Indications for insulin usage:
- When oral medicines fail to control the sugar in maximum doses
- when there are complications to the eyes, kidney or heart,
- when the sugars are very high,
- when there is pregnancy associated with diabetes,
- when intolerant to oral medicines ,
- when diagnosed with latent auto immune diabetes of adults
- when being planned for surgery.
- If diagnosed with type 1 diabetes.
Insulin preparation: There are 3 main types of insulin based on duration of action- short acting, intermediate acting and long acting. • Short acting insulin acts for a short time and peaks fast. This is why this has to be administered with the main meals at least three times a day. • Intermediate acting insulin acts for close to 10 hours and so needs twice daily dosing • The long acting insulin can last for 16-24 hours and thus, needs one or two shots a day • There are premix insulin which comprise short and intermediate acting insulin in one. • Ultra short acting and ultra long acting insulin preparations are now available. • Non injection forms of insulin are now becoming available- studies are on. Nasal, inhaled forms, patches, pills, oral sprays are all forms being researched into to avoid the needle prick. The doses of insulin are usually tailored by the doctor or nurse initially and then adjusted by the patient depending on the sugar reading. Insulin delivery devices are now- a days by pen devices or by continuous subcutaneous devices. The old method of using a vial and syringe is still present. Insulin can be safely administered if used sensibly. Store the insulin in fridges ( not in the freezer) or in a cool room, lightly shake the pen before use if pre mix insulin and roll the insulin pen between the palms of the hand to prevent injecting cold insulin and inject at different sites each time. The needles are to ideally thrown after each injection( though some can use up to 3 injections with a needle) . Sites for injecting: • The thighs on inner side, the outer side and front side are the most preferred sites. • The abdomen wall can be used- but remember not to inject just around the belly button ( umbilicus) inject any place on the flanks more than two finger breaths on either side of the umbilicus. • The arms are not commonly used in adults. • The buttocks and back are used for small children How to inject: • Have the needles changed before injecting • Roll the insulin between the palms of the hands if insulin is cold. • Select the site for injection. It is not mandatory to wipe the area with a spirit wipe. However, if you do, make sure the alcohol or spirit dries out before injecting. • Feel for any thickening or induration. If present, avoid injecting into that site. • If skin is dark at that site avoid injecting there. • Do not inject into dilated veins on the thigh, if present. • Dial the required dose. • There are people who pinch a fold of skin before injecting. It is not necessary to. • Plunge the needle vertically into the site ( perpendicular to skin and not at an angle). Needles are fine and almost painless • Depress the plunger down. The meter will return to zero. • Count to five slowly and remove the pen. • It is common to see a drop of blood after removing the needle. • There is no need for a vigorous massage as is done after deep intramuscular injections. • Do not inject soon before or after an exercise regime. • Rapid acting ( short acting) insulin can be injected in the abdominal wall. The absorption from the thighs is ideal for intermediate and long acting insulin as the absorption is not so fast. The absorption of insulin is slowest if injected in the buttocks. The arm is not ideal for self injection. • The pen device has a spring device which can get worn out over a period of time, maybe after an year or two. Change the delivery system when this happens. The needles after use are to be discarded in a proper manner after putting them in a sharps container. There are places around the world where the used needles are sold again in a fresh pack thus helping spread of disease such as AIDS, Hepatitis B and Hepatitis C. Side effects of insulin: • Hypoglycemia- low sugar • Allergy to the preservative or type of insulin( this is quite rare these days with the advent of purified and human varieties of insulin) • Weight gain • Thickening of the subcutaneous tissue at injection site • Neuropathy- sometimes insulin can cause nerve pain which can be very depressing. Being started on insulin does not mean the end of the road. It is used by the doctor when the sugar levels are very high to bring I down, or when you are undergoing an operation or when you are pregnant or when you have complications affecting the eyes, kidney or heart. It does not mean that insulin once started remains so for the rest of your life. There are needless insulin delivery systems which are present elsewhere. There are other insulin routes available which had been researched, but fell out of favor due to the less efficiency. . While traveling long distances, use a temperature controlled pouch or ice box for keeping the insulin at a cool temperature. If you party, take a small dose before the party, have a snack before you leave, and have the rapid acting insulin after the dinner .Meet your doctor for advice on the dose. Alcohol intake can cause a delayed hypoglycemia(low sugar) The three main insulin delivery options are a pen, syringe, or pump. There are also a few newer insulin delivery systems, including the jet injector. Here are the pros and cons of each insulin delivery method to help you get started. Most of the insurance companies do not approve of these delivery systems which are new and innovative. The pen delivery system is, of course, approved and effective. Pen, Pump, or Syringe? Here’s a rundown of the three different insulin delivery systems, how they work, and their pros and cons. Insulin Syringe You use an insulin syringe to inject insulin into your body with a very fine needle. Pros: • Flexibility. You can choose from many different brands and types of syringes, and you can use them with just about any kind of insulin. • Cost savings. These work more economical than the latest medicines which could be very costly. • People with very regular schedules and consistent meal patterns can do well using this method. Cons: • Time. You have to be meticulous in loading the syringe, remember to warm the insulin if cold , by rolling the cartridge in the palm three or four times. Before injecting you need to check there is no air bubble, attach the needle, and draw the correct dose of insulin into the syringe. • Dosing mistakes. Sometimes error while loading the dose can lead to problems. Insulin Pen An insulin pen works much like a syringe, but it looks like the type of pen you use to write. Insulin pens come in disposable and reusable versions. • Disposable pens come pre-filled with insulin. • Reusable pens use a cartridge filled with insulin. Pros: • Ease and convenience. Pens are convenient to carry about unlike the insulin which ( and still is) comes in bottles.. To use an insulin pen, you just dial up the insulin dose on the pen. Then you press a plunger at one end to inject the insulin through a needle at the other end. • Memory storage. Insulin pens have a handy memory feature that will remind you how much insulin you took, and when you took it. Cons: • Expense. The disposable pens are costly and the ones which could be reused are more economical. However, the reusable ones may have to be changed once in a year or two as the dose dialer spring may become faulty. • Lack of options. Some types of insulin are not available in pen form. Insulin Pump An insulin pump is a device that’s about the same size as a pager. You wear it on your belt or in a pocket, and it delivers a steady stream of rapid acting insulin to your body 24 hours a day through a needle attached to a flexible plastic tube. Whenever you eat, you press a button on the pump to give yourself an extra boost of insulin, called a bolus. The pump is an option for people with type 1 diabetes who have not reached their target blood sugar level using other delivery methods. It’s also a good option for people with diabetes that have very active lifestyles. It’s not clear whether people with type 2 diabetes benefit from using a pump. However among those with type 2 diabetes, who have failed to achieve good sugar control with maximum doses and have to take multiple doses of insulin instead, this is a convenient option. Pros: • Steady insulin release. The pump releases insulin as if mimicking the pancreas. The dose of insulin used will be quite less as it will be delivering tiny doses at pre fixed times. Only short acting insulin is used in this. Pumps are so efficient that you can use less insulin than you would with a syringe or pen. • Ease of use. You’ll no longer have to give yourself injections of insulin throughout the day–the pump will do it for you automatically. You can also eat whenever you choose. • Better blood sugar control. Because it delivers insulin steadily like your pancreas, the pump helps prevent blood sugar swings. • Ease of monitoring. Your pump can communicate with your glucose monitoring system so you can track your blood sugar over time and make changes to your routine as needed. Cons: • Constant wear. You’re going to be attached to this pump nearly all of the time — even when you sleep. • Risks. You need to be very careful about changing the needle every couple of days because there is a slight risk for infection. You also have to monitor your blood sugar levels, because you may be more likely to have a drop in blood sugar (hypoglycemia) with the pump than with a syringe or pen. If the catheter slips out or the pump fails, you might not get the insulin you need and over time your sugars can increase and you could develop a dangerous complication called diabetic ketoacidosis. • Cost. Pumps are costly and so also are the infusion tubing and reservoir. Some of the new ones come with inbuilt sensors as well which are costly. Insurance companies do not approve of this usually. • The infusion tubing and reservoir have to changed once every three days • Sometimes the tubing gets kinked without delivering the insulin which could cause problems • One has to feed in the carbohydrate consumption at the start to prime the pump. • The insulin will not be delivered if there is air in the tubing or if the insulin remaining in the cartridge is very low. Jet Injector Jet injectors don’t have a needle. Instead, they use very high pressure to push a fine spray of insulin through the pores in your skin. Pros: • Needle-free. If you hate needles, a jet injector is an alternative to the insulin syringe or pen. Cons: • Pain. Though needle less, they can cause more pain in some of those with sensitive skin as the insulin is driven inside the body by sheer force. You have a high concentration of nerves close to the surface of your skin. Trying to push insulin through the skin can hurt more than injecting — especially considering how thin needles are. • Uneven insulin delivery. Because they send insulin into the body through the pores, jet injectors may not always deliver an accurate dose. Other options include an insulin patch. Work closely with your doctor to choose the option that best fits your budget, health needs, and lifestyle. Not all the above are available here in Oman. Afreeza is a powder form of insulin which is an ultra rapid acting insulin. The powder is used by an inhaler called the Dreamboat inhaler. Peak levels are reported in 12-14 minutes of inhalation. This is especially beneficial for those with type 1 diabetes who are dependent on insulin for life and also for those with type 2 who become insulin dependent with failure of the pancreas. Close to 5300 patients have been studied in trails across the world and the results so far are promising, but needs further time to be found effective. This has been found to reduce the post meal sugar levels, fasting levels, have less incidence of hypoglycemia( term used for low sugar levels) , reduced weight gain as when compared to rapid acting insulin. However, this may need to be combined with long acting insulin or with oral medicines as the case may be for a better effect. The side effect so far noted has been a non productive cough ( dry cough) Degludec insulin is a new ultra long acting insulin which is still on research programs to test its efficacy. Though it is being marketed for injection once in 3 days or once a week ( which sounds like sweet music) , the effects of the insulin wear off after a day or two. Which means it is still better to have the shots of insulin daily for better control. The sugar control and episodes of low sugar have not shown any improvement over the insulin preparations available in the market today. Continuous glucose monitoring Continuous Glucose monitoring (CGM) devices are in the market for quite some time. These are small gadgets the size of a pager which help to monitor the sugar levels throughout the day and night. On an average a child between the ages 5 and 14 may have to poke the finger for sugar checking at least 50000 times and about 15000 injections of insulin during that time. This is quite phenomenal and frightening. For people on intensive insulin therapy as among those with type 1 diabetes or among those with frequent dips or spikes in their sugar levels which could be related to either food, alcohol or exercise. These machines detect the glucose level just under skin with the help of sensors. These levels are transmitted to a receiver. Pros: • This will give a constant reading and you can adjust the doses accordingly with the help of the health care provider. If the blood glucose reading is 7 mmol/L or 126 mg/dL, it could mean the sugar is going up or down and that is the reading at that time. The machine gives an arrow mark which will give the trend based on the readings just before.. • The tracings can be downloaded and interpreted • The tracings are given for every day in different color lines for easy interpretation • It also gives the average and how many lows one had experienced in the interim. • Alarms are there which could be programmed into the machine which could go on either when sugar swings too low or too high. Cons: • The cost is quite high • Normally the insurance companies do not approve of this unless in certain cases. • The sensors will have to be changed once in 3-7 days. This is costly • This is to be worn at all times. • May not be feasible for children below the age of 12. • One will have to calibrate the machine from time to time so that the readings are accurate. Needle less devices Frequent puncturing of the delicate skin at finger tips and also the insulin shots which are so frequent especially among those with type 1 diabetes are a cause of frustration. Now-a-days needle free CGM devices are coming out. Some are awaiting patents. There will be sensors, a transmitter and receiver. The signals can be sent to smart phones, computers or even laptops. This can be useful for working mothers who have children at home and can remotely access the sugar levels and send information to make corrective steps. The sensors are to be changed once in 3 days which helps prevent skin irritation. The skin top layer which comprises dead cells is painlessly removed and leaves a small abrasion not visible to the naked eye. The Symphony is one brand making such needle free CGM. Dexcom G4 Platinum is awaiting patents rights. This is sleek and hardly noticeable
Cancer care for women
Cancer is one major problem these days and it has become so common to hear of someone known to you, perhaps, on treatment for cancer. It is better to avoid having a cancer than to be treated for one. I do agree that treatment modalities have improved by leaps and bounds and so also have the investigative modalities. Different cancers affecting different areas of the body are known. However, the common ones known among women are the cancer of the breast, the uterus, the ovary and cervix. The drastic changes in lifestyle and increased use of chemicals in various cosmetics and food have led to a steep rise in the prevalence of cancers.
For women above the age of 40 years should be caring for their breasts as much as probably their face ! All it needs a self examination and the earliest changes can be detected by oneself much quicker than a healthcare professional. This is called breast self examination. One can stand in front of mirror and compare the 2 breasts. If the nipple or breast size varies in relation to the other note that down. Feel the breast while lying down. Use the left hand to feel the right breast and the left hand for the right breast. Feel the whole breast from the collar bone to the top of the abdomen and from the armpit to the cleavage with the flat of the hand in a circular motion. Do not panic if you feel any lumps. All lumps need not be cancer. There are lumps which may come and go during the menstrual cycles. Normally the upper and outer part of the breast has the most of lumps. The lower half of the breast can feel like sand on a beach. The area under the nipple can feel like big grains of sand.
It is wise to have the breast examined annually by a doctor who is trained to do so. The doctor will examine the breast by inspection, by feeling for any changes, feeling for any lumps in the breast or in the armpit. The doctor will confirm the presence of lumps by doing an ultrasonogram of the breast. This will detect any lumps hidden in the breast tissue. Sometimes a piece of tissue is taken with a needle which will be inserted into the suspicious lump. A mammogram, a type of X ray examination, will also be performed by the doctor which will have some radiation, but will view the breast in multiple views by pressing the breast tissue for better delineation of any masses. The doctor will look for asymmetry, inversion of the nipple, spots of calcium in the breast tissue and skin deformity. Make it a routine to have a check annually. The check up may take about an hour at the most. These tests are the most commonly performed though there are much more sophisticated tests. It is not wise to perform a mammogram in young women in her thirties as the fat content in the breast at that age is more. However the doctor will decide especially if falling in a high risk category to develop breast cancer. Remember that not all lumps can be detected by the mammogram and tests.
When should you be concerned about a breast examination:
• Family history in a close relative such as mother, sister or aunt.
• If the other breast had been treated for cancer
• If the skin becomes dimpled like an orange peel
• If any lumps are felt in the breast or armpit
• If any blood discharge is seen from the nipple
Similarly any women above the age of 50 years must be careful of the vaginal bleeding. If any bleeding occurs from below after total stoppage of bleeding, one should be concerned and should have a gynecologist examine it. A Pap smear is important and the doctor will decide if a biopsy is needed.
There are tumor markers which can be examined by blood tests at good centers. These are blood tests which show the efficacy of treatment or used for follow up to detect spread. These can also be used to suspect a cancer of the breast, ovary or cervix at an early stage. Tumor markers can be used for a whole lot of cancers besides the ones mentioned above.
Generally women remain subdued as far as society is concerned and they are not even allowed out in public in some of the parts of the world. They are thus forced to swallow their own problems and if there are any, they are not helped out by their male counterparts. There are many symptoms which are attributed to the monthly cycles and some even to the stoppage of the cycles. This newsletter will help address some of the major issues that concern women and also the implications of having diabetes among women. Some of the women do not even speak to the health care providers or even their husbands, about their problems.
Poor diabetic control can impair normal reproductive function. Thus the women with diabetes may have problems conceiving.
Glucose levels may increase in the weeks preceding menstruation
Polycystic ovary: (PCOS)
PCOS is a condition characterized by reduced periods, obesity, acne, increased hair on face, chin. Values of testosterone and another hormone called DHEA will be raised. The condition is called a form of insulin resistance ( a major cause of type 2 diabetes) PCOS can thus be associated with development of type 2 diabetes in the long term. It is usually treated by the obstetrician and gynecologist who may run some tests including an ultrasonogram of the abdomen to look for the ovaries which may be riddled with small fluid containing cysts. This is treated with either metformin or pioglitazone ( both are medicines used in management of diabetes, but can cure the insulin resistance , which in turn will regularize the periods and correct the menstrual irregularities). Usually seen among the adolescent or young women and they would not get pregnant due to the irregularity of periods. In some societies, women after marriage are viewed with suspicion if they do not carry within a year or two.
Fractures among women
Hip fractures are common among those with type 2 diabetes ( almost 2 fold increase than when compared with those without diabetes). Generally fractures are more common among the elderly.
Fractures can be affected by the number and type of falls, the padding of the bony prominences, the strength of the bones and the geometry of the bone. Remember that falls may be due to retinopathy ( when poor eye sight is the cause), poor balance or fall in blood pressure with change in posture, in co-ordination, hypoglycemia(low blood sugar) and muscle weakness.
How to prevent bone loss?
- Regular exercise and a healthy diet.
- Good glycemic control
- Maintaining an adequate intake of vitamin D and calcium
- By avoiding smoking and alcohol.
If above the age of 45 years, have the following done:
Blood tests such as 25( OH) vitamin D3, calcium, blood tests for thyroid and parathyroid and a bone mineral densitometry. This is besides the usual check for eye, heart, blood for lipids, sugar, kidney, hemoglobin, and liver. One must also have a routine mammogram, blood cancer markers, a pap smear of the cervix and a regular check by the gynecologist.
If the bone mineral densitometry( BMD) for short, shows a value of 1.0 – 2.5 SD below normal you will be called osteopenic and if the value is >2.5 SD below normal, you will be labeled as osteoporotic. BMD is a type of scan for the bones where the bone densities are measured at the hip or upper part of thigh bones or the wrist.
How to prevent falls?
- Use of walkers
- Night lamps
- Muscle strengthening exercises.
You can make exercising a joy by doing something out of the way, say for example, you may dance to music within the confines of one`s own room, or use the Hula Loop, climb stairs or walk to the grocery store for a change. Generally women after menopause have chances of developing a heart attack unlike when they had their regular cycles.
Who are prone for fractures?
Those with low BMD( bone mineral density), old age, females, those having light body weight, those with previous fractures or those who smoke cigarette.
Men and women respond differently to sexual dysfunction. Men focus on physiologic function and women on the psychological factors including the quality of relationship. Vaginal dryness and impaired arousal are common among women after menopause. There is little evidence to show benefits of using medicines such as sildenafil ( popularly called as viagra) and tadalafil ( called cialis or snafi)
Pregnancy and diabetes
Most of the patients have a condition called gestational diabetes ( which is diabetes occuring during diabetes and disappear after delivery, but can again come for the next delivery) or people who are already type 1 or type 2 diabetics who become pregnant.
Who is at risk?
• If the BMI >30
• Previous big babies at delivery
• Previous GDM ( Gestational Diabetes Mellitus)
• Family history of DM ( Diabetes Mellitus)
• If belonging to Asian, African or Middle east population
• Diabetes in pregnancy is associated with risks to the baby and mother
• Pre term delivery ( delivery before the expected date)
• Big babies cause problems at delivery
• Associated congenital malformations
• Associated raise in blood pressure in the mother
• Chances of low sugar in the baby after delivery, chances of developing respiratory problems and jaundice ( yellow color)
Before planning pregnancy:
• Reduce weight so that BMI is close to 25
• Maintain good glycemic control.
• Avoid pregnancy if the HbA1c is > 10%
• Avoid unplanned pregnancy
• Assess eye for retinopathy and kidney for nephropathy
Remember that good control only reduces the risk for problems for the baby and the mother, it does not eliminate the risks.
Remember that the sugar levels normalize after delivery, but the risks for developing diabetes type 2 are there if not controlling lifestyle, after delivery.
Also remember that the baby delivered is at risk for developing obesity and type 2 diabetes later on .
Fetal malformation may occur with diabetes, some may have large for age babies, some may have larger tummies either due to more than one baby or large babies or extra water.
Control sugar before planning pregnancy.
Oral contraceptive pills taken for regularizing periods may be associated with poor glycemic control. If on these pills, monitor the sugar and blood pressure from time to time.
Once you become pregnant:
• Make timely appointments with your obstetrician
• Maintain sugar levels at 3.9-5.5mmol/L in fasting and <7.8 mmol/L after meals.
• HbA1c, the 3 month average of sugar, is recommended to be between 6-7%
• Have an eye check if not done in the last 6 months preceding pregnancy
• Diet should be having 30% less calories than before pregnancy
• Diet should contain 50% carbohydrates, 15% protein ( fish, white meat, dairy products, beans, egg) and 35% fat ( polyunsaturated fat)
• Avoid low sugars
• You can exercise- walking is still the best form of exercise. But, consult with your healthcare provider.
• Hydrate yourself well
• REMEMBER that you are caring for another life as well. Hence no rigorous diet.
• It is normal to gain weight during pregnancy.
• The Obstetrician will be checking your weight, blood pressure, feet for swelling and do periodic tests for the growing baby to make sure the baby is growing well and has no problems. Some centers even have facilities for correcting some problems while the baby is still in the uterus without compromising the life of baby and course of pregnancy. ( however it does carry a risk, though).
• Normally a test called GTT ( glucose tolerance test) will be done at 24 weeks You will be given 75 g of glucose to drink and a 2 hours sugar reading will be done. Depending on the levels, diagnosis of diabetes will be made.
• Urine sugar levels are not reliable during pregnancy as there will be sugar in urine even if not pregnant as the glucose spills in urine even at low blood levels.
• Oral medicines for control of diabetes will be stopped once you become pregnant
( however, metformin is safe and so also is glibenclamide during pregnancy and breast feeding).
• However, it is safe to use rapid insulin in suitable doses to prevent sugar fluctuations.
• Periodic sugar measurement and liaise with the Health care providers to correct the dose
• Check sugar before bedtime. If below 7 mmol/L, do have some carbohydrates before bed to avoid low sugars in the early hours of the morning
• Most medicines for blood pressure and for control of cholesterol will be stopped. However there are medicines for control of blood pressure which can be safely used.
• It is safe to continue the thyroid medicine given for low thyroid function.
• Please consult the Health care providers for advice on your regular medications.
• During delivery you will be given a drip which will contain glucose to keep the sugars at level.
• The delivery will be either a normal or cesarean section
• Early breast feeding to prevent low sugars in the baby. This also helps in early bonding between mother and the new baby and also helps the uterus to contract.
• Some women are even started on an insulin pump which will deliver insulin at regular intervals.
Menopause is the phase of life after your periods have stopped. Diabetes and menopause may team up for varied effects on your body, including:
• Changes in blood sugar level. The hormones estrogen and progesterone affect how the cells respond to insulin. After menopause, changes in the hormone levels can trigger fluctuations in the blood sugar level. One may notice that the blood sugar level is more variable or less predictable than before. If the blood sugar gets out of control, one might have a higher risk of diabetes complications.
• Weight gain. Some women gain weight during the menopausal transition and after menopause. This can increase the need for insulin or oral diabetes medication.
• Infections. Even before menopause, high blood sugar levels can contribute to recurrent urinary and vaginal infections. After menopause — when a drop in estrogen makes it easier for bacteria and yeast to thrive in the urinary tract and vagina — the risk is even higher.
• Sleep problems. After menopause, hot flashes and night sweats may keep one up at night. In turn, the sleep deprivation can make it tougher to manage the blood sugar level.
• Sexual problems. Diabetes can damage the nerves of the cells that line the vagina. This can interfere with arousal and orgasm. Vaginal dryness, a common symptom of menopause, may compound the issue by causing pain during sex.
Menopause can wreak havoc on the diabetes control. But there’s plenty one can do to better manage diabetes and menopause.
How to overcome Diabetes during menopause
• Make healthy lifestyle choices. Healthy lifestyle choices — such as eating healthy foods and exercising regularly — are the cornerstone of your diabetes treatment plan.
• Measure your blood sugar frequently. You may need to check your blood sugar level more often than usual during the day, and occasionally during the night. Keep a log of the blood sugar readings and symptoms. Your doctor may use the details to adjust the diabetes treatment plan as needed. Your doctor may also recommend regular hemoglobin A1C testing to reflect your average blood sugar level for the two- to three- month period .
• Ask your doctor about adjusting your diabetes medications. If the average blood sugar level increases, one may either need to increase the dosage of the diabetes medications or begin taking a new medication — especially if one gains weight. Likewise, if the average blood sugar level decreases, one may need to reduce the dosage of your diabetes medications.
• Ask your doctor about cholesterol-lowering medication. If you have diabetes, you’re at increased risk of cardiovascular disease. The risk increases even more when you reach menopause. To reduce the risk, eat healthy foods and exercise regularly. Your doctor may recommend cholesterol-lowering medication as well.
• Seek help for menopausal symptoms. If one is struggling with hot flashes, vaginal dryness, decreased sexual response or other menopausal symptoms, remember that treatment is available. For example, your doctor may recommend a vaginal lubricant to restore vaginal moisture or vaginal estrogen therapy to correct thinning and inflammation of the vaginal walls (vaginal atrophy). If weight gain is a problem, a registered dietitian can help you revise your meal plans. For some women, hormone therapy is an option.
Diabetes and menopause is a twin challenge. Work closely with your doctor to ease the transition.
Driving regulations vary from country to country. But, the fitness to drive especially if one is a diabetic is the same around the world .
Driving is essential for going to work, taking care of family, accessing public and private facilities and institutions, attending classes, interacting with friends and for pleasure. If practicing unsafe driving, it can be a cause of concern for those behind the wheel as well as those on the road.
Those who should not drive if having diabetes:
• Those with recurrent hypoglycemia ( low sugar)
• Those with cataract , those with retinopathy ( diabetic changes in eyes) or color blindness.
• Those with insensitive feet ( they could not feel the foot pedal)
• Those who are on multiple insulin doses
• Those with hypoglycaemia unawareness. These people do not know their sugar levels are below 3 mmol/L (54 mg/dL) as the body does not have any symptoms.
Non diabetic causes to be denied a driving license:
• Those with obstructive sleep apnoea
• Those with unstable angina or heart pain
• Those with epilepsy
• Those who have consumed large volumes of alcohol or other recreational drugs.
• Those with color blindness
Make sure of these while planning a drive:
• Check the glucose level an hour before journey.
• If driving more than an hour, check sugar level after every hour.
• Make sure you stop frequently for hydrating yourself.
• Be careful of taking insulin before driving long hours.
• NEVER DRIVE ALONE
• CARRY GLUCOMETER WITH YOU
• Have either a juice or sugar candy or dextrose tablet or sugar in small container in the car dashboard.
If you feel low in sugar while driving alone:
• Pull off the road and put on the hazard signal.
• Roll down the window glasses both sides.
• Remove the key off the ignition and keep on the seat nearby.
• Take either the sugar or orange juice or candy.
• Check the sugar level using glucometer.
• Call someone for help.
• Rest in the car till help arrives.
• Check sugar level after half an hour. If above 7 mmol/L, drive to nearby resting place or hospital.
When sugar levels go down, the brain gets affected and will lose its cognitive faculty. Decisions will be made at sub conscious level . If the car ignition is not turned off , one may suddenly drive and meet with an accident. If one becomes unconscious, keeping the windows open will help in accessing you.
Make sure you do check sugar level before driving. If low, correct that first and then drive.
Older drivers should note the following:
As age advances, one may notice problems with braking safely, longer response time to an emergency and problems with night vision.
Options available to overcome these in elder drivers:
• Stay physically active
• Regular vision and hearing check
• Use of some chronic medicines may cause drowsiness
• Understand limitations
• Drive under optimal conditions
• Plan ahead
Hypoglycemia or low sugar is one of the nightmares of the patients and the doctors alike. High and low sugars may both present with sweating , confusion and sometimes even unconsciousness.
The commonest causes being taking too much of insulin or some medicines or forgetting to take food, too intense an exercise, consuming alcohol and some tumors of the pancreas.
Generally sweating, shaking of the hands, irritation, craving for food, beating fast of the heart, headache, stomach pain (gastritis) and clouding of consciousness. The body tries to correct the levels itself by an in built mechanism.
For the elderly adults low sugar manifests as confusion, delirium and drowsiness. Tremors and sweating are rare for the elderly with low sugar levels.These can mimic those with a fit or stroke and is, for that strange reason, often misdiagnosed.
For some people the body fails to recognize the features of low sugar. This is dangerous as very low levels are needed for the body to recognize it thereafter. This is called unawareness.
What can be done?
If low sugar happens, drink a can of orange juice or chew on some dry raisins or put some sugar into your mouth. If glucose tablets are available, that is a good option. Chocolates are not a good solution for low sugars as the fat content in chocolates delay the fast rise in sugar. Check your sugar level after 15 minutes and if still low, repeat the above. Get to nearest hospital and get this corrected if needed.
Categories of hypoglycemia:
• Documented hypoglycemia: typical symptoms of hypoglycemia and when the plasma glucose is ≤70 mg%.
• Severe hypoglycemia : An event which requires active assistance of a person to administer glucagon or carbohydrate or adopt any other resuscitative measure.
• Asymptomatic hypoglycemia: An event that is not accompanied by typical symptoms but the plasma glucose ≤70 mg%.
• Probable symptomatic: An event during which hypoglycemic symptoms are not documented with a plasma glucose determination, but presumed to be ≤70 mg%.
• Relative hypoglycemia: An event during which the diabetic patient reports typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but the plasma glucose is ≥ 70mg%.
While driving if low sugar is encountered, drive off the road, put on distress signals, turn off the car, pull down the windows, remove the key from the ignition, take some sugar or orange juice immediately.( you must have a stock of this in the car always) . The brain takes some time to recover from the low sugar and impulsive driving may be initiated leading to accidents. Always check sugar levels before a long drive, break the journey in between long drives and carry an ID mentioning your diabetic status and contact numbers.
Sometimes hospitalization is also needed in serious cases.
The impact low sugars can have on life is very dramatic. For example, developing this while attending an interview or while at the exams or at an important meeting or while driving, can change the course of ones` life. People may then become introverts avoiding social functions for fear of low sugar. They are often mistaken for drunken behavior as well.
There are those without diabetes , those with diabetes and those with pre diabetes, who are neither normal nor diabetic. Those belonging to this group can be prevented from progressing to frank diabetes by following advice from their health care providers.
Who is at risk for developing Pre Diabetes?
• All adults with a BMI ≥ 25 kg/m² who are physically inactive and / or have first degree relatives with diabetes.
• Those who have high blood pressure .
• Those who have an A1c >5.7% .
• Those women delivered baby >9lb
• Those who have acanthosis nigricans( thickened velvety skin at the nape of the neck. This indicates there could be diabetes)
How to diagnose ?
American Diabetes association(ADA) stated that Impaired fasting glucose(IFG) patients have fasting plasma glucose levels between100 mg/dL and 125 mg/dL.For those with impaired glucose tolerance(IGT), 2 hour post glucose levels between 140 mg/dL and 199 mg/dL are significant.
Both IFG and IGT both are at high risk of developing diabetes Mellitus type 2 and atherosclerotic disease cardiovascular disease, retinopathy ( affecting the eyes) and nephropathy ( affecting the kidneys). Most of the time people are reluctant to check for sugar and unfortunately find themselves being diagnosed with diabetes when they present with the dreadful complications such as a stroke, or a heart attack, or blindness or a kidney failure.
It has been shown in various studies that the pre diabetes stage lasts for approximately 7-12 years before onset of clinical diabetes ( when the patient is diagnosed with diabetes)
The silver lining:
If diagnosed with pre diabetes, steps can be taken to prevent the progression to frank diabetes by lifestyle changes such as diet, exercise and increased physical activity and for those with high risk ( as among those with the above mentioned risk factors) medicines such as metformin or pioglitazone or acrabose are used.
Why is pre diabetes important?
The risk of developing an eye problem or heart problem is as high as person with diabetes getting a second heart attack or eye problem. There are more pre diabetes cases than diagnosed diabetes cases around the world.
Diabetes Risk assessment score:
18 – 44 years score 0
45 -64 years score 5
65 years or older score 9
2. Body mass index (BMI)
If BMI is > 25 score 5
If BMI < 25 score 0
3. If a woman who has had a baby weighing more than nine pounds (4 kg) at birth
Yes score 1
No score 0
4. Sibling with diabetes
Yes Score 1
No score 0
5. Parent with diabetes
Yes score 1
No score 0
6. under 65 years of age and do not practice regular exercise at all, or I do it less than three times per week
Yes score 1
No score 0
Total scores and interpretation
If score is 10 or more the risk of developing diabetes is high
If score is between 3 and 9, the risk is intermediate
If score is less than 2, the risk is low
Basic steps while reading a nutrition label:
- Look at the serving size and servings per container. The label will describe the values for a serving. So, If one takes twice the serving, the values should be doubled.
- Look at the calories per serving and the calories from fat. If the commodity contains < 40 cals, it is of low calorie, if <100 cals, it is of a moderate calorie, if <400 cals it is of high calories. Too much of calories will lead to obesity.
- Look for the nutrients to limit- total fat, cholesterol and sodium- these are linked to heart disease, high blood pressure and some cancers. While using canned food, rinse off the liquid as it contains a lot of sodium.
- Get enough of dietary fiber, vitamin A, Vitamin C and calcium. Usually on reading carefully, the calcium content in skimmed milk or full fat milk is the same. But, in yoghurts, the calcium will vary. Look for fiber 3 g and more.
- Look for hidden sugars- for example,high fructose corn syrup. Look for substances ending in -ol or –ose. They are sugars. Remember that 5 g of sugar is the same as a level spoonful of sugar.
- The footnote is the same in all labels. This shows the percentage daily values for an average American who is moderately active. He will need 2000 Kcals a day. For a more active American, 25000 Kcals or more may be needed. The values against each of the main nutrients are mentioned. This label will not change with the food.
- Look for % DV ( Daily value) of 20% and above for nutrients that are good and 5% and below for those which are to be limited.
• The top of the label describes a standard serving size and how many servings a package contains — critical information for interpreting the rest of the numbers on the label.
• A bottle of sweetened ice tea may only have 75 calories per serving. But if that bottle contains two and a half servings and you drink the whole bottle, you’re consuming 225 calories.
• Serving sizes are based on standard measures agreed upon by the USDA and the FDA. One serving of cereal is 3/4 cup, for instance. A single serving of macaroni and cheese is a cup. Most all of the information that follows on the nutrition label is based on that serving size, from calories to grams of fat. So it’s essential to know what a serving is, and to know how much you actually eat.
Phrase Definition ……………and………..What they actually mean
No fat or fat-free Contains less than 0.5 g of fat for each 100 g/ml
Lower or reduced fat Contains at least 25% less fat for each 100 g than original
Low fat Contains less than 3 g fat for each 100 g or 1.5 g for each 100 ml
Low in saturated fat Contains no more than 1.5g for each 100g or 0.75g for each 100ml
Lite or light Contains 25% less kilojoules than the original or comparative product
Sugar free Contains less than ½ g sugar for each 100g
Reduced sugar Contains at least 25% less sugar for each serving than the original product
No added sugar Sugar in any form has not been added as an ingredient
Unsweetened No sugar or sweetener has been added
No preservatives added Contains no added chemicals but may contain natural preservatives
Low sodium Contains less than 120 mg sodium for each 100g
No salt or salt-free Contains 5 mg or less of sodium for each 100g
High fiber Contains between 4.8 g– 6g or more fibre for each 100g
Lean Equal to or less than 10% of total fat
Extra lean Equal to or less than 5% of total fat
Low chole ol Contains 20 mg for each 100g or 10 mg for each 100 ml
• Foods can only be labeled as ‘low in energy’ if it contains no more than 170 kJ for each 100 g of solid food or 80 kJ for each 100 ml of liquids.
• Foods can only be labeled as ‘high in energy’ if it contains 950 kJ for each 100 g of solid food or 250 kJ for each 100 ml of liquids.
• Food labels can no longer appear to be endorsed by a health practitioner (for example medical doctor, dietitian etc), or be associated with testimonials like ‘Mrs X has lost 20 kg by using product Y’.
The use of terms such as ‘healthy’, ‘wholesome’ or ‘nutritious’ is banned.
• Food labels are no longer allowed to state or imply that the product can cure any medical condition.
• Foods that were previously advertised as ‘no sugar added’ or ‘sugar free’ will be banned if the product contains any type of sugar form or derivative such as honey, molasses, sucrose, sugar, fruit juice concentrate, high-fructose corn syrup.
A second phase of regulations is planned and will define food advertising that is targeted at children, the glycemic index and foods that are non-essential for a healthy diet.
Did you Know?
• Fortified, enriched, added, extra and plus actually means that the nutrients such as minerals and fiber have been removed and vitamins have been added while processing. Look for 100% wheat or low sugar cereals.
• Fruit drinks may have little or no real fruit with lots of sugar. Look for 100% fruit juices.
• Natural – may have started with natural ingredients, but while processing will lose the “natural” component.
Food labels are meant for adults and not for children. Please remember that children may need > 2000 Kcals or < 2000 Kcals depending on their level of activity or whether they are boys or girls. Children however will benefit from looking at the calories per serving, the fats per serving, the fibers per serving and make good choices. Most of the children will need food containing more calcium and iron.
If you have diabetes, one needs a blood glucose meter — a small device — to measure, store and display the blood glucose level. Glucometer is commonly used in emergency rooms in hospitals, ambulatory medical care services as in ambulances, helicopters or sea transport while shifting patients. The glucometer is used for analysing sugar leels and adjust dose medication with the help of the health care professional or diabetes educator. This is not used in the diagnosis of Diabetes.
Exercise, food, medications, stress and other factors affect the blood glucose level. Using a blood glucose meter can help better manage the diabetes by tracking any fluctuations caused by these factors.
Many types of blood glucose meters are available, from basic models to more-advanced meters with multiple features and options. The cost of blood glucose meters and test strips varies. Study all the options before deciding which model to buy.. As with any electronic device, this cannot be immersed in water, should not be stored in extremes of temperature and humidity which can affect the device or even the test strips. Most of the new model glucometer devices have an in built check that does not display readings at extremes of temperature. Using a glucometer at high altitude as when climbing high mountains can give erratic readings.
The glucometer uses an enzymatic portion on a test strip which is in a dehydrated state when packed and a detector. The glucose in the blood sample reacts with the enzyme to produce the level which is detected. The commonly used enzymes are hexokinase, glucose oxidase and glucose dehydrogenase
Basics while using any glucometer
- Check the expiration date of the kit
- Make sure the lancets, glucometer, test strips are available globally.
- Make sure the warranty card is filled out and handed over.
- Ask for a demonstration if need be.
- Some meters need a code chip to be inserted with each new box of test strips.
- Always clean the finger tip before pricking the finger tip for the sample of blood. The sides of the non dominant hand are used as the skin is thinner at the side of the fingertips.
- The blood should be flowing well. Do not squeeze the finger tip excessively to get the blood out- this affects the reading.
- Do not reuse the lancets or test strips.
- Dispose the lancets in a sharps disposal bin.
- Remember to use the glucometer often, say at least twice a week. If not used regularly, it may cause the batteries to wear off by discharging or the IC to burn off. It is similar to a motor car that is not used for a month or two. The battery will not work at that time.
- Get the glucometer calibrated often as well as periodic testing of the control solution is necessary.
Choosing the right meter
When selecting a blood glucose meter, it can help to know the basics of how they work.
- To use most blood glucose meters, first insert one end of a test strip into the device.
- Then, prick a clean fingertip with a special needle (lancet) to get a drop of blood.
- Wipe away the first drop of blood.
- Carefully touch the other end of the test strip to the drop of blood and wait for a blood glucose reading to appear on the screen. There are meters which can determine the blood glucose and blood ketone levels as well. These meters are useful for type 1 diabetic patients. It is marketed by the Freestyle under the name Freestyle Optium Xceed.
Blood glucose meters are usually accurate in how they measure glucose, but they differ in the type and number of features they offer. There is a difference between the values obtained by the glucometer and the blood test done at the hospital. The glucometer checks the capillary glucose level. The hospital or clinic estimates the glucose from a sample drawn from the vein.
Here are several factors to consider when choosing a blood glucose meter:
• Cost. Meters vary in price, so shop around. Be sure to factor in the cost of test strips as the insurance doesn’t pay for them. Test strips are the most expensive part of monitoring because they’re used so often. A meter may be the cheapest one on the market, but may not be a good deal if the strips cost twice as much. Also, individually packaged strips tend to cost more, but you might not use all the strips in a container before the expiration date or within the required number of days after opening the container. Figure out which type of strip is most cost-effective for you. Remember that the strips have expiration dates on the cover. Please check it out.
• Ease of use and maintenance. Some meters are easier to use than others. Are both the meter and test strips comfortable to hold? Can you easily see the numbers on the screen? How easy is it to get blood onto the strips? Does it require a small or large drop of blood?
- Also, some brands of meters need to be coded and others have no coding. Code numbers are used to calibrate your meter with the test strips for accurate results. Make sure the strips can be bought from other parts of the world as well so that travel does not be cumbersome.
• Special features. Ask about the features to see what meets your specific needs. For example, some meters are large with strips that are easier to handle. Some are compact and easier to carry. People with impaired vision can buy a meter with a large screen or a “talking” meter that announces the results. Colorful meters that give a quick reading are available for children. Some models have a backlight, which is handy for nighttime readings. Others are manufactured to withstand extreme temperatures, which may be useful for people who spend a lot of time outdoors, such as hikers or construction workers.
• Information storage and retrieval. Consider how the meter stores and retrieves information. Some can track all the information one would normally write in a log, such as the time and date of a test, the result, and trends over time. Some meters offer the ability to download your blood glucose readings to a computer or your cell phone and then email the test results to your doctor.
• Support. Many meter manufacturers include a toll-free number on the back of the meter or packing. Look for a meter that includes clear instructions that demonstrate the correct way to use the meter. Some manufacturers offer user manuals on their websites.
Although finger pricks remain the gold standard for blood sugar monitoring, researchers are developing products designed to take the “ouch” out of the process. You might ask your doctor about these alternatives.
Alternative site monitor Allows blood samples from areas likely to be less painful than your finger, such as your arm, abdomen or thigh Not as accurate as fingertip samples when blood sugar level is rising or falling quickly.
Continuous glucose testing Uses a sensor placed under skin to measure blood sugar level; transmits each reading to a small recording device worn on your body; sounds an alarm if blood sugar level becomes too low or too high Expensive; requires sensor to be replaced every three to seven days depending on the brand; must check blood sugar level with a traditional monitor when dosing for insulin or treating low blood sugar to confirm readings
• Infrared, laser light and electric current technologies are among a few of the possible offerings on the horizon for noninvasive methods of checking blood sugar levels. But, these may cause irritation to the skin where it is placed upon.
Consider these factors that affect meter accuracy and the steps to resolve or prevent the problem:
- Test strip problems —Throw out damaged or outdated test strips. Store strips in their sealed container; keep them away from heat, moisture and humidity. Be sure the strips are meant for your specific glucose meter.
- Extremes of temperature —Keep your glucose meter and test strips at room temperature.
- Alcohol, dirt or other substances on your skin— Wash your hands and the testing site with soap and water before pricking your skin.
- Improper coding— Some meters must be coded to each container of test strips. Be sure the code number in the device matches the code number on the test strip container.
- Monitor problems —Fully insert the test strip into the monitor. Replace the monitor batteries as needed.
- Not enough blood applied to the test strip —Apply a generous drop of blood to the test strip. Don’t add more blood to the test strip after the first drop is applied. Some meters do not need a large drop.
- Testing site location — Blood samples from alternate sites are not as accurate as fingertip samples when the blood sugar level is rising or falling quickly.
Blood glucose monitor quality control tests
When starting a new container of test strips, occasionally perform these quality control tests before using them and when the results seem unusual.
To perform a quality control test, do one or both of the following:
• Test using a control solution. Follow normal blood-testing procedure, but use a liquid control solution instead of blood. These solutions usually come with the monitor and are available at most drugstores and pharmacies. Follow package directions.
• Match the reading with lab results. Take the blood glucose monitor along when visiting the doctor or have an appointment for lab work. Check the blood glucose with the meter at the same time that blood is drawn for lab tests. Then compare the meter’s reading with the lab results. The meter’s result is considered accurate if it falls within 15 percent of the lab test result.
Benefits of exercising:
- Improves body posture and balance
- strengthens the bones and muscles
- improves collateral blood flow
- Improves insulin sensitivity
- improves sugar, blood pressure and lipid levels
- improves endurance levels
- increases the HDL, good cholesterol, levels
- reduces central obesity
- helps to loosen up the taut muscles
- improves flexibility of joints
- psychological well being
- reduces stress
- improves lean body mass
You must have heard from doctors to exercise, but probably not knowing how much to exercise or how to exercise. Lifestyle modification which includes diet, physical activity, cessation of smoking and alcohol, all form the cornerstone in management of diabetes mellitus.
American Diabetes association recommends 150 minutes of exercise a week. There are 3 main types of exercise- aerobics, flexibility and resistance training. Aerobic exercises increase the heart rate and breathing rate. These include jogging, swimming, running, brisk walking, cycling and dancing. Resistance training involves use of weights. Flexibilty exercises include stretching exercises such as gardening, walking, doing household chores and taking the stairs.
Remember the following:
1) do a comprehensive medical check up including the heart, eyes, feet and kidney before starting a program.
2) Do warm up exercises and stretches for 5 minutes before active exercise. Focus on stretching calves, thighs, neck, low back and shoulder group of muscles. Hold the stretch for 30 seconds. Breathe freely.
3) perform the active exercise for a minimum of 20 minutes( you may have to adjust the time according to your age and ability).
4) cool down for 5 minutes where by the heart rate comes back to the levels before exercise.
5) The maximum heart rate to be achieved is calculated as follows- 220 minus your age is the target heart rate. By exercising you should achieve 60-75% of the target heart rate.
6) Try to take a break half way through the exercise regime especially if doing for an hour. Sugar levels can come down and so it is wise to have half a glass of orange juice or have a couple of dates or half an apple or half a banana.
7) Core muscle group involve the muscles supporting the back and abdomen. These also have to be concentrated upon.
8) Do exercises which improve balance like standing on one leg. You may have to hold on to something for support at the beginning.
Beware of these problems before exercising:
Those with eye problems should not do resistance training with weights and heavy exercises which jar the head as it will cause a bleed within the eyes. Similarly, those with feet problems or heart problems also have to be careful with heavy exercises. Cycling and swimming are more beneficial than jogging among those with feet nerve problems or heart problems.
Check the sugar levels before exercising and after cooling down.
Remember to hydrate yourself with fluids while exercising. Check sugar levels before exercising. If the levels are low ( 100 mg/dL or <5.5 mmol/L) always take some snack like bread slice or biscuits so that sugar levels do not fall with the exercise. You can have orange juice or plain candy bars if the sugars are low.Likewise, if sugar levels are very high, reduce the levels with insulin shots and proceed for the exercise regime after consulting with the health care provider.
Never inject insulin before exercising
While doing resistance training, remember not to use heavy weights, but use small weights and increase the repetitions. . Sugar levels fall with exercise unless you do a high intensity exercise ( like sprinting) when the sugars will increase.
Walking is still the best exercise, wear appropriate clothes, avoid exercising outdoors during extremes of climate( hot and cold) and don proper footwear.
Are there any barriers to exercising?
- If a type 1 diabetic, having high blood sugar levels > 300 mg/dL or having ketones in blood.
- If type 2 diabetic having high blood sugar or low blood sugar
- If having an advanced retinopathy ( eye affection in diabetes)- seek consultation with eye specialist before exercising.
- If having nephropathy ( kidney affection in diabetes) – can affect delivery of oxygen to tissues and increase protein in urine.
- If having peripheral neuropathy- ( nerves affected by diabetes)- patients will not have any sensation and so can land in problems.
- If having a heart problem, one is advised not to stress the heart too much
Some common excuses to avoid exercising:
- lack of time
- poor lighting
- harsh climatic conditions
- being overweight and all people are “staring”
- costs of exercising
- racial and cultural reasons
- sweating induced itching of body and mal odour
- Fear of hypoglycemia
Gunner Borg devised an exertion scale , a tool that helped define how hard one felt during any particular activity:
- grade 0 if feeling nothing at all
- grade 1 if feeling very weak
- grade 2 if feeling weak
- grade 3 if feeling moderately weak
- grade 4 if feeling somewhat strong
- grade 5 if feeling strong
- grade 6 if feeling stronger
- grade 7 if feeling very strong
- grade 8 if feeling more difficulty
- grade 9 if feeling very difficult
- grade 10 if feeling extremely difficult
There are some other forms of exercise which can be used to break the monotony.
- Running backwards- less problems for joint injury but have to be in a safe environment.
- Cycle karoke- pedaling on a stationary exercise cycle and singing at the same time. If out of breath, go slow on the cycling. If one can sing well, then increase the tempo of the cycling.
- Troga- yoga on the treadmill. But the speed of the treadmill should not be more than 3 mph. Be careful of falling.Not recommended for the elderly or with joint problems.
What is diabetes?
Diabetes Mellitus ( there is diabetes Insipidus, which is caused by over production of dilute urine due to disorder of pituatary gland ) is a condition caused by either a relative or absolute deficiency of Insulin( produced by the beta cells of the pancreas) which results in increased glucose levels. Type 1 diabetes is when there is an absolute absence of insulin caused by some genetic problems or a destruction of pancreas by some viruses or unknown causes. Type 2 diabetes is caused when there is either not enough insulin to meet the demands or when the insulin is blocked from acting.
Type 1 is usually seen in young people, but can be seen in adults as well. This is less common when compared to type 2 diabetes. There is no treatment yet as successful and effective as insulin injection for those with type 1 diabetes. Research is going on to establish the efficacy of islet cell transplantation and stem cell therapy , but with mixed results.
Type 1 is caused by environmental and genetic factors. Destruction of the pancreatic beta cells by a viral fever can also cause diabetes. Type 2 is caused by poor lifestyle and resulting obesity.
Certain medicines also can worsen the glucose tolerance. Long term steroid administration, anti psychotic medication, hormones are some of the well known offenders.
Who are to be tested?
- Any person who is above the age of 45 years,
- Those who has a family history of diabetes, high blood pressure , high cholesterol levels, heart attack at an young age
- Those with kidney disease
- Those with unexplained weight loss in spite of good appetite
- Those with increased thirst and urination out of proportion to the environmental changes
- Those with problems with eye sight
- Those with waist sizes above 88 cm for men and 80 cms for women ( this differs from race to race)
- Those who experience long time for healing of small cuts and wounds
- Those with polycystic ovarian disease( small water filled swellings on ovaries seen in young women which can lead to hair growth on face, obesity, irregular menstruation and sometimes infertility)
- women who have had diabetes during pregnancy( gestational diabetes)
- Those recurrent urinary infections or boils on skin
- Unexplained weakness
The extent of the epidemic
In today`s world things are moving at a fast pace and often we all struggle to keep pace. This leads to unnecessary mental stress, lack of sleep, improper food intake, smoking, alcoholism or other recreational drug abuse, fast food and intake of large quantities of sweetened beverages in the form of fizzy (carbonated) drinks. This habit coupled with lack of exercise or activity has led to the gigantic proportions at which Diabetes is becoming an epidemic. The arrival of fast food( which unfortunately is very tasty and presentable!), processed food, high calorie food have caught on with the young generation in a big way and the parents do not mind as it is readily available and keeps the children happy and content! Large portion size, eating in front of the TV, eating more at night and lack of adequate physical activity are important factors.
The main culprits
Automation of chores such as having a remote for almost everything- opening and closing the gates, controlling the television, controlling the music system, the air-conditioners, the blinds of the windows, the watering of the garden, switching on the lights and even cooking has made us all so dependant as well as lazy! We even resort to ordering food or things from the market through the phone rather than walk. How many of us prefer to take the stairs than the lift or the escalator? How many of us prefer to walk rather than drive the car even for short errands? The boom of the computer age has worsened the matters by encouraging the children to play games, study, acquire knowledge, socialize, watch movies all within the confines of their rooms leading to an absence of activity outside in the fresh air and leading to another threat, OBESITY. Of course, they may be exercising their hands, eyes and rain, but that alone is not enough!
It has become so bad that if one does not have these “modern diseases” such as high blood pressure or diabetes, one is labeled abnormal!
Let us sit and recollect that the previous generation ( not so long ago) had mostly naturally available food, had plenty of oily food, had enough of sweets made with sugar or ghee, did not use additives or flavoring agents and still were happy and almost disease free. They used to work hard and walk where possible. Medicines were so few those days and so also were the medical facilities. They used coconut oil, there was almost no taboo food and stress was much less.
We have reached a stage where the inevitable cannot be avoided, but it can be delayed by a sensible lifestyle.
BMI ( body mass Index) >25, fat in diet< 30%, Saturated fat < 10%, increased fiber, physical activity 150 minutes per week. If any one of these goals can be achieved the incidence of diabetes can be lessened by as much as 20%! It is time we started something drastic to grab Diabetes by its roots.
Testing for diabetes
Fasting blood sugar >7.0 mmol/L or 126 mg/dL ( this means a fasting period of 8-10 hours)
A post prandial blood sugar of > 11.1 mmol/L or 200 mg/dL ( 2 hours post meal- some doctors advise an hour and half)
HbA1C of >6.5% ( this test gives an average of 3 months sugar readings)
Please be aware that the fasting and post prandial can be misleading depending on what the patient ate, but the HbA1C will give the overall picture.
Please note that a glucometer checks the glucose level on the capillary blood ( at the finger tips) and in the traditional method, blood is taken from the blood vessel at the hospital or clinic. There will be a difference between the different meters at the same time and also a difference between the reading taken from the finger tip and the blood vessel.
The HbA1C is done every 3 months to assess how one is progressing, but it can be done once in 6 months if the control is excellent.
There is a pre diabetes state: if the fasting sugar reading is between 5.6-6.9 mmol/L( 100-125 mg/dL) the patient is labeled as having impaired fasting glucose. If the 2 hour post meal sugar is between 7.8-11 mmol/L(140-199mg/dL) the patient is labeled as having impaired glucose tolerance. If the HbA1C is between 5.7-6.4%, the patient is labeled as having pre diabetes. This means you are not yet a diabetic, but may become one. Usually life style changes are all that matter at this stage. Some doctors prescribe medicines at this stage depending on other factors such as body weight, age, BMI and associated diseases.
Other tests to be done:
Urine sugar estimation is not done these days as much as it used to be done long back. It has become unreliable to monitor diabetes control only on urine sugar levels.
Type 1 diabetics are diagnosed by checking some markers in the blood ( GAD 65, ICA, IAA and C peptide) which will not be normally seen in the blood. This is released by the destruction of the cells producing insulin, the beta cells. C peptide shows how much insulin is being produced by the pancreas.
Other tests of the blood to assess kidneys, liver, lipid profile, urine for protein, check for eyes, heart, feet are to be done periodically to make sure Diabetes has not affected any of these organs.
The eyes ( causing blindness), heart ( attacks ), brain ( strokes or paralysis), kidneys( kidney failure), feet ( numbness or inability to feel or differentiate between hot and cold sensation) and erectile dysfunction in males or infertility among males or females.
Diabetes is the commonest cause of preventable blindness and the commonest cause of amputation ( cutting away an extremity) due to non traumatic causes