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McXtra Care Newsletter | November 2019

Section A

MAIN FEATURE

Understanding Diabetes: Types and Diagnosis

Diabetes as we all know is a condition of impaired glucose metabolism and presence of increased blood glucose (hyperglycemia). The utilization of glucose is regulated by a hormone called Insulin produced by the pancreas.

Type 1 Diabetes occurs due to lack of insulin production by the pancreatic cells. It has a genetic predisposition, sets in rapidly and at an early age (commonly in childhood itself), and is usually not related to lifestyle factors and weight. The cause is linked to destruction of the insulin producing cells of the pancreas by the body’s immune system due to an inherent recognition error (called Autoimmune response). The treatment requires taking Insulin (so also called Insulin Dependent Diabetes Mellitus: IDDM).

Type 2 Diabetes (the more common type constituting >90% of Diabetes cases globally), is a metabolic disease seen in adults. The cause here is linked to the impaired response of the body to insulin (insulin resistance or decreased insulin sensitivity) which leads to ineffective utilization of glucose by the body cells. Lifestyle and risk factors have a contributory role. Type 2 Diabetes can be treated by medicines to reduce blood glucose, and increase glucose utilization, insulin production and insulin sensitivity. (So it is called Non-Insulin Dependent Diabetes Mellitus: NIDDM).

DIAGNOSIS

Diabetic symptoms include increased urination, thirst and hunger, sometimes with weight loss, fatigue, moodiness, vision changes and increased healing time of infections/wounds. While Type 1 Diabetes presents with more pronounced and definite symptoms, Type 2 Diabetes usually gets picked up on routine screening of blood glucose (also called blood sugar) or during health check-up, as often no definitive symptoms may be present. Diagnostic criteria are as below.

Prediabetes (also called Impaired Glucose Tolerance) is a state when blood sugar is raised but not enough to qualify as diabetes, but increasing the risk of developing diabetes. An oral glucose tolerance test-OGGT (fasting sugar followed by 75gms glucose intake and a post 2-hour blood glucose test) may be done to confirm diabetes in cases where fasting blood sugar is persistently in pre-diabetic range. OGGT is also done to confirm or diagnose Gestational diabetes.

The term Post Prandial glucose, refers to blood glucose 2 hours after a regular meal. Though this has importance in monitoring and assessing response to treatment in diabetics, it has low evidence of strong correlation with diagnosis of Diabetes and is not used for the same. Blood sugar fasting, OGGT and Post meal (Post Prandial: PP) show current blood glucose status, and HbA1C gives the blood sugar over past 2-3 months.

Section B

TRENDING FEATURE

Risk Factors and Health Impact of Diabetes

The above are some of the risk factors which increase the chances of developing Type 2 diabetes. Increase in blood glucose over a period of time can cause damage to blood vessels and the nerves, resulting in complications most prominently Cardiovascular disease (CVD), Nephropathy, Neuropathy and effects on the Eye. Therefore, patients should undergo regular Eye examination (including retina), blood pressure measurement, kidney function tests, lipid profile, and health assessment follow up checks along with blood sugar and HbA1C tests.

A dangerous complication called Diabetic Ketoacidosis, a medical emergency can occur due to excessive breakdown of fat by the body cells (in the absence of utilizing glucose) and release of acidic substances called ketones in the blood. This is seen more in Type 1 and is rare in type 2 diabetes as there is still some functioning insulin and glucose utilization. Patient presents with nausea, vomiting, abdominal pain, confusion, thirst-hunger, dry mouth, rapid breathing, urination, and a fruity breath odor along with high sugar and ketones in blood.

Section C

SPECIAL FEATURE

Health Solutions for reducing risk and managing Diabetes

While type 1 Diabetes is treated with Insulin, Type 2 Diabetes is managed by a combination of Diet, Lifestyle modifications and Medicines, with Insulin usage in specific individuals and situations. The target should be to maintain fasting/pre meal sugars between 80-130mg% and post meal sugars less than 180mg%.

Diet solutions

Diabetics should eat a healthy diet rich in vegetables, fruits, legumes and whole grains, low on calories, and fat, and devoid of refined sugars. In fact, such a diet would benefit the health of the whole family in general as it helps cutting down risk of developing diabetes in predisposed people, and maintain weight, BP and a healthy heart. DASH diet is an example of a diet benefitting people with high blood pressure diabetes, obesity or high BMI and heart disease. Weight loss by 4 to 5 kg over few months can cut diabetes risk by 50%.

Diet for Diabetes: The simple 3 Point Approach

Selection of Food Items:
- This should be done considering the Glycemic Index (GI) of foods which is a ranking according to glycemic load (ability to raise blood sugar). Select Good – low GI (55 or less) foods and avoid Bad – high GI (>70) foods.
- Daily cooking oils can include oils like olive, sunflower, rice bran, or sesame. Coconut or Palm oil can also be used 2-3 times a week. 2 teaspoons per person per day is the recommended measure while cooking.

Deciding Proportion of Nutrients:
- Your meal plate should be proportional as well as optimal in all nutrients:
  - 1/2 plate with vegetables (all green vegetables, tomatoes and carrots).
  - 1/4 plate with a starchy item like whole wheat (as roti/breads), brown rice, potato, corn, or any of the pulses (beans, peas or lentils).
  - 1/4 plate with a protein item like lean meat, chicken, or egg. (vegetarian protein sources – paneer/tofu/cottage cheese, yogurt, soyabean, almonds). For vegetarians, pulses are good sources of proteins as well as starch, so plate can have 1/2 non starchy vegetables, 3/8ths pulses, 1/8^th non pulse protein source.
- Omega 3 fat sources should also be included in either lunch or dinner twice a week like fish (salmon, tuna, herring, mackerel, trout) I the 1/4 protein component. (Vegetarians can cook in canola, soyabean, flaxseed oils or take walnuts twice/week).
- Include at least one fruit daily as snack or part of the vegetable half of your meal plate.
- Include one unsweetened beverage and at least 1.5-2 liters of water in your daily diet plan.

Meal timings and frequency
- Timely meals are important.
- If gap between the meals is more than 3-4 hours, have a healthy mid-snack like a whole grain cracker, a fruit, nuts/avacados, yogurt, low fat non fried items or buttermilk. Similar snack can be had at bed time if gap between dinner and bed time is more than 3 hours.
- Meals should not be unduly delayed or skipped. Do not eat very heavily in any single meal.

Lifestyle

Daily at least half hour of physical activity a day as brisk walking, jogging, swimming, cycling, yoga or aerobics should be part of one’s lifestyle. If in a profession involving long hours of sitting, one should get up every 2 hours and take a 5-10 minute walk or do some simple hand and leg stretches. Smoking and alcohol are best omitted from lifestyle.

Medicines

They should be taken in strict accordance with dose, frequency and relation with meals as prescribed medically. Doses should not be skipped or changed on one’s own. Dietary and Lifestyle solutions have to continue with medicines also. Medicines may be prescribed singly or in appropriate combinations.

In type 2 patients Insulin maybe prescribed if blood sugar levels are very high at initial presentation, during acute stress periods like surgery/hospitalization, severe weight loss especially in elderly, inability to tolerate side effects of medicines, inadequate sugar control with medicines, and in compromised liver or kidney function.

Regular blood sugar monitoring is most important and patients may also be recommended SMBG (Self-Monitoring Blood Glucose) by home based/portable glucometers on a daily basis or certain days/week or non-invasive Continuous Glucose Monitoring.

Hypoglycemia or sudden drop in blood sugar may happen occasionally but is rare with regularity, monitoring and accuracy of taking medicines. One must have glucose powder/tablets handy if experiencing dizziness, shivering, ringing, sweating, hunger, palpitation, extreme irritability or anxiety-nervousness.