*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t

To keep the members ofdiabetes care team abreast with

DSME and DSMS concepts

st 1 time in India

You can contribute your articles, opinion, cases, recipes, experiences or write to us to if you want to subscribe to soft copy of IDEJ every month by sending an e-mail to:

thambu@usv.in or shashikala.b@usv.in or neeraj.bhardwaj@usv.in

Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of people with diabetes. This Journal intends to empower your clinic

support staffs for basic counselling of people with diabetes. This journal has been made in good faith with the literature available on this subject. The views and

opinions expressed in this journal of selected sections are solely those of the original contributors. Every effort is

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Hansa Medcell or USV Private Limited assumes no responsibility or liability for personal or the injury,

loss or damage that may result from suggestions or information in this book.

USV as your reliable health care partner, believes in supporting your endeavor to make India the Diabetes Care Capital of the World. We at USV believe in partnering with health care leaders through practice enhancement knowledge series.

Indian Diabetes Educator Journal (IDEJ), first of its kind in India has successfully completed 4 years and continues its endeavor of spreading awareness, knowledge and enabling health care teams in managing diabetes patients and empowering their patients for self-care. We continue to keep the members of diabetes care abreast with concepts of Diabetes Self-Management Education/Support (DSME/S). IDEJ has set a new benchmark in educating the diabetes educator about evolving the concept of DSME/S, reaching to more than 11,000 doctors with hard copies and more than 25,000 doctors and diabetes educators digitally.

India is a vast country with many religions, cultures and communities living together. The country has a plethora of festivals, rituals and cuisines, which makes it a huge problem for a diabetes patient requiring him to seek medical help to be able to stay healthy with optimal blood glucose levels during the festive season and special rituals. In this issue, we talk about different rituals, feasting and fasting during festivals and how can a health care professional help the patient in coping with the diabetes. Our cover story talks about oral health and diabetes.

We sincerely thank our contributors for making this issue delightful reading for our readers. We dedicate this journal to all the health care professionals who are working relentlessly towards making “India a Diabetes Care Capital of the World.”

Sincere Regards,

Expert Contributors of the MonthExpert Contributors of the Month

Dr Chitra Selvan

MD (Med), DM (Endo), MRCP (UK), Endo (Sce)

Assistant ProfessorEndocrinologyMS Ramaiah Hospital, Bengaluru, Karnataka

Dr NS Ramesh

Master (Diab), PGD (Diab), PGD Diab (Australia), PGC Cardio (Vivus), MBBS

Senior Consultant Diabetologist Diaplus Diabetes and Medical Center Bengaluru, Karnataka

Dr Sanjay Reddy

MBBS, MD (Gen Medicine)

Vice President, Primer Academy of Medical Sciences (PAMS); Consultant Diabetologist, Center for Diabetes and Endocrine Care, Fortis Hospital, Bengaluru, Karnataka

Dr Rajesh Agrawal

MD (Medicine), Diabetes, Thyroid, Obesity Specialist

Consultant Physician Dot Clinic, Indore, Madhya Pradesh

Dr Medha Oak

MD (Med)

Consultant Physician, Cardiologist and Diabetologist, Dr OAK Hospital, Mumbai, Maharashtra

Dr Verinder Dhar

MBBS, MD, DM (Endo)

Diabetologist at Opinder Medical Hall, Jammu, Jammu and Kashmir

DT. Devisree

BSC N&D, CDE

Dr Mohan’s Diabetes Specialities CentreChennai, Tamil Nadu

Dr Gurmeet Singh Sandhu

MD (Medicine)

Senior Consultant Diabetologist, Jabalpur Hospital and Research Centre, Jabalpur, Madhya Pradesh

Dr Sharvil Gadve

MD (Medicine), DM (Endo)

Consultant Diabetologist and Endocrinologist Excel Endocrine Centre, Kolhapur, Maharashtra

Dr Manish Agarwal

MB, MD (Medicine), PGCDM in Diabetology, FICP, FICA, FACP (USA), Diploma in Endocrinology (UK), PhD in Diabetes from European International University

Diabetologist and Metabolic Physician Medilink Hospital, Ahmedabad, Gujarat

Dr Rakesh Arora

MD (Medicine), DM (Endo)

Assistant ProfessorEndocrinology, Govt. Medical CollegeAmritsar, Punjab

DT. Shilpa Agarwal

CFN, DNHE, Post Graduation in Hospital Management and MBA in Hospital Management

Nutritionist and Research Coordinator; Director, Medilink Hospital, Ahmedabad, Gujarat

Table of Content

01

04

08

Cover Story: Diabetes and Oral Health

Dr Chitra Selvan

Navratri and Diabetes

Dr Rajesh Agrawal

11

16

13

Glycemic Control During Hindu Fasts

Dr NS Ramesh

Children, Type 1 Diabetes and Diet During Festivals

Dr Medha Oak

Dr Verinder Dhar

Managing Blood Glucose During Parsi Rituals

Dr Sanjay Reddy

21Managing Diabetes During the Fasting Months of Ramadan

Dr Rakesh Arora

28Fasting in Type 1 Diabetes

Dr Gurmeet Singh Sandhu

31Feasting vs. Fasting

DT. Devisree

34Lifestyle Modification: Exercise

40Conference Highlights

41Diabetes Quiz

42Educator Alert

36Lifestyle Modification: Diet

39Diabetes Technology Update

18Diabetes, Diet and Festivals

5 Tips to Manage Diabetes During Festivals

DT. Shilpa Agarwal

Dr Manish Agarwal

Do's and Don'ts During Diwali Festival

Dr Sharvil Gadve

26

1

COVER STORY:Diabetes and Oral Health

ExpertOpinion

Dr Chitra Selvan

MD (Med), DM (Endo), MRCP (UK), Endo (Sce)

Assistant ProfessorEndocrinology, MS Ramaiah Hospital, Bengaluru, Karnataka

Introduction

Diabetes is a common disease with concomitant oral manifestations that affect dental care. An interdisciplinary

team must be engaged to provide effective communication among diabetes expert and dentist. The dentist must be familiar with techniques to diagnose, treat and prevent dental

disorders in patients with diabetes.

Oral complications and manifestations of diabetes mellitus

Various soft tissue abnormalities in the oral cavity have been reported to be linked with

diabetes mellitus. These complications include periodontitis and gingivitis; salivary

dysfunction and taste dysfunction. Oral fungal and bacterial infections have also been reported in patients with diabetes. Other complications are oral mucosal lesions in the form

of stomatitis, geographic tongue, benign migratory glossitis, fissured tongue, traumatic ulcer, lichen plexus, lichenoid reaction and angular chelitis.

Periodontal disease has been reported with increased prevalence and severity in patients with diabetes. Various theories propose

different factors such as advanced glycation end products, changes in collagen structure and altered immune function that may cause impaired polymorphonuclear leukocyte function facilitating bacterial persistence in the tissue and the accumulation of

advanced glycation end products and increased secretion of proinflammatory cytokines such as tumor necrosis factor- and

prostaglandin contributing to continued inflammation.

Poor glycemic control is a major risk factor for gingivitis and periodontitis in diabetes patients. Various risk factors which may make patients with diabetes more susceptible to periodontal disease are poor oral hygiene, poor metabolic control, longer duration of

diabetes and patients who are smokers.

The dentist and physician both play an important role in counseling and supporting patients

with diabetes regarding smoking cessation. The dentist should be engaged in counseling patients and referring them to an expert dealing with smoking cessation.

It is reported that treatment of periodontal disease can lead to a significant reduction in glycosylated hemoglobin (HbA1c).

Periodontitis and diabetes mellitus

2

Salivary and taste dysfunction

A study conducted in patients with type 1 diabetes showed that symptoms of reduced

salivary flow rate and xerostomia were more frequently reported by patients with diabetes,

especially those patients who had developed neuropathy. Other studies conducted in type 2

diabetes patients also showed that xerostomia and hyposalivation were more prevalent in patients with diabetes.

Patients with diabetes usually complain of xerostomia and have a frequent need to drink. The constant dryness of the mouth would irritate the oral soft tissues, which in turn causes inflammation and pain. Patients with xerostomia are more susceptible to periodontal

infection and tooth decay.

Sialosis is another asymptomatic, noninflammatory, non-neoplastic, bilateral chronic diffuse swelling mainly affecting the parotid glands and has been found to be more prevalent in patients with diabetes mellitus.

Metabolic and endocrine diseases may be the causative factor for altered taste sensation in the oral cavity. It is more frequent in

patients with poorly controlled diabetes compared to healthy controls. Diabetes patients suffering from neuropathy are at a higher

taste threshold. Taste disturbance is reported to lead to poor glycemic control by interfering with the ability to maintain a healthy diet.

Oral infection

Oral candidiasis is an opportunistic infection frequently caused by Candida albicans species. Smoking, xerostomia and endocrine

and metabolic diseases are predisposing factors towards causing oral infection.

Candida infection is reported to be more prevalent in patients with diabetes especially in patients who smoke, wear dentures, have

poor glycemic control and use steroids & broad-spectrum antibiotics.

Patients with diabetes are at an increased risk of developing oral bacterial infections. Diabetes patients with associated

complications and poor metabolic control are more prone to spreading and recurrent bacterial infection.

3

Recommendations

¢ Oral manifestations and complications in patients with diabetes mellitus is recognized and reported recently as a major complication linked with diabetes.

¢ Promotion of healthy oral cavity in patients with diabetes is paramount.

¢ Patients should be regularly followed up by dentist and physicians providing

diabetes care.

¢ Dentists should play a major role in identifying the signs and symptoms of diabetes and

their oral complications.

¢ Advice and counsel diabetes patients who smoke regarding smoking cessation, and

vigorous treatment of oral infection either bacterial or fungal in these patients, especially in case of poor glycemic control.

References

1. Al-Maskari AY, Al-Maskari MY, Al-Sudairy S. Oral manifestations and complications of diabetes mellitus: A review. Sultan Qaboos

Univ Med J. 2011;11(2): 179-86.

2. Oral Health Topics. Diabetes. American Dental Association. Available at: https://www.ada.org/en/member-center/oral-health-

topics/diabetes

3. Diabetes: Dental Tips. National Institute of Dental and Craniofacial Research. Available at: https://www.nidcr.

nih.gov/sites/default/files/2019-03/diabetes-dental-tips.pdf

4

Navratri and Diabetes

Introduction

ExpertOpinion

Dr Rajesh Agrawal

MD (Medicine), Diabetes, Thyroid, Obesity Specialist

Consultant Physician Dot Clinic, Indore, Madhya Pradesh

Navratri is one of the widely celebrated festivals among Hindus all over India and Nepal. Navratri is a 9-day festival devoted to

the worship of goddess Durga. The festival is celebrated twice a year; once during March-April (ending on the 9th and final day celebrated as ‘Rama Navami’) and other during September-

October (ending on the 9th and final day celebrated as ‘Vijayadashmi’). During these 9 days, people observe fasts, worship goddess, perform various folk rituals like garba and

dandiya-raas dance and follow unique traditional rituals in

different states with different cultural beliefs.

Challenges of managing diabetes during festivals

Maintaining a balance between health and celebrations is a tight rope walk, especially for

individuals suffering with diabetes or other associated complications.

Erratic meal patterns, unhealthy and improper food such as high-fat, calorie-rich foods with improper

timings.

A sudden change in dietary habits;

postprandial hyperglycemia, ketoacidosis, metabolic

complications leading to renal

dysfunction and major comorbidities.

Abstinence of water and fluids which

may cause dehydration, electrolyte imbalance and hypotension.

5

Delicate balance of food, water and blood glucose levels in

potentially harmful ways.

Diabetes patients often ignore their nutrition/health during navratra fasting.

Fasting means abstinence from food which lowers the circulating glucose levels, decreases secretion of insulin, raises the levels of

glucagon and catecholamines and stimulates the breakdown of glycogen.

Prolonged fasting may deplete glycogen stores, increase the production and oxidation of fatty acids from adipocytes leading to

ketoacidosis. Dehydration may increase the tendency of thrombosis during fasting.

Managing diabetes during festivals

Pre-fast assessment

Before the festival starts, patients should visit their primary care physicians asking if they can observe fast and precautions they

need to follow if they observe fast. In addition, during follow-up visits, physicians should take patient history regarding fasting pattern observed by the patients.

Pre-fast assessment comprises comprehensive history-taking, physical examination and investigations aimed at identifying stigmata of target-organ damage, so that strategies can be made to optimize health during fasts.

6

Medical nutrition therapy during fasting

The American Diabetes Association (ADA) guidelines regards medical nutrition therapy as mandatory part of an overall treatment plan and considers it to be followed during fasting

days as well for achievement of dietary goals.

The patients need to be educated about timings of meals, wise selection of food items, dietary modifications, healthy recipes and nutritional requirements.

The dietary advice should also ensure that customized recommendations are based on the patient, his disease stage, associated complications such as hypertension, nephropathy and

cardiac disease.

Along with this, knowledge about lifestyle activity, glucose monitoring, medications and insulin regimens are also deemed

important for successful blood glucose management and overall medical care.

Pre-fast meal

The pre-fast meal should comprise of “slow release” calories by including complex and nondigestive carbohydrates with low glycemic index, proteins and moderate amount of

fats. It should be a balanced diet providing unprocessed and unrefined cereals,

pulses and lentils, vegetables, fruits, limited oil and nuts to reduce its glycemic index and retain energy availability for longer period. Water and fluids should be adequately

included to prevent dehydration usually if water intake is also restricted during fasting. Meal supplements or replacements can prove to be beneficial as well for good glycemic

control and health.

Meal during fast

In Navratris, the eating pattern has no fixed rule, allowing different kinds of foods, different

cooking practices with different frequencies and timings, some people eating only one or two major meals while others eating particular kinds of foods especially fruits, vegetables

and dairy products at more frequent intervals.

The meal should comprise of all food groups with a judicious distribution of carbohydrates through the entire day. Complex carbohydrates and low-calorie fluids and beverages have low glycemic index and should be preferred. Adequate fluid intake will help in keeping the

body hydrated. Optimum physical activity during nonfasting periods and 15-20 minutes walk followed by major meals (at the end of fast) is beneficial.

7

Do's and Don'ts during the festivals

Do's Don'ts

¢ Break your fast if your blood glucose is <70 mg.

¢ Have low glycemic index foods, such as whole cereals,

pulses, vegetables, fruits before you begin the fast.

¢ Have roasted phool makhana, paneer, water pumpkin raita,

kheera raita as mid-meal.

¢ Amaranth floor can be used for making chapati.

¢ Sweet potato can be used in moderation, instead of potatoes.

¢ Monitor your blood sugar regularly while you are fasting.

¢ If you miss out on medications or insulin; consult your

diabetologist for necessary dose adjustment.

¢ Take long breaks, have small meals every 3 hours.

¢ Resort too much on tea or coffee; rather drink plenty of

water and sugar free beverages like lemonade, buttermilk, milk, etc.

¢ Have fried food items, high starchy food items such as

sago, potatoes, etc.

Medical management during Navratri festival

Medical management of type 2 diabetes mellitus is tailor made, hence no generalizations

can be made. However, patients only on metformin or gliptins or both can be continued with

the same dose. If A1c is <7, pre-Navratri then we must reduce the dose of oral hypoglycemic agents by 40%. During Navratri, people also dance for hours continuously, so snacking before the dance must be prescribed accordingly.

Flexibility is the key to maintaining diabetes health during Navratri festival. If there are signs of high or low blood glucose levels, the patients should act accordingly and take

water or a snack as required. It is also important that the patient is in regular consultation

with the doctor. The right attitude and motivation for staying healthy cannot dampen the festive spirit!

References

1. Gupta L, Khandelwal D, Singla R, et al. Pragmatic dietary advice for diabetes during Navratris. Indian J Endocrinol Metab.

2017;21(1)231-7.

2. Ahuja A. Tips to manage diabetes during Navratri fasting and feasting. Available at: https://www.lifetothefullest.

abbott/en_in/articles/guide-to-diabetes-management-during-navratri-fasting.html

8

Managing Blood Glucose During Parsi Rituals

Introduction

ExpertOpinion

Dr Sanjay Reddy

MBBS, MD (Gen Medicine)

Vice President, Primer Academy of Medical Sciences (PAMS); Consultant Diabetologist, Center for Diabetes and Endocrine Care, Fortis Hospital, Bengaluru, Karnataka

The Parsi population is primarily concentrated in Mumbai and towns to north of Mumbai along the Gujrat border. Cities such

as Pune, Hyderabad, Kolkata and Chennai also have considerable Parsi population.

Common Parsi rituals and ceremonies

Parsi food rituals

The major events in Parsi community are birth, initiation (Navjot) and

marriage. Apart from these, they celebrate seasonal festivals

known as Ganhambars celebrated by community as a whole, and commemorative ceremonies called Jashans, which are either family events or special occasions such as death of a leader or end of war.

Traditionally, fast from eating meat throughout the month of Bahman is the only fast that is observed in Parsi community. In Zoroastrian calendar, the 2nd day of every month and 11th month of every year is dedicated to Bahman Amshapand. One is

expected to be only on ann, fal and shak or grain, fruit and vegetable during this month.

Most Parsis cannot live on vegetarian only diet and hence, consider eating eggs as quite acceptable and some go on even further to believe that eating fish or even fowl.

9

Lifestyle management to manage diabetes in Parsi people

One of the major constraints is a high prevalence of obesity among the community; hence,

essentially a balanced diet and exercise counseling is imperative.

Since, nonvegetarian food predominates; proper processing of nonvegetarian food can be of help like using cooking methods like roasting or boiling, use of oven cooked recipes.

Another important advice is to reduce or stop using coconut and cashew nuts in preparation

of curry and sweets. Bakery products and sweet breads and cakes along with bun maska and tea are strongly discouraged.

Healthy breakfast options rich in fruits and proteins like egg recipe are encouraged. Meat

and nonvegetarian stuff is in abundance and avoiding red meat and oily preparations is advised.

Alcohol consumption should be either discouraged or patients should be made aware about the harms associated with excessive

use of alcohol.

Medicines given during Parsi feasts

The use of therapies like metformin, glucagon-like peptide receptor agonists and dipeptidyl peptidase 4 inhibitors are preferred as they curb appetite and either do not affect weight or reduce weight.

Alpha-glucosidase inhibitors can be used during feasts where carbohydrate content is also high in addition to routine protein-rich food.

Based on their eating habits, conventional regular insulin may work better than rapid-acting analogs.

10

Diets during feasts can be unpredictable and so patients should be taught about adjustment

of insulin doses as per meal content, as well as taking insulin immediately post meal so that the units can be decided as per quantity of meal should be encouraged.

In the month of Bahman, the diet is majorly vegetarian, and so analog insulin may work better than conventional ones. Patients who are on insulin pump boluses like a dual wave or

a square wave ones are needed based on the fat-rich and nonvegetarian foods.

In addition, diet irregularities among Parsis are common and medications causing hypoglycemia should be used with caution and the patients should be properly counseled

about taking care of hypoglycemia.

Recommendations

¢ Parsi diet is rich in nonvegetarian food, fasts are absent and feasts many. Obesity is

common among the Parsi community.

¢ Glycemic management should mainly be centered on drugs reducing weight and

appetite, as well as less likely to cause hypoglycemia.

¢ Patients on insulin should receive education about dose adjustment of insulin.

Reference

1. Joshi AS, Varthakavi PK, Bhagwat NM, et al. Fasts, feasts and festivals in diabetes: glycemic management during Parsi rituals.

Indian J Endocrinol Metab. 2015;19(5):680-2.

11

Glycemic Control During Hindu Fasts

Introduction

ExpertOpinion

Dr NS Ramesh

Master (Diab), PGD (Diab), PGD Diab (Australia), PGC Cardio (Vivus), MBBS

Senior Consultant Diabetologist Diaplus Diabetes and Medical Center Bengaluru, Karnataka

Hindus comprise over 80% of the population of Nepal and India, and over 5% of the population in at least 15 other

countries. Even though, Hinduism followers are not mandatorily required to observe fasts, still there are many day-long and week-long fasts observed by Hindus.

Most Hindu fasting periods extend from dawn to moon-rise or

from dawn to star-rise. The day-long nature of Hindu fasts; however, makes it distinct from the month-long fasts of Ramadan and Buddhist Lent. There are no universal laws for

Hindu fasts; their observance varies from region to region,

family to family and person to person.

Should the health care professionals worry?

Very few health care professionals realize the importance of fasting in patients with diabetes. In spite of the fact that intermittent

fasting is linked with proven health benefits, still fasting without taking adequate safeguards, may predispose individuals on glucose-lowering medication to hypoglycemia. People who abstain from water and other fluids in hot weather are at a risk of

dehydration, dyselectrolytemia and hypotension.

Once the fast is over, people indulge in high-fat, high carbohydrate and calorie-rich foods. This may lead to hyperglycemia peak and

worsening of glycemic fluctuations.

These challenges are baffling for the diabetes care provider. The health professionals caring for diabetes have to customize dietary

plan, physical activity and medications based on patient's condition to achieve sufficient glycemic control on both fasting and non-fasting days, without either hypo- or hyperglycemia.

12

Pre-fast counseling or assessment

Patients should have an assessment before fast to get an insight into their

condition. The health care professional should consider and make the patient

aware about the potential discomforts and risks associated with fasting in

diabetes and various means by which it can be controlled or managed.

Pre-fast counseling should include patient's exact perspective of fasting,

including duration of fast, allowance for liquids and snacks during the fast, acceptance of sublingual foods and freedom to break the fast in case of significant discomfort must be told to patient. Training to patient on symptoms

of hypoglycemia and management is also important.

Pre-fast assessment should include a thorough history, physical examination and investigations aimed at assessing diabetes

complications, so that the management plan can be customized for the patient.

Lifestyle changes

As we all are aware, the first-line therapy is lifestyle modification in type 2 diabetes.

Intermittent fasting is considered to be a lifestyle intervention with multiple health-related benefits, apart from the socio-religious benefits that is the original aim for the fast.

Physical activity should be restricted during fasting periods.

Stress management is an important component of diabetes care. Religious fasting offers an

opportunity to practice meditation, reduce stress and facilitate better glycemic control.

While evidence-based guidelines are available for many aspects of diabetes care, religious

fasting poses a unique challenge. Guidance should be obtained from a thorough understanding of the physiology of fasting, the pathophysiology and clinical manifestation of diabetes and the pharmacokinetic properties of available glucose-lowering drug.

Diabetes care professionals have a responsibility to provide safe, effective, person-centered treatment that respects individual attitudes, wishes and needs.

References

1. Kalra S, Bajaj S, Gupta Y, et al. Fasts, feasts and festivals in diabetes-1: glycemic management during Hindu fasts. Indian J

Endocrinol Metab. 2015;19(2):198-203.

2. Saboo B, Joshi S, Shah SN, et al. Management of diabetes during fasting and feasting in India. J Assoc Physicians India.

2019;67:70-7.

13

Children, Type 1 Diabetes and Diet During Festivals

ExpertOpinion

Dr Medha Oak

MD (Med)

Consultant PhysicianCardiologist and DiabetologistDr OAK Hospital, Mumbai, Maharashtra

Introduction

Type 1 diabetes mellitus is the second most common chronic disease in children in India, accounting for 5-10% of all

diagnosed cases of diabetes mellitus and has an incidence of 3 cases/year/1,00,000. It results from a cellular-mediated

autoimmune destruction of the -cells of the pancreas.

Type 1 diabetes patients do not produce any insulin, resulting in high blood glucose levels.

For children with type 1 diabetes, no other treatment works

other than insulin. Adequate management of type 1 diabetes

requires intensive insulin treatment, monitoring and lifestyle changes.

A child with type 1 diabetes has to take insulin on a regular basis and

also take care of the food being eaten and physical activity based on the

amount and dose of insulin. Luckily three meals and three snacks are now not necessary with newer insulin analogues. Managing teenagers

is bit difficult who are busy with their social activities and studies.

Indian food

We all know that Indian food is heavily influenced by region, religion, traditions, seasons, festivals and cultural choices. Along with that, it is also affected by economic, social, political, occupational and ecological factors. Different cuisines during the

festivals significantly vary from one part of the country to another in terms of ingredients and preparation methods.

14

Treatment goal in children with diabetes

The goal of treatment is to aim for a blood glucose target range, corresponding to 70-130 mg/dL before a meal and <180 mg/dL 2 hours after the start of a meal. It is important to stick to this blood glucose goal to avoid any complications associated with diabetes.

Insulin, nutrition, exercise and monitoring are all essential to achieve this blood glucose goal.

Nutritional requirement in children with diabetes

Nutrition is one of the most important aspects of diabetes management. To understand how different foods affect blood glucose

levels and learning to develop solid meal plans is a crucial part of the daily routine of children affected with type 1 diabetes.

All children with type 1 diabetes need to receive nutrition counseling. Meal plans have to be

individualized to accommodate food preferences, cultural influences, physical activity

patterns and family eating patterns and schedules, both during routine days and festivals. It is also important to understand that the nutritional requirements of children with type 1

diabetes are different than those of adults with type 2 diabetes. More of fiber, vegetables,

fruits and whole grains need to be promoted.

Fats with carbohydrates will make sugar rise slowly but stays longer, whereas proteins do

not affect blood sugars. Sequence of food intake, example proteins/soups first to increase

satiety and then followed by carbohydrates.

Recommendations for children

¢ The first and foremost recommendation is to offer the nutritional advice adapted to cultural, ethnic and family traditions, as well as the cognitive and psychosocial needs of the individual child. Health care professionals suggest that regional culinary habits

should be considered while making a diet plan for children.

¢ Medical nutrition therapy is an important cornerstone of diabetes management.

¢ Parent education on diet is also the most important method adopted to ensure proper recommended diet adherence.

¢ Consistency of food intake is important for children and adolescents on fixed insulin regimens and without any pre-meal insulin dosage adjustment.

¢ Health care professionals should teach children to adjust short-acting insulin doses according to the meal on regular basis and advice food exchange to have sweet in diet.

15

¢ American Diabetes Association (ADA) guidelines allows 2-3 teaspoons of sugar per day to children with type 1 diabetes who are

not overweight; however, if ambiguous instructions such as allow sweets “occasionally” are given, it may be interpreted differently by different children leading to complications or enhancing risks associated with diabetes.

¢ Artificial sweeteners are not allowed in very young children and in children after 12-15 years, it should only be allowed to be consumed once a week.

Many sweeteners are sugar alcohols present in candies and chewing gums e. g., sorbitol, malt. Though they do not spike sugar in blood, or do not need insulin, they should be eaten in moderation; in excess they can spike sugar in type 1 diabetes mellitus.

Reference

1. Kalra S, Das AK, Raghupathy P, et al. Current indicators of nutritional care in children with type 1 diabetes in India: Do we need a

national nutritional guideline? Indian J Endocrinol Metab. 2017;21(15):670-8.

16

5 Tips to Manage Diabetes During Festivals

ExpertOpinion

Dr Verinder Dhar

MBBS, MD, DM (Endo)

Diabetologist at Opinder Medical Hall, Jammu, Jammu and Kashmir

Introduction

From the month of September till December, Indians have festivals lined up starting with Eid, Dussehra, Diwali, Chhath

Puja, culminating with Christmas. This is a testing time for people with diabetes. They have to bear the twin burden of managing their treatment goals to reach target blood glucose

levels and glycosylated hemoglobin (HbA1c) levels as well as indulge in the celebrations and the festivities.

Tip 1: Festival vs. good health

During festivals, diabetes patients tend to become careless and indulge in the gaiety of the

festivals, which may eventually lead to hyperglycemia or hypoglycemia. During festivals, different parts of the country celebrates in different, colorful ways. There is a liberal use of

high calorie, oily food along with sugary and creamy sweets, which may lead to a sudden rise

in the blood glucose levels.

During festivals like Diwali and Christmas, rich foods and cakes are unavoidable. So, it becomes imperative for the patient to ask him/her self “does celebration of a festival come

at the price of good health?”

Tip 2: Plan in advance for the festival season

Diabetes is a demanding condition, with a severe impact on the quality-of-life over a period of time due to the nature of diabetes complications. Hence, the patient should adopt a pragmatic view to ensure good quality-of-life during the festivals. Patients should be advised by the health care professionals about talking to the diabetes team.

The patient should seek the advice of his health care professional to plan his management during the festivals. The health care professional should assess the patient and craft a management plan based on the patient's condition.

Provide structured, personalized education and diabetes team access; advise glucose testing; teach treatment of low or high glucose; advise stopping the fast if intercurrent illness or glucose instability is observed. Clinicians should discuss the importance of hydration with

the patient. If needed, patients should be given travel advice.

1617

Tip 4: Continuous self-monitoring of blood glucose

Tip 5: Diet and exercise

Regular blood sugar monitoring is fundamental to diabetes treatment and everyone needs to learn how to monitor and when to monitor. Regular monitoring will help the patient in finding out if there is a fluctuation in blood glucose level and can help in the prevention of long-term

health complications.

Diabetes patients should be careful about drinking alcohol and should consume food in moderation, preferably with foods that are

rich in protein. Patients should strive to stick to their healthy routines as much as is possible. If it is not possible to eat at regular times during festivals, break the meals into small snacks. The patients should reach out for the healthiest options available for diabetes

patients.

The patients should also exercise during festivals. However, it is advised during festivals when patient is needed to restrict any

strenuous physical activity; daily household chores and routine activities can be performed but any high-intensity exercise must be

avoided.

The simple ways of staying active include going for a walk with the family, performing bending and stretching exercises regularly,

slow dancing, participating in social events and taking the stairs more frequently instead of an elevator.

Tip 3: Medications

The patients should continue their medicines as earlier. There might be a need for the adjustment of the doses based on whether the patients is on fast or is feasting during the festivals. Type 1 diabetes patients should continue with their basal insulin as they may be at an increased risk of glycemic imbalance in absence of insulin.

18

Diabetes, Diet and Festivals

ExpertOpinion

ExpertOpinion

DT. Shilpa Agarwal Dr Manish Agarwal

CFN, DNHE, Post Graduation in Hospital Management and MBA in Hospital Management

Nutritionist and Research Coordinator; Director, Medilink Hospital, Ahmedabad, Gujarat

MB, MD (Medicine), PGCDM in Diabetology, FICP, FICA, FACP (USA), Diploma in Endocrinology (UK), PhD in Diabetes from European International University

Diabetologist and Metabolic Physician, Medilink Hospital, Ahmedabad, Gujarat

Nutrition and physical activity are important parts of a healthy lifestyle when you have diabetes. Along with other benefits, following a

healthy meal plan and being active can help you keep your blood glucose level, also called blood sugar, in your target range. To

manage your blood glucose, you need to balance what you eat and drink with physical activity and diabetes medicine, if you take

any. What you choose to eat, how much you eat and when you eat are all important in keeping your blood glucose level in the range

that your health care team recommends. Becoming more active and making changes in what you eat and drink can seem challenging at first. You may find it easier to start with small changes and get help from your family, friends and health care team.

Eating well and being physically active most days of the week can help you:

¢ Keep your blood glucose level, blood pressure and cholesterol in your target ranges

¢ Lose weight or stay at a healthy weight

¢ Prevent or delay diabetes problems

¢ Feel good and have more energy.

What foods can I eat if I have diabetes?

You may worry that having diabetes means going without foods you enjoy. The good news is that you can still eat your favorite foods, but you might need to eat smaller portions or enjoy

them less often. Your health care team will help create a diabetes meal plan for you that meets your needs and likes.

The key to eating with diabetes is to eat a variety of healthy foods from all food groups, in the amounts your meal plan outlines.

Introduction

19

The food groups are:

Vegetables - Nonstarchy includes broccoli, carrots, greens, peppers and tomatoes; Starchy

includes potatoes, corn and green peas.

Fruits - Includes oranges, melon, berries, apples, bananas and grapes.

Grains - At least half of your grains for the day should be whole grains includes wheat, rice,

oats, cornmeal, barley and quinoa (examples; bread, pasta, cereal and tortillas).

Protein - Lean meat, chicken or turkey without the skin, fish, eggs, nuts and peanuts, dried

beans and certain peas (such as chickpeas and split peas) and meat substitutes (such as tofu).

Dairy–nonfat or low fat - Milk or lactose-free milk if you have lactose intolerance, yogurt and cheese.

Eat foods with heart-healthy fats, which mainly come from these foods:

¢ Oils that are liquid at room temperature, such as canola and olive oil

¢ Nuts and seeds

¢ Heart-healthy fish such as salmon, tuna and mackerel

¢ Avocado.

Use oils when cooking food instead of butter, cream, shortening, lard or stick margarine.

Choose healthy fats, such as from nuts, seeds and olive oil.

What foods and drinks should I limit if I have diabetes?

Foods and drinks to limit include:

¢ Fried foods and other foods high in saturated fat and trans fat

¢ Foods high in salt, also called sodium

¢ Sweets, such as baked goods, candy and ice cream

¢ Beverages with added sugars, such as juice, regular soda and regular sports or energy

drinks.

Learn more about the food groups at the US Department of Agriculture's (USDA) ChooseMyPlate.gov .

20

Drink water instead of sweetened beverages. Consider using a sugar substitute in your

coffee or tea.

If you drink alcohol, drink moderately—no more than one drink a day if you're a woman or

two drinks a day if you're a man. If you use insulin or diabetes medicines that increase the amount of insulin your body makes, alcohol can make your blood glucose level drop too low. This is especially true if you haven't eaten in a while. It's best to eat some food when you

drink alcohol.

When should I eat if I have diabetes?

How much can I eat if I have diabetes?

Some people with diabetes need to eat at about the same time each day. Others can be more

flexible with the timing of their meals. Depending on your diabetes medicines or type of insulin, you may need to eat the same amount of carbohydrates at the same time each day.

If you take “mealtime” insulin, your eating schedule can be more flexible.

If you use certain diabetes medicines or insulin and you skip or delay a meal, your blood glucose level can drop too low. Ask your health care team when you should eat and whether

you should eat before and after physical activity.

Eating the right amount of food will also help you manage your blood glucose level and your weight. Your health care team can help

you figure out how much food and how many calories you should eat each day.

21

Managing Diabetes During the Fasting Months of Ramadan

ExpertOpinion

Dr Rakesh Arora

MD (Medicine), DM (Endo)

Assistant ProfessorEndocrinology, Govt. Medical College, Amritsar, Punjab

Introduction

Ramadan has a major impact on the management of diabetes in the Muslim population.� It is a lunar-based month with a

varying duration of 29/30 days. Muslims who fast during Ramadan are required to abstain from eating, drinking, use of oral medications and smoking from pre-dawn to sunset.

There are no restrictions on food or fluid intake between sunset and dawn.�

What happens when people with diabetes fast?

In diabetes patients, the physiological changes which ensue during fast as well as the medications being taken for diabetes management may lead to the development of complications such as hypoglycemia and hyperglycemia.�

The gap between meals during Ramadan is much longer than in other months of the year which has major implications for

physiology, with changes in the rhythm and magnitude of fluctuations in several homeostatic and endocrine processes. During fasting, circulating glucose level reduces and insulin secretion is suppressed. Glucagon and catecholamine secretion are increased,

which leads to the stimulation of glycogenolysis and gluconeogenesis, which causes an increase in blood glucose level.�

Sleeping patterns are altered (typically sleep is broken before dawn to

enable Muslims to eat before fasting begins).

Increase in blood glucose level occurs during Ramadan fasting.

Body weight typically decreases or remains

stable during Ramadan.

Ramadan fasting is associated with favorable effects on lipid profile in

healthy individuals.

22

Glycemic control and Ramadan

Pre-Ramadan medical assessment

The risks facing patients with diabetes are enhanced during Ramadan, including hypoglycemia, hyperglycemia, diabetic ketoacidosis, dehydration and thrombosis. Not only fasting, feasting also carries substantial risks for individuals suffering with diabetes. The incidence of severe hyperglycemia goes up 5 times in type 2 diabetes patients. In absence of suitable steps taken to

manage blood glucose, patients with diabetes are prone to experience severe hypoglycemia during Ramadan than during nonfasting periods.�

Another study has shown that the main glucose rise occurs at ‘Iftar’ time when intake of sweet and carbohydrate rich foods increase.

Timing of medication and hormonal changes ensuing during fasting also contribute to the glucose rise.�

Patients with diabetes who wish to fast during Ramadan should undergo a medical assessment. They should be provided structured education about undertaking the fast

safely. The assessment should be timed 1-2 months before Ramadan. The medical assessment should be focussed on the overall health of the patient, control of glycemia, blood pressure and lipids.�

This is the time when the physician may adjust the dose, timing or the type of the medication

used to minimize the risk of hypoglycemia in patient.�

RISKS FOR PATIENTS WITH DIABETES DURING RAMADAN

Hypoglycemia Hyperglycemia Dehydration and thrombosis Diabetic ketoacidosis

The major risks related with fasting such as hypoglycemia and hyperglycemia are the same challenges facing people with diabetes

on a regular basis; however, research has shown that the probability of these risks is aggravated due to fasting during Ramadan.�

23

Managing diabetes while fasting

Frequently, the medical recommendation to patients with diabetes during Ramadan is to not fast. However, patients insist on fasting because of their religious and spiritual beliefs. The patients are stratified into “very high”, “high”, “moderate” and “low” risk for diabetes-related

complications during fasting. The most important issues which need to be considered by a diabetic patient and his/her health care providers during Ramadan fasting are:�

One size ‘does not’ fit all

The care needs to be highly individualized as each patient will face their own specific set of risks and complications. The

management plan will be customized for each patient and differ for each specific patient.�

Monitor glucose

Patients should regularly monitor their blood glucose levels multiple times every day;

especially in type 2 diabetes patients who require insulin.�

Eating healthy

The diet pattern is significantly altered during Ramadan fasting. Inappropriate diet,

overeating and insufficient sleep may lead to various health-related complications in diabetes patients. The nutritional advice for diabetes patients should be customized based

on the needs and medical conditions of the individual patient. The aim of a healthy and

balanced diet is to maintain a constant body mass. Food rich in carbohydrates and fats, especially at the sunset should

be avoided.�

Blood glucose Recommendation

<60 mg/dL (blood glucose) Immediately end fast

<70 mg/dL Fast should be broken (especially if insulin, sulfonylurea drugs or meglitinide are taken at pre-dawn)

Exceeds 300 mg/dL Fast should be broken

Sick days Fast should not be undertaken

Recommendations for breaking fast

24

¢ Maintain a constant body mass.

¢ Avoid food rich in carbohydrate and fats at the sunset meal.

¢ Pre-dawn meal should be eaten as late as possible before the start of the daily fast.

¢ Increased fluid intake during fasting hours.

Exercise

Normal levels of physical activity may be followed by the patients. Excessive physical

activity may lead to a higher risk of hypoglycemia and should be avoided, especially during the few hours before the sunset meal.

Daily and repeated cycles of rising, kneeling and bowing also form a part of the exercise routine.�

Medication adjustments during Ramadan

The type of medication being taken to control diabetes may also affect the risk of hypoglycemia during the night and hyperglycemia at

the night.

Counseling the patient

Educating patients is essential for the management of diabetes during the fasting period and after breaking the fast during

Ramadan. Studies have shown that patients who received education demonstrated lesser events of blood glucose fluctuations compared to those who didn't. It will also help in overcoming various myths such as puncturing one's skin for blood glucose testing

4during the fast will break the fast.

25

References

1. International Diabetes Federation. Diabetes and Ramadan: Practical Guidelines. 2016.

2. Al-Arouj M, Assaad-Khalil S, Buse J, et al. Recommendations for management of diabetes during Ramadan update 2010. Diabetes

Care. 2010;33(8):1895-902.

3. Lessan N, Hasan H, Barakat MT. Ramadan fasting: a study of changes in glucose profiles among patients with diabetes using

continuous glucose monitoring. Diabetes Care. 2012;35(5):e37.

4. Ibrahim M, Al Magd MA, Annabi FA, et al. Recommendations for management of diabetes during Ramadan: update 2015. BMJ

Open Diabetes Res Care. 2015;3(1):e000108.

Riskindividualization

Bloodglucose monitoring

Fluids and dietary advice

Exercise advice

Medication adjustments

When to break the fast

RAMADAN FOCUSSED COUNSELING OF A DIABETES PATIENT

26

Do's and Don'ts During Diwali Festival

ExpertOpinion

Dr Sharvil Gadve

MD (Medicine), DM (Endo)

Consultant Diabetologist and Endocrinologist, Excel Endocrine Centre, Kolhapur, Maharashtra

Introduction

Diwali is a Hindu festival which is celebrated with many sweet delicacies and rich, festive food. There is concern that

feasting during Diwali festival can cause significant deterioration in the metabolic profile of patients with type 2 diabetes mellitus. This can actually turn upside down the

blood glucose levels in a patient.

In one of the most popular festivals from South Asia, the celebratory

food can be challenging for managing blood glucose control. Hence,

it is important to plan in advance how to manage carbohydrate

intake through the celebrations and to test blood glucose levels at regular intervals.

Some of the Do's and Don'ts during the Diwali festival for the diabetes festival are mentioned here. Let's take a look at the don'ts first.

Skip the hypoglycemic medication

and exercise regime.

Forget to self-monitor the blood

glucose level.

Eat red meat and fried foods.

Snacks on high-calorie food such as

samosas and papads.

Indulge in heavy drinking.

Forget to carry insulin with you.

27

Do's during the Diwali festival for diabetes patients

Consider lifestyle and

cultural factors when managing diabetes

during diwali festival.

Oral hypoglycemic agents need

to be adjusted in accordance with the expected dietary

change during festivals.

Specialized diet

counseling.

Regularly monitoring the

food and fluid intake.

Instead of sugar, use

jaggery or stevia, prepare

sweets with skimmed

milk at home.

Know the symptoms of

both hypoglycemia as

well as hyperglycemia.

Adjustment of insulin

dosage based on

carbohydrate intake.

Taking small portions of

sweet food; having or

even taking quarter-sized

portion of the sweet foods.

Restrict refined and starchy food

items such as maida, rava, white bread, potatoes, other tubers,

processed foods and meats.

Plan your exercise

schedule, especially in the mornings before the

celebrations begin.

References

1. Mathur N, Mathur R, Rawtani J. Impairment in glycemic control and lipid profile during the Indian festival of Diwali. Int J Diabetes

Dev Ctries. 2016;36(3):380.

2. Festivals and diabetes. Diabetes.co.uk. Available at: https://www.diabetes.co.uk/festivals-and-diabetes.html

28

Fasting in Type 1 Diabetes

ExpertOpinion

Dr Gurmeet Singh Sandhu

MD (Medicine)

Senior Consultant Diabetologist Jabalpur Hospital and Research Centre, Jabalpur, Madhya Pradesh

Introduction

In type 1 diabetes patients, food and eating habits

form an important aspect of management. Fasting is an important time when it

becomes important to acknowledge of diet in diabetes patients.

Why do people fasting?

There are times when fasting cannot be avoided at all. Religious fasting manifests in many different practices and belief systems such as Hinduism, Buddhism and Islam. Sometimes, it is also important to be on fast before medical procedures like surgery or

blood tests. Intermittent fasting with the aim of detoxification is also a common dietary practice.

With this, the question comes up, “whether it is safe for a type 1 diabetes patient to observe fasting?”

What do the recommendations say?

Most of the evidence-based clinical recommendations are to avoid fasting in people with diabetes. The recommendations state that the main health risk

of fasting in diabetes is hypoglycemia, especially if the patient continues to take insulin while fasting without regular blood glucose monitoring.

If the patient has to keep a fast, he should visit his health care provider and plan a management strategy to avoid any health emergencies. It should be

made clear to the patient, that if the patient faces any glycemic emergency, they should be flexible enough to stop the fast. In the case of hypoglycemia,

it is important to break the fast and treat the low blood glucose with food or

drink that contains carbohydrates. In fact, the risk for hypoglycemia is 4.7 times greater than normal during fasting in patients with type 1 diabetes.

29

Fasting during medical procedures

Special diets during fasting in type 1 diabetes patients

There are various medical procedures which may require the patient to be on fasting. Before a medical procedure, the stress endured by the patient may lead to the release of hormones such as adrenaline and cortisol. Both these hormones cause an increase in

glucose level in the blood. In patients with type 1 diabetes, insulin is not produced to balance out these changes and hence, there may be a requirement to administer insulin to maintain normal glucose levels while fasting. It is true that fasting before medical procedure is a

complicated situation in type 1 diabetes patient; however, during such a fasting; the patient is residing in the medical facility and in constant care of health care professionals. This

facilitates proper management of glycemic levels of the patient.

Pregnant women, patients with a history of hypoglycemia, a history of diabetic ketoacidosis

and even those who have to indulge in rigorous physical activity are advised against fasting.

Special diets such as detoxification diets are short-term diets, which range from a few days

to a few weeks, with the aim of removing toxins from the body. These diets include specific

teas, juices or specific vegetables and fruits. However, such diets are not backed by enough research evidence and hence cannot be forced upon the patient by the medical fraternity.

It is recommended that in patients with type 1 diabetes, the diets should be regular and the

patient should continuously monitor their blood glucose level. The meal should combine

protein, fiber and healthy carbohydrates and it will help in keeping the blood glucose level

balanced during fasting.

Frequent monitoring

Frequent monitoring reduces the risk of both hypoglycemia and hyperglycemia and helps

control blood sugar levels. A myth prevalent among patients is that checking their blood

glucose during fasting hours breaks the fast, but this is not true. In fact, checking blood glucose level more often than usual will help patients in making sure that the blood

glucose level stays within optimal levels.

Insulin use during fast

Type 1 diabetes patients should not stop using basal insulin as there may be a risk of hypoglycemia.

Exercise while on fast

If patients exercise during fast, they may be facing the risk of lowering their blood glucose and they should be adequately prepared

to manage any emergency.

Although it is recommended that most people with diabetes can exercise normally during fasting, patients should not overdo

exercise, especially during the evening hours. The risk of low blood glucose is highest during evening hours.

References

1. Caceres V. How diabetics can fast for Ramadan, other holidays or even surgery. U.S. News. Available at: https://

health.usnews.com/health-care/patient-advice/articles/2017-06-22/9-guidelines-for-fasting-when-you-have-diabetes

2. Crompton C. Fasting with type 1 diabetes. Beyond diabetes 1. Available at: https://beyondtype1.org/fasting-with-type-1-diabetes/

30

Feasting vs. Fasting

ExpertOpinion

DT. Devisree

BSC N&D, CDE

Dr Mohan’s Diabetes Specialities Centre, Chennai, Tamil Nadu

Introduction

Intake of proper quantity of the right food at appropriate times is essential for good health. Consuming an excess of rich food

at one go (feasting) or avoiding food intake for a long period of time (fasting) are not good for a person's health, particularly if he/she has diabetes. Unfortunately, especially during the

marriage season and festive season, people end up feasting quite frequently. Conversely, many people undertake fasts of varying duration for religious reasons of religion. While these

deviations from a normal diet may not cause much harm in an

otherwise normal person, they can play havoc with the health of an individual with diabetes.

What happens when we fast?

To put it simply, whenever we fast, our body gets into a conservation mode. The body senses

that food is in short supply and cuts down on calorie expenditure as it is not certain when the

next meal is going to arrive or what exactly that meal will consist of. Hence, the metabolism slows down and when we start having normal food on conclusion of the fast, we end up

gaining weight as we do not expend as much energy as we used to before we started fasting.

What is the trouble with feasting?

Fasting/Feasting with diabetes

The problem with feasting is that most of the foods served in a feast are calorie dense. It is very easy to end up consuming all the

calories that you require for a whole day in just one meal. You could end up gaining weight very easily, particularly if the occasions for

feasting follow one another in rapid succession.

It is ideal that diabetes patients neither fast nor feast. This is particularly so if the blood glucose is uncontrolled. Even in a previously well-controlled patient, a prolonged fast can

turn the sugar control haywire. In fact, many religious texts exempt people with diabetes

from undertaking fasts on the basis that it might harm their health. If, on occasion, a person with diabetes insists on undertaking a fast for religious or other reasons, a few steps can be

taken to minimize the ill-effects on sugar levels. If the fast is intermittent, one can safely omit

the diabetes medication on the day of the fast. In case of prolonged fasting like during the holy month of Ramadan, the scenario is different. Here consideration has to be given to

changing the timing, dosage and nature of medications. It is ideal to consult a physician prior

to commencement of the fast so that these changes can be made at the appropriate time.

31

32

Sweets and diabetes

Despite being diabetic, the idea of completely avoiding sugar in the meal plan is one of the biggest misconceptions in diabetes

management especially during festive seasons.

Balancing sweets into your diabetes meal plan

Although it is possible to include sweets in your diabetes meal plan, they shouldn't play a

big role. Sweets aren't necessary to include, because they lack nutrition, but it is nice to treat yourself every once in a while.

When you decide to indulge a little, substitute sweets for other carbohydrates in your meal,

so you don't have huge spikes in your blood glucose levels. You can also swap a carb-containing food for something with fewer carbohydrates.

Healthy alternatives

A more nutritional option is to find healthy alternatives that fit into your diabetes meal plan

and still satisfy your sweet tooth. Some people enjoy fruit as a substitute. Other options

can include:

¢ Low-fat ice cream or yogurt

¢ Low-fat, low-sugar pudding

¢ Sugar-free Jell.

Artificial sweeteners could be used in moderation. However, these do not contain any

beneficial nutrients. Free sugars should be less than 10% of total calories/day, which includes all added sugars and sugars present in honey, syrups and fruit juices. Alternatives

to sweetened beverages can be water, skimmed buttermilk and low-fat milk.

Sugar substitutes can be used in limited quantity but they are to be avoided during

pregnancy and lactation. Sugar substitutes can be helpful with weight loss and reducing the intake of carbohydrates. Remember, a food labeled as “sugar free” can still have considerable carbohydrate and calories. Remember, in the end, you are trying to maintain a healthy diet just like everyone else and beware of portion sizes, try to stick to foods low in

fat and calories.

Tips to avoid diet disasters when eating out

¢ It’s okay to say no. Think before you answering the question, “Would you like fries with that?”

¢ The “Value Meal” isn’t always the best bargain, especially if you’re getting more food than you’re going to eat.

¢ Get fat-free or low-fat condiments like mustard, ketchup and salsa.

¢ Ask for salt-free fries.

¢ Skip “special sauces” and garnishes.

33

Lifestyle Modifications: Exercise

How exercise helps in diabetes?

Physical activity in diabetes patients is critical for blood glucose management and overall health in individuals with diabetes and prediabetes.

Exercise recommendations as well as precautions to be observed during exercise are dependent on the characteristics and health status of the patient.

Physical activity and exercise recommendations have to be tailored to meet the specific needs of each patient.

The benefits of exercise include:

¢ Improved blood glucose control

¢ Reduced cardiovascular risk factors

¢ Contributes to weight loss

¢ Improved well-being

¢ Prevent or delay development of type 2 diabetes

¢ Improved cardiovascular fitness, muscle strength and insulin sensitivity in patients with

type 1 diabetes.

TYPES OF PHYSICAL EXERCISE

Aerobic exercise (walking, cycling, jogging and swimming)

Balance, resistance activities, others combine flexibility (Tai Chi and Yoga)

Balance exercise (benefit gait and prevent falls)

Resistance (strength) training (exercise with free weights, weight machine, body weight or elastic resistance bands)

Flexibility exercises (improve motion around joints)

34

Aerobic exercise benefits

¢ Increases mitochondrial density, insulin sensitivity, oxidative enzymes, compliance and reactivity of blood vessels, lung function, immune function and cardiac output.

¢ In type 1 diabetes, it increases cardiorespiratory fitness, decreases insulin resistance and improves lipid levels and endothelial function.

¢ In type 2 diabetes, it reduces A1c, triglycerides, blood pressure and insulin resistance.

Resistance exercise benefits

¢ Improvement in muscle mass, body composition, strength, physical function, mental

health, bone mineral density, insulin sensitivity, blood pressure, lipid profiles and cardiovascular health.

¢ In type 1 diabetes, it can assist in minimizing risk of exercise-induced hypoglycemia.

¢ In type 2 diabetes, it improves glycemic control, balance, neuropathic symptoms and

some dimensions of quality-of-life in adults with diabetes and neuropathy.

Benefits of other types of exercise

¢ Stretching increases range of motion around joints and flexibility but does not affect

glycemic control.

¢ Balance training can reduce falls risk by improving balance and gait, even when

peripheral neuropathy is present.

¢ Group exercise interventions (resistance and balance training, Tai Chi classes) may reduce falls by 28-29%.

¢ Yoga may promote improvement in glycemic control, lipid levels and body composition

in adults with type 2 diabetes.

¢ Tai Chi training may improve glycemic control, balance, neuropathic symptoms and quality-of-life in adults with diabetes and neuropathy.

35

Diabetic super fruit: Guava

Lifestyle Modifications: Diet

The fruit of Psidium guajava is known to contain free sugars, yet the fruit juice shows

hypoglycemic effect.

It is considered as poor man's apple of tropical and subtropical countries.

Guava is a small tropical tree

widely grown for its fruit.

The fruit is known for its

nutritional, medicinal and

pharmacological values.

It is included among the

super-fruits with low calorie

profile with high dietary fiber, rich in antioxidant vitamins and

minerals.

Different parts of guava tree

have been extensively studied

including leaves for its medicinal role.

NUTRITIONAL VALUE OF GUAVA

High-fiber

content

Potassium and magnesium

Antioxidant

Vitamins such as C, A and B9

Lutein, beta carotene

and minerals

Guavas are very low in glycemic index and

glycemic load.

Guava fruit extract showed impressive efficacy in

improving dyslipidemia.

Guavas can help to lower and regulate

blood glucose levels.

Extremely healthy food for diabetes patients

and those most at risk for developing diabetes.

Hypoglycemic activity of guava leaves is well

documented; guava leaf extract tea is available in

market.

36

Makhana also known as fox nuts or lotus seeds is low in calories and glycemic index. It has found its place in India from religious ceremonies to fasting dishes, as well as managing blood glucose levels.

This recipe made from roasted and powdered makhane is cooked in milk and tastes heavenly when served cold.

Ingredients needed

¢ Lotus seeds (Makhana) 1 cup

¢ Ghee 2 tbsp.

¢ Full-fat milk 5 cups

¢ Sugar ¾ cup or sugar free

¢ Saffron strands few strands

¢ Nutmeg powder ½ tsp

¢ Pistachio slivers 1 tbsp

Method

Step 1: Heat the ghee in a broad non-stick pan, add the lotus seeds and sauté on a medium flame for 3-4 minutes or till they

turn crisp.

Step 2: Remove from the flame, allow it to cool and blend in a mixer to a coarse powder. Keep aside.

Step 3: Boil the milk in a deep non-stick pan, add the sugar, mix well and cook on a high flame for 2 minutes or till the sugar

dissolves, while stirring continuously.

Step 4: Reduce the flame to medium, add the coarsely crushed lotus seeds, mix well and cook for 19 minutes or till the milk has

reduced to half, while stirring and scraping the sides of the pan occasionally.

Step 5: Add the saffron and nutmeg powder, mix well and cook on a medium flame for 1 more minute.

Step 6: Switch off the flame and allow cooling completely.

Step 7: Refrigerate for at least 1 hour and serve chilled garnished with pistachios.

Recipe of the month: Makhane ki kheer

37

NUTRITION VALUE PER SERVING

Energy: 495 cal Protein: 8.0 g Carbohydrates: 48.1 g Fiber: 0 g

Fat: 22.8 g

Saturated fat: 0 gCholesterol: 40 mg Sodium: 47.5 mg

Source: Tarla Dalal recipes. Available at: https://www.tarladalal.com/Makhane-ki-Kheer-(-Indian-Cooking)-1992r

Potassium: 0 mg

38

Diabetes Technology Update

Self-blood glucose monitoring

Blood glucose monitors

Blood glucose monitors allow patients to track blood glucose patterns and daily blood glucose targets, prevent or detect episodes of

hyperglycemia or hypoglycemia.

It also helps in monitoring one's glycemic response to certain foods, medications, physical activity or therapy change.

Ample clinical study results reveal that maintaining tight glycemic control is critical to effectively managing diabetes, as well as reducing or preventing the various health complications associated with poorly controlled diabetes.

At present, there are various self-testing blood glucose monitors to suit the needs of all

patients with diabetes, even pediatric patients.

Technological advances enable manufacturers to make meters that are less invasive, less painful when testing, require a smaller sample size, are capable of alternate site testing,

provide rapid test results and allow testing without a major interruption to a patient's

daily routine.

Some blood glucose monitors have large memory storage, which can translate to audio

capability and the ability to measure blood pressure or ketones in addition to blood glucose

levels.

Selecting a glucose meter

¢ Ease of use and an easy-to-follow testing procedure

¢ Affordable cost of meter and tesitng supplies

¢ Alternate site testing

¢ Easy-to-read display

¢ Accuracy of test results

¢ Battery type

¢ Cleaning procedure

¢ High-tech features, such as audio capability, blue tooth and cellular capability

39

Conference Highlights

3RD INTERNATIONAL CONGRESS ON DIABETES AND METABOLISM

Date: November 29-30, 2019

Venue: Frankfurt, Germany

Theme: Evincing the Therapeutic Approaches and Development in Diabetes

The conference includes keynote presentations, workshops, technical oral presentation, and poster presentations. By sharing research, participating in forums and collaborating with one another, your work will continue to impact the Diabetes field.

The conference is themed around “Evincing the Therapeutic Approaches and Development in Diabetes” with the aim to

assemble a medical practitioner, a large audience of trade, health care, research and to coach and produce a few fruitful speeches

on the confined topics. This can be an excellent event to network, learn and have interaction with professionals within the field of

Diabetes, Nutrition and Cardiovascular and Metabolic syndrome.

Opportunities for Conference Attendees

Specialists and Educators

¢ Speaker Presentations

¢ Poster Display

¢ Symposium Hosting

¢ Workshop Organizing

Students and Research Scholars

¢ Poster Competition

¢ Young Researcher Forum

¢ Student Attendee

¢ Group Registrations

Business Delegates

¢ Speaker Presentations

¢ Symposium Hosting

¢ Book Launch Event

¢ Networking Opportunities

¢ Audience Participation

Universities, Associations and Societies

¢ Association Partnering

¢ Collaboration proposals

¢ Academic Partnering

¢ Group Participation

Companies

¢ Exhibitor and Vendor Booths

¢ Sponsorships Opportunities

¢ Product Launch

¢ Workshop Organizing

¢ Scientific Partnering

¢ Marketing and Networking with Clients

https://diabetes.cmesociety.com/

40

Diabetes Quiz

With the high calorie, oily foods along with sugary and creamy sweets during festivals:

¢ Sudden spike in blood glucose levels

¢ Low blood sugar levels

¢ Blurry vision, dizziness, headache, confusion

¢ All of the above

Q-1

Which of these should be followed by diabetes patients following Navratri fast?

¢ Eat slow absorbing foods

¢ Do not change the insulin pre- and post-fasting

¢ Skip the medicines for the duration of fast

¢ Eat only twice a day

Q-2

Why should a diabetes patient wear comfortable shoes and sneakers?

¢ To prevent diabetes fallen arch syndrome

¢ To prevent shin splints

¢ To prevent foot injuries

¢ None of the above

Q-3

Answers

1 All of the above

Eat slow absorbing foods 2

3 To prevent foot injuries

41

Educator Alert

IF A DIABETES PATIENT IS ATTENDING A MUSIC/DANDIYA FESTIVAL

FoodCarry your own snacks to ensure that

balanced quantity of carbohydrates and

fats are taken as well as avoid queue at food stalls.

AlcoholAvoid drinking. Make sure to eat a

snack before going to sleep.

Foot careYou will be doing a lot of walking and

dancing; with good fitting, comfortable

shoes. Carry plasters with you to take care of blisters.

InsulinCarry your insulin pen; dispose off the

syringe safely.

Blood glucose levelCheck your blood glucose level before

the festival, avoid missing insulin, eating different types of rich foods, avoid having sugary or alcoholic drinks.

Be aware of what could happen and prepared to take care of yourselves.

Tell your close friends that you have

diabetes.

Finally, have a good time, be safe and healthy.

42

NOTES

43

NOTES

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