Frequently Asked Questions About Diabetes

Diabetes is a chronic disorder affecting a large number of people in India today. The body is unable to utilise and store glucose (a form of sugar) properly. Thus, glucose levels in the blood stream remain high. This is detrimental in many ways to many organs as it affects mainly the blood vessels, among other things.

We recognize three major types of diabetes:
1. Type 1 (formerly called juvenile-onset or insulin-dependent) diabetes, the body completely stops producing any insulin, a hormone that enables the body to use glucose found in foods for energy. Insulin is usually produced by cells in the pancreas and these cells are destroyed in type 1 diabetes due to an attack by the person’s own immune system. Therefore, patients with type 1 diabetes must take daily insulin injections to survive. This form of diabetes usually develops in children or young adults, but can occur at any age. It is relatively less common as compared to type 2 diabetes.
2. Type 2 (formerly called adult-onset or non-insulin-dependent) diabetes results when the body doesn’t produce enough insulin and/or is unable to use insulin properly (insulin resistance). This form of diabetes commonly occurs in people who are over 40, overweight, and have a family history of diabetes, although today it is increasingly occurring in younger people, particularly adolescents. In India, Type 2 diabetes occurs much earlier than in Western countries. Treatments aim to both increase insulin sensitivity as well as increase insulin secretion by the pancreatic cells. Type 2 diabetes is very common, and recent reports suggest that about 10% of the population suffers from it.
3. Gestational diabetes mellitus (GDM): Diabetes recognised for the first time in a pregnant woman who did not have diabetes before she was pregnant. It can occur at any stage of pregnancy, but is more common in the second half. GDM usually disappears after delivery but women with GDM have higher chances of developing diabetes in future.

Prediabetes denotes that blood sugar levels are high, but not high enough to be labelled diabetes. It is usually present before one develops diabetes and is asymptomatic. However, knowing one has prediabetes is a ‘reality check’ as it is a good time to include lifestyle interventions and preventing more serious problems later.

Diabetes is a multifactorial disease and does not have a single cause. Genetic makeup, lifestyle choices, environmental factors in your childhood and adult age and ethnicity are all known to contribute.
Type 1 diabetes is caused by the immune system destroying the cells in the pancreas that make insulin. This is called an ‘autoimmune’ cause, because the body’s immune system is wrongly attacking itself.
There are a variety of ‘risk factors’ for type 2 diabetes, any or all of which increase the chances of developing the condition. These include obesity, sedentary lifestyle, increasing age and wrong diet. Research from our unit shows that both undernutrition during pregnancy as well as diabetes in mother during pregnancy increases diabetes risk in future. Many of these risk factors can be modified, therefore reducing future risk.

Diabetes is detected by laboratory tests that demonstrate a higher than usual blood sugar level. This can be done with the following measures:
Diabetes is diagnosed at fasting blood glucose of greater than or equal to 126 mg/dl. This is measured from blood sampled after 8 hours of fasting. Alternatively, a random or 2-hour post-meal blood glucose level of more than 200 mg/dl also signifies diabetes. The glycosylated hemoglobin test measures your average blood glucose level over the previous 2-3 months. An HbA1C level of more than 6.5% signifies diabetes. This test need not be done in fasting condition.

Often there are no symptoms in diabetes and it is diagnosed by a routine blood test. However, some patients frequently can experience the following symptoms:
§ Increased thirst
§ Frequent urination
§ Feeling hungrier than usual
§ Weight loss
§ Tingling or numbness, clumsiness in the hands and feet
§ frequent infections (skin infections, respiratory infections, urinary tract infections)
§ wounds that don't heal for long periods of time.
§ extreme unexplained fatigue

Diabetes can lead to many complications in different organs if poorly controlled. This includes but is not limited to the heart (heart attacks, heart failure), the nervous system (strokes, nerve damage), eye (cataract, nerve blindness), kidney failure, and blood vessel of the limbs that may require an amputation, and impotence in men. If people keep their blood glucose as close to normal as possible, they can reduce their risk of developing some of these complications.

Fasting blood sugar of less than 100mg/dl and 2 hours post meal sugar of less than 140 mg/dl is considered normal.

Blood sugar targets are the range that the blood glucose should fall into most of the time. Targets for those with Diabetes-

Pre-meal	2 hrs Post meal	HbA1c
90 to 130 mg/dl	< 180	< 7 %

Sugar targets should be individualised for people with diabetes depending on their specific needs and type of diabetes.
Target blood sugar range for those with type 1 diabetes

Age	Fasting BSL (mg/dL)	PP BSL (mg/dL)	HbA1c
Pre-school (Below 5 years)	100-180	110-200	Below 8.5 but more than 7.5
School going (5 – 12 years)	90-180	100-180	Below 8
Adolescents (Above 13 years)	90-130	130-180	Below 7

Target blood sugar range for those with gestational diabetes mellitus (GDM)

Pre-meal	2 hrs Post meal	HbA1c
≤ 90 mg/dl	≤ 120 mg/dl	≤ 6.0 %

Target blood sugar range for those with type 2 diabetes

Pre-meal	2 hrs Post meal	HbA1c
90 to 130 mg/dl	< 180	< 7 %

People with Type 1 diabetes should monitor blood sugar three to four or more times a day. Preferable before every meal and at bedtime.
Women with gestational diabetes (GDM) should test as often they need / as much as possible (4 times a day, fasting + 3 Post meals)
People with Type 2 diabetes should monitor blood sugars at least twice a week at different time of a day. It is also recommended to test blood sugar both - before and after a particular meal to know the effect of food on blood sugar.
Testing frequency may need to be increased during illness, when blood glucose levels are out of range, when activities vary from the usual routine.

Glucometer is a device to measure blood sugar level. Glucometers are small and portable. The results are available in just few seconds. Glucometers are very easy to use and can be used for monitoring of blood sugar levels at home.

Glucometers are reliable if used properly. As we test capillary blood in glucometers and in lab the blood from veins is used for testing, 10% difference in glucometer and lab readings is acceptable. There are many glucometers available in the market. Each meter has its own specific technique. Following the instructions in user manual is very important to get the correct results. It is also important to use glucometer strips before expiry date and store them appropriately.

Normal blood sugar level is in the range of 70- 110 mg/dl. If blood sugar level falls below 70 mg/dl, it is called as hypoglycaemia.

When the patient feels the symptoms, he should check his sugar level on a glucometer and then eat one of the food items mentioned below:
§ 3 teaspoons of glucose powder as it is or in water
§ 3 teaspoons of sugar or powdered sugar
§ 1 tablespoon of Jam
§ 1 tablespoon honey
§ Half a cup of fruit juice
It takes time to release sugar in the blood. After 15 minutes of eating, check the sugar level once again. During the meantime, remain silent without doing much movement or any other activity. If the BSL has not reached level of about 100mg/dl, again eat one of the food items and then check after 15 minutes whether the BSL has increased to more than 100 mg/dl.
In severe hyperglycaemia when there is loss of consciousness or seizures, it may be necessary to consult the doctor and to give 50% or 25% dextrose in the hospital.

When the patient feels the symptoms, he should check his sugar level on a glucometer and then eat one of the food items mentioned below:
§ 3 teaspoons of glucose powder as it is or in water
§ 3 teaspoons of sugar or powdered sugar
§ 1 tablespoon of Jam
§ 1 tablespoon honey
§ Half a cup of fruit juice
It takes time to release sugar in the blood. After 15 minutes of eating, check the sugar level once again. During the meantime, remain silent without doing much movement or any other activity. If the BSL has not reached level of about 100mg/dl, again eat one of the food items and then check after 15 minutes whether the BSL has increased to more than 100 mg/dl.
In severe hyperglycaemia when there is loss of consciousness or seizures, it may be necessary to consult the doctor and to give 50% or 25% dextrose in the hospital.

§ Self monitoring of blood glucose is very important.
§ Check the blood sugar in the night time before sleeping to avoid hypoglycaemia in midnight. BSL should be above 150 mg/dl . So the risk of getting hypoglycaemia becomes less.
§ People who are on NPH insulin injection should also check sugar before sleeping. Due to new insulin analogues the incidence of hyperglycaemia has reduced a lot.
§ Blood sugar level should be checked during or after intense exercise.
§ Teaching patients with diabetes (who are on insulin treatment) to balance insulin dose and carbohydrate intake are necessary to prevent hypoglycaemic episodes.

§ In small children, consistent hypoglycaemia can affect their mental and psychological growth.
§ In heart patients, besides the typical physical discomfort, it can be mistaken as to be a heart attack.
§ If there are consistent hypoglycaemic attacks, gradually a patient is unable to recognise the hypoglycaemic attacks. This is called as hyperglycaemia unawareness.
§ Hypoglycaemia may increase the risk of harm to self or others, such as with driving.

Hyperglycaemia means increased blood sugar levels. Increase blood sugar level happens when the body has too little insulin or when the body can’t use insulin properly. Hyperglycaemia is generally a blood sugar level higher than 200mg/dl. But symptoms may not be noticeable until even higher values such as 250 to 300 mg/dl. Glucose levels that are considered to be to hyperglycaemia can vary depending on type of diabetes. However chronically increased blood glucose levels can produce noticeable organ damage over time.

Common symptoms of hyperglycaemia include:
§ Increased thirst
§ Increased hunger
§ Frequent urination, nocturia
§ Blurred vision
§ Numbness or tingling in the feet
§ Unintentional weight loss
§ Fatigue

Treatment of hyperglycaemia includes:
§ Diet control
§ Regular physical exercise
§ Monitoring of blood sugar levels regularly and annual medical checkups
§ Taking medication as directed by the physician, adjusting insulin dosage
§ Knowing the basics of hyperglycemia (awareness)
Prevention of hyperglycemia includes similar measures like diet and weight control, regular physical activity, monitoring and awareness.
Treatment of acute hyperglycaemia :
If the blood glucose levels are showing HI on glucometer, please check your urine for ketones. Hyperglycaemia with ketones can be a serious problem if you do not treat it. So it is important to consult your doctor immediately. If you fail to treat hyperglycaemia, a condition called Ketoacidosis (diabetic coma )would occur.

Diabetic ketoacidosis is a life-threatening condition. Ketoacidosis develops when your body doesn’t have enough insulin. Without insulin, your body can’t use the glucose for fuel, so your body breaks down fats for energy. When your body breaks down fats, a waste products called ketones are produced. Unfortunately, the body cannot release all the ketones and they build up in your blood which can lead to Ketoacidosis.
Symptoms include:
§ Shortness of breath
§ Pain in abdomen
§ Nausea and vomiting
§ Very dry mouth, fruity smell to breath
Diabetic ketoacidosis needs immediate treatment in the hospital settings.

Increased blood sugars over a long period may damage nerves in the legs and feet. A person might not feel sensations like cold, hot or pain. Therefore diabetic patients are prone for infections. Diabetes may also reduce blood flow to the feet making it even harder to heal any injury or infection. Therefore people with diabetes must take proper care of their feet.

Following guidelines are important for foot care:
§ Don’t walk bare feet.
§ Everyday Check your feet for Blisters, cuts, friction marks, redness or swelling.
§ Wear footwear which is comfortable for you. Avoid footwear with high heels. Don’t wear same footwear all the time.
§ Wear cotton socks of ankle length and soft elastic.
§ Change the socks every day.
§ Wash your feet with mild soap and tap water. Make the skin dry, dry the web spaces and apply moisturiser lotion except web spaces.
§ Cut the nails after bath. Don’t cut the ends.
§ Avoid hot fomentation by hot water, hot water bottle or keeping feet in hot water.
§ Avoid self-medication for corns, calluses or ulcers.
§ Visit holy places early in the morning or in the evening to avoid burn injuries which are common because of bright sun.

Diabetes affects all parts of body from eyes to feet. If we do the regular checkups we can detect the effect of diabetes at early stage and take necessary precautions to prevent the complications.

Following tests should be done once a year by a person with diabetes:
§ Hemogram
§ HbA1c (every quarterly)
§ Urine routine
§ Urine Albumin Creatinine Ratio (UACR)
§ Serum Creatinine
§ Lipid profile
§ Electrocardiogram (ECG)
§ Dilated fundoscopy (Eye checkup for retinopathy)
§ Foot examination
§ Blood Pressure (should be checked at each consultation).
*Doctors may suggest additional tests based on symptoms and existing complications.

HbA1c test measures the amount of blood sugar attached to hemoglobin. HbA1c test shows average amount of glucose attached to hemoglobin over the last three months. E.g. HaA1c of 8 means average of last 3 months blood sugar is ~180 mg/dL.
It's a three-month average because life span of red blood cell is 3 months. If blood sugar levels have been high in recent weeks, HbA1c will be greater.

HbA1c measures average blood glucose level over last 3 months so can be tested every 3 months.
The HbA1C test should be done at least two times a year if sugar control is good.
The HbA1C test should be done every 3 months if treatment is changed or if sugar control is not optimum.

HbA1c target for a person with diabetes is 7%.
More stringent HbA1C target of 6.5% can be set for those with short duration of diabetes; type 2 diabetes treated with lifestyle or metformin only, gestationsl diabetes (diabetes in pregnancy), long life expectancy, or no significant cardiovascular disease.
Less stringent A1C goal 8% may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin.

Three landmark trials (Action to Control Cardiovascular Risk in Diabetes [ACCORD], Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation [ADVANCE], and Veterans Affairs Diabetes Trial [VADT]) showed that lower A1C levels were associated with reduced onset or progression of some diabetes complications.
HbA1c correlates well with the risk of long-term diabetes complications. Elevated HbA1c has also been regarded as an independent risk factor for coronary heart disease and stroke in subjects with or without diabetes.
Two large-scale studies - the UK Prospective Diabetes Study (UKPDS) and the Diabetes Control and Complications Trial (DCCT) - demonstrated that improving HbA1c by 1% for people with type 1 diabetes or type 2 diabetes cuts the risk of microvascular complications (effect of diabetes on eye, nerves, Kidney)by 25%.
Research has also shown that people with type 2 diabetes who reduce their HbA1c level by 1% are 43% less likely to suffer amputation or death due to peripheral vascular disease.

HbA1c can be improved by following tips:
1. Reduce carbohydrates in diet
2. Do daily physical activity for at least 30 min
3. Follow treatment plan given by physician
4. Check blood sugar levels regularly

Yes. Diabetes can be prevented or its onset can be delayed by practicing a healthy lifestyle and achieving ideal body weight.

Lifestyle management is important for prevention of diabetes. Healthy lifestyle includes a balanced diet and regular physical activity.
A. Balanced diet: right combination of carbohydrates, proteins and fats in your food plate.
- Avoid simple carbohydrates such as simple sugars, sweets, jaggery, bakery products, starchy foods (baked potato, sago), outside foods.
- Include more of complex carbohydrates in your daily diet such as whole grains (brown rice, daliya, unpolished grains and millets), whole wheat flour.
- Include fibre rich foods such as leafy vegetables, salads, sprouts, fruits in your daily diet.
- Increase the amount of proteins by including milk and milk products, non-vegetarian foods, pulses and legumes, nuts in your daily diet.
B. Exercise:
- Combination of aerobic exercises and muscle strengthening exercises.
- Regular exercise 30 min daily at least five times a week should be performed.

In its early stages diabetes can be reversed with stringent lifestyle modifications. To maintain the reversal, long term abidance with healthy lifestyle is necessary. Long standing diabetes is difficult to cure or reverse. It can be controlled well healthy lifestyle.

Person with diabetes can perform aerobic exercises (walking, running, jogging, and swimming) as well as muscle strengthening exercises (weight bearing, pull ups, push ups). A prior consultation with a doctor and physiotherapist is recommended to find out safe exercise options.

1. Patients with diabetes and active proliferative retinopathy should avoid activities that involve strenuous lifting; harsh, high-impact activities; or placing the head in an inverted position for extended periods of time.
2. Peripheral neuropathy may result in reduced sensation and position awareness of your feet. Repetitive exercise on insensitive feet can lead to ulceration and fractures. In this case it is advised to limit the choice of exercise to low impact or non-weight bearing activities.
3. Patients with high blood pressure and/or heart disease should avoid strenuous and weight bearing exercises and should gradually increase the intensity of their exercises.
4. Patients with diabetes complications should discuss with their health care professionals before beginning any fitness program.
5. Individuals with type 1 diabetes should avoid exercise if fasting blood glucose is higher than 250 mg/dl and ketones are present. Caution should be used if glucose levels are higher than 300 and no ketones are present.
6. Individuals with type 2 diabetes should avoid exercise if blood glucose is higher than 400 mg/dl. Monitoring blood glucose before, after and possibly during physical activity is necessary to keep blood glucose within an appropriate range.
7. In case of hypo (blood sugar less than 70), it is recommended to correct it first and start exercise only after reaffirming the safe blood sugar. If blood sugar is low (less than 100), it is recommended to eat something before starting exercise.
8. Always consult with an exercise or health care professional before beginning any fitness program.

§ If your blood sugar level is less than 100 mg/dl prior to exercise, have a carbohydrate snack before starting the exercise.
§ If your blood sugar level is higher than 100 mg/dl before exercise, it may not be necessary to take a carbohydrate snack before a light exercise session, but you may need extra carbohydrates during or following the exercise.
§ For long duration and/or high intensity exercise sessions, consume carbohydrate snacks during the activity and also check your blood sugar levels.
§ To avoid hypoglycaemia episodes, check blood sugar level before exercise.
§ If you experience hypoglycemia during exercise then treat it.
§ Always carry a fast-acting carbohydrate food such as glucose tablets or glucose powder when exercising to treat hypoglycaemia.
§ Keep yourself hydrated by sipping on fluids during exercising.

Not directly. Type 2 diabetes occurs when insulin action in your body is impaired, leading to high blood sugar levels. If you eat a lot of sugar, you can put on weight and fat which in turn can lead to impaired insulin action (insulin resistance) and may lead to diabetes. Thus, there is an indirect relation.

A person with diabetes needs to follow a healthy diet plan with the right combination of carbohydrates, proteins, and fats. Such a diet is equally healthy for other members of the family. Thus, it is not recommended to cook separately for a person with diabetes, but the entire family should adapt to a well-balanced diet regimen. Following principles are especially important:
1. Avoid simple carbohydrates such as simple sugars, sweets, jaggery, bakery products, starchy foods (baked potato, sago), and outside, packaged foods.
2. Include more of complex carbohydrates in daily diet such as whole grains (brown rice, daliya, rolled oats), whole wheat flour.
3. Include fibre rich foods such as leafy vegetables, salads, sprouts, fruits.
4. Add proteins by including milk and milk products, non-vegetarian foods, pulses and legumes, nuts in the diet.
5. Remember a healthy plate method where only 25% of your plate should be filled with grains, 25% with protein sources and remaining 50% with salads, vegetables and fruits.

There are no such foods which a person with diabetes should avoid completely. A person with diabetes can even enjoy sweets occasionally by balancing the amount of carbohydrates in the diet.

• Moderation is the key as far as the safety of consuming the sugar free tablets is considered.
• There are some disadvantages of consuming them frequently. Most of the sweeteners, with the exception of sugar alcohols and stevia, are artificial chemicals not found in nature. Our body is unable to absorb them.
• Artificial sweeteners may also lead to food cravings. Research has shown that brain reacts the same way to artificial sweeteners that it does with sugary sweets. Consuming them often may lead to an increased desire for high-calorie foods.
• The American Dietetic Association states that children under 2 years of age, pregnant women and lactating women should not use artificial sweeteners, even though they are deemed safe by the FDA.
• More studies need to be conducted, but scientists believe that there is also a relationship between sweeteners and certain cancers, chronic fatigue syndrome, Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, autism, etc.
• A nutritionist should be consulted before adding these sugar alternatives into a regular diet to ensure that the benefits outweigh the risks.

• Fenugreek seeds may be helpful to people with diabetes. The seeds contain fiber and other chemicals that may slow digestion and the body’s absorption of carbohydrates and sugar. The seeds may also help improve the way body uses sugar and increases the amount of insulin released.
• The amount of fenugreek seeds used in cooking is generally considered safe. When taken in large amount, it can lead to problems like acidity, bloating, some allergic reactions and it can also react with several medications, especially with those that treat blood clotting disorders and diabetes.
• You can take 2 teaspoons of fenugreek seeds (sprouted form) just before or during your meal. Don’t take it on empty stomach if you experience acidity.

• No. Consuming karela and neem leaves cannot cure diabetes.

• Yes. A person with diabetes can eat rice. Prefer brown/ unpolished and long grain (e.g. basmati) or parboiled rice as these varieties have lower glycemic index compared to the polished and short grain (e.g. ambemohor) white rice.
• Consuming these types of rice in moderate quantity will not increase blood sugar levels very rapidly.
• If you want to consume white rice, then restrict the amount of rice to only ½ katori or add lots of vegetables, dals, or sprouts to it to lower it’s glycemic index.

• A person with diabetes can enjoy sweets occasionally by balancing the amount of carbohydrates in the diet.
• If you are planning to eat sweets, then cut down on other carbohydrates in the meal such as rice, chapatti, bhakri, fruits etc.
• Add more amount of fibre and proteins in your food plate.

While jaggery is less processed than sugar, both are fast acting carbohydrates. They have similar glycaemic index (both raise sugar in similar manner). Thus should be used sparingly.

Mental stress can occur when a person has to face the demands of a changed life situation. Getting diagnosed with diabetes imposes new demands on a person such as a change in diet, lifestyle, having to take insulin etc. and adjusting to these can be a source of stress.
It is known that people with diabetes have a 30% higher chance of developing stress disorders such as depression and anxiety.
Stress is also one of the factors which increase a person’s risk of developing diabetes.

It is important to care for both physical & mental health in diabetes. Stress can affect your diabetes control in many ways:
a) Sugar levels not getting controlled despite regular medicines.
b) Recent increase in sugar levels which was controlled earlier.
c) Reduced motivation to comply with diet and physical activity advice.
d) Increased risk of complications of diabetes such as cardiovascular diseases and stroke.

Common symptoms of stress in diabetes are:
a. Disturbed sleep, disturbed or altered food intake.
b. Excessive worry, increased heartbeat, sweating of hands, dryness of mouth.
c. Feeling sad, lack of energy, loss of interest in activities, negative thoughts.
d. Increased use of substances such as alcohol, nicotine, caffeine.

a. Evaluation for identifying causes for stress.
b. Treatment for Depression, Anxiety if present.
c. De-addiction treatment for substance use.
d. Following Sleep Hygiene, relaxation techniques and learning to manage emotions and relationships.
Professional help is available to manage stress in diabetes. Do not hesitate to talk to your doctor or psychologist if you are stressed.