Diabetes Mellitus is a disease that is endemic in India. What was previously a disease of the developed world has made its way through small towns and villages of our country. This can be attributed to improved standards of living, access to food coupled with changes in lifestyle in terms choice of food/physical activities as we have become more developed.

Diabetes Mellitus is defined as a fasting glucose level of ≥126 mg/dl, random glucose of ≥200mg/dl or hba1c of ≥6.5. Prediabetes is defined as fasting glucose 100-125mg/dl or hba1c of 5.7 to 6.4. The constant presence of high glucose levels leads to inflammation and thus induces changes in blood vessels both large and microscopic ones. This predisposes to heart attacks, strokes, circulatory problems in legs, kidney, neuropathy and retinal complications. These complications of diabetes start at prediabetic stage.

It is hence important to prevent diabetes by identification of prediabetes also and start aggressive lifestyle changes. Hence, the diagnosis of prediabetes is a very important one, although it is ignored by patients/medical practitioners alike. Women with gestational diabetes and PCOS are at increased risk of developing diabetes. We Indians have abdominal obesity more than generalized obesity, Hence BMI is a poor marker for cardiovascular risk, instead abdominal girth is better measure of the risk.

What should I do to prevent diabetes mellitus?

1. Reduce carbohydrates (rice, roti, bread, poha, sabudana/seviya, dosa/idli), diary, non-vegetarian foods (since they are calorie-rich even in smaller quantities), oily foods and concentrated sweets.
2. Substitute the above with fiber-rich foods, fruits and vegetables that are low in calories, Consider using healthier grains such as millets, unpolished dhals and grains. Increase vegetarian sources of protein/egg whites, nuts/dry fruits.
3. Quantity of food is just as important as quality of food.
4. Disciplined exercise regimen/cardio and strength training.
5. All these changes should result in decreased abdominal fat and/or overall weight.
6. Regularly get blood tests for diabetes/prediabetes/cholesterol levels, quit smoking and get your blood pressure controlled.
7. Avoid fad diets unless you can make that a long standing change

What should I do once I have diabetes mellitus?

1. All lifestyle changes as mentioned above, except for elimination of most fruits from your diet.
2. Check HBa1c thrice a year and do home monitoring with a glucometer at least a few days/week. Get your medications changed so as to achieve HBa1c levels of 6-7. For people on insulin or frail elderly a slightly higher hba1c may be acceptable.
3. Do not be afraid to use medications, including insulin if lifestyle changes are insufficient. Ultimately all these will reduce your risk of complications of diabetes. Do not fall prey to certain myths about diabetic medications.
4. See an ophthalmologist yearly.

Dr. Indira Kedlaya
Senior Consultant – Internal Medicine
Columbia Asia Hospital
Whitefield, Bengaluru

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Gestational diabetes mellitus is a condition that as many as 9% of pregnant women develop. It increases the risk of issues during pregnancy and delivery. During your pregnancy, your cells have a bit more insulin resistance. This results in an increase in the amount of sugar or glucose in your blood. This additional glucose helps in making more nutrients for your baby.

However, if your cells get too insulin resistant, it can result in your blood sugar level becoming too high. This can be problematic for you as well as your growing baby. Some factors make you more likely to develop gestational diabetes during pregnancy, so it is not always possible to prevent it. However, a pregnant woman can take certain steps to reduce the risk of developing the condition.

Gestational diabetes may harm both the fetus and woman. The possible effects are:

• Increased blood pressure
• An increased risk of preeclampsia
• A higher risk of the woman having type 2 diabetes in future
• Premature birth
• Higher birthweight
• Low levels of blood sugar for the baby at birth

Preventing gestational diabetes

While gestational diabetes isn’t always avoidable, women can take a few steps to reduce their risk of developing the condition.

1. Having a healthy weight when trying for pregnancy

If you want to have a healthy pregnancy, you should look to exercise regularly. If you are looking to conceive, you should try to make lifestyle choices that can help you reach a healthy weight and maintain it before you get pregnant. Studies have shown that one of the most significant risk factors for gestational diabetes is being overweight.

Research has confirmed that a woman whose BMI is higher than 25 is more likely to develop gestational diabetes when she gets pregnant. However, this risk can be reduced by making the necessary dietary changes. If you are looking to lose weight, you should modify your diet by taking steps like:

• Eating smaller portions of food
• Avoiding junk food and packaged food
• Preventing candy and preferring fruit
• Consuming more lean protein, like tofu and fish, which helps in staying fuller for longer.
• Eating plenty of whole grains and vegetables to increase fiber intake
• Avoiding sodas, juices, and coffee drinks with high dairy content and replacing them with black coffee, herbal tea, or sparkling water with lime or lemon slices.

2. Exercising

Exercise is an important aspect of healthy weight maintenance. Exercising can help prevent gestational diabetes, both during and before pregnancy. When you exercise, your body becomes more sensitive to the insulin created by your pancreas, which helps in regulating blood sugar levels.

You should try to become more active even before you get pregnant. It might simply mean making certain long-term lifestyle choices. If you have more of a sedentary lifestyle, you can take measures like:

• Cycle or walk to work
• Park your car some distance away from your destination and walk the rest of the way
• Take the stairs instead of elevators
• Perform leisure activities like gardening, hiking, or playing outdoors with children.
• Try out yoga. It would be a good idea to join a class particularly meant for beginners or pregnant woman
• Performing low impact exercises like swimming
• Join a running club to maintain your motivation.

If you want to avoid gestational diabetes, it is recommended to do around 30 minutes of exercising with moderate intensity for 4-5 days every week. Maintain an intensity that causes you to break a sweat. Good options for cardio exercises include walking, stationary biking, using elliptical machines, and swimming. For pregnant women, it is important to discuss with a doctor about their exercise regimen and get to know about the exercises that are safe for each stage of their pregnancy.

3. Eating right when you are pregnant

Having a nutritious diet when you are pregnant can be particularly challenging because of food aversions, morning sickness, and cravings. However, if you eat well, it ensures that you only gain healthy weight for each trimester and avoid gestational diabetes. Eating non-starchy vegetables and whole grains can help in reducing the risk of developing the condition.

Following are the healthy food choices:

• Lean proteins like beans, tofu, white poultry, and tofu
• Healthy fats from coconut oil, olive oil, nuts, and other plant-based sources of fat
• Low-fat dairy products
• Fruits
• Whole grains like brown rice, oatmeal, bread, and pasta.
• Non-starchy vegetables

Following food items should be avoided

• Processed foods
• Added or extra sugar
• Sugary beverages such as energy drinks, sodas, juices, and store-bought coffee.

Throughout your pregnancy, make sure you visit your gynecologist regularly for routine care. The doctor will ask about any symptoms and even do an ultrasound and pelvic examination. If they do notice any early indications of gestational diabetes, they will give suggestions to help you prevent it.

Dr.Poornima Ramakrishna
Consultant Obstetrics and Gynecology
Apollo Cradle & Children’s Hospital
Koramangala & Jayanagar, Bengaluru.

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Diabetes mellitus (DM), commonly referred to as diabetes, is a group of metabolic disorders in which there are high blood sugar levels over a prolonged period. Symptoms of high blood sugar include frequent urination, increased thirst, and increased hunger. It is a chronic disorder and requires lifelong management. Lifestyle modifications is the key to success of any diabetes management programme which includes regular exercise and healthy diet.

Exercise:

Exercise plays an important role in diabetes management. Exercise recommendations are tailor made and need to be individualized. A regular exercise program can delay the onset of diabetes, help in control of diabetes, prevent diabetic complications and slow the progression of complications.

Unfortunately, many patients with diabetes find that they are unable to exercise, in spite of their best intentions. This might be due to lack of space and time or for want of adequate facilities. However, most people find it difficult to exercise for want of proper guidance as to what exercise to do. Also, many diabetic patients have other complications, which may prevent them from doing all the types of exercise that a non-diabetic individual can do. Compared to antidiabetic medication, exercise has the advantage that it is inexpensive and free of side effects. It also has beneficial effects which range far beyond blood sugar control.

• It lowers blood pressure.
• It helps to correct abnormal blood lipids by raising the good(HDL) cholesterol level.
• It helps in reducing body weight.
• It strengthens the heart and circulatory system.
• It can decrease body fat and increase muscle tone.
• It relieves tension, stress and helps the patient to feel relaxed.
• It increases basal metabolic rate and helps in weight loss
• It improves sleep and the general sense of well-being

Most importantly for a diabetic individual, exercise helps to improve insulin sensitivity. This means that a patient with type 2 diabetes can get good control of blood sugar on a smaller dose of diabetes tablets or insulin if he or she exercises regularly. Like any other treatment modality, exercise also has to be tailored to the individual; what works for your neighbor need not work, or necessarily be good, for you!

Diet:

Dietary management is nothing but knowing what, how much and when to eat in order to keep stable blood glucose levels. Food contains carbohydrate, fats and proteins as source of energy, and many other important ingredients like vitamins and minerals. Each of these has different effects on blood glucose. Hence while planning a healthy diet for diabetes we have to additionally look for calorie content, check if the diet provides optimal and balanced nutrition with sufficient fibre and glycemic index.

Calorie:

Calories are the energy derived from the food with help of insulin. The per day intake of calorie/ calorie requirement depends on type of activity profile (sedentary, moderate, and heavy), age, gender, and nutritional & physiological status of the individual and it is calculated based on the patients Ideal Body Weight (IBW). The ideal body weight (IBW) is calculated by the formula:
IBW = (height in cms -100) X 0.9
The daily calorie intake will be decided and planned by your doctor and dietitian. But it is always necessary to monitor the calorie intake.

Refined Carbohydrates vs. Complex Carbohydrates:
Sugary foods (sugar, sweets, jelly jam etc), refined or processed carbohydrates (white rawa, maida etc) raises the blood glucose rapidly whereas the complex carbohydrates present in vegetables and whole grains increases the blood glucose slowly. Refined foods have a high glycemic index – they cause a sudden and sharp increase in blood sugar. If the body does not use this blood sugar, it is stored as fat. Whole grains, vegetables, and fruits have a lower glycemic index. Naturally occurring carbohydrates (like those found in whole grains, vegetables, and fruits) provide vitamins, minerals, and fiber. In addition, they usually contain fewer calories than foods with added sugar.

Fibre:

Dietary fiber is a source of carbohydrate. Fiber is found in plant-based food like fruit, vegetables, legumes, peas, brown rice, whole-grain breads and cereals. Fiber is not digested or absorbed like other starches, and so has less of an effect on increasing blood sugars, reduces cholesterol, triglycerides and lowers LDL cholesterol The recommendation is to eat 20-35 grams of fiber a day.

Protein:

Protein plays an important role in our body. It accounts for one-fifth of our total body weight. The role of protein includes –

• Builds teeth, muscles, bones, skin and blood.
• Helps with growth and helps repair our body
• Regulates body processes.
• Carries nutrients and oxygen throughout the body
• Fights disease by increasing antibodies and strengthening the immune system.
• Provides a source of energy.

The recommended protein choices are for non-vegetarians are egg white, fish, and lean chicken in moderation. High protein intake from animal sources should preferably be avoided . Vegetarians can include soya, pulses, whole grams (channa, rajmha, green gram, etc.), low fat milk, and dairy products.

Fats:

The role of fat is to

• provide energy and essential fatty acids
• Serves as a source of fat-soluble vitamins (e.g., vitamins A, D, E, and K)
• Improves texture and palatability of food.

Food sources of fat can be Visible (derived from animal fats) like butter, ghee, vegetable oil, vanaspathi or Invisible fat ( Egg, Meat, Nuts and oil seeds). Fats and oily substances like cooking oil, cream, butter and mayonnaise, do not raise blood glucose. It slows stomach emptying and decreases the rate at which blood glucose rises after a mixed meal. But it adds calories and cholesterol. Though fat is important and enhances the taste of food, it is essential to remember that they are concentrated source of calories in foods. Each gram of fat yields 9 calories (twice as many calories as protein or carbohydrates).

Glycemic index:

The Glycemic Index (GI) measures the speed at which food gets digested and converted to glucose. Carbohydrate foods which break down quickly during digestion have the highest GI and foods which break down slowly have the lowest GI . The grading of glycemic index are:

• High >70,
• Medium 56-69
• Low <55

Therefore, healthy diet and regular physical activity can bring about a reduction in HbA1c to the tune of 0.5 to 0.2%, which is equivalent to the effect of the most potent oral antidiabetic agents in the market today.

Dr. V. Mohan
Chairman and Chief of Diabetology
Dr. Mohan’s Diabetes Specialities Centre

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 Dr Shiva Prasad

It is estimated that there are around 150 million people with diabetes worldwide, now, and it’s going to reach more than 350 million by the year 2025. It has also been forecasted that India is going to be the world capital for diabetes.

Why India???? The reason being the so called villages previously are no more villages, towns are no longer towns and semi urban, no longer semi urban but minor cities and cities have become modern cities.

There’s a lot of infiltration from villages and towns towards cites for better job prospects and higher standards of living. This in turn has led to congestion in the cities. People who used to walk for purchase of groceries and vegetables are now using two – wheelers and four – wheelers and door delivery facilities, because of their improved standards of living. Also exercise, which was a part of the individual’s life style, has become absent these days, which has led to increase in obesity rates.

The numbers of IFG & IGT (Impaired Fasting Glucose and Impaired Glucose Tolerance which are known as pre – diabetic state) are increasing due to change in eating habits. People whose diet was mainly ragi, jowar, chapathi and rice has now changed to fat rich foods like pizza’s, burgers, noodles, items filled with cheese and excessive oils to cite a few. This has in turn lead to increase in the rates of obesity. It is said that obesity is the forerunner for diabetes and heart problems.

Diabetes in early stages (Pre – Diabetes, i.e., IFG & IGT) if recognized can be controlled or postponed by following strict diet control as advised by a dietitian and increased physical activity in the form of aerobic exercises like brisk walking, jogging, playing tennis, swimming, etc. (As advised by a diabetologist according to prevailing body condition). Few studies in India and abroad have shown that diet and physical exercise could reverse diabetes in its early stages.

As the standard of living of an individual improves, the stress on an individual in the office also increases to achieve the given targets in a limited time. This has also led to change in eating habits (untimely food). Few studies have shown that stress also increases diabetes irrespective of genetic inheritance, obesity and physical inactivity.

It has been a mis-belief for most of the people that an individual gets diabetes only when he/she has a strong family history of diabetes, which is no longer true. There are lots of studies to substantiate the above. With rapid urbanization and trying to ape (follow) the western culture with respect to eating habits and lifestyle, we find an increased rate of diabetics among young children (School going).

If the same trend continues then the rates of obesity and other heart diseases along with hypertension can be seen at an early age in the years to come. The reason for the above could probably be attributed to both the parents working in high profile jobs. It is assumed that such parents are not finding sufficient time to spend with their wards and are being taken care of either by grandparents or by paid Guardians. This in turn leads to excess of eating at will without supervision. Also simultaneously when the parents have time, they do lot of outings or take their children to fast food joints or pizza joints. This leads to excess calorie intake and obesity ultimately, pre – disposing them to DM at young age.

As this is a computer era, we find a lot of children sitting at home luring onto computer/ television sets. In doing so, they are getting habituated to having unhealthy snacks in-between television watching. Also their physical activity has been reduced to more than 50% when compared to children, going to school 10-15 years back. Also because of high infiltration to cities, the children do not find adequate facilities to play. This has led them to frustration and dis-interest in games, shifting their interest towards in-door entertainment, like computer games and television. By doing so, it increases the rates of obesity and diabetes in young children, virtually the future of the nation.

It is important for everyone to awake and see the threat of life threatening conditions like diabetes and its complications and to take steps to prevent and control diabetes.

The steps to be followed require self motivation and commitment for good health. The steps are as follows:

• Regular physical exercise (aerobic exercise 30 – 60 minutes) in adults as well as children,
• Try walking small distances instead of using vehicles
• Healthy dietary and timely eating habits (avoidance of high calorie and fat containing foods)
• Slit your meals instead of bulky meals.
• Restrict eating outside
• Regularly consume fruits and vegetables.
• De-stress oneself by doing yoga, meditation or playing games or taking up hobbies.
• Create health consciousnesses in oneself.

Probably all these steps would keep you away from life threatening disease like diabetes, obesity, heart attacks, etc. and improve your quality of life. This also helps you to save more on family’s economy from spending too much money and time on health before too much damage is done.

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