DIABETES

KNOW MORE/ALL ABOUT DIABETES

Diabetes is a disease in which there is high amount of sugar (glucose) in the blood. Normally, insulin (a hormone) that is produced by the pancreas (an organ/gland situated behind the stomach), converts glucose into energy so that every cell of our body can utilize this energy to perform its functions. All carbohydrate-rich food we eat in our daily life is converted into glucose and with the presence of insulin, it is converted into energy. Insulin is the key hormone that opens the cell membrane and allows glucose to enter inside the cell so that cell can utilize it as the source of energy. Without sufficient amount of insulin, glucose cannot be transformed to energy and it remains in the bloodstream, and hence, the level of glucose in the blood goes up. The high level of glucose in blood is known as diabetes or hyperglycemia.

The abnormally high levels of glucose in blood can be due to either pancreas not producing sufficient amount of insulin or the cells of the body are not able to utilize the insulin as it should be used normally. The body’s inability to utilize insulin is termed insulin resistance.

This high level of glucose in blood is very harmful to every organ in the body. It gradually deteriorates their functions over a period of time. Raised blood glucose levels can cause blindness, heart attack, stroke, kidney failure, lower limb amputation, etc. It is said that a person with diabetes will not die with diabetes but because of its complications.

According to International Diabetes Federation (IDF), there were 451 million adults living with diabetes worldwide in the year 2017, and it is estimated to increase to 693 million by the year 2045. In India, 77 million adults have diabetes and this number is expected to almost double i.e., 134 million by the year 2045.

Types of Diabetes

1. Type 1 diabetes

2. Type 2 diabetes

3. Gestational diabetes

4. Prediabetes

TYPE 1 DIABETES

Type 1 diabetes is an autoimmune disease in which the body’s own antibodies kill the cells that produce insulin. The occurrence of type 1 diabetes is approximately 5–10%, which is very much less as compared to type 2 diabetes. Insulin is a hormone produced by the pancreas (an organ/gland situated behind the stomach), converts glucose into energy so that every cell of our body can utilize this energy to perform its functions. All carbohydrate-rich food that we eat in our daily life is converted into glucose and with the presence of insulin, it is converted into energy. Insulin is the key hormone that opens the cell membrane and allows glucose to enter inside the cell, so that cell can utilize it as a source of energy. So there is a very limited amount or no amount of insulin in our body. This is called an immune reaction. Mostly Genetic factors and Environmental factors like infections, hygiene, and obesity. Mostly it occurs till the age of 30 years of age but it can occur at any age.

In type 1 diabetes, a patient will be on lifelong insulin treatment. Along with the insulin, they have to monitor their blood glucose regularly and perform regular exercise and follow a diet as per the advice of a physician, diabetologist, or an endocrinologist.

Symptoms

• Frequent urination
• Excessive hunger
• Excessive thirst
• Loss of weight due to unknown reason
• Vision disturbances
• Fatigue

Causes

The cause for type 1 diabetes is mutation of certain genes which is due to hereditary and environmental factors that will exaggerate the conditions. For example, if any one or both parents have type 1 diabetes and you are exposed to any environmental conditions like cold weather, some viral infections, obesity, inappropriate hygiene conditions, early start of solid food, etc. Then you may get type 1 diabetes.

Some studies show that the risk of diabetes increases in a child who is not breastfed or solid food was initiated early in their life and has a genetic predisposition. Furthermore, white people are more prone to develop type 1 diabetes, and the risk is higher in white people who live in a cold environment.

Do I become a risk factor for my child to develop type 1 diabetes?

Type 1 diabetes is a hereditary/genetic disease. If your father has type 1 diabetes, there is an increased risk of developing diabetes in the child if they are exposed to certain environmental triggers. On the contrary, if the mother is a type 1 diabetic then the risk is comparatively lesser. However, the risk is double if both father and mother are type 1 diabetics. This risk decreases gradually with the advancement of your child’s age.

Scientists have found that people with mutations on the human leukocyte antigens (HLA) genes are at a greater risk of developing diabetes when compared to mutation in other genes. There are certain antibody tests available to identify the risk of diabetes in the child, for which your doctor may advise you.

Complications

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is mainly a complication of type 1 diabetes and rarely occurs with type 2 diabetes. DKA occurs when blood sugar is very high for a longer period due to which the liver produces acidic substances called “ketones” at an abnormally high rate in the body. DKA may also lead to diabetic coma.

Hypoglycemia

Hypoglycemia means low sugar levels in the blood. This is a very serious and life-threatening complication of diabetes, if left untreated. Hypoglycemia occurs when blood sugar levels drop to <70 mg/dL (or 4 mmol/L).

TYPE 2 DIABETES

Type 2 diabetes is the most common diabetes prevalent in the world. According to International Diabetes Federation (IDF), 425 million people are suffering from diabetes and it is projected to increase to 578 million people by the year 2030 and 700 million by the year 2045.[iii] Type 2 diabetes accounts for approximately 90% of all diabetes globally. In addition, India has a growth rate of 12.5% to develop diabetes. India accounts for 20% of the world’s population with an increased risk of diabetes in urban sectors.

Insulin is a hormone produced by the pancreas (an organ/gland situated behind the stomach) that converts glucose into energy so that every cell of our body can utilize this energy to perform its functions. All carbohydrate-rich food we eat in our daily life is converted into glucose and with the presence of insulin, it is converted into energy. Insulin is a key ingredient or hormone that opens the cell membrane and allows glucose to enter inside the cell so that cell can utilize it as a source of energy.

In type 2 diabetes body’s cells are not able to use insulin due excess weight, metabolic diseases, genetic factors, etc. Initially, pancreas starts to produce more amount of insulin; however, body’s cell shows resistance to utilize it properly. This situation is called “Insulin Resistance”. Eventually, the pancreas fails to produce insulin to meet the demand, and hence, glucose levels in the blood increase. Higher levels of glucose in the body for a long time cause damage to the body, especially to the organs like kidneys, eyes, skin, nerves, metabolism, etc.

Type 2 diabetes usually presents in elderly people. However nowadays, due to sedentary lifestyle, obesity and high stress levels, it can affect young people as well. It can be managed by education, lifestyle changes (diet and exercise) along with medicines as per the advice of the attending physician, diabetologist or endocrinologist.

Risk Factors

• Age more than 45 years (it can affect individuals of any age but middle aged to elderly are more prone)
• Sedentary lifestyle
• Stressful life
• Overweight or obesity
• History of gestational diabetes (diabetes during pregnancy)
• Family history of diabetes
• Other diseases like high blood pressure, heart disease, stroke, polycystic ovary syndrome (PCOS) or depression
• Abnormal lipid levels such as low high-density lipoprotein (HDL) cholesterol (also known as good cholesterol)  and high triglycerides.

Symptoms

• Frequent urination
• Excessive hunger
• Excessive thirst
• Loss of weight due to unknown reason
• Vision disturbances
• Fatigue
• Itching around groin area
• Wounds takes longer time to heal
• Tingling and numbness at hands or feet.

Causes

The cause of type 2 diabetes is a combination of genetic or hereditary factors and environmental factors such as metabolic disease, low HDL (good cholesterol) and high triglyceride levels, obesity, certain medicines, etc. People who have parents with type 2 diabetes are at an increased risk of developing diabetes. Along with hereditary risk, unhealthy lifestyle such as sedentary life, too much junk food, artificial sweeteners and preservatives containing food, lack of physical exercise, stress, etc., act as triggers in the development of diabetes. Furthermore, the mutation in the genes that are involved in controlling blood glucose levels may increase the risk of diabetes along with environmental factors.

Do I become a risk factor for my child to develop type 2 diabetes?

There is a lifetime risk to develop diabetes in a child with a family history of diabetes. However, one can avoid diabetes by adopting a healthy lifestyle like regular exercise, a healthy diet and by avoiding stress.

Complications

Continuous and high levels of glucose circulating in blood will gradually deteriorate the functioning of various organs.

Acute Complications

Hypoglycemia

Hypoglycemia means low blood sugar levels. This condition arises when patients are on insulin or any medications for diabetes and skip a meal or eat less or do too much physical work.

Hyperglycemic Hyperosmolar State

This is a very rare condition in which blood sugar level is excessively higher and the body starts to drain the excess amount of glucose through urine. This condition leads to dehydration and may lead to coma and death as well. This condition mainly occurs in elderly patients and those who are very sick.

Chronic Complications

Heart and Blood Vessels Diseases

Diabetes can cause heart diseases, high blood pressure, stroke and narrowing of blood vessels (atherosclerosis).

Damage to Nerves (Neuropathy) in Limbs

Over time, uncontrolled diabetes can damage or destroy nerves, resulting in tingling, numbness, and eventually loss of sensation that usually begins at the tips of the toes; as a result feet and fingers and are more likely to be amputated.

Nerve Damage

High blood sugar, over some time, may lead to a poor supply of nutrients in organs and nerves and may damage them. Damage to the nerves of the heart leads to an irregular heartbeat and that to the digestive system causes nausea, vomiting, diarrhea or constipation.

Kidney Disease

Diabetes can cause impaired kidney functions which may lead to dialysis or a kidney transplant.

Eye Damage

Diabetes can damages the blood vessels of the retina and cause blindness. Also, it may cause cataract and glaucoma.

Skin Conditions

People with diabetes are more susceptible to skin problems such as bacterial and fungal infections. Moreover, it may cause hair loss as well.

Slow Healing

People with uncontrolled diabetes are more prone to cuts and blisters catching serious infections. As healing is compromised due to poor blood supply, severe infections may require toe, foot or leg amputation.

Hearing Impairment

Hearing problems are twice compared to normal people in people with diabetes.

Sexual Dysfunction

Due to poor blood supply, diabetic people often have sexual dysfunction and erectile dysfunction.

GESTATIONAL DIABETES

Gestational diabetes occurs in 7–10% of all pregnancies. Usually, gestational diabetes occurs in the second half of pregnancy i.e., after 24 weeks and blood sugar levels return to normal after delivery of the baby. However, women affected with gestational diabetes have a risk of developing lifetime risk of developing type 2 diabetes.

Due to increased weight during pregnancy, the body starts to show resistance to insulin. Insulin is a hormone produced by the pancreas (an organ/gland situated behind the stomach) that converts glucose into energy so that every cell of our body can utilize this energy to perform its functions. Initially, the pancreas starts to produce more amount of insulin but body’s cells shows resistance to utilize it properly. this situation is called “Insulin Resistance”. Eventually, the pancreas fails to produce insulin to meet the demand and glucose levels in the blood increase.

Normally, several hormones are responsible to keep the blood sugar levels in the normal range. However, during pregnancy, these hormone levels may sometimes be disturbed and may affect blood sugar levels.

Symptoms

Symptoms of gestational diabetes include:

• Frequent urination
• Excessive thirst
• Excessive hunger

Risk Factors

• Overweight or obesity
• Family history of diabetes
• Sedentary lifestyle (lack of physical activity)
• Previous gestational diabetes or prediabetes.
• Polycystic ovary syndrome (PCOS).
• African-American, Asian, Hispanic, Alaska Native, Pacific Islander or Native American ethinicity

Will my diabetes affect my child?

Yes, your baby has a risk because of diabetes. However, you can manage it with the help of a doctor and deliver a healthy baby.

Risks to the baby are as follows:

• High birth weight: Growth of the child increases if a mother has diabetes. The baby is larger than normal and the possibility of normal delivery is less.
• Preterm birth (early delivery): Diabetes may increase the chance of early labor or delivery of the baby due to the high weight of the baby
• Difficulty in breathing: High blood sugar may cause to develop respiratory distress syndrome (a condition that makes breathing difficult) in the baby
• Seizures in the baby due to hypoglycemia (low blood sugar levels) in the mother: Hypoglycemia is common in mothers on treatment of gestational diabetes. Hypoglycemia episodes can cause seizures in babies which can be corrected by immediate feeding and glucose solution can help to stop this event
• Stillbirth: Gestational diabetes if left untreated, can result in the baby’s death either before or shortly after birth.

Prevention and Treatment

Adopting a healthy lifestyle always remains the key to prevent gestational diabetes and safeguard the baby.

• Eat healthy foods: Eat more fruits and vegetables, lentils, whole grains. Include foods that are rich in fibers and low in fat. Prepare your meal plan with the help of a nutritionist and stick to it.

• Physical Exercise: Physical exercise before and during pregnancy can be helpful to prevent gestational diabetes. Perform 30 minutes of mild-to-moderate exercise on most days of the week such as daily brisk walk, bicycle ride, swimming, short bursts of activity, mild stretching exercise based on the advice of the doctor.

• Keep a check on weight: Some amount of weight gain during pregnancy is normal and healthy. However, gaining too much weight too quickly may increase the risk of gestational diabetes. Consult a doctor about a reasonable amount of weight gain for you.

PREDIABETES

Prediabetes can also be termed as borderline diabetes. In prediabetes blood sugar level is higher than the normal range but it is not too high to be diagnosed as diabetes, though still it is an alarming condition.

In prediabetes, the body starts to show insulin resistance. Insulin is a hormone produced by the pancreas (an organ/gland situated behind the stomach) that converts glucose into energy so that every cell of our body can utilize this energy to perform its functions. Initially, the pancreas starts to produce more amount of insulin but body’s cell shows resistance to utilize it properly. This situation is called “Insulin Resistance”. Eventually, the pancreas fails to produce insulin to meet the demand and glucose levels in the blood increase.

Sign and Symptoms

Prediabetes does not have significant symptoms. Prediabetics start showing symptoms only when it is converted to type 2 diabetes. One possible sign is darkened skin on the neck, armpits, elbows, knees and knuckles.

Measures to Reverse Diabetes Progression

Prediabetes can be converted to type 2 diabetes but it is not inevitable. Therefore, by adopting lifestyle modifications such as regular exercise and starting a healthy diet one can prevent developing diabetes. To avoid the risk of developing type 2 diabetes one can do the following things:

• Eat nutritious and healthy food
• Do at least 30 minutes of physical exercise a day on most days of the week
• Loose excess weight
• Control your blood pressure and cholesterol
• Stop smoking

What to do if you are diagnosed recently?

Normally, people diagnosed with diabetes are either overweight or obese. So, the first piece of advice by the doctor is to reduce weight. Sudden news that he/she has diabetes confuses the person. Diabetes is a lifelong disease and they have to accept it and live with the forever change. Mainly they need proper education and counseling about every aspect like lifestyle changes (exercise, healthy diet, stress and sleep), blood sugar monitoring, meal planning and portion size, taking regular medicines, etc.

There is ample information available on the internet but the identification of correct and reliable sources remains a challenge. A doctor can help a patient to refer a correct source for information.

Some basic information for newly diagnosed diabetics is:

• Develop a healthy eating plan (take assistance of doctors and nutritionists)
• Start doing regular exercise
• Monitor blood sugar levels and keep a record of the results
• Take medicines prescribed by the doctor regularly if needed
• Learn to identify the difference between the signs of high or low blood sugar and what measures should be taken to avoid it
• Regularly check your feet, skin and eyes to identify early problems.

COVID-19 AND DIABETES

COVID-19 affected the entire world and everybody needs to take precautionary measures not to catch this disease; the risk is even higher for diabetic people. It doesn’t mean diabetic patients are more prone to infection but complications are more if you get infected and the risk is manifold in the case of uncontrolled diabetes.

To decrease the chances of getting affected by COVID-19, get vaccinated as and when you get the chance and follow steps to stay away from getting infected:

• Maintain social distance
• Wear mask to cover nose and mouth in a public place
• Keep good hygiene
• Keep blood sugar levels under control.

Researchers have found that among all people who are admitted to the hospital due to COVID-19, 25% had diabetes. People with diabetes have a higher risk for severe complications as well as a higher chance of death as well. One of the reasons for this could be that high blood sugar levels lowers immunity and thereby reduce the ability to fight against infection. Furthermore, if you have any other complication of the heart or lungs along with diabetes, the severity of infection is more.

Studies have shown that COVID-19 increases the risk of DKA. This condition mainly arises in the absence of insulin. Insulin is responsible to convert glucose into energy and energy is scarce in the absence of insulin. So to overcome this scarcity, the liver starts to break down fat into ketones as another source of energy. The levels of ketones rises and it increases the acidic condition in the blood and urine.

Few people who have severe COVID-19 have been affected with sepsis. To manage sepsis antibiotics along with fluid therapy is required. People with DKA interfere with the electrolyte balance in the blood and thereby making fluid therapy ineffective, and the chance of death increases.

COVID-19 is also infecting the pancreas thereby affecting insulin secretion. This leads to an increase in the sugar levels in the blood worsening the diabetes condition.

What to do if you get infected?

If you are affected by COVID-19, initiate treatment as advised by a Physician. Along with this, follow below mention steps:

• Increase the frequency of monitoring blood sugar levels
• Check for ketones levels and consult immediately if you have symptoms of DKA like fruity smell from breath, difficulty in breathing, dry or flushed face and skin, confusion, stomach pain, nausea and vomiting
• Drink more fluids
• COVID-19 may decrease appetite which has a direct effect on blood sugar levels
• Certain over the counter medicines for cold and cough can interfere with blood sugar levels
• A high dose of aspirin and ibuprofen lowers the blood sugar levels
• Paracetamol may give a false increase levels of blood sugar
• Some anti-diabetic medicines can affect insulin secretion when infected. You should consult a doctor if you are taking Metformin, Pioglitazone or GLP-1 Receptor Agonist medicines.

SCREENING FOR BLOOD SUGAR LEVELS IN DIABETES

There is a rise in blood sugar levels in diabetes and is also called hyperglycemia. Sugar in the blood comes either from the food we eat or is produced by the liver. The blood sugar levels is to be tested for the following reasons:

• To manage disease, whether the level of sugar is high or low
• To check the effect of medicines on blood sugar levels and to further decide therapy
• Monitoring sugar levels is utmost important when deciding insulin dose
• Track your progress in reaching your overall treatment goals
• To check how diet and exercise affect blood sugar levels
• Whether or not other diseases and medicines interfering blood sugar levels
• Parameters that raises blood sugar levels
• Ate a large meal containing sugar and/or fat
• Skipping medicines
• Skipping exercise
• Taking other medicines such as steroids or anti-psychotic medicines
• Some conditions may increase the level of hormones that increase blood sugar levels such as stress, irregularity in menstrual periods, illness or pain
• Dehydration
• Parameters that lower blood sugar levels
• Skip a meal or eat too less
• Done too much exercise or physical activity
• Alcohol
• Side effects from other medications
• Taken more amount of medicines mistakenly.

How to measure blood sugar levels?

Following are certain ways to measure blood sugar levels:

Fingertip: After proper washing your hand, prick on your fingertip with a sharp needle that is called a lancet. Insert test strip in the glucometer. Touch the other side of the test strip to the blood drop. The glucometer will show the result. Some glucometers have memory to record the result of blood sugar levels instead of you noting down the reading every time to keep the record.

Test from another site: Some meters test blood sugar levels from another site other than fingertip such as on underarms, forearms, thigh and base of the thumb. The result differs from that on fingertip as fingertip results fluctuate after a meal, after exercise or after some strenuous work.

When to test blood sugar levels?

Test the blood sugar levels as per the advice by your doctor. Usually blood sugar levels is to be tested depending on the type of diabetes and treatment plan.

Type 1 diabetes:

• Before and after a meal
• Before doing exercise
• Before going to bed

Apart from these timings, one should check blood sugar levels more often at the time of illness, initiating new medicines or change of daily routine.

Type 2 diabetes:

Testing is to be done regularly if the patient is on insulin treatment to decide the dose and manage diabetes.

If the patient is on medicine other than insulin and manages disease by diet as well as regular exercise, a daily blood sugar test may not be required.

Normal Blood Sugar Levels

Test/Disease	HbA1C Test	Fasting Blood Sugar Test	G l u c o s e Tolerance Test	Random Blood Sugar Test
Diabetes	6.5% or above	126 mg/dL or above	200 mg/dL or above	200 mg/dL or above
Prediabetes	5.7 – 6.4%	100 – 125 mg/dL	140 – 199 mg/dL	N/A
Normal	Below 5.7%	99 mg/dL or below	140 mg/dL or below	N/A

What affects blood sugar levels?

Certain conditions such as lack of sleep, stress and use of caffeine may affect blood sugar levels. Some disease conditions like anemia, gout, etc., may also interfere with the test result. Furthermore, hot or humid weather or high altitude may affect the test result as well.

Fasting Blood Sugar

Fasting blood sugar (FBS) measures blood sugar levels after 8 hours of fasting. During fasting there is increased sugar level in blood and to counter the same insulin is produced. The FBS is mainly measured to assess for “Insulin Resistance” which is mainly seen in type 2 diabetes. It may also be done to observe the effectiveness of medicines.

In type 1 diabetes, FBS is used to decide insulin regimen.

In type 2 diabetes FBS is used to check the effectiveness of different medicines given to initiate therapy or to change medicines. It will also give an idea for the assessment of dietary changes made.

Normal Range for Fasting Blood Sugar Levels

Condition	Range
Normal	70–99 mg/dL
Prediabetes	100–125 mg/dL
Diabetes	>126 mg/dL

Targeted Range

The target range for FBS is different for different individuals. The doctor will guide based on the patient’s condition and treatment. Usually target for FBS is in the range from 70 to 126 mg/dL.

What affects fasting blood sugar levels?

Certain lifestyle modifications such as overactivity, stress and some medicines may affect the FBS testing result.

Oral Glucose Tolerance Test

The oral glucose tolerance test (OGTT) is a test to see the body’s ability towards sugar metabolism. It is mainly used to test insulin resistance seen in type 2 diabetes people. A modified version of OGTT is used to screen gestational diabetes patients.

Normally, after taking food, carbohydrates break down into glucose and result in increased blood sugar levels. The pancreas produces insulin that enables the cell to utilize glucose as a source of energy.

How the test is performed?

In this test, an initial blood sample is taken to test your starting blood sugar levels. Then the patient is given a standard amount (75 g) of glucose syrup to drink. After 2 hours a second blood sample is taken and again the blood sugar levels are measured.

In pregnant women, the test lasts for 3 hours in which first blood sample is taken before taking sugar syrup and other two blood samples are taken every hour.

Normally, after 75 g of glucose, the levels of sugar increases in the blood and the body start to produce insulin to lower the levels of sugar. In normal humans, sugar levels reach to optimal levels but in a diabetic patient, sugar levels do not come to normal.

Normal Value of OGTT Test

	Glucose Levels	Interpretation
Fasting	<100 mg/dL (5.5 mmol/L)	Normal glucose tolerance
	100–125 mg/dL (5.6–6.9 mmol/L)	Prediabetes
	126 mg/dL (7.0 mmol/L) and above	Diabetes
2-hour	<140 mg/dL (7.8 mmol/L)	Normal glucose tolerance
	From 140 to 199 mg/dL (7.8–11.1 mmol/L)	Prediabetes
	Equal to or greater than 200 mg/dL (11.1 mmol/L)	Diabetes

Risks and Cautions

Few people may show a reaction to the glucose solution, mostly nausea, vomiting, bloating, etc. If vomiting occurs after testing, a test cannot be done.

OGTT test cannot be done in an individual if the patient:

· Has confirmed diagnosis of diabetes

· Has sugar or dextrose allergy

· Has recent surgery, trauma or infection

· Is under extreme psychological stress

· Have ever experienced hypokalemic paralysis.

Inform the treating doctor if you are taking certain medicines such as anticonvulsants (topiramate or valproate), atypical antipsychotics (clozapine or quetiapine), corticosteroids (prednisone or methylprednisolone), diuretics, quinolone antibiotics (ciprofloxacin or levofloxacin), statin drugs (rosuvastatin and atorvastatin), salicylates (including aspirin), tricyclic antidepressants (clomipramine or imipramine).

Hemoglobin A1C (HbA1C)

Hemoglobin A1C (HbA1C) test is used to check the average blood sugar levels over a period of 2–3 months. Hemoglobin is a protein in the blood which is responsible for the red color of blood. When blood sugar levels increase, the sugar binds with the hemoglobin irreversibly. HbA1C test is the percentage of glycated (sugar bound) hemoglobin in the blood. The life of the red blood cells present in blood, which bear hemoglobin, is 3 months; therefore, this test will give an average blood sugar level of 3 months.

Frequency of HbA1C

Condition	Frequency
Prediabetes	Once a year
Type 2 diabetes	2 times a year
Type 1 diabetes	3–4 times a year

Apart from this, HbA1C is also done while changing therapy. This test provides a baseline of how well one is controlling sugar levels and following the diet and treatment plan.

Normal Value of HbA1C Test

Condition	Range
Normal	<5.6%
Prediabetes	5.7–6.4%
Diabetes	>6.5%

What affects HbA1C levels?

• Any disease of hemoglobin such as anemia may interfere with the results
• Vitamins C and E supplements may affect HbA1C levels
• High cholesterol levels, kidney disease and liver disease may also affect the test results.

Continuous Glucose Monitoring

Continuous glucose monitoring is a special requirement for some people whose blood sugar levels are highly uncontrolled. For this, there is a device called ‘Continuous Glucose Monitor’ which automatically measures blood sugar levels from interstitial fluid (fluid between the cells) through tiny sensors. Sometimes, sensors can be placed under the skin (subcutaneous) of the belly or on the back of the arms. It has a wireless transmitter that sends impulses to monitor like a device.

One can see sugar levels every 5-10-15 minutes. If there is an abnormal drop in sugar levels, the monitor will sound an alarm. The device reading can be easily downloaded on the computer and/or smartphones to see the pattern of sugar levels and this information will help the doctor in the following ways:

• Decide correct insulin dose
• Prepare correct exercise plan
• Prepare diet plan
• Prescribe suitable medicine therapy

Self-monitoring of Blood Sugar at Home

Self-monitoring of blood sugar at home is a safe way to check diabetes and to avoid its complications. As diabetes does not always show symptoms, self-monitoring is always beneficial, particularly in the early stage. Moreover, it can sometimes prove lifesaving in preventing the complications due to continuous high blood sugar. The complications of diabetes includes cardiovascular disease, kidney problems and nerve damage.

Self-monitoring of blood sugar is useful when the patient shows willingness and is committed. This only happens when they have been given enough education on when to test blood sugar levels and how results are interpreted.

Furthermore, there are a number of benefits of self-monitoring of blood sugar at home:

• To prepare an effective diet plan
• Help doctor to plan therapy suitable for the patient
• Decrease incidence of hypoglycemia (low blood sugar levels)
• To decide the effect of physical exercise and strenuous work on blood sugar levels.

On the other side of the coin, there are certain disadvantages of home blood glucose testing as follows:

• Lack of motivation to test
• Lack of knowledge on interpreting the result.

These disadvantages can be overcome by educating patients. Some disadvantages may outweigh the potential benefits:

• Anxiety for own blood sugar testing
• Pain on needle pricking.

COMPLICATIONS OF DIABETES

Acute Complications (Short-term Complications)

Hypoglycemia

Hypoglycemia means lower than normal blood sugar levels. This is a very serious and life-threatening complication of diabetes if left untreated. Hypoglycemia occurs when blood sugar levels drop to <70 mg/dL (or 4 mmol/L).

What causes hypoglycemia?

• Hypoglycemia is often a side effect of anti-diabetes medicines or insulin
• Skipping a meal or eating too less may cause hypoglycemia
• Doing more physical exercise or strenuous work can cause hypoglycemia
• Drinking more alcohol especially when a person has not taken food.

Some non-diabetic causes of hypoglycemia are:

• Certain medicines like aspirin and sulfa drugs
• Some diseases may lead to hypoglycemia such as diseases of liver, kidney, heart and pancreas, certain tumors that produce excess insulin
• Endocrine disease like adrenal gland deficiency.

Symptoms of Hypoglycemia

Most people having mild hypoglycemia may experience the following symptoms:

• Increased pulse rate (heartbeat)
• Weakness (fatigue )
• Pale skin
• Shakiness
• Become anxious (anxiety)
• Increased sweating
• Increased hunger
• Irritability
• Blurred vision
• Tingling or numbness of the lips, tongue or cheek.

People with severe hypoglycemia may experience:

• Confusion, abnormal behavior or both, such as the inability to eat or drink
• Jerky movements (seizures)
• Coma.

Hypoglycemia Unawareness

Over a period after repeated experience of hypoglycemia, may lead to hypoglycemia unawareness. The patients with hypoglycemia unawareness have no symptoms of hypoglycemia which may lead to severe and life-threatening condition.

In case of hypoglycemia unawareness, patients need proper education and regular blood sugar monitoring to avoid any complications. This will aid the doctor in changing the therapy or dose of insulin.

Prevention and Treatment of Hypoglycemia

• People experiencing hypoglycemia should always keep carbohydrate-rich snacks such as granola bars, fruit juice, cookies, candy glucose tablet, etc., with in immediate reach
• One should be cautious, not to eat too much sugar-containing food.
• As per American Diabetes Association, the Rule of 15 should be followed: 15 g of sugar (carbohydrate) rich food followed by 15 minutes of wait for sugar levels to comes to normal
• Always monitor blood sugar levels timely as per advice by the doctor
• If a patient is experiencing frequent episodes of hypoglycemia, the use of continuous glucose monitoring may be helpful as per the advice of the doctor
• Eat meals at regular intervals. One can divide meals at stipulated intervals as per advice of the nutritionist/doctor
• Check sugar levels before doing exercise. Sugar levels reduced during exercise and its effect remain till 1 hour after exercise
• Proper education is at most priority if the episode of hypoglycemia occurs frequently.

Diabetic Ketoacidosis

Diabetes ketoacidosis (DKA) is an acute, serious and life-threatening condition mostly observed in patients with type 1 diabetes and less commonly observed in type 2 diabetes. This condition arises in the absence of insulin. Insulin is responsible to convert glucose into energy. And energy is scarce in the absence of insulin. To overcome this scarcity, the liver starts to break down fat into ketones as another source of energy. The levels of ketones rises and it increases the acidic condition in the blood and urine. This condition is called ketoacidosis and when it is associated with diabetes it is known as DKA. It is a life-threatening condition and it may lead to fluid accumulation in the brain (cerebral edema), heart failure and kidney failure. To identify DKA, ketone testing can be done using urine strips, and some glucometers also have the option of ketone levels testing.

Symptoms

• The fruity smell from breath
• Difficulty in breathing
• Dry or flushed face and skin
• Confusion
• Abdominal pain
• Nausea and vomiting
• Altered consciousness or coma.

Prevention and Treatment

Following are few pertinent points to be kept in mind for the prevention and treatment of DKA:

• Controlling blood sugar levels is the mainstay of treatment for DKA
• Willingness and commitment to managing diabetes by a healthy diet and physical exercise along with insulin treatment
• Always monitor blood sugar levels at least 3–4 times a day or as suggested by the doctor
• Monitor ketone levels when you have symptoms of DKA. Call a doctor or seek medical help in case of high ketone levels.
• Be prepared to act quickly.

Chronic Complications (Long-term Complications)

Diabetes and Heart

Over a period of time, high level of sugar in the blood can damage blood vessels as well as the nerves connected to the heart. Moreover, people with diabetes are also at an increased risk of developing high blood pressure, high cholesterol levels, high triglyceride levels and/or stroke.

High blood pressure: Diabetic people are prone to develop high blood pressure, probably due to damage to the blood vessels and nerves that control the heart.

Stroke and high cholesterol and triglyceride levels: Cholesterol and triglycerides are a type of fat. As diabetes damages, blood vessels, cholesterol and triglyceride accumulate in the damaged parts of vessels. Eventually, this accumulated fat (cholesterol and triglycerides) gets hard and this hard plaque blocks the small blood vessels, which may lead to stroke and heart attack.

Prevention and Treatment

It is advised to monitor blood sugar levels, blood pressure and cholesterol levels and try to keep them in the optimum range.

• Diabetes to be managed following the ABCs where:
  • A: A1C levels (HbA1C Levels)
  • B: Blood pressure (140/90 mmHg)
  • C: Cholesterol levels
  • s: Stop smoking or don’t start

• Manage body weight if overweight or obese
• Follow a healthy diet
• Do 30 minutes of physical activity per day on most days of the week
• Manage stress
• Consume alcohol in moderation only
• Get enough sleep.

Diabetes and Eye

High blood sugar damages all blood vessels in the body, gradually. The blood vessels in the retina of the eye are very small. Sugar particles cause to block this microvessel and leak out the fluid or bleed. This condition may lead to glaucoma, cataract, blurred vision and blindness.

The retina is part of the eye that senses light and send it to the brain, then the brain identifies the picture and we see the world. Damage to vessels of the retina will disturb its function and results in blurred vision and blindness.

Symptoms of Diabetic Retinopathy

There are no early symptoms of diabetic eye disease.

• Blurred or wavy vision
• Change in vision frequently
• Color blindness
• Spots or dark linings
• Flashes of light
• Blindness.

Prevention and Treatment of Diabetic Eye Disease

To treat blurring of the vision, the eye doctor may prescribe some medicines like steroids or laser treatment (for glaucoma and cataract).

Managing diabetes is of utmost importance and for this following points should be kept in mind:

• Stick to the prescribed treatment and take medicines regularly
• Manage body weight, if overweight or obese
• Follow a healthy diet
• Do 30 minutes of physical activity per day on most days of the week
• Manage stress
• Consume alcohol only in moderation
• Get enough sleep.

Diabetes and Lipids

Lipid (fat) level abnormality is commonly observed in type 2 diabetes. Insulin resistance affects lipid metabolism and results in an increased levels of low-density lipoprotein (LDL) cholesterol (bad cholesterol) and triglycerides, and decreased high-density cholesterol (HDL) (good cholesterol). Lipid abnormality associated with diabetes is termed as diabetes dyslipidemia. The cause for diabetes dyslipidemia includes fatty food intake, sedentary lifestyle, obesity, smoking and high alcohol intake.

There is no symptom to identify high lipid levels, and they are usually detected during regular body checkups. If undetected, over time, it may lead to stroke and heart attack.

Prevention and Treatment of Diabetes Dyslipidemia

The doctor may prescribe medicines to lower the lipid levels based on the requirement and lipid levels. However, to manage diabetes following points should be considered:

• Stick to the prescribed treatment and take medicines regularly
• Reduce bodyweight if overweight or obese
• Follow a low-carbohydrate and low-fat diet
• Do 30 minutes of physical activity per day on most days of the week
• Manage stress
• Consume alcohol in moderation
• Get enough sleep.

Diabetes and Feet

High blood sugar levels for a longer period may damage nerves and reduce hamper the blood supply and affect various body parts like the feet. Due to nerve damage, there is gradual loss of sensation and the feet become more prone to cuts and wounds. Moreover, reduced blood supply reduces healing. This condition leads to diabetic foot disease, which is a serious complication and may also lead to amputation.

Symptoms of Diabetic Foot

• Numbness and tingling sensation in feet
• Pain
• Shiny, smooth skin on the feet
• Hair loss on legs and feet
• Loss of feeling in the feet or legs
• Swollen feet
• Wounds or sores that don’t heal
• Changes in the color and shape of the feet and toes
• Cold or hot feet
• Wound on the feet can be see but not felt
• Foul smelling open wound.

Prevention and Treatment of Diabetic Foot

To prevent developing diabetic foot one needs to take care of their feet and consider the following:

• Stop smoking
• Check your feet every day for cuts or any wounds
• Eat a healthy, balanced diet and stay active
• Cut nails carefully
• Wear comfortable footwear
• Use moisturizing cream everyday
• Don’t use blades or corn plasters.

Diabetes and Kidney

Kidney disease is a very common complication of diabetes. Diabetic kidney disease is also known as diabetic nephropathy.

The main function of the kidney is to remove waste products along with excess water from the blood through urine and return the filtered blood to the body. Furthermore, another function of the kidney is to control blood pressure.

High blood sugar levels for a longer time cause damage to the tiny vessels and filtration units present in the kidney leading to an impaired filtration of blood. Therefore, the level of waste and toxic material rises in the blood and damages other organs as well, especially the brain and liver. Also, there is an associated increased risk of developing high blood pressure.

Symptoms of Diabetes Kidney Disease

There are no early symptoms of diabetic kidney disease. Symptoms are visible when kidneys are no longer functioning properly. Following are the symptoms of kidney dysfunction:

• Swelling of the feet, ankles and legs
• Loss of appetite
• Fatigue or feeling exhausted and weak most of the time
• Persistent headaches
• Frequent itching
• Upset stomach
• Nausea and vomiting
• Reduced sleep
• Difficulty in concentrating
• Difficult to control blood pressure
• Diabetes kidney disease can be diagnosed through some blood tests (kidney function test) and urine tests.

Prevention and Treatment of Diabetes Kidney Disease

In order to manage diabetic kidney disease:

• Take regular medicines prescribed by the doctor
• Manage blood pressure
• Manage blood sugar levels.

To manage blood sugar levels:

• Stick to treatment and take medicines regularly
• Reduce bodyweight, if overweight or obese
• Stop smoking
• Do 30 minutes of physical activity per day on most days of the week
• Manage stress
• Consume alcohol in moderation only
• Get enough sleep.

Diabetes and Nerves

High blood sugar can cause nerve damage and this condition is called diabetic neuropathy. Diabetic neuropathy develops very late after the diagnosis of diabetes but it is a very severe complication and may lead to severe problems related with day-to-day activities.

Nerves are very much important in enabling people to feel, touch, move and have some autonomic functions such as heartbeat, breathing, digestion, kidney functions, etc. Damages to nerves may lead to a failure of sending messages to the brain.

Types of Diabetic Neuropathy

Depending on the damage that occurs to various parts of the body, Neuropathy can be classified as:

1. Peripheral neuropathy.
2. Autonomic neuropathy.
3. Proximal neuropathy.
4. Focal neuropathy.

1. Peripheral Neuropathy

It is a very common type of neuropathy. It affects peripheral parts of the body like feet, legs, hands and arms and the symptoms range from numbness to pain.

• Numbness or not being able to feel pain or temperature changes
• Tingling or burning sensation
• Sharp pains or cramps
• Increased sensitivity to touch, especially at night — for some people, even a bedsheet’s weight can be painful
• Serious foot problems, such as ulcers, infection, and bone and joint pain.

2. Autonomic Neuropathy

Autonomic neuropathy affects the autonomous nervous system such as digestion, heart, kidney, sexual organs, eyes, etc. Symptoms include:

• Bladder or bowel problems that may cause urine leakage, constipation, or diarrhea
• Indigestion nausea, vomiting loss of appetite, bloating, acidity
• Increased light sensitivity, difficulty for eyes to adjust from light to dark
• Increased heart rate, feeling dizzy or faint on a sudden change in position
• Decreased sexual response, including trouble getting an erection in men or vaginal dryness in women.

3. Proximal Neuropathy

It is a very rare form of neuropathy and affects the nerves of the thighs, hips, buttocks or legs. Sometimes, nerves of the stomach and chest may also be affected. Symptoms may include:

• Severe pain in a hip, thigh or buttock
• Difficulty in getting up from a sitting position without assistance
• Resultant weakening and shrinking thigh muscles
• Severe stomach pain.

4. Focal Neuropathy

It is also called mononeuropathy as only one nerve is affected. Mostly, nerves of hands, head, leg or torso are affected causing pain. In 25% cases of focal neuropathy, patients experience carpal tunnel syndrome in which compression of nerves in the wrist area cause pain and stiffness of the wrist. Symptoms of focal neuropathy may include:

• Pain, numbness and tingling in fingers
• Weakness involving the hand that may make the patient to drop things
• Difficulty in focusing vision or double vision
• Aching behind the eyes
• Paralysis on one side of the face (Bell’s palsy)
• Pain in isolated areas, such as the front of the thigh, lower back, pelvic region, chest, stomach, inside the foot, outside the lower leg, or weakness in the big toe.

Contact the doctor in case of following signs:

• A cut or sore on your foot that’s infected or won’t heal
• Burning, tingling, weakness or pain in the hands or feet that interferes with daily activities or sleep
• Changes in digestion, urination or sexual function
• Dizziness or fainting.

Prevention and Treatment of Diabetic Neuropathy

Serious nerve damage complications may be prevented in majority of diabetic patients. Regular foot care at home is very much important along with the management of blood pressure.

To manage blood sugar levels:

• Stick to the treatment and take medicines regularly
• Reduce bodyweight, if overweight or obese
• Stop smoking
• Consume alcohol in moderation only
• Regular physical activity per day on most days of the week
• Manage stress

Diabetes and Skin

Skin problems are the one of the first visible signs of diabetes, and sometimes they present as a sign suggesting that a person is having diabetes.

A high level of sugar in the blood may decrease the immune response and as a result the skin becomes prone to bacterial and fungal infections. Furthermore, reduced blood circulation causes a change in the skin collagen, which changes the skin’s texture, appearance and ability to heal.

Types of Diabetic Skin Disease

• Bacterial infections: Most common bacterial skin problems are eyelid sties, boils, nail infections and carbuncles (deep infections of the skin and the tissue underneath). Often, the area around the infection will be painful and warm to the touch, with swelling and redness. Treatment with antibiotic creams or pills will usually clear up these skin problems
• Fungal infections: Most common fungal infection is due to yeast mainly involving the skin in humid area (folds of the skin) such as under the breasts, the groin area, in the armpits, corners of the mouth, under the foreskin of the penis, etc. This fungus creates itchy red rashes, often surrounded by tiny blisters and scales. Treatment of fungal infections involves keeping the area dry and using a combination of topical steroids and antifungal medicines after consultation with a skin doctor
• Diabetic blisters: They are very rare and mainly occur on the backs of fingers, hands, toes, feet and sometimes on the legs or forearms. They are painless and heal on their own. Adequate blood sugar control may reverse this condition.
• Diabetic dermopathy: The main feature of diabetic dermopathy is light brown spots, scaly patches of skin, often occurring on the shins. They are caused by damage to the small blood vessels that supply the tissues with nutrition and oxygen. This skin problem does not require treatment. However, blood sugar control may reverse this condition.
• Eruptive xanthomatosis: Uncontrolled diabetes may lead to this condition in which firm, yellow, pea-like skin growths mainly on the backs of hands, feet, arms, and buttocks, are observed. This usually occurs in patients with high cholesterol levels. Controlling the sugar levels is the main treatment.
• Necrobiosis lipoidica diabeticorum: It is a chronic condition in which small, firm lesions progress to larger plaques of waxy, hard, depressed and yellow to reddish-brown skin. Treatment for necrobiosis lipoidica diabeticorum can include topical and oral medications. The person should also protect the skin from further damage through injury, due to the risk of infection.
• Acanthosis nigricans: It is a problem involving the skin creases which become dark, thick and velvety. This occurs mainly in overweight and obese patients.

Prevention and Treatment of Diabetic Skin Disease

Some antifungal, antibacterial and steroids containing cream may be used. Furthermore, certain over-the-counter lotions, powder and alternative medicines may also be useful.

Certain lifestyle modifications to diabetes skin disease include:

• Apply moisturizer or skin cream prescribed by a doctor for dry skin
• Avoid scratching dry skin, which can create lesions and allow infections to set in
• Treat any cuts immediately
• Avoid hot baths or showers, as they can dry the skin out
• Check feet daily for the presence of numbness or loss of sensation.

To manage blood sugar levels:

• Stick to treatment and take medicines regularly.
• Reduce bodyweight, if overweight or obese
• Stop smoking
• Do 30 minutes of physical activity per day on most days of the week.

Diabetes and Sexual Health

Diabetes has an impact on every aspect of a person’s life. It can also cause sexual problems in both men and women, which is not a widely discussed topic. Moreover, people as well as doctors, often hesitate to discuss sexual problems.

A high levels of sugar affects all nerves of our body and cardiovascular problems may affect sexual problems.

Sexual Problems in Males

Erectile dysfunction

Erectile dysfunction is very much likely to occur in males with diabetes. It usually occurs after 10–15 years of diabetes. Causes for erectile dysfunction can be as follows:

• Damage to nerves or blood vessels supplying the penis
• Poor blood sugar control
• Stress or fear of not being able to achieve an erection.

Damage to nerves or blood vessels supplying the penis: When nerves of the penis are damaged due to high blood sugar levels, it stops sending messages to the brain. Even though a person may have mental stimulation for sexual desire, the penis doesn’t respond to it.

Diabetes causes high blood pressure and poor blood supply and both these will lessen the blood flow to the penis and cause erectile dysfunction.

Poor blood sugar control: Diabetes causes erectile dysfunction also by reducing the production of nitric oxide. Nitric Oxide is responsible for erection. Diabetes also decreases the sexual desire. However, it can be reversed if the blood sugar level is properly controlled.

Stress or fear of not being able to achieve an erection: Not performing well during sex causes anxiety and another psychological factor such as depression in men. This aggregates the stress levels and may lead to further problems. Erectile dysfunction is a physical problem that causes the psychological problem of anxiety about performance.

There are several ways to treat erectile dysfunction. Some medicines such as sildenafil, tadalafil, vardenafil can be prescribed. The use of a vacuum pump device is a method to cause an erection. The patient should be treated based on the advice of the doctor only.

Retrograde ejaculation

Retrograde ejaculation is caused due to backward passing of semen into the urinary bladder. High blood sugar levels impair the functions of the sphincter muscle, which should be closed during sex, allowing the semen to release from the penis. If this muscle is not closed properly, it allows semen to go into the bladder which is known as retrograde ejaculation.

Testosterone deficiency

It is mainly observed in diabetic patients who are overweight or obese. Testosterone is a male reproductive hormone and its deficiency may lead to decreased sexual desire in men. Moreover, losing weight, controlling blood sugar levels and regular exercise can help to treat testosterone deficiency.

Sexual Problems in Females

Diabetes affects sexual function in females as well and present as following:

• Vaginal dryness (lack of vaginal lubrication)
• Pain during intercourse
• Loss of sexual desire (reduced libido).

Vaginal dryness: Blood vessel damage and nerve damage due to diabetes can be the cause of vaginal dryness in females. It is the common problem resulting in sexual dysfunction in females. Vaginal dryness causes pain during intercourse, and hence, decreases sexual desire. The solution to this problem is to use water-soluble lubricants before intercourse. Estrogen cream may also be prescribed in postmenopausal women.

Pain during intercourse: Pain during sexual intercourse may also be due to an infection in the vagina. High blood sugar levels provides a good medium for bacteria, fungus and yeast to grow. The infection causes swelling and redness that causes the pain. Treatment with antifungal cream can be useful.

Loss of desire (reduced libido):Several reasons are responsible for the loss of sexual desire in women with diabetes. High blood sugar levels can damage nerves and blood supply. Damaged nerves of the clitoris may reduce the chances of orgasm in women. Poor blood supply may cause fatigue and can reduce the sexual desire.

Prevention and Treatment of Sexual dysfunction with Diabetes

Sexual dysfunction should be treated based on symptoms.

Managing blood sugar levels may prevent sexual dysfunction and reduce complications. To manage blood sugar levels:

• Stick to treatment and take medicines regularly
• Reduce bodyweight if overweight or obese
• Stop smoking
• Consume alcohol in moderation only
• Regular physical activity per day on most days of the week
• Manage stress.

Diabetes and Bone Health

As diabetes causes metabolic changes and lowers bone mineral density (BMD), it may give rise to osteoporosis, which is a condition in which bones get weak.

Especially, people with type 1 diabetes have poor growth and low BMD. Collagen is responsible for strengthening the bone and excess amount of sugar in the blood attaches to collagen of the bone, which weakens the bone and reduces the BMD.

Some other reasons that affect bone health are:

• People with a sedentary lifestyle and a lack of exercise are at a higher risk for developing osteoporosis
• Some anti-diabetic medicines such as thiazolidinediones, may cause bone loss
• Kidney damage from diabetes may cause calcium to leak out in urine (calcium is needed for strong bones).

Improving Bone Health in Diabetes

• Taking adequate amount of calcium and vitamin D. Good sources of calcium include low-fat dairy products; dark green, leafy vegetables; and calcium-fortified foods and beverages
• Regular weight-bearing and resistance exercise provide strength to bones
• Quit smoking
• Do not consume alcohol
• Take medicines as prescribed
• Manage bodyweight if overweight or obese
• Control blood glucose levels.

LIVING WITH DIABETES

Children Living with Diabetes

Children’s reaction at the time of diagnosis: It is very difficult to explain to children that they have diabetes and have to live with diabetes for a lifetime. It is even hard for parents to accept and adopt these changes as well. The children will be able to cope with the situation only with the support of their parents.

Moreover, education plays a very important role here. Understanding practical difficulties faced by children is hard but not impossible. Sometimes children become irritable as they cannot eat their favorite food like cakes, chocolates, candies,  etc., in the way their friends eat, which is indeed an emotional situation. Some children do not share their feelings with parents and here help from other family members and friends plays a major role.

As a parent, there may be a feeling of guilt, as it is a genetic disease; however, studies say that genetics only has 10–15% chance to pass on diabetes from parent(s) to children. To cope up with the stress of lifelong disease try to live as normal as you can to get the motivation of life. Also, there are lots of people living with diabetes, one can try to join their community to bring joy and motivation, both for the child as well as the parents. People often feel guilty and hesitate to ask for any support and this makes children feel insecure and causes emotional stress. This may give rise to psychological disorders like depression in them. Moreover, to accept and adapt to living with diabetes, with certain precautions will give purpose to life.

Diet and diabetes: Diet plays an extremely important role in children. As it is difficult to take control of what you eat at a younger age, especially when other children eat chocolates, cakes, candies, cookies, etc., which is hard to resist. Sometimes eating junk food in moderations alright but one should always be cautious. Though following the meal and insulin schedule, eating proportion, paying attention to what you eat for a lifetime is not at all easy but making it a routine will certainly help.

Insulin injection for children: Insulin is the hormone that helps in the digestion of carbohydrates into glucose which will be utilized by the cell to produce energy. In a child with type 1 diabetes, the body cannot produce insulin so it has to be provided from outside with the help of an insulin injection or pump. Don’t force a child to take insulin by themselves. Let them be prepared and make them ready to take insulin injections on their own.

The insulin kit contains one disposable or reusable insulin pen, cartridge and needle. Prefilled insulin pens are also available in which dose is adjusted and dose will be delivered underneath the skin (subcutaneously).

The insulin pump will deliver a measured dose of rapid-acting insulin throughout day and night. It is accurate and does not allow hypoglycaemic conditions until skipping of meal and strenuous work has been performed. But it has the disadvantage of carrying a device all the time.

Diabetes and learning: Children with diabetes have difficulty in learning, attention, perception and processing skills. Parents must inform the school management about the condition of the child so they can be taken care of well. Some children may get sick frequently due to diabetes and as a result their learning can be hampered. Every child with diabetes needs personalized care and attention. Parents and school management have to work hand-in-hand to cope up well with the situation.

Exercise: Some routine and regular exercise helps in reducing future complications of diabetes. Blood sugar levels should be checked before starting exercise.

Self-monitoring of blood sugar: Children should check their blood sugar levels 3–4 times a day or as advised by the doctor. It can be done through a blood glucose monitor.

Teenagers Living with Diabetes

When children are progressing towards adulthood, they try to live their life on their own and do not appreciate interference. It has become a concern for parents to talk to their child about everyday blood sugar checks, insulin dose, exercise, diet, etc. If teenagers have newly diagnosed diabetes, it is again difficult for parents to cope up with the change, they should be encouraged to meet other teenagers with diabetes.

Changing and adapting to a diabetic lifestyle is always challenging at any age. One can take the help of an educator or a doctor. The most common concern for the parents are alcohol, smoking habits, peer group, over strenuous work, taking regular insulin doses, etc.

Alcohol and diabetes: Alcohol causes hypoglycemic conditions frequently and several hours later as well. Following are the few tips that any teen/anybody taking alcohol should know:

• Never drink alcohol on an empty stomach. Have a meal before taking alcohol. Drink an ample amount of water along with alcohol
• Drink alcohol in moderate amounts
• Eat food after taking alcohol or before bed.

Smoking and diabetes: Smoking should be avoided in any case. Smoking doubles the risk of heart disease for diabetic patients. Take the help of psychologists and other organizations if smoking becomes a habit.

Diabetes and strenuous work: Too much physical activities make the person exhausted and for a diabetic person, it creates a lot of need for energy and will lead to hypoglycemic conditions. It is mandatory to discuss and educate teenagers with diabetes to avoid strenuous work or being involved in any activities that require more energy.

Elderly People Living with Diabetes

Elderly people are very much prone to get affected by diabetes. Studies show that around 33% of people over 65 years of age have diabetes. Moreover, elderly people are also at risk to develop diabetes-related complications.

The reasons to develop diabetes in old age people include overweight or obesity, family history, other co-existing diseases such as high blood pressure, high cholesterol levels, kidney problems, depression etc. The development of insulin resistance (a major cause to develop diabetes) is due to decreased muscle mass, sedentary lifestyle (low physical activity), dietary habits, reduced pancreatic function when compared to young adults.

Diabetes Care Plan in Elderly People

Diabetes in old age may be associated with co-existing diseases like heart diseases, chronic pain, urinary incontinence (involuntary passing of urine), reduced sleep, dementia (memory disorder), etc. These conditions make it difficult to plan treatment for diabetes and increase the risk to develop diabetes-related complications.

Management of Diabetes

• Monitor glucose levels: Abnormal glucose levels either high (hyperglycemia) or low (hypoglycemia) are risky and can be dangerous to health. The diabetes care plan should include when to check the blood sugar level and when to get the HbA1C test. Someone who is taking diabetes pills should not check blood sugar levels as often as someone who is on insulin. One should check sugar levels as per advice from the treating doctor
• Eat healthy food: Food is one of the major factors affecting blood sugar levels; hence, it should be given priority. While making a diabetes diet plan what to eat, when to eat, how much to eat should be taken into the consideration. For overweight or obese patients diet plan should be to reduce weight. Consult dieticians or nutritionists for better results
• Adapt active lifestyle: Plan your day with at least 15–20 minutes of exercise like walking, mild exercise, etc., for most days of the week. This will help to improve blood sugar levels. The diabetes care plan should be individualistic as per the requirement of the patients and disease conditions; co-existing diseases should be taken into consideration while planning
• Take medicines regularly: Take medicines as prescribed by the doctor as this will help to manage diabetes well and reduce the risk of complications. One should be educated about the side effects of medicines and must be informed by the doctor to plan long-term therapy. In older age, there are chances to miss the dose or double the dose. In these cases, contact the doctor immediately to avoid further ill effects.

Living with Diabetes and Staying Healthy

• Monitor blood pressure: Check blood pressure regularly and adopt a healthy diet, active life and regular medicines
• Maintain cholesterol levels: Manage cholesterol levels below the optimal levels. High levels may increase your risk for heart problems
• Stop smoking: Smoking increases the risk of developing many health problems, like heart attack and stroke
• Eye examination: Diabetic people have the risk of developing certain eye problems such as glaucoma, blurred vision and blindness. Plan yearly eye examination to identify the risk
• Kidney examination: Diabetes may affect kidneys and may lead to kidney failure. Plan yearly kidney examination
• Flu and pneumonia vaccination: Diabetic people are more prone to get flu and pneumonia and this may cause serious concern when compared to normal people. Therefore, yearly flu shots and pneumonia vaccines will help keep you healthy. If you are over 65 years of age, make sure you have had the pneumonia vaccine after consulting your treating doctor
• Teeth and gums: Brush your teeth with a soft toothbrush daily. Get your teeth and gums checked twice a year by a dentist to avoid complications
• Skin care: Keep your skin clean and use moisturizers for dryness. Always check minor cuts and wounds to prevent infections
• Foot care: Check your feet every day for any cuts or blisters or wounds. Also, check for numbness or loss of sensation (cannot feel anything) in feet
• Consult for any concern with the doctor: Always ask for any help regarding your management plan, any health-related issues such as depression, worried about your memory, or having any other concerns. This will enable the doctor to help you in better ways.

Living with Diabetes and Social Life

Life will be changed after being diagnosed with diabetes. People with diabetes have to take all necessary precautions such as diet habits, physical activities, blood sugar tests, medicines, less strenuous work, etc. All these restrictions will separate them from regular social life. They may feel hesitant and restricted to gel with friends and family.

Even if they go out with friends and family, eating outside can imbalance their diet plan, resulting in an imbalance in blood sugar levels.

For type 1 diabetes regular sugar monitoring test and insulin dose has to be done before eating. They have to check in restaurants or some people may check sugar levels and take insulin doses in their vehicles.

It may cause a lot of financial burdens to deal with diabetes, especially for poor and middle-class people. Diabetes is a lifetime disease and the cost of medicines, clinic/hospital visit, sugar testing, complications, etc., may disturb their financial condition and causes depression and other social and psychological issues.

For people with diabetes, emotional well-being is very much essential. This can be achieved easily with the support of the family members. Everyone is important for their family and here are few tips on how a family member can help a person who is diagnosed with diabetes:

• Encourage healthy eating: It is difficult for a diabetic person to accept life changes. They lack everyday motivation. Support of family motivates to cope up well with the disease. Every family member can take a healthy diet as a part of precautions
• Eating out is not a challenge it diabetic person can choose healthy options such as soup, salads, rice items in portions which is available everywhere
• Prepare meal-time according to their daily routine work. Disclosing diabetes in the workplace will provide some relaxation in testing blood sugar, taking insulin doses and eating at other times than official lunchtime
• Include vegetables, whole grains, fruits, low-fat dairy, healthy fats, and lean protein sources in daily meals. A healthy and balanced diet can help you shed excess pounds and reduce your risk of developing other associated diseases such as heart disease
• Exercise together: Regular physical activity plays a significant role in reducing blood sugar levels. Regular exercise helps to reduce insulin resistance, reduces weight in type 2 diabetes and prevents complications and improves the utilization of glucose in the body for type 1 diabetics
• Maintaining and continuing the exercise routine is challenging. However, support from the family or friends by joining for exercise can be helpful and motivating to follow the exercise routine. Plan 30 minutes of exercise everyday for most days of the week. Plan exercise like walking, cycling, aerobic exercise, etc
• Join diabetes support group: Join any diabetes support group and attend programs with family members. This will encourage dealing with the disease and you will not feel that you are alone. Some practical problems and practical solutions will help to cope up with the situations
• Attend the doctor’s appointment with them: Join diabetic people while consulting dieticians or doctors and ask questions on their behalf, in planning and changing their diet to encourage them
• Try to take note of what the doctor suggests them to do. Make or change the lifestyle change based on the doctor’s advice. Ask questions and try to take knowledge of the disease. This will help to take necessary precautions to avoid further complications and help in better sugar control
• Low blood sugar levels: Low blood sugar (hypoglycemia) is one of the common side effects of any diabetes medicine. Knowledge of symptoms of low blood sugar in any family member can be helpful in case of emergencies. During the event of low blood sugar, the patient may experience blurring vision, confusion, fatigue and fainting. Knowledge of these conditions helps to tackle the condition well and save life.

Living with Diabetes and Sexual Life

A good sexual life is one of the important factors discerning a good quality of life. Diabetes may affect sexual life in many ways. In men, it causes erectile dysfunction, ejaculation problems (retrograde ejaculation) and testosterone deficiency; whereas in women, it causes vaginal dryness, infections and pain during intercourse.

This is the area where both doctors, as well as patients, feels hesitation to ask questions. However, one has to speak out about the problem(s) that he/she may be be facing and get it resolved. The problems are different for different individuals and are resolved on one on one basis only. Some certified counsellors or psychologists can help in this matter.

Here are some tips for better sexual life:

• Stop smoking: Smoking causes narrowing of blood vessels and hampers the blood flow in the body. Proper blood flow is a prerequisite for erection throughout intercourse. Quitting smoking can help improve sexual life to a certain extent
• Seek help for smoking cessation if one cannot quit smoking on their own
• Reduce weight: Overweight or obesity may harm sexual life both in males and females. A healthy diet and regular exercise can help to reduce extra weight and can have an impact on sexual life as well. Losing weight can make one feel light with more energy, increases blood flow and may affect the mood also.
• Limit or cut out alcohol: Excess alcohol can contribute to erectile dysfunction. Therefore, either do not consume alcohol or limit the amount of alcohol
• Control the blood pressure: Control the blood pressure with stress reduction techniques like practicing, yoga, meditation, exercise, etc. These lifestyle measures will certainly help in improving health and quality of life
• Control blood sugar levels: Control blood sugar levels in the target range given by the doctor and this is the key factor to improve health conditions
• In case of vaginal dryness: Use water-based lubricants available at the medical store
• Preferably engage in sexual intercourse when the energy level is high. For example, in the morning time when everyone is fresh with a high energy levels and libido is also high
• Reduce stress: Reduce stress by relaxing exercises and yoga. Also, spending time with loved ones will help in reducing stress and increases intimacy between partners
• In case of sensation-related problems try different ways of genital stimulators such as electronic vibrators. Applying hot or cold to the genital area will improve sensations.

Living with Diabetes and Travel

Diabetes should never be a hurdle for enjoying vacations with loved ones. It just requires little extra planning so that diabetes cannot be burdensome while travelling. Sometimes delaying meals, certain foods, weather conditions, lot of physical activity may cause management of diabetes difficult. However, planning well before going on vacation, especially, while going abroad will help in the proper management of diabetes. Below are some tips for planning travel when you have diabetes.

Before going on vacation, visit your treating doctor for check-up to ensure that you are fit to travel and acquire information regarding the following:

• Planning of activities during travelling
• Meal planning
• How to take medicines or insulin doses in different time zones
• Doctor’s letter stating that you are diabetic
• Prescription with dose, medicine timings and history of the disease
• Book a stay near to pharmacy or hospital
• Get sufficient international medical insurance while travelling.

Planning while packing:

• All the insulin and syringes you need for the trip, pack 2–3 times more than required
• Blood and urine-testing supplies; be sure to include extra batteries for your glucose meter
• All oral medicines, glucose tablets, pack 2–3 times more than than required
• Your ID and diabetes identification card/letter from the doctor
• A well-wrapped, airtight snack pack of crackers or cheese, peanut butter, fruit, a juice box, and some form of sugar (hard candy or glucose tablets) to treat low blood sugar
• Keep the prescription and pharmacy bills for security check on airport.

At the airport:

• People with diabetes can carry 3.4 oz. the liquid rule for medicines, fast-acting carbohydrates like juice, and gel packs to keep insulin cool. However, these items are only allowed in hand luggage
• Diabetic people can carry medical equipment (glucometer, insulin pump, continuous glucose monitoring device) at airport security in hand luggage. All medicines and equipment must be supported by documentation from a qualified medical professional
• In the case of diabetic people using an insulin pump or a continuous glucose monitoring device, they shouldn’t pass through whole-body scanners or any X-ray machine. As X-ray waves can affect their functioning
• Some airlines will require you to notify them of your medical equipment before the flight and fill in additional paperwork
• Precautions for insulin pumps and continuous glucose monitoring device in aircraft are due to its wireless functionality. This might interfere with aircraft communication and navigation systems. If an insulin pump or continuous glucose monitoring device cannot function without a wireless signal, then it has to be removed. Upon removal of continuous glucose monitoring device, one should use an insulin pen and glucometer to check the sugar levels. Ask the airlines before travelling.

In the aircraft:

• Call the airline to get information on the timing of the meal to plan insulin dose
• To prevent low blood sugar, carry healthy food such as fruits and nuts, to help prevent low blood sugar
• Get up and move every hour or so during the flight to prevent blood clots
• If the standard meal provided by airlines does not contain enough carbohydrates based on insulin dose. Ask for fruits, crackers rolls in addition to the standard meal
• Carry glucose tablets, cookies, fruit juice along with insulin, medicines and testing materials in case of low blood sugar. These may be helpful on long flights so always carry an extra amount of carbohydrate-rich foods
• Monitor blood sugar levels frequently to change insulin dose.

During travelling:

• Check blood sugar levels frequently than normal days
• Try to follow meal-time and diet as close as possible and try to get healthy meal options such as salads, fruit, yoghurt and sandwiches
• Make healthier choices from the hotel menu and avoid the giant buffet
• Do physical activity in moderate amounts during the day. Don’t go barefoot, not even on the beach
• Hot weather can change the body’s pattern to use insulin. Insulin is absorbed faster than normal in hot weather. Whereas, in cold weather insulin is absorbed more slowly
• Storage of insulin is very much important. Do not store insulin at very hot or cold temperatures. It will destroy insulin. Insulin should be stored at normal temperature.

Tattoos and Piercing, and Living with Diabetes

For many people, having a tattoo and/or piercing is a deep desire, and for some, it may be a ritual. In India, females have their ears and nose pierced to wear earrings and nose rings. However, the question arises whether it is safe in people living with diabetes?

One can certainly go for a tattoo if they have HbA1C levels in the desired range. The HbA1C test shows the average blood sugar levels in the last 3 months. Also, it is always better to take advice from your treating doctor.

Tattoos and piercings do have a chance of getting infected depending on the area involved. There are certain areas of the body where there is poor blood supply, these have a have a higher chance of catching infection. For example, tattoos and piercings made on the bum, shins, ankles and feet take a longer time to heal.

One should not go for tattoos on the arms, stomach or thighs as these are the insulin injection sites and may also lead to infection.

Furthermore, the place from where you get the tattoo or piercing done, also matters. Thoroughly check whether they follow safety and hygiene practices, and use clean equipment. Unhygienic equipment may lead to infection and other illnesses. Do not hesitate to tell them that you are a diabetic.

After having a tattoo or a piercing, clean it well regularly for first few days and you may also use an antibiotic cream as a precaution after consulting your doctor. Also, do check blood sugar levels regularly. Even after taking all the above precautions if you have any infections, contact your doctor immediately.

Smoking and Alcohol, and Living with Diabetes

Smoking

A regular and healthy lifestyle can help to control diabetes. Regular physical activity and a healthy diet have a positive impact on controlling diabetes. However, unhealthy habits, such as smoking and drinking too much alcohol, can make diabetes and its complications worse.

People with diabetes who smoke have a higher risk of developing heart diseases and stroke when compared to non-smokers. Smoking also increases the risk for all diabetes-related health problems, such as kidney disease, nerve damage, and leg and foot infections. Moreover smoking is a risk factor for the development of diabetes in otherwise healthy individuals.

How to quit smoking?

The best thing to do for your health, whether or not you have diabetes, is to quit smoking as soon as you can. Research shows most smokers want to quit. The addictive nature of nicotine can make quitting a major challenge.

• Quit in one shot: Some people plan to quit smoking gradually, but this increases the stress of quitting and trigger new withdrawal symptoms
• Don’t give up: Many people attempt quitting several times before they are successful. Each attempt helps people learn what works for them
• Finding a new, more healthy habit: Breaking the association between smoking and certain activities can be helpful. For example, if a person always starts their day with a cigarette, they could instead start with a short walk around the block
• Ask about nicotine replacement therapy (NRT): It does not work for all people who smoke, and those with diabetes should consult a doctor before trying it
• Counseling: Counseling and psychotherapy can help people understand why they smoke and why they think smoking helps them cope. They also provide support for the emotional challenges of quitting
• Medication: Quit assistance medication can help some people who want to break the habit, such as varenicline. These drugs can reduce cravings, and some also help with the emotional side effects of quitting. People who smoke should talk to a doctor about whether these drugs are safe to use alongside their diabetes medications
• Convince others to join you: If another household member smokes, talk to them about quitting together. This way, people can encourage each other.

Alcohol

Alcohol is a toxin for the liver. When it is consumed in large amount, the liver stops its every function including making blood sugar, and try to get rid of alcohol from the body. This results in lowering of the blood sugar levels.

Alcohol also affects nerve functions and weight gain. Consuming a moderate amount of alcohol i.e., two drinks for men and 1 drink for women will not cause much damage. If you have diabetes and plan to drink:

• Always eat some form of carbohydrate with your drink, such as crackers, bread or pretzels
• Avoid sweet wines, drinks and liqueurs
• Check your blood sugar more often
• Always have a ready source of sugar, such as hard candy
• Talk to your health care provider
• Always carry identification which says that you have diabetes.

100 YEARS OF INSULIN

Insulin discovery has completed 100 years in the year 2021, and it is indeed one of the major events in the history of medicines as well as for the diabetes community. Insulin has made diabetes a manageable disease from life-threatening conditions globally.

Insulin was discovered in Toronto, Canada in the year 1921 from a dog’s pancreas and it was used to check its effect for the first time in a human. In 1921 two Canadian Scientists professor Frederick Banting and his research assistant Charles Best isolated insulin from a dog’s pancreas. Then this insulin was refined for human use, which had brought hope for people with diabetes.

Furthermore, other two researchers Professor John Macleod and colleagues James Collip developed more refined insulin from the cow’s pancreas.

At the beginning of 1922, insulin was given to the first human Leonard Thompson, a 14-year-old boy who was dying from type 1 diabetes at a hospital in Toronto.

In the year 1923, the researchers of insulin received the Nobel Prize. The development of insulin was incredible and has changed the life of millions of people with diabetes, all around the world. The pharmaceutical giant Eli Lilly and Company did an agreement, and manufactured as well as distributed insulin on large scale to make insulin commercially available in July 1923.

Before the advent of insulin, diabetes was an acute disease with survival measured in weeks to a few years. Patients were typically young and would succumb to diabetic ketoacidosis (the body not being able to metabolize sugar and energy correctly). Remarkably, the leading therapy was starvation, which prevented the body from metabolic disarray but resulted in gradual decline due to malnutrition.

ADOPT HEALTHY LIFE

Diet

A diabetic diet or diabetic meal plan is best suited for everyone in today’s stressful environment. It is a nutritional guide that helps people to understand what to eat and when to eat. A diabetic diet includes foods that are rich in nutrients and low in fat and calories. It includes fruits, vegetables, whole grains and protein-rich foods.

The aim of any diabetic diet prepared by nutritionists or doctors is to manage blood sugar level in the specified range and maintain a healthy weight, manage blood lipid and cholesterol levels.

Nutritionists can help to prepare a time table that best fits your routine lifestyle to maintain blood sugar levels as well as the weight. They may also suggest some healthy recipes and cooking tips that reduce cravings for other junk foods which cause damage to the body.

Most of the diabetes diet plans include three meals per day at regular intervals. This time table is suitable for the body’s physiology for better insulin utilization.

Suggested Food Items in Diabetic Diet

A diabetic diet includes healthy carbohydrates, fiber-rich food, fish and good fats.

Healthy Carbohydrates

Carbohydrates include simple carbohydrates (sugars) and complex carbohydrates (starch). All carbohydrates break down into glucose and this will be utilized by our body to produce energy. We can get healthy carbohydrates from:

• Fruits and vegetables
• Whole grains
• Legumes such as beans and peas
• Low-fat dairy products, such as milk and cheese.

Furthermore, it is suggested that foods or drinks with added fats, sugars and sodium that have less healthy carbohydrates, should be avoided.

Fiber-rich Foods

Fibers help in the digestion of food and control blood sugar levels. Fibers are of two types namely soluble fibers and insoluble fibers. Soluble fiber helps control blood sugar levels and cholesterol levels. Insoluble fiber cannot be absorbed in the body and it helps in digestion. Foods that are rich in fiber include:

• Vegetables and fruits
• Nuts
• Legumes, such as beans and peas
• Whole grains.

Fish

Some fish are really good for the heart. They prevent heart diseases as they are rich in omega-3 fatty acids. The fishes that can be included are salmon, mackerel, tuna and sardines. It is suggested to avoid fried fish and fishes with high levels of mercury, such as king mackerel.

Good Fats

Foods having monounsaturated and polyunsaturated fats are good to lower cholesterol levels. These include:

• Avocados
• Nuts
• Canola, olive and peanut oils
• Avoid overtaking these foods as all fats are high in calories.

Foods to Avoid

Diabetes increases the risk of heart disease and stroke by augmenting the development of clogged and hardened arteries. Examples of some foods having a negative impact on diabetes:

• Cholesterol: Cholesterol containing foods includes high-fat dairy products and high-fat animal proteins such as butter, beef, hot dogs, sausage, bacon, egg yolks, liver and other organ meats. Aim for no more than 200 mg of cholesterol a day
• Saturated fats: Try to lower the intake of dairy products such and animal products. Also, limit coconut and palm kernel oils
• Trans fats: Minimize taking trans fats which are found in processed snacks, baked goods, shortening and stick margarine
• Sodium: The goal for sodium content should be less than 2,300 mg/day. Nutritionists or doctors may suggest even less in case of high blood pressure.

Low Carbohydrate Diet

Everyone has different requirements for carbohydrates depending on their activity levels, diabetic goal, sugar levels, complications, etc. Dieticians or doctors can set a limit for carbohydrate content in regular diet.

Carbohydrate content in different diets is as follows:

Diet Type	Carbohydrate Content
Very low carbohydrate diet	<30 g
Low carbohydrate diet	30–130 g
Moderate carbohydrate diet	130–225 g

Two types of carbohydrates include sugar (cookies, cakes, fruits, soft drinks, sweets, etc.) and starch (cereal, bread, rice, potatoes, yam, plantain, couscous, cassava). A low carbohydrate diet is preferred for weight loss and improves blood sugar levels.

Initially, on starting a low carbohydrate diet, people often feel withdrawal effects for two to four days like headache, nausea, lethargy, loss of concentration, irritability and confusion. These withdrawal effects usually remain for a week and after that people experience increased energy levels.

Food that is rich in proteins makes you  feel fuller for a longer time, and hence, inclusion of protein diet will compensate energy levels and reduced requirements of carbohydrate diet.

Some examples of carbohydrate content in some food:

Lunch	Carbohydrate Content
2 slices thick white toast	44 g
Packet crisps	17 g
Cheese and cold ham	0 g
Yoghurt	19 g

Role of Nutrition in Diabetes

Nutrition is very much an essential part of the diabetes care plan. A balanced and nutrition-rich diet that includes proper amount of macronutrients such as carbohydrate, fat, protein and micronutrients such as vitamins and minerals helps to adequately manage diabetes and weight.

Carbohydrates and Diabetes

Carbohydrate from food gets metabolized to glucose in the blood and every cell of the body utilizes it to produce energy in the presence of insulin. Therefore, lowering carbohydrate content in food plays a crucial role in managing blood sugar levels. The main fundamentals of a diabetic diet are to divide carbohydrate contents into portions throughout the day without compromising with the energy levels along with controlled blood sugar levels.

Sugar and Diabetes

People with diabetes who follow a healthy eating pattern can include a small amount of sugar in their diet. However, sugar should be eaten as part of a nutritious meal. For example, one teaspoon of honey with plain porridge, tinned fruit in natural juice and some types of high fiber breakfast cereals with dried fruits, such as natural muesli.

Fat and Diabetes

All fats are high in energy which leads to weight gain. Weight gain may worsen diabetes and develop the risk of complications and rises cholesterol and triglycerides levels. Type of fat is also important. Saturated fat cause more damage and increase chance of heart disease. Foods that are rich in saturated fat include meat fat, full-fat dairy foods, cream, solid cooking fats (such as butter, lard, copha and ghee), oils such as palm and coconut, and products that contain these fats (for example, fried foods, some cakes and biscuits and other convenience foods). Unsaturated fat is healthier than saturated fat. Food that contains unsaturated fats include:

• Polyunsaturated fats and oils: Found in, sunflower, safflower, soybean, corn, cottonseed, grape seed and sesame oils. Also found in oily fish such as herring, mackerel, sardine, salmon and tuna, as well as nuts, seeds and polyunsaturated margarine (check the label)
• Monounsaturated fats and oils: Found in canola and olive oil, avocados, nuts, seeds and canola or olive oil margarine.

Protein and Diabetes

Protein is important for the growth and repair of cells in the body. Most proteins do not have any effect on blood sugar levels. A protein meal makes the stomach fuller for a longer period of time and helps in maintaining calories and carbohydrate contents.

Protein foods include eggs, unsalted nuts, soy products such as tofu, lean meat, seafood and legumes (dried beans and lentils, chickpeas, kidney beans). Legumes also contain carbohydrates, so they may have an impact on your blood glucose levels.

Most of all need at least 2–3 servings of protein per day. Some sample serves of protein foods that are low in fat include:

• One cup of cooked split peas, beans, lentils or other legumes
• 100 g of cooked fish or other seafood
• 65 g of cooked lean red meat
• 80 g of cooked poultry without the skin
• 2 eggs (try poached, scrambled with low-fat milk or boiled rather than fried).

Role of Vitamins and Minerals in Diabetes

Micronutrients like vitamins and minerals play a vital role in managing or preventing diabetes. Here are some vitamins and minerals that play a role in managing blood sugar levels:

Alpha-lipoic Acid and Gamma-lipoic Acid

Alpha-lipoic acid (ALA) is a potent antioxidant and may help diabetic neuropathy and reduce pain from free-radical damage. Moreover, some studies suggest that ALA decreases insulin resistance, and thus, controls blood sugar. ALA helps in managing blood glucose levels by:

• Reducing oxidative stress
• Lowering fasting blood sugar levels
• Decreasing insulin resistance
• Gamma-lipoic acid (GLA) is another naturally occurring antioxidant present in evening primrose oil, borage oil and blackcurrant seed oil. GLA may improve the function of nerves damaged by diabetic neuropathy.

Biotin

Biotin increases the activity of the enzyme glucokinase. People with diabetes have extremely low levels of glucokinase. Glucokinase is responsible for the first step of glucose utilization and supplements of biotin may have a significant effect on glucose levels for both type 1 and type 2 diabetic patients.

Carnitine (L-Carnitine, Acetyl L-Carnitine)

Carnitine reduces the level of fat such as cholesterol and triglycerides from the blood and is utilized to produce energy. Carnitine binds with acyl residues formed in the body, and thus, it is useful to prevent diabetic ketoacidosis.

Chromium

Chromium is an essential nutrient used in the metabolism of carbohydrates and improve glucose tolerance, lowering fasting glucose levels, decrease insulin levels and cut cholesterol and triglyceride levels, whilst increasing HDL-cholesterol levels. Numerous studies have shown that supplemental chromium may raise glucose tolerance in patients with both type 1 and type 2 diabetes.

Coenzyme Q10

Coenzyme Q10 is a potent antioxidant and helps in carbohydrate metabolism. It has been proven that animals suffering from diabetes are coenzyme Q10 deficient. Moreover, clinical trials suggest that coenzyme Q10 may significantly lower blood sugar levels. Coenzyme Q10 also oxygenates the blood, and therefore, can be used in the treatment of diabetic retinopathy.

Inositol

Inositol is used in lowering blood cholesterol levels. It is also effective in diabetic neuropathy.

Manganese

Manganese is one of the key factors in glucose metabolism and its deficiency is very much common in diabetic patients.

Magnesium

Magnesium is a vital element that improves insulin sensitivity and regulates blood pressure. Deficiency of magnesium is seen in diabetic people and their level is extremely low in the case of diabetic retinopathy. Magnesium improves the insulin secretion process, and also reduces insulin resistance. A magnesium supplement may be able to reduce insulin dosage.

A magnesium-rich diet may reduce the risk of diabetes. Researchers have found a link between higher magnesium intake with lower rates of insulin resistance and diabetes.

Potassium

Potassium improves insulin sensitivity; hence, a diet that is rich in potassium can be useful.

Taurine

Low taurine levels result in increased thickness of the blood and increased risk of heart disease in diabetic people. Low levels of taurine are mainly found in people with type 1 diabetes. Supplementary taurine for diabetic patients may be able to correct levels of blood viscosity. Taurine is found in protein-rich foods.

Vanadium

Vanadium helps in a slight increase in insulin sensitivity, and reduction in insulin requirement. Studies on both animals and humans have proved the role of vanadium in managing blood glucose levels.

Zinc

Zinc plays a vital role in insulin metabolism. Zinc has a protective action against beta-cell destruction in the pancreas. Type 1 diabetic patients are often zinc-deficient, and supplements have been shown to lower blood sugar levels in some type 1 diabetes cases.

Vitamin B6

Vitamin B6 (pyridoxine) may be able to improve glucose tolerance, especially in gestational diabetes, or impaired glucose tolerance caused by the birth control pills.

Vitamin B6 also has a strong role to play in the prevention of diabetes-related complications, mainly diabetic neuropathy.

Vitamin B12

Vitamin B12 may have a strong role to play when treating diabetic neuropathy. It is essential for the functioning of nerve cells, and help to reduce nerve damage caused by diabetes.

Vitamin B1

Vitamin B1 is also known as thiamine. Thiamine deficiency is seen in many people with diabetes. Thiamine deficiency can be seen in heart disease and blood vessel damage. It is a water-soluble molecule and it cannot be utilized by the cells of our body. Benfotiamine is a lipid-soluble form of thiamine that can be utilized easily by cells.

Vitamin C

A low level of vitamin C is usually observed in type 1 diabetes patients. Increased vitamin C may reduce sorbitol levels. Sorbitol is dangerous sugar that risks the development of diabetic retinopathy (eye damage), neuropathy (nerve damage) and nephropathy (kidney damage). Vitamin C has also a role to play in insulin resistance in type 2 diabetes.

Vitamin D

Vitamin D may be responsible to boost insulin sensitivity, which is vital for the management of blood sugar levels.

Vitamin E

Vitamin E is an antioxidant and improves insulin activity. In type 2 diabetes it improves glucose tolerance and the antioxidant nature reduces diabetes complications.

Meal Plan

There are various approaches to prepare diabetes diet. Below mentioned three methods are used mostly:

• The plate method
• Carbohydrate counting
• Glycemic index.

The Plate Method

It is a very simple method that emphasizes on eating more vegetables (salads) in a plate. While preparing plate, follow simple steps as mentioned below:

• Fill half plate with vegetables, such as spinach, carrots, tomatoes, etc.
• Fill first quarter plate with protein-rich foods such as sprouts, beans, tuna, lean pork or chicken
• Fill the last quarter with a whole-grain item such as brown rice or a starchy vegetable such as green peas
• Also add nuts or avocados in small amounts
• Add a little amount of fruit or dairy product such as paneer and a drink including water or unsweetened tea or coffee.

Carbohydrate Counting

It is advisable to count the amount of carbohydrate during planning of everyday meal to maintain blood sugar levels. It will definitely help in adjusting insulin dose as well. A dietician or doctor can educate the patient on how to measure the amount of carbohydrates in each meal based on sugar levels, complications, lifestyle, etc.

It’s really important to read carbohydrate contents in every packed food item. Furthermore, serving size in each meal is also important to adjust the dose.

Choose your foods

Based on patient’s conditions, diet plan is prepared and carbohydrate counting is considered as a crucial factor. Normally 1 chapati contains 12 g of carbohydrates, same way one potato contains 12–15 g of carbohydrates, one cup brown rice contains 45 g of carbs, 1 cup low-fat milk contains 13 g of carbohydrates. Dietician or doctor can plan well regarding diet. Some mobile apps are also available which help to find carbohydrate content in the food.

Glycemic Index

In this method foods are selected based on their effect on blood sugar levels. This is ranking method where all foods are given a rank and by making some adjustment in your daily habits, physical activities, planning is being done. It is not necessary to follow a strict regimen, but it makes you learn to combine food items into a meal so that you can consume an appropriate amount.

Combining carbohydrates with either protein or fat is the best method to control blood sugar. Some healthy replacement of foods to meet daily carbohydrate goal are as follows:

Food	Best replaced with
White rice	Brown rice, riced cauliflower
White potatoes (including fries and mashed potatoes)	Sweet potatoes, yams, cauliflower mash
Regular pasta	Whole-wheat pasta, spaghetti squash
White bread	Whole-wheat or multi-grain bread
Sugary breakfast cereal	High-fiber, low-sugar cereal
Instant oatmeal	Rolled oats
Cornflakes	Muesli or low-sugar bran flakes
Corn	Peas or leafy greens

There are certain myths and facts regarding diet plan in diabetes:

Myth: You must not eat any form of sugar. Fact: You can enjoy sweets as long as you learn to manage carbohydrate contents in your meal. Be smart when you want to eat sweets. You can eat sprouts, leafy vegetables and then enjoy the desert.

Myth: You have to lower down carbohydrate contents. Fact: Choosing the type of carbohydrate is the key factor. Eat whole-grain rather than starchy carbohydrates as they are low in carbohydrate content.

Myth: You have to eat special diabetic meals. Fact: The basic principle in a diabetic meal is to cover all essential nutrients with fewer calories. This is a healthy option even for non-diabetics.

Myth: A high-protein diet is best for diabetics. Fact: Too much protein may cause insulin resistance. Diet should be balanced with carbohydrates, proteins, fats, vitamins and minerals.

Be Smart About Sweets

Having diabetes does not mean one cannot eat sugar at all. One can still enjoy sweets but it has to be in moderation.

Managing carbohydrate content like eat less bread or pasta and eat your favorite sweets or desserts. Always take sweets or desserts with the meal only. If you eat sweet alone between the meal, it will raise sugar levels drastically, whereas if you eat it with a meal, sugar levels won’t rise drastically.

Don’t forget to enjoy every bite of sweets or desserts by eating slowly and feel the taste and texture of the sweets that give you satisfaction even though it is in fewer amounts.

While initiating a low carbohydrate diet, you should reduce sugar content in your diet; this will reduce cravings for sweets as well as gives time to your taste buds to adjust with less sugar content, gradually.

You can take an avocado smoothie, dry fruit milkshake as a part of desserts as they contain healthy fat. Fat takes a long time to digest, and therefore, won’t raise the blood sugar, drastically. You can also add peanut butter, ricotta cheese, yoghurt or nuts in your diet.

You can replace unhealthy fat with healthy fats.

Unhealthy Fat	Healthy Fat
Chips, crackers, snacks	Nuts or seeds, cereal, peanut butter, almond butter
Fried foods	Boiled, baked or stir-fried food
Saturated fat from processed meats, packaged meals and takeout food	Red meat, vary your diet with skinless chicken, eggs, fish and vegetarian sources of protein
Commercial salad dressings	Extra-virgin olive oil to dress salads
Butter, cheese in sandwich	Add avocados to sandwiches, vegetables, paneer and tofu

Role of Exercise in Diabetes

Exercise plays a vital role in people with diabetes. It is as important as medicines and diet. It helps to manage weight and thereby improves insulin resistance and controls blood sugar. Every muscle of the body utilizes glucose without insulin when you do exercise and lowers the glucose levels in the blood.

It is essential to include exercise as a part of your routine life. Moreover, you can make exercising more interesting with some modifications. Instead of jogging, running or walking, you can choose any outdoor sports of your choice like cricket, tennis, dancing, Zumba, basketball, swimming, biking, etc. However, be cautious not to overdo or overexert yourself.

Regular exercise will not only help to achieve diabetes control but also reduce the risk of developing diabetes complications.

Always remember to stay hydrated during exercise or playing any sports. Check blood sugar levels before starting exercise. This is very much important while you are on insulin. Also, it is advised that you keep sugar-containing food handy in case of hypoglycemia.

Early you adapt to live with diabetes and make small changes into your routine life, you will start enjoying life early and remain healthy throughout your life. An aim to do exercise 30 minutes a day on most days of the week (at least 4–5 days in a week) will give a better result.

American Diabetes Association suggests aerobic exercise and strength training as a part of physical activity. Aerobic exercise includes asanas in yoga, playing sports, dancing and Zumba, etc. Strength training exercise includes using weight machines, free weights (dumbbells) and resistance bands, and doing bodyweight exercises such as push-ups, lunges and sit-ups.

Strength exercise should be done at least two times a week in addition to aerobic exercise or walking/jogging. Strength exercise helps to increase insulin sensitivity and decrease blood sugar levels.

Benefits of doing regular exercise:

• Increased insulin sensitivity (insulin works better)
• Lower blood sugar levels
• Increased energy and endurance throughout the day
• Weight loss with increased muscle tone
• A healthier heart and lower blood pressure
• Better sleep at night
• Stronger bones and a lower risk of osteoporosis
• Better resistance to illness
• Improved cholesterol, heart rate and blood pressure levels
• Lower stress, anxiety, boredom, frustration and depression.

Role of Meditation and Yoga in Diabetes

Meditation

Diabetes is a complex disorder that affects not only our body but also affects the mind. It has a great impact, emotionally as well as socially. A sudden diagnosis of diabetes will disturb the routine lifestyle of the patients and create lots of confusion and discomfort. This creates psychological issues and stress which further deteriorates the disease and its complications. The natural course of diabetes disease creates a lot of disturbance to the brain and it requires some relaxation for proper neuro-cognitive functions in daily life.

Mindfulness meditation can be one of the solutions to the above problems. It helps the brain in regulation of blood sugar, blood pressure, hormones, etc. It also increases insulin sensitivity by insulin utilization through muscle contraction and relaxation.

Meditation differs from yoga. Some parts of yoga and meditation are overlapped with each other. However, meditation is a mind-based exercise, whereas yoga includes performing asanas that requires flexibility and balance. Yoga also includes mindful meditation as its part to achieve self-realization.

Meditation helps to regulate nerve balance, hormonal balance, heart functions and immune functions without physical activities. So people of any age or any condition can do meditation and get benefits from it.

Some studies show the benefits of mindfulness meditation in improving blood sugar control, diabetic neuropathy and depression. It is well-accepted by people with diabetes and is proven to improve their quality of life. There are different types of meditation as follows:

• Mindfulness meditation
• Transcendental meditation
• Moving meditation
• Concentration meditation

Mindfulness Meditation

American Diabetes Association has shown the beneficial effect of mindfulness meditation in relieving anxiety, stress and depression. This may be helpful to the diabetic people to stay happy and cheerful.

Method: Mindfulness meditation can be done anywhere while sitting on a chair, sofa or any comfortable position. You can do it even while lying down. Bring your focus on your breathing pattern. When your mind begins to wander, return your focus on the breath. Initially, the mind is constantly wandering, just return focus on the breath again. Try to sit in a quiet place with a natural environment for better effect, if possible. Start with 10 minutes and increase gradually to more than 1 hour daily. Doing mindfulness meditation is not easy, it requires practice.

Transcendental Meditation

Transcendental meditation originated in India in the 1950s, by Maharishi Mahesh Yogi. This meditation practice is used throughout the world.

Method: Transcendental meditation is done sitting on the floor with closed eyes and mantra chanting. Mantra can be as simple as one word “OM” or anything. Chant mantra and take a deep breath for 10 minutes every day. Transcendental meditation does not require focusing on breathing as in mindfulness meditation. This will help the mind to clear the thoughts. Studies have demonstrated that transcendental meditation is useful in reducing stress, anxiety, depression, sleep disorders, addiction, etc. It helps to refresh the mind and heart.

Moving Meditation

Moving meditation was originated in ancient China and it includes tai chi, qigong and walking meditation. It is a “mind, body and spirit practice,” that improves mental and physical health.

Method: Moving meditation can be done outdoors or indoors. Take 10–15 steps forward and come back on the same path. Focus on breath and feet together. Walk slowly while relaxing your arms and focus on the sensation, feel your feet as you walk. Qigong integrates posture, breathing, focus and intent by doing slow, gentle movements.

Concentration Meditation

Concentration meditation focuses on a single point such as chanting mantras, listening to some repetitive sounds, counting beads on mala, staring at the flame of a candle, etc. These objects will help to focus and improve concentration.

Benefits of Meditation in Diabetes

Meditation influences the mechanisms that regulate blood glucose levels and influence insulin production.

• It relieves stress and emotional reactivity, which enables the regulation of the hormone levels and reduce insulin resistance and restore insulin secretions
• It boosts the immune system and reduces the inflammatory response common in people with type 2 diabetes and lowers the disease progression
• It reduces oxidative stress that damages the cells which cause insulin resistance and high blood glucose levels.

Yoga

Yoga is a series of mental, physical and spiritual disciplines that originated in ancient India over 5,000 years ago.

The practice of yoga helps to coordinate the mind, body and breath to promote a sense of relaxation and inner peace. Regular practice of yoga can be beneficial in reducing stress, lower blood pressure and improve the overall quality of life and well-being.

Many health experts believe that yoga can improve diabetes condition and protect from its complications such as heart disease.

Yoga involves various body postures and movements (known as asanas), breathing techniques and meditation, which are all designed to promote physical comfort and mental composure.

Benefits for People with Diabetes

Yoga is a very effective and economical treatment option in the prevention of diabetes and its progression. Several studies have shown the positive effect of yoga in diabetes and another chronic disease by reducing mental stress. Mental stress leads to an increase in blood sugar levels and the risk of developing its complications.

Yoga involves controlled breathing techniques and body postures to promote relaxation. This helps to regulate cortisol and other stress-related hormones and thereby beneficial effect in controlling blood sugar levels and blood pressure.

Yoga helps in preventing disease by:

• Production of new β-cells: Yoga postures (asanas) stretch the pancreas, which stimulate the production of insulin-producing β-cells
• Increase glucose utilization: Yoga involves exercise and thereby increase glucose uptake of muscle cells and reduces blood sugar levels, improving blood circulation
• Managing weight: Yogasanas is the best aerobic exercise and helps to reduce weight. Managing weight is one of the most important factors in disease development and its complications.
• Rejuvenate inner peace: Yoga is the way of self realization which brings inner peace and improves the psychological condition of the patients as well as improves quality of life.

Things to Avoid in Diabetes

Diabetes affects blood sugar levels, and uncontrolled blood sugar levels for a long time lead to complications involving many organs and may also cause heart disease, high cholesterol levels, stroke, nerve damage, kidney damage, skin disease, sexual dysfunction, diabetic foot, etc. If you are diagnosed with diabetes here are the things you should avoid and incorporate healthy habits for a better quality of life and avoid serious and life-threatening complications of diabetes.

Mistakes that can Raise Blood Sugar Levels

Skipping Breakfast

Breakfast is not much important meal for many Indians. We often skip breakfast due to our busy schedules. Skipping breakfast may increase blood sugar levels.

Breakfast is the most important meal of the day. Eat a healthy and balanced breakfast such as eggs, nut butter, fresh fruit, yoghurt, whole-wheat pita pockets, or whole-grain bread.

Eating Junk Food

Diet is the most important factor in controlling blood sugar levels. If you have diabetes you cannot eat whatever you like. Junk food will give a spike in blood sugar levels and it is highly dangerous if you have diabetes.

You must constantly count sugar content, fatty foods, junk food in your diet to avoid fluctuations in blood sugar levels. Eating healthy food such as fruits, vegetables, low-fat food, and unsweetened food would help to achieve blood sugar control.

Not Checking Sugar Levels

Diabetic people should constantly monitor their blood sugar levels, especially when they are on insulin. It is difficult to decide a diet plan, exercise plan and medicine plan if you do not check your blood sugar levels.

It is important to take measures in case of a rise or fall in blood sugar levels. Do not ignore in case of a major rise or fall in blood sugar levels and immediately contact a doctor.

Sitting All-day

Avoid sedentary life and adapt active life is important for everyone and when you have diabetes, it is at most important. Most people have a daily routine is to move out of the house, get into your car, reach the office and work on your desk for 8–10 hours and then come back home and watch TV till late in the night. Less physical activity is the biggest reason behind many lifestyle disorders like diabetes, thyroid, heart disease, etc.

Make a habit to walk, climb up the stairs instead of using the lift, park a car at distance and walk, do regular exercise for at least 30 minutes per day, walk while on the phone, etc., may help to get rid of sedentary life.

Working Late at Night

Working late and not taking enough sleep will certainly worsen the disease and may raise the chance of developing diabetes and its complications. Sleep-deprivation will disturb hormonal balance and also impair psychological functions. It may also result in high blood pressure as well as weight gain, which may further deteriorate the disease.

Try to sleep for at least 8 hours to rejuvenate yourself. Moreover, try to finish all your commitments an hour before sleeping.

Stress

Stress will disturb the normal body cycle by some chemical changes. It disturbs cortisol levels and thereby increase the risk of depression and other psychological disorders. Cortisol also disturbs insulin activity and disturbs blood sugar levels.

Manage your stress by doing regular yoga, meditation and exercise. You can also look at ways such as taking a 10-minute break from work, participating in a sport or simply catching up on some sleep during the weekends.

Late Dinner

At the time of the dinner, everyone is relaxed and spending family time or enjoying television. Because of these reasons people often eat more when compare to any other meal and 50% of total calories come from the dinner only. After an entire day of working, people often go to bed immediately after dinner. This is the main reason for gaining weight and the development of diabetes.

Experts suggest that there should be 3 hours gap between dinner and bedtime. Dinner should be light when compared to all other meals. Add more protein as it makes the stomach full for a longer time. Also add healthy fat such as olive oil, avocado, nuts, etc.

Midnight Munching

Midnight munching is eating any snacks after dinner. This habit will give blood sugar spikes and disturb insulin secretion. Eating snacks like chips or crackers again increases weight and affects blood sugar levels.

Having three proper meals in a day along with healthy snacks like nuts, fruits, whole wheat bread sandwiches, etc., in between the meal reduces the urge to eat at night. Even though if you are hungry try healthy snacks like vegetables, hummus, guacamole, etc.

Taking Additional Butter

Butter is a rich source of saturated fat which directly affects insulin secretion. Eating butter with parathas satisfies the taste buds but it disturbs the blood sugar levels. Replace butter with extra virgin olive oil. It tastes better along with health benefits.

Eating too much of Starchy Carbohydrates

Eating too much pasta, potatoes, white bread, etc., raises blood sugar levels. Starchy carbohydrates are complex carbohydrates and will increase sugar levels compare to sugars.

Replace white bread with whole wheat bread and include whole wheat pasta to achieve good blood sugar control and weight loss.

Eating Fish

Eat salmon, tuna, mackerel, and sardines fish. These fishes are rich in omega-3 fatty acids which lower the risk for blood pressure and heart disease and are good for preventing diabetes. Try to take two servings in a week. You can also add chicken or turkey without the skin, tofu, eggs and yoghurt (without fat or low fat).

Smoking

Smoking is responsible for a lot of serious health conditions such as high blood pressure, stroke, diabetes, emphysema (breathing difficulties), cancer of the lungs, prostate, digestive track, etc. Smoking thickens the blood and causes poor blood supply. In diabetes, increased sugar also leads to a poor blood supply. A diabetic person who smokes has an increased risk of developing complications.

Studies show that after 5 years there is a decreased risk of developing diabetes and related complications by 13%, in people who quit smoking. So quitting smoking is always better for your health and family budget as well.

Drinking Aerated Drinks

Aerated drinks contain a high amount of sugar and preservatives that increases sugar spike in the blood. It is also responsible for weight gain and worsens diabetes. A study suggests that those who consume more than two servings of aerated drink or artificially sweetened drinks, have a 20% increased risk of diabetes.

Replace aerated drinks or artificially sweetened drinks with water or fresh fruit juice. An increase in water consumption will reduce the urge for an aerated drink and it may help in controlling blood sugar levels and insulin response.

Alcohol

High amount of alcohol consumption may lead to poor blood sugar control. Sometimes, it may lead to hypoglycemia if a diabetic person skips meal after alcohol.

A diabetic person should consume no more than two servings of alcohol. Care should be taken not to skip a meal after having alcohol. Consuming enough amount water along with alcohol will be advantageous.

DIABETES EDUCATION

Importance of Education

Education is the foundation for people with diabetes. Diabetic people require knowledge and skill to manage the disease. Diabetes education is defined as the procedure to provide knowledge and skill to learn and adapt self-care management of diabetes and modify lifestyle to cope up with the disease and avoid complications related to diabetes. It starts with the self management of the disease and then educates people to make necessary changes in lifestyle to best manage the disease and to avoid long-term healthcare complications.

According to the World Health Organization (WHO), 422 million people around the world have diabetes and 1.6 million deaths are directly due to it every year. Furthermore, the number of people with diabetes is constantly increasing. It is essential to gain better awareness for diabetes education.

Diabetes education helps people in day-to-day management of disease, staying healthy, making informed choices of treatment and lifestyle changes that can be life-changing for people with diabetes.

Diabetes education is not a lecture. It’s real-life guidance, coaching and support proven to help people understand exactly how to best manage their diabetes. Self-management skills are a crucial part of diabetes care and with diabetes education, it can be managed to make people healthy and prevent complications.

The goal of diabetes education is to help people to include self-management practice of diabetes in their routine life and thereby lowering blood sugar levels, blood pressure as well as cholesterol management. Most people with diabetes admit that self-management is important but difficult to practice in their daily life. Diabetes education assists in preparing an individual plan that suits them most and thereby easy to adapt and follow it.

Benefits of Diabetes Education

People with knowledge and skills of diabetes self-management are able to manage the disease and may live healthier life compared to those who do not. Knowledge of how and why to monitor blood sugar, when and why to take medicines, what to do to take care of yourself will help to manage the disease better.

Understanding of disease and its progression will create awareness to identify the initial symptoms and less likely to put you in an emergency and save money as well. Moreover, proper lifestyle modification will aid to avoid or delay diabetes-related complications and keep you healthy.

Diabetes education is often done in groups. You get a chance to meet the people like you. Patients can support each other in achieving better sugar control and make living with diabetes confident and less stressful, and in addition, provides motivation.

Diabetes Education in Children and Adolescents

Having diabetes in children and adolescents itself is a burden. It requires a lot of restrictions in daily life such as taking insulin/medicines, monitoring blood sugar levels, diet, physical exercise, etc. The complicated nature of the disease affects children’s minds, body and psychology. The entire family gets a shock if a child or adolescent is diagnosed with diabetes. Lack of medical insurance to cover the cost of diabetes takes the entire family budget and is a big financial liability. This along with lack of education increases difficulties for the children to cope with the disease.

To date, children and adolescents only had type 1 diabetes, but now teenagers are also being diagnosed with type 2 diabetes due to:

• Strong family histories
• Increasing rates of obesity
• Being overweight.

Children and teenagers diagnosed with diabetes are under stress from the disease and lifestyle changes for their entire life and have the dilemma of managing diabetes in school. Teenagers may have concerns about travel and doing strenuous work, drinking alcohol, higher education, work, etc. Children and their families both need time to adapt to living with diabetes.

How to establish a daily lifestyle with diabetes in children?

Children with diabetes require the support of parents to manage their daily lifestyles. This includes:

• Daily blood sugar monitoring
• Daily insulin dose or medicines
• Dietary management
• Physical exercise
• Coping up with hypoglycemia
• Visiting doctors for checkups regularly.

The main aim of diabetes education for children is to learn self-management of diabetes as early as they can. Moreover, family can support and teach their child to manage it independently. Some suggestions to ease your child’s move to diabetes self-management are as follows:

• It is best to involve your child to manage their diabetes from the beginning. This will help them to become independent and confident. Involve them to choose an injection site. The injection site should be a fatty area of the body like buttocks, belly (avoid the area within 2 inches of the belly button), sides of thighs, back of upper arms. Also, encourage them to test blood sugar timely, as advised by the doctor
• Create or send your child to a diabetes group and/or activities. Children will meet other children with diabetes and learn about diabetes care in a fun, safe and relaxed environment
• With the support of education and guidance, your child can learn to incorporate diabetes care into their everyday life and develop lifelong skills and confidence
• Make sure that the levels of involvement are suitable for their age. Your child’s diabetes educator can offer advice on age-appropriate responsibilities.

Diabetes Self-management Education Depending on Age

Infants and Toddlers

Infants and toddlers are dependent on their parents for insulin injections or insulin pumps and food. A regular blood sugar check is essential, even though it is painful. Education is required to prevent the long-term risk of diabetes.

School-age Children

Adapt the new environment from home to school. At this age, parents should encourage the child to learn self-management of diabetes like insulin injections or pump use, diet management, awareness and reorganization of hypoglycemic symptoms and take sugar sources in case of hypoglycemic symptoms.

Adjust to school timings in meal, exercise and sports. Children are taught not to do too much physical exertion as it may lead to hypoglycemia.

Adolescents

Adolescents should be educated to become independent in managing their diabetes with the help of blood sugar checks, insulin dose, diet and physical exercise. They should be made aware to manage weight in order to avoid further complications. Furthermore, they should be educated to control blood sugar levels in the targeted range as suggested by the treating doctor. In addition, they should be made aware of the dangers of alcohol, smoking and junk food.

Children with Diabetes in School

Many parents whose children are diagnosed with diabetes have concerns for the safety of their children in school. It is the responsibility of the school pertaining to the safety of children with diabetes. Here also, education plays an important role to ensure that teachers understand the disease and its potential risk.

As a part of diabetes management schools should create a checklist of care required for diabetics as follows:

• Blood sugar and ketone body testing kits
• Antiseptic wipes (or cotton and spirit)
• Create awareness in school to identify the symptoms of hypoglycemia such as shaking or trembling, sweating, paleness, hunger, light-headedness, headache, dizziness, pins and needles around the mouth, and mood change
• Always keep glucose tablets or other fast-acting carbohydrates like fruit juice or hard candy (about 10–15 g) handy in case of hypoglycemia that will raise blood sugar levels quickly
• Identify symptoms of hyperglycemia (high blood glucose) which includes excessive thirst, frequent and copious urination, tiredness and blurred vision
• Exercise
• Dietary needs
• Inform physical education teachers that too much of physical activity can cause hypoglycemia.

Diabetes Education to Parents

There are a lot of questions that arise in the mind of parents when their child gets diagnosed with diabetes such as what my child should eat, how to measure blood sugar levels at home, when to give insulin, how to manage diabetes at school, how the child will cope with diabetes, etc.?

Children’s diabetes diagnosis is always more shocking for the parents than the child. Moreover, managing diabetes in children may sometimes lead to frustration. However, changing the lifestyle of the entire family will provide strong support to the child. Take a balanced diet, exercise regularly and visiting a doctor or healthcare provider will certainly give moral support to the child.

To manage diabetes in children, educating parents plays an important role. This includes:

• Understanding of the disease and related complications
• Importance of blood sugar testing
• How to check blood sugar
• Importance of insulin and how to take insulin
• Symptoms and risk factors of low blood sugar level and its prevention
• Symptoms and risk factors of high blood sugar level and its prevention
• Reason and importance of ketone bodies testing (in type 1 diabetes patient)
• Carbohydrate counting
• Importance of regular exercise and sports
• What to do if your child is sick with a cold or the flu
• What to do in emergency conditions
• Managing diabetes in daycare and school.

A diet plan for children is not usually prescribed, and carbohydrate counting is the method used to control blood sugar levels. However, blood sugar measurement before and after (2 hours) the meal is done to see the effect of a meal on sugar levels. A child should take a balanced diet with a high proportion of vegetables and fruits.

Education should be given on early symptoms of hypoglycemia as mentioned below:

• Pale and highly sweating
• Fussy or irritable
• Fatigue (tired)
• Sleepy or drowsy
• Staring into space or glassy-eyed
• Shaky
• Confused or having trouble concentrating
• Complaining of visual problems, headaches
• Dizziness and fainting.

If the above symptoms are seen in children, parents should check blood sugar levels. If it is below 70 mg/dL, give him/her sugar candy, fruit juice, granola, etc., (anything that has 15 g carbohydrates).

If blood sugar levels dropped down drastically and the child has the below-mentioned symptoms, immediately visit the doctor:

• Fainted and difficult to wake up
• Needs glucagon
• Seizure.

How to check ketone bodies?

The level of ketone bodies can be checked with a test strip. Put a drop of urine on a test strip and it will show the levels of ketone bodies present.

Site for Insulin Injection

Site for insulin injection for children should be fatty areas such as buttocks, belly (avoid the area within 2 inches of the belly button), sides of thighs or back of upper arms.

Diabetic children definitely can take part in sports with some precautions. Sports are a great way of exercising to stay fit and also help in lowering blood sugar levels. However, it is recommended to check blood sugar levels before indulging into any sports activities. If blood sugar level is high, it may lead to the production of ketone bodies (diabetic ketoacidosis) and if blood sugar level is low, it may lead to hypoglycemia.

Diabetes Education to Elderly People

Diabetes education to the elderly requires regular assessment to enhance self-management skills as well as to evaluate changes in patient’s functional, cognitive and psychological status. This assessment varies for every individual depending on diabetes-associated complications, other health conditions and therapies. The other factors to be considered for assessment are individual’s cognitive functions, ability to perform daily routine, etc. The diabetes education should be provided to family members as well as caregivers, for better results.

The approach for diabetes education, clinical parameters and treatment should be individualized as each individual’s mental, physical and social status is different and this challenge increases with advancing age. Self-care education should be provided to prevent any undesirable situations such as falls due to hypoglycemia, infection and dehydration due to hyperglycemia, etc.

The individualized care plan includes meal timings, medicine timings, food choices depending on their liking and light physical activities to keep them healthy and fit. To prepare an individualized care plan, following things should be taken into consideration:

Ø Healthy diet

• A diet plan should be set considering patient liking of food to avoid any complications of diabetes and to maintain healthy weight of the patients
• Timely eating and varieties of food options should be planned while making diet plans based on daily routine and personal preferences to increase the quality of life of the patients.

Ø  Say no to sedentary life

• Physical activity is important to be healthy and maintain appropriate blood sugar levels. Also, physical activities should be planned based on the patient’s interests as well as physical and mental abilities
• The co-morbid condition of the patient and associated risk are also taken into consideration while planning physical activities
• Elderly people should do aerobic exercise at least 150 minutes per week and they should not miss exercise for two consecutive days. The elderly patient should not sit for a longer period. They should be advised not to sit longer than 90 minutes at one place. They can take a walk or do some household work.

Ø Blood sugar level monitoring

• It is difficult to set personalized blood sugar levels targets. As there are a lot of things which affect the blood sugar level such as the presence of other diseases, patient’s conditions, willingness to follow lifestyle changes, family support, financial resources, etc.
• Educate regarding the importance of monitoring blood sugar levels, based on the daily routine of the patients
• Education plays an important role to have a problem-solving approach for the self-management of disease so as to identify hyperglycemia and hypoglycemia symptoms, change in therapy by the doctor, need for the dietary plan and physical activities.

Ø Treatment

• Educate elderly patients to address any misbelief regarding non-adherence with the treatment and encourage them to take medicines regularly
• Find out the reasons for non-adherence such as psychological conditions, adverse reaction to medicines, financial barriers, etc.

Ø Diabetes care

• Creating an individualized approach to educate elderly people is to solve problems faced in self-managing diabetes. This can be solved by providing step-wise and practical instructions and taking feedback periodically
• Monitoring cognitive behavior is necessary to check the mental status to follow the instruction in daily routine and tailor the instructions and care plan to meet the desired goal.

Ø Reducing risk

• Provide education related to complications of diabetes, their causes, symptoms and ways to prevent them
• Patients with hypoglycemia unawareness are educated to give more priority on blood sugar checks
• Educate regarding the importance of daily foot care, yearly screening tests such as eye examinations for retinopathy and urine testing for kidney damage
• Preventive care such as smoking cessation reduces the risk for acute as well as the progression of chronic complications
• For patients receiving palliative care and end-of-life care, the focus should be to avoid symptoms and complications due to lack of proper glycemic management and provision should be made to educate the family, clinical staff and/or home health personnel.

Ø Healthy living

• Educate people by giving more emphasis on socializing, family support and promote active life to avoid any psychological disorders such as depression
• The use of new technologies such as social platform (Facebook, WhatsApp) groups, can help to socialize well. However, priority should be of physical meeting.

Diabetes Education to School Authorities

Having diabetes should not be an obstacle for learning in school. Diabetic children should get the same opportunities as normal children. School authorities are also responsible to create a safe and healthy environment for diabetic children. This includes providing daily needs such as blood sugar testing kits and insulin for administration. School authorities should insure the parents that their diabetic child can stay healthy and enjoy the same opportunities and having fun with other children.

Diabetes education plays a vital role for parents as well as school authorities to ensure that children will remain safe and healthy in school. Most schools are ready to support students. Parents should meet with school staff and explain the need for the child to make sure that their child and school authorities can manage diabetes away from home.

Parents should explain specific management plans for diabetes, medicines, dietary requirement and blood sugar testing kits to school authorities.

How to manage diabetes in school for students?

School authorities should be educated to manage diabetes in students:

• Disease understanding
• Causes, symptoms and risk factors
• Symptoms for high blood sugar and low blood sugar levels
• How to check blood sugar levels
• Administration of insulin or other diabetes medicines
• Eat snacks and meals at frequent intervals with enough time to finish it
• Have easy access to water and bathroom as and when required
• Educate school staff especially physical education teacher to not force the student to perform many physical activities as it lowers the blood sugar levels drastically and causes hypoglycemia
• Treat them as normal children in school and on school trips
• Recognize the symptoms of hypoglycemia and keep sugar sources handy as a part of treatment
• School authorities also should know to check blood sugar levels and when to inform doctors and parents in case of emergency
• Parents should inform school staff in case of any changes
• School staff can do little modification to prevent diabetic kids from feeling different from their classmates
• The school also takes care of the requirement of diabetic children during school trips and sports activities
• School should have nearby doctors in case of emergency
• Testing kits, insulin and other medicines should be stored in a clean and dry environment. Insulin should be stored in the refrigerator (2–8°C) until expiry. All medicines should be checked for expiry.

Implementing Diabetes Management Plan in School

• Ensure to implement each individual’s diabetes management plan in school and encourage school staff to understand student’s needs and provide maximum support to them
• All school staff or selected staff should get training and knowledge for diabetes management to take proper care of the students
• Accessibility to the hospital or doctors in case of any emergencies
• School authorities should take consent from parents to make some adjustments in diabetic care plans supported by doctors
• The parents should be communicated in case of little adjustment in the diabetes care plan to minimize the difference between a diabetic child and a normal child.

PSYCHOLOGICAL FACTORS

Psychological Changes

Diabetes is affecting not only the blood sugar levels but also psychology of the patients. This may include sudden mood changes, emotional distress, anxiety, depression, confusion, etc. These mood changes will have an impact on a person’s social and personal life.

Effects on Quality of Life

Diabetes impacts on personal, social, the working life of the people and may affects the quality of life of the patients. Daily blood sugar monitoring, insulin injections, restrictions of physical activities, diet restrictions may lead to frustration after a long time. Although, its opposite is true. A healthy diet, regular physical exercise may improve emotional and mental health.

Sometimes family and friends also struggle to understand mood swings. However, education and knowledge of diabetes to family members and their support helps to get rid of the situations.

Diabetes and Mood Swings

Mood swings due to diabetes are very common. Fluctuations in blood sugar have an impact on the mood and mental status of the patients. Low blood sugar levels cause confusion, irritation, anger and aggression whereas high blood sugar levels may cause nervousness, tiredness and low energy, difficulty in thinking. Moreover, diabetes-related poor mental health may lead to depression and emotional distress.

Depression

People with diabetes have a three times higher chance to be affected by depression when compared to normal people. Depression is a condition in which people feel sadness and loss of interest in activities which were once enjoyable. Diabetes and depression is a vicious cycle. Daily blood sugar checks, insulin injections, restrictions in diet and may make you loose interest in managing diabetes well. When people fail to manage diabetes they again experience depression and a fear of complications.

Individuals may be depressed if for more than two weeks they:

• Are feeling sad for most time in a day or have lost interest in activities which were once enjoyable
• Have experienced symptoms in at least three of the following four categories: Stopped going out, not getting things done at work, withdrawn from family and friends, relied on alcohol and sedatives or are unable to concentrate.

Emotional Distress

Diabetes-associated emotional distress will gradually lead to depression. Emotional distress can be identified as feeling discouraged, worried, frustrated or tired of dealing with the self-management of daily diabetes care.

Due to this behavior people often do unhealthy eating, stop checking blood sugar levels, stop visiting doctor, stop taking medicines and feel angry about living with diabetes. This may lead to the risk of diabetes complications. Emotional distress may look like depression but doctors can differentiate it and help to manage the same.

Improving Quality of Life Tips

• Maintaining healthy diet: Eating healthy food with regular portions at a fixed time may help to maintain blood sugar levels
• Regular physical exercise: Regular physical activity can help to increase mood, reduce blood sugar levels and manage healthy weight
• Taking medicines regularly: Taking medicines at the same time every day help to maintain sugar levels in the ideal range defined by doctors. This will also help in elevating mood
• Have better understanding: Understand diabetes and your conditions. This understanding helps you to make informed decisions in managing diabetes well
• Have realistic diabetes management goals: Set goals that are achievable such as eating vegetables 2 or 3 days a week, drinking plenty of water, walking at least 10 minutes on alternate days, etc. Small achievable goals will promote a sense of well-being
• Adapt diabetes and lifestyle changes: Studies show that adapt to diabetes-related lifestyle changes and remaining attentive to negative thoughts will help in managing blood sugar levels. For instance, an increase in sugar levels make you angry or anxious. Be attentive and not ignoring negative feelings will help to maintain emotional well-being
• Create a strong social network: People who seek support from family and friends have healthy blood sugar levels. To communication with friends and family helps you to better to live with diabetes
• Try new things: Everybody gets bored with monotonous life. Trying new things will elevate mood. For example try new healthy recipes, new sports, etc., after discussing with the doctor.

Social and Family Support in Diabetes

Diabetes is a chronic disease and requires dedication, commitment and attentiveness to manage. Adherence to treatment, diet and regular exercise for the long-term is a part of self-management of disease. This self-management is complex and certainly seeks the support of family and friends.

The major portion of diabetes management is at home, in the presence of family members and friends. Their support, care and motivation influence a person’s mindset in adopting a healthy lifestyle such as a healthy diet, regular exercise as well as medicines and blood sugar testing. This support may lead to improved self-management of disease and better health outcomes. Learning blood sugar monitoring and how to control it is a slow process and adaptation to a diabetes lifestyle change requires a lot of effort. Family members can provide encouragement in managing diabetes in every phase.

It is equally important to educate family members about diabetes as they may also be impacted. Family members can support a healthy diet. A diabetic person does not require special food but a healthy and low carbohydrate diet which also beneficial to normal people to live a healthy life.

Friends and family can support by joining the individual for regular exercise in the gym or walking. They should be educated that regular physical exercise can help in reducing blood sugar levels and prevent further complications related to diabetes. If they understand the importance of lifestyle modification for healthy living, they will selflessly help and support the patient.

Sometimes just talking with family members about what is bothering in the management of diabetes can help with the emotional quotient and well-being of the patient. Family members can provide some practical assistance which is helpful in managing diabetes.

Impact of Social Support for Diabetic People

Many studies have suggested the positive impact of social support in diabetes management. The impact of social support on diabetic people is as follows:

• Support from family and friends can help in improving self-care ability to manage diabetes and thereby improving the adherence to medicines and a healthy lifestyle
• In developing countries like India, the family provides economic support and improves well-being of the patients
• Diabetic people have a higher chance to get affected by depression and other psychological disorders. Emotional support of family will ensure better and healthy life with diabetes
• Family members, especially spouses can support in adapting habits of self-management of disease and plan healthy routine and realistic goals to manage diabetes
• Fluctuating blood sugar levels can greatly affect the mood of diabetic people. By educating the family about the disease effects can help in better management of the disease
• Empathy from the family shows great support in alleviating the burden as much as possible with respect to diabetes complications such as diabetic foot and disability
• Knowledge of certain symptoms of diabetes emergency such as hypoglycemia, diabetic ketoacidosis, etc., in the family members can prove life-saving for the patients
• Some early signs of diabetes complications such as foot injury/ulcer, skin rashes, etc., will help to prevent deteriorating disease.

Support to Children and Elderly People

Diabetes in children requires entire support by the family to manage the disease such as in blood sugar testing, monitoring, insulin injection administration, diet and exercise. The support from family also helps the children to learn self-management of the disease and take care of diabetes on their own.

Diabetes is more common in elderly people. They can monitor blood sugar levels or take insulin injections on their own but sometimes may not have awareness to notice sudden low or high blood sugar levels. The family member can identify it by knowing the signs and symptoms and manage them accordingly. They can also help in remembering doctor’s appointments.

The most important part of diabetes is improving the quality of life. This can be better achieved with the support of friends and family. Together with loved ones you can make diabetes a part of life and not feel it like burden.

Coping up with Diabetes

Diabetes is a lifelong disease and managing it is a full-time job. Patients always find different ways to manage their conditions and thus copping with diabetes is also a lifelong process. Furthermore, the patient has to cope up with the outcome of the disease which arises usually from the complications. The disease outcomes are measured by HbA1c, symptom severity, bodyweight and functional status.

Strategies to develop coping with diabetes includes two major types:

• Complication coping
• Emotional coping

Complication-related coping includes poor blood sugar control possibly due to abandoning following a healthy diet, exercise medicines as well as blood sugar testing. This situation may arise due to neglecting the disease severity subject to the lack of knowledge and education. Complication-related coping can be resolved by medical interventions such as visiting the doctor, changing therapy and/or dose of medicines, telling the patient  regarding the importance of diabetes education by discussing dietary plans and exercise schedules to managing diabetes with the patients. Educating better self-care in diabetes management and weight management helps in achieving the well-being of the patients and thereby better coping with diabetes.

Emotional coping includes the behavior of patients towards diabetes. In other words, emotional coping is how patients perceive negative emotions of diabetes and lack of motivation in controlling diabetes. Developing a strategy for emotional coping includes motivating a person in every step towards managing diabetes. The main focus is to reduce psychological problems such as emotional distress and depression which ultimately leads to better self-care and achieve improvement in blood sugar control. In children and adolescents, the emotional coping strategy helps in reducing frustration and improves metabolic control and health outcomes.

Coping Skill Training

To develop coping training, assessment of a patient’s behavior is a must. Assessment can be done by asking relative questions to the patients such as how they respond to certain difficult situations in managing diabetes or how they deal with the problems in managing diabetes. By doing this, the doctor can easily decide and develop a strategy to manage diabetes.

Furthermore, education plays an important role in coping with diabetes. Coping skills training is based on providing education based on making simple and healthy changes in the routine life of the patient.

Coping skills are mainly considered to communicate effectively and face the problem that you have diabetes in front of people, remove the fear of what other people think of you, behavioral training, developing positive thinking, etc. Following are the strategies that are useful in coping with diabetes:

• Observe yourself closely and think thoroughly regarding the problem and find the solution by yourself or take anyone’s help. For example, if weight is a concern in managing diabetes, then take the help of a dietician and switch to a healthy diet and do regular exercise
• Learn to communicate well to express yourself. Sometimes people cannot explain what they are going through and therefore cannot get correct guidance to manage diabetes. This may be due to the fear to accept diabetes in a public place. For example in the case of adolescents, they may fear to test blood sugar levels in front of their friends. They may feel ashamed, and hence, have difficulty in managing diabetes. The solution to this problem is to face it once and asking the help of your friend to test your sugar levels will definitely help to overcome the situation
• There are certain situations where we tend to overeat such as in a family gathering or party with friends and disturb blood sugar levels. You can opt for healthy options in restaurants and enjoy yourself with friends and family
• There are certain things you cannot do with diabetes. Know your limitations and always develop assertive communication. For example, limit yourself from eating unhealthy, strenuous work or adventure with friends
• Recognize your thoughts or feelings and identify the reflexes in responding to certain problems will be helpful in self-care of diabetes. You can write down the problem and your immediate reflexes and discuss it with your treating doctor, friends or family members. This will help to change your behavior in negative situations, for example, children and adolescents are afraid of hypoglycemia, hence they tend to avoid playing with friends or participating in sports at school. By providing education on how hypoglycemia arises and how to appropriately manage it can allow them to participate in sports and maintain blood sugar levels along side developing social skills.

To sum up, diabetes is a chronic disease and at times, it is difficult to deal with daily life situations. Learning to identify, evaluate and develop the coping skills to live with diabetes will successfully help in improving the quality of life of the people.

Stress-associated Lifestyle Changes

Managing diabetes for newly diagnosed people causes stress such as what to eat, monitoring blood sugar, regular medicines or insulin, lifestyle modification, etc. Changing lifestyles is a big challenge for diabetic people. It is even more difficult and frustrating for people having type 1 diabetes. The stress and chronic disease like diabetes are linked together. Stress related to diabetes is mainly two types; mental and physical stress.

People with diabetes may become overwhelmed. Despite lifestyle modifications and following the instructions of the doctor, managing diabetes may be difficult. Due to which people tend to get mental stress and may experience uncontrolled blood sugar levels. Physical stress is due to sickness or injury. Any physical stress may cause high blood sugar or low blood sugar levels.

Stress and Diabetes

Stress also disturbs the hormone (epinephrine and cortisol) levels. These hormones cause the liver to produce more glucose and thereby raise the levels of sugar in the blood.

Many studies show that people who have diabetes are under stressed and have poor blood sugar control. Continuous stress and anxiety causes conditions known as ‘diabetes burnout’ in which diabetic people start to ignore diabetes completely and adopt unhealthy lifestyles such as eating junk food, drinking alcohol, smoking, etc.

Stress leads to altered mental and psychological conditions and mainly causes raise blood sugar levels in type 2 diabetes and reduce blood sugar levels in type 1 diabetes.

Lifestyle Changes in Diabetes and Stress

• • • Manage stress: Having a daily routine such as blood sugar monitoring, dietary management, exercise, insulin injection and medicines may often lead to stress. Children and adolescents have the stress of study along with the stress due to diabetes, whereas adults have career and job-related stress
    • Start doing the things of your interest like playing favorite sport, learn to play your favorite musical instrument, take a walk with your partner, meditate and/or perform breathing exercises. These all activities make you feel relaxed and reduce stress
    • Take help of doctors: Timely diagnosis of diabetes complications may help in improving the prognosis of the disease. Regular visits of ophthalmologists, heart doctor and diabetes doctor helps to maintain the well-being of a patient. Ask your doctor about any problems that cause stress in managing diabetes
    • Family support: Spending time with friends and family is a great way to feel relaxed and reduce stress. Adapt a good social life by living with friends and family is always helpful in getting rid of emotional distress
    • There are many online support groups for diabetes people, you may join any diabetes group on social media such as WhatsApp or Facebook and share your experiences and learn from the experiences of others as well
    • Always share your problems in managing diabetes with friends and family and seek their help
    • Self-care when stressed out: Stick to the diabetes management plan. Take enough sleep to relax your mind which helps in coping up with stress related to diabetes
    • Try involving in any social activities to help people. Helping others make you feel good and relaxed
    • Practice yoga and mindfulness meditations to reduce stress and improve mental health
    • Take short breaks from the routine schedule. Travel to someplace to relax
    • Anger management: Stress levels are too high while you are angry. Find out what makes you angry and take care not to get angry. Take a deep breath, lie down and drink water to divert your mind from the situations.

INSULIN AND OTHER TREATMENT

Role of Insulin

Insulin Mechanism

In normal humans, after eating, carbohydrate breaks down into glucose and enters into the blood. The pancreas responds to the amount of glucose in the blood and starts producing insulin, which allows glucose molecules to enter into the body’s cells and produce energy.

When insulin levels are high, excess glucose is converted into glycogen and stored in the liver. When insulin levels go down, the liver releases glycogen in the form of glucose to keep the blood sugar levels within the normal range.

Need to Prescribe Insulin

People with type 1 diabetes cannot produce insulin on their own and they need insulin to be administered from outside for survival. People with type 2 diabetes cannot utilize insulin properly and in some cases, insulin is abandoned even through a healthy diet, regular exercise and following medical therapy. In such cases, patients require insulin for their survival.

How to start insulin?

Insulin dose can be changed based on blood sugar levels. Thus, it is important to record blood sugar levels and insulin dose. It takes some days to fix the insulin dose. The doctor will give the minimum amount of insulin based on your conditions and blood sugar levels. Based on the record of blood sugar levels and insulin dose taken by the patient, the doctor will fix the insulin dose depending on the target range or desired range of blood sugar that may vary from patient-to-patient.

Along with insulin, counting carbohydrate in each meal is important, and therefore insulin dose changes on a day-to-day and meal-to-meal basis.

Types of Insulin

Insulin is classified based on its onset of effect (how quickly it acts) and duration of effect (how long it controls the blood sugar levels). There are several factors to be considered to determine the type of insulin that suits the patients. These factors are type of diabetes, patient’s lifestyle, blood sugar levels and fluctuations in blood sugar levels in a day. The types of insulin are discussed below.

Long-acting Insulin

As the name suggests, the effect of long-acting insulin remains throughout the day. Long-acting insulin has consistent activity throughout the day. The examples of long-acting insulin are:

• Lantus (glargine insulin): Release of insulin is steady with no peak effect. Its effect can last up to 24 hours. It is usually injected once a day but can be taken twice-daily
• Toujeo (glargine insulin): Toujeo has the strength of 300 units/mL, so is three times the concentration. It is given once a day and lasts for at least 24 hours. It should not be confused with regular Lantus which has a strength of 100 units/mL. Toujeo is given for safety by a disposable pen only. Toujeo gives a slower, steadier glucose profile, especially during the night
• Levemir® (detemir insulin): Release of insulin is steady with no peak effect. Its effect can last up to 18 hours. It is usually injected twice-daily
• Basaglar (insulin glargine biosimilar): Release of insulin is steady with no peak effect. Its effect can last up to 24 hours. Its effect starts in 1.5 hours after administration
• Tresiba (degludec): Release of insulin is steady with no peak effect. Its effect can last up to 42 hours. Its effect starts in 1.5 hours after administration.

Intermediate-acting Insulin

Intermediate-acting and long-acting insulin are also called background or basal insulins. Intermediate-acting insulin has a cloudy appearance and it has to be mixed well before administration. This insulin starts its action within 60–90 minutes after injection. It has the peak action in 12 hours and its effect lasts for 16–24 hours. Protamine in intermediate-acting insulin is a type of protein that slows the action of this insulin.

The examples of intermediate-acting insulin are:

• Humulin® NPH (human isophane insulin): It starts its effect in 1–3 hours after injection with peak effect at 5–8 hours. It remains in the body to show its effect for up to 18 hours.

Short-acting Insulin

Short-acting insulin starts its effect within 30 minutes. Thus, it is to be taken 30 minutes before a meal. Its peak effect is within 2–3 hours after administration and its effect can last up to 3–6 hours. Short-acting insulins currently available are:

• Humulin R, Novolin®ge Toronto (insulin regular): It starts its effect 30 minutes after injection. Peak effect observed in 2–3 hours and the effect lasts for 6.5 hours
• Entuzity (insulin regular): It starts its effect 15 minutes after injection. Peak effect observed in 4–8 hours and its effect lasts for up to 17–24 hours.

Rapid-acting Insulin

A rapid-acting insulin is useful in preventing blood sugar spikes after a meal. It starts its effect in 3–20 minutes after injection. Peak effect observed in 1–3 hours and its effect lasts for up to 5 hours.

This type of insulin acts as body’s natural insulin to initiate its action. It minimizes the side effect of blood sugar spikes after a meal. The caution to be taken is that you should take a meal immediately after rapid-acting insulin injection.

The examples of rapid-acting insulin are:

• Fiasp (faster-acting insulin aspart): It starts its effect in 4 minutes after injection. Peak effect observed in 0.5–1.5 hours and its effect lasts for up to 3–5 hours
• Humalog (insulin lispro): It starts its effect in 10–15 minutes after injection. Peak effect observed in 1–2 hours and its effect lasts for up to 3–4.75 hours.
• NovoRapid (insulin aspart): It starts its effect in 9–20 minutes after injection. Peak effect observed in 1–1.5 hours and effect lasts up to 3–5 hours
• Apidra (insulin glulisine): It starts its effect in 10–15 minutes after injection. Peak effect observed in 1–1.5 hours and its effect lasts for up to 3.5–5 hours.

Although these insulins are long-acting, they are clear and do not need mixing before injecting

If you need to start using insulin, your doctor or diabetes nurse educator can help with education and support. They will teach you about:

• the type and action of your insulin
• how, where and when to inject insulin
• how to rotate injection sites
• where to get your insulin and how to store it safely
• how to manage low blood glucose
• how to keep a record of your blood glucose levels and insulin doses
• who will help you to adjust insulin doses?

Mixed Insulin

Mixed insulin contains a pre-mixed combination of either rapid-acting or short-acting insulin, together with intermediate-acting insulin. This eliminates the need to draw insulin from more than one bottle. The examples of pre-mixed insulin are:

• Rapid-acting and intermediate-acting insulin
  • Ryzodeg 70:30 (70% long acting Degludec, 30% rapid Aspart)
  • NovoMix® 30 (30% rapid, 70% intermediate Protaphane)
  • Humalog® Mix 25 (25% rapid, 75% intermediate Humulin NPH)
  • Humalog® Mix 50 (50% rapid, 50% intermediate Humulin NPH)
• Short-acting and intermediate-acting insulin
  • Mixtard® 30/70 (30% short, 70% intermediate Protaphane)
  • Mixtard® 50/50 (50% short, 50% intermediate Protaphane)
  • Humulin® 30/70 (30% short, 70% intermediate Humulin NPH).

Insulin Administration

Most of the people administer insulin by themselves only. Syringe denotes the amount of insulin in the needle. The doctor will help to choose the ideal needle and syringe based on the insulin dose to be taken. A shorter needle gives a shallow injection of insulin and a longer time for insulin to show its effect. The doctor will help to find the right needle and syringe combination.

Nowadays, the administration of insulin has become very easy with the use insulin pens. Insulin pens are disposable or reusable. Disposable insulin pens have insulin cartridges and pens. It is discarded after the cartridge is empty. Reusable insulin pens have a removable cartridge or prefilled syringe. When this cartridge or prefilled syringe is finished, a new one is inserted. The insulin pen has a disposable needle that has to be changed after every use. Dose adjustment of insulin is available on pen devices.

Insulin Pumps

An insulin pump is a programmed device that has an insulin reservoir which remains outside and then the insulin is injected through the cannula and a thin plastic tube. The cannula is to be inserted in the fatty tissue just below the skin. This has to be changed every 2–3 days. Only rapid-acting insulin can be used in an insulin pump.

The pump is pre-programmed to deliver a small amount of insulin to keep blood sugar levels stable. You can also give an insulin dose through pump yourself after a meal. Another type of pump has no tubes and attaches directly to your skin, such as a self-adhesive pod.

A jet injection device is a good option to inject insulin without a needle. After placing over your skin, press the button and a measured amount of insulin is administered.

Inhalable insulin comes in the premeasured inhaler. In an inhaler, short-acting insulin can be used. It should not be used in people with lung diseases such as asthma, COPD (Chronic Obstructive Pulmonary Disease) and smoking.

Insulin Storage

Insulin syringe and Insulin pen once opened should be stored at room temperature only. Extra insulin pens or syringes should be stored in a refrigerator 2^oC – 8^oC. Do not expose insulin to excessive heat or cold or direct sunlight. Keep insulin in insulated carry bags during travelling.

Insulin Injection Site

Insulin should be administered through the skin in fatty tissue (subcutaneously) in fatty layers of the body such as the abdomen, upper arms, thigh and buttocks. Insulin absorption also depends on the site of administration. For instance, insulin absorption is faster from the abdomen. Absorption is slower when injected into the thigh, buttocks and upper arms.

Factors Affecting Insulin Absorption

• Insulin absorption is increased by injecting into an exercised area like thighs or arms
• Insulin absorption increases in high temperatures such as due to a hot shower, bath, hot water bottle, spa or sauna
• Insulin absorption increases by massaging the area around the injection site
• Insulin absorption is increased by injecting into muscle – this causes the insulin to be absorbed more quickly and could cause blood glucose levels to drop too low
• Insulin absorption can be delayed by overuse of the same injection site, which causes the area under the skin to become lumpy or scarred (known as lipohypertrophy).
• Insulin absorption can be delayed by insulin that is cold (for example, if insulin is injected immediately after taking it from the fridge).
• Insulin absorption can be delayed in case of cigarette smoking.

Disposal of Used Insulin Syringes

Used syringes, disposable pens, needles, cannulas and lancets must be disposed off in puncture-proof containers as per government regulations.

ROLE OF MEDICINES

Diabetes Medications

Type 2 diabetes can be managed by medicines which include the following:

Metformin

Metformin is generally the first medication prescribed for type 2 diabetes. It works primarily by lowering glucose production in the liver and improves insulin sensitivity so that cells of the body can utilize insulin more effectively. Metformin can also be combined with other drugs for type 2 diabetes.

Some people experience B-12 deficiency and may need to take supplements.

Possible side effects:

• Nausea
• Abdominal pain
• Bloating
• Diarrhea.

Sulfonylureas

Sulfonylureas work by stimulating the pancreas to secrete more insulin. Examples include glyburide, glipizide and glimepiride.

Possible side effects include:

• Low blood sugar
• Weight gain.

Alpha-glucosidase Inhibitors

These medicines help to break down starchy foods and sugar as well as reducing glucose absorption in the small intestine. They also block some enzymes to slow down the digestion of starches and lowers blood sugar levels. Alpha-glucosidase inhibitors should be taken before meals.

Examples include acarbose and miglitol. Possible side effects include:

• Stomach upset
• Bloating and gas
• Diarrhea
• Nausea
• Cramps.

Glinides

Glinides helps the pancreas to secrete more insulin. They act faster than sulfonylureas, and the duration of their effect in the body is shorter. Examples include repaglinide and nateglinide.

Possible side effects include:

• Hypoglycemia
• Weight gain.

Thiazolidinediones

Thiazolidinediones increase the sensitivity of the body’s tissues to utilize insulin. Examples include rosiglitazone and pioglitazone.

Thiazolidinediones help to reduce glucose in your liver. They also help fat cells to use insulin better.

Possible side effects include:

• Risk of congestive heart failure (do not use if you have heart disease)
• Risk of bladder cancer (pioglitazone)
• Risk of bone fractures
• High cholesterol (rosiglitazone)
• Weight gain.

Dipeptidyl Peptidase-4 Inhibitors

Dipeptidyl peptidase-4 (DPP-4) inhibitors help the pancreas to release more insulin after meals. These drugs can also help the pancreas make more insulin. They lower the amount of glucose released by the liver. They work by reducing blood sugar without causing hypoglycemia (low blood sugar).

Examples include sitagliptin (Januvia), saxagliptin (Onglyza) and linagliptin (Tradjenta).

Possible side effects include:

• Risk of pancreatitis
• Joint pain.

Glucagon-like Peptide 1 Agonists

Glucagon-like peptide 1 (GLP-1) receptor agonists are injectable medicines that slow down digestion and help lower blood sugar levels. These drugs are similar to the natural hormone called incretin. They increase β-cell growth and thereby increase insulin secretion. They decrease your appetite and reduce the use of glucagon. They also slow stomach emptying. These are all important actions for people with diabetes.

Their use is often associated with weight loss, and some may reduce the risk of heart attack and stroke. The American Diabetes Association (ADA) recommends certain GLP-1 agonists in atherosclerotic cardiovascular disease, heart failure or chronic kidney diseases are predominant along with diabetes.

Examples include exenatide (Byetta, Bydureon), liraglutide (Saxenda, Victoza) and semaglutide (Rybelsus, Ozempic).

Possible side effects include:

• Risk of pancreatitis
• Nausea
• Vomiting
• Diarrhea.

Sodium-glucose Cotransporter-2 Inhibitors

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors increase the removal of glucose through the kidney by affecting the blood-filtering functions and inhibiting the return of glucose to the bloodstream. Therefore, as a result there is more amount of glucose excreted through urine. These drugs may reduce the risk of heart attack and stroke in people with a high risk of these conditions.

The American Diabetes Association (ADA) recommends certain GLP-1 agonists in atherosclerotic cardiovascular disease, heart failure, or chronic kidney diseases are predominant along with diabetes.

Examples include canagliflozin (Invokana), dapagliflozin (Farxiga) and empagliflozin (Jardiance).

Possible side effects include:

• Risk of amputation (canagliflozin)
• Risk of bone fractures (canagliflozin)
• Risk of gangrene
• Vaginal yeast infections
• Urinary tract infections
• Low blood pressure
• High cholesterol.

NEWER TOOLS

Smart Insulin Pens

Smart insulin pen offers an insulin pen with a smartphone application that can keep the track of insulin dose and timings. This smart device provides reminders, alerts and reports as well. This device is connected via Bluetooth to a smartphone. Some smart insulin pens offer the additional benefit of fine-tuning the insulin dose.

This feature is an add-on to the normal insulin pens which uses a prefilled cartridge. Smart pens have the advantage of ease of use, affordability and offer many benefits to people who depend on insulin. Following are the characteristic features of a smart insulin pen:

• It automatically calculates insulin dose based on current blood sugar levels, carbohydrate amount in a meal, active insulin from the previous dos and other settings as prescribed by doctors
• It has an alert for dose timings to prevent missing doses
• Calculates the amount of insulin dose based on blood sugar levels
• Deliver accurate half-unit doses
• Sends notification when insulin storage temperature exceeds normal temperature and also insulin expiry
• Records and share monitoring data to doctors whenever required
• Compatible with any smartphone to track the disease results.

Some smart pens come with dose calculator therapy modes that calculate insulin dose based on meal size and timings. This avoids the counting of carbohydrates in each meal. A smart pen gives many benefits of an insulin pump with affordable cost and inconvenience of device attached to the body.

Smart insulin pen device is easy to use. Once you download the application and it is paired with your device, you can download real-time data for blood sugar levels and insulin dose.

Continuous Glucose Monitors

Continuous glucose monitor (CGM) has tiny sensors which reach below the surface of the skin. These sensors measure the glucose in the fluid between the cells (extrastriatal fluids) every few minutes and transmits the data wirelessly to a device or smartphone.

It avoids puncturing fingers to measure blood sugar levels as well as the associated pain. CGM monitors blood sugar levels at set time intervals i.e., every 5 minutes. This can help the doctor to identify the sugar levels pattern throughout the day and how meals or any food affects blood sugar levels. This in turn helps to optimize the treatment plan. It also sends alert in case of blood sugar levels is too high or too low.

Furthermore, it is useful to monitor blood sugar levels effectively, especially to a patient with hypoglycemia unawareness. Even though blood sugar levels are under control, it has the advantage of finger prick elimination.

Continuous Glucose Monitor Connected with Insulin Pump

A newer combination of CGM connected with an insulin pump has an advantage of insulin injection based on blood sugar levels. This device is programmed to deliver basal insulin (continuous) or rapid-acting insulin dose after a meal as close as the natural release of insulin.

The insulin pump will incorporate blood sugar levels from CGM and adjust the appropriate amount of insulin dose on its own. This gives an alert on low blood sugar levels or high blood sugar levels and releases the necessary dose of insulin and keeps you worry-free. This is very much helpful in case of some strenuous activity or playing sports. Moreover, several options are available in the market. Choose the one which suits your lifestyle and budget.

Diabetes Smartphone Applications

Diabetes smartphone applications can track blood sugar levels and show the daily trend of blood sugar levels, monitor diet and suggest recipes, physical exercise and suggest to connect with diabetic people and diabetic educators as well. You should monitor blood sugar levels and modify diet and/or exercise after consultation with your doctor only. As a need for diet, exercise may vary from person-to-person.

Lasers for Needles to Monitor Blood Glucose

A non-invasive device that can measure blood sugar levels without any prick. This device measures blood sugar levels with the help of a laser on a person’s skin and by using the spectroscopic technique (a technique that measures various particles reacting with light) to measure blood sugar levels. This device requires more research to make it portable and convenient to use.

Artificial Pancreas

The artificial pancreas is a step ahead of CGM connected with an insulin pump. In CGM connected with an insulin pump, a manual insulin dose is required during mealtime. The artificial pancreas makes a person free from this daily task.

The artificial pancreas is a single device that monitors blood sugar levels every 5 minutes and provides a combination of insulin and glucagon automatically throughout the day and night and releases the correct amount of insulin. This system can be monitored by a doctor as well as patients.

This provides quite a peaceful and stress-free life to diabetic individuals, especially children and adolescents. This artificial pancreas was approved by the Food and Drug Administration (FDA) in the year 2016 and is now available in the market.

Pancreatic Islet Transplantation

This is an experimental treatment and researchers are still studying pancreatic islet transplantation. This treatment is mainly designed for type 1 diabetes patients. In type 1 diabetes, pancreatic islets are destroyed by the body’s antibodies. The pancreatic islet transplant procedure takes the pancreatic islet from the donor and replaces it with that of the patient. This procedure is under research and available only to those who enroll in the study.

Bariatric Surgery

Bariatric surgery is a weight loss surgery and is preferably performed on a severely obese person. This surgery can help a type 2 diabetic to lose excess weight and control blood sugar levels. Moreover some people with diabetes will no longer require diabetes treatment after bariatric surgery. The outcome of this surgery on diabetes may vary from person-to-person, type of bariatric surgery and amount of weight a person has to loose. Researchers are still studying the long-term outcomes of bariatric surgery in people with diabetes.

 

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[i] Cho, N. H. et al. IDF Diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res. Clin. Pract. 138, 271–281 (2018).

[ii] International Diabetes Federation (ed) (2019) IDF Diabetes Atlas, 9th edn. International Diabetes Federation, Brussels, Belgium.

[iii] Subramani SK, Yadav D, Mishra M, Pakkirisamy U, Mathiyalagen P, Prasad G. Prevalence of Type 2 Diabetes and Prediabetes in the Gwalior-Chambal Region of Central India. Int J Environ Res Public Health:2019;16(23):4708. Published 2019 Nov 26.