To keep the members of DSME and DSMS concepts · Diabetes and Endocrine Clinic, Ludhiana, Punjab. Dr. Lavanya Katakam MD (General Medicine), ... Diet-Related Behavioural Tips 51 53

*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 diabetes patients. This Journal intends to empower your clinic support

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

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

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

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

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

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

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

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

Capital of the World.

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

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

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

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

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

coping and reducing risks.

This issue cover story gives insights on the importance of exercise for people with diabetes. People with

diabetes can achieve their targets by various ways; however, it is important for them to take precautions while

exercising so as to not injure themselves while achieving result-focused goals. This issue also covers a

section on diabetes and women’s health – A double challenge for women with menopause.

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

We dedicate this journal to all the healthcare professionals who are working relentlessly towards making “India

a Diabetes Care Capital of the World”.

Sincere Regards,

Dr. Ajay Vasant Rotte

MBBS, PGDHHM, DFID, IDC, MBA(Hospital Management)

CEO and Senior Diabetologist, United CIIGMA Hospital, Aurangabad, Maharashtra.

Dr. Milind Katta

MBBS, Diabetology (CPS), CCGDM, CCEBDM, CCD, FICM, DPHARM

Consultant Critical Care Specialist and Diabetologist, Balaji Hospital and Sugun Hospital, Andheri, Mumbai.

Dr. Samir Dasgupta

MD

Consultant Diabetologist and Endocrinologist, Rabindranath Tagore Surgical Centre, Kolkata, West Bengal.

Dr. Ramesh Omprakash Goyal

MD (General Medicine & Therapeutics),DM (Endocrinology)

Consultant in Diabetology & Endocrinology, Apollo Hospitals, Ahmedabad, Gujarat.

Dr. (Wg. Cdr.) Arun Kumar

MD (Medicine), DM (Endocrinology)

Senior Consultant Endocrinologist, Arunosha Labs Pvt. Ltd., Delhi.

Dr. Parimal Swamy

MD, Dip. (Preventive Health Care)

Apollo, Sugar Balance Centre, Asthama-Allergy Care Centre, Jabalpur, Madhya Pradesh.

Dr. S. Sridhar

MD, DM (Endo – PGI, Chandigarh)

Assistant Professor, Department of Endocrinology and Metabolism,Madurai Medical College; Consultant Endocrinologist, Vadamalayan Hospital, Madurai, Tamil Nadu.

Expert Contributors of the MonthExpert Contributors of the Month

Dr. Jamal Ahmad

MD (General Medicine), DM (Endocrinology), FCCP, FRCP, PhD (Medicine), DSc (Endocrinology)

Physician and Endocrinologist, Diabetes and Endocrinology Super Speciality Centre, Aligarh, Uttar Pradesh.

Dr. Banshi Saboo

MD, PhD

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

Dr. Gurpreet Singh

MBBS

Consultant and Head, Minerva Medica Diabetes and Endocrine Clinic, Ludhiana, Punjab.

Dr. Lavanya Katakam

MD (General Medicine),

DM (Endocrinology)

Consultant Diabetologist and Endocrinologist, Aswini Endocrine Center, Guntur, Andhra Pradesh.

Ms. Umasakthy G.

MSc, RD, PGDDE

Senior Executive Dietician and Diabetes Educator, Dr. Mohan’s Diabetes Specialities Centre, Gopalapuram, Tamil Nadu.

Table of ContentCover Story:

Exercise Prescription for Diabetes 01Dr. S. Sridhar

Being Active: Special Concerns for

Women with Diabetes 06Dr. Jamal Ahmad

Taking Medications:

Your Diabetes Report Card 09Dr. Arun Kumar

Healthy Coping:

Pursuit for A Healthier Tomorrow 21Dr. Ramesh Omprakash Goyal

Assess and Address the

Risk of Diabetic Foot 23Dr. Ajay Vasant Rotte

Six Protective Herbs to

Include in Your Diet! 27Dr. Milind Katta

Why Settle For Normal When

You Can Reach Optimal? 29Dr. Sameer Dasgupta

Monitoring: Diabetes by the Number

13Dr. Banshi Saboo

Problem Solving:

Coping with Uncertainty of Diabetes 15Dr. Parimal Swamy

Reduce Your Risk: Neutralise the

Effects of High Blood Sugar Naturally 18Dr. Gurpreet Singh

Diabetes and Menopause:

A Double Challenge

32Dr. Lavanya Katakam

Role of Medical Nutrition

Therapy in Diabetes Management 34Ms. Umasakthy G.

Table of Content

Shopping Smart 50

Diet-Related Behavioural Tips 51

53

Recipe 54

References 55

Eat Out, Be Wise! 49

47National Diabetes Educator

Program (NDEP) Best Practices

Dr. Shachin Kumar Gupta

Tools in Diabetes:

Livongo for Diabetes 40

Future Trends: “Ouchless”

Patch Promises Needle-Free

Diabetic Monitoring42

Diabetes Educator of the Month 43

Busting the Myth:

Egg Yolk Must be Discarded 44

45Get Active!

Superfood: Beans (Lente carbs)/ फिलयां

1

ExpertOpinion

Benefits of exercise in the prevention of type 2 diabetes (T2DM)

'If exercise was a pill it would be prescribed to every patient' was noted among some of Australia’s leading experts and

1was published in the journal ‘The Guardian’. Globally, T2DM has reached epidemic proportions and is associated with an increased risk for cardiovascular disease (CVD) and

2premature mortality. A sense of change in people’s lifestyle must be implemented for this reason.

Dr. S. Sridhar

MD, DM (Endo – PGI, Chandigarh)

Assistant Professor, Department of Endocrinology and Metabolism,Madurai Medical College; Consultant Endocrinologist, Vadamalayan Hospital, Madurai, Tamil Nadu.

3A dual strategy of aerobic activity and strength training makes sense:

¢ Aerobic activity, like walking or swimming,

strengthens the heart, lungs and muscles. It helps

control blood pressure and blood sugar. It keeps

arteries flexible. It is also essential for maintaining or

losing weight and excess body fat. All of these are

key strategies for many people with diabetes.

¢ Strength training helps muscles respond better to

insulin, the hormone that ushers blood sugar into

cells. A single bout of it can make muscle cells

"listen" to insulin better for 12 hours or more. It also

improves muscle mass, muscle strength, blood pressure and body composition.

Cover Story: Exercise Prescription for Diabetes

Aerobic activity

Table 1: Strategies to stay active for people with diabetes

Activity

Duration

Intensity

Frequency

At least 30 minutes per day

Moderate-intensity activity; means that the person should feel

warm, mildly out of breath and mildly sweaty

If the person aims to do 30 minutes per day then he/she should do

this at least 5 times per week so that he/she can reach a

total of 150 minutes a week

At least 30 minutes or less per day

If using weight for example dumbbells; try to do at least

1 set of 8–12 repetitions per activity

At least 2 days a week

Walking, jogging, cycling or group fitness classes

Muscle strengthening activity

Walking uphill, weight lifting or other muscle strengthening

resistance exercises

4Exercising caution

People with diabetes need to be a bit more careful about exercise than other people. Here are some tips for exercising safely with diabetes:

¢ Start slowly: If the patient is new to exercise, start with a low-impact activity like walking,

swimming or bicycling and then gradually increase the intensity.

¢ Time it right: The best time to exercise is an hour or so after eating when your blood sugar is

likely to be a bit higher.

Miscellaneous benefits of exercise

¢ Helps people achieve and maintain a healthy weight and prevents obesity

¢ Reduces feelings of stress, anxiety and depression

¢ Builds and maintains healthy bones, muscles and joints

¢ Boosts energy level

¢ Improves quality of sleep

Flexibility exercise

Flexibility exercise increases the ability to bend joints and stretch muscles through a full range of motion.

Some activities include:

¢ Stretching (sit and reach)

¢ Warm-up and cool-down

Muscle strengthening exercises/Resistance exercises

2

3

¢ Know your limits: Ask the patient to check their blood sugar before and after exercise to see

how their body responds to exertion, particularly in elderly and brittle diabetic individuals and people with type 1 diabetes (T1DM).

¢ Protect your feet and eyes:

– Make sure that the patient uses appropriate footwear with supportive midsoles and socks to avoid blisters so as to avoid skin ulcers.

– If the patient has nerve pain or loss of sensation, ask him/her to avoid activities that could cause pressure ulcers or stress fractures.

– If the patient has developed blood-vessel abnormalities in one or both eyes (diabetic retinopathy), ask them to not lift heavy weights or perform other activities that cause a sudden increase in blood pressure that can trigger bleeding in the eye.

¢ Be prepared: People with diabetes must always have water and snacks handy when they

exercise. Especially, carbohydrate-rich snacks are very important as that can quickly boost blood sugar if it gets too low.

Exercise prescription

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

The first step in developing the exercise prescription is to conduct an exercise assessment that addresses:

Personal goals for exercise

¢ Improved blood glucose control

¢ Weight loss

¢ Increased strength and endurance

¢ Begin competitive athletics

¢ Reduce CVD risk

Exercise history

¢ Type of exercise that is currently performed or has been performed in the past

¢ Effect of exercise on health and diabetes control

¢ Enjoyment of activity

4

Diabetes and medical history

¢ Type and duration of diabetes

¢ Current level of blood glucose control [glycated haemoglobin (HbA1c)]

¢ Presence of complications

¢ Current diabetes treatment regimen

¢ May range from meal planning and oral agents to intensive insulin therapy or some combination of each

¢ Adjustments may need to be made to meal plan or medication to accommodate exercise and prevent hypoglycaemia

¢ Frequency of self-monitoring of blood glucose (SMBG)

SMBG may need to be more frequent to determine the effects of exercise and prevent hypoglycaemia. Continuous glucose monitoring system (CGMS) may also be considered to see the impact of exercise on blood glucose levels (immediate post activity and after a few hours).

¢ Frequency and severity of hypoglycaemia especially in relation to exercise will indicate the types of adjustments that need to be made so that the risk is minimised

¢ Co-morbid conditions should also be assessed in order to develop a safe plan that will minimise risks

Motivational/ Psychosocial issues

¢ Social support: Exercise buddy and emotional support from family members and friends Interest, past successes and challenges with exercise

¢ Selection of time of day and frequency of exercise that be consistent and convenient taking in to account the lifestyle of the individual

5

Important pointers for DEs

¢ The American Diabetes Associat ion (ADA) recommends that individuals with T2DM should perform at least 150 minutes of moderate-intensity aerobic exercise training or at least 75 minutes of vigorous aerobic exercise training per week.

¢ People with diabetes should avoid exercising alone and going into remote areas.

¢ Good foot care should be practiced by wearing well-fitted shoes and cotton socks and inspecting feet every time after exercise. Advice patients to keep feet dry.

People with diabetes are encouraged to exercise regularly for better blood sugar control and to reduce the risk of

CVDs as well as have a healthier heart, better weight control and stress management.

Realistic plan for the individual

A realistic short-term plan should be developed to ensure success. The plan should be adjusted after the person achieves success, to reach more long-term goals.

¢ The plan should fit in the daily routine of the individual in terms of frequency (number of times a week), duration and time of the day

¢ Type, ease and intensity of exercise

¢ Should be fun and enjoyable

¢ Should include daily activities such as housework, walking to and fro from the bus, marketing, and expanding the same to 30 minutes of exercise a day

6

ExpertOpinion

Introduction

Although diabetes presents with mostly similar symptoms in both men and women, there are some symptoms and complications which are unique to women like gestational diabetes, polycystic ovary syndrome, vaginal infections and monthly hormonal changes which affect insulin action. The physiological monthly menstrual cycle and blood sugar levels in women with diabetes can affect each other to varying degrees.

Dr. Jamal Ahmad

MD (General Medicine), DM

(Endocrinology), FCCP, FRCP, PhD

(Medicine), DSc (Endocrinology)

Physician and Endocrinologist, Diabetes and Endocrinology Super Speciality Centre, Aligarh, Uttar Pradesh.

Being Active: Special Concerns for Women with Diabetes

Menstrual cycle and hormones – effect on diabetes

¢ Studies have shown that glucose control differ in follicular and luteal phase of 5menstrual cycle due to hormonal changes.

¢ Oestrogen and progesterone hormones interact with insulin hormone and may

increase the body’s resistance to own or injected insulin. These effects differ between

individuals.

¢ Due to these interactions, diabetic women may experience a surge in blood glucose

levels which may occur for three to five days either before, after or during menstruation.

¢ These effects may be consistent or may vary from one month to another making it more

difficult to monitor and predict blood glucose levels.

¢ Increased progesterone levels may trigger food cravings making management of

diabetes more difficult.

Effect of diabetes on menstrual cycle

¢ Research indicates that menstruation starts, on an average, a year later in women with T1DM and they are more prone to have menstrual problems before age of 30 as

compared to women without diabetes.

¢ Diabetes in women have also been associated with increased chances of having

longer menstrual cycles and periods, heavier periods and earlier onset of 6menopause.

7

Use a period tracker app

Compare cycle with sugar

levels and note monthly trends

or pattern

Look out for increased

symptoms of premenstrual

syndrome which may indicate

poor blood sugar control

Monitor mood changes,

bloated or tender

feeling before, during and

after your periods

Simultaneously monitor and record blood glucose levels

‘Careful monitoring of menstrual cycle changes and blood sugar levels along with suitable lifestyle modifications involving

physical activity, nutrition and development of healthy habits play a significant role in proper diabetes management’

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

Pregnancy in women with diabetes requires planning, stringent monitoring and proper

diabetes management to ensure healthy baby and healthy mother. The DE plays an 7,8important role in conveying these important points:

¢ Pre-conception counselling and planned pregnancy are critical to improving

maternal and foetal outcomes. Pre-conception glycaemic control and preventive

health services enable successful pregnancy outcome.

¢ All women and adolescents of reproductive age with diabetes should be educated about risks of unplanned pregnancies. They should also be educated about family planning options.

¢ Diabetes treatment in pregnancy is a combination of medical nutrition therapy,

physical activity and weight management.

¢ If prescribed, insulin is preferred medication during pregnancy. Timely follow-up and

monitoring are essential.

¢ There is a concern about the safety of exercise in pregnancy. Pregnant women with

diabetes should be advised to monitor foetal activity and blood glucose levels before

and after exercise. Physical activity should be limited to 15–30 minutes.

¢ Women who have been physically active prior to pregnancy are encouraged to continue an active lifestyle.

6Monitoring blood glucose levels and menstrual cycle changes

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

and healthy pregnancy.


¢ Menstrual cycle and hormonal changes have an impact on diabetes and vice versa in women with diabetes.

¢ Pre-conception counselling, lifestyle modification and close monitoring of blood glucose levels during pregnancy are critical for healthy pregnancy.

The key for women with diabetes is to know how their menstrual cycle affects their diabetes and vice versa by careful

monitoring it. They should compare their cycle with their blood glucose levels and note any trends that they see so that they

can be prepared for diabetes management changes in future months.

8

9

ExpertOpinion

Introduction

Diabetes being a complex, chronic illness requires continuous medical care with multi-factorial risk-reduction strategies beyond glycaemic control. Continuous patient self-management education, monitoring and support are critical to prevent acute complications and decrease the risk of

8development of long term-complications.

Dr. (Wg. Cdr.) Arun Kumar

MD (Medicine), DM (Endocrinology)

Senior Consultant Endocrinologist, Arunosha Labs Pvt. Ltd., Delhi.

Taking Medications: Your Diabetes Report Card

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

¢ The report card aids in the chronic care model implementation and has all essential

patient data along with the important parameters related to diabetes check-up in an

easily accessible format.

¢ It may also include information about risk factors, target goals, meaning and

importance of each quality measure, lists of previous self-management goals set by 9the patient and a space to input new goals.

¢ The format for diabetic report card is not fixed and different diabetic care centres can

create a format tailored to their needs. A common and essential detail is related to the 10,11,12, ABCs of diabetes.

A is for A1c

A1c/HbA1c can also be reported as estimated average glucose (eAG). It gives a picture of the

average blood glucose control for the past 2 to 3 months and is an indication of how well the

diabetes management plan is working.

Suggested target: Below 7%

How often? At least twice a year

B is for blood pressure

Blood pressure is the force of blood flow inside the vessels. When blood moves with too much force through the vessels (termed high blood pressure or hypertension), the heart has to work harder and the risk for heart attack, stroke, eye problems and kidney diseases increases.

Suggested target: Below 140/90 mmHg or lower in some cases

How often? At every visit

C is for cholesterol

Cholesterol is a waxy substance found in blood and the cholesterol numbers can give information

about the amount of fat in the blood. There are different types of cholesterol. High-density

lipoprotein (HDL) cholesterol helps protect the heart and low-density lipoprotein (LDL) cholesterol

can clog the arteries. Hence, LDL is often called the "bad cholesterol" or "lousy cholesterol". High

triglycerides increase the risk of heart attack or stroke.

Suggested LDL target: Below 100 mg/dL

How often? At least once a year

Apart from above parameters, the expanded ABCs of diabetes can also be incorporated in the diabetic9, 12–14report card. These include the following:

A is also for albuminuria

It means the presence of protein in the urine. Screening for these levels can detect early kidney

damage which can be stopped from progressing to kidney failure and prevent requirement for

dialysis or kidney transplantation later on.

Suggested target: Below 30 mg of protein


A is also for aspirin

After consultation with the doctor, low-dose aspirin therapy in suitable patients can help prevent

heart attacks and strokes.

How often? At each medical visit, people with diabetes should be evaluated to determine the appropriateness of aspirin use. If prescribed, aspirin should be taken on a daily basis.

D is for diabetes education

Both patients and care providers should be made aware of the

need for ongoing medical nutrition therapy and diabetes self-management education to enable the

achievement of diabetic management goals and prevent diabetes-related complications.

Suggested resources: Dieticians, diabetes educators

How often? Ongoing, emphasis is on it being a continuous process

10

E is for an eye exam

Regular eye check-ups can catch diabetic eye disease early providing the opportunity to intervene with effective treatment and thus help to preserve vision.


F is for foot care

Regular foot examination and proper foot care are of utmost importance to prevent serious infection and amputation later on. The loss of sensation due to diabetic neuropathy makes it difficult to feel and realise when something is wrong with the feet.

Hence, it is vital to examine visually.

How often? Check feet daily. Remind doctor to check them at every visit. Get an extensive foot

examination performed once a year.

G is for glucose (sugar) monitoring

Monitoring of glycaemic status by patient/healthcare provider is considered a cornerstone of

diabetic care in achieving glycaemic control and preventing diabetes-related complications. SMBG

allows patients to assess response to therapy and SMBG data can aid health professionals to guide

treatment and management plan.

How often? Frequency and timing of SMBG should be determined by the particular needs and goals

of each patient and decided by discussing with the doctor.

H is for health maintenance

Patients with diabetes are at high risk for complications, hospitalisation and death from influenza

and pneumococcal disease. This can be avoided by timely immunisation with safe and effective

vaccines which are available readily.

How often? Flu vaccine, every year; pneumococcal vaccine, at least once

I is for identifying special medical needs

Voicing health concerns at every visit can help the doctor identify possible problems and refer for speciality care if needed.

How often? When needed

Other parameters like kidney function screening, smoking status, stool occult blood examination can also be added as necessary in

the diabetic report card.

11


¢ Use of diabetic report card can help in easy access to diabetes management related information and assessment of the same.

¢ Evaluation of records can help to change management plan to suit the people with diabetes better and achieve targets/goals for each parameter.

A diabetes report card can help ensure patients to keep a track of important facts thereby,

maintaining control on diabetes and prevent complications related to diabetes in future.

12

13

ExpertOpinion

Introduction

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

15India.Dr. Banshi Saboo

MD, PhD

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

Monitoring: Diabetes by the Number

Glycaemic control is a cornerstone of diabetes management. Blood glucose 16targets are individualised based on:

¢ Duration of diabetes

¢ Age/life expectancy

¢ Co-morbid conditions

¢ CVD or advanced microvascular complications

¢ Hypoglycaemia unawareness

¢ Individual patient considerations

¢ HbA1c: Less than 7%

¢ HbA1c may also be reported as eAG: Less than 154 mg/dL

¢ Before a meal (preprandial plasma glucose): 80 – 130 mg/dL

¢ One or two hours after a meal (postprandial plasma glucose): Less than 180 mg/dL

15,17,18Make it count – number of steps to make a difference

Structured exercise in the form of aerobic and resistance training have been found to be 16beneficial in diabetes management. With the growth of paedometry, the physical activity

recommendations have focused on the number of steps to be taken per day (i.e., 10,000

steps/day).

The following numbers are defined for optimally targeting glycaemic control:

Although walking is also a great place to start, studies have shown that persons with

T2DM naturally walk at a speed (intensity) that is slower than that associated with minimal

intensity (i.e., moderate) required to harness the health benefits, despite increasing their 17number of steps taken per day. Hence to make the steps count, ‘Pick Up Pace’ program

prescribed increased walking speed (thus, intensity of walking) during 30 minutes bouts,

to a level that elicited significant improvements in cardio-respiratory fitness over

12 weeks in a group already walking >10,000 steps/day.

Another strategy suggested to preventing T2DM is ‘walk more, sit less and exercise’ as 18depicted in the alongside figure.

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

Here are few ways to burn approximately 100 calories:

¢ Jump rope continuously for 10 minutes

¢ Walk briskly through the mall for 20 minutes

¢ Enjoy a short aerobics class for 15 minutes

¢ Swim laps without stopping for 10 minutes

¢ Push your child in a stroller or take the dog for a walk for 30 minutes

In order to maintain good health, every diabetic should know a number of different figures relating to their bodies.

These include height, weight, blood pressure and cholesterol levels.


¢ Optimal glycaemic levels should be targeted based on individual patient considerations.

¢ Physical activity should be performed at the required intensity to obtain the health benefits associated with it.

14

Sit l

ess

Avoid

takin

g <

5,00

0 st

eps/d

ay

and

limit

prolo

nged

sitti

ng b

outs

Accumulate 3,000 steps/day

at 100 steps/min

Walk More

Exercise

Take 7,500 steps/day

15

ExpertOpinion

Introduction

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

Screening for prediabetes and risk to develop diabetes in future should be assessed either informally by identifying risk factors or through validated tools in asymptomatic

8individuals.

Dr. Parimal Swamy

MD, Dip. (Preventive Health Care)

Apollo, Sugar Balance Centre, Asthama-Allergy Care Centre, Jabalpur, Madhya Pradesh.

Problem Solving: Coping with Uncertainty of Diabetes

Testing should be considered in overweight or obese individuals with other risk factors like

hypertension, dyslipidaemia, CVD, physical inactivity, etc. For other persons without any

risk factors, testing every three years should begin at the age of 45 years.

¢ ‘Prediabetes’ is the term used for persons whose body glucose levels are too high

to be considered normal but it does not meet the diagnostic criteria of diabetes.

¢ Prediabetes is associated with obesity (especially abdominal or visceral obesity), high blood pressure and dyslipidaemia with high triglycerides and/or low HDL

cholesterol.

8Prediabetes: A risk factor for increased diabetes and CVDs

Defining prediabetes

Fasting plasma glucose 100 – 125 mg/dL (Impaired fasting glucose)

Or

2 hours plasma glucose during 75 g oral glucose tolerance test 140 mg/dL to 199 mg/dL (Impaired glucose tolerance)

Or

HbA1c 5.7 to 6.4%

Progression to diabetes can be delayed and may even be prevented if healthy interventions are done at this stage. These include:

¢ Eating well: A healthy diet rich in fruits vegetables, fruits and whole grains with lean proteins and certain kind of fat.

¢ Getting active: Increase physical activity and avoid prolonged sedentary periods. Accumulation of small steps like taking the

stairs or walking an extra block can contribute to staying fit.

¢ Weight loss: Changing eating patterns and regular exercise can aid in weight loss which makes a big difference in

prediabetes.

¢ Medications: Along with lifestyle modifications, some patients may be prescribed medication like metformin to help lower

blood glucose levels.

¢ Regular testing: Yearly testing should be done in patients with prediabetes to catch and recognize the progression to diabetes

early.

8,19What can be done to stay healthy?

¢ Along with the above changes, interventions to increase emotional and

behavioral health support are equally important.

¢ DSME forms an integral part of optimal diabetes management.

¢ Patients should be encouraged to seek help and open up regarding their

emotional status and concerns.

¢ Caregivers, family members, friends or support groups can contribute to ensuring

psychological well-being.

¢ If needed, professional medical help from psychologists and psychiatrists should

also be sought.

Psychological and behavioural support

16

There are several uncertainties in diabetes; however, uncertainty is important because it relates to self-management behaviours

among those with diabetes. Eating well and getting active are the starting points to eradicate uncertainty in diabetes.


¢ Prediabetes should be considered a risk factor for development of diabetes and CVD.

¢ Early intervention in the form of life style modification can help delay or prevent the development of diabetes mellitus.

¢ Psychological well-being is also an important component of successful diabetes management.

17

18

ExpertOpinion

Introduction

The role of healthy dietary habits and exercise cannot be stressed enough for the successful and effective management of diabetes. These are natural ways to neutralise the effects of high blood sugar and prevent the development of related complications.

Dr. Gurpreet Singh

MBBS

Consultant and Head, Minerva Medica Diabetes and Endocrine Clinic, Ludhiana, Punjab.

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

Studies have proven that skipping breakfast adversely affects the body’s mechanisms for

glucose homeostasis and related gene expressions. Skipping breakfast is correlated with

increased postprandial glycaemic response in both healthy individuals and individuals with 20diabetes. Different studies have demonstrated increased blood sugar levels throughout

21the day and increased HbA1c levels as a result of skipped breakfast.

Other advantages of a nutritious breakfast in regular breakfast eaters:

¢ Aids in weight reduction and keeping it off

¢ Have lower LDL cholesterol levels

¢ Have overall healthier eating habits

¢ Are more likely to meet their daily fibre goal

¢ Feel better, have improved attention span and are able to concentrate better

The king of meals – breakfast

A Champion’s breakfast

The key to a healthy ideal breakfast is to choose a variety of food so that there is a balance

of carbohydrate, protein and fat. These can be:

¢ Whole grains: Oatmeal, whole wheat or whole kernel corn using recipes

¢ Lean protein: Eggs, Greek yoghurt, low-fat cottage cheese and tofu

¢ Healthy fat: Nuts, light butter, seeds and avocados

¢ Fruits and vegetable (but skip or limit juice)

¢ Lower fat dairy: Non-fat or low-fat milk, rice, almond, coconut or soy milk

¢ The viscous and gel-forming properties of soluble dietary fibres decreases

macronutrient absorption, reduces postprandial glucose response and decrease

total and LDL cholesterol.

¢ Insoluble cereal dietary fibres and whole grains are associated with reduced diabetes risk.

¢ Dietary fibres contribute to the improvement of insulin sensitivity, modulation of gut hormone secretion and reduction of various metabolic and inflammatory markers

associated with metabolic syndrome.

22The benefits of dietary fibres

¢ Moderate intensity physical activity has been shown to improve insulin sensitivity.

¢ Both aerobic exercise and resistance training have a beneficial effect.

¢ Gentle stretching for 5 to 10 minutes helps body warm up and get ready for aerobic

activities. It also helps keep joints flexible, prevent stiffness, and may help reduce the

chance of injury during other activities such as walking or swimming.

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

The ‘Diabetes Prevention Program’ (DPP) study administered as structured curriculum with sections on lowering calories, increasing

physical activity, self-monitoring, maintaining healthy lifestyle behaviours and psychological, social and motivational challenges was

successful in significantly reducing the incidence of diabetes.

The two major goals of DPP intensive, behavioural, lifestyle intervention were to achieve and maintain a minimum of 7% weight loss and

150 minutes of physical activity per week similar in intensity to brisk walking. The goals were the same but the method was 8individualised.

19

For a successful and effective management of diabetes, the trick is to keep the metabolism going all day long at a steady rate.

The simple solution for this is to eat a good breakfast: don’t forget fibre – try oatmeal with fresh fruit or fat-free yoghurt,

stay away from large coffee drinks with whipped cream, sweetened cereals, and breakfast pastries.


¢ Morning meal has many health benefits for all people and especially for a person with diabetes. Hence, it should not be skipped.

¢ Incorporation of dietary fibres has a positive effect on glycaemic control.

¢ Participating in regular moderate-intensity physical activity also has beneficial effects in the management of diabetes.

20

21

ExpertOpinion

Introduction

Diabetes, particularly T2DM is categorised under the term ‘lifestyle diseases’. As the name suggests, diabetes is not an acute medical condition which can be managed by just popping a pill. Diabetes is a chronic complex health condition requiring continuous medical care with ‘multifactorial risk

8reduction strategies beyond glycaemic control.’

Dr. Ramesh Omprakash Goyal

MD (General Medicine & Therapeutics), DM (Endocrinology)

Consultant in Diabetology & Endocrinology, Apollo Hospitals, Ahmedabad, Gujarat.

Healthy Coping: Pursuit for A Healthier Tomorrow

¢ Having negative feelings about diabetes and its management.

¢ Experiencing thoughts of giving up and seeking ‘freedom’ from this confining and often frustrating condition.

Signs of diabetes burnout

¢ Too much dependence on medication is a change required in people with diabetes.

¢ Significant evidence exists that support the multifactorial approach to diabetes management in

which lifestyle modifications like regular exercise, healthy diet, smoking cessation, focus on

mental well-being along with ongoing patient self-management education and support play a

huge role in prevention, delay and modification of diabetes disease course to a more favourable

outcome.

¢ Furthermore, relying on only medication without other interventions can cause unnecessary

increased dosage and number of anti-diabetic medication potentially exposing the patient to more

side-effects. Also, development of associated mental and physical complications cannot be

prevented or managed efficiently by intake of medicines alone.

However, the requirement for constant effort and monitoring of various parameters to ensure good

diabetic management can cause a person with diabetes to feel overwhelmed. These diabetes self-

management demands and continuous endeavour to maintain ideal parameters can eventually lead to a state of frustration, disillusion and

somewhat submiss ion to the condition of diabetes that they no longer care. This is termed as

24, 25‘diabetes burnout’. It can manifest as subtle negative changes in attitude towards diabetes management to full blown destructive behaviour and associated psychological changes.

¢ Decreasing efforts in diabetes management and participating in self-destructive

behaviour e.g., eating whatever one want despite knowing its adverse effects on blood

sugar levels, estimating quantities of insulin required rather than checking blood sugar

levels and injecting precise amounts, etc.

¢ Avoiding medical appointments or discussions about diabetes.

¢ Denying their diagnosis of diabetes, often giving excuses.

¢ Psychological changes like stress, anxiety, depression, emotional states like anger, resentment, shame, guilt and helplessness.

¢ A person resorting to self-destructive behaviour while experiencing burnout may

subsequently suffer from fatigue and/or hyperglycaemic episodes which in severe cases can lead to coma.

Tips to deal with diabetes burnout

¢ Seek support: Support can be from a spouse, family member, friend, support groups or

professional counsellor. Even a little help from others can help ease the burden the person

may be experiencing.

¢ Acceptance: It is what it is. Think of positive things that have happened because of the

timely diagnosis of diabetes. Early diagnosis gives the chance to intercede, avoid

development of complications and make a positive difference in the quality of life.

¢ Take small steps: Once the healthy lifestyle changes are made into ‘habits’, it becomes

second nature and daily routine to a person. Take one day at a time rather than thinking of

it as a whole pending list of to-dos.

¢ No judgements: Be kind to yourself. Engage in activities you like. Experiment new recipes

and bring variety to the diet.

Diabetes burnout is the state of frustration and somewhat submission to the condition of diabetes. Helping understand,

address and overcome the mental and emotional impact of having diabetes can help people with diabetes.


¢ Depending too much on medication without changes in lifestyle and diet is detrimental to proper diabetes management.

¢ Look out for signs of diabetes burnout in people with diabetes and support them in overcoming it.

22

23

ExpertOpinion

Introduction

Diabetic neuropathy along with peripheral arterial disease (PAD) leads to foot ulcers and amputation in people with diabetes. Diabetic foot complications are a major cause of morbidity and mortality in people with diabetes. Early identification, assessment and treatment of patients with diabetes and feet at risk for ulcers or amputations can delay or prevent negative outcomes.

Dr. Ajay Vasant Rotte

MBBS, PGDHHM, DFID, IDC, MBA (Hospital Management)

CEO and Senior Diabetologist, United CIIGMA Hospital, Aurangabad, Maharashtra.

Assess and Address the Risk of Diabetic Foot

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

Poor glycaemic controlPeripheral neuropathy with

loss of protective sensationCigarette smoking Foot deformities

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

Visual impairmentDiabetic kidney disease

(especially patients on dialysis

¢ Patients at risk should be made aware of the implications of foot deformities, loss of protective sensation (LOPS) and PAD; the

proper care of foot, nail and skin; the importance of using appropriate footwear and performing foot examination on a daily

basis.

¢ Patients with LOPS should be advised to palpate or visually inspect the foot using an unbreakable mirror for early recognition of

foot problems.

¢ Patients’ understanding and their physical capability to conduct proper foot surveillance should be assessed. Where necessary,

the patients’ caregiver or family members should also be educated on the same to assist with their care.

¢ A comprehensive foot examination should be performed at least annually by health care provider and the foot should be

inspected at every visit.

Preventive measures

26Key components of comprehensive foot examination:

¢ When examining the feet of a person with diabetes, remove their shoes, socks, bandages

and dressings and examine both feet meticulously.

¢ The examination should include inspection of the skin (colour, thickness, dryness,

cracking) for infection, sweating, ulceration, calluses and blistering.

¢ Neurological assessment should be performed (10 g monofilament testing with at least

one other assessment: pinprick, temperature, vibration).

¢ Vascular assessment of pulses in the legs and feet is another component of comprehensive

foot examination.

Risk stratification should be done based on history and foot examination findings and

preventive/ treatment measures should be instituted accordingly.

¢ Well-fitted walking shoes or athletic shoes that cushion the feet and redistribute

pressure can be used to manage people with neuropathy or evidence of increased

plantar pressures (e.g., redness, warmth or calluses).

¢ People with bony deformities (e.g. Hammertoe, prominent metatarsal heads, Charcot

foot) may need extra wide/deep shoes or may even require custom moulded shoes.

¢ Thorough workup and immediate treatment should be given to patients with

neuropathy presenting with acute onset of red, hot, swollen foot or ankle and Charcot

neuropathy should be excluded.

8Management of diabetic foot

¢ General footwear recommendations include broad and square toe box, padded

tongue, quality lightweight material and sufficient size to accommodate a cushioned

insole.

¢ Screen for infection. If present, appropriate empirical antibiotic therapy should be

given.

¢ Foot ulcers and wound care may require care and intervention by a podiatrist,

orthopaedic or rehabilitation specialist experienced in management of individuals with diabetes.

¢ Hyperbaric oxygen therapy may be considered for selected people with diabetic foot

ulcers.

24

Inform patients regarding the risk factors that precede a diabetic foot ulcer and also advise them on weight management,

monitoring blood glucose levels and good maintenance practices such as keeping feet clean and moisturised.


¢ Diabetes related foot problems are a significant problem in people with diabetic neuropathy.

¢ Risk assessment and early initiation of preventive measures in the form of patient education and daily foot examination along with a comprehensive foot examination at least once a year can help reduce adverse outcomes.

¢ Thorough work up and appropriate treatment measures in the form of medical or surgical interventions should be instituted without delay whenever indicated.

25

26

ExpertOpinion

Introduction

Herbs and spices are an integral part of Indian cooking. They are excellent flavour enhancers and can be a health-conscious cook’s best aide. Apart from providing exciting flavours to your taste buds, they also have a variety of health benefits. In this article, we shall be discussing the benefits of six such herbs that can boost the health factor and also the taste factor especially when incorporated into a diabetic person’s diet.

Dr. Milind Katta

MBBS, Diabetology (CPS), CCGDM,

CCEBDM, CCD, FICM, DPHARM

Consultant Critical Care Specialist and Diabetologist, Balaji Hospital and Sugun Hospital, Andheri, Mumbai.

Six Protective Herbs to Include in Your Diet!

¢ Bitter gourd also known as bitter melon or karela is a unique, intensely bitter fruit rich

in vital vitamins and minerals. It is commonly used in Indian cooking and has long

been used as a natural remedy for treating diabetes.

¢ Apart from its blood glucose lowering effect, bitter melon has been traditionally

known for its other medicinal properties such as anti-cancer, anti-inflammatory,

anti-viral and cholesterol lowering effects.

¢ The presence of phenolic compounds makes it a potential antioxidant and anti-

mutagen.

27–29Momordica charantia (Bitter gourd)

¢ Ashwagandha is an ayurvedic herb also known as Indian ginseng or winter cherry.

¢ It has been associated with hypoglycaemic, diuretic and hypocholestrolaemic effect.

¢ It is marketed in powder form by various brands in India and it can be incorporated in

small amounts into various recipes.

27Withania somnifera (Ashwagandha)

¢ Gurmar is a perennial shrub found over top of woody trees in the tropical forest of

India is also known as Merasingi.

¢ It is a reputed herb in ayurvedic medicine and is associated with anti-hyperglycaemic effect and hypolipidaemic effect.

¢ Literature also associates this herbal plant with anti-obesity, anti-inflammatory, anti-microbial, hypolipideamic and anti-arthritic activity.

¢ Malabar kino, also known as Indian kino tree, has long been believed to have

medicinal properties in Ayurveda.

¢ Studies have shown this plant has effective blood glucose lowering effect and its

glycaemic effect can be comparable to add-on therapy in patients with T2DM.

31Pterocarpus marsupium (Malabar kino)

¢ Curry leaves, also known as kadi patta, are extensively used in Indian cooking as

flavouring agents in curries like dal, sambar, rasam and chutneys.

¢ Its health benefits include anti-diabetic effects along with antioxidant and anti-

hypertensive effect.

32Murraya koenigii (Curry leaves)

¢ Rosemary, also known as mehndi, is a popular herb used in Italian and French

cuisine.

¢ Studies have shown it improves hyperglycaemia and dyslipidaemia and aids in increasing antioxidant levels thus reducing the risk of chronic diseases such as CVDs.

33Rosmarinus officinalis (Rosemary)

27

27,30Gymnema sylvestre (Gurmar)

Thus, addition of the above herbs to diet can aid in management of diabetes along with

providing dietary variety. However, it is important to understand that they are not a

substitute for anti-diabetic medications and it is always advised to make major dietary

modifications only in consultation with a doctor and dietician.

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

and managing their symptoms of diabetes.


¢ Various herbs and spices can be incorporated into diet of a person with diabetes to harness its medicinal properties and anti-diabetic effect.

¢ It is important to convey that these measures do not substitute treatment and are used only in addition to medication and other management measures for controlling blood sugar levels.

28

29

ExpertOpinion

Introduction

The diagnosis of diabetes comes with a huge challenge of

convincing the patient to consciously adopt a healthier, active

and responsible lifestyle.

The term ‘responsible’ implies making a conscious decision

to manage diabetes in the most suitable way which will

improve and sustain better quality of life.

Dr. Samir Dasgupta

MD

Consultant Diabetologist and Endocrinologist, Rabindranath Tagore Surgical Centre, Kolkata, West Bengal.

Why Settle For Normal When You Can Reach Optimal?

Apart from constant self-monitoring and assessment of glycaemic levels and lifestyle

modifications, it also includes being responsible enough to follow healthcare

professionals’ prescriptions and have regular check-ups as advised to assess risk factors.

Ideal diabetes management treats the person with a holistic approach and a diabetic

management team include medical and healthcare professionals in various specialities, 34e.g., physicians, nurses, dieticians, pharmacists, mental health professionals and DEs.

Catch it early: Screening for diagnosis of diabetes

¢ Testing should be done in overweight or obese adults who have other risk factors like family history, hypertension, high triglyceride levels, physical inactivity, women with

polycystic ovary syndrome, etc.

¢ People with prediabetes (HbA1c levels ≥5.7%, impaired glucose tolerance, or impaired fasting glucose should be tested yearly).

¢ Women diagnosed with gestational diabetes should have lifelong testing every

3 years

¢ For all other adults, screening should begin at age of 45 years and if results are

normal, repeat testing done every 3 years or earlier if needed.

Tips to overcome obstacles and navigate the way to 8,34optimal health in diabetes

Comprehensive medical assessment and diabetic care plan

¢ Confirm diagnosis, characterise and classify diabetes, record past medical and family history.

¢ Assess lifestyle and behaviour patterns; tobacco, alcohol or substance use.

Record medication taking behaviour and immunisation history.

¢ Screen for psychosocial conditions, barriers to diabetes self-management,

episodes of hypoglycaemia and pregnancy in women. Assess co-

morbidities.

¢ Perform physical examination and record height, weight, body mass index and blood pressure. Eyes, thyroid, skin and foot should also be examined.

¢ Perform required laboratory investigations like HbA1c levels, lipid profile,

liver function tests, renal function tests, etc.

¢ Set a management plan with goals for different parameters, including

therapeutic treatment plan with anti-diabetic medications, referrals to specialists including dietician and DE, lifestyle

modifications, and use of glucose monitoring devices.

¢ CV risk assessment and staging of chronic kidney disease if present.

Monitor and maintain blood glucose levels in desired range

¢ SMBG is an integral part of effective therapy.

¢ Perform HbA1c levels at least twice a year in persons having stable glycaemic control

and quarterly in patients whose therapy has changed or who are not meeting

glycaemic goals.

¢ HbA1c <7%, preprandial capillary plasma glucose 80–130 mg/dL, peak postprandial

capillary plasma glucose <180 mg/dL is the recommended glycaemic targets for

many non-pregnant adults. More or less stringent glycaemic goals may be

appropriate as per patient characteristics.

Appropriate pharmacological and lifestyle intervention

¢ Nutrition: Encourage healthy low calorie eating pattern. Individualised

medical nutrition therapy is recommended.

¢ Physical activity: Regular moderate to intense physical activity improves

diabetes related parameters. Aerobic training along with resistance

training should be considered in appropriate individuals. Breaking up

prolonged sedentary time may also be encouraged.

¢ Medication: Use of insulin or oral hypoglycemic agents as appropriate.

¢ Mental healthcare: Ensure emotional well-being and convey to not feel

hesitant to ask for help if they are having trouble coping.

30

Immunisation

¢ Make sure people with diabetes are appropriately immunized against influenza and

pneumonia.

DSME and support

¢ Take part in diabetes education forums in group or individual sessions: Awareness regarding diabetes and related complications is important in self-

management.

¢ Have a sick day plan: stress or illness requires more frequent monitoring of blood

glucose, ketones in urine or blood, and ongoing communication with physician.

¢ Have a hypoglycaemia plan: Learn to identify related signs and symptoms, know

how to manage it.

Preventing CVDs and other complications

¢ Ensure controlled blood pressure and lipid levels.

¢ Quit smoking, incorporate healthy dietary habits, and consider aspirin therapy.

¢ Have regular screening for neuropathy, eye and kidney disease.

If diabetes is uncontrolled, it can damage the heart, blood vessels, eyes, kidneys, and nerves. This is why it is so important

to get screened for diabetes and take steps to prevent it way earlier in order to avoid complications.


¢ Optimal health parameters can be achieved only when people with diabetes are educated and made aware of diabetes, its implications and preventive measures.

¢ Healthcare professionals’ team based approach, DSME, SMBG, healthy lifestyle interventions, comprehensive and regular medical assessment are all important steps in ideal diabetes management.

31

32

ExpertOpinion

Introduction

Menopause is the general term used to describe the phase of

a woman’s life after the cessation of menstrual cycle – usually

around the age of 50. Menopause can also occur when

ovaries are removed during surgery for other medical

reasons.

For some women, the end of menstruation can be sudden. For most, the menstrual cycle comes to a gradual halt becoming less frequent with longer intervals before finally stopping

altogether.

Dr. Lavanya Katakam

MD (General Medicine),

DM (Endocrinology)

Consultant Diabetologist and Endocrinologist, Aswini Endocrine

Center, Guntur, Andhra Pradesh.

Diabetes and Menopause: A Double Challenge

Menopause can cause various physical and emotional symptoms in women. It presents a

twin challenge in women with diabetes due to the combined effects each condition has on 35the body.

36,37Menopause and diabetes: What to expect?

Blood glucose

level fluctuations

¢ Changes in

oestrogen and

progesterone levels

affect body's

sensitivity to insulin

causing variable

and unpredictable

blood glucose

levels.

Weight gain

¢ Menopause and

aging is associated

with increase in

total body fat,

decline in muscle

mass and

abdominal

redistribution of

fat.

¢ Weight gain can

increase the need

for oral diabetic

medicine or insulin

Infections

¢ High blood glucose

levels along with

drop in oestrogen

level creates ideal

condition in urinary

tract/vagina for

bacteria/yeast to

thrive in and thus

increase the chance

of aquiring urinary

tract and vaginal

infections.

Sleep problems

¢ Hot flushes and

night sweats leads

to sleep deprivation

which in turn

makes control of

blood glucose levels

tougher.

Sexual dysfunction

¢ High blood glucose

levels can damage

the nerves of the

vagina causing

thinning and

inflammation of

vaginal walls

(vaginal atrophy)

¢ Vaginal dryness in

menopausal phase

can cause pain

during intercourse.

Though menopause can make it harder to keep blood sugar levels under check, there are plenty of simple steps which can be taken to better manage diabetes and menopause.

Tips for diabetes management during menopause

¢ Healthy lifestyle changes: Eat healthy, avoid smoking, reduce alcohol intake, and exercise

regularly.

35,37How to tackle this twin challenge?

¢ Monitor blood glucose levels more frequently: Check more often during the day and

occasionally during the night too. Keep a log of blood sugar reading and symptoms and

adjust diabetes medications accordingly in consultation with the doctor. Test HbA1C

regularly.

¢ Seek help for menopausal symptoms: Expert advice can be sought from dietician for

weight gain issues. Vaginal lubricant may be recommended by the doctor to restore vaginal

moisture or vaginal oestrogen therapy to correct vaginal atrophy. Option of hormone

replacement therapy (HRT) can be discussed in women whose quality of life is significantly

affected by menopausal symptoms.

¢ Get assessed for heart disease risk: Undergo blood pressure and cholesterol screening.

¢ Protect bone health: Assess bone density. Take calcium and vitamin D supplements as

needed.

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


¢ Menopause in women with diabetes presents a dual challenge due to the impact of both conditions on the body causing significant physical and emotional impact.

¢ Women with diabetes in the menopausal phase must be made aware of what to expect and how to manage the associated symptoms for improving the quality of life.

33

34

ExpertOpinion

Introduction

Medical nutrition therapy is an essential key to people living

with diabetes and who want to prevent diabetes.

Medical nutrition therapy plays a major role in the following

levels:

¢ Primary prevention

¢ Secondary prevention

¢ Tertiary prevention

Ms. Umasakthy G.

MSc, RD, PGDDE

Senior Executive Dietician & Diabetes Educator, Dr. Mohan’s Diabetes Specialities centre, Gopalapuram, Tamil Nadu.

Role of Medical Nutrition Therapy in Diabetes Management

Primary prevention: Includes the guidelines to delay or prevent the onset of diabetes.

Secondary prevention: Includes the guidelines to control and manage the existing

diabetes status.

Tertiary prevention: Includes the guidelines to prevent or delay the progression of

diabetes and its complications.

¢ Reduce blood sugars as close to the normal range

¢ Reduce blood lipid levels to decrease the risk of CVD

¢ Reduce blood pressure as close to normal range

¢ Prevent or slow down the progression of chronic complications by changing lifestyle and

nutrition intake

¢ Assess the nutritional needs considering personal and cultural preferences and

willingness to change

¢ Achieve and maintain a reasonable weight

¢ Achieve normal growth and development in children and adolescents

¢ Maintain a balance between diet, medications and physical activity

Diabetes control depends to a great extent on following the right diet. Knowing what to eat and what not to eat is very important. Diet has long been linked to the development of obesity, diabetes and CVD, and dietary modification is one of the cornerstones of chronic

38disease prevention.

Aims of medical nutrition therapy

Nutrition forms an important pillar in managing diabetes and diet becomes the baseline of the

treatment. Following and adhering to the nutrition principle and meal planning is the most

challenging aspect of managing diabetes. Hence education plays a major role in translating the

nutritional principles into practice. DEs are the prime person in mediating these dietary

guidelines and to make them adhere.

Nutritional requirements are almost same for people with diabetes as for people who do not

have diabetes. A nutritional approach has to be individualised and tailor-made. Dietary

guidelines can be formulated according to the type of diabetes. But, diet need not be a complete deviation from the normal diet. Special dietary advice is needed in people who have diabetic

nephropathy or cardiomyopathy.

Following are the basic dietary guidelines that are necessary to achieve the aims of medical 39nutrition therapy. Let us start with the macro and micronutrients:

¢ Carbohydrates

¢ Protein

¢ Fats

¢ Fibre

¢ Fluids

¢ Vitamins and minerals

Calorie requirements are calculated based on Ideal body weight, body mass index and waist-hip ratio.

How to calculate these parameters:

Ideal body weight = Height (cm) – 100) * 0.92Body mass index = Weight in kg/ height in m

Waist-hip ratio = Waist (cm)/ hip (cm)

Calories

Body mass index Classification Recommended calories

<18 Underweight 40 kcal/kg

18 to 24.9 Normal weight 30 kcal/kg

25 – 29.9 Overweight 25 kcal/kg

30 – 34.9 Obese 20 kcal/kg

>35 Morbid obesity 20 kcal/kg

Source: Raghuram et al; Diet and Diabetes, NIN, Hyderabad, 1997.

Table 2: Recommended calorie intake based on BMI

35

A female person is considered to have central obesity if her waist-hip ratio is more than 0.85 and a male person has central obesity if

his waist hip ratio is more than 0.9.

Calories are derived from major nutrients such as carbohydrates, fats and protein.

People with diabetes need not restrict carbohydrates but they can change the type of carbohydrate they take. Carbohydrates are converted to blood glucose quickly within an hour or so after a meal. The level of glucose in the blood is directly related to the amount of carbohydrate taken. Both the

quantity and quality of carbohydrates influence the metabolic response to the ingestion of

carbohydrate (FAO/WHO, 1998).

Cereals and pulses contain complex carbohydrates which are broken down into simple sugars

before they get absorbed. But sugars, honey, jaggery and jam contain simple sugars which are

directly absorbed into the blood. These are the refined carbohydrates that cause a rapid rise in blood

sugars, hence are not recommended for a person with diabetes.

Approximately, 60–65% of the total calories can be obtained from carbohydrates. It is

recommended to choose whole grain cereals like brown rice, wheat, ragi, jowar, bajra, barley, and

oats than maida, rava, vermicelli and pasta. Sweets and desserts are often high in sugars and fat 40and tend to be in low in other essential nutrients. As cereals continue to be the main staple and

provide the bulk (60% – 70%) of total energy intake in Asian Indian diets, data on the health impact

of cereals are of great significance. Cereal-based diets consumed in the past were rich not only in 41 fibre but also in other micronutrients and have been associated with a lower risk of CVD andT2DM.

However, because of changing food processing technology and the modern milling process, the

refining destroys the structure of the grain kernel and removes dietary fibre and other essential 42micronutrients in grains. Intake of many refined grains including commonly used types of white rice can also induce high

43, 44glycaemic responses. Long-term consumption of refined grains has been associated with a higher risk of T2DM and CVD.

Carbohydrates

Protein is a nutrient that is necessary for bodybuilding and many essential functions in our body. 0.8 g of good quality protein is the daily recommended allowance. 15–20% of the total calories are derived from proteins. Vegetarian sources of protein are whole grams and pulses and contain fibre. Animal protein sources like chicken, egg, fish, beef, pork, mutton, lamb, sausages, organ meats, prawns, crab, milk and milk products are rich in protein as well as fat.

One must always choose chicken, fish, egg white, pulses, milk and milk products. It is better to restrict the intake of beef, pork, mutton, sausages, organ meats, prawns and crabs.

Protein may be restricted when the kidney function is affected in an individual with diabetic

nephropathy.

Protein

36

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

Requirement of vitamins and minerals are same as normal individuals. But as people with

diabetes are more prone to infections and other complication, they may require a litter higher

quantity. Daily intake of greens, vegetables, fruits, cereals, pulses, milk and milk products can

provide adequate vitamins and minerals.

Vitamins and minerals

Dietary fibre is the indigestible part of the food and has unavailable carbohydrates. Fibre is found

in plant foods like vegetables, fruits, pulses, whole grains. 25 g of fibre per day is the

recommended fibre allowances. Diets containing high dietary fibre can reduce blood sugar, cholesterol and blood pressure. High fibre foods like vegetables and greens are low in calories and glycaemic index, hence they are recommended in the daily diet. In addition, dietary fibres can relieve constipation and are helpful to treat patients with CVD.

Fibres

Adequate intake of fluids is recommended. 2 – 3 litres of water per day is recommended. It can be included as buttermilk, lemon juice, tomato juice and soups. Fruit juices are not advised as the

fibre is broken while making juices. Porridges are better to be avoided as they have a high glycaemic index.

Fluids

37

Fats

Avoiding alcohol is better for a person with diabetes. 1 or 1 ½ pegs per day may be allowed.

Alcohol beverages are high in calorie and low in other nutritive value. When consumed in higher

amounts, alcohol weakens the heart muscles, nerves and increases blood pressure and

cholesterol levels. Diabetes patients are prone to hypoglycaemia when consumed in excess.

Glycaemic index is a way to classify carbohydrates according to how quickly they are absorbed and raise the blood glucose levels.

Foods like white rice, white bread, sugars, jaggery, maida are high glycaemic foods and can raise the blood glucose level. Foods like

whole wheat, wheat bread, brown rice, legumes and pulses have a moderate glycaemic index and can be used in moderation. Green

vegetables and green leafy vegetables are low glycaemic index foods and are recommended in plentiful amounts.

A study from the Chennai Urban Rural Epidemiology Study (CURES) quotes that it would be advisable to substitute foods with a

lower glycaemic index as this could substantially reduce the glycaemic load and therefore possibly the risk of diabetes and CVD in 45the future.

One must fill half their plate with vegetables and greens. One-fourth of the plate must be filled

with whole grains, whole grams or pulses, non-vegetarian foods, curd and the remaining

one-fourth needs to be filled with cereals like brown rice, wheat or ragi. Portion sizes must always

be taken care of.

Have a healthy plate

The beneficial effect of diets rich in fruits and vegetables has been well recognised for the

prevention of chronic diseases, especially CVD, as they contain substantial amounts of nutrients 46–49such as folate, antioxidant, Vitamin K and dietary fibre.

Vegetables like potato, yam, colocasia, tapioca and sweet potato are starchy in nature. They can

increase the blood sugars when consumed with the rice or wheat. Hence, it is better to restrict

them. Root vegetables such as carrot and beetroot are high in calories, can be used in

moderation or in combination with low-calorie vegetables. Vegetables that can be consumed in

plenty amounts are: beans, gourd vegetables, brinjal, broad beans, broccoli, cauliflower,

Vegetables and fruits

38

Alcoholic beverages

A note on glycaemic index

Individuals who have pre-diabetes or diabetes should receive individualised medical nutrition therapy in order

to achieve their treatment goals.

cabbage, chow-chow, knoll khol, kovakai, ladies finger, mint, onion, papaya, tinda, plantain flower, plantain stem, spinach, lettuce,

onion, tomato, pumpkin, etc.

Fruits like banana, mango, jackfruit, chikku, custard apple and grapes are better to avoid. Fruits like apple, guava, orange, papaya,

musk melon, sweet lime, watermelon, pears, peach, kiwi, jamun are recommended in allowed quantity. Eating whole fruit is

advisable.

¢ Biscuits and bakery products except brown bread need to be avoided as they contain trans fats too other than sugars

¢ Any cereal like gruel or porridge form is not advised

¢ Always choose wholesome vegetables, cereals and pulses

¢ Choose fat wisely

¢ Combination of 2 or 3 oils are recommended

¢ Restrict salt intake. Papad, pickle and salted foods may be avoided

¢ Clear soup, buttermilk, unsweetened lemon or tomato juice, salads are low in calories and can

be consumed whenever one feels like

In conclusion, the best nutrition advice is to follow an individualised

meal plan that is designed to meet the goals of diabetes management. Best diet will always meet

the physical, metabolic and lifestyle requirement of an individual with diabetes. DEs are the core

person who can plan a well-balanced diet that can control blood sugars and prevent complications.

These educators can make a patient understand his or her nutritional needs and educate regarding

lifestyle modification.

By making few behavioural and lifestyle changes with effective planning, putting them into action and anticipating inevitable occasional setback are the ways to succeed despite having diabetes. It is essential to assess the readiness to change and set realistic short- and long-term goals. Self-

tracking the eating and activity patterns, and weighing regularly help to track for success in diabetes control. As the journey continues, keep revising and changing goals.

Few dietary tips

39

The Livongo app is designed to help people manage with diabetes by giving them easy access to their Livongo blood glucose

readings and trends, providing them with fresh ideas and enabling them to learn from other people with the same condition.

Tools in Diabetes: Livongo for Diabetes

Actionable pattern analyses

Most meters only provide a single blood sugar value and no feedback on ways to change

behaviours. However, Livongo uses artificial intelligence; their reinforcement learning

algorithms deliver trends and actionable, customised insights to members.

One-click free strip – always

Test strips are expensive and a hassle to get from the pharmacy. These are critical barriers to

frequent missing. Livongo gives their members as many test strips as and when needed,

delivered right to their door.

Over-the-meter air updates

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

40

Real-time support

Hypoglycaemia (severe low blood glucose readings) and hyperglycaemia (severe high

blood glucose readings) without immediate support can lead to significant health

consequences and emergency room visits. Livongo’s Diabetes Response Specialists call or text in minutes providing 24/7 support when readings are out of range.

Livongo creates a community to support members!

50Here’s what Livongo can do!

Convenient coaching

The annual time spent in a healthcare setting is 0.1%. The other 99.9% of that time

is spent without a readily available clinician that knows you and has access to your

data. Livongo has their own Certified DEs that are standing by to advice on

nutrition, lifestyle and diabetes management.

Data sharing keeps others in the loop

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

A Livongo-connected community

Lack of social support leads to depression, anxiety and reduced mental health. Studies show the positive health impact on HbA1c of

peer-to-peer support – anonymous and private community peer support provides motivation for success.

41

A new microneedle patch, filled with dozens of tiny polymeric needles just 0.6 millimetres

long, could provide pain-free injections.

Researchers have shown that the microneedle patch could deliver lidocaine, a common 51painkiller, within five minutes of application. In contrast, the drug in a commercial

transdermal patch took 45 minutes to penetrate into the skin. This new way to administer

painkillers quickly is good news for people who squirm at the sight of needles. Given the

innovative technique for administering drug non-invasively, the patch can also be used in 52home-care settings.

This non-invasive adhesive patch can measure blood glucose levels directly through the skin

without the need to draw blood by finger-prick sampling for calibration. The patch, based on

a miniaturised pixel array platform, pulls glucose out from fluid between cells across hair 53follicles and can monitor blood glucose levels over several hours.

It has been suggested that the patch technology lends itself to low-cost, high-volume

production, which could address the need to develop a non-invasive, patient-friendly and

affordable glucose monitoring platform for the growing global population of patients with 53T1DM and T2DM.

This technology could then be developed as an affordable, wearable sensor that sends 53clinically relevant glucose measurements to the diabetes patient's phone or smartwatch, wirelessly.

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

42

Diabetes Educator of the Month

Contributed by

Ms. Minal Gada

CDE, MSc

Nurture Health Solutions.

Intervention by DE

DE took a detailed history of her and found that she had a history of gestational diabetes mellitus. She checked her sugar levels and

found that she is having prediabetes.

DE advised her to lose weight and control her blood sugar levels by following a proper

healthy diet and engaging in some physical activity.

She told the DE that she has read many quick and easy ways online for losing weight and

controlling sugar levels such as soup diet, juice diet, etc. So she doesn’t wish to work-out or

stay active. The DE explained to her that these diets are not nutritionally adequate. She will

gain back her weight after switching to her normal routine diet. The DE explained her that

healthy eating is an important part of lifestyle modification.

DE also explained to her that prediabetes is a warning sign and this can be completely reversed

with proper diet and exercise. If not controlled at this stage it will progress to T2DM which is a systemic disorder that affects all the parts of your body mostly eyes, nerves, heart, kidneys etc.

DE explained her importance of physical activity and weight loss in controlling blood sugar levels.

She understood the importance of her being diagnosed as having prediabetes. She was

motivated to start with healthy eating habits and exercise to control her blood sugar levels.

43

A 36-year-old woman, mother of one, was diagnosed with

prediabetes. She had read so many different ways to lose

weight to attain an optimal glucose level and so she believed

there is no point in getting active when there are so many

easier shortcuts. To clear her misconceptions related to diet

and weight reduction and promote a healthy and active

lifestyle in her she was referred to a DE by her doctor.

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.

Busting the Myth: Egg Yolk Must be Discarded

Fact: Egg is a good source of protein. Egg yolk is a good source of vitamins like Vitamin A,

Vitamin B12 and Vitamin D. Egg yolk contains choline which is required for brain development, muscle and nerve function.

Recent studies have shown that egg consumption is not associated with the risk of CVD and cardiac mortality in the general population. Hence 1 egg/day can be consumed by healthy individuals.

In another recent study published in American Journal of Clinical Nutrition, it was found that

people with prediabetes or T2DM who consumed a 3-months high-egg (>12 eggs/week)

weight-loss diet with a 6-months follow-up exhibited no adverse changes in

cardiometabolic markers compared with those who consumed a low-egg (<2eggs/week)

weight-loss diet.

An egg is a no carbohydrate and high protein option. Hence whole eggs can be advised to people having diabetes provided they

restrict or eliminate saturated and trans fat from their diet.

44

Get Active!

Physical activity to reduce the risk of diabetes

Vigorous physical activity, exercise and fast walking are negatively associated with the incidence of T2DM, whereas leisure,

sedentary activities are positively correlated with T2DM. Overweight and obesity increase the risk of developing diabetes. Hence it is

important to keep the weight in control in order to prevent diabetes. Exercising has many positive effects in reducing weight and

preventing the risk of diabetes.

45

Benefits of regular exercising

¢ Helps to reduce insulin resistance and increase insulin sensitivity.

¢ Helps to lower blood glucose, blood pressure, HDL cholesterol and triglycerides.

¢ Helps to reduce the risk of prediabetes and T2DM and also other complications like

heart diseases and stroke.

¢ Strengthens your heart, muscles and bones.

¢ Improves blood circulation to the muscles and helps to keep your body flexible.

Exercises can be aerobic, resistance and flexibility exercise. Aerobic exercises such as brisk walking, dancing, swimming, cycling, etc. makes the heart and bones stronger, helps to reduce the risk of prediabetes and T2DM by maintaining the blood glucose levels. Exercise

helps to improve glucose transporter type 4 (GLUT-4) mediated uptakes of glucose into the muscles.

¢ It is important to choose an exercise which you will like to do.

¢ The best rule of thumb of safe workout is to listen to your body. If you feel tired, have too much fatigue, pain, injury or shortness

of breath, you need to slow down. You can change the workout or go for lower intensity activities.

¢ It is important to start the exercise with warm up and some stretching exercises.

Points to remember while exercising

¢ This should be followed with at least 20 to 30 minutes of aerobic activity. It should not be so intense that it causes shortness of

breath or intense pain.

¢ The aerobic exercise should be followed by 5 to 10 minutes of cool down exercises or stretching.

¢ Moderate intensity physical activity for 2–3hours/week is recommended.

46

National Diabetes Educator Program(NDEP) Best Practices

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

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

how to manage their condition. This program is under the auspices of the Indian Association of Diabetes Educators

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

promoted by USV.

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

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

Join NDEP Facebook page to know more about it!

47

NDEP is the backbone of diabetes care and works with DEs to

reduce the burden of diabetes by facilitating the

implementation of proven approaches to prevent or delay the

onset of T2DM and the complications of diabetes. Diabetes is

the only condition that can be managed majorly by patients

upon educating them with DSME. By working together,

educators and patients can optimise the healthcare team to

successfully manage diabetes over the long-term. We thank

USV for undertaking this noble work of disseminating

knowledge and preventing diabetes progression among

individuals in our community.

48

Contributed by

Dr. Shachin Kumar Gupta

Diabetologist

NDEP Trainer, Bhopal.

Eat Out, Be Wise!

West Indian cuisine

West India includes the states of Goa, Gujarat, and Maharashtra. The cuisine of

Western India is diverse. Gujarat is worldwide known for food, the

Maharashtrian cuisine is diverse and ranges from bland to fiery hot. Goan

cuisine is dominated by the use of rice, coconut, seafood, Kokum, cashew-nuts.

49

Gujarati cuisine

Khandvi is made of gram flour and buttermilk which are good source of proteins and is a

good snack option, steamed Patra, methi thepla, moong dal dhokla/khaman (made of

gram flour), handwa (made with a mix of buttermilk, flour, coriander, chillies, lentils and

rice) dal dhokli (good source of complete proteins) and muthiya are other healthy options.

Healthy options

Maharashtrian cuisine

Steamed/Baked kothimbirvadi made of gram flour, buttermilk and coriander make a

healthy evening snack option. Usal or dahi usal, methi pitla with jowar bhakri, aamti, dalimbi usal, varan bhaat, roasted thalipeeth are other healthy options.

Goan cuisine

Steamed fish, grilled chicken, solkadhi, stir-fried vegetables, grilled mushrooms, fish

recheado are other healthy options.

Shopping Smart

Fat-free cereals

In today’s world, due to the paucity of time and busy lifestyles, breakfast cereals are gaining immense popularity. Manufacturers are marketing them as low fat meal replacers and are asking us to replace two of our traditional home cooked meals with these highly processed cereals loaded with additives.

Usually products marked as low fat or fat free can be misleading as they may be high in sugar content. In order for the fat-free food to maintain its taste, the fat has to be replaced by either sodium, sugar or something else that will give it a similar flavour and texture.

For example, if you have a look at the list of ingredients mentioned on a cereal packet, it has

honey, malt extract and sugar (8.4 g in 30 g cereal) making the product high in simple

carbs/sugar. This means you are consuming sugar coated cereal, which can induce increased appetite and be detrimental to your

sugar levels.

Studies have shown that the body utilises more energy metabolising a meal from less-processed foods than highly processed foods,

which means lesser calories leftover for the body to store as fat.

50

Diet-Related Behavioural tips

Control at home environment

¢ Eat meals with family members instead of eating while watching

TV or using the computer or phones.

¢ Have healthy snacks at your disposal like fruits, vegetables, protein

bars and sprouted pulses.

¢ Keep tempting food out of sight as well as prevent buying them.

¢ Do not skip meals because you may end up eating more in the next meal instead plan

what you will be carrying in advance.

¢ After meal take a 5 minute walk before you go back to your desk.

Control at your work environment

51

¢ Fill half your plate with vegetables, quarter with lean protein and the other quarter

with starch.

¢ Use smaller plates, bowls, and glasses while eating so that the portion size is reduced.

¢ Politely refuse second servings.

Control your mealtime environment

¢ Drink large glass of water before eating.

¢ Avoid high-calorie add-ons such as cream with your coffee, butter, mayonnaise and

salad dressings.

¢ Read foods labels to ensure that you are making a healthier choice.

¢ Don’t snack while cooking meals.

¢ Use a quarter spoon if you want to taste your product.

Daily food management

¢ Take small bites and chew your food well.

¢ Don’t consume food rich in salt like processed, packaged foods and bakery products.

¢ Order à la carte rather than buffet style.

¢ Order some vegetables or a salad for an appetiser instead of eating bread to prevent

overeating.

¢ Limit alcohol intake.

¢ If you are going to a friend place then offer to carry some low calories dishes.

Eating out and social eating

¢ Make exercise a priority and a planned activity in the day.

¢ If possible, walk the entire or part of the distance to work.

¢ Park at the end of the parking lot and walk to the store or office entrance.

¢ Always take the stairs all of the way or at least part of the way to your floor.

¢ If you have a desk job, walk around the office frequently.

¢ Do leg lifts while sitting at your desk.

Exercise well

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

52

53

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

Health benefits

Superfood: Beans (Lente carbs) / Qfy;ka

¢ Good source of protein, fibre and minerals like magnesium, copper, etc.

¢ Controls appetite

¢ Prevents constipation, improves gut health

¢ Helps control blood sugar levels

¢ Reduces blood pressure and cholesterol levels

How to consume?

¢ It can be added in salads and vegetables

¢ It can be consumed as beans curry

¢ It can be used for making tikkis

¢ Combination of beans and rice makes it a complete protein

Dosage

30 g–60 g three days a week

Method for preparing dressing:

¢ Heat olive oil in a frying pan

¢ Sauté the onion, capsicum, tomato and carrot. Close the lid and allow cooking until soft

¢ Spread the mixture evenly

¢ Break the eggs on the vegetables

¢ Add black pepper powder and salt

¢ Cook until done

¢ Serve hot with one slice of multigrain bread/whole wheat chapatti

Serves: 1

Ingredients Amounts

Egg 1 whole , 2 whites

Oil 2 tsp.

Onion (finely chopped) 1 no.

Capsicum (chopped) 1 no.

Tomato (finely chopped) 1 no.

Carrot (grated) 1 no.

Coriander leaves Few

Black pepper and salt To taste

*1 tsp.= 5 g

Spanish omelette

Recipe

54

55

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NOTES

NOTES

60

Documents

To keep the members of DSME and DSMS concepts · Diabetes and Endocrine Clinic, Ludhiana, Punjab. Dr. Lavanya Katakam MD (General Medicine), ... Diet-Related Behavioural Tips 51 53