Diabetes used to be considered a disease affecting the affluent society about 5 decades ago. Since then it has been rampant all over the world irrespective of cast, creed, religion, gender, financial position or even age. It has become so common it is quite natural to even ask if one is normal if not having diabetes ! The emotions and shock when one is labeled as having diabetes varies from person to person.
Pre- diabetes is a condition in which one is not normal and one is not having diabetes .This is a grey area in between where one can either progress to develop diabetes or reverse the state and remain without being labeled as having diabetes. The unfortunate fact is that there are as many people with pre-diabetes as there are people with diabetes. The purpose of this newsletter is to highlight the importance of this condition so that remedial steps can be taken to prevent the escalation.
Those with pre-diabetes are more prone to develop cancers of the liver, stomach, intestines, breast or uterus about 1.2 to 3 times more than a normal person. This population is also at risk to develop heart related problems or stroke like as for a person having diabetes.
Who have to be screened?:
- Those who are aged 45 years or older,
- Those who have a strong family history of diabetes,
- Those who are overweight or obese,
- Those who lead a sedentary lifestyle,
- Those who have a waist circumference > 42 inches males and 38 inches for females,
- Those with heart related disorders, high cholesterol, high blood pressure,
- Those with non alcoholic fatty liver disease, those with polycystic ovarian disease(PCOD),
- Those who had gestational diabetes( diabetes surfacing when pregnant) or who have given birth to babies weighing > 4 kg or 9 lb,
- Those having sleep disorder called sleep apnoea,
- Those on chronic glucocorticoid use,
- Those on antipsychotic medications,
- Those having acanthosis nigricans( a thickened velvety skin on nape of neck or armpits),
- Those belonging to the Asian/Afro American, Native American or Pacific islander,
- Children born to a mother who had gestational diabetes.
The blood tests which are checked are the fasting sugar level, 3 month average of sugar and the sugar levels 2 hours after main meal. If the fasting sugar level is between 100-125 mg( 5.5 to 6.9 mmol) or post meal sugar is 140-199 mg( 7.7 to 11 mmol) or 3 month average of sugar is between 5.7 to 6.4 one is diagnosed as having pre-diabetes.
There are questionnaires available around the world which can assess the risk- the Canadian, the American, the Finnish and the CDC screening test for pre-diabetes are some to name a few.
Once diagnosed as having pre-diabetes it is important to maintain a healthy lifestyle by cutting down on body weight by adequate physical activity, controlled food portions, adequate sleep, reduced stress, and by quitting smoking.
Doing exercise of at least 150 minutes of moderate physical activity a week helps in boosting the insulin sensitivity( this means the body responds well to the insulin secreted within the body), helps in improving muscle strength and co-ordination, improves blood circulation, digestion and flexibility. One must engage in a physical activity that one can pursue and maintain. In the times of the Covid, one can do multiple indoor exercises as well such as yoga, dancing, skipping rope, hula hoop, climbing stairs, Zumba, floor exercises and exergames.
Reduction of weight is also of prime importance. For every kg weight loss, the risk of developing diabetes is reduced by 16% and if one loses 7% body weight from initial weight, there is a 60% reduction in chances to progress to diabetes. Some may resort to medicines to help them lose weight, some may get operated to lose weight. The so called fad diets are numerous and may cause nutrient deficiencies. One needs carbohydrates as they are the prime fuel in the body for its activities. Most of the diets avoid carbohydrates and concentrate on high fat and protein diet which can aggravate gout or high cholesterol levels.
Controlling food portion is important as well the time taken to eat. One must chew thoroughly before swallowing. As explained in previous newsletters, eating off a red colored dish or eating with the non dominant hand or chewing the food properly all help in reducing the intake by promoting early satiety. Incorporating more fiber into the diet, by avoiding processed food and sweetened beverages also help in regulating the sugar levels. Incorporating a small walk after meals helps in digestion and also to prevent the high sugar excursions. Washing the mouth with a mouth wash can trick the brain into thinking a sweet dish was taken. Consumption of junk food is also to be avoided in those who are striving to lose weight.
Did you know that smoking increases risk of developing diabetes by 61% if smoking a pack or more and by 44% in average smokers? It is also interesting to note that quitting smoking for 5 years can reduce risk of diabetes by 13%, and after 20 years of not smoking a person’s risk of developing of diabetes is equal to that of a non-smoker.
Things have taken quite a turn with the start of this year due to the Corona Virus which belongs to the same class of SARS, MERS viruses of the yesteryear. Over the months, many messages had been popping up on social media or speculations based upon personal opinions and those who were and are striving to find answers also did not have much to answer because this was unprecedented.
We are inching towards the end of another year… what should have been a time for travel, outdoor picnics or for many to reflect on how the year passed, whether they met their targets set for the new year and what resolutions were to be planned for the coming year, have all been thrown to the winds with the havoc this tiny organism called CoVid brought about. Despite the many negative things that befell the socioeconomic aspect there were so many things that we must be grateful to the virus which none could so effectively bring about such as reduction in pollution, reduction in junk food consumption and helping a healthier lifestyle, building up healthier family ties, spending more time with family, learning to be content with what one has, learning to unearth hidden talents and open up creativity, realizing the importance of the Almighty and most importantly, caring and thinking of others.
A lock down had helped in maintaining physical distancing around the world and this meant prevention of travel across borders. This was ridiculed by many as it was unpleasant and led to difficulties. The viral load depends upon certain factors such as: coughing and sneezing has more viral load than when speaking, a closed small space has more viral load than an open space, a large crowd can have more viral load than a small group, a long exposure can be more dangerous than a brief exposure, but I must stress these all can be turned upside down if a person with reduced immunity is at the receiving end. A person with low immunity is one who has undergone transplantation, has very poor kidney or liver function, is having cancer or is undergoing treatment for the same, one who is on immunosuppresants for certain diseases, one who is on long term steroid therapies, one who is diabetic ,pregnant and nursing mothers, asthmatic or having heart related issues. Those who are very obese or who are chronic smokers have less respiratory reserve and hence can get more serious outcomes. Those with diabetes may get the infection as is with any other infection, but the outcome depends upon the presence or absence of associated problems with diabetes.
Now, one can understand the reason and justification behind the lock down. It is cruel to maintain family ties during these difficult times when the families are staying apart and cannot meet, but it is in the best interests. One can always be in touch with through the phone or video calls unlike in the past when this would not have been possible as freely as of today.
The usual course is fever, throat pain, body pain, non productive dry cough, loose stools which may appear altogether or in bits and lasts 7 to 9 days or more. Absence of fever does not mean absence of infection! Many have resorted to purchasing a pulse oximeter which measures the oxygen saturation on the fingertips by a probe which can be applied easily. A normal saturation is from 94% upwards. A drop of 4% when talking or walking is a sign of reducing oxygenation but this must be cross checked by a healthcare provider.
The diagnostics: It is wise to have the blood tests, CBC and CRP done for anyone who has the above mentioned symptoms or who is in contact with anyone already infected or who is unwell for more than 3 days and unresponsive to common measures. The need for a chest X ray or other tests to determine inflammatory markers will be decided upon by the health care provider. There are the classical or rapid swab tests using the RT PCR technique and the point of care tests such as the Quidals Sofia SARS Antigen FIA Kit®, the Talis One Covid-19 test kit by Talis Biomedical® and the Accula SARS Cov-2 kit by Mesa Biotech®. There is a salivary test as well being studied into. There is a paper based tests, E25Bio direct antigen rapid test which is being used in some countries. If positive, the person is advised to isolate him/herself completely for at least 14 days. Upon completion of the self isolation and 3 days of asymptomatic period, most orgnizations insist on a repeat blood testing before allowing them to come to office or they may be allowed to work from home. The molecular test for CoVid detects genetic material ( polymerase Chain reaction test) and the rapid antigen test tests some proteins related to the CoVid. As these are rapid and economical, these are used for mass screening, but may not be very sensitive.
Self isolation means to be staying apart from other colleagues at place of work or other family members at home . Donning face masks at home when interacting with the affected. Preferably, the aged and young, the sick and nursing mothers must not interact with the affected. The room where one is isolated and the washroom have to be well cleaned as that is a closed space which can become potentially an infectious area for others. Using the air conditioner is not harmful, but it is prudent to have the filter cleaned periodically.
It is important to know how to manage during these times to help contain the virus without affecting the society.
If affected by the virus, the patient must observe the following:
- Stay at home, away from work and office, whatever the work he/she is doing.
- Avoid public transport and that includes shared taxis and other modes of transport.
- Avoid mingling with unaffected family members
- Isolate yourself to a room with an attached washroom.
- If on treatment for diseases such as blood pressure, diabetes, high cholesterol, heart disease, please continue using them and monitor the progress. Some may notice high sugar levels which will need the oral medicine to be substituted with insulin. Stressing oneself can worsen the level of control of these diseases.
- Maintain personal hygiene, use the mask properly.
- Do ones` own laundry and dry the clothes out in the sunshine, if feasible. Do not mix the clothes with those of the non affected members.
- Let the food cooked be kept outside the room and the vessels used must be disposable.
- Disinfect the room daily twice taking care to disinfect the surfaces commonly touched such as the doorknobs, flush handles, electrical switches, chargers of the gadgets, remote devices, table tops, screen of gadgets, keyboard, counter tops and floor of the washroom and tub as they all come into contact with body secretions.
- One can order in food or even do self cooking which can further reduce the load of other family members. Wash the fruits and vegetables well before using them.
- Please do simple exercises indoors without straining yourself.
- Warm saline gargling of the throat is good
- Infusion of warm water with lemon, ginger and honey is useful and a time tested home remedy.
- Avoid smoking and alcohol.
- Get sleep.
- Avoid listening to CoVid related news or posts on the social media so you do not stress yourself.
- Listening to music, prayers, Holy recitations can help.
- Avoid visitors
- If developing high fever despite treatment, developing chest tightness, shortness of breath or altered behavior such as becoming confused or losing consciousness needs urgent medical help. If one has a good quality pulse oxymeter( a device clipped on to the finger tip to measure oxygenation) a reduction of oxygenation of 4 with talking or walking is ominous and needs help. Normal oxygenation is above 94%.
- Upon completion of the 14 days self quarantine and 3 days of being asymptomatic, one must undergo a medical check which involves a CBC and CRP blood test and some places insist on an Antibody test before being pronounced as fit to work.
There are many areas in the health care facility which are earmarked for CoVid patients separately and so also the washrooms too. It is inconvenient, but it is best if respected as nobody wishes to get infected just by carelessness. All health care providers may insist on having the Covid test done depending upon the setting however uncomfortable this may be. All over the world, it reached a position where there were not enough beds to match the influx of patients and many times, many had to be sent home on treatment if they were stable. It is a tricky question to decide who may deteriorate and who may not, because the virus is unpredictable.
Those with diabetes who are infected by the virus may notice fluctuations in sugar levels, mostly higher excursions. This may need change to insulin till the infection gets controlled. The outcomes worsen if the sugar levels are generally uncontrolled before getting infected. Conservative measures such as warm salt water gargling of the throat, taking paracetamol, warm food, avoiding cold fluids including cold milk and juices help.
The Covid times have brought about many good things in the world, with people exhibiting hidden talents, unearthing creative ideas, people resorting to a digital world ( online groceries, food, medicines, education), but this is unthinkable for many in remote areas or those without basic amenities such as electricity or education. The virus has helped Mother Earth to heal herself up, clean up the air, and also to help improve family ties and quality time together.
An antibody test will help those who want to know if they can rejoin offices for work after the customary 2 weeks of isolation or if they want to travel overseas. This is not a diagnostic test for the infection. This will not replace the other diagnostic tests which are in vogue today. The antibody test if negative can mean the following:
- The person never got infected,
- Person maybe in the first ten days of infection,
- Person may be having poor immunity.
- The level of antibody may fall in 3 months.
- Positive antibody does not mean one is immune.
The antibody test can be used to identify convalescent plasma donors and also verification of vaccine response. It was also seen that the SARS- CoV-2 IgG did not cross react with other respiratory viruses.
The restrictions will soon be eased and life may come back to how it was during the pre CoVid times, to an extent. It is the responsibility of each and every one of us to prevent the spread by doing our parts and also thus help the new generation to live in a better place.
Many have asked about taking a Flu shot. It is best to have the Flu vaccine in October or November yearly. This may not prevent all the viruses in the world, but can help in building up the immunity and also reduce the severity. A pneumococcal vaccine is also recommended for those with diabetes and the elderly people above the age of 65 years. If pneumococcal vaccine was taken before the age of 65 years, repeat one at 65 years after which a life long immunity is developed.
God bless us all and a special thanks to those in all walks of life who are striving to help keep the society safe, placing their lives and health at risk.
Skin care during the CoVid times:
- One uses plenty of sanitizers or soaps to clean. These can cause further dehydration and dryness of the skin. Remaining indoors in an air conditioned room can also aggravate the dryness.
- One can use cool water or lukewarm water. Using hot water to wash hoping to kill the virus can damage the skin and normal flora on the skin.
- Avoid antibacterial cleansers on the skin.
- Use gloves while using disinfectants to clean the surfaces as they may cause problems with direct skin contact.
- After washing, pat dry and apply hypo allergenic non fragrant and non dyeing moisturizers. A moisturizer containing either urea, hyaluronic acid or glycerin will be most ideal.
- Oil based creams or petroleum jelly will help trap the moisture, but can cause smudges and so one may need to use gloves to prevent he smudging.
- Care of the face especially after removing the face mask needs special mention too. Use of soap free cleansers which are non comedogenic are ideal. If one has an oily skin, one can use water soluble moisturizers.
- One may need to treat acne ( avoid popping them) and comedones by consulting a skin specialist. If there are small blisters use of an antibacterial cream after consulting a doctor will help.
Exercising is an important step in the management of any chronic illness such as diabetes mellitus, hypertension , high cholesterol levels and heart disease. Many had been depending upon the gym or outdoor activities for meeting their needs. Due to the Corona Virus, outdoor activities, swimming, and going to the gym has become obsolete.
The Covid period brings about increased stress levels, probably more food intake , being more at home ( indoors) and probably less physically active. This can be a problem for those with chronic illnesses such as diabetes, high cholesterol or high blood pressure. The benefits of exercising include improving the blood flow to the lower half of the body, helps strengthen bones and muscles, delays ageing, improves posture and balance besides controlling the high blood sugar, cholesterol and blood pressure.
However, shame, laziness, being overweight, issues with weather and fear of hypoglycemia are some of the excuses heard to prevent exercising. The commonest excuse is the lack of time. Now, thanks to the Corona Virus, this excuse does not hold good !!!! There may be plenty of time.
Before embarking on a fitness program, especially if one has never done exercises regularly, get a medical checkup done by the doctor which may include an assessment of the heart as well. Though exercises are beneficial, they can cause problems for some with certain problems like eye, kidney, joint, nerve or heart problems.
- The activity must be of at least 150 minutes of moderate aerobic activity a week
- Include different activities so you do not get bored. You can walk, cycle, jog, do water exercises, skip the rope, do the hula hoop, aerobics, zumba dance indoors.
- Remember to start slow and progress slowly.
- Stretching before exercises is very important.
- Allow time for recovery.
- You need not do all the activities at one go. You can conveniently space them out in intervals.
- Be flexible. Do not punish your body.
- Keep a diary to record the progress you made.
- Reassess yourself every month.
- Set new goals
- Push outside your comfort zone as the body gets adjusted to the exercise quite soon and one will notice that the body needs to be pushed further to achieve more.
- Do “listen” to your body. If weak or paining, do give a break and make sure all is okay. The injuries related to exercise too had been detailed in an earlier newsletter.
- It is important to get at least 150 minutes of physical activity done a week. The amount of sweating varies from person to person. An adequate work out must make the heart rate go up to reach 70% of the target heart rate. The target heart rate can be calculated by subtracting your age from 220. There must be not more than 2 consecutive days of inactivity( unless one is sick). One can add some resistance exercises, flexibility and balance training twice or thrice a week. Avoid prolonged sitting by walking around the office cabin every half an hour.
- Walking for ten minutes after a heavy meal helps a lot in digestion as well as has been found to help regulate the sugar levels. Different aims for getting one to exercise are there- such as to look good or to fit into dresses that are 2 sizes smaller, to look good for a reunion of friends…or to be physically fit and for some to reach their target goals in the management of diabetes or high blood pressure.
- Being diabetic , one has to check the sugar levels before starting the exercise. If the sugar levels are more than 300 mg (16 mmol/L) reduce the levels before starting the exercise. Do not inject insulin soon before the exercise or after the exercise as the sugar levels might suddenly go down.
- The mode of exercise will depend on personal preferences, the intensity of exercising will be measured by the heart rate and also the talk test( one should not be able to talk normally while exercising). The exercises must be done to allow at least 150 minutes of moderately intense exercises such as brisk walking, jogging, swimming or cycling. This can be done spaced out over a week or every alternate day to total at least 150 minutes a week. The frequency and duration of exercise are more important than the intensity of the exercises.
- Tai Chi, Yoga, Pilates, skipping rope, stationary cycling, performing household chores, garden work, fishing, sailing,dancing, elastic resistance bands, floor exercises, climbing stairs, jumping, spot running, lunges forward and sideways, and playing the X box all are different forms of exercise.
During these difficult times, many in different walks of life have their own stress and making ends meet. One has to find ways to overcome these, I understand it is easier said than done, but we all must strive to. Exercising forms part of a means to help. It does not have to be a chore or one does not have to sweat it out at the gym- the gyms are closed due to the Covid. The exercise can be any activity one likes doing for a period of time to help improve quality of life. Exercising helps improve sleep, stress levels, blood flow, posture, muscle and eye coordination. This also helps control post meal sugar excursions, controlling blood pressure and cholesterol. Activities such as walking the pet, playing with kids, mall walking, dancing, hula hoop, taking the stairs, meditation, yoga, gardening or yard work, fishing, cleaning the house all contribute to getting active though the scale of intensity may vary between the activities.
There are so many tracking devices which can help in setting goals, planning workouts, motivation, challenging, social support, monitoring progress on daily, weekly or monthly logs. Technology has caught up with lifestyle as much as in various other aspects of life. There are smart watches such as Apple®, FitBit®, Jawbone®,Misfit® and Atlas wrist band® to name a few. There are in-built apps in the modern smartphones that can also help. There is an app called Zombie,Run!® which can convert a simple exercise to a game of survival. There is a world of such apps out in the technology world. The trackers needed may change depending upon what level of activity one desires for.
As mentioned in an earlier newsletter, having a good pair of shoes for sports is essential. Be careful when buying pointed shoes ( narrow toe box) as that will encourage crowding together of the toes with possible corns, callosities, fungal infection between toes and never ending foot discomfort. During the times of Covid, one may resort to purchasing footwear online. The pictures may look great, but a footwear needs to be bought during the end of the day as the feet may swell a bit, one must choose a type in which toes can wriggle about and which fits comfortably. Sometimes the salesperson may coax you into buying one which “looks great” and may be tight, but they insist it will loosen up with time. However every time one wears such footwear may be so traumatic. Always have the feet measurement checked with the Brannock device, a device seen in the shoe shops to measure size, but hardly used! The feet can widen or lengthen with ageing as the foot arches may sag and ligaments holding the bones may weaken. Thus, one foot may be bigger than the other. Checking on a wet footprint will give an idea about the arches of the foot. If the full footprint is seen, it means a flat foot, if the imprint has only the toes and heel it means the arch is very high. The footwear must, ideally, be customized in such cases. Be careful of high heels as it may cause foot pain. Remember to change footwear often after checking for wear and tear. Inspect the sole and insides for sharp objects that may have pierced the sole. Allow the shoes to breathe by rotating them often. Caring of the feet is of prime importance especially when diabetic.
Treadmill is the commonest equipment bought for the home gym and is also one of the commonest equipment used if one frequents the gym. It is often believed that cardio exercises such as running, jogging or cycling help lose weight and also to keep one fit. But, it is worthwhile to note that the low intensity exercises help the body to adapt over a period of time thereby losing its efficiency at reducing the calories burned per minute.
Most of the people buy the treadmill and it soon becomes a dread mill- some use it as a storage space for books and other commodities. Some use the treadmill as a stand for hanging clothes.
There are, however, some points to ponder before buying one.
The advantages of a treadmill:
- Can exercise indoors despite adverse climate
- The smooth cushioned belt is kinder to the joints than when running on hard surfaces outside.
- Those who have no baby sitter or those who cannot leave home can benefit having this at home.
- This can be folded and kept aside if space is being compromised.
- Can listen to audio or see videos while on the treadmill.
- The programmable workout can be done to make the treadmill more interesting
- Can be monotonous
- The force of impact while stamping on the belt can cause injuries or pain to the knee, ankle or hip joints for some.
- While running or walking outside, the muscles make small adjustments to improve the coordination and balance which is not there while on the treadmill.
- While walking or running outside, the hamstring muscles ( muscles of the back of thigh and calf) help to propel the body forward. This does not take place while on the treadmill as the machine pulls the body forward.
- There is no wind resistance which can be encountered while exercising outdoors.
- There is nothing to match the downhill running on the treadmill. While running downhill, there has to be good coordination between the muscles of the front of thighs and lower leg muscles.
- Can fall off the treadmill with injuries if not concentrating while on the treadmill
- Adequate footwear is essential as the footwear can wear and tear easily due to the friction.
- Cannot enjoy the sights outside, no fresh air and also change in pace is not possible.
Points to ponder while buying one:
- There are two types- manual and motorized type. The manual needs one to use force to start it moving and some need even an inclination, but once it gets moving, the inclination cannot be adjusted unless you come off the machine. The manual one costs lesser than the motorized one.
- Stand on the belt and see if there is any jerky movement or instability of the base of the machine
- Look for a continuous duty rating of > 1.5 HP
- The belt size must be at least 48” long and 16” wide.
- The control panel must be easily accessible
- There must be an emergency stop button which can be used if there is a mishap.
- Look for the programmable versions available where the pace and inclination can be adjusted.
- Addition of audio and video plug ins cost more
- Water bottle holders are another option.
- Look for the warranty period
- If any other person besides you is planning on using the machine, please buy the high end machine. Those who are heavily built need a sturdy machine.
- Regular servicing or maintenance is needed.
Before using the treadmill, do the following:
- Proper attire including good shoes
- Make sure you are fit to undergo the exercise. If a first timer, make sure the doctor clears you of any heart, eye, kidney or nerve problems. If having back pain, ask the doctor before starting the treadmill.
- Make sure the sugar levels are not too high or too low. Correct the sugar levels before the exercise.
- Carry with you an ID card mentioning you are diabetic. Have fast acting carbohydrates with you( 3 pieces of dates or a granola bar). Carry either orange juice or water which can be had midway between a heavy work out if the work out lasts more than an hour. If you feel dizzy or complain of difficulty breathing, do consult a doctor before continuing.
- Adequate warm up is essential, start slow and then build up the pace or inclination and also stop slowly. Do not suddenly stop unless it is an emergency.
- Leave a space behind while on the belt, it is safer you have some space behind in case you slip.
- Hold on to the side railings while using an inclination or losing balance. It is better not to use the incline.
- Swing arms if possible as in natural walking.
- The short bursts of fast pace followed by slow pace improve the fitness levels as well do not exhaust the body.
- Keep back straight and not slouched over.
It is known the Fasting happens during the month of Ramadan during the day light hours. Different parts of the world have different timings for fasting due to the discrepancy in daylight timing. Though it is an important pillar of the principles of Islam, there are certain times when fasting is medically not advisable. This had been detailed in an earlier post. There is an app called DAR SaFa , which is available in the Play store ( Android users) and I store ( I phone users) . This app is available both in English and Arabic and is easy to navigate.
- The circadian rhythm of the body gets changed as those observing the fast are generally sluggish during the day ( especially after 1 pm till breaking the fast at Ifthaar) and become more active at night and some go for recreational sport activities at night or watch movies or television at night. This leads to less hours of sleeping which can affect their level of wakefulness the next day. There is a reduction in total sleep time, delayed sleep habits and reduced rapid eye movement sleep( REM sleep)
- When sleep is deprived, it leads to headache, irritability and lack of concentration. It is similar to the phenomenon of jet lag.
- This also translates to decreased productivity at work or errors in judgment or even road accidents.
It is advised to consult the health care team regarding fasting at least a month before the start of the Holy Month. A trial fasting can be done and adjustments n dosing can be made thus ensuring a safe Ramadan.
The health care team will first ascertain which category the patient belongs to in terms of risk stratification. The patients are classified as either low or moderate risk, high risk and very high risk.
|Low or moderate risk
||Well controlled type 2 diabetes
|Type 2 diabetes on metformin, DPP4 Inhibitors( Galvus®, Januvia®,Trajenta®) or GLP 1 RA( Victoza®) or sulphonyl urea( Gliclazide or glimiperide)
||Poorly controlled type 2 diabetes
|Well controlled type 1 diabetes
|Well controlled type 2 diabetes but on multi dose insulin therapy
|Pregnant Type 2 diabetic or gestational diabetes on diet control and or metformin
|Those diabetic patients performing intense physical labour
|Kidney disease stage 3
|Those with stable complications such as stroke, heart disease
|Very High risk
||Poorly controlled type 1 diabetes
|Those with recurrent hypoglycemia or unawareness of hypoglycemia
|Those who had very high sugar levels with or without ketosis in past 3 months
|Those who have any acute illness
|Those who have end stage kidney disease or stage 4 kidney disease
|Gestational diabetes on insulin therapy
Besides the above criteria, the type of medicines the patient is on, the previous Ramadan experiences, the type of diabetes, the presence of associated medical problems and social or working conditions also are to be considered.
Some countries have different religious views which have to be respected. Some may insist on fasting though they are labelled as very high risk or high risk. This has to be discussed with the patient and family members .
Be prepared for multiple sugar level testing either by the finger pricking ( glucometer) or the flash glucose sensors or continuous glucose monitors. The sugar levels before suhoor, midday, and after ifthaar are important, but depend upon the major food intake. Some take more food after the Tharawiah prayers.
When the sugar levels are either more than 300 mg/dl( > 16.7 mmol) or less than 70 mg/dl( <3.9 mmol) fasting is to be stopped immediately.
- Normally working hours are shortened for those observing the fast and work is started late.
- It is important to get 7 hours sleep
- Break the fast with a small meal- dates, buttermilk or tender coconut water are the best. Having lots of fried food or sugary beverages or eats can upset the rhythm of the body and indigestion can set in.
- Have a reasonable meal after night prayers. Alternatively some have the meal after an hour of breaking the fast.
- Take a diet having some carbohydrates, lentils, vegetables, proteins, fruits and some dairy produce to make it balanced. Generally, whole grains, temperate fruits, legumes, green salads, tuna, sardines, salmon fish, skinless poultry, not more than ten non roasted nuts are included in the diet. Proteins can help maintain satiety and also preserve lean body mass.
- Avoid taking too much salt , sugar or fried food.
- Avoid drinking too much coffee or tea as these can promote diuresis which can cause excess urination and dehydrate one in the morning.
- Please sleep some time after the dinner and after Suhoor meal so as to keep the body rhythm as it is.
- At Suhoor try taking food that digests slowly- lentils, beans, rice, yogurt, are good.
- Some prefer having one meal at 11 pm and drink water at Suhoor.
- If you need to check the sugar, please check before the Suhoor prayers.
- Exercises such as walking can be done after the Tharaawiah. Please avoid exercising heavily before breaking the fast as the body will already be exhausted.
- Please drive early back home before Ifthaar as traffic can get rash at that time. Car pooling is an option if feasible.
- Please follow traffic rules, wear the seat belt, signal properly while driving as all these can get deranged when tired. Drive less than the speed limit so that you have enough time to respond to an emergency.
- The driver in the next lane might be tired as well
- Jumping the signals are common at that time before breaking the fast.
- The response time to braking might be delayed due to fatigue.
- Please avoid driving long distances during that time, if possible.
- If you feel tired or sleepy, please stop the car on the side and take a power nap.
- While parking the car, please make sure the hand brake is applied, turn off the car. These appear silly but have been done due to the lack of concentration.
- While at work, try sharing work that demands heavy physical exertion and work in groups to help.
- Eating throughout the night will not help the body the next day as the digestion cycle is 6-8 hours.
- Overeating or eating wrong food leads to indigestion, gastritis, loose stool and vomiting.
- Having junk food is not advisable for the same reason.
- Regarding medicines the timings and doses may change during Ramadan. Please ask your treating doctor before Ramadan starts. There are so many medicines which have been added to the array of blood sugar lowering medicines. However, it is advisable to ask the health care team which medicines can be used and also the timing of the medicines so as to be able to fast safe.
- There may be times when fasting is not safe for the patient. Please discuss with the doctor.
Lot of money has been pumped in the research to make the management of diabetes less painful and better to help in better compliance of medications. People are always curious to know what is new and how they can be better managed. All said and done one must never forget the lifestyle habits which include getting in at least 150 minutes of moderate physical activity, controlling food portions, reducing stress and avoiding smoking and alcohol.
There are a lot of new modalities in sugar checking and monitoring which was detailed in earlier blog. There are some more which are pending patent and approval.
When the sugar levels do not improve with adequate dose of oral sugar lowering therapies, there were not many options but to start on an injectable therapy. All the new formulations have to prove they are beneficial to the heart and do not harm the heart. This is because heart related problems are the commonest cause of mortality.
There is a class of oral medicine called Sodium Glucose Transporter 2 inhibitor which controls sugar by preventing the re-absorption of glucose by the kidneys. This causes approximately 70 g of glucose to be excreted through the urine. One has to drink more fluids to prevent urinary infection. Dapagliflozin, Empagliflozin and Canagliflozin are available around the world. Canagliflozin is not available in Oman. These are also available in combination with metformin which helps to complement the effect of the medicine. Many are under the impression this is a substitute for insulin and is a wonder drug. This must be carefully used after consultation with the health care provider. This class of medicine must be used only for those with type 2 diabetes.
As the duration of diabetes advances, the pancreas may not be able to control the sugar levels despite being on maximum tolerable dose of oral sugar lowering medicines. There are times when insulin has to be initiated ( detailed in an earlier blog). Insulin commonly causes weight gain which has been a major point of concern. There are fixed drug combination which combine a group of medicines called GLP 1 RA which helps to control diabetes by reducing glucagon levels and also help in controlling appetite and thus help in reducing weight and long acting insulin. Xultophy ® combining Liraglutide and Degludec and Soliqua® combining Lixisenatide and Glargine are the available brands. These preparations may have stomach upset and so the dose is titrated gradually.
The dose has to be adjusted as per the health care providers advice.
There are insulin preparations which work for longer than 24 hours. Insulin Glargine long acting ( Toujeo® U-300- this means there is 300 units of insulin in cartridge), Insulin Degludec( Tresiba®)
Dulaglutide ( Trulicity®) is to be taken once a week which helps reducing the appetite and weight. This belongs to a class of drugs called GLP 1 RA.
There are cholesterol lowering medicines coming in injectable forms which need to be given once in 2 weeks. It is a prefilled singe use syringe. These are expensive and may need to be combined with cholesterol lowering tablets to help reduce the levels. Evolocumab and Alirocumab are the types available in the market.
Please discuss with the treating doctor regarding the feasibility of using these as part of your treatment regimen.
Lifestyle modification involving adequate physical activity is a cornerstone in the management of diabetes. It complements the effect of the medicines used in the management. There are different forms of physical activity both indoors and outdoors which can be followed towards reaching the goal.
Fishing is a popular outdoor recreational activity which can be followed by any person or any age or gender irrespective of how fit you are. There may be parts of the world where fishing is not practical due to paucity of fresh water lakes. Going fishing has often not considered as an exercise.
There are different types of fishing- it can be a leisurely type where one casts the line and waits for the catch while sitting on a chair probably reading a book or drinking beverages or snacking which might be rich in calories or can be as part of a sport or can be fishing while kayaking which are demanding.
The benefits of fishing are many such as the following:
- It is an enjoyable pastime where one can liaise with the beauty of nature in silence except for the sound of the water rhythmically rapping against the hull of the boat or the rocks and the sound of the sea gulls, crickets or frogs depending upon the location.
- This translates into a wealth of emotional, mental and physical benefits due to the relaxation involved.
- The absence of television, computers or even phone range signals might even relax one even further.
- The relaxation lasts long after the fishing is over.
- This can be made enjoyable by going along with friends or families or classmates. These days one spends a lot of time on the screen that prevents face to face contact, laughter and discussions in a real world setting.
- Even if going alone, one can use the time to reflect, listen to songs or even make decisions which would not have been possible in a regular day to day life.
- Generally the air will be pollution free which is good for the lungs and health. It also helps those with respiratory problems.
- One will get plenty of sunshine if fishing during the day which is good for vitamin D as well as for the body rather than spending time indoors.
- While fishing, one may have to move up and down the bank of the water body to set an ideal place for the catch. Sometimes one will have to wade in the water knee or waist deep which involves core muscles as one fights to regain balance against the water current which helps as a passive strength training for the lower abdominal and leg muscles.
- Fishing is a low impact exercise. Casting the line, rowing the kayak or climbing rocks to reach a better position all help to strengthen the arm muscles as well as the back. A lot of muscles which are rarely used in day to day living are used while fishing.
- Some even cook their catch and make the whole day affair very enjoyable.
While embarking on fishing it is wise to have someone experienced in this field to help tide over a crisis or unpleasant surprise. One will need to also be familiar with the local geography and possible currents and weather changes. Certain areas might need the use of means of communication other than the regular mobile network.
However as with any exercise or sport, injuries while casting, threading the bait, reeling in as well as injuries by the bite of the fish or slipping while wading are possible.
The above article was taken with permission from https://outdoorempire.com/11-reasons-fishing-makes-you-healthier-happier/
There are many types of insulin each working in its own unique manner, some types of insulin are suitable for one but not for another. Normally basal insulin acting for almost 24 hours is used once at night and rapid acting insulin used with the main meals is used thrice or twice as the case warrants. Most insulin preparations come either in pen delivery devices which are disposable or refill pens. Some preparations of insulin still come in vials or small bottles. The pen delivery devices are easy to use and for those who are visually handicapped there are audible clicks while turning the dose dialer to help know the dose. The basal insulin is clear looking insulin. This acts for 16 hours to 36 hours. Normally does not cause low sugar spells and can be taken before or after food. The dose is usually dependent upon the fasting sugar levels. There is also premixed insulin preparations available which is a combination of short acting and intermediate acting insulin.
The commonly available basal insulin ( long acting) preparations in Oman are: Insulatard®, Detemir ( under brand name Levemir®), Glargine 100 units/ml( under brand name Lantus®), ultra long acting Degludec (under brand name Tresiba®) and ultra long acting Glargine 300 units/ml (under the brand name Toujeo®).
The bolus insulin (rapid acting insulin) comes either in small bottles or vials or pen delivery devices (either as disposables pens or those which can be refilled with cartridges) This insulin is clear looking insulin. This is generally taken 15 minutes to half an hour before the main meals.
The commonly available brands in Oman are Human Actrapid®( which can also be given into the veins in the hospitals when sugar levels are really high) Humalog Lispro®, Novorapid ® and Glulisisne ( under the brand name,Apidra®).
The basal ( long acting) insulin is preferably injected on the thigh and the rapid acting insulin on the abdominal wall avoiding 2 finger breadths around the navel or belly button.
The commonly available premixed insulin preparations available in Oman are Human Mixtard 30/70®, Humalog Mix 25/75®, Humalog Mix 50/50®, Novomix 30/70® and Novomix 50/50®. Because there is a clear and a milky insulin as the constituents, the insulin preparation bearing vial or cartridge will have to be shaken before use.
There are some barriers facing the patients and the treating doctors when advising insulin. The fear of low blood sugar levels, the fear of the pain associated with the needle prick, the need for having to check the sugar levels frequently, the cost of the insulin, the possible negative impact insulin can have on ones social and married life, the scary feel associated with the insulin, the impact insulin has on ones friends are the common barriers. There are some who have seen their near or dear ones die or having developed a kidney failure or having amputated a limb after staring insulin. They feel the insulin was responsible for all this. The uncontrolled sugar levels can damage the eyes, the nerves, the blood flow to the legs, the heart, the brain, kidneys and once the damage has set in, insulin cannot help reverse the damage, but can help further worsen the damage. The insulin can cause weight gain, might cause allergy or numbness for some and episodes of low sugar when the patient has taken too high a dose and either exercised or taken less food.
Insulin is safe during pregnancy, in those with very advanced kidney failure and heart failure.
There are however some points to be considered while using insulin:
- Insulin is to be stored either in a cool room. It is never to be frozen by placing in the freezer. If frozen by any chance, it cannot be thawed and is best discarded.
- Insulin can be taken along while traveling by carrying it wrapped in between ice packs or by using cooled gel holders. Sometimes you might need a certificate while traveling to be allowed in the cabin bag.
- Never leave insulin in the car especially during the summer as it can get damaged and lose its efficiency.
- Always check the expiry date especially while buying large amounts of insulin.
- Do not inject cold insulin. Roll the pen between the palms of the hand for six to seven times to lightly warm it.
- Rotate the site every time you inject.
- The site to be injected must be lightly cleaned with a swab. Check the site of injection for small swellings or bumps. These sites are to be avoided as the insulin will not act well if injected into those areas.
- The dose to be injected is dialed if using a pen insulin delivery system.
- Inject perpendicular to the skin after the needle is plunged fully. Plunge the dialer button to deliver the insulin.
- After the dose has been delivered, count to five and remove the pen, lightly wipe the injection site and cap the pen again to place it back in the refrigerator or in a cool room away from direct sunlight. Sometimes a drop of blood is seen coming after the injection. Light pressure to that site for half a minute will help.
- There is no need for a vigorous massaging of the site after the injection has been given.
- You will need to have the food consumed within ten to fifteen minutes of the rapid or premix insulin shots to prevent low sugar levels.
- Dispose the needles in a sharps container. It is advisable to change the needles after every injection.
- Do not wipe the needles with an alcohol swab as it removes the silicone coating on the needles and makes the injections painful.
- The dose of insulin will have to modified when traveling by long haul flights involving more than 15 hours either towards the East or the West.
- If going for a party at night, it is safe to take the long acting insulin before the party if the patient is on a mix of short and long acting insulin. Take the rapid acting insulin after you come back home, and checking the sugar levels. Taking the rapid insulin before the party can lead to low sugar levels as there will be a delay in eating the food. Moreover, one is not sure of the kind of food either and how much one would consume.
- During Ramadan, please consult with your doctor on how best to take insulin.
- The dose of insulin always remain the same. The dose of insulin depends upon the sugar levels while checking.
- If I am sick and have not taken food, I do not need to take my insulin shots. When sick, though the appetite is compromised, the sugar levels will be high in response to the body`s defense mechanisms. Check the sugar levels and inject accordingly after consulting with your doctor. You might need either a smaller dose or higher dose depending upon the sugar levels.
Normally one unit of rapid acting insulin corrects sugar spike caused by intake of 10-15 gm of carbohydrate. (this is called the insulin to carbohydrate ratio) The carbohydrate content of food can be understood by referring to apps available on the smartphones or by checking on some sites such as www.carbsandcals.com
Another number to known is the insulin sensitivity factor. If you divide 1800 by the total dose of insulin taken in a day it will give the insulin sensitivity factor. Suppose you inject 50 units of insulin a day ( add all the insulin doses taken on a day), divide 1800 by 50 to get 36. This means by injecting one unit of insulin 36 mg/dL or 2 mmol/L of sugar comes down. This number will vary from person to person.
There are so many new insulin preparations and combinations being researched and soon to come into the market.
Points to consider while exercising if you are on Insulin:
Please check the sugar levels before exercising. If sugar level is < 5 mmol/L or 90 mg/dL, take 20 g carbohydrate, wait till the sugar levels reach 7 mmol/L ( 126 mg) . If sugar levels are between 10-15 mmol/L( 180-270 mg/dL) you can still exercise but be reminded that the sugar levels go up while exercising. If sugar levels before exercising are above 15 mmol/L (more than 270 mg/dL), check ketone levels in blood( there are blood ketone meters available with Freestyle® which uses a test strip for ketone like using the glucose test strip) If the blood ketone is between 0.6 to 1.4 mmol/L, you can do moderate intensity exercise and drink more fluids for half an hour. If the blood ketone levels are more than 1.5 mmol/L, you need to meet the doctor for correction of the sugar and ketone levels with insulin and IV fluids. Upper abdominal pain and nausea or vomiting can be sign of high blood sugar levels.
During the exercise you might need to snack in between depending upon the duration . An exercise time of not more than an hour needs no carbohydrate replacement, if the exercise duration is between an hour to 2 hours, take 30-60 gm carbohydrate snack and some water. If the exercise duration is more than 2 hours, take 30 gm carbohydrate every 20 minutes with water.
Prevention of low sugar levels after exercise : If doing exercise 2 hours after taking basal insulin, reduce the dose of basal insulin by 20%. If doing the exercise in the late afternoon or evening, reduce the dose of basal insulin by 20% at night to prevent low sugar episodes. A short sprint before or after the exercises causes a spike in sugar levels which prevent getting low sugar following the exercise regime. A proper cooling down after exercise can prevent the high sugar levels soon after exercising.
New insulin delivery devices .
This is a super slim pump device which delivers only bolus (rapid acting ) insulin. The cartridge can store 200 units which means less frequent refilling of the insulin. Squeezing 2 buttons simultaneously on the pump allows 2 units bolus dosing.
- Companion Medical`s InPen®
This is the first insulin pen with in-built Bluetooth- sends the dose data to a phone and app automatically. This calculates and recommends the optimal dosing of insulin, tracks the history and timing of the dose, monitors the temperature of insulin, displays the last dose and insulin on board available. This can even send reports to the health care team if synchronized.
This a Bluetooth enabled meter which helps in diabetes education by paying an annual fee besides monitoring sugar levels and administering insulin.
- Tandems T Slim X2, OmniPod Dash System also are soon to hit the markets.
Some new glucose monitoring devices:
- Abbots Lifestyle Libre Pro®-
After the sensor is applied on to the body, there is no need for the patient to interact with the system. There is no need for the finger stick calibration. This can monitor 2 weeks of continuous glucose monitoring.
This is a contact lens with a reader device which can check the sugar levels from the eye tears. The lens has a wireless chip and a miniaturized glucose sensing device. A tiny pin hole in the contact lens helps the tear drop to seep in for glucose sensing. The electronic connections lie outside of the normal eye thus not harming the normal eye. There is a wireless antenna inside the contact which is thinner than the human hair and this helps to communicate the information to the wireless device.
- Medtronics MiniMed Pro Infusion®-
This has a very small catheter and has lesser tendency for blockage. The tubing has a side port which be used for insulin delivery even if the main port is blocked.
This calculates and recommends precise bolus dose. This prompts the patient to take action by predicting low levels. This has an inbuilt continuous glucose monitoring devise. The insulin can be delivered every 5 minutes, if set to deliver so.
Forgetting things has always been a matter of concern for most of the people. Most are concerned about the scare of Alzheimer’s as well. It has to be emphasized that our forefathers had been much better off during their days. Just as the body ages, the brain too ages and so also a decline in cognitive power can ensue. That is inevitable, but one can delay the onset and slow the progress of the decline with some efforts.
Now- a- days with the advent of improved technology, people are able to communicate better and faster and people from across the globe can be connected easily, but it has caused other problems as well. People are so busy peering into their mobile phones or electronic gadgets, they get frequent eye strain issues and dry eyes, neck and back pain due to the hunched posture, finger pain and wrist pain due to punching the buttons and have the lost of communication and eye contact. There are, however, a lot of people who use the mobile devices as an organizer which stores telephone numbers or helps schedule their appointments or remind them of things to be done. It has reached a point where people have almost stopped taxing their brain or mental capabilities to a point where they do not even recollect their families phone numbers !!! Strangely, many pharmaceutical companies have started capitalizing on this weakness and have brought about “magic cures” to help boost memory. Some medicines being taken for regular ailments have also been implicated in loss of memory !
Most of the time, the brain is not stretched to use its full potential causing it to be dull and lazy.
There are some good and harmless ways to get over this handicap before it gets out of control.
- Reading a book
- Learning a new language
- Play games
- Visiting a museum
There are good steps which can be done to help wake up the “sleeping brain”. There are the right handed and the left handed people. For the right handed people the right side of the brain is not used much and likewise for those who are left handed.
Neurobics is a type coined for the exercises which help the brain.
Playing Sudoku, chess, solving crosswords or the Rubiks cube are effective neurobics. Writing or drawing with the non dominant hand helps wake up and fire the sleeping side of the brain.
Trying to guess the dish by tasting it while blindfolded also helps to stretch ones imagination. You can add up fun by asking to guess the ingredients used in the cooking of the dish.
Playing exergames ( video games which involve exercise as in X box, play station, Kinect or Wii Fit ) helps creative skills and burns calories as well. These are particularly useful for those staying in places of extremes of climate, for the aged, for those shy to go outdoors and for those who do not have many friends. These also help the younger generation to bond well with the elders and people with joint problems can get moving as well. I do agree a walk in garden or beach side or a park will have its own benefits, but if unfavorable, this is a good alternative.
It goes without mentioning that adequate sleep, getting enough sunshine, exercise, having a good social support and a healthy diet all help in boosting brain power.
Try remembering phone numbers or appointments without the help of the mobile gadgets or the organizer.
Socialising and staying calm also help boost the brain functioning. Being stressed out does jolt your brain to standstill. When you are stressed, the brain refuses to think straight.
Though there are medicines which do claim improvement of brain ability, I am not competent enough to comment on those. I would rather you try boosting the mental power the natural way.
The winter is coming and it is time for special care for your body. This is a time where one tends to have more parties and celebrations, will definitely eat and drink without guilt and sleep well due to the cold weather. But there are certain things to be careful of- the water intake might go less which can result in urinary infection or stones, indigestion due to excess spicy food, and dry skin especially on the exposed parts of the body. People might exercise less outdoors in view of the cold climate. You could still exercise indoors and can go outside dressing appropriately for the climate conditions outside.
Moisturizers help in treatment and prevention of dry skin. Besides this, it also protects sensitive skin and improves skin tone and texture. The moisturizers act by trapping water in the outermost layers of the skin and acts as a temporary barrier to water loss.
Moisturizers usually contain humectants and emollients which help retain moisture. They also claim to contain peels of fruits and fragrances to make it smell pleasing. But, for those with sensitive skin, these adulterants can cause irritation and allergy. The expensive moisturizer does not always mean it is the best.
For those with normal skin, apply water based creams which are non greasy ( non oily)
For those with dry skin, use one with a heavier oil base. Petrolatum based one s are ideal.
For those with oily acne prone skin, use lotions and must be noncomedogenic( not closing the pores which can worsen the acne). Most of the soaps and face washes can dehydrate the skin further. Use of foam free face wash is recommended.
For those with sensitive skin prone for rashes, allergy and irritation, look for ones with soothing ingredients such as aloe or chamomile. These are non perfumes usually.
Use moisturizers soon after bathing.
Heavy creams are used in areas where dry skin is there and hence the face is spared of heavier creams.
Some of the brands of moisturizers come with a sun protection as well.
If the skin dryness does not improve, please do consult a skin doctor.
Hydration and eating healthy are essential to retain the glow and moisture of the skin.