Diabetes mellitus -Type 2 and It's dietary management By: Ms.Ummeayman Rangwala, FoodTechnologist, PFNDAI The nations fourth largest killer after heart disease, cancer and stroke is diabetes mellitus. China and India the emerging superpowers are thought to be the major victims of such diseases, which are associated with unhealthy lifestyle. World Health Organisation (WHO) and International Diabetes Federation (IDF) have ranked India - No.1among the top 10 countries in people with diabetes, followed by China & USA. India already has 35m diabetics, the largest number for any country, and by '25, WHO estimates the figure to go up to 73.5m. Diabetes is becoming a major threat to global public health, as it is regularly getting worse due to an increasing trend towards unhealthy diet & sedentary lifestyle. Diabetes Mellitus and its major types Diabetes Mellitus, a serious chronic disease, characterised by abnormalities in the metabolism of carbohydrate, protein and fat is caused by lack of insulin that is produced by β-cells of pancreas. Insulin is a carrier of glucose from the bloodstream to cells that rely on glucose for energy. When the pancreas does not produce enough insulin or when the body is unable to effectively use the insulin it produces, there is an accumulation of sugar in the blood and the condition of diabetes mellitus arises. Pancreatic damage by viral infections or due to genetic factors disables β-cells to produce insulin and leads to type 1 diabetes, also known as IDDM (Insulin dependent diabetes mellitus) as the patient has to rely on an exogenous source of insulin for survival The other type of diabetes mellitus is type 2, also known as NIDDM (Non Insulin Dependent Diabetes Mellitus). This condition can be managed with lifestyle measures alone, but oral drugs and insulin are often required to achieve a good metabolic control. The third type of diabetes is gestational diabetes mellitus, develops during some cases of pregnancy but usually disappears after pregnancy. Type 2 diabetes mellitus "Prevention is better than Cure", Type 1 diabetes is unpreventable, it can only be controlled by insulin injections, thus we will focus mainly on type2 diabetes mellitus which is the most preventable form of diabetes and 95% diabetics have this condition. Type2 diabetes is the most frequently spotlighted because it is essentially preventable by dietary control and exercise. Research has shown that during pre-diabetes if an action is taken to manage blood glucose, type 2 diabetes can be delayed or prevented from ever developing. But the dilemma is that almost a third of people with diabetes do not even know that they are suffering with diabetes because like its partners in crime, high blood pressure, high cholesterol, high blood sugar is not associate with obvious symptoms. Very general symptoms, which include excessive thirst, constant hunger, excessive urination, weight loss for no reason, rapid hard breathing, vision changes, drowsiness occur suddenly and many have no symptoms at all, they are diagnosed after many years of onset. Early diagnosis and effective management can prevent type 2 diabetes. It is very important to control diabetes as uncontrolled diabetes over a long term can lead to blindness, impotence, kidney damage, poor circulation and nerve damage which may lead to amputation of limbs, heart disease and strokes. Diabetes can be diagnosed with a simple blood test .If the Fasting Blood Glucose (Taken 10 or more hours after the last meal) is more than 110mg% and if the post parandial blood glucose (taken 2 hours after a full meal) is more than 140mg%, the person is diabetic. Blood glucose can be monitored at home using a glucometer. Dietary Considerations for Diabetics Death can result from hypoglycaemic coma in diabetics and therefore utmost care should be taken in diet. Diabetics should always eat according to the plan. The desired end is a positive health, a regeneration of the body, and not merely an absence of symptoms. This is why it is important to remember to take food at correct, regular time. For those who are on oral drug therapy along with diet therapy, it is important to remember that they do not have to take extra medicine for extra food. Patients taking insulin or anti-diabetes tablets should be careful of their doses as hypoglycaemic or low blood glucose level can occur if the patient skips or delays a meal, does excessive physical exertion, or is ill and stressed Although sugar has been labelled as a taboo for diabetics, it's more important to keep an eye on the total carbohydrate intake rather than on just the amount of sugar consumed. They can consume a modest amount of sugar, but this must substitute their carbohydrate intake and not be added onto it. A large intake of sugar laden processed and packaged foods should be avoided, as these are causative agents of obesity, which is considered as a major risk factor leading to diabetes and its complications. Obesity results from an imbalance between energy intake and energy expenditure. It is characterised by pathological accumulation of triglycerides thereby promoting insulin resistance in muscles, liver and other tissues. In type 2 diabetes, the ability of insulin to inhibit lipolysis is impaired that leads to increased FFA secretion into plasma, which induces insulin resistance. According to ADA (American Dietetics Association), for type 2 diabetics the calories are restricted to 25-30 cal/Kg to bring down weight to normal range. Fats are restricted to 20 percent of total intake and adequate complex carbohydrates rich in dietary fibers should form about 60-65% of total intake. An intake of 25gm /100kcal or 40g dietary fiber per day from a variety of food sources is desirable .It provides physical barrier which protects carbohydrates from the digestive effects of enzymes. Fiber also releases a gastrointestinal insulin secretion namely GIP which enhances glucose-induced insulin secretion .It is also associated with improved peripheral insulin action by increasing insulin receptor binding. This way the oral drug or the insulin requirements are considerably reduced. With the increase awareness of diabetes and importance of reduced blood sugar (glucose) levels, the consumers are now interested in only managing their blood sugar levels. Some consumers are choosing foods based on their glycemic impact, this ignorance of consumers has given a
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Instrutions for ast for slitWILLIAM B. COBB, M.D. KEITH MATHENY, M.D. EWEN TSENG, M.D. KENNY CARTER, M.D. INSTRUCTIONS FOR ALLERGY SKIN TESTING
FOR SUBLINGUAL DROPS TREATMENT
1. Discontinue all antihistamines, oral or nasal sprays either
prescription or over the counter, 5 days prior to the testing
appointment. Please be aware that some sleep aid medications such
as Advil PM or Tylenol PM contain an antihistamine,
2. Wear a sleeveless shirt. The testing is done on the upper arms from the shoulders to the elbows. 3. Testing appointment will take between 1-2 hours. 4. Call to reschedule if you: A. are ill – have fever – are on antibiotics less than 48 hrs B. have hives C. are wheezing/having an asthma attack D. have taken steroid treatment in the last 4 weeks prior to E. forget to discontinue antihistamines F. are unable to keep your appointment G. have a sunburn If allergy treatment needs to be started, you will need another appt. and A, B, C listed above will apply for this appointment as well. ANY QUESTIONS OR TO RESCHEDULE CALL:
972/596-4005 x103 or x119
WILLIAM B. COBB, M.D.
KEITH MATHENY, M.D.
EWEN TSENG, M.D.
KENNY CARTER, M.D.
ACKNOWLEDGEMENT OF INFORMATION READ ON ALLERGY SKIN
TESTING AND ADMINISTRATION OF IMMUNOTHERAPY - SUBLINGUAL
PLEASE READ AND BE CERTAIN YOU UNDERSTAND THE FOLLOWING
INFORMATION PRIOR TO SIGNING THE CONSENT FOR TESTING OR
INDICATIONS FOR SKIN TESTING
The patient has seen the doctor, physician assistant, or nurse practitioner with allergy
symptoms and has tried the typical medications such as antihistamines/decongestants,
steroid nasal sprays without successful symptom management. This procedure is to
determine if a patient is allergic to an airborne pollen/allergen.
PROCEDURE FOR SKIN TESTING
The patient has been instructed to discontinue all antihistamines 5 days prior to
scheduled skin test. There is a panel of antigens (pollens, molds, dust mites, and cat &
dog) that are administered individually in the subcutaneous tissue on the upper arms. The
antigens used are native to this area. Upon beginning, each allergen is administered at a
very weak dilution. If the antigen does not reveal positive in a formulated measurement,
the allergy technician will then administer a stronger dilution of the same antigen. There
are 5 dilutions the technician may use. If none of these show a positive reaction by
measurement on the skin, the patient is not allergic to that specific antigen. All reactions
are recorded and the record is shown to the doctors for determination of treatment.
The purpose of sublingual immunotherapy is to decrease your sensitivity to allergy-
causing substances, so that exposure to the offending allergen (pollen, mold, mites, and
animal dander) will result in fewer and less symptoms. This does not mean that
immunotherapy is a substitute for avoidance of known allergens or for the use of allergy
medications, but rather is a supplement to those treatment measures.
Sublingual immunotherapy is known to lead to the formation of "blocking" or protective
antibodies and a gradual decrease in the allergic antibody levels. These changes may
permit you to tolerate exposure to the allergen with fewer symptoms. You, in effect,
become "immune" to the allergen. The amount of this immunization is essentially the
same for each person unless reactions occur and the doses have to be adjusted. In most
patients this takes approximately 3-4 years from the time a maintenance level is reached
in the treatment.
INDICATIONS FOR IMMUNOTHERAPY
To qualify for immunotherapy, there must be documented allergy substances in the
environment that cannot be avoided. Documentation of allergy is either in the form of a
positive skin test or a positive blood test. In addition to demonstrable allergy by one of
the mentioned tests, problems such as hay fever or asthma should occur upon exposure to
the suspected allergen, or you may have history or a severe reaction to an insect sting.
Due to the inherent risks of immunotherapy, avoidance measures and medical
management should be attempted first.
Improvement in your symptoms will not be immediate. It usually requires 3 to 6 months
before any relief of allergy symptoms is noted, and it may take 12-24 months for full
benefits to be evident. About 85-90% of allergic patients on immunotherapy note
significant improvement of their symptoms. This means that symptoms are reduced,
although, not always completely eliminated.
Allergy drops usually begin at a very low strength. This dosage is usually administered 3
times per day per week for approximately 12 weeks. After this time, the drops are
increased in strength given the same way as the first level. The goal is to achieve a
therapeutic strength, often called the "maintenance level". The maintenance level will
differ from person to person. The frequency of the drops reduces the chance of reaction
and permits the maintenance level to be reached within a reasonable amount of time.
After the maintenance dose is achieved, there will be no increase in strength of the drops.
DURATION OF TREATMENT
It usually takes 6-9 months to reach a maintenance dose level depending on the severity
of allergies. This time may be longer if there are reactions or if the allergy drops are not
taken on a regular basis. For this reason, it is very important that the recommended
dosing be followed. If you anticipate that you cannot maintain the immunotherapy
dosing, you should not start the treatment. Immunotherapy may be discontinued at the
discretion of one of Dr. Cobb, Dr. Matheny, Dr.Tseng, or Dr. Carter if the drops are
frequently missed, as there is an increased risk of reactions under these circumstances.
Most immunotherapy patients continue treatment for 3-4 years, after which the need for
continuation is reassessed.
INITIAL EXTRACT PRESCRIPTION
Your initial prescription includes all of the antigens you tested positive to on
the initial testing at the 1st level of treatment. In order to use these vials prior
to their expiration date – 3 months from the date of preparation – you will
need to administer the drops as scheduled. If the vial expires before the
expected completion time of this level, an evaluation will be made to
determine remixing the serum.
NO VIAL WILL BE RELEASED UNTIL YOU HAVE AN EPI-PEN
AND HAVE BEEN EDUCATED ON ITS PROPER USE IN AN
*Each time a new vial is dispensed, you will need to bring your Epi-pen to
maintain a record of its expiration date with your allergy records.
Females of childbearing age: If you become pregnant while on
immunotherapy, notify the allergy department staff so your doctor may
determine an appropriate dosage. Immunotherapy will not be increased
during pregnancy, but may be maintained at a constant level. The decision
however, must have the consent of your obstetrician.
Please notify the allergy department staff if you have any new prescription
medications, particularly medication for high blood pressure, migraine
headaches, and glaucoma. "Beta Blocker" medications change our
emergency protocol for treatment of a generalized (systemic/anaphylactic)
SIDE EFFECTS/REACTIONS TO ALLERGY DROPS
Since allergy drops contain the very allergens to which you are allergic, they
occasionally cause reactions. The symptoms may occur soon after your
allergy drops or may occur to a milder degree later. Severe reactions tend to
begin very promptly after administration.
(A) Normal local reactions/side effects:
• Mouth itching *If mouth itching develops, take an antihistamine. For a quicker response you may also take a liquid antihistamine sublingually (under the tongue). *Consider decreasing your dose to one per day; build back up to 3 times per day as tolerance increases (typically 1 dose a day for 3 days, 2 doses a day for 3 days, then back to 3 doses a day). • Stomach ache *Consider decreasing you dose to one dose a day; build back up to 3 times a day as tolerance increases (typically 1 dose a day for 3 days, 2 doses a day for 3 days, then back to 3 doses a day). (B) Systemic allergic reaction:
On rare occasions a highly sensitive individual may develop
symptoms of a systemic allergic reaction. These symptoms will
possibly consist of itching or swelling of the throat, nose eyes, palms
and skin; hives, sneezing, runny nose, coughing, and wheezing. If
these occur, take an antihistamine (e.g., Benadryl, Allegra, Clarinex,
Zyrtec, Xyzal, etc…) and/or bronchodilator (quick relief inhaler -
anti-wheezing medication), go to the nearest emergency facility, or
call 911. If symptoms continue, administer your Epi-pen.
• REPORT ANY IMMEDIATE OR DELAYED ALLERGIC
REACTION BEFORE YOU ADMINISTER YOUR NEXT
ALLERGY TREATMENT SO THAT THE PROPER
ADJUSTMENT CAN BE MADE.
If you have any questions, please contact the office at 972/596-4005 x103 or
Current Concepts age of 40 years10 and are increasingly seen in youngchildren.11 Eating disorders are more prevalent inindustrialized societies than in nonindustrialized so-cieties and occur in all socioeconomic classes and major ethnic groups in the United States.12-14 Thedisorders appear to be caused by a combination of ANNE E. BECKER, M.D., PH.D., STEVEN K. GRINSPOON, M.D., ANNE KLIBANSKI, M.D.,