DiabetEASE February-March 2014 by Dan Cisneros

FEBRUARY-MARCH 2014

CONTENTS

behindthescenes

COVER STORY AND FEATURES

Philippine Society of Nephrology

My FitFil Story

La Vie Bohème, Nikki

Jose Martin Punzalan puts the spotlight on the country’s nephrologists and the activities they have been doing to promote kidney care.

Alexa Villano rides the Fitness Boot Camp bandwagon to experience firsthand the workout inspired by the hit TV show, The Biggest Loser.

Michaela Sarah De Leon writes about the change Nikki started from within her health. Now she’s off to change the world.

The DiabetEASE team gets a photo-op with Nikki Gil.

regulars 6 | EDITOR’S EDICT 8 | WE’VE GOT MAIL 9 | SWEET NEWS ON THE COVER: Nikki Gil breaks free from the controversy she faced last year. She talks about the changes she made in her life and the positive change is about to bring to the world.

in depth 21

Menopause and Diabetes

Kidney Care and Chronic Kidney Disease Update

When diabetes and menopause come together, the body may be facing a more complicated mess. Dr. Jocelyn Isidro discusses the signs and symptoms any diabetes patient should be wary of.

The importance of kidney function has been highlighted in the past to prevent diabetes. Nephrologist Dr. Isabel Duavit gives an update on the latest treatments to protect that bean-shaped organ.

FEBRUARY-MARCH 2014

Photography by Arrian Alcantara Styling by Denice Cajulis & Isabel Yu of Stylelist Inc. Bandeau top by Lovelace | Pants by Eric Delos Santos Hair & Make-Up by Ken & Roman Location: Miriam College Mini-Forest and Women’s Art Gallery Special thanks to Dr. Rosario Lapus, External Office & Tricia Portillo

Polycystic Ovary Syndrome – More Than a Fertility Problem

Dr. Patricia Maningat elaborates the connection between Diabetes and Polycystic Ovary Syndrome, a disorder that certainly impacts a woman’s life.

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Educator’s Corner

Fightin’ For Fitness

The New Cholesterol Guidelines: What’s the fuss? The American College of Cardiology and the American Heart Association recently released new guidelines on blood cholesterol. Just how important is it for diabetes patients and why the controversy surrounding it? Dr. Yvette Amante explains.

Ballroom Workout Wonders Break a sweat while twirling or marching to Latin music. Learn the basic steps of ballroom dances like Merengue, Cha-cha-cha, and Salsa from dance instructor Ana Palma.

Righteous Recipes

Good Food Guide

(Sugar-Free) Sweets for Your Sweet Dessert lovers rejoice! Chef Junjun de Guzman is back with sweet treats that won’t have you reaching for a blood sugar monitor. Here are three sugar-free sweets recipes for Valentine’s Day.

Diets for Kidney Conditions What kind of diet is good for the kidneys especially for patients with kidney disorders? Nutritionist Edreilyn Manalo explains the kidney’s function and the nutrients to prevent renal diseases.

FEBRUARY-MARCH 2014

sections 12

You Ask, We Answer

Are malunggay supplements effective in managing diabetes? Once known as the “poor man’s” food, malunggay is now used everywhere. Is it also suitable for diabetes? Dr. Maria Leonora Capellan investigates.

Stress Busters

No-Sweat Tricks to Stress

When things go wrong and you just want to give up, how do you deal with it? Aencille Santos gives the four As of busting stress when a complicated situation arises.

Product Spotlight

Healthy Cereal and Healthy Cereal Hunt With many cereals in the market, how do you know which one is the best? Mylene C. Orillo writes about the importance of choosing a cereal and its health benefits. Meanwhile, Alexa Villano scours the grocery shelves and round up six cereals you can check out and taste for yourself.

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Living Well

Lessons in Surviving Diabetes Letty Bernardo feared for her life after discovering she had diabetes. Excel Dyquiangco interviews her on the changes she made following the discovery of her condition.

Dos and Don’ts

Diabetes in Pregnancy Dr. Kristine Denise Corvera lists down helpful reminders to make a pregnant diabetes patient’s life easier in the journey to motherhood.

Affairs to Remember

Doodles & Dreams FEBRUARY-MARCH 2014

EDITOR’S EDICT

MEDICAL ADVISORY BOARD Ramon F. Abarquez Jr., MD Professor Emeritus, University of the Philippines College of Medicine; Academician, National Academy of Science and Technology

Misogynistic Disease “ A woman is like a tea bag – you never know how strong she is until she gets in hot water. ” ~ Eleanor Roosevelt

Mary Ann Lim-Abrahan, MD Past President, Philippine Lipid and Atherosclerosis Society; Professor, University of the Philippines College of Medicine–Endocrine Section Abdias V. Aquino, MD President, Philippine Society of Hypertension; Past President, Stroke Society of the Philippines; Past President, Philippine College of Physicians Corazon VC. Barba, PhD, RND Past President, Nutritionist-Dietitian’s Association of the Philippines

Is diabetes a woman hater? In some respects, diabetes is harder on women than it is on men. Death rates for men have fallen in the last 30 years, whereas rates for women have not. In general, women have less heart and kidney disease than men. Diabetes though, strips off this female advantage. Women without diabetes often get these ailments when they hit menopause, but diabetes makes them just as likely as men to have heart and kidney disorders regardless of age. Heart attacks are also more fatal and debilitating in women than men with diabetes. And more women go blind from diabetes than men. Diabetes also puts a unique burden on women and their unborn children. Pregnancy woes such as miscarriage, premature labor, high blood pressure, and birth defects in the baby hold added torment for women with diabetes. In celebration of International Women’s Day (March 8th) and World Kidney Day (March 13th) this year, we feature topics such as polycystic ovary syndrome, gestational diabetes, and menopause as well as diet and care tips for people with kidney disease. May you prove to be strong when you get into any hot water – including diabetes! Peace and thank you,

Joy C. Fontanilla, MD, FACE, FPCP, FPCDE, FPSEM, CCD

Editor-in-Chief

FEBRUARY-MARCH 2014

Ricardo E. Fernando, MD Founder and President, Institute for Studies on Diabetes Foundation, Incorporated Ruby T. Go, MD Past President, Philippine Lipid and Atherosclerosis Society; Head, Endocrine Section, Chinese General Hospital Augusto D. Litonjua, MD President, Philippine Center for Diabetes Education Foundation; Founding President, Philippine Society of Endocrinology and Metabolism; Philippine Association for the Study of Overweight and Obesity Roberto C. Mirasol, MD Past President, ASEAN Federation of Endocrine Societies; Past President, Philippine Society of Endocrinology and Metabolism Antonio R. Paraiso, MD Medical Specialist III, National Kidney and Transplant Institute; Assistant Professor, College of Medicine, University of the East Ramon Magsaysay Memorial Medical Center Ma. Teresa Plata-Que, MD Past President, Philippine Diabetes Association; Consultant, East Avenue Medical Center; National Kidney and Transplant Institute Tommy S. Ty-Willing, MD Past President, Diabetes Philippines; Trustee, Philippine Center for Diabetes Education Foundation; Founding President, Philippine Lipid Society; Consultant, Metropolitan Hospital

CONTRIBUTORS Publisher: FAME Publishing, Inc. Editor-in-Chief: Joy Arabelle C. Fontanilla, MD Assistant Editors: Mylene C. Orillo Michaela Sarah de Leon Art Directors: Donna I. Pahignalo Editorial Coordinator: Alexa Villano Senior Writers: Ma. Cristina Arayata Jose Martin Punzalan Aencille Santos Gelyka Ruth Dumaraos

Marie Yvette Rosales-Amante, MD, FACE, FPCP, FPSEM

A graduate of the University of the Philippines College of Medicine, Dr. Amante took up her residency in internal medicine at the University of Connecticut, and had her Fellowship in Endocrinology, Diabetes and Metabolism at the University of Massachusetts. She is the Asst. Secretary of the American Association of Clinical Endocrinologists-Philippine Chapter and Endocrinology Section Chief at the Asian Hospital and Medical Center.

Graphics and Layout: Dan Cisneros

Jocelyn Capuli-Isidro, MD, FPCP, FPSEM Overall Marketing Manager: Hudson P. Pelayo Marketing Assistant: Godfrey Santos Group Sales Manager: Ma. Elna P. Jagape Senior Account Managers: Noel A. Ongkingco Charlotte Aireen Punzalan

Dr. Isidro is a Consultant Endocrinologist at the Makati Medical Center and the St. Luke’s Medical Center, Global City. She is also a member of the medical bureau of Diabetes Center Philippines or the Philippine Center for Diabetes Education Foundation, Inc.

Representatives: Leonard Anthony D. Baluyot Arjay Yano John Paul Rodriguez Advertising Assistant: Irina Mae Carampatana Officer-in-Charge, Circulation Department: Armando Sandajan Executive Assistants: Angeli M. Mamaril

Maria Isabel de Leon-Duavit, MD

Dr. Duavit is a clinical associate professor at the UPPGH and nephrology consultant at PGH, Asian Hospital and Medical Center, Las Pinas City Medical Center, Medical Center Parañaque, as well as Medical Director of Kobe Dialysis Unit and BBraun Avitum Dialysis Center, Alabang.

Legal Counsel: Castillo, Laman, Tan, Pantaleon and San Jose Law Firm

Patricia D. Maningat, MD

Diabetes is not a one-size-fits-all disease. The information in DiabetEASE, therefore, is not meant to substitute for a health professional’s advice and readers are cautioned to consult with their healthcare provider before putting any of its contents into practice.

DiabetEASE is published by Friendly Alliances and Media Expressions, Inc. (FAME, Inc.). No part of the magazine may be reproduced in any manner without the permission of the publisher. Unsolicited manuscripts, photographs, and artwork will not be returned unless accompanied by self-addressed stamped envelopes. Address all correspondence and subscription inquiries to FAME Inc., Suite 503 Narra Building, 2276 Pasong Tamo Extension, Makati City, Philippines. Tel. Nos. 892-0723 to 24; 894-0483; 813-5433 or 36; Fax No. 892-8514; E-mail: diabetEASE.famepublishing@gmail.com. All rights reserved. Copyright 2014 by FAME, Inc.

Dr. Maningat is an endocrinologist at St. Luke’s Medical Center-Global City and the Philippine General Hospital. She is also a visiting consultant at Our Lady of Lourdes Hospital and Cardinal Santos. She is a member of the Research Faculty of the University of the Philippines, National Institute of Health, and a visiting fellow at the Rockefeller University in New York.

Ana Palma

Ms. Palma is a dance teacher and choreographer based in Manila. Her expertise includes Latin American Ballroom, Salsa, Belly Dancing, and Samba. She has been competing in dance competitions since 1999 and was a choreographer for ABC 5’s Shall We Dance. She is also the founder of Cachimbo Dance Company Manila, Sueños Dance Studio, and A Dance Company.

FEBRUARY-MARCH 2014

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find us on www.facebook.com/diabetEASE

Dear DiabetEASE, Thank you for featuring the 4-Minute Workout in your Dec-Jan issue. I was initially skeptical about it, but after trying it out, I felt the results. Hope you’ll feature more workouts for busy people like me. – Mark via e-mail Hi DiabetEASE, I love that you dedicated an issue about Obesity and did a feature on Hazel Chua from the first season of the Biggest Loser Pinoy Edition. Hope you’ll feature the other four members of Team Biggest Loser in your next issues.

@diabetEASEmag Have you ever featured herbal remedies for diabetes? Since many supplements have been coming out, I would appreciate clarifications on what to drink on top of what I eat and what exercises I do.

– Mariel via e-mail

– Natalie via e-mail DiabetEASE welcomes feedback from readers. Please send your comments, questions and suggestions through any of the following: Snail mail: 503 Narra Building, 2276 Pasong Tamo Extension, Makati City 1232 Philippines Email address: diabetEASE.famepublishing@ gmail.com Fax number: (+632) 8928514 Telephone numbers: (+632) 8920723 to 24; 8940843; 8135433 or 36 DiabetEASE reserves the right to edit materials for publication.

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Erratum: In the December-January issue of Righteous Recipes, we failed to give the right procedure of the Chicken Relleno Loaf. We regret the error. For the procedures, like us on Facebook.

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FEBRUARY-MARCH 2014

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sweetnews

new set of blood pressure guidelines released by the Eighth Joint National Committee, eased treatment targets for the elderly aged 60 and above to 150 mm Hg / 90 mm Hg or higher. Meanwhile, young hypertensive patients or those with chronic kidney disease, or diabetes regardless of age are recommended to go through drug treatment when the systolic pressure is 140 or higher and if the diastolic pressure is 90 or higher. In the last guidelines published in 2003, the blood pressure was less than 140/90 mm Hg for most patients with hypertension and 130/80 mm Hg for patients with kidney conditions or diabetes. However, easing the guidelines became a cause for worry for some experts, who think that this may lead to increased high blood pressure cases in America. “On the individual patient level, that makes our job easier. We don’t have to push blood pressures quite as far down,” said Dr. Eric Peterson of Duke University Medical Center in the USA. “On the other hand, from a population level, I have some concerns that this less aggressive push will ultimately translate into higher blood pressures on America’s front and perhaps in the end, more cardiovascular events,” he said. The tendency will be for blood pressure to go high especially in the elderly. There might be some pushback to loosening control of blood pressure among those who treat patients with diabetes and chronic kidney disease. In the end, he explains that the new guideline will have some positive effects in discussing what is and is not known in treating hypertension that could lead to more research. Alexa Villano with a Med Page Today report D

besity and overweight worldwide ballooned in the last 30 years following the failure of governments to implement proper eating programs, specifically in developing countries. “The growing rates of overweight and obesity in developing countries are alarming. On current trends, globally, we will see a huge increase in the number of people suffering certain types of cancer, diabetes, strokes, and heart attacks, putting an enormous burden on public healthcare systems,” said Steven Wiggins, a co-author of the report entitled Future Diets released by the Overseas Development Institute. The study further showed that one in three adults around the world are overweight or obese based on the food he or she eats and that these weight conditions rose in rich nations from 200 to nearly 600 million over the same period. The author called on politicians to act on the problem, adding that campaigns for public awareness are not enough. “The challenge is to make healthy diets viable whilst reducing the appeal of foods, which carry a less certain nutritional value,” he said. The number of cases increased by a third in South Africa and nearly doubled in China and Mexico. Meanwhile, North Africa, the Middle East, and Latin America caught up with Europe on the regional level. The United States, Belgium, New Zealand, and Mexico accounted for the larger part of the increase in sugar consumption by 20 percent. This also includes sweetener consumption. Fat consumption increased in East Asia and Southern Africa. Even with a higher consumption of fruits and vegetables, the report noted that 850 million people in poorer nations do not meet their basic needs. Alexa Villano with a Medical News Today report D

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Obesity balloons to almost 1 billion

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BP treatment guidelines eased

FEBRUARY-MARCH 2014

Diabetes complications worsen with mild depression

ccasional mild depression may worsen type 2 diabetes complications, highlighting the need to broaden patient care options, according to a new study from McGill University’s Douglas Mental Health University Institute in Montreal. “It is important not to separate treatment for depression from treatment for diabetes,” explains Dr. Norber Schmitz, associate professor of psychiatry at the university. “Depression is associated with poor diabetes management. If management of diabetes is stressful, people may not follow guidelines. We need to look at the whole picture, what are the mental problems, physical problems, and try to find an integrated treatment approach to those with symptoms of depression.” In the study, it was found that those who experienced low-level depression many times were nearly three times more likely to have greater disability, such as reduced

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mobility, poor self-care, and worse quality of life compared to those without depression. More than 1,000 participants underwent a battery of surveys assessing symptoms of depression, diabetesrelated health complications, and the health-related quality of life based on the individuals’ own perceptions of how burdensome their health problems were. As the frequency of mild depression increased, the risk of impaired health and quality of life increased as well. The rate of poor functioning in daily activities such as work and self-care was 50 percent higher in patients with one minor depression episode than those who had none. Those with four or more bouts of mild depression had 300 percent greater risk of poor functioning and 250 percent at greater risk for impaired health-related quality of life than those without depression. Aencille Santos with a report from Reuters Health D

intellectualyst.com

Under 6 hours sleep ups diabetes risk

leeping six hours a day or less significantly increases the risk of type 2 diabetes in adults, said a recent study in Australia. According to a new study from the University of Newcastle, Australia, sleeping less than six hours a day resulted in 30 percent higher risk of developing insulin resistance and type 2 diabetes. The researchers examined the results of earlier studies on diabetes risk. A total of 212,388 adults over 45 years old were counted in the researches.

FEBRUARY-MARCH 2014

The normal sleeping hours for 64.7 percent of the participants were at seven to eight hours a day. The researchers also found that sleeping less than seven hours or longer than 10 hours were also linked to higher rates of obesity. Reduced sleep was found to increase grehlin in the body, a hormone that stimulates appetite, and decrease leptin, a hormone that suppresses appetite. The researchers noted that while sleeping less is linked to type 2 diabetes risk, sleeping longer had no relation to the risk of cardiovascular disease. The research was unable to determine how much of the short sleeping was connected to a sleeping disorder. They were also uncertain if the participants had type 2 diabetes before the study was made. Alexa Villano with diabetes.co.uk D

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Nutrition labels face FDA revamp

Wine, dark chocolate may ward off diabetes

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abels for nutrition facts will be updated to keep up with the current food development since 1990s, the USA Food and Drug Administration (FDA) says. “The food environment has changed and our dietary guidance has changed. It’s important to keep this updated so what is iconic doesn’t become a relic,” Michael Taylor, FDA’s deputy commissioner for food says. The agency feels the need to conduct a makeover after working on the issue for almost a decade as recent studies reveal that more people are reading labels. Results from the study initiated by the Department of Agriculture bare that 42 percent of working adults read labels. It also showed that adults have the bigger probability to use the labels. Michael Jacobson of the Center for Science in the Public Interest also said that nutrition labels today ‘haven’t been as effective as they should be.’ Meanwhile, healthcare practitioners suggest that the calorie content must be more visible than the unfamiliar substances that people tend to ignore on the label. Nutrition advocates also call on the agency to add a line for sugars and syrups that are added to food and drinks when being processed. They observed that some sugars found in food are listed separately among other components. Other suggestions include more specific percentage for whole wheat, clearer measurements such as the use of teaspoons and grams for added sugars, adjustments of recommended serving sizes to avoid deception and confusion, and package front labeling for easier reading. Gelyka Ruth R. Dumaraos with a Yahoo! News report D

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But Diabetes UK cautious

iabetes UK warns the public against a flavonoidrich diet as a measure to prevent type 2 diabetes, which was the claim of an earlier study published in the Journal of Nutrition. Dr. Alasdair Rankin, director of Research for Diabetes UK, commented that while the study suggested a link between flavonoids and reduced risk of type 2 diabetes, there’s a need to interpret the findings with caution. Flavonoids can be found in berries, apples, pears, onions, and also in red wine and dark chocolate – thus leading to press reports that consumption of red wine and dark chocolate help reduce risk of developing the condition. It was emphasized that though high flavonoid consumption and lower type 2 diabetes risk seem to happen together, it does not necessarily mean that one is causing the other. According to Dr. Rankin, while the study is interesting, it didn’t convince them that flavonoids really help prevent type 2 diabetes. An earlier study published in the journal found that people who consume more flavonoids are more likely to have a reduced rate of insulin resistance and better blood glucose regulation. Rankin added that they recommend having a healthy lifestyle, which involves regular physical activity and a balanced diet rich in fruits and vegetables. Dr. Rankin still advises limiting consumption of wine and chocolate. “This advice would be very unlikely to change even if further research demonstrates that flavonoids reduce type 2 diabetes risk,” he said. It is because any health benefit from flavonoid would be significantly outweighed by the calories in chocolate and alcohol in wine. Ma. Cristina C. Arayata with a report from Diabetes UK D FEBRUARY-MARCH 2014

youaskweanswer Maria Leonora D. Capellan, MD

Dr. Capellan is an endocrinologist at the Makati Medical Center and St. Luke’s Medical Center Global City.

Are malunggay supplements effective in managing diabetes?

Recently, the malunggay plant has been making waves in the world of diabetes. Some claim that it has beneficial effects on lowering blood sugar levels. As I look through datas, you will be amazed that a lot has been done in the search for its beneficial effects including lipid lowering. Moringa oleifera produces phytochemicals (chemicals produced by plants) namely 4- benzyl isothiocyanate, niazimicin, pterygospermin, benzyl isothiocyanate.1 In the phytochemical investigation of this plant, the presence of flavonoids (group of phytochemicals which are important components of healthy diets because of their antioxidant activity) that may be responsible for the stimulation of glucose uptake in peripheral tissues and regulation of the activity and expression of the rate-limiting enzymes involved in carbohydrate metabolism.2,3 This was the theory of Dr. Gupta wherein he experimented this plant in diabetic rat subjects and concluded that there is a significant antidiabetic and antioxidant activity.1 His study is experimental and needs further evaluation. There were local studies on malunggay leaf on human subjects and they showed conflicting results. The subject population in these studies were quite small. These include Comparative Effects of Moringa Oleifera Lam. Tea on Normal and Hyperglycemic Patients enrolling 43 subjects - 30 from normal patients

FEBRUARY-MARCH 2014

Malunggay and Diabetes:

What’s the Score?

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he malunggay plant also scientifically known as “Moringa oelifera” is known in different parts of the world under various names like horseradish tree or drumstick tree. It was once known as “a poor man’s vegetable”, but is now known as a ”miracle tree” or “nature’s medicine cabinet“ by many scientists and health workers because it is loaded with many vitamins and minerals that can be used for many ailments. Aside from its many medicinal benefits, this plant proves to be a low maintenance plant to grow and can easily be propagated in all kinds of soil. Most of its parts have been proven to be useful for consumption and medicinal use.

and 13 from to hyperglycemic group. It showed a significant two hours postprandial lowering of blood sugar in the diabetic group by a mean drop of 28.15 mg/dL using M. oleifera tea but it did not show any effect on normal subjects.4 Another study on the effect of malunggay capsules on lipid lowering and glucose levels showed no significant differences in body weight, body mass index, fasting blood sugar, serum glucose two hours after 75 gms glucose load, total cholesterol, HDL, and triglycerides between malunggay and placebo group.5 Research on the effectiveness of malunggay on blood sugar control is very promising as shown in numerous studies in animals though these are experimental evidences. More thorough investigations or studies should be conducted to provide good results that will benefit our patients. At present malunggay tablets were categorized by BFAD as nutritional supplement and deemed not to replace present treatment of diabetes. D A review of the medical evidence for its nutritional, therapeutic and prophylactic properties. J Trees of life. 2005; 1:5. 2 Evaluation of antidiabetic and antioxidant activity of Moringaoleifera in expiremental diabetes. Gupta et al. Journal of Diabetes. Vol 4 (2012) pp 164-171. 3 Antidiabetic andtioxidant potential of B –sitosterol in streptozocin-induced hyperglycemia. JGupta et al. JDiabetes .2011; 3: 29-37 4 Comparative Effects of Moringa Oleifera Lam. Tea on Normal and Hyperglycemic Patients. Ples, M. and Ho, eHealth International Journal. 5 Effects of Malunggay Capsules on Lipid and Glucose levels. Sandoval, M. and Jimeno,C. . ActaMedicaPhilippina. vol 47. no.3 2013. 1

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educators’corner

The new cholesterol guidelines: What’s the Fuss? By Dr. Marie Yvette Rosales-Amante

What is cholesterol and why is up on the inside of artery walls, profile — typically reports: contributing to artery blockages it so important? The word “cholesterol” comes from the Greek word chole, meaning “bile” and the Greek word stereos, meaning “solid, stiff”. Cholesterol is a lipid (fat) produced by the liver. Cholesterol is vital for normal body function. Every cell in our body has cholesterol in its outer layer. There is good and bad cholesterol. LDL (bad) cholesterol can build

that can lead to heart attacks and strokes. High LDL cholesterol levels mean higher risk. High-density lipoprotein (HDL) cholesterol is known as “good” cholesterol because it helps prevent arteries from becoming clogged. Higher HDL cholesterol levels generally mean lower risk. A blood test to check cholesterol levels — called a lipid panel or lipid

• • • •

Total cholesterol HDL cholesterol LDL cholesterol Triglycerides

Based on current standards: Most people should aim for an LDL level below 130 mg/dL (3.4 mmol/L). If patients have risk factors for heart disease, such as diabetes, the target LDL may be below 100 mg/dL (2.6 FEBRUARY-MARCH 2014

educators’corner mmol/L). If at very high risk of heart disease, the LDL goals may be below 70 mg/dL (1.8 mmol/L). Based on current practice, in general, the lower the LDL cholesterol , the better. Statins (simvastatin, atorvastatin, pravastatin, lovastatin, rosuvastatin) are the drugs of choice for LDL-lowering. In November 2013, the American College of Cardiology and the American Heart Association released new clinical practice guidelines for the treatment of blood cholesterol. Not all medical organizations ended up agreeing or supporting the new guidelines. The Expert Panel, which formulated the new guidelines, was composed of 13 members and three ex-officio members, which included primary care physicians, cardiologists, endocrinologists, and experts in clinical lipidology, clinical trials, cardiovascular epidemiology, and guideline development. The Expert Panel was charged with updating the clinical practice recommendations for the treatment of blood cholesterol levels to reduce atherosclerotic cardiovascular disease (ASCVD) risk using data from randomized controlled trials (RCTs) and systematic reviews and metaanalyses of RCTs. ASCVD included: coronary heart disease (CHD), stroke, and peripheral arterial disease,

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all of presumed atherosclerotic origin. The recommendations were intended to provide a strong evidence-based foundation for the treatment of cholesterol for the primary and secondary prevention of ASCVD in women and men.

What’s New in the Guidelines? 1. Firstly, there is an identification of four statin benefit groups. The new guideline recommends moderate- or high-intensity statin therapy for these four groups: • Patients who have cardiovascular disease; • Patients with an LDL, or “bad” cholesterol, level of 190 mg/dL or higher; • Patients with Type 2 diabetes who are between 40 and 75 years of age; and • Patients with an estimated 10year risk of cardiovascular disease of 7.5 percent or higher who are between 40 and 75 years of age (the report provides formulas for calculating 10-year risk). In terms of clinical practice, physicians can use risk

assessment tools in some cases to determine which patients would most likely benefit from statin therapy, rather than focusing only on blood cholesterol to determine which patients would benefit. 2. A New Perspective on LDL–C and/or Non-HDL–C Treatment Goals • The Expert Panel was unable to find RCT evidence to support continued use of specific LDL–C and/ or  non-HDL–C treatment targets. The guideline represents a departure from previous guidelines because it doesn’t focus on specific target levels of low-density lipoprotein cholesterol, commonly known as LDL, or ‘bad cholesterol,’ although the definition of optimal LDL cholesterol has not changed. Instead, it focuses on defining groups for whom LDL lowering is proven to be most beneficial. • The appropriate intensity of statin therapy should be used to reduce ASCVD risk in those most

educators’corner likely to  benefit. • Non statin therapies do not provide acceptable ASCVD risk reduction benefits compared to their potential  for adverse effects in the routine prevention of ASCVD. 3. Global Risk Assessment for Primary Prevention • This guideline recommends use of the new Pooled Cohort Equations to estimate 10-year ASCVD risk in both white and black men and women. • By more accurately identifying higher risk individuals for statin therapy, the guideline focuses statin therapy on those most likely to benefit. • It also indicates, based on RCT data, those high-risk groups that may not benefit. • Before initiating statin therapy, this guideline recommends a discussion by clinician and patients. 4. Safety Recommendations • This guideline used RCTs to identify important safety considerations in individuals receiving treatment of blood cholesterol to reduce ASCVD risk. • Using RCTs to determine statin adverse effects facilitates understanding of the net benefit from statin therapy. • Provides expert guidance on management of statin-associated adverse effects, including muscle symptoms. 5. Role of Biomarkers and Noninvasive Tests • Treatment decisions in selected individuals who are not included in the four statin benefit groups may be informed by other factors as recommended by the Risk Assessment Work Group guideline.

Proponents of the new guidelines say that the likely impact of the new recommendations is that more people who would benefit from statins are going to be on them, while fewer people who wouldn’t benefit from statins are going to be on them. Doctors may also consider switching some patients to a higher dose of statins to derive greater benefit as a result of the new guidelines. In addition to identifying patients most likely to benefit from statins, the guideline outlines the recommended intensity of statin therapy for different patient groups. Rather than use a “lowest is best” approach that combines a low dose of a statin drug along with several other cholesterollowering drugs, the panel found that it can be preferable to focus instead on a healthy lifestyle along with a higher dose of statins, eliminating the need for additional medications. The guidelines are intended to serve as a starting point for clinicians. Some patients who do not fall into the four major categories may also benefit from statin therapy, a decision that will need to be made on a caseby-case basis.

Critics

The critics of the new ACC/AHA treatment guidelines are mainly concerned about the sudden departure from treat-to-goal, “lower LDL cholesterol is better“ and riskbased treatment approaches. The reason given was that randomized clinical statin trials used fixed doses of cholesterol-lowering drugs to reduce cardiovascular events. But then again, the critics argued, industry-sponsored statin clinical trials were not designed to develop guidelines. The American Association of Clinical Endocrinologists (AACE) says it can’t support the new cardiovascular risk guidelines issued by the AHA and ACC because it is out of step with its own recommendations. “After careful consideration by the appropriate scientific committees of our organization, AACE declined to endorse these new cholesterol and obesity guidelines,” the organization said in a statement. “There are multiple reasons for this decision, including, principally, the incompatibility of these new guidelines with our existing guidelines.” AACE welcomes the intent of the

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educators’corner

AHA and ACC in the creation of these new guidelines but cannot endorse them.The endocrinology group faults the new AHA/ACC guidelines for focusing exclusively on randomized clinical trials and for not including studies published since 2011. “They are highly restrictive regarding the database considered and omit much new information… Taken together, these actions have resulted in a considerable number of at-risk patients being omitted from consideration.” And, AACE says that the new cardiovascular disease calculator that was published along with the guidelines—and generated the most controversy—is already outdated. “It is based upon outmoded data that has not been validated, and therefore has only limited applicability.” Lastly, AACE disagrees with removal of the LDL targets

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and the idea that statin therapy alone is sufficient for all at-risk patients, noting that many who have multiple risk factors, including diabetes and established heart disease, will need additional therapies.

Conclusion

At this point, it is clear the new ACC / AHA guidelines have stirred some confusion and division among medical practitioners. More studies and expert panels on cholesterol management are bound to enlighten us in the near future. Nevertheless, the basic principles remain: healthy lifestyle is a mainstay of cardiovascular disease prevention, and patients should be treated as individuals with unique concerns and not mere cholesterol numbers. D

specialadvertisingfeature educators’corner

Diabetes… a cardiovascular condition? By Ma. Rosario C. Sevilla, MD, FPCP, FPCC

Individualized therapy in type 2 diabetes

ADVANCE trial, prevention of complications

Lesser hypoglycemic episodes with gliclazide

Reduction of all-cause death and CV death with gliclazide

Diabetes is considered a cardiovascular disease equivalent. This has been accepted as fact among clinicians since the early 2000s. Its impact on the risk for developing coronary artery disease, cerebrovascular disease and peripheral arterial disease, referred to as, macrovascular complications, has made every physician keenly aware of the importance of screening and controlling blood sugar levels in all patients. Prof. Angelo Avogaro’s lecture on August 2, 2013 entitled, “From Guidelines to Clinical Practice: The Place of Sulfonylureas Today”, was interesting because, as an endocrinologist, he easily acceded to the point that Diabetes is a disease of the blood vessels, thus opening the flood gates to cardiologists assuming a greater role in the management of the disease. Most importantly, he provided a concise summary of the urgent issues in the management of diabetes, namely, intensive vs. standard control, prevention of microvascular and macrovascular complications, hypoglycemia as a separate risk factor, and comparison of the different drugs available for blood sugar control. Queries and insights came to mind, as he made each presentation. INDIVIDUALIZED THERAPY Prof. Avogaro stated that each patient should be treated differently. Less intensive control is recommended for the higher risk patient. Initially, it felt that Prof. Avogaro, and the authors of this guideline, were suggesting that it is futile to even attempt to alter prognosis in patients on the higher end of the spectrum. Therefore, it is better to just let their HbA1c values remain elevated. However, this may also be interpreted as a justification for screening for DM at age 40 years, and exerting tighter control early in the disease, when it may be possible to modify the patient’s prognosis. PREVENTION OF MICROVASCULAR AND MACROVASCULAR COMPLICATIONS The case for early intervention is further substantiated by the ADVANCE trial, which showed that intensive glucose control could significantly reduce the relative risk for microvascular complications, but not macrovascular events. Considering that the mean age of subjects were 66 years, and majority were hypertensive and overweight, then perhaps tighter glycemic control, at this point in their lives, may have been too late to significantly alter the occurrence of macrovascular events. Again, these results imply that early detection and control should become the norm. Further, this may also imply that the follow-up period of five years in the ADVANCE study was not long enough to observe any significant IMPACT on macrovascular complications.

the arguments against aiming for more intensive control. COMPARISON OF THE DRUGS AVAILABLE FOR BLOOD GLUCOSE CONTROL Although hypoglycemia has been attributed mainly to the use of sulfonylureas, it was interesting to see the data comparing gliclazide to other diabetes medications, including sitagliptin, and how there were less hypoglycemic episodes with the use of gliclazide, unlike the other sulfonylureas. In another meta-analysis, which compared gliclazide to other sulfonylureas, the data suggested a trend towards benefit associated with the use of gliclazide, i.e., there is a 10% reduction in Total Death and a 13% reduction in Cardiovascular Death with patients on gliclazide but neither of these results reached statistical significance. Prof. Avogaro ended with a litany of the disadvantages associated with the other drug classes used for blood sugar control. Although these have been cited in medical news headlines in the past several months, I am not sure if most clinicians are aware of these adverse drug reactions. In summary, Diabetes Mellitus is, indeed, a cardiovascular disease and must be afforded the same type of urgency that is usually given to a heart attack or a stroke. Patients do not die of microvascular complications, although these may significantly lower the patients’ quality of life. The macrovascular complications of coronary artery disease, cerebrovascular disease, and peripheral arterial disease will still mediate the final mode of exit for diabetic patients. Therefore, prevention, early diagnosis and early appropriate treatment are still critical components of proper medical care of diabetes mellitus. To achieve this goal, heightened awareness of the condition among clinicians, in addition to the endocrinologists and diabetologists, is mandatory. Cardiologists will necessarily form part of the medical team, not only because of the heart and vessel involvement, but also because most of the adverse drug reactions of hypoglycemic agents are cardiovascular in nature – pedal edema, congestion, heart failure, etc. Patients will, inevitably, consult their cardiologists for these complaints, thus, the nuances in the choice of medications (including adverse drug reactions), across and within drug classes, need to be regularly brought to the cardiologists’ attention. Finally, it would seem that the dilemma on how low to go with blood sugar control is still unresolved, and that the magic HbA1c value remains elusive at this point.

Gliclazide (Diamicron MR 60mg) is an original research product of Servier. Gliclazide is a sulfonylurea which was proven to effectively control blood glucose levels, protect the HYPOGLYCEMIA kidneys and the heart with the least hypoglycemia and no Severe hypoglycemia was determined to weight gain. Daily dose may vary from 30 to 120mg per day, be associated with an adverse clinical outcome i.e. from ½ to 2 tablets taken orally in a single intake at or death and this has been considered one of FEBRUARY-MARCH breakfast time. 17 2014

fightinâ&#x20AC;&#x2122;forfitness

Ballroom Workout

Wonders By Ana Palma

allroom partner dancing as an exercise is a fun all-around physical and mental activity. It fights muscle loss, osteoporosis, and depression. It can also be beneficial in preventing Alzheimerâ&#x20AC;&#x2122;s. It can also promote better cardiovascular health and increased flexibility and coordination. For diabetes patients, ballroom dancing is simply great for losing weight and controlling glucose levels. Meanwhile, the social aspect of ballroom dancing can be a great option for people who get easily distracted, tired, or lazy during regular exercise routines. A participant can make friends, hang out, and exercise all at the same time. The first step is to decide whether to dance socially or competitively. All types of dances can be danced both ways, but choosing one determines the kind of training needed. The second step is to choose a dance that suits you. All the dances have different levels of intensity, some are slow and require stronger muscles while other dances can be fast and require more agility.

FEBRUARY-MARCH 2014

Rumba is a very sexy and slow dance. Cha-cha-cha is livelier. Samba is fun and energetic. The Jive is positively heart thumping and requires good stamina. And then there are the Foxtrot, Waltz, Tango, and Quickstep. While the Rumba, Samba, and the Jive are good for partner dancing, dances like Salsa, Cha-cha-cha, Merengue, Bachata, the Latin Hustle (or locally called Swing), and Argentine Tango, are great for social dancing in clubs as they are as popular as street dancing. For group dancing, Line Dancing and Latin Cardio are great options. These are fun and inexpensive ways of learning ballroom dancing without a partner. The basic steps can be taught by an instructor. For this issue, we focus on Latin Cardio, which includes Jive, Bachata, and Samba basic foot works.

fightinâ&#x20AC;&#x2122;forfitness Piece of advice: Before engaging in high energy Latin Cardio, warm-ups and stretching before dancing are very important to avoid tense or pulled muscles, cramps, and/or injury. I always advise my students to do warm-ups before dancing and cool-downs after an exercise.

Warm-ups and Stretching: 1. Neck Side-to-Side drop your head to the left and right.

3. Shoulders Lift and Drop

2. Neck Rotation

place arms on the side and push rib cage to left and right.

4.Shoulder Rotation

drop your head down, left, back, and right; repeat this on the opposite direction.

7. Leg Swing

5. Ribcage Side-to-Side

swing your right leg to the front, side, and back. Repeat this combination on the opposite leg.

6. Hip Rotation push hips to the front, left, back, and right. Repeat this combination on the opposite side.

The Latin Cardio Dances We focus on the three Latin Cardio dances: the Merengue, Salsa Shine, and the Cha-cha-cha.

Merengue A. March in Place. Begin marching in place on the first beat. Start with your right foot and take a step on every beat. B. Side-to-Side basic. (step right foot [RF] to right side, put left foot [LF] and RF together. LF closes next to RF). Repeat the steps for eight counts. Do the same steps on your left side.

C. Rocking Step. Step forward with your RF. Replace weight on LF. Repeat for eight counts. Do the same step on the opposite side starting with your LF, stepping forward (you can do as many as you want on every pattern). Repeat

FEBRUARY-MARCH 2014

dancewithdebbie.biz.com

Music: Merengue music, ex. El Tiburon

fightinâ&#x20AC;&#x2122;forfitness Salsa Shines Counting method: 1-2-3, 5-6-7 pause on 4 and 8 Timing: quick-quick-slow, quick-slow

quick-

A. Basic Step. forward and back. RF steps in place, LF steps forward, replacing weight on RF. LF steps in place or slight stepping at the back, RF steps back and replace weight on LF.

B. Side-to-Side Basic. RF steps in place. LF steps to left side, replacing weight on RF. LF closes to right and RF steps to right side, replacing weight on left side. C. Suzy Q Step. RF steps in place or slightly to the side. LF crosses to RF. RF stays in place, then LF cross. Repeat the pattern on your left side. Repeat

123rf.com

A. Forward and Back Basic. RF steps in place. LF steps forward, replacing weight on RF. Do three cha-cha-chas (chasseâ&#x20AC;&#x2122;) backward. RF steps back, replacing weight on LF. Do three cha-cha-chas forward. Repeat. B. Side-to-Side. RF steps to the side, replacing weight on LF. Do chachachas in place. Repeat this pattern on the opposite side, starting with your LF stepping to the side. Repeat. C. Forward and Back basic. Do three Cha-cha-chas forward and

back. RF steps in place. LF steps forward, replacing weight on RF. Cha-cha-cha backward. RF steps back, replacing weight on LF. Do cha-cha-chas forward starting with your RF. Continue doing chacha-cha forward with your LF. Do the last cha-cha-cha starting with your RF. LF steps forward, replacing weight on RF. Cha-chacha backward, starting with your LF, then cha-cha-cha from your right. Finally, do the last cha-chacha starting on your left side. Repeat

godanceknox.com

Cha-cha-cha

For more information on ballroom dancing, log on to www.adancecompany.com or visit them at V.G. Miranda Bldg. 9699 Pililla Street San Antonio Village, Makati. Contact them at 09178398957.

FEBRUARY-MARCH 2014

indepth

Menopause and Diabetes These two conditions, menopause and diabetes, can be a double whammy

ageology .com

By Jocelyn Capuli-Isidro, MD

â&#x20AC;&#x153;I am 49 years old and I suddenly feel a lot of changes in my body. I easily get tired, irritated, and fatigued by the usual chores I used to do effortlessly. My menstruation is going haywire. I think I am entering menopause. Itâ&#x20AC;&#x2122;s becoming a bigger problem with my diabetes! My doctor has raised red flags on my glycosylated hemoglobin (Hba1c, the average blood sugar for the last three months), on my cholesterol with levels reaching the heavens, and my on-and-off urinary tract infections are no joke.â&#x20AC;?

he above is a heavy statement we commonly hear from our diabetes patients entering the period of menopause. Menopause is defined as permanent cessation of menstruation and fertility. It occurs in the 40s or early 50s because of decline in the production of reproductive hormones. The ovaries produce less estrogen and progesterone. When the symptoms of both menopause and diabetes collide, the patient is in a dilemma as to whether the symptoms are from diabetes per se or from the onset of menopause.

1. Blood sugar fluctuation - The response of the cells to the action of insulin is diminished upon the decline of the reproductive hormones namely estrogen and progesterone. The insulin resistance is heightened leading to poor control in blood sugar levels. As mentioned above, menopausal symptoms can mimic the symptoms of diabetes, which can be misleading to patients. Hence, blood sugar monitoring is warranted.

Changes with menopause

2. Weight gain - Menopause is a harbinger of progressive weight gain. We know that weight management is an integral part in the management of diabetes. With menopause, patients whose weights have not been well-managed may face a problem of continued weight gain. The abdomen deposits fats due to estrogen loss. Bodies become apple-shaped from the pear-shaped body figure we see during premenopausal stage. This is the point

Menopausal symptoms such as hot flashes, irritability and mood swings, and fatigue can be mistaken as symptoms of low or high blood sugars. In such cases, if the blood sugars are not properly monitored, patients may resort to consuming unnecessary calories leading to increase in the level of their blood sugars. The following are the clinical situations and bodily changes that are usually encountered by diabetic women entering the menopausal stage.

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indepth where structured diet and physical activities have to be strictly in place. Diet should be low-fat, high-fiber, with no sweets, and exercise should be at least 30 minutes per day. 3. Sleep disturbances - The loss of reproductive hormones can also lead to insomnia and daytime sleepiness. Postmenopausal women become loud snorers too. In a diabetic patient, these can be interpreted as symptoms of low blood sugar. And instantly, this can lead to unnecessary calorie loading which again can worsen the blood sugar control. 4. Vaginal infections - Poorly controlled blood sugars lead to increased incidence of vaginal infection and urinary tract infections. Bacteria thrive well in the presence of high blood sugar. Similarly, estrogen, the hormone which actually encourages production of natural antimicrobial substances in the urinary bladder and makes the lining of the bladder stronger and hard for the bacteria to penetrate the bladder wall, is diminished. The natural defense against bacterial penetration is lost. 5. Sexual problems - Diabetes in itself can lead to the development of sexual problems like vaginal dryness and loss of sex drive among women. These problems become even worse as they enter menopause. Estrogen lack causes thinning of the vaginal lining, which causes pain during sexual intercourse. A consultation with the obstetrician and gynecologist maybe helpful in addition to the regular visits to the diabetes specialist in order to maintain wellcontrolled blood sugar levels. 6. Heart disease and stroke risk Non-diabetic women are protected from heart diseases and stroke until menopause. This protection is derived from the positive effects that we get from the female hormones. However, diabetes per se overrides this protection even before menopause. Diabetic women are at risk for heart diseases and stroke even before they lose their menstruation. Development of blockade in the arteries of the heart and brain characterized by thickening and hardening of the arteries can lead to stroke or

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coronary artery disease. On top of that, cholesterol control can be very difficult as a diabetic patient enters menopause. Bad cholesterol and triglycerides continue to go up and the good cholesterol declines. These further increase the risk for atherosclerosis (blockade of the arteries due to cholesterol deposit) in the major arteries of the body. Hence, at this time baseline stress test or stress echocardiogram maybe advised by the physician to screen for silent heart disease. 7. Osteoporosis. Type 1 diabetes is a risk factor for premenopausal osteoporosis because the bone formation is impaired due to the absence of insulin. In type 2 diabetes, the bone mineral density is not directly affected by diabetes since there is still circulating insulin in the blood prior to menopause, but fracture risk may be increased as the risk for fall due to fluctuating blood sugars increase. As type 2 diabetic patients enter menopause, the decline in the hormone estrogen makes the bones brittle and prone to fracture.

Changes in management

These scenarios just strengthen the need for close monitoring of blood sugars and regular follow-up with the attending endocrinologist/diabetologist. Blood sugar log is necessary to monitor the blood sugars. Capillary blood sugars fasting and two hours after eating will be reflective of the blood sugar control of the patient. This is complemented by getting the Hba1c. Based on these parameters, medications may need to be adjusted by your health care providers. Regular follow-ups will also allow your physician to closely monitor your cholesterol, screen you for postmenopausal osteoporosis, recurrent urinary tract infections, and vaginal infections, and most importantly, screen you for heart disease and stroke. In the menopausal stage, treatment of diabetes, more than ever becomes multidisciplinary. At the onset of menopause in a diabetic patient, consultations with the endocrinologist/diabetologist, cardiologist, obstetrician-gynecologist are a must. Indeed, diabetes and menopause are twin illnesses that we need to fight. The artillery must be complete and evolve to ensure their defeat. But the only way we can launch an effective plan of attack is if patients and doctors work together in harmony. D

indepth

com

Kidney Care and Chronic Kidney Disease Update connect-pr

od.s3.am

azonaws.

By Ma. Isabel D. Duavit, MD

idney disease has been clearly recognized as a common complication of diabetes mellitus (DM), with as many as 30 percent of patients with DM having this complication. Your kidneys are important because they remove waste products from the body by filtering blood and producing urine. In addition to removing drugs and toxins, they also balance the body fluids, release hormones that control blood pressure, regulate salts (sodium, potassium, phosphorus, calcium), promote production of red blood cells, and keep the bones healthy. Chronic kidney disease (CKD) is defined as having some type of kidney abnormality such as presence of protein in the urine, and/or having decreased kidney function for three months or longer. If your kidney disease is caused by diabetes, then your doctor will give a diagnosis of chronic kidney disease secondary to diabetic kidneys (formerly known as diabetic nephropathy).

Kidney function tests

CKD may be a silent disease, and early kidney disease rarely has symptoms. Generally, diabetic kidney disease is considered after a routine urinalysis and screening for microalbuminuria in the setting of diabetes. Laboratory testing using either serum creatinine or the presence of albumin in the urine have been recommended screening measures. With these tests, your doctor can tell how well your kidneys are working:

1. Urine albumin or albumin-creatinine ratio (UACR). This is a sensitive urine test that can detect small amount of protein (known as microalbuminuria) long before there is evidence of kidney disease in the usual blood tests. Protein is not normally found in the urine. When the kidneys are damaged, protein spills from blood into the urine. Microalbuminuria is defined as albumin excretion of more than 20 μg/min, or albumin-to-creatinine ratio (µg/g) > 30. This phase indicates early kidney disease and calls for aggressive management at which stage the disease may be potentially reversible (i.e., microalbuminuria can regress). Persistent albuminuria is confirmed when albumin is >300 mg/d or >200 μg/min on at least two occasions three to six months apart. 2. Creatinine. Creatinine is a waste product usually removed by the kidneys from the body and eliminated through the urine. When the kidneys are damaged, creatinine levels increase in the blood. You can get an estimate of your kidney’s filtering ability by computing for your kidney’s estimated glomerular filtration rate (eGFR). It is the basis for establishing the stage of CKD. The higher the creatinine, the lower the eGFR, and the worse your kidney function is.

Kidney disease categories

Current guidelines classify CKD based on estimated glomerular filtration rate (eGFR) and albuminuria to estimate the risk of progression or associated cardiovascular or renal FEBRUARY-MARCH 2014

indepth

*KDIGO â&#x20AC;&#x201C; Kidney Disease: Improving Global Outcomes

events (see chart above). More recent epidemiological evidence indicates that patients with proteinuria with higher eGFR may have greater risk for progressive loss of renal function than patients with more advanced reductions in eGFR who have little or no proteinuria. Patients with chronic kidney disease stages one to three are generally asymptomatic; clinical manifestations typically appear in stages four to five. Once your GFR is known, your doctor can plan and modify treatment according to the stage of kidney disease you have. Treatment Without proper treatment, the time between the start of diabetic kidney damage to end stage kidney failure (also known as end stage renal disease or ESRD) is about five to seven years. The lower your stage when you begin treatment, the greater the chances of success in trying to delay progression to a later stage. Here are the steps you need to take to prevent diabetic kidney disease progression: 1. Control your blood sugar. In addition to capillary blood glucose monitoring (CBG), your doctor will request

FEBRUARY-MARCH 2014

for a test known as HbA1c (glycosylated hemoglobin), which will indicate your blood sugar control in the past three months. Ideally, blood glucose should be maintained at near-normal levels (premeal levels of 70-130 mg/dL and hemoglobin A1C [HbA1c] levels < 7 percent. It is possible that more intensive blood glucose control may benefit kidney function more in people with diabetes. However, one needs to balance the potential benefits of improved sugar control on the rate of loss of kidney function with the greater propensity for hypoglycemia or low blood sugar.Patients with kidney disease are much more likely to suffer adverse events related to hypoglycemia. It is therefore recommended that blood glucose targets should be individualized. For example, corresponding HbA1c targets may be less than 7.5 percent in an elderly patient with a coexisting chronic disease such as CKD (chronic kidney disease) or even higher such as 8 percent or more in patients with very poor health and decreased life expectancy. 2. Control blood pressure. For people with diabetic kidney disease, lowering blood pressure to approximately 140 mm Hg systolic is

indepth associated with a significant reduction in the incidence of kidney failure. However, just like sugar control, current guidelines recommend individualized blood pressure targets. A goal of less than 130/80 mm Hg, for example, may be beneficial, especially if there is protein in the urine. Your doctor will probably give you a high blood pressure medication that blocks the renin-angiotensin system known as ACE (angiotensin converting enzyme) inhibitor or an ARB (angiotesin receptor blocker) since studies have shown that these medications can decrease protein in the urine and retard progression of kidney failure. Evidence exists that employing these drugs and lowering blood pressure to approximately 140 mm Hg systolic is associated with reducing your risk to develop end stage kidney failure) by 25 to 28 percent. 3. Take all your medicines regularly. Although the most effective way of slowing the loss of kidney function is by controlling blood sugar and blood pressure, focusing on them alone does not provide adequate treatment for patients with diabetic kidneys. CKD is not a single process that can be reversed by just improved blood pressure and sugar control. A variety of therapies will be required to target the many factors that affect disease progression. High cholesterol, for example, can cause blood vessels to become clogged and further impair blood supply not only to your kidneys but also to your heart and brain. If the cholesterol and other fatty substances in your blood (known as lipids) are high, you may need to be given anti-cholesterol medications called statins to lower them. If vitamin D levels are low, you may be given vitamin D supplementation. If there are already complications of kidney disease such as acidosis, increased phosphorus (hyperphosphatemia), and anemia, you will be given medications to minimize the complications and slow the rate of progression of your kidney disease. 4. Follow your diet. Recent studies have indicated that a healthy diet is associated with a reduced risk of developing CKD and slower progression of early kidney disease among individuals with type 2 diabetes. A diet with significant amount of fruits and vegetables, moderate amounts of saturated fat and simple sugars, low amount of salt, and reduced amounts of protein may be helpful. Protein intake recommendations range from 0.60.8 gram per kg of body weight. However, reduction in

protein intake is not recommended for everyone and you need to discuss with your doctor regarding the diet that is best suited for you.With advancing renal disease, protein restriction may be as much as 0.8-1 g/kg/d and the diet may also include phosphorus and potassium restriction. All diabetic patients should consider reducing salt (sodium chloride) intake at least to less than 5-6 g/d, in keeping with current recommendations for the general population, and may benefit from lowering salt intake to even lower levels. A recent study demonstrated that a low-sodium diet enhanced the kidney and heart protection effects of blood pressure medicine angiotensin receptor blockers (ARBs) in type 2 diabetic patients with nephropathy. 5. Get regular exercise and target ideal body weight. No restriction in activity is necessary for persons with diabetic kidneys, unless warranted by other associated complications of diabetes. It is recommended to have exercise training of more than 150 minutes per week. Older patients or patients with evidence of atherosclerotic disease should have a cardiovascular evaluation and clearance prior to initiating an exercise regimen. It is also recommended for overweight patients to lose weight because modest weight losses of 5-10 percent have been associated with significant improvements in cardiovascular disease risk factors (i.e., decreased HbA1c levels, reduced blood pressure, increase in HDL cholesterol, decreased plasma triglycerides) in patients with type 2 DM. 6. Avoid substances that can cause further kidney damage. Once you have kidney disease, it is recommended that you check with your doctor first before taking any medicines or herbal supplements because a lot of these are metabolized by your kidneys. Nephrotoxins are substances that may further damage kidneys in patients. Certain antibiotics and some over-the-counter medicines like pain medicines can be toxic to the kidneys, causing permanent damage. The most common pain-relieving medicines known as nonsteroidal antiinflammatory drugs (NSAIDS) in particular can make your renal function much worse and should be avoided. Dosages of most medications (e.g. antibiotics) need to be adjusted according to the level of kidney function. You should also require clearance for certain procedures that may require use of contrast (e.g.,CT scan). You should also avoid smoking and alcohol. FEBRUARY-MARCH 2014

indepth 7. Follow up with your doctor as often as you are told. Regular outpatient follow-up is key in managing diabetic kidney disease successfully. With each encounter, your doctor can discuss with you goals of management including blood glucose and blood pressure targets, as well as modify your medications, diet, and exercise regimen. Regular monitoring for complications, presence of infections, and laboratory assessment are also done at this time. You may be referred to a kidney doctor (nephrologist) and a dietitian who will work along with you to make your kidneys last longer. However, some patients with chronic kidney disease may progress to end-stage kidney failure. The rate of progression depends on the successful implementation of said preventive measures and on the individual patient. If your GFR decreases to less than 10-15ml/min (stage 5) your doctor will already recommend dialysis and/or transplant to replace the work of your failed kidneys. At this level, the kidneys are no longer able to support your body in a reasonably healthy state. In most cases when your GFR decreases to below 20, your doctor will usually advise that you arrange for a permanent access for dialysis. Timely initiation of dialysis is important to prevent the uremic complications of kidney failure that can lead to significant morbidity and death.In diabetic patients, starting earlier is useful when water volume overload renders blood pressure

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uncontrollable, when the patient experiences poor appetite and weight loss or other uremic symptoms, such as severe vomiting, inability to sleep or too much sleeping, progressive weakness,occurrence of seizures and spontaneous bleeding. Refusal of dialysis which is the treatment for uremia, may lead to a progressive decline in general health and ultimately leading to death. According to the Philippine Renal Disease Registry in 2011, diabetes was responsible for 42 percent of all end-stage renal disease (ESRD) cases who were started on dialysis in our country. Except in patients with severe complications, renal transplantation should also be considered because it offers the best degree of medical rehabilitation in patients with uremia and diabetes. This option must be discussed early on with the patient and his or her family. Transplantation even before dialysis (preemptive transplantation) is becoming increasingly popular in some centers. Preemptive transplantation can be considered when eGFR decreases to below 20. Diabetes is the leading cause of chronic kidney disease in the Philippines. Having diabetes does not always mean your kidneys will fail. Regular screening and outpatient follow-up is important in managing diabetic kidneys. Ensuring optimal glucose control, optimizing blood pressure, and treating other associated complications of diabetic kidneys are also crucial. If these steps are not taken to slow the worsening of kidney function, the kidneys may eventually fail, and either dialysis or kidney transplant would be needed to live. D

indepth

Polycystic Ovary Syndrome – More Than a Fertility Problem

fssc.com

By Patricia D. Maningat, MD, MSc, FPCP, DPSEM

olycystic Ovary Syndrome (PCOS) is the most common hormonal disorder in reproductiveage women affecting between 4-12 percent in this age group. The name of this disorder is quite misleading because not all women with multiple cysts in the ovaries have PCOS.

What is PCOS?

By definition, a syndrome is composed of a group of signs and symptoms that identify patients with a particular disorder. For PCOS, although the cause is not yet clearly established, the key features include androgen (male hormone), excess insulin resistance (ineffective insulin function and high insulin levels) and abnormal gonadotropin (reproductive hormone) dynamics. It is recognized as an important metabolic and reproductive disorder with increased risk for developing type 2 diabetes mellitus. PCOS impacts several aspects of a woman’s life including physical appearance, fertility, morbidity and quality of life. During a normal menstrual cycle, the hormonal milieu causes the stimulation and development of a dominant follicle in the ovary, followed by ovulation in mid-cycle, and then by either pregnancy when the egg is fertilized by a sperm; or menstruation when no fertilization occurs. It is thought that in PCOS patients, the ovaries are extra-sensitive to the stimulus of reproductive hormones, producing more androgens compared to estrogen.

Because of this imbalance, several follicles are stimulated with no dominant follicle, leading to failure of ovulation. The presence of several follicles on the surface of the ovaries lead to the term multiple cysts or “polycystic ovaries”. High levels of androgens lead to development of acne and hirsutism (male-pattern of hair distribution) and can induce or worsen insulin resistance. Conversely, high insulin levels and insulin resistance exacerbate androgen production and lead to metabolic abnormalities.

How can you tell it’s PCOS?

There is no definite test to diagnose PCOS and our best guide to date is based on recommendations given by three expert committees (National Institutes of Health (NIH), Rotterdam group, and the Androgen Excess Society). The NIH requires the presence of menstrual abnormalities and hyperandrogenism clinically or by laboratory tests, and does not require the presence of polycystic ovaries. The Rotterdam criteria requires two out of three signs be present: hyperandrogenism, menstrual abnormalities, and/or polycystic ovaries. The Androgen Excess Society requires hyperandrogenism plus either abnormal menses or polycystic ovaries. Although lacking a consensus, they share a common focus on PCOS as an ovarian disorder. And because PCOS may share similar signs and symptoms with other conditions such as adrenal gland disorders, ovarian tumors, steroid excess FEBRUARY-MARCH 2014

indepth from Cushingâ&#x20AC;&#x2122;s syndrome, and hormonal imbalances due to thyroid or pituitary problems, all three expert groups advocate that other causes must be ruled out before making a diagnosis of PCOS. The signs and symptoms of PCOS vary among patients but women consult for three primary reasons: menstrual irregularities, infertility, and symptoms associated with androgen excess (hirsutism and acne). The diagnosis is often made based on clinical history and physical examination while laboratory exams are done to exclude other causes mentioned above. The initial onset of PCOS is around puberty and progresses slowly during the reproductive years. Therefore if a woman develops these signs and symptoms rapidly, another cause should be sought. Having menstrual periods that are few and far between (longer than 35 days, or fewer than eight cycles/ year) may be clues to having anovulatory cycles. However, some women with PCOS may have normal menses. Signs of androgen excess may be absent in some women, but when present, include acne and hirsutism or sometimes male-pattern baldness (androgenic alopecia). Hirsutism is the presence of coarse hair in a male pattern of distribution (sideburn area, chin, upper lip, around the nipples, chest, lower abdominal midline and inner thigh). There is still some debate about whether the diagnosis of high androgens should be based on laboratory values of circulating androgens (free or total testosterone) or on clinical signs and symptoms alone. Problems with using laboratory values as the sole basis for diagnosing hyperandrogenism are that the normal range of testosterone in different populations has not been adequately validated; the available testing methods are imperfect,, and some women with PCOS have testosterone levels within normal. Thus, this area is still ripe for research. Some women may have enlarged ovaries discovered on ultrasound. Ovaries are considered polycystic when eight or more follicles per ovary are seen and follicles are less than 10mm in diameter. These ultrasound findings are present in majority of women with PCOS, but also in up to 25 percent of normal women which is why not all experts agree that this should be a criterion for diagnosis of PCOS. Some PCOS women have normal menstrual cycles, but typically PCOS patients have their first period at a normal age, then gradually develop irregular periods, often leading to absence of menstruation. PCOS is the leading cause of infertility caused by anovulation. The laboratory abnormalities in reproductive

FEBRUARY-MARCH 2014

hormones include elevated levels of testosterone and LH (luteinizing hormone) or an increased LH to FSH (follicle stimulating hormone) ratio. However, because LH and FSH are secreted in a pulsatile manner throughout the day, a single determination of the level of these hormones may not be accurate, thus they are not used in the diagnosis of PCOS. Your doctor may request for other more specific tests to exclude some of the disorders mentioned above.

What links PCOS, diabetes, and other disorders?

Why discuss PCOS here? Is it related to diabetes and other medical conditions? There is an intricate and complex relationship between PCOS and metabolic conditions like diabetes, insulin resistance and abnormal lipid profiles. Many women with PCOS are obese, more commonly with central obesity having a waist to hip ratio more than 0.85. high androgen levels are thought to drive the development of central obesity. Independent of obesity, women with PCOS may have insulin resistance accompanied by high insulin levels, glucose intolerance (tested by checking blood sugars during fasting and two hours after drinking a sugar drink) and abnormal lipid levels (low HDL and high triglycerides). The evidence linking PCOS with cardiovascular disease directly is still lacking, but because both insulin resistance and abnormal lipids increase the risk for cardiovascular disease, it is plausible that PCOS increases cardiovascular risk as well. Therefore it is important that women with PCOS be screened for glucose and lipid abnormalities. Persistent anovulation and irregular menses lead to unopposed estrogen stimulation to the uterus, which increases the risk for endometrial hyperplasia (thickening), and endometrial cancer. Women with PCOS have three times the risk of developing endometrial cancer. Obesity is also associated with increased risks for these disorders.

How is PCOS treated?

Because the primary cause of PCOS is still unknown, treatment is directed at the symptoms of the patient. There is no therapy that addresses all the aspects of the syndrome, and treatment decisions are dependent on whether or not fertility is desired because many treatments to address hirsutism, obesity, and acne may be contraindicated in

indepth pregnancy. Treatment approaches for chronic anovulation for those desirous of pregnancy should start with screening both male and female partners for causes of infertility before starting medical therapy. Medication options include clomiphene citrate, an anti-estrogen that results in ovulation induction in women with PCOS. Those who do not respond to clomiphene may be given secondline agents of injectable gonadotropins or reproductive hormones. Surgery (e.g. ovarian wedge resection, drilling) is offered when medical therapy is not successful. For those who do not want to get pregnant, the goal is to maintain a normal endometrium to decrease the risk of endometrial cancer. Combination oral contraceptives, medroxyprogesterone or leuprolide can be used with the goal of normalizing menstrual bleeding. For those with high androgens, combination oral contraceptives are used to treat hirsutism and acne. Other agents that can be used are spironolactone, flutamide ,and finasteride. A new treatment for unwanted facial hair is eflornithine hydrochloride cream, which is applied on the affected areas and has been shown to decrease hair growth. Mechanical and cosmetic means such as shaving, waxing, electrolysis, and laser hair removal are effective

means for controlling the appearance of unwanted hair. It is also important to address the metabolic disturbances associated with PCOS, especially insulin resistance, diabetes, and abnormal lipid profiles. Lifestyle changes including diet, exercise and weight reduction for those who are overweight or obese are cornerstones of management, whether or not drug therapy is started. Smoking cessation and reduction of alcohol intake are important to decrease the risk for cardiovascular disease. Metformin is the medication of choice and reduces insulin resistance and has been shown to decrease the risk of developing diabetes in the general population, although there is no data on PCOS in particular. It has also been shown to reduce levels of androgens in circulation. Many studies have shown that metformin restores menstrual cyclicity and may increase ovulation rates. However, it has not consistently been shown to increase live birth rates. Each of these therapies has their own risks and benefits and should be assessed and discussed by the patient and physician. Treatment goals must be agreed upon as well. With more research and better understanding of this syndrome, we may one day be able to target therapies toward the specific cause. D

FEBRUARY-MARCH 2014

feature

The Epitome of Kidney Care Vigilance By Jose Martin Punzalan

he rise in kidneyrelated diseases in the country is proof enough of how crucial the job of doctors is when it comes to caring for Filipinos. In the last decade, nephritis, nephrotic syndrome and nephrosis made it among the top 10 leading causes of mortality. Add to that the prevalence of comorbid diseases like diabetes and hypertension, which join nephritis, nephritic syndrome, and nephrosis in the top 10 list. Doctors need now more than ever to hone their skills and knowledge. Medical organizations like the Philippine Society of Nephrology play such a big role in the advancement of

kidney care in the country.

Care and Research

The Philippine Society of Nephrologists or PSN is a non-stock, nonprofit, and non-political professional medical organization of physicians specializing in adult and pediatric care for patients suffering from kidney disease. It serves as a cohesive body that ensures that its members are trained in the highest standards of excellence and are provided with the best tools to conduct groundbreaking research so that all of them are ultimately able to provide the best possible care and treatment for their

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patients. It also provides guidelines in the delivery of proper renal care and ensures their strict implementation. They actively engage in the development of public health programs aimed at the awareness, prevention, and treatment of renal disease. They encourage the conduct of research projects that hopes to improve upon nephrologic care in general. To promote this goal, the society created the Philippine Journal of Nephrology (PJN). Established in 1986, it is their official scientific publication wherein research papers in their specialty are regularly published.

Origins

Nephrology was just emerging as a medical subspecialty in 1971. Wanting to bring the medical advances in nephrology home to their countrymen, a pioneer group of nephrologists fresh from their training abroad under some of the best mentors in their field decided to form the organization under the leadership of its first president Dr. Filoteo Alano. He also served as the first editor-in-chief of the PJN. Like most medical organizations, the PSN also regularly holds conventions that serve as a venue for its members

feature to gain high-level scientific enlightenment and for intense fellowship. Their first national scientific convention was held in 1974 with the then Secretary of Health Dr. Clemente Gatmaitan, Sr. as keynote speaker. It was initially held every two years, but by 1985, they did it annually. As the organization kept growing, now with hundreds of fellows, diplomates, and affiliate and associate members, they conduct their conventions twice a year.

Accomplishments

The organization has been very active in working to improve the state of nephrology here in the Philippines in the last four decades of its existence and they have spearheaded several key actions to accomplish those. Being the premiere society for nephrology, it is their duty to make sure that Filipino nephrologists are the best at what they do with a standardized quality in subspecialty training. In 1982, among their first accomplishments was organizing the Specialty Board (PSN-SB) and Training Program Accreditation Board (PSN-TPAB) whose task is to evaluate qualified graduates of the subspecialty training for certification as diplomate or for elevating their ranks to fellow, and to accredit the subspecialty training programs of various hospitals all over the country. According to the PSN, these are all done to achieve the highest standards in the practice of nephrology and ensure that training programs remain current and well-rounded in developing renal physicians with a strong academic orientation and interest in doing

research while maintaining humane and compassionate patient care. In order to provide an even more specialized care and to more adequately address the renal care needs of pediatric patients, pediatric nephrologists from the PSN formed their own organization, the Pediatric Nephrology Society of the Philippines (PNSP). Despite being an independent organization, it still remains to be under the umbrella of the PSN. Monitoring the state of kidney health and renal care in the Philippines is another initiative that the PSN has undertaken. In 1995, the organization created the Kidney Biopsy Registry and Renal Disease Registry to collect objective data on the major renal diseases and the status of dialysis and renal transplant in the country. The Renal Registry project is done with the Department of Health and the National Kidney and Transplant Institute (NKTI). In 2002, the PSN took over leading the celebration of the Kidney month from NKTI. Held in June, this involves various public awareness programs and lay fora held nationwide. They also spearhead the celebration of World Kidney Day held every second Thursday of March. On March 13 this year, they conducted a Patient Benefit Forum at the Chinese General Hospital. Other chapters of the organization will also be having their own activities on that day in their region. With all of these efforts, regardless of how much kidney disease proliferates in the country, the nation can rest assured that the Philippine Society of Nephrology remains vigilant to ensure that the best kidney care facilities are available and affordable for all. D FEBRUARY-MARCH 2014

Photos from Fit-Fil and Milo Appex Facebook

feature

The author (front, left) together with the BGC beginner’s team after completing the 500 workout challenge

Rowing on dragonboat day

Fun run with the Milo Apex group

Participants doing warm-up before Zumba

My FIT-FILs Story Alexa Villano was a reluctant participant in the workout that matched an entire season of the Biggest Loser Philippines. She tells her tale of how FIT-FILs tested her mettle and made her more conscious of her health.

t was a cold December night at the Bonifacio Global Center Ampitheater. I watched as the coaches blew their whistle, signaling the start of the Fit-Filipinos (FIT-FILs) workout. “Let’s Go, FitFils!” Coach Tonette Dimaguila shouted as the advanced participants began doing the TRX movements. Coach Irene Rafil moved left and right as each member began lifting their legs. It was a very fast workout. I was in the beginners group. We were to do the same thing minutes later.

Reluctant Participant

As the workout wore on, I found

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myself and the rest of my group huffing and grunting as we did one workout after the other. I thought, “how did I get myself into this mess?” I wasn’t even supposed to be part of the group. I was supposed to be an onlooker who will later write a short feature on Fit-Fils while I sit comfortably in front of a computer screen. But Coach Jim Saret gave me the ultimatum. “If you’re coming to watch, you might as well participate.” I pondered the idea of joining for a moment. I was out of shape. I just wanted to watch how they did it. I knew the workouts in the camp were rigorous. Coach Jim was a coach for the weight loss program/reality TV

feature show The Biggest Loser, after all. I was reluctant in the beginning, but I agreed to join the remaining six out of 12 workouts.

60-40 Rule

A big group gathered in the middle of the Bonifacio Amphitheater. There were teenagers, moms, daughters, health enthusiasts, and even foreigners. I joined the group led by Biggest Loser contestant Hazel Chua. Three categories comprised the camp with two groups each: beginners, intermediate, and advanced. The workouts were different for each group. It was important for the coaches to know if it was our first time to join and if we had any prior health conditions. Before we began, Coach Jim asked everyone if they’ve been following the recommended diet made by the nutritionists of Nestlé. I literally heard a chorus of groans and saw many guilty faces. If the exercise was challenging enough, eating right was another thing. It was almost the holidays, but Coach Jim reminded everyone to stay disciplined and focused if they want to feel better. I even heard him say “60 percent nutrition and 40 percent workout”. And then we began. The coaches led by Coach Irene and Coach Prince kicked the session off with the 4-minute

Fit-Fil participants doing the squat as warm-up before the workout.

workout. After the warm-up, the group was divided into two for the kick-boxing and Zumba sessions. To cool down, the group joined together again and did a dance battle. After the workout, I immediately went to the nutritionist assigned to the beginner’s group, had my weigh-in and got the list of food recommended for the 1,800 calorie diet. It was later reduced to 1,600.

Keeping Deadlines

During the first session, I found

myself talking to Coach Tonette about my concerns with the workout. I told her that I was rushed to the hospital days before going to camp. I also told her that keeping up with pending deadlines also prevented me from focusing on my health. What she told me hit me. “Deadlines will always be there”. She firmly told me to put my health as a priority. I realized from there Coach Jim’s inspiration behind FIT-FILs. While his goal was to get many Filipinos to be fit, healthy, and strong, it wasn’t just about the physical component but also the mental and psychological.

Many of My Firsts

From the Zumba and kickboxing, the next session was followed by dragonboat racing. It was core training on my third session followed by the metaphysical games, fun run in Bonifacio, and, finally, the graduation–the 500 workout. Other exercises include metafit race, aqua training, and TRX. Female participants doing push-ups

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feature The FitFil program saw many of my firsts. It was my first time I did dragonboat racing and the first time to do a rigorous 500 workout, which consists of all the 12 workouts in the program. The 500 workout really tested my mettle. I couldn’t decide whether it was more painful or more challenging. I did the TRX. I struggled to do pull-ups with the hurdle, medicine ball bouncing with Coach Raffy Tan pushing me to give my all in throwing the ball, tire lifting, jumping jacks, burpees, planking with push-ups, kettle bell lifting, lunges, and crunches in a span of 45 minutes. Many times I almost broke down, cried, and walked away. My body was aching. I was totally exhausted. It felt like an episode of the Biggest Loser in an open environment. The fun run was also another first. I was never a fan of running, but Coach Tonette encouraged me. The challenge was to run the whole five kilometer span as I struggle to keep my flag from being taken away from me. I alternated between walking and running as I felt blisters beginning to grow on my feet. It helped that the coaches were there to encourage us. Of all the workouts, the

The anaconda workout

dragonboat racing was a defining moment. We were trained on the basics of canoeing and later almost shoved into the Manila Bay to race against each other as the coaches and the Philippine Dragon Boat team watched.

Fitness Does Not End

Surviving six days of training was an accomplishment. While it’s recommended to do all 12 sessions, I already felt light, happy, and strong even with just six sessions. I still struggle with eating right and exercising, but the coaches were very supportive. Those who finished all 12 sessions had medals to show for their effort. The coaches looked on proud as their graduates went home with the attitude and commitment to stay healthy. At the graduation, Coach Jim reminded everyone that the journey to fitness does not end. It will always boil down to discipline, determination, and motivation. All the sweat would go to waste if none of the three are

present. I know my journey to getting fit with FIT-FILs is just beginning, but I’m willing to go farther. D *About FIT-FILs The Fit-Filipinos (FIT-FILs) Movement is a personal advocacy began by Coach Jim in 2011 with the aim of getting one million Filipinos to be healthy, strong, and fit. With various workouts in the market, the purpose of FIT-FILs is exercising while having fun through a scientifically, based program which anyone can do whether or not one is a beginner.

A Fit-Fil participant tries to move a giant tire as part of the metafit games

FEBRUARY-MARCH 2014

stressbuster

No-Sweat Tricks to Stress Make these 4 A’s your strategy to avoiding stress and its negative impact on your health By Aencille Santos

hen stress kicks in, your body is in survival mode. Chronic stress with little or no relief distresses the body that eventually leads to adverse health conditions. In fact, nine out of ten patients who visit the doctor’s office are for stress-related ailments and complaints, according to Mayo Clinic. Don’t fall prey to stress. Here are Mayo Clinic’s 4A’s of Stress Management in a nutshell to get you over stress.

Avoid.

Choose your battles rather than facing all potential stress sources that come your way. Take control of surroundings. Don’t jump into situations that you know will drive you nuts. Learn to say no. Say ‘no’ especially when you have too much on your plate.

Ask for change. Open a discussion among your peers to create a better scenario in the future. Manage time better. Prioritize and organize your tasks to avoid getting overwhelmed.

Adapt.

If you fail to prevent a stressor from getting to you, adapting is the next step. Be realistic. Things beyond your control will occur, so stop striving for 100 percent perfection and don’t sweat the small stuff. Stop negative thoughts. Don’t replay the stressful situation in your head, think progressively, and focus on a solution.

our control. Let go and accept the things the way they are. Talk to someone. You’re not alone in the struggle. You have your loved ones who would be more than willing to share the burden. Forgive. Escape from the negative energy of holding a grudge and it will grant you peace in life. Practice positive self-talk. Pump yourself up with positive words. Who else will better encourage you than yourself? Keep the faith. The connection with your spirituality will be a good source of strength through these times. D

Look at things in a better light. Consider the ‘good’ in every ‘bad’ situation.

Accept.

There are things beyond

Delete and delegate. Learn to trust your peers and delegate tasks.

Alter.

If stress originates from an outside factor, don’t wait until it blows up in your face. Communicate feelings respectfully. Find good timing and properly communicate how you feel in certain situations.

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Top and pants by Eric Delos Santos

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ver story ]

he change began from the inside. No trace of the breakup is apparent in Nikki Gil. Not in her stride, nor in her vibe. Not even in her gigantic fashion billboard along Edsa. Nikki is simply the epitome of the beautiful, healthy, sexy, and intelligent Filipina that some regular girls could only dream of becoming. Now, she looks the part of someone who’s had a weight lifted off her shoulders. Nikki Gil is breaking free. Nikki maybe the epitome of beauty today, but she once suffered insecurities because of beauty. When Nikki was young, she had a bout with adolescent acne, which was cystic by nature. Like most kids in their adolescent age, she was at a stage when she was still establishing her identity. “I was starting to create my brand as a teenager and that’s when it happened. It was heartbreaking and many would make it superficial. But to an emotionally unstable teenager, that was something very challenging to do,” she says. “Of course, I’m happier with my skin now, but (the experience) gives you a chance to work on the inner person.” “No matter how much we take care of ourselves on the outside, if you’re not a good person inside, it will show. I make sure I take care of the inner person as well,” she says. She meditates, reads books, and takes care of her health. “I meditate. I read a lot. I try to be a nice person to people around me. I try to be professional and

hardworking,” she says. In the mornings of her days-off, she has her munimuni time and rolls around the bed for another 20 minutes. “I wish I could say I pray in the morning, but sometimes I’m super busy. When I’m not rushing for work, I go through what I’m going to do the whole day (with God),” she says. Most girls in her shoes would get a major makeover. Her physical changes are not as pronounced. It’s in the finer details where the changes lie and the people around her are starting to notice. “It was never a conscious effort. I don’t know if I’ll chop off my hair or whatever, but people have been saying that there was a change physically. Maybe because I have more time to work out now,” she says. Today, Nikki keeps herself fit and healthy. She regularly goes to the gym. She does simple workouts like cardios, boxing, yoga, running, and lifting weights. She is also a little more careful about what she eats. She doesn’t avoid rice, but she doesn’t eat as much as

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[c she used to. She also goes to the spa every now and then for her usual girly treatments. She now enjoys running and is considering training to prepare for a triathlon someday. “I know the difference. I felt the difference of living a healthy lifestyle and not living healthy. I’m much happier. I really feel the difference, the shift in my mood when I am not able to workout or sleep well. After I eat junk food, I can feel a shift in my mood so I prefer to take a healthier route,” she says.

Nikki is less stressed now that she’s decided that she’s wasted enough energy stressing about her breakup. “I just stopped caring at some point. I think I was able to get all of the pieces of my broken heart already. I’m going to move on and give this to someone who deserves it,” she says. In Nikki’s case, the makeover happened when the weight was lifted off her shoulders. “I’m not harassed or problematic anymore. He’s not my problem anymore,” she says with a slight giggle. “I guess it was more of a vibe than an effort to go through a makeover. I think the makeover happened inside more than anything else and it’s reflecting on the outside, which is better.” She’s now at a point when the whole issue doesn’t affect

her in any way, positively or negatively. “I learned to be able to discuss it from a more distance point of view. I guess that’s when you really know you’re fine,” she says. Even with the whole debacle, Nikki is not jaded by the idea of loving again. In fact, her ultimate “happily ever after” is raising a family. “I learned not to regret ever falling in love even if it was with the wrong person. I learned that relationships are more effective if you have the same values. I learned that not everyone’s like that. I learned that it won’t help to be jaded or cynical or it won’t help for you to carry whatever baggage that is into a new relationship because that will be unfair,” she says. “Not everyone is like that. You can’t generalize people and I learned that what you sow, you will reap. And in the words of my girl, Alicia Keys, ‘What goes around, comes around. What goes up, must come down’,” Nikki says. She smile knowing that she will find someone who will be prepared for her and will have the same values as her. “And it will be beautiful.” She once mentioned that she’s working on her core as she tries to move on from the breakup and she says she doing a good job. “I think I’m back on my feet. I’ve been back on my feet for some time now. It’s just a manner of maybe opening up to newer possibilities, new

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relationships, more friends, more emotional investments, and making sure that whatever took place in the past did not affect the way I invest in people in terms of trust,” Nikki says. Nikki would like to take some time off, stay abroad like New York, and study. She wants to add more to her craft as an actress and be more independent as she does that. She’s found her passion in acting and sees herself doing it even when she becomes older or eventually gets married and has kids. “I think I have a good chance of staying (in show business), because I’m a character actress and people always need character actresses,” she says. “If God wants me to stay here for much longer, I’ll stay. But if not, then I trust His direction.” Nikki takes her craft seriously. She takes every role handed to her. Nikki is not the kind of actress that chooses her parts like a prima donna. “I just want to share my craft. For me, it’s art. Like when you’re painting, you don’t just paint one thing. You paint a lot of things. Or when you’re singing, you don’t just sing one song. You sing different things. That’s how I see it. I want to be able to live different lives through the characters that I’m portraying,” she says. Her work ethic as an actress is extremely professional yet at this point, she still wants the work ethics of veteran actors to rub off on her. It shows in the way she handled the day’s photo

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shoot with no sleep at all. She admires the likes of Cherie Gil, Eula Valdez, and Joel Torre. “I would like (their work ethics) to rub off on me, because they’re so much more professional. They studied. There was no such thing as a small role for them. I love it when I’m surrounded by veterans because I feel like I’m absorbing their energy. I’m learning so much from them,” she says. But she shows in her role as Misty in Maria Mercedes, that what she lacks in experience, she makes up for in research. “I did my homework. I researched, definitely. I watch movies. When certain characters affect me, I’ll watch it again and try to study the nuances. I read a lot of acting books. What I lack in experience, I make up for in research,” she says. In another life, Nikki would have been a lawyer, an advertising executive, or a pastry chef. In fact, she graduated with a degree in English Literature from Ateneo de Manila for her pre-law course. “Once upon a time, I wanted to take up law. That’s not happening anymore. We’ll see though. Initially, that’s what I wanted to do to the course,” she says. More than anything else, she chose English Literature because of her love for books. “I like reading. I like to read. It was something I could take along with me to work. I can just bring a book or my laptop,” she says,

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adding that she reads on the set, between takes, and even in the comfort room. Nikki is such a voracious reader that in the past four months, she’s read 10 books. Her favorite books among the 10 that she read are Wonder, Art of Racing in Rain, Crazy Rich Asians, and Essays in Love. Her favorite authors are Haruki Murakami, John Greene, Alain de Botton, Jane Austen, and David Levithan. She uses her love for books to improve her craft. “They say when you read a book, you get to live so many different lives and in that sense, I’ve become more. I know how to empathize. I read about different people’s experiences, different characters, and different ways of dealing with things. It came in handy,” she says. In another life, Nikki could have become something else other than an actress. “I want to say I always saw myself like this, but I can’t imagine myself being anything else apart from this. I probably could if I tried, but I wouldn’t be in love with it as I am doing what I am doing,” she says. It must be a coincidence that Nikki’s blog’s name is Gil the World, because the first thing she would change if she did get the opportunity to change the world is to heal it by getting rid of social media. She wants the people to write

letters to each other and talk to each other face-to-face. She wants everyone to be diplomatic about certain things without resorting to being rude about an issue. “I would do that because it makes people mean. It makes people very self-conscious and self-absorbed. It just sucks the fun out of life because you’re always watching. You’re always fearing about what it might look like on Instagram,” she says. Nikki wants to change the world and enjoy it at the same time. “I enjoy it definitely because we only have one life. I’ll make sure in the process of enjoying it, I’m affecting lives around me and I’m doing my part in making it a better place. It doesn’t have to be a big scale thing. It could be in the life of one person and I would already have that much effect,” she says, which reminded us of her first appearance on television. She walks in confidence along the busy streets of Manila. Her hair moves with her every step. She sings a hopeful song amidst the mess of a city. “Sana saan man patungo sa buhay, may pag-ibig, may pag-asa, may saya at saysay…” In a way, the commercial defines her: Natural. Unconventional. Smart. Beautiful. A literary Bohemian in every way. Nikki Gil will always be the girl singing a very hopeful song in our minds. La Vie Bohème, Nikki Gil. The world is a better place because someone like you is in it.D

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Cardigan by Bayo | Dress by Max Santos

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righteousrecipes

(Sugar-Free) Sweets for Your Sweets for Your Sweet Sweet By Chef Junjun de Guzman Photos by Jose Martin Punzalan

ou wonâ&#x20AC;&#x2122;t pass up these Valentineâ&#x20AC;&#x2122;s Day sweets. These desserts are for diabetes patients and health advocates looking for sugar-free versions of their favorite sweets. Make these even sweeter by giving them to people you love on the day of love.

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righteousrecipes

No Added Sugar Apple Bake

Nutrition facts per serving: 192 calories 9g fat 27g carbohydrates 3g protein

Serves 5-6 persons Preparation Time: 20 minutes Baking Time: 20 minutes Ingredients: Base 5 pcs 2 tbsps ¼ cup 1 tbsp ½ tsp

Apple, peeled, cored, and sliced Fresh orange juice Sweetener All purpose flour Cinnamon

Topping ½ cup cup ½ cup 1 tsp. ¼ cup

All purpose flour Rolled oats, pulverized Sweetener Cinnamon Butter

Procedure: 1. Base: Toss apple with orange juice. Add in other ingredients and mix well. Put into ramekins and set aside. 2. Topping: Mix flour, oats, sweetener, and cinnamon together and cut in butter. Put on top of apple base. Bake for 20 minutes to 30 minutes at around 350˚F.

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righteousrecipes

Nutrition facts per serving: 190 calories 9g fat 27g carbohydrates 3g protein

Banana Walnut Bread

Serves 8-10 persons Preparation Time: 15 minutes Baking Time: 60 minutes Ingredients: 1 cups All purpose flour 1tsp Baking powder ½ tsp Baking soda pinch Salt ½ cup Sugar substitute or sweetener 2 cups Ripe bananas, mashed (5 pcs) 3 tbsps Heavy cream 2 tbsps Sour cream 2 tsps Vanilla extract 3 tbsps Canola oil ¼ cup Chopped walnuts, toasted Procedure: 1. Preheat oven to 350˚F. Grease and line a 3” small pan. Set aside. 2. Sift flour, baking powder, salt, and baking soda in a bowl. Add in sugar substitute. Set aside. 3. In another container, combine bananas, heavy cream, sour cream, oil, and vanilla. Add this mixture to the flour mixture. Stir just until combined. Add in walnuts and pour into prepared pan. 4. Bake for 45 to 55 minutes or until toothpick inserted in the center comes out clean. Let cool in the pan for 10 minutes then invert and remove, continue cooling completely. Slice into serving pieces and serve. FEBRUARY-MARCH 2014

righteousrecipes

Nutrition facts per serving: 172 calories 14g fat 13g carbohydrates 3g protein

Serves 6-8 persons Preparation Time: 30 minutes No Baking Ingredients: Crust 1 ¼ cups Sugar-free cookies* 2 tbsps Sweetener 3 tbsps Butter Filling 1 cup Cream cheese, cubed at room temperature ¼cup Sweetener 2 tbsps Low-sugar strawberry jam, melted 2 tbsps Water 1 packet Unflavored gelatin ½ cup Sour cream 1 can Canned strawberry pieces, drained and blended

Strawberry Cheesecake

Procedure: 1. Crust: Mix graham crumbs and sweetener together. Add in butter. Press into a 9” removable bottom pan. Bake for 10 minutes in a 350°F oven. Cool. 2. Filling: Bloom gelatin in water for five minutes. Heat over water to melt. Beat cream cheese and sweetener together. Add in jam, strawberries, and sour cream. Pour gelatin while continually mixing. Pour into the graham crumbs crust. Chill for three hours or overnight. *Murray Sugar Free Shortbread Cookies or any brand of sugar free cookies

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goodfoodguide

FEBRUARY-MARCH 2014

goodfoodguide

Diets for Kidney Conditions

blogspot.com

By Edreilyn C. Manalo, RND

hen a person has kidney disease, diet is an important part of the treatment plan. The diet may change over time if the kidney disease gets worse. The doctors refer the patients to a Registered Dietitian who will help them plan their meals to know the right foods in the right amounts. Dietary needs change with the different stages of kidney failure. Other than reducing salt and fat intake, there is no standard kidney disease diet. The one most often given to

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patients with kidney disease is a protein restricted diet ( 0.6-0.8 g/ kg BW) where total calories, sodium, potassium, phosphorus, and fluids are restricted in the diet. On the other hand, a patient who is undergoing dialysis needs a diet which is high in energy and protein (1.1- 1.5 g/kg BW) restricted phosphorus, sodium, and potassium. Amount of calcium and phosphorus are monitored by this time. Diet restrictions are not indicated in the first stage of Chronic Kidney Disease, unless hypertension is present. Sodium

and energy (for weight loss) would be limited here. In the second stage, restrictions in the electrolytes may be not necessary. Strict dietary modifications are necessary on the third stage while many nutrients are monitored during the last stage of CKD. If the kidneys are not working properly, the waste builds up in the bloodstream and the patient may feel weak, tired and sick. Some people with kidney disease may retain fluid because kidneys regulate bodyâ&#x20AC;&#x2122;s fluid balance so if it cannot perform its function, it leads to puffiness, swollen

goodfoodguide ankles, hands and feet, and gasping. Getting the right amount of calories in any diet is important to the well-being, because it provides the body with energy, helps it stay within healthy weight, and uses protein for building muscles and tissues. Below are the nutrients which are vital in the management of renal disease:

Protein

Body uses protein for building muscles, repairing tissue, and fighting infections. People who are not on dialysis need to follow a diet with controlled amounts of protein. This can help regulate the amount of waste in the blood. Protein comes from animals and plant- based products. On the other hand, patients who are undergoing dialysis may consume increased amount of protein in their diet because the treatment was a catabolic event and there is protein losses into dialysate.

Sodium and Fluid

Sodium is a mineral found naturally in food. It is often related to kidney disease and high blood pressure. Therefore, the amount of sodium will have to be limited in the diet. It is found in large amounts in table salt and in food that have added table salt such as: • seasonings like soy sauce, teriyaki sauce, and garlic or onion salt

• most canned foods • processed meats like ham, bacon, sausage, and cold cuts • salted snack foods like chips and crackers Too much sodium can trigger thirst which causes the body to hold more water that can lead to swelling, fluid weight gain, rise in blood pressure, and more work for the heart.

Phosphorus and Calcium

Phosphorus is a mineral found in all foods. Large amounts of phosphorus are found in: • dairy products such as milk, cheese, yogurt, ice cream, and pudding, nuts and peanut butter Eating food high in phosphorus will raise the amount of phosphorus in your blood. When phosphorus builds up in your blood, calcium is pulled from the bones. Over time, your bones will become weak and break easily. A high level of phosphorus in your blood may also cause calcium phosphorus crystals to build up in your joints, muscles, skin, blood vessels, and heart. Calcium is a mineral that is important for building strong bones. However, good sources of calcium are also high in phosphorus. The best ways to prevent loss of calcium from your bones are to follow a diet that limits high-phosphorus foods.

Potassium

Potassium helps your muscles and heart work properly. Too much or too little potassium in the blood can be dangerous. With hemodialysis, you will probably need to limit your intake of high-potassium foods. Large amounts of potassium are found in: • certain fruits and vegetables (like bananas, melons, oranges, potatoes, tomatoes, and some juices) • milk and yogurt • protein-rich foods such as meat, poultry, pork, and fish

Vitamins and Minerals

Patients with kidney problem are often deficient in water- soluble vitamins (e.g., Vitamin C, B Vitamins) because of: 1) poor intake of nutrient-dense foods and dietary restrictions; and 2) losses during dialysis. The doctor will recommend supplements for those who are deficient depending on patient’s condition. D

Edreilyn C. Manalo, RND Edreilyn C. Manalo is a nutrition-dietetics practitioner for clinical and hospital nutrition and weight management. She finished Bachelor of Science in Nutrition and Dietetics at Centro Escolar University; studied Bachelor of Science in Chemistry at Adamson University, and obtained a certificate of internship at the St. Luke’s Medical CenterQuezon City (SLMC). Edreilyn is a board passer in Nutrition and Dietetics, year 2013. She is currently a member of the Nutritionist-Dietitian Association of the Philippines (NDAP) and Philippine Association of Nutrition-Delta Chapter of CEU.

FEBRUARY-MARCH 2014

productspotlight

FEBRUARY-MARCH 2014

productspotlight

Healthy Cereals Your guide to choosing the right breakfast cereal By Mylene C. Orillo

typical Filipino breakfast consists of fried rice, tuyô, egg, ham, hot dogs, and/or spam. Rice has always been a Filipino staple. We can’t live without rice. We start and end our day with eating rice. But due to the changing times, the demand for convenience plays an important role in changing consumer habits, thus having less time to prepare breakfast in the morning. Grain-based cereal is the first choice for modern, healthier, and ready-to-eat meals. It has increasingly replaced the American breakfast, consisting of fatty meat that can lead to all sorts of gastrointestinal disorders.

But how do you really choose a healthy breakfast cereal amongst other brands? Each of them promising this and that only to find out that they were made with refined grains with nearly no fiber and have so much sugar.

What to look for

Elaine Magee, MPH, RD of WebMD Weight Loss Clinic says that the trick in finding a healthy breakfast cereal is to look for its full, healthy attributes – low in sugar with no saturated fat and trans fat – but still tastes great! “It doesn’t matter how good for you a cereal is; if it FEBRUARY-MARCH 2014

productspotlight doesn’t taste good, you’re probably not going to eat it day after day,” Magee said. Sandra Affenito, PhD, RD, CDN, an associate professor in the Department of Nutrition at Saint Joseph College said, “It may be helpful for the consumer to review the ingredient listing of a Nutrition Facts label to identify added sugars rather than reading the amount of total sugar grams listed on the label.” Magee’s criteria for best-tasting, healthy breakfast cereals are first, it needs to have a whole grain as the first ingredient and five grams of fiber per serving. Sugar needs to be around 25 percent calories or less, unless dried fruit is among the top three ingredients. She also chooses cereals that are easily found in the supermarket.

Here are Magee’s top eight healthy cereals: Brand Name Post Grape-Nuts Trail Mix Crunch* Nutrition Facts 5 grams fiber and 22 percent calories from sugar

Brand Name Fiber One Bran Cereal*

First three ingredients

Nutrition Facts 14 grams fiber, 0 percent calories from sugar

Brand Name Fiber One Honey Clusters*

First three ingredients Whole-grain wheat bran, corn bran and cornstarch. You can add cinnamon, fresh or dried fruit and/ or roasted nuts to enhance flavor

Nutrition Facts 13 grams fiber, 15 percent calories from sugar

Whole grain wheat, malted barley and sugar, followed by raisins and wheat bran

FEBRUARY-MARCH 2014

First three ingredients Whole-grain wheat, corn bran and wheat bran

Brand Name Quaker Oatmeal Squares Nutrition Facts 5 grams fiber, 19 percent calories from sugar First three ingredients Whole oat flour, whole-wheat flour and brown sugar

productspotlight Brand Name Kashi Heart to Heart Honey Toasted Oat Cereal

Brand Name Raisin Bran* Nutrition Facts 7 grams fiber, 40 percent calories from sugar (in Kellogg’s brand)

Brand Name Frosted Mini Wheats* Brand Name Shredded Wheat* Nutrition Facts 6 grams fiber, 0 percent calories from sugar (for a generic brand) First three ingredients 100 percent whole grain cereal; you can add fresh or dried fruit and nuts. Or if you want frosted variety, it has 6 grams fiber and gets 23 percent of its calories from sugar

Nutrition Facts 6 grams fiber, 24 percent calories from sugar First three ingredients Whole-grain wheat, sugar and high-fructose corn syrup

First three ingredients Whole wheat, raisins and wheat bran. Sugar is listed fourth in the ingredient list, but many of the calories from sugar come from the raisins

Nutrition Facts 5 grams fiber, 18 percent calories from sugar First three ingredients Whole oat flour, oat bran and evaporated cane juice. This is a higher-fiber alternative to Cheerios.

* Cereals are available in Unimart, Rustans Supermarket, SnR, and Landmark * This cereal has been pulled out of the market

Benefits

Studies show that people who eat cereals have less bad low-density lipoprotein cholesterol (LDL) and lower levels of total blood cholesterol. It also promotes increased intake of calcium if eaten with low-fat fortified milk at breakfast. Eating cereals regularly may also protect against cardiovascular diseases. Girls who eat cereals are also less likely to become overweight and tend to have healthier body weights if eaten frequently. But as they say, eating healthy is about eating smart. It’s not about depriving ourselves of the food we love or are used to eating. It’s about eating a balanced meal, feeling great, having more energy, and keeping ourselves healthy. With reports from WebMD D

FEBRUARY-MARCH 2014

productspotlight

Healthy Cereals Hunt By Alexa Villano

M rockviewchurch.com

any variations of the breakfast cereal floods the market – from regular, whole wheat, low-fat, gluten-free, to sugar free. DiabetEASE scoured the grocery aisle so you won’t have to go on a tireless hunt. Don’t forget though that not all cereals found in the aisles in the supermarket are sugar-free. Always read the labels and nutritional facts.

FEBRUARY-MARCH 2014

productspotlight Kellogg’s Special K Original (PhP 130.00)

- Who has not heard of Kellogg’s? One of America’s foremost brands, the company came out with the Kellogg’s Special K, which is low in fat. Its Asian variation contains information on eating the cereal for two meals (breakfast and dinner) along with fruit and coffee. The Special K brand comes in different variations such as almond vanilla, and oats and honey, but nothing beats the Special K Original, which has a sugar content of 8.3 g. Its other variations contain 8.4 to 10.6 grams of sugar.

Nestlé Low Fat Fitnesse Original (PhP 101.00) - Nestle has been in the forefront of

promoting a healthy lifestyle following the launch of their Nestlé Wellness Campaign. One of their brands, Fitnesse has gained a huge following with their 14-Week Challenge, where two meals of the day consists of Fitnesse cereal. Other flavors include plain whole grain, chocolate, fruits, honey and almond, and strawberries and crispy red fruits.

Kellogg’s Mueslix Raisin and Almond Crunch (PhP 189.00) - For strict vegetarians, Kelloggs’ Mueslix is for you as it contains raisins, almonds, whole wheat oats, and barley.

FEBRUARY-MARCH 2014

productspotlight Great Grains Cranberry Almond Crunch (PhP 399.00) - Cranberry almond crunch is one

of the many flavors available for those who want to have their carbo and fruit together in one bowl. The cereal is not sugar-free, but its ingredients are whole wheat, wheat flour, whole rolled oats, and vegetable oil. Unlike its competitors, Great Grains boasts of going through less food processing.

Post Foods Bran Flakes (PhP 345.00)

- Great Grains’ sister cereal Bran Flakes on the other hand has a lower sugar dose of five grams. It has whole wheat grain and bran. It is an excellent source of fiber good for the digestive system.

Nature’s Path Multigrain Oatbran Cereal 13.05 oz (PhP 224.00) - Nature’s

Path is a rare cereal made from organic ingredients. Their Multigrain Oatbran contains whole oat flour and brown rice flour. Although it has no artificial sugar, the cereal contains evaporated cane juice as a substitute.

Cereals are available in Unimart, Rustans Supermarket, SnR, health stores, and online shops. D

FEBRUARY-MARCH 2014

livingwell

Lessons in Surviving Diabetes By Excel V. Dyquiangco and the Medical City Patient for Partnership

prepforshtf.com

etty Bernardo fears for her life. She, at 67, fears the complications that other diabetes patients suffer and die from, giving her reason to really fight to survive. “I was thinking of the complications of diabetes. This scares me and makes me stay away from all of the temptations in life,” says Letty. She got the news of her life when she was 30. She just gave birth and noticed that she was thirsty more often and she urinated more than usual. She had lost weight from 170 pounds to 140 pounds in a span of two months. At first, she thought this could be cured by taking medicines and other

When once Letty Bernardo feared for her life because of diabetes, she now finds solace in the lesson that taught her to keep on persevering to survive supplements. She thought wrong. After much prodding from her loved ones, she finally consulted a doctor and got news that definitely shook her life. “When I learned of the news, I was scared since my father had [diabetes],” she says. “I asked myself why I had to suffer from this of all people.”

Resisting Temptations

In the 38 years that Letty lived with the disease, she resisted temptation. Her weakness was sweets. It wasn’t easy to adjust. “I admit I was a pasaway patient and I was stubborn,” she says. “I ate any

type of food – and I love sweets. I thought the medicines would just do the trick so I just kept on eating, unaware of its repercussions.” Everything changed when she joined the Diabetes Support Group of the Medical City three years ago. With the Support Group, she met and got acquainted with a lot of people who also have diabetes, who encouraged her and gave her feedback with the right kind of food to eat. Joining the group also made her realize that she shouldn’t solely depend on her medicines. “What I need is constant monitoring, diet and exercise,” she says. “With the group, I feel young. I meet people. FEBRUARY-MARCH 2014

livingwell I get inspired, encouraged and challenged when I hear that they are managing their diabetes properly.” It also helps that her family is supportive of her condition. “I have a nephew in the United States who keeps on telling me that if I feel this way or that, it may be linked to heart disease. So he always says that I need to be careful with what I eat and with my lifestyle,” she says.

Major Life Changes

Her carbohydrate intake, specifically rice, and the ingestion of fruits (as these are considered sweets in themselves) was lessened. “In place of rice, I eat crackers. But oftentimes, during 11 p.m. at night, I get hungry so I eat crackers again,” she says. She does Zumba now and makes sure she gets a full eight-hour sleep. “Having diabetes is indeed a difficult process,” she says. “There may be a lot of sacrifices involved but the rewards and the benefits outweigh the other. This should be based solely on the information that you get from the experts so before taking any kind of medicine, you need to consult with your doctor first.”

Hard Lessons Learned

She is now the Vice President of the group that supported her in her fight against the disease. She joins

the TMC Diabetes Support Group at least once a month to attend lectures and talks about the illness. As Vice President, she encourages other people with diabetes that it’s not enough to just take medicines. “I tell them that they need to constantly monitor their condition,” she says. “I tell them to exercise and to take care of their diet.” She also learned to persevere to improve her condition and to stay determined in her fight against the illness. She teaches the same thing to her grandchildren who are also aware of the disease. “Everything should all be total hard work and patience. Don’t give up and keep on asking for help from experts and professionals” she says. For those who share the same burden, this is the hard lesson that she offers: “Diet, eat less carbohydrates, do some exercises, and monitor your sugar levels” she says. “You also need to consult your doctor. When I was first diagnosed with this disease, I thought it was already the end of the world but that shouldn’t be the case. If many people – even the older ones – have done a successful job in keeping their sugar levels stable, then there is no reason for you not to do it also and to survive.” D

FEBRUARY-MARCH 2014

Everything should all be total hard work and patience. Don’t give up and keep on asking for help from experts and professionals

dosanddon’ts

Diabetes in Pregnancy By Kristine Denise S. Corvera, MD

iabetes, whether acquired prior to or only during pregnancy, affects both the mother and her unborn baby. For instance, it places the mother at higher risk of developing high blood pressure. Babies of mothers with poorly controlled diabetes tend to be macrosomic or large and fat. Macrosomia puts babies at risk for shoulder injuries during delivery, and low blood glucose levels immediately after they are born. Managing diabetes in pregnancy entails the concerted effort of a team of health practitioners-endocrinologist, obstetrician, pediatrician/neonatologist (new born specialist), dietitian/nutritionist, and health educator. The diabetic mother must also participate in her care by following some simple guidelines:

DO’S Eat a healthy, balanced diet. This point cannot be over emphasized as an expectant mother eats for two – herself and her baby. For diabetic mothers, a special meal plan is designed to lower the proportion of carbohydrates. Simple sugars or sweets and foods with high glycemic index that cause a rapid rise in blood sugar levels are best avoided.

to record all the results of sugar monitoring and to present these to your doctor during follow-up so that she may make appropriate changes in the diet or medication dose. Make a food diary. Listing the types and amount of foods eaten alongside blood sugar results gives both the mother and her doctor a feedback of which foods raise sugar levels disproportionately, and which foods don’t.

IIlustration by Calvin Saquibal

Divide feedings into small, frequent meals. Diabetic mothers are advised to eat three meals and three snacks a day regularly. This ensures that the growing fetus receives a constant supply of nutrients, and the mother’s blood sugar levels do not fluctuate significantly throughout the day.

Exercise. Engage in moderate physical activity such as walking, low-impact aerobics or swimming. Consult your doctor about the most suitable form of exercise for you.

Monitor blood sugar levels frequently and record results. Experts recommend that diabetic mothers check their sugar levels up to seven times a day. Your doctor may tailor this according to individual needs. It is very important

Eat poorly. Crash-dieting, skipping meals, or starving oneself in an effort to lose weight or to lower high sugar levels can have dangerous effects on both the mother and her baby. Both may suffer from hypoglycemia or dangerously low

sugar levels in the body, while the baby may become growth-retarded or small-for-age. Limiting food intake too much or skipping meals can lead to a state in the mother’s body that is similar to starvation. Some studies suggest that this may adversely affect the baby’s mental development. Work instead with your doctor and dietitian to curb weight gain during pregnancy by devising a special meal and exercise plan for you. Start a new strenuous exercise program. If you have not been exercising regularly prior to the pregnancy, now is not the best time to start on high-impact exercises. Engage instead in low-impact aerobic exercises. Alter medication dosage without doctor’s knowledge. Some mothers may need insulin injections to control blood sugar levels. It is unwise to skip or alter the insulin dose without your doctor’s approval as doing so may lead to dangerously low or high blood sugar. D FEBRUARY-MARCH 2014

dosanddonâ&#x20AC;&#x2122;ts

Diyabetes sa Pagbubuntis

Mga Dapat at Hindi Dapat Gawin Isinulat ni Kristine Denise S. Corvera, MD Isinalin sa Tagalog ni Ma. Teresa C. Dumana

dugo matapos maipanganak. Ang pangangalaga at pagkontrol ng diyabetes sa pagbubuntis ay kinakailangan pagtulungan ng isang grupo ng mga propesyonalâ&#x20AC;&#x201C;endocrinologists, obstetrician, pediatrician/ neonatologist (newborn specialist), dietitian/nutritionist at health educator. Kinakailangan ding pangalagaan ng buntis na may diyabetes ang kanyang sarili at sundin ang ilang simpleng hakbang:

upang maiayon sa inyong kalagayan ang iyong diyeta at dosage ng mga gamot. Kumain ng wasto at balanseng pagkain. Dahil kumakain para sa dalawa ang nagdadalang-tao â&#x20AC;&#x201C; para sa sarili at sa kanyang sanggol, napakahalaga na itoâ&#x20AC;&#x2122;y masunod. Kinakailangan ang pagplano ng pagkain na makapagpapababa ng konsumo ng carbohydrates. Dapat din iwasan ang pagkain ng mga matatamis at mga pagkaing mataas ang glycemic index na maaaring makapagpataas ng asukal sa dugo. Kumain nang madalas pero pauntiunti. Pinapayuhan ang mga inang may diyabetes na kumain ng anim na beses - almusal, tanghalian, hapunan, at tatlong merienda araw-araw. Tinitiyak nito ang sapat na sustansiya ng sanggol sa sinapupunan, at pag-iwas sa biglaang pagtaas at pagbaba ng sukat ng asukal sa dugo. Suriin madalas ang sukat ng asukal sa dugo at ilista ito. Payo ng mga eksperto sa mga inang may diyabetes na alamin ang sukat ng asukal sa dugo hanggang pitong beses sa isang araw. Maaring itakda ng doktor kung ilang beses ito gagawin base sa indibidwal na pangangailangan. Mahalaga na maitala ang bawat resulta at ipakita sa doktor tuwing konsultasyon

FEBRUARY-MARCH 2014

Gumawa ng talaan ng kinakain. Ang paglista ng klase at dami ng kinain kasabay ng pagtala ng sukat ng asukal sa dugo ay makatutulong sa ina at sa doktor upang malaman kung aling mga pagkain ang nakakapagdudulot ng pagtaas ng asukal sa dugo at kung alin ang hindi. Mag-ehersisyo. Ang nagbubuntis ay pinapayuhan din magsagawa ng mga di gaanong nakakapagod na ehersisyo (moderate physical activities) tulad ng paglalakad, low-impact na aerobics, o paglangoy. Kumonsulta muna sa inyong doktor para malaman kung ano ang pinakamainam na ehersisyo para sa iyo.

Magpakagutom. Ang biglaang pagdiyeta, pagliban sa pagkain, o paggutom sa sarili upang mabawasan ng timbang o mapababa ang sukat ng asukal sa dugo ay maaaring magdulot ng masamang epekto sa ina at sa sanggol. Maaari silang makaranas ng hypoglycemia o pagbagsak ng asukal sa katawan, habang ang sanggol naman ay maaaring

maging maliit para sa kanyang edad. Ang sobrang pagbabawas o pagliban sa pagkain ay maglalagay sa katawan ng ina sa isang sitwasyon na maihahalintulad sa pagkagutom. May ilang pag-aaral na nagsasabi na maaari itong makaapekto sa pag-unlad ng kaisipan ng sanggol. Mas makabubuti kung makipagtulungan sa doktor o dietitian upang maiwasan ang sobrang pagtaas ng timbang sa pamamagitan ng paggawa ng espesyal na plano ng pagkain at sapat na pagehersisyo. Magsimula ng nakakapagod na ehersisyo. Kung hindi ka nag-eehersisyo bago ka magbuntis, hindi ito ang tamang panahon upang magsimula ng labis na nakakapagod na ehersisyo, o high impact exercises. Mas makakabuti ang hindi gaanong mabigat o nakakapagod (lowimpact aerobic exercise) na ehersisyo. Ibahin ang dosage ng gamot nang walang pahintulot ng doktor. May ibang mga ina na nangangailangang magturok ng insulin upang makontrol ang antas ng asukal sa dugo. Hindi tama na ipagpaliban o ibahin ang insulin dose kung walang pahintulot ng doktor dahil puwede itong magdulot ng masyadong mababa o mataas na asukal sa dugo. D

IIlustration by Calvin Saquibal

ng diyabetes, maranasan man ito bago mabuntis o habang buntis ay nakaaapekto di lamang sa ina kundi pati na rin sa sanggol sa kanyang sinapupunan. Halimbawa, maaaring tumaas ang presyon ng dugo ng buntis na may diyabetes. Ang mga sanggol ng mga inang hindi kontrolado ang kanilang diyabetes ay karaniwang nagiging macrosomic o masyadong malaki at mataba. Maaaring malagay sa panganib ang mga sanggol na macrosomic tulad ng pagkakaroon ng pinsala sa balikat habang isinisilang, at pagbagsak ng asukal sa

affairstoremember

Foot problems take center stage at 19th NADE

t was all about foot problems as diabetes educators and medical experts gathered together last November 20, 2013 at the Edsa Shangri-La Hotel for the 19th National Assembly of Diabetes Educators organized by the Diabetes Center Philippines (aka Philippine Center for Diabetes Education Foundation). With the theme “Put Your Best Diabetic Foot Forward: Practices that Save Limbs and Change Lives,” those present discussed the latest studies and practices on taking care of the feet, one of the most vulnerable parts of the body affected in people with diabetes. Topics included management of diabetic foot infections by Dr. Raquel Ecarma; surgical and nonsurgical treatment of lower limb ischemia by Dr. Martin Villa, the role of new technologies including stem cell therapy in diabetic foot care by Dr. Luinio Tongson and overview of the IDF diabetic foot guidelines by NADE Chair Dr. Joy Fontanilla. Canadian guest speaker Helen Cochrane, CPO

(c), MSc, Project Director of the Philippine School of Prosthetics and Orthotics, and Deputy Director of the Sri Lanka School of Prosthetics and Orthotics discussed ways to choose the right diabetic footwear. Optimal nutrition for wound healing was also covered by Dr. Jesus Fernando Inciong during the Abbott lunch symposium. The convention also paved way for the induction of new Associate Diabetes Educators led by Drs. Tommy TyWilling and Cynthia Halili-Manabatand workshops in the afternoon facilitated by Drs. Teresa Plata-Que and Pepito dela Peña. Alexa Villano D

Front From L to R: Drs. Tommy Ty Willing, Teresa Plata-Que, Joy Fontanilla and Cynthia Halili-Manabat Rear From L to R: Ms. Linda Inocencio, Drs. Myla Capellan and Joey Miranda

FEBRUARY-MARCH 2014

affairstoremember

DP holds 30th annual convention to stop diabetes

embers of Diabetes Philippines (DP) and others interested in diabetes gathered for the 30th annual convention last November 21-22, 2013 at the Edsa Shangri-La Hotel. This year’s theme, “Forging an Alliance to Stop Diabetes”, brought together DP president, Dr. Richard Elwyn Fernando and other experts in the field discussing the latest studies on diabetes and its effects on the body. The “Dr. Augusto D. Litonjua Endowed Lectureship” awarded to Prof. Pavel Hamet, MD of the Universite de Montreal, tackled Fighting Renal Impairment in Diabetes: Tools of Today and Tomorrow. Meanwhile, the “Dr. Ricardo E. Fernando Endowed Lectureship” was presented by Dr. Agnes D. Mejia, who discussed the “CVD-CKD: Stop the Vicious Cycle”. “Metabolic syndrome is associated with a high prevalence of CKD [chronic kidney disease] that increases with more components of the syndrome. Even morbid

L to R: Drs. Tommy Ty - Willing, Pavel Hamet, and Augusto D. Litonjua

obesity, known to result in obesity-related glomerulopathy, results in reduction in renal plasma flow and glomerular filtration rate (GFR) both of which improve with weight reduction,” she said to the audience. She said to stop the vicious cycle, one must look into three factors-metabolic syndrome, family history, and national health programs. Alexa Villano D

IIlustration byDonna I. Pahignalo

doodles&dreams

FEBRUARY-MARCH 2014