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.
This is a devise connected to a glucometer which can transfer data to a remote system or website.
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.
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
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
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
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
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
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
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
This is an app which can fit into any routine, has 12 simple exercises which are scientifically formulated.
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.
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.
Smoking has been the passion of many though the prevalence has come down from a lofty 40% in 1965 to 20.9% in 2006. 90 % of the smokers were below 20 years of age. 18.1% of the adult females and 23.9% of the adult males smoked in a survey conducted across some continents in 2008. It sure must be higher now.
Peer pressure, stress at work, status symbol, a recreation, a pastime, copying their role models all are causes of initiating smoking.
All are aware that smoking is associated with reduced life span, higher risk of different types of cancers, digestive problems, staining of the teeth, leg problems and also problems during pregnancy.
Those who remain in the company of smokers are equally at risk for developing complications– called environmental tobacco smoke. Children whose parent/s smoke had a higher chance of being an asthmatic , having recurrent respiratory infections or even ear infections.
Diabetes and smoking
Among those with diabetes who smoked , the risks were greater than those who did not smoke and had diabetes.
Metabolic control was poor among the diabetic patients who smoked. The following were noted among the diabetic patients who smoked:
• Increased fluctuations in sugar levels and HbA1c, the 3 month average of sugar
• Increased blood pressure and retinal blood flow
• Increased bad cholesterol- LDL and triglyceride
• Associated increase in adrenaline, growth hormone or cortisol which could increase glucose levels.
• There could be associated alcohol intake with an increased high fat diet consumption.
• Less likelihood of exercising.
• There may be a progression of complications such as retinopathy, neuropathy and nephropathy.
Cessation of smoking is an important step in the management of diabetes management. This is associated with less chances of developing a heart related disorder, stroke, cancer or leg vascular disease and improving life expectancy. Those who benefit most are those who quit at a younger age, those who have lesser tobacco pack years. Smoking cessation has health benefits for all ages even after the age of 65 years or even after smoking related complications develop. Mortality rates of those smokers who have abstained for more than 15 years closely approach that of those non smokers.
Withdrawal symptoms -craving, depression, anger, frustration, irritability and sleep disorders.
The treatment of withdrawal includes psychological treatment, positive reinforcement and medicines which help to replace nicotine such as nicotine patches kept on the skin ,nicotine containing chewing gums, lozenges, nasal sprays or even inhalers.
Menthol cigarettes or low tar cigarettes do not reduce the risk for hazards to smoking.
Electronic cigarettes have not yet been approved for withdrawal, though many claim to find them beneficial.
Benefits of cessation of smoking
Half of the excess cardiovascular risk is eliminated in first year of quitting. There is 30- 50% excess risk for lung cancer even after quitting for almost 10 years.
The highest risk for the development of type 2 diabetes occurred in the first 3 years after quitting but this risk gradually declined to 0 at 12 years.
In lighter vein…….
- 46% admitted to not eating sweets when smoking and 38% admitted smoking calmed them down…..
- But, those who stopped smoking were found to gain 3.8 to 4 kg per year in men and among women a 2.8-3 kg increase per year. But, this increase can be prevented by good lifestyle management.
- I even had patients tell me they felt smoking was able to control their diabetes better due to the absence of weight gain as well as by not eating sweets. But, the hazards of smoking outweigh these small “benefits”.
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
** low in calories and highly nutritious
* empty calories
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.
- 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
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 –
In 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 –
This 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 –
It 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
This is also in practice now.
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.
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.
- 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.
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:
|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
||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
||Contains less than ½ g sugar for each 100g
||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
||No sugar or sweetener has been added
|No preservatives added
||Contains no added chemicals but may contain natural preservatives
||Contains less than 120 mg sodium for each 100g
|No salt or salt-free
||Contains 5 mg or less of sodium for each 100g
||Contains between 4.8 g– 6g or more fiber for each 100g
||Equal to or less than 10% of total fat
||Equal to or less than 5% of total fat
||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
• 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?
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.
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:
• 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.
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”
Basic steps while reading a nutrition label:
- Look at the serving size and servings per container. The label will describe the values for a serving. So, If one takes twice the serving, the values should be doubled.
- Look at the calories per serving and the calories from fat. If the commodity contains < 40 cals, it is of low calorie, if <100 cals, it is of a moderate calorie, if <400 cals it is of high calories. Too much of calories will lead to obesity.
- Look for the nutrients to limit- total fat, cholesterol and sodium- these are linked to heart disease, high blood pressure and some cancers. While using canned food, rinse off the liquid as it contains a lot of sodium.
- Get enough of dietary fiber, vitamin A, Vitamin C and calcium. Usually on reading carefully, the calcium content in skimmed milk or full fat milk is the same. But, in yoghurts, the calcium will vary. Look for fiber 3 g and more.
- Look for hidden sugars- for example,high fructose corn syrup. Look for substances ending in -ol or –ose. They are sugars. Remember that 5 g of sugar is the same as a level spoonful of sugar.
- The footnote is the same in all labels. This shows the percentage daily values for an average American who is moderately active. He will need 2000 Kcals a day. For a more active American, 25000 Kcals or more may be needed. The values against each of the main nutrients are mentioned. This label will not change with the food.
- Look for % DV ( Daily value) of 20% and above for nutrients that are good and 5% and below for those which are to be limited.
• The top of the label describes a standard serving size and how many servings a package contains — critical information for interpreting the rest of the numbers on the label.
• A bottle of sweetened ice tea may only have 75 calories per serving. But if that bottle contains two and a half servings and you drink the whole bottle, you’re consuming 225 calories.
• Serving sizes are based on standard measures agreed upon by the USDA and the FDA. One serving of cereal is 3/4 cup, for instance. A single serving of macaroni and cheese is a cup. Most all of the information that follows on the nutrition label is based on that serving size, from calories to grams of fat. So it’s essential to know what a serving is, and to know how much you actually eat.
Phrase Definition ……………and………..What they actually mean
No fat or fat-free Contains less than 0.5 g of fat for each 100 g/ml
Lower or reduced fat Contains at least 25% less fat for each 100 g than original
Low fat Contains less than 3 g fat for each 100 g or 1.5 g for each 100 ml
Low in saturated fat Contains no more than 1.5g for each 100g or 0.75g for each 100ml
Lite or light Contains 25% less kilojoules than the original or comparative product
Sugar free Contains less than ½ g sugar for each 100g
Reduced sugar Contains at least 25% less sugar for each serving than the original product
No added sugar Sugar in any form has not been added as an ingredient
Unsweetened No sugar or sweetener has been added
No preservatives added Contains no added chemicals but may contain natural preservatives
Low sodium Contains less than 120 mg sodium for each 100g
No salt or salt-free Contains 5 mg or less of sodium for each 100g
High fiber Contains between 4.8 g– 6g or more fibre for each 100g
Lean Equal to or less than 10% of total fat
Extra lean Equal to or less than 5% of total fat
Low chole ol Contains 20 mg for each 100g or 10 mg for each 100 ml
• Foods can only be labeled as ‘low in energy’ if it contains no more than 170 kJ for each 100 g of solid food or 80 kJ for each 100 ml of liquids.
• Foods can only be labeled as ‘high in energy’ if it contains 950 kJ for each 100 g of solid food or 250 kJ for each 100 ml of liquids.
• Food labels can no longer appear to be endorsed by a health practitioner (for example medical doctor, dietitian etc), or be associated with testimonials like ‘Mrs X has lost 20 kg by using product Y’.
The use of terms such as ‘healthy’, ‘wholesome’ or ‘nutritious’ is banned.
• Food labels are no longer allowed to state or imply that the product can cure any medical condition.
• Foods that were previously advertised as ‘no sugar added’ or ‘sugar free’ will be banned if the product contains any type of sugar form or derivative such as honey, molasses, sucrose, sugar, fruit juice concentrate, high-fructose corn syrup.
A second phase of regulations is planned and will define food advertising that is targeted at children, the glycemic index and foods that are non-essential for a healthy diet.
Did you Know?
• Fortified, enriched, added, extra and plus actually means that the nutrients such as minerals and fiber have been removed and vitamins have been added while processing. Look for 100% wheat or low sugar cereals.
• Fruit drinks may have little or no real fruit with lots of sugar. Look for 100% fruit juices.
• Natural – may have started with natural ingredients, but while processing will lose the “natural” component.
Food labels are meant for adults and not for children. Please remember that children may need > 2000 Kcals or < 2000 Kcals depending on their level of activity or whether they are boys or girls. Children however will benefit from looking at the calories per serving, the fats per serving, the fibers per serving and make good choices. Most of the children will need food containing more calcium and iron.
Benefits of exercising:
- Improves body posture and balance
- strengthens the bones and muscles
- improves collateral blood flow
- Improves insulin sensitivity
- improves sugar, blood pressure and lipid levels
- improves endurance levels
- increases the HDL, good cholesterol, levels
- reduces central obesity
- helps to loosen up the taut muscles
- improves flexibility of joints
- psychological well being
- reduces stress
- improves lean body mass
You must have heard from doctors to exercise, but probably not knowing how much to exercise or how to exercise. Lifestyle modification which includes diet, physical activity, cessation of smoking and alcohol, all form the cornerstone in management of diabetes mellitus.
American Diabetes association recommends 150 minutes of exercise a week. There are 3 main types of exercise- aerobics, flexibility and resistance training. Aerobic exercises increase the heart rate and breathing rate. These include jogging, swimming, running, brisk walking, cycling and dancing. Resistance training involves use of weights. Flexibilty exercises include stretching exercises such as gardening, walking, doing household chores and taking the stairs.
Remember the following:
1) do a comprehensive medical check up including the heart, eyes, feet and kidney before starting a program.
2) Do warm up exercises and stretches for 5 minutes before active exercise. Focus on stretching calves, thighs, neck, low back and shoulder group of muscles. Hold the stretch for 30 seconds. Breathe freely.
3) perform the active exercise for a minimum of 20 minutes( you may have to adjust the time according to your age and ability).
4) cool down for 5 minutes where by the heart rate comes back to the levels before exercise.
5) The maximum heart rate to be achieved is calculated as follows- 220 minus your age is the target heart rate. By exercising you should achieve 60-75% of the target heart rate.
6) Try to take a break half way through the exercise regime especially if doing for an hour. Sugar levels can come down and so it is wise to have half a glass of orange juice or have a couple of dates or half an apple or half a banana.
7) Core muscle group involve the muscles supporting the back and abdomen. These also have to be concentrated upon.
8) Do exercises which improve balance like standing on one leg. You may have to hold on to something for support at the beginning.
Beware of these problems before exercising:
Those with eye problems should not do resistance training with weights and heavy exercises which jar the head as it will cause a bleed within the eyes. Similarly, those with feet problems or heart problems also have to be careful with heavy exercises. Cycling and swimming are more beneficial than jogging among those with feet nerve problems or heart problems.
Check the sugar levels before exercising and after cooling down.
Remember to hydrate yourself with fluids while exercising. Check sugar levels before exercising. If the levels are low ( 100 mg/dL or <5.5 mmol/L) always take some snack like bread slice or biscuits so that sugar levels do not fall with the exercise. You can have orange juice or plain candy bars if the sugars are low.Likewise, if sugar levels are very high, reduce the levels with insulin shots and proceed for the exercise regime after consulting with the health care provider.
Never inject insulin before exercising
While doing resistance training, remember not to use heavy weights, but use small weights and increase the repetitions. . Sugar levels fall with exercise unless you do a high intensity exercise ( like sprinting) when the sugars will increase.
Walking is still the best exercise, wear appropriate clothes, avoid exercising outdoors during extremes of climate( hot and cold) and don proper footwear.
Are there any barriers to exercising?
- If a type 1 diabetic, having high blood sugar levels > 300 mg/dL or having ketones in blood.
- If type 2 diabetic having high blood sugar or low blood sugar
- If having an advanced retinopathy ( eye affection in diabetes)- seek consultation with eye specialist before exercising.
- If having nephropathy ( kidney affection in diabetes) – can affect delivery of oxygen to tissues and increase protein in urine.
- If having peripheral neuropathy- ( nerves affected by diabetes)- patients will not have any sensation and so can land in problems.
- If having a heart problem, one is advised not to stress the heart too much
Some common excuses to avoid exercising:
- lack of time
- poor lighting
- harsh climatic conditions
- being overweight and all people are “staring”
- costs of exercising
- racial and cultural reasons
- sweating induced itching of body and mal odour
- Fear of hypoglycemia
Gunner Borg devised an exertion scale , a tool that helped define how hard one felt during any particular activity:
- grade 0 if feeling nothing at all
- grade 1 if feeling very weak
- grade 2 if feeling weak
- grade 3 if feeling moderately weak
- grade 4 if feeling somewhat strong
- grade 5 if feeling strong
- grade 6 if feeling stronger
- grade 7 if feeling very strong
- grade 8 if feeling more difficulty
- grade 9 if feeling very difficult
- grade 10 if feeling extremely difficult
There are some other forms of exercise which can be used to break the monotony.
- Running backwards- less problems for joint injury but have to be in a safe environment.
- Cycle karoke- pedaling on a stationary exercise cycle and singing at the same time. If out of breath, go slow on the cycling. If one can sing well, then increase the tempo of the cycling.
- Troga- yoga on the treadmill. But the speed of the treadmill should not be more than 3 mph. Be careful of falling.Not recommended for the elderly or with joint problems.