How to recognise and manage Diabetes: Dr. Anoop Misra, Director, Diabetes Foundation of India(DFI)

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Padma Shri Dr. Anoop Misra
Chairman, Fortis-C-DOC Centre of Excellence for Diabetes,
Metabolic Diseases and Endocrinology
Chairman, National Diabetes, Obesity and Cholesterol
Foundation (N-DOC)
Director, Diabetes and Metabolic Diseases, Diabetes
Foundation (India) (DFI)

Diabetes in Indians: How to recognise and manage

About 63 million people are afflicted by diabetes in India and this figure is about to rise to 80 million by 2025. Adverse metabolic factors (excess insulin levels in blood, high triglyceride and high cholesterol levels) are evident in Indians at an early age. Indians have a greater risk of diabetes which tends to manifest 5-10 years earlier as compared to other races. In particular women are at equal or greater risk of developing pre-diabetes, diabetes and diabetes related complications, as compared to men. The main causative factor for diabetes, obesity in India is increasing continuously; 13-50% in urban population and 8-38% in rural
population. Increase in obesity is associated with increased chances of having fatty liver disease, night time obstruction in breathing and certain cancers as well.

What is wrong with Indians who develop diabetes?

• Generalised Obesity: BMI ≥25kg/m2 [ (weight/(height in metres)2, BMI is an indicator of obesity]. These cut offs of BMI is lower for Indians than western population because of the endency of Indians to develop diabetes at a lower weight.
• Abdominal Obesity: As the waist grows larger, insulin becomes increasingly ineffective in your body, therefore levels of this hormone rise. Men ≥90 cm, women ≥ 80 cm have abdominal obesity and can develop diabetes in future.

Other visible manifestations that indicate increase risk of diabetes:

• Acanthosis Nigricans: a dark velvety change in texture and thickening of the skin affected (behind the neck, under arms, thigh folds). It is strongly correlated with increased risk of diabetes even in children.

Fig.1- A 50 years old patient with velvety dark pigmentation of the skin at the back of neck called ‘Acanthosis Nigricans’ and a fat lump called ‘buffalo hump’. Presence of these features indicates increased risk of diabetes.

Fig.2- A 42 year old female weighing 110 kgs with fasting blood glucose of 150mg/dl having skin tags, this indicates increased risk of diabetes.

Fig.3- A 25 years old female not overweight but with irregular menses, polycystic ovarian disease and excess facial hair indicating increased risk of diabetes.

Buffalo Hump: (Fig.1) excess of fat deposition at back of neck shows high risk for diabetes.
Skin Tags: (Fig. 2) a skin tag is a benign (non-cancerous) skin growth that can occur on the body or face. They can be are smooth or wrinkled, skin-colored or just slightly darker than skin color. This indicates risk for future diabetes.
Hirsutism: (Fig.3) excess facial and body hair, especially on girls and women, can be another sign of insulin resistance, which increases risk for developing diabetes.

Double Chin: (Fig.4) excess fat deposition under chin also indicates risk for diabetes.
Other risk factors are;
– Physical inactivity
– Consumption of calorie dense diet
– Low fruits and vegetables intake
– Women delivering a child more than 4kg
– Young girls with swelling in the ovaries (Polycystic Ovarian disease)

How to diagnose diabetes?

Testing should be done in all asymptomatic individuals whose BMI ≥25kg/m2 and/or above mentioned conditions.

Common symptoms of diabetes include: increased thirst, frequent urination, dry mouth, unexplained marked weight loss, increased hunger, and blurred vision. In 50% of the patients, no symptoms are present.

A blood test is done to diagnose diabetes. Following are the diagnostic criteria.

• Fasting blood glucose ≥126 mg/dl indicates diabetes.
• 2 hour post glucose load ≥ 200mg/dl (after 75g glucose load)
• Random blood glucose ≥200mg/dl along with other symptoms of diabetes.
• HbA1c ≥6.5%. Some of these values are taken together to reach a diagnosis.

How to manage diabetes?

Diabetes can be prevented with healthy lifestyle choices including regular exercise and balanced diet

Most patients need oral drugs, and some need insulin for control of blood sugar.

Indians have a greater
risk of diabetes which
tends to manifest 5-10
years earlier as compared
to other races.
In particular women are
at equal or greater risk of
developing pre-diabetes,
diabetes and diabetes
related complications, as
compared to men.
The main causative
factor for diabetes,
obesity in India is
increasing continuously;
13-50% in urban
population and 8-38% in
rural population.

Lifestyle Modifications:

a) Diet:

  • Limit Carbohydrates:

–     Carbohydrate intake should be approximately 50–60% of the total calorie intake.

–     Prefer complex carbohydrates over refined carbohydrates. Complex carbohydrate sources are 🙁 whole wheat, brown rice, pearl millet [bajra], finger millet [ragi], pulses and legumes (red gram [tur dal], soya, horse gram [kulthi]).

–     Low GI foods (e.g., oats [jai], parboiled rice, whole pulses, beans [fali], and legumes (sabut anaj) and some whole fruits [like guava, apple, etc.]) should be preferred. High GI foods (refined flour, root vegetables such as yam [sooran/shakarkand], potato, tapioca[a type of shakarkand], colocasia [arbi], etc.) should be consumed in moderation.

  • Eat Healthy Fats:

–     Fats should provide not more than 15-30% of total energy/day and Saturated Fatty Acids should provide no more than 10% of total energy/day. MUFA(Monounsaturated fatty acid) should provide 10-15% of total energy

–     Increase monounsaturated fats (MUFA) in the diet, as healthy alternative to trans-fat and refined polyunsaturated fats.

–     Monounsaturated fatty acid (MUFA) rich sources in the diet include olive oil/canola oil/mustard oil, avocados, nuts like almonds, cashews, pecans, olives.

–     Essential Polyunsaturated fatty acids (Linoleic acid/omega 6) should be derived from dietary sources which are: vegetable oils like soybean, primrose, safflower oil, durum wheat, eggs, poultry, and nuts.

–     Dietary sources of omega3 fatty acids include: Flaxseeds, chia seeds, walnuts, canola oil, olive oil, fish oil, and fish.

–     Complete dependence on just one vegetable oil does not ensure optimal intake of various fatty acids use of two or more vegetable oils is recommended. For example rotate olive/canola/mustard oil. Minimum consumption of butter and ghee and use of partially hydrogenated vegetable oils should be avoided.

  • Increase Dietary Fiber Intake:

–     The total dietary fiber in daily diet should be 25–40 g/ day (e.g.1 small apple gives 1.0 g of fiber; 100 g of whole wheat flour gives 1.9 g of fiber). A minimum of four or five servings per day of fruits and vegetables is recommended (i.e., approximately 400–500 g/day including three vegetable and two fruit portions [e.g., 100 g of (one katori) raw vegetables (e.g., cauliflower, brinjal, etc.)=20–30 Kcal; 100 g of fruit e.g., one apple=59 Kcal]). Fruits should be eaten whole, preferably with the skin, whenever feasible instead of fruit juices.

  • Get Enough High Quality Protein:

–     Protein intake should be based on body weight. The protein intake should provide 10–15% of the total calories/day in sedentary to moderately active individuals. Recommended protein sources:

–     Non-vegetarian: egg white, fish, and lean chicken.

–     Vegetarian: soya, pulses, whole grams (channa, rajma, green gram, etc.), milk, and low fat dairy products like cow’s milk, cottage cheese.

  • Watch Food Portion Size:

–     Weight loss is the key when it comes to control insulin resistance. Eating small portions at regular intervals throughout the day doesn’t let you remain too hungry and prevents from overeating in the next meal. Gap between two meals should be 3-4 hours.

  • Eat Berries:

–     Berries like blueberries, strawberries which contain bioactive compounds called anthocyanins (which are polyphenols) have shown to improve insulin resistance.

  • Cinnamon: 2-3 grams/day (½ teaspoon) freshly grounded cinnamon helps to improve blood sugar control, helps to reduce body weight and abdominal girth, reduces blood fats (Lipids: triglycerides, total cholesterol, LDL cholesterol),helps in lowering blood pressure.

Weight loss:

–     5-10% of weight loss in patients with diabetes helps in reducing sugar levels, blood pressure, helps to control cholesterol and triglyceride levels.

–     Drug therapy can be added to lifestyle changes for increasing weight loss if needed.

Physical Activity:

– Recommended physical activity for adults is 60 min every day, which should include at least 30 min of moderate intensity aerobic activity, 15 min of work-related activity, and 15 min of muscle strengthening exercises with weights.

Oral Medications:

– Obese individuals may also need help of medications for optimal control of blood sugar levels and weight loss. In obese patients there is resistance to the action of insulin, in such patients gradual escalation of oral anti-diabetic drugs is recommended along with diet and physical activity. Insulin therapy may be needed in case of failure to respond to oral drugs.

In obese patients
there is resistance to
the action of insulin,
in such patients
gradual escalation
of oral anti-diabetic
drugs is recommended
along with diet and
physical activity.
Insulin therapy may
be needed in case
of failure to respond
to oral drugs.

–  Commonly used medicines for diabetes and weight loss are :Metformin, Liraglutide (Victoza), Dulaglutide (Trulicity), SGLT-2 Inhibitors (Canagliflozin/Dapagliflozin/ Empagliflozin)

Managing diabetes in non-obese individuals:

In non-obese individuals there is less of insulin secretion, hence beyond a certain point oral anti-diabetic drugs fail and insulin is needed to control blood glucose levels.

Follow up:

It is important to have periodic checkups for assessment of blood sugar control and early detection of complications. Annual checkup of eyes (fundus), foot testing including vibration perception and ankle reflex, kidney function tests which include urine micro albumin, should be done along with other tests. Regular blood glucose monitoring needs to be done for optimal control.

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