CME INDIA Presentation by Dr. Basab Ghosh, Senior Diabetologist, Agartala, Tripura.

Diabetes management is based on understanding of three pillars.

Medical research is going on to give better treatment to the mankind. Clinicians regularly update themselves to deliver better service to their patients. But what about the approach of the patients towards their own treatment? Only medicines cannot keep a diabetic fit. Diabetes management is based on understanding of three pillars – firstly, diabetes education about the disease, needs of regular medication, how to prevent its complications, etc; secondly, regular exercise and, thirdly, timely modified diet.

If one pillar is missing or fragile, the assembly of diabetes management will have poor outcome. Do the patients follow the advice (medical counseling) before coming to the conclusion that it’s a treatment failure? A cardiac patient advised to stop smoking! A liver disease patient is advised to stop alcohol! Pan masala, Gutka, Khaini, etc. are strictly not to be taken in food pipe related cases! Yes, the concerned doctors never get tired to take the strain to explain those life-style modification tips to the patient – why, because lifestyle modification by medical-counseling is the first line treatment for those cases!! Are the patients serious enough to believe those words (medical-counseling) from the experts and tell themselves – “let us follow it seriously to have a beautiful life”?

I met one Member of Parliament, a retired IPS, in Chennai. He was suffering from very high cholesterol level and being an energetic young expert advised him – what to do and what not to do! At the end of my strenuous lecture, he coolly looked at my eyes and said, “… dekh beta, mai har roti pe do chamoch ghee leta hu…. uske baujut agor mera cholesterol control ho sakta hai to dubara eha aunga, nehi to Delhi pe elaj karaenge.” I accepted this slap on my medical knowledge and ensured him the medicine will do the miracle!! (Otherwise, my Director will teach me a lesson, for non-commercially dealing a regular VIP client!!!)

Diabetes education:

The spiritual leader Ramakrishna Paramahamsa explained medical-counseling in the best possible way in “Sri Sri Ramakrishna Kathamrita”, in the chapter “Brahmacharya” to explain tomogun (pride). One group of doctors does not tell anything to their patients if they do not take medicines properly; they are the “Adhom baidya” (Worst category doctors) according to Ramakrishna Paramahamsa. Another group tries to explain the patients politely the consequences of not been having the medicines correctly; they are the “Modhyam baidya” (Middle category doctors). The “Uttam baidya” (Best category doctor) would force ruthlessly the patients to have the medicine correctly because the doctor knows those medicine would save the life of the patient! Strict medical-counseling is must in diabetes management.

Diabetes education is nothing, but methodical medical-counseling and it always pays off! Diabetes practice without diabetes education is impossible; in fact, any chronic disease requires strict counseling from day-1 as well as follow-ups. Research shows diabetes education increases adherence to treatment and ultimately gives better outcomes.

Exercise:

Regular exercise in the form of 30-minute brisk walking daily, at least five days in a week, is very essential for anybody including diabetics and it is medically proven in evidence-based medicine (Fig 1). Due to exercise our heart pumps well and whole body is oxygenated to have a better overall outcome. Our muscles sensitivity improves, so it utilizes body insulin properly to have a better blood sugar level, which is the ultimate target for diabetes treatment. I tell my patients do any exercise, but do it regularly! Regularity is essential for body physiology. Gardening, car washing, washing clothes, cleaning floor, doing household works, all are very good exercise – do it regularly! 

Fig 1: Exercise 30 minutes daily at least 5 days in a week

Diet:

Diet is an important parameter to keep ourselves fit. We must know what we are eating! However I believe at what time we are eating is equally important to maintain normal body physiology. Breakfast is very essential and it should be balanced with nutrients. It is medically proven with evidence that skipping breakfast is an important cause of obesity. Even when we skip breakfast that disturbs our blood sugar levels. Timely breakfast is very important to maintain normal body physiology. Three major meals – breakfast, lunch and dinner along with four to five intermediate snacks every day is ideal diet pattern. But that intermediate snacking is not in many of my patients’ daily routine – they believe in two to three major heavy meals in a day and that’s it!! One of my American friends once told me “What you eat in three meals we consume that in 13 portions!”

One third of the total daily diet portions should be covered by green leafy vegetables (Fig 2) and fruits (Fig 3). Approximately 3-5% of total daily calories should come from fruits. The sugar and calorie content of fresh and dried fruits are the main difference between them. The drying process causes the fruit to lose water mass and volume, making the sugars and nutrients more concentrated. As a result, dried fruits contain more calories and sugar than fresh fruit. However, it does not mean they are less healthy for people with diabetes. It is essential to note that dried fruits can be a nutritious and diabetic friendly snack if consumed in moderation.

Fig 2: Green leafy vegetables and salad.

Fig 3: Fruits are must in the daily diet.

The food pyramid (Fig 4) has been used for years by the American Diabetes Association to promote “healthy” diabetic eating, to guide the eating habits of the overall population. And this food pyramid is attractive and reliable for dietary guidelines worldwide.

It has long been based on the following food groups:

• 6-11 servings of grains and starches per day
• 3-5 servings of vegetables
• 2-4 servings of fruit
• 2-3 servings of milk
• 4-6 oz of meat and meat substitutes
• Fats, sweets and alcohol should be a special treat

Fig 4: Food pyramid. Daily what to eat! 1 Serving = 200ml cup size.

What is a Serving?

Grains: 6 ounces per day. One serving sizes = ½ cup cooked rice, pasta or cooked cereal; 1-ounce dry pasta or raw rice; 1 slice bread; 1 cup ready-to-eat cereal flakes. 1 ounce = 30 gr. 1 cup = 200ml volume.

Vegetables: 2 ½ cups per day. Serving sizes = 1 cup equivalent of vegetables is 1 cup raw vegetable or vegetable juice, 2 cups leafy salad greens. 1 ounce = 30 gr. 1 cup = 200ml volume.

Fruits: 2 cups per day. Serving sizes =1 cup equivalent is 1 cup fruit or ½ cup of 100% fruit juice (orange juice, etc.) or 1/3 cup of a fruit juice blend. 1 ounce = 30 gr. 1 cup = 200ml volume.

Protein foods (meat, poultry, fish, dry beans and nuts): 5 ½ ounces per day. Serving sizes = 3 ounces cooked lean meat, poultry or fish; 2 egg whites or 1 complete egg; ¼ cup cooked beans; 1 tbsp. peanut butter; ½ ounce unsalted nuts / seeds. Note that ¼ cup cooked beans = 1 ounce protein equivalent but ½ cup cooked beans = 1 vegetable. 1 ounce = 30 gr. 1 cup = 200ml volume.

Fat-free or low-fat dairy foods (milk, yogurt and cheese): 3 cups per day. Serving sizes: 1 cup equivalent is 1 cup milk or yogurt, 1½ ounces natural cheese such as cheddar cheese, or 2 ounces processed cheese. 1 ounce = 30 gr. 1 cup = 200ml volume.

The serves of grains and starches has become a little less in recent years but is still promoted as the predominant “base” of most healthy diets. A diabetic meal plan comprises a balanced diet plan such that there are the right amounts of proteins, carbohydrates, fat, fibers, and minerals. The diabetes food pyramid gives full information on the diabetic diet plan that helps the patient in getting the proper amount of energy and helps to control diabetes properly. The takeaway message is, “Eat all but in moderation.”

References:

1. https://diabetes.org/newsroom/press-releases/2022/american-diabetes-association-2023-standards-care-diabetes-guide-for-prevention-diagnosis-treatment-people-living-with-diabetes
2. https://www.thehealthsite.com/fitness/the-food-pyramid-the-secret-to-eating-healthy-and-losing-weight-43472/
3. Sri Sri Ramakrishna Kathamrita

Discover CME INDIA

• Explore CME INDIA Repository
• Examine CME INDIA Case Study
• Read History Today in Medicine
• Register for Future CMEs

Get CME INDIA Highlights

Curated articles in your inbox.

SUBSCRIBE!

You have Successfully Subscribed!