with diabetes.

It is not enough to lose weight and then return to previous eating habits. Instead, the diet modification should be a

springboard to a long-term lifestyle change.

34

Studies have shown the positive association between the pace of life and heart

diseases, attributed mainly to stress and way of living. It is also well-evident that fast-

paced lifestyle and mechanisation has decreased physical activity among people, and

increased the incidence of obesity, stress, smoking, diabetes and other health issues.

The chronic exposure to stress can have delirious effects on the physical and mental

health of the population. Therefore, it is important for people to take extra measures to

keep them healthy to be fit for survival in this fast-moving world.

39, 40Managing diabetes through a fast-paced life

Diabetes can be managed through family vacations, recreation and leisure activities which have positive effects on family unity, and

can assist in reducing stress and increase family bonding, togetherness and agreement which can reverse the effects of

psychological issues. Prayers and involvement in religious activities have been found to be beneficial in keeping positivity in life.

Most people tend to run from home to work and later from work to home; juggling a fast-paced life. It is important for people with

diabetes to opt for nutritious and healthy food instead of a “fast-pace-fast-food” world.

ExpertOpinion

Dr. Sandeep Suri

MD, FIDM, MBBS

Consultant Medicine at Holy Help Hospital, Hisar, Haryana.

38Fast-pace of life and its impact on health

Increasing modernisation and mechanisation have turned the

life into a fast-paced, and has devastating effects on the

health of the people. The pace of life in major cities is now

much quicker than before. Researchers believe that this

increase in speed will affect more people than ever because

the majority of the world's population is now living in urban

centres.

Juggling Between a Fast-Paced Life and Diabetes

35

¢ People with diabetes should opt for coconut water and healthy juices over carbonated drinks.

¢ They must give priority to healthy diet snacks over fast fried food.

¢ They can perform stretching exercise while sitting in the workplace.


¢ Spending time with the family is an effective strategy to de-stress and meal times are the best time to mingle with the family.

¢ It is important for people to take time out for themselves and their families to keep themselves fit for survival in this fast-moving world.

¢ People with diabetes must choose to eat healthy during work hours to stay on track.

One of the major drawbacks of this increasingly modern and fast life is limited time for self and family which

can be the root cause of many problems and can lead to devastating health conditions.

36

ExpertOpinion


Chief Physician and Diabetologist,Sai Hospital, Palakkad, Kerala.

Most people have a sedentary lifestyle due to which they tend to ignore certain signs. Most think “It is just the result of working on my phone or laptop all day”. However, DEs must know there is a link between diabetes and frozen shoulder (or

41other muscular and skeletal problems).

Do Not Ignore that Frozen Shoulder:It Could be a Sign of Diabetes

Introduction

41What exactly is a frozen shoulder?

42Frozen shoulder occurs in 3 stages:

¢ Freezing: Pain slowly becomes worse; until the range of motion is lost (lasts 6 weeks to

9 months)

¢ Frozen: Pain improves, but the shoulder is still stiff (lasts 4 to 6 months)

¢ Thawing: Ability to move the shoulder improves; until returning to normal or close to

normal (lasts 6 months to 2 years)

Frozen shoulder is characterised by what is called “loss of passive range of motion”. Passive

range of motion can be described as the movement of joints through the range of motion by

another person or equipment with no effort from the person himself. A frozen shoulder, the

shoulder is physically stuck with no active or passive range of motion.

Frozen shoulder occurs when the flexible tissue that surrounds the shoulder joint becomes inflamed and thickened. Experts believe chronic inflammation in the joint – similar to osteoarthritis or rheumatoid arthritis – could occur as a result of hyperglycaemia, which could increase swelling in the joint.

Another source says that diabetes and degenerative joint disorders or osteoarthritis cases

are very common and go parallel to each other; has diabetes is directly linked to vitamin D deficiency, calcium deficiency, decreased immune response and osteoporosis.

Managing this condition will include sugar, diet and physiotherapy control. No medication or

surgery is needed unless it is an extreme case and goes on for years without improvement. Massaging the area with a heating pad for 15 minutes twice or thrice a day helps.

Dr. T. S. Ramaswamy

37

41Exercises for frozen shoulder

Towel stretch

¢ Hold one end of a three-foot-long towel behind the back and grab the opposite

end with the other hand

¢ Hold the towel in a horizontal position

¢ Use the good arm to pull the affected arm upward to stretch it

¢ Cross-body reach

¢ Sit or stand

¢ Use the good arm to lift the affected arm at the elbow and bring it up and across

the body, exerting gentle pressure to stretch the shoulder

¢ Hold the stretch for 15 to 20 seconds

Armpit stretch

¢ Using the good arm, lift the affected arm onto a shelf about breast-high. Gently

bend the knees, opening up the armpit

¢ Deepen the knee bend slightly, gently stretching the armpit, and then straighten it

¢ With each knee bend, stretch a little further but do not force it


¢ DEs must make sure that people with diabetes only carry out light stretches so that they do not strain the shoulder further, and if the pain persists or increases they should consult a doctor immediately.

¢ DEs must encourage people with diabetes to have an active physical life on the diagnosis of diabetes in order to avoid such conditions.

Frozen shoulder is one of those lesser-known diabetes complications, one that does not get discussed much as

compared to vision loss, nerve damage, kidney issues and a host of others.

38

DEs play a vital role in helping people with diabetes to identify possible

challenges and strategies and to overcome those challenges through

DSME. The major components of DSME include healthy eating, taking

medication, exercising, monitoring glucose, problem-solving for glucose 43management, reducing the risk of complications and living with diabetes.

Contributed by

MSc.

Dietitian, Dr. Mohan’s Diabetes Specialities Centre, Domalguda, Hyderabad.

Introduction

The prevalence of diabetes in India is showing a sharp upswing, and as we know, uncontrolled diabetes can lead to complications such as heart disease, stroke, kidney failure, and vision loss. The person with diabetes has to accept his/her condition to live with diabetes, eliminating its symptoms and trying to avoid or reduce its complications with regular treatment, medications, along with changes in lifestyle.

Understanding the Challenges, Strategies andRole of Diabetes Education

Medical nutrition therapy (MNT)

One of the significant pillars in the treatment of diabetes is MNT. T1DM is managed

with insulin as well as with dietary changes and exercise. OHAs are the initial line of

pharmacotherapy in most of the people with T2DM.

The choice of medications for diabetes is individualised, taking into account the

effectiveness and side-effect profile of each medication, person’s underlying health

status, any medication compliance issues and cost to the persons or healthcare

system.

Ms. Sara Mushrifa

Challenges faced in MNT

Providing MNT to the people with diabetes poses many challenges. Adherence problems include drug regimen and patient-

related barriers.

Drug regimen and adherence challenges

Barriers to adherence can be associated with the medications themselves. Commonly cited barriers in this category include drug

39

44,45 costs, adverse effects, increasing regimen complexity, or increased frequency of dosing.

People with diabetes can make wrong decisions when their understanding is incomplete.

For example, after experiencing hypoglycaemia, the person may discontinue the drug which

would result in high blood sugar levels. Many a time, people with diabetes get confused

about the medication timings and dosage. Sometimes a particular medication can be

continued by the person for years due to negligence. The rising cost of the drug also

becomes a barrier in adherence. Insurance companies changing payment terms and tiers of

classification can also result in non-adherence. A person with diabetes experience of

adverse effects also adds to the factor of non-adherence. People with diabetes often stop the

medication after experiencing the adverse effects and do not have a follow-up with the

treating consultant regarding the same.

Patient-related barriers

People with diabetes perception of medical management also pose a challenge. These people view

therapy intensification as a personal failure and believe more strongly that complications would

develop. Hence, they do not follow the drug advised by the treating consultant on a regular basis.

Progression from oral medications to insulin therapy is common. However, for many reasons,

people with diabetes often perceive this negatively – fear of administering injections or may view

this progression as a personal failure or even as an end stage of diabetes.

Examples of system-related barriers include insufficient

counselling time with DEs and lack of appropriate follow-up 46appointments with the treating consultant. Patient-related

barriers can be highly individualised, including poor health literacy, misunderstanding or fear of

drugs, fear of worsening disease, lack of skills to perform SMBG, poor injection technique, poor

family dynamics or health habits, lack of knowledge with regards to dosage adjustments, 47,48depression, and concurrent medical conditions.

Summary

For achieving optimal control of blood sugars, the person with diabetes must be counselled by the DE on the following points:

¢ Types of diabetes, and which type of diabetes they have (the misconception persists that a person who takes insulin has TIDM)

¢ Goals of therapy including HbA1c, fasting and postprandial glucose goals, and how to correlate self-monitoring results with

overall HbA1c

¢ Lifestyle modifications including exercise and MNT

¢ Medications (with possible barriers addressed as well)

¢ DSME including SMBG

¢ Appropriate foot care and sick-day management

40

OHAs are the initial line of pharmacotherapy in most of the people with T2DM. T1DM is managed

with insulin as well as with dietary changes and exercise. One of the significant pillars in the treatment of diabetes is

MNT. Providing MNT to the people with diabetes poses many challenges such as costs, adverse effects, increasing

regimen complexity and incomplete understanding of the person about medication. DEs play a vital role in helping people

with diabetes to identify possible challenges and strategies and to overcome those challenges through DSME.


To overcome challenges in MNT:

¢ DE should inquire people with diabetes about self-monitoring habits and injection technique and should resolve any knowledge-based discrepancies.

¢ People with diabetes should also be instructed thoroughly on the use of oral medications, including dosing, storage procedure, efficacy and adverse effects.

¢ DE should pay special attention to people with diabetes taking insulin. They should provide in-depth counselling regarding insulin, site of injection, and the

importance of regular administration, storage dosage adjustment and correction

for hypoglycaemia.

¢ To counter people with diabetes perceptions, the DE can emphasise that oral

drugs and insulin are tools to improve health. Just as a builder may need special

and multiple tools instead of simply a hammer and nails to build a house,

similarly, the person may need multiple drugs. DE should make people with

diabetes understand why a treating physician shifts from oral medication to

insulin. They have to properly address and remove the fear of insulin initiation in

people with diabetes.

¢ DE can simplify regimens by changing to once-daily extended-release

formulations. Ancillary supplies, such as monitors, strips, needles, and pen needles, should be written as prescriptions to enhance the likelihood of insurance

coverage. Pill organisers, alarms or calendars, and blister packaging could enhance adherence.

¢ People with diabetes who are technologically inclined can be introduced to cell

phone applications to enhance their knowledge regarding the recent trends in diabetes management, oral medication and insulin.

Multiple Feathers on DEs Cap

The different hats worn by DEs – How can a DE ensure good health for a long-term person with diabetes even during phases where there is stagnant development?

41

The DEs are an integral part of the diabetes management team. The role of the educator is to enable people with diabetes to manage their diabetes-related health to the best of their ability, to allow them to make choices and take actions based on informed judgment, and to enhance

49the quality of life of people with diabetes.

The long-term person with diabetes, observe several highs and lows along with several restrictions in his/her daily life. It is important for DEs to not give up on these people and not let

the people give up on themselves. Diabetes is a burdensome disease that requires the person

with diabetes to make numerous daily decisions

regarding food, physical activity and medications.

DSME is critical in laying the foundation with ongoing support to maintain gains made 50during education.

The paradigm of diabetes management has shifted to focus on empowering the person

with diabetes to manage the disease successfully and to improve their quality of life.

Diabetes education needs to be individualised – reflecting the uniqueness of each

person. What should be learned and how it should be learned varies from person to person.

49People with diabetes should recognise that:

¢ Adjustment to diabetes is ongoing; it needs to be addressed in the early stages and

throughout the life cycle.

¢ Living with diabetes often requires changes to lifestyle that are difficult for most people

with diabetes to achieve and sustain.

¢ Diabetes-related stress is common; particularly fear of hypoglycaemia and long-term complications.

¢ Diabetes-related distress is common and can persist for years after the diagnosis, manifesting itself as anger, fear and frustration.

¢ Clinical depression is more prevalent among people with diabetes than the general population.

¢ People can use different cognitive and behavioural strategies to cope with the demands of diabetes- and treatment-related stresses.

Along with the person with diabetes, determine personal targets for treatment – including blood glucose, lipid values, blood

pressure, HbA1c, meal planning and physical activity to improve people outcomes with diabetes.

42

¢ Location: Berlin, Germany

¢th th Date: 27 – 28 September 2018

Diabetes meeting 2018 conference will focus on the latest and exciting innovations in all areas of diabetes research. This year’s annual congress highlights the theme, “Diabetes from monitoring to management” which reflects the innovative progress in diabetes disease research. Diabetes conferences will bring together diabetologists and scientists under a single roof to discuss the topics which include, but not limited to, diabetes types and symptoms, diabetes complications, diabetes and the elderly, clinical diabetes and diagnostic approaches, metabolic syndrome, diabetes associated disorders, diabetes medications, management of diabetes, gestational diabetes, alternative medical therapies for diabetes, computerised applications in diabetes and diabetes technology.

Upcoming Diabetes Educator Conferences

th 5129 International Congress on Prevention of Diabetes and Complications

Conference snippets

¢ Diabetes types and symptoms

¢ Technologies for the treatment of diabetes: New

insulin conveyance systems: Inhaled, transdermal

and embedded devices

¢ Clinical diabetes and diagnostic approaches: Novel

research and treatment strategies on diabetes

¢ Alternative medical therapies for diabetes: Chinese

medicine and acupuncture

¢ Young researchers in proteomics and molecular medicine

¢ Poster presentation

¢ Workshop

43

Tool: Smart Pen for People with Diabetes

52,53 InPen

The InPen insulin injector pen is an easy-to-use pen that not only helps calculate the doses

but also keeps track of injection data.

When paired via Bluetooth with the smartphone app, the InPen delivery system keeps tabs

on how many units the person had received at his/her last injection, when they took them,

and other helpful information.

InPen was designed for insulin-dependent individuals, 12 years and older, undergoing

multiple daily subcutaneous injections. It can deliver 0.5 to 30 units of insulin, dialled in half-

unit increments.

Key points

¢ InPen shows the current status at a glance, from the last dose to active insulin to

recent doses.

¢ The dose calculator helps take the guesswork out of dosing. The person with

diabetes is required to enter their blood glucose, and what they intend to eat and the

correct dose is recommended, taking into account recent doses to avoid insulin

stacking.

¢ InPen provides an individual with optional dose reminders, reminders to check blood

glucose after dosing, and temperature alerts for their insulin.

¢ InPen helps with reporting, the person with diabetes can share their therapy

summary with their care providers, so it is easier to see the big picture when adjusting the care plan.

The InPen app is the other half of InPen’s smart diabetes management tool. Using information transmitted from the pen, the app can

track insulin therapy; calculate doses, share therapy data with the doctor or family, and much more.

InPen is compatible with all Apple iOS devices that support iOS 10 or greater. An Android version of the app will be coming soon.

Future Trend: Watson Artificial IntelligenceHelping People with Diabetes

Artificial intelligence (AI) is being used today to help people with diabetes to manage their thglucose. The study was presented at the ADA 78 scientific sessions. They announced

findings from three data presentations at ADA, including real-world data underscoring the

value of machine learning and analytic tools in diabetes.

The average person with diabetes has to make more than 180 decisions daily based on

careful monitoring of their glucose, nutritional intake and activity level. Using Watson, the

Sugar.IQ™ app gives people with diabetes powerful, personalised insights to help them

makemore informed decisions to better manage glucose levels and keep them in the target

54range.

Findings of the presented study

¢ A study presented at ADA found that people with diabetes using the Sugar.IQ™ spent 36 more

minutes per day in healthy glucose range compared to before they used the app. This included

30 minutes less time in hyperglycaemia (>180 mg/dL) and 6 minutes less time in

hypoglycaemia (<70 mg/dL). This represents more than 9 additional days in a year that a

person with diabetes is spending in a healthy glucose range.

¢ A significant number of people with T2DM are not compliant with their medications after one

year. After three months, 31% of people had discontinued their diabetes medications

altogether; by six months, the number increased to 44%, and by one year 58% of people had

stopped treatment. This study suggests interventions are needed to improve adherence

and avoid gaps in therapy that can be associated with serious outcomes for people with

diabetes.

¢ The study also found that certain T2DM medications classes are associated with fewer

instances of cardiovascular events, including heart failure, heart attacks and strokes,

demonstrating the power of machine learning techniques to help practitioners develop

new insights that can positively affect the care of people with diabetes.

44

Take home message

¢ AI, machine learning and analytics are changing the way people manage their health.

¢ Sugar.IQ™ helps to keep blood sugars in normal ranges for 9 extra days over a period of a year.

¢ The study included data for 324,136 adults (mean age 55 years, 46% women) and showed that after one year, 58% of

people with diabetes had stopped their treatment, and suggested interventions are needed to improve adherence.

45

Diabetes Educator of the Month

Contributed by

Ms. Twinkle Dedhia

BSc, PGCND (Specialisation-Diabetes and Cardiac Care)

Nurture Health Solutions.

Intervention by DE

The DE took a detailed history of the child. The DE explained to the mother that T1DM is an

autoimmune condition where the beta cells that produce insulin stop functioning due to an

autoimmune reaction. People with T1DM need to be on insulin therapy lifelong.

The mother was under the impression that people with diabetes are first given medicines

and then insulin if blood glucose levels are not under control.

The DE explained to her that people who have T2DM initially start with medicines and later

on if uncontrolled have to take insulin.

The DE counselled her that her son will be able to lead a normal life. She taught them

carbohydrate counting and asked them to take insulin for the amount of carbohydrates he is eating. She assured them that carbohydrate counting would give them the much-needed

flexibility and he can enjoy his favourite foods provided he takes adequate insulin. They were very happy and relieved to hear that as

the mother was concerned about refraining him from attending his friend’s birthday parties.

The mother was afraid that her son will not be able to participate in sports. The DE told her it

will be good for her son’s health if he is physically active and gave her examples of great

sportspersons like Wasim Akram and Kyra Shroff who have T1DM yet have excelled in their

field. She counselled them that indulging in physical activity would in fact help in improving

insulin sensitivity and keep his blood glucose levels under control. She asked the mother to

check her son's blood glucose levels pre and post activity. She also helped her with a list of

foods that need to be taken by her son pre and post workout. The dietician/nutritionist also

provided guidelines to manage high and low blood glucose levels.

Mrs. Gori was happy to visit the DE and get her doubts clarified.

A 7-year-old boy was diagnosed with T1DM. He is very adamant to go back to school. He is unable to have a normal school life like

other kids. Mrs. Gori (his mother) is worried and has come to visit a DE.

Following sections are contributedby Nurture Health Solutions

Nurture Health Solutions is a true health and well-being

company offering niche comprehensive health and

wellness solutions to corporates and individuals.

46

Query: My husband is a 57-year-old man. He works in a bank. He has been living with diabetes,

hypertension and high cholesterol for years. He has not been doing much apart from popping pills. Lately, we went to the clinic to check his blood pressure as he was sweating profusely at any time of the day. His blood pressure was 148/90 mmHg. At the same time, his HbA1c level was 7.5%. What can I do to make his lifestyle much better than it is and improve his numbers?

DE: A healthy balanced meal plan and exercise will help him improve his blood glucose levels

and reduce high cholesterol levels. A healthy balanced meal comprises of high fibre, complex

carbohydrates, good quality proteins and fats, vitamins and minerals. Exercise plays a very

important role in reducing high cholesterol levels. People having high blood pressure should

avoid doing resistance training. He can do aerobic exercises like walking, brisk walking, etc. Salt recommendation for people with

hypertension is less than 1 tsp per day; packaged and processed foods (chips/biscuits/ready to eat foods) also contribute to the salt

intake. Hence, reading food labels is very important. Low sodium salts are not advised – as people end up having it in excess– as

they are under the impression it will not increase their blood pressure. Your husband can get a customised meal and lifestyle plan

from a qualified dietician to suit his lifestyle.

Query: I am a 52-year-old woman, mother of 3 children. I have been taking metformin for diabetes for the past 8 years. Of late, I have

bad hot flushes early in the morning. Sometimes I feel too cold. I believe I am entering the menopause phase. I want to know if anti-

diabetic medicines have any effect on menopause. If yes, how can I manage it better?

DE: Hot flushes are a common symptom of the menopause experienced by 75% of menopausal

women. It can be as described as a sudden feeling of warmth or heat in the body. During

menopause, hormonal changes cause fluctuations in blood glucose levels. Weight gain is also

common during this phase. This can increase the dosage or frequency of anti-diabetes

medicines. Following a healthy meal plan and physical activity will help in preventing weight gain and control blood glucose levels.

Query: I am a 38-year-old working woman, weighing 286 kgs. My body mass index (BMI) is 32.4 kg/m . Recently I

was diagnosed with diabetes. My doctor has asked me to

make drastic changes in my diet like cutting down on sugar,

carbohydrates, etc. I am so used to the food that I normally eat and do not really enjoy diet food. I

do not feel too full and tend to overindulge by night. Can you suggest some alternative for rice,

pasta, sugar and desserts?

DE: You do not need to stop carbohydrates completely, but just need to modify the quality and

quantity of carbohydrates you are consuming. Replace your simple carbohydrates like simple sugars, fruit juices, and refined flour with complex carbohydrates like broken wheat, barley, oats, jowar, nachni, whole fruits, vegetables etc. You can enjoy your rice, pasta and potatoes just by modifying the method of preparation. You should cook the rice

/pasta/potato a day prior, cool it in a refrigerator for 24 hours and then eat it without heating it at high temperature. By doing this, there is a formation of retrograded starch which prevents sudden spikes in post-meal blood sugars. You do not need to opt for diet

Frequently asked questions

Family and Diabetes Corner

47

foods but go for healthy balanced meals instead. A healthy balanced diet comprises of high fibre

complex carbohydrates, good quality proteins and fats, vitamins and minerals. You can get a

customised meal and lifestyle plan from a qualified dietician to suit your lifestyle.

Query: My father-in-law, 70-year-old, has been living with diabetes for a very long time. He is

also a heart patient. Due to the medications for these conditions, he is inclined to develop renal issues. Lately, he has been also complaining of vision problems. He said there are white patches which appear for a few seconds and then disappear. What could possibly be the problem?

DE: Effective management of diabetes requires sustained glycaemic control to lower the risk of

complications. Chances of complications increase with long-standing diabetes. Organs at

increased risk of damage with high blood glucose levels are eyes, kidney and nerves. The appearance of white patches and vision

problems could be due to diabetic retinopathy where the eyes are affected due to high blood glucose levels. Renal issues can

increase the blood pressure and aggravate this condition.

Query: I am a 53-year-old man, diagnosed with diabetes several years ago. I used to use sugar in moderation in all food items,

especially tea. A few months ago, my colleague suggested using artificial sweetener or stevia. I thought this would work on reducing

my blood sugar levels; however, I see no change with artificial sweeteners. Is there any

alternative you suggest?

DE: People having diabetes are not advised to completely stop sugar intake. It is recommended

to them 10% of calories should be from simple carbohydrates (sugar) as the brain requires

glucose for functioning. Not all artificial sweeteners are calorie-free; some of them like sugar

alcohols still provide 50% of calories and contribute to the carbohydrate intake. Hence can

affect the blood glucose levels also artificial sweeteners have their own side-effects and are not

advised to be consumed in large amounts on a regular basis. Stevia is a natural sweetener;

hence stevia leaf powder can be consumed.

Busting the myth: Sugar-free packaged juices can be consumed in liberal amounts

Fact: Sugar-free does not mean “calorie-free” or “fat-free”.

Making healthy food choices have become a necessity in today’s world. Due to a busy lifestyle, everyone thinks that instead of

grabbing a fruit or two, drinking a glass of packaged fruit juice equates to eating healthy and nutritious food, but it is not true, not only

packed juices even fresh juices are unhealthy in comparison to fresh fruits. For instance, at least 4–6 fresh fruits are needed to make

a glass of juice at home as the juice is strained it results in more calories and carbohydrates and no fibre at all. In case of packaged

juices –the skin of the fruit is removed, and the fruit is pasteurised to kill the harmful bacteria present– Due to peeling of the skin

many essential nutrients that are present in the skin are lost; pasteurisation denatures the enzymes and destroys minerals and

vitamins that are present in the fruit. The additives in the packaged food, such as artificial food flavours, colouring agents and

preservatives, are also detrimental to one’s health.

48

Get Active!

Increasing physical activity in the daily routine

‘Sitting is the new smoking’. Staying active throughout the day is an effective way to lose weight and improve the body’s ability to

use insulin and thus maintain good blood glucose control. Simple ways to increase physical activity in life each day are:

¢ Walk around while talking on the phone or during TV commercials.

¢ Do any type of house chores of your choice for at least 30 minutes.

¢ Park at the far end of the shopping centre parking lot and walk to the store.

¢ Take the stairs instead of the elevator or escalator. If taking the escalator, walk up escalators instead of just taking a ride.

49

¢ Make your family and friends outings active, such as walking in the park, cycling together,

going for bowling, swimming, shopping, etc.

¢ Do not stay seated for more than 30 minutes. Walk around for 5 minutes every 1 hour.

¢ Walk the dog: Do not just watch the dog walk.

¢ Choose to walk over a vehicle for travelling to short distances.

¢ Replace a tea/coffee break with a brisk 10-minute walk. Ask a friend to go with you.

¢ Get off the bus a stop earlier and walk to the destination.

¢ Go grocery shopping outside.

National Diabetes Educator Program(NDEP) Best Practices

NDEP – National Diabetes Educator Program has been ongoing since 7 years. It has been developed with the objective

of creating DEs. A DE is a healthcare professional who is specialised and certified to teach people with diabetes how to

manage their condition. This program is under the auspices of the Indian Association of Diabetes Educators (IADE) and

Dr. Mohan’s Diabetes Education Academy (DMDEA), a unit of Dr. Mohan’s Specialties Centre, and is promoted by USV.

The program is being conducted in 150 NDEP centres across India.

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

Join NDEP Facebook page to know more about it!

50

We all know that education is the cornerstone of diabetes treatment. We busy physicians do not have time to educate our patients in daily routine practice. So we were in need of a person who can guide our patients about diabetes so that they

Contributed by

Dr. Shachin Kumar Gupta

MD (Medicine)

Consultant Diabetologist,

Krishna Diabetes Clinic and Educational Research Centre, Bhopal, Madhya Pradesh.

51

can live a happy and healthy life without complications. This dream was fulfilled by NDEP run by USV Pharma. When USV Pharma

people approached me to become a mentor for this program, I thought can a Pharma company do such a noble cause? I immediately

agreed for the same and for last the 7 years I am successfully conducting this program. I feel proud to be a part of this noble cause,

and a lot of patients are benefited by this program.

Thanks to Dr. V. Mohan, Dr. Shashank Joshi, his team and USV Pharma for doing such a noble deed.

Eat Out, Be Wise!

Tomato shorba

Why is it called tomato shorba and not just tomato soup? Well, tomato shorba is a thick and

spicy version of either a vegetable or meat gravy which has a soup-like consistency.

History of tomato shorba, spiced Indian tomato soup, dates back to Persian times and this

soup is totally different from the regular tomato soup.

Warm up your winter evening with a bowl of freshly made tomato shorba – spiced Indian

tomato soup. Flavoursome and so comforting!

Ghugni

Ghugni, popularly known as Ghugni chaat in North India, is a lip-smacking snack, which

can be had especially on monsoon evenings. The Ghugni can also be prepared as a side-

dish and eaten along with roti. The addition of the tamarind chutney heightens the taste

buds and leaves you asking for more.

South

Pesarattu dosa

Dosa is undeniably one of the most popular South Indian delicacies, and there are several versions of it. Pesarattu dosa is a preparation native to Andhra Pradesh. It is a snack or a

breakfast meal made with green gram; sometimes served with plain upma (pesarattu with upma is known as MLA pesarattu) and ginger chutney.

This dosa, loaded with the goodness of lentils, is light on the stomach and can make for a

delectable treat for the taste buds.

East

North

Pesarattu

Swasthi

West

Dal dhokli

It is a good combination of cereal and pulses that make it a complete protein meal. Apart from being easy to prepare, healthy and filling, it is capable of carrying the entire meal on

its own and does not require any accompaniment.

52

Shopping Smart

53

Sugar-free chocolates/Sweets

Many people assume sugar-free sweets or chocolates have fewer calories and are a boon for those who are having diabetes and for

weight watchers. Unfortunately, the truth is that a sugar-free product does not mean it is a calorie free, carb free or fat-free product.

The calories are still on a higher side. Most of the times, the products labelled as sugar-free have a higher amount of fat, and fat-free

products have a high amount of sugar. Many of us tend to exceed the portion size just because product label mentions it has sugar-

free, and thereby indirectly increase our calories and fat intake. It is advisable to read the food labels carefully and compare the

amount of carbohydrate as well as fat, especially the saturated fat before considering it as a healthy sugar-free product.

¢ They are low in cholesterol, fat and sodium, and hence becomes an ideal snack to satiate those in-between meal hunger

pangs.

¢ Beneficial for those suffering from high blood pressure, heart diseases and obesity due to their high magnesium and low

sodium content.

¢ Recommended for people with diabetes due to low glycaemic index.

¢ Makhanas being gluten- free and low in calories serves an ideal snack option for weight loss.

Superfood: Makhana/मखाना

54

Nutritional benefits

¢ Fox nut or lotus seeds, commonly known as Makhana, are currently the oldest

known plant seeds containing numerous health benefits. It is often added to food,

as an ingredient, and can be eaten raw or cooked.

¢ Makhana also finds significance in religious ceremonies in India and is a popular ‘fasting’ dish prepared during Navratri and other occasions, and is a healthy alternative to chips, chivdas and farsans.

¢ Roasted makhana pops have a high volume to mass ratio, so they can be very filling, and can be consumed as a mid-evening

snack. One may also add paneer and salad vegetables to the mix and make makhana paneer chaat to add a bit more crunch

and nutrition to the snack.

¢ Makhanas can be eaten in the form of a vegetable.

Recommended dosage

How to consume?

¢ One bowl in a day.

Method

¢ Mix paneer, tomatoes, cucumber and coriander in a large bowl. Add Makhana, lemon juice, salt and pepper to it. Toss and serve well.

Serves: 2

Ingredients Amounts

Makhana (roasted) 1 cup

Low fat paneer ½ cup

Tomato (diced) ½ cup

Cucumber (diced) ½ cup

Coriander (chopped) 1 tbsp

Lemon juice 2 tbsp

Black pepper powder ¼ tsp

Salt to taste 1 tsp

Recipe

Makhana paneer chaat

55

Secret behind grandma recipe

Paneer ke phool

Paneer phool, also known as paneer doda, is a gem from grandma’s nuskhe.

Paneer ke phool is a flower that is majorly found in India and used in various medicines in Ayurveda. They are sweet and have

sedative and diuretic properties. It is said to combat insomnia, nervous exhaustion, asthma and diabetes.

It is said to be useful not only for regulating the insulin level inside our cells but also it helps in repairing the beta cells of the pancreas

which produce insulin.

56

How to consume?

¢ Soak 10–15 pcs. of paneer phool in water overnight.

¢ Next morning squeeze out the paneer phool to bring out the extract in water.

¢ Filter it through the sieve.

¢ Drink that water on an empty stomach.

References

1. Festivals of India. Available at: https://www.indiacelebrating.com/festivals-of-india/

2. Kalra S, Bajaj S, Gupta Y, et al. Fasts, feasts and festivals in diabetes-1: Glycemic management during Hindu fasts. Indian Journal of

Endocrinology and Metabolism. 2015;19(2):198–203.

3. Dutta D, Biswas K, Sharma M, et al. Managing diabetes during Navratris with special focus on Durga Pujas. J Soc Health Diabetes.

2015;3:84–8.

4. Ahuja A. 7 Do's and don'ts for diabetics to enjoy festivals. 2017. Available at: https://food.ndtv.com/health/7-dos-and-donts-for-

diabetics-to-enjoy-festivals-1212153

5. Diwekar R. A seven-point guide to healthy Diwali feasting. 2017. Available at: https://www.livemint.com/Leisure/

FIz8lL6zPFrHd4AaeqEssN/A-sevenpoint-guide-to-healthy-Diwali-feasting.html

6. Managing diabetes during festival. Available at: https://apollosugar.com/world-of-diabetes/diabetes-management/managing-

diabetes-during-festivals/

7. Baliga V. Managing diabetes during festivals. Available at: https://www.medlife.com/blog/managing-diabetes-during-

festivals/#physical-activity-when-fasting

8. Kirk JK and Stegner J. Self-monitoring of blood glucose: Practical aspects. Journal of Diabetes Science and Technology.

2010;4(2):435–439.

9. Agarwal S. Here is how you can have a sugar-free Diwali. Deccan Chronicle. Available at: https://www.deccanchronicle.com/

lifestyle/health-and-wellbeing/161017/heres-how-you-can-have-a-sugar-free-diwali.html

10. Is the current ‘glucocentric’ approach to management of type 2 diabetes misguided? Therapeutics Initiative. 2016. ISSN 2369-

8691.

11. Subramanian S and Hirsch IB. Personalised diabetes management: moving from algorithmic to individualized therapy. Diabetes

Spectrum. 2014;27(2):87–91.

12. Boels AM, Hart HE, Rutten GE, et al. Personalised treatment targets in type 2 diabetes patients: The Dutch approach. Primary Care

Diabetes. 2017;11:71–77.

13. Hamdy O. Diabetic ketoacidosis. 2018. Available at: https://emedicine.medscape.com/article/118361-overview

14. Yazla S, Özmen S, Kıyıcı S, et al. Evaluation of olfaction and taste function in type 2 diabetic patients with and without peripheral

neuropathy. Diabetes Metab Res Rev. 2018;34:e2973.

15. Hyperglycemia (High Blood Glucose). 2014. Available at: http://www.diabetes.org/living-with-diabetes/treatment-and-

care/blood-glucose-control/hyperglycemia.html

16. BD Getting Started. Exercise and Diabetes. Available at: https://www.bd.com/resource.aspx?IDX=10241

17. Jhingan AK. How to fast and feast safely in the festive season when you have diabetes. Available at: https://www.huffingtonpost.in/

dr-ashok-kumar-jhingan/how-to-fast-and-feast-safely-in-the-festive-season-when-you-have-diabetes_a_23225926/

18. Kelly G and Alsabbagh W. “Managing medications during Ramadan fasting.” Canadian Pharmacists Journal.

2017;150(3):146–149.

19. Alomi YA. Update 2017- Drug therapy during holy month of Ramadan. Available at: https://www.researchgate.net/profile/

Yousef_ Alomi/publication/317180074_Update_2017-_Drug_Therapy_during_Holy_Month_of_Ramadan/links/

592aecefaca27295a80b751e/Update-2017-Drug-Therapy-during-Holy-Month-of-Ramadan.pdf

57

20. Aadil N, Houti IE and Moussamih S. “Drug Intake during Ramadan.” British Medical Journal. 2004; 329.7469:778–782.

21. Saul N. A False Sense of Hypoglycemia. Joslin Communications. 2012. Available at: http://blog.joslin.org/2012/02/a-false-sense-

of-hypoglycemia/

22. Anastasopoulou C. Pseudohypoglycemia. 2017. Available at: https://emedicine.medscape.com/article/124795-overview#a4

23. False hypoglycemia. Voice of Diabetes. Available at: https://nfb.org/Images/nfb/Publications/vod/vodspr0503.html

24. Rintala TM, Paavilainen E and Åstedt-Kurki P. Everyday living with diabetes described by family members of adult people with type

1 diabetes. Int J Family Med. 2013; 2013: 967872.

25. Helping a loved one with diabetes. Available at: https://www.webmd.com/diabetes/help-loved-one

26. Etie M. “Management of type 2 diabetes mellitus in older patients: current and emerging treatment options.” Diabetes Therapy.

2013;4.2:239–256.

27. Nash D, Koeing JB and Chatterton ML. Why the Elderly Need Individualized Pharmaceutical Care. The Office of Health Policy and

Clinical Outcomes Thomas Jefferson University. 2000.

28. Diapedia. Therapeutic strategies in type 2 diabetes. Available at: https://www.diapedia.org/31040851104/rev/24

29. Iglesias P, Heras M, Heras M, et al. Diabetes mellitus and kidney disease in the elderly. Nefrologia (English Version) 2014;

34:285–92.

30. Powers MA, Bardsley J, Cypress M, et al. Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position

Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition

and Dietetics. Diabetes Care. 2015;38(7):1372–1382.

31. Cultural Considerations in Diabetes Education. AADE Practice Synopsis. 2015. Available at: https://www.diabeteseducator.org/

docs/default-source/default-document-library/cultural-considerations-in-diabetes-management.pdf?sfvrsn=0

32. Dhar S. Air pollution linked to 3.2 million diabetes cases in a year. 2018. Available at: https://timesofindia.indiatimes.com/

home/environment/pollution/air-pollution-linked-to-3-2-million-diabetes-cases-in-a-year/articleshow/64810915.cms

33. Wilson M. Evansville Courier and Press. 2018. What we eat and drink plays a role in diabetes. What about what we breathe?

Available at: https://www.courierpress.com/story/news/local/2018/08/10/study-air-pollution-diabetes-health-washington-

university/917925002/

34. Yadavar S. As Controversy Grows, Firecrackers Emit Toxins 200 to 2,000 Times Above Safe Limits. Available at:

http://www.indiaspend.com/cover-story/as-controversy-grows-firecrackers-emit-toxins-200-to-2000-times-above-safe-limits-

37233

35. Healthline. The Best Diabetes-Friendly Diets to Help You Lose Weight. Available at: https://www.healthline.com/health/diabetes/

diabetic-friendly-diets-to-lose-weight

36. Healthline. The Best Diabetes-Friendly Diets to Help You Lose Weight. Available at: https://www.healthline.com/health/diabetes/

diabetic-friendly-diets-to-lose-weight#what-should-you-reduce

37. Eenfeldt A. Diet Doctor. How to reverse type 2 diabetes. Available at: https://www.dietdoctor.com/diabetes

38. Qidwai W, Khusk IA, Shamim U, et al. Fast pace of life and its impact on health: results of a study from the largest city of Pakistan.

Pak J Public Health. 2016;6(4).

58

39. Buswell L, Zabriskie RB, Lundberg N, et al. The relationship between father involvement in family leisure and family functioning:

The importance of daily family leisure. Leisure Sciences. 2012;34:172–90.

40. Hornberger LB, Zabriskie RB, Freeman P. Contributions of family leisure to family functioning among single-parent families.

Leisure Sciences. 2013;32:143–161.

41. Don't Ignore That Pain: Frozen Shoulder May Be a Sign of Diabetes. Available at: https://m.dailyhunt.in/news/india/english/fit-

epaperfit/don+t+ignore+that+pain+frozen+shoulder+may+be+a+sign+of+ diabetes- newsid-94198303

42. Dubois W. Thawing Out a Frozen Shoulder, with Diabetes. Available at: https://www.healthline.com/diabetesmine/frozen-

shoulder#1

43. Mensing C, Boucher J, Cypress M, et al. ‘National Standards for Diabetes Self-management Education’. Diabetes Care.

2000;23:682–689.

44. Odegard PS and Capoccia K. ‘Medication taking and Diabetes: a systematic review of the literature’. Diabetes Educ.

2007;33:1014–1029.

45. Bubalo J, Clark RK, Jiing SS, et al. ‘Medication Adherence: pharmacist perspective’. J Am Pharm Assoc. 2010;50:394–406.

46. Ross SA. ‘Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes’. Am J Med. 2013;126(9

suppl1):S38–S48.

47. Edelman S and Pettus J. ‘Challenges associated with insulin therapy in type 2 diabetes mellitus”. Am J Med. 2014;127(suppl

10):S11–S16.

th48. Beardsley RS, Kimberlin CL and Tindall WN. ‘Communication Skills in Pharmacy Practice”. 5 ed. Baltimore, MD: Lippincott

Williams & Wilkins; 2007:38–49.

49. International Curriculum for Diabetes Health Professional Education. International Diabetes Federation, 2008. ISBN:2-930229-62-

4. Available at: http://idf.org/component/attachments/attachments.html?id=708&task =download

50. Powers MA, Bardsley J, Cypress M, et al. “Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position

Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition

and Dietetics.” Clinical Diabetes: A Publication of the American Diabetes Association. 2016;34.2:70–80.

th51. Scientific Program. 29 International Congress on Prevention of Diabetes and Complications. Available at:

https://diabetesmeeting.conferenceseries.com/scientific-program

52. Companion Medical. Smart Insulin Delivery Inpen. Available at: https://www.companionmedical.com/inpen/#qqm24w-accordion

Companion InPen® App.

53. Companion InPen® App. Available at: https://itunes.apple.com/us/app/companion-inpen-app/id1236236656?mt=8

54. Watson Artificial Intelligence (AI) Helping People with Diabetes. 2018. Available at: http://www.diabetesincontrol.com/sugar-iq-

watson-artificial-intelligence-ai-helping-people-with-diabetes/

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Documents

To keep the members of DSME and DSMS conceptsAlthough it is all fun and fair, people with diabetes are always over the edge during such times. There is a need for pre-fast counselling