Friday, May 10, 2013
Sunday, March 20, 2011
by Dr Unnikrishnan A.G
Diabetes educators are a new group of health professionals who are changing the diabetes management scenario in India. Though, in Western countries, they have been around for decades, it is only now that their presence is required urgently in India. This is because the prevalence of diabetes is rapidly increasing in our country and we now need the help of doctors, diabetes educators , nutritionists as well as other allied health professionals to control this epidemic of diabetes.
Who is a diabetes educator?
It is well known that the health of the diabetic subject is in his or her own hands. This is the concept of “Self Management”. Many patients feel that self-management means that they are free to decide and choose what therapy they must take (or must not take!). While this is true to an extent, the actual meaning of self-management is that a diabetic patient becomes informed, and updated about his or her illness, which helps them to take charge of their diabetes. Essentially, this means that patients watch their own nutrition, sugar, exercise, and become compliant with medication. Self-management leads the way for good health and independence in making the right lifestyle choices.
However, this means several hours or even weeks or months of diabetes education to the patient. A single visit and a prescription from a doctor might help in short-term control, but a lifetime of diabetes needs a more rigorous adherence to drugs and lifestyle modifications. This is where a new breed of professionals, called diabetes educators make their mark. The diabetes educators are the interface between the doctor and the patient. They help the patient to understand the disease, adhere to the doctors advice and even in successfully maintaining glucose control by improving the home blood glucose monitoring.
All over the world, diabetes educators are in great demand, as research has shown that they help the patient to understand diabetes, as well as empower him to adhere to medication, lifestyle changes as well as home blood glucose monitoring.
What do diabetes educators do?
Diabetes educators could be trained-graduates, health professionals, nurses, dietitians, pharmacists, exercise specialists, doctors, and social workers. In general diabetes educators are people who have been trained in assisting with the care of diabetic patients. They help diabetic subjects in living a healthier, more fulfilling life with diabetes.
Diabetes educators work in a many places. You could find them in our hospital teaching patients in group classes. Sometimes they could work with patients individually. They also help the doctor, and are found in the diabetologists’ clinics.
One of the most useful roles for a diabetes educator is in helping you cope with the diagnosis of diabetes, when it is first detected. They will impart the necessary knowledge and skills that you require. Most importantly, they help the patient to be independent by teaching them self-management skills throughout their lifetime of living with diabetes. .
How does a diabetes educator go about his or her task?
The first task that the diabetes educator undertakes is to try to know you as an individual. Next the diabetes educator will help you to tailor create a self-management plan that works for you, and is based on your age, work schedule, your daily activities and eating habits, or if you have another coexisting medical illness. All your family members must ideally interact with the diabetes educator and learn more about diabetes management: techniques and timing of injecting insulin or taking diabetes pills. The diabetes educators will also help you to make healthy food choices, and assist you in bringing about a good exercise schedule and also teach you about self-monitoring your blood sugar. Finally, the diabetes educator helps you to decide and understand when you need to call your doctor to report a change in your health status.
Adjusting emotionally to diabetes
It’s all in the mind, said a wise person. Research has now shown that happiness is not linked to fame or money or success or a good family backing, but is linked to how satisfied you are with your present life status. In other words, whatever the problems that you encounter, if you are contented, you’ll still be happy!! This is called the “emotional quotient” as opposed to the “intelligence quotient”. Extensive research has also shown that subjects who are emotionally well-adjusted tend to live longer than dissatisfied sulkers. The diabetes educator plays a crucial role in helping the patient to achieve emotional adjustment with the disease.
The cricket coach concept
In this regard, the role of a diabetes educator is similar to that of a cricket team’s coach. The diabetes educator helps you and your family to win the match against diabetes!! For instance, many a diabetic has fallen prey to the syndrome of “denial”. In the early stages, when a patient has been recently found to have diabetes, in some cases, he or she repeatedly checks sugars several times over several months, till the diagnosis is established without doubt, i.e. when some problem happens. By then, several months of high blood sugars have ensued, and this often sets in an irreparable cascade of damage to organs like eyes, kidneys, heart and nerves. In some patients, this period of denial can last for years, and it is not very uncommon to see patients who have had uncontrolled sugars for 4 or 5 years, coming to a doctor only when they develop life threatening complications. The diabetes educator also helps the patient come to terms with diabetes.
Diabetes educators help your family too. For, in essence, the lifestyle recommended for diabetes is a model lifestyle that is meant for all people. For instance, it has already been well proven in research studies conducted in the United States that diet control and exercise can prevent diabetes. In other words, if our family members were to make healthy food choices, they could prevent diabetes. Our children would grow and develop as they would if they didn't have diabetes!!! With your doctor’s approval, the diabetes educator interacts with the dietician to make a personalized meal plan, and also interacts with the physiotherapist to make a good exercise schedule keeping in mind the lifestyle of the patient.
Many patients have several questions and points to clarify, even after they have left the hospital. For instance, what should you do when you feel that your blood sugars are low ? How is an insulin syringe used? Where can you inject insulin? How do your diabetes pills work and when should you take them? Diabetes educators can teach you about all your diabetes-related medication. In coordination with the doctor, they help you to make the right decisions.
Self-management of blood sugars
As doctors, we do come across the occasional motivated patient who is able to control their diabetes by regularly checking blood sugar and readjusting insulin. With the advent of diabetes educator, assisted by the telephone, these patients can benefit by clearing their doubts and learn about glucose monitoring. A diabetes educator can help you learn about buying and using a glucometer. Also, the diabetes educator helps you to readjust your diet and exercise based on your glucose profile. You can clarify your questions and also find out how individual foodstuffs, stress and medicines affect glucose control.
A diabetes educator provides support and encouragement. You can talk to him or her about your fears about diabetes. They often help to reassure you, and make you understand that these emotions are normal. When your diabetes is out of control, the doctor helps you by treating the illness. However, the diabetes educator helps you to cope with the stress of the problems that you encounter. New life events, like taking up of a new job, a new residence or a new school can cause anxiety about the revelation of the disease, and also about healthy choices. The diabetes educator helps you plan and adjust your life for these events.
The diabetes educator tailors your lifestyle and activities to suit your illness. Diabetes educators understand that each patient is different. They for instance will understand the special needs of the older people, of small children and of pregnant mothers. They are able to adjust and get along with people from different cultures, classes and regions. In other words, they are a secular group, who serve the patients irrespective of class, creed, religion or economic status. At our institute, we have started the diabetes educators training course, and have found that they are a group of smart, intelligent and friendly persons, who are ushering in a new era of diabetes management. These health professionals are part of the new changes in diabetes management, and herald a new generation, who will finally make sure that the diabetic patient is empowered to make the right choices for their health-related requirements.
Wednesday, November 10, 2010
Monday, March 3, 2008
Imagine two people working in the same office, sitting behind a computer. Both are young, middle aged men of the same height. Both start working at 8.30 am and go home at 5.30 pm. Both have thin parents. Let us further imagine that both do not do rigorous exercise or indulge in competitive sports. For a moment, may I ask you to further consider that both eat food in similar quantities. However, what if their weights were to be different? What if one of them, Mr. A, were have a weight of 66 kg, and the other gentleman (Mr. B) were to be 90kgs in weight? This is important, because obesity and diabetes (and heart disease and hypertension) go hand-in-hand.
You will agree that this situation is not uncommon. Haven’t we seen people eating and eating but remaining thin? Haven’t we seen fat people doing morning walks, making us wonder why they are still fat? It is quite easy for people to say that this is “hereditary”, but it is quite common to see siblings with different body weights. As a doctor, I often see brothers and sisters with very different body fat measures.
What is the reason for this? Well, emerging research seems to offer a NEAT solution to this problem. The concept of NEAT or Non-Exercise Activity Thermogenesis is fast catching on worldwide, leading to sweeping policy changes by corporate decision makers and human resource development staff worldwide.
NEAT is Non-Exercise Activity Thermogenesis
What is NEAT? To begin with, everyone understands that if we take in too much energy, but do not spend it with activity, we will become fat. Well, all of us have one major source of energy: food or calorie consumption. And this energy is expended in 3 ways: firstly by the energy needed to digest food (diet induced thermogenesis), which is a miniscule aspect. Secondly is the exercise that we carry out, which can help us to lose energy. Finally, comes NEAT, which is the amount of energy that we expend on our day-to-day activities.
Recent research has shown that the energy that we spend on day-to-day activities is the most important indicator of our body weight. Therefore, imagine once again, in the case of the two men that I alluded to earlier. What if the thin Mr. A, is also hyperactive, jittery, restless, always moving about, and running around for small errands (even without being asked to) all the time? What if the fat Mr. B spends his day slouched in his chair, ordering people around, and is a man who uses his limbs only to punch the keyboard of the computer, and runs only when he has to catch the closing doors of an elevator/ lift?
What’s the NEAT-savvy person like?
In other words, NEAT is determined by the activity that you do as part of your daily life, and not as active exercise. Several studies have shown that increasing NEAT throughout the day is superior to hours and hours of intensive activity in the gymnasium. In other words, the work that you do, the profession that you choose becomes a marker for your weight, and subsequent risk of diabetes and heart disease.
A manual laborer or a policeman, would, just by the activity involved in his profession, be in a better position to prevent diabetes, as compared to a person who sits in a white-collar-office job! A housewife who has to shop for groceries, clean the house as well as cook the food is likely to be more healthy than the memsaab who orders the menu, watches TV serials and freaks out on kitty parties. In other words, dear reader, primitivity is the name of the game!! By discovering high tech gadgets, we are gifting ourselves with obesity. Imagine the remote control, the TV, the hands-free blue tooth devices, the wi-fi gizmos and the luxury sedans: aren’t they all reducing our NEAT ? And to increase our NEAT, we only have to go back to a primitive hunter-gatherer society, where intense physical activity is the rule of the game!!
All this does not mean that diet and planned exercise are not important. Of course they are. But the point is, activity that is incorporated into our daily work is better, because it is much easier to sustain in the long term. Exercise and diet requires that bit of voluntary effort- some call it will power- which is not very easy to practice.
So, how can we all incorporate NEAT in our lives ? Well imagine a large room where a hundred people are relaxing on lounge chairs, and all are watching a world cup cricket match on a giant digital screen. Can we make them spend more energy at that time? Yes, we can, if we are able to make them stand and watch the match. And we can make them stand by two ways: firstly, by removing the lounge chair, which leaves them with no option but to stand (a social strategy). The second method would be to change their mind, i.e. to make them want to stand (a individual behavioral strategy).
The Social Strategy to increase NEAT
Several corporations in the United State are practicing this. There are now offices with no chairs at all!! The employee stands behind a computer. Sometimes, he stands on a treadmill floor, which means that he is forced to move his legs and walk while he works at his job!! This would make the employees more active and less likely to fall sick with diabetes and heart disease, and eventually this would translate into profits for the company. Add to the fact that health-related corporate expenditures are brought down, and you have a very useful strategy indeed.
Several corporations in the United States are insisting on walking meetings. This means that people are actively walking during the meeting, instead of sitting in chairs and drinking tea and biscuits. Walking meetings are more swift, short, crisp and business-like. In addition, several business firms have started rewarding employees and teams that have begun to become more activity-savvy.
Behavioral Techniques to increase NEAT.
It is well known that what we see in the media dominates our attitudes and tastes. Eating pizzas, potato chips, using gizmos and drinking fizzy drinks are all desires created within us by the media. What if the media tells us to exercise? What if movie stars, sportspersons and corporate honchos were to tell us about their physical activities? Wouldn’t that make it more fashionable to become a physically active and fit person? While this has been actively employed to change behavior in the west, many of the so-called role models for Indian youth continue to champion the cause of soft drinks and potato chips.
At the biological level, there are a lot of studies looking at molecules that can activate the brain and make people more physically active. These molecules act on the brain and inculcate the desire to do work, and to be a more active person. In other words, they increase NEAT. However, many of these drugs are still in the research phase at present.
In addition, several scientists, notably from Dr Levine’s laboratory at the Mayo Clinic in the United States, are trying to quantitate NEAT and give it a measurable value. This means that like blood pressure, cholesterol and blood sugar, physical activity will soon have a measure and can be expressed in numbers. Who knows, the next millennium may well herald the use of several strategies (including medicines) that can increase our physical activity levels! And what is more, we may be able to accurately measure our energy expenditure, and doctors may be able to titrate this too!
Implications for India
Indians have more abdominal fat. This abdominal obesity makes them more prone to develop type 2 diabetes, which is the most common type of diabetes worldwide. Abdominal fat excess makes the body resistant to insulin, which is a hormone that can lower blood glucose. Insulin resistance causes high blood glucose levels i.e. diabetes mellitus. Untreated, diabetes leads to heart attacks, kidney failure, foot amputations and blindness. The impact of this catastrophic illness on a growing economy like ours is likely to be devastating.
India is currently among the fastest growing economies in the world, and our GDP is increasing by 8-9% per year. However, this comes with the price that we have to pay in the form of lifestyle diseases like diabetes and heart disease. It is logical to postulate that the exponential increase in diabetes, obesity and heart disease might ultimately slow down India’s economic growth. Only drastic, societal changes in diet and physical activity can tackle this epidemic. Hence, it is important that both doctors and the public at large join hands with governmental and non-governmental agencies to influence the genesis of a vibrant, healthy and physically active India.
Sunday, January 20, 2008
To begin with, hypothyroidism, or a failure of the gland, is a very common thyroid disease. Hypothyroidism can present with tiredness, fatigue, decreased memory, weight gain and constipation. Women are more commonly affected than men. Infertility and menstrual irregularity are common features of hypothyroidism.
The diagnosis of hypothyroidism is very simple to make: a TSH (thyroid stimulating hormone) level that is high suggests hypothyroidism. A high TSH means that the thyroid gland has failed, and that the pituitary is making more TSH to stimulate the gland. In addition, the T4 level (T4 is a hormone produced by the thyroid gland) is often, but not always low in this setting. The TSH is the best test to make the diagnosis, and is easily available in most laboratories. A simple tablet (containing synthetic T4) called levothyroxine is usually needed lifelong to treat these patients.
Hypothyroidism in pregnancy could be particularly dangerous, as the developing fetus does not have a functioning thyroid gland in its initial 3 months. Hence, the fetus is dependant on the mothers thyroxine supply for the first 3 months, and this supply is critical for the baby’s brain development. Early, appropriate and precise levothyroxine therapy is needed in this situation to optimize pregnancy success and the baby’s IQ.
In addition to hypothyroidism, hyperthyroidism or overactivity of the thyroid gland can also occur. Hyperthyroidism presents with weight loss, severe anxiety, palpitations, trembling and a prominence of the eyes. Hyperthyroidism is diagnosed when the TSH level is very low. There are several anti-thyroid agents (like carbimazole) that can treat this disease. Some cases may require surgery or radioisotope (I-131) therapy.
Finally the thyroid may develop swellings, which may be benign or cancerous. An astute combination of blood tests, scans and needle biopsy of nodules can help in clinching the diagnosis. If malignant, the cancer needs to be removed surgically. Lifelong levothyroxine therapy is usually needed.
Of special concern is the emergence of a group of diseases called subclinical thyroid disorders, where the hormone abnormalities are only “mild”. Subclinical hypothyroidism is one such condition where there is “mild” thyroid failure. Patients with subclinical hypothyroidism need careful evaluation and therapy if they have any subtle complaints pertaining to hypothyroidism.
(I am an Endocrinologist at the Amrita Institute of Medical Sciences, Cochin . I am also the Editor of the Journal of Thyroid Research and Practice, and web editor of http://www.indianthyroid/society.com )
Saturday, December 8, 2007
Priya, just 24 years old, was 5 months pregnant. She was justifiably anxious, and endearingly excited at the prospect of motherhood. During these days of leisure, the evenings were spent on telling and retelling horror stories. Usually, I was asked to narrate one, given my interest in the occult and the supernatural. The dark, mountainous, forestry and the night made a perfect ambience for this.
Today, however, Rohan and Priya wanted a different story from me. Priya had been reading about pregnancy on the internet, and was surprised to find that the baby got programmed in the mother’s womb. And this programming, she read, could determine almost every aspect of the baby’s health. She was excited, and wanted to know more. And like a fool, I had promised to tell her the story behind all this, only to realize later what a difficult task it would be to explain these things to a non-medical person.
“ A dark, dark concept indeed!” mused Rohan, sipping away at his drink, “ Who on earth would have thought that the mothers womb would set the tone for a lifetime? Come, come, you must tell us this story..”
Even the cloudy night broke into a sweet, expectant drizzle, as if the clouds could wait no more to hear my story. I decided to do an impromptu dramatization. I decided to throw away those hard facts and focus on telling the tale. I decided to enjoy myself in creating this story of part-fact, part fiction. I began ..
“ Almost a century ago, Britain had been suffering from the throngs of the Industrial Revolution. The economy was at an all-time low, and the middle classes in Britain were starving. The Renaissance had come and gone, but the Da Vincis and Michelangelos could hardly feed the world. Sandwiched between two World Wars, Britain’s poor were the most affected. Great Britain was not so great anymore. And the pangs were most acutely felt in Southampton and the nearby areas. Workers in steel mines, coalfields and related industry worked hard.
These workers would work for very little wages, sometimes running into only a few pence. After working for over 15 hours in a day, they would have little time for anything afterwards. They would brawl in the Inns, drink beer till their heads swam and then slept till their next shifts. The women were poorly structured, and looked starved and malnourished. At about that time, Dr Jones (name not changed as the existence of this doctor is purely fictious, I clarify!), a young doctor working tirelessly in for the miners noticed a thing or two about the pregnant women there. The women looked starved,. And when they became pregnant, their eyes took on a deathly pallor that bespoke of malnutrition. Dr Jones had dedicated his life to these miners and their families. He could not help noticing how he and his family too- just because of the heavy poverty that had descended on the times- had started looking as unhealthy as the miners themselves.
And when Dr Jones’s wife, young bonny lass of all but 24 years ( Priya Shuddered) delivered, Dr Jones was stunned to find out that the baby was only 1.3 kgs. Dr Jones checked the records…1.5 kg, 2 kg, 1.3kg, 1 kg, 900 g… he found that not a single child born in the area had an adequate birth weight of 2.5 kgs. For the next one year, Dr Jones would tirelessly collect the names and addresses of all the little babies that were born in the area. His clinic was filled with records of babies, their weights, their parents weights etc. Dr Jones was sure it was nothing to do with smoke or the coal. The low birth weight had everything to do with poverty, lack of food and maternal malnutrition. However, Dr Jones could hardly finish his work. He was stuck with pneumoconiosis, a lung disease that people exposed to coal mines got. One day he coughed out a few liters of blood and breathed his last. His clinic was temporarily shut down…”
I paused, in a typical storyteller style. Indeed, I was feeling guilty for having made up such a story. The story was, of course, based on fact, but the characters were completely fictitious! I paused to look at my audience. Their faces glowed in the light of the fireplace by the verandah. Their faces were eager, rapt with attention. Encouraged, I decided to take the plunge into a second odyssey of fiction. I continued.
“ The place was the same, but the year was 1970 (or was it 1962?). Britain had changed. Riding on the success of World War II and on the fiery speeches of Churchill, and spurred no doubt by Britains closeness to America, England was on a roll. Having woken from its Colonialist dream, the economy was booming. The stock indices were rising, manufacturing was on the increase and people were getting richer. There was plenty to eat and drink all around. In Herefordshire, and other areas near Southampton, a new disease was on the rise. People would eventually call it lifestyle diseases a decade later, and in 1988, it would be called Syndrome X. Simply put, people were getting Syndrome X, which was a constellation of obesity, diabetes, hypertension, high cholesterol. And this syndrome X eventually led to heart attacks.
Back in the areas where Dr Jones had set up his clinic, things were different. There were no coal miners, but people of new-found wealth. People were spending, children were eating, television was “in”. The situation is quite similar to India, with its newfound wealth today. Next to Dr Jones’ now-shut-down clinic was now a huge, modern, county hospital, with lush gardens and a smart-tiled roofs and floors. The hospital offered stat-of-the art facilities for the local community. The patients walking in no longer had tuberculosis or lung disease, but instead, died of diabetes, hypertension and heart attacks. The old and dead Dr Jones’ son Simon was now working there as a physician. He, like his father had an intuitive mind, and noticed a very odd thing. The people who were getting diabetes and hypertension and heart attacks were all children born to the miners of the city. Their wealth had grown, but Simon could see that the diseases went beyond the simple explanation of prosperity-induced diseases. Simon remembered his mother saying something about his father having made a list.
One night, Simon sought out Dr Jones office and traced out all the names of the children born to miners- the children with low birth weight, whose addresses the old Dr Jones had so diligently recorded just before his death.
Simon traced out and tested each and everyone of the low birth weight babies, who were all grown-up adults by now. His observations were staggering: more than 90% of them were obese. And more than three fourth were either hypertensive, or had diabetes or had a heart attack, or had some combination of all these.
Dr Jones’s death and Simon’s efforts did not go in vain. Researchers like Dr Barker took up cudgels against this disease, and this new concept was called the thrifty phenotype hypothesis. According to this concept, babies born to malnourished mothers are likely to be underweight. And what is more, when these underweight babies would grow up, they were at a high risk of developing heart attacks, obesity, diabetes, hypertension and high cholesterol level. This was a paradigm shift in the understanding of diabetes and heart attacks. Since then low birth weight children have been shown to be at very high risk of diabetes and heart attacks, and this has even been shown in babies studied from Pune, India.”
I had finished telling a highly fictionalized account of the low birth weight theory of diabetes. I was not sure whether my audience had understood a word. At that point, Rohan asked, “ How exactly do people born small get diabetes and therefore heart disease when they grow up? Have scientists found out how this happens? ”
I was happy that people were still listening to this yarn. I replied, “ Yes, of course. Subjects with a low birth weight are at risk of diabetes because their pancreas has been deprived of nutrition during their mother’s pregnancy. This nutritionally deprived pancreas cannot produce enough insulin. As you know, insulin is a hormone that can control blood glucose and when the body is deprived of enough insulin, diabetes eventually occurs”
“ What about very fat babies, whose weight at birth is 5 or 6 kg? Are they not at risk of developing diabetes in future? Doesn’t obesity lead to diabetes?” asked Priya.
Another excellent question, I thought, and answered, “ You are right. Excess fat makes the body resistant to insulin. If insulin cannot act properly, diabetes ensues. Thus very thin, as well as very fat babies are at high risk of developing diabetes when they grow up. A birth weight of about 2 to 4 kgs is ideal. However, these are all hypotheses, and have never been conclusively proven. And I caution you: don’t bother to do repeated ultrasounds on your baby to find out its size. Theories are theories, and life is life! However, if research establishes this theory as fact- we will have a new tool of preventing diabetes, obesity and heart attacks. A tool that begins before the very beginning, indeed, even before birth: a method that could be called primordial prevention, or even, interventional fetal programming in the years to come ”
As we dispersed at night to our respective rooms, the young couple thanked me for the interesting story, for it made more sense to them at this time of their lives, as they were expecting to become parents soon. As everyone left, my wife and me decided to take a walk into the forest.
A few kilometers away, we spotted a herd of deer drinking water from a moonlit lake. The lake, perched on a mountain top, looked iridescent in the reflected moonlight. We saw the swarming deer, some sauntering slowly, some leaping gracefully and others running majestically on the banks. I could even spot a few baby deer, cuddling up to their parents. Did all this birth weight theory make any difference to the world? Did all these deer even know about diabetes? Who took care of them? Are scientists and researchers devoting their lives to chase esoteric and irrelevant hypothesis? Though the answer will probably never be known as long as science exists, the question on whether science should exist is always worth an ask!
(The author clarifies that the entire story is fiction. The social, political and economic aspects described are all part of this work of fiction. However, the scientific aspects, the theory called the “thrifty phenotype”, the links between birth weight and diabetes, as well as the case of the scientific report from Pune are all based on fact. Any resemblance to any other person or event, - including any resemblance of the narrator to the author himself- is completely coincidental! )