Gestational diabetes mellitus

Diabetes and risk of PAD

Diabetes and peripheral arterial disease(PAD)

Diabetes and prevention of kidney diseases

Prevention of cardiovascular disease in diabetic individual

Hair care for diabetic individuals

Benefits of video consultation

डायबिटीज का रोकथाम इलाज से बेहतर है

डायबिटीज के बारे में आम जानकारी.

COVID 19 and we:): Chapter 1: sabzion ko kaise dhoyen

Here are a few foot care habits you can adopt and try to do every day.

1.     Inspect your feet: Looking carefully at your feet each day, including between the toes. Looking is particularly important if you have reduced sensation in your feet, as you may not notice anything wrong at first until you look.

Check your feet and toes, inspecting the tops, sides, soles, heels, and the area in between the toes. Use a magnifying hand mirror to look at the bottom of your feet.If you’re physically unable to inspect your own feet, use a mirror or ask someone to help. Contact your doctor immediately if you discover any

·       sores,

·       redness,

·       cuts,

·       blisters, or

·       bruises or

·       bleeding

·       nail problems.

·       Look out for athlete's foot (a common minor skin infection). It causes flaky skin and cracks between the toes, which can be sore and can become infected. If you have athlete's foot, it should be treated with an antifungal cream.

2.     Wash your feet: Wash your feet every day in warm water with mild soap. Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in. Your diabetes may make it difficult to sense water temperature with your feet.

3.     Dry your feet: Pat your feet to dry them and make sure to dry well. Infections tend to develop in moist areas, so make sure you dry the area between your toes well.

4.     Moisturize dry skin: Use a moisturising oil or cream for dry skin to prevent cracking If the skin on your feet feels rough or dry, use lotion or oil. Do not use lotion between your toes. Moisturize your feet but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But don't moisturize between the toes—that could encourage a fungal infection. However, you should not apply it between the toes, as this can cause the skin to become too moist which can lead to an infection developing.

5.     Antiseptic solutions can burn your skin. Never use them on your feet without your doctor’s approval.

6.     Never use a heating pad, hot water bottle, or electric blanket on your feet.

7.     Avoid walking barefoot. Most people know to avoid hot pavement or sandy beaches, but even walking barefoot around the house can cause sores or injuries that can get infected.

8.     Protect your feet from heat and cold.

9.     Always wear socks with shoes or other footwear. However, don't wear socks that are too tight around the ankle, as they may affect your circulation.

10.  Never attempt to remove corns, calluses, warts, or other foot lesions yourself. Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers. See your doctor or podiatrist.

11.  Don’t sit with your legs crossed or stand in one position for long periods of time.

12.  Consider using an antiperspirant on the soles of your feet. This is helpful if you have excessive sweating of the feet.

13. Take proper toe nail care:  Cut nails carefully. Trim your toenails after washing your feet, when your nails are soft.

12. Tips for choosing right Footwear; Shoes and socks

13.If you have neuropathy, or nerve damage that has affected foot sensitivity, you may overlook cuts or bumps. You can help protect your feet by wearing shoes at all times.

Choosing right Shoes

·       Choose comfortable, well-fitting shoes with plenty of room, especially in the toe box. Never buy tight shoes hoping they will stretch. Shoes, trainers and other footwear should Fit well to take into account any awkward shapes or deformities (such as bunions).

·       Have broad fronts with plenty of room for the toes.

·       Have low heels to avoid pressure on the toes.

·       Have good laces, buckles or Velcro fastening to prevent movement and rubbing of feet within the shoes.

·       Do not wear shoes made out of plastic or other materials that do not breathe. Choose leather, canvas, or suede.

·       Avoid thong sandals, flip-flops, pointed-toe and open-toe shoes, and very high heels.

·       Wear shoes that can be adjusted with laces, buckles, or Velcro.

·       Inspect the inside of your shoes every day for tears or bumps that may cause pressure or irritation.

·       If you have nerve damage, give your feet a break or change shoes after five hours to change the pressure points on different areas of your feet.

·       If you experience repeated problems with your feet, ask your doctor if special shoes would help.

Choosing right Socks

·       Socks can provide an extra layer of soft protection between your foot and your shoe.

·       Wear clean, dry socks, or non-binding pantyhose. Avoid socks or hosiery with seams that can cause additional pressure points or are too tight on the leg.

·       Wear socks to bed if your feet are cold.

13. Look for symptoms of foot problems:

Prevention is better than cure so always stay alert and try to catch the problems in the begening to avoid  complications. So It’s important to recognize early warning signs of foot problems, such as:

·       burning, tingling, or painful feet

·       loss of sensation to heat, cold, or touch

·       changes to the color or shape of your feet

·       loss of hair on the toes, feet, and lower legs

·       thickening and yellowing of the toenails

·       onset of red spots, blisters, sores, ulcers, infected corns, or ingrown toenails

If you have any of these symptoms, call your doctor immediately. Delay may result in serious health complications.

14. Potential complications

Following the tips above can help you to avoid foot problems.

As stated above, high blood sugar levels over time can cause nerve damage and circulation problems. These problems can cause or contribute to foot problems.

Left unnoticed or untreated,

• ·       sores,
• ·       ingrown toenails, and
• ·       other problems

can lead to infection.

Poor circulation makes healing an infection difficult.

So it’s best to avoid them if possible.

Infections that do not heal can cause skin and tissue to die and turn black. This is called gangrene. Treatment can involve surgery to amputate a toe, foot, or part of a leg.

15. Visiting the doctor

A doctor should examine your feet at every visit and do a thorough foot exam once a year. If you have a history of foot problems, you should be checked more often. Your health care provider should also give you information on foot care and answer all your questions. Report any corns, calluses, sores, cuts, bruises, infections, or foot pain.If necessary, your doctor can recommend a podiatrist who specializes in diabetic foot care or give you information about special shoes that may help.

Remember: Diabetes-related foot problems can worsen very quickly and are difficult to treat, so it’s important to seek prompt medical attention.

What can I do to help prevent foot ulcers?

As a rule, the better the control of your diabetes, the less likely you are to develop complications such as foot ulcers. In general, you can lower your risk of diabetes-related complications by keeping your blood sugar in the goal range and seeing your doctors for regular checkups.

1) So You can keep your BGL in a goal range by:

·       By regulary monitoring your BGL and HBA1C level, blood cholesterol levels etc

·       By doing regular exercise and eating a balanced diet rich in fruits and vegetables

2) Treatment of diabetes and other health risk factors

Also, where appropriate, treatment of high blood pressure (hypertension), high cholesterol level and reducing any other risk factors will reduce your risk of diabetic complications. In particular, if you smoke, you are strongly advised to stop smoking.

3) And you can prevent foot related problems by doing Regular foot care as advised by your doctor .

Clinical foot exams : Check the blood flow and sensation in feet. The frequency of these clinical exams will depend on which type of diabetes patient have:

• 1.     In people with type 1 diabetes, annual foot exams should begin five years after diagnosis.
• 2.     In people with type 2 diabetes, annual foot exams should begin at the time of diagnosis.

Most people with diabetes are reviewed at least once a year by a doctor and other health professionals. Part of this review is to examine the feet to look for problems such as reduced sensation or poor circulation. If any problems are detected then more frequent feet examinations will usually be recommended.

What if I develop a foot ulcer? What care can I expect if I am admitted to hospital with a diabetic foot problem?

Seek medical help if your foot infection doesn't improve in a day or two, or becomes significantly worse.You should tell your doctor straightaway if you suspect an ulcer has formed.  

If you have a diabetic foot problem, you will be able to get most of the treatment you need from your treating physician.

However, there are some problems which may require you to go into hospital for treatment. You should expect to be treated by a team which deals especially with people who have diabetic foot problems. This team usually includes:

• ·       A specialist in diabetes.
• ·       A surgeon who deals with diabetic foot problems.
• ·       A person qualified to diagnose and treat foot disorders (a podiatrist - previously called a chiropodist).
• ·       A diabetes nurse specialist.
• ·       A tissue viability nurse (who assesses whether the skin and underlying tissues of your feet have been affected by circulation changes due to diabetes).

You should be given information about your foot condition.

Aim of treatment:Treatment aims

• ·       to dress and protect the ulcer,
• ·       to prevent or treat any infection and
• ·       also to help your skin to heal.

• You will have your diabetes assessed and checks will be made to make sure you have not developed complications such as kidney disease (or if you have already developed complications, to make sure they are not becoming any worse).
• You will have an examination of both feet to check for ulcers, cuts and abrasions to the feet, signs of poor circulation, areas of numbness and the development of Charcot's arthropathy. This is a condition in which the sensation of pain is reduced because of the diabetes, resulting in damage to bones, such as tiny fractures.
• You will have a general examination to make sure you do not have a high temperature (fever) or any other signs of a severe generalised infection.
• If you have an ulcer, this will be checked for infection; baseline measurements of the size and depth will be taken.
• You may be asked to have an X-ray or scan of your foot to make sure the bones have not been affected by your condition.
• The ulcer is usually covered with a protective dressing. A nurse or podiatrist will normally examine, clean and re-dress the ulcer regularly.A podiatrist may need to remove any hard skin that prevents the ulcer from healing. Also, depending on the site and size of the ulcer, they may protect it from further injury by using padding to take the pressure off the area.You may also be advised to wear special shoes or have a cast made for your foot to keep the pressure off the ulcer. Antibiotics will be advised if the ulcer or nearby tissue becomes infected. Sometimes a small operation is needed to drain pus and clear dead tissue if infection becomes more severe.In some cases, the arteries in the legs are very narrow and greatly reduce the blood flow to the feet. In these cases an operation to bypass or widen the arteries may be advised. Many foot ulcers will heal with the above measures. However, they can take a long time to heal. In some cases, the ulcer worsens, becomes badly infected and does not heal. Sometimes infection spreads to nearby bones or joints, which can be difficult to clear, even with a long course of antibiotics. Occasionally, the tissue in parts of the foot cannot survive and the only solution then is to surgically remove (amputate) the affected part.

What increases the risk of developing foot ulcers?

1.     If you have reduced sensation to your feet . The risk of this occurring increases the longer you have diabetes and the older you are.

2.     If your diabetes is poorly controlled. This is one of the reasons why it is very important to keep your blood sugar (glucose) level as near normal as possible.

3.     If you have narrowed blood vessels (arteries) .

The risk of this occurring increases the longer you have diabetes, the older you become and also if you are male. The risk also increases if you have any other risk factors for developing furring of the arteries. For example, if you

·       smoke,

·       do little physical activity,

·       have a high cholesterol level,

·       high blood pressure (hypertension) or are

·       overweight.

4.     If you have had a foot ulcer in the past.

5.     If you have other complications of diabetes, such as kidney or eye problems.

6.     If your feet are more prone to minor cuts, grazes, corns or calluses which can occur:

·       If you have foot problems such as bunions which put pressure on points on the feet.

·       If your shoes do not fit properly, which can put pressure on your feet.

·       If you have leg problems which affect the way that you walk, or prevent you from bending to care for your feet.

7.     Are foot ulcers serious?

Although foot ulcers can be serious, they usually respond well to treatment. However, foot ulcers can become worse and can take a long time to heal if you have diabetes, particularly if your circulation is not so good.

8.     In addition, having diabetes means you are more likely to have infections and an infection in the ulcer can occur. Occasionally, more serious problems can develop, such as tissue death (gangrene).

What are the risk factors for diabetic to develop foot problems? Why are people with diabetes prone to foot ulcers?

Over time, diabetes that is not carefully managed can lead to foot complications. You have an increased risk of developing foot problems if you:

• 1.     Have had a foot ulcer in the past
• 2.     Have nerve damage: Reduced sensation of the skin on your feet(DN).
• 3.     Have poor circulation: Narrowing of blood vessels going to the feet(PAD).
• 4.     Have any foot deformities

If you have any of these risk factors, particularly a previous foot ulcer, you may be at increased risk of foot problems

Why is foot care important?

Over time, diabetes can lead to various complications, many of which can be serious if they are not identified and addressed promptly.
·       Foot problems are a common complication in people with diabetes.
·       In people with diabetes because of poor glycemic control and long duration of disease they have nerve damage (reduced sensation in the feet) and poor circulation problems, they develop foot ulcers. and
·       because of deceased immunity thire foot ulcer is prone to infection, which may become severe. 
·       Ulcers sometimes need treatment with dressings, medication and, when appropriate, surgery.
·       More serious complications include deep skin and bone infections.
·       Gangrene (decay and death of tissue) is a very serious complication; widespread gangrene may require amputation.
·       Approximately 5 percent of people with diabetes eventually require amputation of a toe or foot.
·       However, this can be prevented in most situations by managing blood sugar levels and committing to daily foot care.

CHAPTER 15: How can I help if I think someone is having a hypo?

The symptoms of hypos can often be mistaken for drunkenness. So, if you see someone acting oddly, especially if you know or suspect they have diabetes, check if they have:

• ·       A medical alert bracelet or similar.
• ·       An insulin pen or syringe, or glucose testing kit.
• ·       Glucose gel or sugary sweets.

Help them sit down quietly. If they have their own glucose gel, help them take it.Otherwise, give them sugary sweets, two teaspoons of sugar, or a glass of sugary drink or fruit juice (even if you're not sure they're having a hypo, it's safer to do this).Keep a careful eye on their level of responsiveness, breathing and pulse. If they get better, make sure they check their blood glucose. If they don't improve, call emergency doctor.

CHAPTER 14: What should I do if my blood sugar is low?

• Don’t panic 1^st you learn how to recognise symptoms of hypo and then you learn management.
• At my clinic I usually teach my patient about normal level of BGL and low BGL levels and how to recognise and manage them.
• A 'hypo' is usually defined as a blood glucose below 60 mg/dl.
• If you sugar is <60 or if you have symptoms of hypo don’t drive.
• I advise my patients to keep glucose powder with them at home in the fridge and even they can carry with them while traveling or driving. So, they are advised to take 3 table spoon of glucose powder and drink with a glass of water and check BGL after 5-10 min if it is >70 they are safe. after that They can eat some glucose tablets or sugary sweets (jelly babies are ideal) or drink fruit juice or a sugary drink. After that they should report to their treating physician. Relax for 15 minutes or so while your blood glucose rises. Check your blood glucose again. Don't drive until at least 45 minutes after it has risen above 70 mg/dl. You may also need to eat another snack, or a meal if it's due - your medical team can advise.

CHAPTER 13: How often should I check my blood sugar

It depends on type of diabetes and medications you are taking

·       If you are T1DM patient then you need to monitor frequently depending on your control level your treating physician guides you how frequently you need to check BGL. Usually I recommend that you check at least 3 times a day, including before each meal and and also check for midnight hypoglycaemia. Frequency of monitoring will depend on level of your BGL control.

·       If you are type 2 diabetes and on only Oral tablets, I usually recommend to check BGL on lab monthly and if possible, patient can check once or twice on glucometer in between. If you are on oral plus insulin then I recommend weekly monitoring if they are under control other wise may recommend more frequent monitoring.

·       If you're driving and taking insulin or other medication that could cause hypos, I recommend that you should check your blood glucose two hours before you start driving and every two hours while you are driving.

CHAPTER12: How can I prevent hypos?

Here are steps you can take to reduce the risk of hypos. These include

·       Not skipping or delaying snacks or meals.

·       Learning about the right dose of insulin you need for a given amount of carbohydrate.

·       Adjusting your insulin if you're exercising vigorously.

·       Avoiding alcohol, and particularly drinking on an empty stomach.

·       Speaking to your medical team in advance of situations where your normal eating will be disrupted (e.g., at Ramadan, or if you're travelling or working shifts) so you can work together to adjust your insulin dose.

·       If you're taking sulfonylureas tablets and getting symptoms that you think may be hypos, speak with your team. They may be able to change your medication, as there are many alternative treatments for type 2 diabetes that don't cause hypos.

·       Keeping a supply of sugary drink, fruit juice or glucose tablets to hand at all times, so you can treat symptoms early.

·       Checking your blood glucose regularly.

·       If, despite all your best efforts, you continue to experience frequent and debilitating hypos, you you inform your treating diabetes physician.

CHAPTER11.How I can recognize that I am having Hypos?

Symptoms of hypoglycaemia: If your blood sugar drops below 60 mg/dl you may experience:

·       Feeling weak or tired and hungry.

·       Feeling shaky and sweaty, with cold, clammy skin.

·       Irritability and poor concentration.

·       Headache and feeling sick.

·       Palpitations.

·       Blurred vision.

If your blood sugar continues to drop, you may develop:

·       Confusion and drowsiness.

·       Poor co-ordination.

·       Difficulty speaking.

·       Irrational behaviour.

·       Collapse and loss of consciousness.

·       In very severe cases, hypoglycaemia can be fatal.

CHAPTER 10:what causes Low BGL(HYPOS)

·       For T1DM: skipping of meals/or more than required insulin injection and some other factors related with type of insulin or diet or exercise. People with type 1 diabetes need insulin in injection form, because they don't produce any insulin of their own.

·       For T2DM: People with type 2 diabetes sometimes need insulin if their blood sugar can't be controlled with other tablets. If you're using insulin injections, the amount of insulin you need depends on lots of factors, including how much food you've eaten. More insulin than you need can drop your blood sugar below normal levels, causing a 'hypo'. So too can some antidiabetic tablets have used in type 2 diabetes, particularly sulfonylureas.

CHAPTER 9: what is Hypoglycemia or low blood sugar?? do we need to worry??

Hypoglycaemia or Low Blood Sugar (Low BGL)

Low blood sugar (hypoglycaemia) is often known as a 'hypo'. It can make you feel unwell and affect your ability to drive. Simple steps will reduce the risk, and allow you to treat a hypo early, before it causes more serious complications.

Any BGL level <60 is kwon as  hypoglycaemia.

yes it is dangrous. you doctor will guide you about this problem.

CHAPTER 8: WHAT are The normal levels of BGL??

	Normal level in mg/dl	target BGLin mg/dl
Fasting BGL(FF)	70-100	<100 but not <70
Post lunch BGL(PP)	70-140	<140 but not <70
random	70-180	keep between 110-160 but never <70

Blood sugar - what's normal?

Under normal circumstances, your body does a remarkable job of keeping your blood sugar (in the form of glucose) stable. Usually your body releases a hormone called insulin, produced by your pancreas, in response to rises in blood sugar. Your body's cells need glucose as fuel to allow them to function. Insulin acts as a 'key', opening the door of your cells to allow in glucose. Another hormone helps raise your blood sugar if it gets too low.

as given above in the table anything more than upper limit is called as diabetes.  and diabetes is diagnosed based on raised BGL .

CHAPTER 7: Is Role of health education important in diabetes management??

Health education as an important tool in both applying different level of prevention as well as screening high risk patients for early diagnosis and management of diabetes.

CHAPTER 6: How we can apply different levels of prevention in case of diabetes??

Taking diabetes as an example

For diabetes obesity is a known risk factor (there are many but we are taking just one example). So, a person who is going to develop diabetes passes through following stages:

1.     Development of risk factor e.g. Bad eating habits+Sedentary lifestyle:

Measures taken: Primordial prevention: Eat healthy+ adopt healthy lifestyle and do exercise regularly.

How we do it?

By health education; educating people about healthy lifestyle.

2.     Risk factor has developed e.g. Obesity

Measures taken: Primary prevention: Reduce weight+do exercise directed in reducing weight.

How we do it??

Again, by health education: educating people about healthy lifestyle. Encouraging them to lose weight by eating right kind of food and doing regular exercise etc.

3.     Obesity causes diseases e.g. Diabetes

Measures taken: Secondary prevention: Optimum Management of both risk factor and disease to prevent complications of disease.

4.     Diabetes causes complications:

Measures taken: Tertiary prevention: treating complications properly to prevent further damage and death.

For diabetes, we can apply all the levels of prevention but for that you need to meet your doctor early in course of your disease so that your doctor can put you under different levels of prevention to help you to live a healthy life. There are a lot of things we can do for prevention of diabetes.