நீரிழிவை எதிர்கொள்வது எப்படி ?

Defeating Diabetes is the key to good health
Dr. Rajeshkumar Shah, M.D., Consulting Physician and Cardiologist

Diabetes is an extremely common disease and in most patients, silent to start with but unfortunately relentless and irreversible disease. Diabetes mellitus (DM), the Latin term means ‘honeyed urine’. Diabetes as a disease was well known to ancient Indian Physicians, Sushruta in 400 B.C. noted MADHUMEHA. It is now known that more than 70% of middle aged Indians will suffer with non-insulin dependent diabetes during their life time. Results of a ten year analysis from Southern India (1994 – 2004) reveal a trend towards increasing prevalence in both urban and rural population and more number of younger persons, particularly women, presenting with diabetes. Though diabetes is caused by a complex interaction of genetic (inherited tendency for the disease) and lifestyle factors, the most obvious reason for this increase in the number of young diabetics is OUR PRESENT LIFESTYLE. Apart from smoking, stress, sedentary lifestyle, calorie dense processed packaged junk food and obesity, SLEEP DEPRIVATION appears to have more profound effects on blood sugar than previously appreciated. Now there is evidence of the direct link between just one sleepless night and impaired utilisation of insulin leading to a high blood glucose level. While a good lifestyle can help override the harmful manifestations of bad genes, a bad lifestyle can nullify the blessings of good genes.
In almost 50% of cases diabetes is not recognised! Reasons being:
·      Individual neglect
·      Mildness or even absence of symptoms
·      Inadequate medical care
So the Indian government intends to start mandatory screening for diabetes in the age-group of 25 – 70 years across the country in the next two years. It is estimated that presently there are 51 million diabetics in India alone (as against a 30 million diabetics worldwide in 1980) and is set to rise to 87 million by 2030. Apart from these, India presently also has 40 million people with impaired glucose tolerance (pre-diabetes). These people have a fasting plasma glucose level between 100 – 125 mg/dl and/or a post-prandial (two hours after food) glucose level between 140 – 199 mg/dl. People who are on the verge of becoming full-blown diabetics offer a great opportunity for primary prevention (preventing or delaying the onset of full-blown diabetes) by counseling and convincing them to implement appropriate therapeutic lifestyle changes (T. L. C.).
Early onset of diabetes is very WORRYING as it means that longer time would be available for potential long-term complications to set in. Long standing uncontrolled high blood sugar level can damage almost every organ of the body and in general the uncontrolled diabetic will have a poorer quality of life and well being. Diabetes is the leading cause of:
·      Adult blindness
·      Lower limb amputations
·      Irreversible kidney failure
Due to accelerated blocking and/or hardening of blood vessels it also increases the risk of coronary artery disease and heart attack, stroke, nerve damage resulting in neuropathic pain, impotency, bladder and bowel dysfunction, loss of sensation in feet, legs, hands etc. Combination of insufficient blood flow and damaged nerves makes one vulnerable to repeated infections and delayed wound healing.

Primary Prevention:
It Means preventing or delaying the onset of type-2 diabetes mellitus (DM) in those at high risk (obese or with pre-diabetes). This is made possible by promoting weight reduction through appropriate healthy diet and increased physical activity. Patient education about DM, nutrition and excercise is the cornerstone in the primary prevention of DM.

What is Diabetes?
In simple terms, diabetes is a metabolic disorder in which the body is unable to control the amount of sugar in the blood, because the body either does not produce enough insulin or there is resistance to the action of insulin. This leads to high levels of sugar in the blood, passing of sugar in the urine. Initially patient may have a variety of symptoms such as excessive thirst, excessive appetite and excessive urination. Delayed wound healing, frequent infections, nausea, vomiting and weight loss may be othersymptoms. If uncontrolled over several years, DM may damage almost every tissue and organ of the body.

–     Under normal circumstances the blood glucose level never rises above 160 mg/dl even after food.
–     Normally the kidney does not allow any glucose to be lost and hence the urine is sugar free. However if the blood glucose level rises above 180 mg/dl, sugar “spills over” into the urine.

How does Diabetes develop? 
The conversion of sugar to energy requires the presence of hormone insulin, which is produced by the pancreas. There are two main types of diabetes:

·      Insulin dependent diabetes – Also known as Type One diabetes or Juvenile diabetes. Here there is a shortage of insulin. This is because of damage to insulin producing cells in the pancreas, as a result of viral and other infections and/or an abnormal reaction of the body’s immune system against its own insulin producing cells in the pancreas. In general this happens to children and young adults. Diabetes develops fairly quickly and if not treated it may result in drowsiness and diabetic coma. In addition to diabetic diet, these patients always need insulin for survival.
·      Non-insulin dependent diabetes – Also known as Type Two diabetes or Maturity onset diabetes. Usually occurs in the middle and older age group. Here apart from unhealthy lifestyle, there is also a genetic component; 40% risk if both parents have type-2 DM. Here the available insulin is ineffective. These people do not require insulin to survive. Many can be treated by diabetic diet and excercise to promote weight loss. Some may require a combination of diet, excercise and tablets. In a small percentage of patients it may be necessary to add insulin to achieve adequate control. Here the presence of symptoms is no guide to the level of sugar in the blood and it is essential that the disease is treated even when there are no symptoms. Regular monitoring of blood sugar, HbA1c and indicators for kidney and heart disease etc. is necessary to ensure that treatment is adequate and effective.
In every type of diabetes, monitoring and necessary treatment must be maintained throughout life. This is necessary not only to avoid symptoms and the risk of coma, but also to minimize the risk of any later complications.

For Diabetes Prevention and Health Enhancement: 
For primary prevention of diabetes it is very important to inculcate healthy eating habits right from early childhood. Educating children about junk food and providing them with healthier food/snacking options would ensure that children will be less prone to eat junk food even when they grow up. Childhood obesity is associated not only with increased risk of DM but also earlier disease onset. To prevent childhood obesity:

–     Promote breast feeding and discourage use of infant formula and complimentary feeds. For young children, Nutrient dense natural unprocessed fruits, vegetables and dry fruits are to be encouraged. Over advertised, overhyped Boost and energy providers should be avoided. Avoid over-feeding your child.
–     Encourage the child toexcercise and be physically active.
–     Limit screen time (T.V., COMPUTER, VIDEOGAMES ETC.) to less than one hour/day .
–     Ensure adequate sleep and regular sleep hours.
–     Promote the use of COARSE GRAINS (MILLETS). Until forty years back – before green revolution happened, millets (Bajara, Jowar, Ragi, Nachni, Kangni, kodrey etc.) used to be the mainstay of diet in most of rural and semi-urban India. Millets have low Glycemic Index (G.I.) – they breakdown slowly, hence glucose is released slowly into the bloodstream and hence easier to metabolise. It also has iron which helps prevent anaemia. Being drought and pest resistant, it is also easy to cultivate. Paddy cultivation needs 20 times more water!
–      
Diabetic Diet: Excercise and Diet are the two most important aspects of diabetes treatment. Strict adherence to Diet and Excercise will help in achieving ideal body weight and minimise the need for tablet and insulin. To ensure enjoyment and compliance, diet should be similar to patient’s customary diet. Do not fast or skip a meal. Small frequent meals are advised.
Principles:
–     Foods which should be avoided completely: Sugar, Jaggery, Glucose, honey, jam, softdrinks, squashes, bottled sauces, buns, pastries, sweet biscuits, desserts, fruit tinned in syrup, coconut and coconut water, alcoholic beverages, dates, figs, raisins, mangoes, chiku, grapes, custard apple, jackfruit,
banana, boost, bournvita, complan, horlicks.
–     Foods which can be eaten but need to be regulated to some extent: Polished rice, iddli, kaldosai, ravadosai, ragidosai, pesaratdosai, ravaupma, poha (rice flakes ), puffed rice (pori ), dhokla, wheat rotis, full fat milk and milk products, carrot, beetroot, peas, ground nut oil, sunflower oil, olive oil, all fats.
–     Foods which can be eaten regularly and freely, provided your weight does not become excessive: All green leafy vegetables, salad vegetables, mushrooms, onions, tomatoes, cucumber, broccoli, olives, jalapenos, gherkins, cauliflower, bitter-gourd, brinjal, beans, broad beans, sprouts, chow-chow, capsicum, cluster beans, drumstick, ginger, ladies finger, mint, raw papaya, plantain stem, lotus stem, tindola, turiya, all dhals, pulses etc. Nuts like walnuts, almonds, pista and groundnuts.
–     Beverages such as Tea, coffee (without sugar), soda water, tomato juice, lemon juice, clear soups, skimmed buttermilk.
–     Fiber rich foods such as fenugreek seeds powder, flax seeds and Isabgol help reduce the need for medicines.
–     Eating Out: With a little extra care you can eat out and still follow your diet. Wherever possible, select generous portions of vegetables, salads, avoid fats and sugar, choose baked, grilled, or boiled food, as opposed to fried food.
Excercise:
Is very good because it burns up energy, lowers your blood sugar and makes insulin act more effectively and thus helps reduce the need for medicines. It also helps reduce the bad cholesterol, increase the good cholesterol, lower blood pressure and improve blood circulation.
Caution: Too much excercise may lead to Hypoglycaemia (Low Blood Sugar). As a precaution always carry sugar candy with you.
Hypoglycaemia:
Symptoms: Trembling, sweating, tingling around the mouth, excessive hunger, palpitation (awareness of ones own heart beat), headache, giddiness, confusion, weakness, blurred vision, children may vomit, changed behaviour. Occasionally convulsions and loss of consciousness.
If hypoglycaemia occurs during night, the symptoms may wake you up.
Precautions:
–     Always carry some form of sugar.
–     Always carry some identification that you have diabetes treated with insulin.
–     Always inform your companion, that there is a possibility that you could become hypoglycaemic.
Preventing Hypoglycaemia:
–     Don’t miss meals or snacks.
–     Don’t delay your meals.
–     Make sure that you are eating sufficient food.
–     Don’t over-excercise. Before extra excercise or physical activity, increase your carbohydrate intake or reduce insulin dose.
A word of warning:
Although the aim is to prevent hypoglycaemia, you must not achieve this by running a constantly high blood sugar (which over a prolonged period will cause serious and permanent damage to all tissues and organs.

Is your diabetes under control?
In the year 2007, American Diabetic Association (ADA) had set out the following treatment goals for adults with diabetes:

1)  Glycaemic control:
·      HbA1c (GlycatedHaemoglobin), Reflects blood sugar level over the previous 2-3 months. Different labs may use different methods for assessing A1c levels, and these results in significant variations in measurements. Accurate assessment requires dedicated instrumentation and expensive reagents.
·      ADA recommends an A1c< 7%.
·      Pre food blood sugar: 90-130 mg/dl.
·      Post food (90 minutes after beginning of a meal): <180 mg/dl
2) Blood pressure:  less than 130/80
3) LIPIDS:
LDL Cholesterol:   < 100 mg/dl
HDL Cholesterol:  > 40 mg/dl
Triglycerides:       < 150 mg/dl
Achieving and maintaining the above goal will help eliminate symptoms related to DM and also reduce or eliminate the long term complications of DM.

Complications
Acute complications: Diabetes Keto Acidosis (DKA) – This a complication of insulin deficiency combined with excess of glucagon, cortisol etc. In the absence of insulin fat is broken down and ketones are made. ketones are poisonous acids. DKA, Can result in death if not recognised early and treated immediately. It should be avoided at all cost. To prevent DKA it is important that Patient is educated about symptoms (nausea, vomiting, abdominal upsets, breathlessness, extreme weakness, excessive urination, thirstiness, confusion) and precipitating factors such as infections or heart attack or stress – all of which increase the need for insulin. Patient on insulin should remember to take the same as advised. When blood sugar is >300mg/dl – measure urinary ketones.

Chronic (long term) complications of DM have been mentioned earlier.
Care of the feet: To prevent foot ulceration and infection:
–     Wash your feet daily in warm water using mild toilet soap.
–     Dry your feet carefully and dust with plain talcum powder.
–     When the toe nails need cutting, do this after bathing, when the nails are soft and pliable. Do not cut them too short.
–     Wear good fitting shoes. Do not walk about in bare foot.
–     Make it a daily routine to feel inside your shoes for stones, nails etc.
–     Do not smoke.
–     Undergo check-up for early diagnosis and assessment of peripheral neuropathy.
Care of the Eye:
Blindness from Retinal Hemorrhages can be prevented by photocoagulation of diseased blood vessels, if undertaken before vision has deteriorated too seriously. Therefore, it is essential that you must have your eyes examined regularly – Ideally, annually.
NEWER ORAL GLUCOSE-LOWERING AGENTS – A Word of Warning
Some of the recently introduced agents  (ten to thirty times more expensive than the still very much effective and useful older drugs), with limited clinical experience but still widely prescribed with considerable enthusiasm are said to be associated with an increased risk of toxicity to vital organs such as kidney, liver and even increased risk of heart attack. I hope that physicians in India, based on their judgement and experience, will voluntarily refrain from prescribing such agents and not wait for the regulatory Authorities in India to officially announce the discontinuation of such agents from the Indian market.

Dr. Rajeshkumar Shah, M.D.
Better Health Foundation – a resource center for people with health needs.
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