1 time in India - IJCP Group _ May.pdf · Consultant Diabetologist, Kolkata Dr Vinanti V Pol MBBS,...

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To keep the members ofdiabetes care team abreast with

DSME and DSMS concepts

st 1 time in India

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support staffs for basic counselling of people with diabetes. This journal has been made in good faith with the literature available on this subject. The views and

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Care Capital of the World. We at USV believe in partnering with health care leaders through practice enhancement knowledge series.

Indian Diabetes Educator Journal (IDEJ), first of its kind in India successfully continues its endeavor of spreading awareness, knowledge and enabling health care teams in managing diabetes patients and empowering their patients for self-care. We continue to keep the members of diabetes care team abreast with concepts of Diabetes Self-Management Education/Support (DSME/S).

Most emergencies in diabetes are related to disruptions in a person’s blood sugar levels. This issue of IDEJ takes a deeper look into various complications of emergencies in diabetes and ways to resolve them. These

include overview and management of diabetic ketoacidosis, hypoglycemia, soft-tissue infections, diabetic coma, hyperglycemic emergencies and acute coronary syndrome. Lifestyle modifications are often advised for people at high risk of diabetes and patients with diabetes. Our cover story talks about how walking can benefit

patients with diabetes in managing their blood glucose levels.

We sincerely thank our contributors for making this issue delightful reading for our readers. We dedicate this journal to all the health care professionals who are working relentlessly towards making "India a Diabetes Care Capital of the World".

We hope that the information provided here would be of help to you in raising awareness among patients about

diabetes emergencies and providing optimum care in managing these acute complications.

Sincere Regards,

Expert Contributors of the MonthExpert Contributors of the Month

Dr Anil Vijaya Kumar

MD (General Medicine)Gr. Dip Diabetology (Aus)

Consultant Physician, Diabetologist - Bishop Benziger Hospital, Kollam, Kerala

Dr Debasis Babu

Diabetologist and Specialist in Preventive CardiologyPresident, Diabetes Awareness and You Kolkata

Dr Kiran Bharus

MSc (Clinical Research)

Diabetes Educator Diabetes Awareness and You, Kolkata

Dr Sumana Kunnuru

MD, DM (Endo), SCE (UK)

Assistant Professor, Dept. of EndocrinologyNIMS, Panjagutta, Hyderabad

Dr Ipsita Ghosh

MBBS (Gold Medalist) MD (Internal Medicine)DM (Endocrinology)

Consultant Endocrinologist, Kolkata

Dr Seema Bagri

MBBS, D Diabetology

Consultant Diabetologist, Mumbai

Dr Supriya Datta

MBBS, MD (Medicine)

Consultant Diabetologist, Kolkata

Dr Vinanti V Pol

MBBS, Dip DiabetologyMasters in Diabetology

Diabetes Specialist and Obesity Consultant, Suagr Care Diabetes Clinic and Aastha Health Care, Mumbai

Dr Manikandan GR

MDS (Periodontics)

Consultant Periodontist Assistant Editor, Healtalk Journal of Clinical Dentistry, Bangalore

Dr BS Narendra

MBBS, MD, DM (Endocrinology)

Consultant Endocrinologist Apollo Hospitals, Seshadripuram, Bangalore

Dr KK Aggarwal

MBBS, MD

President, Heart Care Foundation of India New Delhi

Dr N MD Athaullah

MBBS, MD

Consultant Physician and Diabetologist Hyderabad

Dr G Kiran

MBBS, MD

Managing Director and Senior Consultant Diabetes Clinic and Research Institute Hyderabad

Table of Content

01

04

07

12

14

23

18

Cover Story: Walk to Beat Diabetes


Diabetic Ketoacidosis: Detection and Management

Dr Sumana Kunnuru

Tackling Soft-tissue Infections in Diabetes

Dr N MD Athaullah

All that you should Know About Diabetic Coma

Dr Ipsita Ghosh

Hyperglycemic Emergencies in Diabetes

Dr Vinanti V Pol

Acute Coronary Syndrome in Diabetes

Dr Supriya Datta

Hypoglycemia in People with Diabetes

Dr Kiran Bharus

Dr Debasis Babu

30

28Tips to Plan for Avoiding DiabetesEmergencies

Dr BS Narendra

26What to Do in Diabetes Emergencies?

Dr Seema Bagri

42Conference Highlights

43Diabetes Quiz

10 Myths that Need to be Busted before a Diabetes Patient Goes to See a Dentist

Dr Manikandan GR

44Checklist for Emergencies in Diabetes

36Lifestyle Modification: Exercise

Dr KK Aggarwal

38Lifestyle Modification: Diet

41NDEP Best Practices

Dr G Kiran

1

ExpertOpinion

Walking with diabetes


MD (General Medicine)Gr. Dip Diabetology (Aus)

Consultant Physician, Diabetologist - Bishop Benziger Hospital, Kollam, Kerala

Cover Story: Walk to Beat Diabetes

It is important to prioritize physical activity for patients with type 2 diabetes. Physical activity improves blood glucose

control as well as:

¢ Reduces cardiovascular risk factors

¢ Facilitates weight loss

¢ Improves well-being.

What does the research say?

A study conducted by Di Loreto et al established that significant benefits in health and reductions in health care costs can be

achieved by bringing about modest increases in patient's physical activity.

- -The study by Di Loreto et al suggested that a target of 27 metabolic equivalents (METs) h �/week � is a reasonable target of energy

expenditure for patients with diabetes who were previously sedentary. The goal corresponds to a 5-km daily walk (1 h/day at a pace

of 3 mph or 45 min/day at a pace of 4 mph). This can bring down fasting plasma glucose (FPG) by 0.9 mmol/L, glycated hemoglobin

(HbA1c) by 1.5%. Brisk walking was reported to be the most common form of leisure time physical activity practiced by patients with

type 2 diabetes participating in the research.

How much is good enough?

It is recommended that a good starting target for patients with diabetes is to increase walking by at least 1.2 miles/day or 30 minutes or 2,400 steps/day. The Standards of Diabetes Care 2019 from American Diabetes Association recommends that all individuals with diabetes should be encouraged to reduce the amount of time spent being sedentary by breaking up periods of sedentary activity of more than 30 minutes by briefly standing or walking, or performing other light physical activities.

As per the position statement on physical activity/exercise and diabetes by the American Diabetes Association, prolonged sitting interrupted by brief (≤5 min) stretches of standing or light intensity walking every 20-30 minutes improves glycemic control in sedentary overweight or obese people as well as in women with impaired glucose management. In adults with type 2 diabetes, interrupting prolonged sitting with 15 minutes of post-meal walking and with 3 minutes of light walking and simple body-weight resistance activities every 30 minute improves glycemic control.

STEP COUNTERS, WALKING AND DIABETES

¢ Promote walking in your patients by

setting goals for your patient via the use of electronic step counters.

¢ Patients can continuously monitor

their progress in achieving the target steps during the day.

2

TIPS TO RECOMMEND WALKING

¢ While recommending targets, keep in mind that these recommendations are increments over the present level of walking of the patients.

¢ Greater health benefits accrue with more physical activity.

¢ You can help your patients continue to walk towards a more

optimal goal of 3.2 miles or 77 minutes or 6,400 steps or even more.

¢ Start with small changes.

WALKING A MILE WHETHER AT ONCE OR DIVIDED UP ACROSS THE DAY BURNS ABOUT 100 KCAL

Take the stairs Park your vehicle a little

farther from the destination

Conduct a walking meeting

The role of a diabetes educator

¢ Make your patients with diabetes walk.

¢ Help patients in setting stepwise goals towards meeting the recommended walking targets.

¢ Encourage the patients to reduce the amount of time spent being sedentary

¢ Simple counseling programs can play a key role in increasing physical activity in large number of patients.

3

References

1. Hill JO. Walking and type 2 diabetes. Diabetes Care. 2005;28(6):1524-5.

2. Di Loreto C, Fanelli C, Lucidi P, et al. Make your diabetic patients walk: long-term impact of different amounts of physical activity on

type 2 diabetes. Diabetes Care. 2005;28(6):1295-302.

3. American Diabetes Association Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl 1).

4. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and diabetes: A position statement of the American Diabetes

Association. Diabetes Care. 2016;39(11):2065-79.

5. Hill JO, Wyatt HR, Reed GW, et al. Obesity and the environment: where do we go from here. Science. 2003;299(5608):853-65.

4

Diabetic Ketoacidosis: Detection and Management

ExpertOpinion

Introduction

Dr Sumana Kunnuru

MD, DM (Endo), SCE (UK)

Assistant ProfessorDept. of EndocrinologyNIMS, Panjagutta, Hyderabad

Diabetic ketoacidosis and hyperosmolar hyperglycemic state are the two most serious acute metabolic complications of

diabetes.

Usually it occurs due to combination of absolute or relative

insulin deficiency and an increase in counterregulatory

hormones (glucagon, catecholamines, cortisol and growth

hormone).

DIABETIC KETOACIDOSIS IS CHARACTERIZED BY THE TRIAD OF

Uncontrolled hyperglycemia Metabolic acidosis Increased total body ketone concentration

What causes diabetic ketoacidosis?

The most common factor causing diabetic ketoacidosis is infection. Other factors which may also lead to diabetic ketoacidosis may

be inadequate insulin therapy, pancreatitis, myocardial infarction, cerebrovascular accident and drugs. In younger patients, factors

which may cause them to not take insulin such as fear of weight gain, fear of hypoglycemia, rebellion against authority and stress of chronic disease may also cause diabetic ketoacidosis.

Many patients including children, adolescents and adults have been reported to present with diabetic ketoacidosis without any of

the above-mentioned factors. Such patients have a strong family history of diabetes, a measurable pancreatic insulin reserve, a low

prevalence of autoimmune markers of -cell destruction and the ability to discontinue insulin therapy during follow-up.

5

DRUGS THAT MAY CAUSE DIABETIC KETOACIDOSIS

¢ Corticosteroids

¢ Thiazides

¢ Sympathomimetic agents

¢ Pentamidine

¢ Conventional antipsychotic/atypical antipsychotic drugs

How to identify diabetic ketoacidosis?

The classical symptoms of diabetic ketoacidosis include abdominal pain, tenderness, fruity odor, deep sighing respiration

(Kussmaul breathing) and the other history include polyuria, polydipsia, weight loss, vomiting, dehydration, weakness and mental

status changes.

Managing diabetic ketoacidosis

Successful treatment of diabetic ketoacidosis needs correction of dehydration, hyperglycemic and electrolyte imbalances;

identification of comorbid precipitating events and most important is frequent patient monitoring.

TREATMENT OF DIABETIC KETOACIDOSIS

Fluid therapy Insulin therapyPotassium

therapyBicarbonate therapy

Phosphatetherapy

Transition to subcutaneous insulin

Prevention of diabetic ketoacidosis

Proper patient education, better access to medical care and effective communication can help in prevention of diabetic ketoacidosis.

¢ Early contact with the health care provider.

¢ Emphasize the importance of insulin during an illness.

¢ Review of blood glucose goals and the use of supplemental short- or rapid-acting insulin.

¢ Initiation of an easily digestible liquid diet containing carbohydrates and salt when nauseated.

¢ Education of family members on sick day management.

6


¢ Keep the patient informed about all aspects of care for the person with diabetes including medication options for treating diabetes, the action of all insulins that may be incorporated into their care, meters and lancet devices and their appropriateness for the individual, and keeping up with new technology, pumps and sensors.

¢ Teach patients to have medication available to suppress a fever and treat an infection.

¢ Educate patients and family members about keeping record of glucose values including assessing and documenting temperature and urine/blood ketone testing, insulin administration, oral intake and weight.

References

1. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-43.

2. Bajaj S. RSSDI clinical practice recommendations for the management of type 2 diabetes mellitus 2017. Int J Diabetes Dev Ctries.

2018;38(Suppl 1):1-115.

3. ICMR Guidelines for management of type 2 diabetes. 2018. Available at: https://www.icmr.nic.in/content/guidelines-management-

type-2-diabetes.


7

Hypoglycemia in People with Diabetes

ExpertOpinion

Dr Kiran Bharus

MSc (Clinical Research)

Diabetes Educator Diabetes Awareness and You, Kolkata

Level 1 hypoglycemia Level 2 hypoglycemia Level 3 hypoglycemia

Measurable glucose concentration<70 mg/dL but ≥54 mg/dL

Measurable blood glucose concentration <54 mg/dL

Severe event

Clinically important independent of the severity of acute hypoglycemic symptoms

Immediate action needed to resolve the hypoglycemic event

Altered mental and/or physical functioning requiring assistance from another person for recovery

WHAT CAUSES HYPOGLYCEMIA?

Insulin or oral antidiabetic medications

Delayed meals Exercise Alcohol

Presence of critical illness Hormone deficiencies

ExpertOpinion

Dr Debasis Babu

Diabetologist and Specialist in Preventive Cardiology President, Diabetes Awareness and You, Kolkata

Hypoglycemia is a condition characterized by abnormally low blood glucose, which in extreme cases can lead to unconsciousness

and death. It is an important health consideration for people with diabetes as well as for health care providers dealing with the

treatment of diabetes. Throughout the day, depending on multiple different factors, blood glucose levels vary. Low blood glucose or

hypoglycemia is when blood glucose levels have fallen, so low that it needs action to bring it within the target range.

8

How to identify hypoglycemia?

Every individual's reaction to low blood sugar is different. Patients with diabetes should be encouraged to do self-monitoring of

blood glucose (SMBG) especially when they feel their levels dropping. Some of the most common symptoms are: feeling shaky;

being nervous or anxious; sweating, chills and clamminess; irritability or impatience; confusion; fast heartbeat; feeling lightheaded

or dizzy; hunger; nausea; color draining from the skin; feeling sleepy; feeling weak or having no energy; blurred/impaired vision; tingling or numbness in the lips, tongue or cheeks; headaches; coordination problems, clumsiness; nightmares or crying out during sleep and seizures.

Hypoglycemia may be inconvenient or frightening to patients with diabetes. Level 3 hypoglycemia may be recognized or

unrecognized and can progress to loss of consciousness, seizure, coma or death.

The above symptoms are experienced due to the release of a hormone called adrenaline (fight and flight) and the inability for the

brain to function in the usual way. In some individuals, there is a failure to sense the fall in sugar levels. There is failure in the secretion of adrenaline that triggers the symptoms. This is called “Hypoglycemia unawareness”. This is generally the result of

repeated episodes of hypoglycemia.

Inhibition of endogenous insulin

Glucagon releaseAdrenaline and growth hormone release

Cortisol releaseAutonomic symptom onset

Cognitive dysfunction

Coma, seizure

Lower boundary of physiologic euglycemia

Hypoglycemia

Symptomatic hypoglycemia

Neurophysiologic dysfuction

Severe neuroglycopenia

82.8 mg/dL

68.4 mg/dL66.6 mg/dL

57.6 mg/dL

50.5 mg/dL

46.8 mg/dL

27.0 mg/dL

90

80

70

60

50

40

30

9

Why is hypoglycemia dangerous?

Hypoglycemia can cause acute harm to the person with diabetes or others, especially if it causes falls, motor vehicle accident or other injury.

In a research study, a history of level 3 hypoglycemia was associated with greater risk of dementia. Level 3 hypoglycemia is also

associated with mortality.

Young children and elderly are especially vulnerable to hypoglycemia. They can't recognize hypoglycemic symptoms and

effectively communicate their needs.

MANAGING HYPOGLYCEMIA

Checking sugar levels every 15 minutes in rule of 15 prevents hyperglycemia as people tend to eat

more during a hypoglycemic episode.

The choice of carbohydrate given is important. Complex carbohydrates that contains fat as well (like in chocolates) slow glucose absorption and do not give the desired results. Hence, simple carbohydrates like sugar tablet, table sugar, honey, corn syrup, candies should be used.

The amount required by different individuals is different and should be discussed with the health care

team. Infants may require lesser than toddlers.

If there is inadequate response, maintain a 5% dextrose drip and refer to hospital

immediately.

10

SMBG is the only way of preventing hypoglycemia.

STEPS TO BE TAKEN

If glucose monitor is available, random plasma glucose should be taken.

If patient is brought in unconscious state, give 25-50 mL of 25% dextrose IV.

If recurrent hypoglycemia persists, check for renal function and hypothyroidism.

If glucose monitor is not available, and patient is conscious, she should be treated with

oral glucose/sweets/sugar.

Injectable glucagon should be used to treat someone with diabetes when their blood glucose is too low

to treat using the 15-15 rule. If severe hypoglycemia is not managed promptly, it can be life-threatening.

11

HOW TO TREAT LOW BLOOD SUGAR (HYPOGLYCEMIA)

Step 1Eat/Drink 15 g carbs

Step 2Wait 15 minutes

Step 3Check blood

Step 4Less than 70 mg/dL?

Repeat Steps 1-4


¢ Educate patients about the causes and symptoms of hypoglycemia including hypoglycemic unawareness.

¢ Counsel patients and their family members with practical solutions of treating hypoglycemia (keeping a candy with them all the time) and appropriateness of when to seek medical help.

¢ Dietary intervention such as eating at regular intervals, bedtime snacks to prevent overnight hypoglycemia.

¢ Exercise management including glucose monitoring and type of snacking before and after.

¢ Overall lifestyle management with medication adjustments and adherence.

References


type-2-diabetes


3. Cryer PE, Davis SN, Shamoon H. Hypoglycemia in diabetes. Diabetes Care. 2003;26(6):1902-12.

4. Shafiee G, Mohajeri-Tehrani M, Pajouhi M, et al. The importance of hypoglycaemia in diabetic patients. J Diabetes Metab Disord.

2012;11:17.

12

Tackling Soft-tissue Infections in Diabetes

ExpertOpinion

Introduction

Dr N MD Athaullah

MBBS, MD

Consultant Physician and Diabetologist Hyderabad

Soft tissue infections are potentially life-threatening conditions, requiring prompt diagnosis and treatment.

Patients with diabetes are at an increased risk for skin infection. The feet of patients with diabetes are prone to plantar forefoot ulcers associated with tissue destruction and

infection.

A study reported that individuals with diabetes are at 1.5 times increased chance of developing cellulitis as compared to those without diabetes.

Why are patients with diabetes at an increased risk of infection?

The skin of a diabetes patient is more susceptible to skin infections. Many of these require quick diagnosis and immediate treatment, so that severe complications or fatal outcomes may be avoided.

Impaired leukocyte chemotaxis, adherence and intracellular bacterial killing are some of the reasons making patients with diabetes

more prone to acquiring infections. In addition, antigen-specific cell-mediated immunity and impaired proliferative response to

pathogens such as Staphylococcus aureus, which is one of the most common cause of skin infection, also attributes to incidence of

infections in patients with diabetes.

COMMON INFECTIONS

Bacterial infections

Group A streptococcal infections

Group Bstreptococcal infections

Staphylococcal infections

Acute otitis externa

Necrotizing fasciitis

Hyperglycemia leads to an increase of severity of soft-tissue skin infections

What to do?

Normalization of glucose levels promotes prompt relief of symptoms of infection and bacterial eradication, rational treatment of

infection contributes to rapid correction of glucose level. Comprehensive treatment includes rational antibiotic therapy and normalization of glucose levels.

13

Glycemic control is important for recovery, wound healing, hydration and avoidance of infections

Choice of antibiotics depends on the severity of the disease and potential etiologic agents.

Wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy.

Empiric antibiotic therapy can be narrowly targeted at Gram-positive cocci in many

patients with acute infections. Patients at risk of infection with antibiotic-resistant organisms or with chronic, previously treated or severe infections require broad-

spectrum regimens and should be referred to specialized care centers.

Foot ulcers and wound care may require care by a podiatrist, orthopedic or vascular surgeon, or rehabilitation specialist experienced in the management of individuals with

diabetes.


¢ Educate patients that infections can be prevented by maintaining normal glucose levels.

¢ Educate patients about taking care of skin and recognizing early signs of soft-tissue infections.

References

1. Smith AJ, Daniels T, Bohnen JM. Soft tissue infections and the diabetic foot. Am J Surg. 1996;172 (6A):7S-12S.

2. Suaya JA, Eisenberg DF, Fang C, et al. Skin and soft tissue infections and associated complications among commercially insured

patients 0.64 years and with and without diabetes in the US. PLoS One. 2013;8(4):e60057.

3. Gangawane AK, Bhatt B, Sunmeet M. Skin infections in diabetes: A review. J Diabetes Metab. 2016;7:644.

4. Butranova OI, Razdrogina TN. Antibiotics for skin and soft tissue infections in type 2 diabetes mellitus. Int J Risk Saf Med. 2015;27

Suppl 1:S57-8.


type-2-diabetes

6 American Diabetes Association Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl 1).

14

All that you should Know About Diabetic Coma

ExpertOpinion

Introduction

Dr Ipsita Ghosh

MBBS (Gold Medalist) MD (Internal Medicine)DM (Endocrinology)

Consultant Endocrinologist, Kolkata

Diabetic coma is a life-threatening diabetic complication that may be due to a reduction or an elevation in blood glucose

level beyond a critical value and results in compromised basic functions of the brain and loss of consciousness, which can even be fatal.

CAUSES OF DIABETIC COMA

Diabetic ketoacidosis Diabetic hyperosmolar syndrome Hypoglycemia

CLINICAL FEATURES FOR EARLY RECOGNITION

Osmotic symptoms like increased thirst and hunger

Increased frequency of urination

Fatigue, dry mouth, fruity

smell, nausea and vomiting

What causes diabetic coma?

Diabetic ketoacidosis

Diabetic ketoacidosis, common in type 1 diabetes mellitus, is a combination of high blood sugar and ketones as measured in blood or urine.

1615


Osmotic symptoms like

increased thirst and hunger

Increased frequency of

urination

Fatigue


HungerTremors and tinglingSweatingWeaknessPalpitations

Diabetic hyperosmolar syndrome

Blood sugar levels more than 600 mg/dL or 33.3 mmol/L, associated with severe dehydration and osmotic symptoms.

Hypoglycemia

Blood sugar levels below 70 mg/dL, some patients may have symptoms with lower or higher levels as well.

16

Risk factors for diabetic coma

Older age and complications increase the risk of hypoglycemic coma.

RISK FACTORS FOR DIABETIC COMA

Insulin

delivery problem

An illness, trauma or surgery

Poorly managed diabetes

Deliberately skipping meals or insulin

Alcohol use

Illegal drug use

Complications of diabetic coma

It can cause permanent injury of brain tissue in patients with diabetes.

Permanent brain damage Death

¢ Monitor blood glucose (self-monitoring or continuous blood glucose monitoring)

¢ Medication adherence and adjustment

¢ Check urine ketones

¢ Immediate treatment of hypoglycemia

Can diabetic coma be prevented?

17

Treatment of hypoglycemia

Administer sugar, glucose tablets or sweetened drinks immediately, check blood glucose level after 1 hour to make sure its back to normal, then administer 10-20 g of bread or biscuit to avoid recurrence.

Rule 1: Do not stop taking

insulin if unwell, or even

if unable to eat.

SICK DAY RULES

Rule 2: Check blood

glucose level every

4 hours till one

feels better.

Rule 3: If blood glucose

<200 mg/dL, usual dose of

medications to continue; if

>300 mg/dL, visit doctor as soon as possible.

Rule 4: If unable to eat meal,

one should take at least

5 glasses of sugar-free

liquids per day.


¢ Educate patients about the hazards of high blood glucose as well as the dangers of hypoglycemia.

¢ Individualize blood glucose targets based on patient's specific situation.

¢ Make patients aware about continuous monitoring of blood sugar, adherence to medication and monitoring of complications.

References

1. Lu Z, Liu J, He Q, et al. Analysis of risk factors for hypoglycemic coma in 194 patients with type 2 diabetes. Med Sci Monit.

2017;23:5662-8.

2. Diabetic coma. Mayo Clinic. Available at: https://www.mayoclinic.org/diseases-conditions/diabetic-coma/symptoms-causes/syc-

20371475. Accessed on March 12, 2019.

18

Hyperglycemic Emergencies in Diabetes

ExpertOpinion

Introduction

Dr Vinanti V Pol

MBBS, Dip. DiabetologyMasters in Diabetology

Diabetes Specialist and Obesity Consultant, Suagr Care Diabetes Clinic and Aastha Health Care, Mumbai

Along with diabetic ketoacidosis (DKA), one of the diabetes emergencies is hyperosmolar hyperglycemic state (HHS).

Unlike DKA, it does not always present with coma. Alterations in consciousness can be present without command not associated with ketosis. It's a potentially life-threatening

emergency.

FEATURES OF HHS

Severe hyperglycemia Hyperosmolality Dehydration

These result from a combination of absolute or relative insulin deficiency and an increase in counterregulatory hormones, which result in increased hepatic glucose production and impaired glucose utilization in peripheral tissues.

DEHYDRATION AND OSMOLARITY

Hyperglycemia

Osmotic diuresis

Dehydration

Hyperosmolarity

Glycosuria

Increased glomerular filtration rate (GFR)

Hypovolemia

Hyperglycemia

Decreased GFR and renal glucose loss

19

What precipitates HHS?

HHS usually presents in older patients with type 2 diabetes and carries a higher mortality than DKA.

PRECIPITATING FACTORS

Ineffective action or decreased secretion of insulin.

Dehydration and electrolyte imbalance due to osmotic diuresis caused by glycosuria

due to less intake of water.

Noncompliance with treatment.

Infections.

Elevated levels of counterregulatory hormones such as glucagon, catecholamines,

cortisol and growth hormone.

Identifying HHS

As per the American Diabetes Association (ADA) recommendation, plasma glucose >600 mg/dL and a mental state where most patients present with mental stupor or coma is reflective of HHS.

HHS also demonstrates that many patients present without significant decline in the level of consciousness and many patients can present with mild-to-moderate level of ketosis.

20

Polyuria, polydipsia

and polyphagia

SYMPTOMS OF HHS

Weight loss associated

with weakness

Dehydration (dry buccal

mucosa, sunken eye balls,

poor skin turgor, tachycardia,

hypotension and hypovolemic shock in severe cases)

Kussmaul's respiration

(shallow rapid

breathing), acetone

breath, nausea and vomiting

Diagnostic criteria

Plasma glucose

Sodium bicarbonate

Urine or serum ketones

Total serum osmolality

Mental status Anion gap Arterial pH

Venous pH

Clinical recommendation

>600 mg/dL

>15 mmol/L Negative or small

>320 mosm/kg

Obtundation, combativeness or seizures

Variable >7.3

>7.25

Can HHS be prevented?

Many cases of HHS can be prevented by better access to medical care, proper patient education and effective communication with the health care provider during an intercurrent illness.

More frequent monitoring of blood glucose and a urine or blood ketone monitoring in ketosis-prone patients is needed to prevent HHS.

IMPROVED EDUCATION OF THE PATIENT

¢ Early contact with the diabetes health care team.

¢ Emphasize the importance of insulin therapy.

¢ Review of blood glucose goals and the use of supplemental short- or rapid-acting insulin.

¢ Having medications available to suppress a fever and treat an infection.

¢ Initiation of an easily digestible liquid diet containing carbohydrates and salt when

nauseated.

21

Investigations needed

for diagnosis

Immediate RBS

Urine ketones with urine analysis

Arterial blood gas

Serum: Creatinine, blood urea nitrogen; electrolytes with anion gap; osmolality

HbA1c

ECG, chest X-ray, USG: Abdomen and pelvis

CBC for leukocytes to rule out underlying infection

Goals of therapy

¢ Improvement of circulatory volume and tissue perfusion

¢ Gradual decrease in glucose and plasma osmolality

¢ Correction of electrolyte imbalance

¢ Identification and prompt treatment of comorbid precipitating causes

Fluid therapy

Initial fluid therapy is directed toward expansion of the intravascular, interstitial and intracellular volume all of which are

reduced in hyperglycemic crisis and restoration of renal perfusion. Adequate fluid and caloric intake have to be ensured.

Initial fluid of choice is normal saline infused at 15-20 mL/kg body weight per hour or 1-1.5 L/hr for the first hour. The goal is to replace half of estimated water deficit over period of 12-24 hours till blood pressure is stabilized. Administration of insulin without

fluid replacement may aggravate hypotension.

Subsequent choice for fluid replacement depends on hemodynamic, the state of hydration, serum electrolyte levels and urinary output.

Insulin therapy

The mainstay in the treatment of DKA involves the administration of regular insulin via continuous IV infusion or by frequent subcutaneous or intramuscular injections.

A continuous infusion of insulin at a rate of 0.1 units/kg/hr is administered and should be continuously monitored. The rate of insulin infusion should be adjusted to maintain blood glucose between 150 and 200 mg/dL. If the patient is treated with noninsulin therapies or medical nutrition therapy alone, he may require insulin for management of HHS.

Managing HHS

22

Potassium therapy

Add IV potassium to each liter of fluid administered:

¢ <3.5-40 mEq/L

¢ 3.5-4.5-20 mEq/L

¢ 4.5-5.5-10 mEq/L.

Bicarbonate therapy

ADA guidelines recommend that patient with pH <6.9 should receive 1 ampoule of bicarbonate (100 mmol) in 400 mL NS at the rate

of 50 mmol/hr.

Other therapies

If accompanied by ketosis, vomiting or alteration in the level of consciousness, marked hyperglycemia needs temporary adjustment of the treatment regimen and immediate care from the diabetes care team.


¢ To emphasize the importance of oral hypoglycemic agents/insulin during an illness and the reasons never to discontinue without informing the health care team.

¢ Educate family members on management of sick days, fasts and other days as well as to keep a check on blood sugar levels.

¢ Motivate the patient for a healthy diet and lifestyle modifications.

References


2. Kitabachi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-43.

3. Passquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: A historic review of the clinical presentation, diagnosis, and

treatment. Diabetes Care. 2014;37(11):3124-31.

23

Acute Coronary Syndrome in Diabetes

ExpertOpinion

Introduction

Dr Supriya Datta

MBBS, MD (Medicine)

Consultant Diabetologist, Kolkata

Type 2 diabetes mellitus is an independent risk factor for both micro- and macrovascular complications. Diabetes doubles

the risk of cardiovascular events.

Acute coronary syndrome (ACS) in diabetes mellitus is a very

dreaded complication leading to mortality and morbidity and

patients must be aware of its consequences.

A case of acute myocardial infarction

¢ Mr Arun, a 40-year-old executive was doing perfectly well since morning, till he had an

unusual heaviness in his chest and felt, he was out of air (shortness of breath).

¢ He had ignored similar symptoms couple of months back.

¢ As the condition progressed, he had sweating, vertigo and was rushed to the nearest

ICU where he was diagnosed to have acute myocardial infarction.

¢ Baseline investigations showed raised fasting blood glucose (FBG), postprandial blood glucose (PPBG), glycated hemoglobin (HbA1c), lipid profile altered with

increased total cholesterol (TC), increased low-density lipoprotein (LDL) cholesterol, increased high-density lipids.

¢ He had a family history of type 2 diabetes mellitus and dyslipidemia and was a smoker as well. His body mass index (BMI) and waist circumference was high.

¢ He had undiagnosed hypertension.

Management

Use of antiplatelet agents, statins, -blockers, angiotensin-converting enzyme (ACE) inhibitors apart

from revascularization either pharmacological or invasive depending upon time of presentation.

24

Other pharmacological agents to be added on discharge after stabilization must include a sodium-

glucose co-transporter 2 (SGLT2) inhibitor (unless contraindicated).

Gold standard in ICU set-up: Insulin via insulin infusion set (continuous insulin infusion) with self-

monitoring of blood glucose.

Risk factors for diabetes are usually present, but

ignored!

Patients lack education about the basic lifestyle

changes.

WHAT IS THE TAKEAWAY FROM THIS CASE?

ACS is a common presentation of type 2 diabetes mellitus

particularly in young patients with erratic lifestyle (dietary discrepancy and sedentary habits).

There may not be any preceding symptoms of chest pain or

other features of cardiovascular diseases.

Subclinical

atherosclerosis

(disease progression,

atherosclerotic

clinical events)

Infection (decreased defense mechanism, increased pathogen burden)

Inflammation (increased IL-6, CRP, SAA)

Hyperglycemia (higher age, oxidative stress)

Insulin resistance (hypertension, endothelial dysfunction)

Dyslipidemia (increased LDL, TG; decreased HDL)

Thrombosis (increased PAI-1, TF; decreased EPA)

IL-6: Interleukin-6; CRP: C-reactive protein; SAA: Serum amyloid A; LDL: Low-density lipoprotein; TG: Triglyceride; HDL: High-density lipoprotein; PAI-1: Plasminogen activator inhibitor-1; TF: Tissue factor; EPA: Eicosapentaenoic acid.

HOW DIABETES LEADS TO CORONARY HEART DISEASE?

25


¢ Educate patients about the complications of ACS and its consequences.

¢ Motivate the patient for a healthy diet, stop smoking and regular exercise.

¢ Make patients aware about the importance of self-monitoring of blood glucose.

26

What to Do in Diabetes Emergencies?

ExpertOpinion

Introduction

Dr Seema Bagri

MBBS, D Diabetology

Consultant Diabetologist, Mumbai

A diabetes-related emergency, usually due to a severe drop or rise in blood sugar levels, can quickly become serious or even

life-threatening, if not treated promptly. The most important issues which should be ensured to offer proper care to a patient with diabetes are given below.

It is imperative to identify a patient in diabetes emergency.

The signs that can help in identification of a diabetes emergency are:

In case of hyperglycemic emergency:

¢ Extremely high blood glucose

¢ Initially, increased thirst and urination

¢ Dry mouth and tongue

¢ Weakness, nausea and fever

¢ Hallucinations, confusion or seizures.

In case of hypoglycemic emergency:

¢ Inability to swallow

¢ Seizures or convulsions

¢ Loss of consciousness

IDENTIFY AN EMERGENCY

p Give a fast-acting carbohydrate such as glucose tablets or gels, juice, raisins, sugar or

honey to the patient in case of hypoglycemic emergency.

p In case of hyperglycemic emergencies, offer the patient a lot of fluids.

p Ensure that the patient is taking medications regularly.

p Regularly check the patient's blood glucose.

p See the doctor, if there is no relief in the symptoms.

PROVIDE TREATMENT

27

Hyperglycemic emergencies including diabetic ketoacidosis and hyperglycemic

hyperosmolar state are usually caused by:

1. Infection: Urinary, respiratory, skin

2. Infarction: Myocardial infarction, stoke, bowel, bone, skin

3. Infant on board: Pregnancy

4. Indiscretion with diet: Noncompliance with diabetic diet (e.g., sugar, carbohydrates or

alcohol)

5. Insulin lack: Skipped insulin dose, failure of insulin pump.

It is important to be aware of these precipitating factors leading to hyperglycemic emergencies.


¢ Educate patients that diabetes emergencies can quickly become serious and even life-threatening.

¢ Tell the patient to always carry with them treatment for hypoglycemia.

¢ Ensure a "sick-day" plan for the patient in the event of illness, injury or surgery.

¢ Regularly check blood glcuose levels.

References

1. Campbell A. Recognizing and responding to diabetic emergencies. Diabetes self-management. 2018. Available at:

https://www.diabetesselfmanagement.com/blog/recognizing-and-responding-to-diabetic-emergencies/

2. Dingle E, Clouse AL, Brown A, et al. Assessment and treatment of five diabetic emergencies. Journal of Emergency Medical

Services. 2018.

KNOW THE FIVE I'S

28

Tips to Plan for Avoiding Diabetes Emergencies

ExpertOpinion

Introduction

Dr BS Narendra

MBBS, MD, DM (Endocrinology)

Consultant EndocrinologistApollo Hospitals, Seshadripuram Bangalore

It is important to plan for emergencies by visualizing all the situations that may arise leading to a diabetes emergency.

Other comorbidities.

Whether the patient is at home or at

hospital.

HOW TO PLAN FOR DIABETES EMERGENCY?

Think through all the available resources such

as a insulin pen or a vial.

Recurring hypoglycemia.

Insulin dose, other oral medications, lifestyle

of the patient.

An answer to all the queries above will help the diabetes educator in devising a back-up plan so that the diabetes emergencies can

be prevented.

Set lower glycemic goals

In healthy patients with few co-existing chronic illnesses and intact cognitive function and functional status, lower glycemic goals such as A1c <7.5% should be set.

In case of older patients with multiple co-existing illnesses, cognitive impairment or functional dependence the glycemic goals should be less stringent; A1c <8.0-85.

Screening for diabetes complications

Individualized screening in older patients, particular attention should be paid to complications that may lead to functional impairment.

In case of an elderly diabetes patient

29

In case of children and adolescents

Comprehensive nutrition education at diagnosis and monitoring carbohydrate intake to ensure optimal

glycemic control.

Frequent glucose monitoring before, during and after exercise to prevent, detect and treat

hypoglycemia.

Educate patients to prevent hypoglycemia during exercise, after exercise and overnight following exercise.

This includes reducing prandial insulin dosing for the meal/snack preceding exercise, increasing

carbohydrate intake and eating bedtime snacks.

Assess for psychosocial and diabetes related distress, encourage developmentally appropriate family

involvement in diabetes management tasks.

Reference


30

10 Myths that Need to be Busted before a Diabetes Patient Goes to See a Dentist

ExpertOpinion

Dr Manikandan GR

MDS (Periodontics)

Consultant Periodontist Assistant Editor, Healtalk Journal of Clinical Dentistry, Bangalore

It is a sad fact that India is considered to be the diabetes capital of the world at the present. Oral health plays a prominent role in the

glycemic control of the diabetes patients. Still, we come across many patients who do not consider oral health to be a serious affair

and face various complications. Some people are privy to many long-standing myths and taboos about dental health which has been passed to them through folklore or family members. In this era of evidence-based medicine, misleading myths are nothing more

than a Pandora's box and they have to be shattered in due course with scientific evidence. Let's take a look at some of the myths and

the facts behind them.

Myth 1: I don't have to inform my dentist about my diabetes history

The patient may think dentist have no need to know about his or her diabetes history. So, majority of the patients may not tell deliberately or they may even

forget. Diabetes patients should be managed well while during dental procedures. Dentist should make sure that the patient has optimum blood glucose levels and should frequently monitor blood glucose using tests like

random or fasting and postprandial blood sugars and glycated hemoglobin in cases where it is needed. The wound healing process may be delayed in these patients after dental extraction too. Also, the drugs patient is taking for diabetes

may have interact with other drugs prescribed by the dentist. Another complication that can happen while in the dental chair may be a probable hypoglycemic episode; however, it is not universally true. Patients on insulin therapy or antidiabetes medications (i.e., sulfonylureas

and meglitinides) whose side effects include hypoglycemia may experience difficulties. An appointment scheduled after a meal or snack is recommended for those patients who are at risk of hypoglycemia. Most patients with diabetes are recommended to eat a meal or snack every 4-5 hours. Patients with gestational diabetes are recommended to eat every 2-3 hours. To avoid hypoglycemic

episodes during a dental procedure, including a prophylaxis, blood glucose values are to be obtained. If the blood glucose level is below 70 mg/dL, then treat the patient accordingly. The patient should consume 15-20 g of a carbohydrate source and get their

“Every human being is the author of his own health or disease.” —Buddha

31

blood retested after 15 minutes. If the blood glucose value is above 70 mg/dL, the patient should consume a meal or snack to prevent

recurrence of hypoglycemia before proceeding with the dental treatment. If the blood glucose value is still under 70 mg/dL, repeat the treatment. Long appointments will require an additional blood glucose reading to make sure the values are not dropping below

70 mg/dL. Readings at the end of appointments are important to make sure the patient is safe to leave the office, particularly those who will be driving.

Carbohydrate sources for treating patients with hypoglycemia (70 mg/dL or lower)

¢ Glucose tablets

¢ 1 tube glucose gel

¢ 8 hard candies

¢ Raisins

¢ 4 oz of regular soda

¢ 4 oz fruit juice

¢ 8 oz skim milk

These choices will raise blood glucose values quickly. High-fat foods will slow the absorption rate. The antidiabetes medication,

-glucosidase inhibitors, alone do not cause hypoglycemia. However, it is usually prescribed in combination with another

antidiabetic medication or insulin that may cause hypoglycemia. Only a glucose or lactose food source is effective for treating

hypoglycemia with this combination. The dental emergency kit should, therefore, contain a glucose (i.e., glucose tablets or gel) or a lactose (i.e., low-fat or non-fat milk or yogurt) source for treatment of hypoglycemia.

If the hypoglycemic episode is severe and the patient is unable to swallow, glucagon should be administered to raise the blood

glucose values. Glucagon will increase the hepatic glucose release, resulting in a release of insulin. Glucagon should also be a

component of the dental emergency kit with specified or all members of the dental team having the ability to administer the drug.

Myth 2: Diabetes has no relation with dental diseases … I am sure!

Periodontal disease has been reported to be the sixth complication of diabetes, along with neuropathy, nephropathy, retinopathy,

micro- and macrovascular diseases. Many studies have been published describing the bidirectional interrelationship exhibited by diabetes and periodontal disease. Studies have provided evidence that control of periodontal infection has an impact on improvement of glycemic control evidenced by a

decrease in demand for insulin and decreased A1c levels.

In addition to periodontal infection and gingival inflammation, a number of other oral complications have often been reported in patients with diabetes. These include

xerostomia, dental caries, candida infection, burning mouth syndrome (BMS), lichen planus

and poor wound healing. Proper management of these complications requires that they first must be properly diagnosed. Many of the problems can be properly identified by provision of a comprehensive oral examination at each medical or dental visit.

In addition to emerging evidence supporting periodontal disease as a potential risk factor for developing diabetes complications, evidence also suggests that periodontal disease may

be a risk factor for the development of type 2 diabetes and possibly gestational diabetes. In fact, one large study showed that people with periodontal disease have almost two times

increased risk of type 2 diabetes than people with healthy gums.

The next question that researchers set out to answer is whether periodontal infection adversely affects glycemic control in people with diabetes. There is a growing body of evidence supporting the long-held clinical observation that periodontal infection adversely

affects glycemic control. There are 20 research studies implicating that long-term blood sugar

was lower after gum treatment. This means that treating gum disease may help in a better management of diabetes.

32

Myth 3: I cannot believe that my lethargy in going for a dental cleaning will adversely affect my blood sugar levels

Myth 4: Even when I don't eat too much sweets, why do I experience tooth decay?

Diabetes can lead to marked dysfunction of the secretory capacity of the salivary glands. This process is often associated with salivary gland dysfunction. Xerostomia is qualitative or quantitative reduction or absence of saliva in the mouth. It is a common complication of head and neck radiation, systemic diseases and medications.

Individuals with xerostomia often complain of problems with eating, speaking, swallowing and wearing dentures. Dry, crumbly foods, such as cereals and crackers, may be particularly difficult to chew and swallow. Denture wearers may have problems with denture retention, denture sores and the tongue sticking to the palate. Patients with xerostomia often complain of taste disorders (dysgeusia), a painful tongue (glossodynia), and an increased need to drink water, especially at night.

Xerostomia can lead to marked increase in dental caries, parotid gland enlargement, inflammation and fissuring of the lips (cheilitis), inflammation or ulcers of the tongue and buccal mucosa, oral candidiasis, salivary gland infection (sialadenitis), halitosis and cracking and fissuring of the oral mucosa. In patients with xerostomia, development of dental caries can be rampant and severe and, if left untreated, can result in infection of the dental pulp and tooth abcess.

The onset of caries requires Streptococcus mutans bacteria. These bacteria adhere well to the tooth surface and produce higher

amounts of acid from sugars than other bacteria in the mouth. When the proportion of S. mutans in plaque is high (in the range of 2-10%) a patient is at high risk for caries. The combination of bacteria in the presence of a dry mouth and a source of sugar intake may lead to a high dental caries risk.

33

Diabetes might also result in increased bone resorption among those who wear dentures. It is possible that the measurements taken during fabrication of the current denture may differ

after a year. So, frequent replacement of dentures may be needed in diabetes patients. Reduced blood supply can make gums vulnerable to damage from poorly-fitting dentures. Gums can sometimes recede, exposing bones directly. With reduced saliva, your mouth is more

vulnerable to infection generally. This can include infection of dentures sores, which can be

serious, but it can also include a number of minor infections, such as cheilitis or candida

(thrush). This minor fungal infection is about twice as common in diabetes patients as in others.

A combination of factors appears to play a role in this process. BMS is a chronic, oral pain condition associated with burning sensations of the tongue, lips and mucosal regions of the

mouth. The pathophysiology is mainly idiopathic but can be associated with uncontrolled diabetes, hormone therapy, psychological disorder, neuropathy, xerostomia, and candidiasis.

Generally, there are no detectable lesions associated with the syndrome, which is based

solely on patient report of discomfort.

Treatment is targeted at the symptoms and requires attention to glycemic control, which will

result in reduction of other complications involved in the process. Medications often used for

this condition, benzodiazepines, tricyclic antidepressants and anticonvulsants, have been shown to be effective therapies. Care must be taken in prescribing these medications to patients with diabetes because of associated xerostomic effects.

Myth 5: I will sue my dentist for giving me plastic false teeth that keeps me on toes always

Myth 6: The dentist treatment seems to have worsened the symptoms, there is burning sensation in my mouth!

Myth 7: Where is my mouthwash? I have a dental appointment and can't see him without using my mouthwash!

Simple rinsing with mouthwash may mask the current day oral hygiene but underlying pathology still remains. However, preprocedural mouth rinse just before commencing a dental procedure seems to have some advantages. Even though no scientific evidence exists that a pre-procedural rinse prevents infections in patients or dental health care workers, the Centers for Disease Control and Prevention (CDC) states that it does reduce the level of microorganisms in the mouth that can enter the patient's bloodstream during a dental visit. During a professional cleaning, scaling and polishing instruments, such as slow-speed handpieces, prophy (polishing) cups and ultrasonic scalers, create splatter and aerosols that allow microorganisms to leave the mouth and contaminate clinical surfaces, instruments and personnel in the treatment room.

34

Aerosols are fine mists that contain bacteria. The mist is expelled from the mouth when the ultrasonic scaler and other water-based dental instruments are used. The water component used to cool the instrument and flush debris contains bacteria from the mouth and can easily contaminate people and surfaces outside of the treatment zone. Additionally, when the hygienist is polishing the teeth, splatter occurs when the motion of the slow-speed handpiece and polishing cup picks up paste and saliva. All dental health care workers must wear protective equipment at all times during treatment and thoroughly disinfect the treatment room after the patient is dismissed. However, even with the best infection control practices, microorganisms can remain.

Myth 8: I may have diabetes associated renal complication, but my dentist does not need to know about it.

Diabetes patients with renal problems may have impaired drug excretion. Drugs used in dental sedation and general anesthesia should be used with caution and in consultation with a physician. Renal diseases influence the use of other drugs in dentistry,

particularly nonsteroidal anti-inflammatory drugs (NSAIDs) and some antimicrobials. Platelet dysfunction may occur in renal

patients giving rise to a bleeding tendency. Patients on hemodialysis may be heparinized. Dental treatment should be carried out on the day after dialysis. Renal condition is optimal at this time and the anticoagulant effect has stopped. The arm with vascular access

for dialysis (the surgically created arteriovenous fistula) should not be used for venipuncture by the dentist. Patients who have had a kidney transplant may need corticosteroid cover, have a bleeding tendency if anticoagulated, may have gingival hyperplasia if

taking cyclosporine and are prone to infection due to immunosuppression.

Myth 9: I have neural problems due to my diabetes, but how does it concern my dentist?

The neuropathic problems may affect the oral tissues also and they may manifest as frequent atypical neuralgias and phantom pain sensations. These patients may also experience difficulty in handling dentures and they may break them by accidental slipping from

their hands most of the times. Dentist needs to know the prescribed neuropathic medications to avoid drug interactions. Diabetic neuropathy could be the underlying cause of BMS in patients with diabetes. The nerve damage in diabetic neuropathy has been reported to show an increase in the Langerhans cells that are associated with immune disturbance. Therefore, it is crucial to screen

patients who have symptoms of BMS for diabetes mellitus.

Many medical conditions, particularly diabetes, predisposes patients to the development of more severe and progressive forms of periodontal disease. In an effort to focus attention on the need for better oral health outcomes for patients with diabetes and periodontitis or other oral complications, providers should take several action steps, including:

¢ Ask individuals with diabetes about their oral health, specifically if they have noticed any signs of infection, bad breath or a bad taste in their mouth or if they have any other symptoms.

¢ Inquire about the last dental and oral health examination.

¢ Remind individuals with diabetes that they need periodic dental and periodontal examinations (every 6 months or more frequently) as recommended by the American Dental Association.

¢ Encourage contact with patients' dental care provider if they notice signs of infection such as sore, swollen or bleeding gums; loose teeth; mouth ulcers or pain.

¢ Perform an oral examination.

¢ Refer all diabetes patients without a dental provider, regardless of oral findings or complaints, to a dentist for preventive care.

Glycemic control is probably the single most important component in maintenance of good oral health in individuals with diabetes, attention to all these steps will be very helpful toward achieving improved overall oral and systemic health. So, the diabetes patient should know these things next time they consult a dentist and proper communication can benefit them with good treatment outcomes. As quoted by someone ‘mouth is a mirror of diseases’, oral manifestations may point to many underlying systemic pathologies. Make routine dental care a habit and be stringent in keeping the oral cavity healthy using brushing and flossing daily. Let the healthy smile stay with you forever!!!

Myth 10: My dentist fools me by asking me to get my teeth cleaned every summer and winter, I will not pay next time

35

References

1. Diabetes - a global threat. Lancet. 2009;373(9677):1735.

2. World Health Organization. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Geneva: World

Health Organization; 2009.

3. Moore PA, Zgibor JC, Dasanayake AP. Diabetes: a growing epidemic of all ages. J Am Dent Assoc.2003;134 Spec No:11S-15S.

4. Jain S, Saraf S. Type 2 diabetes mellitus - Its global prevalence and therapeutic strategies. Diabetes Metab Syndr. 2010;4(1):48-56.

5. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the expert committee on the diagnosis and

classification of diabetes mellitus. Diabetes Care. 2003;26 Suppl 1:S5-20.

6. Bell G, Large DM, Barclay SC. Oral health care in diabetes mellitus. Dent Update. 1999;26(8):32-8, 330.

7. Baldwin E. Oral health. Lancet. 2009;373(9664):628-9.

Lifestyle Modifications: Exercise

ExpertOpinion

Dr KK Aggarwal

MBBS, MD

President Heart Care Foundation of IndiaNew Delhi

The American Diabetes Association (ADA) recommendations suggest that a wide range of activities inclusive of yoga can have

significant impacts on A1c, flexibility, muscle strength and balance. Flexibility and balance are especially significant in older adults with diabetes to maintain range of motion, strength and balance.

Yoga is a lifestyle, a Vedic philosophy.

Yoga and Diabetes

¢ Yama: Don'ts

¢ Niyama: Do's

¢ Asana: Postures

¢ Pranayama: Parasympathetic breathing

¢ Pratyahara: Withdrawal of senses

¢ Dharna: Focussing

¢ Dhyan: Contemplation

¢ Samadhi: Being absorbed in the consciousness (Transcend)

ADA RECOMMENDATION

Flexibility training and balance training are

recommended 2-3 times/week for older adults with diabetes. Yoga may be included based on

individual preferences to increase flexibility,

muscular strength and balance.

8 LIMBS OF YOGA AS DESCRIBED BY PATANJALI

Stress and diabetes

Long-term stress can cause long-term high blood glucose levels. Yoga is a shift of stress from sympathetic to parasympathetic mode.

YAMA

¢ Ahimsa in mind, thoughts and action

¢ Brahmacharya: living a disciplined life

¢ Satya: being truthful to ourselves about diet

¢ Asatya: not stealing (white sugar, white rice and white

maida)

¢ Aparigraha: avoid accumulating food materials which

are not diabetes friendly

NIYAMA

¢ Tapas: regular exercise

¢ Santosha: living with contentment

¢ Shaucha: internal and external hygiene especially foot

hygiene

¢ Ishvara Pranidhana: dedication, devotion and surrender

¢ Svadhyaya: shift your consciousness to shift from

sympathetic to parasympathetic mode

36

ASANAS

Any posture which stimulate

manipur chakras in your body

(parasympathetic and sympathetic ganglion)

Yogic stretches at celiac plexus Pranayama is slower and

deeper breathing with reduced

respiratory rate

YOGA DOES NOT CURE DIABETES!

Reduces weight(even 5% reduction is important)

Better HbA1c control

(Yama & Niyama)

Increases immunity (shift from sympathetic to parasympathetic

mode)

37

Fruit of the Month: Elephant Apple

Apple

The fibers in apples helps in stabilizing blood sugar levels, it may improve insulin sensitivity and reduce insulin resistance

and may also prevent type 2 diabetes.

Elephant apple

Finds a mention in Ganesha shloka, it has antidiabetic properties.

“Gajananam Bhoota Ganadi Sevitam,

Kapittha Jambuphalasarabhakshitam;

Umasutam Shooka Vinasha Karanam;

Namami Vighneswara pada pankajam.”

“Oh Elephant-faced, worshipped by the existing beings, of all living beings,

tasting the elephant apple (kaith) and jambolana (Jamun), the son of Uma,

destroyer of grief, I bow to the lotus feet of Ganesha who is lord of all.”

Evergreen large shrub, with fragrant flowers or leaves.

Fruit pulp is sour and used in Indian cuisine in jams, curries

and jellies.

It has different properties like

wound healing, diabetes and bone fracture, in cuts and burns,

abdominal pains.

Lifestyle Modifications: Diet

38

NUTRITIONAL VALUE OF ELEPHANT APPLE

Carbohydrates Tannins Flavonoids and triterpenoids Betulinic acid, sitosterol and stigmasterol

Elephant apple potentiates the

insulin effect.

It increases the pancreatic

secretion of insulin from cells of

islet of Langerhans.

Elephant apple causes significant

reduction in blood glucose level in patients with diabetes.

39

This is a quick recipe incorporating the goodness of pineapple, cucumber and mango mixed with lime juice and chilli powder in a spicy Mexican-inspired fruit salad.

Ingredients needed

¢ One fresh pineapple (peeled, cored and chopped)

¢ Sliced strawberries (2 cups)

¢ Large cucumber, peeled and diced (1)

¢ Mango, peeled and diced (1)

¢ Lemon (1 juiced)

¢ Chilli powder with lime (1 pinch/to taste)

Method

Step 1: Combine pineapple, strawberries, cucumber and mango in a bowl.

Step 2: Add lemon juice and mix well.

Step 3: Sprinkle chili powder over the top and stir.

Step 4: Top salad with more chili powder.

Recipe of the month: Mexican-inspired fruit salad

NUTRITION VALUE PER SERVING

Energy: 116 cal Protein: 1.6 g

Fat: 0.5 g

Carbohydrates: 30.7 g

Cholesterol: 0 mg

Fiber: 4.4 g

Sodium: 5 mg

Source: Shircliff A. Mexican-inspired fruit salad.allrecipes.com

40

NDEP Best Practices

Dr G Kiran opined that it is very important to encourage and make the diabetes educators feel that they are vital in executing the basic fundamental principles of managing diabetes.

At his Diabetes Care and Research Institute” the educators are integral part of physician-patient communication raising awareness among patients about the following:

The medicines prescribed to control

blood sugar, pressure and cholesterol

are not by choice they are to be

considered as life-saving drugs.

The responsibility of establishing

proper communication and developing

trust to erase the burden of myths

about diabetes rests majorly on the

shoulders of the Diabetes Educator.

Patients on insulin need supervision on

injection techniques every visit.

Education on hypoglycemia prevention and management

Self-monitoring of blood glucose and documentation

Utilizing patient's time to raise awareness about diabetes, while they

are waiting for their appointment.

Dr Kiran fully supports the NDEP program stating that at his clinic, he tries to make proper use of the diabetes educators for guarding

patient health and improving clinical practice.

ExpertOpinion

Dr G Kiran

MBBS, MD

Managing Director and Senior Consultant, Diabetes Clinic and Research Institute, Hyderabad

41

Conference Highlights

2019 DIABETES IN INDIAN COUNTRY CONFERENCE

Date: August 6-9, 2019

Location: Cox Convention Center, 1 Myriad Gardens, Oklahoma City, USA

Workshop categories include

¢ Clinical

¢ Nutrition

¢ Diabetes Education

¢ Physical Activity

¢ Trauma Informed Approaches

¢ Data

The participants will:

¢ LEARN the latest information and earn CME/CE credits

¢ NETWORK with other grantees and clinicians

¢ SHARE best practices

¢ SHOWCASE successful work in American Indian and Alaska Native communities

Target audience

The Indian Health Service (IHS), Tribal and Urban Clinicians; Community Health Providers and Special Diabetes Program for Indians (SDPI) grantees

Link: http://www.cvent.com/events/2019-diabetes-in-indian-country-conference/event-summary-42992398ac

534edc9936ded9e6857ef1.aspx

42

43

Diabetes Quiz

Which of the following will probably NOT cause a diabetes emergency in a patient with a history of diabetes controlled by medication?

¢ Eating a regularly scheduled meal

¢ Unusual exercise or fatigue

¢ Overeating

¢ Infection

Which of the following is a common sign or symptom of a patient experiencing a diabetes emergency?

¢ Slow pulse

¢ Pale, clammy skin

¢ Elevated blood pressure

¢ Decreased respiratory rate

Diabetic coma is life-threatening condition that results in:

¢ Hyperglycemia

¢ Ketoacidosis

¢ Dehydration

¢ All of the above

Answers

Eating a regularly scheduled meal

All of the above

Pale, clammy skin

Q-1

Q-2

Q-3

44

Checklist for Emergencies in Diabetes

Prepare an easy to carry, insulated and waterproof diabetes emergency checklist for emergencies in diabetes.

A range of symptoms including dizziness, shakiness, pale coloring, hunger, nervousness, nausea, irrational behavior, confusion, personality change crying, sweating, headache, blurry vision, sluggishness, poor coordination and light-headedHYPOGLYCEMIA

Blood glucose <70 mg/dL

Can be caused by too much insulin and not enough glucose in the bloodstream

At the onset of any symptoms, test blood sugar

Treat low blood sugar immediately

If blood sugar returns to normal, let the patient eat

HYPERGLYCEMIA

Blood glucose >200 mg/dL

Can be caused by not enough insulin, too much food, illness, inactivity or stress

Assortment of symptoms include: frequent urination, increased thirst and hunger, lethargy, blurry vision, abdominal pain, nausea and confusion

Treat high blood sugar immediately

Check for ketones if blood sugar is 240 mg/dL

Do not exercise

At the onset of any symptoms, test blood sugar

45

Disclaimer: Although great care has been taken in compiling and checking the information given herein to ensure that it is accurate, the publisher shall not be in no way directly or indirectly responsible for any error, omissions or inaccuracy in this publication whether arising from negligence or otherwise. IJCP Publications Ltd. does not guarantee, directly or indirectly, the quality or efficacy of the product or service described in the advertisements or other material which is commercial in nature in this publication.

Copyright 2019 IJCP Publications Ltd. All rights reserved.

The copyright for all the editorial material contained in this book Indian Diabetes Educator Journal, Issue No. 50, May 2019, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

This book is Published and Edited by IJCP Academy of CME at Regd. Office: E-219, Greater Kailash Part - 1, New Delhi - 110048. E-mail: [email protected], Website: www.ijcpgroup.com, HIP/IN/Mumbai/2439 as a part of its social commitment towards upgrading the knowledge of Indian doctors.

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