Diabetes is a condition where there is too much sugar in the blood due to lack of or insufficient insulin produced by the pancreas. Proper management of diabetes through diet, exercise, medication and monitoring of blood sugar levels is important to prevent serious complications such as blindness, nerve damage, heart disease and amputation. The document provides guidance on diabetes self-management including healthy eating through use of food exchanges and groups, monitoring blood sugar levels, treating hypoglycemia and ketoacidosis, and balancing food, exercise and medication.

1. Diabetes Care Management

2. What is Diabetes? Diabetes is a condition in which there is too much sugar (glucose) in the blood. Although sugar is needed to provide energy for the body, when in excess, it causes problem. Persons with diabetes have excess sugar because they lack or have deficient supply of insulin.

3. What is Insulin? Insulin is a substance produced by pancreas, an organ situated behind the stomach. Insulin is required for sugar (glucose) to enter the cells of the body where it is utilized. It is as if insulin is the key which opens the door to allow sugar (glucose) to enter. When sugar is absent or deficient or is defective, sugar remains in the blood in high amounts.

4. Diabetes “ Mild Disease” Serious consequences

5. Diabetes Mellitus A Serious Disease Leading cause of new cases of blindness 25 times more prone to eye problems 6 times higher risk for Paralysis (stroke) 5 times more prone to Kidney failure 20 times more prone to lower limb amputation Nerve damage causes loss of sensation 2-3 times higher risk for heart attack

6. Diabetes Indian context High prevalence Life style changes further accentuate the high genetic predisposition Under diagnosed due to low awareness Perhaps occurs a decade earlier Non obese/lean Type II fairly common Treated less seriously as considered “Mild Disease”

7. Differences between Type 1 & Type 2 Low risk to develop Ketoacidosis High risk to develop Ketoacidosis Insulin may be required for achieving good diabetes control Dependant on insulin for life Illness develops slowly Illness develops rapidly Often over weight and have an apple shape Patient are young, lean, and thin Develops later in life after >30 years Develops at an early age <30 years Type 2 Type 1

8. Insulin Monitoring Diet Education Exercise Treatment of Type 1 Diabetes

9. Insulin Monitoring Diet Education Exercise Treatment of Type 2 Diabetes Oral Agents

10. How You Manage Your Diabetes Follow a Healthy Meal Plan Take your Medication Regular Exercise Test blood sugar Regularly

11. Self Management

12. Self Management Keeping Track of your Blood Sugar Take an active part in the treatment of your Diabetes

13. Taking Charge of your Diabetes It means keeping your Blood Sugar as normal as possible Your blood sugar may alter because of : Eating Tablets or Insulin administration Exercise Illness Stress

14. Benefits of Normal Blood Sugar It makes you feel normal, and comfortable in your daily life It will help prevent the long term complication of the Diabetes

15. Learning Self Management It requires your time and efforts It requires your full participation in the treatment It requires self care practice in your daily life It requires close co-ordination with your Doctor and Diabetes Care Team

16. How to do Self- Management? Test Your Blood Sugar regularly Record your Blood sugar readings in the Diary Identify the Blood Sugar Patterns Use your Blood Sugar results to adjust your diet and Insulin Take help of your Doctor and Diabetes Care Team

17. Setting your blood Sugar targets Optimal blood sugar levels are : > 180 145-180 80-144 Post Prandial mg/dl > 140 111-140 80-110 Fasting mg/dl Poor Borderline Good Blood Sugar

18. Setting your blood Sugar targets Keeping your blood sugar in this range help you to prevent the long term complications of the Diabetes i.e. eye, kidney and nerve damage. Use Insulin, if advised.

19. Diabetes and Emergencies

20. Hypoglycemia Reduction in Plasma glucose concentration below the normal value of 60 mg/dl (3.3mmol/L) Symptoms : Hunger pains Excessive sweating and anxiousness Weakness Palpitation/Trembling Headache Blurring of vision Irritability/Confusion Sleepiness Faintness/loss of consciousness (coma)

21. Hypoglycemia Defined as blood glucose < 2.1 mmol/L Some diabetes develop hypoglycemia when BG > 2.1 mmol/L Some diabetics do not have symptoms at very low BG Hypoglycemic unawareness HYPERGLYCEMIA NORMAL HYPOGLYCEMIA

22. Causes Of Hypoglycemia Taking more exercise than usual Delay or omission of a snack or main meal Administration of too much medication Eating insufficient carbohydrate Over-indulgence in alcohol Mistake in sulphonyureas’s dosage

23. Treatment Mild Hypoglycemia Relieved by : 1 glass of fruit juice or soft drink 3 heaped teaspoons of sugar, honey or 3 - 5 sweets Repeat if symptoms not relieved after 5 to 10 minutes If next meal not immediately due, take 30 g complex carbohydrate JUICE COKE

24. Diabetic Ketoacidosis DKA is an acute life threatening complication of diabetes and occurs as a result of excessive production of ketones due to uncontrolled (or undiagnosed) hyperglycemia. Symptoms Excessive urination and thirst Nausea, vomiting and abdominal pain Deep rapid breathing Mental confusion Fruity Smell

25. Management Goal Results of animal studies, retrospective analysis of large patient populations, and prospective clinical trials suggested a link between degree of hyperglycemia and risk of late diabetic complications. DCCT conclusively proved that late diabetic complications can be prevented, onset delayed and progression retarded by Good Metabolic Control.

26. Management Goal Achieve as good a control as possible. Within constraints of individual ability and willingness, patients should be encouraged to aim for best possible control without increasing risk of serious hypoglycemia. Every incremental improvement in control translates into concrete benefits for patients. Take insulin, if advised.

27. Diabetes and Diet

28. Importance of Nutrition Advice Nutrition therapy is an integral part of management Diabetes is a metabolic disorder affecting carbohydrate, fat and protein metabolism Effective tool in combination with physical exercise and preferable to pharmacological therapy For patients with IGT; those at risk of; or in early stages of type 2 diabetes Inappropriate nutrition can make best planned pharmacological intervention ineffective

29. Food Groups Food Exchange Cereals Pulses Milk and Milk products Vegetables Fruits Fat, Oils and Nuts Meat, Fish and Eggs

30. Cereals are the staple diet in most cultures. They are rich in carbohydrate and a fair source of minerals and B Group vitamins. Commonly used cereals are Wheat Flour, Rice, Maize, Bajra, Jowar,Ragi etc Processed cereal based food items are Roti, Paratha, Puri, Idli, Dosai, Biscuit, Bread, Dinner Roll, Macaroni, Noodles etc Cereals

31. Pulses Pulses (legumes and Dals) are an important source of protein for Vegetarians Some of the common pulses are whole and/or, dehusked and split dals, Green gram, Bengal gram, Rajmah, Black gram, Cow pea, Red gram dal etc.

32. Milk and Milk Products Milk is an universal food for all age groups. Milk contains good quality protein. Buffalo milk is richer in fat as compared to Cow's Milk. Milk is also consumed in the form of Yogurt, Cheese, Cottage Cheese (paneer), Milk Powder etc.

33. Vegetables Vegetables are important for their mineral, vitamins and fibre content. Vegetables classified into 3 groups. Green Leafy Vegetables: like Spinach, Lettuce, Cabbage, Fenugreek etc. Roots And Tubers: like Potato, Onion, Yam, Carrot, Beet root, Radish, Turnip etc Other Vegetables: They are Peas, Brinjal, Cauliflower, Ladyfinger, Gourd etc.

34. Fruits Fruits are a rich source of Vitamin C, most fruits are also good source of carbohydrates. Yellow fruits like Mango and Papaya are rich in carotene. Common fruits are apple, banana, grapes, orange, guava etc.

35. Fat,Oils & Nuts Oilseeds and nuts are rich source of fat, energy, vitamins and minerals. In addition they also provide proteins. Peanuts, Pistachios, Almonds, Cashew, Coconut, Walnut are part of this group Visible fats commonly consumed in India are butter, Ghee, hydrogenated oils, and various vegetable oils. Fats are a concentrated source of energy providing 9 kcal/g.

36. Meat, Fish & Egg Rich in protein, vitamins, iron and phosphorous. Egg is considered the best quality protein. It contains all the essential amino acids in adequate proportions. Flesh foods are also a good source of vitamin B12. Common sources are mutton, chicken, fish, egg, pork, beef etc

37. Food Exchanges Food exchanges are food equivalent units designed to facilitate easy variation in diet. Exchange lists with specified caloric values are made by experts. These lists contain specified quantities (weight/size/measure) of food items which are units . A single unit within the group has the same caloric value and therefore can be interchanged.

38. Food Exchanges Thus one unit of a cereal exchange - one medium chappati, can be exchanged for three-fourth katori cooked rice or one idli or two medium slices of bread. One chappati cannot be exchanged for two spoons of Ghee although calories from both is the same.

39. Dietary Recommendations Diabetes Food Pyramid Cereals & Pulses 8-12 Units 10-14 units (veg) Fruits 2-3 Units Vegetables 3-4 Units Milk & Milk Products 2-3 Units Meat & Fish 1-2 Units Fats, Oils & Nuts 2-3 Units

40. Dietary Recommendations Carbohydrates: 55-65% mainly complex carbohydrates Fats: 20-30% saturated 10% poly-unsaturated 10% mono-unsaturated 10% cholesterol < 300 mg/day Protein: 12-20% Sodium: < 6 g/day hypertensive diabetic< 3 g/day

41. Free Foods Foods that have few or no calories and can be consumed in large quantity to satisfy hunger are called free foods Raw vegetables like tomato, cabbage, lettuce, cucumber etc Tea, coffee without milk or sugar Plain lemon juice (nimbu pani) without sugar Clear vegetable soups

42. Practical Guidelines Utilize food exchanges to introduce variety Use household measures Make corrections on existing meal plan and pattern rather than introduce new regimen Meal timings, frequency and quantity to be adjusted according to activity and insulin/drug regimens

43. Foods to be Avoided / Restricted Refined sugars and products made from it sugar, gur, honey, glucose, jam, jelly, sweet chutney, cake, pastry, mithai, jalebi, ice cream, gulabjamun, barfi chocolates, toffees, sweets, etc soft drinks, sherbets, squash, and sweetened fruit juices Fried Foods like pakora, samosa, puri, kachori, sev, chiwra, salted nuts, mixture etc

44. Summary Diabetic diet A person with diabetes can eat almost any healthy food that other people normally eat provided the food is balanced within the permissible caloric limits, and daily requirements are adequately distributed between the different meals and during the day

45. Good Management of Diabetes Requires Balancing Food intake, Exercise and Medication