Basics of DIABETES

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About The Author in General Medicine in 1971, Dr. Joseph started his career at Fatima Mission Hospital at Pala in Kerala, India. He continued there as the Chief Physician for a long tenure of 16 years.

Dr. Antony George Joseph MBBS, MD (General Medicine) Specialist Internist Aster Medical Centre - Al Hilal

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Dr. Antony George Joseph brings over 40 years of professional experience in medical service. After obtaining his MD

After a short stint of three years as a professor at the Government Medical College in Aurangabad, Maharashtra, Dr. Joseph moved on to St. Thomas Hospital in Changanacherry, Kerala and practiced there for another 15 years. Dr. Joseph migrated to Qatar in 2007 to join DM Healthcare. The veteran doctor is now a Specialist Internal Medicine, mainly focusing on diabetes management and prevention of lifestyle diseases.

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Preface Living with diabetes can be challenging.

It is all the more difficult, if proper care and resources are not accessible to patients in time. A part of the solution is to have enough information about the disease to enable him or her to fight against the disease.

At the time of consultation, all the aspects of diabetes is not often discussed in detail due to the time constraints. This

book discusses diabetes in a very simple language and is an attempt to overcome this difficulty.

Type 2 diabetes, accounts for majority of diabetes. Hence, the information provided in this book is mainly concentrated on Type 2 diabetes.

1

Understanding diabetes

Knowing Diabetes Mellitus, what the reasons are and identifing the symptoms.

(Page 2)

2

Blood sugar level

What is the normal and abnormal blood sugar levels?

(Page 3)

3

Prediabetes

Know about prediabetes and risk.

(Page 4)

4

Risk of developing diabetes

What are the risk factors that may lead to developing diabetes in a person?

(Page 5)

5

Control of sugar

Undestanding how our body controls blood sugar levels naturally.

(Page 6)

6

Aims of treating diabetes

Why diabetes should be treated and how it should be controlled?

(Page 7)

7

The complications of diabetes

Understand the different health threats that develop due to diabetes.

(Page 8)

8

While meeting your doctor

Things to remember and do during a medical appointment with a doctor.

(Page 11)

9

Medical tests for diabetes

Different tests that are usually done for patients with diabetes.

(Page 12)

10

Managing diabetes

Detailed information of how and what should be done to manage diabetes.

(Page 16)

11

Drugs for diabetes

What different medication and drugs are used to control diabetes.

(Page 24)

12

Diabetes in special situations

Diabetes management during special situation like Ramadan fasting, during pregnacy, driving and diabetes of senior citizens.

(Page 25)

1 Understanding Diabetes Diabetes mellitus is a chronic illness and it involves the way by which your body deals with sugar.

The condition results in high blood sugar level and complications resulting from this.

Why you develop diabetes?

It is due to one of the two reasons

1. The body does not produce enough insulin-a hormone from pancreas.

2. Your cells in the body resist the action of insulin-known as insulin resistance.

So it is either insulin deficiency or insulin resistance.

When do I suspect diabetes mellitus?

Classic features are:

Diabetes is one of the major public health concerns of 21st century. Diabetes is on the rise worldwide, affecting more than fifty million people on the globe. The cost of managing diabetes and its complications is becoming enormous. Thus diabetes is becoming a burden not only for individual but also for the family and the society. The increasing prevalance of obesity, sedentary lifestyle and unhealthy eating habits account for the dramatic increase in the incidence of diabetes all over the world.

• Polyuria (increased amount of urine) • Polydipsia (increased thirst) • Polyphagia (excessive hunger) In addition you may experience • • • • •

Weight loss Blurring of vision Numbness in hands and feet Non healing ulcers Infection in vulvar region in women and foreskin of penis in men

The prevalance of diabetes is alarmingly high in Qatar also. The incidence of diabetes is said to be 15.4 in adult population in Qatar. Numerous studies have shown that life style changes make a significant impact on the prevention and control of diabetes.

Page 2

Basics of Diabetes

2 Blood Sugar Level When is my blood sugar level abnormal?

For the diagnosis of diabetes the criteria are

• Fasting blood sugar of 126 mg or more • Random blood sugar 200 mg or more • A blood sugar level of more than 200 mg two hours after taking 75 g glucose on a fasting state.

• HbA1c level (three months average blood sugar) of more than 6.5 %.

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3 Pre-diabetes

When your fasting blood sugar level is between 110 mg and 125 mg or blood sugar two hours after a meal (Postprandial blood sugar) is between 140 mg and 199 mg or the HbA1c level between 5.7 % and 6.4 %.

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What are the risks for pre-diabetes?

Those diagnosed as pre-diabetc are at risk of developing diabetes if proper lifestyle modification (diet and exercise) is not made. Also they have the same risk of developing cardiovascular complications (heart attack, stroke) as a person with diabetes can encounter.

Basics of Diabetes

4 developing Diabetes Who are at risk of developing diabetes

Doctors and researchers have found that persons who are obese are at high risk for developing Type 2 diabetes.

• Persons who are overweight.

• Persons who have less physical activities.

• Persons whose parents have a history of diabetes.

• Women who gave birth to over weight babies.

• Women who had gestational diabetes (diabetes during pregnancy).

• Women with PCOD (Poly Cystic Ovarian Disease).

• People who have metabolic syndrome, a cluster of high triglyceride and low HDL (High density lipoprotein), impaired glucose tolerance, abdominal obesity, high blood pressure and elevated uric acid.

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5 Control of Sugar Glucose is the fuel to provide energy for body. Blood glucose level is maintained by food you take and by breaking down glycogen in the liver when you starve at night.

How does our body control sugar?

The blood sugar is mainly controlled by insulin, a hormone from pancreas.

Pancreas is situated in the abdomen and secretes insulin into the blood in response to food intake.

Insulin acts like a key to open the door of cells for entry of glucose into them.

This process lowers the blood sugar level. As the sugar level returns to normal the insulin secretion from pancreas stops. The hormone also moves glucose from the blood into muscles and other tissues so they can use it for energy. In addition, insulin helps the liver absorb glucose, storing it as glycogen in case the body needs energy during stress or exercise.

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Basics of Diabetes

6 Aims of treating Diabetes What are the aims of treating diabetes?

• To keep blood sugar level as normal as possible and thus to have alleviation of symptoms.

• To prevent micro vascular complication Retinopathy - involvement of Eyes Nephropathy - involvement of Kidney Neuropathy - involvement of nerves • Reduction in the incidence of macro vascular complication (involvement of heart, brain and blood vessels to the limbs).

The aim in a patient with diabetes is to have: • Fasting blood sugar less than 120mg%.

• After food (2hrs) blood sugar less than 140mg%.

• Blood pressure (BP) less than 130/84.

• Low Density Lipoprotein (LDL) less than 100mg%.

• HbAIc less than 6.5% and in elderly 7%.

How well you need to control diabetes?

We need to individualize blood sugar control for a given person. For elderly, for persons with associated heart diseases, for persons staying alone and for person receiving multiple doses of insulin, tight control of sugar is not advised. This may precipitate hypoglycemia (low blood sugar level) which in these situations may be detrimental.

Where as in persons receiving metformin, ( an anti diabetic drug unlikely to cause hypoglycemia) diabetes can be kept under good control without fear of hypoglycemia.

Target Blood Sugar Values FASTING BLOOD SUGAR

2 HOURS AFTER FOOD

HBA1C

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7 complications of diabetes Diabetes targets many vital organs in the body like heart, kidney, eye and nerves.

High levels of glucose acts like a toxic substance (Glucotoxicity).

Persons with diabetes are likely to suffer from loss of vision, kidney failure, heart attack, nerve affection, stroke, delayed wound healing, amputation of toes or lower limbs. These complications are responsible for hospitalization and premature deaths. What we should know is that most of these are preventable.

The most important complications are, 1. Heart disease Coronary heart disease, stroke, and diseases of limb blood vessels cause 80% of deaths in diabetics. The risk of developing heart disease in diabetic is four to five times higher than normal population. This risk is aggravated by Page 8

hypertension, high cholesterol, smoking and microalbuminuria. Heart diseases have earlier onset and may be painless (silent attacks) in people with diabetes. Outcome of the disease is poor compared to non-diabetics.

2. Stroke Brain involvement due to damage to its blood vessels is more common in persons with diabetes. This can lead to paralysis of parts of the body.

3. Nerve damage Excessive sugar levels injure small blood vessel nourishing nerves. This will lead to neuropathy .This can cause numbness and burning in hands and feet. Fainting, flatulence diarrhea urinary bladder dysfunction may occur due to autonomic nerve involvement.

4. Erectile dysfunction Erectile dysfunction in men is also a result of neuropathy .More than 50% of men with long duration of diabetes may have this problem. Smoking, poor control of sugar and lipids, diseases of blood vessels and drugs used for treatment of co-existing hypertension also influence erectile dysfunction.

5. Kidney involvement (Nephropathy) One of the important causes of kidney damage is diabetes. This will in many cases ultimately require dialysis or kidBasics of Diabetes

7

ney transplant. Presence of microalbuminuria detects involvement of kidney at an early stage. Annual screening for microalbuminuria can help to start intervention to slow the progress of kidney damage. Good control of both diabetes and high B.P. is essential for prevention and for halting the progress of kidney disease. Proteins need to be restricted in patients with established kidney disease.

6. Eye damage (Retinopathy) Retinal damage and blindness are serious threat to persons with diabetes.

Other problems like glaucoma and cataract are also more common in per-

sons with diabetes. Eye muscle paralysis can occur due to diabetic nerve damage. Frequent change in vision due to fluctuating sugar levels is also encountered in diabetics.

7. Foot problems Lack of sensation on the foot, dryness of skin, deficiency of blood circulation and high level of blood sugar make it a fertile ground for infection. Foot complication is a major cause for lower limb amputation all over the world. The pity is that most of these are preventable by self-care and timely intervention by a care giver.

Self Care Pointers TRAIN YOUR MIND TO MIND YOUR FEET

Persons with diabetes can prevent foot complications with self care.

A . You keep blood sugar and cholesterol in good control.

B. Do not smoke.

C. Inspect your feet daily. Look and feel for injuries, in growing nails, corns calluses. Use a mirror to inspect the bottom of your feet.

D. Wash your feet daily with warm water dry them rubbing with a towel before sleep. Apply moisturizing cream in case of dry skin to avoid irritation, scratching and resulting injuries.

E. Trim your nails away from flesh. Those with tremors and poor vision should seek help to do this to avoid injury.

F. Always use foot wear. These should cover whole feet Break into a new pair of shoes gradually.

Look for any foreign body inside the foot wear before wearing it.

G. When you visit your health care provider remove your shoes and socks so that he can inspect your feet on each visit and identify high risky cases.

F. Avoid self care of foot problems and seek medical help to prevent complications.

G. Foot exercises will enhance blood circulation and help prevent foot problems.

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8. Gum infection Diabetes makes you more susceptible for gum infection and dental caries.

Bad dental hygiene aggravates the situation.

9. Skin infections Dry skin of diabetes and itching of skin can cause bacterial infections in the skin.

10. Hypoglycemia (low blood sugar) If your blood sugar level drops below normal level it is known as hypoglycemia. This can happen if you skip a meal, delay a meal or do unaccustomed physical exertion. Alcohol consumption also can induce hypoglycemia. This may also happen when medication is up titrated to control blood sugar, if the dose happens to be higher than required.

The symptoms of low blood sugar are sweating, hunger, tremors, headache palpitation, drowsiness, confusion, fits and unconsciousness. Those who have diabetes since a long time, those with neuropathy and those with repeated hypoglycemic episodes may not get warning signals. This is known as hypoglycemia unawareness. Unconsciousness may be their presenting symptom. (All persons with diabetes should carry an identification tag to identify them if they are found unconscious.)

To treat low blood sugars consume sugar or fruit juices as you experience symptoms of it. Do not increase food intake (especially if you are overweight) to prevent recurrent hypoglycemia, but reduce anti diabetic medicines.

Hypoglycemia carries high risk in persons with diabetes, who has heart disease, who are elderly and who stays alone. In them intensive control of blood sugar is not advisable.

11. Diabetic ketoacidosis It is a potentially fatal complication. This is more common in Type 1 diabetes. It is an indication of severe insulin deficiency. This condition may be precipitated by stress, infection and pregnancy. The body breaks down fat for energy in the absence of insulin. This produces toxic substances known as ketones.

The symptoms are loss of appetite abdominal pain, vomiting, and typical fruity smell of ketones in the breath. If not treated promptly the patient may lapse into unconsciousness. When you suspect ketosis emergency consultation with a doctor and hospital admissions are needed.

To prevent hypoglycemia never skip or unduly delay a meal. Check your blood sugar regularly. Carry sugar with you to take in case of emergency.

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Basics of Diabetes

8 While meeting your doctor

What to remember when you meet your doctor?

What your doctor may do for you during the visit?

Be fasting for checking blood sugar and cholesterol here is no restriction for taking water. Minimum eight hours (ideal twelve hours) fasting is required.

Keep a list of symptoms and developments since you last met your doctor.

• Enquiry regarding your symptoms since last visit. Your adherence to diet and exercise plans.

• Advice regarding cessation of smoking and excessive indulgence in alcohol.

• To check weight and blood pressure.

• To examine insulin injection sites and foot.

• To plan necessary investigation.

• Feeling regarding general health.

• Any low blood sugar episode.

• Records of self monitoring of blood sugar (by Glucometer) and blood pressure levels.

• Be prepared to clear your doubts regarding diet and exercise.

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9 Medical tests for diabetes A Blood Glucose Test measures the amount of sugar called glucose in a sample of your blood.

Blood from veins is more reliable for glucose testing. The tests are usually done at a medical laboratory to determine the level of blood sugar.

Self monitoring of glucose Self monitoring of glucose can be done using glucometer (portable glucose test machine). Blood sugar levels from finger tips (capillaries) by glucometer may be slightly higher than venous blood. A high value by a portable device should be confirmed by lab test before confirming a diagnosis of diabetes.

Adjustments in insulin doses can be made by self educated patients. Glucometer values give information about sugar values on several days at different timings at home setting compared to a single value on a planned day at lab visit.

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Basics of Diabetes

9

1. HbA1c This test gives an idea about previous 3 months blood sugar levels. It reflects the amount of sugar in hemoglobin in red cells. The higher the blood sugar levels the more hemoglobin with attached sugar. The normal Hb A1c level is 5.7%.when it is in between 5.7 and 6.5 it is pre-diabetes. A level beyond 6.5 % suggests diabetes.

The value of Hb A1c is influenced more by the previous months blood sugar levels. Anemia and certain Hb diseases (hemoglobinopathies) may interfere with the result. This value should be assessed approximately every three months.

Estimated Average Glucose (eAG) This is a new term to understand HbA1c better. eAG uses the same units as usual blood sugar measurements. The formula to convert HbA1c to eAG is: eAG (mg/dl)=(HbA1c x 28.7) - 46.7 This translatim of HbA1c to eAG results in better understanding of the average glucose level for the patients and care givers.

2. Glucose tolerance test This test is helpful to predict development of diabetes in persons with borderline blood sugar values.

How it is done After overnight fasting (for eight hours), fasting blood sugar is estimated. Take 75g of glucose. Remain seated for next 2 hours. Collect blood at the end of 2 hours. Interpretation:

READINGS

FASTING

AFTER 2 HRS

Fasting hyperglycemia

110 -125mgs

<140 mg

Impaired G.T.T

<126 mgs

140-----199 mgs

Diabetes

>126 mgs

> 200 mgs Page 13

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3. Lipid profile Lipid profile measures the various components of cholesterol in blood. This is preferably done after overnight fasting. There are mainly 5 components in lipids.

These are the normal values for normal people. In people with diabetes the cholesterol values should be still lower. Because diabetes itself is a significant risk for developing heart disease. The LDL level needs to be lower than 100 mg for those with diabetes.

NORMAL LIPID LEVELS ARE Total cholesterol (normal value) <200 Triglycerides <200 HDL (High Density Lipoproteins - good cholesterol) >35 LDL (Low Density Lipoproteins) <130 VLDL (Very Low Density Lipoproteins) <50

4. E.C.G. and stress test (TMT)

6. Blood pressure check

Persons with diabetes should have screening tests to rule out heart involvement. Many diabetics can have heart attacks with no symptoms (silent heart attacks) or may have atypical symptoms. For the same reasons elderly patients with diabetes need to undergo stress test before starting exercise program.

BP (Blood Pressure) need to be monitored on each visit. Diabetes aggravates the risk for kidney failure. Along with high blood sugar high BP is a serious threat to kidneys.

5. Kidney function tests When diagnosis of diabetes is confirmed kidney function tests are done to assess the initial status. These tests are repeated periodically to assess any deterioration in kidney function.

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Normal BP

120/80 >

Pre hypertension

140/90 >

Stage 1 hypertension

160/100 >

Stage 2 hypertension

160/100 <

In those with diabetes the upper limit of BP should be 130/84. In normal persons the upper limit of BP can be up to 140/90.

Basics of Diabetes

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7. Urine testing

8. Proteins

Urine testing for glucose is not reliable because, 1. It does not reflect the blood sugar level at the given time as urine in urinary bladder was collected during the course of many hours prior to testing.

2. Depends on the renal threshold (level at which glucose starts filtering into urine), this level may be variable in different persons.

3. Some drugs and pregnancy can give a false positive test for sugar.

4. It does not detect hypoglycemia (low blood sugar).

Standard tests for albumin detect albuminuria above 300 mg /liter. It is an indication of kidney damage.

Microalbuminuria measures urinary loss of small amount of proteins not detectable by ordinary tests for albumin. Since this test (in the absence of urinary infection) detects kidney involvement due to diabetes at an early stage it is to be done once in a year. A positive test also predicts a possibility of subsequent stroke and heart disease.

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10 Managing Diabetes

Managing diabetes involves four components. All these components are equally important. Ignoring one is like trying to occupy a chair without one leg.

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DIET

PHYSICAL ACTIVITY

MEDICINE

SELF EDUCATION

Basics of Diabetes

10 DIET We receive energy for performing various functions from the food we take.

The main components of food are carbohydrates (starch), proteins and fats.

We get four calories of energy from one gram of carbohydrate and protein. One gram of fat gives nine calories. A manual laborer needs 3000 to 3500 calories daily whereas a sedentary worker requires only 1500 calories. An overweight person may have to restrict calories intake to 1000 to 1200 to achieve weight reduction.

A diabetic diet should take into account the following facts: Age of the person, the sex, the type of job he is engaged in and the food habits of the community he belongs to.

The diet should only need minor adjustment in the daily family menu. This will lessen the hardship of the person who prepares food and will be more affordable. In fact a diet good for a person with diabetes is equally good for all the persons in the family. It should be rich in vegetables, fruits with less quantity of fats and carbohydrates (starch). the carbohydrates should be complex.

hydrates (starch) and the rest ½ with vegetables and fruits.

Plate Model To offer you a rough estimate when you take food in a plate ¼ of it should be filled with proteins (fish/lean meat /egg white), ½ of the remaining with carbo-

The diet should also address coexisting problems like high blood pressure, Page 17

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high lipids and overweight. Each person should discuss his diet with his physician/dietician rather than following a fixed menu.

A person with diabetes needs to take food at regular intervals and the quantity each time should be more or less same. Diabetics with frequent wide fluctuations in blood sugar (brittle diabetes) and who have frequent tendency for low blood sugar need to divide their food into more frequent intervals to overcome this .Fruits may be taken in-between meals rather than immediately after food. This will prevent a high peak in blood sugar after a meal as well as prevent a low blood sugar in between the meals.

The fiber in diet

Fiber is not digested or absorbed by your body. Also fiber when taken along with carbohydrate delays the absorption of carbohydrates from intestine.

This will prevent sudden surge in blood sugar level after the meal. Food high in fiber include vegetables, some fruits like oranges, legumes (peas, beans, lentils) and whole grains.

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Heart healthy fish

Fish is a good substitute for fat rich meat as a source for proteins. Fish such as salmon, mackerel, tuna, sardines are rich in omega 3 fatty acids which can lower triglycerides (a type of bad cholesterol).

Good fats

Good fats contain polyunsaturated fats. They are found in peanuts almonds walnuts and avocados. They can raise the level of good cholesterol (HDL) in your body. The total amount of these nuts need not exceed 30 grams/ day. Large amounts will increase the caloric supply.

Fats to avoid

High fat containing meat products like beef, sausages to be avoided. Fats in processed snacks are harmful. Egg yolk, shellfish and liver are rich in cholesterol.

Plan your meals

The amount, content and timing of the meals (especially the carbohydrate content) may be kept more or less same all days. Otherwise blood sugar tends to fluctuate and sometimes hypoglycemia may be precipitated. This is all the more important for those on insulin and sulfonyl urea type of oral anti diabetic agents. Those persons with diabetes who have tendency for wide fluctuations in blood sugar (brittle diabetes) need to divide their total food into more frequent intervals to prevent low blood sugar levels. With the help of a dietician you can learn about food Basics of Diabetes

10

exchanges (different kinds of food with same caloric values and same carbohydrate content) which can be exchanged one for another.

Glycemic index

This is a comparison of rise in blood sugar level for two hours after a food item as compared to glucose. Food with high glycemic index indicates higher carbohydrate content of that food. As the fiber content increases in a food its glycemic index is lowered.

For example white bread has a higher glycemic index than whole grain bread.

Similarly white rice has a higher glycemic index when comparing with whole grain rice. Fat rich food may have a low glycemic index due to their high fat content but are not good from health point of view.

Glycemic indices of some common food Glucose 100 White bread

100

Honey 90 Sugar 89 Ice-cream 57 Peas 31 Cornflake 85 Parboiled rice

79

Noodles 75 Yogurt 30 Banana 80 Apple 62 Orange 49

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Caloric values of various food items per 100 grams Milk 65 Butter 740 Cheese 350 Ice-cream 170 Egg 150 Fish 220 Beans 20 Cabbage 10 Cucumber 10 Potato 80 Grapes 60 Orange 35 Peanut roasted

570

Bread 230 Rice 120 Cornflake with milk

205

Chocolate biscuits

520

Banana 80 Apple 56 Dates 281 Guava 66 Mango 70 Papaya 32 Watermelon 26 Ghee 910 Cow milk

100

Honey 90 Page 20

Artificial sweeteners

Artificial sweeteners and sugar substitutes are found in a variety of food and beverages marketed as ‘sugar free ‘or ‘diet’.

Aspartame (equal): Saccharine and sucralose (splendra) are some of them.

They are good alternative to sugar for persons with diabetes and for those who wish to control weight. There is no evidence that they cause cancer in humans though there was some evidence that saccharine caused cancer in rats.

Basics of Diabetes

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Diet providing approximately 1500 calories suitable for a diabetic patient BREAKFAST Wheat rotti(chappathi)/or iddli 2 nos Or brown bread 3 slices Egg white 1 nos 10.30 AM One fruit (orange/guva/equivalent watermelon) One cup butter milk (low fat) LUNCH Rice 2 cup Or Wheat rotti (chappathi) 2 nos Fish/ or chicken wings 75 grm Cooked vegetables (not roots like potato) Green salads (as much as you want) 4.00 PM Coffee/tea with 50 ml milk One fruit (orange/guva/equivalent watermelon) DINNER Wheat rotti (chapattis) 2 nos Beans/pulses 25 grams Cooked vegetables (not roots like potato) Salads (as much as you want)

CALORIC REQUIREMENT FOR VARIOUS PERSON For overweight 20 cal/kg/day For ideal weight 30 cal/kg/day For underweight 40 cal/kg/day

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PHYSICAL ACTIVITY (EXERCISE) Exercise is essential for the management of diabetes especially for overweight persons. There is no substitute for exercise.

Exercise has following benefits.

1. It lowers blood sugar.

2. It reduces blood cholesterol.

3. Exercise reduces blood pressure.

4. It enhances the endurance of heart and prepares it to withstand any insult better.

5. It improves mood and gives better sleep.

How to exercise

You need to exercise for 30 to 45 minutes per day for 5 to 6 days in a week.

Minimum exercise need to be at least four hours in a week. Exercise to be done before food. The initial five minutes (warm up period) and the last five minutes (cooling down period) of the exercise may be done slowly. Elderly persons, persons with long standing diabetes and persons with compromised heart functions should undergo initial medical evaluation to ascertain their ability to undertake exercise program.

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Basics of Diabetes

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Snack-activities

In addition to regular exercise all should try not to miss any chance to have small in between activities. For example: • Taking stairs in place of lifts.

• Walking for short destinations instead of taking car.

• Parking car little away to walk some distance to shops or offices.

• Getting down from bus or getting in to bus a little away from destination with intention to walk.

• To do some gardening.

In persons with diabetes if exercise lowers blood sugar they should reduce the diabetic medicines rather than increase food intake. This is all the more essential for those who are overweight.

3. Energy spent by physical activities: This is 15 to 30 % of total daily energy expenditure and is variable.

CALORIC COST OF VARIOUS ACTIVITIES FOR A 70 KG PERSON Cycling 10 miles/hr

350 cal

Cycling stationary

315cal

Dancing aerobic light-

280

Cooking 0 Scrubbing floor Lying watching TV

196 0

Persons with diabetes who go for long walk should carry a supply of sugar with them for emergency (low blood sugar). All diabetics also should wear an identification tag during outdoor physical activities and travel.

Standing 21

How we burn calories

Computer typing

Total energy expenditure is influenced by three factors.

1. Resting metabolic rate: This is the minimum requirement of energy needed to sustain all body’s function in arresting state. This represents 60 to 75 %of total daily energy expenditure. This is affected by body size age of the person, gender and climate.

2. Thermic effect of food: Energy required for digestion and absorption of food. This represents 10% of total daily energy expenditure.

Treadmill light effort

419

Sitting and reading

21

Walking 3/miles per hour Running 5miles/hr Running 10 miles/hr

196 35 490 1050

Jogging 420 Office work

35

Swimming 350 Swimming breast stroke

704

Stretching (yoga)

281

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11 DRUGS FOR TREATMENT OF DIABETES Oral therapy should be initiated after a short trial of therapeutic life style changes or when the blood sugar is very high. Single drug therapy with metformin is the initial choice.

Second or a third agent may be added if response to single agent is not satisfactory. Some of the concomitant diseases may contraindicate the use of oral agents.

Tablets (Oral hypoglycemic agents)

Sulfonylureas: Example:- glybenclamide, diaonil, glimipride, glipizide, glyclazide. Mainly they stimulate insulin secretion from beta cells in pancreas.

Biguanides: Example:- metformin They increase the sensitivity of insulin (increase the efficiency of available insulin) and decrease glucose production in liver.

Thiazolidinediones: Example:- pioglitazone. They also increase the sensitivity of insulin.

Alpha glucosidase inhibitors: Inhibits breakdown of starch to glucose in intestines and so decrease the blood sugar level after food.

DPP 4 inhibitors: These drugs inhibit the degradation of two hormones (GLP-1 and GIP) which increase the Page 24

insulin secretion and reduce production of glucagon (a hormone which raises blood sugar levels). Examples vildagliptin (galvus) sitagliptin (januvia) saxoglyptin (onglyza).

Insulin therapy

Many types of insulin are available to suite many situations .Sufficient dose (up to 1 unit per kilogram weight) is required to control the blood sugar. Once daily long acting or twice daily intermediate acting and short acting insulin are available. The required dose and the type of insulin are decided by your physicians. Weight gain and episodes of hypoglycemia are side effects of insulin therapy.

Situations when insulin therapy is required: • Persons in whom oral therapy fails to achieve sugar control.

• Complications of diabetes like ketoacidosis.

• New patients with very high blood sugar levels.

• During severe infections.

• During pregnancy.

Basics of Diabetes

12 DIABETES IN SPECIAL SITUATIONS

DIABETES & FASTING DURING RAMADAN It is a time for spirituatiual reflection, prayers and purification of body mind and soul. As a part of self control Muslims fast from dawn to sunset. It is better for persons with diabetes to have a visit to their diabetes care giver to take advice before fasting.

Anyone who would be putting their

health at serious risk is exempted from fasting. Example:- people with uncontrolled diabetes, people with complications of diabetes like damage to eyes and kidneys.

During fasting body uses glucose for activities from the previous meal. After 8 hours body depends on stored glucose in liver as source of energy.

Later to maintain blood sugar, body will break down fat as a source of energy.

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Persons with diabetes who are controlled on diet, metformin or DDP4 inhibitors(januvia ,galvus, onglyza) can undertake fasting as any other person as the risk of hypoglycemia is least with these drugs.

Those who are on sulfonylureas(daonil. glimipride,glyclazide)and insulin have the risk of hypoglycemia on fasting.

They should consult their physicians regarding adjustment of dosages before fasting. They should at least in the initial days self monitor blood sugar levels to see the trend with change in food intake. They need to break fast in case of low blood sugar level, (blood sugar testing will not break a fast).

At dawn (Sehri) they should have a balanced diet. Meals should contain complex starchy food like chappathi, whole grain bread, lentils oats. These will release glucose slowly and maintain blood sugar level for a long time. They also make you less hungry. Coffee and sugary drinks may promote urination and dehydration so may be avoided

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Ending fast (Iftar) Dates are good source of energy and fiber. Limiting to 1 or 2 dates will prevent high sugar surge.

You must eat fruits, plenty of vegetables and drink plenty of water to prevent constipation.

It is a good time to stop smoking and to take a decision to stop it for rest of your life.

Basics of Diabetes

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DIABETES AND DRIVING

Persons with diabetes can have problems for driving due to 1 Poor vision 2 Due to low blood sugar (hypoglycemia) during driving 3 Neuropathy of feet Persons with diabetes can have poor vision due to diabetic complications in eyes in the form of retinopathy. They are also more prone for cataract and glaucoma (diseases which can impair vision) it is important for your as well

as others safety to seek care from your ophthalmologist .Sometimes refractive errors need correction by changing /or using lenses.

During long hours of driving you may develop low blood sugar. Remember to stick to usual meal plan. Take care that you carry enough sugar in the vehicle to use in case of such an emergency. Check blood sugar frequently (every 2 hours)in case of long driving.

Neuropathy of the feet (causing weakness of muscles and diminished sensation in feet) also may interfere with ability to drive.

Carry an identification tag.

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DIABETES & PREGNANCY High blood sugar may occur in pregnancy as a result of: 1. A person with pre-existing diabetes becoming pregnant.

2. A woman developing diabetes during pregnancy (known as gestational diabetes).

Some women develop diabetes for the first time during pregnancy. This condition is known as gestational diaPage 28

betes. This happens around 24 weeks of pregnancy. High blood sugar from motherâ&#x20AC;&#x2122;s blood crosses placenta to baby .But insulin from mother does not cross placenta. So babyâ&#x20AC;&#x2122;s pancreas starts producing extra insulin. This can cause low blood sugar in babies after birth.

Treatment of gestational diabetes should include diet control, exercise and if necessary medicines. Target blood sugar levels should be fasting blood sugar90 mg/dl and after food 120 mg/dl. Some women with gestational diabetes can develop diabetes in later life.

Basics of Diabetes

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DIABETES IN SENIORS Incidence of diabetes increases with age.

Over 10 % of people above age of 65 have diabetes. Half of them may remain undiagnosed. Insulin resistance is exag-

gerated with aging. Sometimes cancer of pancreas may be manifested in old age as diabetes. Symptoms of hypoglycemia may be atypical. Hypoglycemia unawareness is more common in old age. Staying alone adds to the risks from hypoglycemia. Stay connected to community. Be familiar with emergency/ ambulance phone numbers.

Diabetes is a lifetime disease. It cannot be cured. But it can be kept under good control with a healthy lifestyle (diet and exercise) and medicine. The most important player in this game is you. Your care giver and family members have only supporting roles to play.

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