To keep the members of DSME and DSMS concepts · Specialist, DOT Clinic, Indore, Madhya Pradesh....
54
Transcript of To keep the members of DSME and DSMS concepts · Specialist, DOT Clinic, Indore, Madhya Pradesh....
*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:
[email protected] or [email protected] or [email protected]
Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of diabetes patients. This Journal intends to empower your clinic support
staffs for basic counselling of diabetes patients. 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
made to ensure the accuracy of information but Hansa Medcell or USV Private Limited will not be held responsible for any inadvertent
error(s). Professional are requested to use and apply their own professional judgement, experience and training and should not
rely solely on the information contained in this publication before prescribing any diet, exercise and medication.
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 healthcare partner believes in supporting your endeavour to make India a Diabetes Care
Capital of the World.
Indian Diabetes Educator Journal (IDEJ) is a first-of-its-kind initiative in India developed to strengthen the
concepts of Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS)
among the members of diabetes care team, especially the diabetes educators (DEs).
IDEJ content is developed based on seven self-care behaviours defined by American Association of Diabetes
Educators (AADE) i.e., healthy eating, being active, monitoring, taking medication, problem solving, healthy
coping and reducing risks.
This issue cover story gives insights on carbohydrate counting. There are several different ways people with
diabetes can manage their food intake to keep their blood glucose within their target range and one such
method is 'carbohydrate counting'. Carbohydrate or carb counting is a method of calculating grams of
carbohydrate consumed at meals and snacks.
We sincerely thank our contributors for making this issue delightful reading for our readers.
We dedicate this journal to all the healthcare professionals who are working relentlessly towards making “India
a Diabetes Care Capital of the World”.
Sincere Regards,
Dr. P. Mithun Chakravarthy
MD (General Medicine), DM (Endocrinology)
Consultant, GSL Medical College and Hospital; Lalitha Endocare and Skincare, Rajahmundry, Andhra Pradesh.
Dr. H. Babul Reddy
MD (General Medicine), DNB (General Medicine), DM (Endocrinology)
Consultant Endocrinologist, KIMS Hospitals, Kondapur, Telangana, Hyderabad.
Dr. Rajesh Agravval
MD
Diabetes Thyroid Overweight and Hormone Specialist, DOT Clinic, Indore, Madhya Pradesh.
Dr. Masood Batin
MD (Medicine)
HOD, Department of Medicine and Diabetology (Diabetic Clinic In-charge), Mission of Mercy Hospital and Research Centre, Kolkata.
Dr. Sunil Kumar Kota
MD (General Medicine), DNB (Endocrinology)
Consultant Endocrinologist and Diabetes, Thyroid Super-specialist, Diabetes & Endocare Clinic, Berhampur, Odisha.
Dr. Salam Ranabir
DM (Endocrinology), FACEAssociate Professor, Medicine,Regional Institute of Medical Sciences, Imphal, Manipur.
Dr. Anirban Sinha
MD (Medicine), DM (Endocrinology), FACE
Assistant Professor, Dept of Endocrinology, Medical College, Kolkata.
Expert Contributors of the MonthExpert Contributors of the Month
Dr. Vivek Mathew
MD, DM (Endocrinology)
Associate Professor, Endocrinology, St. Johns Medical College, Bangalore.
Dr. Ashok Jhingan
MD, FIAMS
Diabetes Education and Research Foundation, Primus Super Speciality Hospital, New Delhi.
Dr. Shrinivas A. Patil
MD, DM (Endocrinology)
Consultant Endocrinologist and Diabetologist, Unique Diabetes, Thyroid and Hormone Care Centre, Sangli, Maharashtra.
Ms. A. Hema
MSc
Dietitian & Diabetes Educator, Dr. Mohan’s Diabetes Specialities Centre, Madurai.
Dr. Shruti Khare-Aterkar
MD (Medicine), DM (Endocrinology)
Consultant Endocrinologist and Diabetologist, Department of Endocrinology and Diabetology, Shalby Hospital, Ahmedabad, Gujarat.
Table of ContentCover Story: Healthy Eating –
All About Carbohydrate Counting 01Dr. Anirban Sinha
Being Active: Get Moving!
08Dr. Vivek Mathew
Taking Medications: Be Your Own
Health Advocate 11Dr. Sunil Kumar Kota
Diabetic Foot: Protect to Prevent
19Dr. Masood Batin
Role of Spices in
Fighting Diabetes 21Dr. P. Mithun Chakravarthy
Diabetes Care in Practice
24Dr. H. Babul Reddy
Fasting During Ramadan
26Dr. Rajesh Agarwal
Monitoring: Cornerstone of
Glucose Monitoring 13Dr. Ashok Jhingan
Problem Solving: Unfortunate
Changes Associated with Diabetes 15Dr. Salam Ranabir
Healthy Coping: Pave Your Way
Through Recreational Activities 17Dr. Shrinivas A. Patil
Diabetes and Women’s Health:
Diabetes – A Predisposing Factor to
Vaginal Infections 29Dr. Shruti Khare-Aterkar
Reduce your risk: Don’t Forget
the Dentist 31Ms. A. Hema
Table of Content
Shopping Smart 42
Diet-Related Behavioural Tips 43
Superfood: Pumpkin Seeds/ 44
Recipe 45
References 46
Eat Out, Be Wise! 40
39National Diabetes Educator
Program (NDEP) Best Practices
Tools in Diabetes: BlueStar –
The Perfect App for Diabetes
Prescription34
Future Trend: IDx-DR –
An Artificial Intelligence System
that Detects Diabetic Retinopathy
in Primary Care
35
Diabetes Educator of the Month 36
Busting the Myth: Diet or Health
Foods Do Not Raise Blood Glucose
Levels. People with Diabetes can Eat
them in Liberal Amounts
37
38Get Active!
1
ExpertOpinion
Introduction
When a person consumes food containing carbs, his/her body breaks down the digestible carbs into sugar leading to a rise in blood sugar levels. Different amounts of carbs have different effects on blood sugar levels. A high carb meal (such as a plate of pasta and a breadstick) will raise blood sugar more than a low carb meal (such as a grilled chicken breast,
1salad and broccoli).
Dr. Anirban Sinha
MD (Medicine), DM (Endocrinology), FACE
Assistant Professor, Dept of Endocrinology, Medical College, Kolkata.
In an individual with type 2 diabetes mellitus
(T2DM), the pancreas may not make enough insulin or the cells in his/her body may have trouble using insulin properly. Eating the right amount of carbs at each meal and taking
diabetes medications, including insulin, if
needed, may help keep blood sugar closer to 1target levels.
2What is carbohydrate counting?
Carbohydrate counting is one of many meal planning options for managing blood glucose levels. This may give the person more choices and flexibility when planning meals.
Eat right
Carbohydrates are the primary foods that affect glucose levels.
Foods with carbohydrates
– Breads, crackers and cereals
– Pasta, rice and grains
– Starchy vegetables, such as potatoes, corn and peas
– Non-starchy vegetables such as broccoli, salad greens and carrots
– Milk and yogurt
– Fruits and juices
– Sweets and desserts
¢
¢
Cover Story: Healthy Eating – All About Carbohydrate Counting
2
Blood glucose
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Fruit: ½ hr
Starch: 2 hrs
High fiber: Starch – 2.5 hrs
Protein: 2–5 hrs
Fats/Oils: 4–6 hrs
Time (hrs)
How many carbs should people with diabetes eat?
Everyone needs a different amount of carb.
The amount of carbohydrate intake of a person depends on his/her age, height, weight, level of physical activity, current blood glucose level and blood glucose target.
The doctor or dietitian gives personalised carbohydrate targets for each meal and snack to people with diabetes.
Test ADA Goals
HbA1c Under 7%
Blood sugar (before meals) 70–132 mg/dL
Blood sugar (1–2 hrs after meals) Under 180 mg/dL at peak
Table 1: ADA recommended blood sugar levels before and after meals
HbA1c: Glycated haemoglobin; ADA: American Diabetes Association
Thumb tip1tsp.
Thumb1 oz.
Handfull½ cup
Palm1 cup3 oz.
Fist1 cup
8 fluid oz.
To calculate carb choices: Divide the total grams of carbs by 15 (1 carb choice = 15 g of carbs)
For example:
Total carbs = 22 g
Therefore, 8 crackers would be equal to 1½ carb choices
¢
¢
¢
22 divided by 15 = 1.47 (round to 1.5)
3How to use the nutrition facts on food labels?
¢Look at the serving size. All the information on the label is mentioned there. Compare the portion size that the person eats to the serving size listed on the panel. If the serving size is one cup and the person eats two cups, he/she is getting twice the calories, fat and other nutrients listed on the label.
Meal
Snacks
Carb limits for women Carb limits for men
30 to 60 g 45 to 75 g
15 to 30 g 15 to 30 g
Table 2: Amount of carbohydrate needed by an individual
Starches 15
Fruits 15
Milks 12
If a person is trying to lose weight, the doctor may ask him/her to use the lower number in these ranges for carb counts by meal.
Non-starchy vegetables 5
Meats 0
Fats 0
Summary
Sample meal with 4 carb choices
Add these foods to complete the meal, these provide nutrients other than carbs
¢
¢
¢
¢
¢
¢
¢
1 slice of whole wheat bread (1 carb choice)
½ cup mashed potatoes (1 carb choice)
½ cup canned peaches (1 carb choice)
1 cup skim milk (1 carb choice)
3 ounces of chicken (0 carb choice)
1 green salad (0 carb choice)
1 to 2 tablespoons of dressing (0 carb choice)
3
Important pointers for DEs
¢
¢
¢
¢
5When eating out, remember:
Portion sizes are often large
One may get more fat and sodium (salt) than needed
When eating out choose for steamed tomato-based sauces (red) instead of cream-based sauces (white).
Select grilled, roasted, broiled, lightly sautéed, baked and poached vegetables.
Select lentil soup, chicken tikka; go easy on naan bread or get lighter pappadams instead. Avoid fried items.
–
–
Carb counting is one form of meal planning that can help people with diabetes manage their blood sugar levels.
Ready, set, start counting!
¢
¢
Find out how many calories are in a single serving. It's smart to cut back on calories if
the weight has to be controlled.
The daily value is how much of a specific nutrient a person needs to eat in a day.
Percent (%) daily value tells how much of a nutrient is in one serving of
food–compared to the amount you need each day.
Check the serving size
Remember! one package may
contain more than one serving
Check calories
Limit these nutrients
Get enough
of these nutrients
}% Daily value*
Total fat 8g
Saturated fat 4.5 gram
12%
23%Trans fat 0 gram
Cholesterol 25 mg 8%
Sodium 105 mg 4%Total carbohydrate 12g 4%
Dietary fiber 0 gramSugars 12 gram
0%
Protein 8g
Vitamin A 8% Vitamin C 0%Calcium 30%
Iron 0%
Vitamin D 25%*Percent daily values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs:
Calories 2,000 2,500
Total Fat Less than 65 gram 80 gramLess than 20 gram 25 gramSaturated fat
Cholesterol Less than 300 mg 300 mg
Dietary fiber 25 gram 30 gram
Calories per gram:Fat 9 Carbohydrate 4 Protein 4
Total carbohydrate 300 gram 375 gramSodium Less than 2,400 mg 2,400 mg
••
•
Nutrition factsServing size 8 fl oz (240 mL)
Amount per serving
Calories 150 Calories from fat 70
Footnote
Quick guide to % daily value
5 % or less is low
20% or more is high
¢
¢
4
5
Tabl
e 3:
Cal
orie
s ch
art
Mea
l tim
ings
Men
u12
00 c
alor
ies
(am
t)
On
wak
ing
Mor
ning
7.0
0 a.
m.
Wat
er1
glas
s1
glas
s1
glas
s1
glas
s1
glas
s
Tea/
Coff
ee (n
o cr
eam
, no
suga
r)
Oat
mea
l por
ridge
(oat
s: o
ats
bran
1:1
) Coo
k oa
ts a
nd o
ats
bran
mix
ture
in w
ater
and
the
n
add
milk
1 cu
p (1
50 m
L)
1 so
up b
owl
(2 t
bsp
oats
) +
100
mL
skim
milk
1 cu
p (1
50 m
L)
1 so
up b
owl
(2.5
tbs
p oa
ts)+
150
mL
skim
milk
1 cu
p (1
50 m
L)
1 so
up b
owl
(3 t
bsp
oats
)+
150
mL
skim
milk
1 cu
p (1
50 m
L)
1 so
up b
owl
(3.5
tbs
p oa
ts)+
150
mL
skim
milk
1 cu
p (1
50 m
L)
1 so
up b
owl
(4 t
bsp
oats
)+
200
mL
skim
milk
1400
cal
orie
s (a
mt)
1600
cal
orie
s (a
mt)
1800
cal
orie
s (a
mt)
2000
cal
orie
s (a
mt)
Han
d po
unde
d/Re
d po
ha
(add
veg
gies
& s
prou
ts)
+ Low
fat
milk
(no
crea
m, n
o su
gar)
th
3/4
soup
bow
l
1 cu
p (1
50 m
L)
½ s
oup
bow
l
1 cu
p (1
50 m
L)
th
3/4
soup
bow
l
1 cu
p (1
50 m
L)
1 so
up b
owl
1 cu
p (1
50 m
L)
1½ s
oup
bow
l
1 cu
p (1
50 m
L)
Idli
(can
add
oat
s an
d ve
ggie
s)/
Dos
a* w
ith p
udin
a/ m
int
chut
ney
and
sam
bhar
Egg
whi
te o
mel
et*/
Boile
d eg
g
whi
tes
with
mul
tigra
in c
hapa
ti
Frui
ts (a
s pe
r the
por
tions
men
tione
d be
low
)
+ Wal
nuts
/Alm
onds
Sala
d (c
ucum
ber,
tom
ato,
car
rot,
lett
uce,
oni
on, r
adis
h)
+ Chap
ati
OR
Brow
n ric
e
+ Spro
uts
usal
/ Dal
(med
ium
cons
iste
ncy)
+ Curd
/But
term
ilk
(uns
alte
d/un
swee
tene
d)
OR
1 de
sser
t bo
wl
th3/
4 d
esse
rt b
owl
1 de
sser
t bow
l/1 g
lass
OR
½ s
oup
bow
l
1 de
sser
t bo
wl
1 de
sser
t bo
wl/1
gla
ss
OR
th3/
4 s
oup
bow
l
1/2
soup
bow
l
1 de
sser
t bow
l/1 g
lass
OR
1 so
up b
owl
th3/
4 s
oup
bow
l
1 de
sser
t bow
l/1 g
lass
OR
1½
sou
p bo
wl
1 so
up b
owl
1 de
sser
t bow
l/1 g
lass
11:0
0 a.
m.
Lunc
h
2 no
./2 n
o. (s
mal
l)
+ 1
bow
l
3 eg
g w
hite
s +
2 no
.
(5’’
diam
eter
)
1 po
rtio
n
3 no
.
1 qu
arte
r pla
te
2 no
. (5’
’ dia
met
er)
1 po
rtio
n
3 no
.
1 qu
arte
r pla
te
4 no
. (6.
5’’ d
iam
eter
)
1 po
rtio
n
3 no
.
1 qu
arte
r pla
te
3.5
no. (
6.5”
dia
met
er)
1 po
rtio
n
3 no
.
1 qu
arte
r pla
te
3 no
. (6.
5” d
iam
eter
)
1 po
rtio
n
3 no
.
1 qu
arte
r pla
te
2.5
no. (
6.5”
dia
met
er )
3 no
./2 n
o. (m
ediu
m)
+1
dess
ert
bow
l
3 eg
g w
hite
s +
2 no
. (6.
5’’)
3 no
./3 n
o. (s
mal
l)
+1
dess
ert
bow
l
3 eg
g w
hite
s +
3 no
. (6.
5’’)
4 no
./3 n
o. (s
mal
l)
+ 1
½ d
esse
rt b
owl
4 eg
g w
hite
s +
3 no
. (6.
5’’)
4 no
./3 n
o. (s
mal
l)
+ 2
des
sert
bow
l
1 w
hole
egg
+3
egg
whi
tes
+4
no. (
6.5’
’)
Pack
ed lu
nch:
6
Tabl
e 3:
Cal
orie
s ch
art
(tab
le c
ontd
...)
Mea
l tim
ings
Men
u12
00 C
alor
ies(
Am
t)14
00 C
alor
ies
(Am
t)16
00 C
alor
ies
(Am
t)18
00 C
alor
ies
(Am
t)20
00 C
alor
ies
(Am
t)
Sala
d (c
ucum
ber,
tom
ato,
carr
ot, l
ettu
ce, o
nion
, rad
ish)
+ Dal
par
atha
*
+ Cucu
mbe
r yog
urt
dip
Sala
d (c
ucum
ber,
tom
ato,
car
rot,
lett
uce,
oni
on, r
adis
h)
+ Chic
ken/
Fish
(oni
on b
ased
gra
vies
or g
rille
d) +
Chap
ati
Roas
ted
chan
na/R
oast
ed
soyn
uts/
Spro
uts
sala
d
+ Gre
en t
ea
Sala
d (c
ucum
ber,
tom
ato,
car
rot,
lett
uce,
oni
on, r
adis
h)
+ Chap
ati
Mid
- Eve
ning
Din
ner
1 qu
arte
r pla
te
2 no
. ( 5
’’ di
amet
er)
1 de
sser
t bo
wl
1 qu
arte
r pla
te
75 g
2 no
. (5’
’ dia
met
er)
1 ha
ndfu
l/1 q
uart
er
plat
e
1 cu
p (1
50 m
L)
1 qu
arte
r pla
te
2 no
. (5’
’ dia
met
er)
1 qu
arte
r pla
te
2 no
. (5.
5” d
iam
eter
)
½ s
oup
bow
l
1 qu
arte
r pla
te
100
g
2.5
no. (
6.5”
dia
met
er)
1 ha
ndfu
l/1 q
uart
er
plat
e
1 cu
p (1
50 m
L)
1 qu
arte
r pla
te
2.5
no. (
6.5”
dia
met
er)
1 qu
arte
r pla
te
2 no
. (6.
5” d
iam
eter
)
½ s
oup
bow
l
1 qu
arte
r pla
te
100
g
3 no
. (6.
5” d
iam
eter
)
1 ha
ndfu
l/1 q
uart
er
plat
e
1 cu
p (1
50 m
L)
1 qu
arte
r pla
te
3 no
. (6.
5” d
iam
eter
)
1 qu
arte
r pla
te
2 no
. (8”
dia
met
er)
1 so
up b
owl
1 qu
arte
r pla
te
100
g
3.5
no. (
6.5”
dia
met
er)
1 ha
ndfu
l/1 q
uart
er
plat
e
1 cu
p (1
50 m
L)
1 qu
arte
r pla
te
3.5
no. (
6.5”
dia
met
er)
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
1 qu
arte
r pla
te
3 no
. (6.
5” d
iam
eter
)
1 so
up b
owl
1 qu
arte
r pla
te
100
g
4 no
. (6.
5’’ d
iam
eter
)
1 ha
ndfu
l/1 q
uart
er
plat
e
1 cu
p (1
50 m
L)
1 qu
arte
r pla
te
3.5
no. (
6.5”
dia
met
er)
Brow
n ric
e
+ Usa
l/Dal
(med
ium
con
sist
ency
)/
Sam
bhar
/Ras
am
+ Curd
/But
term
ilk (u
nsal
ted/
unsw
eete
ned)
1 d
esse
rt b
owl
th3/
4 d
esse
rt b
owl
1 de
sser
t bow
l/1 g
lass
½ s
oup
bow
l
1 de
sser
t bo
wl
1 de
sser
t bo
wl/1
gla
ss
½ s
oup
bow
l
½ s
oup
bow
l
1 de
sser
t bow
l/1 g
lass
1 so
up b
owl
th3/
4 s
oup
bow
l
1 de
sser
t bow
l/1 g
lass
1 so
up b
owl
1 so
up b
owl
1 de
sser
t bow
l/1 g
lass
OR
OR
OR
OR
OR
OR
Brow
n ric
e1
dess
ert
bow
l½
sou
p bo
wl
th3/
4 s
oup
bow
l1
soup
bow
l1½
sou
p bo
wl
7
Tabl
e 3:
Cal
orie
s ch
art
(tab
le c
ontd
...)
Mea
l tim
ings
Men
u12
00 C
alor
ies(
Am
t)14
00 C
alor
ies
(Am
t)16
00 C
alor
ies
(Am
t)18
00 C
alor
ies
(Am
t)20
00 C
alor
ies
(Am
t)
Sala
d (c
ucum
ber,
tom
ato,
car
rot,
lett
uce,
oni
on ,r
adis
h)
+ Chic
ken/
Fish
(oni
on b
ased
grav
ies
or g
rille
d)
+ Chap
ati
1 qu
arte
r pla
te
75 g
2 no
. (5’
’ dia
met
er)
1 qu
arte
r pla
te
100
g
2.5
no. (
6,5”
dia
met
er)
1 qu
arte
r pla
te
100
g
3 no
. (6.
5” d
iam
eter
)
1 qu
arte
r pla
te
100
g
3.5
no. (
6.5”
dia
met
er)
OR
OR
OR
OR
OR
OR
1 qu
arte
r pla
te
100
g
3.5
no. (
6.5”
dia
met
er)
Brow
n ric
e 1
des
sert
bow
l ½
sou
p bo
wl
½ s
oup
bow
l1
soup
bow
l
OR
OR
OR
OR
OR
OR
1 so
up b
owl
Low
fat
milk
(no
suga
r/no
crea
m)
3–4
tsp/
pers
on/d
ay o
r 500
mL/
pers
on/m
onth
*All
mad
e in
less
oil
usin
g no
n-st
ick
pan
Bedt
ime
Oil
cons
umpt
ion
1 cu
p (1
50 m
L)
Pre
ferr
ed: C
anol
a oi
l,
grou
ndnu
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8
ExpertOpinion
Understand what stops people with diabetes from being active
Some of the reasons why people with diabetes avoid physical activity are:
Lack of time, for working individuals or who are occupied to look after dependants.
Lack of encouragement, support or companionship from family and friends.
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Dr. Vivek Mathew
MD, DM (Endocrinology)
Associate Professor, Endocrinology, St. Johns Medical College, Bangalore.
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Lack of self-management skills, such as the ability to set personal goals, monitor progress or reward progress toward such goals.
Lack of energy due to health complications, injury such as blisters.
Lack of appropriate weather conditions such as too cold or too hot weather, rainy 6season etc.
Being Active: Get Moving!
7The real reason we don't exercise is our desire to avoid any experience of discomfort – Sherry Pagoto.
Suggestions for overcoming physical activity barriers
Although exercise is one of the cornerstones of diabetes management, it remains by far the most underused. Given its positive health impact, it is critical that DEs encourage almost all of their diabetic and prediabetic people to become and remain regularly
6physically active.
6DEs must advise the following to their patients
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Adults with diabetes should be encouraged to engage in at least 150 minutes of moderate to vigorous intensity exercise per week. Physical activity should be planned in such a way that there is no more than two consecutive days without activity.
Younger individuals can also undergo shorter duration of vigorous intensity exercise, if “lack of time” is a limiting factor.
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Patients could also engage in resistance training on non consecutive days with 2 to 3 sessions per week.
For those that lack time to exercise, identify at least three 30 minute time slots that they could use for physical activity. People with diabetes should invite their friends and family members to exercise with them.
Patients should first convince themselves that if they give it a chance, physical activity will increase their energy level and then try it.
People with diabetes should learn how to warm up and cool down to prevent injury, and to exercise appropriately considering their age, fitness level, skills and health status.
8Simple ways to be more active
At home: Advise people with diabetes to walk their dog and play fetch, work in their
garden and clean their house.
At work: Advise them to walk to lunch, exercise in their chair, take the stairs and stand
while talking on the phone, reading or eating.
When out: Advise them to go dancing, talk a walk after dinner, wear a pedometer.
Prolonged sitting: Advice patients to move around every 30 minutes breaking the
prolonged sitting.
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Individuals with proliferative retinopathy, severe neuropathy and ischaemic heart disease should be guided to undergo medical evaluation before exercise is initiated.
If peripheral neuropathy is present, patients may benefit from switching to non-weight-bearing activities such as swimming or stationary cycling to minimise trauma and potential injury to their feet and lower extremities.
Mothers should exercise with their kids. They can go for a walk, play tag or other running games; they can also get an aerobic dance or exercise tape. This way they can spend time as well as exercise together.
Important pointers for DEs
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Advice patients to keep track of their activity which will help them feel good about themselves.
Older individuals may be encouraged to undergo flexibility and balance training like yoga which may also improve muscle strength.
Breaking activity into three 10 minute sessions throughout the day is as good as one 30 minute session. This can help them fit exercise into their schedule.
Even if they are inactive and out of shape now, they can improve their health by moving just a little more. Ask them to take small steps to add more movement into their daily lifestyle. In time, they will find that they are stronger and will be able to move even more.
Individuals on insulin and secretagogues could develop hypoglycaemia following physical activity and they may need to ingest carbohydrates pre exercise, if pre exercise plasma glucose is less than 100 mg/dL.
Patients should find themselves an exercise buddy as they are more likely to commit to regular physical activity
while being accountable.
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11
ExpertOpinion
What do patients need to know about the medications they use?
There are several types of medications that are often 9recommended for people with diabetes:
Insulin and pills that lower the blood sugar levels
Anti-hypertensive’s which lower blood pressure
Statins which lower cholesterol
Aspirin which lowers risk of heart attack
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Dr. Sunil Kumar Kota
MD (General Medicine), DNB (Endocrinology)
Consultant Endocrinologist and Diabetes, Thyroid Super-specialist, Diabetes & Endocare Clinic, Berhampur, Odisha.
Medications come with specific instructions for use and they can affect the body differently depending on when and how the patients take them. So it’s important for
patient to pay attention to how they feel and how their body reacts to each new medicine
or treatment. They should be able to understand if they’ve noticed any side-effects. It’s
also important for them to know the names, doses and instructions of the medications
they’re taking, as well as the reasons they are recommended for.
Taking Medications: Be Your Own Health Advocate
Patients should make a questionnaire list and DEs must answer these questions for their
benefit. It is better that the patient is well-versed with medication names and side-effects 9 in case of emergency. In addition, a diabetes medicines checklist should be provided by
DEs to their patients.
10Strategies for remembering to take medicines on time
If patients often forget to take their medication, they should try to remind themselves by
linking it to a specific activity such as watching the news every night or brushing teeth.
Advise patients to set an alarm on their clock radio or cell phone as a reminder.
The patients can use technology such as smartphones and other handheld devices that can
provide texts, emails or other reminders to help them keep track of their medication
schedule.
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Important pointers for DEs
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DEs must help patient’s to fit medication routine into their daily schedule.
Some over-the-counter products, supplements or natural remedies can interfere with the effectiveness of prescribed medicines. DEs must ask their patients about any supplements they take so that the DE can make the best recommendations for their care.
There is a very high lack of knowledge among patients regarding the medications they use, this should be
corrected to ensure and attain positive clinical results.
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13
ExpertOpinion
Why is it important to have a glycated haemoglobin (HbA1c) target?
For women with diabetes who are planning to 11conceive
It is very important to have a strict diabetes management plan in order to deliver a healthy baby. Uncontrolled diabetes has its effects on the baby and the mother. Some of the effects on the baby are early delivery of infants, loss of the foetus in vitro,
birth defects, baby weighing more than 10 pounds.
Dr. Ashok Jhingan
MD, FIAMS
Diabetes Education and Research Foundation, Primus Super Speciality Hospital, New Delhi.
Some of the risks for the mother are increased bladder and urinary tract infections, high
blood pressure and/or protein in the urine, problems with delivery, possibly requiring
C-section.
An HbA1c of <7.0% is recommended in most patients. A 1% increase in HbA1c levels is
associated with a 17%–35% increase in the risk of cardiovascular disease and a
15%–25% increase in the risk of mortality in subjects with T2DM. In non-diabetics, a
1% increase in HbA1c, increases all-cause mortality risk by 26%.
12To avoid too many complications
Monitoring: Cornerstone of Glucose Monitoring
13Types of monitors
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Traditional fingerstick: These glucometers show blood glucose at a specific
moment in time.
Alternate site monitoring: Some meters require a small drop that can be obtained
by a blood sample from a less-sensitive body part (like the forearm).
Continuous glucose monitoring (CGM): A tiny sensor is worn below the skin,
usually on the abdomen or arm, for about a week at a time. A transmitter attached to the sensor sends a signal wirelessly to a handheld receiver which displays the current glucose level and graphs of recent values. CGM also shows decision that can be made regarding food, activity and insulin/medications.
Tip
If patients want to see how their body responds to meals, ask them to wait for 1–2 hrs after eating to check their blood sugar levels as 14the peak blood glucose levels are often likely to occur around two hours after meals.
12Make blood glucose monitoring as painless as possible
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Advise patients to choose a meter that requires a very small blood sample.
Use the thinnest lancets possible (33 gauge or higher) and change them regularly.
Use a lancing device that has an adjustable tip, and set it for the lowest setting that still produces a sufficient blood drop.
Prick the sides of the fingers rather than the tips and “milk” the finger after pricking. rd th thUse the 3 (middle), 4 (ring) and 5 (pinky) fingers on each hand and rotate the sites.
Consider obtaining blood samples from an “alternate site” rather than the fingers.
Important pointers for DEs
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DEs should also monitor long-term blood sugar 13control – HbA1c, estimated average glucose (eAG),
blood pressure, weight, cholesterol levels for cardiovascular health, urine and blood testing for good functioning of kidneys, dilated eye exams to avoid complications in the eye, and foot exams and sensory testing to avoid ulcers and diabetic foot.
Tiny bits of food and sugar on the hands can cause a disturbance in meter readings, patients should be sure to wash up before each test.
Tight glucose control reduces complications in diabetes.
14
ExpertOpinion
Are you travelling or is there a change in 15your routine?
Changes in routine can present a number of difficulties from meal times to medication schedules. Shift work can alter the body’s circadian rhythms which respond to natural daylight
15 and darkness. Consequently, blood sugar levels can be affected thereby altering sleep times which can lead to hyperglycaemia or hypoglycaemia. Changes in sleep or shift
16times can also affect your eating pattern during the day.
Dr. Salam Ranabir
DM (Endocrinology), FACE
Associate Professor, Medicine,Regional Institute of Medical Sciences, Imphal, Manipur.
Changing routines is a complex process and involves more than simply rearranging blocks
of time. Daily routines influence the integration of diabetes self-management (DSM) into
daily life. A study showed that integrating DSM into daily life involves changing behaviours and learning new skills, both of which require modification of established routines. A key finding in a study mentions that modification of existing routines is often challenging because routines become habits and are therefore undetectable to those needing to change them.
A strong encouragement and support from family and friends can help overcome this
issue.
Problem Solving: Unfortunate Changes Associated with Diabetes
17General travel tips
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Patients should pack more test strips, insulin, syringes, pens and other diabetes equipment than they will need for the trip. They should also pack a spare meter in case of loss or damage.
They should have a written note on details of emergency contacts.
If flying, insulin, syringes/pens and testing equipment should be kept and divided between two pieces of hand luggage.
To help prevent deep vein thrombosis and to make the trip more comfortable, patients are advised to move about the cabin and do the chair-based exercises regularly.
If the patient is travelling overseas, he/she must make be prepared for different foods, changes in time zones and extreme climates as well as being prepared for mishaps such as delays and misplaced baggage. Planning a trip for a person with diabetes is important.
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Important pointers for DEs
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DEs must advise patients that it is healthier to prepare home-cooked meals in advance to ensure they are eating nutritious food. Planning meals days in advance can be used so they are not rushing to cook food in-between shifts.
Advise them to bring their own healthy snacks to work rather than buying something processed from a shop or a vending machine.
Patient should always be prepared to treat low glucose while travelling as travelling may disrupt their normal
routine for both eating and dosing insulin. Patients should pack extra diabetes supplies and keep it handy,
so that they could easily access it when required.
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Emotions that arise when patients 18think of diabetes
Diabetes can affect a person, physically and emotionally. Living with it every day can make one feel discouraged, angry, stressed or even depressed. It is natural to have mixed feelings about diabetes management and experience highs and lows. It is important to recognise these emotions as normal and to take steps to reduce their negative impact on life.
The way a person deal with emotional lows is called “coping.” There are lots of ways to
cope with the lows in life—and not all of them are good for health (smoking, overeating, 18not finding time for an activity or avoiding people and social situations).
However, there are healthy coping methods that one can use to get through tough times 18(faith-based activities, exercise, meditation, enjoyable hobbies, joining a support group).
Healthy Coping: Pave Your Way through Recreational Activities
Activities that can help them work through these emotions
Having a support network
is key to healthy coping.
Some examples of healthy coping methods are:
Gardening
Gardening can provide aerobic activity, strength and flexibility training. It can also fulfil the need to be outdoors, breathing fresh air in the sunlight.
19Aquatic exercise
Performing aerobic exercises in the pool is a great low-impact exercise because the water helps to support a person’s weight, it can reduce the stress on the feet and joints and it provides resistance which helps to strengthen muscles. Simply walking in the water helps improves mobility, gait and balance all of which are important for elders.
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ExpertOpinion
Dr. Shrinivas A. Patil
MD, DM (Endocrinology)
Consultant Endocrinologist and Diabetologist, Unique Diabetes, Thyroid and Hormone Care Centre, Sangli, Maharashtra.
20,21Art therapy
Art therapy can help someone with diabetes regain a sense of control and maintain a feeling of independence through painting, drawing and colouring. Some of the benefits of art therapy are it increases self-esteem and confidence, provide relaxation and balance, taps into one’s creative side; help break through rather than breakdown and assists personal growth and insight.
22Diabetes Conference 2018
Mind, body and spirit: Creating balance through diabetes education and support by AADE.
A diabetes conference and product fair were held at Holiday Inn, Saratoga Springs, NY 12866 on
Friday, April 13 to Saturday, April 14, 2018. Thought-provoking topics like Strategies to
“weather the storm”; mindful management of inpatient glycaemic control; exercise and diabetes:
from evidence to practice; American Diabetes Association (ADA) standards of medical care in
diabetes – 2018 were discussed.
Important pointers for DEs
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DEs should observe the behavioural change in patients. Some of the symptoms are decreased interest or pleasure in activities, avoids discussing diabetes with family and friends, sleeps most of the day and feels like diabetes is conquering himself/herself.
Physical activity can influence their mood. If patients are sad, anxious, stressed or upset, ask them to go for a walk, stand up and stretch or take a bicycle ride. Exercise increases the hormones in the brain that will help them feel good.
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It is important to understand that treating emotional health of people with diabetes is as important as treating their physical needs.
Introduction
Diabetic foot complications are one of the main reasons for diabetes-related hospitalisation and lower extremity amputations. This condition can be managed and patients can avoid amputations due to improper diagnostic and
23therapeutic approaches.
Diabetic Foot: Protect to Prevent
The risk of ulcers or amputations is increased in people who have the following risk
factors: poor glycaemic control, peripheral neuropathy with loss of protective sensation (LOPS), cigarette smoking, foot deformities, pre-ulcerative callus or corn, peripheral artery disease (PAD), history of foot ulcer, amputation, visual impairment, diabetic kidney
23disease (especially patients on dialysis).
ADA 2018 recommends that all people with diabetes should have their feet inspected at every 23 visit.
Dermatological assessment
Skin status: Colour, thickness, dryness, cracking sweating
Infection: Check between toes for fungal infection
Ulceration calluses/blistering: Haemorrhage into callus
24Some pointers for a comprehensive examination
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Key components of the diabetic foot exam
Musculoskeletal assessment
Deformity (e.g., claw toes, prominent metatarsal heads, Charcot joint)
Muscle wasting (guttering between metatarsals)
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ExpertOpinion
Dr. Masood Batin
MD (Medicine)
HOD, Department of Medicine and Diabetology (Diabetic Clinic In-charge), Mission of Mercy Hospital and Research Centre, Kolkata.
Neurological assessment
10 g monofilament + 1 of the following four
– Vibration using 128 Hz tuning fork
– Pinprick sensation
– Ankle reflexes
– Vibration perception threshold
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23Foot Care Guidelines by ADA 2018
The examination should include inspection of the skin, assessment of foot deformities,
neurological assessment (10 g monofilament testing with at least one other assessment: pinprick,
temperature, vibration) and vascular assessment including pulses in the legs and feet.
Important pointers for DEs
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DEs should provide general preventive foot self-care education to all people with diabetes.
DEs should recommend a broad and square toe box, laces with three or four eyes per side, padded tongue, quality lightweight materials and sufficient size to accommodate a cushioned insole as general footwear recommendations for people with diabetes.
Hyperbaric oxygen therapy (HBOT) in patients with diabetic foot ulcers has mixed evidence supporting its use as an adjunctive treatment to enhance wound healing and prevent amputation. HBOT should be a topic of shared decision making before treatment is considered for selected patients with diabetic foot ulcers.
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Recognising the importance of starting treatment early may allow DEs to prevent progression to severe
and limb-threatening infection and halt the possibility of amputation.
Clove
An equivalent of one or two cloves per day helps to improve cardiovascular and diabetes risk factors in
25T2DM.
Role of Spices in Fighting Diabetes
High levels of circulating insulin can lead to many of the secondary signs of diabetes such as 25nerve, kidney and eye problems as well as build-up of plaque in the arteries. Cinnamon
increases insulin efficiency and hence is very helpful in diabetes.
Cinnamon
Garlic has been recommended to help reduce high cholesterol levels and high blood pressure thereby reducing the incidence of heart disease. Raw garlic might help reduce blood sugar levels as well as reduce the risk of atherosclerosis. This is particular interest as diabetes
26increases a person’s risk of atherosclerosis-related inflammation.
Garlic
Ginger is a popular herb known for its intense, spicy flavour and warming aroma. A clinical study showed that ginger inhibits enzymes that affect how carbohydrates are metabolised and insulin sensitivity as a whole, thereby leading to greater glucose absorption in the muscles. Ginger also has the potential to help reduce the risk for diabetes complications due
27to its lipid-lowering effects.
Ginger
21
ExpertOpinion
Dr. P. Mithun Chakravarthy
MD (General Medicine), DM (Endocrinology)
Consultant, GSL Medical College and Hospital; Lalitha Endocare and Skincare, Rajahmundry,Andhra Pradesh.
The seeds contain fibre and other chemicals that may slow digestion and the body’s absorption of carbohydrates and sugar. A study showed that daily dose of 10 g of fenugreek seeds soaked in hot water may help control T2DM. Another study suggested that eating baked goods such as bread made with fenugreek flour may reduce insulin resistance in people with
28T2DM .
A quick guide to use spices
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The recommended doses of turmeric by The University of Maryland’s Complementary and
Alternative Medicine Guide are:
– Cut root: 1.5–3 g per day
Dried or powdered root:1–3 g per day
Fluid extract (1:1): 30–90 drops per day29Tincture (1:2): 15–30 drops, 4 times per day.
A pinch of turmeric on scrambled eggs, on top of roasted vegetables, rice, in soup or just to a plain glass of milk.
While preparing green tea, it is recommended to add ginger as it adds to the flavour as well as helps keep the upper respiratory tract clear. To prepare basil ginger tea: Take one cup of water, add 5 basil leaves, 3–4 ginger slices, 1
thtsp tea leaves and 1/4 cup of milk. Boil for 5 minutes and remove from heat. Strain and 30serve. Add honey to replace sugar.
Soak a cinnamon stick in warm water and drink it with a drop of honey about two-three times a 31day, this helps soothe a scratchy throat
Mix cloves, basil, cardamom and mint in tea and replace the sugar with honey. This drink will 32calm nerves and help de-stress.
Fenugreek seeds (methi dana): Soaked fenugreek seeds can be consumed on an empty stomach. This will help relieve acidity. Methi dana is excellent for regulating blood sugar. People with diabetes benefit a great deal from consuming fenugreek water. Sprouted
fenugreek is even better as it has 30–40% more nutritive properties over soaked fenugreek 33seeds.
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The art of seasoning
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Fenugreek seeds
Important pointers for DEs
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When spices are consumed in moderation, health benefits can be derived, however, an overdose of any spice can lead to indigestion or even ulcers.
Black pepper aids in digestion, congestion, an upset stomach and can also help stop the bleeding on a cut when applied topically. It also has all the essential nutrient contents. It promotes weight loss and relieves toothache.
DEs must recommend patients to make optimal use of the resources provided by nature.
34Effectiveness of curcumin in diabetes
A study found that people with prediabetes who were given curcumin for a period of 9 months were less likely to develop the full-blown condition.
Controls blood sugar
Protects against diabetes
Improves function of β-cells that make insulin in the pancreas
May reduce diabetes-related complications: In a clinical study, researchers gave test subjects curcumin over a long period of time. As a result, these people appeared to have fewer symptoms of liver disorders. The compound curcumin was also reported to be active against diabetic vascular disease, and it seems to speed wound-healing
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The use of spices and herbs should be a part of patient’s nutritional diet plan as they have demonstrated their effectiveness in
lowering blood glucose, boosting insulin sensitivity, reducing high blood pressure and cholesterol, etc.
Introduction
There is a gap in the knowledge for when, what and how Diabetes Self-Management and Educational Support (DSMES) should be provided for adults with T2DM to maximise outcomes. To address this gap, a position statement containing an algorithm of DSMES was written with a goal to provide healthcare teams, with information to better understand the diabetes education and support
35process and how it can be integrated into routine care.
Diabetes Care in Practice
Critical stage 1
Diagnosis: This is an important time to initiate the education process for daily
self-management. All newly diagnosed people with T2DM should receive DSMES and medical nutrition therapy (MNT).
35Four critical times to assess provide and adjust DSMES
Critical stage 2
Annual assessment: A patient may be within target on HbA1c goals yet could benefit
from having additional education and support.
It includes:
Patients with long-standing diabetes and limited prior education
Patients that have a change in medication, activity or nutritional intake
Patient if pregnant or planning to conceive
Patients with HbA1c out of target can also be considered
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Critical stage 3
New complicating factors: Health conditions such as renal disease or stroke; emotional factors such as anxiety and clinical
depression, etc.
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ExpertOpinion
Dr. H. Babul Reddy
MD (General Medicine),DNB (General Medicine),DM (Endocrinology)
Consultant Endocrinologist, KIMS Hospitals, Kondapur, Telangana, Hyderabad.
Critical stage 4
Transitions in care: They are referred as times to re-evaluate diabetes care goals and self-
management needs such as insurance coverage that results in treatment change and/or age that affects self-care (e.g., to adulthood or age-related cognitive decline).
35An example of integrating DSME in routine care
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Patient profile: Ms. Sophie is 58-year-old woman with T2DM since 5 years
Medication: Metformin (1000 mg, twice a day).
Health conditions: Hypertension, hyperlipidaemia, obesity and depression (she takes an
additional 4 pills a day for these conditions). Over the past 5 years, Sophie’s HbA1c has been <8%. Now, it is 8.5%.
Solution: Ms. Sophie is at critical stage no. 2 (annual assessment of education, nutrition, and
emotional health needs).
– She needs ongoing support as it is critical for maintaining behavioural change(s).
– Her lifestyle decisions and changes can affect HbA1c levels; therefore there is a need to review her eating patterns and
activity.
– It is important for DEs to understand that diabetes is a progressive disease and that she may need medication change
based on food patterns, activity, and glucose patterns.
– Diabetes can be a burden; therefore helping Ms. Sophie cope with the ongoing burden of diabetes is required. The DE should counsel her and her caregivers or family members.
Important pointers for DEs
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DEs must understand that sometimes managing diabetes gets over-whelming for patients, therefore there is a need to simplify overall self-management plan and adjust goals.
Maintaining contact for continued evaluation, support and adjustments addresses critical factors that promote positive clinical, psychosocial and behavioural outcomes.
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The ongoing process of facilitating the knowledge, skill, and ability are necessary for diabetes self-care. Standardised DSME
is strongly associated with a substantial improvement in people with diabetes.
Introduction
Ramadan (Sawm) is one of the five pillars of Islam. Its literal meaning is “to refrain”. This holy month is intended to teach Muslims self-discipline, self-restraint and sympathy for the poor. Although people with diabetes are exempt from fasting
36according to the Holy Quran, many still choose to.
Fasting During Ramadan
Muslims who have diabetes should be made aware that they should have a full medical assessment and education at least 2 months 36 37,38before Ramadan begins because there are some major complications associated with fasting in people with diabetes.
Hypoglycaemia: Decreased food intake is a well-known risk factor for hypoglycaemia.
Hyperglycaemia: Hyperglycaemia can result in osmotic diuresis and result in volume and electrolyte depletion.
Dehydration: Restraining of fluid intake during the fast for a prolonged period.
Dyselectrolytaemia: Abnormalities in fluid, blood concentration and urinary excretion of electrolytes are seen in people with
diabetes during fasting.
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Pre-Ramadan counselling for people with diabetes
Other exemptions include the old and frail, the acutely unwell, those with chronic illnesses
in whom fasting would be harmful to their health, children under the age of puberty, those
with learning difficulties, those who are travelling, women who are menstruating, 36pregnant or breastfeeding women.
26
ExpertOpinion
Dr. Rajesh Agravval
MD
Diabetes Thyroid Overweight & Hormone Specialist, DOT Clinic, Indore, Madhya Pradesh.
Ensuring the safety of fasting in people with diabetes
39Increase safety by learning the warning symptoms
37 Maintain glycaemic control
40 Adjusting medications as per the food intake
40 Avoid hypotension
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Hyperglycaemia: Increased thirst, frequent urination, increased hunger
Hypoglycaemia: Sweating, rapid pulse, shakiness, dizziness, weakness
Patients should test blood glucose before and 2 hours after Iftar, before Sohur and at mid day. It should be stressed that its essential for patients to at least do frequent self-monitoring blood glucose test systems (SMBGs) in the first few days of fast so that they become aware of their glycaemic profile with the changed level of meal intake and with altered dosage of medications and/or insulin.
The choice of oral anti-diabetes drug (OAD) should be individualised. In general, OADs that act by increasing insulin
sensitivity are associated with a significantly lower risk of hypoglycaemia than compounds that act by increasing insulin secretion. Changes of medications should be individualised depending on diet
and lifestyle, risk of hypoglycaemia and baseline glycaemic control. In patients with well controlled
diabetes oral hypoglyceamic agent (OHA) timing may require change . Secretogogue to be avoided.
The dosage or the type of anti-hypertensive medication or both may need to be adjusted to prevent hypotension.
41Benefits of fasting
Fasting may provide a way to reduce calories intake, weight loss, smoking cessation and life style modification. For people with diabetes who choose to fast, Ramadan may help to strengthen the therapeutic alliance between patient and physician and may
provide an opportunity to improve diabetes management with a focus on self-care and the regulation of medication and meal timing.
27
Important pointers for DEs
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DEs must recommend dietary advice as it is traditional to break the fast with dates and milk. However, for people with diabetes, dates should be limited to a maximum of three. It is a common practice of in taking large amounts of foods rich in carbohydrate and fat, especially at the sunset meal, this should be avoided.
An important part of the management is to educate individuals with diabetes and their family and alter their therapy with clear guidance.
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Don’t skip Suhoor (pre-dawn meal). Due to the longer hours of fasting, a person is more likely to feel dehydrated and tired
during the day. Furthermore, skipping Suhoor also encourages overeating during Iftar, which can cause unhealthy weight gain.
People with diabetes themselves are responsible for day-to-day management of their
diabetes, which requires considerable time and effort.
ExpertOpinion
42Overview of vulvovaginal candidiasis
Vulvovaginal candidiasis is a common infection worldwide in women, and its incidence has increased in the past decade. Hyperglycaemia is the major cause of increased susceptibility of people with diabetes to vulvovaginal candidiasis. Increased glucose levels in genital tissues enhance yeast adhesion and growth.
Dr. Shruti Khare-Aterkar
MD (Medicine), DM (Endocrinology)
Consultant Endocrinologist and Diabetologist, Department of Endocrinology and Diabetology, Shalby Hospital, Ahmedabad, Gujarat.
Diabetes and Women’s Health: Diabetes –A Predisposing Factor to Vaginal Infections
Patients typically complain of irritation, itching, and burning. Symptoms are often prominent just before the patient's menstrual
period.
43Clinical manifestation and evaluation
On examination, the clinician will often encounter vulva and vaginal erythema, excoriations, thick white adherent discharge, and swelling. Some patients will have little to no discharge.
To diagnose this condition, the clinician should perform a pelvic exam, a vaginal wet mount, pH testing, and testing to exclude other aetiologies of vaginal discharge and infection (specifically gonococcal and chlamydial disease).
In patients with candidal vulvovaginitis:
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Inflammation is evident during a pelvic exam.
The cervix is typically normal and not inflamed.
Cervical motion tenderness and abnormal discharge from the cervical os is absent.
The vaginal pH is typically less than 5.
On a vaginal wet mount, Lactobacillus is noted as the prominent bacteria and also
most likely inflammatory cells are observed.
29
¢Whiff test is negative (a fishy odour when potassium hydroxide is applied to the discharge on a slide). After potassium hydroxide application, budding yeast, hyphae, or pseudohyphae is observed on microscopy.
42Management in people with diabetes
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¢
women with diabetes
Proper glucose control is important in the the management of vulvovaginitis in women with diabetes.
Patients should also be advised to keep Lactobacillus topical agents as the standard
first-line therapy for vulvovaginitis in .
Important pointers for DEs
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¢
Proper control of glucose is paramount in management of this infection.
Before starting any anti-fungal therapy it is important to note para-clinic findings, positive culture for vaginitis with or without presenting signs of Candida
vaginitis, especially in those with risk factors such as diabetes mellitus.
In patients treated with oral sulphonylureas, oral antifungal agents may affect glucose control because of potential drug interactions resulting in increased blood sulphonylurea levels and hypoglycaemia.
Although vaginitis is not a dangerous disease, it can be disabling and upsetting to patients. It is important to address social issues and sexual dysfunction in addition to the infection itself.
30
If diabetes is not well controlled and blood sugars are consistently high; this creates an environment of high sugar in the mucus
membranes and develops an environment for the overgrowth of both bacteria and yeast causing vaginal infection in women.
ExpertOpinion
Introduction to oesophagal candidiasis (thrush)
Oesophageal thrush is a fungal infection of the oesophagus. The condition is also known as oesophageal candidiasis. Fungi in the family Candida cause oesophageal thrush. There
are about 20 species of Candida that can cause the 44 condition, but it’s usually caused by Candida albicans.
Traces of the fungus Candida are normally present on the
surface of the skin and within our body.
Ms. A. Hema
MSc
Dietitian & Diabetes Educator Dr. Mohan’s Diabetes Specialities Centre, Madurai.
Reduce Your Risk: Don’t Forget the Dentist
Normally immune system can regulate the good and bad organisms in our body. Sometimes, though, a shift in the balance between the Candida and our healthy bacteria
can cause the yeast to overgrow and develop into an infection.
Oesophageal candidiasis is one of the most common opportunistic infections in patients with impaired cellular immunity, such as human immunodeficiency virus (HIV) infection.
However, it can be found in individuals with no HIV infection and no evidence of 45opportunistic infections to suggest immunodeficiency.
Why are people with diabetes at risk for oral thrush?
Risk factors
In uncontrolled diabetes, there is too much of sugar in the saliva and
also importantly, uncontrolled diabetes hurts the immune system, which helps the Candida to survive and thrive. The increased incidence
of gastroesophageal reflux, as well as Candida infections are examples
of aggravating factors. In addition, a number of structural changes 46occur in the oesophagus in people with diabetes.
People who are healthy have fewer chances of developing this infections. People with compromised immune systems, such as those with HIV, AIDS, cancer or older adults are at higher risk. People with
diabetes are also at an increased risk of developing oesophageal thrush and other oesophageal disorders, especially if the blood sugars are not under good control.
31
Patients with oesophageal candidiasis may remain asymptomatic or may present with one of the classic symptoms of infectious oesophagitis, such as dysphagia, painful swallowing and chest pain. The other insignificant symptoms may include as those of nausea, vomiting and bleeding gums. It is also possible for the infection to spread to the inside of the mouth and become oral thrush.
Creamy white patches on the inside of the cheeks and on surface of the tongue
White lesions on the roof of the mouth, tonsils and gums
Cracking in the corner of the mouth
In uncontrolled diabetes, these symptoms are neglected by patients or confused with
indigestion till it worsens and becomes difficult for management. Hence proper management of earlier stages isrecommended.
Oesophagogastroduodenoscopy with brushings and biopsy remains the most sensitive and specific method for oesophageal candidiasis diagnosis. Endoscopy demonstrates scattered or coalescent yellow-white mucosal plaques which confirm the diagnosis. Although oesophageal candidiasis in the majority of cases, is an incidental finding during
o , its detection and treatment can provide significant
symptomatic relief to patients.
The goals of treating oesophageal candidiasis is to kill the fungus and prevent it from
spreading. This prevents the fungus from spreading and works to eliminate it from the body.
The medication can come in a variety of forms, such as tablets, lozenges, or a liquid that you can swish in your mouth like mouthwash and then swallow. Strict control of diabetes along with treatment for oesophageal candidiasis is recommended for people with diabetes.
The symptoms of oral thrush include:
¢
¢
¢
esophagogastroduodenoscopy
Future health complications
The risk for complications after the development of oesophageal candidiasis is higher in people with comprised immune systems. These complications becomes significant as oesophageal candidiasis spreads to other areas of the body. People with diabetes and those who have oesophageal candidiasis are even at higher risk as their chances of
increasing the infections and its spread to the other organs such as liver, intestine, lungs are faster which becomes difficult to control. The spread can be controlled and reduced when proper treatment for oesophageal candidiasis is given along at early stages with strict control of blood sugars. If untreated the infection and its spread can be severe and life-threatening. Prompt and careful treatment can reduce the pain and discomfort.
32
Symptoms
Important pointers for DEs
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¢
¢
¢
¢
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¢
Good glycaemic control: Ensure that all the four pillars of diabetic management are followed religiously for control of blood sugars.
Understanding diabetic complications: Educate the patient regarding the complication of disease.
Ensure good oral hygiene: to have a regular follow-up with the dentist to ensure good oral hygiene along with blood sugar control.
Treat yeast/fungal infection: Educate the patient to visit the consultant to treat the infection on earlier stages.
Limit the carbohydrate/Yeast foods: Educate the patient to limit the foods that contain excessive yeast and sugars.
Include probiotics when on antibiotics: Educate the patient to include more curds, dhokla, etc.
Educate the patient
Early treatment along with good control of diabetes would prevent the treatment of oesophageal candidiasis.
33
Oesophageal thrush can be painful. If it is left untreated, it can become a severe and even life-threatening condition; reducing
glucose levels and maintaining oral hygiene can help control this condition.
For a T2DM patient, keeping a log of daily glucose readings, exercise, medications and food items can be crucial. The BlueStar app, this is where the application comes in handy; for the real-time management of a patient. With the touch of a fingertip, the app on the phone gives a patient a 24 hrs guide and support, clinical decisions, the timing of blood sugar tests, medications dosage as well as
47helps in sending reports back to the doctor in question.
Tools in Diabetes: BlueStar – The Perfect App for Diabetes Prescription
48How does BlueStar help?
¢
¢
¢
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Receive real-time, precise and personalised feedback: BlueStar serves up 1 of 12,000+
unique messages in real-time.
Raise diabetes IQ and manage diabetes better: BlueStar includes access to numerous interactive tools, articles, and videos from diabetes experts. BlueStarU, developed in partnership with the AADE, offers diabetes education in short, easy-to-read lessons that are based on diabetes treatment
plan. People can submit their general diabetes
questions to ask an educator and get answers
from certified DEs.
Connect instantly with a care team: With BlueStar’s smart visit reports, a patient can instantly share their diabetes data and
trends with any member of their care team.
Real-time medication management assistance: BlueStar helps patients calculate their meal-time insulin dose.
48Clinical evidence
Clinical evidence published in the journals of diabetes technology and therapeutics, diabetes care, health communication and many more show a mean reduction of 1.7 to 2.0 point HbA1c drop for individuals living with T2DM who used the BlueStar app.
BlueStar should not be used by people with type 1 diabetes, gestational diabetes
or who use an insulin pump. BlueStar is not intended to replace the care provided by a 49licensed healthcare provider.
This app is available on iOS and Android.
Caution:
34
An algorithm with the insights of an ophthalmologist developed by leading retina specialists, IDx-DR is the first and only FDA authorised artificial intelligence system for the detection of diabetic retinopathy.
Using the Topcon NW400, any trained staff member can capture high quality retinal images and submit them to IDx-DR. The diagnostic algorithm analyses the images, searching for the same signs of disease that a clinician would, without the need for a clinician to interpret the image or results.
High performance in real-world clinical settings
Results in less than a minute
Minimal operator training
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High performance in a real-world clinical setting
In a 2017 US. clinical trial involving 900 subjects with diabetes, IDx-DR demonstrated
87% sensitivity and 90% specificity at detecting more than mild diabetic retinopathy in fundus images.
Future Trend: IDx-DR – An Artificial Intelligence System that Detects Diabetic Retinopathy in Primary Care
50How IDx-DR works?
Using a fundus camera, the trained operator captures two
images per eye.
The images are submitted to the IDx-DR client on a
local computer.
IDx-DR analyses images for signs of diabetic retinopathy, providing results in less than a minute.
Negative: For more than mild diabetic retinopathy. Retest in 12 months.
Positive: For more than mild diabetic retinopathy.
Refer to an eye care professional.
IDx-DR outputs
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Outputs include JPG, PDF, and XML files
Easy to read results with three possible outcomes:
– Exam quality insufficient
– Negative for more than mild diabetic retinopathy: Retest in 12 months
– More than mild diabetic retinopathy detected: Refer to an eye care professional
35
Diabetes Educator of the Month
A 48-year-old man was suffering from diabetes for the past 5 years. He had not checked his sugar levels in the last4 months. He stands 5 feet 8 inches tall and weighs 95 kgs. He has a non-healing ulcer under his left foot since the last4 weeks. He visited a DE to seek advice on lifestyle changes that needs to be adopted to get his diabetes under control.
Contributed by
Ms. Shefa Syed
Post Graduate Diploma in Clinical Nutrition and Dietetics, Graduation in Food Science and Nutrition
Health Coach, Nurture Health Solutions.
Following sections are contributed
by Nurture Health Solutions
Nurture Health Solutions is a true health and well-being
company offering niche comprehensive health and
wellness solutions to corporates and individuals.
Intervention by DE
The DE took a detailed history of him and noticed that he has been following a very erratic lifestyle. Four months ago, his HbA1c was 12%. His eating habits were very unhealthy. DE counselled him to check his recent blood sugar levels. DE also advised him to visit a
qualified podiatrist for the treatment of his foot ulcer. DE explained him that the ulcer is not healing
because of high blood sugar levels. He has diabetes for the last 5 years and therefore he must be
careful about complications like diabetic foot, diabetic retinopathy, neuropathy and nephropathy.
The podiatrist diagnosed the ulcer as grade 1 diabetic foot ulcer according to Wagner diabetic foot
ulcer system. He underwent debridement of the ulcer and was advised a strict dietary regimen post
debridement for healing of the wound. DE advised him a healthy eating pattern with regular meal timings. DE advised adequate fibre and protein intake for maintaining his blood glucose levels. Healthy low carbohydrate and low-calorie snacks options were also advised.
Post debridement the DE counselled him on the diabetic foot care guidelines to prevent diabetic foot in the future. DE asked him to inspect his feet daily for any sores or blisters. He was instructed to always wear thick and soft socks (avoid slippery stockings), use a good moisturiser on heels and feet but not between the web spaces of the toes as the area between the toes is prone to dampness which promotes an environment for infections.
DE got him introduced to a diabetic shoe specialist who designs footwear keeping in mind the kind and size of the wound. The footwear is designed in such a way that while walking there is less pressure on the area of the wound which is known as off-loading.
DE also explained him that inadequate sleep and stress can also affect the blood glucose levels. Good sound sleeps for 6–8 hrs is recommended and yoga or meditation 10–15 mins in a day will help him to de-stress and keep his blood glucose levels in the normal range. DE also advised him to
lose weight as he was obese. Low calorie dietary regimen with adequate fibre and protein sources was planned to help him lose weight and control his blood glucose levels. He was asking to offload his feet as much as possible for complete wound healing. He followed the foot care guidelines and dietary regimen as advised. With time, his wound healed completely and sugar levels were also under control. He was now on the path of living a healthy lifestyle.
36
Busting the Myth: Diet or Health Foods Do Not Raise Blood Glucose Levels. People with Diabetes can Eat them in Liberal Amounts
Fact: Diet or health foods generally offer no special benefit. Most of them still raise
blood glucose levels and are usually more expensive. Foods which are labelled sugar free are usually high in fat and those labelled fat free are usually high in sugar.
All diet foods provide carbohydrates (glucose) and calories. Eating too much of any food will give rise to blood glucose levels which will further increase requirement for insulin for glucose uptake into the cell. Be aware of the fact that not all diet/health foods are genuine. The brown bread could be made of caramelised sugar and refined flour and will spike the blood glucose levels more than the regular bread. Most diet foods are also high in sodium and can raise blood pressure levels which can prove detrimental to our health.
37
Get Active!
Aerobic exercise and diabetes
The adoption and maintenance of physical activity are critical for blood glucose management and overall health in individuals with pre-diabetes and diabetes.
Aerobic exercise helps the body use insulin better. Aerobic activity involves walking, jogging, running, cycling, swimming, dancing or playing tennis.
It is mandatory for people with diabetes to seek a proper guidance from a DE if they wish to go beyond purposeful walking, to make sure that they are not at risk for cardiovascular, orthopaedic or other problems.
If the patient hasn’t been very active recently, he must start slow with 5 or 10 minute workout a day and then increase it by a few minutes each week. Gradually step up from walking to running aiming for 30 minutes of moderate-to-vigorous intensity aerobic exercise at least
5 days a week or a total of 150 minutes per week.
Daily exercise or at least not allowing more than 2 days of elapse between exercise sessions
is recommended to enhance insulin action.
Swimming is highly recommended as it exercises both upper and lower body muscles at the
same time and it is especially good for those who
have numbness or lack of sensation in the feet (from
diabetic neuropathy).
Measuring of blood glucose levels before and after activity (and during it, if needed) is essential. Always advise patients to keep a training log, record the intensity and duration of activity and blood glucose readings.
Prolonged sitting should be interrupted with bouts of light activity every 30 minutes for blood glucose
benefits at least in adults with T2DM.
Wearing the right footwear is of utmost importance. It is better to take advice of a podiatrist
or a foot care specialist while purchasing footwear. To help prevent foot problems, one should wear comfortable, supportive shoes and take care of the feet before, during and after physical activity.
38
National Diabetes Educator Program(NDEP) Best Practices
NDEP – National Diabetes Educator Program has been
ongoing since last 7 years. It has been developed with
the objective of creating DEs. A DE is a healthcare
professional who is specialised and certified to teach
people with diabetes how to manage their condition.
This program is under the auspices of the
Indian Association of Diabetes Educators (IADE) and
Dr. Mohan’s Diabetes Education Academy (DMDEA), a
unit of Dr. Mohan’s Specialties Centre, and is promoted
by USV.
The program is being conducted in 150 NDEP centres
across India.
For more information, follow us on: https://www.facebook.com/NDEPCOURSE/
Join NDEP Facebook page to know more about it!
39
Eat Out, Be Wise!
East Indian cuisine
East India is located by the east coast of India near the Bay of Bengal including the states of West Bengal, Bihar, Jharkhand and Orrisa. Eastern India also comprise of the easternmost states of India; Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura.
Sattu or fried gram flour is mixed with spices and filled in wheat dough balls, rolled and cooked with ghee. The gram flour can be roasted and cooked along with curd/buttermilk rather than frying it. Also the wheat dough balls can be cooked without ghee. Curd along with
some salad can be used as an accompaniment to complete the meal.
Bihar
Jharkhand
Aloo chokha is prepared with mashed potatoes, fried onion and spices, and eaten as a side dish with roti or rice. Onion can be used without frying it. Multigrain roti/brown rice can be
eaten along with it, some curd and salad can be added to complete the meal.
Arunachal Pradesh
Rice is a staple food. They prefer to cook their rice in the hollow bamboo over some hot coal.
Brown rice can be used instead. Dal along with some vegetables can be used to get the perfect carbohydrate and protein combination.
Manipur
Chahhao kheer is prepared using rice, milk and cardamom powder. It is generally garnished with dried fruits like raisins or other nuts. Brown rice/broken wheat can be used. Skimmed milk can also be used.
Meghalaya
Doh khlieh is a salad made out of minced pork, onions and chillies. Beans along with tomatoes, carrot and some lemon can be squeezed in. Also brown rice or quinoa can be added.
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Mizoram
Paanch phoron torkari is made in both vegetarian and non-vegetarian fashion. In the vegetarian version, brinjal, pumpkins and potatoes are used to make this dry dish and in the non-vegetarian version, it is mostly prepared with chicken. Paneer/tofu can be added. A salad can be a good accompaniment with this dish.
Sikkim
Sha phaley is bread stuffed with ground beef and cabbage made into semi circles and then deep fried. Whole wheat bread can be used. Instead of deep frying, baking or grilling can be done. Also, tofu/cheese can be added for the extra protein.
Tripura
Wahan mosdeng or chilli pork is a dry dish, without gravy. It can also be cooked with gravy to
eat alongside the staple food of the region - white rice. Brown rice/multigrain roti can be eaten
instead of white rice.
41
Shopping Smart
Multigrain high fibre biscuits
When we have hunger pangs in between meals or for some of us as soon as we wake up, we often reach out for the biscuits labelled “multigrain/high fibre“ and finish almost the entire packet, assuming it is a healthier option. Biscuits, even the low sugar, high fibre variety are not very healthy and not the best option when it comes to snacking. To make the biscuits crunchy and crispy, manufacturers add fats and sugar. To make a healthy choice, read food labels and make sure the first ingredient is whole wheat flour, multigrain flour and oats. There should be no added sugar and refined flour in the product.
42
Diet-Related Behavioural tips
Behavioural tips for people with diabetes
The psychological make-up of people with diabetes plays a central role in self-management behaviours. Social support from family, peers, friends, fellow patients and others is of utmost importance in the management of diabetes. Positive social support has been associated with improved medication, dietary and exercise adherence, decreased depression, smoking cessation, good diabetes self-management and improved clinical outcomes.
The DE should make every attempt to instill the right attitude in the patient by effective counselling.
Behavioural therapy
DE can change the behaviour by applying the following:
Self-monitoring: DE can ask patients to keep written records of what they eat (when? what? how
much? etc) and all other factors that could probably influence blood glucose readings like stress, sleep, activity, menses, etc.
Controlling stimulus and environmental cues: DE can ask patients to eat in a small plate, avoid
the route which has a sweet shop, etc.
Gradual changes: Patients should be advised to start taking small
steps first (e.g., start walking 15 mins/day to begin with and then
gradually increase the duration and pace).
Positive reinforcement: When patients makes small changes, recognise them with verbal
appreciation, rewards, group appreciations, etc.
If patient thinks that he cannot live a normal life with diabetes henceforth, he/she can be counselled to think about present and the strategies for coping, e.g., spirituality, leisure activities, family time.
DE can also approach family members to assist the patient in coping with the condition.
43
44
Pumpkin seeds have been found to contain ingredients that have a blood glucose-lowering effect and eating these seeds may help people with diabetes to maintain their sugar levels. These seeds are rich in dietary fibre too, a factor that is believed to lower the risk of T2DM. Pumpkin seeds also improve the insulin sensitivity of muscles, liver and heart by the action of its compound (D- chiro- inositol). They contain phytochemicals that may prevent both high blood pressure, blood sugar spikes, and provide heart-protective properties.
How to consume?
Eat pumpkin seeds raw or roasted and unsalted. Sprinkle into soups, cereals, salads, smoothies or yoghurt.
Superfood: Pumpkin Seeds/
Dosage
The total daily intake should 10 g/day.on an average be
Health benefits
Method for preparing dressing:
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¢
¢
Combine all the ingredients in a mixer and blend till it is smooth and frothy.
Pour the shake into a glass.
Serve immediately.
Serves: 1
Ingredients Amounts
Apple cubes (unpeeled)
Cinnamon (dalchini) powder
Chilled soya milk/ low fat milk (unflavoured)
Sugar substitute (optional)
½ cup
1 pinch
1 cup
1 tsp
Apple cinnamon soya shake
Recipe
45
References
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1. Lilly Diabetes. My carbohydrate guide. Available at: http://www.lillydiabetes.com/_assets/pdf/ld 9 0766_carbguide.pdf
2. American Diabetes Association. Carbohydrate counting. 2017. Available at: http://www.diabetes.org/food-and-
fitness/food/what-can-i-eat/understanding-carbohydrates/carbohydrate-counting.html
3. Taylor Wolfram. The basics of the nutrition facts label. Academy of nutrition and dietetics. 2016. Available at:
https://www.eatright.org/food/nutrition/nutrition-facts-and-food-labels/the-basics-of-the-nutrition-facts-label
4. Use the nutrition facts label. Available at: https://www.nhlbi.nih.gov/health/educational/wecan/eat-right/nutrition-facts.htm
5. American Heart Association. Tips for dining out. Available at: http://www.heart.org/HEARTORG/GettingHealthy/
NutritionCenter/ DiningOut/Dining-Out_UCM_304183_ SubHomePage.jsp
6. Overcoming barriers to physical activity. 2017. Available at:
https://www.cdc.gov/physicalactivity/basics/adding-pa/barriers.html
7. Colberg SR. Practical pointers - encouraging patients to be physically active: what busy practitioners need to know. Clinical
Diabetes. 2008;26(3):123–127.
8. AADE7 Self-care behaviours. Being active. Available at: https://www.diabeteseducator.org/living-with-diabetes/aade7-self-
care-behaviors/being-active
9. AADE 7 Self-care behaviours. Taking medication. Available at: https://www.diabeteseducator.org/living-with-
diabetes/aade7-self-care-behaviors/taking-medication
10. Must remember—10 tips to help remind you to stay on schedule. Available at: http://www.bemedwise.org/
documents/must_remember10tips.pdf
11. Almekinder E. Pre-existing diabetes and pregnancy. Available at: https://www.thediabetescouncil.com/pre-existing-
diabetes-and-pregnancy/
12. All about HbA1c and 33 reasons to maintain healthy HbA1c levels (Part 1). Available at: https://www.selfhacked.com/blog/
hba1c-what-is-it-and-why-is-it-important/
13. AADE. Glucose monitoring what’s in it for me? 2017. Available at: https://www.diabeteseducator.org/docs/default-
source/living-with-diabetes/tip-sheets/blood-glucose-monitoring/ whatsinitforme-final.pdf?sfvrsn=6
14. AADE 7 Self-care behaviours. Monitoring. Available at: https://www.diabeteseducator.org/living-with-diabetes/aade7-self-
care-behaviors/aade7-self-care-behaviors-monitoring
15. Fritz H. The influence of daily routines on engaging in diabetes self-management. Scandinavian journal of occupational
therapy. 2014;21(3):232–240.
16. Diabetes.co.uk. Shift work and diabetes - night shifts. Available at: http://diabetes.co.uk
17. Diabetes.co.uk. Travelling and diabetes. Available at: http://www.diabetesnsw.com.au/
18. AADE 7 Self-care behaviours – Healthy coping. Available at. https://www.diabeteseducator.org/living-with-diabetes/aade7-
self-care-behaviors/healthy-coping
19. Leibs A. Accessible exercise and recreation. Available at: http://diabetesselfmanagement.com
Centres for disease control and prevention.
20. Diabetes.co.uk. Diabetes and colour, music and art therapy. Available at: http://diabetes.co.uk
21. Diabetes alive. Art therapy. http://www.diabetesalive.org.au
22. My AADE network. Available at:: http://www.myaadenetwork.org
23. American diabetes association standards of medical care in diabetes—2017. Diabetes care. The journal of clinical and
applied research and education. 2018;41:S1.
24. Boulton AJM, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: A report of the task
force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of
Clinical Endocrinologists. Diabetes Care. 2008;31(8):1679–1685.
25. Wood S. Cinnamon and cloves: Benefits in diabetes probed. Available at: https://www.medscape.com/viewarticle/788348.
26. Shinta D. Can you eat garlic if you have diabetes? Available at: http://healthline.com
27. Ludwig J. The potential health benefits and risks of ginger for type 2 diabetes. Available at: http://everydayhealth.com
28. Goldman R and Jewell T. Diabetes: Can fenugreek lower my blood sugar? Available at: http://healthline.com
29. Burns J. Diabetes and Turmeric: is it good or bad? Available at: http://thediabetescouncil.com
30. Read and digest. Basil ginger tea: recipe and health benefits. Available at: https://readanddigest.com/basil-tulsi-ginger-tea-
recipe-health-benefits/
31. Vasudeva S. A spice that cures: 5 great benefits of cinnamon. Available at: https://food.ndtv.com/food-drinks/5-great-
benefits-of-cinnamon-1218191
32. Moghul SN. Healthy Foods: 10 ways to use cloves for good health. Available at: https://www.indiatimes.com/health/
healthyliving/healthy-foods-10-ways-to-use-cloves-for-good-health-241116.html
33. Fenugreek seeds: here's how eating soaked or sprouted methi dana will benefit your health.
https://food.ndtv.com/health/fenugreek-seeds-heres-how-eating-soaked-or-sprouted-methi-dana-will-benefit-your-
health-1757158
34. Johnson J. "What's the evidence that turmeric treats diabetes?” Available at: https://www.medicalnewstoday.com/
articles/317721.php
35. Bardsley J, Baker K and Powers M. Diabetes self-management education and support algorithm of care: tools for use and
dissemination. AADE in Practice. 2017;5(5).
36. Mughal S. Preparing Muslims with diabetes for Ramadan. Journal of Diabetes Nursing. 2011;15(7):245–246.
37. Ahmad J, Pathan MF, Jaleel MA, et al. Diabetic emergencies including hypoglycemia during Ramadan. Indian Journal of
Endocrinology and Metabolism. 2012;16(4):512–515.
38. Hui EYL. Evaluation of glycaemic control and diabetes treatment strategies during the religious fasting period of Ramadan.
Imperial College London, University of London. 2013
39. Hyperglycemia and hypoglycemia in type 2 diabetes. 2018. Available at: https://www.ncbi.nlm.nih.
gov/pubmedhealth/PMH0072694/
Available at:
Available at:
Informed Health Online.
47
40. Alsafadi H, Wilson J and Patel V. Managing diabetes in people fasting during Ramadan. Diabetes and Primary Care.
2011;13(3):152–159.
41. Bhat MH. Diabetes and Ramadan. Available at: http://www.greaterkashmir.com/news/op-ed/diabetes-and-
ramadan/250981.html
42. Bohannon N. Treatment of vulvovaginal candidiasis in patients with diabetes. Diabetes Care. 1998;21(3):451–456.
43. Jeanmonod R, Jeanmonod D. Candidiasis, vaginal (vulvovaginal candidiasis), Available from: https://www.ncbi.nlm.nih.
gov/books/ NBK459317/
44. Pappas PG, Kauffman CA, Andes D, et al. “Clinical practice guidelines for the management of candidiasis: 2009 update by the
infectious diseases society of America’’.2009;48(5):503–35.
45. Saleem N, SaimaIjaz I and Lodh O. “Esophageal candidiasis in a patient with uncontrolled diabetes mellitus and recurrent
abdominal pain, symptomatic or incidental? A case report and brief literature review”. Journal Of Medicine Cases. 6
(11):523–526.
46. Macedo DPC, Oliveira NT, Aline MA, et al. Esophagitis caused by Candida guilliermondii in diabetes mellitus: fist reported
case. Medical Mycology . 2010; 48:862–865.
47. Bluestar. Prescribed by doctors; World’s first diabetes prescription app. Available at: https://www.dr-hempel-network.com
48. Bluestar. Manage your diabetes your way. Available at: https://www2.bluestardiabetes.com/
49. BlueStar Diabetes. Available at: https://itunes.apple.com/in/app/bluestar-diabetes/id700329056?mt=8
50. IDx Transforming healthcare through automation. Available at: https://www.eyediagnosis.net/
2015;
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