E-Education

Importance of Diabetes education

Diabetes is one of chronic, yet manageable, diseases. Therefore, understanding of disease is crucial for the Diabetes patients to live healthy life.
Early diagnose of Diabetes and interventions can prevent further Diabetes complications.
Diabetes education promotes public wellness.

1. Nutriment

• It is true that diabetes patients should avoid sugar. Both sugar and starch increase glucose level. However, almost every food such as meat, milk, fruit juice etc., increase glucose level as well. Therefore, patients with diabetes need food restriction. Best way to learn more about meal plan is too see nutritionist. Everyone should have different meal plan depends on his or her health status.

2. Ideal body weight

• Maintaining Ideal body weight helps cells to utilize glucose better. Also helps to keep blood pressure and cholesterol level in normal range.

3. Balanced meal plan

• ncrease Complex carbohydrates (e.g. whole grains) intake. Avoid any food that contains too much of sugar (e.g. honey, jam, jelly, syrup, soft drinks, pie, cake) Increase fiber intake (e.g. fruit, vegetables). Decrease saturated fat intake. Decrease sodium intake. Make sure to eat at regular time of the day and similar portion of meal each time. Check blood glucose after each meal.

4. How to calculate ideal body weight?

• Males: IBW = 106+ (6x inches in ht. above 5 ft.)= Ideal wt. in pound
  • Example 6’2’’ man
    • Example 6’2’’ man
• Females: IBW= 105+ (5x inches in ht. above 5 ft.)= Ideal wt. in pounds
  • Example: 5’5’’ woman
  • 105 + (5 x 5) = 130 +/- 10% = 117-143 pounds

5. How to calculate daily calorie needs?

• Calculate BMR
  • Female: 65+ (4.3 x weight in pounds) + (4.7 x height in inches) – (4.7x age in years)
  • Male: 66 + (6.3 weight in pounds) + (12.9 height in inches) = (6.8x age in years)
  • If you are sedentary: BMR x20%
  • If you are lightly active: BMR x30%
  • If you ae moderately active (You exercise most days a week): BMR x40%
  • If you are very active ( you exercise intensely on a daily basis or for prolonged periods): BMR x 50%
  • If you are extra active ( you do hard labor or are in athletic training): BMR x 60%
  • Add this number to your BMR

6. How to increase daily activity to lose weight?

• Every 3500 calories is equivalent to one pound. If you exercise to burn off 500 calories a day you should lose approximately one pound per week. Ideally, you should do a combination of both such as cut back 250 calories and burn an extra 250 calories by exercising or increase daily activity. 1 hour of fast paced walking and 30 minutes of running can burn extra 250 calories.
• A healthy weight loss goal is to lose 1/2 pounds to 2 pounds per week. Losing more than 2 pounds per week will mean that weight is less likely to stay off permanently. Never cut back to fewer than 1200 daily calories for female and 1500 calories for male without medical supervision.

7. How to design balanced meal plan?

• Once you know how much calories you need per day, next step is to design balanced meal. “Meal swap” method can be adapted to plan balanced meal. Among six food groups (Vegetables and fruits, grains and fiber, protein, fats), decide how many calories you are going to consume from each food group and swap within same group. For example, you can eat 1/2 bagel (approximately 1 oz) instead of 1/2 cup of sugar-frosted cereal.

8. How to calculate calories?

• Once you know how much calories you need per day, next step is to design balanced meal. “Meal swap” method can be adapted to plan balanced meal. Among six food groups (Vegetables and fruits, grains and fiber, protein, fats), decide how many calories you are going to consume from each food group and swap within same group. For example, you can eat 1/2 bagel (approximately 1 oz) instead of 1/2 cup of sugar-frosted cereal.

Carbohydrates in diabetes management

• 200 grams of carbohydrates per day (45-60 grams per meal; 15-20 grams for snacks) 1 gram of Carbohydrates is equivalent to 4 calories.
• Includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk
• Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation, remain a key strategy in achieving glycemic control.
• The use of glycemic index and load provides only modest benefit
• Sucrose-containing foods can be substituted for other carbohydrates as part of the meal plan
• Avoid excess calories (adjust to maintain desirable weight or prevent weight gain)
• Consume a variety of fiber containing foods (20-30 grams of dietary fiber per day)
• Sugar alcohols and nonnutritive sweeteners are safe within recommended daily intake levels

Fat and cholesterol in diabetes management

• Limit saturated fat to 7% of total calories (each gram of fat provides 9 calories)
  • 9 x total grams of fat in diet = calories from fat
  • Calories from fat ÷ total calories = % fat of total calories
• Minimize intake of trans fat and reduce dietary cholesterol to 200 mg/day
• Two or more servings of fish per week provide n-3 polyunsaturated fatty acids
• Protein in diabetes management
• If normal renal function, no need to restrict usual protein intake (15–20% of calories)
• Protein should not be used to treat acute or prevent nighttime hypoglycemia (increases insulin response without increase blood glucose concentrations)

9. Note:

• TLC (Therapeutic Lifestyle Change Diet
• Limit Saturated and Trans Fats in the Diet
• Limit Cholesterol Intake to 200mg/day
• Increased consumption of Omega-3’s
• Aim for 20-30g of fiber each day
  • Fiber found in Fruits, vegetables, whole grains, beans and legumes
  • Think fiber, think water (Doubles in size in the stomach)
• Focus on a plant based diet
  • Consume less animal proteins and products
  • Do not eliminate protein, replace it (beans, soy, nuts/seeds)
• Limit the total amount of fat in Diet
  • (55% calories from carbohydrates, 20% calories from protein, 25 calories from fat)

Alcohol in diabetes management

• Limit daily intake to one drink per day or less for women and two drinks per day or less for men
• To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food
• Carbohydrate coingested with alcohol (as in a mixed drink) may raise blood glucose

1. Type 1 Diabetes

• Intermediate or Long-acting Basal Insulin AND pre-meal Rapid or Short Acting Insulin

2. Type 2 Diabetes:

• Healthy Diet and Exercise prior to initiation of any pharmacotherapy.

3. Biguanides

• Metformin (Glucophage, Glucophage XR®)
• Primarily decreases hepatic glucose production and also increases peripheral insulin sensitivity. (Opens the door of cells so glucose can be utilize better)
• 1st line agent in most patients
• No hypoglycemia risk
• Monitor diarrhea and abdominal cramping. It can be reduced by taking with food)

4. 2nd Generation Sulfonylureas

• Glimepiride(Amaryl®)
• Glipizide (Glucotrol®, Glucotrol XL®)
• Glyburide (Diabeta®, Micronase®)
• Micronized glyburide (Glynase®)
• Stimulates insulin secretion from the pancreas
• 2nd line agent
• Risk of Hypoglycemia is very common
• Any agent should be taken before meals

5. Combination of Biaguanides and 2nd generation Sulfonylureas

• Glipizide/Metformin (Metaglip®)
• Glyburide/Metformin Glucovanc®)

6. a-glucosidase inhibitors

• Acarbose (Precose®)
• Miglitol (Glyset®)
• Prevent digestion of Carbohydrates

7. Thiazolidinediones

• Pioglitazone (Actos®)
• Pioglitazone/Metformin (ActosPlusMet®)
• Primarily increase insulin sensitivity. Also decreases hepatic glucose output

8. Meglitinide

• Repaglinide (Prandin®)
• Nateglinde (Starlix®)
• Increase insulin secretion from pancreas

9. Amylin Mimetics

• Pramlintide (Symlin®)
• Slows down the movement of food through the intestine. This slows down the absorption of glucose from the intestine, which reduces sudden increases in blood glucose.

10. GLP-1 AG(incretin Mimetic)

• Exenatide (Byetta®)
• Exenatide ER (Byduron®)
• Liraglutide (Victoza®)
• Dulaglutide(Trulicity*)
• Increases insulin and decrease glucagon when glucose levels are elevated, increases satiety

9. DPP-IV Inhibitors

• Sitaglipitin (Januvia®)
• Sitagliptin/Metformin (Janumet®)
• Saxgliptin(Trajenta*)
• Saxgliptin/Metformin(Jentadueto*)
• linagliptin (Onglyza®)
• alogliptin (Nesina®)
• alogliptin/metformin(Kazano*)
• slogliptin/pioglitazon(Oseni*)
• Prevents incretin breakdown

10. SLGT-2

• Canagliflozin (Invokana®)
• Canagliflozin/Metformin(Invocamet*)
• Dapagliflozin(Farxiga*)
• Dapagliflozin/Metformon(Xigduo XR)
• Empagliflozin(Jandiance*)
• Empagliflozin/linagliptin(Glyzambi*)
• Reduces renal glucose reabsorption and increasing urinary excretion of glucose

How Insulin works in our body?
The body naturally makes different amounts of insulin at different times. Smaller, steady amounts are produced between meals and overnight (sometimes called basal or background insulin). Larger amounts are produced when you eat (sometimes called bolus insulin). Together, they can help manage your blood sugar (glucose) all day, every day.

Because you can’t make insulin or don’t make enough for your body’s needs when you have diabetes, you may need to use more than one type of manufactured insulin to get the same effect. These different types of insulin work at different rates and for different amounts of time.

It is imperative to follow 5 steps for diabetes: Diet, exercise, medication, examination, and education. Among these steps, Examination step is to check on the current status of health and this step helps to plan for treatment and the observe the progression of the condition.

1. Diabetes is diagnosed through various tests.
2. Amount of medications are determined according to the severity of the condition.
3. The importance of diet planning and exercises are recognized.
4. Restart blood glucose level management
5. Examination becomes the basis of glucose level management

Glucose Urine Test

The advantage of glucose urine test is one can perform it anytime and anywhere. On the other hand, the disadvantage of the test is that the result does not represent the current glucose level and one can only depend on the color to estimate the result. It is difficult to accurately determine the glucose level from this.

To estimate whether glucose level is well maintained, this test becomes a very useful tool. Dip the test strip into the urine sample and let it sit for approximately 10-30 seconds, and then the color of the test strip is observed and recorded. The results are recorded as 0, +, ++, +++, and when 3 out of 4 test results are shown as 0 (no urinal glucose), then it is assumed that glucose level is maintained well.

Glucose urine test is recommended before mealtime, and when performed in the morning, it is recommended to be taken during the second urination after drinking a cup of water. When glucose level needs to be monitored closely, urine test is performed 4 times a day (before each mealtime and at bedtime) and when the condition improves, the test is performed 1-2 times for every 2-3 days. Some medications and vitamins such as aspirin and vitamin C may influence the urine test results and may lead to negative result when the actual glucose level is high. When such results are suspected it is recommended to consult a doctor.

Urine test methods include Test Tape, Diastix, and Clinistix. When the glucose level above 2% is observed for every urine test, it is advised to also take the ketone test through Keto-Diastix or Keto-Clinistix. When the presence of ketone is confirmed through this ketone test then it is very important to go to the doctor immediately.

Ketone is produced when the blood glucose level drops significantly and the body starts to burn fat for energy. (To picture this easily, think about burning desks and books when there are no trees (fuel) left to burn for heat in winter. The smoke, produced from burning desks and books, is analogous to the ketone)

Blood glucose test

While blood glucose test allows an accurate measurement of current glucose level, the biggest downsides are that it requires drawing blood and the price of the test is higher than that of glucose urine test. But the development of blood glucose test methods are growing very fast so that patients can use this test easily at home.

The blood glucose test is recommended to be performed frequently for following patients: those who need insulin injections, those who are diagnosed as pregnancy diabetes (gestational diabetes), those who have difficulty in distinguishing colors, those who have poor vision, and lastly those who have tried other glucose tests but failed to obtain the accurate result.

The blood glucose test is recommended to be performed before breakfast (normal level is below 120), an hour and a half after dinner (normal level is ~170), and patients who receive insulin injections every morning before breakfast need to take this test at 4pm to properly measure the amount of insulin (normal range is 120-160).

If the blood glucose level goes above 250 when tested at 4pm, it means the amount of insulin injected in the morning is insufficient, and if the glucose level stays at 100 then the amount of insulin is too much. The record of the dates, time, and test results become a very helpful resource to the doctor on planning treatment.

Hemoglobin A1c Test
Hemoglobin is produced from bone marrow and is found in red blood cells. It contributes to delivery of oxygen to cells and prevents anemia. The hemoglobin usually lasts about 120 days and it also contains a certain amount of glucose depending on how much the bloodstream contains glucose. Therefore, the result of this test became important in examining the average blood glucose level for past 3-4 months, and the treatment plans are also based on this result. The downside of this test is that the blood sample needs to be sent to the laboratory. But the test machine is available for purchase yet expensive and there are also companies that take the tests through mail orders. The test strips are also on the pricey side. When the test result is 7.0 (equivalent of 150 in blood glucose level), the blood glucose level for the past 3 months is considered to have been well maintained, and the maximum normal range is 8.0 (equivalent of 180 in blood glucose level). The highest blood glucose level that a machine can measure is 14.0.

Development of glucose test methods

Many diabetic patients have been wishing for glucose tests that do not require drawing blood, but there has not been significant progress on this method.

Gluco Watch, the company that introduced the watch-type blood glucose test to the market, had to close due to lack of accuracy and reasonable pricing competition. The most useful method is to use both blood glucose test and glucose urine test regularly and also perform the test to measure the 3-month glucose level.

Chronic Complications
There are 3 conditions that need to be constantly monitored: blood pressure, diabetes, and glaucoma. These conditions need to be examined and treated regularly, since surgery option is not available. If these conditions stay untreated, lots of complications arise. Complications of diabetes include retinopathy due to bursting of blood vessels of the eyes, and usually these complications start before one could realize.

Eventually these complication may cause blindness and also lead to nerve damages which would cause pain on fingers. When infections arise this may lead to amputation in worst cases. When protein leaks from the kidney, it may cause nephropathy and high blood pressure, eventually leading to hemodialysis.

The body would not be able to prepare against infections, and this will increase tinea pedis on feet, urinary tract infection for women. When urinary bladder functions improperly, one cannot urinate normally and stomach functions are also interrupted due to nerve damages. Extremely low glucose levels also bring significant damages to the brain. Moreover, infections on nerves also weakens the senses and cellular activities are also weakened due to low oxygen levels. These complications worsen once infections are started as well.

** Preventative Measures for Complications

1. Avoid smoking and drinking alcohols once diagnosed as diabetes
2. Monitor and maintain blood pressure, cholesterol level, and fat levels at a normal range
3. Perform blood glucose tests regularly to make sure to stay in normal range
4. Try to maintain average blood glucose level from 3-month period at 7.0
5. Regularly visit doctors for routine check ups

Acute Complications
I. Hypoglycemia (Low glucose level)

I. Hypoglycemia (Low glucose level)
Many diabetic patients have experienced the moment of low glycemic level. The symptoms of hypoglycemia are being chilliness, shivering, and cold sweat, and in these cases sugar such as orange juice and candies need to be taken immediately. The instances of low glucose levels are when one took an excessive amount of medications, did strenuous exercises, or skipped a meal. If low glycemic condition goes untreated properly, it may make one very difficult to talk and sometimes unconscious. Then 911 needs to be called immediately and if glucagon shots are available, they may be given to the patient.

II. Hyperglycemia (High glucose level)
Symptoms of high glucose level is not as dangerous as those of low glucose level, but they include increased urination , thirstiness, and hunger, along with weight loss and vision weakness. If high glycemic condition goes untreated, ketones are accumulated which make the body very acidic, and in extreme cases it may lead to death. It is very important to evaluation the reasons for such high glucose level and plan a treatment. One needs to monitor whether he/she takes a balanced diet and proper amount of medication.

When patients with diabetes pay less attention to foot care, it may lead to foot ulcers and gangrene, and even amputation in worst cases.

The immune functions of patients with diabetes rapidly weaken when blood glucose level increases and blood circulation is poor due to atherosclerosis. Therefore, bacterial infections occur easily on small cuts and bruises on feet. When this condition is not treated properly on time, it may lead to gangrene, meaning death of areas of the feet such as toes.

In order to prevent complications involving feet due to atherosclerosis and neuritis, blood circulation throughout the legs and feet needs to be maintained well. Also, blood glucose level needs to be regulated well to prevent the progression of complications.

1. Carefully observe the feet whether there are cuts or tinea pedis.
2. The feet should not be kept too dry or too damp. It is recommended to wash one’s feet everyday in warm water, and dry them properly with a dry towel. If the feet become too dry, then massage them with lotion for moisturization.
3. Avoid heat. Patients with diabetes may be more affected by heat due to weakened sensitivity level, so it is easier to get burns and frostbites.
4. Toenails are recommended to be cut when they become soft after washing feet. They need to be clipped horizontally and not too short, and if there are ingrown toenails then visit the physician.
5. Avoid small shoes or heels. Shoes with heels increase the chance of callus formation, and in this case the patient should not attempt to remove it by cutting it or using the removal medication.
6. When the sensitivity of the feet weakens, feet are more prone to cuts and bruises. Patients should not go on barefoot, and flip flops are also not recommended due to low protection.
7. In order to increase blood circulation, avoid corsets, belts, or tight socks that might interfere the circulation. It is recommended to wear socks that are made for easy absorbance of sweat. Avoid crossing legs, and it is recommended to bend the legs occasionally and exercise ankles as well.
8. Avoid smoking which also interrupts blood circulation.

A. Skin: Skin is the outermost layer that protects our body and releases any impurities through sweat along with regulation of heat and relay of senses. Patients with diabetes take a longer time to completely heal from burns or cuts on skin. Especially they tend to suffer more from infections. It is very important to take a shower frequently and apply lotion for hydration of skin. If there are cuts or swelling of skin that involves pain, one needs to go to the doctor immediately.

B. Mouth: Always maintain a clean state of mouth by brushing teeth, flossing, and massaging of gum. Also it is recommended to have a regular dental check up for every 6 months, and one needs to inform the dentist that he/she has diabetes. Always go to see a doctor if there are oral infections or any discomfort.

C. Eyes: One of the common symptoms of hyperglycemia (high glucose level) is blurred vision. This symptom disappears when blood glucose level returns to normal. It is recommended to have a vision check up for prescription glasses when blood glucose level is at a normal range. Blurred vision may also appear when blood glucose level drops. When diabetes persists for several years, capillaries of the eyes thicken and vision may become worse when retinopathy comes in. Regular vision check up for every 6 months is also recommended.

D. Alcohol: Blood glucose tends to decrease by alcohol consumption, since alcohol blocks the production of carbohydrates in the stomach and therefore prevents the replenishment of glucose. But individuals with consistent alcohol consumption also may have a normal range of average blood glucose level from 3 months. But it is recommended to stop drinking to regulate diabetes.

E. Smoking: Patients with diabetes tend to have more frequent medical conditions involving blood streams, and nicotine from smoking contracts the blood vessels and thickens which is very bad. It is very important to stop smoking for good blood circulation.