What is Diabetes’?

Diabetes is a chronic disease in which there is excess of glucose (sugar) in the blood.

Diabetes is a disease that affects 30 million people in India and approximately 150 million world wide .It is one of the leading major cause of blindness, heart disease, kidney failure, amputations and digestive disorders. The major causes of diabetes are heredity, immune system dysfunction and viruses’. Among the contributory causes are obesity, lack of exercise and improper nutrition that results from over consumption of processed, chemically treated, over cooked, high fat, high glycemeric, packed and nutrient deficient food.

Diabetes is a serious chronic condition where the body either doesn’t make, or properly use insulin. This causes the sugar to build up in your blood stream instead of going into the cells of the body. This means that your body cannot make the energy it needs from the food you eat.

Every one of us needs to be concerned about diabetes. Energy is produced from glucose and is produced from our food. If we are not eating properly, we are not producing efficient energy.Then we begin storing fat, and set the stage for illness and disease. Any time one of our basic needs is out of balance, the body is under stress and cannot function properly.

Why Do You Develop Diabetes?
The question why you developed ‘Diabetes’ is not always easy to answer. Heredity is considered an important cause. Children of the parents with no diabetes are less likely to develop diabetes than children of parents with diabetes. Obesity and sedentary lifestyle are major contributing factors. Alcoholic beverages when taken in excess damage the pancreas and cause the diabetes. Higher consumption of bitter tapioca, maize sugar, salt and low protein diet during the childhood increase the risk of developing diabetes. Those with low (1.5kg or lower), high (3.8kg and higher) birth weight, stress high blood sugar (during an infection, heart attack and mental stress), diabetes during pregnancy, and men and women with hypertension run the risk of developing diabetes. Viral gastroenteritis ,  mumps and chickenpox may precede  development of type 1 diabetes.

When Diabetes’ Is Suspected?
Diabetes is an insidious disease. infact, moderately high levels of blood glucose (180 – 200mg/dl) produce no symptom and, may go unnoticed for many months or, even years. Most patients with type 1 diabetes pass large volumes of urine, experience an increase in the frequency of urination, undue thirst and hunger, and rapid weight loss. These provide clues to diagnosis of diabetes

Men and women with type-2 diabetes may not have the above symptons. Some of them may experience an increases in the frequency of urination and abnormal thirst. They may how ever feel tired, irritable, lack concentration at work, proneness to infection, delay in wound healing, intense itching and need for frequent change of eye glasses.

If you foresee the risk of developing diabetes, get your fasting blood test 2-hrs after a drink of 100gms of glucose at least once a year after 45 yrs of age. Blood glucose values of 200mg/dl and higher would suggest diagnosis diabetes mellitus.

Can Diabetes Be Cured?
Diabetes cannot be cured, but can be effectively controlled. People with diabetes feel well and healthy when their blood glucose is controlled. The decrease in life span of a diabetic is restored to maintaining good blood glucose in control (90-130mg/dl at fasting and less than 180mg/dl 2h after meals).

Some times patients may not need any tablet /insulin or, even diet control to keep their blood glucose in control. This period  is called honeymoon phase(in type-1 diabetes ). The duration may vary from a few days  to over six months. Some patients mistake this fore cure of diabetes.

Management of Diabetes
To keep your blood glucose in control through out the day you need diet modifications, regular exercise, medicine (tablets/insulin).

The tablet or insulin injection is not need immediately after the diagnosis of diabetes is made (unless your doctor feels this is an emergency). If you are obese you need to reduce the your weight through the diet control and giving up sedentary habits, so that ‘your insulin’ works better. Your treatment should be started and, supervised by an expert in diabetes, you should review in it every it every 3-6 months to help to keep your blood glucose in control. You should register in a diabetic clinic for a regular blood pressure check ups, timely investigations, eye check-ups, ECG and advice for care.

Treatment is aimed at maintain the blood glucose in the normal range and HbA1c less than 7% by balancing  food intake with oral medication or insulin and physical activity year after year to prevent complications if diabetes .

An emotional stress (a death in family ,displeasure at work or at work or at home)may increase and disturb the control of diabetes. You need to discuss the problem with your doctor for suitable adjustment in dosage of medication and stress control exercises.

By keeping a good control of diabetes at all times, you will be able to prevent the complications of diabetics affecting the nerves, eyes, kidneys, heart and blood vessels.

Diet
The general guidelines on diet are:

1. In a typical day’s meals and snacks, you should have 1500-1800 calories with 60% contribution from the carbohydrates, 20% from fat and 20% from proteins. You may need extra calories for your physical work or less calorie weight reduction. If you are on calorie –restricted diet, make sure to take 50-60% of calorie as complex carbohydrate (whole cereals)to prevent any feelings of weakness.
2. You should eat a variety of items of food every day. Do not skip meals .Avoid snacks, unless you are advised so (example during insulin treatment) don’t over eat.
3. Eat fruits and vegetables. Use less oil in cooking, eat less or, avoid fried foods, milk cream or food cooked in coconut milk.
4. Avoid ready to eat food preparations and, sweet and sugary drinks (canned beverages) that provide empty calories (no vitamin or essential minerals).
5. Keep regular check on your weight maintain this with in the estimated limit.
6. Check your hemoglobin and proteins in blood samples at 6 months or year’s interval. Suitable correction in diet format or supplement may become necessary.
7. Restrict protein consumption after you are informed your kidney damage.
8. Despite a good control of blood glucose, if your blood lipids are high, you will need lipid lowering drugs regularly .some times your doctor may advice you lipid –lowering drugs from the beginning of your diabetes treatment.
9. Match your mealtime to the form the insulin and insulin injection schedules as explained by your doctor or the diabetes nurse educated.
10. Its is the amount of dietary fibers in your diet with whole cereals, lenthils.

Exercise
Exercise promotes muscular and burns sugar. Therefore, you may need a reduction in the dose of tablet or insulin. Exercise also promotes good circulation and, maintains weight.

Regular exercise like 1/2 - hr - 1 hour of brisk walking improves the effect of insulin.

All diabetics need exercise, but the type and the amount will vary for each individual would benefit from long walks (2-3km/day), gardening walking to office or shopping complex, cycling short distances or, playing golf.

If you are taking insulin you will find that increasing your level of exercise may cause a significant  fall in your blood glucose, some times producing hypoglycemia ,you may therefore need to balance your food and insulin dose.
If your type of exercise lasts longer e.g. badminton /tennis playing, you need to take sugar juice at regular intervals. Discuss this you dietician and diabetics nurse educator.

If you are on tablets, you can perform extra exercise without worry of experiencing hypoglycemia.

If your are overweight and your diabetes is controlled alone, low blood glucose would not occur with an increase in amount of exercise.

The diagnosis of ‘diabetes’ need not scare you to give up the sports you like . Many people with diabetes have excelled in highly competitive sports.

Tablets
The tablets used in treatment of diabetes are sulphonylureas, Glitazones and metformin.they vary in their duration. They vary in their duration of action and in potency to reduce blood glucose. They are fully absorbed when the stomach is empty. The sulphonyurea tablet should be taken 30 mins before food, once or twice in a day as directed by doctor. Metaformin and glitazones tablet is generally advised after meal.  

Tablet(s) is not form of insulin.The sulphonylurea (su) tablets are only useful for patients with type-2 diabetes whose pancreas still produce insulin.
They are ineffective in type1-daibetes where the pancreas cannot produce insulin. The SU tablets increase the release of insulin from the pancreas while metformin improve the benefits of insulin. The Su tables become progressiveively in effective with increase in duration of the diabetes (after5-10years).

Insulin
The different preparations of insulin include:

1. Rapid acting insulin (soluble crystalline insulin):It starts working in 30-50 mins after an injection and the effective lasts for 4-6 hours.
2. Intermediate acting insulin (NPH_Insulin, lente-insulin): It starts working 1-2 hours after an injection and works for over 12-16 hours.
3. Long acting Insulin (Protamine –zinc Insulin.Ultralente Insulin) : It starts working 2-3 hours  after an injection and remains so far 18-24 hours.
4. Mixed rapid acting and Intermediate acting Insulin: Available in 30:70 and 50:50. ratio. In some patients, 2 daily injections of mixed insulin may offer better control of blood glucose. On a fixed daily dose, the pre mixed insulin offers convenience and better dose effect.

When you obtain a fresh supply of insulin, please check its type and that it is within its expiry date and the form of insulin is the same that you have been prescribed. The expiry date is printed on the package containing the insulin bottle. Every bottle of insulin carries the distinctive color code on the paper pack to indicate the type of insulin it contains (red for short acting, blue for intermediate acting and purple for mixed insulin). When in doubt, show your empty insulin bottle to the pharmacist/chemist and seek help. The insulin bottle needs to be stored in refrigerator to prevent any loss to potency of insulin.

Use the right type of insulin syringe (40u/100u)to load your prescribed dose of insulin. Roll the insulin bottle containing milky insulin preparation (intermediate and long acting insulin) between your palms a few times for thorough mixing, before usage.

After the subcutaneous injection in any part of the body, insulin is absorbed well. Most people find the upper arms, thighs and lower abdomen as convenient sites for injection of insulin. The lower abdomen is how ever not only very convenient but offers consistent absorption of insulin from the injected site.

Following the subcutaneous injection of insulin, the insulin effect in evident after 30-45 mins. Hence food is advised after 30 mins, of a subcutaneous insulin injection.

Make sure that the area you have chosen to inject insulin is clean and dry . yo can use bath soaps and dry hand towel to make the area clean and dry. If you are using an alcohol swab. Make sure that alcohol has evaporated before you inject insulin .The injection with the fine needle is not painful. The insulin syringe capped and stored properly, is reusable for the same patient. This carries no increase in the risk of an infection.

Inject insulin by inserting the needle till the hilt at 90%(vertical) into the fatty tissue under the skin; push the plunger all the way down to inject insulin loaded into the syringe, with draw the needle and press the site of injection with a cotton wool swab, to prevent any leakage of insulin through the needle tract. Do not rub the injection site. Do not inject insulin deep into the muscles.

Keeping Diabetes under Control:
Whether your treatment consists of diet alone, diet and tablets or diet and insulin, your need regular blood tests to keep a check on your blood sugar. Urine sugar tests are not a reliable indicator of diabetes control.

When blood glucose remains higher than 200mg/dl for 8-10 weeks, the concentration of glycosylated hemoglobin (HbA1c) rise. A (HbAlc) measurement therefore reflects the blood glucose control over a preceeding 2-3 months period, while the estimates of blood glucose indicate the glucose value at the time of blood test. HbA1c values between 6-7% indicate very good control on diabetes. You should aim at keeping your blood glucose in the normal range  i.e. between 90-130mg/dl when fasting and  less than 180mg/dl after meals and HbAlc around 7% frequent tests for blood glucose are necessary when starting treatment with insulin.

If you are doing capillary blood glucose test using a hand held glucometer, do not squeeze the finger to bring out a sample after you have pricked. This invariably gives a low glucose value. Ask your diabetes nurse for a demonstration of capillary blood glucose test.

Urine test for sugar is not reliable indicator of diabetes control. Although spillage of sugar in urine occurs when the blood glucose exceeds 180mg/dl in the majority of healthy persons, this is not always so in a patient with diabetes. Most patients diabetes of many years acquire an increase in the rental threshold for glucose (capacity to prevent spillage of glucose in to urine). Hence urine test for glucose is not helpful for assessing control of diabetes in the presence of urinary infections, the bacteria eat up the sugar present in urine, there by making urine test for sugar unreliable.

Dietary Advice for Diabetic Patients(1800 Kcal)

Dietary Advice for Diabetic Patients(1500 Kcal)

Diet Exchange System
A specific amount of food can be exchanged by another from the same EXCHANGE category. The food exchange that are listed below, selecting a wide variety of foods from each exchange. At first you should measure all the foods to be sure of the amounts.

Diet Exchange System

General advice

• Preferably restrict rice to one meal every day.
• Have whole grams, Green leafy vegetables 2-3 times a week with rice/chapatti. Whole cereals and grams to be preferred over refined ones. Sprouted grams to be included in at least one meal a day.
• Fruits with edible skin are preferred to fruit juices. Fruits, washed well to be had with the peel where ever possible
• Remove cream from milk, Curds, Buttermilk and Skin and Chicken.
• Eat small quantities at frequent intervals as suggested. Daily should be well distribute between the three meals-breakfast, Launch and Dinner, with two snacks, A variety of foods that are well balanced in your daily diet.
• Have regular timings for meals and have a light dinner 11/2 - 2 hours prior to sleep.
• Reduce consumption of oil and coconut used in cooking.
• Do not add soda or baking powder to any foods. (like dosa &idly batter)
• Green leafy vegetables and salads to be included more in the daily diet.
• Foods containing large amounts of carbohydrate must be limited as starch is converted in to sugar in the body and may increase blood sugar levels if taken excessively.
• It is recommended that carbohydrates provide 50 to 60% of the kcal.
• Approximately 40% to 50% should be from complex carbohydrates. The remaining 10%to 20% of carbohydrates could be from simple sugar.
• Fats should be limited to 20% of total kcal, And proteins should provide 20 to 30% to total kcal.
• Start a walk for 15 mins and gradually increase it to 40 mins remain active throughout the day. (Consult your doctor before starting).