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Travel and Diabetes

Travel and Diabetes

Aeroplane-In-Sky-Wallpaper                                        cruise-ship

 

In todays world,one needs to relax in between to recharge ones mental and physical faculties. Just being a diabetic should not ruin your chances for a pleasurable trip.

See Your Doctor Before You Go
Before a long trip, have a medical exam to make sure your diabetes is in good control. Schedule the exam with enough time to work on your control before you depart. Get immunization shots — if you need them — at least one month before you leave. If the shots make you sick, you’ll have time to recover before your trip. Some countries do insist on some vaccinations which are mandatory. Most of the vaccines are available at the Tertiary care centers here in the Sultanate. They will issue a vaccination card as well which you may have to produce at the port of entry.

You might be needing a letter stating you are carrying the insulin shots, the glucometer kits, syringes and the pump in your carry bag. The site www.OneBag.com will help. The site diabetesaliciousness.blogspot.com  also helps in knowing rules at airports around the world.

Before any trip, get two papers from your doctor: a letter and a prescription. The letter should explain what you need to do for your diabetes, such as take diabetes pills or insulin shots. It should list insulin, syringes, and any other medications or devices you use. The letter should also list any allergies you have or any foods or medications to which you are sensitive.

The prescription should be for insulin or diabetes pills. You should have more than enough insulin and syringes or pills to last through the trip. But the prescription may help in case of emergency. It may be useful to have a prescription in the language of the country you are visiting as English is not widely spoken or understood in some parts of the world.  The sites https://translate.google.com as well as packitup.com give an idea how to do this translation.

It is safer to have enough stock of the medicines with you. It will be cumbersome to hunt for a doctor and schedule an appointment in the middle of enjoyment. This can even ruin your vacation. Carry enough stock of batteries for the glucometer or pump.

Prepare for an Emergency Abroad
No matter where you go, wear a medical ID bracelet or necklace that shows you have diabetes. If you’re leaving the country, also learn how to say “I have diabetes” and “sugar or orange juice, please” in the language or languages of the countries you’ll visit.

Insure yourself if need be. InsureMy Trip.com can help.

Medical IDs
Many people with diabetes, particularly those who use insulin, should have a medical ID with them at all times.
In the event of a severe hypoglycemic episode, a car accident, or other emergency, the medical ID can provide critical information about the person’s health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc. Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can’t speak for themselves.
Packing Tips
The second rule of travel for a person with diabetes: pack at least twice as much medication and blood-testing supplies as you think you need. Pack all of them in your carry-on bag so that your medication is always with you (checked luggage can get lost). Keep a photograph of the medicines you are on in your smartphone. This will help in case the prescription is lost.
Whether you travel by car, plane, boat, bike, or foot, you’ll want to keep this “carry-on” bag with you at all times. Pack this bag with:
• all the insulin and syringes you will need for the trip
• blood  testing supplies (include extra batteries for your glucose meter)
• all oral medications (an extra supply is a good idea)
• other medications or medical supplies, such as glucagon, antidiarrhoeal medication, antibiotic ointment,  drugs for motion sickness.
• your ID and diabetes identity card
• a well-wrapped, air-tight snack pack of crackers or cheese, peanut butter, fruit, a juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood glucose.
Eating in the Air
When you fly, you can request a special meal low in sugar, fat, or cholesterol. Make your request at least two days before the flight.
If you take insulin, wait until you see your food coming down the aisle before you take your shot. Otherwise, a delay in the meal could lead to low blood glucose. To be safe, always carry some food with you. If your meal is delayed or an order is mixed up, you won’t be stuck with an empty stomach.
I am on insulin

  • When you travel with insulin, give some thought to where you’ll be storing your supplies. Insulin does not need to be refrigerated, but insulin stored in very hot or very cold temperatures may lose strength.
  • Do not store your insulin in the glove compartment or trunk of your car. Backpacks and cycle bags can get quite hot in the direct sunlight. If you plan to travel by car or bike or to be out in the elements, take steps to protect your insulin. Many travel packs are available to keep your insulin cool.
  • In general, you should stick with the exact brand and formulation of insulin that you have been prescribed by your doctor.
  • However, if you run out while you are on the road, and your regular brand is unavailable, you may substitute another brand’s equivalent formulation (for example, NovoLog for Humalog, Humulin R for Novolin R). Changes in formulation (for example, from rapid-acting Humalog to to short-acting Humulin R) require medical supervision.

Insulin can come as U-40, U-80 U-100 and U-500. This means one ml of that insulin could have either 40 units or 80 units or 100 units or 500 units.
If you need to use these insulin preparations, you must buy new syringes to match the new insulin to avoid a mistake in your insulin dose. If you use U-100 syringes for U-40 or U-80 insulin, you will take much less insulin than your correct dose. If you use U-100 insulin in a U-40 or U-80 syringe, you will take too much insulin. However, the pen devices do not have these problems.

Crossing Time Zones
If you take insulin shots and will be crossing time zones, talk to your doctor or diabetes educator before your trip. Bring your flight schedule and information on time zone changes. Your doctor or educator can help you plan the timing of your injections while you travel.

Remember: eastward travel means a shorter day. If you inject insulin, less may be needed. Westward travel means a longer day, so more insulin may be needed.Visit www.voyagemd.com for insulin dose calculation while going on long hours. One may also need to adjust the insulin dosages when going on trekking or climbing mountains when abroad.

  • To keep track of shots and meals through changing time zones, keep a watch on the home time zone until the morning after arrival.
  • Keep the home time in the watch for half a day after arriving so that you take the shots of insulin at the normal time as back home. The time can be set after 8 hours.
  • If on an insulin pump, change the time to new country before take off and program the pumpaccor
  • If one injects insulin while in flight, those traveling frequently suggest you be careful not to inject air into the insulin bottle. In the pressurized cabin, pressure differences can cause the plunger to “fight you.” This can make it hard to measure insulin accurately.
  • Checking the blood glucose while traveling is as important as when at home. Also, check the blood glucose level as soon as possible after landing.
  • Jet lag can make it hard to tell if one have very low or very high blood glucose.

Welcome to a new place
After a long flight, take it easy for a few days. Check your blood glucose often. If you take insulin, plan your activities so you can work in your insulin and meals.

  • If you are more active than usual, your blood glucose could go too low. Take along snacks when hiking or sightseeing. Don’t assume you will be able to find food wherever you are.
  • No matter what kind of diabetes you have, it’s smart to watch what you eat and drink when traveling. Avoid tap water overseas. This includes ice cubes made from tap water.
  • Ask for a list of ingredients for unfamiliar foods. Some foods may upset your stomach and hurt your diabetes control. But you will also find foods that give you a healthy taste of culture.
  • Wear comfortable shoes and never go barefoot. Check your feet every day. You should look for blisters, cuts, redness, swelling, and scratches. Get medical care at the first sign of infection or inflammation.
  • Go wherever your heart leads you. Just remember that you take your diabetes with you. Take your self-care along, too.
  • It is always refreshing to have soda, slushies or coffee when traveling. Remember that these can have a lot of calories and carbohydrates.Try to have plain coffee with low fat milk rather than the fancy Cuppa Mocha, Starbucks or Latte which can pack quite a lot of calories. You must enjoy the vacation and so even if you wish to have all these, go for a stroll after the meals or these beverages.
  • Those planning on visiting a beach, must remember to carry some cool fluids and keep the medicines cool. Those who wish to have their blood sugar checked by pricking must remember to wash their hands well before doing so. Some have alcohol while in the pool or on a beach.
  • The effects of alcohol can be blunted while in water and so many may consume more to get the “kick”. Alcohol can increase the sugar levels. Cocktails can be pretty dangerous in terms of calories and sugar levels.
  • Please do not walk barefoot however beautiful the beach may be.
  • For those on an insulin pump, have the pump disconnected while taking off or landing as the pressure changes can sometimes deliver more insulin than needed. During the reconnection, remember that small air bubbles must be removed or else less insulin will be delivered. The extreme heat can sometimes damage the insulin in the infusion tubing which can work less effectively.

Carry the following with you to avoid problems at the airport
• Some document from the doctor mentioning you are diabetic
• A document to explain why carrying an insulin pump, glucometer, lancets for pricking blood, test strips, insulin pens and the needles, insulin storage cans or packs.
• Carry enough stock of insulin
• Quick acting carbohydrates such as glucose powder.( remember that chocolates, juices may get damaged with travel and the glucose tablet may harden)
• Slow acting carbohydrates such as biscuits or cereal bars.
• Let the flight attendant know of your diabetes as low sugar can mimic drunken behavior!
• Inform the flight attendant or airlines of your diabetes status, so they know what to do if traveling long distances. They may give you extra leg room seats.
• You can also request for a special menu which comes with some of the leading airlines.
• While flying, never aim for perfect glucose control ( keep the levels between 8 – 13 mmol/L or 144 – 203 mg/dL)
• Check the sugar levels in between if long haul flights( more than 4 hours)

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weight loss

weight loss

weight lossweight

 

Weight loss
Sometimes despite the intense effort and hard work put in, the weight loss is not as expected . One also tends to notice that a plateau has been hit after a period of time when the weight remains stationary. This is the dangerous time when one may give up out of frustration and all the weight lost will be regained in no time.

Given below are some of the labels on food items and what they actually mean:

 

Phrase Definition
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 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 fiber 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 cholesterol 20 mg for each 100g or 10 mg for each 100 ml

 

Some of the diets available are mentioned hereunder

Diet type                 1                                            2                                                3                                                4                                                5

Flexibility                 Yes                                        No                                             No                                            No                                          No
Limitation             no food is off limits      single food type               fat and proteins                  limited fat                              replacement meals

Physical activity     Yes                                       No                                         Optional                                   Yes                                      Optional

Sustainability            Yes                                    No                                               No                                            No                                  Costly, No

 

Diet type 1 :  DASH, LEARN, TLC, Mayo Clinic, Mediterranean, Weight watchers

Diet type 2  : Fad

Diet type 3:   Glycemic index diet, Nutrisystem, Sugar busters

Diet type 4: Low Fat

Diet type 5 : Meal replacement ( HMR, Jenny Craig, MEDIFAST)

 

DASH = Dietary Approaches to Stop Hypertension; HMR = Health Management Resources; LEARN = Lifestyle, Exercise, Attitudes, Relationships, Nutrition; TLC = Therapeutic Lifestyle Changes.
While selecting a weight loss program, it should be
• Flexible
• Enjoyable
• Balanced
• Should suit ones budget

There are many medicines and programs which claim to reduce weight. Remember that there is no short cut to weight reduction. It needs patience, support of friends and family and tremendous will power. Usually those with weight issues refrain from socializing, swimming and partying for fear of being ridiculed in public. This leads them to become introverts and they take to eating for comfort which further worsens their predicament. These people have to be coaxed and motivated into moving into a program slowly. Most of these people are fed up of being told about diet and exercise and look for short cuts. The market exploits this weakness. Remember that there is no perfect diet to reduce weight. There is must be more of expenditure of energy than the intake of food. Generally, fried food, less of salt, less of junk food, less of starch are the necessary steps. A rapid weight loss will increase the uric acid levels in many.

What causes a weight-loss plateau?
The progression from initial weight loss to a weight-loss plateau follows a typical pattern. During the first few weeks of losing weight, a rapid drop is normal. In part this is because when calories from food are reduced, the body gets needed energy by releasing its stores of glycogen, a type of carbohydrate found in the muscles and liver. Glycogen holds on to water, so when glycogen is burned for energy, it also releases water, resulting in substantial weight loss that’s mostly water.
A plateau occurs because the metabolism — the process of burning calories for energy — slows as you lose muscle. The weight-loss efforts result in a new equilibrium with a now slower metabolism.
At this new equilibrium, calories eaten equals calories expended. This means that to lose more weight, one has to either increase the level of physical activity or decrease the intake of food. Using the same approach that worked initially may maintain your weight loss, but it won’t lead to more weight loss. Some people feel they should eat more due the workout.

How can you overcome a weight-loss plateau?

b1
If  at a weight loss plateau, you may have lost all of the weight you will, given the number of calories you’re eating each day and the time you spend exercising.
Reassess your habits. Look at the food habits and work out regimes.
Cut more calories. Reduce your daily calorie intake by 200 calories — provided this doesn’t put you below 1,200 calories. Fewer than 1,200 calories a day may not be enough to keep you from feeling hungry all of the time, which increases your risk of overeating. In addition, this reduced calorie intake should be sustainable. If not, you’ll regain the weight you’ve lost and more.
Step up your workout. Increase the amount of time you exercise by an additional 15 to 30 minutes. You might also try increasing the intensity of your exercise, if you feel that’s possible. Additional exercise will cause you to burn more calories. Consider adding resistance or muscle-building exercises. Increasing your muscle mass will help you burn more calories.
Pack more activity into your day. Think outside the gym. Increase your general physical activity throughout the day by walking more and using your car less.
Maybe the weight you’re striving for is unrealistic for you. If you’ve improved your diet and increased your exercise, you’ve already improved your health even without further weight loss. For those who are overweight or obese, even modest weight loss improves chronic health conditions related to being overweight.

Whatever you do, don’t revert back to your old eating and poor exercise habits. That may cause you to regain the weight that you’ve already lost.

Remember any physical activity will go a long way to good health and lift up your mood as well. It always is good for toning up your muscles and joints rather than having to surrender to medicines.
Check weight, waist circumference of the fit of your clothes to analyze the progress. Please also remember that the weight loss may be quick initially and then it will plateau out before dropping again. The amount of weight loss per week varies from person to person and so it is obvious that the results of a certain program in which Mr or Ms A lost weight may not be enough or may be too much for Mr or Ms B. Some get bored of the monotonous diet and it is okay to cut lose once in a while. But, if it is done quite frequently, it can be enough to jolt once the sugar levels go alarmingly high which motivate the person to do better.
Exercise in any form is welcome in the quest for weight reduction. One can split the sessions to three sessions of ten minutes each rather than half an hour at one time. The post meal stroll does work well.

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Summer and Diabetes

Summer and Diabetes

summer                                                 summer-t2

 

Summer is here again. Here, in the Middle east, there are just 2 seasons, summer and a cool season ( not exactly winter). The months from October to March are the months when the mercury drops to pleasant levels. The remaining part of the year is generally quite hot and dry. There are areas in the Middle East where the winter months can be at sub zero temperatures. Many people flock to such places to enjoy the temperature during those times. There are a lot of people from around the globe who constantly live in very cold climates and they look forward to the summer here to get a good tan or just bask in the sun. Vitamin D levels are linked to the exposure to effective sunlight. Though there is plenty of sunshine in some parts of the world , people do not go out in the sun or even if they do, they are covered in their traditional dress so that the exposed areas are minimised. Liberal usage of sunscreen lotions also plays an important role in the development of Vitamin D deficiency.
Sun screen lotions have been marketed by many companies. It is useful to know all these lotions come with a Sun Protection factor (SPF). This number measures how well that lotion will protect from harmful UVB sun rays. These do not protect from harmful UVA rays of the sun. If your skin will burn in 10 minutes of exposure to bright sunlight, a lotion of SPF 15 will protect from sunburns for 150 minutes approximately( 10 x 15). This will of course, depend on the skin type and also the activity being done in the outdoors. Please also note that a lotion of SPF 50 will not mean it will protect 2/3 times more than a lotion with SPF 30. All these lotions may be allergic for those with sensitive skin. Try out a small sample on your wrist and see if okay before purchasing. For effective sunscreen, douse on the lotion at least 30 minutes before going outdoors. Rub in a good measure till the white color of the lotion disappears. Coconut butter (available from the germinating coconut) is a good natural sunscreen. One can periodically apply the sunscreen depending on how long one will be outdoors and also depending on skin type. Cold yoghurt can help in removing the itching and irritation after getting sunburns. The skin becomes red soon after it is burnt and may start peeling off the next day. Many remain in the swimming pool to be away from the heat. But, if in an outdoor swimming pool, the part of the skin exposed may get burnt without ones knowledge until he or she gets out of water. Use wide hats, remain in the shade from time to time and hydrate well also help.
Tips handling the summer:

Hydration with fluids:

• Be well hydrated with non sugary drinks
• Stay off alcohol, caffeinated drinks, fizzy drinks and sports drinks
• Plain water is a good source of fluids- which has no calories
• Tender coconut water is good for hydration
• Pocari sweat can increase the sugar levels for many
• Watermelon juice will increase the sugar levels
• Take small frequent sips from time to time rather than a large quantity at one time.
• There are excellent mocktails made with seasonal fruits such as Pappaya, pomegranate, banana, berries with some milk and sugar if needed. People add a squeeze of lemon with mint leaves to enhance the flavor and cool the body. It need not be chilled to give a cool feeling. The throat may get inflammed by taking too cool drinks while climate is hot.
• Buttermilk is a healthy drink. Adding ginger or chillies will enhance the flavor.
• Dark sago seeds is cooling. These can be soaked for an hour or so and they swell to form light black small jelly soft globules. These can be added to the juices made at home.

 

Heat Exhaustion

This happens when one does vigorous exercise or heavy work outdoors in the sun. Muscle cramps, feeling nauseated, dizzy, having rapid heart rates and feeling very feverish can be markers pointing towards exhaustion. Some collapse due to the heat (called Heat stroke). This can be avoided by exercising in a cool place or indoors or before the temperature climbs up. Have sips of water to cool down, some even wrap a wet towel on their head or face to cool down. Have a bath in normal temperature water. Exercise at times when the sun is not hot- maybe early in the day or late in the evening.

Proper clothing

Wear cotton based clothes which are airy and help evaporate the sweat. Dress in loose sized dress and not using skin tight clothes.

• Carry on yourself plenty of water and snacks. Carry a glucometer as well. Do check the sugar if feeling dizzy.

• Store the glucometer, test strips and insulin in cool places. Never leave them in the car in the summer. There are even times when the medicines stored in blisters do get damaged when left in the car in the heat.

• One can use an umbrella or a wide hat to shade away the heat while walking.

• The eyes and skin can become very dry due to the excess use of air conditioners especially when the draft is aimed towards the face. Use a soothening eye drops which can be prescribed by the eye doctor and moisturizing creams to make the skin moist. One may have to use these quite frequently during the day.

• Remember to keep the windows of the car down a little especially when parked in the sun and also use screens to ward off the direct sunlight.

• Normally the water coming from the water taps or that stored in the overhead tanks will be quite hot. Some even get burnt due the extreme heat of the water. This can be a problem especially among those who are diabetic and who have nerve problems which prevent them from realising the water is hot. Scalds of the private areas are even seen when washing after toilet. It is best to store water overnight in large containers to prevent this from happening.

 

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Cholesterol

Cholesterol

 

Dietary Cholesterol is seen in all animal products such as meats, dairy products and eggs, deep fried items, processed food and some of the bakery products containing trans fats and saturated fats. Cholesterol is made in the liver and is essential to build up cell membranes, formation of sex hormones and form bile acid which help in digestion of fats.

 

Diabetes has long been considered a risk factor for developing a heart disease. The risk is approximately 2 to 4 times more than those without diabetes getting a heart disease. 65% of the deaths among those with diabetes are related to heart diseases. However, even among those with diabetes, the risk varies among individuals and is influenced by gender, duration of diabetes , presence of raised blood pressure, poor cholesterol control and smoking history. The elder the patient, the higher is the risk for developing a heart disease. Among the fairer sex, the protective effect of estrogen can prevent a heart disease till they stop menstruating.  Having a higher body mass and high uric acid levels are also known to trigger heart diseases.

Though maintaining normal or near normal sugar levels can improve the outcome of diabetes in general, good control prevents the progression of or delays the onset of microvascular complications such as the eye, kidney and nerve damage ( retinopathy, nephropathy and neuropathy). However, tight control of the blood pressure and cholesterol levels are important in preventing the progression to or delay the onset of developing macrovascular complications such as stroke, blood vessel diseases of the legs and heart attacks.

The cholesterol panel ( Lipid profile) is generally done after a 12 hour fasting. The blood is collected and the total cholesterol, triglycerides, LDL cholesterol, HDL cholesterol, ratio of cholesterol to HDL and LDL to HDL cholesterol is measured. The HDL cholesterol is the good cholesterol. The ratios mentioned above indicate the tendency to develop a block in the blood vessel. Cholesterol can get deposited in the inner linings of the blood vessels causing varying degrees of blocks. The blood vessel involvement is diffuse among those with diabetes and it has also been shown that numbers of collateral blood vessels are reduced among those with diabetes. The plaque which consists of the cholesterol deposit, can get dislodged and travel in the blood causing blocks elsewhere from its origin. Having pre diabetes, especially the increased glucose levels after meals only ( called IGT) is also a risk for developing a heart disease.

Better investigative modalities and better awareness among the people have helped improve the outcome, but because of sedentary lifestyle and enhanced use of junk food, high cholesterol levels and even heart attacks are quite common among the young.

But, when levels of cholesterol are high, it can get deposited in walls of arteries( blood vessels carrying blood from heart) . Normal levels < 5.2 mmol/L

HDL C ( High density lipoprotein cholesterol) is called the good cholesterol. This transports cholesterol from the blood and artery walls to the liver where it gets converted to bile which help in digestion of fats. Risk of coronary heart disease increases by 2-3% for every 1.0 mmol/L fall in levels of HDL C. Normal level > 1.0 mmol/L.

LDL C ( Low density Lipoprotein cholesterol) is called the bad cholesterol. This helps to transport cholesterol to various body cells and deposit the excess in walls of the arteries. Normal levels < 1.7 mmol/L if diabetic or < 2.3 mmol/L if not diabetic.

The cholesterol can get deposited on the inner linings of the blood vessels causing blocks in the eyes, heart supplying blood vessels, brain and kidneys causing blindness, heart attacks, strokes or paralysis, erectile dysfunction among males and kidney failure.

 

According to the data available with the various governing bodies around the globe, for every 10 mg/dL or 0.25 mmol/L increase of HDL, the good cholesterol, the risk for developing a heart attack is reduced by 2-3%. Similarly for every 1 mmol/L or 88.7 mg/dL increase of triglyceride level, the risk of developing a heart disease increases by 30% among men and 75% among women.

The main cholesterol level to be kept under control is the LDL cholesterol. The lower the level of LDL, less is the risk to develop a heart attack. Similarly, higher the HDL, the protective cholesterol, better is the outcome.

 
Non pharmacological ways to improve the HDL levels and reduce the LDL levels:

• Exercise
• Reduce smoking
• Increased consumption of avocados, a handful of non roasted non salted dry nuts( walnuts, almonds, pistachios).
• Olive oil or canola oil to be taken
• Reduction or avoiding red meat ( mutton, beef, pork, organ meat such as liver, gizzard)
• Reduction of deep fried food items
• Reduced intake of prawns, crabs and lobster.
• Reduced intake of full cream dairy products

When to treat with medicines?

When lifestyle modification and diet control alone do not help in lowering the levels, one will have to reconsider options of pharmacotherapy.

Guidelines from around the world have stressed the need for treatment with medicines in the following groups of people:
• If aged between 40-75 years with >7.5% risk of developing a heart attack in the next ten years

• If aged < 40 years with LDL cholesterol levels >190 mg/dL

• If person has suffered from any of the following:
• Heart attack
• Stroke or paralysis
• Transient ischemic attack ( features of stroke which reversed due to incomplete block to blood flow to brain)
• Those with peripheral artery disease of the extremities
• Those who have undergone revascularization procedures to improve blood flow in either heart or extremities

The risk for developing a heart attack is estimated by the health care professionals by using calculators incorporating ones race, gender, age, total cholesterol, LDL cholesterol, HDL cholesterol, blood pressure, use of medicines for controlling blood pressure, smoking and diabetes mellitus.

Normally the lipid profile ,which tests the various cholesterol types, is done after a 12 hour fasting. There are tests also which are available to assess how much of cholesterol has already lined the vessels. ( coronary angiogram, coronary calcium scoring and carotid doppler) Check the lipid levels once in 3 months if the levels are high or else once in 6 months. The doctor will advise when to start the medicines and if needed, when to stop the medicines. Some of the tests done to check heart functioning will also indirectly determine the lining of the vessels supplying the heart.( ECHO cardiogram and Stress Treadmill testing)

Statins, fibrates and drugs which reduce absorption of cholesterol from the intestines,ezetimibe, are used in treatment of high lipid levels. The former group is generally used around the world. Niacin is still being used in some parts of the world

A note on statins

Statins are generally found to have some side effects such as muscle pain and altered liver enzyme levels. It has also been associated with a 0.5% increase in chance in developing diabetes which led to a scare among the patients and health care providers.

However, statins have benefits besides lowering cholesterol levels, statins also help in stabilizing the plaque formation , reducing the inflammation of the blood vessels and regression of blocks to an extent. The plaque which is a mixture of calcium, lipids,fats and blood elements can get “fractured” and can shower small blocks through the blood vessels which can cause block at distant sites.

The benefits of taking a medicine to lower cholesterol far outweigh the risks associated with the medicine.

The benefits of taking medicines to control cholesterol go along way beyond just control of high levels. Cholesterol deposition almost always occurs in the inner lining of the blood vessels. People of some races are more prone for developing heart attacks when compared to people of other races. Some people inquire if they can stop the medicines for cholesterol once the levels are normal. Being a diabetic, the chances of getting a heart attack are high and so taking this tablet will go a long way to prevent the onset of developing a serious heart disorder. If intolerant to statins, there are other classes of medicines which can be used to control the cholesterol levels.

Some of the commonly used statins are Simvastatin, Fluvastatin, Atorvatstain and Rosuvastatin.

The dose needed depends on the treating health care professional and the need for starting the treatment as to whether it was for prevention or for treatment. If high doses are needed, the side effects can be minimized by addition of ezetimibe ( drug to impair absorption of cholesterol from intestines) or fibrates.

The liver enzyme levels and muscle enzyme level are checked frequently after starting therapy. A baseline level of the above enzymes are taken in some centers before commencing therapy.
The triglyceride levels are high among the Asians and South Indians due to their dietary habits and genetic make up. However among those in the rest of the world, LDL levels are high and targeted for control.

 

Exercise and impact on cholesterol

Link between coronary heart disease and cholesterol levels are well established through various studies.
Sedentary lifestyle adds to the risk for development of heart problems.

It has been shown by various studies that men who exercised more 75% of the maximum heart rate ( 220-age in years) at least 3 times a week for 12 weeks have reduced risk for developing heart disease. However, such studies have not been done on women.

In post menopausal women benefits of exercise were seen among those who exercise for 70% maximum heart rate for 24 weeks and who were on hormone replacement therapy. It was shown low to moderately intense exercise among post menopausal women improved outcomes.

The intensity, duration and frequency of exercise, the initial HDL C levels and length of the training period determine the benefits of exercise on cholesterol levels.

 

Exercising regularly for 8 months or jogging for 6 months or 3 weeks of diet control or brisk walking for three months can help reduce the LDL cholesterol. 5-10% body weight reduction can reduce the cholesterol levels. Recommendation is 150 minutes of moderate exercise or 1000 Kcals to be burned per week.
Omega 3 capsules taken once daily( containing fish oil) help to reduce a triglyceride levels to an extent. For the vegetarians, flaxseeds can be taken in place of Omega 3 capsules. There are no studies establishing the benefits of taking this to prevent heart attacks or strokes.

 

The diet should contain- 50-60% of total calories as carbohydrates, < 30% as fats, 15% as proteins, < 10% as polyunsaturated, < 20% as monounsaturated and 20-30 g of dietary fiber.

A note on oils.

 

Replacing saturated and transfats with monounsaturated and polyunsaturated fatty acids can help improve the cholesterol levels.

If monounsaturated acids are used, there is a 12% reduction in total cholesterol and 15% reduction in LDL cholesterol. If polyunsaturated acids are used, cholesterol reduction by 19% and LDL by 22% is observed in studies.

Monounsaturated fatty acids are always better than polyunsaturated oils.

Remember that any oil when it is boiled loses its good properties. Hence, even olive oil or canola oil will not do any good if they are boiled.

Olive oil comes as extra virgin type and Pomace type. The extra virgin is used for raw consumption and the pomace type for cooking. Olive oil is actually the juice of olives unlike most of the oils made from the seeds.

 

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Obesity

Obesity

BMI               BMI 2      BMI 3

There are people who look good when thin, there are others who look good when fat. Generally when type 2 patients are uncontrolled in their sugar control, there is weight loss due to the excess catabolism by glucose.

Increased obesity was observed in all ages, genders, races and educational levels with an increased magnitude among those in their 20`s with some form of college education. One fourth of the children and adolescents between the ages 6 and 17 are overweight!

Effects of being obese

Negative attitudes towards obesity are very common, lead to depression and these people experience discrimination from society. They usually try their level best to find excuses from shying away from exercise such as blaming the sweating, the itching, and the discomfort by rubbing of thighs and increased axillary pad of fat and having rashes between skin folds on the neck, axilla, below the breasts, in the groin and between the thighs. Getting dresses also is a problem though there are some shops that cater only to the oversized.
The risk is deadly!
Control of weight is important to prevent or manage blood pressure, diabetes, joint related problems, cancer of the endometrium and ovaries among women and cancer of the colon, snoring and disturbed sleep patterns( called Obstructive sleep apnoea), gall stones, impotence and even depression.

The impact of obesity

Disease                                                   Relative risk in men                            Relative risk in women

Type 2 diabetes                                                   12.7                                                          5.2
Hypertension                                                       4.2                                                             2.6
Heart attack                                                           3.2                                                            1.5
Colon cancer                                                         2.7                                                             3
Angina                                                                      1.8                                                           1.8
Gall bladder disease                                            1.8                                                            1.8
Ovarian cancer                                                        —                                                             1.7
Joint problems                                                       1.4                                                          1.9
Stroke                                                                         1.3                                                          1.3

Normally people tend to gain weight with age due to change in their physical activity or small changes in diet. Weight gain can also be seen during pregnancy, menopause, adolescence, just after marriage or among those who stop smoking.
What causes obesity?

All are aware of the sedentary lifestyle- spending more time on the couch or bed. Too much of a dependence on automated chores such as having remote controlled devices for almost every chore at home- such as for opening and closing the gates, the doors, for raising and closing the blinds, for turning on and off the lights , turning on and off the cooking range, even controlling the television, having washing machines and what not!

It is a well known fact that when there is a mismatch between the intake of food and the expenditure of calories, obesity sets in.

Many still to this day blame their genes and poor forefathers for their obesity!

There are some other causes for obesity :

Cessation of smoking can cause an increased appetite and reduced metabolic rate which can cause a modest raise of weight. (NO! This does not mean smoking is good for weight control!)
• There are medicines such as anti diabetic medicines, anti depressants, steroids in large doses for a long duration and some medicines for treatment of fits which can cause weight gain.
Types of fat

There are two types of fat on a person. They are subcutaneous fat and visceral fat. The former is seen just under the skin and latter seen internally around the organs.

Subcutaneous fat acts like a cushion to protect the body. It acts a storehouse of energy. Excess subcutaneous fat will give the flabby arms and thighs and is easily burned off with exercise than with diet alone.

Visceral fat increases the waist line tightening the internal organs. Thin people also have visceral fat which makes them as prone for diabetes and cardiovascular diseases as much as for obese people. Excess visceral fat is linked to increased triglycerides ( bad cholesterol), reduced High density lipoprotein ( good cholesterol), elevated blood pressure and elevated blood glucose.

Belly fat goes by many names such as beer belly, pot belly, abdominal fat, organ fat or intra-abdominal fat. Visceral fat is located inside the peritoneal cavity packed in between the internal organs as opposed to subcutaneous fat ( found underneath the skin) and intra muscular fat ( found interspersed in skeletal muscle) An excess of visceral fat is known as central obesity and the abdomen protrudes excessively.
Role of fat: Fat serves as a site for storage of energy, fat effects release of fatty acids in response to signals and functions as an endocrine organ

Apple sized, Pear sized, and Lemon on match stick are different ways to describe those overweight or obese.

There are variations of the size of a person with changes in gender and ageing.

In males, there is a greater lean mass, bone mineral mass, muscle mass in arm, reduced fat mass, less limb mass, greater central fat and larger stronger bones ( there are exceptions though)

Among women, after pregnancy there is increased visceral and central adiposity. Subcutaneous fat is more among women

How to measure level of obesity?

There are different methods to measure accurately the quantity of body fat- underwater densitometry, dual energy X ray absorptiometry, total body water estimate and bioelectric impedence.

Body Mass Index (BMI)
BMI is a common term used by the health care team to describe if you are in range for normal weight to height . This is calculated by dividing the weight in kilograms by the square of the height in meters.
BMI does not reflect the regional fat distribution. But, BMI may not be suitable for measuring among the elderly due to reduced lean body mass.

Although Asians have lower BMI than westerners, they have a higher % of body fat. Only 1/5 of the total body fat is located centrally of this ¾ is subcutaneous. Visceral fat usually increases in both sexes.
A person of BMI 25 has a 5 fold risk of developing type 2 diabetes than a person of BMI 22. If the BMI is increased to 30, the risk is increased to 28 times and the risk is increased to 93 times if the BMI is raised to 35 and more.
The common misconception that only visibly over weight and obese people have belly fat needs to be debunked. Waist to hip ratio is a better marker than the weighing scale in knowing how much belly fat one has.

If the waist Hip ratio is <0.8 (males) < 0.75(females) the risk is low
If the waist to hip ratio is 0.96-1.0 (males) or 0.81-0.85 (females) the risk is moderate
If the waist to hip ratio is >1.0 (males) and >0.85 (females) the risk is high
While assessing the treatment options, the healthcare professional has to take into account the expectations, the level of motivation, the activity history, screen for psychiatric disorders and eating disorders. There are so many diets available in the market each one claiming to be better than the other. The same applies to the various health programs each claiming to give better weight reduction than the other competitors. Losing weight can be frustrating to both the clinician and the patient.

How to reduce weight?

Even a 5-10% weight reduction can help to reduce blood pressure, lipids, insulin resistance, prevent joint problems and improve the quality of life and improve the psyche of the patient.

A simple step of reducing just a spoon of sugar a day can help you reduce 500 cals a day!

Though there are many medicines to help reduce weight, remember there are side effects with each. There are herbal medicines as well. Some of the so called weight loss powders have had side effects due to some of the chemicals incorporated in them. But, the silver lining is that there is nothing to beat a controlled food intake, eat sensibly and exercise in some form to burn off more than what you ate. There are just no short cuts to reducing weight. You need essential nutrients and you need a good breakfast. Drink plenty of fluids in the form of water and go for natural unprocessed food.

Doing some stepping or spot jogging exercises while watching television, pilates exercises, Yoga or Tai Chi , doing some aerobics or hula hoops in the confines of your room, can also help to reduce weight. This negates the excuses of not having a good neighborhood for exercising.

Visceral fat deposition can be reduced by losing weight the healthy way, de-stressing by meditation and deep breathing exercises, hydrating well with fluids, taking a healthy diet containing enough of fiber, fruits and vegetables, wheat bran, fish, non roasted nuts, green tea avoiding junk food, fruit punches, alcohol and leading a life which is physically active.
Did you know Ghee and Butter contain essential fatty acids? You may recollect that those in the past generation ( and even today)used to have thick rotis ( made with dough of wheat) with a dash of ghee or butter on them for food in parts of northern India. But, you must also remember that these people used to expend the energy as well. Having such rotis and relaxing on a sofa, in today`s world can be a suicide.

More processed food contains less of vitamin B12.

Read more in the post titled, “Weight loss”

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Cancer care for women

Cancer care for women

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.

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women and diabetes

women and diabetes

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

elderly 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.

Sexual dysfunction

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

Pregnant-woman

 

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

Why important?
• Diabetes in pregnancy is associated with risks to the baby and mother
• Miscarriages
• 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
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.

 

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Driving and diabetes

Driving and diabetes

texting-driving-04_0distracted-driving_100375446_l

 

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.                                                                                                        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

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Pre Diabetes

Pre Diabetes

s3                                     s2

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:

1. Age
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

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Reading Nutrition labels

Reading Nutrition labels

Basic steps while reading a nutrition label:

nutrition-facts-label   how-to-read-nutrition-labels-zoom2-1024x525

  • 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.

Also remember…..
• 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.

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