SAI RURAL DIABETES SPECIALITIES CENTRE

WDF-MDRF RURAL Diabetes prevention Project What is diabetes? Diabetes mellitus is a metabolic cum vascular disorder in which the body’s capacity to utilize glucose, fat and protein is disturbed due to insulin deficiency and /or insulin resistance. This could lead to damage of blood vessels if left uncontrolled. In people with diabetes there is insufficient insulin activity in the body. Insulin is a hormone produced by beta cells of islets of Langerhans in the pancreas. Action of insulin on the food: Most of the food we eat is broken down into glucose and other simple sugars. Glucose gets absorbed into the blood stream which enters into the cells and is used for energy. As the blood glucose rises, insulin is released from the pancreas. Cells have receptor sites on the outside. When insulin attaches to the receptor sites, a passage is made and glucose enters into the cell. Thus insulin regulates the blood glucose level. When there is an insulin deficiency, glucose cannot enter into the cells and remains in the blood which leads to high blood sugar levels. Normal plasma Glucose Levels: Fasting 70-100mg/dl Post Prandial 100-140mg/dl Insulin deficiency may be relative or absolute and may be due to

1. Insufficient production of insulin by the pancreas. 2. Sufficient production of insulin but non release into the blood stream. 3. Increased demand for insulin by the body tissues.

4. Destruction/inactivation of insulin by enzymes and other factors produced by the liver and endocrine glands such as pituitary gland, adrenal cortex, thyroid etc.,

Symptoms of Diabetes:

1. Increased thirst 2. Increased hunger 3. Excessive urination 4. Weight loss 5. Weakness and tiredness 6. Delayed wound healing 7. Numbness in hands and feet 8. Blurred vision 9. Itching in genitals.

Risk factors for diabetes:

1. Family history of diabetes 2. Over weight /obesity 3. High blood pressure or hyperlipidemia 4. Those with previous bad obstetric history

a. Recurrent abortions b. Still births c. Congenital malformations d. Big baby (over 3.5kgs at birth)

5. Mental stress 6. Physically inactive people (sedentary jobs)

Diet & Diabetes: Diet is the most important aspect in the treatment of diabetes, but there is no single diabetes diet. Your doctor or dietitian will work with you to come up with a plan suited to your needs. They may talk to you about using food exchanges or carbohydrate counting to plan your meals. The old idea that rice should not be taken is fallacy. All cereals contain the same amount of starch.e.g, rice, wheat, Jowar etc.It is the quantity that matters.

Vegetable proteins like dhal, pulses and legumes are better than animal proteins. Combination of cereals and pulses will enhance the protein quality. Mushrooms are low in calorie, but rich in protein. Fibre rich foods are very good in controlling diabetes and for reducing serum cholesterol. Rich sources of natural fibre are whole cereals, pulses like Bengal gram, black gram, green gram and green leafy vegetables. Soluble fibre from fenugreek seeds taken either as sprouted or in powder form can be used as a supportive therapy. Intake of saturated fat should be reduced to prevent increase in serum chooesterol.Use vegetable oils in moderation and a mixture of monosaturated oils like groundnut or gingelly oil and polysaturated oils like saffola or sanola is best. The intake of total calories is to be reduced by those who are overweight. Foods should be distributed into small frequent feeds. Skipping a meal or fasting is not really advisable. Vegetables that can be taken in unlimited amounts are:- Ash gourd, Beans, Bitter gourd, Bottle gourd, Brinjal, Brussels sprouts, Broccoli, Cabbage, Cucumber, Cauliflower, Cow-chow, Cluster beans, Coriander leaves, Cowpea-pod (karamani), Capsicum, Drumstick, Ginger, Greens (all varieties), Knolkhol, Kovai, Ladies finger, Mint, Onions, Papaya (raw), Plantain flower, Plantain stem, Ridge gourd, Snake gourd, Tomato (raw and ripe),Turnip, White radish. Carrot, beetroot, peas and double beans can be used in moderation. Potatoes, Yam, colocasia and tapioca are better avoided. Free Foods: Skimmed buttermilk, unsweetened lime/tomato juice, clear soup, and pepper water (rasam), vegetable salads like tomatoes, cucumber, onion, white raddish, lettuce and capsicum. A bowl of salad (100 gms) = 25 calories.

AVOID Sugar, honey, glucose, jam. jaggery, sweets, cakes, pastries, tender coconut water, sweetened soft drinks, banana, mango, jack fruit, custard apple (sitaphal) and dry fruits, especially if overweight. Apple, orange, sweetlime, papaya, guava, pear, muskmelon and watermelon etc., may be taken in consultation with Diabetologists/Dietitian when blood sugar is under control. Food items that are equivalent to 200 calories are: 3 Idlies (or) 3 Chappatis (or) 2 Dosas (or) 1-3/4 cups of Rice. KEY MESSAGES

• No Fasting or Feasting • Avoid direct sugar. • Restrict calories if obese. • Use unlimited amount of low calorie foods.

EXERCISE & DIABETES: Why exercise?

1. Reduces weight. 2. Improves blood sugar control. 3. Reduces the dose of diabetic medications. 4. Improves the quality of life.

What does exercise do for the heart?

1. Improves blood circulation. 2. Strengthens the heart. 3. Lowers blood pressure. 4. Increases HDL (good cholesterol) 5. Decreases LDL (bad cholesterol)

Tips for smart and safe exercise

1. Consult your doctor before beginning exercise programme. 2. Always carry a diabetic identity card. 3. Stay alert for signs of low blood sugar during or several hours after

exercise. 4. Have rapidly absorbable carbohydrate sources ready like sugar,

glucose and candy. 5. Monitor blood sugars before and after the exercise. 6. Take carbohydrate snacks if blood glucose levels are less than

100mg/dl. 7. Drink plenty of fluids before and after and if necessary during

exercise to avoid dehydration. How often, How much and How long?

• Try to do exercise every day, minimum of 5 days a week. • Start slowly and work up gradually every week. • Brisk walking of 5 to 6 km/hr should be done if possible. If not,

whatever best you can achieve, will suffice.

Time: Exercise should last for at least 30 minutes and go up to one hour if possible. There should be a warm up and cool down period for each session. Warm up: Prepares body for vigorous activity; helps prevent strains and injuries to muscles. It should last for 5-10 minutes. Cool down –Helps restore circulation to normal levels, prevents cramps, sore muscles and post-exercise dizziness. This should also last for 5 to 10 minutes. Choose your exercise Walking, running, cycling, swimming, playing team games, dancing, jogging, brisk walking, tennis - choose whatever suits your personality, but stick to it. Regularity is more important.

Risks and precautions:

1. Patients with eye disorders should avoid exercise that involves straining (e.g.) bending or lifting weights.

2. Proper walking shoes are essential. 3. Monitor closely for blisters. 4. Pain is a warning sign. If pain and cramps occur, seek medical advice. 5. Elderly people or those with long standing diabetes should not do

weight lifting. 6. Avoid strenuous exercise or vigorous sports during the first few

months of pregnancy. Walking and swimming are good. 7. To prevent hypoglycemia after strenuous exercise, eat some

carbohydrate containing foods. Tips for increasing exercise in daily life:

1. Choose a longer route while walking. 2. Walk to the store instead of using a vehicle. 3. Use staircase instead of (lift) the elevator. 4. Park your car farther away. 5. If you are in a sedentary job, try to stretch out for few minutes every –

hour and take a short walk within the office whenever possible.

When should you stop exercise?

1. Chest pain or discomfort. 2. Dizziness. 3. Severe headache. 4. Fever or severe infections. 5. Muscle, ligament or tendon strain. 6. Pain. 7. Cramps. Prevention of Diabetes: The prevention of Diabetes Mellitus in the Indian population now ranks first in the world even ahead of China. In the last twenty years there has been a three fold increase in the prevalence of diabetes and today it is estimated that there are over 32 million people with diabetes in India.

The problem in diabetes is that very often it is silent. The symptoms of diabetes such as increased thirst and urination, etc., occur only when the diabetes is severe. In early stages it can remain totally asymptomatic. Moreover after 10-15 years duration of diabetes, the prevalence of all diabetes related complications increase markedly. These include Retinopathy leading to blindness; Nephropathy leading to kidney failure, Heart attacks, Gangrene of the feet, Stroke and even less known complications Impotency, or sexual weakness. Thus diabetes is a serious threat to public health and this shows the urgent need for prevention of diabetes. I. PRIMARY PREVENTION:

Primary prevention refers to the prevention or the postponement of diabetes in those who are susceptible to diabetes. Early detection is the key to prevent and control diabetes. As diabetes is largely asymptomatic, regular screening for diabetes is most important.

Indications for screening:

a) Positive Family History: It is a well known fact that diabetes is caused mostly due to hereditary factors. Hence it is clear that screening of diabetic families would be the first priority. Risk of diabetes:- If both parents are diabetic 99% If one parent is diabetic 50% If any other relative is diabetic 25% Hence it is clear that any one who has positive family history should be screened for diabetes. The onset of diabetes is earlier in Indians i.e. around 20-30 years of age. If the family history is strong e.g., members of more than two generation in the family have diabetes, the first screening could be done even by 20 years of age and thereafter on a yearly or two yearly bases.

b) Obesity Obesity causes resistance to insulin. Your body makes insulin but the extra weight prevents it from using the insulin the way it should be used. For this reason, obesity is another risk factor for diabetes. c) Which test is to be done? The Glucose Tolerance Test (GTT) is the confirmatory test since it helps to diagnose even the early stage of diabetes. Most people check only Fasting, Postprandial or Random Blood Sugar which may not reveal diabetes until it is at a more advanced stage. Even if the GTT results show normal values at the time of testing, it does not mean that the person will never develop diabetes. Such individuals should have an annual GTT done if the family history of diabetes is very strong.

II. SECONDARY PREVENTION:

Secondary Prevention refers to the prevention of complications once diabetes set in. This can be achieved by good control of diabetes with the help of diet, exercise, medication and regular monitoring of blood sugars. Blood sugars can be checked even on daily basis with the help of blood sugar meters which facilitates quick determination of blood sugars. Since blood sugars tend to fluctuate a lot from day to day or hour to hour, HbA1C (Glycosylated haemoglobin) test should be done to assess the blood sugar for the previous 2-3 months.

III. TERTIARY PREVENTION:

Tertiary prevention refers to the rehabilitative measures once the complications have set in. For example, for Diabetic retinopathy, Laser Photocoagulation will help to prevent or reduce the incidence of blindness. Laser photocoagulation helps to seal leaking blood vessels in the retina and thus prevent visual loss.

It is recommended that at least once a year every diabetic individual should do a complete checkup of all complications especially the eyes, kidneys, heart and feet in order to reduce the morbidity due to diabetes.

KEY MESSAGES

• Diabetes is preventable • Eat less; Walk more. • Fatness is not fitness • Fight childhood obesity • Prevent diabetic complications

IV. DIABETIC RETINOPATHY Prolonged high blood sugar in a diabetic patient produces changes in the blood vessels all over the body. The damage to the blood vessels of the retinal is called diabetic retinopathy. The blood vessels in the retina can be examined directly and non invasively and so even the earliest changes can be diagnosed. a) Highlights of diabetic retinopathy Diabetic retinopathy can be assessed only by retinal examination. Retinal test is different from glasses testing. Beware! Early stages of diabetic retinopathy will not produce any sight loss. Hence only by retinal examination diabetic retinopathy can be diagnosed. Retinal examination should be done once a year. b) Types of diabetic retinopathy Non-Proliferative Diabetic Retinopathy (NPDR). Proliferative Diabetic Retinopathy (PDR). In early diabetic retinopathy there are small dialations of the capillary walls in the retina which is called as microaneurysms.At this stage good control of diabetes and regular follow up examination of the retina is necessary. In the next stage, small haemorrhages, accumulation of fluid, cells and fat can occur. This is the warning stage and there is no specific treatment even in this stage. The point to be noted here is that sight will not decrease in these stages and so retinopathy can be detected only by routine examination.

In severe cases fluid can collect in the critical “seeing area” of the retina called macula. Mild to moderate disturbances in the vision may be present. Laser photocoagulation can be done to bring down the fluid accumulation and prevent permanent damage to macula. In proliferative diabetic retinopathy, abnormal blood vessels develop in the retina, which are very weak and have a tendency to bleed. Once there is a bleed there will be sudden and sometimes total loss of sight. Once there is sight threatening retinopathy, a test called Fundus Fluorescein Angiography (FFA) and laser treatment should be done. c) Common queries regarding Diabetic Retinopathy: 1. Is laser treatment for diabetic retinopathy harmful to eyes? No. Laser treatment prevents progression of diabetic retinopathy and detieration of sight. 2. How is (Cataract) lens opacification treated? Cataract surgery is done by a technique called Phako emulsification which is mistaken for laser. 3. Is glass test and retinal test are same? No. Retinal test is entirely different from the glasses testing. Retinal test should be performed every year after dilatation with eye drops. 4. What is the normal prevalence of Diabetic retinopathy? In a population based study done by using retinal photography, the prevalence of Diabetic Retinopathy was 19%. 5. How often retinal examination has to be done? For Type 1 Diabetes – every year after 5 years of onset of diabetes For Type 2 Diabetes – at the onset of diabetes and every year thereafter.

V. DIABETES & KIDNEYS:

Diabetes is one of the most common systemic disease to affect the kidney. a) Why kidney damage? Small blood vessels in the kidney filter out the waste products from the body. High blood pressure and high blood sugar can damage these vessels thereby they will not be able to do their functions effectively. b) Stages of diabetic kidney damage In the beginning stages of kidney damage, traces of protein also called albumin begins to appear in the urine. This stage is called Microalbumiuria. Early kidney damage has no symptoms and can be treated with diet and medicines and is reversible. As the kidney damage gets worse, large amounts of protein can be detected in the urine which is called as the stage of Proteinuria or overt nephropathy. By this stage, the damage is often irreversible in most cases. Finally the stage of renal failure sets which can rapidly progress to End Stage Renal Disease which requires either Dialysis or Transplantation to sustain life. c) Investigations If albuminuria is detected the following investigations are recommended:

• Check for the history of other renal diseases in the family. • Check for urinary tract infection through urine and culture sensitivity

test. • Ultrasound examination of the kidneys. • Measurement of urea and serum creatinine and comparison with

previous levels. • 24 hr urine collection for protein excretion. • Blood pressure measurement. • Check ECG and Chest X-ray. • Retinal examination.

d) Risk factors leading to kidney disease: 1. Poor control of diabetes. 2. Long duration of diabetes. 3. Uncontrolled blood pressure. 4. Genetic Factors (Family History of kidney disease). e) How to prevent kidney disease? 1. Diagnosing diabetes at an early stage by regular screening. 2. Once diabetes is diagonosed, it should be kept under very good control. 3. Tight control of blood pressure (130/80mm/Hg) helps to prevent kidney damage. 4. Regular screening for microalbuminuria to identify early stages of kidney damage. 5. Use of ACE inhibitors or other drugs, which have very good effect in early stages of kidney disease. 6. Regular checkup at diabetes centre. 7. Strict diet as advised. If there is proteinuria, the protein intake in the diet may have to be reduced.

KEY MESSAGES

• Diabetic kidney disease is one of the commonest causes of kidney failure.

• Kidney disease is asymptomatic till late stages. • Kidney disease is preventable by early detection of diabetes and

good control of diabetes and blood pressure. • Screening for diabetic kidney disease should be done at least

annually. VI. DIABETES & FEET: As diabetic patient’s age or the duration of diabetes increases, they may develop diminished sensation and decreased peripheral circulation in the feet and thus are at an increased risk of developing foot infections; especially in those with poorly regulated diabetes. Common problems in diabetic foot are:

a) Decreased blood supply (Ischaemia) The ischaemic leg, besides absent or reduced pulses, also has other characteristic features. The skin may become thin and there is usually loss of hair on the foot and ankle. Fissures are very common and ulcers may be painful. It may also be cold to touch. b) Decreased Sensation (Neuropathy) The neuropathic foot also has some characteristic features. The feet tend to be warm and dry and relatively insensitive to touch. Neuropathy may affect the muscles of the foot causing clawing of the foot. All this causes the fat pads covering the bones of the feet to be moved away from its position, thus exposing it to weight bearing areas. Any weight bearing area without adequate protection tends to open and form a wound called as an ulcer. In order to protect the leg, nature offers a mechanism by which it thickens the skin to avoid forming a wound. This protective mechanism will lead to problems such as callus and corns in later stages due to irritation of the tissues beneath. These can break down and lead to ulcers. c) Infection Both ischaemic and neuropathic lesions are commonly complicated by infection. Common symptoms of infection are fever, redness, swelling or pain .Pus may also be seen in the lesions. d) Combined Lesions It is common for a patient to have all the processes mentioned above occurring at the same time. Thus a person can have an infected neuropathic lesion with poor blood circulation. To identify and treat the common problems of diabetic foot every individual with diabetes should know what are the abnormalities to look for in their feet. Early detection and prompt attention can not only help save feet, they can also be life saving.

e) How to look after feet? i. Keep feet clean - wash them regularly. ii. Use only lukewarm water - no hot water, heating pads, hot water bottles, iodine or alcohol. iii. Keep the feet dry - especially between toes use unscented lotion or cream to keep skin soft. iv. Use only medicines recommended by your doctor or chiropodist (Podiatrist) v. Cut toe nails straight across, not deep into the corners to help avoid ingrown toe nails. vi. Never use razors, knives or corn caps to remove corns. vii. Wear shoes or slippers at all times-never walk bare foot even at home. viii. Wear good fitting shoes/slippers-not tight or worn-out ones. Boots should be used only for short periods. ix. Check your feet daily and see your doctor or chiropodist immediately about foot problems. f) How to self examine your feet? Sit on a bed or comfortable flat surface with legs drawn close to your body and hold a big size mirror beneath your feet 6-12 inches away and look for: i. Any cracks ii. Peeling of the skin. iii. Abnormally dry skin. iv. Colour change in any area. v. Any wound that has occurred. vi. Any shiny appearance on the feet. g) Feel your feet with your hands for: i. Abnormally cold feet ii. Any thickening of skin in the soles, especially beneath the big toe. iii. Any protruding bone beneath the feet. iv. Any change in the shape of the feet. v. Swelling of the feet. vi. Localized redness or warmth of the feet. vii. Ulcers or wounds. Inform your doctor if any of the above is present!

KEY MESSAGE

Look after your feet as you would look after your face. VII. DIABETES & HEART: a) What causes Heart attacks? A sudden block usually due to a blood clot that affects the normal blood flow to the heart is the usual cause of a heart attack. Deposition of fat in the walls of blood vessels is known as atherosclerosis. b) Warning signals for heart attack Angina Pectoris This term means chest pain but it could also be a discomfort behind the stanum or breastbone-produced by exertion and relieved by rest. Angina Equivalent Breathlessness, pain in the arms and jaw, especially on the exertion which is also relieved by rest. c) Symptoms of heart Attack

• Prolonged chest discomfort, lasting more than a few minutes, usually behind the breast bone-heaviness; choking or a feeling of pressure of tightness.

• Difficulty in breathing • Sweating • Weakness and palpitation.

d) Risk Factors for heart attack

• Diabetes mellitus • High cholesterol levels in the blood • High blood pressure • Obesity • Stress • Smoking • Positive family history of heart attacks • Low levels of HDL • Sedentary life style/Lack of exercise.

e) How to prevent heart attacks? Three kinds of lipids are present in the blood.

• HDL (high density lipoproteins). • LDL (low density lipoproteins) and • Triglycerides

Total cholesterol level in the blood is used as a screening tool. One should aim for a total cholesterol level less than 200mg/dl and LDL less than 100mg/dl to decrease the risk for heart attacks. For diabetic patients the level for LDL (bad) cholesterol should be less than 100mg/dl.Triglycerides in the blood tend to be high when blood glucose is high. High triglycerides also tend to lower the HDL or the good cholesterol.

• Lower the fat intake and increase the fibre intake in the diet. • Regular exercise for at least 30-45 mins at least 5 times /week • Maintaining ideal body weight • Control your blood pressure • Check your cholesterol once in six months and keep LDL (bad)

cholesterol within the normal limits if necessary with drugs like Statins.

• Increase HDL (good cholesterol) by exercise. • Control diabetes well. • Stop smoking • Reduce stress. • Aspirin if recommended by your doctor.

VIII. GESTATIONAL DIABETES (GDM) a) What is Gestational diabetes? Gestational Diabetes Mellitus (GDM), or diabetes during pregnancy, is one of the most common health problems affecting pregnant women. GDM is defined as a glucose intolerance of variable severity with appearance of diabetic symptoms in a woman who has not previously been diagnosed with diabetes.

Maternal hyperglycemia has a direct effect on the development of foetal beta cell mass. The recognition of glucose intolerance during pregnancy is more relevant in the Indian context as Indian women have 11 fold-increased risk of developing GDM compared to white women. It is not only associated with increased pregnancy morbidity but also increases the likelihood of subsequent diabetes in the mother and increased susceptibility to the development of obesity and diabetes in the off spring. Thus GDM puts both mother and child at risk. It is important to detect these GDM cases because if unrecognized, pregnancy may end in the perinatal death or foetal wastage. Therefore, screening is very essential. While ideally all pregnant women should undergo screening for glucose intolerance, it is imperative that high-risk indications are defined. Indications for screening for diabetes during pregnancy:

• Family history of diabetes • History of unexplained perinatal loss (death of baby from 7 months of

pregnancy to 7 days of birth) • History of having given birth previously to a very large infant, a still

birth, or a child with a birth defect. • Maternal obesity • Having too much amniotic fluid (polyhydramnios) • Hypertension • Sedentary lifestyle • HDL Cholesterol <35mg% • History of polycystic ovarian syndrome.

b) How is gestational diabetes diagnosed? Gestational diabetes is diagnosed with a blood sugar screening test and OGTT. World Health Organization (WHO) had proposed using 2 hour 75gms OGTT, where if plasma glucose concentration is above 140mg% at 120min,diagnosis of GDM should be made.

c) Management of gestational diabetes: Focuses on keeping blood glucose levels in the normal range. . Specific treatment will be determined by your physician based on:

• Your age, overall health, and medical history • Severity of the disease • Meal plan & basic nutrition recommendations: Diet at 30-35cal/kg

body weight is prescribed. Calorie intake is altered to maintain optimal weight gain of 1.5 kg month in the non-obese and 1kg per month in the obese.

• Exercise to be modified as required • Importance of Blood glucose monitoring and control: Maintenance

of normal glycemic status before conception and during pregnancy is essential to prevent foetal complications and for good outcome, since the organogenesis is completed by 6th week after conception, at a time when most of the women are no even aware of their pregnancy.Maintenance of mean blood glucose level around 105mg% is ideal for good foetal outcome.

• Insulin injections: Withdraw oral hypoglycemic tablets and introduce insulin since these tablets (medicines) can cross the placenta and stimulate the fetal β cell and produce hypoglycemia in neonate.

d) How Diabetes in Pregnancy Affects the Mother and the Baby: Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy. The complications of gestational diabetes are usually manageable and preventable. The key to prevention is careful; control of blood sugar levels just as soon as the diagnosis of gestational diabetes is made. Infants of mothers with gestational diabetes are vulnerable to several chemical imbalances, but the commonest are:

• Macrosomia refers to a baby that is considerably larger than normal. • Hypoglycemia refers to low blood sugar in the baby immediately

after delivery. • Miscarriages, stillbirth, baby with heavy birth weight, hypotrophic

infants, and small for dates, children with lethal or handicapping congenital malformations.

• The pregnant mother may develop recurrent urinary tract infections, hydramnios, toxaemia etc.

e) Recommendations to diabetic mother during pregnancy:

• Withdraw oral hypoglycemic tablets and introduce insulin • Maintain mean blood glucose level around 105mg% for good fetal

outcome. • The future risk of developing diabetes for you is two fold, if you

become overweight but maintaining ideal weight approximately halves the risk.

• Keep a watch over gain in weight • Look for swelling of feet • Take care of hypoglycemic events and prevent injury to foetal brain. • Never neglect urinary tract infections. • Report immediately any adverse ultra sonography findings to your

doctor. • Your pregnancy with diabetes is itself a high risk and has to be taken

care by a team consisting of diabetologist, obstetrician and in the later stages by a neonatologist.

• Be better equipped with diabetes education: Ask your doctor details regarding diet, blood sugar test by glucometer, self-injection of insulin and adjustment of dosage and in the recognition of hypoglycemia and its management.