Did you know that every ten seconds a person dies from diabetes related complications?
Diabetes is the fourth leading cause of global death by any disease.
Remember that heart problem is the number one cause of death among those with diabetes. It is said that a person does not die of diabetes, but instead of the heart ailment. The presentation can be just as a spasm of the blood vessels supplying the heart muscles or a frank attack where the blood vessel supplying the heart muscle is blocked completely or the heart may be enlarged.
The pain normally associated with heart attack is absent for those with diabetes. Hence, any “simple” chest discomfort may warrant a heart check up rather than treat it as simple gastritis or “gas”. Sometimes the discomfort may travel down the left arm, neck, back or to the shoulder. If the discomfort is associated sweating and faintness, consult with your doctor immediately. There are many tests that the cardiologist( doctor who specializes in heart diseases) will order for.
Control of the blood pressure and lipids are more important to prevent a heart attack. Sugar control is not all that important to prevent an attack, though. There are medicines which may have to be started by the health care professional to prevent such a calamity.
An ECG ( electrocardiogram) is done with patient in resting state and can tell if an ongoing chest pain is related to the heart or not or if a previous episode of chest discomfort was from the heart. It also tells about the rate.
An ECHO cardiogram is also done either in resting or under some form of exercise. This shows the size of the chambers of the heart, the dimensions of the valves, the blood flow and other parameters.
A Treadmill test will show how the heart copes with exercise. Patients with problems in their back bones or knees cannot do this test unless under supervision. Changes in the heart rate, rhythm , blood pressure may be noted which can point towards a block in the coronary vessels.
A coronary angiogram is a test done to map the coronary vessels. This is done by either introducing a tube through a vessel in the thigh or through a normal cannula in the arm. A dye is injected and films are shot. Blocks can be seen which are interpreted by either the radiologist or cardiologist. The blocks can be stented or ballooned or operated depending on the site and number of blocks.
The doctor will check the kidney function periodically to check if there is the beginning of kidney disease. Reduction of urine output and swelling of the face, body and feet with losing consciousness is a late feature. The presence of microalbumin in urine is an early feature which needs treatment. However, having menstrual periods, a mild urinary infection, having exercised just prior to giving the sample or having fever, the levels of microalbumin can be high. The health care provider will determine if another test is to be repeated. With proper control of sugar, blood pressure the levels improve. Some need medications to help reduce the levels.
Sometimes , dialysis or transplantation is needed when the kidneys reach a terminal stage. Consult with your doctor regarding the diet to be followed if there is such an event. You may have to consult a nephrologist( specialist in kidney diseases).
This is probably the most important of all the organs as far as we all are concerned. What is the use in living, if your eyes are not working or you are blind? Diabetes is the commonest cause of preventable blindness. One would never enjoy the beauty around us and the marvels of the Almighty if it were not for the eyes. Strangely even with good eyesight, we sometimes do “not see” the marvels of God.
Most of the people decide to meet the eye doctor when their eye sight is quite bad…. Till then most meet with the optician who checks the power of the glasses and they are happy.
Good control of sugar can prevent the onset of eye disorders. High blood pressure can also damage the eyes. Being a smoker too can affect the eye sight. It is generally believed that eye sight will become poor with advancing age due to onset of cataract (clouding up of the lens) , Being a diabetic can even make a young patient susceptible to development of cataracts.
The ophthalmologist( the doctor who specializes in eye diseases) will check the pressure in the eyes, look for cataract and also for the retina after instilling drops in the eyes. The eyes will be out of focus for close to an hour or two after the test. Remember checking the power of the eyes is not the test for diabetes check up. Close to 70% of the retina will be damaged before problems arise in vision. It is important to prevent these complications from arising by having an annual checkup with your eye doctor.
Changes in sugar levels can affect the clear fluid in which the lens is bathed in the eye. Thus there is a blurred vision which many people compare to a curtain kept in front of their eyes. The clear fluid becomes turbid when high sugar levels occur and then clears up when the sugar level normalizes. It is, therefore, important to mention to the eye specialist you are diabetic and whether under good control or not. It is wise to have new reading glasses when the sugar levels are normal.
When to meet the eye doctor?
• Blurred vision
• Trouble reading
• Seeing double
• Injury to eye
• Spots or floaters in the eyes
• Eyes get red and itchy
• You cannot see things on the outside of your eye vision field.
Know your eyes
The eyes are your mirror to the outside world. The eyes are covered by eye lids protecting it from external trauma or injury. This also prevents the eyes from drying out. Light enters through the cornea and travels through the center of the iris, which is the colored part of the eye. Light then falls on the retina situated at the back of the eye which then converts these signals to signals which can be read by the brain and is transmitted through nerves to the brain for us to understand what we are seeing. All this happens in fractions of seconds …
Know some terms
Glaucoma: This is term used when the pressure in the eyes increase. This can happen in those with a longer duration of diabetes. The vision of the eye is gradually lost. The eye doctor will perform tests which will determine how severe it is and will prescribe either eye drops or surgery.
Cataract: This is term used when the lens becomes cloudy. Normally elderly people get cataracts even without being a diabetic. Cataract may occur in younger adults if they are diabetic. The eye doctor will advise what to do after checking for cataract. For some people the retinopathy will become worse if treated for cataract and for some glaucoma may develop.
Retinopathy- this is term used to mean damage to the retina, the nerve layer of the eye. About 70 percent of the retina has to be damaged for one to show changes in eye sight. By this time, it will be so severe, complex treatment plans will have to be made with outcomes resulting in compromised vision. The small blood vessels in the back of the eye balloon out and may form pouches. They may start leaking. This may cause swelling of the nearby parts of the eye and even cause a lifting up of this layer, called retinal detachment. The eye doctor will advise how to get treated depending on the stage the eyes are.
Often, this is the most neglected of all the body parts. It has been studied that women care more for their feet than men. It has also been shown in studies that the foot problems are less among the muslim population due to the washing of their feet for prayer 5 times a day. One should pamper the feet at night daily.
The feet may swell up ( due to high blood pressure, kidney disease, the effects of the medicines you are given, or heart disease). You may notice the skin becomes dry (which can cause itchiness), the nails can get deformed, you may notice white rashes between the toes, decreased sensation to hot and cold and small wounds go unnoticed unless pointed out by somebody.
You have to inspect your feet daily with a mirror, apply moisturizing cream to the top and bottom of the feet ( avoid the areas between the toes), trim the toe nails straight ( taking care not to cut the corners), use one size extra shows or footwear, avoid narrow footwear, use loose cotton stockings, check the inside of the shoes daily and wash your feet daily, but dry them properly. Never cut calluses( thickened skin) yourself as it will risk injury.
The doctor will usually check the pulsations of the feet blood vessels, check for temperature sensation, check for fine sensation with a thread and the reflex at the ankle. You may need to have custom made footwear in some cases.
Remember to show the doctor for any wounds or cracks or ulcers that may develop. Remember that any infection can spread rapidly in diabetic patients which may sometimes need an operation resulting in loss of limb. Coupled with smoking, diabetes is dangerous combination.
Sometimes the legs may ache while walking or may have cramps at night. This can be the starting feature of a nerve problem. Consult your doctor if this happens.
Get educated. One key to preventing diabetic skin problems is to understand what causes them. Talk to your doctor. Learn about diabetic skin complications, what your particular risks are, and how you can lower them.
Control your diabetes. Controlling the blood glucose within normal range can go far toward preventing common diabetic skin complications.
To get a handle on your diabetes, strive for a healthy weight, eat right, cut back on salt, maintain a healthy blood pressure, and exercise. That’s a tall order, but talk to your health care team for support.
Be aware. If you suffer from diabetic nerve damage (neuropathy), you can have an infected cut, scratch, or skin puncture and not know it. Don’t let a small problem turn into a big one .Check your feet, ankles, in between your toes and legs regularly for wounds that aren’t healing.
Do something about wounds and sores. Don’t neglect wound care. If you find a nick, a scratch, a small cut, anything that isn’t healing or that worries you, talk to your doctor immediately.
Cover up. This simple first line of defense can help you avoid the cuts and scratches that can lead to infection. Whether you’re gardening or walking the dog, cover your legs with long pants and your feet with flat, good-fitting shoes.
Practice good skin care. Keeping skin clean and dry, but not too dry, is key to good diabetic skin care.
Keep skin comfortably dry, especially at armpits, toes, and groin. Talcum powder can help.
But avoid drying skin out. Skin that’s too dry can crack, itch, and get infected, so prevent that by taking short, lukewarm showers or baths and using mild soaps and shampoos when you wash. Avoid deodorant or scented cleansers, which can be harsh on sensitive skin.
Moisturize if your skin is dry . The best time to moisturize is right after a shower or bath, when skin is still moist.
Dry well by patting gently — don’t rub — focusing on underarms, between legs, under breasts, and between toes.
Diabetes and teeth
This is probably the most neglected of the various aspects of ones body. Many are unaware that care of the mouth is as important as looking after the eyes, feet or heart when one has diabetes.
Some presentations will be :
• Slow healing time after dental procedures
• Fungal infections coming very frequently( white patches)
• Dry mouth
• Cavities in the teeth
What can be done to minimize the risk
• Brush your teeth after every meal and floss the space between the teeth at least once daily.
• Use oral antibacterial rinses to wash away the germs
• Meet the dentist at least yearly once.
The gums ( pink tissue on which the teeth are embedded) can become soft, spongy and start bleeding. Later on the gums may detach themselves from the teeth causing them to have pockets. These pockets can harbor organisms which can erode into the underlying bone and can cause the tooth to be loose. The infection may spread at an alarming rate that you may have to be hospitalized and the infection can even spread to as far as the brain through the rich network of blood vessels on the face.
High Blood Pressure ( Hypertension)
Blood pressure has 2 values- a systolic ( the reading at top) and a diastolic ( reading at the bottom). This is checked at every visit to the doctor by a machine called sphygmomanometer. The most accurate one is the one using mercury( which are rare these days). Often, digital and air driven machines are used and freely available for use at home or office. Normally the blood pressure can be high when consulting with the doctor( due to anxiety). If found high, recheck either at home first thing in the morning and before going to bed for a week. Show the readings to the doctor for making a decision. Alternatively, a machine can be left attached to the body which will record the pressure for a week during the days for varying periods up to a week. The average of those readings will determine of you are having high blood pressure or not. This can help detect blood pressure fluctuations while asleep. Most of the serious side effects of high blood pressure ( heart attacks and strokes) are in the early hours of the morning after midnight.
If found to have high blood pressure, the doctor will advise you to cut down on salt intake. (Pickles, sauces, tinned vegetables, ketchup, salted butter, sausages and hams all contain salt in excess) Besides this, you will be asked to reduce the consumption of red meat, fried food, smoking and alcohol. You will also be advised to increase intake of fruits and vegetables. The doctor will advise you to
Try out relaxation methods. This may vary from person to person- such as dancing, listening to music, playing golf, walking, reading, gardening, painting, yoga classes, swimming and so forth. ALCOHOL and SMOKING DO NOT FORM HEALTHY RELAXATION TECHNIQUES!.
The normal blood pressure is < 130/80 mm Hg. Even reducing the pressure by 20/10 mm Hg has significant benefits on the various organs such as heart, eyes, kidneys and brain. Very often, more than one medicine may be needed to control the blood pressure. Sometimes the doctor has to prescribe blood pressure medicines to control the leak of protein in the urine though the blood pressure reading will be normal. Most of these medicines help to protect the kidneys and heart as well. The blood pressure will never reach zero as the body will take measures to correct itself. Only 18% of the diabetic patients reach the target goal of blood pressure.
This is a state of disillusion, frustration and a meek submission to diabetes which results in complete disregard to blood sugar level management. This is regarded as “freedom” from this confusing , frustrating and ever demanding condition. This is often seen many years after commencement of treatment.
This burnout is usually accompanied by varying levels of stress, anxiety, depression and labile emotions.
- Scared of living with diabetes
- uncomfortable social situations- cannot swim, cannot party, cannot be out for late night meetings, cannot do this or that…
- overwhelmed and angry with diabetes
- feeling “alone”
- Feeling diabetes is taking too much of mental and physical energy
- Food deprivation
- concerns about the future- “Can I marry?”, “Will I be able to conceive or have a normal sexual life”, “How long can I live?”
The commonest modes of presenting can be:
- Self destructive behavior
- Eating or drinking whatever one wants knowing fully well it is not good for those with diabetes.
- Improper insulin shots or lying about medicine intake
- Improper maintenance of log books
- Fabricating glucometer readings
- Complications of diabetes can set in which in turn makes things worse to a point of suicidal behavior.
How to overcome a burnout?
- Stay focused and motivated. Do not attempt to be perfect- forgive those occasional high sugar levels if other readings are fine.
- Identify barriers to care of diabetes and resolve them.
- Edit negative thoughts
- Enroll into support groups
- Speak with a friend or health care professional
- Rethink exercise schedule
- take a break
- Laugh it off
A check list:
Ask yourself whether you have done the following:
• Enough medicines are there with you.
• Have you had the blood tests for cholesterol, liver, kidney, hemoglobin , urine for protein, sugar and 3 month average of sugar at least once in the past 6 months.
• Have you had a foot check , an eye check by eye doctor and a heart check such as having an ECHO cardiogram and Treadmill test in the past one year. There are instances when the treadmill could not be done due either being overweight or having knee or back problems.
• If an elderly male, have you had a PSA test done in the past one year ( this is a blood test for the prostate) Alternatively, you could meet with a Urologist, the specialist for these problems.
• If an elderly male or female, have you had the calcium, vitamin D levels checked in the past year and a bone mineral density which is a scan for the bones showing if they are prone for fractures. Vitamin D levels, if very low, will need a correction with medicines and a recheck done depending on the doctors advice.
• Women after the age of menopause or those with a strong family history of cancer of the breast should have a mammogram ( special X ray of the breast) done once yearly.
• Thyroid levels can be checked yearly once , unless on treatment.
• Distended abdomen, “gaseous feeling” and belching with a mild upper chest discomfort can sometimes be a marker for something sinister. Have a gastroscopy done to make sure there are no ulcers.
• All bleeding from below is not from ‘piles”. It may also be worthwhile to have a colonoscopy done.
• Have you been monitoring your progress and if you can see no improvement in either the sugar levels or weight, you must seriously reconsider your options. Please do not always find fault with the doctor or the medicines, the reason could be elsewhere.
• Have you got the glucometer serviced or checked out especially if more than an year old
• Have you shown the Insulin delivery devise to the doctor once a year if the refilled pens are being used. Faulty devices can lead to errors in dosing.
• All said and done, there is no point in doing an annual whole body scan to make sure all is well. There are so many things which may go unnoticed and also will be risk of too much of radiation.
• Please check the footwear daily for wearing out or foreign bodies. They can prevent serious mishaps later.
• Have you had an annual Flu vaccine? This will reduce the flu which occurs while traveling a lot
• For those above 65 years of age a pneumococcal vaccine is useful. This is to be taken just once in a lifetime.
Once we are born, we all have to die someday. During the course of our life, we learn a lot from our experiences, sometimes we do not. We all wish to live longer and age gracefully. You may recollect that our grandparents lived longer and healthier. This is largely due to reduced stress levels, natural unprocessed food, more of physical activity and less dependent on automated gadgets or electronic gadgets.
Ironically, people of today look for shortcuts to everything for example weight reduction surgery, face lift surgeries various plastic surgical techniques to help beat natural aging and also gadgets which can remotely control everything in life from opening the gates, switching on the lights, locking the house and what not. Who knows, maybe in the near future we may even have drive in hospitals where you drive into the OPD room, speak out your symptoms into a machine , get a token, have blood drawn for tests and have the doctor give the medicines at another counter.( like as in Mc Donalds drive through)
Life has indeed become so fast, we hardly have the time to stop and think of ourselves. There are so many age defying cosmetics flooding the market these days.
Many people with diabetes live to a ripe age by leading a healthy lifestyle and regular check. However, some are lucky not to have diabetes until their middle years, but become diabetic after 65 years or more. In a study around 7% of the older adults were diagnosed as having diabetes by noting high fasting sugar, whereas 6% were diagnosed based on their post meal sugar levels.
Common changes with advancing age
Glucose intolerance increases and slowing of the glucose absorption occurs with advancing age. There is a decline in lean body mass, there may be an increase in body fat due to increasing insulin resistance. There may be a decline in level of physical activity.
The medicines that were once doing well in controlling sugar levels may not work as effective as age advances.
Older adults may not perceive hunger and may not feel thirsty as well. Digestion becomes delayed. Bowel habits may not be regular as before. Skin may become dry. The response to low sugar levels are much slower as age advances. Low sugar levels may manifest as confusion and dizziness. Tremors and sweating are not common.
- Reduced vision, reduced mobility and memory loss is also common. Mistakes while dosing the medicines are also common.
- Complication of the eye, nerve and kidney is directly linked to the level of sugar control. Maintaining good levels can delay the onset or progression of the above complications.
- However, heart diseases stroke, and blood vessel problems are directly linked to the control of blood pressure and cholesterol panel. This is one reason why doctors prescribe medicines for cholesterol even when the levels are normal.
- With advancing age, any of the above complications are possible. The recovery from the complications will not be as smooth as when coming at a younger age.
- Some need assistance while walking such as a physical support or a walking stick. The floor in most of the places has a smooth surface and planting the feet is quite a hazard.
- Most of the time, older adults feel embarrassed to address their fears to their dependents. They may feel better to mention those to their healthcare providers. This is quite normal
There are not many studies involving older adults. However, based on some of the studies, the following are applicable:
- Sugar levels between 7 to 8.5 mmol/L is acceptable
- Blood pressure ≤ 140/80 mm Hg
- Total cholesterol ≤ 5.2 mmol/L
- HbA1C ( the three month average of sugar ) is not reliable in older adults as red cell span may be reduced with advancing age. Diseases of the kidney and liver may affect the value.
However, the levels of blood sugar and 3 month average are not to be as stringent as for that of a younger person.
Increase in urine output may be due to urinary bladder irritation or dysfunction, medications for reducing blood pressure or due to prostate enlargement in males and not always due to high blood sugar levels.
Low sugar levels can mimic having a fit or stroke.
- The check up for the older adults must be more regular and frequent. The annual eye, heart check and foot check may have to be done more frequently if there are minor problems.
- Assessment of the kidney function is made by blood tests which may show changes. This can be tackled if checked for.
- Care of the feet may need heel protection, extra cushioning of wheel chair of bedding and prevention of dry skin is important.
- Driving at this age may be troublesome due to the reduced vision, reduced judgment and reflexes.
- Have the calcium, vitamin D levels checked as well as the bone mineral density. Older men have to be assessed for prostate as well.
- Make sure the older patient above 65 years must have taken a vaccination against pneumonia once and a vaccine against flu yearly.
- Many of the older adults may be having medicine such as diuretics ( which increase urination), hormones such for post menopause or steroids , and anti depressants which may worsen sugar control.
- Maintain good oral hygiene, check the feet, the skin folds for fungal rashes and boils which may go unnoticed by the patients.
- Make sure the bowels move once a day as constipation is very common.
The consultation with the health care professional:
- It will be useful if a small handbook can be used for mentioning their concerns as they may forget during the consultation.
- Maintaining a log book of the sugar readings and a diary of food intake will help to make inferences and plan management.
- The consultation can take more time than normal making the patient understand what is expected.
- The waiting period can be a problem as well. It will be worthwhile to have the blood and urine samples drawn early and they can have a light snack while waiting for their turn.
- Most of these adults are on many medicines and so may have gastritis.
- It is worthwhile to have a check by Gastroscopy ( a tube inserted through mouth to see if any ulcers in the stomach) or colonoscopy( tube inserted through anus to look for any problems down below)
- It sure pays to empathize with the elderly. They need the love and attention.
- Exercises in this age group are to be carefully planned.
- For those with eye problems or after laser treatment, it is advised to avoid intense exercises which may further increase the pressure.
- For those with neuropathy, it is advisable to perform exercises such as walking or cycling. Be careful of weight lifting.
- Jogging and swimming can be done if they have been doing the same routine over the years.
- However, get the doctors advice and clearance before planning a regime.
- Any exercise in water is useful and safe for the joints. It helps to burn calories as well.
- Walking together in groups or even performing aerobics, Yoga or Tai Chi also help in a better way as combining enjoyment with exercises make this pleasurable and motivated to continue with this. Yoga, meditation also help in relaxation.
The aims of management:
- The management of older adults involves avoiding low sugar levels, avoiding weight gain or loss in excess and to maintain well being.
- Metformin, gliclazide, Vildagliptin and Sitagliptin are safe to use among the oral medicines.
- Insulin is safe if used sensibly. The advent of pen devices has helped the patient care. It allows accurate dosing and gives audible clicks while dialing the dose. Using the bottle of insulin and syringe may be clumsy at times and can give erroneous dosing which can be quite a headache.
- It is better to have simple treatment plans rather than complex regimes difficult to remember.
- The patient care given, the patient care giver, the patient care process and the patient care outcome are very important in the management of this elder population.
Hypoglycemia or low sugar is one of the nightmares of the patients and the doctors alike. High and low sugars may both present with sweating , confusion and sometimes even unconsciousness.
The commonest causes being taking too much of insulin or some medicines or forgetting to take food, too intense an exercise, consuming alcohol and some tumors of the pancreas.
Generally sweating, shaking of the hands, irritation, craving for food, beating fast of the heart, headache, stomach pain (gastritis) and clouding of consciousness. The body tries to correct the levels itself by an in built mechanism.
For the elderly adults low sugar manifests as confusion, delirium and drowsiness. Tremors and sweating are rare for the elderly with low sugar levels.These can mimic those with a fit or stroke and is, for that strange reason, often misdiagnosed.
For some people the body fails to recognize the features of low sugar. This is dangerous as very low levels are needed for the body to recognize it thereafter. This is called unawareness.
What can be done?
If low sugar happens, drink a can of orange juice or chew on some dry raisins or put some sugar into your mouth. If glucose tablets are available, that is a good option. Chocolates are not a good solution for low sugars as the fat content in chocolates delay the fast rise in sugar. Check your sugar level after 15 minutes and if still low, repeat the above. Get to nearest hospital and get this corrected if needed.
Categories of hypoglycemia:
• Documented hypoglycemia: typical symptoms of hypoglycemia and when the plasma glucose is ≤70 mg%.
• Severe hypoglycemia : An event which requires active assistance of a person to administer glucagon or carbohydrate or adopt any other resuscitative measure.
• Asymptomatic hypoglycemia: An event that is not accompanied by typical symptoms but the plasma glucose ≤70 mg%.
• Probable symptomatic: An event during which hypoglycemic symptoms are not documented with a plasma glucose determination, but presumed to be ≤70 mg%.
• Relative hypoglycemia: An event during which the diabetic patient reports typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but the plasma glucose is ≥ 70mg%.
While driving if low sugar is encountered, drive off the road, put on distress signals, turn off the car, pull down the windows, remove the key from the ignition, take some sugar or orange juice immediately.( you must have a stock of this in the car always) . The brain takes some time to recover from the low sugar and impulsive driving may be initiated leading to accidents. Always check sugar levels before a long drive, break the journey in between long drives and carry an ID mentioning your diabetic status and contact numbers.
Sometimes hospitalization is also needed in serious cases.
The impact low sugars can have on life is very dramatic. For example, developing this while attending an interview or while at the exams or at an important meeting or while driving, can change the course of ones` life. People may then become introverts avoiding social functions for fear of low sugar. They are often mistaken for drunken behavior as well.
Basic steps while reading a nutrition label:
- Look at the serving size and servings per container. The label will describe the values for a serving. So, If one takes twice the serving, the values should be doubled.
- Look at the calories per serving and the calories from fat. If the commodity contains < 40 cals, it is of low calorie, if <100 cals, it is of a moderate calorie, if <400 cals it is of high calories. Too much of calories will lead to obesity.
- Look for the nutrients to limit- total fat, cholesterol and sodium- these are linked to heart disease, high blood pressure and some cancers. While using canned food, rinse off the liquid as it contains a lot of sodium.
- Get enough of dietary fiber, vitamin A, Vitamin C and calcium. Usually on reading carefully, the calcium content in skimmed milk or full fat milk is the same. But, in yoghurts, the calcium will vary. Look for fiber 3 g and more.
- Look for hidden sugars- for example,high fructose corn syrup. Look for substances ending in -ol or –ose. They are sugars. Remember that 5 g of sugar is the same as a level spoonful of sugar.
- The footnote is the same in all labels. This shows the percentage daily values for an average American who is moderately active. He will need 2000 Kcals a day. For a more active American, 25000 Kcals or more may be needed. The values against each of the main nutrients are mentioned. This label will not change with the food.
- Look for % DV ( Daily value) of 20% and above for nutrients that are good and 5% and below for those which are to be limited.
• The top of the label describes a standard serving size and how many servings a package contains — critical information for interpreting the rest of the numbers on the label.
• A bottle of sweetened ice tea may only have 75 calories per serving. But if that bottle contains two and a half servings and you drink the whole bottle, you’re consuming 225 calories.
• Serving sizes are based on standard measures agreed upon by the USDA and the FDA. One serving of cereal is 3/4 cup, for instance. A single serving of macaroni and cheese is a cup. Most all of the information that follows on the nutrition label is based on that serving size, from calories to grams of fat. So it’s essential to know what a serving is, and to know how much you actually eat.
Phrase Definition ……………and………..What they actually mean
No fat or fat-free Contains less than 0.5 g of fat for each 100 g/ml
Lower or reduced fat Contains at least 25% less fat for each 100 g than original
Low fat Contains less than 3 g fat for each 100 g or 1.5 g for each 100 ml
Low in saturated fat Contains no more than 1.5g for each 100g or 0.75g for each 100ml
Lite or light Contains 25% less kilojoules than the original or comparative product
Sugar free Contains less than ½ g sugar for each 100g
Reduced sugar Contains at least 25% less sugar for each serving than the original product
No added sugar Sugar in any form has not been added as an ingredient
Unsweetened No sugar or sweetener has been added
No preservatives added Contains no added chemicals but may contain natural preservatives
Low sodium Contains less than 120 mg sodium for each 100g
No salt or salt-free Contains 5 mg or less of sodium for each 100g
High fiber Contains between 4.8 g– 6g or more fibre for each 100g
Lean Equal to or less than 10% of total fat
Extra lean Equal to or less than 5% of total fat
Low chole ol Contains 20 mg for each 100g or 10 mg for each 100 ml
• Foods can only be labeled as ‘low in energy’ if it contains no more than 170 kJ for each 100 g of solid food or 80 kJ for each 100 ml of liquids.
• Foods can only be labeled as ‘high in energy’ if it contains 950 kJ for each 100 g of solid food or 250 kJ for each 100 ml of liquids.
• Food labels can no longer appear to be endorsed by a health practitioner (for example medical doctor, dietitian etc), or be associated with testimonials like ‘Mrs X has lost 20 kg by using product Y’.
The use of terms such as ‘healthy’, ‘wholesome’ or ‘nutritious’ is banned.
• Food labels are no longer allowed to state or imply that the product can cure any medical condition.
• Foods that were previously advertised as ‘no sugar added’ or ‘sugar free’ will be banned if the product contains any type of sugar form or derivative such as honey, molasses, sucrose, sugar, fruit juice concentrate, high-fructose corn syrup.
A second phase of regulations is planned and will define food advertising that is targeted at children, the glycemic index and foods that are non-essential for a healthy diet.
Did you Know?
• Fortified, enriched, added, extra and plus actually means that the nutrients such as minerals and fiber have been removed and vitamins have been added while processing. Look for 100% wheat or low sugar cereals.
• Fruit drinks may have little or no real fruit with lots of sugar. Look for 100% fruit juices.
• Natural – may have started with natural ingredients, but while processing will lose the “natural” component.
Food labels are meant for adults and not for children. Please remember that children may need > 2000 Kcals or < 2000 Kcals depending on their level of activity or whether they are boys or girls. Children however will benefit from looking at the calories per serving, the fats per serving, the fibers per serving and make good choices. Most of the children will need food containing more calcium and iron.
If you have diabetes, one needs a blood glucose meter — a small device — to measure, store and display the blood glucose level. Glucometer is commonly used in emergency rooms in hospitals, ambulatory medical care services as in ambulances, helicopters or sea transport while shifting patients. The glucometer is used for analysing sugar leels and adjust dose medication with the help of the health care professional or diabetes educator. This is not used in the diagnosis of Diabetes.
Exercise, food, medications, stress and other factors affect the blood glucose level. Using a blood glucose meter can help better manage the diabetes by tracking any fluctuations caused by these factors.
Many types of blood glucose meters are available, from basic models to more-advanced meters with multiple features and options. The cost of blood glucose meters and test strips varies. Study all the options before deciding which model to buy.. As with any electronic device, this cannot be immersed in water, should not be stored in extremes of temperature and humidity which can affect the device or even the test strips. Most of the new model glucometer devices have an in built check that does not display readings at extremes of temperature. Using a glucometer at high altitude as when climbing high mountains can give erratic readings.
The glucometer uses an enzymatic portion on a test strip which is in a dehydrated state when packed and a detector. The glucose in the blood sample reacts with the enzyme to produce the level which is detected. The commonly used enzymes are hexokinase, glucose oxidase and glucose dehydrogenase
Basics while using any glucometer
- Check the expiration date of the kit
- Make sure the lancets, glucometer, test strips are available globally.
- Make sure the warranty card is filled out and handed over.
- Ask for a demonstration if need be.
- Some meters need a code chip to be inserted with each new box of test strips.
- Always clean the finger tip before pricking the finger tip for the sample of blood. The sides of the non dominant hand are used as the skin is thinner at the side of the fingertips.
- The blood should be flowing well. Do not squeeze the finger tip excessively to get the blood out- this affects the reading.
- Do not reuse the lancets or test strips.
- Dispose the lancets in a sharps disposal bin.
- Remember to use the glucometer often, say at least twice a week. If not used regularly, it may cause the batteries to wear off by discharging or the IC to burn off. It is similar to a motor car that is not used for a month or two. The battery will not work at that time.
- Get the glucometer calibrated often as well as periodic testing of the control solution is necessary.
Choosing the right meter
When selecting a blood glucose meter, it can help to know the basics of how they work.
- To use most blood glucose meters, first insert one end of a test strip into the device.
- Then, prick a clean fingertip with a special needle (lancet) to get a drop of blood.
- Wipe away the first drop of blood.
- Carefully touch the other end of the test strip to the drop of blood and wait for a blood glucose reading to appear on the screen. There are meters which can determine the blood glucose and blood ketone levels as well. These meters are useful for type 1 diabetic patients. It is marketed by the Freestyle under the name Freestyle Optium Xceed.
Blood glucose meters are usually accurate in how they measure glucose, but they differ in the type and number of features they offer. There is a difference between the values obtained by the glucometer and the blood test done at the hospital. The glucometer checks the capillary glucose level. The hospital or clinic estimates the glucose from a sample drawn from the vein.
Here are several factors to consider when choosing a blood glucose meter:
• Cost. Meters vary in price, so shop around. Be sure to factor in the cost of test strips as the insurance doesn’t pay for them. Test strips are the most expensive part of monitoring because they’re used so often. A meter may be the cheapest one on the market, but may not be a good deal if the strips cost twice as much. Also, individually packaged strips tend to cost more, but you might not use all the strips in a container before the expiration date or within the required number of days after opening the container. Figure out which type of strip is most cost-effective for you. Remember that the strips have expiration dates on the cover. Please check it out.
• Ease of use and maintenance. Some meters are easier to use than others. Are both the meter and test strips comfortable to hold? Can you easily see the numbers on the screen? How easy is it to get blood onto the strips? Does it require a small or large drop of blood?
- Also, some brands of meters need to be coded and others have no coding. Code numbers are used to calibrate your meter with the test strips for accurate results. Make sure the strips can be bought from other parts of the world as well so that travel does not be cumbersome.
• Special features. Ask about the features to see what meets your specific needs. For example, some meters are large with strips that are easier to handle. Some are compact and easier to carry. People with impaired vision can buy a meter with a large screen or a “talking” meter that announces the results. Colorful meters that give a quick reading are available for children. Some models have a backlight, which is handy for nighttime readings. Others are manufactured to withstand extreme temperatures, which may be useful for people who spend a lot of time outdoors, such as hikers or construction workers.
• Information storage and retrieval. Consider how the meter stores and retrieves information. Some can track all the information one would normally write in a log, such as the time and date of a test, the result, and trends over time. Some meters offer the ability to download your blood glucose readings to a computer or your cell phone and then email the test results to your doctor.
• Support. Many meter manufacturers include a toll-free number on the back of the meter or packing. Look for a meter that includes clear instructions that demonstrate the correct way to use the meter. Some manufacturers offer user manuals on their websites.
Although finger pricks remain the gold standard for blood sugar monitoring, researchers are developing products designed to take the “ouch” out of the process. You might ask your doctor about these alternatives.
Alternative site monitor Allows blood samples from areas likely to be less painful than your finger, such as your arm, abdomen or thigh Not as accurate as fingertip samples when blood sugar level is rising or falling quickly.
Continuous glucose testing Uses a sensor placed under skin to measure blood sugar level; transmits each reading to a small recording device worn on your body; sounds an alarm if blood sugar level becomes too low or too high Expensive; requires sensor to be replaced every three to seven days depending on the brand; must check blood sugar level with a traditional monitor when dosing for insulin or treating low blood sugar to confirm readings
• Infrared, laser light and electric current technologies are among a few of the possible offerings on the horizon for noninvasive methods of checking blood sugar levels. But, these may cause irritation to the skin where it is placed upon.
Consider these factors that affect meter accuracy and the steps to resolve or prevent the problem:
- Test strip problems —Throw out damaged or outdated test strips. Store strips in their sealed container; keep them away from heat, moisture and humidity. Be sure the strips are meant for your specific glucose meter.
- Extremes of temperature —Keep your glucose meter and test strips at room temperature.
- Alcohol, dirt or other substances on your skin— Wash your hands and the testing site with soap and water before pricking your skin.
- Improper coding— Some meters must be coded to each container of test strips. Be sure the code number in the device matches the code number on the test strip container.
- Monitor problems —Fully insert the test strip into the monitor. Replace the monitor batteries as needed.
- Not enough blood applied to the test strip —Apply a generous drop of blood to the test strip. Don’t add more blood to the test strip after the first drop is applied. Some meters do not need a large drop.
- Testing site location — Blood samples from alternate sites are not as accurate as fingertip samples when the blood sugar level is rising or falling quickly.
Blood glucose monitor quality control tests
When starting a new container of test strips, occasionally perform these quality control tests before using them and when the results seem unusual.
To perform a quality control test, do one or both of the following:
• Test using a control solution. Follow normal blood-testing procedure, but use a liquid control solution instead of blood. These solutions usually come with the monitor and are available at most drugstores and pharmacies. Follow package directions.
• Match the reading with lab results. Take the blood glucose monitor along when visiting the doctor or have an appointment for lab work. Check the blood glucose with the meter at the same time that blood is drawn for lab tests. Then compare the meter’s reading with the lab results. The meter’s result is considered accurate if it falls within 15 percent of the lab test result.
Benefits of exercising:
- Improves body posture and balance
- strengthens the bones and muscles
- improves collateral blood flow
- Improves insulin sensitivity
- improves sugar, blood pressure and lipid levels
- improves endurance levels
- increases the HDL, good cholesterol, levels
- reduces central obesity
- helps to loosen up the taut muscles
- improves flexibility of joints
- psychological well being
- reduces stress
- improves lean body mass
You must have heard from doctors to exercise, but probably not knowing how much to exercise or how to exercise. Lifestyle modification which includes diet, physical activity, cessation of smoking and alcohol, all form the cornerstone in management of diabetes mellitus.
American Diabetes association recommends 150 minutes of exercise a week. There are 3 main types of exercise- aerobics, flexibility and resistance training. Aerobic exercises increase the heart rate and breathing rate. These include jogging, swimming, running, brisk walking, cycling and dancing. Resistance training involves use of weights. Flexibilty exercises include stretching exercises such as gardening, walking, doing household chores and taking the stairs.
Remember the following:
1) do a comprehensive medical check up including the heart, eyes, feet and kidney before starting a program.
2) Do warm up exercises and stretches for 5 minutes before active exercise. Focus on stretching calves, thighs, neck, low back and shoulder group of muscles. Hold the stretch for 30 seconds. Breathe freely.
3) perform the active exercise for a minimum of 20 minutes( you may have to adjust the time according to your age and ability).
4) cool down for 5 minutes where by the heart rate comes back to the levels before exercise.
5) The maximum heart rate to be achieved is calculated as follows- 220 minus your age is the target heart rate. By exercising you should achieve 60-75% of the target heart rate.
6) Try to take a break half way through the exercise regime especially if doing for an hour. Sugar levels can come down and so it is wise to have half a glass of orange juice or have a couple of dates or half an apple or half a banana.
7) Core muscle group involve the muscles supporting the back and abdomen. These also have to be concentrated upon.
8) Do exercises which improve balance like standing on one leg. You may have to hold on to something for support at the beginning.
Beware of these problems before exercising:
Those with eye problems should not do resistance training with weights and heavy exercises which jar the head as it will cause a bleed within the eyes. Similarly, those with feet problems or heart problems also have to be careful with heavy exercises. Cycling and swimming are more beneficial than jogging among those with feet nerve problems or heart problems.
Check the sugar levels before exercising and after cooling down.
Remember to hydrate yourself with fluids while exercising. Check sugar levels before exercising. If the levels are low ( 100 mg/dL or <5.5 mmol/L) always take some snack like bread slice or biscuits so that sugar levels do not fall with the exercise. You can have orange juice or plain candy bars if the sugars are low.Likewise, if sugar levels are very high, reduce the levels with insulin shots and proceed for the exercise regime after consulting with the health care provider.
Never inject insulin before exercising
While doing resistance training, remember not to use heavy weights, but use small weights and increase the repetitions. . Sugar levels fall with exercise unless you do a high intensity exercise ( like sprinting) when the sugars will increase.
Walking is still the best exercise, wear appropriate clothes, avoid exercising outdoors during extremes of climate( hot and cold) and don proper footwear.
Are there any barriers to exercising?
- If a type 1 diabetic, having high blood sugar levels > 300 mg/dL or having ketones in blood.
- If type 2 diabetic having high blood sugar or low blood sugar
- If having an advanced retinopathy ( eye affection in diabetes)- seek consultation with eye specialist before exercising.
- If having nephropathy ( kidney affection in diabetes) – can affect delivery of oxygen to tissues and increase protein in urine.
- If having peripheral neuropathy- ( nerves affected by diabetes)- patients will not have any sensation and so can land in problems.
- If having a heart problem, one is advised not to stress the heart too much
Some common excuses to avoid exercising:
- lack of time
- poor lighting
- harsh climatic conditions
- being overweight and all people are “staring”
- costs of exercising
- racial and cultural reasons
- sweating induced itching of body and mal odour
- Fear of hypoglycemia
Gunner Borg devised an exertion scale , a tool that helped define how hard one felt during any particular activity:
- grade 0 if feeling nothing at all
- grade 1 if feeling very weak
- grade 2 if feeling weak
- grade 3 if feeling moderately weak
- grade 4 if feeling somewhat strong
- grade 5 if feeling strong
- grade 6 if feeling stronger
- grade 7 if feeling very strong
- grade 8 if feeling more difficulty
- grade 9 if feeling very difficult
- grade 10 if feeling extremely difficult
There are some other forms of exercise which can be used to break the monotony.
- Running backwards- less problems for joint injury but have to be in a safe environment.
- Cycle karoke- pedaling on a stationary exercise cycle and singing at the same time. If out of breath, go slow on the cycling. If one can sing well, then increase the tempo of the cycling.
- Troga- yoga on the treadmill. But the speed of the treadmill should not be more than 3 mph. Be careful of falling.Not recommended for the elderly or with joint problems.