*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:

shashikala.b@usv.in or rashmi.garse@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 ismade 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 notrely 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 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 25,000 doctors and diabetes educators digitally.

We all know that aging is inevitable along with the complexities associated with the life of an individual with type 2 diabetes. Aging is also a major risk factor for type 2 diabetes. The good news is that there are feasible ways to effectively manage, treat and live a healthy life with type 2 diabetes. As the New Year rolls in, we bring to you several insights into how to lead a healthy life and age gracefully. This issue discusses several topics including health of bones and eyes. It also tackles several other interesting diabetes management regimens such the role of intermittent fasting, self-management, nutraceuticals, stress and functional medicine in managing diabetes. This issue's cover story talks about the role of healthy life and aging in diabetes patient.

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 Praveen Gupta

MBBS, MD (Medicine)

DiabetologistAdvanced Diabetes Care Centre (ADCC), Firozabad, Uttar Pradesh

Dr Dharmendra

MD (Medicine)

Consultant Physician and Diabetologist, Kanpur, Uttar Pradesh

Dr S Chakravorty

MD (Med), FICP, FIACM, Dip. in Diab (UK)

Senior Consultant Physician and Unit Head, Dept. of Internal Medicine, Diabetology and Critical Care, Metro Multispeciality Hospital, Noida, Uttar Pradesh

Dr ML Balamurugan

MBBS, C. Diab (Australia), PG Dip (Diab), FCIP

Consultant Family Physician and Diabetologist, Sri Ragavendra Nursing Home, David Colony, KK Nagar and Joint Managing Director, Trichy Diabetes Speciality Centre (P) Ltd., Thillai Nagar; Trichy, Tamil Nadu

Dr BS Nagaraja

MBBS, MD, FICP

Professor of MedicineBowring and Lady Curzon HospitalBangalore, Karnataka

Dr Pravishal Adling

MBBS, D. Diabetology, PGDCED (RCP-UK)

Consultant Diabetologist, Director-Dr Adling's Diabetes Care Clinic, Pune, Maharashtra

Dr M Srikanth

MD (Physician) Eqv. MBBS, MHSc (Diab),  PGDHSc (Diab), FCD, FDRC (WHO cc)

Chief Physician, Dr Srikanth's Diabetes Specialities Centre, Vijayawada, Andhra Pradesh

Dr Amol Hartalkar

MBBS, MD (Medicine), FAIMER Fellow (GSMC-FRI, Mumbai)

Consultant Physician, Cardio-Diabetologist, Dr Amol Hartalkar’s Clinic, Undri, Pune, Maharashtra

Dr Sushil Kotru

MD (Medicine), PG Dip. in Endo (South Wales, UK), MSc (Clin Endocrinol), FIDM (CMC-Vellore), ACCD (Clev Clinic), PG Certificate Course in Clinical Cardiology

Consultant and Head, Max Endocrine, Diabetes & Obesity Care Centre, Max Super Specialty Hospital, Bathinda, Punjab

Dr Deepak Patil

MBBS, DD (Mum), MD (Med, USAIM), PGDD (USA)

Consultant Diabetologist, Bandra, Mumbai, Maharashtra

Dr Sandeep Suri

MBBS, MD, FIDM, FDFM

Consultant Diabetologist, Holy Help Hospital, Hisar, Haryana

DT Merlin Daya

BSc-N&D Dietitian and Diabetes Educator

Table of Content

01Cover Story: Diabetes, Healthy Life and Happy Aging

Dr BS Nagaraja

24Keep Your Vision Safe: Eyes and Diabetes

Dr ML Balamurugan

41Lifestyle Modification: Exercise

47Diabetes Quiz

48Educator Alert

42Lifestyle Modification: Diet

45Diabetes Technology Update

46Conference Highlights

05Bone Health and Diabetes: A Guide to Optimal Care

Dr Deepak Patil

09Exercise Routine in Diabetes for a Healthy Life

Dr Sushil Kotru

13Dealing with Twin Problems: Diabetes and Menopause

Dr Amol Hartalkar

15Intermittent Fasting and Healthy Aging:Is There a Connection?

Dr M Srikanth

21Gut Microbiota and Healthy Living in Diabetes Patients

Dr Praveen Gupta

18The Troubling Triad: Diabetes, Aging and Falls

Dr Pravishal Adling

28Redefining Diabetes and Self-Management

Dr S Chakravorty

30Nutraceuticals for Diabetes

Dr Dharmendra

34Stress-free Life and Healthy Aging in Diabetes Patients

Dr Sandeep Suri

37Healthy Aging with Diabetes

DT Merlin Daya

1

COVER STORY:Diabetes, Healthy Life and Happy Aging

ExpertOpinion

Dr BS Nagaraja

MBBS, MD, FICP

Professor of MedicineBowring and Lady Curzon Hospital,Bangalore, Karnataka

Introduction

Aging is inevitable and so are the complexities linked with the

life of an individual with type 2 diabetes. In fact, aging is also a

major risk factor for type 2 diabetes. The good news amidst all this is that there are feasible ways to effectively manage, treat

and live a healthy life with type 2 diabetes.

Aging is inevitable

Curbing it at the prediabetes stage

Aging is the process during which structural and functional changes accumulate in an

organism as a result of the passage of time. The changes manifest as a decline from the

organism's peak fertility and physiological functions until death.

Impaired glucose intolerance is associated with aging and postprandial hyperglycemia is a prominent characteristic of

type 2 diabetes. Age-related insulin resistance is associated with changes in body composition and physical inactivity among

other factors, which may partially explain the greatest relative benefits of the intensive lifestyle intervention. However, even though

we age chronologically as years progress, we can still remain biologically young by lifestyle modifications.

One of the biggest challenges with diabetes is that millions of individuals have prediabetes, indicating that their blood glucose levels

are higher than normal but not high enough to termed diabetes. People with higher blood glucose values are at an increased risk of developing type 2 diabetes later in life as well of cardiovascular diseases like heart attack

and stroke.

If the prediabetes level is noticed, then its progression to full blown diabetes can be

prevented or delayed by several lifestyle behavioral changes including healthy eating and

adopting a physically active daily routine. Losing weight in those who are overweight or

obese may also help. People who are fortunate to get their prediabetes detected should

seek doctor's help into get a plan for healthier food choices, regular exercise and quitting

smoking. Regular monitoring of blood glucose levels is also advisable to keep a tab on the

fluctuations in the blood glucose levels.

2

Live better and age well with diabetes

We all know that diabetes is a chronic illness and cannot be completely cured. However,

there are various ways in which patients can manage their diabetes and lead a vibrant and healthy life.

Diet and exercise are the most effective ways in which people can control their blood

glucose levels. It is an undisputable fact today that there is not a “one size fits all” diabetes

diet. Even though changes are important in diet, there is flexibility to decide what can be on

the menu. Restrict the quantity of food eaten, make healthier choices for each type of food,

focus on getting enough non-starchy vegetables and less starchy foods and meats, fit

fruits, low-fat dairy and whole grains, and limit added fats, sugars and sodium in diet.

Another important aspect of healthy aging is being active. Physical activity not only keeps people fit, it also helps in lowering blood

glucose levels. Among other benefits of adequate physical activity are improvement in A1c, blood pressure and cholesterol; feeling

energetic; stress relief; burning calories; maintaining flexible joints; increased strength; improved balance in elderly to prevent falls and reduced risk for heart disease and stroke. The four main categories of exercises which have been reported to have important

benefits are:

Aerobic exercises

Walking, aerobics, bicycling, tennis, dancing, gardening, playing with grandchildren, swimming, raking leaves and

golfing.

Stretching

Basic stretches, yoga and Pilates.

Strength training

Lifting free weights, using resistance bands, climbing stairs,

calisthenics, carrying groceries, gardening, yoga and tai chi.

Balance exercises

Walking backwards or sideways, walking heel to toe in straight

line, standing on one foot and standing from a sitting position.

3

Source: https://www.who.int/ageing/events/world-report-2015-launch/healthy-ageing-infographic.jpg?ua=1

4

Three 10-minute spurts of

activity throughout the day

are just as good as one 30-minute session.

TIPS FOR A HEALTHY LIFE AND HAPPY AGING

A multivitamin supplement

can help fill nutrient gaps in

your diet, but should not be used as a substitute for

healthy foods.

Keep track of your

medicines.

If the numbers are high, don't

panic! A combination of meal

planning, physical activity and medicine can help lower A1c,

blood pressure and cholesterol.

References

1. American Diabetes Association. Living healthy with diabetes: A guide for adults 55 and up. Available at: http://main.diabetes.org/dorg/PDFs/living-healthy-booklet-american-diabetes-assoc.pdf

2. Kalyani RR, Golden SH, Cefalu WT. Diabetes and aging: Unique considerations and goals of care. Diabetes Care. 2017;40(4):440-3.

3. World Health Organization. Ageing and Health. Available at: https://www.who.int/ageing/events/world-report-2015-launch/healthy-ageing-infographic.jpg?ua=1

5

Bone Health and Diabetes: A Guide to Optimal Care

ExpertOpinion

Dr Deepak Patil

MBBS, DD (Mum), MD (Med, USAIM), PGDD (USA)

Consultant Diabetologist, Bandra, Mumbai, Maharashtra

Introduction

Diabetes has complex effects on bone health. Several studies

have shown that risk of fracture is increased in type 2

diabetes. However, it is still a topic of debate that to what extent the metabolic abnormalities of diabetes have a

potential effect on bone metabolism, structure, quality and

mineral density.

Osteoporosis in diabetes

Diabetes and fracture risk

Osteoporosis is marked by low bone mass, increased fragility, decreased bone quality and

an increased fracture risk. Patients with type 1 or type 2 diabetes are among those who are

at an increased risk of diabetes. Type 2 diabetes mellitus is associated with an increased

bone mineral density but a puzzling increased risk for skeletal fracture.

Patients with type 2 diabetes generally have an increased risk of falling because of

peripheral neuropathy, possible hypoglycemia, nocturia and visual impairment. Bone

quality changes may also be affected by microvascular complications related with diabetes.

Several studies have linked diabetes mellitus with increased fracture risk. In fact, it has

been shown that the risk of hip fracture in women with type 1 diabetes is sixfold higher

compared with those without diabetes. Another study revealed that the hazard ratios for

hip fracture were higher for men with diabetes and women aged 35 to 44 and were null

statistically in men over 74 years and women over 84 years. One of the hypotheses suggests that age or menopause related changes may overshadow the effects of

diabetes on fracture risk.

6

How does diabetes affect bone metabolism?

Do antidiabetes medications affect bone health?

The increased bone mass density in patients with type 2 diabetes occurs in conjunction with decreased overall bone turnover.

Expression of bone turnover markers osteocalcin, type 1 cross-linked C-telopeptide and type 1 cross-linked N-telopeptide. This has effect on bone health.

Type 2 diabetes patients also have hyperinsulinemia which could be responsible for

increased bone mass density. Insulin can interact with insulin-like growth factor 1 (IGF-1)

receptor present on osteoblasts due to its structural similarity. IGF-1 has been shown to

have a positive correlation with bone mass density in human and mouse models.

Hyperinsulinemia can also contribute to the increase in adipogenesis within the bone

marrow stem cell niche.

Obesity, closely associated with type 2 diabetes has also been reported to be the number

one predictor of type 2 diabetes mellitus.

Insulin, insulin-sensitizing drugs, drug increasing insulin secretion and incretin mimetics

are some of the agents used in the treatment of diabetes. Even though these treatments produce certain beneficial outcomes but some have undesirable side effects like weight

gain and further reduced bone health. However, metformin which is often the first-line of

drug used in diabetes treatment promotes osteogenesis, which leads to increased bone

mass density. Hence, it has been proven to be an effective method for both glucose

utilization and bone health.

Menopause and bone health in women with diabetes

Menopause is a natural phenomenon linked with decline of ovarian function as well as increasing levels of follicle-stimulating

hormone (FSH). Osteoporosis is also one of the most prevalent diseases in menopausal women, and is strongly associated with low

quality of life. The major health threat of osteoporosis is osteoporotic fractures. It has

been found that hormone status regulated bone mass accretion, especially that of estrogen. At menopause, the normal bone turnover cycle is impaired by estrogen

deficiency. During the menopausal transition period, the average reduction in bone mass

density is about 10%. However, in women who are greater than 60 years old and/or

greater than 10 years postmenopausal, menopause hormone therapy is not appropriate and other medicines should be considered.

It has been found that menopause hormone therapy significantly increases bone mass

density. Menopause hormone therapy is also effective in preventing osteoporotic

fractures.

7

Antiosteoporotic medications on type 2 diabetes and glucose metabolism

The agents approved for the treatment of osteoporosis are bisphosphonates, denosumab,

teriparatide, strontium ranelate and selective estrogen receptor modulators. Studies have shown that these medications have minimal, if any, effect on glucose metabolism.

However, bisphosphonates have been shown to be linked with reduction in the risk of

developing diabetes.

Management of patients with type 2 diabetes and osteoporosis

In patients with type 2 diabetes and osteoporosis indicate a higher glycated hemoglobin

(HbA1c) target (≤7.5-8%) to avoid hypoglycemia and falls, which will further increase the

risk of fracture. Proper control of blood pressure is also important to avoid falls.

Lifestyle intervention with medical nutrition therapy and exercise forms the cornerstone of therapy of type 2 diabetes mellitus and

coexistent osteoporosis. Modest weight loss, a Mediterranean-style diet rich in monounsaturated fats and long-chain omega-3 fatty

acids, as well as nuts and seeds, appropriate intake of calcium and vitamin D with careful consumption of fatty milk products, and

limited intake of alcohol and sodium are an ideal medical nutrition therapy for diabetes patients with reduced bone health.

Intense walking at least 150 minutes/week combined with moderate-intensity aerobic type of exercise is indicated for type 2

diabetes mellitus and weight-bearing exercise for osteoporosis.

8

Cessation of smoking is very important for these patients and counseling should be a part of

routine care of a patient with diabetes and osteoporosis.

Eventually most patients need pharmacologic therapy, and metformin should be the first-

line pharmacologic therapy, sometimes even initiated at diagnosis concurrently with lifestyle interventions. In case of uncontrolled blood glucose after 3 months, other

hypoglycemic agents such as sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4

(DPP-4) inhibitors, sodium glucose cotransporter-2 (SGLT-2) inhibitors, glucagon-like

peptide-1 (GLP-1) receptor agonist or basal insulin should be considered. The effect of anti-osteoporotic medications on the incidence of type 2 diabetes mellitus and on glucose

metabolism should also be considered.

References

1. Hordon LD. Bone disease in diabetes mellitus. UpToDate. Jun 17, 2019. Available at: https://www.uptodate.com/contents/bone-disease-in-diabetes-mellitus

2. Chau DL, Edelman SV. Osteoporosis and diabetes. Clinical Diabetes. 2002;20(3):153-7.

3. Valderrabano RJ, Linares MI. Diabetes mellitus and bone health: epidemiology, etiology and implications for fracture risk stratification. Clin Diabetes Endocrinol. 2018;4:9.

4. Sundararaghavan V, Mazur MM, Evans B, et al. Diabetes and bone health: latest evidence and clinical implications. Ther Adv Musculoskelet Dis. 2017;9(3):67-74.

5. Ji MX, Yu Q. Primary osteoporosis in postmenopausal women. Chronic Dis Transl Med. 2015; 1(1): 9-13.

6. Paschou SA, Dede AD, Anagnostis PG, et al. Type 2 diabetes and osteoporosis: A guide to optimal management. J Clin Endocrinol Metab. 2017;102(10):3621-34.

The role of a diabetes educator

¢ Make the patient aware that both aging and lifestyle changes affect type 2 diabetes and osteoporosis.

¢ Counsel the patient and caregivers about the importance of healthy diet and physical exercise for the prevention and treatment of both diabetes and osteoporosis.

¢ Ensure that strict HbA1c targets are avoided to prevent hypoglycemia, falls and fractures.

¢ Counsel the insulin users to regularly monitor their blood glucose levels and use caution to avoid hypoglycemia.

9

Exercise Routine in Diabetes for a Healthy Life

ExpertOpinion

Dr Sushil Kotru

MD (Medicine), PG Dip. in Endo (South Wales, UK), MSc (Clin Endocrinol), FIDM (CMC-Vellore), ACCD (Clev Clinic), PG Certificate Course in Clinical Cardiology

Consultant and Head, Max Endocrine, Diabetes & Obesity Care Centre, Max Super Specialty Hospital, Bathinda, Punjab

Introduction

We all agree that physical activity is important for everyone's

health and assumes special significance if one has diabetes.

Exercise is recognized as an essential part in the management of the diabetes. If done regularly, exercise not

only helps people with diabetes to lead a healthy life despite

the existing diabetes. However, it is unfortunate that since it is

completely dependent on the patient, it is often the most neglected aspect of management of disease.

How does exercise help?

Regular physical activity forms a significant part of effective weight maintenance, improving overall health and managing diabetes.

Several clinical and epidemiological studies have shown that regular exercise not only helps in preventing and regulating blood

glucose levels in diabetes patient, but it also reduces the risk of death due to heart disease and stroke, helps in reducing weight,

reduces the risk of colon cancer, strengthening bone, muscles and joints, enhances immune system, increases stamina, lowers

blood pressure, helps in digestion, reduces serum lipid levels, improves blood circulation, provides skin a healthy glow and reverses the aging process.

Strengthening the heart, muscles and bones

Reducing stress Aiding weight loss Lowers blood glucose, blood pressure and blood fats

Increasing oxygen levels in the body

Improving blood circulation

Toning muscles

10

Physical activity vs. exercise

Physical activity includes all movement that increases the energy use in the body, whereas

exercise is planned structured physical activity. Exercise helps in improving blood glucose control in type 2 diabetes, reduces cardiovascular risk factors, contributes to weight loss

and improves well-being.

In fact, it has been proven that regular exercise can prevent or delay the development of

type 2 diabetes. Regular exercise also benefits people with type 1 diabetes such as

improved cardiovascular fitness, muscle strength, insulin sensitivity.

Since the challenges related to the management of blood glucose change with diabetes

type, activity type and presence of diabetes-related complications, the physical activity or exercise recommendations should be

customized to the specific needs of an individual with diabetes.

Types of exercise and physical activity beneficial in healthy living

Can exercise help in reversing diabetes?

¢ Aerobic exercise involves repeated and continuous movement of large muscle groups.

Activities such as walking, cycling, jogging and swimming rely primarily on aerobic

energy-producing systems.

¢ Resistance (strength) training includes exercises with free weights, weight machines

and body weight or elastic resistance bands.

¢ Flexibility exercises improve range of motion around joints.

¢ Balance exercise benefit gait and prevent fails.

¢ Activities like tai chi and yoga combine flexibility, balance and resistance activities.

Structured lifestyle intervention trials including physical activity for at least 150-175

min/week and dietary energy restriction targeting weight loss of 5-7% have showed

reduction of 40-70% in the risk of developing type 2 diabetes in people with impaired

glucose tolerance. In another systematic review, it was concluded that compared with

usual care, diet and physical activity promotion programs reduced type 2 diabetes

incidence, body weight and fasting blood glucose while improving other cardiometabolic

risk factors.

11

What are the effects of exercise?

Exercise such as aerobic exercise can improve whole-body insulin sensitivity in individuals with type 2 diabetes. Moderate and

vigorous training improves insulin sensitivity but a lesser intensity may also improve insulin action to some extent.

Training can also enhance the responsiveness of skeletal muscle to insulin with increased expression and/or activity of proteins involved in glucose metabolism and insulin signalling. Both aerobic and resistance exercise also stimulate glucose transporter

type 4 (GLUT4) abundance and blood glucose uptake, even in presence of type 2 diabetes.

Fuel mobilization, glucose

production and muscle

glycogenolysis.

ACUTE EFFECTS OF EXERCISE

Post-exercise glycemic

control/blood glucose levels.

Acute changes in muscular

insulin resistance.

Acute changes in liver's

ability to process glucose.

The role of a diabetes educator

¢ Make the patients aware about the health benefits related with different types of exercises.

¢ Encourage patients to decrease the amount of time spent in daily sedentary behavior.

¢ Advise them to prolong sitting should be interrupted with bouts of light activity every 30 minutes for blood glucose benefits, at least in adults with type 2 diabetes.

¢ Encourage structured exercise and physical activity.

12

References

1. Diabetes and Exercise. May 24, 2018. Available at: https://drmohans.com/diabetes-and-excercise/

2. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2016;39(11):2065-79.

3. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care. 2010; 33(12): e147-67.

13

Dealing with Twin Problems: Diabetes and Menopause

ExpertOpinion

Dr Amol Hartalkar

MBBS, MD (Medicine), FAIMER Fellow (GSMC-FRI, Mumbai)

Consultant Physician, Cardio-Diabetologist, Dr Amol Hartalkar’s Clinic, Undri, Pune, Maharashtra

Introduction

Various reports have suggested effects of menopause on

diabetes risk in healthy women. Links have also been

established between diabetes and the timing of menopause.

Diabetes risk and menopause

Metabolic changes which occur during the menopausal transition include an increase in and the central redistribution of adipose

tissue, as well as a decrease in energy expenditure. Additionally, there is an impairment of insulin secretion and insulin sensitivity

and an increase in the risk of type 2 diabetes mellitus.

The risk of diabetes increases with age in women and men. The increased free testosterone

and decreased sex hormone-binding globulin (SHBG) in menopause are implicated in the

pathophysiology of the observed greater risk of type 2 diabetes and impaired fasting glucose in postmenopausal women. But, it is important to clarify here that the evidence

linking menopausal sex hormone changes with increased diabetes risk is weak, although

rapid changes as observed with oophorectomy may increase risk. Natural menopause does

not modify the impact of diabetes prevention interventions among women at high risk for diabetes, but studies have shown that early menopause is associated with a greater risk of

type 2 diabetes.

Midlife risk factors

The concurrence of menopause and diabetes in midlife raises a doubt about the possible

link between menopause and increased diabetes risk. Type 2 diabetes risk factors in

midlife women include unfavorable changes in endogenous sex hormones, adiposity and

insulin resistance, as well as disorders of sleep and mood.

14

Postmenopausal hormone therapy

Type 2 diabetes management in menopausal women

Patients treated with hormone therapy had a significant decrease in the incidence of type 2

diabetes in several studies. Evidence suggested that postmenopausal hormone therapy decreases the risk of developing diabetes mellitus. Postmenopausal hormone therapy has

neutral or beneficial effects on glycemic control among women already diagnosed as having

diabetes mellitus. In fact, hormone replacement therapy has been independently associated

with decreased HbA1c levels. However, hormone replacement therapy should not be given for diabetes treatment.

Many women in midlife experience climacteric symptoms including hot flushes and night

sweats. This results in an indication to receive hormone replacement therapy. It has a favorable effect on glucose homeostasis both in women with and without type 2 diabetes

mellitus.

The cornerstone of diabetes management and healthy life is lifestyle intervention, including diet and exercise. Most of these women will eventually need pharmacologic

therapy. The most suitable agents should be selected according to their metabolic,

cardiovascular and bone effects, taking into consideration the specific characteristics and

comorbidities of each postmenopausal women.

References

1. Slopien R, Wender-Ozegowska E, Rogowicz-Frontczak A, et al. Menopasuse and diabetes: EMAS clinical guide. Maturitas. 2018;117:6-10.

2. Polotsky HN, Polotsky AJ. Metabolic implications of menopause. Semin Reprod Med. 2010;28(5):426-34.

3. Karvonen-Gutierrez CA, Park SK, Kim C. Diabetes and menopause. Curr Diab Rep. 2016;16:20.

4. Brand JS, van der Schouw YT, Onland-Moret NC, et al; InterAct Consortium. Age at menopause, reproductive life span, and type 2 diabetes risk: results from the EPIC-InterAct study. Diabetes Care. 2013;36(4):1012-9.

5. Kim C. Does menopause increase diabetes risk? Strategies for diabetes prevention in midlife women. Women's Health. 2012; 8(2):155-67.

6. Szmuilowicz ED, Stuenkel CA, Seely EW. Influence of menopause on diabetes and diabetes risk. Nat Rev Endocrinol. 2009;5(10):553-8.

7. Kim C, Edelstein SL, Crandall JP, et al; Diabetes Prevention Research Group. Menopause and risk of diabetes in the Diabetes Prevention Program. Menopause. 2011;18(8):857-68.

8. Paschou SA, Anagnostis P, Pavlou DI, et al. Diabetes in menopause: risks and management. Curr Vasc Pharmacol. 2019;17(6):556-63.

15

Intermittent Fasting and Healthy Aging: Is There a Connection?

ExpertOpinion

Dr M Srikanth

MD (Physician) Eqv. MBBS, MHSc (Diab), PGDHSc (Diab), FCD, FDRC (WHO cc)

Chief Physician, Dr Srikanth's Diabetes Specialities Centre, Vijayawada, Andhra Pradesh

Introduction

Intermittent fasting refers to any diet where there is one or

more “fast day” per week. On a fast day, person may consume

between 0 and 800 kcal/day. Usually, these diets come in the form of “5:2” where a person eats a healthy balanced diet

for 5 days/week and consumes 500-600 kcal/day for

2 days/week.

The 5:2 diet

The 5:2 diet, or the fast diet, prescribes only 2 days of severe caloric

restriction per week. Through these varying methods of intermittent

fasting, the level of overall caloric restriction achieved can be

equivalent to the traditional caloric restriction programs, but ease of implementation and improved long-term compliance is evident

with intermittent fasting. Overeating on the “feed day” due to increased hunger followed on from the “fast day” is obviously a

concern with these approaches. Studies have shown that even after fasting every other day, participants reported no compensatory

eating and high levels of satiety throughout the duration of the study.

How does intermittent fasting help?

Currently, intermittent fasting has become widely popular. There is certain evidence showing that resting energy expenditure can be

increased after short-term fasting. Several studies have shown that intermittent fasting can be as effective as calorie-restricted diets for weight loss and cardioprotection.

It is a novel and potentially more efficacious intervention for weight loss, preservation of lean mass and improved metabolic health in humans. Dietary restriction and intermittent

fasting have also been considered as nutritional hormetins as they induce stress response

and eventually lead to physiological hormesis by modulating the levels of stress chaperones

such as heat shock proteins, antioxidants such as vitamin E and co-enzyme Q, and enhancing redox enzyme activities. Intermittent fasting and dietary restriction regimen may

act by establishing a conditioning response which helps the organism to remain in survival

mode by focusing on every conservation, so that the body shifts from metabolic to

maintenance activities.

16

Intermittent fasting and healthy aging

Intermittent fasting in diabetes

Intermittent fasting has well-documented age-related benefits, in addition to potential

positive effects on the brain. Intermittent fasting plays a role in slowing down aging by various possible mechanisms. The first mechanism is reduced inflammation. Inflammation

is a biological defense mechanism occurring naturally when the immune system detects

threats, like a damaged molecule, toxic compound or pathogen. However, too much

inflammation can cause cardiovascular diseases, atherosclerosis, type 2 diabetes, rheumatoid arthritis and some cancers.

Another antiaging mechanism is through reduced accumulation of molecules damaged by free radicals. Free radicals are unstable

molecules that can damage cells, causing aging and illness. Evidence has suggested that intermittent fasting may be a way to offer some protection against many of the diseases associated with aging.

Intermittent fasting is known to improve sensitivity to the blood glucose-lowering hormone insulin and to protect against fatty liver.

Some case reports published in BMJ Case Reports have established that planned intermittent fasting may help to reverse type 2

diabetes.

In a case series, 3 men aged between 40 and 67 tried out planned intermittent fasting to see if it might ease their symptoms. They

were on a combination of oral hypoglycemic agents for the management of their disease. After 10 months of management including intermittent fasting, 2 of the 3 patients were able to stop taking all their medicines, while the third discontinued 3 out of the 4 drugs

he was taking. They all lost weight (in the range of 10-18%) as well as reducing their fasting and average blood glucose readings.

The patients were also able to stick to their dietary schedule without too much difficulty. The case series gives impetus to the fact

that 24-hour fasting regimens can significantly reverse or eliminate the need for medication for diabetes.

1617

References

1. Barnard J. Dietary interventions for weight loss and essential aspects of nutrition post-bariatric surgery. In: Practical Guide to Obesity Medicine, 2018.

2. Ravussin E, Redman LM. Calorie restriction in humans. In: Molecular Basis of Nutrition and Aging, 2016.

3. Dog JL. Intermittent fasting may be a powerful tool for healthy aging. Healthy Living. April 27, 2019.

4. Quiclet C, Dittberner N, Gassler A, et al. Pancreatic adipocytes mediate hypersecretion of insulin in diabetes-susceptible mice. Metabolism. 2019;97:9-17.

5. Furmli S, Elmasry R, Ramos M, et al. Therapeutic use of intermittent fasting for people with type 2 diabetes as an alternative to insulin. BMJ Case Rep. 2018; 2018. pii. bcr-2017-221854.

18

The Troubling Triad: Diabetes, Aging and Falls

ExpertOpinion

Dr Pravishal Adling

MBBS, D. Diabetology, PGDCED (RCP-UK)

Consultant Diabetologist, Director-Dr Adling's Diabetes Care Clinic, Pune, Maharashtra

Introduction

The population suffering from diabetes mellitus is rapidly

increasing in our society. It is a progressive disorder which is

associated with various health issues. Tendency to fall is one of the major health issues for older adults with diabetes,

which may lead to adverse events and even death.

One of the greatest health challenges facing elderly with

diabetes is falls. Risk of falling is higher in older women with

diabetes as compared to older men.

What contributes to falls?

Decreased sensorimotor function

Diabetic peripheral neuropathy is a common complication associated with diabetes patients. The damage to the large nerve fibers

results in decreased sensorimotor function. Patients with peripheral neuropathy with diminished plantar sensation on their feet have been observed to exhibit increased postural sway. The loss of proprioceptive feedback during standing and walking in turn

leads to increased risk of falls.

With the increasing severity of peripheral neuropathy, there is a higher risk of falls while completing tasks in the standing

position.

Annual incidence of falls in

elderly individuals with

diabetes mellitus - 39%.

Diabetes mellitus individuals

are at a higher risk for falls.

Falls are a major concern for

elderly.

19

Musculoskeletal or neuromuscular function

Lower physical activity, muscle strength and poor postural control are also significant risk

factors that influence gait patterns leading to increase in the tendency to fall in patients

with diabetes.

Low plantar flexion strength has also been observed to be associated with increased sway

among diabetes patients negatively affecting the gait. Reduced muscle strength also

contributes to reduced walking speed and an increased double support phase of the gait cycle.

Other factors associated with diabetes such as psychotropic medications and polypharmacy can also contribute to the increased

risk of falls. Patients with diabetes frequently experience symptoms of painful polyneuropathy. Chronic disabilities which are

associated with generalized body pain also increase the risk of repetitive falls.

How to prevent or protect falls?

Footwear for the elderly

¢ Screening for diabetic peripheral neuropathy with the help of biothesiometer, 128 Hz

tuning fork, ankle brachial index and good clinical examination of the feet during

doctor's visits will identify early stages of AT RISK FOOT, which can guide us to offer protective measures and to prevent further complications.

¢ Daily inspection of both feet with the help of small mirror, before going to bed, can also

help us to identify minor injuries on time.

Looking at various causative factors in development

of foot problems in diabetes patients, it is extremely important to advise our patients, to use protective

footwear. As the foot biomechanics are different in

each individual, they should be offered customized

footwear. The ideal diabetes footwear should have following characteristics as shown in the image.

Footwear that provides offloading of the localized

stress is widely used in people suffering from

diabetes. The casts and cast walkers used in diabetes

patients significantly restrict normal gait.

It has been suggested in various researches to modify designs for offloading footwear such as reduction in strut height and reduced

weight. This would help in improving postural stability, which may reduce the risk of fall significantly.

Extra depth for accommodating insoles

Tough heel counter

Tough and lightweight outer solesVelcro

High and wide toe box

Padded inner surface

20

References

1. Crews RT, Yalla SV, Fleischer AE, et al. A growing troubling triad: Diabetes, aging, and falls. J Aging Res. 2013;2013:342650.

2. Schwartz AV, Hillier TA, Sellmeyer DE, et al. Older women with diabetes have a higher risk of falls: A prospective study. Diabetes Care. 2002;25(10):1749-54.

3. Vinik AI, Camacho P, Reddy S, et al. Aging, diabetes, and falls. Endocr Pract. 2017;23(9):1117-39.

4. Yang Y, Hu X, Zhang Q, et al. Diabetes mellitus and risk of falls in older adults: a systematic review and meta-analysis. Age Ageing. 2016;45(6):761-7.

The role of a diabetes educator

¢ Ensure adequate foot care in patients.

¢ Encourage them to wear offloading footwear.

21

Gut Microbiota and Healthy Living in Diabetes Patients

ExpertOpinion

Dr Praveen Gupta

MBBS, MD (Medicine)

DiabetologistAdvanced Diabetes Care Centre (ADCC), Firozabad, Uttar Pradesh

Introduction

Several studies have reported that gut microbiome dysbiosis

is an important factor in rapid progression of insulin

resistance in type 2 diabetes mellitus.

The gut microbiome dysbiosis may refurnish intestinal barrier

functions and host metabolic and signaling pathways, which are directly or indirectly related to the insulin resistance in

type 2 diabetes mellitus.

The metabolites that are derived from the microbes interact with the epithelial, hepatic and cardiac cell receptors that

Abnormal CNS function

Stress/diseaseHealthy status

Healthy gut function

Abnormal gut function

Healthy CNS function

modulate host physiology. Xenobiotics including dietary components, antibiotics and nonsteroidal anti-inflammatory drugs have a strong impact on the gut microbial composition and can promote dysbiosis. Any alteration in the gut microbiota can shift the host

metabolism towards increased energy harvest during diabetes and obesity.

Metabolomics and gut microbiota

The link between gut ecosystem and diabetes

The synergistic activities of the gut microbiome and the host are a reflection of overall human metabolism at the systemic level.

It was revealed in a study that the probiotics, prebiotics or their combination showed that gut microbiota community was significantly altered by probiotic/prebiotic intervention, and thus induced various systemic changes in the metabolic profiles of

different tissues. The concentration of Bifidobacterium breve, Bifidobacterium longum and Bacteroides distasonis while there has

been a decline in ratios of Escherichia coli and Clostridium perfringens. Fat metabolism was also improved as concentrations of

glucose and hepatic triglycerides in the plasma in groups that were administered prebiotics were also reduced.

The gut microbiota plays an important role in

maintaining the optimal state of host health and in the

pathogenesis of numerous metabolic diseases such

as obesity, diabetes, chronic kidney disease and atherosclerosis and intestinal disease such as

inflammatory bowel diseases and colorectal cancer.

In a way similar to gastrointestinal tract supplies nutrients to cells and tissues, the metabolites

originating from the gut microbiota provide this

22

supply through the circulatory system. Various signaling

pathways are involved in the several interactions

amongst gut microbiota-derived metabolites, the gut microbiota and the host immune system. These complex

interactions between the gut microbiome and its host

play a hugely important role in maintaining good health,

and may implicate the onset of diabetes like diseases.

Regulation of glucose homeostasis by gut bacteria

Prebiotics and probiotics in diabetes

Obesity contributes an increased risk of multifactorial diseases such as type 2 diabetes.

It has also been reported that type 2 diabetes is associated with a reduced abundance of

butyrate-producing microbes and an increased abundance of Lactobacillus spp. This offers a

clue that Gram-negative bacteria and proteobacteria might induce the pathogenesis of type 2

diabetes through an endotoxin-induced inflammatory response. Similarly, bile acids are

involved in glucose metabolism also plays an important role in diabetes.

Studies in pregnancy have also shown that major gut microbial shifts occurring during

pregnancy affect host metabolism. Certain oral hypoglycemic agents like metformin also

interfere with the intestinal microbiota. Specific members of the microbiota may be reduced

in diabetes and when administered to murines exerted antidiabetes effects.

Probiotics and/or prebiotics could be a promising approach to improve insulin sensitivity by

favorably modifying the composition of the gut microbial community, reducing intestinal

endotoxin concentrations and reducing energy production.

Prebiotics, nondigestible fiber compounds and other oligosaccharides can potentially

change the activity of advantageous bacteria in the large intestine, which reduces

inflammation and metabolic endotoxemia.

The antidiabetic effects of probiotics include reducing proinflammatory cytokines through a

NFB pathway, reduced intestinal permeability and lowered oxidative stress. Probiotics

have been proven to reduce fasting glucose and insulin levels in a preclinical setting as well

as in human trials.

Insulin resistance

Disturbed gut �ora

Disturbed glucose homeostasis

Chronic in�ammation

Endocannabinoid system/LPS

Adipose tissue

23

The role of probiotics, prebiotics and synbiotics resulted in reduced intestinal permeability and decreased circulating endotoxins,

lowering inflammation and oxidative stress. These also have antilipolytic activities in adipocytes and improve insulin sensitivity

through GLUT4 by the up-regulation of 5'AMP-activated protein kinase signaling in muscle and liver tissue. Resistant starch and synbiotics may have favorable antidiabetic effects.

References

1. Sharma S, Tripathi P. Gut microbiome and type 2 diabetes: where we are and where to go? J Nutr Biochem. 2019; 63:101-8.

2. Aw W, Fukuda S. Understanding the role of the gut ecosystem in diabetes mellitus. J Diabetes Investig. 2018;9(1):5-12.

3. Tilg H, Moschen AR. Microbiota and diabetes: an evolving relationship. Gut. 2014; 63:1513-21.

4. Haas WC. The role of prebiotics in diabetes mellitus. 2015, RELIAS Media. Available at: https://www.reliasmedia.com/articles/135594-the-role-of-prebiotics-in-diabetes-mellitus

5. Kim YA, Keogh JB, Clifton PM. Probiotics, prebiotics, synbiotics and insulin sensitivity. Nutr Res rev. 2018; 31(1): 35-51.

6. Shah NJ, Swami OC. Role of probiotics in diabetes: a review of their rationale and efficacy. EMJ Diabet. 2017; 5(1):104-10.

24

AneurysmHemorrhages

“Cotton wool”Spots

Abnormal blood vessels

Superior rectus muscle

RetinaFovea

Optic disc

Sclera

Lens

Pupil

Cornea

Ciliary body

Inferior rectus muscle Healthy eye Diabetic eye

Optic nerve

Central retinal vein and artery

DIABETIC RETINOPATHY

Keep Your Vision Safe: Eyes and Diabetes

ExpertOpinion

Dr ML Balamurugan

MBBS, C. Diab (Australia), PG Dip (Diab), FCIP

Consultant Family Physician and Diabetologist, Sri Ragavendra Nursing Home, David Colony, KK Nagar and Joint Managing Director, Trichy Diabetes Speciality Centre (P) Ltd., Thillai Nagar; Trichy, Tamil Nadu

Introduction

In diabetes patients, all structures of the eyes are susceptible

to the harmful effects of diabetes. Patients with diabetes are

at an increased risk of visual disability compared with individuals without diabetes. Diabetes-related eye disease

has a strong link with the control of blood glucose and

duration of diabetes. Uncontrolled blood glucose levels may

cause several eye-related problems, which may affect the lids, cornea, muscles, lens, retina and the nerves. These can

lead to blindness if left untreated.

Diabetic retinopathy

Diabetic retinopathy is a complication of diabetes and may lead to blindness. It changes the

blood vessels within the retinal tissue, causing them to leak fluid and distort vision. It is of

two types: nonproliferative diabetic retinopathy and proliferative diabetic retinopathy.

In the early stages of the disease, retinopathy in diabetes does not show any symptoms. The condition is often at an advanced stage when symptoms become noticeable. The signs

and symptoms of retinopathy in diabetes includes: blurred vision, the impairment of color

25

vision, floaters or transparent and colorless spots and dark strings that float in the patient's field of vision, patches or streaks that

float in the patient's field of vision, poor night vision, sudden and total loss of vision.

In usual cases, diabetic retinopathy affects both the eyes.

Complications associated with diabetic retinopathy

What causes the ocular complications in diabetes?

The complications associated with diabetic retinopathy are:

¢ Newly formed blood vessel leaks into the vitreous gel filling the eye blocking the light from reaching Vitreous hemorrhage:the retina. Symptoms include loss of vision and sensitivity to light, or floaters in milder cases.

¢ Scar tissue can pull the retina away from the back of the eye. It is Detached retina:characterized by the appearance of floating spots in the individual's field of vision,

flashes of light and severe vision loss. If the retina is detached, it presents a significant

risk of total vision loss when untreated.

¢ The normal flow of fluid in the eye may become blocked as new blood Glaucoma:vessels form. The blockage causes a buildup of ocular pressure, increasing the risk of

optic nerve damage and vision loss.

Any patient with diabetes is at an increased risk of diabetic retinopathy. However, the risk of ocular damage is increased in case of patients:

¢ With uncontrolled blood glucose levels

¢ With high blood pressure

¢ With high cholesterol

¢ Pregnant

¢ Who smoke regularly

¢ With chronic diabetes.

The key cause of diabetic retinopathy is the damage to the network of blood vessels to

retina. High glucose levels damage these vessels and restrict the flow of blood to the retina.

26

Treatment of diabetic retinopathy

Preserving eye health in diabetes patients

Factors such as severity, type of diabetic retinopathy and patient's response to diabetes

treatment guides the treatment strategy of diabetic retinopathy. In nonproliferative diabetic

retinopathy, doctor usually decides to monitor the person's eye closely without intervening.

However, the patients are advised to closely monitor their blood glucose and delay the development and progression of diabetic retinopathy. In patients with proliferative diabetic

retinopathy, the patient needs immediate surgical treatment. Various surgical options

available are focal laser treatment (photocoagulation), scatter laser treatment (pan retinal

photocoagulation) and vitrectomy.

Early blindness due to retinopathy in diabetes patients is usually preventable with routine checks and effective management of the

underlying diabetes. It is important to ensure that the risk of vision loss is minimized. The only way to prevent with diabetes can

prevent diabetic retinopathy is to attend every eye examination scheduled by their doctor.

Patients with diabetes who successfully manage their blood glucose levels will help to prevent the onset of a severe form of diabetic

retinopathy. Another contributing factor is high blood pressure. Patients with diabetes need to control their blood pressure by: eating

a healthy balanced diet, regularly exercising, maintaining a healthy body weight, smoking cessation, strictly controlling alcohol

intake, following the antihypertensive regimen and attending regular screenings.

An early detection of symptoms increases the effectiveness of the treatment.

27

References

1. Diabetes-related eye problems. Dr Mohan’s Diabetes Specialties Centre. May 22, 2018. Available at: https://drmohans.com/diabetes-related-eye-problems/

2. What to know about diabetic retinopathy. MedicalNewsToday. Available at: https://www.medicalnewstoday.com/articles/183417.php#treatment-options

3. Turbert D. Diabetic eye disease. American Academy of Ophthalmology. Jan 28, 2019. Available at: https://www.aao.org/eye-health/diseases/diabetic-eye-disease

The role of a diabetes educator

¢ Inform the patient about the eye damage that he/she may be at risk of due to diabetes.

¢ Control of blood glucose and hypertension is an essential element in managing eye health.

¢ Regular eye screening of the diabetes patients as recommended by the doctor.

28

Redefining Diabetes and Self-management

ExpertOpinion

Dr S Chakravorty

MD (Med), FICP, FIACM, Dip. in Diab (UK)

Senior Consultant Physician and Unit Head, Dept. of Internal Medicine, Diabetology and Critical Care, Metro Multispeciality Hospital, Noida, Uttar Pradesh

Introduction

India ranks second in global diabetes prevalence with

77 million people suffering with diabetes in 2019. The

prevalence of type 2 diabetes is increasing in migrant Indians as reported from several studies. Currently, in urban metros

of India the prevalence of diabetes is fast approaching the

figures commonly reported in the affluent migrant Indians.

Indians are prone to a greater degree of insulin resistance and

a stronger genetic predisposition to diabetes. Obesity,

especially central obesity and increased visceral fat due to

physical inactivity, and consumption of a high-calorie or high-

fat and high sugar diets are major contributing factors for the development of type 2 diabetes mellitus.

Approach for diabetes management

Even though there are several national and international guidelines for clinicians for

effective management of type 2 diabetes resulting in improved patient outcomes. Despite

various available guidelines, diabetes management practices in India remain less than

satisfactory. Among several reasons, some of the most important factors are diverse

cultures, religions languages, food habits, lifestyles and traditions that impact

management practices for diabetes.

Individualizing therapy

Choice of a treatment regimen should consider the patient's general health status and

associated medical disorders. This patient-centric approach may be referred to as the

ABCD-EFGH (Patients Age, BMI, Complications, Duration of Diabetes, Established CVD,

Financial condition, Glycemic status & Chances of Hypoglycemia) approach for diabetes

management.

The drug choice should be based on patient preferences as well as patient's condition,

disease and drug characteristics, with the goal of reducing blood glucose levels while

minimizing side effects, especially hypoglycemia and weight gain.

29

Self-management of diabetes

A patient-centered definition of type 2 diabetes mellitus should be considered as a starting point for enhancing diabetes self-

management. It is important for health care professionals to counsel their patients regarding their health seeking behavior,

physical activity and weight management. Self-management is a self-

control exercise, as there are complex interactions between patient's traditional and religious beliefs, social norms and peer pressure, and

something that requires individual capability.

Approaches to self-management should consider using health

promotion strategies that recognize this complexity. The mainstay of

self-management strategies that health care workers direct at

patients to undertake at home in managing their type 2 diabetes

mellitus include:

¢ Increasing physical activity

¢ Healthy eating to control the blood glucose and

¢ Weight management.

References

1. Masupe TK, Ndayi K, Tsolekile L, et al. Redefining diabetes and the concept of self-management from a patient's perspective: implications for disease risk factor management. Health Educ Res. 2018; 33(1): 40-54.

2. Maladkar M, Patil S, Viswanathan H. Redefining the therapeutic wheel of diabetes management. J Cardiol Cardiovasc Ther. 2018;12(2):001-6.

The role of a diabetes educator

¢ Promote healthy eating and physical activity for prevention and self-management of type 2 diabetes.

¢ Patient literature on type 2 diabetes mellitus should include self-management for the significance on the physical, social and psychological changes that results from diagnosis of type 2 diabetes mellitus.

¢ Consider social ontological perspective of the patient while devising a self-management goal and regime for patients.

30

Nutraceuticals for Diabetes

ExpertOpinion

Dr Dharmendra

MD (Medicine)

Consultant Physician and Diabetologist, Kanpur, Uttar Pradesh

Introduction

Nutraceuticals are substances which are no traditionally

recognized nutrients bit they have physiological effects on

human health body. It can be a food or a part of food and provides medical or health benefits, including prevention and

treatment of disease.

There are various nutraceuticals which have been used in

clinical practice to target the pathogenesis of diabetes

mellitus, metabolic syndrome and their complications and to

favorably modulate many biochemical and clinical endpoints.

The nutraceuticals used in diabetes include antioxidant vitamins, such as vitamins C and E, flavonoids, vitamin D, conjugated linoleic acid, omega-3 fatty acids, minerals such as chromium

and magnesium, alpha-lipoic acid, phytoestrogens and dietary fibers.

Nutraceuticals and diabetes

Several medicinal plants are used as hypoglycemic in the Indian system of medicines.

Nutraceuticals denote foods having medicinal effect on the health of human beings.

Nutraceuticals have the capability to control diabetes.

Nutraceuticals are non-specific biological therapies used to promote wellness, prevent

malignant processes and control symptoms. For instance, high isoflavone intake (20-100 mg/day) is associated with lower incidence and mortality rate of type 2 diabetes, heart

disease, osteoporosis and certain cancers. Omega-3 fatty acids reduce glucose tolerance

in diabetes. Coffee is another great nutraceutical. Lipoic acid is a universal antioxidant, which has now been used in the treatment of

neuropathy in diabetes. There are three categories of nutraceuticals used in diabetes.

Nutrients

¢ Substances with established nutritional functions.

¢ Examples: Vitamins, minerals, amino acids and fatty acids.

Herbals

¢ Herbs or botanical products as concentrates and extracts.

31

Dietary supplements

¢ Reagents derived from other sources serving specific functions, such as sports nutrition,

weight-loss supplements and meal replacements.

¢ Examples: Pyruvate, chondroitin sulfate and steroid hormone precursors.

Some important nutraceutical antidiabetic herbs

It is used to reduce blood glucose level and has potent antioxidant activity, which may account for the hypoglycemic potential. Hypoglycemic activity of the onion is attributed to the allyl propyl

disulfide and allicin.

Onion (Allium cepa)

Garlic has strong antioxidant activity and rapid reactivity with potential hypoglycemic property.

Allicin has been shown to have significant hypoglycemic activity.

Garlic (Allium sativum)

Neem inhibits action of epinephrine on glucose metabolism, resulting in increased utilization of peripheral glucose.

Neem (Azadirachta indica)

Aloe vera maintains glucose homeostasis by controlling the carbohydrate metabolizing enzymes

and stimulates insulin release from pancreatic -cells.

Aloe vera

32

It increases utilization of glucose; either by direct stimulation of glucose uptake or via the mediation of enhanced insulin secretion.

Holy fruit tree (Aegle marmelos)

It acts through release of insulin from pancreatic -cells, which accounts for the hypoglycemic

activity.

Babhul (Acacia arabica)

Flax seeds are the dried ripe seeds, which contain antioxidants and have high dietary fiber that can

help diabetics by inhibiting lipid peroxidation and scavenging of hdroxy radicals.

Flax seeds (Linum usitatissimum)

Jamun works by mediating insulin release mechanism or due to alteration in hepatic and skeletal

muscle glycogen content. In India decoction of kernels of Eugenia jambolana is used as household

remedy for diabetes.

Jamun (Eugenia jambolana)

Bitter gourd may act by increasing hepatic glycogen. The fruits and seeds yielded a polypeptide,

p-insulin, which was considered like bovine insulin. The fruit powder has a blood glucose level

reducing activity.

Bitter gourd (Momordica charantia)

Tulsi has resulted in significant reduction in blood glucose levels in rat modals. It may act by

cortisol inhibiting potency. Leaf powder, when taken along with food for 1 month, in rats was known to reduce fasting blood glucose level.

Tulsi (Ocimum sanctum)

33

References

1. Johri S. Role of nutraceuticals in diabetes. Scientific India. May 23, 2014. Available at: http://www.scind.org/31/Health/role-of-nutraceuticals-in-diabetes.html

2. Davi G, Santilli F, Patron C. Nutraceuticals in diabetes and metabolic syndrome. Cardiovasc Ther. 2010; 28(4): 216-26.

3. Kochhar A, Pathak N. Nutraceutical based approach to combat diabetes mellitus. Curr Res Diabetes Obes J. 2018;8(2):001-4.

The role of a diabetes educator

¢ Nutraceuticals are food supplements and have nutritional value.

¢ There is increasing demand by patients for use of the natural products with antidiabetic activity.

¢ A well-balanced vegetarian diet chosen to form a variety of foods when complemented with other healthy lifestyle practices would significantly decrease the risk for diabetes mellitus.

¢ The efficacy of hypoglycemic herbs is achieved by increasing insulin secretion, enhancing glucose uptake by adipose and muscle tissues, inhibiting glucose absorption from intestine and inhibiting glucose production from hepatocytes.

34

A Stress-free Life and Healthy Aging in Diabetes Patients

ExpertOpinion

Dr Sandeep Suri

MBBS, MD, FIDM, FDFM

Consultant Diabetologist, Holy Help Hospital, Hisar, Haryana

Introduction

Stress has been known to have a negative effect on the health

of the people, and is a considered to be a serious barrier in

diabetes-related health outcomes. Type 2 diabetes is a chronic condition requiring a demanding treatment regimen

aimed at managing blood glucose within optimum levels and

prevent the development or progression of micro- or

macrovascular diabetes complications.

Role of stress in the onset of diabetes

In an individual already predisposed to diabetes, stressful experience has been found to be a contributory factor in the onset of the

disease. Family and workplace stress have been recognized as triggers for the onset of both type 1 and type 2 diabetes. Among

other factors are included high family chaos and behavioral problems, which also lead to stress.

In stressful situation, hypothalamic-pituitary-adrenal (HPA) axis is activated leading to various endocrine abnormalities such as

high cortisol and low sex steroid levels that antagonize the actions of insulin. Simultaneously, an increase in visceral adiposity is also

seen, which plays an important role in diabetes by contributing to insulin resistance.

Stress has a physiological, psychological, behavioral and

environmental link with A1c levels in diabetes patients. Stress

hyperglycemia, which is the development of hyperglycemia during

acute illness, is another connection between stress and glucose

homeostasis in the body. Finally, stress can also induce the

development of type 2 diabetes indirectly by promoting obesity and

metabolic syndrome.

Stress and diabetes control

Stress management

Stress and sympathetic response to stress represent factors, which are strongly

associated with development of type 2 diabetes. Learning and implementing stress management techniques can lead to improved glycemic status. Breathing may reduce the

sense of stress, reduce sympathetic drive and improve cardiovascular function.

Additionally, psychological stress can alter gastrointestinal transit time thereby altering

glucose handling. Psychological stress management regimens have also been shown to

improve long-term glycemic control. Reductions in sympathetic activity through altered

breathing patterns can also influence fasting blood glucose. Sympathetic efferent activity

in the liver, the main location of glucose production, causes an increase in production of the

enzyme responsible for the rate limiting steps for gluconeogenesis.

Physical exercise is known to improve insulin sensitivity, glycemic status, weight maintenance and cardiovascular health in

individuals with diabetes. Maintenance of glycemic control is especially important during exercise in insulin sensitive tissues such as skeletal and cardiac muscle.

Along with the physiological impact of stress on glycemia, it also interferes with the ability

to self-manage diabetes. When a person is stressed out, it is difficult to do every day self-

care tasks such as monitoring glucose frequently, following a meal plan and correctly preparing or remembering to take insulin or oral medications at the right time. In a study

where techniques for coping with stress and self-efficacy and social support was used to

improve the stressful condition of people, the results showed that stress management

techniques could help patients to control their blood glucose levels as well as long-term

complications of their blood glucose levels such as diabetic foot ulcer and blindness.

There are three approaches to stress management in diabetes patient which go hand-in-

hand; remove or minimize the source of stress; change the response to the stressful situation and modifying the long-term

effects of stress.

Tackling the source of stress

Small stressors can be managed by time management and organizational techniques. Self-help books may also be useful for

patients to find ways to structure their lives and manage their time and stressors. Minimizing the source of stress is helpful. Effective

problem-solving strategies are important for minimizing the source of stress.

35

References

1. Lloyd C, Smith J, Weinger K. Stress and diabetes: A review of the links. Diabetes Spectrum. 2005;8(2):121-7.

2. Zamani-Alavijeh F, Araban M, Koohestani HR, et al. The effectiveness of stress management training on blood glucose control in patients with type 2 diabetes. Diabetol Metab Syndr. 2018;10:39.

3. Hilliard ME, Yi-Frazier JP, Hessler D, et al. Stress and A1c among people with diabetes across the lifespan. Curr Diab Rep. 2016;16(8):67.

4. Marcovecchio ML, Chiarelli F. The effects of acute and chronic stress on diabetes control. Sci Signal. 2012;5(247):pt10.

The role of a diabetes educator

¢ Counsel the patient that stressful experiences have an impact on diabetes.

¢ Help the patients with interventions that may help them in preventing or coping with stress.

¢ Make sure the patient gets adequate psychosocial support.

36

Several diabetes-specific approaches that may help the individual cope better with diabetes are setting-specific, realistic self-

management goals. Setting up realistic, measurable and achievable goals specifically stating the measurement criteria indicating

success are helpful as motivators.

Change outlook towards stress

Stress management techniques emphasize changing the response to stress. When the

response to chronic or acute stress results in rage and reactive behavior, a thought-stopping and reflective technique may be helpful. It can help by preventing negative consequences of

the impulsive behaviors associated with anxiety and rage. Some other approaches include

learning how to induce a more relaxed feeling.

Changing the long-term effects of stress

Distraction and involvement in pleasurable activities may be used to help minimize the

influence of stress-producing activities. These may include active participation in a hobby or exercise program. However, if a person

with diabetes is experiencing severe stress, referral to a mental health professional may be the most effective approach.

Healthy Aging with Diabetes

ExpertOpinion

DT Merlin Daya

BSc-N&D Dietitian and Diabetes Educator

Introduction

The prevalence of type 2 diabetes increases with advancing

age. Elderly people are more prone to develop diabetes-

related complications. Clinical features of diabetes in the elderly could be different. Diabetes in elderly people is often

diagnosed with a delay due to atypical symptoms (dementia,

urinary incontinence).

Diabetes and elderly

What happens during aging?

The elderly population is growing both in developed and developing countries but at a

faster rate in developing countries. Although increasing age is a risk factor for the

development of type 2 diabetes mellitus (T2DM) and there are several reports on diabetes in

elderly populations there are few, describing the clinical profile of patients with T2DM aged

90 years and above, and none in Asian Indians. One of the study included patients with T2DM

above 90 years of age who had a mean duration of 23 ± 14 years showed that survival of T2DM beyond 90 years of age is possible,

even in Asian Indians whose current life expectancy is less than 70 years. This study shows that age is just a number and doesn't

hinder healthy living.

Aging causes changes throughout the entire body. A person's basal metabolic rate–the

amount of energy the body expends at rest–declines with age. By some estimates, a

person's basal metabolism drops by 2% per decade starting at age 20. This decline may be

due to several factors, including poor lung function, heart function and blood circulation.

The mineral content of bones also decline with age, leaving older people with weaker, more brittle bones. This may be related to poor nutrition, deficient of calcium absorption, inactivity

and in women, hormonal changes after menopause.

How diabetes contributes to aging?

There is evidence to support that high blood glucose itself can contribute to aging. Age contributes to diabetes complications

including cardiovascular disease, diabetic eye disease, diabetic nerve disease and diabetic kidney disease.

37

Why and how the body ages, regardless of diabetes?

Aging can make diabetes more difficult to control. As people's attention declines with age, they may be less able to focus on the

tasks associated with diabetes management, such as carbohydrate counting, meal planning, blood glucose monitoring and determining correct insulin doses. Furthermore, loss of vision acuity may make it more difficult to accurately monitor blood glucose

levels or draw up insulin doses.

Here are a few ways, on how the body changes as getting older:

¢ Bones become small and less dense

¢ Muscles lose strength and flexibility

¢ Metabolism slows

¢ Joints lose cartilage

¢ Vision and hearing worsen

¢ The heart changes in size and speed

¢ Skin becomes thinner

¢ The immune systems slows.

Important points for diabetes educators

While there is no such thing as a fountain of youth, there are a number of steps that can be taken to counteract some of the

deleterious effects of aging and diabetes, which helps to remain vital well in the older years. Here are some of those steps:

Exercise daily

An exercise physiologist or other specialist can help find a routine that's appropriate for fitness level. Regular exercise such as

jogging, bicycling, swimming and walking can help improve the blood sugar level, coordination, weight loss and helps to decrease

the risk of cardiovascular disease and overall health.

Take medicines on schedule

It's important to take medicines exactly as prescribed by the doctor. Try not to skip doses

and never use more of less of a medication without checking with the physician. Set an

alarm to have a meal or take medicine.

Quit bad habits

Quitting smoking and limiting drinking can lower the chances of developing diabetes

complications. Avoid drinking to reduce the risk of other metabolic disorders including

cardiovascular disease, psychiatric problems such as depression, sleep problems, nerve damage, bone loss and falls.

38

Stay mentally active

Staying physically active can help keep the mind alert, but staying mentally active is important too. The keys to stay mentally active are staying connected to other people socially, constantly learning new things and making mind work in new and different way.

Here are some ideas for giving mind a workout:

¢ Learn a foreign language

¢ Can do dancing with a possible movement and good music

¢ Find a new hobby

¢ Do crossword puzzles or word search puzzles regularly

¢ Play electronic games

¢ Join a book discussion group

¢ Stress can negatively impact health and blood sugar level. Certain activities like

meditation or yoga may help lower the stress level.

Regular checkups

Periodical checkup can keep minor healthy problem from turning into major ones. This includes regular doctor checkups, eye

examinations, kidney tests, foot exams, dentist visits and vaccinations.

Plan healthy meals

The Goals of following a healthy diet:

¢ Protects against chronic diseases

¢ Preserves immune function, digestive health, functional ability, bone health, oral

health and vision

¢ Benefits for cognitive function, mental health and well-being

¢ Minimizes risk of weight loss, undernutrition, low nutrient status, deficiency

diseases (e.g., anemia)

¢ Aids recovery from illnesses.

The calorie requirements are reduced by 20-30% as compared to normal adults. It is important to have a balanced diet with

adequate hydration. There are several factors that affects food choices such as isolation, dentition, depression, disability, intake,

absorption and utilization of nutrients, transport, access, mobility and income, institutionalization, reduced taste perception and

chronic illness. Hence, Dieticians should educate:

¢ On what to eat, how much to eat and which foods to choose?

¢ When eating out, plan to pack meal to eat later.

39

¢ One restaurant dish might be enough for two meals or more. Include a variety of different colored, flavored, and textured

vegetables.

¢ As aging progress people lose interest or rather has distaste for food, so one has to be encouraged to try different food menus

and different cooking methods.

¢ Add flavor to the meals with herbs and spices.

Aging is inevitable process and it is important to take care of the body and mind to live a full meaningful and energetic life.

References

1. Di Angelantonio E, Kaptoge S, Wormser D, et al; Emerging Risk Factors Collaboration. Association of cardiometabolic multimorbidity with mortality. JAMA. 2015;314(1):52-60.

2. Mohan V, Anjana RM, Ranjit U, et al. Clinical profile of elderly patients (over 90 years) with type 2 diabetes seen at a diabetes centre in South India. Diabetes Technol Ther. 2019. Oct 22. (Epub ahead of print)

3. Dinsmoor RS. Healthy aging with diabetes. Diabetes Self-Management. 29th Dec, 2006.

4. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care. 2014;37(Suppl 1):S14-S80.

5. Brown JB, Nichols GA, Perry A. The burden of treatment failure in type 2 diabetes. Diabetes Care. 2004;27(7):1535-408.

6. Ali MK, Bullard KM, Saaddine JB, et al. Achievement of goals in U.S. Diabetes Care, 1999-2010. N Engl J Med. 2013;368(17):1613-24.

40

Lifestyle Modifications: Exercise

41

Two ways to get a ballpark idea if your weight is healthy or not are body mass index (BMI) and waist circumference.

BMI measures your height compared to your weight.

BMI doesn't measure belly fat, and it is important. Too much belly fat can increase the risk for type 2 diabetes, heart disease

and stroke.

Waist circumference (waist size) considers belly fat and helps in the prediction of the risk of health problems from being

overweight.

Women whose waist measures more than 35” and men whose waist measures more than 40” are at higher risk. Losing weight

can reduce belly fat and lower that risk!

Source: CDC. Healthy weight. Available at: https://www.cdc.gov/diabetes/managing/healthy-weight.html

BMI: Less than 18.5; weight status: underweight

WEIGHT STATUS

BMI:18.5-24.9; weight status: normal

BMI: 25-29.9; weight status: overweight

BMI: 30 or greater; weight status: obesity

Warming up for winter exercises

Diabetic super fruit: Date plums

Lifestyle Modifications: Diet

Diospyros lotus, grows from Punjab to Kashmir, with their soft flesh packing a rich,

sweet velvety taste.

The fruits also have toffee notes in its sugay, succulent flesh.

Date plum's skin is edible, unlike the tannin-rich, bitter fuyu persimmon.

Date plum leaves are highly

antioxidant and anti-

inflammatory.

Owing to its medicinal

properties are largely used

in treating fever, anxiety,

stress and also diarrhea.

Fruits can be consumed

raw or cooked.

Fruits can be dried, when it

acquires a date-like flavor.

NUTRITIONAL VALUE OF DATE PLUM

Plums are rich in

antioxidants which are

helpful for reducing

inflammation and

protecting cells from

damage by free

radicals.

Plums have a

potential to increase

levels of adiponectin,

a hormone that

plays a role in

blood glucose

regulation.

The fiber in plums

are partially

responsible for their

effects on blood

glucose.

Plums are

associated with a

lower risk of

type 2 diabetes.

Plums are high in

polyphenol

antioxidants, with

positive effects in

reducing the risk of

diabetes.

120 calories, 31 grams of

total carbohydratesVitamins A and C Excellent source of fiber Cholesterol free

42

Ingredients

¢ Whole wheat flour 2 Tbsp.

¢ Refrigerated Pizza crust 1 can

¢ Vegetable cooking spray

¢ Olive oil 2 Tbsp.

¢ Low-fat ricotta cheese ½ cup

¢ Dried basil ½ tsp.

¢ One small onion, minced

¢ Two cloves garlic, minced

¢ Salt

¢ Shredded part-skim mozzarella cheese 4 ounces

¢ Mushrooms chopped 2 cups

¢ Red pepper, cut into strips 1 large

Methods

Step 1: Preheat oven to 425 °F.

Step 2: Spread whole wheat flour over working surface. Roll out dough with rolling pin to desired crust thickness.

Step 3: Coat cookie sheets with vegetable cooking spray. Transfer pizza crust to cookie sheet. Brush olive oil over crust.

Step 4: Mix low-fat ricotta cheese with dried basil, onion, garlic and salt. Spread this mixture over crust.

Step 5: Sprinkle crust with part-skim mozzarella cheese. Top cheese with mushrooms and red pepper.

Step 6: Bake at 425 °F for 13-15 minutes or until cheese melts and crust is deep golden brown.

Step 7: Cut into 8 slices and serve.

Recipe of the month: Two Cheese Pizza

43

NUTRITION VALUE PER SERVING

Energy: 420 cal Protein: 20 g Carbohydrates: 44 g Sugar: 5 g

Sodium: 580 mg

Source: Tasty recipes: For people with diabetes and their families. March 2011. CDC, NDEP

Fat: 19 gSaturated fat: 7 g

Cholesterol: 25 mgFiber: 3 g

44

Diabetes Technology Update

New glucagon formulations

There are two new forms of fast-acting glucagon; one is puff-up-your-nose version and the other one its ready-to-use glucagon

emergency pen.

Eli Lilly has come up with rescue glucagon that you can simply “puff-up-your-nose” to quickly boost blood glucose. The “EpiPen-

style” being developed by Xeris Pharmaceutical is a liquid glucagon pen and ready-to-use glucagon emergency pen, which does not

require any mixing or preparation.

These are being developed by Eli Lilly and Xeris Pharmaceuticals, respectively and are under various phases of clinical trials.

If approved, this would be the first new types of glucagon in more than six decades!

Source: New glucagon formulations. 2019. Available at: https://www.healthline.com/diabetesmine/new-diabetes-technology-expected-2019#1

45

Conference Highlights

Theme: Exploring new insights and promoting awareness on diabetes health care

Date: February 17-18, 2020

Venue: Osaka, Japan

Target audience: Scientists, clinicians, surgeons, physicians, young researchers, industry representatives and students.

Aim of the conference: This Diabetes Asia 2020 includes speaker talks, keynote and poster presentations, exhibition, symposia

and workshops. This international conference will help in interacting and meeting with diabetes and endocrinology experts, leading

renowned speakers, diabetologist, dieticians, doctors, scientists, physicians, scientists, physicians, surgeons exploring their

research through the world.

The aim of the international conference is to provide an opportunity to share knowledge, proficiency along with unparalleled

networking prospects between several medical and industrial experts in the field of diabetes, endocrinology, hypertension and obesity.

4TH INTERNATIONAL CONFERENCE ON DIABETES AND ITS COMPLICATIONS

46

Diabetes Quiz

Why are a healthy diet and regular exercise so important if you have diabetes?

¢ They keep depression at bay

¢ Eating raises blood glucose; exercise lowers it

¢ Being overweight can be dangerous for people with diabetes

¢ All of the above

Q-1

The risk for type 2 diabetes mellitus includes:

¢ Family history

¢ Being overweight

¢ High intake of dietary fat

¢ All of the options listed are correct

Q-2

Green vegetables and fruits are important for healthy aging in diabetes patients.

¢ True

¢ False

Q-3

Answers

1 All of the above

All of the options listed are correct 2

3 True

ANSWERS EVERY PATIENT OR CAREGIVER SHOULD KNOW!

47

Educator Alert

Are you eating out?

Urban Indians have been frequently eating out at least once a month, and with increasing

restaurant portions have gotten a lot bigger.

Unless there are restrictions in place, eating out is a recipe for regular overeating.

48

Plan ahead Start smart Order wisely Share and savor

TIPS FOR EATING OUT

Decide what you are going to order before you go and have a snack that

contains fiber and protein.

Drink a big glass of water as soon as you sit down, skip the chips and salsa or bread that comes to your table before you order.

Choose baked, steamed, grilled or broiled instead of fried, breaded, crispy or

creamy to reduce fat and calories. Ask for veggies instead of fries or other high-calorie side dishes.

Share your main dish or eat half and wrap up the rest for later. Enjoy the

occasional sweet treat.

Source: Centers for Disease Control and Prevention (CDC). Eating out. Available at: https://www.cdc.gov/diabetes/managing/eat-well/eating-out.html

49

NOTES

NOTES

50

Disclaimer: Although great care has been taken in compiling and checking the information given herein to ensure that it is accurate, the publisher shall not be in no way directly or indirectly responsible for any error, omissions or inaccuracy in this publication whether arising from negligence or otherwise. IJCP Publications Ltd. does not guarantee, directly or indirectly, the quality or efficacy of the product or service described in the advertisements or other material which is commercial in nature in this publication.

Copyright 2019 IJCP Publications Ltd. All rights reserved.The copyright for all the editorial material contained in this book Indian Diabetes Educator Journal, Issue No. 58, January 2020, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.This book is Published and Edited by IJCP Academy of CME at Regd. Office: E-219, Greater Kailash Part - 1, New Delhi - 110048. E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com, HIP/IN/Mumbai/2593 as a part of its social commitment towards upgrading the knowledge of Indian doctors.

https://www.facebook.com/NDEPCOURSE/

http://emedinews.in/ http://emedinews.in/2019/idej_June.html http://emedinews.in/2019/idej_July.html

http://www.usvmed.com/IDEJ.html

Connect with us

51