Required Information about Type-2 Diabetes
There can be no denying the fact that diabetes is fast assuming the proportions of an epidemic.The number of diabetic patients being admitted to hospitals is on the rise. Statistics show that no age-group is currently safe from falling prey to this deadly disease.
Diabetes is a metabolic disorder that leads to high blood sugar levels. Carbohydrates from the food consumed by us daily are converted into glucose before being used by our body cells. The insulin hormone, which is produced in pancreas (beta cells), helps glucose to enter into the cells of the body and produce the required energy for our metabolism.The blood glucose levels shoot up owing to insulin resistance as well as the subsequent deficiency of insulin (which are caused by the failure of beta cells), eventually leading to diabetes.
Though there are four types of diabetes (type-1, type-2, special type and gestational), this booklet primarily focuses on type-2 diabetes (since this is the one that occurs most commonly).The symptoms of type-2 diabetes are: frequent urination (polyurea), excessive thirst (polydipsia), excessive appetite (polyphagia) and weight loss. However, it must be remembered that these symptoms appear when blood sugar is very high and that initially, diabetes remains undetectable.
DIABETES IS THUS A SILENT KILLER.
Risk factors of Type-2 diabetes are:
1) More than 40 years of age
2) If members of one’s family have suffered previously from this disease, then one should consider himself or herself more prone to developing type-2 diabetes. If either parent had diabetes then the risk of developing this disease is 40%. If both had diabetes, then the risk is 80%. If any sibling has diabetes then the risk is 10%.
3) Obesity (i.e. if the body mass index is more than 25). Body mass index (BMI) can be measured at home.The formula is to divide the weight (in kilogram) by the square of height (in meter). For example, if your weight is 85 kg and height 1.75 m, then your BMI is 85/ 1.75^2 = 85/ 3.0625 = 27.754.
4) If your blood pressure and cholesterol levels are more than normal.
5) There are signs of insulin resistance and impaired glucose tolerance.
6) Recurring infections (viz. on skin or on sexual organs, or TB).
7) Arterial diseases.
8) Sedentary lifestyle. Diabetics can have a healthy life by exercising regularly and following healthy food habits. One needs to exercise for at least 30 to 45 minutes every day. Aerobic exercises like skipping, swimming, badminton, tennis, squash, treadmill etc are recommended. It is best to consult a physician in advance. Remember that though walking is a good exercise for diabetic patients, it should be brisk (For eg: 2 kms in 30 minutes). One must never exercise on an empty stomach or after a large meal. Nevertheless, one can exercise at any other time of the day. Everybody should try to maintain the ideal weight. An easy and quick method is to calculate one’s height in centimeter and then subtract 100. Generally, obese people can consume 25 calories per kg while normal people can consume 35-40 calories per kg. However, diet charts for patients must be prepared by a dietician as protein, carbohydrate and fat are required in a specific ratio.
Diabetes is an obstinate disease. Blood glucose levels thus need to be controlled all the time. Besides these, a few cautionary steps such as the following must be taken:
i) Each patient must test blood pressure every two months, besides checking lipid profile, urine albumin, eyes and ECG every year.
ii) Foot care must be adequate. Feet must be cleaned every day. One must always wear cotton socks and never walk barefoot. If there is any wound, it must be treated immediately and a doctor must be consulted.
iii) Medicines must be consumed even while suffering from fever or any other kind of illness.
iv) Blood sugar must be controlled before pregnancy (HbA, C<6.5). During pregnancy, no diabetic medicines are allowed other than metformin and insulin.
v) Usually, patients need insulin if they have been suffering from diabetes for more than 15 years.
vi) Weight loss should be preferred as it is beneficial and is a modifiable risk factor.Tobacco intake in the form of smoking or consuming khaini, gutkha, zarda, guraku etc. should be given up as early as possible.
Facts about Hypoglycemia
What is Hypoglycemia (low blood sugar)?
Abnormally low sugar levels in one’s blood can be defined as hypoglycemia. It can prove to be dangerous if neglected. It is important to recognize the symptoms and treat them promptly.
Causes of Low Blood Sugar
- Overdose of insulin or anti-diabetic tablets
- Skipping or delaying a meal
- Unusual exertion or too much exercise
- Irregular intake of insulin, tablets and meals
- Excessive alcohol intake
The normal range of blood sugar is between 80-100/110mg/dl (while fasting) and 140mg/dl (two hours after meals). Blood sugar levels ranging from 111-125 mg/dl while fasting (IFG) and 141-199 mg/dl after meals (IGT) are identified as pre-diabetic range. It has been observed that about one third of pre-diabetics eventually become diabetic in future (while many more go on to suffer from ischemic heart disease in the long run). However, they can prevent this by changing their food habits and exercising on a regular basis.
Diabetes brings forth long-term risks. At any given point of time between 5-20 years, it causes cardiovascular diseases like ischemic heart disease (angina and myocardial infarction), stroke and peripheral vascular disease (which necessitates amputation at times). Diabetes is also harmful for kidneys (kidney failure), nervous system (neuropathy) and eyes (blindness).
Symptoms of Low blood Sugar
Symptoms of low blood sugar may differ from person to person (also when it comes to the same person) from time to time. The symptoms are:
- Excessive hunger
- Palpitations (rapid heartbeat)
- Blurred vision
- Change in behavior or mentality. These symptoms might be followed by blackouts and fainting if not treated in young type-1 diabetic individuals. Convulsions (fits) may also appear as one of the symptoms
Treatment of Hypoglycemia
- If the symptom is mild, take any food or drink that is readily available
- Take sugar or glucose if the symptom is very severe
- If you become unconscious, contact the doctor immediately as intravenous glucose needs to be administered in such cases.
Foot Care for Diabetes
Over the years the blood circulation in the legs and feet of diabetics may deteriorate and the nerves may become less sensitive.
Diabetes can affect the feet in the form of (i) Neuropathy (ii) Peripheral Vascular disease (iii) Infections
Neuropathy leads to ulcers mainly by reducing the perception of pain and trauma inflicted by foreign bodies. It can also be caused by walking in ill-fitting shoes. Excessive pressure on the sole can eventually lead to the formation of callus which in turn can lead to ulcers
(ii) Peripheral Vascular Disease
Defects in microcirculation or major arterial occlusion may contribute to the development of ulceration and lead to ulcers that fail to heal.
Infection due to diabetic foot ulcers can be either superficial or deep, and can sometimes turn out to be life threatening.
Important Aspects of Foot Care
Examine the feet thoroughly every day.The skin should ideally be undamaged and smooth. In case of problems in viewing the entire foot, use a mirror.
- Check the spaces between the toes. There should be no pressure marks or cracks
- Check the nails.There should be no redness or swelling around them
- There should be no crack
- Check the colour of the skin; any visible blotch needs further examination
Prevention of Hypoglycemia
- Follow a four meals pattern (breakfast, lunch, evening snacks & dinner)
- Strictly abide by the routine for food and medications
- Include low calorie foods like buttermilk, tomato juice, clear soups and salads in between the meals
- Reduce the dose of medication and consult your doctor for dosage adjustments
- Take extra food if you end up exercising more than you normally do and check with our dietician in order to be able to do so
Cleanse your feet by washing them with lukewarm water and soap. Avoid long foot baths that reduce skin resistance. Dry the feet carefully and pay special attention to the spaces between the toes to prevent athlete’s foot.
The toe nails should be trimmed regularly. One can do this easily right after washing the feet when the nails become soft. Nails should be trimmed properly with nail clippers or nail scissors.
The skin of the feet should not become so dry that it gets cracked. It needs to be moisturized with a skin cream every time after it has been washed.
Cold feet can be counterbalanced by massage and foot exercises as well as by not wearing thin socks and light shoes. Avoid dipping your feet in hot water. Use woolen socks and a woolen blanket in bed.
Calluses on the skin
Pressure marks, corns, calluses and cracked feet indicate that the feet are being overtaxed.
The reasons have to be identified and eliminated. They can be caused by anything from ill-fitting footwear to friction.Thick calluses may be reduced by gentle filling with a pumice stone or callus file after bathing.
Never puncture blisters caused by footwear or overtaxing of the feet. Cover the blister with a piece of dry gauze to protect it from getting punctured. If there is blood or pus oozing from the blister, a doctor needs to be consulted immediately.
About half of the foot related problems leading to foot ulcers can be prevented with adequate footwear. Before stepping into a pair of shoes, ensure that you are not feeling uncomfortable owing to the presence of things like pebbles, nails, etc. inside the shoes. The shoes should be flexible and there must be enough room for your feet.The best socks to wear are woolen or cotton socks. Avoid walking barefoot.
Suggested dietary advice
- Healthy Diet
- Free foods
- Black coffee or tea
- Tomato juice or lime juice
- Clear soup
- Buttermilk (dahi ka ghol)
- Green, leafy vegetables
- Fresh green salads
- Other vegetables barring roots and tubers
Foods in limited quantity
Cereals & pulses
Refined cereal products like refined wheat flour (maida), semolima (rava), etc.
Vegetables like green peas, beetroot, beans, green plantain and fruits like guava, apple, watermelon, orange, ripe papaya and sweet lime. Egg white can be consumed frequently but whole eggs should be restricted to two per week.
Fish or chicken can be taken in small quantity every day and cooking medium should preferably be sunflower oil, rice bran oil, soya bean oil, mustard oil or any low cholesterol oil. Try to use as less oil as possible, (ideally ½ liter of oil per month per head)
Foods to be avoided
- Sugar, honey, jiggery, glucose, jam, sweets, desserts, barfi, payasam, ice-cream etc.
- Bakery products like cakes, pastries and cream biscuits
- Fried Rice
- Food cooked in excessive oil
- Fats like dalda, butter, margarine, coconut oil and ghee
- Red meat or organs like kidney, liver head etc.
- Root vegetables like yam, colocasia tapioca and sweet potato
- High calorie fruits like banana, grapes, zapota, custard apple, wood apple, jackfruit and ripe mango
- Dry fruits like dates, raisins, currants, cashew nuts, almonds, groundnuts, etc.
- Sweetened and aerated drinks, fruit juices, squash and proprietary drinks
Recommended food items
- Food containing high fiber like green leafy vegetable salads
- Whole pulses like roasted Bengal gram and germinated pulses
- Inclusion of whole wheat flour in a day’s menu (at least for one meal) is advisable
Diabetic Heart Disease : Some Useful Information
Deposition of fat on the walls of the blood vessels.
This term means chest pain, but it could also be a discomfort felt behind the breastbone, typically caused by exertion and relieved by rest.
Breathlessness accompanied by pain in the arms and jaws, caused by exertion and relieved by rest.
Usually caused by a complete block in the coronary arteries, and is associated with the destruction of parts of the heart muscle.
Symptoms of Heart attack
Prolonged discomfort in one’s chest, usually behind the breastbone, lasting for more than a few minutes. Heaviness, choking, acoompanied by a feeling of pressure. Difficulty in breathing. Sweating. Weakness. Palpitation.
Risk factors for heart attack
- Diabetes mellitus
- High cholesterol levels in the blood (especially LDL or bed cholesterol)
- High blood pressure
- Family history of heart disease
- Low levels of HDL (High density lipoprotein or good cholesterol)
- Sedentary life style
- Lack of exercise
How to reduce the risk of heart attacks
- Lower the fat intake and increase the fiber intake
- Exercise regularly
- Maintain your ideal body weight
- Control your blood pressure
- Check your cholesterol once every six months and contain LDL (bed) cholesterol within the normal limit.
- Increase HDL (good) cholesterol by exercise
- Stop smoking
Note : As E.C.G. is taken while the patient is resting, the results maybe normal but it may not mean that his or her heart is in perfect condition. In these situations, the doctor may recommend certain other tests like echo cardiogram, treadmill (for cardiac stress test) or when necessary, a coronary angiogram.
Instruction for self administration of insulin
All insulin dependent diabetic individuals as well as some non-insulin dependent diabetic individuals require insulin injections daily. Insulin injections can be taken by the patients themselves. It can save lives and help in preventing diabetic complications.
Insulin is measured in units. Always use U-40 syringes for U-40 insulin and U-100 syringes for U-100 insulin.
Materials required for insulin injection
- Disposable insulin syringes or your personal insulin device
- Denatured spirit
Sites of Injection
The sites of insulin injection influence the insulin absorption. Insulin is best absorbed by the abdomen. The sites are:
- Upper and outer parts of thighs
- Upper arms
The process of delivering the injection
Procedure for loading single insulin
- Clean the cap of the bottle with cotton dipped in denatured spirit.
- Draw as much amount of air up into the syringe as the amount of insulin required.
- With the insulin bottle upright, insert the needle into the bottle and inject the air into it.
- Turn the bottle upside down making sure the needle is below the surface of the insulin and draw up the correct dose of insulin into the syringe.
- Gently tap the syringe to remove air bubbles. The syringe is finally ready for administration.
- For insulin pen devices, you need to dial the units of insulin necessary [follow the guidelines mentioned].
Steps for self-injection
Irrespective of the site of insulin injection, the procedure remains the same.
- Wash your hands
- The skin should be stretched widely to prevent the needle from entering the muscle
- Insert the needle vertically (i.e.) at 90 degrees. In case of insulin pens, just inject them straight (90 degree) into the skin (usually pens have smaller needles)
- Now, release the skin and inject the insulin into the skin
- Place the cotton near the injected area and remove the syringe
- Do not massage the injected area
DO’S AND DONTS FOR THE ADMINISTRATION OF INSULIN INJECTIONS
Irrespective of the site of insulin injection, the procedure remains the same.
- Take insulin 30 minutes before food, or as advised by your doctor
- Use appropriate syringes (U-40 insulin for U-40 syringes) (U-100 insulin for U-100 syringes)
- Use the correct “injection sites’
- It can also stored in a pot of cold water after being wrapped carefully with a plastic bag
- Self inject insulin instead of counting on others
- Store insulin in cold vessels while traveling (25-30°C temperature is usually sufficient)
- Reduce insulin by 2 or 3 units if you develop low sugar levels
- Roll the insulin bottle between your palms if it is chilled
- Skip or stop insulin without consulting your doctor
- Use bent or blunt syringes
- “Self inject” in your arms
- Store insulin in a refrigerated space
- Use syringes more than 3-4 times (needles in case of pens)
- Expose insulin to direct sunlight
- Take insulin when the bottle is very cold
- Shake the insulin bottle till it gets cloudy
Painless injection procedures can be now adopted by taking insulin through pen injections which have microfine needles. The procedures for these are quite different from those mentioned above.
Significance of the HbA1c Test
HbA1c is an excellent index for long term diabetes control (over preceding 2-3 months). Unlike blood sugar levels which tend to fluctuate day to day and even hour to hour, the HbA1c test is a true index for average blood glucose control (during previous 2-3 months). HbA1c test is done in this laboratory rapidly and precisely using the “Gold Standard” of the HbAlc testing without interference from Schiff base, lipemia, temperature fluctuation, pH or normal sample degradation.
Test your HbAlc every 3 months
Foot problems can make diabetics suffer majorly. Over the years, the blood circulation in one’s legs and feet may deteriorate and the nerves may become less sensitive.
(2) Peripheral Vascular Disease
Neuropathy results in ulceration as the perception of pain and trauma inflicted by foreign bodies or ill-fitting shoes becomes progressively difficult. Excessive pressure on the sole leads to the formation of callus that can crack and lead to ulceration.
Peripheral Vascular Disease
Defects in Microcirculation on major arterial occlusion may contribute to the development of ulceration and lead to failure of healing of the ulcers.
Infections in the form of diabetic foot ulcers can be either superficial or deep and can on occasions turn out to be life threatening.
SCHEDULES FOR DIABETES CHECK-UPS RECOMMENDED BY US
1. Daily/Weekly: Monitor blood glucose levels at home with the help of glucometers
2. Monthly: Blood sugar tests along with urine routines
3. Quarterly: (once every 3 months)
- Blood sugar tests
- Urine routine
- (Computerised) HbA1C by HPLC (2/3 Months)
- Creatine, P/C Ratio Protein crealinine Ratio/ Microalbumin creatinine ratio
4. Six Months: Blood Sugars, Urine Routine, Computerised HbA1C – (2/3 Months)
- Creatine P/C Ratio Microalbumin creatinine ratio Lipid profile Microalbumin
5. Yearly : (Complete check-up)
- Blood sugars
- Retinal Test (Eye)
- Kidney Function Test- including Microalbumin
- X Ray (Chest)
- Diabetic Panel
- Electrolytes, Haemogram, Urine – complete examination
- Foot Examination & Foot Pressure Study
- Dental Screening
- Other special tests (Treadmill, Echo, USG Abdomen etc)
- Any other abnormal parameter which needs re-assessment
* Note :These are but just rough guidelines and may have to be individualized
Diabetic Panel with HBA1C
Hb; ESR; Creatinine; Liquid Profile; FBS & PP;TSH;
Urine micro albumin creatinine Ratio; SGPT;
Albumin; HbA1C; Urine R/E
|Fasting Blood sugar||70-100 mg/dl|
|Post prandial blood sugar||<140 mg/dl|
|Cholesterol||Below 200 mg/dl|
|Triglycerides||Below 150 mg/dl|
|HDL Cholesterol||Above 40 mg/dl|
|LDL Cholesterol||Below 100 mg/dl|
|Blood urea||13-43 mg/dl|
|Serum Creatinine||Male : 0.8 -1.3 mg/dl|
|Computerised HbA1c||Below 5.6% normal Value|
|5.6% – 7.0% Good Control|
|7.1% – 8.0% Fair Control|
|Above 8.0% – Poor Control|
Above 8.0 Above 64 Poor Control
(2-3 Weeks control)
|Degree of control||Non-Pregnant Adults||Pregnant Women|
|Normal value of excellent control||Below 220||Below 200|
|Good control||220 – 259||201 – 230|
|Unsatisfactory control||260 – 309||231 – 260|
Note : These are but just approximate guidelines. Your doctor will prescribe specific tests for each and every patient.