1 time in india - ijcp grouphealth professionals' conduct, sensational headlines about failed,...

*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t

To keep the members ofdiabetes care team abreast with

DSME and DSMS concepts

st 1 time in India

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Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of people with diabetes. This Journal intends to empower your clinic

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

opinions expressed in this journal of selected sections are solely those of the original contributors. Every effort is

made to ensure the accuracy of information but Hansa Medcell or USV Private Limited will not be held responsible for any inadvertent

error(s). Professional are requested to use and apply their own professional judgement, experience and training and should not

rely solely on the information contained in this publication before prescribing any diet, exercise and medication.

Hansa Medcell or USV Private Limited assumes no responsibility or liability for personal or the injury,

loss or damage that may result from suggestions or information in this book.

USV as your reliable health care partner, believes in supporting your endeavor to make India the Diabetes

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 and has successfully completed 4 years. IDEJ

is developed with the aim of keeping the members of diabetes care team abreast with concepts of Diabetes

Self-Management Education/Support (DSME/S). IDEJ has set a new benchmark in educating the diabetes

educator about the evolving concept of DSME/S, reaching to more than 8,000 doctors with hard copies and

more than 25,000 doctors and diabetes educators digitally.

July 1 is celebrated as Doctor's day and we at IDEJ pay tribute to our healers for their unmatched service to the

society. Type 2 diabetes treatment is usually started with oral hypoglycemic agents, but with time and the

progression of the disease, the need for insulin becomes unavoidable. In this issue of IDEJ, we talk about

various aspects of insulin therapy in diabetes patients; changeover to insulin therapy, insulin use in children

and adolescents, use of insulin pumps in elderly diabetes patients, challenges faced in effective insulin

therapy, use of insulin along with other oral agents and self-management of blood sugar while a patient is on

insulin.

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”. Sincere Regards,

Expert Contributors of the MonthExpert Contributors of the Month

Dr Santosh Kumar Singh

MBBS (WB), MD (PAT), DM (BHU)

Endocrinologist and DiabetologistPatna, Bihar

Dr Anjali Bhatt

MBBS, MD (Med), MSc (Endocrine)

Consultant Endocrinologist Endoclinic, Pune, Maharashtra

Dr G Prakash

MBBS, MD (General Medicine), D Diab

Chennai, Tamil Nadu

Dr Shivaprasad KS

MBBS, MD, DM (Endocrinology)

Consultant - Endocrinology, Mazumdar Shaw Medical Center, Bengaluru, Karnataka

Dr Sameer Aggarwal

MBBS, DM-Endocrinology (AIIMS), New Delhi

Vice President-RSSDI Haryana; Head-Endocrinology and Metabolism, Apex Plus Super Speciality Hospital, Rohtak, Haryana

Dr Vinod K Abhichandani

MBBS, MD

Diabetes and Endocrine PhysicianRamanand Clinic and Bodyline Hospital Ahmedabad, Gujarat

Dr Pradeep G Talwalkar

MD (Bom), FICA, FICP

Consulting Diabetologist, Panel Consultant-Air India and ONGC; Honorary Consultant, Shushrusha and Dhanwantari Hospital, Mumbai, Maharashtra

Dr Jugal Gada

MBBS, MD (Med), DM (Endocrinology), SCE (Royal Challenge of Physicians, UK)

HormoEnCore Clinic, Mumbai, Maharashtra

Dr Ankit Srivastava

MBBS, MD-Medicine & DM-Endocrinology (IPGMER&R, Kolkata), Fellow (ACE)

Head, Dept. of Endocrinology and Metabolism Medanta-ARAM Hospital, Ranchi, Jharkhand

Dr ML Balamurugan

MBBS, C Diab (Australia), PG Dip in Diab

Consultant Family Physician and Diabetologist, Sri Raghavendra Nursing Home; Joint Managing Director, Trichy Diabetes Sepciality Centre (P) Ltd, Trichy, Tamil Nadu

Dr Manjunath Goroshi

MBBS, MD, DM in Endocrinology (KEM Hospital, Mumbai)

Consultant Endocrinologist, KLES, Belagavi and Goroshi Clinic, Belagavi, Maharashtra

Table of Content

01

04

07

10

13

19

16

Cover Story: Doctor's Day – A Day to Celebrate Healers of Humanity


When to Initiate Insulin Therapy in Type 2 Diabetes Mellitus

Dr Sameer Aggarwal

Insulin with Other Oral Agents


Use of Insulin Therapy in Adolescents

Dr Ankit Srivastava

Different Forms of Insulin Delivery System


Barriers to Insulin Therapy

Dr Jugal Gada

Transitioning to Insulin Therapy

Dr G Prakash

27Older Adults and Insulin Pump Therapy

Dr Shivaprasad KS

29Self-care Behavior and Insulin Therapy

Dr Anjali Bhatt

22Relationship Between Insulin Therapy, Weight Gain and Hypoglycemia


32Lifestyle Modification: Exercise

37Conference Highlights

38Diabetes Quiz

39Use and Care of Disposable Insulin Injections

33Lifestyle Modification: Diet

36NDEP Best Practices

Dr ML Balamurugan

1

COVER STORY:Doctor's Day – A Day to Celebrate Healers of Humanity

ExpertOpinion


MD (Bom), FICA, FICP

Consulting DiabetologistPanel Consultant-Air India and ONGC; Honorary Consultant, Shushrusha and Dhanwantari Hospital, MumbaiMaharashtra

National Doctor's Day is celebrated every year on July 1. This day is especially marked to

recognize and celebrate the contributions of the doctors towards the society. In India, the day is

also marked as the birth and death anniversary of one of the greatest doctors of the country,

Bharat Ratna, Dr Bidhan Chandra Roy. We may have marked one day on our calendars to pay

homage to the doctors, but the doctors make relentless efforts towards achieving the goal of affordable, good quality treatment to all and finding cure for all diseases, which continue to

baffle humanity. Doctors are instrumental in working with other health care professionals towards realizing the aspirations of medicine to become the most humane of the sciences. We acknowledge the massive

contribution by generations of doctors in alleviating suffering over the centuries through better science and treatments, which

started as early as 16th century.

“Medicines cure diseases, but only doctors can cure patients!”—Carl Jung

Changing lives!

Even though the common perception is that the doctors save lives, but their importance in the lives of patients goes far beyond that. They also make a difference by helping patients lead a better quality of life. A patient's ability to enjoy life, even if they can't be

cured, makes a huge difference to them and to their families. It is the doctor who plays a crucial role in educating and helping a diabetes patient to live a fulfilling and normal life with diabetes.

2

Winning the trust of the patients

The patient-doctor relationship and partnership are pivotal therapeutic relationship in

medicine. Patients do not necessarily want more drugs or more interventions from their

doctors, but they want a partnership with their doctor in which they feel at ease to discuss

their concerns and treatment options that fit into the context of their lives. In a diabetes patient, it is important that the doctor understands the patient's preference of treatment and base their judgments on their medical intuition as well as the patient's choice.

Patients need to tell their story in their own way to

the doctors and the doctors need to establish how

those problems are affecting the patient's life. This gives a perspective to the doctor whether the

problem first stated by the patient is the primary problem or merely an introduction to

something else that is in fact of greater importance to the doctor. The medical profession has evolved into “patient-centered” consultation, and this has enhanced the patient's

experience with their doctors enabling them to move their lives in a positive direction, where

they feel, they are being heard and they are cared for. This trust in the doctor gives the patient a better control of their symptoms and the doctor a better control of the outcome.

A doctor who communicates with their patient effectively are able to achieve higher levels of

adherence to the prescribed treatment.

Doctors and professionalism

In today's context, medical professionalism lies at the heart of

being a good doctor. The values that doctors embrace sets a

standard for what patients expects from their medical practitioners. The practice of medicine is uniquely identified by

the need for quick judgment in the face of uncertainty. Doctors end up taking responsibilities for these judgments and their

consequences. It can be said that a doctor's up-to-date knowledge and skill offers the explicit scientific and often tacit

experiential basis for these judgments for patient's life, but medicine is marked with so much unpredictability that doctors are required to use their wisdom as well as technical ability in

making such judgments. This makes them vulnerable towards the charge that their decisions are neither transparent nor accountable.

The medical professionalism of the doctors has been defined as a set of values, behaviors and relationships that underpin the trust

that public has in doctors.

3

Is this the best time for the medical profession?

Even though doctors play a significant role in delivering the findings of science to patients in a variety of health care settings; yet we are living in an era of frequent public inquiries into

health professionals' conduct, sensational headlines about failed, inadequate or unethical care, constant surveillance of performance and outcomes, violence against doctors and growing criticism from user groups and patients. It is the need of the day that the new age

doctors acquire skills-based education to be able to offer compassionate care; have excellent support systems to avoid doctor burn-out and clinical supervision. Doctors also need to appreciate the links between people's lifestyles, their domestic, cultural and social

circumstances and their illness by looking only at the biological changes within the body.

References

1. Working Party of the Royal College of Physicians. Doctors in society. Medical professionalism in a changing world. Clin Med

(Lond). 2005;5(6 Suppl 1):S5-40.

2. Nolan P. Time for humanity from doctors towards patients. Postgrad Med J. 2003;79(938):667-8.

4

When to Initiate Insulin Therapy in Type 2 Diabetes Mellitus

ExpertOpinion

Dr Sameer Aggarwal

MBBS, DM-Endocrinology (AIIMS), New Delhi

Vice President-RSSDI Haryana; Head-Endocrinology and Metabolism, Apex Plus Super Speciality Hospital, Rohtak, Haryana

Goals of Insulin therapy

TO ACHIEVE OPTIMAL GLYCEMIC CONTROL

Type 2 diabetes is a progressive disease and many patients eventually require and benefit from insulin therapy. Research has

shown that early and aggressive intervention to lower blood glucose reduces the risk of complications of the disease.

Patients with extreme hyperglycemia (fasting plasma glucose [FPG] >250 mg/dL,

random plasma glucose >300 mg/dL and

A1c >10%).

Presence of ketonuria or symptomatic diabetes with polyuria, polydipsia and

weight loss.

Patients on maximal doses of available combinations of oral antidiabetic agents

who do not meet glycemic targets.

INITIATE INSULIN THERAPY

Insulin resistance, usually as a consequence of obesity, is a major factor in the development of type 2 diabetes, but it is progressive

-cell failure that leads to worsening of hyperglycemia over time.

5

The stepwise approach

Traditionally, there has been a stepwise introduction of glucose-lowering interventions, with the final “step” of insulin therapy

being administered 10-15 years after diagnosis. The drawback of this stepwise approach is that the introduction of successive interventions after treatment failure is often delayed, exposing

patients to many years of uncontrolled hyperglycemia.

Clinicians recommend stepwise diabetes treatment, provided

that “an A1c of ≥7.0% serves as a call to act to initiate or change

therapy.”

ADA RECOMMENDATION FOR INSULIN THERAPY

The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present or when A1c

levels (>10%) or blood glucose levels (≥300 mg/dL) are very high.

Initiating insulin

Insulin should be initiated when glycemic goals are not attained after 2-3 months of maximally dosed dual oral therapy. For patients intolerant to

one or more oral glucose-lowering agents and who do not achieve glycemic

control with oral monotherapy, as well as those with a personal preference,

earlier initiation of insulin is indicated. Various studies including INSIGHT trial

has shown that treatment satisfaction is improved as well as quality of life for type 2 diabetes patients who had started using insulin.

Insulin therapy may be initiated as an augmentation, starting at 0.3 unit/kg or as

replacement, starting at 0.6-1.0 unit/kg.

Augmentation therapy can include basal or bolus insulin.

When using replacement therapy, 50% of the total daily insulin dose is given as basal, and 50% as bolus, divided

up before breakfast, lunch and dinner.

Replacement therapy includes basal-bolus insulin and correction or premixed insulin.

6

Early intensive insulin therapy

Lowering glycemia has been shown to improve insulin resistance as well as endogenous insulin secretion. It has also been suggested that a brief course of insulin therapy in subjects

with newly diagnosed type 2 diabetes not only restored, but also maintained, -cell function,

resulting in prolonged glycemic remission.

Evidence suggests that early intensive therapy may slow the progression of diabetes and

reduce the risk for long-term complications through preservation of remaining -cell

function. The Diabetes Control and Complications Trial (DCCT) showed that compared with conventional insulin therapy, intensive insulin therapy lowered A1c levels by 1.8% points

and reduced the risk for microvascular complications.

References

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

2. Pearson TL. Initiating insulin in the type 2 diabetes patient. Medscape Diabetes & Endocrinology. Available at: https://www.

medscape.org/viewarticle/567952

3. Swinnen SG, Hoekstra JB, DeVries JH. Insulin therapy for type 2 diabetes. Diabetes Care. 2009;32(Suppl 2):S253-9.

4. Petznick A. Insulin management of type 2 diabetes mellitus. Am Fam Physician. 2011;84(2):183-90.

The role of a diabetes educator

¢ Regularly and objectively explain to the patient, the progressive nature of type 2 diabetes.

¢ Avoid using insulin as a threat or describe it as a sign of personal failure or punishment.

¢ Educate and involve patients in insulin management.

7

Transitioning to Insulin Therapy

ExpertOpinion

Dr G Prakash

MBBS, MD (General Medicine), D Diab

Chennai, Tamil Nadu

Although oral antidiabetic medications initially may be effective for controlling hyperglycemia, these agents often fail to maintain

adequate glycemic control as the disease progresses making the need for insulin mandatory in most patients. The uncertainty about

how best to make the transition from oral therapy to insulin is one of the reasons for the typically long delay in starting insulin for

patients with type 2 diabetes mellitus.

Studies have shown that when appropriate glycemic targets are sought, with systematic titration of insulin dosage, several methods

of beginning insulin may be successful. It has been suggested that either starting with a single injection of basal insulin or premix insulin or starting with 3 injections of short-acting insulin before each meal with basal insulin at bedtime are effective in secondary

oral drug failure. Studies also suggest that continuing oral therapies and adding insulin may improve glycemic control in

uncontrolled hyperglycemia.

Understanding the need for insulin therapy

The dual defect of gradual decline in insulin secretion and insulin resistance are present at the onset of disease in those destined to have type 2

diabetes. While insulin resistance generally remains constant throughout the course of the

disease, the -cells of the pancreas gradually

becomes unable to secrete enough insulin to

overcome the degree of insulin resistance. As

pancreatic -cell function progressively deterio-

rates, some degree of absolute insulin deficiency develops, resulting in chronic hyperglycemia. This leads to essentially all patients who develop

type 2 diabetes eventually having reduced levels of insulin secretion.

FFA: Free fatty acid; TNF-: Tumor necrosis factor-; GLUT4: Glucose transporter isoform 4.

8

INSULIN REGIMENS

Basal insulin: Most convenient initial insulin regimen; can be added to metformin and other oral agents.

The starting doses can be estimated based on body weight and the degree of hyperglycemia, with

individualized titration over days to weeks as needed.

Prandial insulin: Individuals with type 2 diabetes may require doses of insulin before meals in addition

to basal insulin. The recommended starting dose of mealtime insulin is either 4 units or 10% of the basal

dose at each meal. Titration is done based on home glucose monitoring or A1c. With significant additions to the prandial insulin dose, particularly with the evening meal, consideration should be given to

decreasing the basal insulin dose.

Premixed insulin: Premixed insulin contains both a basal and prandial component, allowing coverage of

both basal and prandial needs with a single injection. The NPH/Regular premix is composed of 70% NPH

insulin and 30% regular insulin.

Approach to insulin therapy

Starting with a single injection of insulin to control basal glycemia while continuing oral therapy is the simplest approach, and lends

itself to stepwise addition of mealtime injections as needed to bring most patients to glycemic targets in a logical and practical way.

The initial dosage of insulin is individualized based on the patient's insulin sensitivity. Insulin therapy may be started with a set dosage, such as 10 units of basal insulin daily or by using weight-based equations. When using replacement therapy, 50% of the

total daily insulin dose is given as basal and 50% as bolus, divided up before breakfast, lunch and dinner.

Titration of insulin over time is critical to improving glycemic control and preventing diabetes-related complications. Fasting glucose readings are used to titrate basal insulin, whereas both preprandial and postprandial glucose readings are used to titrate mealtime

insulin. Physicians may increase or decrease basal and/or bolus insulin by 10% based on the patient's home glucose readings.

9

Intensification of insulin therapy

Switching therapies between intravenous and subcutaneous insulin

Therapy should always be intensified when it fails to maintain glycemic control to an A1c <7.0% as per American Diabetes

Association (ADA) recommendations. When adequate glycemic control is not achieved in patients who already are receiving optimum dosages to current oral antidiabetic medications, either another oral antidiabetic agent should be added to the therapeutic regimen or insulin should be initiated. No more than 3 months should be allowed to elapse without modifying the therapeutic

regimen of patients who are not meeting glycemic targets.

A study published in Diabetes Care has shown that in critically ill patients with diabetes or

hyperglycemia who are admitted to intensive care units (ICU), intravenous infusion of insulin

is the recommended treatment. During the post-acute phase, many guidelines and

recommendations suggest switching to subcutaneous insulin when patients begin eating regular meals and are moved to a lower-intensity care setting.

References

1. Riddle MC. Making the transition from oral to insulin therapy. Am J Med. 2005;118 Suppl 5A:14S-20S.

2. Avanzini F, Marelli G, Donzelli W, et al. Transition from intravenous to subcutaneous insulin. Diabetes Care. 2011;34(7):1445-50.

3. A timely transition to insulin: identifying type 2 diabetes patients failing oral therapy. Formualry. 2005;40:114-30.



6. Pearson TL. Initiating insulin in the type 2 diabetes patient. Medscape Diabetes & Endocrinology. Available at:

https://www.medscape.org/viewarticle/567952



¢ Educate patients regarding self-monitoring of blood glucose and diet.

¢ Educate patients using insulin about avoidance and treatment of hypoglycemia.

10

Insulin with Other Oral Agents

Introduction

The rationale for combining insulin with oral therapy is minimization of the adverse effects of insulin treatment

(hypoglycemia and weight gain). If basal insulin has been titrated to an acceptable fasting blood glucose level (or if the dose is >0.5 units/kg/day) and A1c remains above target,

then the recommendation is to consider advancing the treatment to combination injectable therapy.

Combination injectable therapy with insulin sensitizers

Insulin sensitizers have been proven safe and effective when combined with insulin

therapy. Combination of insulin with metformin is indeed associated with better glycemic control fewer hypoglycemic events and less weight gain than treatment with insulin alone.

If the patients have no intolerable side effects, metformin should be continued when

patients are initiated on insulin therapy. The advantage of such a combined therapy is reduced insulin dose requirements, easier dose titration and improved compliance.

Metformin is usually continued indefinitely after the patient starts insulin therapy because it

reduces cardiovascular risk in overweight patients with type 2 diabetes.

Thiazolidinediones improve insulin sensitivity but may increase weight gain, fluid retention and risk of congestive heart failure

when combined with insulin. Thiazolidinediones also have not been shown to reduce macrovascular complications or all-cause mortality.

Combination injectable therapy with insulin secretagogues

Insulin secretagogues such as sulfonylureas and glitinides can be combined with insulin, especially when only basal augmentation is being used. Usually, by the time insulin is required for meals, insulin secretagogues are not effective or necessary.

Although other sulfonylureas are used with insulin, glimepiride is the only sulfonylurea approved by US FDA for use in combination with insulin. The only consistent benefit of such

therapy is reduced insulin dose requirements, which may result in less daily injections, easier dose titrations and improved compliance.

ExpertOpinion


MBBS (WB), MD (PAT), DM (BHU)

Endocrinologist and Diabetologist Patna, Bihar

11

Combination injectable therapy with incretin therapies

Incretin therapies include dipeptidyl-peptidase IV inhibitors and glucagon-like peptide-1 (GLP-1) agonists.

A GLP-1 receptor agonist can be added to basal insulin or multiple doses of

insulin. The combination of basal insulin and GLP-1 receptor agonist has

potent glucose-lowering actions and less weight gain and hypoglycemia compared with intensified insulin regimens. Two different once-daily fixed

dual combination products containing basal insulin plus a GLP-1 receptor

agonist are available.

Modern day sulfonylurea like glimepiride can be added with insulin therapy as per a study published in Vascular Health and Risk

Management in 2012.

PRACTICE SUTRA

Once a basal/bolus insulin regimen is initiated, dose titration is important, with adjustments made in both

mealtime and basal insulins based on the blood glucose levels and an understanding of the

pharmacodynamic profile of each formulation.

After the diabetes is controlled, the patient may be weaned off of oral medications.

Oral medications should not be abruptly discontinued when starting insulin therapy because of the risk of

rebound hyperglycemia.

To maximize benefit without causing significant adverse effects, it is important to consider the

mechanism of action for different therapies.

12

References




4. Basit A, Riaz M, Fawwad A. Glimepiride: evidence-based facts, trends and observations. Vasc Health Risk Manag. 2012;8:463-72.


¢ Inform the patient about the actions of insulin, the impact of food and physical activity on blood glucose.

¢ Make patient aware about the importance of self-monitoring of blood glucose and the importance of overall blood glucose control.

13

Use of Insulin Therapy in Adolescents

ExpertOpinion

Dr Ankit Srivastava

MBBS, MD-Medicine & DM-Endocrinology (IPGMER&R, Kolkata), Fellow (ACE)

Head, Dept. of Endocrinology and Metabolism, Medanta-ARAM Hospital Ranchi, Jharkhand

Introduction

India is among the top 3 nations with the largest incidence and prevalence of children with type 1 diabetes under both

age groups below 15 years and below 20 years. Type 2 diabetes is most commonly seen in older adults, but it is

increasingly seen in children, adolescents and younger adults due

to rising levels of obesity, physical inactivity and poor diet.

In countries where there is limited access to insulin and inadequate

health service provision, children and adolescents with limited

access to insulin suffer terrible complications and early mortality.

Type 2 diabetes in the young

Glycemic control

Type 2 diabetes in youth has some unique features like a more rapid decline in -cell function and an enhanced development of

diabetes complications. Type 2 diabetes also leaves a negative impact on youths of ethnic and racial minorities and can even occur

in complex psychosocial and cultural environments. This makes it difficult for these youngsters to sustain healthy lifestyle changes and self-management behaviors. Obesity, family history of diabetes, female sex and low socioeconomic status.

A reasonable A1c target for most children and adolescents with type 2 diabetes treated with oral hypoglycemic agents alone is <7%. Stricter A1c targets such as (<6.5%) may be individualized in patients, if the patient can endure it without significant hypoglycemia or other adverse effects of treatment.

A1c targets for patients on insulin should be customized, considering the relatively low rates of hypoglycemia in youth-onset type 2 diabetes. A lower target A1c in youth with type 2

diabetes is justified by lower risk of hypoglycemia and higher risk of complications.

14

INSULIN THERAPY IN YOUTH

¢ The majority of children and adolescents with type 1 diabetes should be treated with intensive insulin regimens, either

via multiple daily injections or continuous subcutaneous insulin infusion.

¢ An A1c target of <7.5% should be considered in children and adolescents with type 1 diabetes but should be

individualized based on the needs and situation of the patient and family.

Source: American Diabetes Association. Standards of Medical Care in Diabetes-2019.

¢ Initial basal insulin treatment in youth with marked hyperglycemia (blood glucose ≥250 mg/dL), A1c ≥8.5% without acidosis are diagnosis who are symptomatic with polyuria, polydipsia, nocturia and/or weight loss.

¢ In patients with ketosis or ketoacidosis, treatment with subcutaneous or intravenous insulin should be initiated to rapidly correct the hyperglycemia and the metabolic derangement.

¢ Subcutaneous insulin therapy should be continued while metformin is initiated when the acidosis is resolved.

¢ Basal insulin therapy is also recommended, if the A1c target is not met with metformin monotherapy.

¢ Multiple daily injections with basal and preleam bolus insulins is recommended, if patients on basal insulin (up to 1.5

units/kg/day) are unable to meet the target A1c level.

¢ In patients initially treated with metformin and insulin who are meeting glucose targets based on home blood glucose

monitoring, insulin can be tapered over 2-6 weeks by reducing the insulin dose 10-30% every few days.

1615

Current pharmacologic treatment options for youth-onset type 2 diabetes are limited to two approved drugs—insulin and

metformin. When ketoacidosis or ketosis is present, patient requires a period of insulin therapy until fasting and postprandial glycemia have been restored to normal or near-normal levels. Insulin therapy is also needed if there is metformin intolerance or

renal or hepatic insufficiency.

References

1. American Diabetes Association. Children and adolescents: Standard of Medical Care in Diabetes-2019. Diabetes Care.

2019;42(Suppl 1):S148-64.

2. NICE Guideline, No. 18. Education for children and young people with type 2 diabetes. 2015. National Collaborating Centre for

Women's and Children's Health (UK), London.


¢ Start educating children and young people with type 2 diabetes and their family members/carers from the time of diagnosis.

¢ Educate children and young people about the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control.

¢ The education program should be tailored to the needs of each child or young person with type 2 diabetes.

Different Forms of Insulin Delivery System

ExpertOpinion


MBBS, MD, DM in Endocrinology (KEM Hospital, Mumbai)

Consultant Endocrinologist KLES, Belagavi and Goroshi Clinic, Belagavi, Maharashtra

Introduction

Discovery of insulin was one of the greatest medical discoveries

of the last century. The newer methods of insulin delivery aim to deliver insulin with minimal

invasiveness in an accurate and precise manner and to reduce patient burden.

Insulin delivery system in use

Insulin can be administered subcutaneously through various methods such as vial and syringe, insulin pen and continuous

subcutaneous insulin infusion.

Vial and syringe

Conventional insulin administration involves subcutaneous injection with syringes marked in insulin units. Direct

subcutaneous insulin injections are still the most common form of

delivery, using a needle and syringe. The capacity of the syringe

selected depends on the dosage of insulin. Other factors such as

needle gauge and needle length, are also important and should be

adjusted for comfort. There are two color insulin syringes are

available, one is red which should be used for 40 IU/mL insulin and

orange one should be used for 100 IU/mL insulin. Interchange of syringes may lead to serious complications like hypoglycemia and

hyperglycemia.

Recently, an injection port has been designed known as i-Port Advance. It is the first device to combine an injection port and an inserter in one complete set that eliminates the need for multiple injections without the need to puncture the skin for each dose.

This device is helpful for the insulin requiring patients having needle phobia and helps them to achieve glycemic control effectively.

16

Insulin pen

To overcome the inconvenience and inaccuracy of insulin vials and syringes, insulin pens

were developed. The newer insulin pens are reusable, accurate and equipped with safety

features such as audible clicks with each dose to improve accuracy and reduce the chances of human errors. Insulin pens are more accurate, convenient, less painful and patient friendly

but come with increased cost compared to vial and syringe.

Recently, NovoPen Echo has been designed to give children and parents increased

confidence, it combines dosing in half-unit increments with a simple, easy-to-use, memory function. The newer pen needles are shorter and thinner, less painful and requires less thumb force and time to inject insulin resulting in improved patient satisfaction.

Continuous subcutaneous insulin infusion

The current generation of insulin pumps are more patient friendly as a result of smaller size and smart features such as built-in-dose calculators and alarms. However, this delivery

system is associated with higher cost, increased risk for subcutaneous infections,

inconvenience of being attached to a device, and theoretically a higher risk for diabetic ketoacidosis.

Sensor-augmented pump therapy

With the improvements in continuous glucose monitors (CGM), it has become possible to combine two technologies (pump and

CGM) in the management of diabetes. The new generations of CGMs are more accurate, smaller in size and shown to improve

glycemic control in patients with diabetes. Sensor-augmented pump requires patient involvement for using CGM glucose readings

to adjust insulin pump delivery. The drawbacks associated with sensor-augmented pumps are that they are susceptible to human errors and require patients to wake up to manage nocturnal hypoglycemia.

17

Novel approaches to deliver insulin

Implantable insulin pumps

Implantable insulin pumps are still under developmental phase. This type of pump will be small,

extremely discreet and of very little weight. It will be implanted surgically, and will deliver a continuous

basal dose of insulin and a bolus dose when required.

Inhaled insulin

The first inhaled product was a dry powder formulation available as 1 mg and 3 mg doses to be taken

with the help of an inhaler device. In clinical trials, it was shown that it could reduce postprandial blood

glucose and A1c significantly in patients with uncontrolled type 1 and type 2 diabetes.

Another device which is under Food and Drug Administration (FDA) approval is Afrezza in which the

onset of action of inhaled insulin is 15 minutes and duration of action is 2-3 hours. It is also ideal for postprandial blood glucose control. This device is currently under FDA approval process.


¢ Educate the patients about the interval between insulin injection and mealtime.

¢ Tell patients that it is important for those who use insulin to practice self-management of blood glucose.

¢ Teach patients how to correctly use their insulin devices.

References

1. Insulin delivery devices. Available at: https://www.diabetes.co.uk/insulin/Diabetes-and-insulin-delivery-devices.html

2. Shah RB, Patel M, Maahs DM, et al. Insulin delivery methods: Past, present and future. Int J Pharm Investig. 2016;6(1):1-9.

3. Al-Tabakha, MM, Arida AI. Recent challenges in insulin delivery systems: A review. Indian J Pharm Sci. 2008;70(3):278-86.

18

Barriers to Insulin Therapy

ExpertOpinion

Dr Jugal Gada

MBBS, MD (Med), DM (Endocrinology), SCE (Royal Challenge of Physicians, UK)

HormoEnCore Clinic Mumbai, Maharashtra

Introduction

The initial treatment of people with type 2 diabetes involves diet and oral glucose-lowering agents, but with time, many

people with type 2 diabetes require insulin therapy. The initiation of insulin therapy is a difficult transition for both people with type 2 diabetes and health care professionals.

The emergence of new several new insulin analogs and insulin delivery technologies has made insulin therapy safer, effective and more convenient than ever before. A big part of

the problem are the myths about insulin therapy that patient

and health professionals alike harbour and which act as barriers in insulin therapy. Insulin initiation has been generally

associated with negative emotions, fears, anxiety as well as a

personal failure in managing disease.

Obstacles to insulin therapy that can be overcome: Patients

Obstacles to insulin therapy that can be overcome: Health care professional

¢ Feelings of personal failure

¢ Needle anxiety

¢ Social embarassment and stigma

¢ Fear of weight gain

¢ Fear of hypoglycemia

¢ Fear of complications

¢ Perceived complexity of insulin regimes

¢ Cost

¢ Time-consuming to teach

¢ Lack of resources and support staff

¢ Fear of hypoglycemia

¢ Weight gain

¢ Patients may not adhere to complex regimen

Needle anxiety

Patients may associate injections with those that they have received in the past for other purposes. Various injection aids may ease administration of insulin as well as help reduce

patient anxiety and perception of pain by concealing the needle. Psychological counseling may also be effective in those who exhibit true needle phobia.

Studies have shown that various durable and refilled disposable insulin pens are available

which have demonstrated increased accuracy, efficacy, safety, patient preference and improved adherence to therapy.

19

Weight gain

If the patient being prescribed insulin is already overweight or obese, it can lead to further insulin resistance and poor glycemic control. Research studies have claimed that basal insulin analog, insulin detemir, is associated with less weight gain, compared with neutral

protamine Hagedorn (NPH) insulin.

According to the American Diabetes Association (ADA), metformin therapy should be

maintained while adding insulin as this may reduce weight gain. Dietary and exercise regimens can also help in reducing the anabolic effects of insulin on body weight.

Fear of hypoglycemia

This is the primary barrier which health care professionals come across while starting insulin

therapy. Even though the rate of severe hypoglycemia requiring medical intervention is relatively low in type 2 diabetes, still patients are afraid of hypoglycemia.

Insulin analogs mimic the actions of endogenous insulin and help in reducing the incidence

and severity of hypoglycemic events. Various studies have shown that insulin analogs -

rapid-acting and long-acting are associated with less hypoglycemia than human insulin.

Hypoglycemia can be prevented by understanding

the relationship between carbohydrate content and insulin and insulin dose needed, understanding the time-action profile of insulin

preparations, knowing when to inject and how to time meals and physical activity, and being

aware of potential drug interactions, including the effects of alcohol.

Insulin is a life sentence!

Insulin therapy is not always permanent in nature. Some people require short-term or temporary, insulin therapy when they take certain drugs such as steroids to treat other medical conditions. Generally, when the steroids are discontinued, the person no longer

requires insulin therapy. A management program of diet and exercise, based on self-blood glucose monitoring allows reduction in dosage and withdrawal of insulin without hospitalization.

20

Complexity of the insulin regimens

It is a common perception among patients and health care professionals that adhering to

complex insulin regimen will be too difficult and time consuming. Newer insulin regimens and pen devices decrease the complexity of insulin therapy. The 1-2-3 regimen, based on biphasic insulin as part 70/30, starts with a single daily injection and adds further injections

as needed.

Cost

Diabetes treatment can be expensive, especially for patients who have limited or no medical insurance coverage. The ADA treatment algorithm recommends initiation or intensification of insulin therapy over the use of 3 oral agents, based on both

effectiveness and cost.


¢ Make the patient aware that they may need insulin as a result of the natural course of the disease and not a failure on their part.

¢ Educators should tell patients that the complications are a result of the progressive disease and have nothing to do with the start of the insulin therapy.

¢ Explain to the patient that insulin injections now are relatively painless with smaller-diameter needles for ease of entry into the skin.

¢ Talk to the patient about the strategies for preventing hypoglycemia.

References

1. Cosson E, Mauchant C, Benabbad I, et al. Perceptions of insulin therapy in people with type 2 diabetes and physicians: a cross-

sectional survey conducted in France. Patient Prefer Adherence. 201;13:251-60.

2. Meece J. Overcoming barriers to insulin therapy. Pharmacy times. Available at: 2008; https://www.pharmacytimes.com/

publications/issue/2008/2008-10/2008-10-8703

3. Cohen M, Crosbie C, Cusworth L, et al. Insulin - not always a life sentence: withdrawal of insulin therapy in non-insulin dependent

diabetes. Diabetes Res. 1984;1(1):31-4.

4. Peragallo-Ditko V. Insulin therapy for type 2 diabetes. 2005. Available at: https://www.diabetesselfmanagement.com/managing-

diabetes/treatment-approaches/insulin-therapy-for-type-2-diabetes/

21

Relationship Between Insulin Therapy, Weight Gain and Hypoglycemia

ExpertOpinion


MBBS, MD

Diabetes and Endocrine Physician Ramanand Clinic and Bodyline Hospital Ahmedabad, Gujarat

Introduction

Insulin is the most potent therapeutic agent available since last hundred years to correct elevated blood glucose levels.

Everyone with type 1 diabetes needs insulin to stay alive, and millions of people diagnosed with type 2 diabetes world-over require insulin to control their blood glucose levels.

However, even insulin exerts side effects. One of the most

common concerns expressed by people who use insulin is

that it tends to cause weight gain. In fact, research from the United Kingdom Prospective Diabetes Study (UKPDS) showed that the average person with type 2 diabetes gained about 4 kg weight in his first 3 years of insulin use.

Insulin therapy has been shown to benefit the prognosis in patients with type 2 diabetes, but its initiation is often delayed owing to

concerns about hypoglycemia, weight gain and clinical inertia. Weight gain is a key player involved in the pathophysiology of type 2 diabetes and aggravates the overall risk for adverse cardiovascular outcomes.

Weight gain as a barrier to insulin therapy

The great benefits of insulin therapy are often undermined by weight gain. Weight gain becomes physiologically and psychologically

unacceptable especially in patients with diabetes most of whom are already overweight. The fear of weight gain with some

medications contributes to psychological insulin resistance, which in turn discourages these patients from accepting or adhering to

insulin therapy.

22

How does insulin lead to weight gain?

Does not weight gain make blood sugar harder to control?

Insulin is a hormone that promotes the uptake of sugar (glucose) by almost all of the body's cells, including muscle, liver and fat cells. At any given time, our cells are also utilizing glucose for fuel. If our caloric intake is greater than our energy expenditure, we tend to accumulate excess glucose in our body. Muscle and liver cells store this extra glucose in a form called “glycogen”. Fat cells store the

extra glucose as fat.

When our muscle, liver and fat cells are unable to take in all of the glucose from the food we eat, an unnatural form of weight loss

takes place. When blood glucose levels exceed a certain threshold, some of the excess glucose passes into the urine, which causes polyuria.

Once insulin therapy begins and blood glucose levels return to normal, the excess urination and loss of glucose through the urine

halts. Storage of our food in the form of fat or glycogen is resumed and our weight returns to a level that is appropriate for our food

intake and exercise patterns.

Yes, weight gain can induce insulin resistance, which may make it difficult to control blood sugars. But one has to look at the initial

weight gain as a temporary investment in a lifetime of better health.

Insulin

Cell

Blood sugar

23

HOW DOES INSULIN CAUSE WEIGHT GAIN? DOES-DEPENDENT EFFECTS

High doses:

¢ Induces differentiation of new adipocytes from precursors.

¢ Cross-agonist of insulin-like growth factor 1 (IGF-1) receptor leading to somatotropic changes, pseudo-acromegaloid

features.

¢ Hypoglycemia increased intake of rescue carbohydrates.

¢ Hypoglycemia induces surge in cortisol, human growth hormone and ghrelin.

¢ Often, high carbohydrate intake to prevent hypoglycemia.

Physiologic doses:

¢ Indices lipoprotein lipase expression and glucose uptake.

¢ Stimulates de novo biosynthesis of fatty acids and triglyceride.

¢ Increased uptake of carbs and fats into tissues.

Low doses:

¢ Suppresses glycosuria/polyuria.

¢ Suppresses ketoacidosis. Blocks muscle catabolism.

¢ Allows anabolic effects of resistance training/exercise.

Is there a solution?

Accept the fact that with insulin use and lower blood sugars, there is a tendency to put on some initial weight. So, how can one avoid

gaining too much weight? Here are few tips:

Avoid hypoglycemia

If a patient is experiencing any low blood sugars (typically defined as a blood glucose of <70 mg/dL), he must talk to his doctor about

possibility of cutting back on the insulin and certainly, avoid defensive snacking.

Not only do recurrent low blood sugars compel one to eat food that normally one would avoid, it also indicates that the patient is overinsulinized. Excess insulin will promote the build-up of fat stores and further weight gain.

24

Reduce doses whenever possible?

Cutting back on carbohydrate intake is one way to

accomplish this. Eliminating carbohydrate-containing drinks is a smart move. So, is cutting out between-meal

snacks. At mealtimes, one may reduce portions of carbohydrate-rich foods such as potatoes, rice, bread, pasta and cereal. One can increase portions of lean meats

and non-starchy vegetables. Physical activity can help

lower insulin requirements by improving insulin sensitivity.

High-carb diet

frequent eating sedentary lifestyle

High insulin

Low insulin

Low-carb diet

intermittent fasting exercise

Extra walking throughout the day may allow one to lower dose of long-acting (or “basal”)

insulin. Moderate exercise after meals may allow the patient to significantly reduce his rapid-acting mealtime (“bolus”) insulin. Health care team needs to be consulted for making appropriate dose adjustments.

Lifestyle, Lifestyle, Lifestyle

These happen to be the three most important words in diabetes management. Stress reduction, physical activity and healthy eating

all help us to lose weight. And weight loss, in turn, helps insulin to work better! When insulin works better, one's insulin needs go down, which helps to lose even more weight. One of the best ways to start on the road to a healthier lifestyle is to meet with a

registered dietitian or a qualified diabetes educator with expertise in both diabetes and weight management. Meal planning guidance and education has been shown to reduce insulin-related weight gain.

25

Choose medications wisely

The exact choice of insulin and oral medications along with weight loss interventions are important considerations in the overall management of patients with type 2 diabetes. When using a long-acting insulin, “basal” analog options such as degludec or levemir

tends to produce less weight gain than intermediate-acting insulin such as neutral protamine Hagedorn (NPH).

One of the major barriers to insulin therapy for type 2 diabetes patients is the fear of additional and unnecessary weight gain.

A healthy diet, vigorous and consistent exercise, and the use of insulin-sparing agents with insulin should reduce the problem of weight gain.


¢ How to use glucometer?

¢ Tips for best/easiest way to monitor.

¢ When to check your blood sugar?

¢ What the numbers mean?

¢ What to do if your numbers are off target?

¢ How to record your results and keep track over time?

References

1. NIDDK 2001-2003 National Health Interview Survey among adults with diabetes.

2. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood glucose control with sulphonylureas or insulin compared with

conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-53.

3. Van Gaal L, Scheen A. Weight management in type 2 diabetes: current and emerging approaches to treatment. Diabetes Care. 2015;

38(67:1161-72.

4. Hodish I. Insulin therapy, weight gain and prognosis. Diabetes Obes Metab. 2018;20(9):2085-92.

5. American Diabetes Association. Obesity management for the treatment of type 2 diabetes: Standards of Medical Care in Diabetes-

2019. Diabetes Care. 2019;42(Suppl 1):S81-9.

6. Monk A, Barry B, McClain K, et al; International Diabetes Center. Practice guidelines for medical nutrition therapy provided by

dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc. 1995;95(9):999-1006; quiz 10078.

26

Older Adults and Insulin Pump Therapy

ExpertOpinion

Dr Shivaprasad KS

MBBS, MD, DM (Endocrinology)

Consultant - Endocrinology, Mazumdar Shaw Medical Center, Bengaluru, Karnataka

Introduction

Insulin pumps are devices that deliver rapid-acting insulin

throughout the day to help manage blood glucose levels. Most insulin pumps use tubing to

deliver insulin through a cannula, while a few are attached directly to the skin, without tubing.

Elderly and insulin pumps

While using an insulin pump in an elderly patient, it is important for the health care team to assess patient needs and tailor therapy in

the context of age-related disabilities. Barriers to pump therapy include poor vision, dexterity and cognitive status. The indications for pump therapy include glucose variability, hypoglycemia and poor glycemic control with traditional insulin regimes.

Some of the concerns of the elderly while selecting an insulin pump are given below:

¢ Is it going to be too heavy for me?

¢ How will I remember, when to check my glucose and when to

inject a bolus dose?

¢ How will I know when to change the batteries?

¢ I have poor eyesight, can I read the screen properly, is it safe for me?

¢ If I forget that I have already taken a dose, will the pump help prevent me from injecting too much?

¢ I have arthritis and trouble using smaller devices. Will I be

able to use it properly?

¢ How will I know if the pump is operating properly?

¢ Some of these new pumps I hear about are technically very advanced, can I use something simple?

¢ Is it easy to purchase?

27

Efficacy of insulin pumps when used in elderly

Findings of a research study has reported that insulin delivery profiles do not differ considerably between younger and older individual. The study has concluded that the effectiveness and safety of insulin pump therapy is mostly equivalent in younger and

elderly diabetes patients.

The available pumps have features that can assist older patients in administering insulin such as audio blousing, remote controls,

beaming technology and insulin on board.


¢ Help the patient in making the best and most informed decision possible regarding the insulin pump.

¢ Teach the patient about the correct use of insulin pump.

References


2. Stephens EA, Heffner J. Evaluating older patients with diabetes for insulin pump therapy. Diabetes Technol Ther. 2010;12 Suppl 1:

S91-7.

3. Matejko B, Cyganek K, Katra B, et al. Insulin pump therapy is equally effective and safe in elderly and young type 1 diabetes patients.

Rev Diabet Stud. 2011;8(2):254-8.

4. Akers J, Setter SM. Insulin pump therapy in senior patients. Pharmacy Times. 2007. Available at: https://www.pharmacytimes.

com/publications/issue/2007/2007-05/2007-05-6475

28

Self-care Behavior and Insulin Therapy

ExpertOpinion

Dr Anjali Bhatt

MBBS, MD (Med), MSc (Endocrine)

Consultant EndocrinologistEndoclinic, Pune, Maharashtra

Introduction

Insulin therapy has been proven to be effective in management of type 2 diabetes. Self-management education

for adults with type 2 diabetes improves knowledge, skills and motivation to adhere to insulin therapy. Attitude and a sufficient level of knowledge are two of the most important

aspects of self-care. Neglect of self-care may lead to poor metabolic control in diabetes patients.

Is patient education of value?

A study reported that microlearning education focused on

survival skills, insulin injection technique and lifestyle management was able to significantly improve patient's attitudes

towards insulin and activation measures for self-care. In another

study, the COACH patient program was aimed at supporting and educating patients who were prescribed insulin glargine

30 U/mL. It was seen that patients who actively participated

in the COACH patient-support program showed improved adherence and persistence to the use of glargine.

Addressing the needs of the patients

It is important for the health care provider to continuously address the needs and demands of patients suffering with chronic disease like diabetes. Regular follow-up is important in averting any long-term complications. Studies conducted in India have shown that patients

show poor adherence to treatment regimens due to poor attitude towards the disease and poor health literacy among the general public. The use of home blood glucose monitors and

prevalent use of A1c as an indicator of metabolic control has contributed to self-care in diabetes and hence shifted more responsibility to the patient. In this context, another study

conducted in Scotland, has suggested that the role of health professionals is crucial in patient's understanding of their blood glucose fluctuations with appropriate self-care action.

29

Self-care in diabetes

The 7 self-care behaviors given below are useful for both clinicians and educators treating patients as well as for researchers evaluating new approaches to care. Self-report is by far

the most practical and cost-effective approach towards self-care assessment. Diabetes self-care needs the patient to make dietary and lifestyle modifications along with the support from the health care staff to maintain a higher level of self-confidence leading to a successful

behavior change.

7 ESSENTIAL SELF-CARE BEHAVIORS, WHICH PREDICTED GOOD OUTCOME

1. Healthy eating

2. Being physically active

3. Monitoring of blood glucose

4. Compliant with medications

5. Good problem-solving skills

6. Healthy coping skills

7. Risk-reduction behaviors

Compliance to self-care activities

Diabetes patients are required to follow a complex set of behavioral actions to care for their diabetes on a daily basis. These actions

include following a positive lifestyle behavior such as meal plan and appropriate physical activity; taking insulin or other medications when indicated; monitoring blood glucose levels; responding to and self-treating diabetes-related symptoms; following foot care guideline and seeking individually appropriate medical care for diabetes or other health-related problems.

30


¢ Inform patients about taking effective care for the disease.

¢ Educate patients that self-monitoring of glycemic control is the cornerstone of diabetes management.

References

1. Mendez CE, Eiler C, Walker RJ, et al. Insulin therapy for insulin resistant patients—harm or benefit? Diabetes. 2018;67(Suppl 1).

2. Bogun MM, Jelesoff NE, Nassar CM, et al. Innovative tailored microlearning approach to insulin self-management education shows

high engagement levels among diverse adults. Diabetes. 2018;67(Suppl 1).

3. Zhou FL, Yeaw J, Karkare S, et al. Impact of a structured patient support program on adherence and persistence with basal insulin

therapy at 12 months. Diabetes. 2018;67(Suppl 1).

4. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord.

2013;12(1):14.

5. deWeerdt I, Visser AP, Kok G, et al. Determinants of active self-care behaviour of insulin treated patients with diabetes: implications

for diabetes education. Soc Sci Med. 1990;30(5):605-15.

6. Toljamo M, Hentimen M. Adherence to self-care and glycaemic control among people with insulin-dependent diabetes mellitus.

J Adv Nurs. 2001;34(6):780-6.

7. Mishali M, Omer H, Heymann AD. The importance of measuring self-efficacy in patients with diabetes. Fam Pract. 2011;28(1):82-7.

31

Lifestyle Modifications: Exercise

Exercise recommendations from ADA guidelines 2019

Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness. Both physical activity and exercise are important. Exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors,

contribute to weight loss and improve well-being.

ADA recommendations

¢ Children and adolescents with type 1/type 2 diabetes or prediabetes should engage in 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least

3 days/week.

¢ Most adults with type 1 and type 2 diabetes should engage in 150 minutes or more of moderate- to vigorous-intensity

aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity. Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for younger and more

physically fit individuals.

¢ Adults with type 1 and type 2 diabetes should engage in 2-3 sessions/week of resistance exercise on nonconsecutive days.

¢ All adults, and especially those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior. Prolonged sitting should be interrupted every 30 minutes for blood glucose benefits, particularly in adults with type 2 diabetes.

¢ Flexibility training and balance training are recommended 2-3 times/week for older adults with diabetes. Yoga and tai chi may

be included based on individual preferences to increase flexibility, muscular strength and balance.

Resource:

American Diabetes Association. Lifestyle management: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42

(Suppl 1): S46-60.

32

Fruit of the month: Water caltrop

Lifestyle Modifications: Diet

Trapa natans has a number of important health benefits including its ability to improve

digestive health, strengthen bones, manage diabetes, protect cardiovascular health, boost the immune system and lower blood pressure.

It plays a significant role in the regulation, prevention and management of diabetes.

Edible nuts produced by the trees and

shrubs of the Castanea genus.

Water caltrop is a

low glycemic food.

It prevents the spikes and

drops in blood sugar, which

may act as precursor to

the development of diabetes in healthy patient.

It shows dose-

dependent improvement

in oral glucose tolerance.

It causes blood

sugar to rise slowly as compared to high

glycemic foods.

Plants spread by the rosettes and fruits

detaching from the stem.

Raw water chestnuts are slightly sweet

and crunchy.

NUTRITIONAL VALUE OF WATER CALTROP

Carbohydrates, fixed oils and fats in seed extracts. Tannins, flavonoids and glycosides in pericarp extract of fruits.

It exhibits

hypoglycemic effect

and normalizes the

blood glucose levels.

33

This is an instant dosa recipe prepared with buckwheat and urad dal. It's different from the regular dosa recipe is that the ingredients are powdered, tempered and then

mixed into a batter, which can be cooked immediately to make yummy dosas.

Ingredients needed

¢ 1 cup buckwheat (Kutto or Kutti no daro)

¢ 1 tbsp urad dal or split black lentils

¢ 1 tbsp oil

¢ 1 tsp mustard seeds

¢ ¼ tsp asafoetida

¢ 2 tsp finely chopped green chillies

¢ 2 tbsp finely chopped coriander

¢ Salt to taste

Method

Step 1: Combine the buckwheat and urad dal in a mixer and blend to a fine powder.

Step 2: Transfer the powder in a deep bowl and keep aside.

Step 3: Heat the oil in a small pan and add the mustard seeds.

Step 4: When the seeds crackle, add the asafoetida and sauté on a medium flame for

a few seconds.

Step 5: Add the tempering, green chillies, coriander, salt and approximately 2 cups of

water and mix well.

Step 6: Heat a non-stick tava (griddle) and grease it lightly with oil.

Step 7: Pour ¼ cup batter in a circular manner. Pour a little oil in the holes of the dosa

and cook on both the sides till golden brown in color.

Step 8: Repeat step 7 to make 8 more dosas.

Step 9: Serve immediately with green chutney.

Recipe of the month: Buckwheat dosa

34

NUTRITION VALUE PER SERVING

Energy: 92 cal Protein: 1.9 g

Fat: 4.5 g

Carbohydrates: 11 g

Cholesterol: 0 mg

Fiber: 1.5 g

Sodium: 3.4 mg

Source: Dalal T. Buckwheat Dosa, Tarla Dalal's latest recipes.

35

NDEP Best Practices

36

ExpertOpinion

Dr ML Balamurugan

MBBS, C Diab (Australia), PG Dip in Diab

Consultant Family Physician and Diabetologist, Sri Raghavendra Nursing Home; Joint Managing Director, Trichy Diabetes Sepciality Centre (P) Ltd, Trichy, Tamil Nadu

Dr ML Balamurugan opines that a course in diabetes

management for diabetes educators is the need of the hour.

He has been running a course for the last 5 years.

¢ Live demo of foot scan using biothesiometer and pedometer

¢ Live demo of benefits of diabetes mellitus foot wear to students

¢ Module on diet conducted by dietitian; practical tips given for planning diet for

diabetes patients

¢ Module on exercise

¢ Live demo of self-monitoring of blood glucose instrument to students

¢ Future plans: Add more number of teaching centers and participants.

Some highlights of his course

Conference Highlights

Conference on Advances in Diabetes and Insulin Therapy (ADIT 2019)

Date: 7th-9th November, 2019

Venue: Istanbul, Turkey

Program Highlights

¢ Advances and dilemmas in pharmacological management of T1DM and T2DM

¢ Adjunct therapies in T1DM

¢ Latest EASD/ADA consensus for treatment of hyperglycemia in T2DM

¢ Hypoglycemia in T2DM

¢ Antiplatelet therapy in diabetes

¢ Management of heart failure in diabetes: are we making progress?

¢ Management of people with diabetes and established CKD or CVD

¢ Year in review: news and top developments in diabetes management

¢ Diagnosis and evidence-based management of atypical forms of type 2 diabetes

¢ Retinal imaging as a tool in predicting microvascular complications

¢ Challenging patient cases

¢ Diabetes and obesity

¢ Complications in diabetes

¢ Lifestyle strategies for managing glycemia in diabetes

https://www.adit-conf.org/

37

Diabetes Quiz

Answers

Yes

Yes

Lipolysis

Insulin injections in the stomach area work the fastest.

¢ Yes

¢ No

Q-1

The insulin pump is a good tool for achieving tight glycemic control.

¢ Yes

¢ No

Q-2

Insulin promotes all but one of the following:

¢ Lipolysis

¢ Lipogenesis

¢ Protein synthesis

¢ Glucose entry into cells

Q-3

38

Use and Care of Disposable Insulin Injections

Insulin should not be shaken since bubbles can interfere with proper dosing.

Keep unopened containers in the refrigerator until first use.

Rotate of the injection site helps

reduce irritation and bruising and improves absorption.

Wash hands before injecting

medication.

If changed in appearance, discard and use a new vial or

pen to ensure potency.

Unopened expiration dates of

medications should be checked prior to use. Once vial or pen is

opened, follow manufacturer's

instructions on when to discard.

Store injectables that are in use at room temperatures to avoid

variation of absorption and comfort.

Never freeze insulin, if frozen insulin should be discarded.

Insulin should be injected into subcutaneous fat, avoiding muscle.

Encourage patients to avoid the areas if exercising that muscle group soon after the injection

as it may affect the speed of insulin absorption.

If using the thighs, it is recommended to avoid within

one hand width of the groin or

the knee.

39

40

NOTES

41

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. 52, July 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/2467 as a part of its social commitment towards upgrading the knowledge of Indian doctors.

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