Polycystic Ovarian syndrome (PCOS)

The cause of polycystic ovarian syndrome is unknown but most experts think that several factors including genetics could play a role.

Polycystic ovarian syndrome affects millions of women around the world. Its prevalence is much higher in women of South Asian origin. It is one of the leading causes of fertility problems in women and runs in families.

It is also thought that insulin may be involved in the development of polycystic ovarian syndrome. Many women with PCOS have insulin resistance. When tissues are resistant to the effects of insulin the body has to produce more insulin to compensate. The high levels of insulin found in the bodies of women with PCOS and insulin resistance stimulate the ovaries to produce large amounts of testosterone which results in many of the symptoms of the condition.

It is estimated that 10% of women who are obese and have PCOS develop T2DM by 40 years.  A higher proportion develops impaired glucose tolerance by this age. Because of its link to diabetes, if PCOS not managed properly, it can lead to additional health problems in later life.

(Source - balance – Mar-April 2013)

Know Your Diabetes Numbers

Target blood glucose for most people with diabetes:

In the morning before eating and before meals, it should be ≥ 70 mg/dl  and ≤120 mg/dl.

1 ½  - 2 hours after eating, it should be ≤160 mg/dl.

What level of blood glucose is too low?

Less than 70 mg/dl

What level of blood glucose is too high?

Over 180 mg/dl : Talk to your doctor on next visit.

Over 300 mg/dl for 2 or more readings over 12 – 24 hours:  call your doctor.

Over 500 mg/dl: Call your doctor immediately or go to emergency room.

Always check your blood glucose levels: 

• Every day when you get up in the morning and at least one more time during the day
• If you take pills for your medication, check before breakfast and 2 hours after your biggest meal of the day.
• If you take insulin for your diabetes, check before each meal and at bedtime.

Your doctor may ask you to check your blood glucose level at other times as well.

Check any time you feel like your sugar is too high or too low.

How do you feel if your blood glucose is low?

Sweaty, shaky, fast heart - beat, dizzy, headache, not thinking clearly, hungry, tired, blurred vision, confused, moody or angry.

How to treat low blood glucose 

First eat 15 g of fast acting carbohydrate such as 

½ cup fruit juice

1 cup skimmed milk

1 tablespoon honey or sugar

A sweet

Then, test your blood glucose.

Test your blood glucose again in 15 minutes.

If sugar is not over 70 mg/dl, eat another 15 gm of fast acting carbohydrate.

Eat some protein and carbohydrate as soon as you can to stop from going low again. Try eating half a sandwich of peanut butter, meat or chicken or have your next meal or the meal you missed.

How do you feel if your sugar is high?

Increased urination, increased thirst, tired, blurred vision, dry skin/dry mouth.

What to do if you think you have high blood glucose.

Check your blood glucose as soon as you can.

Some tips to help you keep blood glucose low 

• Eat 3-4 small meals a day.
• Eat your main meals 4 -5 hours apart.
• Do not skip meals.
• Eat less food.
• Avoid the second helping.
• Do not snack between meals.
• Do not drink fruit juice, sodas or sweet tea but drink calorie free liquids such as unsweetened tea or coffee, or just plain water.
• Avoid foods high in sugar such as cake, pie, sweetened cereals, honey, jam, jelly.
• Do not add sugar to food.

At MVH, we advise all people with diabetes to manage their diabetes well so that they can live a normal span of life in perfect health.

Prevent India from becoming the Diabetes Capital of the World

Are there other ways of tackling the problem? 

Life style modification and drug intervention in people with impaired glucose tolerance are Post primary prevention strategies which delay the development of Type 2 Diabetes mellitus. 

We need to concentrate on Primary prevention which is more important to reverse or halt the disease. 

One area of focus can be women with Gestational Diabetes Mellitus (GDM) who are an ideal group for primary prevention as they as well as their children are at increased risk of future Type 2 Diabetes Mellitus. 

Studies indicate that women with GDM have an increased lifetime risk of developing diabetes 16 years after the first pregnancy when compared with controls. One third of children born to mothers with GDM get evidence of IGT or T2DM. 

Pregnant women with glucose intolerance, due to decreased insulin secretion or action, have excess of glucose amino acids and lipids. When these elements cross the placenta, the foetus responds by secreting large quantities of insulin. This eventually causes decrease in foetal pancreatic reserve and results in risk for developing diabetes later.

So, screening for GDM is essential. 

Are we screening pregnant women at the right time?

Screening for glucose intolerance  is usually between 24 -28 weeks but foetal islets of Langerhans differentiate during 10th -  11th  weeks and begin to release insulin in response to nutrients as early as 11th  – 15th  weeks of gestation .

So undetected glucose intolerance in the early weeks of gestation influence foetal growth resulting in large babies for GDM mothers despite good glucose control in the third trimester.

Another area to focus on is the occurrence of T2DM within families. 

Is the familial nature of T2DM only due to genetic factors?

The genetic factor may be due to the major role played by maternal mitochondrial DNA in the transmission of the disease. A study revealed that children exposed to maternal diabetes before birth are at higher risk of obesity and diabetes than their unexposed siblings. This suggests that the increased risk is not only due to genetic causes.

Therefore, it is essential to focus on intrauterine environment, especially in our country. In India, both under -nutrition and over- nutrition exist during pregnancy. Both, nutritional deprivation or nutritional plenty can result in changes in pancreatic development and response to insulin that may lead to adult onset GDM or T2DM. So, both small – for date infants and large for date infants are at risk for future diabetes.

The aim should be to help pregnant women to have infants born with weight that is appropriate for gestational age by both sufficient and fitting nutrition and good blood glucose control.  (Fasting - < 90 mg/dl and peak < 120 mg/dl.)

(Ref: Transgenerational Transmission of Diabetes – Sesiah.V, Balaji.V, Balaji, Madhuri.S, Das, Ashok.K)

Managing Type 1 Diabetes at School

‘When Divya (11) requested her class teacher permission to use the restroom for the third time in an hour, the older woman warned her against playing the fool. Embarrassed the child returned to her seat. Divya is not alone. Several children with Type 1 diabetes suffer in silence without proper support in school and among peers.’

   - The Times of India 

Children with diabetes gradually learn to become more independent in self managing activities as they progress through childhood and adolescence. However, they may need help to carry out their regular diabetes management tasks in school. So, ideally a school should provide amenities for

• Maintaining good blood glucose control, 
• Helping the student with diabetes care tasks, and 
• Having trained diabetes personnel for effectively managing  diabetes .

Diabetes management involves checking blood glucose levels throughout the day, following a specially made meal plan, getting regular physical activity, maintaining a healthy weight and taking insulin or other medications to keep blood glucose levels in the target range and to prevent hypoglycemia or hyperglycemia. 

Planning for school events, special events, field trips, and extracurricular activities, correct disposal of sharps and materials that come in contact with blood, dealing with emergencies, and with the emotional and social aspects of living with diabetes are other issues of managing diabetes. 

Low blood glucose or hypoglycemia can happen suddenly and is dangerous for the child with diabetes. It is more likely to occur before lunch, at the end of the school day, during or after physical education classes, or as the result of unexpected physical activities. When the level of blood glucose falls, the child may not be able to manage on their own Sometimes, its symptoms are mistaken for misbehaviour. 

If a child experiences hypoglycemia:

• Never leave them alone 
• Never send them anywhere alone
• The  class teacher or any responsible school staff should be around to help the student, and
• The remedy for hypoglycemia should be readily available in the classroom and administered immediately. 

What is Hyperglycemia?

High blood glucose or Hyperglycemia can develop over a period of time, usually as a result of too much insulin, missing or delaying meals or snacks, not eating enough food (carbohydrates).  Trained staff should be available for quick, safe and appropriate care for students with diabetes. 

Checking Blood Glucose

At school, children with diabetes usually check their blood glucose– 

• Before and after eating snacks and meals
• Before physical activity, or
• When there are symptoms of hypoglycemia or hyperglycemia. 

Many children can check their own blood glucose level. Others need supervision. Still others need to have this task performed by trained diabetes personnel. All students, even those who can independently perform blood glucose monitoring, may need to be helped when experiencing low blood glucose. Blood glucose levels should also be checked whenever the teacher observes symptoms because some children may not recognize the symptoms.

Children must be allowed to check their blood glucose levels and take the necessary actions if the levels are too high or too low as quickly as possible, wherever they are and whatever activity they are doing. Taking immediate action is important to prevent symptoms of severe hypoglycemia such as coma or seizures.

Another important factor is a safe method for disposal of sharps and materials that come into contact with blood.

A specific plan for proper disposal of lancets and other materials that come into contact with blood protects other students and staff members.

Lancets and needles can be disposed of in a plastic or metal container with a tight-fitting lid. Some students may leave the lancet in their lancet device and take it home for disposal. 

Diabetes management in the school

The basic facilities a school should have are:

• Health care support ,
• A record of each student’s diabetes care plan prepared by the student’s   own health care team,
• Emergency care plans in case of Hypoglycemia and Hyperglycemia, and
• Training school personnel about diabetes and its management.

Responsibilities of the Teacher:

Health : the teacher should …

• Be aware of the student’s needs 
• Allow students to monitor blood glucose, inject insulin and take other medications, eat snacks for routine diabetes management and for treatment of low blood glucose levels, have easy access to the bathroom, and to drinking water,
• Know that a child with diabetes needs to eat meals and snacks on time. 
• Learn what to do in an emergency
• Recognize changes in the student’s behaviour that could be a symptom of changes in blood glucose levels 
• Know when and how to contact trained diabetes personnel.
• Know where supplies to treat low blood glucose are kept and where students with diabetes normally keep their supplies. 
• Provide information for substitute teachers about the day-to-day and emergency needs of the student. 
• Communicate with the school authority and the parents/guardian regarding the student’s progress or any concerns about the student.
• Inform the parents/guardian in advance of  class parties, field trips, and other special events. 

Education: The teacher should…

• Provide a supportive learning environment such as  extra classes or make up missed classroom assignments for students with diabetes.  
• Provide permission for doctor appointments and sick days.
• Treat the student with diabetes the same as other students, except when acting in response to their medical needs.

Responsibilities of Parents/Guardian :

The parents should…

• Inform the school principal as well as the teacher that the child has diabetes at the time the student joins the school .
• Submit documents of  the diabetes management plan issued by their child’s diabetologist to the school …
• soon after the child has been diagnosed with diabetes,
• at the beginning of each school year, and
• when there are changes in the child’s diabetes care plan.
• Give correct emergency contact information to the school and update the school about any changes.
• Learn what facilities the school provides for health care and emergency.
• Inform the school authorities about the diabetes care the child can manage at home.
• Inform the school about any changes in the child’s health or in doctor’s orders.
• Provide all supplies and equipment such as blood glucose monitoring equipment, supplies for insulin administration and urine and blood ketone testing, snacks, quick-acting glucose products, and a glucagon emergency kit necessary for the child’s health care. 
• Keep a tab on supplies and restock them, as needed and also replace supplies that have expired (if they are stored in school).
• Inform school authorities when the child plans to participate in school activities before or after school .

Responsibilities of the Student with Diabetes

They should know:

• When they should monitor their blood glucose levels, take insulin or other medication, have a snack or eat a meal.
• What to do when blood glucose level is too low or too high.
• Who to contact if they are not feeling well.
• Where the daily and emergency diabetes supplies are stored.
• Who to contact when they need to use the supplies.

The child with diabetes should: 

• Learn how to contact people who will help them in school.
• Always carry a quick-acting source of glucose.
• Communicate with teachers or other school staff members if they feel symptoms of low or high blood glucose.

(reference:  http://ndep.nih.gov/publications)

Free food

Are you are diabetic and get hunger pangs even after eating the permissible quota of food?  Think of low calorie food called free foods. They give a feeling of fullness.

Fresh salads made of cabbage, onions, lettuce, tomato, cucumber, radish and capsicum with only lime  salt, pepper or chat masala. Do not add any salad dressing like mayonnaise or olive oil.

Buttermilk or  Lemon juice without sugar,

Clear soups and rasam without butter or oil

SNACKING 
For people who can have snacks at work

• Always carry some snack with you- fruits (one at a time), nuts (6-7 at a time), curds/buttermilk,  roasted legumes,  

carrot/ cucumber/tomato slices, and 

Marie biscuits. 

• If a snack is provided at the work places healthier choices include  – fruits, popcorn without butter, chaat varieties such as  bhel puri, channa masala, fruit chaat,  vegetable sandwiches with whole wheat bread, roasted legumes, roasted soy nuts, peanuts, salads and soups. 

         AVOID samosas, puris, bondas, vadas, bajjis, puffs, cakes and pastries etc.

Food exchange list

Add variety to your diet by using the food exchange system.

Is your diet monotonous? Use the food exchange list for variety. For breakfast have idli, bread, dosa. Do not add sugar or jaggery to vegetables or pulses when cooking.

Keep cucumber or roasted channa for snacking between meals.

Before lunch or dinner, drink a glass of butter milk or rasam or clear soup, then have a plate of salad and finally the main meal to feel full.

Do not drink on an empty stomach. Limit to 2 ounces per day. When drinking, a person with diabetes should eat salad and not the usual snacks. 

Adjust calorie content of the salad, snack or drink with that of the day’s diet.

Avoid alcohol if diabetes is not under control and if there are complications.

Food Exchanges

Food exchanges are described here for the food groups – Cereals, Pulses, Milk and Milk products, Meat.

In the exchange list, each portion given for a particular food group has the same calorie value. This will allow you to substitute one item from a food group for another one in a given meal. For example, if you usually take 1 ½ cups of rice for a meal and you want to have chapathi instead, then you can substitute rice with 2 chapathis.

Cereals Exchange   

Each portion = 85 cals

Rice -1 cup- 25 g (Raw), 80 g (Cooked)

Phulka/Chapathi 1 (6“diameter), 25g (Flour) (without oil or ghee)

Idli 1 (2 “diameter), 50g (cooked)

Dosai (7” diameter), 34g (cooked).

Pulse Exchange   

Each portion = 85 cals, Protein = 3-7 g.

Dals- Redgram, Greengram, Bengalgram, Lentil, etc (cooked, plain dal without oil) l cup (Cooked), 25g. (Uncooked)

Sundal  or whole gram -  ½ cup (Cooked), 25g (Uncooked)

Milk Exchange    

Each portion = 80 cals.

Milk (Cow)- ¾ cup, 120 ml

Milk (Buffalo) - ½ cup, 68 ml

Skimmed Milk -1 ¾  cup, 275 ml

Curds - ¾ cup, 135 g

Buttermilk-  1 ¾ glass, 360 ml

Paneer (Chhena – cow’s milk)-  ¼ cup (8 small cubes), 20 g  

Cheese-  1 cube, 25 g

Meat/ Fish Exchange     

Each portion = 85 cals,  Protein = 4 to 7 g. 

Egg – 1,50 g

Chicken-  ½ cup. (4 pieces) ,75 g  or Mutton -  ½  cup (3 pieces), 70 g

Minced Meat -  ¼ cup , 40 g 

Mackerel -  2 ½  pieces, 85 g 

Seer fish -  1 ½  pieces ,65 g

Shark -  2 ½ pieces, 85 g

Prawns - ½ cup (4 pieces), 90 g

Millets for People with Diabetes

Dr. Vimala Sanjeevi & Ms. Rohini U.

Dept. of Nutrition.

Millets are a group of small-seeded grasses which can grow in dry lands and land with poor soil quality and requires much less water that rice and wheat. They are a major crop in the semi – arid tropics of Asia and Africa. They are a rich source of Vitamin B especially niacin, B6, folic acid, and minerals such as calcium, phosphorus, iron, potassium, magnesium and zinc.

Millets include jowar (great millet), ragi (finger millet), korra (foxtail millet), arke (kodo millet) and sama (little millet). All these are available in the form of rice (example: foxtail millet rice), rawa (example: jowar and bajra rawa) and flour. These may look coarse and unappealing when compared to mill polished white rice, but provide immense health benefits.

Millets are part of our forgotten tradition. People  forget that 50 years ago everyone was eating these grains. There are different millets, each with a unique flavour.

Millets are very nourishing

      

 In general,

• Millets contain lignans that act against hormone - dependent cancers and also help reduce risk of heart disease. 
• The high phosphorus content plays a vital role in maintaining the cell structure of the human body. 
• Lecithin is excellent for strengthening the nervous system. 
• They are gluten free and so are appropriate for those with celiac disease or other forms of allergies or intolerance to wheat. 
• Millet is alkaline and easily digested and has low glycemic index. 
• Millet protects from constipation and has a probiotic effect. 
• The high levels of tryptophan in millet produce serotonin which is calming. 
• All millets show high antioxidant activity. 
• The high protein content makes it a significant addition to a vegetarian diet.

For people with diabetes, millets contain insoluble fibre that reduces the secretion of bile acids, increases insulin activity and lowers triglycerides and prevents spikes in the level of blood glucose. They are a good substitute for rice. The magnesium acts as a co-factor for more than 300 enzymes including those involved in the body’s use of glucose and secretion of insulin. The B vitamins help in processing carbohydrate from foods. The fat content is 75% heart healthy PUFA.

Consuming carbohydrates that have been processed or refined can cause extreme ups and downs in blood glucose levels, overwork the liver and pancreas and rob the body of existing vitamin and minerals such as calcium and magnesium from its stores in order to break down and digest food properly.

How to use millets

Include it gradually into your diet.

• Mix it with rice or use it instead of rice and potatoes. 
• Add millet flour to idli/dosa batter or chapatti dough. 
• Make cookies, cakes, bread and laddus with whole wheat and jowar flour and jaggery. 
• Use millet rawas and millet rice to make khichdi/upma with lentils and vegetables. 
• Use sprouted millets in salads and soups. 
• Add millet to your favourite chopped vegetables and make a stir fry. 
• Make breakfast porridge with cooked millet and add your favourite nuts and fruits to it.

Regular consumption of millet is associated with reduced risk of T2DM.

Artificial Sweeteners: A Boon or Bane?

Dr. Patricia Trueman

Dept. of Diet &Nutrition

Today “size zero” is the fashion and in an effort to maintain and reduce weight the market is flooded with foods that contain sugar substitutes (artificial sweeteners). 

Artificial sweeteners and other sugar substitutes are found in a variety of food and beverages marketed as "sugar-free" or "diet," including soft drinks, chewing gum, jellies, baked goods, candy, fruit juice, and ice cream and yogurt.

Just what are all these sweeteners? And what's their role in your diet?

Sugar substitutes are loosely considered any sweetener that you use instead of regular table sugar (sucrose).

Artificial sweeteners are just one type of sugar substitute. 

The following chart lists some popular sugar substitutes and how they're commonly categorized.

 

Possible Health Benefits of Artificial Sweeteners

• One benefit of artificial sweeteners is that they don't contribute to tooth decay and cavities.

They may also help with the following:  

 

 

• Weight control. One of the most appealing aspects of artificial sweeteners is that they are non-nutritive — they have virtually no calories. In contrast, each gram of regular table sugar contains 4 calories. A teaspoon of sugar is about 5 grams. For perspective, consider that one 200 ml can of a sweetened cola contains 8 teaspoons of added sugar, or about 160 calories. If you're trying to lose weight or prevent weight gain, products sweetened with artificial sweeteners rather than with higher calorie table sugar may be an attractive option.  

 

• Diabetes. Artificial sweeteners may be a good alternative to sugar if you have diabetes. Unlike sugar, artificial sweeteners generally don't raise blood sugar levels because they are not carbohydrates.

The Health Dangers of Artificial Sweeteners

Here's a list of the top four artificial sweeteners, along with information about what's in them and the negative impact they can have on your health.

1. Aspartame

What's in it: Phenylalanine, aspartic acid and methanol.

Reported side effects: Headaches, fibromyalgia, anxiety, memory loss, arthritis, abdominal pain, nausea, depression, heart palpitations, irritable bowel syndrome, seizures, neurological disorders, vision problems, brain tumors and weight gain

Your body converts the amino acid phenylalanine to neurotransmitters that regulate your brain chemistry. These important neurotransmitters are:

• L-dopa
• norepinephrine
• epinephrine 

The resulting increased levels of neurotransmitters can cause problems in the physiology of your brain -- problems which have been linked to a variety of psychiatric disorders. You can also be prone to anxiety attacks, depression, headaches, seizures, and tremors. Phenylalanine and aspartic acid directly impact brain and central nervous system functions; evidence shows they play a role in mood disorders, memory problems and other neurological illnesses.

The second largest component of aspartame is aspartic acid. Aspartic acid functions as a major excitatory neurotransmitter in your brain. People who suffer from depression or have brain atrophy have been found to have low levels of aspartic acid in their bodies. As you might expect, the chemical is found in abnormally high levels in people who suffer from seizures and strokes. In very high doses, aspartic acid can cause brain damage and cell death.

Methanol is converted into formaldehyde when metabolized.  Makers of aspartame say methanol and its by-products are quickly excreted.  But research has found measurable amounts of formaldehyde in the livers, kidneys and brains of test subjects after ingestion of aspartame.

At high temperatures, phenylalnine breaks down into diketopiperazine (DPK), a known carcinogen. Phenylalnine is especially dangerous for people with the hereditary disease, phenylketonuria.

2. Acesulfame-K

What's in it: Acesulfame-K is a potassium salt containing methylene chloride, a known carcinogen.

Reported side effects: Long term exposure to methylene chloride can cause nausea, headaches, mood problems, impairment of the liver and kidneys, problems with eyesight and possibly cancer.

Concerns: Of all artificial sweeteners, acesulfame-K has undergone the least scientific scrutiny. Early studies showed a potential link between the sweetener and development of multiple cancers in laboratory animals.

3. Sucralose

What's in it: Sucralose is a synthetic additive created by chlorinating sugar. Manufacturers say the chlorine in sucralose is no different from that in table salt. Fact: the chemical structure of the chlorine in sucralose is almost the same as that in the now-banned pesticide DDT.

Reported side effects: Head and muscle aches, stomach cramps and diarrhea, bladder issues, skin irritation, dizziness and inflammation

Concerns: Research has shown sucralose can cause shrinking of the thymus gland, an important immune system regulator, and liver and kidney dysfunction. A recent study by Duke University found sucralose reduces healthy intestinal bacteria, which are needed for proper digestion and can impact the effectiveness of prescription and other drugs.

According to the Sucralose Toxicity Information Center, the absorbed sucralose and its metabolites (chemically altered substances) concentrate in the liver, kidney, and gastrointestinal tract.

One study on sucralose showed an increase in glycosylated hemoglobin (meaning damage to the oxygen carrying part of a red blood cell). Research in animals has shown:

1. Up to 40 percent shrinkage of the thymus gland. (Critical for the response to disease – the ‘heart’ of our immune system)
2. Enlarged liver and kidneys
3. Atrophy of lymph follicles
4. Reduced growth rate
5. Sucralose affects the glucose and insulin response to glucose ingestion, the mechanism responsible is not known.

 4. Saccharin

What's in it: Saccharin is a sulfa-based sweetener; its primary ingredient is benzoic sulfimide.

Reported side effects: For those with sulfa allergies, saccharin may cause nausea, diarrhea, skin problems or other allergy-related symptoms.

Concerns: Early safety studies of saccharin showed the sweetener caused bladder cancer in rats. The FDA recently lifted the requirement that saccharin be labeled as a probable carcinogen on food packaging. The link between saccharin and bladder cancer has contributed to saccharin being the most investigated of all artificial sweeteners.

 

Each one of us should now decide: Are artificial sweeteners a boon or bane?
And should we include it in our diet? 

References:

1. Medical Author  Melissa Conrad StopplerMD
    Medical Editor William C. Shiel Jr. MD FACP FACR Medicine Net on Health.com
2. Author: Betty Kovacs, MS, RD
Medical Editor: William C. Shiel Jr., MD, FACP, FAC Medicine Net on Health.com
3. Dr. Mercola Artificial Sweeteners -- More Dangerous Than You Ever Imagined Mercola.com Take control of your Health