All posts in Nutrition

Fasting during Ramadaan

Fasting during Ramadaan

ramadaan feasting                                                                             ramadaan feasting 2

Fasting from dawn to dusk in the holy month of Ramadan for healthy adult Muslims has been ordained and physically sick Muslims are exempt from it. However many Muslims with mild to moderate Diabetes, Hypertension and other medical conditions do want to fast.

The purpose of this presentation is make some recommendations how one can fast safely in light of research on fasting. Many are concerned they cannot fast when they have diabetes mellitus . Please consult with your doctor.

Some people may need some tests to be done to assess fitness for fasting.
The salient features of fasting are :
 It is a voluntary undertaking rather than being ordered by a physician
 There is no selective food intake i.e. protein only, juice only, fruit only , water only etc
 There is no total calorie malnutrition i.e. it not a semi starvation diet.
 An exercise in self discipline i.e. from constant nibbling , drinking, smoking etc
 Psychological effect on the body and additional prayer give additional peace.
People who should ideally not fast, but can fast under supervision
 Diabetes Mellitus Type 1
 Those who get recurrent low sugar levels.
 Chronic Renal Failure including Renal Transplant
 Severe heart and lung conditions
 Severe Epilepsy
 Severe Migraine
 Physically sick ( Quran 2: 184-185)
 Traveler on a journey
 Women during menstruation
 Pregnant and lactating women
 pre pubertal children

Do you know?
 Blood glucose and Insulin levels will fall during the fast.
 The first few days will take some adjustment. If in doubt( headache, sweating, dizziness) check sugar or blood pressure.
What to do during the fasting:
 Beware the sweets and the fried food.
 Remember that by eating throughout the night will not help one tide over the next day. Instead indigestion and gas related problems may set in.
 Fluid intake must be adequate during the night to make up for the reduced intake during the day
 Having too much of sweets or fried food during the Sahoor can lead to dryness of the mouth which can be a cause of concern during the fast.
Points to remember while breaking the fast at Ifthaar:

  • Drink enough water, butter milk or juice. A glass of water melon juice, butter milk or tender coconut water will be a good option to break the fast. One need not add glucose. Water melon juice is sweet by itself and usually people add more sugar. Water melon has a higher glycemic index.
  • Try to be careful with the fried and sweet food. Take them in moderation.
  • Have a good Ifthaar or Isha meal. Have your prayers and then go for a walk to allow digestion.
  • Have some fruit at about midnight if need be. Have a good Sahoor of needed.
  • Avoid too salty food at Sahoor as that can make the mouth dry forcing more fluid intake.
  • Check the sugar level 2 hours after Ifthaar to decide whether  any additional dose of medicines is needed.

Exercise and Ramadhaan
 One can exercise during the month. Please check the sugar before exercise. One can exercise lightly before Isha or after the heavy meal.
 Try to avoid strenuous workouts as the body may be tired due to the lengthy fast.
 Those who want to exercise before Iftaar should check their sugar before exercise. If sugar is below 100mg(5.5 mmol/L) avoid exercising.
 Those with type 1 diabetes are exempt from fasting as their sugar levels are dependant on insulin. However, there are some who do fasting alternate days only. This is depending on your health status.

Some more tips

 Check sugar levels just before Ifthaar and before the Sahoor meal.
 One can check the sugar levels at 7 am before going to work. If the sugar levels are either too low or too high, it is wise to seek medical advice immediately. You may be advised to forego the fast that day.
 Time your medicines between Iftaar and 1am.
 If on long acting insulin such as Glargine or detemir, it is advised to take 20% less either at Ifthaar or Sahoor time
 Normally the doses of most of the medicines could be reduced during the month.
 The medicines have to be tailored in such a way that there is no hypoglycemia
 Be careful of sulphonyl ureas and rapid acting insulin
 Among the sulphonyl ureas, gliclazide is safe in that the chances  of hypoglycemia is lesser and the weight gain is minimal.
 Intermediate acting insulin are avoided during the month due to the 10-12 hour action which can go into the period of fasting

 

The essence of Ramadhaan is the same all over the world, but the flavors may differ.

Have a blessed Ramadhaan

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sugar sweetened beverages

sugar sweetened beverages

It is of a major concern that the increased consumption of sugar sweetened beverages has been linked to the development of the dangerous chronic illnesses such as diabetes type 2, hypertension and coronary heart disease.

The increased consumption has been a potential contributor to the pandemic of obesity.

Unlike carbohydrates which have a high fiber content, the sugar sweetened beverages are nutrient poor and are often accompanied by intake of salty fast food as well. High levels of fructose corn syrup promote insulin resistance as well as fatty liver which can lead on to diabetes type 2.

The pictures given below show the amount of sugar in some of the commonly used things. It is eye popping. Out here in the Middle East, Coca Cola and Mountain Dew are considered like the national drinks and no party is complete without a similar beverage.

sugar beverages                  sugar beverages 2

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Diabetes and digital age

Diabetes and digital age

Though close to 85% use the internet even if from the low socioeconomic  population, digital technology and web based application usage has been very slow to catch on when compared to the boom experienced in the retail shopping and banking sectors worldwide. The vast majority of online communities, mobile applications ( Apps, as they are commonly known) and web sites have been very sluggish in integrating with the mainstream health care stream.

Social networking sites such as Facebook, Twitter, Instagram, WhatsApp and many others I am unsure of, have helped transform social life in a big way to a point where people avoid face to face contact. But these sites have also helped create a platform to support sharing of knowledge, communication and understanding, lever positive behavioral changes and also help in using the audiovisual mode of communication which lingers longer in memory.

More frequent consultations will be costly and not affordable to many even this day. This way of e- health will help tide over this if used well. This will help in increasing treatment adherence, health related behaviors as well as give a feeling of being looked and cared for.

But, there are some barriers to accepting the digital technology such as :

  • in those with physical or visual impairment
  • those who are illiterate
  • those who do not read or speak english
  • those residing in geographically remote areas
  • those with social phobias
  • those concerned about their privacy

 

Telephones have become more than just a gadget to either receive or make a call. With the new generation smartphones, one can record conversations, take excellent photographs, transfer them instantly through internet, chat with friends on the social media, create presentations for meetings, store data in excel format, fax documents, scan documents, use the phone as an organizer, store songs and movies which can be played when alone or bored. Now – a days, these smartphones have also taken the role of a health assistant which can track the progress in exercise schedule, diet, weight loss, and store personal data such as sugar readings over the past 3 months with a graphical representation included. These can be uploaded where you are on this planet and can be linked to the doctors phone for an instant viewing. The list is endless. Maybe there is an app which can remind one to take the medicines on time in case one has forgotten.

There were days when people used log books to record their sugar readings and might even forget to get them when coming for the consultation. Now – a – days with advancements in technology, there have been significant developments in the way a person with diabetes can record their progress or even hide their frustrations by making excuses such as worn out batteries and even having forgotten them at home.

Things have become so technological these days with the data being uploaded to a remote system or a good mobile devise or even the doctors chambers. This comes particularly handy among the young children who sometimes tell lies to escape the wrath of their parents. The data is instantly shared with the parents phone devise helping them keep a track of the events.

There are numerous applications ( Apps) which can be downloaded either for free or for a price which can help in various functions and even take over as a personal health secretary. The list is so vast and all have not been mentioned here. Some are free to download , some have to be paid for.

 

Some apps for nutrition include :  Fooducate, Carbs and Cals, Carbmaster free, calorie counter, calorie tracker, daily burn, lose it, Go meals, weight watchers mobile

Some apps for exercise include: my fitness pal, run tracker,workout trainer

Some for glucose monitoring include: Bant, dLife, Glucose buddy, GluCoMo, Wave sense, Glooko, DBees.com, Glucatrend diabetes, VRee, On track, Handylogs sugar
Ihealth wireless smart glucomonitoring system and TelCare wireless glucose meter can help synchronize ( or sync ) the data with an App, website or even an i cloud.

 

Ditto

ditto glucose data system

This is a devise connected to a glucometer which can transfer data to a remote system or website.

Glook O

glooko

This is a cable connecting a phone to a glucometer. This can be uploaded to the cloud .
Some of the Apps can even show long term trends and graphically represent them making the visualization much better ( if all is going well) . The only problem is one will have to enter the data and allow the App to take care of the rest. This data can be shared with the health care provider almost immediately which helps taking health care to another level.

Diabetes Pal- this helps even recording and advising on level of physical activity and can record the glucose readings as well.

Glucose Buddy

diabetest apps_0

This app lets you record blood glucose levels and note the time of day—such as “before breakfast” or “during activity.” You can view trend graphs, interact in the Glucose Buddy forums, and record insulin injections, exercise, and food eaten. You can also sync your phone to an online account to manage your data on Glucose Buddy’s website. Devices: iPhone, iPod Touch, iPad

WaveSense Meter
wavesense app

 

Manufacturer AgaMatrix’s app lets you log blood glucose levels and type in personal notes. You can record the amount of insulin injected and the number of carbohydrates eaten, and view one-, three-, seven-, 14-, 30-, and 90-day trends in graph or chart form. High, in-range, and low readings are color coded in the logbook. And you can e-mail your stats to family or your doctor. The app comes loaded with about 50 diabetes-related videos. Devices: iPhone, iPod Touch, iPad
OnTrack

Medivo-Acquires-OnTrack-Diabetes

With this app one can log and store the blood glucose level as well as food intake, blood pressure, weight, exercise, pulse, A1C results, body fat percentage, and medications  taken. For each entry,  personal notes can be added. Results can be exported via e-mail to your medical team. Devices: Android phones

 

Lose It

 

lose it app

Track  weight loss, daily food intake, and exercise with this comprehensive app. Meals taken can be added instantly (from a list of common foods, brand-name foods, and restaurant meals, or  own recipes) and watch the sliding scale climb toward the recommended daily calorie limit. One can record exercise (choose from a long list of activities), graph the weight loss, get reminders, and share the progress on Facebook and Twitter. Devices: iPhone, iPod Touch, iPad

Calorie Counter by MyNetDiary

my net diary app

With this app, eon can record meals (choose from an expansive food library that includes restaurant picks), exercise, water intake, medications,  weight and measurements. Food selections include nutrition facts

dLife-

app for DM

This app gives an idea of food and how it affects the sugar, recipes and even short videos. The diabetes website dLife makes a diabetes application that you can use to log glucose levels, find recipes and nutrition information, watch dLife videos, and connect with the dLife community and experts to get answers to your diabetes-related questions. Aside from logging the sugar levels, you can graph daily, weekly, or monthly levels and track trends—all of which  can be e-mailed to yourself or your health care provider. Devices: iPhone, iPod Touch, iPad
Fooducate

 

fooducate-diabetes-app-icon

This app could be your shopping companion on the next trip to the grocery store. You can scan barcodes, search for products, and browse categories to find foods you’re shopping for. By selecting a food, you’ll get a list of health pros (100 percent whole grain!) and cons (loaded with high-fructose corn syrup!) and can compare it to similar products. Keep track of products you eat regularly by “liking” a food. Then, next time you hit the store, you can pull up a “my likes” list of foods you might want to buy again. Devices: iPhone, iPod Touch, iPad
7 MINUTE WORKOUT

7 minute workout app

This is an app which can fit into any routine, has 12 simple exercises which are scientifically formulated.
SWORKIT –

sworkit-app-e1360796738997

This has exercises for strength training, yoga, cardio and stretching. All one has to do is to select a workout category, and how long the exercise plan should be for. Accompanying videos will help show how to perform the exercises properly with minimum injury and maximum effect.

 

 

 

 

 

 

 

RUNKEEPER-

run keeper app

This is an app which is ideal for those interested in cycling, running, swimming and biking. This has an in built Goal Coach which sets a realistic goal to follow.
ManageBGL is an app that offers a simulated insulin pump. This is of use among those who are having Type 1 diabetes or those having type 2 diabetes with multiple doses of insulin.This needs some input such as current and previous blood sugar levels, carbohydrate intake, insulin dose and this will predict the future glucose readings and aid in auto calculation of bolus insulin dose.

To help those who are handicapped with poor eyesight, some glucometers have come with a voice readout.
Sharing the data through social media such as WhatsApp, TalkRay , Viber, Instagram and Facebook have made the modes of sending across data almost instantaneously. If you ever noticed, a once upon a time luxury called email, has now almost become mandatory. There have been instances when patients have even used the above to send me snaps of the medicines they wish to have refilled or even to send me snaps of some ulcers on their foot to help monitor the progress and even to help with their appointments. Scanning and sending their test results from the far corners of the world can be sent across through one of these portals.

 

 

 

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Winter and Diabetes

Winter and Diabetes

Winter-Snowman (1)winter

 

Normally during the cold winter months, the levels of HbA1C, the 3 month average of sugar, can be higher due to higher food quantity consumed to combat the cold, the frequent outdoor barbeques and probably excess liquor consumption with the co incident Christmas and New Year festivities. People spend more time indoors in places where the weather is extreme. Lack of adequate physical activity and excess sleeping hours cuddled up under the warm blankets add more insult. It is quite natural to gain 5-6 kilos during the winter.

Blood Sugar Testing

GlucometerThe finger tips may be cold and so warm them by rubbing them together or wrapping them around a hot mug before pricking the finger for testing. In places where it snows, the glucometer kit has to be kept warm in covered bags so that errors do not come in the readings

 

 

 

Exercising

It is difficult to work up a sweat while exercising during this time and one may feel cold after the exercise due to the evaporation. Remember to dress adequately while going for outdoor exercises. Hydration with adequate amounts of fluids is still important even in the colder months. Dehydration can increase the sugar levels.

yoga       Tai Chi

 

 

Hula Hoop             swimming

Exercise such as skipping rope, doing the Hula Hoop, aerobics, dancing, yoga, swimming in thermal controlled swimming pools or working out in an indoor gymnasium do wonders. The benefits of exercise are the same whether done during winter or summer!!

Some blame the cold for exercising outdoors, but then they also blame the summer heat and humidity when that sets in.

Care of Skin

It is important to take good care of the skin as it can dry quite fast. Adequate and generous application of moisturising creams, and sunscreen if going to winter sports such as skiing or snow surfing or those just trekking in the snow laden mountains are very important. Adequate hydration keeps the skin shining and hydrated.

Those with neuropathy ( where the nerves of the feet are not working properly) may have difficulty in gauging the heat of water used for bathing.

Take care of the feet. Do not use hot water bags to keep yourself warm. Use multiple layers of clothing or socks at night to the feet. In some countries warm fireplaces keep the rooms warm, but beware the carbon monoxide accumulation.

Food & Beverages

Alcohol may cause a sense of warmth caused by dilatation of blood vessels, but the same may be lost after some time. Manage the consumption of alcohol wisely. Try to take hot beverages and easily digestible food such as soups, oats, porridge, steamed food and some fruits. Black tea with crushed ginger and black pepper is a good drink to even soothe the throat. Remember that excess red meat consumption can lead to high cholesterol levels in some races. The temperature can get quite low at night and it is natural people may eat more to raise their body temperature. Remember you do not need that much food at dinner whether it is summer or winter. It is healthier to sleep on a lighter stomach.

Frequent respiratory infections , mostly viral, are quite common. It is wise to have a Flu vaccine taken once a year rather than have to take multiple courses of antibiotics and medications to combat the infection. The elder adults should have a shot of pneumococcal vaccine once in their life.

It is also quite common to get infections due to food poisoning from eating out .

Use tissues, frequent washing of hands  using soap and water or sanitizers especially before shaking hands with others help to prevent transmission.

Gargling of the throat with warm saline helps. So also does steam inhalation.

Fizzy cool sugary drinks do not help whether it is summer or winter.

Enjoy the winter because you will wish it was like this when summer blasts in.

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Salt

Salt

Though essential, there are many bad effects with salt when taken in large amounts over a long period of time. The kidneys cannot get rid of this in time which leads to water retention, hypertension ( raised blood pressure) and studies have shown this is also important in development of osteoporosis among women even with normal calcium levels.

Processed or canned food contain salt in plenty. These may not taste salty.
Fat free or low fat food usually have high sodium content.

Tricks to give a salty taste without really adding salt are to use vinegar or to squeeze lemon on to the dish.

Rock salt gives the taste of salt but is very low on sodium content.

Sodium content in some commonly used foodstuff:

  • A teaspoon of light soya sauce has 365 mg salt.
  • Dark soya sauce has 200 mg in a teaspoon
  • Reduced salt soya sauce has 185 mg in a teaspoon.
  • A small cup of French fries has between 200 to 400 mg salt.
  • Chicken rice has a whooping 1290 mg salt !!
  • A glass of milk (250 ml) has 80-120 mg salt.

Did you know?

One level teaspoon of salt is the equivalent of 2300 mg of sodium

Reducing the salt by 3000 mg a day can reduce the risk of developing a heart event , stroke and death by any cause by phenomenal percentages.

Salt is seen in these forms. Look for these on the nutrition labels.:
• Monosodium glutamate
• Disodium phosphate
• Sodium citrate
• Sodium nitrite
• Sodium nitrate
• Sodium benzoate
• Sodium ascorbate
• Baking powder
• Baking soda

These are salty…….

  • Salt and seasoned salt (or salt seasonings)
  • Boxed mixes of potatoes, rice, or pasta
  • Canned meats
  • Canned soups and vegetables (with salt)
  • Cured or processed foods
  • Ketchup, mustard, salad dressings, other spreads and canned sauces
  • Packaged soups, gravies, or sauces
  • Pickled foods
  • Processed meats: lunch meat, sausage, bacon, and ham
  • Olives
  • Salty snack foods
  • Monosodium glutamate or MSG
  • Soy and steak sauces
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glycemic index

glycemic index

glycemic-index-chart

Glycemic index ( GI )of a food is the increase in blood glucose ( above fasting glucose) 2 hours after ingestion of a constant amount of food divided by a reference food( usually glucose).

To make this easy to understand, if the GI of a particular food is 72, this means that 72% of the ingested food is converted to glucose within the body after 2 hours of consumption.

GI reflects the rate at which carbohydrate is absorbed and digested by the body. Try to aim for low GI food combined with medium or high GI food rather than have more of high GI food. Whatever be the diet chosen, the dietary management has to be combined with physical activity for maximum benefit. A diet which suits one person may not suit all. It is advisable to see which food increases the sugar levels by checking the sugar levels after each food ( this is painful, but this can help to decide which food suits a person).
Low GI food stuff with the GI levels
Yoghurt low fat 14             Milk chocolate 24             Multi grain bread 48          Broccoli 15            Spaghetti 27              Parboiled rice 48                      Celery 15                              Skimmed milk 32                 Carrot juice 45               Bell peppers 15          Fat free milk 32   Jams and marmalade 49            Spinach 15                         Apple 38                         Low fat ice cream 50            Tomato 15                      Plum 38                   Orange juice 52                       Soya beans boiled 16             Pears 38               Kiwi 53                          Artichoke 15           Apricots dried 31                     Banana 54                            Asparagus 15

Black beans 41               Sweet potato 54              Cauliflower 15          Boiled lentils 29                  Egg plant 15                Boiled kidney beans 29      Lettuce 15                                 Green beans 15                          Peanuts 15                             Cucumber 15

 

Medium GI food with their GI levels

Oat bran 55                       Rye-flour bread 64                        Rice, brown 55                 Apricots (tinned in syrup) 64         Fruit cocktail 55 Raisins 64                          Spaghetti, durum wheat 55           Macaroni cheese 64        Popcorn 55                                             Beetroot 64 Muesli 56                          Mars bar 64                                          Mangoes 56                         Black bean soup, tinned 64         Potato, boiled 56

Cake , tart 65                  Mini Wheats (wholemeal) 57           Potato, steamed 65 *       Table sugar (sucrose) 65       Apricots 57

Barley, flakes 66             Potato, new 57              Pineapple 66         Digestives 58              Rice, white 58     Croissant 67         Pizza, cheese 60               Ryvita 67                          Hamburger bun 61      *Ice-cream 61 Whole meal bread 69     Shredded Wheat 69          Muffin (unsweetened) 62                Potato, mashed 70
High GI food with their GI levels
White bread 71                    Broad beans 79                     Golden Grahams 71                 Jelly beans 80                                               Millet 71             Pretzels 81 **                         Watermelon 72                     Rice Krispies 82                     White rolls 73                          Potato, micro waved 82    Puffed wheat 7                   Cornflakes 83                             Corn chips 74                      Potato, instant 83                                       Chips75

**Potato, baked 85             Rice pasta, brown 92             Doughnut 76                      Wafer biscuits 77 **                 Rice cakes 77

Dates 103
** low in calories and highly nutritious
* empty calories

 

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Bariatric surgery

Bariatric surgery

Bariatric surgery is known to be the most effective and long lasting treatment for morbid obesity and many related conditions, but now mounting evidence suggests it may be among the most effective treatments for metabolic diseases and conditions including type 2 diabetes, hypertension, high cholesterol, non-alcoholic fatty liver disease and obstructive sleep apnea.

People are often reluctant to undergo surgery for fear of pain and the possible scars on their body. Some buy time by dieting and doing other herbal cures. These may last for a short time and the weight loss may rebound in a short period. The weight loss will not be permanent in these methods.

Indications:

  • Please be informed that this is not useful among those with type 1 diabetes in curing diabetes.
  • Bariatric surgeries help in almost full cessation of medicines for diabetes type 2, blood pressure and cholesterol after the surgery. Of course, one may have to take a multivitamin tablet or an iron tablet after the surgery.
  • This will be done only of the BMI is >40 or >30 with other medical problems.
  • Please be reminded that not all people who are overweight or obese will benefit from the surgery and so also some not so obese people will benefit from this surgery to help adjust their metabolic dysfunction thereby improving their quality of life.

Work up prior to surgery

doctors-image

Normally all fat people will carry some risk for surgery as they will have many associated problems. A thorough medical check up is normally done which will include blood tests, chest X ray, spirometry to check the lung function, a detailed heart check up , a check up by the anesthetist ( doctor who puts you to sleep during the surgery) and the dietitian. Normally the patient , after medical check up, will be admitted the night before the surgery and be discharged the day after the surgery after performing an X ray to check for leaks ( you will made to drink a medicine and then X ray will be taken). Normally the person can go for work in office after 5 days. This is a procedure done by laparoscope and so pain is very much reduced.

Types of surgeries:

There are two main types of bariatric surgeries – Restrictive and malabsorbptive. “Restrictive” means reducing the size of the stomach that prevents the patient from eating more than a small amount of food. “Malabsorbptive” means that the patient eats normally but the carbohydrate and fat are not absorbed from the gut leading to loss of weight. The common three operations done for obesity all over the world are Gastric Banding, Sleeve Gastrectomy , Mini bypass and Gastric Bypass.

Gastric Banding

bandIn this, a PVC band is applied to the uppermost part of the stomach to restrict the size of the stomach. Thus  there is an artificially small gastric pouch. When the patient takes more than a little food, he feels full rapidly and if he eats more he feels like vomiting. This will need frequent filling up of the band to narrow the opening. It can be relaxed as well when needed. This is not much of use in the adult population these days.
Sleeve Gastrectomy

sleeveThis operation utilizes a series of staplers to run across the stomach to restrict the size of the stomach, to convert it into a tubular structure. The great advantage of this operation is that it does not require frequent adjustments like the gastric band does. Also it is quite easy to perform in experienced hands, and the time taken for surgery is also not much. The average weight loss after sleeve gastrectomy is about 25-30 kg. Depending on the excess weight an individual has, it can be more. In other words, several patients have lost about 50-80 kg after this operation!

 

Gastric Bypass

BypassIt is a more complex operation which bypasses the second half of the stomach by connecting the first half of stomach directly to the intestine. Although this is a technically challenging operation compared to the sleeve gastrectomy, it is more useful in obese patients who are also diabetic, hypertensive, and have cholesterol and triglyceride problems. However the major issue with gastric bypass is the need to take calcium, iron and vitamin B12 supplements as the nutrients are not absorbed sufficiently following this operation.

A Mini Bypass

mini bypassThis is also in practice now.

Side effects:

The common fear is whether these operations carry any major side effects. As far as the sleeve gastrectomy is concerned, the major side effects are in the immediate post operative period, when the surgeon worries about a possible leak. This happens only in a tiny proportion of patients, that too those who are very fat, in the region of around 200 kg. Even in such patients, in the last year or two special devices have been introduced to support the stapler line and prevent leak. Thus with each passing year, these operations are becoming safer.

Conclusion:

The era of bariatric surgery questioned is over, it is now accepted with nearly over forty lakh patients having undergone this surgery from all over the world. With this background, it is best to use it judiciously to make patients lose weight, take control over their diabetes, hypertension, and live healthy long lives. (One study showed that on an average patients live 15 years more after performing bariatric surgery) The sun has not set on Bariatric surgery. It has just risen.
These metabolic surgeries are being done to help control the weight and even get rid of diabetes, hypertension and increased lipids. But, it needs the person to be motivated for the rest of life to keep the beneficial effects of the procedure. These can cost quite a lot, but can be tried to contain those who are extremely obese and or dependent on just too many medicines for their metabolic control.
The surgery will help reduce the intake of medicines for blood pressure, diabetes and high blood lipids, which will make the patient feel much better than having to take so many medicines.

The success of the surgery will depend largely up on the determination of the patient and the ongoing effort by the patient to adhere to the instructions given by the medical and surgical team. One will have to adhere to a diet pattern during the post operative phase. The patients will have to be on a lifelong supplement of vitamins and some on iron as well.
Liposuction removes the subcutaneous fat and not the visceral fat. So, it may help in better look, but the dangerous visceral fat will remain as it is.

What is metabolic syndrome?

This is a condition in which excess body fat is collected and deposited on the body which has an adverse effect on life. Those with metabolic syndrome have the following as well:

  • High Body mass index
  • High blood pressure
  • Polycystic ovaries
  • High blood lipids
  • High waist circumference( >90 cm in males and >80 cms in females)
  • Sleep disorders
  • Fatty liver

Those with metabolic syndrome are prone to develop the following:

  • Type 2 diabetes
  • Coronary heart disease
  • High blood pressure
  • Cancers of the endometrium (inner lining of the uterus), colon and breast.
  • Stroke
  • Infertility
  • Mental disorders
  • Sleep disorders( sleep apnoea)
  • Liver and gall bladder disease

The management will need the support of many specialties including even a psychologist opinion.

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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?

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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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