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JUNE - JULY 2016

Vol 6 No 2

60

Annual testing

CAN SAVE YOUR LIFE


Importance of thyroid tests
The many benefits of garlic
Lixisenatide - a promising option

www.diabeteshealth.co.in

June - July 16

MISSION

Editor
Dr A G Unnikrishnan
Publisher
W P Vasandani
Editorial Consultants

to spread awareness and knowledge of diabetes

Dr M K Mandal
Mr Vandan Agarwal

and its consequences throughout India

Dr Imtiaz Hasan
Dr Rajesh Javherani
Dr Vedavati Purandare
Dr Anjali Bhatt
Dr Manish Bothale

to motivate the population to take

preventive measures

Dr Reina Khadilkar
Dr Abhijit Joshi
Dr Ashok Gavande
Foot Care Specialist:
K V Kavitha
Diet & Nutrition:
Gauri Kukade

to empower all those affected


to participate in their own

healthcare management

Priya Chaudhari
Fitness & Lifestyle:
Gouri Ambardekar PT
Assistant Editor
Sunila Kelkar
Sub Editor
Spandana Birajdar

Printed and published by W P Vasandani on behalf of Chellaram


Foundation. Owned by Chellaram Foundation, Gazdar House, Third Floor,
629-A, J. Shankar Sheth Road, Mumbai - 400002. Printed at Nectar
Prints Pvt. Ltd. Unit No 4, 37-A, Murlimal Shrikishindas Compound,
L.B.S. Marg, Bhandup (West), Mumbai 400 078

Designer

Reproduction of content, in part or whole is prohibited.

Milind Joshi

This magazine provides general news, opinions, information and tips for
health and well-being pertaining to Diabetes. It is advisable to consult with
a practicing physician before making any changes to your healthcare
routine. The views expressed in the articles are of the authors, and not of
the Publisher. No representation is made or warranty given (either
expressed or implied) as to the completeness or accuracy of the
information contained. Readers should verify the information and
wherever necessary consult with their doctor before they act on it. Diabetes
Health does not necessarily endorse the products advertised in the
magazine and accepts no liability for any direct or indirect loss arising
from the use of the information and the material contained in the
magazine.

Contacts:

Editorial :
Sunila Kelkar
editorial@diabeteshealth.co.in / 020 6683 9777 Ext: 714

Advertising :
Dr Ashok Gavande
advt@diabeteshealth.co.in / 022 6635 5600 Ext: 106

Send your stories, questions, opinions


and suggestion to editorial@diabeteshealth.co.in

Just diagnosed
I'm 22 years old and
was recently diagnosed
with Type 1 Diabetes.
On reading your
April-May'16 issue, I
found that the
magazine focuses
on Type 2
Diabetes. I would
be grateful if you
could share
more
information on
Type 1
Diabetes. I
also feel that
the language
should be made simpler for
patients to understand the disease
and motivate them to overcome it.
Shikha Gupta, Mysore

I'm encouraged that public awareness of


Diabetes is increasing through grass-roots
efforts and endeavors like your magazine. As a
physical therapist and a parent of culturally
influenced teens, I'm exposed to and alarmed
rate at the rising number of overweight,
unhealthy and at-risk children. I'm equally
alarmed at the lack of knowledge in the general
population with regard to understanding healthy
eating habits. I support this initiative of yours in
its mission to heighten public awareness of this
epidemic. We all must assist schools and public
institutions in being more accountable in the
role they play in cultivating this unhealthy state.
We must support education that involves the
whole child, which includes fitness and
nutrition. We have resources: fresh food,
knowledge and people. It is past time to take
action.
Shazia Ahmed, Meerut
Dear Shazia,

Dear Shikha,
We will certainly try to bring you more
information on Type 1 Diabetes. In
our next issue do check out our expert
view on Type 1 Diabetes. Also, if you
do have specific questions drop us an
email anytime!
- The DH team

02 DIABETES HEALTH JUN-JUL 16

Save the next generation

We appreciate the views that you have put


forward and we are trying our level best to make
people more aware of this lifestyle disorder. We
do hope that more people like you join hands in
preventing this debilitating disease.

- The DH team

The art of motorcycle


maintenance
Mr X comes to meet me. He is 53 years and an avid biking
enthusiast. He owns, as he proudly tells me - a bike like no
other. A motorcycle - black, shiny, a true beast! A monster that
whirrs like a rocket to conquer the road, yet purrs like a kitten in
the hands of Mr X. He describes the weekly washings and the
monthly check ups it needs the fuel it guzzles. He details the
infinite, meticulous care that he offers the bike. Till now, he has
mentioned nothing about his health. I pause and think, should I
bring up the subject at all? Should I tell him - that if he spends a tiny fraction of the motorcycletime to take care of his health, how much better he could be? Following my better judgement, I
try not to douse his passion. I guide the conversation diplomatically towards his health.
Friends, this article is not trying to tell people not to follow their passion, and to pursue Diabetes
care instead. As our cover story on annual check-up for Diabetes implies - a little passion for
Diabetes care can help you pursue your real passions in a longer, healthier and happier manner.
Diabetes is a silent disease which damages the blood vessels - capable of leading to blindness,
foot amputations, kidney failure and heart attacks. The bad news is that despite "apparently"
good glucose control, these complications can creep up silently. The good news is that these
complications can be detected early and stopped in their tracks with simple measures. This is
the reason for an annual Diabetes check up to screen for detecting complications. But what
about simply controlling blood glucose levels and treating complications as and when they
appear? This is not easy because by the time diabetic complications have broken their silence
and caused symptoms like poor vision or reduced urine output, it might be too late to halt their
progress adequately.
In the book titled "Zen and the Art of Motorcycle Maintenance" the author debates these twin
philosophies of life. Should we proactively look for problems and sort them out? Or to repair the
motorcycle whenever it breaks down? While there are no overarching answers in life - in the
science of Diabetes care, early screening for Diabetes complications could prevent future
catastrophes.
Back to the present - I smile gently, even as Im able to guide Mr X towards a decision on his
Diabetes management. He says that he is worried about check-up as it would detect problems
which he would then have to solve! I counter that if he already has these problems, is it not better
to solve them? Mr X agrees, and though it has been time consuming, this conversation has been
fulfilling.
Sometimes the most important decisions in life require a little push. We hope this issue of
Diabetes Health provides it towards your better health!!
Wishing you health and happiness, always!

Dr A G Unnikrishnan
Editor

JUN-JUL 16 DIABETES HEALTH 03

COVER STORY
Testing is important
10

Timely medical tests: Why they matter!

The importance of regular testing

PEOPLE
Coming to terms with your diagnosis
36

Being responsible!

Your family relies on you

DIABETES CARE
Managing Diabetes in your day-to-day life...
42

EDUCATION

Beware of this silent disease

A skin infection that often goes unnoticed in people


with Diabetes

Because knowledge is your best ally in dealing with


Diabetes

62

30

Factors that increase your risk of Diabetes

The importance of thyroid function tests

Certain tests that need to be done

Triple Diabetes threat

NUTRITION
Eat smart, eat healthy and enjoy life!
50

The many benefits of garlic

The goodness of the herb

Recipes

46

Lixisenatide: A promising option

The benefits of once a day injection in people with


Diabetes

04 DIABETES HEALTH JUN-JUL 16

News

The latest updates from the world of Diabetes

74

Baked chicken parmesan cutlets

75

Cream of vegetable soup


40

Testing Room - C-peptide test

FITNESS

Know your tests and their implications

56

61

The science of exercise

Is physical exercise the best medicine in people with


Diabetes?

DIAB-E-TECH
A special column detailing the latest technology to
improve fitness

Medicine Cabinet - Premix insulin

Our new feature keeps you updated on your meds


72

Ask Diabetes Health

Our experts answer your queries on Diabetes


76

Answers to Diabetes Health Quiz

Answers to the April-May'16 Diabetes Health Quiz and


the lucky winners
78

Health Predictions

What's on the cards for the coming months?


80

Health Bytes

People share their fitness mantra

alth
iabetes He
Win free D
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n
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t
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subsc

70

Workout powerhouse!

The complete cardio workout

REGULAR
2

Diabetes Health Forum

Letters from Diabetes Health readers

8
h Quiz - Page 6
lt
a
e
H
s
te
e
b
ia
The D
tory - Page 73
S
s
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Share yo
JUN-JUL 16 DIABETES HEALTH 05

NEWS

Statins therapy

Statins are a class of drugs known to reduce


cholesterol levels in the body. Previous
studies have shown that statins do lower
cholesterols; and thus, reduce the risk of
heart diseases. Also, these trials have only
assessed the efficacy of statins in specific
population with elevated lipid levels. Hence
the benefits of statins in treating
intermediate risk patients without heart
disease in an ethnically diverse population
remain unclear.
In line with the same thought, a study
published in the New England Journal of
Medicine, assessed 12,705 participants
across 21 countries who did not have heart
disease and were at intermediate risk. They

06 DIABETES HEALTH JUN-JUL 16

were divided into two groups one group was


given rosuvastatin at a dose of 10mg per
day and the other received placebo. The
study showed that the low density
lipoprotein (LDL) or bad cholesterol level
was 26.5 per cent lower in the rosuvastatin
group compared to the placebo group.
In short, the study showed that low doses
of rosuvastatin worked wonders even in
those at intermediate risk across a
diverse population as there was significant
reduction in the risk of heart diseases
compared to the placebo group.

Source: The New England Journal of Medicine

NEWS

New hope for Diabetes


A new class of drugs called GLP-1 analogues
is making an impact in Diabetes care. Some
common examples include Lixisenatide,
Liraglutide, Exenatide and Dulaglutide.
These injectibles can reduce blood glucose
and also reduce body weight. In addition
they have favourable effects on blood
pressure and cholesterol too.

and were at high risk of major adverse


cardiovascular events. The study was divided
in two group one that received Liraglutide
and the other placebo. It was observed that
the group that received Liraglutide showed
significant reduction in cardiovascular risk.
This study indicated that the treatment may
prevent cardiac events.

But do all these benefits indicate a reduction


in heart attacks? Well a new study done on
GLP-1 analogue (Liraglutide) called the
LEADER study was was conducted which
assessed the cardiovascular safety of
Liraglutide over a period of 5 years in more
than 9000 adults who had Type 2 Diabetes;

This is good news for people with


Diabetes as they are prone to cardiac
illnesses.

Source: Press release

NEWS

Protein power
Diets high in proteins have shown beneficial
effects on maintaining glucose levels in
short-term trials; and thus, have been
suggested as potential strategy in people
with Type 2 Diabetes. However a new study
published in the American Journal of
Epidemiology has shown that increased
intake of protein, especially animal
protein, increases the risk of Type 2
Diabetes. The study investigated a total of
4,146,216, of which 15,580 cases developed
Type 2 Diabetes. The intake of total, animal
and vegetable protein was calculated for
each individual. It was observed that
participants who consumed a greater
amount of animal protein were at a higher
risk of Type 2 Diabetes, whereas the intake
of vegetable protein reduced the risk of
Type 2 Diabetes. Also, substituting
vegetable protein for an equal exchange of

08 DIABETES HEALTH JUN-JUL 16

animal protein and carbohydrates was


associated with reduced risk of Type 2
Diabetes.
These data suggest that adopting a diet rich
in plant-based proteins should be
considered for Type 2 Diabetes prevention.
This has an important public health
implication, since proteins and
carbohydrates are often exchanged for one
another in the diet. Also, both the type of
protein and the type of carbohydrate have
been associated with Type 2 Diabetes risk.
However, confirmatory results from dietary
intervention studies are required to provide
support for dietary recommendations to
increase intake of vegetable protein in place
of animal protein.

Source: American Journal of Epidemiology

Pain treatments

Adhesive capsulitis (commonly known as


frozen shoulder) is a painful disorder, where
the movement of the shoulder is restricted.
Having Diabetes increases your risk of
developing a frozen shoulder. A study
published in the Journal of Back and
Musculoskeletal Rehabilitation was carried
out to clarify the effects of continuous
passive motion (CPM) treatment in Diabetes
mellitus patients with frozen shoulder.
CPM is carried out by a CPM device, which
constantly moves the joint through a
controlled range of motion which is
increased over time. The goals is to control
post-operative pain, reduce inflammation,
provide passive motion in a specific plane of
movement, and protect the healing repair or
tissue.
Forty patients were divided into two groups.
The first (n = 21) received CPM movements
while the second underwent conventional

physical therapy (CPT), which involved


stretching, range of motion (ROM) and
pendulum exercises. After a four week-long
physical therapy program the participants
were instructed to continue the same regime
at home for eight weeks. The participants
rated the pain they felt at night (both while at
rest and in motion). There was significant
improvement in both groups.
Both CPT and CPM therapies seemed to be
beneficial in treating frozen shoulder in the
participants with Diabetes mellitus; however,
the CPM group showed more distinct
improvement in the function and pain
levels. Thus, suggesting that CPM may be a
better way of managing the discomfort
associated with a frozen shoulder.

Source: Journal of Back and Musculoskeletal


Rehabilitation

JUN-JUL 16 DIABETES HEALTH 09

Timely medical tests:

Why they matter!


Dr Anjali Bhatt shares the importance of regular testing.

COVER STORY

A silent killer
Mr Shah (name changed) had Diabetes for
many years, but since last year he had
severe cramps in his feet while walking. He
also experienced numbness or tingling
sensation in his legs and feet.
Mr Fernandez (name changed) has had
Diabetes for three years. He recently found
out that his neighbour had a silent heart
attack. The idea of a silent heart attack
sounded frightening.
Mrs Tripathi (name changed) had gestational
Diabetes which later led to a diagnosis of
Type 2 Diabetes. A routine urine test has
shown the presence of slightly higher levels
of albumin (protein).
Often times, there is a misconception
amongst people who have Diabetes - all you

need to monitor and manage is your blood


sugar levels. Unfortunately, what isn't known
is that Diabetes Mellitus is a silent killer.
In all three cases the consulting
diabetologist would direct the patients to go
in for in depth testing on a regular basis. In
case of Mr Shah, he would be directed to a
foot specialist (podiatrist) to determine what
the pain, tingling sensation and the
numbness indicate. Mr Fernandes would be
encouraged to visit a cardiologist to
determine his heart health. Mrs Tripathi
would be referred to a nephrologist to check
how well her kidneys are functioning.
These minor symptoms and indications in
people with Diabetes are often warning signs
of larger complications which often follow
Diabetes. The sugar level fluctuations which
occur when you have Diabetes can also
cause damage to various organs of the

JUN-JUL 16 DIABETES HEALTH 11

body. They include heart disease and stroke,


kidney problems, nerve damage, problems
with eyesight, sores and skin infections on
feet and gum disease that can lead to loss of
teeth. This damage is often silent. For
instance, as in the case of Mr Fernandez's
neighbour, heart disease may be silent
without any chest pain till one day the
patient suffers a catastrophic heart attack.
However, not all patients with good blood
glucose control are complication-free. This
is because though the blood glucose levels
may be normal once a month when the
patient checks, during the interim period,
glucose fluctuations may pass undetected.
These silent fluctuations in the day or night
can predispose to complications. Every
person with Diabetes, whether his glucose is
controlled or not, therefore should undergo
an annual check-up to look for Diabetes
related complications.

12 DIABETES HEALTH JUN-JUL 16

Why an annual Diabetes


check-up matters
Mr Mehta's third opinion
Mr Mehta has had Diabetes for 5 years.
Once in 6 months, he carries out a fasting
and a post meal blood sugar test. Last
week, however, his doctor mentioned that he
requires an annual Diabetes check-up and
gave him a list of tests HbA1c
Fasting Glucose
Post Meal Glucose
Blood Pressure
Total Cholesterol
LDL Cholesterol
Triglycerides

HDL Cholesterol
ECG/ Treadmill test

Targets for Diabetes control


for various parameters

Liver function tests (LFT) (certain liver


enzymes called AST and ALT, which
suggest hepatic damage)

HbA1c - <6.5 %

Urine for Microalbuminuria

Fasting Glucose - 80-130 mg/dL

Blood Urea, Serum Creatinine

Post Meal Glucose - less than 180 mg/dL

Foot Evaluation to Prevent Ulcer


Eye Check Up
Mr Mehta was worried. Why were all these
tests being asked? Mr Mehta worked as a
senior bank manager - he usually underwent
annual blood tests - simple tests like
haemoglobin, blood glucose, urine test,
ECG and a chest X-ray. But this array of tests
bewildered him. Were all these tests really
required? Was he being over investigated?
It was not a question of affordability indeed, the entire cost of testing came to
less than 0.1 per cent of his annual salary!
However, he did not like testing at all. Indeed
he did not even like to take the anti-diabetic
pill which he had been prescribed. However
he had tried stopping the pills secretly,
watched his blood glucose levels shoot up and had therefore decided that it was better
to continue these medications.
Worried, Mr Mehta went to a senior and
more qualified doctor. That doctor also told
him that it was better to do the test. When
Mr Mehta told him that wouldn't this lead to
unnecessary over-diagnosis, the doctor said
that - all the more better, you can take all
precautions, then! Mr Mehta was thoroughly
confused. He decided to see Mr Banerjee,
his neighbour. He knew that Mr Banerjee
had Diabetes for many years and was on
insulin. He went with the list of tests to Mr
Banerjee. Mr Banerjee was a professor in the
Gov. Engineering College, and widely
respected by all. Mr Mehta would never
forget what Mr Banerjee told him!
Mr Banerjee said, Mr Mehta, why do you

Blood Pressure - <130/80 mm hg


Total Cholesterol - <180 mg/dL
LDL Cholesterol - <100 mg/ dL
Triglycerides - <150 mg/ dL
HDL Cholesterol - >45 mg/dL
Note: The target for LDL is <70 mg/dL for person with Diabetes with
coronary disease. Recommendations modified from guidelines issued
by the American Diabetes Association and American Association of
Clinical Endocrinologists. Targets may be different if you have other
co-existing illnesses.

hesitate? Have an annual check-up (once a


year) to rule out silent diabetic complication
affecting the eyes, kidney, nerves and heart.
This can prevent more overt and dangerous
complications. Otherwise, if you get major
complications, you will need to see a
different specialist at least once every week
to treat various problems. Which is better,
seeing the doctor and having a check-up
once a year or once every week to treat the
complications associated with Diabetes?
Thus convinced, Mr Mehta went ahead with
his annual Diabetes check-up.
Diabetes Mellitus has been called a silent
killer. Left untreated, it can damage the
kidneys, nerves, eyes and heart. This
damage may be silent. For instance, heart
disease may be silent, without even chest
pain till, one day the patient suffers a
catastrophic heart attack. Good control of
Diabetes can prevent diabetic complications.
However, not all patients with good control
are complication-free. This is because
though the blood glucose levels may be
normal once a month when the patient

JUN-JUL 16 DIABETES HEALTH 13

checks, during the interim period, glucose


fluctuations may pass undetected. These
silent fluctuations in the day or night can
predispose to complications. Every person
with Diabetes, whether his glucose is
controlled or not, therefore should undergo
an annual check-up to look for diabetic
complications.
Many people with Diabetes believe that only
when complications occur, they need to be
treated. This is wrong. By the time a
complication like kidney failure or loss of
vision occurs, they are virtually difficult to
reverse. Therein lies the importance of
screening for complications. If a patient
undergoes testing and a problem is detected
in the pre-complication stage, treatment is
effective. An example is drug treatment to
prevent kidney failure in people with
microalbuminuria.
Your first step is to know your risk. Visit your
health care provider and ask about your risk
of developing any complications associated
with Diabetes. Most of us have risk factors
that raise our risk for these deadly diseases.

For many of the risk factors, there are things


we can do to lower our risk. Risk factors
determine whether an individual will develop
Diabetes and its related complications.
Some risks can be lowered by lifestyle
modification through diet, exercising,
quitting smoking and reducing alcohol.
Understand the risk of onset of Diabetes
related complications can help you
determine how to lower them in order to
lead a longer and healthier life. Some of the
risk factors include:
Being overweight
Having high blood glucose (sugar)
Having a history of Diabetes during
pregnancy, called gestational Diabetes
Having high blood pressure
Having high cholesterol levels
Being physical inactive
Smoking
Having unhealthy eating habits
Age, race, gender and family history of
Diabetes and associated
complications
It is important Not to ignore any
warning signs with
regards to your health
when they present
themselves.
That patients prepare
themselves to face reality
whenever they meet a
doctor. Take a step back,
relax and look at the
situation objectively.
Not to delay your
diagnosis or treatment
for an excessively long
period.

14 DIABETES HEALTH JUN-JUL 16

Annual Diabetes check-up


versus annual health check-up
Many of the tests in the annual Diabetes
check-up are common to an annual health
check-up. For example blood glucose, ECG,
lipid profile are common tests. However
some tests are exclusive for Diabetes - like
microalbuminuria and Diabetes eye i.e.
retina photography. In addition, there are
some tests which are not part of usual
Diabetes testing, for instance a chest X-ray,
vitamin D-3 or B-12 test. Nevertheless it
may be useful to add these tests to a
Diabetes check-up. Chest X-ray, for instance,
may pick up tuberculosis, which is quite
common in Indian persons with Diabetes.
Indeed, Diabetes lowers immunity and
makes people prone to difficult-to-treat
tuberculosis. Vitamin D deficiency is
common in Diabetes. Simple Diabetes
drugs like metformin may induce deficiency
of vitamin B-12. Hence tests like chest X-ray
and vitamin levels are useful for Diabetes
too.

and combine the Diabetes and the general


health annual tests, and carry the new,
hybrid testing on a single day every year.
Sometimes, where cost is a concern, these
tests can be completed over a year or two in
several clinic visits.

Annual tests lead to treatment


changes
Certainly, finding out problems can lead to
diet, exercise and medication changes. Diet
may have to be modified according to the
presence of high glucose level, high
cholesterol or high uric acid levels. In the
presence or absence of complications,
exercise prescriptions vary. For instance,
persons with heart disease may need to limit
their activity. People with diabetic retinal
disease should not lift weights - as this can
induce bleeding into the eye and blindness.
People who have diabetic nerve damage
affecting sensation should break up their
exercise routine into two or three short
periods, rather than completing the same at
one go. Prolonged walking in people with

The best strategy is to sit with your doctor,

JUN-JUL 16 DIABETES HEALTH 15

nerve damage to the feet can lead to ulcers.


Medications too may be changed depending
on cholesterol and glucose readings. In
presence of microalbuminuria, your doctor
may prescribe pills to prevent further kidney
damage. Non-medication treatments also
exist. For example, if retina photography
suggests impending, dangerous damagethen a simple treatment called laser therapy
can prevent blindness. Nerve-damage
related deformities to the feet can lead to
ulcers and even amputation - these
devastating problems can be prevented by
the use of a protective footwear. Wherever
there are blocks in blood supply to the heart
or the feet, blood thinners like aspirin may
be prescribed.

What are these tests for


actually?
The various tests that are required and their
rationale have been listed below. These tests
are needed for two reasons. Diabetes is a
disease where several parameters need to be
kept under control. In addition to the blood
glucose levels, the three-monthly average
blood glucose level, called the HbA1c test
needs to be kept below 6.5 per cent in a
person with Diabetes.
Testing a lipid profile is also important.
According to a new publication which
appeared in the European Heart Journal,
new guidelines suggest that fasting may not
be really required for a lipid profile test,
though it may be ideal.
Another example is the simple urine test.
This can pick up silent urinary infection, very
common in Diabetes. Some drugs for
Diabetes, called gliflozins can also lead to
urinary infections as a side effect, as they
push out glucose in the urine. The simple
urine test also measures ketone bodies,
which are somewhat dangerous chemicals

16 DIABETES HEALTH JUN-JUL 16

seen when blood glucose is very high, or


paradoxically in starving patients - as well as
patients on some drugs. However the most
important urine test is to measure
microalbuminuria. The explanation for this
test is complicated, but goes something like
this - the diabetic kidney can be compared
to a coffee filter that filters out the liquid
coffee, leaving the debris above. Similarly,
the kidney filters out clear urine, leaving the
proteins in the blood. When a coffee filter is
damaged, solid pieces accompany the
filtered fluid. Similarly, when the diabetic
kidney suffers an early damage, proteins like
albumin can leak through in the urine. This
stage is called microalbuminuria. This is an
early feature of diabetic kidney disease and
is part of every complications seen.
Microalbuminuria occurs almost a decade
before kidney failure and dialysis is needed.
At the stage of microalbuminuria,
medications to protect the kidney are very
effective. Moreover, a patient who knows that
he has developed microalbuminuria will be
extremely cautious and control Diabetes
carefully. Microalbuminuria is just an
example, but there are a lot of things done
at an annual check-up of a person with
Diabetes.
The aim of these additional tests is to detect
the Diabetes related complications at early
stages which are often asymptomatic. These
tests provide a fair understanding of risks
and complications that may arise, they often
fail to pinpoint some serious complications
often associated with Diabetes. In addition
to these tests, people with Diabetes must
also undergo these routine tests during
follow up

HbA1c every 3 months

Lipid profile with measurement of


fractions like LDL and HDL cholesterol
levels and triglyceride levels every 6-12
months

Serum Creatinine every 12 months if


normal and every 3-6 months if
abnormal.

Urine microalbumin every year if normal


and every 3-6 months if abnormal.

ECG - to be checked every year

Stress test, ECHO and cardiology


consultation depending on the ECG
test result

Retina check-up - to be done every year


if normal, every 6 months if mild to
moderate retinopathy and every 3
months for severe retinopathy or if laser
treatment is done.

Neurovascular evaluation of foot - This


involves testing for fine touch (by
monofilament), vibrations (by
biothesiometry or tuning fork) for
evaluation of neurological sensation
and Ankle brachial index for evaluation
of blood circulation of feet to be done
at least once every one year. If required,
the doctor may advise you to do a foot
scan.

Dental check-up - once every 6 months


Depending on the test
results, doctors may
advise the following tests
for a more detailed
evaluation:

Hemogram

Vitamins B12, D3

Thyroid function tests at


least once every year
after the diagnosis of
Diabetes. In addition to
the laboratory tests,
blood pressure and BMI
are also checked.

Clinical assessment tests


Blood pressure testing
An important part of taking care of yourself
is keeping your blood pressure under
control. High blood pressure - also called
hypertension - raises your risk for heart
attack, stroke, eye problems and kidney
disease. As many as 2 out of 3 adults with
Diabetes have high blood pressure. Having
your blood pressure checked regularly and
taking action to reach your blood pressure
target can prevent or delay Diabetes
problems. Blood pressure is the force of
blood flow inside your blood vessels. When
your health care team checks your blood
pressure, they record two numbers, such as
120/80 mmHg. You'll hear them say this as
"one-twenty over eighty. Both numbers are
important:
The first number is the pressure as your
heart beats and pushes blood through
the blood vessels. Health care providers
call this the "systolic" pressure.
The second number is the pressure when

Let us look at these tests in


depth.

JUN-JUL 16 DIABETES HEALTH 17

the vessels relax between heartbeats. It's


called the "diastolic" pressure.
When your blood moves through your
vessels with too much force, you have high
blood pressure. Your heart has to work
harder when blood pressure is high and your
risk for Diabetes problems goes up. High
blood pressure is a problem that won't go
away without treatment. Measuring blood
pressure is a quick, non-invasive and
painless procedure. Both Diabetes and high
blood pressure increases your risk of heart
attack, stroke and eye and kidney disease.
Because of this, people with Diabetes have a
lower blood pressure target than the general
public. The general guidelines are as under:-

stroke, kidney failure, peripheral artery


disease and hypertensive retinopathy (eye
damage)

BMI test
The measurement called Body Mass
Index(BMI) is ordinarily used to find out if
someone is underweight, a healthy weight,
or overweight. BMI takes into account your
weight and height and is in general, a good
indicator of how much body fat you have.
This is a key factor to determine whether or
not your weight is likely to affect your health.
The easiest way to measure body fat and
gauge obesity is to calculate body mass
index (BMI).

Normal BP - less than 120/80


Pre-hypertension - 120-139/80-89
High BP (stage 1) - 140-159/90-99
High BP (stage 2) - higher than 160/100
Slight variation to these numbers is quite
normal, but very high blood pressure
(Hypertension) poses health risks such as
heart attack, congestive heart failure,

Tests done for annual


complications screen
ECG/ Treadmill test - To rule out heart disease
Urine for Microalbuminuria - To detect early kidney disease
Blood Urea, Serum Creatinine - To detect early kidney
disease
Foot evaluation to prevent ulcer - To find out nerve or
blood vessel disease
Eye Check Up - To diagnose early diabetic retinopathy
Liver function tests (LFT)* - Lipid control drugs need LFT
monitoring
* LFT here mainly implies certain liver enzymes called AST and ALT,
which suggest hepatic damage.

18 DIABETES HEALTH JUN-JUL 16

Using the BMI measurement system, if the


BMI is:
less than 18.5 - one is classed as
underweight
In the range 18.5-23 - one is classed as
being a healthy weight
In the range 23-24.9 - one is classed as
overweight
In the range 25-39.9 - one is classed as
obese
Over 40 - one is classed as morbidly
obese (which means excess weight is
particularly harmful for your health)

Waist circumference test


Increased amount of fat around your belly
and waist increases your health risk of Type
2 Diabetes, high blood pressure, high
cholesterol and heart disease. It is advised
that waist measurement should not be more
than 40 inches for men and 35 inches for
women. People with larger waist

circumference may be required


to lose weight.

Monofilament test of
the feet
This inexpensive test determines
whether the person is at the risk
of developing a neuropathic
ulcer. During testing, a filament
is pressed on specified parts of
the foot. As the filament bends
it exerts a pressure of 10 grams
on the area of the foot where it
has been pressed. Lack of
resulting sensation indicates
that the person has lost
sensation in that part of the
foot.

Blood Tests
HbA1c
One of the most important
interventions in Diabetes
treatment is early diagnosis and
rapid corrections of blood sugar,
and more importantly
diagnosing the pre-diabetic
population (those with borderline blood
sugars but not in the diabetic range). The
HbA1c is a blood test which gives average
blood sugars of past 3 months. It can never
be overemphasized that a person with
Diabetes should regularly check his or her
HbA1c and maintain it at a level as advised
by the doctor. If done every 3-6 months it
gives information regarding the blood sugar
control and indicates if patients have
regularly been taking medicines.
Normal: <5.7 per cent
Pre Diabetes: 5.7-6.4 per cent
Diabetes: > 6.5 per cent
The advantage of HbA1c test is that it can

be done at any time of the day, no special


preparation like fasting is required. The test
should be done from a standardised lab
which frequently does the test and has a
good quality control program. However
HBA1c has some short comings such as
some haemoglobinopathies (i.e., abnormal
haemoglobin synthesis) and anaemia can
alter levels. In such patients methods which
are not affected by such disorders can be
used.
The test is very important for woman who
has Diabetes and is planning a pregnancy.
Such woman should plan a pregnancy only
when HbA1c is controlled or not more than
1 per cent higher than the upper limit. But at
the same time it is not a good test to

JUN-JUL 16 DIABETES HEALTH 19

Diabetes related visit


Discuss with your doctor openly regarding health issues as it
helps them assess the severity of your condition. If you have
Diabetes, check whether you have to come fasting.
Remember to carry your
Previous medical records and prescription (arranged as per
the dates)
o Blood sugar levels, HbA1c , serum creatinine, Urine
examination, Lipid profile
o Recent fasting and post meals blood sugar levels
Food diary (a food chart of what you have eaten the past
3-7 days)
Blood glucose records done by glucometer at home
Medications (bring the medications you are taking, if on
insulin get the pen and discuss in details how many units
you take in a day)
List of questions and concerns that you may have

monitor blood sugar in pregnancy; where


only fasting and post meal blood sugars
should guide treatment decision.

Lipid profile test


It is a blood test that can measure the
amount of cholesterol and triglycerides in
your blood. If you have Diabetes then you
should check your cholesterol levels once
every year. A lipid profile typically includes:
Total cholesterol - this test measures all
of the cholesterol in all the lipoprotein
particles.
High-density lipoprotein cholesterol
(HDL-C) - measures the cholesterol in
HDL particles; often called "good
cholesterol" because it removes excess
cholesterol and carries it to the liver for
removal.
Low-density lipoprotein cholesterol
(LDL-C) - calculates the cholesterol in

20 DIABETES HEALTH JUN-JUL 16

LDL particles; often called "bad


cholesterol" because it deposits excess
cholesterol in walls of blood vessels,
which can contribute to atherosclerosis.
Usually, the amount of LDL-C is
calculated using the results of total
cholesterol, HDL-C and triglycerides.
Triglycerides - measures all the
triglycerides in all the lipoprotein
particles; most is in the very low-density
lipoproteins (VLDL).
Very low-density lipoprotein cholesterol
(VLDL-C) - calculated from
triglycerides/5; this formula is based on
the typical composition of VLDL
particles.
Non-HDL-C - calculated from total
cholesterol minus HDL-C.
Cholesterol/HDL ratio - calculated ratio
of total cholesterol to HDL-C.
An extended profile (or advanced lipid
testing) may also include low-density
lipoprotein particle
number/concentration (LDL-P). This
test measures the number of LDL
particles, rather than measuring the
amount of LDL-cholesterol. It is
thought that this value may more
accurately reflect heart disease risk in
certain people.

Liver function tests


Liver function tests are used to measure
specific liver enzymes and proteins in your
blood. They are used to identify problems in
the liver. Alanine transaminase (ALT)
metabolizes protein. High levels of ALT in
the blood indicate lowered functioning or
liver damage. Aspartate transaminase (AST)
is an enzyme found in the heart, liver and
muscles. Usually, an ALT-to-AST ratio helps
diagnosis liver problems.

Serum Creatinine
Serum creatinine blood test indicates how
well your kidneys are working. Creatine is a
compound that is made primarily in the liver
and then transported to the muscles. It
functions as an energy source for muscle
activity. Once in the muscle, some of the
creatine is spontaneously converted to
creatinine. The amount of both creatine and
creatinine depend on muscle mass, so men
usually have higher levels than women.
Creatinine is one of the substances that
kidneys normally eliminate from the body.
High levels of creatinine may indicate that
your kidney is damaged and not working
properly. Your doctor may order a blood test
to assess your creatinine levels if you show
signs of kidney disease. These symptoms
include:
fatigue and tiredness
loss of appetite
swelling in the face, ankles or
generalized swelling all over the body
lower back pain near the kidneys

changes in urine output and frequency


high blood pressure
nausea and vomiting
However, early stages of kidney disease may
not present any symptoms, so testing
creatinine can be used to detect early kidney
failure. Creatinine blood tests require
drawing of blood to be tested. Results of the
creatinine blood test are measured in
milligrams per deciliter or micromoles per
liter. The normal range for creatinine in the
blood may be 0.6-1.3 milligrams per
deciliter, although this can vary from lab to
lab, between men and women and by age.

Thyroid function tests


Please refer to page no 30 for a detailed
explanation on the Thyroid Function Test

Vitamins B12 and D3


Both tests tell you how much vitamin B-12
and D-3 is in your blood. Deficiencies in
vitamins B-12 and D-3 can cause significant
health effects like neuropathy and bone
disorders, respectively, 25-Hydroxyvitamin D

JUN-JUL 16 DIABETES HEALTH 21

(25OHD) is the major circulating form of


vitamin D that is tested. For testing, blood is
drawn and the collected sample is tested in
a laboratory. The normal values for vitamin
B-12 are 200-900 pg/mL (picograms per
milliliter) and the normal values for vitamin
D-3 are 40-100 ng/mL (nanograms per
milliliter)

Urine test
Microalbuminuria urine test
The blood vessels in the kidney filter waste
from the blood and this waste is expelled
from the body in form of urine. Proteins are
normally retained in the bloodstream by the
kidneys. When these blood vessels are
damaged, it may cause excess of protein
(albumin) to spill in the urine. Albumin
excretion in urine increases in patients with

Diabetes, especially those with uncontrolled


blood sugar levels over a period of time.
This condition is known as Diabetes
nephropathy. Positive urine microalbumin is
the earliest indicator of diabetic
nephropathy. You can check whether you
have nephropathy or the degree to which
you have it by doing the microalbuminuria
test. As the condition indicates,
microalbuminuria refers to the detection of
small quantities of albumin (protein) in the
urine. Since microalbuminuria is a marker of
generalised vascular disease, it may also be
associated with stroke and heart disease.
The reading are predicted as
Normoalbuminuria: <30 mg/day
Microalbuminuria: 30-300 mg/day
Proteinuria: >300 mg/day
If the results are in the microalbuminuria
range it might indicate incipient nephropathy
(initial stage of development of nephropathy)
and may predict the progression of diabetic
kidney disease. This implies that patients
need to take adequate measures in
controlling their blood glucose and blood
pressure. This also helps the doctor to
modify the treatment plan to include
medications used to treat hypertension (high
blood pressure) and congestive heart failure
to reverse or halt the progression of
nephropathy.
Note - The National Kidney Foundation
guidelines for the management of patients
with Diabetes and microalbuminuria
recommends that all patients with Type 1
Diabetes older than 12 years and all patients
with Type 2 Diabetes less than 70 years
should have their urine tested for
microalbuminuria every year when their
blood glucose as well as blood pressure are
under control. In cases where the glucose
control is not as good as desired, the
physician may recommend testing more
frequently.

22 DIABETES HEALTH JUN-JUL 16

Safe guarding your heart


health
ECG
Electrocardiography (ECG) is the process of
recording electrical activity of the heart by
placing electrodes on the body. These
electrodes detect tiny electrical changes on
the skin that arise during each heartbeat.
The electrocardiogram can measure the rate
and rhythm of the heartbeat, as well as
provide indirect evidence of blood flow to
the heart muscle.
The ECG is a relatively simple test to
perform. It is non-invasive and does not
hurt. An electrode lead, or patch, is placed
on each arm and leg and six are placed
across the chest wall. The signals received
from each electrode are recorded. The
printed view of these recordings is the
electrocardiogram.

ECHO test
An echocardiogram is a test that uses sound
waves to create pictures of the heart. The
picture and information it produces is more
detailed than a standard X-ray image. There
is no exposure to radiation during an
echocardiogram. It is a non-invasive and
painless procedure.
Echo also can pinpoint:
heart muscle that aren't contracting well
because of poor blood flow or injury
blood clots inside the heart
fluid buildup in the pericardium (the sac
around the heart)
Structural abnormalities in the heart
valves
problems with the aorta (The aorta is the
main artery that carries oxygen-rich
blood from your heart to your body)
flow of blood through your heart's
chambers and valves (in case of Doppler
echocardiogram)

JUN-JUL 16 DIABETES HEALTH 23

A small probe (transducer) is placed on


various locations on your chest and upper
abdomen and directed toward the heart.
This device releases high-frequency sound
waves. The transducer picks up the echoes
of sound waves and transmits them as
electrical impulses. The echocardiography
machine converts these impulses into still or
moving two-dimensional or threedimensional pictures of the heart.

Stress test
Stress tests are tests performed to
determine the amount of stress that your

heart can manage before developing either


an abnormal rhythm or evidence of ischemia
(not enough blood flow to the heart muscle).
The most commonly performed stress test is
the tread mill exercise stress test. As your
body works harder during the test, your
heart has to pump more blood. The test
detects whether there is adequate blood
supply reaching your heart during a stress
inducing event.
While testing you're hooked up to an
equipment to monitor your heart rate.
Initially, you walk slowly on the treadmill.
After a certain time frame, the inclination of
the treadmill is increased to provide a little
resistance to your walk so that you feel like
you're climbing a hill. The speed is also
increased gradually to make you walk faster.
You may be asked to breathe into a tube for
a couple of minutes. You can stop the test at
any time if you need to.
During testing your heart rate, breathing,
blood pressure, electrocardiogram (ECG)
and the degree of tiredness is monitored

Importance of an annual foot


check-up
People with Diabetes are prone to foot
problems. Nerve damage leads to decreased
sensation in legs and feet. Thus injuries to
the foot are not sensed. These injuries, when
ignored, can get infected. Ulcers may form.
Sometimes the infection may ascend up the
leg to the body. To save life, the foot may be
surgically removed through a process called
amputation. Diabetes is the most common
medical cause for performing amputations
in the world. Sometimes block to blood
vessels can lead to complete death of a
finger or even the foot - this is called
gangrene. The affected gangrenous part
looks black and needs to be removed.
These problems can be predicted by tests

24 DIABETES HEALTH JUN-JUL 16

ultrasonography. A Doppler ultrasound of


the lower limbs helps diagnose blood clots,
poorly functioning valves in your leg veins
causing accumulation of blood or other
fluids, blocked arteries, decreased blood
circulation into your legs, bulging arteries
(aneurysms) and varicose veins.
During testing, the patient is asked to lie
down and a special gel is applied to the area
to be examined. The gel allows better
transmission and reception of the ultrasound
waves. The ultrasound wand is placed and
moved on the skin. There may be some mild
discomfort. The information is sent to the
computer and images are seen on the
monitor. During the test, a whooshing
sound, which is the sound that the
ultrasound machine makes to represent your
blood moving through your body, is heard.

like Doppler (assesses blood flow), nerve


conduction/biothesiomtery tests (a simple
electricity based test to asses nerve damage
by assessing sensation) and even a simple
X-ray of the foot can help. Foot scan is a
special test that assesses the pressure
exerted by various aspects of the sole of the
foot and may predict the site of ulcer.
It is best to meet a diabetic foot specialist
(called a podiatrist) annually - who will then
advise the correct tests.

Colour Doppler test


The Colour Doppler ultrasound is a noninvasive test. It estimates the amount of
blood flow by bouncing high-frequency
sound waves (ultrasound) off the red blood
cells. It is widely available, easy-to-use and
less expensive than other imaging methods.
Colour Doppler is extremely safe and does
not use any ionizing radiation. Colour
Doppler examination presents a clear picture
of soft tissues that do not show up well on
X-ray images or conventional

A normal reading signifies no narrowing or


other abnormality or clots. The size and
position of veins are normal and there is
normal blood flow in blood vessels that
supply oxygen and nutrients. An abnormal
reading is denoted by a high pitched or
turbulent sound or an irregular flow may
indicate the exact location where an artery is
blocked or narrowed and the presence of
varicose veins. It also identifies if the blood
vessels that supply oxygen and nutrients to a
fetus are abnormally increased or decreased.

Biothesiometry test
Biothesiometer is an instrument which aids
the podiatrist (foot specialist) to detect early
nerve damage. It delivers minute but
identifiable vibration to the feet. During
testing, a probe is placed on the big toe. The
probe which is controlled by a dial can be
made to vibrate in varying intensities. The
person being tested has to indicate whether
s/he is able to feel the vibration and the
reading on the dial at that point is then
recorded. The reading is in the range of
0-50 volts. The reading is lower for younger

JUN-JUL 16 DIABETES HEALTH 25

people denoting a higher sensitivity towards


the vibration. The reading progressively
increases with the age of the patient. The
risk of neuropathy or ulcer increases if the
reading is greater than 30-40 volts.

Diabetes and your eye


Retina exam
General misconceptions surrounding eye
check-ups are that it only checks your vision
or a change in prescription for your
prescription glasses. But eye check-up for
people with Diabetes should focus on the
retina. The retina, through which we
perceive the external world, is classically
affected by Diabetes. Fundoscopy allows a
doctor to see the retina and other structures.
It may detect some signs of other eye
diseases like retinal changes due to high

26 DIABETES HEALTH JUN-JUL 16

blood pressure, cataract as well as


Glaucoma. It is considered to be 90-95 per
cent accurate and can detect the early signs
of many serious diseases like brain tumour.
Retinal photography screening monitors
your eye health though accurate
photographic documentation which remains
available for future reference.
During testing, the patient is asked to sit
comfortably or may lie in supine (face
upwards) position to minimise head
movements. The patient is then asked to
fixate on a target directly ahead or above the
face at a distance. The best view of the
fundus is obtained through a dilated pupil
and this is especially true in older patients.
Note: Patient are advised to minimise
movement while the bright light shines into
the eye as failing in doing so will cause
considerable discomfort. The doctor will
allow you to rest for 10-15 seconds during

Diabetes tests for children


Children should have their HbA1c frequently tested.
Generally, they do not have formal screening for
complications like blood pressure, lipids, eyes, feet and
kidneys until they are 12 years old. However, their
weight, height and general health should be regularly
monitored.

the prolonged examination.


A normal results show normal retina, blood
vessels and the optic disc appear normal.
Abnormal findings indicate:
Diabetic retinopathy (damage to the
retina due to high sugars) or
hypertensive retinopathy (damage to the
retina due to high blood pressure) (mild, moderate, severe).
Vascular occlusions (blockage of blood
vessel, usually by a clot).

medications, whether you have persisting


eye problems e.g. glaucoma and if you have
a strong family history of glaucoma

Diabetes and dental health


People with Diabetes who have regular high
blood glucose levels are more likely to get
dental problems. There are several possible
reasons:
An increase in sugars in gingival fluid

Infection and inflammation on retina or


vitreous (clear gel that fills the space

between the lens and the retina).


Evidence of cataract.
Retinal tear or detachment.

Macular degeneration (loss of vision in


the centre of the visual field).
Features of glaucoma (increased
pressure) in the optic nerve.
Word of advice
The effect of the bright light used in retinal
fundoscopy to dilate the pupil lasts for three
to four hours. Hence, the patient should be
informed in advance so that somebody can
accompany them on their way back home.
Driving on your own should be avoided.
Also, prior to testing, it is best to inform your
doctor about any allergic reactions to

General guidelines prior to any tests


Tell your doctor about any medicines (including over-thecounter, herbs and vitamins) you take.
Stop prescribed medication only on the doctor's advice.
Enquire about fasting norms prior to testing. You may be
asked not to eat, drink or smoke before the test.

JUN-JUL 16 DIABETES HEALTH 27

(fluid between teeth and gums) can lead


to an increase in dental cavities.
High blood glucose levels can cause
dehydration, leading to reduced saliva
in the mouth. This can cause an
increase in plaque and tartar, which in
turn can lead to gum disease.
Long-term high blood glucose levels
can cause the narrowing of blood

vessels to gums, which can lead to


reduced blood supply, causing
increased rate of infection.
You should tell your dentist that you have
Diabetes and find out if you're going to have
any treatment that means you can't eat or
drink for a few hours afterwards, as you may
need to alter your Diabetes medication.
During a dental check-up, the dentist will
check for bleeding gums or bad breath
(indicative of onset of gum disease),
toothache (a sign of tooth decay), cavity, a
white or red patch in your mouth or an ulcer
that hasn't cleared within three weeks. It is
especially important for people with Diabetes
to take care of their teeth and gums and
have regular check-ups. Your dentist will
recommend how frequently to visit.

To conclude
For health check-ups to be meaningful there
are three important factors:
Tests need to be conducted with a target
in mind based on a person's age, gender,
health concerns.
Testing must be conducted within
established international guidelines in
recognised laboratories.
Unnecessary testing ought to be avoided
to lower harm through radiation. Also,
appropriate medical counseling must be
made available to every patient to
correctly interpret test results and
determine the further line of treatment.
Try and make the most of your check-up so
that it benefits you. Keeping these simple
points in mind will enable you to manage
your time better as well as benefit from the
consultation. Also, remember that doctors
are here to help you lead a better life so be
as honest as you can during your visit.

Dr Anjali Bhatt is a certified Diabetologist.

28 DIABETES HEALTH JUN-JUL 16

The importance of
thyroid function tests
Thyroid is a butterfly shaped organ located
in the front of the neck, just below the voice
box and weighs just about 15-25 grams in
adults. It is an organ which is active even
before birth and has a specific role and
function to play. The thyroid gland is
involved in regulating the metabolism in the
human body by producing hormones that
facilitate energy production. These principal
hormones include T3 (triiodothyronine) and
T4 (thyroxine). These hormones are required

30 DIABETES HEALTH JUN-JUL 16

every minute by every cell, tissue and organ


and hence fluctuations in their levels can
cause serious health complications. The
Thyroid Stimulating Hormone (TSH)
secreted by the master endocrine gland, the
pituitary gland, controls the major steps
involved in the synthesis and secretion of the
thyroid hormones.

EXPERT VIEW

Dr A Velumani
discusses why the
commonly
prescribed thyroid
function tests
matter.

T3 and T4. These levels in totality can


easily aid in classifying the underlying
condition as hypo or hyperthyroidism.
Thyroid antibody test - This test
determines the presence as well as the
extent of autoimmune damage to the
thyroid. Antibodies against Thyroglobulin
(TG - protein produced by normal as well
as cancerous thyroid cells) and Thyroid
peroxidase (TPO) are tested for their
presence and levels. Presence of either of
these antibodies generally marks a
presence of Hashimoto's thyroiditis in
hypothyroid patients; while in those
affected by hyperthyroidism, it marks the
presence of an autoimmune thyroid
disease.
Non-invasive tests - It involves a
radioactive iodine uptake scan and
thyroid scan, which is usually done along
with the former test, that aid in assessing
the rate of functioning of the gland. They
are used for identifying the size of the
gland, determining the presence of
nodules (hot and cold), post thyroid
cancer surgery follow up, etc. Ultrasound
of the thyroid gland may also be
recommended to identify and classify the
nodules as benign or malignant.

Thyroid function tests explained


Thyroid function tests are recommended on
whether the disorder is functional or
anatomical. Physical examination is
generally the preliminary protocol to assess
for presence of nodules or inflammation in
the gland. Few popular tests include:
Biochemical/Hormone estimation These include testing for serum levels of
T3, T4 and TSH hormone and also free

Biopsy - Fine Needle Aspiration Cytology


(FNAC) is a popular biopsy technique
recommended to assess a small piece of
the tissue from the gland/nodule which is
collected using a small needle by an
experienced pathologist.

When are thyroid function tests


recommended?
Thyroid function tests (TFTs) are
recommended for diagnosing, monitoring as
well as managing of thyroid dysfunctions.
The most basic is the blood hormone test,
which is cheap, quick and has significant

JUN-JUL 16 DIABETES HEALTH 31

diagnostic value from a clinical perspective.


The following population are generally
recommended for testing:

Women above 25 years of age

Women who are planning a pregnancy


or are pregnant

Individuals with high cholesterol levels

Individuals who experience symptoms


like tiredness, fatigue or those who
gain and lose weight rapidly

Women experiencing abnormalities in


their menstrual pattern or affected by
fertility issues

Those with a family history of thyroid


disorders

Individuals with goiter

32 DIABETES HEALTH JUN-JUL 16

Testing
Reliability
The blood hormone tests are considered to
be reliable and are the first step in diagnosis.
However, interpretation of the results
become very important and an experienced
endocrinologist is required. Levels of free
and bound hormones need to be studied
taking into consideration the symptoms,
history and current medications and
conditions if any.
Pre-test preparation
The pre-test preparation for thyroid depends
on the category of the test recommended. In
case of blood tests, no fasting is required if
only the levels of thyroid hormones are
going to be tested. However, in case of nonblood tests like iodine uptake and thyroid
scan, fasting is necessary.

In case of the hormone or antibody test, a


simple venipuncture is done for blood
collection. The serum sample is then tested
to measure thyroid hormone levels. The
newer methods of testing are more sensitive,
safe and easy to operate. The technological
advancements have been designed to easily
manage error free handling of huge sample
volumes, yet maintain the sensitivity and
robustness of the testing principle intact.
Imaging tests like the iodine uptake and
thyroid scan involve intake of radioactive
iodine to identify its concentration in the
thyroid gland. Other popular radioisotope
utilised for thyroid scan is Technetium.

(Previous mentioned values are the conventional


laboratory ranges used; adopted from kit inserts)

Values in test reports between laboratories


may also vary due to difference in technique,
automation, platform, quality systems and
methodology. However, normally they
should not vary significantly if reports from
reputed laboratories are compared.

Diabetes and thyroid function


Many reports suggest the presence of a
thyroid disorder, especially hypothyroidism.

Interpreting test results


Interpretation of thyroid test results is
generally done taking into consideration the
hormone levels together. The different
clinical representations include:
Hyperthyroidism - Increase in levels of
FT3, FT4 and low TSH
Hypothyroidism - Decrease in levels of
FT4, FT3 and high TSH in case of
primary hypothyroidism. This stands true
in 98 per cent cases of hypothyroidism.
Elevated levels of FT3 - Generally
indicate T3 toxicosis caused by mild toxic
nodular hyperthyroidism.
Other factors which can affect thyroid
hormone levels include radioiodine therapy,
certain drugs and conditions like exogenous
thyroid replacement, hyperthyroxinemia, etc.
to name a few.
The normal range of thyroid hormones can
vary slightly between laboratories.
T3 - 60-200 ng/dL
T4 - 4.5-12 g/dL
TSH - 0.3-5.5 IU/mL
FT3 - 1.70-4.2 pg/mL
FT4 - 0.7-1.8 ng/dL

JUN-JUL 16 DIABETES HEALTH 33

This is seen in higher frequency among


people with both Type 1 and 2 Diabetes. The
general cause is assumed to be the
presence of an organ-specific autoimmune
condition. This easily becomes a risk factor
for triggering other such conditions as well.
Hyperthyroidism is documented to affect
glycaemic control as well as provides fuel for
an increased insulin requirement.
Hypothyroidism, on the other hand, is
thought to delay the rate of clearance of
insulin from the blood; decreasing its
requirement.
The American Diabetes Association
recommends that every person with Type 1
Diabetes should be tested for thyroid
dysfunction as the risk is comparatively
lower for those with Type 2 Diabetes. People
with Type 2 Diabetes are more susceptible to
hypothyroidism. Irrespective of the type of

34 DIABETES HEALTH JUN-JUL 16

Diabetes, every person with Diabetes is


recommended to be screened for thyroid
disorders by doing the TFT and scanning for
anti-TPO antibodies, especially in case of
people with Type 1 Diabetes.

TFT for pregnant women with


Diabetes
Women with Type 1 Diabetes are more
susceptible to thyroid disorders during
pregnancy. Fluctuating thyroid hormone
levels are common in postpartum thyroiditis
which can later develop into hypothyroidism.
In case of pregnant woman with Diabetes,
management of blood glucose and thyroid
hormone levels is crucial. Hyperthyroidism, if
not controlled, can lead to foetal
complications. Thyroid testing in already
known and susceptible cases becomes

essential so that we can


monitor therapy and
diagnose new cases,
respectively. The TFT
wherein TSH levels alone or
in combination with T3 and
T4 is measured becomes a
good clinical indicator. TSH
levels are also used to
monitor and adjust dosage
of supplement.

Limitations of TFT
TFTs are a reliable tool for
assessing thyroid
dysfunctions; however, there
is a possibility that their
values could mismatch due
to:
the levels of T3, T4 and TSH influencing
each other. Therefore abnormality in one
level becomes an early indicator
ingestion of thyroid related drug, recent
radioiodine therapy or surgery
thyroiditis or presence of other
non-thyroidal illness
syndromes like T3 toxicosis, TBG
deficiency, Familial Dysalbuminemic
Hyperthyroxinemia, Low T3 syndrome,
etc.
involvement of drugs like anabolic
steroids, glucocorticoids, phenytoin,
propranolol, lithium, amioderone etc.
the test being performed during the long
transition period from normal to
abnormal or vice versa.
Also, mismatched values in levels of T3, T4
and TSH can indicate multiple conditions
like near past or near future illness, presence
of sensitive or lethargic thyroid feedback
mechanism, influence of drugs, etc.

Fortnightly variations in test reports are


possible in many situations. For example in
thyroiditis, due to damage of thyroid cells,
the hormones leak. This creates a picture of
hyperthyroidism and once the immune
attack is over, the patient ends up becoming
hypothyroid for life.

To conclude
People with Type 1 Diabetes need to test for
antibodies (anti-TPO) and TSH every year. In
case of people with Type 2 Diabetes, a TSH
test must be conducted once every five years
after a positive diagnosis. However, routine
screening for thyroid dysfunction in people
with Diabetes helps in diagnosing thyroid
abnormalities. An early diagnosis will always
result in timely medical intervention thereby
lowering the risk of any resulting
complication.
Dr A Velumani is the Chairman, Managing Director and
Chief Executive Officer of Thyrocare, a fully automated
diagnostic laboratory in more than 2000 cities/towns in
India and internationally.

JUN-JUL 16 DIABETES HEALTH 35

Being
responsible!
Mr Jagadish Mirji shares with Spandana Birajdar the impact
Diabetes has made in his life.

PEOPLE
Name: Jagadish Mirji
Age: 62 years

The journey so far


I have enjoyed a care free life. I love fried
food, especially French fries and have a
sweet tooth. I have worked in sales and
marketing and had a very stressful life. At
times I would miss my meals and rely solely
on fried food and chips to compensate. I
was not physically active as my work
commitments gave me little time to do
anything. At times I do feel that if I had
made some effort back then to look after
myself better, I could have delayed or even
prevented getting Diabetes at an early age.

Dealing with the diagnosis


My mother and her side of the family had a
strong history of Diabetes. It never occurred
to me that I may get Diabetes. I was
diagnosed with Type 2 Diabetes at the age of
26. Initially, I could not believe it. Being
diagnosed with Diabetes at such young age;
and this was back in the 80s when things
were unknown.
The way medicines, diet and exercise have
evolved now is tremendous. I didn't know
anything back then. The only advice I got
was to stay away from sugary food items.
There were no restrictions on other things. I
used to take my medicines and eat normally.
The concept of portion control was unheard
of.

The change
Initially, my diet was the same except for
eating sweets. Diabetes felt like a small
hurdle that I would cross over with ease. For
the first few days, I watched what I would eat
and walked for about 30 minutes a day. As
the years went by I started getting lax with
my diet and exercise. I still had the care free

attitude. But when I started getting tired


often and was not able to do justice to my
work. I realized that my health is going for a
toss. Even taking a vacation was not helping.
In fact I would feel even more exhausted on
trips and getaways. Since I had no other
complaints I assumed that all was well. But
that was not the case, my blood sugar levels
were worse than when I was diagnosed.
That's when I realised that I need to take my
condition seriously and start making
conscious efforts in managing my condition.
My wife took total charge of my health and
made sure that I start eating healthy and go
for regular walks. My wife has always been
my biggest strength and stood by me in my
toughest of times. It is because of her
constant efforts and concerns that my
Diabetes has been under control for the past
30 years.

My diet
The first step that I took was to modify my
diet completely and start walking. It was not
easy to go off sweets and fried foods
completely since it is my weakness. But yes,

JUN-JUL 16 DIABETES HEALTH 37

over the years I have learnt to control the


urge to indulge to an extent. I do have
sweets but a very small portion of it every 15
days. Fried foods were another thing I had to
work on. So now instead I bake them and
satisfy my palate.
As of now, my day starts at 6 am and I have
glass of water with soaked methi dana
seeds. After my morning work, I have two
almonds and a walnut and go for a 40
minute brisk walk. I then have a small bowl
of upma/poha or one small dosa with
sambhar or a vegetable sandwich and a cup
of sugarless tea at around 8.30 or 9 am. By
11 am, I have a medium-size fruit either

38 DIABETES HEALTH JUN-JUL 16

apple/orange/pear. I have my lunch by 1 pm


which includes 2 small rotis, a bowl of
vegetable and salad. I also have a cup of dal
and a small bowl of rice. At 3.30 or 4 pm I
have 2-3 marie biscuits with sugar less tea or
a vegetable sandwich or a bowl of roasted
chana. I have my dinner by 8 or 8.30 pm
which usually consists of 2 rotis, a bowl of
vegetables and a bowl of salad and dal. At
times I do have a bowl of rice at night, but
that's very rare. I round off my day with a
glass of milk. I try to squeeze in 15-20
minutes of comfortable paced walking after
every meal. I do not do strenuous exercises
and just stick to walking as I'm most
comfortable with it.

My advice
Your family is your biggest strength, you can
only look after them well if you take the
initiative and look after yourself well. Live for
yourself first and things will automatically fall
in place. Today I'm happy with myself
because all these years I have provided well
for my family. I feel content and there is no
other better feeling than being gratified with
yourself. Take care of yourself and do your
best to look after yourself well. Discuss your
concerns with family and friends and you will
be amazed how everyone will always be
there to help you. In the end, good support
from friends and family, especially your
spouse makes living with Diabetes a much
easier journey.

temptations at time. But that does not imply


that I have failed in looking after myself.
Don't be harsh with yourself, take small
steps to help feel better or compensate by
exercising more. But don't punish yourself
and keep feeling guilty all the time. Be
responsible for yourself and your family.

Also, I personally feel that small changes go


a long away. It has not been an easy ride,
even after so many years I still give into

JUN-JUL 16 DIABETES HEALTH 39

TESTING
ROOM
C-Peptide Test

Dr Suganthi Kumaran simplifies the C-peptide test.

C-Peptide: Stands for Connecting peptide.


C-peptide is a substance produced by the
beta cells in the pancreas when proinsulin
splits apart and forms one molecule of
C-peptide and one molecule of insulin.
Insulin is a hormone that is vital for the body
to use its main energy source, glucose.
Since C-peptide and insulin are produced at
the same rate, C-peptide is a useful marker
of insulin production. Also, insulin reduces
sugar by helping its uptake by the cells for
energy. C-peptide does not reduce the sugar
levels in the blood.
C-peptide is excreted by the kidney. Its half
life is 3-4 times longer than insulin. Insulin's
half life is 4-6 minutes. (Half life represents
the amount of time, the hormone stays in
the blood). Hence C-peptide stays in the
blood longer than insulin and for every
molecule of insulin secreted there is a
C-peptide. As insulin is produced
intermittently and disappears quickly from
the blood, C-peptide is a more robust
method to assess the insulin producing
capacity of the body.

How is it measured?
A blood test, after 8-12 hours of fasting, will
reveal C-peptide levels in the blood.
Simultaneously the blood sugar levels will
also be measured.

Normal Range:
0.8-3.1 ng/mL (nanograms/millilitre)

Interpretation of values:
High values - Generally indicate that high
levels of insulin is produced in the body to
tackle high blood sugar levels and may be
due to:
Type 2 Diabetes since it is caused by
insulin resistance

Insulinoma (a tumor of the insulinproducing islet cells in the pancreas,


causing low blood glucose levels)
Excess intake of sulfonylureas (a class of
medicine used to treat Diabetes by
stimulating the pancreas to secrete more
insulin, hence called secretagogues)
Obesity which causes insulin resistance
Low values - A low level of C-peptide is
associated with a low level of insulin
production and may be due to:
Type 1 Diabetes Mellitus (caused by
destruction of beta cells of islets of
Langerhans which releases both insulin
and C-peptide)
Supression of insulin production by
treatment with insulin
Hypoglycaemia (low sugar values caused
by insulin like growth factor secreting
tumours (insulin independent
hypoglycaemia).

Why is it done?
For each molecule of insulin secreted there
is a molecule of C-peptide; hence, it gives an
indirect measure of the insulin secreted by
the pancreas.

Significance of the test:


The C-peptide test aids in Differentiating between Type 1 and 2
Diabetes.
Recognising the causes of
hypoglycaemia (low blood sugar feeling)
whether it is drug induced or due to a
hormone producing tumour.
Monitoring insulin production after
removal of an insulin producing tumour
(insulinoma)

Dr Suganthi Kumaran is a Consultant Physician.

JUN-JUL 16 DIABETES HEALTH 41

DIABETES CARE

Dr Reina Khadilkar discusses cellulitis (skin infection) that


often goes unnoticed in people with Diabetes.
Beauty is skin deep' goes the saying.
Philosophically, beauty transcends the
superficial skin barrier and lies in the inner
core of the person, making his or her heart a
warm place to be loved by everyone. The
saying describes the heart and has nothing
to do with the skin. But as specialists in
Diabetes related care, we certainly are ever
so cautious about the beauty of the skin.
I'm not talking about the cream and peaches
complexion or for that matter, the smooth
honey coloured skin so envied by half the
population. Infections of the skin that could
be perilous in a person with Diabetes is what
worries me.

Protect thy skin


The skin is the largest organ of the body
with a total area of about 20 square feet.
Yes, it is an independent organ. Although
seen superficially by us, it does the most
important job Protecting our inner organs.

of fat and connective tissue. The skin is a


tough organ and normally a strong barrier
that resists entry of infection even if there are
breaks in the skin in the form of abrasions or
cuts. The skin is richly supplied with blood
vessels and nerves; and throughout our lives
they protect us from outside invasions
keeping our inner body safe and healthy.
This equation however changes in a person
with Diabetes. With its penchant for
destroying the nerve tissue and causing
blockages in blood vessels, Diabetes slowly
attacks the ability of any organ to fight back
and the skin is no exception. Cause for
worry? Certainly!

Cellulitis explained
Infection of the skin and the structures
below (subcutaneous tissue) is known as
cellulitis. Usually cellulitis starts as a result of
entry of bacterial organisms into the broken
skin either through cuts, abrasions or skin
diseases like fungal infections. The

Protecting us from invading organisms.


Regulating our body temperature, thus
helping us feel cold, hot, touch and pain
sensations.
The skin is divided into two layers, the upper
superficial and lower deep tissue. The upper
superficial layer is again divided into the
uppermost epidermis and lower dermis. The
epidermis, the outermost layer of skin, acts
like a waterproof barrier and designs our
skin tone. The dermis, beneath the
epidermis, contains tough connective tissue,
hair follicles and sweat glands. The deeper
subcutaneous tissue (hypodermis) is made

JUN-JUL 16 DIABETES HEALTH 43

organisms start spreading in the layers of


skin causing it to swell, become red and
painful. The area involved becomes swollen
and there is difficulty in the movement of
that part. In a normal person with a good
defence system in place, the infection gets
restricted to a small area, can rapidly
respond to treatment and gets cured
completely in a short span of time.
In people with Diabetes, the infection of the
skin can rapidly progress to become life- or
limb-threatening. The causes are
multi-factorial:
In people with Diabetes, high blood sugar
levels act as a good feeding medium for
the rapid growth of organisms.
Secondly, the lack of good blood flow
caused by the damage to the vascular
system, as a part of the disease process,
prevents delivery of antibiotic drugs that
are necessary to control the infection. A
very trivial looking infection thus spreads
like a wildfire through the skin tissue
causing damage to the affected part and

44 DIABETES HEALTH JUN-JUL 16

even spreading to the organs like the


kidneys and lungs, eventually threatening
life.

Cellulitis and Diabetes


In people with Diabetes, cellulitis most
commonly affects the lower limbs. Nerve
damage in people with Diabetes prevents
the individual from identifying that the
infection has started mainly because of
absence of pain. Usually a simple scratch, a
fungal patch, even a blister caused by hot
water that has gone unnoticed acts like an
entry point. Organisms like Staphylococcus
or Streptococcus find their way into the skin
and multiply rapidly leading to cellulitis.
Neglect, poor nutrition, poor hygiene and
lowered immunity as a result of the disease
add to the flaring up of a minor infection.
The affected area becomes swollen, red and
painful. Fever, chills and occasionally
dehydration may be there. In late cases, the
patient may be drowsy and in a
semi-comatose state. Cellulitis in its very

severe form causes blackening and rapid


destruction of the affected tissue, which can
be dangerous as it leads to gangrene of the
affected limb and even death due to multiple
organ failure. This is known as necrotising
fasciitis and has to be treated on an
emergency war-footing.
In the early stages cellulitis appears as a
reddish shiny area localised to a particular
site, especially where there has been a cut or
injury. There is increased heat at that site
and pain. Mild feverishness may be felt.
Later on the reddish area extends and the
skin becomes tense and shiny. There is
severe pain and fever. As the cellulitis
progresses, the skin starts becoming bluish
and dusky, the severity of pain increases
which now becomes throbbing in nature and
the general condition starts deteriorating
rapidly.

Treatment

To conclude
The results and outcome of necrotising
fasciitis are not very good. It is therefore
imperative to identify this trivial looking
problem at the start and nip it in the bud.
Like any other illness, more so in this, it
always helps to reach the hospital at the
earliest sign of infection. Regular inspection
of the feet and hands, identifying injuries or
skin problems, proper footwear, proper foot
care and above all, strict control of blood
glucose levels by regular check-ups will
prevent this life-threatening complication.
Although it looks unassuming, cellulitis is a
danger lurking under the skin and must be
stopped in time by proper care and
treatment.

Usually a simple
scratch, a fungal
patch, even a
blister acts like
an entry point
for organisms to
find their way
into the skin and
multiply rapidly
leading to
cellulitis.

Dr Reina Khadilkar is Consultant Foot Surgeon.

Once a diagnosis of cellulitis is


made, doctors usually admit the
patient and start intravenous
antibiotics. Blood glucose levels are
monitored and insulin is initiated.
Local care either by dressing or
surgical management is done with
complete rest of the affected part. In
early cellulitis, there is a good
response and the patient settles well.
It is therefore important to visit your
doctor at the earliest. In patients who
do not respond to this regimen,
surgical removal of the infected
tissue is done. Sometimes this
procedure may need to be repeated
till the infection comes under
control. In severe cases, amputation
of the affected limb is done as a lifesaving measure. For severe cases,
patients are managed in the ICU and
may have to undergo repeated
surgical procedures.

JUN-JUL 16 DIABETES HEALTH 45

Lixisenatidea promising
option

Dr Ameya Joshi discusses the advantages of once a day injection for people
with Type 2 Diabetes.
Lixisenatide is a glucagon like peptide-1
(GLP-1) mimetic recently approved for use in
India in combination with oral anti-diabetic
drugs or basal insulin for treating Type 2
Diabetes in adults whose blood glucose
levels are not well controlled on these
treatments alone. It is administered by
subcutaneous injection once daily.

46 DIABETES HEALTH JUN-JUL 16

What are GLP-1 receptor


agonists?
GLP-1 is a naturally-occurring peptide that is
released within minutes of eating a meal. It
is known to suppress glucagon secretion
from pancreatic alpha cells and stimulate
insulin secretion by pancreatic beta cells. It
is used as an add-on treatment for Type 2

EDUCATION
Diabetes. GLP-1 receptor agonists are
derived from gut hormones and may be
used as a secondary therapy when other
medications fail to sufficiently lower blood
glucose levels. Pre-clinical studies also
suggest that GLP-1 receptor agonists have
the potential to preserve pancreatic islet bcells, which may help to provide more stable
metabolic control long term. They are
approved by European association for study
in Diabetes as well as the American Diabetes
Association, but are not advised for
treatment of people with Type 1 Diabetes.
GLP-1 receptor agonists are known to lower
glucose, reduce risk of hypoglycaemia (as a
result of their glucose-dependent action)
and promote weight loss.

Initiating therapy
Lixisenatide is available in injectable prefilled pen form. The starting dose of
Lixisenatide is 10 microgram per day for two
days and then 20 micrograms per day. The
'treatment initiation pack' contains a twoweek supply of 10 microgram doses (green
pre-filled pen) and a two-week supply of 20
micrograms (purple pre-filled pen).

people with Type 1 Diabetes


women during pregnancy
nursing mothers
inpatients with known hypersensitivity to
the drug
people with a past history of acute
pancreatitis
people who have had renal failure

Interactions with other drugs


Lixisenatide delays gastric emptying.
Therefore, absorption of agents like
paracetamol or oral contraceptives can be
affected if taken 1-4 hours of lixisenatide
administration. It is better to use other
medications 1-4 hours after taking
lixisenatide.

Side effects of lixisenatide


Nausea, vomiting, dyspepsia, diarrhoea,
upper respiratory infections, headache,
backache, hypoglycaemia, local allergies
and anaphylaxis have been described in
some rare cases.

Caution: Lixisenatide should be avoided by:

JUN-JUL 16 DIABETES HEALTH 47

Cardiovascular risk and Lixisenatide


Heart disease and stroke are the number
one causes of death and disability among
people with Type 2 Diabetes. People with
Diabetes are two to four times more likely to
suffer from these conditions. Because of
this, the U.S. Food and Drug Administration
had sought to study the effects of drugs
prescribed to treat elevated blood glucose in
patients with Type 2 Diabetes on
cardiovascular health. Evaluation of
Lixisenatide in Acute Coronary Syndrome
(ELIXA) study examined 6,068 people from
49 countries, randomly assigning them to
lixisenatide or placebo, with a follow-up
period of more than two years.
Marc Pfeffer, Dzau Professor of Medicine at
Harvard Medical, Senior Physician in
Cardiology at Brigham and Women's
Hospital and Principal Investigator for the
ELIXA trial said, "There has also been some
hope that some of these drugs may improve
cardiovascular health. This is the first report

of a clinical trial designed to assess


cardiovascular outcomes in this class of
drugs and we have shown that patients and
their healthcare providers should have no
cause for concern, even if they are at high
risk for heart-related problems."
Specifically, the ELIXA study found no
increased risk for cardiovascular death, heart
attack, stroke, unstable angina (chest pain)
or heart failure in people with Type 2
Diabetes who had recently experienced
acute coronary syndrome events (an
umbrella term referring to when blood
supplied to the heart muscle is suddenly
blocked) and were therefore at high risk for
additional heart problems.
Recently, it was reported that a research
project called the LEADER study showed
that GLP-1 agonists may reduce
cardiovascular risk.

Source: Diabetes.org

48 DIABETES HEALTH JUN-JUL 16

Lixisenatide and metformin

Advice to readers

Metformin is advocated as monotherapy


while lixisenatide is used as an add on to
metfotmin. The efficacy of both is similar
(nearly 0.8-1.0 reduction in HbA1c). Studies
have shown that Lixisenatide can achieve a
significantly greater reduction in post
prandial (after meal) blood glucose levels
during standardised testing of people with
Type 2 Diabetes whose blood sugar levels
were insufficiently controlled on metformin
alone.

In a growing segment of injectable GLP-1


analogues, lixisenatide (now available in India)
is an attractive option because of its ability to
manage glucose and its weight friendliness. It
also betters post meal blood glucose levels
and minimizes risk of hypoglycaemia .
Dr Ameya Joshi is an Endocrinologist at KEM
Hospital, Mumbai.

JUN-JUL 16 DIABETES HEALTH 49

s
t
i
f
e
n
e
b
y
n
a
m
e
Th
c
i
l
r
a
of g

NUTRITION

Gauri Kukade shares the nutritional


benefits of garlic.
Garlic (lahasoon) is a must have in every
kitchen. The spice is a highly nutritious
vegetable with very few calories, containing
trace amounts of other nutrients that
contribute to its universal status of a
powerful, beneficial healer. The body
strengthening effects of this herb are
thought to be due to its active ingredient
allicin - giving garlic its distinctive taste and
smell. Whether you take your garlic
powdered, salted, or minced or in
supplement form, you can reap the
surprising benefits of this multipurpose herb
for optimal health.

How it helps?
Diabetes
Garlic increases insulin release and regulates
blood sugar levels in your body, especially if
you have Diabetes. It aids in lowering blood
sugar levels and may be used (under
doctor's supervision) by people with
Diabetes in addition to their regular regime
of insulin and special diets. Researchers
have found that certain compounds in garlic
such as allicin, allyl propyl disulfide and Sallyl cysteine sulfoxide work by increasing
the amount of insulin in the blood by
blocking the liver's inactivation of insulin,
making more insulin available to the body. A
study published in the Journal of Medicinal
Food found that garlic was highly effective in
increasing one's insulin content in the body
and improved glucose tolerance.
While more research is still required to know
the full extent of garlic's effectiveness. People
with Diabetes may benefit by taking moderate

JUN-JUL 16 DIABETES HEALTH 51

amounts of garlic as a supplement. Raw and


cooked garlic or aged garlic extract not only
help regulate blood glucose but also possibly
prevent or lessen the effects of some of the
complications of Diabetes
Precaution: Discuss with your doctor or a
medical professional on the advisability of
taking garlic for your type of Diabetes and
health conditions. Although garlic is not
considered toxic as a food by the American
Food and Drug Administration, it may cause
side effects for certain individuals and for
anyone taking it in large quantities.
Note: Garlic may interact with several medications;

so consult your physician before you incorporate


garlic in your diet, especially if you are on
medications.

Antibacterial and Antiviral


properties
Garlic can help keep both bacterial and viral
infections at bay. They help control bacterial,
viral, fungal, yeast and worm infections.
Fresh garlic is thought to play a role in
preventing food poisoning by killing bacteria
like E. coli, Salmonella enteritidis, etc.
Since it has both antibacterial and antiviral
properties, garlic is great when it comes to
treating skin infections. The chemical ajoene
found in garlic may help treat fungal skin
infections like ringworm and athlete's foot.

Blood pressure

The beneficial properties of garlic can be attributed to


the following constituents:
Variety of potent sulphur-containing compounds which
give garlic its characteristic pungent odour
Allicin, the vital compound in the pod, is known to have
great antibacterial, antiviral, antifungal and antioxidant
properties. That is why garlic is best had when it's finely
chopped, minced or pureed.
Allicin, along with other compounds like ajoene, alliin,
etc. are known to have a healing effect on your
circulatory, digestive and immunological systems and aid
in lowering blood pressure, detoxification, healing, etc.
Garlic is also a reliable source of selenium.

52 DIABETES HEALTH JUN-JUL 16

Aged garlic extract between 600 and 1,500


milligrams (mg) was found to be just as
effective as the drug Atenolol prescribed for
hypertension in a 24-week period, according
to a 2013 study published in the Pakistan
Journal of Pharmaceutical Sciences. The
polysulphides present in garlic are converted
into a gas called hydrogen sulphide by red
blood cells that helps dilate your blood
vessels and helps control blood pressure.
Also, garlic supplements can achieve these
effects efficiently without the bad breath
compared to raw garlic.

Heart disease
With age, your arteries tend to lose their
ability to stretch and garlic can help
maintain their elasticity. Garlic can help
lower the risk of heart disease by lowering
total LDL 'bad' cholesterol. A 2000 study
published in the journal Annals of Internal
Medicine found the effect of garlic on total
cholesterol levels in people with elevated
levels and it was observed that garlic
moderately reduced cholesterol levels. It also

helps protect the heart from the damaging


effects of free oxygen radicals. The sulphurcontaining compounds of garlic also prevent
the blood vessels from becoming blocked
and slow the development of atherosclerosis
(hardening of the arteries).The anti-clotting
properties of ajoene (a compound present in
garlic) helps prevent the formation of clots
inside your blood vessels.

Colds and sore throat


Garlic's allicin can serve as a health aid
during times of illness. A 2001 study
published in the journal Advances In
Therapy found that a daily garlic
supplement can reduce the number of colds
by 63 per cent compared to not taking
supplements. Moreover, the average length
of cold symptoms was also reduced to
70 per cent, from five days in the control
group to 1.5 days in the garlic supplement

group. These findings suggest that the


allicin-containing supplement has a
protective effect against the common cold.
Its antibacterial properties help in treating
throat irritations. Garlic may also reduce the
severity of upper respiratory tract infections.

Cancer
Garlic's anti-cancer properties
are due to the presence of allyl
sulphides. Diallyl sulphide
found in garlic inhibits the
transformation of PhIP (a type
of compound that has been
associated with increased
incidence of breast cancer)
into carcinogens.

Anaemia

Food Value
(100gm edible portion)

Nutrient
Energy
Protein
Carbohydrate
Fat
Calcium
Iron
Phosphorus
Vitamin C

value
149kcal
6gm
33gm
0.5gm
30mg
1.3mg
310mg
13mg

Diallyl sulphides present in


garlic increase the production of ferroportin

JUN-JUL 16 DIABETES HEALTH 53

The healthiest
way of
cooking garlic

(a protein that helps in the absorption and


release of iron) and improves iron
metabolism all of which helps prevent
iron deficiency and associated diseases
like anemia.

Toothache
It can help relieve toothaches due to its
antibacterial and analgesic (pain relieving)
properties.

Asthma
Garlic has been found effective in reducing
the severity of asthmatic attacks.

Chest Diseases
Garlic has proved to be highly effective in
certain diseases of the chest. It has been
found to reduce fetidity of the breath in
pulmonary gangrene. It is also used as
remedy in the treatment of pneumonia
and tuberculosis.

Digestive system disorders


Using raw garlic is recommended in most of the recipes. If you
cannot tolerate raw garlic, add chopped garlic towards the end
of the cooking time to retain maximum flavour and nutrition.
Too much heat for too long will reduce the activity of the
health-promoting sulfur compounds that have formed by
letting it sit for 5-10 minutes; it will also make garlic bitter.
Therefore expose garlic to heat for as little time as possible (515 minutes).
If you would like to combine garlic with oil, we recommend
that you avoid high-temperature heating of this oil-garlic
mixture. Keeping the heat at 250F/121C or lower will help
preserve the health benefits of both the garlic and the oil. This
same principle applies to the oven roasting of garlic bulbs
themselves. We do not recommend the 350F/177C
temperature range that you will find in most recipes and
websites. Once again, a lower temperature is needed to help
preserve health-protective compounds in garlic.

54 DIABETES HEALTH JUN-JUL 16

Garlic is one the most beneficial foods for


the digestive system. It stimulates
peristaltic action and the secretion of the
digestive juices. It has an antiseptic effect
and is an excellent remedy for infectious
diseases and inflammations of the
stomach and intestine.

Recommendation
It is recommended that adults consume
no more than one clove two or three
times a day
Children can have one quarter to one half
a clove once or twice a day.
Gauri Kukade is a certified nutritionist.

e
c
n
e
i
c
S
e
s
e
i
Th f Exerc
o

FITNESS

Erika Gebel Berg discusses whether physical activity is the best medicine.

It's free. Most people can't get enough of it.


Yes, it's the crux of healthy living: exercise.
And while just about everyone is better off
working out regularly, exercise is, in some
sense, the perfect drug for Diabetes. Not
only can it improve blood glucose control,
which in itself reduces the risk of Diabetes
complications, but research suggests it may
combat heart disease, weight gain,
depression and more.

Glucose on the go
Muscle contractions have a powerful effect
on how the body processes glucose, the
original biofuel. The muscles are the major
consumer of glucose during exercise. It's not
surprising since they do most of the work. In
each cell, muscles store dense packets of
glucose, accounting for around 2,000
calories worth of energy throughout the
body, according to Sheri Colberg-Ochs, a
professor of exercise science at Old
Dominion University in Virginia, USA. "[This
energy] just stays there unless you contract
the muscle.
During exercise, the muscles deplete their
individual glucose reserves. To help restock
their glucose supplies, the muscles change
in two important ways: They become more
sensitive to insulin, a hormone that escorts
glucose from the bloodstream into body
cells, and they also start to absorb glucose
on their own, independently of insulin. This
second pathway created during exercise is a
boon for anyone with Type 2 Diabetes, which
is marked by insulin resistance. "When the
body is at rest, it has one mechanism for
getting glucose out of the bloodstream. That

way is insulin," says Colberg-Ochs. "What's


so good about exercise is that even if the
muscles are insulin resistant at rest, that's
irrelevant with exercise.
Exercise's effect on glucose use occurs
not just in people with Type 2 but in
almost everyone, including those with
Type 1 and prediabetes. A large study
found that, in people with
pre-Diabetes, lifestyle changes
that included 150 minutes
a week of moderate
intensity exercise
reduced the risk of
progression to
full-blown Type 2 Diabetes
by 58 per cent.
Exercise makes a little insulin go a
long way. That's generally a good
thing. But people who get their
insulin from a shot or a pump can
end up with too much insulin in
the body. That can cause blood
glucose to go too low
(hypoglycaemia), particularly
when glucose is diverted to the
muscle cells during exercise.
"That's why some people with
Type 1 Diabetes shy away from
exercise," says Colberg-Ochs. But
they needn't. "If you plan ahead
and reduce insulin intake, you can
go through exercise without
swings in blood glucose. People
with Type 2 Diabetes can also
suffer from hypoglycaemia with
exercise because of medication,
but the risk isn't as great.

JUN-JUL 16 DIABETES HEALTH 57

Exercise's short-term effects can last


anywhere from two hours to three days,
according to Colberg-Ochs. "That's
generally why, when we talk about how often
people should exercise, we say that they
should do it at least every other day, though
probably every day is better. Other benefits
of regular physical activity can last a lifetime.

Muscle up
If you keep at it and incorporate resistance
training into your routine, exercise can
provide additional opportunities to help with
blood glucose control by building muscle.
"Over the long term, there can be a change
in muscle composition that can favour
getting glucose into the cells," says Ronald
Sigal a professor of medicine, kinesiology,
cardiac sciences and community health at
the University of Calgary in Canada. "Also,
over time, there are changes in body
composition that can help glucose uptake,
such as an increase in muscle mass.
Weight is made up of more than just
pounds; the relative amounts of muscle and
fat, how much fat is inside the muscle and

58 DIABETES HEALTH JUN-JUL 16

where the fat is found on the body are far


more important fitness criteria than simply
weight alone. Muscles can use fat or glucose
for energy; as fat tissue in the body is
decreased, the muscles become better at
using glucose for their energy needs.
Exercise can tip the scale toward a healthier
body composition. The best way to build
muscle is through resistance training. It
involves working the muscles against an
opposing force by, for example, lifting
weights or one's own body weight (as with
push-ups, sit-ups, or yoga). One study of
older men with Type 2 Diabetes found that a
four-month resistance training program
skimmed off some of the visceral fat from
deep inside their abdomens, which is known
to be particularly bad for the heart. Every
ounce of muscle is a glucose-burning
powerhouse, so the more muscle a body
has, the better it will be able to control blood
glucose levels. "You can only fit a certain
amount of (glucose) in muscle, but if you
have more muscle, then you can store
more," says Colberg-Ochs.
So, what type of exercise is best for people
with Diabetes? A 2007 study in the Annals of

Internal Medicine compared four different


approaches to fitness: aerobic exercise,
resistance training, both aerobic and
resistance sessions, or no exercise at all. In
the six-month study, previously inactive
participants with Type 2 Diabetes who were
from 39 to 70 years old worked out three
times a week. All exercising groups lowered
their A1C (a measure of the average blood
glucose over the previous two to three
months) but those who combined aerobic
and resistance training saw the greatest
improvements in blood glucose control. To
get the most from exercise, says Sigal, who
led the study, you should do both: get your
heart rate up and build muscle.

Raising the pulse


Better blood glucose control would be
reason enough to exercise, but the benefits
of regular workouts stretch further, into heart
health. This is of particular importance to
people with Diabetes, for this reason: Adults
with Diabetes are two to four times as likely
to die from heart disease as those without
the disease. The major risk factors for heart
attack and stroke are abnormal levels of
blood fat including cholesterol, triglycerides
and high blood pressure. "Exercise helps
with fat metabolism," says Colberg-Ochs.
"One of the responses to training is that

muscles can better utilize fat as a fuel. It gets


fat out of the bloodstream and anywhere
else it shouldn't be.
While individual studies have produced
conflicting results on exercise's effects on
blood fats, an analysis of several high-quality
trials suggested that physical activity can
reduce the levels of LDL ("bad") cholesterol
by 5 per cent. Other research suggests
exercise raises HDL ("good") cholesterol
independently of weight loss. Its effect on
blood pressure is less clear, but the overall
picture is that exercise yields modest
reductions. Some studies have found that
exercise lessens markers of inflammation,
which is thought to contribute to
atherosclerosis, the accumulation of fat and
cholesterol in artery walls. "Exercise tends to
improve the function of the lining of blood
vessels," says Sigal. "Over time, there is
reduction in inflammation, which is
associated with decreased cardiac risk.
Many studies suggest that people who are
more fit have less risk of dying from heart
attacks or strokes. Yet it remains to be
proved that exercise causes people to have
healthier hearts.
How much exercise is enough to reap its
benefits? The consensus from studies on
people with Diabetes is that 150 minutes of
moderate aerobic activity each week, plus

two or three strength training sessions, is


adequate.

Weighty debate
If one's goal includes losing weight, picking
the appropriate exercise program gets more
complicated: The effect of exercise on body
weight is one of the most controversial areas
of research. In principle, weight loss is
simply a matter of energy balance: Burn
more calories than you eat and you'll lose
weight; eat more calories than you burn and
you'll gain. So it would seem to make sense
that shedding calories via workouts should
spur weight loss, but research hasn't
consistently supported that conclusion. To
lose weight, research suggests that up to an
hour a day may be necessary, far more than
the 150 minutes a week of moderate
exercise that has been shown to improve
blood glucose levels. "The amount a person
has to exercise to lose the amount they want
to lose may be considerable," says Sigal.
Exercise alone doesn't seem to help people
drop much weight unless they also limit how
many calories they consume. The problem
may be that exercise increases hunger and
it's all too easy to offset the calories burned
in an hour long sweat session with a single
muffin. Yet, most successful long-term
weight-loss programs have an exercise
component. This suggests that exercise is a
key part of weight maintenance. In a large
national study, 90 per cent of participants
who had lost 30 pounds or more and kept
the weight off for over a year exercised an
average of seven hours a week.
Blood glucose, heart health and weight

maintenance aren't the only areas where


exercise seems to improve the outlook for
people with Diabetes. One study of people
with Type 2 Diabetes, known as Look
AHEAD (for Action for Health in Diabetes),
found that participants who got more fit had
fewer symptoms of depression and a better
quality of life than those who stayed on the
couch. This is important because research
shows inactive adults with Type 2 are almost
twice as likely to be depressed as those who
are physically active. It's also been shown
that exercise can ease anxiety, boost mood,
improve self-esteem and make sleep more
peaceful. However, these mental benefits
tend to be more dramatic in those who are
less physically active or psychologically
healthy before they start exercising and they
generally peak after weeks of regular aerobic
exercise. Scientists are also avidly exploring
whether exercise can stave off some types of
cancer or help people recover from cancer.
"In people with breast cancer or prostate
cancer, regular exercise reduces fatigue,"
says Sigal. And there's some evidence that
physical activity helps people learn, as well
as keeping the mind intact in old age.
Exercise research has provided some
fascinating insights on what movement can
do. And though not all the science has been
worked out, the proven benefits of exercise
for people with Diabetes provide a clear
incentive to get moving now.
Courtesy: Diabetes Forecast

MEDICINE
CABINET
Know your medicine one dose at a time!
By Dr Vedavati Purandare

Premix insulin
Mechanism of action

Advantages

When people have Type 2 Diabetes, their


body either does not use insulin (insulin
resistance) or does not make enough insulin
(insulin deficiency). Some people with Type
2 Diabetes need to take insulin injections.

The benefit of pre-mixed insulin is that the


fast- and long-acting insulin is combined.
Hence, no mixing of insulin is necessary and
two injections per day are sufficient.

Broadly the 3 categories of insulin are:

Side-effects

rapid acting

Weight gain

long/intermediate acting

Hypoglycaemia (low blood glucose level)

premixed
Premix insulin combines rapid and
long/intermediate acting acting insulin types
in various proportions like 50:50, 30:70.
For e.g. premixed insulin 30:70 is a
combination of 30 per cent rapid acting
insulin and 70 per cent intermediate acting
insulin. The long acting insulin controls
blood sugar (blood glucose) throughout the
day. The rapid acting insulin controls blood
sugar after the meals.

Rx
Premix insulin is administered in the form of
subcutaneous injections. This insulin
injection is available in the form of vial/
syringe and cartridge for pen device. It
appears milky white.

Who should take Premix


insulin?
Doctors advise premix insulin therapy to
patients with Type 2 Diabetes mellitus who
require insulin for blood glucose control.

Caution
You should not take premix insulin if you are allergic to insulin premix or to any of
the ingredients of the medication
have low blood glucose (hypoglycaemia)

Dr Vedavati Purandare is a consultant


Diabetologist.

JUN-JUL 16 DIABETES HEALTH 61

Triple Diabetes Threat

DIABETES CARE

Andrew Curry highlights how these factors join together


to up your risk for Diabetes
Nature or nurture? When it comes to
Diabetes, it's a little bit of both. The genes
you inherit from your parents can increase
the chance that your body will develop the
symptoms of Diabetes, namely, the inability
to produce enough insulin to move glucose
from your bloodstream to fuel your cells, the
ability of your cells to respond to insulin, or
both.
But genes are only a part of the equation.
For most people, environmental factors from
the food they eat to the microbes they're
exposed to play a much more significant
role. That's certainly the case for Type 1, a
disease where genetics accounts for up to
half of the total risk.
When it comes to Type 2 Diabetes,
tremendous advances in genetics research
in the past few decades haven't uncovered a
single Diabetes gene. Instead, they've
found dozens, each representing a tiny
increase in your overall risk for Diabetes.
Yet as the costs of analysing human DNA
drop, researchers are discovering that other
kinds of Diabetes, such as monogenic (see
All in the Genes, below) and gestational,
can run in families. At the same time, they're
developing new approaches to predicting
and treating the disease.

Family ties
Experts say that while genetics plays a big
role in Type 2 Diabetes, the increase in the
number of cases has little to do with
heredity. On an evolutionary time scale, the
past few decades are barely the blink of an
eye. This epidemic isn't caused by genes,
says Jose Florez, a researcher at the Broad
Institute and Harvard Medical School and

chief of the Diabetes unit at Massachusetts


General Hospital. Genes don't change that
fast.

Home grown Diabetes


The growth of Type 2 cases has to do with
the interaction between our genes, the world
we live in, and the choices we make. One
way to think of the genetic risk for Type 2
might be as a seed. A seed by itself won't
grow into a tree. But take that seed, put it in
a pot of soil, and add water and sunlight,
and it stands a good chance of flourishing.
And the genetic factors that put some
people at greater risk for Type 2 are the
seed-full of dangerous potential but usually
harmless unless you add excess calories and
lack of exercise. Seen from that perspective,
the Type 2 Diabetes epidemic makes far
more sense. For countless generations,
people have been carrying the seeds of
Type 2 around unnoticed. It took our
modern lifestyle, heavy on calories and light
on exercise, to fertilize and water them.
Everyone placed in our contemporary
environment, with high-calorie, nutritionally
poor food and a sedentary lifestyle, is more
vulnerable, says Florez. Genetics just
makes some more vulnerable than others.
Much of the work on the genetics of Type 2
has focused on figuring out why some
people are more at risk than others. So far,
there are about 80 known genes that can
put you at a greater risk for Type 2 Diabetes.
Although some people with no particular
genetic risk factors still get Diabetes, just as
people with higher risk factors often don't
have Diabetes. Some genes make people a
little less sensitive to insulin. Some interfere

JUN-JUL 16 DIABETES HEALTH 63

with the body's ability to make insulin.


Others make people more likely to be
overweight or obese, both risk factors for
Type 2. It's possible there are so many
variants that have a small effect that you'd
need to track 500 variants to account for
heritability, says National Institute of Health
researcher Clifton Bogardus.
These genes have been discovered mostly
thanks to advances in gene sequencing
technology in the last decade. As scanning
the human genome gets cheaper,
researchers are able to analyse hundreds of
thousands of people for tiny genetic
differences and then compare what they find
with Diabetes rates. Certain differences line
up with higher or lower risk, telling scientists
there's probably a connection. These big
coalitions have worked together to amass
huge numbers of cases to see which variants
are more common, says Bogardus.

Future applications
Even if researchers could identify all of the
genes that increase Diabetes risk, it's not
clear that the information would be all that
helpful in terms of predicting who will get
Type 2 Diabetes. Mark McCarthy, a geneticist
at the University of Oxford in England, says
we already have a pretty good set of
indicators. Family history, BMI [body mass
index], and ethnicity are all much stronger
predictors right now, he says. There are
many different things that impinge on
individual risk, and the prediction we get
from genes is not that strong. (Ethnicity
isn't the same as genetics, McCarthy points
out: Ethnic groups sometimes share genes,
but also share cultural norms, favourite
foods, and other factors that go above and
beyond genetics.)
If doctors already have effective ways to
predict who's at higher risk for Type 2, why
sink more money and time into genetic

64 DIABETES HEALTH JUN-JUL 16

research? McCarthy says knowing more


about genetics will help researchers slice
and dice an incredibly complex disease.
Because there are so many pathways,
researchers say it's more accurate to think of
Type 2 as hundreds of different diseases, all
with the same symptoms. One potential
benefit of genetics research might be to
narrow down the pool of people being
prescribed Diabetes drugs. The drug
industry is having a really tough time. So
many of the drugs they develop don't work
in humans or have really nasty side effects,
McCarthy says. Genetics can guide
pharmaceuticals to places they should be
intervening and where they're more
effective.

are blindsided there's no family history, and


all of a sudden their child has a
life-threatening chronic disease with no
known cure. Scientists are increasingly
realising that genes play an outsized role.
Take, for instance, the distribution of Type 1
Diabetes in populations around the world. If
Type 1 Diabetes were truly a random
phenomenon, it would be equally distributed.

Take metformin, one of the most common


drugs prescribed to people with Type 2. It's
usually highly effective. Except that in a
minority of patients it just doesn't work. And
in others it causes side effects, such as
severe diarrhoea. If DNA could predict who
will benefit from drugs like metformin and
who won't, patients would get the right
drugs faster.
In the meantime, doctors say people with a
family history of Type 2 should be even more
conscious of maintaining a healthy diet and
exercising regularly. You're not doomed
based on the bad deck of cards you
inherited from your parents. We know you
can do something about it: Lifestyle can
trump your genes, Florez says. That's a
comforting thought for people who already
have Diabetes but worry about their family
members' or children's risk.

Family tree
Most Type 1 cases seem to occur in
isolation. Only 10 per cent of patients have
a family history. Type 1 tends to come out of
the blue, says Janelle Noble, a geneticist at
Children's Hospital Oakland Research
Institute. People don't expect it, and parents

JUN-JUL 16 DIABETES HEALTH 65

Still stronger evidence comes from studies


of identical twins. Identical, or monozygotic,
twins share all of their DNA. It stands to
reason that if Type 1 were purely genetic,
identical twins would always share Diabetes,
or at least develop it at the same time. But
they don't sometimes one twin will have
Type 1 while the other is spared, a big clue
that more than genes are at play.

Joined forces
Unlike Type 2, where dozens of different
genes can all make small contributions to

increased Diabetes risk, in Type 1 a dozen


specific genes play a huge role. Together,
these genes make proteins called human
leukocyte antigens (HLA). Each of these
genes can have thousands of more than
13,000 possible variants, and some of these
variants can have a profound effect in raising
or lowering the risk for Type 1 Diabetes,
whether there's a family connection or not. It
makes sense that these genes, which help
regulate the immune system, would be
involved in Type 1, a condition in which the
immune system reacts against and destroys
insulin-producing pancreatic beta cells.
Noble has spent most of her career trying to
untangle HLA. Calling it a gene does its
complexity a disservice. HLA, which was first
identified almost 40 years ago, is far more
complex than a simple on-off switch. It has
thousands of possible variations that can
raise or lower the odds of Type 1. To put it in
perspective, Noble compares variations of
HLA genes to frozen desserts: Ice cream,
sorbet, and frozen yogurt are all cold, and
each can come in many flavours. Altogether
there are 13,000 possibilities and everyone
has two scoops, one from their father and
one from their mother. Your Diabetes risk
has a lot to do with which two flavours out of
those 13,000 you have in this particular
gene, Noble says.
Some HLA flavours protect you from
Diabetes, and others put you at higher risk.
Some ethnic groups have more protective
flavours. That helps explain why Type 1
Diabetes is relatively rare in some
populations and more common in others.
It's possible to test for risk factors that are
strong, and several research groups are
trying to do just that. The next step would be
to find ways to catch and halt Type 1 in the
earliest stages, before the immune system
has destroyed the body's insulin-producing
beta cells. The Holy Grail is stopping it
before it starts, says Noble. Genetic testing

66 DIABETES HEALTH JUN-JUL 16

can help researchers find high-risk


candidates for new treatments.

All in the genes


In some rare cases, Diabetes can be purely
genetic. When a single mutation causes
insulin resistance or makes the body stop
producing enough insulin, researchers call it
monogenic Diabetes. Examples include
neonatal Diabetes and Maturity Onset
Diabetes of the Young (MODY).
Monogenic Diabetes has been connected to
mutations in about 20 genes; a mutation in
any of them can cause a child or adult to
develop Diabetes. Because genetic
mutations can be passed down to children
or run in families, if doctors suspect a
patient's Diabetes is monogenic they may

recommend genetic testing to better


evaluate the risks. One sign of MODY, for
example, is three or more generations of
people with Diabetes in a given family.
Courtesy: Diabetes Forecast

In a lighter vein

Pressing this
button 10 times
helps me burn 10
extra calories!

JUN-JUL 16 DIABETES HEALTH 67

TheDiabetesHealthQuiz

Lucky winners will get:

How well do you know your


Diabetes? Choose the correct
answer from the choices given
below, tear/scan this page and
send it to us. We have goodies
for those who get all the
answers correct. Remember,
every question has only one
correct answer!

1st prize:
1 year subscription of
Diabetes Health

So get set, and go!

2nd prize:
Diabetes Health
T-shirt

1. Prediabetes is a reversible condition.


(a) True

(b) False

2. Diabetes can be cured with diet, exercise and medication.


(a) True

(b) False

3. People who are obese are more likely to develop Type 2 Diabetes.
(a) True

(b) False

4. The C-peptide test helps diagnose _________ Diabetes.


(a) Type 1

(b) Type 2

(c) Both a and b

(d) None of these

5. Liraglutide is administered_____ to treat high blood sugar levels.


(a) Once a day

(b) Once a week

(c) Twice a day

(d) None of these

6. __________ is a condition in which the kidneys are unable to conserve water.


(a) Diabetes mellitus

(b) Diabetes insipidus

(c) Gestational Diabetes

(d) None of these

7. Which of the following has the highest fibre content?


(a) Pear

(b) Peas

(c) Lentils

(d) Broccoli

8. A person with Diabetes should avoid foods that are high in (a) Fat

(b) Carbohydrates

(c) Sodium

(d) All of these

9. Diabetes ketoacidosis is more commonly seen in people with ______ Diabetes.


(a) Type 1

(b) Type 2

(c) Gestational

(d) Both a and b

10. Eating small frequent meals helps manage blood sugar levels better.
(a) True

Name:
Age:
Tel:
Email:
Mailing address:

Occupation:
Mobile:

(b) False

To participate:
Fill up the quiz and your details.
Scan this page and mail it to:
Editorial@diabeteshealth.co.in

Answers in Diabetes Health


Aug-Sep 16 issue
Answers to previous
DH Quiz [Apr-May 16] on page 76

Workout
powerhouse!
Gouri Ambardekar shares her view on ellipticals.
An elliptical trainer or a cross-trainer is a
stationary exercise machine. It is used to
simulate stair climbing, walking or running
without exerting pressure on the joints (your
feet never leave the pedal). It gives a good
total body workout as it exercises all the
major muscle groups.

Helping patients with Diabetes


A person with Diabetes would benefit from
using an elliptical. It not only gives you a
good workout but also aids in weight loss.
The amount of calories you burn depends

70 DIABETES HEALTH JUN-JUL 16

on the ramp height, resistance level and the


speed with which you walk. You can easily
burn 270-400 calories during a 30 minute
workout (Data from Harvard Medical School
based on people ranging from 125-185
pounds). And because your feet never leave
the pedals, the elliptical provides a
low-impact workout that is friendly for your
joints and back. Patients with neuropathy
(burning and tingling sensation in the feet)
or arthritis can use this machine with ease.
I would personally recommend using
ellipticals as it is one of the best work out
options in people with Diabetes.

DIAB-E-TECH

Advice to readers
A few points to keep in mind when using the
elliptical Posture - Do not slouch while working out
on a cross trainer it makes your work out
easier and thus ineffective.
Keep your spine straight and your abdominal
muscles firm. Poor posture will lead to lower
back pain and muscular imbalances.
Avoid workout plateau/Keep changing the
resistance levels - By not doing so, no
matter how long you work out you will not
see the desired results and your workout will
plateau. When working out you should feel
the resistance to push and pull during each
stride. Continue at a moderate pace and
stop when the workout gets over exhausting.
Enter your information accurately - Most
machines are calibrated for a 70 kg person.
By personalizing your information you will
get a more accurate calorie reading.
Do not use only your forefoot - Most
people use only their forefoot to propel
forward instead of planting the entire foot on
the pedal and putting their weight on the
heel. This puts a lot of pressure on the
forefeet. It is best to sit back on your heel so
that it allows the large muscle groups to
work out harder.
Ergonomical design - Although many are
available in the market not all may be
necessarily good. I always advise people to
choose the ones which are well
ergonomically designed. Machines that are
poorly designed depend excessively on the
user's leg power increasing the speed of the

Advantages of ellipticals
include:
It provides a good cardiovascular
total body workout.
It involves movement of the entire
body simulating walking or running.
Raises your heart rate and keeps it
up for an extended period of time
improving your aerobic fitness level.
Aerobic exercises help decrease the
risk of Type 2 Diabetes and manage
your blood sugar levels better if you
have Diabetes. Besides the health
benefits, ellipticals are a fun way to
get a good workout as it improves
your mood and reduces your stress
levels.
It not only builds strength and
muscle endurance in the lower body
(the quadriceps, hamstrings, glutes
and calves) but also works on your
upper body (arms, chest and back)
when you actively use the handles.
The more the muscles work, the
more calories you burn.
movement of handles. As a result, the
person feels no resistance while working out
and only flows with movement of the
machine. Hence it is very important to
choose the machine that offers a
harmonious combination of arm and leg
exercise in the correct ratios.

Gouri Ambardekar is a certified Physiotherapist.

Physiotherapist rating
Effectiveness in weight loss 3.8
Ease on joints 4

Patient rating
Effectiveness in weight loss 4
Ease on joints 4
JUN-JUL 16 DIABETES HEALTH 71

DIABETES
and
ME
Do you have a diabetes story to tell?
1st prize:
1 year subscription of
Diabetes Health

If you or someone you know


has Diabetes, and you'd like
to share the experience
with us, write to us along with
your name and address to
editorial@diabeteshealth.co.in

2nd prize:
Diabetes Health
T-shirt

Share your Diabetes story with us, and


we'll publish it in our next issue. One
winning story will get a year's
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Experts at Chellaram Diabetes Institute, Pune answer your queries on Diabetes.


Send your questions to editorial@diabeteshealth.co.in
I was just diagnosed with Type 1 Diabetes. My blood
sugar control is moderate. I really enjoy having sweet
potatoes and was wondering whether I can have them
from time to time. Could you please guide me on the
portion size, the frequency and the best way to have
them (boiled, baked etc)? Also, are sweet potatoes a
healthier choice than normal potatoes?
There is no restriction on the consumption of normal
potato/sweet potato in people with Diabetes. But the
recommended quantity is lesser than other fruits and
vegetables. You can have cup (7-8 small pieces) in
baked/boiled form preferably mixed with other vegetables
and prepared in less oil. Try to incorporate more fibre in
your diet in the form of raw salad, steamed sprouts etc
along with this vegetable. You can have sweet potatoes
once or twice a week (depending on your sugar levels).
Although there is a slight difference in values of few
nutrients the nutritive value of both sweet and normal
potatoes is almost the same.
Priya Chaudhari
Consultant Nutritionist

I'm a 40 year old man with Type 2 Diabetes and


on insulin since 2 years. I weigh 109 kg and my
BMI is 33. Despite following diet and exercise
instructions I'm gaining weight gradually.
Recently, I have read that there is a once a
week injection available to manage Type 2
Diabetes. Do these types of newer injections
work in people with Diabetes? Is it insulin or
some other injection? Could you please tell me
more about this newer injection?
In the management of Type 2 Diabetes there are
two medicines which can be administered as an
injection - Insulin and GLP-1 analogues. Recently,
once a week injection (Dulaglutide) was approved
in India for the treatment of Type 2 Diabetes. It is a
GLP-1 analogue, which decreases blood glucose
levels by increasing insulin secretion and
decreases glucagon (a hormone which increases
blood glucose level) levels. It also slows gastric
emptying and stimulates the satiety center thereby
leading to weight loss. Dulaglutide thus helps in
managing Diabetes and might lead to weight loss
in obese subjects with Type 2
Diabetes mellitus. It is available
in a single dose prefilled
syringe (Dose 0.75 mg or
1.5 mg). It has to be injected
beneath the skin over the
abdomen (same like insulin).
Hypoglycaemia is observed
when Dulaglutide is used in
combination with a
sulfonylurea or insulin. So
please check with your doctor
whether this new medication is
suitable for you.
Dr Vedavati Purandare
Consultant Diabetologist

JUN-JUL 16 DIABETES HEALTH 73

Baked Chicken
Parmesan
Cutlets

Ingredients:
4 chicken breast pieces
1/2 cup grated Parmesan cheese
1/2 teaspoon garlic powder
1 teaspoon dried parsley leaves
Salt and pepper as per taste
1 cup beaten egg whites seasoned with
salt and pepper
2 cups toasted whole wheat bread
crumbs

Method:
1. Preheat the oven to 350 degrees. Mix the
Parmesan cheese, garlic powder, parsley
leaves, salt and pepper.
2. First dip the chicken in the egg whites
making sure it is well coated. Then roll
them over in the bread crumbs mixture

74 DIABETES HEALTH JUN-JUL 16

By Gita Jaishankar

ensuring that the chicken breasts are


fully covered with the bread crumbs.
3. If needed, the same procedure can be
repeated again to ensure even coating.
Arrange the chicken pieces on a baking
pan and spray them evenly with any oil
spray.
4. Bake at 350 degrees for 45 minutes,
turning them over once in between.
Note: You can also roast the asparagus for a
richer flavour. Make sure to add the pureed
spinach at the end, so that the spinach does
not overcook and lose it nutrients.

Nutritive value per serving:


Energy: 645 kcal
Carbohydrate: 54 gm
Protein: 55 gm
Fat: 25 gm

Cream of
Vegetable
soup
Serves - 2

Ingredients:

By Priya Chaudhari

8. Boil till done.


9. Serve hot with grated cheese on it.

30 gm carrot

Nutritive value per serving:

30 gm cabbage

Energy: 129 kcal

30 gm broccoli

Protein: 5.5 gm

20 gm zucchini

Fat: 6 gm

20 gm cauliflower

Carbohydrate: 12 gm

1 tbs olive oil

Fibre: 1.5 gm

1.5 tbs whole wheat flour


150 ml skimmed milk
4 cloves garlic
10 gm (1/2 cube) - grated cheese
Salt as per taste
Black pepper as per taste
tsp Oregano (optional)
tsp Basil (optional)

Method:
1. Chop all the vegetables.
2. Crush garlic.
3. Take 1 tsp oil in a pan, add garlic, cut
vegetables, and stir fry. Keep aside.
4. Take remaining oil in a pan add wheat
flour. Roast it till brown.
5. Add milk, stir continuously to avoid
lumps.
6. Add stir fried vegetables and water as
per the required consistency.
7. Add salt, pepper, basil and oregano.

JUN-JUL 16 DIABETES HEALTH 75

Answers to

The Diabetes Health Quiz April-May '16

1. A low carb diet is the best diet for people with


Diabetes.
a: True - An increasing amount of research is
showing that a low carb diet is a strong choice for
people with Diabetes. A low carb diet not only
improves blood glucose level and aids in weight loss
but also improves heart health. A healthy low carb
diet should comprise the following:
Good amount of vegetable intake
Modest increase in fat intake from natural sources
Moderate protein intake
Low reliance on processed food, sugar and grains

3. Metabolic syndrome is a constellation of d: All of the above (high blood pressure, blood
sugar and triglycerides) - increasing your risk of
heart disease, stroke and Diabetes. Having just one of
these conditions doesn't mean you have metabolic
syndrome. However, any of these conditions increase
your risk of a serious disease.
4. A 30-minute walk three times a week is adequate
amount of exercise for a patient with Diabetes.
b: False - Studies have that shown people with
Diabetes who want to lower their blood sugar levels
and stay physically fit should walk 30 minutes at
least five days a week. Also, if you are pressed on
time then you can break your fitness routine by doing
three 10 minute walks on a given day. The aim
should be to do 150 minutes of workout each week.
5. Maintaining good oral health is a must in people
with Diabetes.
a: True - People with Diabetes are at special risk for
periodontal (gum) disease, an infection of the gum
and bone that hold the teeth in place. Periodontal
disease can lead to painful chewing difficulties and
even tooth loss. Good blood glucose control is the key
to controlling and preventing mouth problems. Daily
brushing and flossing, regular dental check-ups and
good blood glucose control are the best defense
against the oral complications of Diabetes.

2. People with Type 2 Diabetes have b: Excess blood sugar - Insulin resistance is a
condition in which the body produces insulin but
does not use it effectively. When people have insulin
resistance, glucose builds up in the blood instead of
being absorbed by the cells, leading to prediabetes or
Type 2 Diabetes. Over time the beta cells fail to keep
up with the body's increased need for insulin. Without
enough insulin, excess glucose builds up in the
bloodstream, leading to prediabetes, Diabetes and
other serious health disorders.

6. It is safe to exercise when your blood sugar levels


are b: 100-250mg/dL - For most people with Diabetes
this is a safe pre-exercise blood sugar range. Lower
than 100 mg/dL increases your risk of hypoglycaemia
(low blood sugar feeling). Hence it is advised to
consume 15-30 gm of carbohydrates, such as fruit
juice, fruit, crackers or even glucose tablets before
starting your workout. Higher than 250 mg/dL puts
you at the risk of ketoacidosis (a serious complication
of Diabetes that needs immediate treatment).
7. Which of the following is an artificial sweetener?
d: Both b and c (saccharin and aspartame) -

Artificial sweeteners are synthetic sugar substitutes,


but may be derived from naturally occurring
substances, including herbs or sugar itself. They are
also known as intense sweeteners because they are
many times sweeter than regular sugar. An attractive
alternative to sugar; they add virtually no calories to
your diet. In addition, you need only a fraction
compared with the amount of sugar you would
normally use for sweetness. Aspartame (Equal,
NutraSweet) and saccharin (SugarTwin, Sweet'N
Low) are examples of artificial sweeteners.

key role in helping sugar (glucose), a major source of


energy for your muscles and other tissues, enter your
cells. Without enough insulin, your body begins to
break down fat as fuel. The symptoms develop quickly
and it is best to check your blood sugar levels
immediately and visit the doctor at the earliest.

8. Is honey a good substitute for sugar?


b: False - There is no advantage to substituting
honey for sugar in a Diabetes eating plan. Both
honey and sugar will affect your blood sugar level. In
fact, honey is sweeter than granulated sugar, so you
might have to use a smaller amount of honey for
sugar in some recipes. Also, honey has slightly more
carbohydrates and calories per teaspoon than
granulated sugar. If you prefer the taste of honey, go
ahead and use it, but only in moderation. Be sure to
count the carbohydrates in honey as part of your
Diabetes eating plan.
9. The warning signs of diabetic ketoacidosis
include d: All of these (dry mouth, high blood sugar levels
and excess ketones in urine) - Diabetic ketoacidosis
is a serious complication of Diabetes that occurs when
your body produces high levels of blood acids called
ketones. The condition develops when your body does
not produce enough insulin. Insulin normally plays a

10. An Hba1c of <7 per cent implies __________


blood glucose control c: Good - For most people who have previously
diagnosed Diabetes, an A1C level of 7 per cent or less
is a common treatment target. Higher targets of up to
8 per cent may be appropriate for some individuals. If
your A1C level is above your target, your doctor may
recommend a change in your Diabetes treatment
plan. Remember, the higher your A1C level, the
higher your risk of Diabetes complications.

Lucky winners
1st prize:
1 year subscription of
Diabetes Health

Balpreet Kaur, Chandigarh

2nd prize:
Diabetes Health
T-shirt

Rameshchandra Dalal, Pune


Iboyaima Yenzkhom, Imphal
Dr Seth Srinivasa Reddy, Andhra Pradesh

June - July 2016


Aries (Mar 20 - Apr 21)

Cancer (Jun 22 - Jul 23)

You will enjoy a period of peace


and tranquillity. Spending alone
time will help you sort things that have
been bothering you for a while. Health will
be good. Try not to over indulge while eating
out as you may suffer from digestive
problems. Take extra care of your skin as
you are prone to allergies and skin rashes.
Opting for some fun filled activity will boost
your self-confidence.

Avoid getting into unnecessary


arguments as this may increase
your blood pressure and exhaust you.
You may feel physically and mentally drained
at times, don't worry as these changes are
temporary and things will improve with time.
Socialising with friends and family will help you
feel much more relaxed and refreshed. Don't
lose hope as things will brighten up eventually.
Lucky numbers: 2, 5, 6 and 8

Lucky numbers: 3, 7 and 8

Taurus

(Apr 22 - May 21)

Career opportunities will improve.


Focus on your family life and spend
some quality time with them. Remember to
control your diet to keep complications at
bay. Take special care of your eyes, nose
and throat as you are prone to allergies,
cold and flu. Pay extra attention to health
and hygiene. Try yoga and meditation to
help you feel better.
Lucky numbers: 1 and 9

Leo

(Jul 24 - Aug 23)

You are prone to allergies and


infections. Be extra vigilant as you
may suffer from eye infections. Dental
problems like ulcers and gum inflammation
are also indicated. Take extra care of your
health and do not neglect issues that are
constantly bothering you. Maintaining a
healthy diet and getting some physical activity
will bring some relief as well as boost your
immune system.
Lucky numbers: 7 and 9

Gemini (May 22 - Jun 21)


Stress levels will increase so do
not indulge yourself in excess work
as this will worsen your condition.
Excessive worrying will take its toll on your
health; hence pay special attention to diet.
Bouts of acidity and stomach problems are
indicated. Exercising will help keep your
mind of things. Don't neglect your health
and if the need arises visit the doctor.
Lucky numbers: 4 and 5

78 DIABETES HEALTH JUN-JUL 16

Virgo

(Aug 24 - Sep 23)

Health will take a back seat


during this period. Those with
existing ailments need to be extra
careful. Avoid self-medication as this will only
worsen the condition and bring in temporary
relief. Visit the doctor if you notice something
is amiss. Chest pain and knee problems are
also likely. You may also suffer from a bout of
food poisoning; hence, it is advised that you
avoid eating outside and eat healthy.
Lucky numbers: 5 and 6

Nandita reads the cards exclusively for the Diabetes Health magazine.

Libra

(Sep 24 - Oct 23)

Try Yoga as it will help you feel


more positive. Frequent travelling
can take a toll on health, so be extra
careful about your food and try to maintain
regular bedtimes and some amount of
exercise while away from home. Minor health
issues are likely and should not be taken for
granted.
Lucky numbers: 1, 2 and 7

Capricorn (Dec 22 - Jan 20)


Frequent headaches and
emotional disturbances will take its
toll on your health. Problems related to
the eye, skin and digestion are also
indicated. You need to be extra careful and
guard yourself against cuts, bruises and
injuries. Avoid over eating as this may have
negative impact on your overall health.
Unexpected health problems may crop up.
Lucky numbers: 5 and 7

Scorpio

(Oct 24 - Nov 22)

Minor health problems are


indicated. Those of you suffering
from chest pain should be extra careful
and follow the doctor's advice. Frequent
back pains and restlessness might prevent
you from performing daily tasks. Don't lose
hope, things will improve with time. Also, it
is advised that you visit the dentist for a
regular check-up to keep oral complications
at bay.

Aquarius (Jan 21 - Feb 19)


Regular medical check-ups will
resolve most of your health issues.
You may suffer from minor fractures
hence be extra careful when travelling. Cold,
cough and asthma will dampen your spirits.
Ear infections and joint pains may also
bother you. Do not stress yourself, try going
for a vacation to help you feel relaxed and
refreshed.
Lucky numbers: 2, 3 and 6

Lucky numbers: 2 and 5

Sagittarius (Nov 23 - Dec 21)


This period may be stressful for
you, which may lead to physical
discomfort thus hampering your
overall fitness. Diseases related to the
abdomen, heart, eyes, lungs are also indicated.
Those suffering from blood related disorders
need to be extra vigilant. Maintain your diet,
exercise and get regular health check-ups to
avoid problems later.
Lucky numbers: 1, 4 and 8

Pisces

(Feb 20 - Mar 20)

Being calm and seeing the positive


side of the situation will prove to be
fruitful. Taking constant efforts to
maintain your diet will finally show its
result in maintaining your immunity and
vitality. Sticking to or starting a new fitness
regime will help you feel rejuvenated and
positive about yourself. However, don't go
overboard with your workouts and allow your
body to recover.
Lucky numbers: 1, 3 and 4

JUN-JUL 16 DIABETES HEALTH 79

HEALTH BYTES

Every little bit helps!


Perdy Biddlecombe discusses with Spandana Birajdar
the importance of staying fit.

A little about me

My diet plan

I'm 18 years old and live in


Glasgow, Scotland. I'm taking a
gap year at present and I'm
travelling through Asia and
Europe. This coming September
I'm hoping to pursue a course in
the field of medicine at the
University.

Breakfast (8:00 am) - I have cereal


with fruit and a cup of almond milk
as it is a good substitute for normal
milk

During my childhood days, I was


very active and use to play a lot
of hockey. Currently, I don't get a
chance to go to the gym often
but I'm aware that physical
fitness is very important in one's
life. I try to incorporate physical
activity every day. For example, I
take the stairs and walk to my
workplace or the grocery store. I
prefer walking as I can do it at
my own pace and I thoroughly
enjoy it.

My stay fit mantra


I walk every day for about an hour. On weekends I go
hiking with my friends. Since I'm travelling I make a
point to swim each day. So swimming has become a
big part of my routine.
My diet has no restrictions. But I do have a sweet tooth
so I have to try really hard to avoid eating excess of
sweets. Also, I make conscious efforts to incorporate
more fibre in my diet. I personally feel that in order to
stay fit you should get adequate amount of sleep, start
your day early and should not skip your meals so that
you remain energetic throughout the day.

80 DIABETES HEALTH JUN-JUL 16

Lunch (12:30 pm) - I have a pasta


salad with lots of vegetables like
peppers, sweet corn etc
Evening snack (4:00 pm) - I have a
slice of cake with some tea.
Dinner (6:30 pm) - I have meat
usually steak, with vegetables or rice
or potatoes. I ensure that I consume
sufficient amount of proteins during
the day
Any other snack time - If I happen
to get hungry then I have an apple
or any other fruit

Advice to readers
Fortunately Diabetes does not run in
my family. But I'm aware about the fact that Diabetes is
on the rise and that people really need to start taking
care of themselves. People often feel that once they are
diagnosed with Diabetes they need to cut out food
groups from their diet but that's not true, you just need
to watch your portion size. Physical activity and diet are
the two main pillars in managing your Diabetes well.
So if you start eating right and exercising then you
have won half the battle. Every little effort counts and
small changes go a long away to make a difference. So
stay healthy and stay happy.
Every issue of Diabetes Health has real-life health stories of
both people with and without Diabetes. Send your stories to
editorial@diabeteshealth.co.in

Reg. No.: MAHENG/2011/38903