All posts in Complications

Understanding insulin

Understanding insulin

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.

 

Some precautions:

  • 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.

Some myths:

  • 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.

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Updates in insulin delivery devices and glucose monitoring

Updates in insulin delivery devices and glucose monitoring

New insulin delivery devices .

  • LifeScan One Touch Via®

index

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®
  • In pen

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.

  • OneDrop Premium®-

One-Drop 2

 

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.

Image Slim X2     Omnipod 2

 

 

 

 

 

 

 

 

 

 

 

Some new glucose monitoring devices:

  • Abbots Lifestyle Libre Pro®-

LibrePro 1   LibrePro 2

 

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.

 

  • Google Contact Lens®-

google contact

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®-

MiniMed

 

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.

  • Medtronics 630G®-

MiniMed 630

 

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.

 

 

 

 

 

 

 

 

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Exercising the brain

Exercising the brain

                                                                                    exergames-2brain-games-2

exergames-2Forgetting 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.

Sudoku

brain-games

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.

exergames

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.

 

 

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Using moisturizers

Using moisturizers

                                                                       moisturizer-2

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.

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Exercise tips in cold weather

Exercise tips in cold weather

 

Tai chi

It is a welcome change in the climate after months of scorching heat in the middle East. This might last for a couple of months before the scorching heat picks up again. It is the time for outdoor partying, smell of inviting barbeques and probably increase in bad cholesterol levels !!!!! It is also the time for contracting viral fevers. Have you had your annual flu shot? The Flu Vaccine at least helps against many of the strains of virus which are getting more complex with each passing year.

Losing weight is something the doctor always stresses on. Interestingly, you might notice that the males are generally reluctant to address the obesity as well as their female counterparts. Moreover, weight loss is slower among those with diabetes due to the medicines they are on and also due to diabetic dysregulation. But , that cannot be used as an excuse for losing weight or even trying to.!!!! There is always a weight loss plateau that is to be expected and that should not deter yourself from continuing, but will need a self assessment as how to overcome the plateau.

Many now blame the cold weather and cold breeze and wish to remain cuddled under the blankets or remain indoors and try eating more to keep the body heat.

Impulsive eating can occur when stressed ( positive stress is during a vacation and negative stress during a personal tragedy) , when angry, when depressed or when worried about an upcoming event or even when stewing over a conflict at office or work. This often leads to impulsive eating followed by the guilt and again feeling low followed by eating again which gets you nowhere healthy !!!

Bed time snacking

People might keep on snacking to give them the so called energy while staying up awake while working late hours. There are certain occasions when you are allowed to snack especially when having an early light dinner and sleeping late. But, there are certain things to be known while snacking.

  • Warm milk contains tryptophan and helps in sleep
  • A bowl of cereal with milk or a glass of labaan( butter milk) , crackers or bread and cheese all can cause sleep due to the carbohydrate content.
  • Sources of hidden caffeine and fatty food such as burgers can impair with sleep.
  • Alcohol ( nightcap) might cause nightmares, frequent awakening, night sweats  and headache for some which can impair with sleep. Drink plenty of water after the sleep.
  • Protein rich and high fat food will cause problems in digestion which can impair sleep.
  • Spicy food and smoking can impair with digestion.

So make healthy choices while snacking. Snack is just a small meal and not another meal.

The winter months are a cause for celebrations and family outings . The smell of barbeque fills the air after the sun sets. People might eat more of meat and prawns which might increase the cholesterol levels. You can however go a walk outside as the climate is much better than the hot humid summer climate.

Generally sugar levels and cholesterol levels rise with the increased food and alcohol consumption during the winter months.

 


      image 3                                                    aqua aerobics 2

You can safely exercise indoors if the weather outside is not to your liking. Tai Chi, Pilates, using the Hula Hoop, dancing to music,  yoga, skipping rope or just spot jumping helps burn calories. Zumba or kick boxing are options that needs a trainer to help you out. For the fitness freaks who like to sweat it out in a gym, try something new at the gym or use resistance bands. You can swim or do any exercise in the pool as water is kind to the joints. Aqua aerobics is catching up in a big way as it is entertaining and kind on the joints as well. One can enjoy shopping by walking in the malls and doing window shopping !!!! Walking is still a good exercise. Take care of your footwear and use proper clothing if walking outdoors. Cover your head and neck if very chilly. The new form of play station using the X box helps you engage in interactive games and helps you combine entertainment with exercise and it can be enjoyable when performed with either family of friends.

For those who are interested in resistance training using small weights, remember to always warm up, stretch and do repetitions of ten to twelve in a smooth controlled motion. The muscles might ache at the beginning, Give a rest in a between and try these on alternate days to help the muscles to recover.

How to overcome barriers to exercise?

  • Break the times of exercise to smaller periods if it not practical to spend 30 minutes a day for five days a week.
  • Identify causes of waste of time such as watching the television, lying on the sofa. See if these can be overcome.
  • Reframe the concept of exercise such as walking the dog or taking the kids for playing, playing ball on the beach or even dancing, walking in a mall, walking around a large airport terminal while waiting for the flight.
  • Join a group who can motivate you.
  • Watch the television or listen to music while exercising.
  • Take stairs instead of the lift or escalators.
  • When ill, do not exercise.

There are numerous apps which can be downloaded from the app store if you have a smartphone. These can monitor the progress and can even motivate you to get moving.

Ask yourself why you want to lose weight:

Questions Yes No
Look better
Feel better
Feel comfortable in clothes
Improve self image and confidence
Improve physical stamina
Improve energy levels
Improve sleep
Be a role model for my family
Improve the blood pressure, cholesterol and diabetes
Reduce joint pain
Improve life expectancy

 

You might want to add more…..such as want to look good at a function or don those clothes which you outsized and so on…..

 

Write down the challenges and obstacles you face towards achieving the goals. The more honest you are with yourself, both in recognizing the obstacles and coming up with realistic strategies, greater are your chances at succeeding. Let that be your New Year resolution.

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Pancreas transplantation

Pancreas transplantation

transplant

 

This is a novel step in the management of diabetes. Many people, even today, fail to understand the indications for transplantation. Many assume this can be done for almost anybody with diabetes.  Incidentally, as early as 1890 in England, the first transplant involving fragments of sheep pancreas was first tried on a young boy with uncontrolled diabetes. Improved surgical techniques, better immunosuppressive medicines and healthier recipients have helped improve the outcomes.

What is pancreas transplantation?

This is a surgical procedure involving transfer of a healthy pancreas from a deceased donor to a person whose pancreas no longer functions at all.

Indications:

This is reserved only for those with type 1 diabetes , but does not form part of standard treatment.

  • When standard insulin treatment cannot control diabetes type 1
  • Poor sugar levels
  • Kidney damage in those with diabetes type 1
  • Frequent insulin reactions

Types:

  • Pancreas only transplant
  • Simultaneous pancreas- kidney transplant
  • Pancreas transplant after kidney transplant

Normally the endocrinologist or the diabetologist refers the patient to the nephrologist, the specialist in kidney diseases, who will run some tests to assess extent of kidney function. Once the possibility of transplant is considered, the transplant team is consulted. The team comprises a medical transplant doctor, a transplant surgeon, diabetes educator, a social worker, a psychologist and a financial advisor.

Pre requisites:

It will be assessed if you are a healthy candidate to tolerate the procedure, if there is anything in your records to hinder the success of the procedure or if you are compliant with the advice given by the team. It is an emotional, mental, physical and financial burden on the family and the patient.

Not to be forgotten are the legal issues associated with the transplantation ( still considered a taboo in many parts of the world), availability of donor, blood group and the severity of the kidney damage. Most of the centers have a waiting period which varies. The donor must be aged between 4 and 55 years and free from diabetes and must not be obese. There are areas in the world where organ donation is a business and various trade rackets have been busted.

Do your homework well….

Find out about the transplant center- the number and type of transplants done there, survival rates, the support given, the recovery phase stay and travel arrangements. The cost of the procedure is also of importance and how much the insurance will cover.

After the transplant you can expect the following:

The surgery can last for 4 to 6hours generally.

Stay in the intensive unit for the first few days- this is for frequent monitoring and to cut back on visitors during the crucial first few days. There will be frequent blood checks. The attendants will be asked to wear a face mask and those with common cold, fever or cough should be refrained from attending on the patient. Frequent hand washing with a hand sanitizer is needed.

 

Insulin is no longer needed as the new pancreas starts functioning. That will be the striking change the patient notices. However, one should also bear in mind the possibility of a rejection, possibility of a bacterial, viral or fungal infection as immunity is compromised by the medicines taken to prevent the rejection.

Failure of the pancreas to function can also occur for some unfortunate people.

immunosuppressive drugs

 

The side effects of the medicines to prevent rejection include:

 

  • Weak and thin bones
  • High blood pressure
  • High cholesterol levels
  • Puffiness of the face
  • Diarrhea or constipation
  • Gums can be swollen, mouth ulcers can occur
  • Acne on the face

Survival rates:

These depend on a lot of factors. Based on data from around the world, 72% of the simultaneous pancreas- kidney transplant survive after 5 years, 59% of the pancreas after kidney transplant survive after 5 years and 52% of pancreas only transplants survive after 5 years.

 

 

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Neuropathy and Diabetes

Neuropathy and Diabetes

numbness feet

 

Neuropathy is a complication that is bothersome and not very often addressed or treated properly. This complication gradually develops over a period of time and is not always due to diabetes mellitus. This can be due to smoking or excessive alcohol intake as well. However,  longer the duration of diabetes, chances of developing a neuropathy are higher. Neuropathy can be aggravated by insulin and some medicines. Rapid control of sugar is known to cause neuropathy for some people.  Classically the neuropathy first affects the feet and toes and may gradually ascend.

 

numbness feet 2

 

 

There are four major types of neuropathy

  • Peripheral neuropathy- this is the commonest form which affects the feet and hands. This can present in many forms. There may be numbness of the digits and reduced ability to feel changes in temperature or pain. Patients may complain of  tingling or burning, feeling of insects crawling on the body, sharp pains at night, and some may experience extreme sensitivity to even the lightest of touches. Some may experience difficulty in walking or can have ulcers or deformity of the feet.
  • Autonomic neuropathy: This part of the nervous system controls the functioning of the eyes, heart, lungs, stomach,intestines and sex organs. Thus, a dysfunction of this part of the nervous system may cause either of the following: urinary bladder problems ( too much urine or lack of control in holding the urine), constipation or diarrhoea, slow emptying of the stomach leading to fullness, difficulty swallowing, dryness of vagina, erectile dysfunction in males, reduced sweating, problems regulating body temperature, difficulty in eyes adjusting to a dark room when coming from a bright room. Some people have variations in blood pressure while getting up from lying down posture leading to imbalance.
  • Radiculoplexus neuropathy- affects bigger nerves and hence the numbness can affect the thighs, buttocks, hip and legs. Characterestically patients complain of difficulty getting from sitting position. Some may complain of abdominal swelling and weak muscles.
  • Mononeuropathy- this is the type of neuropathy affecting one single nerve. This may disappear over a period of time. No long term complications associated with this type. There maybe difficulty in focusing of the eyes, paralysis of one side of the face with deviation of angle of mouth, carpal tunnel syndrome where there is numbness of one  part of the palm with weakness of muscles or loss of sensation. This can be corrected by a small surgery.

 

For details on how to test for neuropathy, please refer to the blog on feet.

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A dazzling smile

A dazzling smile

smile 2smile

 

If eyes are the window to the soul, then the smile offers a look into the health of the pancreas. Diabetes can affect the kidneys, feet, heart and eyes just as much as it could affect the oral health. Oral hygiene has often been the most neglected even among those without diabetes.
A smile is fat free, sugar free, reduces blood pressure, can relieve pain and depression, requires no battery and is free of cost.
There are about 500 micro organisms in the mouth which make a human bite quite dangerous ( more dangerous than an animal bite). Some of the micro organisms are helpful and some are harmful. There have some studies which tried studying the organisms in the mouth and predicting the heart health as these organisms could travel by blood stream and get deposited in the coronary vessels.
The oral cavity contains teeth, the gums which hold the teeth together, the bones on which the teeth rests, the tongue, saliva which bathes the mouth and the pink mucosa lining the mouth inside.
Those with diabetes are more prone for developing gum disease and it progresses twice faster than those without diabetes. Serious gum disease could worsen the sugar control and will need an intensification of treatment. The ability to fight the bacteria is affected in those with diabetes. Further , the diabetes is also a good medium for the organisms to thrive.

 

A look into your mouth:
Gums:  teeth 6

 

 

Gingivitis is a mild form of gum disease, periodontitis is a more serious form of the same. Pockets form between the gums and the teeth which get filled with organisms, pus and then deepen. This can lead to destruction of bone around the teeth, leading to loosening of the teeth and subsequent falling off. The habit of using tobacco rolls or tobacco containing sweetened “paans” can cause a small burn on the insides of the pink mucosa which can later lead on to cancer.
Dry mouth can be due to snoring, poor sugar control, use of too much of alcohol based mouthwashes, some medicines, and also due to kidney diseases. Low salivary production can be a sign of diabetic neuropathy ( autonomic neuropathy) . Saliva helps in digestion of the food while chewing, protects the gums and teeth against the plaques and acid deposition which can damage the teeth and cause decay.
Thrush is a type of fungal infection common among those with diabetes.

 

Teeth
• Soda, energy drinks, carbonated sweetened beverages and lemon water can damage the enamel which is the protective outer coating of the teeth. For people who have recurrent episodes of low sugar, they consume a lot of sweets which could damage the teeth. Speak with the health care provider on ways to prevent low sugar spells and thereby reduce the intake of sweets, thus protecting the oral hygiene.

 

Brushing

Technique of brushing teeth

• Brushing the teeth effectively is to dislodge the plaques which build up at the gum line.
• The tooth brush must meet at the outer and inner surfaces of the teeth at an angle of 45 degrees.
• Move the toothbrush in short strokes, vibrating it back and forth across gum line, gums and tooth surfaces. This involves up and down movements, movements across and also movements to clean the inner sides of the teeth. For brushing the chewing surface, hold the brush horizontally and brush. For cleaning the inner side of the teeth, hold the brush vertically and move it up and down.
• Stiff brushes will not help remove plaques
• Brushing too hard can do more harm and even damage the protective enamel.
• Use a brush size that fits inside your mouth comfortably. A soft bristle brush is good for the gums and also to brush for at least 2 minutes.
• Those with arthritis or braces of the teeth can use an electric brush instead. The electric brush is effective and some of them have a 3000 rpm.
Tooth pastestoothpaste
• There are so many tooth pastes which have flooded the market. Generally the fluoride containing tooth pastes are better.
• Sensitive teeth are due to the damage of the enamel. There are so many toothpastes available for that as well.
• The junk food culture and consumption of processed food items have damaged the teeth enamel more than the yesteryears.
• Use of turmeric is good for those with gingivitis ( diseases of the gums). Use of clove in those with dental aches is another well known home remedy. These have also been incorporated in some of the tooth pastes.
Flossing:

  flossing 1
Dental floss is a string which helps dislodge food between the teeth. Measure an arms length of floss, roll around the index finger of one hand and roll the other free end around the index finger of the other hand. Slide the floss gently between the teeth, keeping the floss taut across the thumbs and floss up and down in a shoe shine manner following the curve of the teeth. Sometimes blood may come while flossing. Do not floss too hard.
Tongue:
Clean the tongue using the under surface of the toothbrush head. The use of metallic cleaners and too vigorous cleaning is to be discouraged to avoid damage to the taste buds on the tongue surface.
Mouth wash:mouthwash

Water is a good mouth wash after any meal. However, there are breath fresheners which make the mouth feel, smell and taste fresh after any meal. There are treatment rinses containing fluoride which help prevent plaque deposition and decay of teeth.
Avoid alcohol containing rinses to avoid dry mouth.
Ask the dentist whether these are needed.

Meet with the dentist at least twice a year to make sure all is well. It is safer and lighter on the purse to have the problem sorted out earlier.
Change your tooth brush at least once in 3 months are if bristles have splayed earlier to that.

 

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Let us walk to good health

Let us walk to good health

From time immemorial, man has been walking for traveling to reach one place, to hunt and gather food for self and family and also in search of a better place to live. Those were the days when there was no transport. God gave humans the legs so they could walk upright which is a feature not common among the animals by nature, though some animals can walk upright with training. Unfortunately, with the advent of modern transportation facilities as well as time pressures and deadlines to be met, people have literally forgotten to use their legs for the use they were meant to be used.

 

Benefits of walking
This is probably the safest form of exercise which can be done by anybody provided the eyesight is good and there is no neuropathy ( affection of the nerves which can cause lack of sensation on the feet making the person unaware of where the feet are planted on the ground).
The farther, faster and more frequently one walks can definitely improve the benefits by many folds. Walking also improves the balance and strengthens bones and muscles besides improving circulation.
Walking is proven to prevent the onset of diabetes, depression, cancer, joint problems, osteoporosis ( fragile bones) and heart ailments. This also helps the worsening of the above. The swinging action of the arms, the strides taken while walking, the fresh air , the sights to enjoy ( one does not get these benefits while walking the treadmill in the confines of either the gymnasium or home) and change in pace while walking navigating the turns all help in improving the muscle power and co-ordination.
Walking in groups with either your colleagues or with friends and family all could be entertaining as well you could even do long distances without being aware of the distance covered at all.

Walking at a speed of 6 km/hour , which amounts to a brisk walk, can burn up to 600 Kcals. But, may be not all can walk as fast. Some may be having either knee or back problems which needs a slower pace. But walking at any given speeds whether unaided or with the help of a walking stick is much better than not walking at all. Parking the car away from where you wish to go and just walking to your destination helps. You may still park close to your destination ( especially during the summer time when the heat maybe quite strong) and take a longer route rather than choosing the shortest route or just walking along the aisles in the malls are good options.
Walking with small children and pets is also a good option.

Ensure the following before walking:
• Check the blood sugar before walking.
• Ask your health care provider if it is safe to embark on a regime.
• Go at a pace comfortable. Walking should not leave one gasping for breath.
• It is okay to rest in between.
• It is okay to take sips of water in between the walk and before the walk.
• If you experience feeling of nausea, chest discomfort, pain in the arms, jaw or back while walking, please seek medical help immediately.

Stretching before any exercise program:
Proper stretching before any exercise or even walking can help tone up the body and prevent joint problems.
Some of the commonly done stretches:

 

Calf stretches- calf stretch

 

Stand at an arms length distance from the wall. Keep one leg forward with knees slightly bent. The other leg with knee straight and heel down. Keeping back straight, move hips towards the wall and feel the stretch. Hold for 30 seconds, relax and repeat with other leg.

 

Quadriceps stretch- quadriceps stretch

 

While supporting a fixed structure, grasp the ankle with one hand and pull the heel up and down till one feels the stretch in the front of the thighs. Hold for 30 seconds, relax and then repeat with other side.

 

Hamstrings stretch-

hamstrings

 

Sit on one chair, and keep the other leg on another chair in front. Keeping the back straight, bend the pelvis forward till a stretch is felt in the back of the thighs.

 

Low back stretch- lying on the back with the feet kept flat and knees bent, bend the knees ( both together or separately) towards the chest using both hands. If one has knee problems, one can hold hands behind the thighs instead.

 

Chest stretches- chest stretches

Clasp hands behind the head. Pull elbows gently by pinching the shoulder blades together.

How to walk?

The ideal way of walking involves walking upright, head held up eyes looking forward, chest pulled out, shoulders thrown back, landing the feet on the heel and taking the stride on their toes. Swing the arms freely slightly bent at the elbows. Walking with small weights held in the hands further enhance the calories burned.
The neck, shoulder and back must be relaxed and not stiff. While walking the treadmill one usually does not maintain these as people have to be holding onto the side railings and the back is usually arched back and stiff to prevent slipping.
Please make sure the footwear is of a good quality and have the insoles and heels checked for wear and tear. View the shoes from behind. If the shoe is tilted to one side, it is time to change the shoes. Change the shoes after it has done 400-600 km.

walking to good health 17
One should dress appropriately in attire that suits the climate, a comfortable and well padded pair of shoes, a scarf or hat as the case may be and some music if needed to be played and listened with an ear phone if needed. Generally the pavements are safe, but it still pays to look ahead and down as well.
150 minutes of any exercise a week is recommended. You can do 30 minutes 5 days a week or split that every day in some form like three sessions of ten minutes each or two sessions of fifteen minutes each.
The long term goal is to make 10000 steps a day. This is ideal for maintaining good health.
One needs to walk at least 30 minutes a day to maintain his or her weight and at least 45 minutes a day to have some weight reduction.
A pedometer is a small device which can be clipped on to the belt or kept in your pocket close to your body. This will count the steps one takes during the course of your daily chores such as walking, climbing stairs, jogging and even adventure sports. But, pedometers vary in their function.

clipped on pedometer

pedometer

 

Get to know your pedometer

 

Ease of use: Some of the pedometers just have to be clipped and it starts. These will be needed to be reset to zero the next day so you could count the number of steps taken.

All pedometers have a battery which needs to be replaced depending on the life.
Some pedometers need to have the data fed in such as date and time, the weight of the person, the length on ones stride which will be calculated and input fed in.
The extra benefits: Some just give the number of steps taken during the day till one resets it back to zero. Other pedometers count the calories burned during the activity, the distance walked and some even upload the data to a remote computer which will maintain a log book of the progress.
Accuracy: generally all pedometers are accurate. However change of strides such as a sudden increase in pace ( or decrease) , jogging in between or even climbing stairs in between the walk may not be counted by the machine( after all it is a machine) and so the calories counted may not be very accurate in that way.
Get a pedometer that has good back lighting so it could be easy to use both indoors and outdoors and also during either the day or night.
Some pedometers are small, others are big. Go for a size that suits you.
The pedometer must have a sturdy clip to help attach on the waistband or have a strap.
Price is also of major concern.
The recent smartphones have an app which could be downloaded for performing the same function as that of a pedometer.
Before you use the pedometer regularly the following are to be noted:

 

  • Please attach the pedometer on yourself for three days in succession whenever you are awake. The total number of steps covered in 3 days divided by three will give the average steps in a day. This is called the baseline steps. ( This will also give you an idea how many steps you had taken in a day which might be embarrassing)
  • Once you know the baseline steps, set up short term goals such as adding a thousand steps a day, for example, to your baseline number which you do target for a week.
  • Once you have achieved this short term goal, you could set yourself another goal. You could reward yourself and make this interesting.

 

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Love your feet !!

Love your feet !!

Feet are, strangely, the most neglected of all the body parts. There are many who pamper their feet, more ladies than men. The feet are an important part to be checked for while being a diabetic. Generally the problems with the feet can occur whether one has either type 1 or 2 diabetes, whether young or old and in any part of the feet though generally the under surface are affected more than any other part of the feet.
Feet are the parts of the body that keep one mobile, that maintain the balance and stance of a person, help drive us around, help us to swim, pedal a cycle, go on hikes or trekking, the list is endless.
Causes of foot problems while having diabetes mellitus:

foot ulcers

 

Trauma to the foot due to poor or ill fitting footwear, not wearing a footwear,
Foot deformities such as an in growing toe nail caused by improper nail clipping, having flat foot when the arches of foot collapse, having claw toes, having over ridden toes.
Poor blood flow to the feet due to small blocks in the blood vessels
Neuropathy due to diabetes which leads to poor sensation- impaired sensation to temperature changes or pain or touch.
Lack of proper access to proper education.
Living alone.
Poor socioeconomic conditions
Poor control over blood sugar, blood pressure and cholesterol.
Smoking
Previous amputation or ulcer foot
Poor eye sight

 

What can be done to prevent foot problems?

foot ulcer

DFU- Diabetic foot ulcer

 
Maintain good blood sugar and blood pressure control
Maintain normal lipid levels
Stop smoking
• Regular exercise
Check the feet regularly- check for cracks or fissures on the heels. Check between the toes for any fungal infection.
• While clipping the nails make sure it is cut straight taking care not to take the corners. The corners can be filed.
Do not cut callosities which are thickened pads of skin. Have either a trained podiatrist( who specializes in foot care and pedicure) manage it. You also use a pumice stone after bathing to rub down the thickened skin.
Apply moisturizing creams on the feet and under surface before retiring at night. Take care not to apply moisturizing creams between the toes as they will retain moisture and favor fungal infection. Use the ones containing Aloe Vera or vitamin E.
Use a hand held mirror to check the under surface of the feet.
Use cotton based socks without tight bands. Some socks now come with silicone impregnated gel pads as well.
Use shoes that are one size bigger. Buy the shoes towards the end of the day when the feet will be swollen slightly. There should be enough room for the toes to wriggle comfortably. Wear and also the sole of the footwear for any nails or sharp objects. Pointed shoes are not advisable.
Check the inside of the footwear with the hands for any irregularity or wearing off.
Have the feet checked at least once by a health care provider.

ingrowing toe nail 1

Ingrowing toe nail due to improper cutting of nails

ingrown-toenail 2

 

 

Look at the difference in the left foot

Charcots foot

 

This is a foot disorder that can happen to almost anybody with diabetes. The loss of deep sensation leads to destruction, degeneration and disorganization of the bones and joints of the foot. The foot can be swollen, warm to touch and be red. But, the pulses of the feet will be normal on examination. Once suspected of this, you will be referred to either a foot care team or the orthopedic doctor. Normally, the foot will be immobilized in a cast. This will be removed after a period of time as suggested by the team and protective custom made footwear will be given.

For those who are used to wearing high heel footwear, the pressure while walking is shifted to the forefoot and there will be strain on the Achilles tendon at the back of the foot ( the thickened cord felt behind the ankle)

Regular check up of the feet:
The feet will be checked for color, any cracks, any infection between the toes, any deformities, any callosities, and non healing wounds, any color changes, the skin of the feet, the hair growth and the nails.
Blisters are water filled collections ,corns are thickened skin due to repeated friction, calluses occur usually on the bottom of the feet which are due to thickened pads of skin, and bunions are those out projections seen from the joint of the big toe which is a structural deformity.

Clawing of toes

bunion 2
The feet will be checked for local warmth, the sensation will be checked with a monofilament, the sensation to appreciate hot and cold sensations, vibration sense will be checked. The pulse will be checked for on the feet. The ankle brachial index ( comparing the pressure of the ankle and arm BP are compared to assess blood flow) are checked in high risk feet.

A podoscan can be used to measure the pressure while walking or stepping.

Customized foot wear is often required when there is a problem to the feet which have to be designed by cobblers specialized for this.

There are tests to measure the amount of blood flow to the legs such as an ultrasound Doppler test ( which is non invasive) or an angiogram which is invasive. If blood flow is compromised ,depending on the severity, either medicines or stents or surgery are advised.
Ulcers ( breach of the skin) may heal with medicines or may remain active or in some people may progress rapidly to cause infection. In some cases, an amputation is performed to save the limb or even life. There are many comfortable prostheses available in the market to get over the handicap.

 

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