Diabetes- Non-pharmacological management

Welcome to Med Pods, the podcast on topics of internal medicine from the Department of Medicine at AFMC. This is 10th in our series of podcasts that we've had on various topics of relevance in this subject. Today, we do the second in the series of the topics on diabetes mellitus. We spoke to Wing Commander Sandeep Kumar, Associate Professor in the Department of Medicine, who spoke on various aspects related to the pathophysiology of diabetes, the various types of diabetes and how we go about diagnosing and screening for diabetes in asymptomatic people. Today, we shall dwell deeper into this topic by going into the various aspects related to management of diabetes. Welcome back, Sandeep. Thank you, sir. So, from our last podcast on this topic, we discussed the fact that diabetes is predominantly a silent disease. It's a metabolic disease characterized by hyperglycemia and most of the toxicity that happens to the tissues is because of the increased level of glucose. So, when we manage diabetes, we manage similarly. Now, most often the patient asks us that why do you need to treat something which is so silent and not causing them any problem? And it also becomes a challenge to make the patients take a drug for a condition where there is no symptom. So, please tell us why do we treat diabetes? Sir, our audience, for that matter, our students would frequently encounter various patients. They may ask them the questions, so what I am a diabetic, so what I am having a blood glucose of 300 milligram per deciliter. So, the reason for treating is that initially, as you told, sir, it's a silent disease, but over the period of time, over the period of chronic hyperglycemia, this will lead to certain complications which these and these complications are not only disabling but also fatal. So, diabetes malitis causes certain vascular complications and certain infectious diseases which lead to a poor outcome in the patients who are diabetic. So, let's understand what are the vascular complications? So, diabetes can involve the smaller vessels that in that setting, it is called as microvascular complication or when it involves a larger vessel, they are called as a macrovascular complication. So, when the vessels of size less than 10 micrometer is involved, it is called as microvascular complication and the complications include retinopathy, nephropathy and neuropathy. And the macrovascular complication includes coronary artery disease, peripheral artery disease and cerebral vascular accidents or strokes. And we may recall our previous discussions, the majority, the leading cause of the blindness and leading cause of the neuropathy and the kidney disease in the world is diabetes malitis. So, having said that, let us understand what is the mechanistic explanation, why does this complication happens? So, it has been seen that the when there is a hyperglycemia or blood glucose is higher in the blood, this glucose gets attached to certain proteins in the intravascular or extravascular compartments. Initially, this attachment to the proteins is very, very temporary and reversible, but once the patient is exposed to the chronic hyperglycemia, there is an arrangement which is called as amadori arrangement happens and this becomes a irreversible attachment of the glucose to the proteins and also to the lipids to some extent and there is a formation of certain molecules, these are called as advanced glycosylation end products and these are irreversible damage to the proteins which happen and these advanced glycosylation end products interfere with the structure of the proteins in the sense they cause the disorder with the cross linking of the proteins, they decrease the nitric oxide, oxide synthetase, they impair the endothelial dysfunction, they disrupt the extracellular matrix composition and structure and also they alter the various gene expression and as a result, they cause the microvascular and macrovascular complication which we just discussed and it is not only vascular abnormality, sir, but the diabetes also predispose one to various infections. In fact, all kind of infection can happen at the increased prevalence, increased incidence in the patient with the diabetes, but there are certain specific infection which happen in the diabetic patient, namely the emphysemitus piloniferitis emphysemitus polycystitis and malignant arthritis externa and also mucormycosis. We can recall the experience of a mucormycosis from the patients who from the COVID-19 epidemic where there was increased occurrence of mucor and also it was seen in the higher frequency in the diabetic patients. So, we understand that any chronic hyperglycemia predisposes these tissues to undergo irreversible changes which leads to these complications and I think once we make our patients understand this, they would be more motivated to get treated for diabetes and control their glucose levels better. So, we also understand especially in type 2 diabetes that the day the diabetes is diagnosed, this disease has already been there in the body for a few years and has caused its damage which is irreversible. So, we do find patients at the time of diagnosis to have certain complications. So, when we detect diabetes in a patient, how do we screen them for these complications? Yes, sir. So, once we have a diagnosis of type 2 diabetes, so there is a clear cut protocol which comes from the guidance of ADA as we have discussed last time and for the respect to the nephropathy, once the type 2 diabetes is diagnosed, we should immediately do his urine albumin creatinine ratio and any level more than 13 milligram per gram is said to be an albuminuria and this should be repeated subsequently over the period of time and has to be confirmed on two occasions and although we would be restricting our discussion only to type 2 diabetes, but yes, if the patient is a type 1 diabetes, then the screening for urine albumin creatinine ratio should be done once the duration is more than 5 years. So, if a type 2 diabetes has already developed albuminuria or there is already the establishment of the chronic diabetic kidney disease, then this frequency of monitoring of urine albumin creatinine ratio is increased to as high as 1 to 4 times a day and this stage, the patient should also consult a nephrologist. Now, coming to the retinopathy which is another microvascular complication, sir. So, at the onset of the type 2 diabetes, the patient should go undergo the screening for the retinopathy and if it is absent, then the screening can be done as the frequency of every 1 to 2 years. However, on the if it he already has a established retinopathy, then screening has to be done 2 to 3 times in a year and appropriate treatment according to the level or severity of the retinopathy has to be done. On the other hand, in the type 1 diabetes, the screening of retinopathy at the onset should be done within the 5 years of onset and the ADA does not specify the latest one. So, it means that at least within 5 years, he should once undergo the retinopathy screening and then subsequently, according the level, we can repeat it every 1 to 2 years if the retinopathy is not present and if it is present, we do it at the increased frequency levels. Now, coming to the neuropathy, so patient all the patients of type 2 diabetes should be assessed at the onset of the type 2 diabetes for the presence of neuropathy and in fact, not only the type 2 diabetes, but also in the pre-diabetes, the neuropathy can be present and in fact, all the other complications which we just discussed before. So, how do we screen for the neuropathy? So, patient should be should have a careful clinical history and the clinical examination. So, at least once in a year at the onset of type 2 diabetes, we start screening for the neuropathy by doing a various test and what are these clinical tests? We can do a simple 128 Hertz tuning for a vibration test which can be employed. We can check for the pinprick and temperature sensation and we can also do an ankle reflex as well as 10 gram monofilament testing in these patients and if there is no presence of neuropathy at the onset in type 2 diabetes and then it has to be repeated every year early for the development of the neuropathy in the type 2 diabetes patient. Another screening which is very important and more often we forget and it is very, very peculiar which occurs at increased incidence in our population in Indian setting is that a food disease which happen in the diabetes. So, every patient of the diabetes should also be counseled to have a proper foot care and the patient should be educated at the onset of the diabetes that every evening they should rinse their foot in the normal water. I want to highlight normal water means a normal temperature water and not a hot water because if you ask the patient to dip their feet in the hot water because of neuropathy they may get a burn injury because their sensation may be impaired to perceive the temperature, hot temperature. So, every evening they should rinse their foot in the normal temperature water, dry it and have a self-inspection done specifically in the souls by utilizing the non-breakable mirror if there is any injury to the foot or micro trauma which are present should be brought to the notice of the treating doctor and not only this care of the foot which has to be done every day but also the patient with the diabetic has to be careful with respect to whatever footwear they wear and appropriate guidance should be given in appropriate setting the patient should avoid tightly fitting or loosely fitting footwear and the basically the kind of footwear like we use a sandal wearing which in the Indian setting the trauma or edge to the edges at the edges of the footwear should be avoided and very, very pertinent the bare foot walking in the diabetic patient should be avoided and we should counsel our patient to avoid doing that. So, this is very important and I think our students must revise this aspect because every microvascular complication that happens in diabetes to a great extent is preventable and also if it has already occurred to some extent reversible if the glycemic control is adequately achieved. So, screening for them looking for them and then accordingly monitoring and managing the glucose control will help in prevention of these complications. Now, let us move on to the aspect of management or treatment of these patients and like in all chronic diseases, diabetes as well the non-pharmacological aspects are very important and often forgotten. I think we must reiterate this in our podcast that we must start management of diabetes first as a baseline with the non-pharmacological aspects of which the most important are lifestyle modification, the diet and exercise. So, what are the lifestyle modification advice that you would like to give to your patients? Yes sir, lifestyle modification is the most pertinent intervention which we do in the patient with diabetes malitis and as we know from the pathophysiology it is a lifestyle disease and it has been seen even in the scientific studies that the lifestyle modification can reduce your HVA1c to as high as 2 to 2.5 percent and that is higher than the most of the drugs which are available for the treatment of the diabetes malitis but sadly this is not commonly employed in the real life scenarios in a day to day practice. So, and the other thing which we need to understand with respect to lifestyle is it is not only the exercise and diet which we would be discussing in detail but also other aspects of the life. So, let us understand what are the other aspects of lifestyle modification which are important apart from the diet and exercise. So, number one is your addictions with respect to tobacco and alcohol. So, tobacco consumption in like in India people you chewable tobacco is used and smoking is done that should be stopped. Any diabetic should not because that treat is supposed to increase atherosclerotic disease occurrence and even the alcohol should be ideally be not to be consumed but the male should restrict their drink to the less than two units per day and the females the women should consume less than one unit per day but yes the guidance says that you should avoid consuming alcohol in the diabetic patient and alcohol not only it is you know deranges your metabolic profile and the glycemic control but also it has an increase you know it causes the increase predisposition to the hypoglycemia in the diabetic patient because they interact with the various drugs which we will understand and discuss subsequently and once we have understood the addiction it is also important to have a optimist that we should you know counsel our patient to have a very very positive and optimist attitude towards a life and they should you know we should educate them to reduce their stress they should have a proper sleep pattern and in fact they should increase improve the sleep hygiene and when I talk about sleep hygiene I am not only talking about the quantity of the sleep I am also talking about the quality of the sleep they should have at least six to eight hours of uninterrupted sleeps and the overall as I discussed earlier their outlook and the attitude towards life has to be positive and the patient should be counseled how to stay happy so having said that let's come to the most important aspects of the lifestyle management and these are the component of the your diet and exercise so what I want to highlight here is that they we have you know a lot of information which is available in fact I often say in my OPD that everyone in this world would have a some or other advice to give on diabetic whether or not he is a basically medical personal or not so basically it is very important as a student or I would you know tell our audience to have a very very simple approach towards how to approach management lifestyle management in our patients so let us understand what should be the principle with respect to the nutrition so in fact it is a scene that we often follow our western textbook and we try to you know the same way we becomes rigid with respect to our prescription and we ask our patient to do certain you know nutritional modifications which are not possible in a real life for example if you tell a south Indian patient to eat roti every day a wheat based chapati every day I think we are not doing justice to his life and that is not a proper attitude towards the nutrition management in our diabetic patient so let us understand what is a what should be the basic principle which we should you know understand whenever we are approaching the nutritional management in the patient number one is that we should respect the patients basically the you know the dietary habits his cultural the traditional and the cultural way of eating patterns should be respected and we should not take away you know the enjoyment of the food the pleasure of the eating in our diabetic patients and in fact we should you know try to utilize the foods which are available in their day-to-day life and which they grow like the farmers which they have in their vicinity and try to you know utilize those foods into their day-to-day life and another thing which we should need to emphasize or we need to focus is that of course we should you know assess the patients affordability and should advise in the nutritional intervention which are possible within his economic budget so I just give you the highlights that we can any obese patient who is a sedentary who does not do any kind of the activity we should advise about 20 to 25 kilocalories per day which they should be taking and so and the patient who has basically does not have a very sedentary lifestyle he's have an inactivity but not a completely sedentary we can add who we can advise them to have about more than 25 kilocalories kg per day of the their dietary consumption so how do we do the you know the how do we take the record of the calories so this importance of maintaining the calorie budget or calorie economy is very very important these days we have a various the application which are available by using the smartphones and we can enter whatever the food and we can calculate we can see what are the calories content of the various foods and so we can arrive at whatever the ideal calories we should be consuming which I told can be about 20 to 25 and the patient who are very very active they can consume 30 kilocalories per day in the diabetic patients and it has been seen that the patient if they have a negative calorie intake for example every day if you are having a 500 kilocalories deficit that would account to about 3500 kilocalories over the week duration and that would translate into about a 500 milligram of the weight loss that is about half kg of the weight loss so what I'm trying to emphasize by this message is that the lifestyle or nutritional management does help but there is a sustenance or persistence and it provides a lot of motivation from the patient's perspective as well as the treating doctor's perspective so let's discuss various macronutrients and micronutrients how what are the basic principle when we choose them so if we come to the carbohydrate so basically the patient should be advised to consume reduced amount of the carbohydrate intake and they should be consuming more of a complex carbohydrates and there should be inclusion of non-starchy vegetables, whole fruits, legumes, hall grains, nuts and seeds and low fat dairy products should be included in their diet and in our Indian scenarios there is abundance of availability of such foods in our rural areas and also in our urban areas as well and in fact as I told earlier so basically whatever dietary advice when we are interacting with our patients of type two diabetes this should translate into some kind of weight reduction and it has been said that the patient of type two diabetes should have at least five percent of the weight reduction whenever he's overweight or obese then only we can see that our patient is following a appropriate nutrition of guidance or prescription if our patient is not doing that then we should counsel, interact and supervise our patient, motivate him and try to understand where are the fallacies which are happening and with respect to fiber the patient should consume increased fiber diet and it has been said that about 14 grams per thousand calories of the fiber should be included in their diet and they should also avoid consuming and this is a basically pattern of eating in these days in our life that we consume more of a sugary sweetened beverages so these sugary sweetened beverages like packed juices and your the soft drinks and cold drinks which come should be avoided and should not be consumed even the refined carbohydrate the biscuits, sugary biscuits which are formed from the refined carbohydrate should be avoided and the patient when it comes to the proteins so basically the patient even the proteins can cause the you know the impaired the patient insulin secretion and cause the insulin resistance but the patient should appropriate amount of the protein consumption should be done and the guidance for this comes from the Indian society for the diabetes research that every patient should consume about 15 percent of the total calorie intake should be from the proteins and similarly about 30 percent of the calorie intake should come from the fats in the diabetic patient but such fat should be should be constituting about them more of a mono unsaturated fat and a polyunsaturated fat and we can consume and this the foods which contains more mono unsaturated and polyunsaturated fats are like the seafoods fish nuts and various seeds and it has been seen that such kind of the fats can reduce occurrence of the cardiovascular disease in the diabetic patients then there is also increased fat and patterns of you know consumption of herbal supplements and micronutrients we got without elaborating more I would just try to tell my audience here is that there is a no literature or there's no scientific evidence with respect to you know the substitution of these micro nutrients in the patients or herbal supplements in these patients as of now on the contrary there has been certain studies which have shown that certain you know nutrient supplementation like beta carotene can be deleterious or they can be harmful so we don't have any evidence with respect to these micronutrient supplementation in the diabetic patient then the patient should consume about you know the restrict the salt intake and it should be less than about about a six gram salt so in a practical life I would say that if you have the spoon which we use the teaspoon there should be one teaspoon in a day should be and it should be non-heaping kind of a teaspoon amount of the salt should be consumed in a whole day and now coming to the exercise pattern and then again it is very very important again I would try to reiterate that our patient this kind exercise prescription whenever we have a device should translate into some kind of the weight reduction in our patients and exercise is one of the most important intervention in the diabetic patient and when I say exercise it is not only aerobic exercises but also the strengthening exercises and flexibility exercises which are helpful and it has been seen that even strengthening and flexibility exercises reduces the insulin resistance and helps in better glycemic control and so basically it has been prescribed by the various learned societies that the adults patient with the type of diabetes should exercise at least 150 minutes or more of a moderate to vigorous intensity exercises and they should not have absence of more than two consecutive days in a week and the people who are fit and they can afford to run about 9.7 kilometers and why I'm saying 9.7 kilometers because it has come from the research and it has been seen that once the people does such amount of the vigorous exercises it is better and they can exercise as less as 75 minutes per week and it would translate into better glycemic control and I've already told that the you know resistance exercises about two to three sessions in a week are helpful and what are the resistance exercises means like the simple like one once we do in a gym like a weight-wearing exercises and the exercises like where we utilize our own weight as a resistance like you're doing the pull-ups and push-ups and they also because the muscles are involved and they improve the insulin resistance in the at the muscle level and yes there is a lot of you know questions which comes to us sir in our day-to-day practice with respect to yoga. Yoga definitely is very very helpful and we have a scientific evidence with respect to that and it encompasses the flexibility, balance and improves the insulin resistance in diabetic patients. So this is basically it is a very very broad science lifestyle modification but basically in a given time I try to give the principle and concept which should be applied whenever we're approaching our patients with for the lifestyle modification in our diabetic patients. So I can understand how elaborate this is and so you can imagine how difficult it will be for a patient to understand and to follow so it's very important for us to keep it simple you must ensure that we do not change the patient's diet so much that he does not want to comply with our advice. So we should go by what is their cultural background is affordability and just do those minor modifications in the diet of the patient by removing the bad things adding a few good things for which the plate concept that we follow very simplistically explained can be a good advice. So can you Sandeep can you put that ADA's plate method in just one or two minutes for the for our students to understand I think that's the best simplest way to explain. Yes so the ADA plate method is a very very simple approach which a diabetic patient should be doing it and we as a physician or treating doctor should be telling our patients so what a plate method tells us that like if we take a plate which is equivalent to about a nine-inch plate or for that matter whatever plate we use at our homes to eat our meals so it is been said that a half of our plate should constitute about the leafy vegetables and one quarter should constitute the lean proteins like we can have a chicken eggs and the and should avoid the red meat and all and the left one quarter which should be used for the starchy carbohydrate like a roti so we can very well imagine so that our plate we can split it into two halves one half should be of the green leafy vegetables other half is split into two and that one quarter of that should be constituting the lean proteins and the another one quarter should be constituting our carbohydrates like a chapati or even a rice in a diabetic patients. Okay so this is a topic which is which actually elicits a lot of discussions and queries from patients which our students must understand so at least two of them we'll address now one being the question regarding the artificial sweeteners whether they are safe can they be used and which ones are safer comparatively if at all the advice. Yes sir so there is increase fat so I've already told that we should live within a calorie budget so for example we I have decided a 20 kilo calories per kg per day for my patient in which we have calculated about according to a sedentary habit so if I'm able to meet that then the patient may be allowed to have a normal you know sugar added to the is one one not T because Indian people may have a you know lot of liking for the T yes but moderation and you know the tightening of the frequency has to be done but yes there is increased fat about the various non-nutritive sweetness which are available and the more awareness happens because of the various advertisements and availability in the market and the you know the increase the marketing strategy about the companies but yes according to the ADA guidance the non-nutritive sweeteners like sucralase aspartame acid sulphame k and saccharine all these are available can be utilized in around two to three times in a day and they however it has been highlighted there that does not translate into better glycemic control so as of now the guidance says they can be utilized however there is a literature and their studies which are coming up with respect to all these which have named that they may be associated with the increased occurrence of the cardiovascular disease and also with the cerebrovascular diseases so now coming once we have these two information that as of now we have a guidance that yes it can be utilized on the other hand I'm telling that there's increased evidence which is coming that it may be associated with increased occurrence of the atherosclerotic cardiovascular disease so what is a final message which we should take from the this today's talk so message would be that you know using non-nutritive sweeteners would not do a massive difference in your patient so it is all about the calorie budget so you know even and it add on to the cost of the your management of the patients so in fact your patient should have a normal natural non-processed non-packed based diet they should be consuming as long as my patient is living within the calorie budget which I have designed for him I no need I don't need to use a non-nutritive sweetness because they are not the intervention which causes a massive difference now as a coming to your second part of the question yes this is a very very you know in fact it is not only fancy but also the glamorous food patterns which are being you know the propagated or discussed not only by the medical professionals but also every lay man is discussing these days about various eating patterns and even the social media has pulled off you know the various the freelance dietician or dietary advisors who you know propagate or tell us about various diets so there are certain diets which are being discussed like keto diet and Mediterranean diet dash diet that stands for dietary approaches to stop hypertension low carb diet very low carb diet low fat very low fat diet vegan vegetarian diet and non-vegetarian diet and even intermittent fasting patterns and all about this so basically so message is that again that is why I told earlier that we try to make the a nutritive approach towards a diabetic nutrition management to be try make it more often a complex approach however if we keep it as simple we would be you know fitting under all the good things which are included in these dietary patterns so important is that you know the patient should be living within that calorie budget and the quality of the food which we have a discuss should be focused on so as long as the patient is doing that he would be good enough so let's address the individual diet so it has been seen in the research that to an extent a Mediterranean diet means the what is a Mediterranean diet sir people who lived around the Mediterranean sea in the Europe it has been seen that these people used to consume or they do consume more fish and other seafood they consume plant-based diet they use olive oil as a principle source of dietary fat and they try to consume low red meat low you know the dairy products and rarely consume the highly dense concentrated sugars and honey and it has been seen that these patients and this was shown in a study in the predimate study that these patients had decreased occurrence of the diabetes mellitus and also the cardiovascular events and another dietary approach which is done is that dash dietary approaches to stop hypertension and in these patients these consumes more fresh foods vegetables low fat dairy and grains and poultry and fish is consumed in this type of dietary fat and it has been seen that it is helpful in you know the reducing the BP and when it comes to the other very very fancy diet which is a ketogenic diet what is a ketogenic diet it is being increasingly utilized and it says that about 70% of the calories when consumed from the fat means you are having a no carbohydrate but 70% of the calories you are taking from the fat and such translate into the weight reduction and people have seen that their glycine the diabetes also improve however in the medicine whatever we tell us to do is based only on the scientific research and evidence it produces so whatever evidence we have that the the final verdict is that there is no evidence supporting that it has a high major benefit with respect to diabetes management on the contrary it may be associated with a certain disadvantages and it has been seen that patients who consume keto diet they may have a keto flu which is manifested in the form of fatigue weakness GI disturbances and because patients these patients are not consuming whole grains, legumes, fruits which are proven as a cardiovascular benefit which we saw in a Mediterranean type of the diet hence because the deficiency of these important you know nutrient as well as it has been seen that selenium deficiency happen so these patients may have cardiac arrhythmia so the keto diet does not prove the test of the scientific evidence and even other diets except there's a some benefit which we have seen in the Mediterranean type the diet and the dash diet which we have seen so the final verdict is the name of the diet does not matter but the good part of the good constituent and the living within the calorie budget so these are important so can consuming more fresh fruits, vegetables you know whole grains limiting the you know consuming the lean proteins like poultry, egg white and avoiding you know the dairy products and the red meat and the energy dense or sugary grains and all would translate into better diabetic control and the so such kind of pattern may constitute whatever level of the pattern of the diet it may be but so that is the principle behind these dietary approaches towards the diabetes. So rightly said I think that should be understood that whatever be the nature of that only two aspects to them have been proven beneficial one how consistent the patient can be in following them for a long period of time and two what is the amount of calorie restriction that he is able to achieve in that period and I think that would mean a simplistic approach to diet and only then patient can comply for a long period of time. So I think we have approached the non-pharmacological aspects of management of diabetes with our comprehensive discussion that we've had today this is something that we must always understand very well ourselves to some extent follow in our day-to-day life so that we can explain to the patients and also make them comply and it's not just the first time that they come to us every visit we need to re-emphasize the importance of lifestyle modification diet and exercise to ensure that the patient continue to gain benefit throughout their lives. The next important aspect of diabetes management is drug therapy and this is something that we would like to leave for the next edition of our podcast so the simple fact that it's a very complicated field of numerous amounts of drugs that are available and more and more that are appearing every day we need to understand how these drugs act where do they act what are the benefits what are the contraindications and side effects for our students to actually become conversant with all the pharmacology that is associated with diabetes management. So Sandeep what we will do is that in our next edition we shall approach the drug therapy of diabetes and that's where we would start with understanding the various insulin secretobox the drugs which act through in-pritin mechanisms the SGLT2 inhibitors and of course the most important drug being insulin which we shall discuss in more detail. I'm sure today's podcast would have given them a great insight into understanding why we manage diabetes and once we start managing diabetes how important it is to approach it with the non-pharmacological means before going into the drug therapy. So thank you Sandeep for this time that you have made for us and I'm sure the students would have benefited greatly. Thank you sir. Thank you for the opportunity sir.