From time immemorial, man has been walking for traveling to reach one place, to hunt and gather food for self and family and also in search of a better place to live. Those were the days when there was no transport. God gave humans the legs so they could walk upright which is a feature not common among the animals by nature, though some animals can walk upright with training. Unfortunately, with the advent of modern transportation facilities as well as time pressures and deadlines to be met, people have literally forgotten to use their legs for the use they were meant to be used.
Benefits of walking
This is probably the safest form of exercise which can be done by anybody provided the eyesight is good and there is no neuropathy ( affection of the nerves which can cause lack of sensation on the feet making the person unaware of where the feet are planted on the ground).
The farther, faster and more frequently one walks can definitely improve the benefits by many folds. Walking also improves the balance and strengthens bones and muscles besides improving circulation.
Walking is proven to prevent the onset of diabetes, depression, cancer, joint problems, osteoporosis ( fragile bones) and heart ailments. This also helps the worsening of the above. The swinging action of the arms, the strides taken while walking, the fresh air , the sights to enjoy ( one does not get these benefits while walking the treadmill in the confines of either the gymnasium or home) and change in pace while walking navigating the turns all help in improving the muscle power and co-ordination.
Walking in groups with either your colleagues or with friends and family all could be entertaining as well you could even do long distances without being aware of the distance covered at all.
Walking at a speed of 6 km/hour , which amounts to a brisk walk, can burn up to 600 Kcals. But, may be not all can walk as fast. Some may be having either knee or back problems which needs a slower pace. But walking at any given speeds whether unaided or with the help of a walking stick is much better than not walking at all. Parking the car away from where you wish to go and just walking to your destination helps. You may still park close to your destination ( especially during the summer time when the heat maybe quite strong) and take a longer route rather than choosing the shortest route or just walking along the aisles in the malls are good options.
Walking with small children and pets is also a good option.
Ensure the following before walking:
• Check the blood sugar before walking.
• Ask your health care provider if it is safe to embark on a regime.
• Go at a pace comfortable. Walking should not leave one gasping for breath.
• It is okay to rest in between.
• It is okay to take sips of water in between the walk and before the walk.
• If you experience feeling of nausea, chest discomfort, pain in the arms, jaw or back while walking, please seek medical help immediately.
Stretching before any exercise program:
Proper stretching before any exercise or even walking can help tone up the body and prevent joint problems.
Some of the commonly done stretches:
• Calf stretches-
Stand at an arms length distance from the wall. Keep one leg forward with knees slightly bent. The other leg with knee straight and heel down. Keeping back straight, move hips towards the wall and feel the stretch. Hold for 30 seconds, relax and repeat with other leg.
• Quadriceps stretch-
While supporting a fixed structure, grasp the ankle with one hand and pull the heel up and down till one feels the stretch in the front of the thighs. Hold for 30 seconds, relax and then repeat with other side.
• Hamstrings stretch-
Sit on one chair, and keep the other leg on another chair in front. Keeping the back straight, bend the pelvis forward till a stretch is felt in the back of the thighs.
• Low back stretch- lying on the back with the feet kept flat and knees bent, bend the knees ( both together or separately) towards the chest using both hands. If one has knee problems, one can hold hands behind the thighs instead.
• Chest stretches-
Clasp hands behind the head. Pull elbows gently by pinching the shoulder blades together.
How to walk?
The ideal way of walking involves walking upright, head held up eyes looking forward, chest pulled out, shoulders thrown back, landing the feet on the heel and taking the stride on their toes. Swing the arms freely slightly bent at the elbows. Walking with small weights held in the hands further enhance the calories burned.
The neck, shoulder and back must be relaxed and not stiff. While walking the treadmill one usually does not maintain these as people have to be holding onto the side railings and the back is usually arched back and stiff to prevent slipping.
Please make sure the footwear is of a good quality and have the insoles and heels checked for wear and tear. View the shoes from behind. If the shoe is tilted to one side, it is time to change the shoes. Change the shoes after it has done 400-600 km.
One should dress appropriately in attire that suits the climate, a comfortable and well padded pair of shoes, a scarf or hat as the case may be and some music if needed to be played and listened with an ear phone if needed. Generally the pavements are safe, but it still pays to look ahead and down as well.
150 minutes of any exercise a week is recommended. You can do 30 minutes 5 days a week or split that every day in some form like three sessions of ten minutes each or two sessions of fifteen minutes each.
The long term goal is to make 10000 steps a day. This is ideal for maintaining good health.
One needs to walk at least 30 minutes a day to maintain his or her weight and at least 45 minutes a day to have some weight reduction.
A pedometer is a small device which can be clipped on to the belt or kept in your pocket close to your body. This will count the steps one takes during the course of your daily chores such as walking, climbing stairs, jogging and even adventure sports. But, pedometers vary in their function.
clipped on pedometer
Get to know your pedometer
Ease of use: Some of the pedometers just have to be clipped and it starts. These will be needed to be reset to zero the next day so you could count the number of steps taken.
All pedometers have a battery which needs to be replaced depending on the life.
Some pedometers need to have the data fed in such as date and time, the weight of the person, the length on ones stride which will be calculated and input fed in. The extra benefits: Some just give the number of steps taken during the day till one resets it back to zero. Other pedometers count the calories burned during the activity, the distance walked and some even upload the data to a remote computer which will maintain a log book of the progress. Accuracy: generally all pedometers are accurate. However change of strides such as a sudden increase in pace ( or decrease) , jogging in between or even climbing stairs in between the walk may not be counted by the machine( after all it is a machine) and so the calories counted may not be very accurate in that way.
Get a pedometer that has good back lighting so it could be easy to use both indoors and outdoors and also during either the day or night.
Some pedometers are small, others are big. Go for a size that suits you.
The pedometer must have a sturdy clip to help attach on the waistband or have a strap. Price is also of major concern.
The recent smartphones have an app which could be downloaded for performing the same function as that of a pedometer. Before you use the pedometer regularly the following are to be noted:
Please attach the pedometer on yourself for three days in succession whenever you are awake. The total number of steps covered in 3 days divided by three will give the average steps in a day. This is called the baseline steps. ( This will also give you an idea how many steps you had taken in a day which might be embarrassing)
Once you know the baseline steps, set up short term goals such as adding a thousand steps a day, for example, to your baseline number which you do target for a week.
Once you have achieved this short term goal, you could set yourself another goal. You could reward yourself and make this interesting.
Cause of type 1 diabetes:
Type 1 Diabetes is due to an absence of insulin secretion by the pancreas from birth. Most of the cases of type 1 diabetes are caused by unknown triggers which results in varying amounts of destruction of beta cells in a genetically susceptible person. However, in some cases the pancreas can be damaged by auto immune diseases in which the body cells are destroyed by some cells due to unknown causes. A simple viral fever may cause the virus to attack the heart or pancreas leading onto diabetes.
Younger adults will show slower destruction of the β cells in comparison to younger children .
There are plenty of Type 1 Diabetic patients who are living well into the nineties. They all went through a tough time when diabetes management was at a very primitive stage. There were no sophisticated blood glucose monitors, no good hospitals or technology to support them, no education materials, no support groups or no insulin as well. People had to monitor the urine and be on a starvation diet to try and find a cure for this. Insulin changed the way these patients handled life. The people who have lived long to see the 2 world wars, have told they have learned this from life: “ Learn to live in spite of having Diabetes” and “take one step at a time” and “Live life to its fullest- enjoy every moment of it and thank the Almighty”.
Today there are so many advances in the field of science which brought about the discovery of insulin, the glucometer devices which could even store data of previous readings, smart phones which could guide one to monitor ones diet, remind to take medicines and even plot their progress, have alternate sources to deliver insulin, alternate devices to check sugar levels painlessly and stem cell therapy and transplantation of the pancreas.
Type 1 diabetes mellitus used to be called insulin dependent diabetes mellitus. It used to be associated with children alone. There are a lot of young people and adults who are being diagnosed as having type 1 diabetes.
Those people who lose weight dramatically, do not thrive properly, get admitted for vomiting and abdominal pain are found to have diabetes mellitus type 1. It is generally seen younger the patient at time of diagnosis of diabetes, higher the chances of having type 1 diabetes. There are some people who are diagnosed with diabetes when they visit the hospital with either failing vision or kidney problems. There is a higher incidence of young adult presenting with type 2 diabetes as well.
Blood tests such as GAD 65 antibodies ( Glutamate acid decarboxylase), IAA ( Insulin auto antibodies), ICA ( Islet cell antibodies) , are some of the commonly used tests run to diagnose type 1 diabetes. However, all these may not be positive in the early stages as that depends on the damage to the islet cells of pancreas. The estimation of Insulin levels and its precursor, C peptide done in fasting and after food are also used to define type 1 diabetes.
Though many genetic markers have been identified, the widespread use of genetic screening is yet to be justified and implemented
Insulin still remains the mainstay of treatment and is usually a lifelong. There is no magic cure yet for Type 1. However, research is still on to the efficacy of a stem cell therapy. Islet cell transplantation and pancreas transplantation have also been done at selected centers round the world, but the prohibitive costs, the post transplantation medications to reduce the rejection and the uncertainty of life long cure have not led to much enthusiasm.
There are advances coming up in the self monitoring devices and also novel ways to administer insulin.
Young adults or children must be informed about a partial remission of the diabetes where either a low dose of insulin or no insulin may be needed in the early phase. This is called the “honeymoon” phase of diabetes when there will be some activity of the pancreas but not enough to maintain sugar levels.
One has to take multiple injections a day to match the food intake just because the pancreas refuses to secrete insulin which keeps the sugars down. Some may need to take a combination of long acting insulin at night time and one with each main meal of the day. There different insulin preparations which have been detailed in the post titled,”insulin in diabetes”. Insulin can be given by pens which are easy to use and have small needles. Some patients may need multiple doses. Some may need insulin to be administered by a pump which delivers insulin in small doses based on food intake and physical activity.
Insulin has to be stored in the refrigerator ( not the freezer compartment) when not in use.
Never skip a dose of insulin as the sugars may increase and cause even an unconscious state which can kill if not treated in time.
Likewise, if you inject too much, the sugars can drop to dangerously low levels and can make you unconscious and can kill.
Have a sugary drink or sugar at hand always.
When you feel sweating or shivering, it can mean the sugars are low.
Remember to change the needles daily.
Rotate the site of injection daily. These can be given on the thighs and abdomen. Pinch a fold of skin and inject at right angles. Do not inject if the skin is too hard on pinching or dark in color. Normally the rapid acting insulin is given on the abdomen and the long acting given on the thighs.
When sick, it is a common mistake to either reduce the dose of insulin or omit the dose as there is reduced food intake. However when sick, the hyperglycemia demands a slightly higher dose of insulin.
Teenage girls can have eating disorders and may omit the dose of insulin with a hope to control their weight, with grave consequences.
As you grow up or have stress during exams, job interviews, marriage or family matters, the sugar levels can increase. As you grow up, the insulin levels will also increase.
If having a party or attending a buffet, you are allowed to take insulin in two separate doses like 30% before the party and 70% after the party. If you take 30 units at night of rapid insulin, take 10 units before the party and 20 units after the party to cover the food intake.
Be careful of alcohol intake and dancing after that as the sugars can drop down.
Advantages of insulin pumps over multiple daily injections :
• Ease of calculation
• Less insulin stacking
• More reliable
• Very low doses 0.01U to 0.025 can be given in those using the pump.
• Fewer skipped doses
• Less hassles with time zones
• Discreet insulin delivery
Requirements before embarking on insulin pumps:
• Should be willing to check blood glucose many times and should be able to count carbohydrates
• In toddlers, the pump can be placed between the shoulder blades or butt.
• The tip of the cannula of the infusion tubing can be blocked by the inflammatory cells causing errors in dosing.
• The settings in a young child should have high and wider range, in those with hypo unawareness, set the hypoglycemic setting higher, and those who are pregnant, set the narrower and lower range.
The accessories have to be changed once every 3 days. This is a costly matter.
Checking the blood glucose:
You need to check sugar levels quite frequently. Ideally, a pre meal and 2 hour post meal sugar check will be needed.( 7 tests a day) This will have to be done at the initial stages till you know the “signals” your body sends. Some have to check their sugars when they have had a new food or while at a party. There are machines that require a lot of blood sample for the testing and some which need very less. The finger pricks are done at the tips ( in medical terms, the pulp) of the fingers. This is a very sensitive area and the repeated pricks for the rest of your lives can affect the sensation of these wonderful parts. You will need to have a glucometer machine that will check the blood sugar and blood ketones as well. Most of the machines have data storage facilities and also some can be connected to a network and data can be transferred to a remote system such as ones parents or doctors or nurse. ( Read more of this in the post titled, Diabetes and Digital age )
Self monitoring of blood glucose can help detect low sugar or high sugar levels, help titrate the dose of insulin, can be used to assess sugar levels when sick or pregnant and also to check how the levels are after a workout.
Earlier good control of sugar levels will delay the onset of the feared complications of diabetes such as the retinopathy ( eye) , neuropathy( nerves), nephropathy( kidney), heart disease.
The variability in sugar readings are more important than a stray high reading.
Good sugar control will lead an improvement of
• 76% in incidence of retinopathy
• 47-54% reduction in progression to severe eye problems
• 39% reduction in onset of microalbuminuria
• 54% reduction in onset of kidney diseases
• 60% reduction I onset of developing neuropathy
• 42-57% reduction in onset of heart related diseases.
Periodic Check up:
The parents will accompany the child to get more understanding of the management. It is important to have the eyes checked, the feet checked and urine checked for microalbumin leak once annually after the age of 12 years. It is important to check the blood pressure and lipid profile if above 12 years of age. The 3 month average of sugar, HbA1C is to be done thrice a year. The most recent guidelines state a 3 month average sugar level of 7.5% for any age of child till the age of 18. The values were higher in the previous years.
The complications are the same as those which a person with type 2 diabetes can have. The success of the quality of life depends on the near normal levels one can attain. It can get frustrating and depressing at times and definitely may even lead to quarrels with parents. They are concerned about the good health, though some parents may become over protective. Having high blood glucose can poison the body and slow it down! It can affect studies as well. Diabetes can affect the kidneys, eyes, heart, nerves and sensation of the limbs. Maintaining near normal sugars is the key to success to prevent these complications. Regular check up with the doctor or nurse can help lead a near normal life. If there is a problem such as difficulty in seeing while at class, please inform the teacher or parents. They may not understand the magnitude of the problem and may think it is way of escapism. Most of the schools have a medical wing having a trained nurse. A note from the health care provider can help the school authorities to take care. The child should be allowed to snack if low sugar levels are detected while in class, must have their parents notified in an emergency, but must not be restricted from regular playing and activities. Take care of the feet- use footwear all the time even while on the beach. You may accidentally cut yourself which can take a long time to heal. Check your feet daily. Use cotton socks and use one size extra large footwear. Use a moisturizing cream on the feet taking care not to apply it between the toes. If you cannot feel either hot or cold sensations, please mention to your doctor or nurse urgently.
Take care of the eyes and tell your parents or your teacher if there is a problem. They can guide you to the doctor or nurse. Remember that eyes can get cloudy when the sugar levels increase. Brush the teeth well and take care of them by visiting the dentist once annually.
You can exercise like other people. You may tire easily. Before exercising, check your sugar levels , if high, check on blood ketone levels as well. Do not exercise if low sugar levels are seen on checking. If blood ketone levels are more than 1.5 mmol/L, give yourself 15% of the basal insulin with a pen separately. Drink a glass of non sugar drink every hour. Check again after an hour. If not feeling well, losing consciousness or dehydrated or vomiting with abdominal pain, go immediately to the hospital.
Do not exercise immediately after injecting insulin as it can get absorbed soon and cause low sugars. It depends on which part of the body you inject and which group of muscles you exercise. If you inject onto thighs and go for jogging, it will be absorbed faster. If sugars are low before the exercise, have a carb snack ( biscuits or juice) before the program. Do not give bolus injections for the snacks taken to prevent low sugars.
Warm up for 5 minutes, stretch for 5 minutes and then go into activity for about 20 minutes and allow 5 minutes for cooling down. You are to drink non sugary fluids every half an hour. You can have a carbohydrate snack- a biscuit or a fruit juice to bring up low sugars. CHOCOLATES DO NOT INCREASE THE SUGAR LEVELS INSTANTLY DUE TO ITS HIGH FAT CONTENT. Preferably do not use heavy weights while exercising as it increases the pressure in your eyes which can cause a bleed into the eyes. If you go for a sprint( high intense exercise), the sugars will increase! This is due to the increase in some hormones which increase the sugar levels.
If the doctor says you have retinopathy ( eyes are affected by Diabetes), avoid lifting heavy weights and strenuous workouts.
Read more in the blog: Exercise and Diabetes
If having high blood sugar:
This is a medical emergency. If the blood sugars are high and if there are ketones in the blood the following can be done before going to the hospital.
Blood glucose Blood ketones Insulin dosage
>200mg% <0.6 mmol/L One unit Rapid insulin for each 50mg%above 100 Mg%
>200 mg% 0.6-1.5 mmol/L 10% of TDD of rapid insulin
>200mg% >1.5 mmol/L 20% of TDD as rapid insulin
TDD means total daily dose. To convert sugar in mg% to mmol/L divide by 18
If the blood sugar is 345 mg%, the extra insulin has to be calculated as follows:
345- 100 = 245 mg%
Give one unit for each 50mg% above 100mg%
This means you have to give 5 units of rapid acting insulin ( 245/ 50)
Check sugar and blood ketones every hour till normal. You can use the Freestyle Optium Xceed meter for this. You can place blood as for checking the sugar on the strips for ketones and sugar.
For example, if the blood glucose is 22 mmol/L, the excess is 16.5 mmol( 22-5.5) You have to give one unit rapid for each 2.7 mmol excess. This means, 16.5 / 2.7 which is equal to 6 units.
Blood sugar In mmol/L Excess sugar above 5.5 mmol/ 2.7 Extra Rapid Insulin to be given
15 9.5/2.7 3.5 units (3 u)
16 10.5/2.7 3.8 units ( 3 u)
17 11.5/2.7 4.25 ( 4 u)
18 12.5/2.7 4.6 ( 4 u)
19 13.5/2.7 5 ( 5 u)
20 14.5/2.7 5.3 ( 5 u)
21 15.5/2.7 5.7 ( 5 u)
25 19.5/ 2.7 7. 2 ( 7 u)
Remember that the first 5.5 mmol of sugar is not counted for correction. The value above that is used for calculation. So please do not give a rough 10 units for any emergency at home. The aim is to correct the excess sugar. Do not feed the child after this dose of insulin. At this dose of insulin, the child will not go into low sugar. Make the child drink water hourly. Check the sugar every 15 minutes. If vomiting or abdominal pain or losing consciousness, get the child to hospital immediately.
The TDD means the total daily dose of rapid taken in a day. If it is 6+12+8, the total is 26 units. 10% of this is 2.6 units
20% of the total daily dose is 6+12+8= 26 and 20% of this is 5.2 units.
This needs some quick calculation. The best will be to give something like 4 units insulin, then calculate the exact amount.
If hypoglycemia ( when sugar levels fall down) develops, drink orange juice or take sugar or dates. In somecountries glucose tablets are available. Wait for half an hour. Recheck and if needed take more orange juice. You can have a handful of raisins( dry grapes) also if needed.
Glucagon kits will be available in the pharmacy. This is used for treatment of low sugar levels before reaching the hospital.
If less than 8 years of age or weighing less than 25 kg give 500 mcg of glucagon Intramuscularly. If weighing more than 25 kg or more than 8 years of age, give 1 mg of glucagon intra muscularly. Check sugar levels again in 10 minutes. Take to the hospital if not better.
Having type 1 diabetes does not prevent you from enjoying life to the fullest.
Never go for adventure sports alone.
If going for high altitude trekking, remember high altitude trips mimic mountain sickness ( headache, intestinal discomfort and fatigue)
Increased blood sugar and insulin resistance can occur at high altitudes. Sugar levels can fall with the increased activity.
Glucometers may not be accurate at cold temperature; the insulin may freeze as well.
Deep sea diving:
In those who dive deep, no unconsciousness has been reported. However, it is better to check the sugar levels an hour, half an hour and just before diving.
The transition from a child to an adult
• Kids just want to be kids. Child is a child first. Diabetes comes second.
• They strive for a little more independence each year. They do not want to stand out from the crowd. How the child accepts diabetes will depend on how, you as a parent, look at it. If you feel diabetes is a tragedy, the child will feel that way as well. However if you look at it as a fact of life that requires attention and discipline, the child will be prepared for a healthier future.
• Checking sugar frequently is painful but the child will gradually understand the importance.
• Remind them to be snacking in between playing hours.
• Remind independence comes with responsibility as they grow from a child to a teen.
• If your child reports a high blood sugar, do not scold them. They may be trying their best. Shower them with praise when they do well. Remember that nobody is perfect.
• Ups and downs of sugar levels are part of growing up and changes in body hormones as they grow into their teens.
• It is worthwhile checking how each food affects the sugar before and after eating and before and after exercise.
This is one area many are still unsure of. It is generally assumed cutting down the carbohydrate intake to as low as possible when one is a diabetic helps in control of diabetes.
” Gastronomic voyeurs have long proposed that eating is a holistic form of exercise involving various muscles necessary for scooping up the food, chewing it and getting the food to the mouth.”
Restaurants and supermarkets have taken marketing to whole new level. Terms such as biggies, jumbos, king size, grand,supreme and prompts such as all-you-can-eat -buffets and two-for-one -specials are enough to lure the unwary.
A good diet should contain 50% carbohydrate, 30% fat and 20% protein according to the American Diabetic association. One should aim for a weight loss of 5-7 % of the body weight. Most of the diets turn out to be failures as they are not practical or planned to give drastic results. Normally diabetics find it difficult to reduce weight and maintain weight loss when compared to a non diabetic. Some of the medicines taken for diabetes treatment also can cause weight gain.
Generally pregnant women and growing up children need more calories.
Culture or “habits” may have taught many of us to eat in response to any triggers such as stress, boredom, and guilt. We may multitask and eat and then wonder,” How on earth did I manage to eat that whole bag of chips or that large burger?”
Food , as a four letter word, is both a necessity as well as a burden when taken in excessive amounts. You must be familiar with the age old saying, “Eat to live and not live to eat”.
As one ages, the body weight may increase as you may be consuming more calories than needed. This coupled with the decreased physical activity and excuses such as “too tired from work”, “I just need to sleep for some time” ,” I shall grab a bite and then start”, and sink into the cozy sofa to seal the fate.
The daily need of calories depend on the following:
• The body size
• The age
• The height and weight.
• Level of activity
• Gender- whether male or female
• If pregnant.
Levels of activity
A person is labelled non active if the person is doing just normal activities such as going to work, shopping and going to school.
If the person does some physical activity such as walking for 2-4 kms daily or some form of exercise besides regular activity, the person is labelled moderately active.
If the person does heavy workouts like a gym workout, good games of squash, tennis or badminton or swimming, cycling, or walking more than 4 kms a day, the person is labelled very active.
One kilogram of body weight will equal 7700 calories. To reduce one kilogram over a week, one will have reduce 1100 calories daily. This may sound impossible. But, reducing the sugar intake by just one spoon daily can reduce the calorie intake by 500 calories. That is not a big burden, is it ?
The table given below will show the caloric needs based on age, gender and level of activity
If one observes the above table carefully, the calorie intake for both gender groups is maximum between the ages 18-25 . Thereafter the recommended caloric intake comes down to that of a 10-15 year old irrespective of your level of activity. Well, that is something to seriously think about.
A healthy breakfast will include whole grains, lean protein such as peanut butter, lean meat, fish, poultry and hard boiled eggs, low fat dairy such as yoghurt, cheese and milk and a portion of fruits and vegetables.
Know the food
Starches are bread, grains, cereal, pasta, and starchy vegetables like corn and potatoes. They provide carbohydrate, vitamins, minerals, and fiber. Whole grain starches are healthier because they have more vitamins, minerals, and fiber.
Eat some starches at each meal. Eating starches is healthy for everyone, including people with diabetes.
Examples of starches are bread , pasta, corn, potatoes, rice, cereals, beans, lentils, yam
What are healthy ways to eat starches?
• Buy whole grain breads and cereals.
• Avoid fried and high-fat starches such as regular tortilla chips and potato chips, french fries, pastries, or biscuits. Try fat-free popcorn, baked or potato chips, baked potatoes, or low-fat muffins.
• Use low-fat or fat-free plain yogurt or fat-free sour cream instead of regular sour cream on a baked potato.
• Use mustard instead of mayonnaise on a sandwich.
• Use low-fat or fat-free substitutes such as low-fat mayonnaise or light margarine on bread, rolls, or toast.
• Eat cereal with fat-free (skim) or low-fat (1%) milk
Vegetables provide vitamins, minerals, and fiber. They are low in carbohydrate. Examples of vegetables are lettuce , broccoli, vegetable juice, spinach, peppers, carrots, tomatoes, Celery, cabbage, greens. What are healthy ways to eat vegetables?
• Eat raw and cooked vegetables with little or no fat, sauces, or dressings.
• Try low-fat or fat-free salad dressing on raw vegetables or salads.
• Steam vegetables using water
• Mix in some chopped onion or garlic.
• Use a little vinegar or some lemon or lime juice.
• Add a small piece of lean ham or smoked turkey instead of fat to vegetables when cooking.
• Sprinkle with herbs and spices.
If you do use a small amount of fat, use canola oil, olive oil, or soft margarines (liquid or tub types) instead of fat from meat, butter, or shortening.
There are two types of vegetables- the starchy and non starchy. The starchy vegetables can increase the sugar levels- potatoes, corn and peas are included. Non starchy vegetables include broccoli, cabbage, sprouts, carrots, cucumber green, egg plants, ladies fingers (Okra), mushrooms, bell peppers, iceberg lettuce, tomatoes to name a few. These help in adding fiber and also keep the stomach full without increasing the sugar levels. Fruits
Fruits provide carbohydrate, vitamins, minerals, and fiber.
What are healthy ways to eat fruits?
• Eat fruits raw or cooked, as juice with no sugar added, canned in their own juice, or dried.
• Buy smaller pieces of fruit.
• Choose pieces of fruit more often than fruit juice. Whole fruit is more filling and has more fiber.
• Save high-sugar and high-fat fruit desserts such as peach cobbler or cherry pie for special occasions.
• Feel the fruits before purchasing them. If fruits are very soft, they are sweeter.
• Generally speaking bananas from the Philippines, grapes, dates, mangoes, water melon, cherries and pineapple are very sweet
Milk provides carbohydrate, protein, calcium, vitamins, and minerals.
What are healthy ways to have milk?
• Drink fat-free (skim) or low-fat (1%) milk.
• Eat low-fat or fat-free fruit yogurt sweetened with a low-calorie sweetener.
• Use low-fat plain yogurt as a substitute for sour cream.
Meat and Meat Substitutes
Meat and meat substitutes provide protein, vitamins, and minerals.
Examples of meat and meat substitutes include chicken , fish, eggs, peanut butter
What are healthy ways to eat meat and meat substitutes?
• Eat chicken or turkey without the skin.
• Cook meat and meat substitutes in low-fat ways: broil , grill, stir fry, roast, steam and micro wave
• To add more flavor, use vinegars, lemon juice, soy sauce, salsa, ketchup, barbecue sauce, herbs, and spices.
• Cook eggs using cooking spray or a non-stick pan.
• Check food labels. Choose low-fat or fat-free cheese.
Fiber diet can slow the gastric emptying and slow down the rate of glucose absorption from the intestine. Water soluble fiber includes oats and bran. Men need 38 g of fiber day and women need 25 g a day.
But, do remember………
This does not mean one should avoid carbohydrates in total. Please be reminded that carbohydrates are needed for setting up the energy levels during the day.
One should have a hearty breakfast, a moderate lunch and a light dinner.
It will be worthwhile to have an approximate 45 grams carbohydrate inclusion with each of the main meals ( Normally a healthy person has 3 main meals and snacks in between).
Spread the carbohydrate intake during the day to help one curb hunger and thereby prevent overeating.
A toast of bread with an egg will fill you longer than a couple of toasts with jam.
Please be reminded that fish, chicken, Turkey Ham, eggs do not have carbohydrate.
But, addition of cheese or cream or milk while beating the gees to make them creamier, can shoot up the carbohydrate content.
Addition of bread crumbs and other coverings such as chick pea flour or corn flour can also send the sugar levels high.
All vegetables growing below the ground do contain some amount of carbohydrate and so excess consumption of the same can upset the sugar levels.
Those who are on insulin roughly need a unit of insulin for every 12-15 grams of carbohydrates taken.
Given below are 3 options for a meal containing 45 grams of carbohydrates
One cup of cooked oatmeal - 32 gram carbohydrate
Half medium sized banana - 13 grams of carbohydrate
A Hard boiled egg and some black coffee – no carbohydrate
2 scrambled eggs - no carbohydrate
A slice whole wheat bread – 15 grams
An orange - 18 grams
A cup of low fat milk - 14 grams
3 Rye bread pieces – 24 grams
Half cup non fat cheese – 5 grams
One cup blueberries - 15 grams
Avoid fizzy carbonated drinks and sugar free items as one may compensate by eating or drinking more.
Some tips for breakfast:
Those who eat a healthy and balanced breakfast regularly manage their body weight better as well as have better concentration. The breakfast is what sets the tempo and energy levels for the day.
• Turkey sandwiches are a good option.
• Smoothies with berries and low fat yoghurt are another good option
• Whole grain oat meal with fruits or nuts
• Making a French toast with whole grain bread dipped in batter made from egg white, cinnamon powder, salt to taste and vanilla essence makes a delicious dish. This can be topped with thinly sliced apples , berries or bananas.
• Do not watch television or use the computer while eating as many studies show an increased consumption of food and improper chewing of the food as well.
• Mid day snacks can be either fruits, low energy granola bars, non salted or non sweetened nuts comprising pistachios, walnuts, almonds, pecan , pine nuts and hazel nuts.
• 2 tablespoonfuls of olive oil is enough a day. Light olive oil is more processed than either the virgin or extra virgin olive oil. The light olive oil is lighter in color, but not lighter in calories or fat. Even too much of olive oil is not healthy.
• Having a bowl of salads is a healthy low calorie option ( of course without the rich creamy sauce or dressing).
• Base meals on starchy foods such as potatoes, bread, rice and pasta, choosing wholegrain where possible.
• Eat plenty of fiber-rich foods – such as oats, beans, peas, lentils, grains, seeds, fruit and vegetables, as well as wholegrain bread and brown rice and pasta.
• Eat at least five portions of a variety of fruit and vegetables each day, in place of foods higher in fat and calories.
• Eat a low-fat diet and avoid increasing your fat and/or calorie intake.
• Eat as little as possible of: fried foods, fizzy drinks and confectionery high in added sugars
• Eat breakfast.
• Watch the portion size of meals and snacks, and how often you are eating.
• For adults, minimize the calories you take in from alcohol.
• Chew food thoroughly rather than gulping down the food.
• A small gesture such as cutting back on a spoon of sugar a day or even using the salad dressings or mayonnaise as dips rather than mix with the salads can cut back on calories.
Try having food on a 9 inch plate with half the plate comprising non starchy vegetables, the other quarter comprising one half of starchy vegetables or grains and the other quarter with protein. The tendency to have plate of 12 inches is quite common these days to get value for money.
Some dairy product can be added such as glass of low fat milk or low fat yoghurt. No second helpings! Food must not be more than an inch deep in plate ………!
Eat slowly, chew well. It gives enough time for the brain to register the stomach is full.
If you feel hungry after meals, try brushing your teeth or drinking water or having non starchy vegetables.
Eat more of vegetables which are non starchy ( those grown below the ground contain more starch)
Choose whole grains instead of processed grains
Use liquid oils rather than solid fats (solid fats contain high amounts of saturated fats which have high calories)
Use non fat or low fat dairy products
Drink water in plenty. Use less of fruits juices, cocktails, alcoholic beverages.
Lentils and kidney beans have more proteins and less fat
Beware of high calorie snacks which taste good
Beware of junk food.
Some of the commonly used items and their caloric values: Item Quantity Calories
Canned beans ½ cup 127
Bread One loaf 70
Normal butter ( salted) Big spoon 102
Non fat creamy cheese 28.35 g 23
Low fat cheddar cheese 28.35 g 79
Half fat creamy cheese 2 big spoons 64
Full fat mozzarella 28.35 g 90
Non fat yoghurt Cup 137
Flavored non fat yoghurt Cup 162
Low fat yoghurt Cup 155
Flavored low fat yoghurt Cup 250
Full fat yoghurt Cup 150
Flavored full fat yoghurt Cup 292
Non fat milk Cup 86
Full fat milk Cup 150
Boiled egg One 66
Egg mixed with oil fried 2 197
Fried falafel 28.35 g 111
Dried dates 5 114
Fried potatoes ½ cup 87
Fruit juice Cup 117
Beef 85.05 g 176
Roasted beef 85.05 g 211
White rice ½ cup 103
Brown rice ½ cup 108
Spaghetti macaroni Cup 197
Nuts ¼ cup 161
Peanut ¼ cup 212
Almonds ¼ cup 211
All oils One big spoon 120
Mushroom Cup 18
Mixed vegetables 1 cup 38
Ice cream 10-12% fat ½ cup 143
Fruit salad ½ cup 47
Chicken 28.35 g 56 Cereals:
Some have cereals with milk or some just put in a handful or two into their mouth and chew on them. The market is flooded with innovative labels and cereal boxes have attractive packs to lure the people. Most of the cereals are made targeting the kids and so they are rich in sugar.
• Go for the ones made for adults
• Read the nutrition labels well
• If sugar is written near the top half of the label, it means the sugar content is more.
• High fructose corn syrup, honey coated cereals, dextrose are all forms of sugar.
• Look for serving size- some may have one cup, some half a cup
• Look for calories per serving- Go for the ones which have < 160 cals per serving.
Go for adequate portions of vitamins and minerals, have some fruits and vegetables and limit trans fats, saturated fats. Did you know?
• Stress levels and infections can increase the sugar levels.
• Sports drinks contain as much sugar as in a fizzy drink
• Dried fruits contain more carbohydrates
• Birth control pills can increase the sugar levels.
• Prolonged moderate intensity exercise can predispose to low sugar during or after the exercise
• High intensity exercise for a short time can lead to high sugars!
• Cold temperatures and high altitude can increase the risk of low sugars
• Repeated episodes of low sugar can reduce the body`s ability to recognize low sugar. The counter regulatory response by the body is also blunted in such patients.
Is this the shape of things to come?
This is an interesting concept to follow:
To get the maximum of the food one has try these tips:
Pick food from different groups such as using fruits, vegetables, low fat milk, yoghurt, whole grain bread, pasta, brown rice, lean meat, fish, poultry and eggs.
Fasting from dawn to dusk in the holy month of Ramadan for healthy adult Muslims has been ordained and physically sick Muslims are exempt from it. However many Muslims with mild to moderate Diabetes, Hypertension and other medical conditions do want to fast.
The purpose of this presentation is make some recommendations how one can fast safely in light of research on fasting. Many are concerned they cannot fast when they have diabetes mellitus . Please consult with your doctor.
Some people may need some tests to be done to assess fitness for fasting. The salient features of fasting are :
It is a voluntary undertaking rather than being ordered by a physician
There is no selective food intake i.e. protein only, juice only, fruit only , water only etc
There is no total calorie malnutrition i.e. it not a semi starvation diet.
An exercise in self discipline i.e. from constant nibbling , drinking, smoking etc
Psychological effect on the body and additional prayer give additional peace. People who should ideally not fast, but can fast under supervision
Diabetes Mellitus Type 1
Those who get recurrent low sugar levels.
Chronic Renal Failure including Renal Transplant
Severe heart and lung conditions
Physically sick ( Quran 2: 184-185)
Traveler on a journey
Women during menstruation
Pregnant and lactating women
pre pubertal children
Do you know?
Blood glucose and Insulin levels will fall during the fast.
The first few days will take some adjustment. If in doubt( headache, sweating, dizziness) check sugar or blood pressure. What to do during the fasting:
Beware the sweets and the fried food.
Remember that by eating throughout the night will not help one tide over the next day. Instead indigestion and gas related problems may set in.
Fluid intake must be adequate during the night to make up for the reduced intake during the day
Having too much of sweets or fried food during the Sahoor can lead to dryness of the mouth which can be a cause of concern during the fast. Points to remember while breaking the fast at Ifthaar:
Drink enough water, butter milk or juice. A glass of water melon juice, butter milk or tender coconut water will be a good option to break the fast. One need not add glucose. Water melon juice is sweet by itself and usually people add more sugar. Water melon has a higher glycemic index.
Try to be careful with the fried and sweet food. Take them in moderation.
Have a good Ifthaar or Isha meal. Have your prayers and then go for a walk to allow digestion.
Have some fruit at about midnight if need be. Have a good Sahoor of needed.
Avoid too salty food at Sahoor as that can make the mouth dry forcing more fluid intake.
Check the sugar level 2 hours after Ifthaar to decide whether any additional dose of medicines is needed.
Exercise and Ramadhaan
One can exercise during the month. Please check the sugar before exercise. One can exercise lightly before Isha or after the heavy meal.
Try to avoid strenuous workouts as the body may be tired due to the lengthy fast.
Those who want to exercise before Iftaar should check their sugar before exercise. If sugar is below 100mg(5.5 mmol/L) avoid exercising.
Those with type 1 diabetes are exempt from fasting as their sugar levels are dependant on insulin. However, there are some who do fasting alternate days only. This is depending on your health status.
Some more tips
Check sugar levels just before Ifthaar and before the Sahoor meal.
One can check the sugar levels at 7 am before going to work. If the sugar levels are either too low or too high, it is wise to seek medical advice immediately. You may be advised to forego the fast that day.
Time your medicines between Iftaar and 1am.
If on long acting insulin such as Glargine or detemir, it is advised to take 20% less either at Ifthaar or Sahoor time
Normally the doses of most of the medicines could be reduced during the month.
The medicines have to be tailored in such a way that there is no hypoglycemia
Be careful of sulphonyl ureas and rapid acting insulin
Among the sulphonyl ureas, gliclazide is safe in that the chances of hypoglycemia is lesser and the weight gain is minimal.
Intermediate acting insulin are avoided during the month due to the 10-12 hour action which can go into the period of fasting
The essence of Ramadhaan is the same all over the world, but the flavors may differ.
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 OnTrack
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 Fooducate
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. SWORKIT –
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.
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. Check up:
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.
When oral medicines fail to control the sugar in maximum doses
when there are complications to the eyes, kidney or heart,
when the sugars are very high,
when there is pregnancy associated with diabetes,
when intolerant to oral medicines ,
when diagnosed with latent auto immune diabetes of adults
when being planned for surgery.
If diagnosed with type 1 diabetes.
Insulin preparation: There are 3 main types of insulin based on duration of action- short acting, intermediate acting and long acting. • Short acting insulin acts for a short time and peaks fast. This is why this has to be administered with the main meals at least three times a day. • Intermediate acting insulin acts for close to 10 hours and so needs twice daily dosing • The long acting insulin can last for 16-24 hours and thus, needs one or two shots a day • There are premix insulin which comprise short and intermediate acting insulin in one. • Ultra short acting and ultra long acting insulin preparations are now available. • Non injection forms of insulin are now becoming available- studies are on. Nasal, inhaled forms, patches, pills, oral sprays are all forms being researched into to avoid the needle prick. The doses of insulin are usually tailored by the doctor or nurse initially and then adjusted by the patient depending on the sugar reading. Insulin delivery devices are now- a days by pen devices or by continuous subcutaneous devices. The old method of using a vial and syringe is still present. Insulin can be safely administered if used sensibly. Store the insulin in fridges ( not in the freezer) or in a cool room, lightly shake the pen before use if pre mix insulin and roll the insulin pen between the palms of the hand to prevent injecting cold insulin and inject at different sites each time. The needles are to ideally thrown after each injection( though some can use up to 3 injections with a needle) . Sites for injecting: • The thighs on inner side, the outer side and front side are the most preferred sites. • The abdomen wall can be used- but remember not to inject just around the belly button ( umbilicus) inject any place on the flanks more than two finger breaths on either side of the umbilicus. • The arms are not commonly used in adults. • The buttocks and back are used for small children How to inject: • Have the needles changed before injecting • Roll the insulin between the palms of the hands if insulin is cold. • Select the site for injection. It is not mandatory to wipe the area with a spirit wipe. However, if you do, make sure the alcohol or spirit dries out before injecting. • Feel for any thickening or induration. If present, avoid injecting into that site. • If skin is dark at that site avoid injecting there. • Do not inject into dilated veins on the thigh, if present. • Dial the required dose. • There are people who pinch a fold of skin before injecting. It is not necessary to. • Plunge the needle vertically into the site ( perpendicular to skin and not at an angle). Needles are fine and almost painless • Depress the plunger down. The meter will return to zero. • Count to five slowly and remove the pen. • It is common to see a drop of blood after removing the needle. • There is no need for a vigorous massage as is done after deep intramuscular injections. • Do not inject soon before or after an exercise regime. • Rapid acting ( short acting) insulin can be injected in the abdominal wall. The absorption from the thighs is ideal for intermediate and long acting insulin as the absorption is not so fast. The absorption of insulin is slowest if injected in the buttocks. The arm is not ideal for self injection.• The pen device has a spring device which can get worn out over a period of time, maybe after an year or two. Change the delivery system when this happens. The needles after use are to be discarded in a proper manner after putting them in a sharps container. There are places around the world where the used needles are sold again in a fresh pack thus helping spread of disease such as AIDS, Hepatitis B and Hepatitis C. Side effects of insulin:• Hypoglycemia- low sugar • Allergy to the preservative or type of insulin( this is quite rare these days with the advent of purified and human varieties of insulin) • Weight gain • Thickening of the subcutaneous tissue at injection site • Neuropathy- sometimes insulin can cause nerve pain which can be very depressing. Being started on insulin does not mean the end of the road. It is used by the doctor when the sugar levels are very high to bring I down, or when you are undergoing an operation or when you are pregnant or when you have complications affecting the eyes, kidney or heart. It does not mean that insulin once started remains so for the rest of your life. There are needless insulin delivery systems which are present elsewhere. There are other insulin routes available which had been researched, but fell out of favor due to the less efficiency. . While traveling long distances, use a temperature controlled pouch or ice box for keeping the insulin at a cool temperature. If you party, take a small dose before the party, have a snack before you leave, and have the rapid acting insulin after the dinner .Meet your doctor for advice on the dose. Alcohol intake can cause a delayed hypoglycemia(low sugar) The three main insulin delivery options are a pen, syringe, or pump. There are also a few newer insulin delivery systems, including the jet injector. Here are the pros and cons of each insulin delivery method to help you get started. Most of the insurance companies do not approve of these delivery systems which are new and innovative. The pen delivery system is, of course, approved and effective. Pen, Pump, or Syringe? Here’s a rundown of the three different insulin delivery systems, how they work, and their pros and cons. Insulin Syringe You use an insulin syringe to inject insulin into your body with a very fine needle. Pros: • Flexibility. You can choose from many different brands and types of syringes, and you can use them with just about any kind of insulin. • Cost savings. These work more economical than the latest medicines which could be very costly. • People with very regular schedules and consistent meal patterns can do well using this method. Cons: • Time. You have to be meticulous in loading the syringe, remember to warm the insulin if cold , by rolling the cartridge in the palm three or four times. Before injecting you need to check there is no air bubble, attach the needle, and draw the correct dose of insulin into the syringe. • Dosing mistakes. Sometimes error while loading the dose can lead to problems. Insulin Pen An insulin pen works much like a syringe, but it looks like the type of pen you use to write. Insulin pens come in disposable and reusable versions. • Disposable pens come pre-filled with insulin. • Reusable pens use a cartridge filled with insulin. Pros: • Ease and convenience. Pens are convenient to carry about unlike the insulin which ( and still is) comes in bottles.. To use an insulin pen, you just dial up the insulin dose on the pen. Then you press a plunger at one end to inject the insulin through a needle at the other end. • Memory storage. Insulin pens have a handy memory feature that will remind you how much insulin you took, and when you took it. Cons: • Expense. The disposable pens are costly and the ones which could be reused are more economical. However, the reusable ones may have to be changed once in a year or two as the dose dialer spring may become faulty. • Lack of options. Some types of insulin are not available in pen form. Insulin Pump An insulin pump is a device that’s about the same size as a pager. You wear it on your belt or in a pocket, and it delivers a steady stream of rapid acting insulin to your body 24 hours a day through a needle attached to a flexible plastic tube. Whenever you eat, you press a button on the pump to give yourself an extra boost of insulin, called a bolus. The pump is an option for people with type 1 diabetes who have not reached their target blood sugar level using other delivery methods. It’s also a good option for people with diabetes that have very active lifestyles. It’s not clear whether people with type 2 diabetes benefit from using a pump. However among those with type 2 diabetes, who have failed to achieve good sugar control with maximum doses and have to take multiple doses of insulin instead, this is a convenient option. Pros: • Steady insulin release. The pump releases insulin as if mimicking the pancreas. The dose of insulin used will be quite less as it will be delivering tiny doses at pre fixed times. Only short acting insulin is used in this. Pumps are so efficient that you can use less insulin than you would with a syringe or pen. • Ease of use. You’ll no longer have to give yourself injections of insulin throughout the day–the pump will do it for you automatically. You can also eat whenever you choose. • Better blood sugar control. Because it delivers insulin steadily like your pancreas, the pump helps prevent blood sugar swings. • Ease of monitoring. Your pump can communicate with your glucose monitoring system so you can track your blood sugar over time and make changes to your routine as needed. Cons: • Constant wear. You’re going to be attached to this pump nearly all of the time — even when you sleep. • Risks. You need to be very careful about changing the needle every couple of days because there is a slight risk for infection. You also have to monitor your blood sugar levels, because you may be more likely to have a drop in blood sugar (hypoglycemia) with the pump than with a syringe or pen. If the catheter slips out or the pump fails, you might not get the insulin you need and over time your sugars can increase and you could develop a dangerous complication called diabetic ketoacidosis. • Cost. Pumps are costly and so also are the infusion tubing and reservoir. Some of the new ones come with inbuilt sensors as well which are costly. Insurance companies do not approve of this usually. • The infusion tubing and reservoir have to changed once every three days • Sometimes the tubing gets kinked without delivering the insulin which could cause problems • One has to feed in the carbohydrate consumption at the start to prime the pump. • The insulin will not be delivered if there is air in the tubing or if the insulin remaining in the cartridge is very low. Jet Injector Jet injectors don’t have a needle. Instead, they use very high pressure to push a fine spray of insulin through the pores in your skin. Pros: • Needle-free. If you hate needles, a jet injector is an alternative to the insulin syringe or pen. Cons: • Pain. Though needle less, they can cause more pain in some of those with sensitive skin as the insulin is driven inside the body by sheer force. You have a high concentration of nerves close to the surface of your skin. Trying to push insulin through the skin can hurt more than injecting — especially considering how thin needles are. • Uneven insulin delivery. Because they send insulin into the body through the pores, jet injectors may not always deliver an accurate dose. Other options include an insulin patch. Work closely with your doctor to choose the option that best fits your budget, health needs, and lifestyle. Not all the above are available here in Oman. Afreeza is a powder form of insulin which is an ultra rapid acting insulin. The powder is used by an inhaler called the Dreamboat inhaler. Peak levels are reported in 12-14 minutes of inhalation. This is especially beneficial for those with type 1 diabetes who are dependent on insulin for life and also for those with type 2 who become insulin dependent with failure of the pancreas. Close to 5300 patients have been studied in trails across the world and the results so far are promising, but needs further time to be found effective. This has been found to reduce the post meal sugar levels, fasting levels, have less incidence of hypoglycemia( term used for low sugar levels) , reduced weight gain as when compared to rapid acting insulin. However, this may need to be combined with long acting insulin or with oral medicines as the case may be for a better effect. The side effect so far noted has been a non productive cough ( dry cough) Degludec insulin is a new ultra long acting insulin which is still on research programs to test its efficacy. Though it is being marketed for injection once in 3 days or once a week ( which sounds like sweet music) , the effects of the insulin wear off after a day or two. Which means it is still better to have the shots of insulin daily for better control. The sugar control and episodes of low sugar have not shown any improvement over the insulin preparations available in the market today. Continuous glucose monitoring Continuous Glucose monitoring (CGM) devices are in the market for quite some time. These are small gadgets the size of a pager which help to monitor the sugar levels throughout the day and night. On an average a child between the ages 5 and 14 may have to poke the finger for sugar checking at least 50000 times and about 15000 injections of insulin during that time. This is quite phenomenal and frightening. For people on intensive insulin therapy as among those with type 1 diabetes or among those with frequent dips or spikes in their sugar levels which could be related to either food, alcohol or exercise. These machines detect the glucose level just under skin with the help of sensors. These levels are transmitted to a receiver. Pros: • This will give a constant reading and you can adjust the doses accordingly with the help of the health care provider. If the blood glucose reading is 7 mmol/L or 126 mg/dL, it could mean the sugar is going up or down and that is the reading at that time. The machine gives an arrow mark which will give the trend based on the readings just before.. • The tracings can be downloaded and interpreted • The tracings are given for every day in different color lines for easy interpretation • It also gives the average and how many lows one had experienced in the interim. • Alarms are there which could be programmed into the machine which could go on either when sugar swings too low or too high. Cons: • The cost is quite high • Normally the insurance companies do not approve of this unless in certain cases. • The sensors will have to be changed once in 3-7 days. This is costly • This is to be worn at all times. • May not be feasible for children below the age of 12. • One will have to calibrate the machine from time to time so that the readings are accurate. Needle less devices Frequent puncturing of the delicate skin at finger tips and also the insulin shots which are so frequent especially among those with type 1 diabetes are a cause of frustration. Now-a-days needle free CGM devices are coming out. Some are awaiting patents. There will be sensors, a transmitter and receiver. The signals can be sent to smart phones, computers or even laptops. This can be useful for working mothers who have children at home and can remotely access the sugar levels and send information to make corrective steps. The sensors are to be changed once in 3 days which helps prevent skin irritation. The skin top layer which comprises dead cells is painlessly removed and leaves a small abrasion not visible to the naked eye. The Symphony is one brand making such needle free CGM. Dexcom G4 Platinum is awaiting patents rights. This is sleek and hardly noticeable
Driving regulations vary from country to country. But, the fitness to drive especially if one is a diabetic is the same around the world .
Driving is essential for going to work, taking care of family, accessing public and private facilities and institutions, attending classes, interacting with friends and for pleasure. If practicing unsafe driving, it can be a cause of concern for those behind the wheel as well as those on the road. Those who should not drive if having diabetes:
• Those with recurrent hypoglycemia ( low sugar)
• Those with cataract , those with retinopathy ( diabetic changes in eyes) or color blindness.
• Those with insensitive feet ( they could not feel the foot pedal)
• Those who are on multiple insulin doses
• Those with hypoglycaemia unawareness. These people do not know their sugar levels are below 3 mmol/L (54 mg/dL) as the body does not have any symptoms. Non diabetic causes to be denied a driving license:
• Those with obstructive sleep apnoea
• Those with unstable angina or heart pain
• Those with epilepsy
• Those who have consumed large volumes of alcohol or other recreational drugs.
• Those with color blindness
Make sure of these while planning a drive:
• Check the glucose level an hour before journey.
• If driving more than an hour, check sugar level after every hour.
• Make sure you stop frequently for hydrating yourself.
• Be careful of taking insulin before driving long hours.
• NEVER DRIVE ALONE
• CARRY GLUCOMETER WITH YOU
• Have either a juice or sugar candy or dextrose tablet or sugar in small container in the car dashboard.
If you feel low in sugar while driving alone:
• Pull off the road and put on the hazard signal.
• Roll down the window glasses both sides.
• Remove the key off the ignition and keep on the seat nearby.
• Take either the sugar or orange juice or candy.
• Check the sugar level using glucometer.
• Call someone for help.
• Rest in the car till help arrives.
• Check sugar level after half an hour. If above 7 mmol/L, drive to nearby resting place or hospital.
When sugar levels go down, the brain gets affected and will lose its cognitive faculty. Decisions will be made at sub conscious level. If the car ignition is not turned off , one may suddenly drive and meet with an accident. If one becomes unconscious, keeping the windows open will help in accessing you.
Make sure you do check sugar level before driving. If low, correct that first and then drive.
Older drivers should note the following:
As age advances, one may notice problems with braking safely, longer response time to an emergency and problems with night vision.
Options available to overcome these in elder drivers:
• Stay physically active
• Regular vision and hearing check
• Use of some chronic medicines may cause drowsiness
• Understand limitations
• Drive under optimal conditions
• Plan ahead
Hypoglycemia or low sugar is one of the nightmares of the patients and the doctors alike. High and low sugars may both present with sweating , confusion and sometimes even unconsciousness.
The commonest causes being taking too much of insulin or some medicines or forgetting to take food, too intense an exercise, consuming alcohol and some tumors of the pancreas.
Generally sweating, shaking of the hands, irritation, craving for food, beating fast of the heart, headache, stomach pain (gastritis) and clouding of consciousness. The body tries to correct the levels itself by an in built mechanism.
For the elderly adults low sugar manifests as confusion, delirium and drowsiness. Tremors and sweating are rare for the elderly with low sugar levels.These can mimic those with a fit or stroke and is, for that strange reason, often misdiagnosed.
For some people the body fails to recognize the features of low sugar. This is dangerous as very low levels are needed for the body to recognize it thereafter. This is called unawareness.
What can be done?
If low sugar happens, drink a can of orange juice or chew on some dry raisins or put some sugar into your mouth. If glucose tablets are available, that is a good option. Chocolates are not a good solution for low sugars as the fat content in chocolates delay the fast rise in sugar. Check your sugar level after 15 minutes and if still low, repeat the above. Get to nearest hospital and get this corrected if needed.
Categories of hypoglycemia: • Documented hypoglycemia: typical symptoms of hypoglycemia and when the plasma glucose is ≤70 mg%.
• Severe hypoglycemia : An event which requires active assistance of a person to administer glucagon or carbohydrate or adopt any other resuscitative measure.
• Asymptomatic hypoglycemia: An event that is not accompanied by typical symptoms but the plasma glucose ≤70 mg%.
• Probable symptomatic: An event during which hypoglycemic symptoms are not documented with a plasma glucose determination, but presumed to be ≤70 mg%.
• Relative hypoglycemia: An event during which the diabetic patient reports typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but the plasma glucose is ≥ 70mg%.
While driving if low sugar is encountered, drive off the road, put on distress signals, turn off the car, pull down the windows, remove the key from the ignition, take some sugar or orange juice immediately.( you must have a stock of this in the car always) . The brain takes some time to recover from the low sugar and impulsive driving may be initiated leading to accidents. Always check sugar levels before a long drive, break the journey in between long drives and carry an ID mentioning your diabetic status and contact numbers.
Sometimes hospitalization is also needed in serious cases.
The impact low sugars can have on life is very dramatic. For example, developing this while attending an interview or while at the exams or at an important meeting or while driving, can change the course of ones` life. People may then become introverts avoiding social functions for fear of low sugar. They are often mistaken for drunken behavior as well.