Cardio Diabetes_2017 book

578 Exercise and Physical Activity in Diabetes Mellitus

Metabolic and Hormonal Effects of Exercise related to the exercise. In moderate aerobic exercise
in Diabetes: it increases or remain unchanged

During the past 30 years, much has been learned *Hypoglycemia occurs if hyperinsulinemia exists
about the metabolic and hormonal adaptations that during moderate intensity aerobic exercise, exercise
occur during physical exercise. These information’s in prolonged (> 30 to 60 min) and if no extra snacks
can be used to develop strategies for the manage- are taken before or during moderate intensity exer-
ment of persons with diabetes who wish to partici- cise.
pate in sports or other various vigorous recreational
activities. During exercise several cardio vascular * Normoglycemia remains unchanged if exercise is
humoral and metabolic responses occur in a highly brief and mild to moderate in intensity and appropri-
integrated fashion to ensure the delivery of oxygen ate snacks are taken before and during moderate in
and metabolic fuels to working muscle and remove intensity exercise.
metabolic end products.
*Hypoglycemia occurs if hypoinsulinemia exists
Type 1 Diabetes: during exercise is very intense and excessive carbo-
hydrate taken before or during exercise.
The transition from rest to moderate exercise char-
acterized by the activation of sympathetic and hor- TYPE 2 DIABETES:
monal systems that stimulate the use of the glucose
stored in the muscle and liver and the release of free The metabolic and humoral effects of exercise in
fatty acids by the adipose tissue. Rate of glucose ox- T2DM resulting in cardio vascular risk reduction has
idation during moderate intensity exercise estimated been dealt in detail in this chapter. Exercise induced
to be 2 mg/kg/min in adults and these leads to a stimulation of such uptake involves many factors.
fast decreased in blood glucose concentration due They include increased post-receptor insulin sig-
to impairment in the glucagon counter regulatory re- naling, increased glucose transporter protein and
sponse. Even with a sufficient glucose and adrena- mRNA, increased activity of hexokinase and gly-
line response to physical exercise in T1DM, elevated cogen synthase, decreased release and increased
levels of exogenous insulin may directly or indirectly clearance of free fatty acids, increased muscle glu-
inhibit glucagon secretion due to its antagonist effect cose delivery as a result of increased muscle capil-
and reduce lipolysis and proteolysis. The huge rate lary density, changes in muscle composition favoring
of carbohydrate oxidation during physical exercise in increased glucose disposal and changes in adipose
T1DM could be one of the factors leading to hypogly- tissue mass and distribution. Decrease in visceral fat
cemia. Several factors affect the blood glucose levels result in decreases in tumor necrosis factor (TNF) and
during exercise including an energy balance inade- free fatty acids, leading to decreased insulin resis-
quate to demand of exercise, added to an excessive tance. Exercise training in T2DM has been shown to
amount of insulin administered to the sub cutaneous produce anti- atherosclerotic lipid profile and other
areas involved in the exercise, increased the rates of cardiovascular risk factors. Resistance training has
insulin absorption promoting hypoglycemia. There is also been shown to improve insulin sensitivity and
also increase in insulin sensitivity by 40% for 48hrs. glucose metabolism.
Studies also reflect two main defenses against by
hypoglycemia are impaired in T1DM. As these indi- Physical Activity, Exercise Screening,
viduals are unable to decrease the levels of circu- Programming and Remcommendations in
lating insulin and have impaired glucagon response. Diabetes:
Even the adrenaline response may be less robust
and due to the signs and symptoms of hypoglyce- In many patients with both T1DM and T2DM, adequate
mia related to autonomic regulation are impaired. It glycemic control can often be achieved by dietary
has been shown that repeated hypoglycemia T1DM, changes, regular physical activity, structured exer-
induces what is termed as hypoglycemia associated cise and weight control. Specific recommendations
autonomic failure (HAAF). and guidelines for exercise in diabetes have been
published by the American Diabetes Association
So the metabolic and hormonal responses of T1DM (AHA) and the American College of Sports Medicine
patients to exercise depend on the intensity and du- (ACSM)3. Advice to be tailored to individuals taking
ration of exercise, the patient blood sugar control into account of their choices, personal goals, levels
level, dose and site of pre-exercise insulin injection, of fitness, contra indications and available resources.
timing of the pervious insulin injection and the meal

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Cardio Diabetes Medicine 2017 579

Screening and Physical Examinations : Table 3 : Creteria For Consideration Of
Graded Exerise Stress Testing
Most individuals with diabetes should have complete
history and physical examination done under the  Age > 40 yrs with or without cardiovascular risk
guidance of a health care provider, paying particular factors other than DM
attention to identify any long term complications of
diabetes. Screening for acute and chronic glucose  Age >30 yrs and
control, physical limitations, medications including
insulin regimen and microvasaular and macro vas-  T1DM or T2DM of > 10 yrs duration
cular complications associated with the heart, blood
vessels, eyes, kidneys, feet, and nervous system. As  Hypertension
mentioned earlier, the presence of diabetes related
complications or other co-morbidities like cardiovas-  Cigarette Smoking
cular disease, neuropathy, nephropathy, retinopathy
and hypertension can affect an individual’s ability to  Dyslipidemia
undertake certain type of physical training, increase
cardiovascular risk or pre-dispose to injuries. Patients  Proliferative or Pre-Proliferative retinopathy
with uncontrolled hypertension, severe autonomic
neuropathy, severe peripheral neuropathy or history  Nephropathy, including micro albuminuia.
of foot lesion and unstable proliferative retinopathy
in diabetes are not fit for the physical training. Phys-  Any of the following regardless of age
ical examination should be focused on identifying
these conditions by appropriate means. In older indi-  Known or suspected CAD, CVD or PAD
viduals particularly those with the increased CAD risk
factors, a graded exercise stress test will be helpful  Autonomic neuropathy
to identify the under lying CAD, an exaggerated hy-
pertension response to exercise and post exercise  Advance nephropathy with renal failure
orthostatic hypotension. The elevated number of
cardiovascular risk factors like old age, diabetes > *CAD : Coronary artery disease , CVD : Cerebro-
10yrs, waist circumference, elevated cholesterol lev- vascular disease, PAD : Peripheral arterial disease
els and a family history of heart disease also to be
accounted. For young active patients with diabetes Exercise Programming and Prescription
of brief duration and no evidence of long term com-
plications do not require an exercise stress test and In exercise programming, if there are no contra in-
formal exercise prescriptions but they need specific dications, the types of exercise a patient performs
recommendations regarding protocols for managing can be matter of personal choice. Aerobic or endur-
exercise and avoiding injuries. Symptomatic individu- ance exercise has been the most studied mode of
als may benefit from diagnostic cardiac stress testing physical conditioning, and the resultant increases in
both for diagnostic purposes and also to assist in cardio respiratory fitness in patients with T2DM have
safe and effective exercise. Graded exercise testing been consistently associated with improvements in
may be undertaken in low risk and other individuals modifiable cardiovascular risk factors independent of
to determine fitness levels (Table 3) weight loss. In general, moderate – intensity aerobic
exercises for the endurance phase use large group
of muscles are maintained continuously and are
rhythmic in nature such as walking, jogging, swim-
ming, cycling, rowing, stair-climbing are preferred.
And also there is good evidence that intermittent
high-intensity and resistance exercises can be man-
aged successfully resulting in improved insulin sen-
sitivity and better glycemic control. Most programs in
diabetes now include a combination of aerobic and
resistance exercise to achieve to maximum benefits
from a physical training program. Due to the high
incidence of underlying CAD and increased risk for
exercises induced CV events and orthopedic injuries,
adoption of a moderate intensity like walking rather
than a vigorous physical activities like jogging and
running may be more suitable program in diabetes
particularly in middle age and above is mandatory.
Walking has several advantages over the other forms

Cardio Diabetes Medicine

580 Exercise and Physical Activity in Diabetes Mellitus

of exercise. Apart from neuromuscular stability, walk- gradually from conditioning phase and for safe tran-
ing has accessibility, social companionship, lack of
special equipments, easily tolerable exercise in inten- sition to original state.
sity, fewer muscle skeletal and orthopedic problems
of the legs, knee and feet. Exercise Prescription :

Aerobic Exercise Recommendations : This could specifically address certain questions like
what type of exercise (mode), how much, (Intensity)
Aerobic exercise has been the mode of physical ac- how long (duration) and how often (frequency) and
tivity traditionally recommended for diabetes man- rate of progression of the program (Progression).
agement and prevention. The American college of While these are interrelated and will vary depending
sports medicine (ACSM) recommends moderate – on the goals of physical activity in the individual pa-
intensity training for at least 30min/day or 5 days tient and the patients choices, needs, back ground
/week (a total of at least 150 min/week), vigorous and health condition. While imparting the exercise
intensity training for at least 20min/day on 3days/ prescription to patients with diabetes safety rec-
week (at least 60-75 min/week). For patients with ommendation should be incorporated concerning
T1DM, exercise recommendations are closely aligned the mode, frequency, duration and intensity of the
with those for apparently healthy people. Recommen- advised exercise. Timing of medications, food and
dations for women with uncomplicated gestational glucose monitoring in relation to exercise should be
diabetes (GDM) include engaging in 30 min of mod- discussed.
erate intensity activity like brisk walking on most
days of the week (150 min/week) Guidelines and Recommendations for Exer-
cise in Diabetes:
Each Aerobic Exercise Session Generally Has
3 Different Phases : there are several guidelines and recommendation
from authorities like ADA and ACSM available which
Warm-up phase includes 5-10 min of physical activ- incorporate the beneficial effect of all types of phys-
ity done at a lower intensity such as cycling slowly. ical training program suitable for all types of diabe-
This will help to prevent muscle injury and facilitates tes population. Before considering the recommen-
a safe transition from rest to exercise by stretching dations, it is better to formulate certain facts before
postural muscles, increasing blood flow elevating presenting the particular exercise like discussing the
body temperature and increasing O2 availability and patient’s expectation, establishing the realistic goals,
metabolic rate. mode, frequency, intensity and rate of progression
of the activity and developing a plan to keep track
Conditioning Phase of progress. Safety considerations like contra-indi-
cations, medication in relation to exercise, glucose
is the most important for achieving fitness and other monitoring, snacking, appropriate foot wear, identi-
goals like enhancing cardiac respiratory fitness, mus- fication tag or bracelet all be accounted for (Tables
cle strength and endurance or flexibility. 4 & 5)

Cool down Phase includes at least 3-5 min of doing
a lower-intensity activity to help the body to recover

TABEL 4: GENERAL GUIDELINES FOR EXERCISE IN DIABETES

Exercise used to reduce weight should be combined with dietary measures

Exercise should be appropriate to the person’s general physical condition and lifestyle.

Moderate intensity aerobic exercise should be part of the daily schedule, if possible accumulation 150 min
each week. More vigorous exercise (> 70% of VO2 max) undertaken 3-5 times per week. Pervious sedentary
patients may have to buildup exercise volume gradually starting with as little on 5-10 min/day.

Multiple shorter exercise sessions lasting at least 10 min/ day are probably as useful as a single larger
session

If vigorous exercise is taken, low intensity warm-up and cool-down periods to be included.

Resistance exercise to be performed 2 -3 times / week to be progressed to 3 sets of approximately &
resistance type exercise at relatively high intensity if scalable.

Use of proper footwear and if appropriate other protective devices

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Cardio Diabetes Medicine 2017 581

Exercise is extreme cold or heat to be avoided
Inspection of feet before and after exercise is necessary

TABLE 5 : SPECIFIC CONSIDERATIONS FOR EXERCISE IN T1DM and T2DM

Specific considerations for exercise in Type T1DM

Avoid hypoglycemia during exercise by :

 Avoiding heavy exercise during peak insulin action

 Using non-exercising areas for insulin injection

 Reducing pre-exercise insulin dosages by 20 – 50%, if multiple daily injections are used, using an insu-
lin pump and also decreasing the basal before exercise. These are individualistic based on blood glucose
monitoring.

 Monitor glycemia before, during and after as necessary.

 Taking extra carbohydrate before and hourly during exercise. This also to be individualized and based
on blood glucose monitoring.

 After prolonged exercise, monitor glycemia and take extra carbohydrate to avoid delayed hypoglycemia.

 Use extra caution in monitoring glycemia if exercise is being performed within 24 hrs of a hypoglycemic
episode.
Specific considerations for exercise in Type T2DM

 Hypoglycemia is less common in T2DM during exercise then in T1DM and extra carbohydrate usually
unnecessary.

 Patients on insulin or sulphonylureas may need to reduce the doses during exercise day guided by
glucose monitoring

Recommendations : Adults with diabetes should engage in 2–3 sessions/
week of resistance exercise on nonconsecutive days.
Pre-exercise medical clearance is generally unneces-
sary for asymptomatic individuals prior to beginning Flexibility training and balance training are recom-
low- or moderate-intensity physical activity not ex- mended 2–3 times/week for older adults with diabe-
ceeding the demands of brisk walking or everyday tes. Yoga and tai chi may be included based on in-
living. dividual preferences to increase flexibility, muscular
strength, and balance.
Most adults with diabetes should engage in 150 min
or more of moderate-to-vigorous intensity activi- Individuals with diabetes or pre diabetes are en-
ty weekly, spread over at least 3 days/week, with couraged to increase their total daily incidental (non
no more than 2 consecutive days without activity. exercise) physical activity to gain additional health
Shorter durations (minimum 75 min/week) of vigor- benefits.
ous intensity or interval training may be sufficient for
younger and more physically fit individuals. To gain more health benefits from physical activity
programs, participation in supervised training is rec-
Children and adolescents with type 1 or type 2 dia- ommended over non supervised programs. (Table 6)
betes should engage in 60 min/day or more of mod-
erate or vigorous intensity aerobic activity, with vigor-
ous, muscle-strengthening, and bone-strengthening
activities included at least 3 days/week.

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582 Exercise and Physical Activity in Diabetes Mellitus

Table 6—EXERCISE TRAINING RECOMMENDATIONS: TYPES OF EXERCISE, INTENSITY,
DURATION, FREQUENCY, AND PROGRESSION

Aerobic Resistance Flexibility and Balance

Type of Exercise *Prolonged, rhythmic *Resistance ma- *Stretching: static,

activities using large chines, free dynamic, and other

muscle groups (e.g., weights, resistance stretching; yoga

walking, cycling, and bands, and/or * Balance (for older
swimming) adults): practice stand-
body weight as re- ing on one leg, exercis-
*May be done contin-
sistance exercises

uously or as HIIT es using balance equip-

ment, lower-body and

core resistance exercis-
es, tai chi

Intensity *Moderate to vigor- *Moderate (e.g., 15 *Stretch to the point of

ous (subjectively ex- repetitions of an tightness or slight dis-

perienced as “mod- exercise that can comfort
erate” to “very hard”) be repeated no

more than 15 times) *Balance exercises of
to vigorous (e.g., light to
6–8 repetitions of

an exercise that moderate intensity

can be repeated no

more than 6–8

times)

Duration *At least 150 min/ *At least 8–10 ex- *Hold static or do dy-
Frequency
week at moderate to ercises with com- namic stretch for 10-

vigorous intensity for pletion of 1–3 sets 30 s; 2-4 repetitions of

most adults with dia- of 10–15 repetitions each exercise

betes to near fatigue per

*For adults able to set on *Balance training can
run steadily at 6 miles be any duration
per h (9.7 km/h) for every exercise ear-
ly in training

25 min,75 min/week

of vigorous activity

may provide similar

cardioprotective and

metabolic benefits

*3–7 days/week, with *A minimum of 2 *Flexibility: >2-3 days/

no more than 2 con- nonconsecutive week

secutive days with- days/week, but * Balance: >2-3 days/
out exercise preferably 3 week

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Cardio Diabetes Medicine 2017 583

Progression *A greater emphasis *Beginning training *Continue to work on

should be placed on intensity should be flexibility and balance

vigorous intensity moderate, involv- training, increasing du-

aerobic exercise if ing 10-15 repeti- ration and/or frequency

fitness is a primary tions per set, with to progress over time

goal of increases in

exercise and not weight or resis-

contraindicated by tance undertaken

complications with a lower num-

ber of repetitions

(8-10) only after

* Both HIIT and con- the target number

tinuous exercise of repetitions per

training are appropri- set can consistent- *HIIT=HIGH INTENSITY

ate activities ly be exceeded.
for most individuals *Increase in resis- INTERVAL TRAINING.

with diabetes tance can be

followed by a
greater number of
sets and finally by
increased training

frequency

Life Style Phsical Activity and Its Pyramid :

In addition to the contemporary exercise guidelines, randomized clinical trials have now shown that
a life style approach to physical activity will be beneficial in promoting cardio vascular fitness and pre-
vention of cardio-metabolic disorders. This will be an alternative approach to sedentary people who
are not compliant with formal exercise program. Practicing physicians and allied health care providers
should advise their patients to integrate multiple short session of physical activity into their daily rou-
tines to reduce non-exercise activity thermogenesis. The spontaneous physical activities of daily living
represent another way of energy expenditure for many people. The activity pyramid analogous to the
U.S. food guide pyramid had been suggested as a model for the increasingly sedentary public. (Fig 2)

FIG 2: The Activity Pyramid Model Analogous to Food Pyramid

Cardio Diabetes Medicine

584 Exercise and Physical Activity in Diabetes Mellitus

This activity pyramid presents a tiered set of weekly and Diabetes, American Diabetes Association, Virginia, USA, Exercise and
goals to promote improved cardio respiratory fitness Diabetes, American Diabetes Association, 2013, pages135 -145.
and health by negating the constellation of bio chem-
ical changes leading to cardiovascular risk. 5. Dareen K. McGuire Nikolaus Marx, Effect of Lifestyle Interventions on
Coronary Heart Disease Risk in Patients with Diabetes, Saunders – Elsevier
Prevention of T2DM : Inc., Diabetes in Cardiovascular Disease, Philadelphia, USA, Read Elsevier
India Private Limited, 2015, pages 139-153.
Epidemiological studies have shown that reduction
of 30% to 40% developing T2DM with brisk walking
for at least 30min/day. Clinical trials demonstrated
that regular walking or other moderate exercise in
addition to dietary change and modest weight loss-
es resulted in a 58% reduction in the transition of
pre-diabetes to diabetes. In the Nurses Health Study,
moderate and vigorous levels of physical activity are
associated with reduced incidence of overall cardio-
vascular events among diabetic women aged 30-55
years.

Summary :

The incidence of diabetes mellitus increasing expo-
nentially all over the world throwing more burden on
the health care delivery system.

Sedentary life style not only increases the burden of
diabetes but also jeopardizes the cardiovascular sys-
tem in the form of clustering of metabolic risk factors.

Regular physical exercise produces several cardio-
vascular benefits in diabetes which out-weigh the
risk associated with it.

Cardiovascular benefits of exercise in terms of antia-
therosclerotic, antithrombotic, antiinflammatory, anti
arrhythmic and psycho social well being are much be
beneficial in diabetes.

Before undertaking an exercise program of any type
in both T1DM and T2DM, a prudent screening and ap-
propriate formulation inculcating special precautions
are mandatory.

For recommending and prescribing an exercise pro-
gram, guidelines of authorities like ADA, ACSM and
others to be incorporated.

References :

1. Balducci S, Zanuso S, Cardelli P, et al: Changes in physical fitness predict
improvements in modifiable cardiovascular risk factors independently of
body weight loss in subjects with type 2 diabetes participating in the
Italian Diabetes and Exercise Study (IDES), Diabetes Care 35(6):1347-
1354,2012.

2. Green DJ. O’Driscoll G, Joyner MJ, et al: Exercise and cardiovascular
risk reduction : ti-me to update the rationale for exercise? J Appl Physiol
(2):766-768, 2008.

3. American Diabetes Association Position Statement. Standards of medical
care in diabetes, 2008. Diabetes Care 2008; 31(Suppll):S12-S54.

4. Sheri R. Colberg, Combined Aerobic and Resistance Training for Adults

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Cardio Diabetes Medicine 2017 585

Medical Nutrition Therapy in Cardiodiabetes

Dr. AKHILESH VERMA

MBBS MD Medicine
Senior Consulting Physician

Abstract : amount will not only help to manage the blood sugar
but will also lower the cholesterol and blood pressure
WHO, world health statistics report 2016 shows isch- . American Diabetes Association suggest control the
emic heart disease contributed 12.4% for total deaths carbohydrate intake to control the blood sugar.2
in India. Data confirms India’s overwhelming non-
communicable disease burden. Non communicable A cardiodiabetic diet encourages to eat more fresh,
diseases in both sexes is rampantly going up in In- whole foods and less saturated fat and salt. The role
dia and hence need to discuss about role of diet as of diet as a therapy is discussed in different scien-
therapy in cardiodiabetes. tific studies but mostly western and paucity of them
taking indian diet and with perspective of food habits
A medical nutrition therapy in cardiodiabetic en- of Indian. The diet plan discussed here incorporates
courages to eat more fresh, whole foods and less basics of both diabetics and heart health from indian
saturated fat and salt. The role of diet as a therapy as well as western standpoint.
is discussed in different scientific studies.
To improve cardiac health more nutrients rich food
The diet plan discussed here incorporates basics of such as fruits , vegetables, whole grains, low fat dairy
both diabetics and heart health from indian as well items, poultry, fish and nuts should be used in diet..
as western standpoint.Small change in cooking hab- Limiting the intake of food high in calories and so-
its will give good result. So, forget frying foods and dium like fried snacks, papad, pickels and all fast
cook healthier by using steam, broil, roast and grill food, will be useful.Faulty lifestyle unhealthy diet,
as alternatives. physical inactivity, smoking, tobacco chewing and
alcohol are major contributing factors for rise in the
In general nutritional recommendation for cardiodia- cardiodiabetes.
betes is controlling
Probability of developing heart disease and stroke
portion size, limiting consumption of saturated trans- is twice in diabetics, as compared to nondiabetics.
fat and amount of Dietary modification not only helps managing blood
sugar but will also play pivotal role in lowering cho-
carbohydrates to achieve healthy body weight. The lesterol and blood pressure too, The write up will dis-
ABC Strategy in the nutritional therapy will be A cuss about common myths and wrong practices and
Awareness of sugar, B- Balance of the salt and C dietary habits of Indian culture and ethnics.
Control of the body weight.
WHO, world health statistics report 2016 shows isch-
Keywords: emic heart disease contributed 12.4% for total deaths
in India. Data confirms India’s overwhelming non-
Cardiodiabetes, diet therapy, medical nutrition communicable disease burden. Non communicable
diseases in both sexes is rampantly going up in In-
Cardiodiabesity is a hybrid term used to define and dia and hence need to discuss about role of diet as
describe the well-known relationship between type-2 therapy in cardiodiabetes..
diabetes mellitus, obesity, metabolic syndrome and
cardiovascular disease. The term cardiodiabesity is Lifestyle modification is key to primary prevention as
not only useful to describe this framework but also well as included in all stages of treatment strategy
to highlight the need to consider all the risk factors
and health outcomes combined in clinical practice.1
Eating right type of food, at right time and with right

Cardio Diabetes Medicine

586 Medical Nutrition Therapy in Cardiodiabetes

and secondary prevention. Medical Nutritional Man- saturated fats should be preferred. Try to avoid sat-
agement is pointing towards life style modification, urated fat and transfat. The caloric value by fats in
sepcifically in the obese where losing some pounds diet should not exceed 25-35% .
will be beneficial for reducing blood pressure too. The
first and foremost important point will be cessation Peanut butter and buttermilk should be preferred
of smoking, limiting alcohol and increase in physical over meat, buttter, whole milk, cream and cheese
activity.
The foods rich in omega 3 fatty acids like tuna fish,
There is no one diabetic diet that can suit all. . Modi- rich in PUFA like avocado, walnuts should be inte-
fication of normal well balanced diet -based on nutri- gral part of diet therapy in cardiodiabetic. A fistful of
tional needs of the individual will be more appropriate nuts like almonds will bring positive changes when
approach. Diet calculated in term of total calories tak- included in daily diet.
ing in consideration ratio of carbohydrates, protein
and fat should be individualized. A simple and fruitful approach in nutrition therapy is
one third of ttoal carlories distributed for early morn-
Of the total calories carbohydrates contribute 50to ing and breakfast. Another one third for mid morning
60% , Protein 15-20%, Total fats 25-35%, Saturated fat snacks popularly knonwn as munch and lunch. The
less than 7%, Polyunsaturated fats upto 10%, Mono- rest one third can be distributed in evening snacks
unsaturated fats upto 20% and cholesterol less than and dinner.
200 mg/day in ideal balanced diet.3
Whole grains should be priority at breakfast. Whole
Ideal meal plan should include three to four serving grain , fruts and vegetables are good sources of fiber,
of carbohydrates at each meal ( each serving of 15 which will control the blood suggar and will lower the
gms), complex carbohydrrates are good , high in risk of the heart disease. Half cup of cooked oat meal
fiber. Unpolished rice, ragi, whole wheat should be topped with coriander, banana and yoghurt can be
preferred over polished rice. ideal breakfast sometimes can be replaced for whole
wheat english muffins topped with two teaspoonful
Fibers are of two types soluble;. oat, psyllium, of peanut butter and apple.
gum fruits like guava and apple and insoluble viz.
wholegrain, pulses, vegetables, fruits like oranges At lunch at least two serving of fish as omega 3 fatty
and sweetlime. Serving fruit in form of the juice or acids in fish such as salmon and tuna improves heart
mashup is more common . Taking fruit as whole health and help in managing blood sugar. Steamed
should be preferrred choice over the juice or mashup brocolli, baked potato with skin with vegetable such
. Whole wheat, parboiled rice ,pulses, fenugreek and as beans, cauliflower and carrots topped with low fat
fruits with skin are rich in fiber. salad dressing sometime with sprouted beans and
small orange makes ideal lunch menu.
In the ,management of obesity when you plan to re-
duce the weight skipping any meal should be strictly Heart healthy dinner should include source of protein
avoided. As amount of food taken after skipping any such as beans, soya food, poultry or fish with whole
meal will be more in amount, to satisfy the satiety, wheat fulka.. Half cup of beans tomato, onion and
adding more calories.. The punchline will be taking low fat cheese. One third cup of brown rice with salsa
food before you feel hungry , and not before 3-4 or dal. The alternative food can be baked chicken ,
hours of last eating. Here the role of fibres is cru- with one cup of peas, one slice of whole wheat bread
cial. Nondigestible carbohydraes forms the bulk and tossed with salad with low fat salad dressing. Dinner
improves satiety helping individual to control the cal- should be taken at least two hour before retiring to
ories . sleep. Adequate sleep between 7 to 8 hours prefera-
bly during night time will help in weight management
Proteins are not converted into sugar as fast as car- program. Short sessions of yognidra are proved use-
bohydrates are converted. Adding eggwhite in diet or ful in managing diabetic and hypertensive patients. 4
sprouted beans and pulses for vegetarian will defi-
nitely help in weight management as it keeps sati- Diabetics should avoid sugar, honey, jiggery, cake,
ety center satisfied for longer period as compared to pastries, roots and tubers like potato, tapioca, butter,
carbohydrates. Digestion of proteins will also require ghee and fried preparation, fruits like jackfruit and
some energy, hence less energy will be stored. Fif- mango.
teen to twenty percent of total caloric value may be
derived from protein. Cardiac patients should avoid cholesterol rich food
like whole milk and milk products, egg yolk, shell-
Regarding fats, monounsaturated fats and polyun- fishes like prawns, crabs and lobsters, organ meats

GCDC 2017

Cardio Diabetes Medicine 2017 587

like liver, kidney, brain etc., sweets like pastries, ice-
cream , butter , ghee, fried items like vada, chips,
samosa and alcoholic drinks and carbonated bever-
ages.

Adding extra salt as topping. baking powder, baking
soda, salted chips, pocorns, papad, pickles, dried
fish, canned and salt preserved food, readymade
foods like noodles and fast food. should be avoided

Fenugreek, Garlic, curry leaves, coriander leaves and
seeds, ginger have been proved scintifically for exhib-
iting properties to reduce blood sugar and or choles-
terol5. Cooking oil should not be used for more than
10-15 ml /day. Preferably use combination of cooking
oils like groundnut, sunflower, ricebran, mustard.

It can be aptly said if we are using nutrition as ther-
apy in cardiodiabetes small change in cooking hab-
its will give good result. So, forget frying foods and
cook healthier by using steam, broil, roast and grill
as alternatives.

In general nutritional recommendation for diabetes
is controlling portion size, limiting consumption of
saturated transfat and amount of carbohydrates to
achieve healthy body weight. The ABC Strategy in the
nutritional therapy will be A Awareness of sugar, B-
Balance of the salt and C Control of the body weight.
and can be achieved definitely by monitoring of the
ABC A1C, Blood Pressure and Cholesterol.

References:

1. Elena García-Fernández, et al Mediterranean Diet and Cardiodiabe-
sity: A Review Nutrients. 2014 Sep; 6(9): 3474–3500.

2. American Diabetic Association guidelines 2016.

3. Nihal Thomas et al , A practical Guideline to diabetes mellitus 7th Edition
2016 Jaypee publication PN 39-56.

4. Amita S1, Prabhakar S, Manoj I, Harminder S, Pavan T. Effect of yoga-nidra
on blood glucose level in diabetic patients. Indian J Physiol Pharmacol. 2009
Jan-Mar;53(1):97-101.

5. Spices in the management of diabetes mellitus Xinyan Bi a,1 , Joseph Lim
a,1 , Christiani Jeyakumar Henry a,b,⇑ a Clinical Nutrition Research Centre
(CNRC), Singapore Institute for Clinical Sciences (SICS), Agency for Science,
Technology and Research(A*STAR),

Cardio Diabetes Medicine

588 Prevention of Non-Communicable Diseases - Whom to Focus?

Prevention of Non-Communicable
Diseases - Whom to Focus?

PROF.DR.SESHIAH , MD., FRCP, D Sc., (Hony)

Founder of Dr.V.Seshiah and Dr.V.Balaji
Diabetes care centre and Research Institute, Chennai.

Abstract: follow a healthy lifestyle pattern. “GDM is the mother
of Non communicable Diseases” and “Diabetes is
Preventive measures against Type 2Diabetes Mellitus synonyms to vascular disease”
(T2DM) and associated cardio vascular complications
should start during intra-Uterine period and continue GDM and Maternal hyperglycemia are used inter-
throughout life from early childhood. Preventive med- changeably in this article.
icine starts before birth. In this aspect, Gestational
Diabetes Mellitus(GDM) offers an important opportu- Key Words: Non-communicable Diseases, Gestation-
nity for the development, testing and implementation al Diabetes Mellitus, Cardio-vascular diseases
of the clinical strategies for prevention of diabetes
and Non-Communicable Diseases(NCDs). Gestation- INTRODUCTION
al Diabetes Mellitus (GDM) is defined as glucose
intolerance of varying severity first detected during The prevalence of diabetes is increasing globally
the present pregnancy. GDM may play a crucial role and India is no exception. The concern is that India
in the increasing prevalence of diabetes and obesity. would be having the highest population of diabe-
Insulin resistance, increased atherogenic lipid profile, tes by 2025.The increased prevalence is attributed
inflammatory markers, hypertension and endothelial to the aging population structure, urbanization, the
dysfunction lead to increased risk for Cardio Vas- obesity epidemic, and physical inactivity1. While all
cular Diseases(CVD) .GDM is associated with short these factors contribute to the epidemic of diabe-
term maternal, fetal, neonatal consequences for both tes, early life exposures are emerging as potential
mother and the offspring. In most instances the glu- risk factors. The ‘‘fetal origin of disease’’ hypothesis
cose intolerance reverts to normal but substantial proposes that gestational programming may critically
number of women with GDM have increased lifetime influence adult health and disease. Gestational pro-
risk of developing diabetes at over three times com- gramming is a process whereby stimuli or stresses
pared to control after sixteen years of index preg- that occur at critical or sensitive periods of develop-
nancy. By 17 years of age one third of children born ment, permanently change structure, physiology, and
to GDM mothers have had evidence of pre diabe- metabolism, which predispose individuals to disease
tes, T 2 DM, Metabolic syndrome, impaired insulin in adult life. Traditionally and convincingly, lifestyle
sensitivity and secretion. The underlying pathogenic modifications and drug interventions have proved to
mechanism for the abnormal metabolic profile could delay or postpone the development of overt diabetes
be due to epigenetic changes induced by fetal ex- in persons diagnosed to have impaired glucose toler-
posure to hyperglycemia, intrauterine milieu Inter- ance. This is a post primary prevention strategy. The
ieur. Hence timely action taken now in screening all primary prevention of Type 2 DM at best would mean
pregnant women for glucose tolerance, achieving eu- to keep genetically or otherwise susceptible individ-
glycemia in them may prevent in all probability the uals normoglycemic and not only preventing Type 2
epidemic of non communicable diseases. Female DM from developing. The primary prevention is more
gender is key to prevention of non communicable important than post primary prevention, as this effort
diseases. The Post partum follow up is very essen- is likely to reverse or halt the epidemic of disease.
tial and pre GDM women should be advised against Women with Gestational Diabetes Mellitus (GDM) are
gaining weight, similarly their off-springs should also an ideal group for the primary prevention of diabetes

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as they are at increased risk of developing diabetes velopment of fat mass and leptin production. Leptin
predominantly Type 2 DM as are their children. Ges- reduces energy intake and suppresses the insulin
tational Diabetes Mellitus is defined as carbohydrate secretion via leptin receptors on pancreatic β-cells.
intolerance of variable severity with onset or first rec- Abnormal functioning of this adipoinsular axis may
ognition during the present pregnancy. Women with lead to hyperphagia, dysregulation of the energy bal-
GDM have an increased lifetime risk of developing ance and excessive adiposity8
diabetes, at over 3 times compared to controls at
16 years after index pregnancy2. By 17 years of age Maternal Obesity and It’s Influence on Off-
one-third of children born to GDM mothers have had Spring and CVD
evidence of IGT or T 2 DM3.
Exposure to maternal hyperglycemia in intrauterine
Impact of maternal hyperglycemia life confers an additional risk of developing cardio-
vascular disease in later part of life. This risk is in-
it has been now recognized that GDM may be playing dependent of any genetic predisposition or adiposity.
an important role in increasing prevalence of diabe- Studies are required to explain the mechanisms of
tes. Also, causing insulin resistance, obesity, dyslip- maternal hyperglycemia conferring the cardiovascu-
idemia, increased inflammatory markers , endothelial lar risk . There is an increasing interest in another
dysfunction , hypertension and ultimately leading to hypothesis on maternal obesity that leads to meta-
increased risk of cardiovascular diseases. Maternal bolic consequences in offspring’s. This can add up
hyperglycemia in pregnancy is an independent risk to accelerate the obesity epidemic too which is in-
factor for putting the offspring at increased risk of dependent to genetic or environmental factors.9 The
IGT, obesity , hypertension at 7 years of age, while glycemic index of diets also has an influence on
CV risk continues to increase from adolescent to birth weight of offspring’s. Exposure to high-glycemic
adulthood. There is also effect on childhood adipos- index diets led to higher birth weight and skinfold
ity which is only evident in girls and not boys4 .There thickness compared to exposure to a low glycemic
has been an association of maternal hyperglycemia diet.
with offspring’s adiposity and insulin resistance. In-
trauterine exposure to hyperglycemia has deleterious It can be safely concluded that exposure to a hyper-
effects that are in addition to those related to genetic glycemic environment in the intrauterine life is asso-
predisposition5 Also, in utero exposure to hyperin- ciated with increased occurrence of impaired glucose
sulinemia is an independent predictor of abnormal tolerance and a defective insulin secretary respons-
glucose tolerance in later childhood. Maternal hy- es. Gestational Diabetes Mellitus: gives an opportuni-
perglycaemia in pregnancy predisposes both mother ty where in development of T2DM and cardiovascular
and child at future risk of developing diabetes and Disease in young Women can be prevented. Women
cardiovascular diseases6. with previous gestational diabetes (pGDM),are at in-
creased risk of developing Type 2 diabetes. Some-
Glucose that normally acts as fuel for developing fe- times GDM may represent an early stage in the nat-
tus, in hyperglycemic state becomes deleterious for ural history of Type 2 diabetes. Also in subsequent
growing fetus. That gave rise to hypothesis called, years after the index pregnancy, these women with
“The fuel-mediated teratogenesis”, that first pro- pGDMshow deranged cardiovascular profile with an
posed the explanation for the association of exces- increased incidence of cardiovascular disease.
sive growth of fetus with maternal hyperglycemia.
Maternal insulin does not cross placenta freely while Steps to ameliorate
maternal glucose does and in response to that fetal
pancreas tries to balance by producing more insu- UNIVERSAL TESTING
lin. This in turn acts as fetal growth hormone and
becomes responsible for promoting growth and ad- Women of Asian origin and more so ethnic Indians,
iposity. are at a higher risk of developing GDM and subse-
quent type 2 diabetes. Universal screening for GDM is
Role of adipoinsular axis essential and early screening should be done in pop-
ulation where there is a higher prevalence of T2DM.
An endocrine feedback loop called as adipoinsu- As per new recommendations all women should be
laraxis connects the endocrine pancreas with adi- screened for GDM even if there are no symptoms.
pose tissue and the brain. This axis regulates hunger Compared to selective screening universal screening
and fat storage through the hormones named insulin of GDM detects more cases and ultimately improves
and leptin. Insulin is responsible for promoting de- maternal and neonatal outcomes.

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590 Prevention of Non-Communicable Diseases - Whom to Focus?

>Based on the Hyperglycemia and Adverse Pregnan- load*, irrespective of her fasting/ nonfasting status
cy Outcome (HAPO) study, International Association and without regard to the time from the last meal. A
of the Diabetes and Pregnancy Study Groups (IAD- venous blood sample is to be collected at 2 hours for
PSG) has suggested the guidelines10. Predominantly estimating plasma glucose by the GOD-POD method.
HAPO study was performed in Caucasian population GDM is diagnosed if 2-hour PG is ≥ 140 mg/dL(7.8
and population from India, China, South Asian coun- mmol/L). In case 75 g glucose packet is not available,
tries (except city of Bangkok, Hong Kong), Middle remove and discard five level teaspoons (not heaped)
East and Sub Saharan countries were not included. of glucose from a 100 g packet which is freely avail-
The IADPSG recommendations include; that diagno- able. In hospitals where glucose is supplied in bulk, a
sis of GDM is made when any of the following plas- cup or container of 75 g may be used. The marketed
ma glucose values meet or exceed: Fasting: 92 mg/ glucose is available in anhydrous form.
dL, (≥ 5.1 mmol/L), 1-hour: 180 mg/dL ( ≥ 10.0 mmol/L)
, 2-hour: 153 mg/dL (≥ 8.5 mmol/L) with 75 g OGTT. As glucose concentrations are affected little by the
The IADPSG also suggests: Fasting plasma glucose time since the last meal in a normal glucose tolerant
(FPG); 126 mg/dL(> 7.0 mmol/L) and A1C > 6.5% in woman, it makes it a rationale to perform this test in
the early weeks of pregnancy is diagnostic of overt the nonfasting state. After a meal, a normal glucose
diabetes. Fasting >92mg/dL and <126 mg/dL is di- tolerant woman would be able to maintain euglyce-
agnosed as GDM. mia due to brisk insulin response against glucose
challenge. Whereas, a woman with GDM would not
Disadvantages of the IADPSG be able to do so due to impaired insulin secretion
Recommendations are: that leads to increase in her glycemic levels with
glucose challenge and the glycemic excursion may
Most of the time pregnant women do not come in exaggerate further. There are several advantages of
the fasting state because of belief that they should the DIPSI procedure such as: Pregnant women need
not fast for long hours. The dropout rate is very high not be fasting, it causes least disturbance in routine
if they are asked to come back for repeat test for activities of a pregnant woman, and it serves as both
glucose tolerance. In many situations attending the screening and diagnostic procedure. This single-step
first prenatal visit in the fasting state is almost im- procedure has been approved by Ministry of Health,
practical. • The hall mark of GDM is that In all cases Government of India. It is also recommended by
FPG values do not reflect the 2-hour post glucose WHO, Federation of Gynecologist and Obstetrician
with 75 g oral glucose [2-hour plasma glucose (PG)]. and Ministry of Health Government of India.
Two hour PG values are much higher in ethnically
Asian Indians compared to Caucasians as they have The chances of detecting unrecognized type 2 diabe-
high insulin resistance. The insulin resistance during tes before pregnancy (pre-GDM) is likely to be missed
pregnancy is further increased,hence FPG is not an if usual recommendation for screening between 24
appropriate option to diagnose GDM in Asian Indian weeks and 28 weeks of gestation is followed. In case
women. About 76% of pregnant women would have where 2-hour PG is > 200 mg/dL in the early weeks
missed the diagnosis of GDM made by WHO criterion of pregnancy, she may be a pre-GDM and in this case
by following FPG > 5.1 mmol/L as cut-off value, in A1C of ≥ 6.5 becomes confirmatory. A pregnant wom-
this population. an found to have normal glucose tolerance (NGT), in
the first trimester, should be tested again for GDM
Diabetes in Pregnancy Study Group India (DIPSI), around 24th–28th week and finally around 32nd–34th
has recommended single step procedure for diag- week.
nosing GDM in community11. DIPSI diagnostic criteria
of 2-hour PG ≥ 140 mg/dL is similar to WHO criteria Conclusion
2-hour PG ≥ 140 mg/dL. This was developed due to
the practical difficulty in performing glucose toler- FEMALE GENDER: THE KEY TO DIABETES PREVEN-
ance test in the fasting state, challenge of women TION and thus Maternal health is the link to the NCD
revisiting the antenatal clinic and that too in fasting epidemic. GDM is the mother of non communicable
state. Hence, it was important to have a test that de- disease. Hence preventive measures against Type 2
tects the glucose intolerance at first visit itself, irre- DM should start right from intrauterine period and
spective of fasting or fed state. continue throughout life from early childhood.GDM
offers an important opportunity for the development,
Procedure In the antenatal clinic should include ,after testing and implementation of clinical strategies for
completing preliminary clinical examination of preg- diabetes prevention and NCD12. Public Health Priority
nant women, she should be given 75 g oral glucose is to initiate the action in screening all pregnant wom-

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Cardio Diabetes Medicine 2017 591

en for glucose intolerance, achieving euglycemia in its complications, 1: Diabetes Med 1998; 15 :539-53.
them and ensuring adequate nutrition. This in turn in
all probability, will help in preventing the epidemic of Inadequacy of FPG to diagnose GDM
diabetes and CVD.DuringPostpartum period, women
should be screened periodically for glucose intoler- * In relation to FPG, there is a considerable variability
ance and advised proper diet plan and physical ac- between countries noted in the HAPO study with FPG
tivities. Their off-springs should also be advised to diagnosing only 22% of GDM in women in Bangkok
follow the healthy diet and healthy lifestyle. and Hong Kong compared with up to 71% in some
US centres .
References
* A low diagnostic rate of FPG has also been report-
1. Hunt KJ, Schuller KL. The increasing prevalence of diabetes in pregnancy. ed in Asian Indians with a fasting plasma glucose
ObstetGynecolClin North Am 2007;34:173-99. 5.1 mmol/l (92 mg/dl) diagnosing only 24% of GDM .

2. Henry OA, Beischer NA. Long-term implications of gestational diabetes ( Strategies for Implementing the WHO Diagnostic
for the mother.BaillieresClinobstetGynaecol 1991;5:461-83. Criteria and Classification of Hyperglycaemia First
Detected in Pregnancy. Stephen Colagiuri, Maicon-
3. Bernard L Silvermen, Nam H Cho, et al. Long-term effects of the intra- Falavigna, Mukesh M. Agarwal, Michel Boulvain,
uterine Environment . Diabetes care 1998;21:B142. Edward Coetzee, Moshe Hod, Sara Meltzer, Boyd
Metzger, Yasue Omori, Ingvars Rasa, Maria Inês,
4. Wing Hung Tam, Ronald Ching Wan Ma, Risa Ozaki, et al. In Utero Veerasamy Seshiah, David Simmons, Eugene Sob-
Exposure to Maternal Hyperglycemia Increases Childhood Cardiometabolic ngwi, Maria Regina Torloni, Hui-xia Yang. DRCP. 103
Risk in Offspring. Diabetes care 2017;40:679-686. (2014) 364-372 )

5. KrishnaveniGV ,Hill JC, Leary SD, etal. Intrauterine exposure to maternal * FPG is not an appropriate option to diagnose GDM
diabetes is associated with higher adiposity and insulin resistance and in Asian Indian women as insulin resistance is higher
clustering of cardiovascular risk markers in Indian children. Diabetes Care compared to Caucasians.
33;402-404, 2010
* Increased IR during pregnancy in Asian Indian
6. V.Seshiah,David McIntyre, Moshe hod et al.Matching diagnosis and man- Women and escalates further in GDM
agement of diabetes in pregnancy to local prioritis and resources: An
international approach.2009. IJGO. (Das S, Behera MK, Misra S, Baliarsihna AK. Β-cell
function and insulin resistance in pregnancy and
7. Maternal Environment and the Transgenerational Cycle of Obesity and their relation to fetaldevelopment.MetabSyndrRelat
Diabetes - Dana Dabelea and Tessa Crume – Diabetes, Volume 60 – July disorder 2010; 8(1): 25-32.
2011 – P 1849-1855
* In all GDM, FPG value do not reflect the PPG, which
8. McMillen  IC,  Edwards  LJ,  Duffield  J,  Muhlhausler  BS.  Regulation of leptin is the hallmark of GDM
synthesis and secretion before birth: implications for the early program-
ming of adult obesity.  Reproduction  2006;131:415–427 (Weiss PA, Haeusler M, Tanmussino K, Haas J. Can
glucose tolerance test predict fetal hyperinsulinism?.
9. Catalano PM. Obesity and pregnancy-the propagation of a viscous cycle? British Journal of Obstetrics and Gynecology 2000
J ClinEndocrinolMetab 2003;88:3505-3506 (107) 1480 – 1485)

10. Strategies for Implementing the WHO Diagnostic Criteria and Classifica- * Fasting may be impractical and questionable in set-
tion of Hyperglycaemia First Detected in Pregnancy. Stephen Colagiuri, tings where the detection of hyperglycemia in preg-
MaiconFalavigna, Mukesh M. Agarwal, Michel Boulvain, Edward Coetzee, nancy based on fasting values is low.
Moshe Hod, Sara Meltzer, Boyd Metzger, Yasue Omori, Ingvars Rasa,
Maria Inês, Veerasamy Seshiah, David Simmons, Eugene Sobngwi, Maria (Strategies for Implementing the WHO Diagnostic
Regina Torloni, Hui-xia Yang. DRCP. 103 (2014) 364-372 Criteria and Classification of Hyperglycaemia First
Detected in Pregnancy, 2013)
11. C. Anjalakshi, V.Balaji, MadhuriBalaji, Et Al. A Single test procedure to
diagnose gestational diabetes mellitus.ActaDiabetologia (2009) 46:51-54 ((South-East Asians had the lowest BMI, lowest fast-
ing yet highest 2-hr glucose level on 75-g glucose
12. Thomas A Buchanan, Anny Xiang, Siri L Kjos, Richard Watanabe. “What tolerance test.
is gestational diabetes?” Diabetes Care 30(2): S105-111, July 2007
V. W. Wong etalDiabet. Med. 29, 366–371 (2012)))
Diagnostic Criteria:-
* A Prospective study was undertaken to elucidate a
GDM is diagnosed if any one value is abnormal But FPG test procedure irrespective of the last meal timing to
is given importance(International workshop conference diagnose GDM
on gestational diabetes diagnosis and classification:
Consensus Forum Report. November 7th, 2008)

GDM 2-hour PG >140mg/dl similar to that of IGT out-
side pregnancy (WHO).

Alberti K, Zimmett P. WHO Consultation, Definition,
diagnosis and Classification of diabetes mellitus and

Cardio Diabetes Medicine

592 Prevention of Non-Communicable Diseases - Whom to Focus?

Conclusion:- (Balaji V, MadhuriBalaji, Anjalakshi C, Cynthia A,
Arthi T, Seshiah V. (2011). Diagnosis of gestational
2 hr PG ≥ 140 mg/dl with 75g oral glucose diabetes mellitus in Asian-Indian women.Indian J En-
administered in pregnant women in the fasting or docrinolMetab. July 2011, Vol 15, Issue 3, pp. 187-190)
non fasting state, without regard to the time of the
last meal is able to identify women with GDM. WHO Observations and Recommendations
2013
Rationale
(a) For a pregnant woman, the request to attend fast-
Performing this single test procedure in the ing for a blood test may not be realistic because of
fasting or non-fasting state irrespective of the last the long travel distance to the clinic in many parts of
meal timing is rational as glucose concentrations the world, and increased tendency to nausea in the
during the Glucose Tolerance Test will be affected fasting state. Consequently nonfasting testing may
least by the time since the last meal in Normal Glu- be the only practical option.
cose Tolerant women but will in GDM.
(b)There was no statistically significant difference in
(Catalano PM et al. Carbohydrate metabolism during the glycaemic response between non-fasting and
pregnancy in control subjects and women with GDM. standard OGTT in diagnosing GDM.
Am J Physiol 264: E60-67, 1993 )
c) A 2-step procedure requiring attendance on 2 sep-
(Anjalakshi C, Seshiah V, Balaji V, Madhuri S Balaji, arate occasions is often not feasible in many low and
Ashalatha S, Sheela Suganthi, Arthi T, Thamizharasi middle income countries. Not recommended
M, A single test procedure to diagnose gestational
diabetes mellitus. ActaDiabetologica 46 (1) : 51-54, (Strategies for Implementing the WHO Diagnostic
March 2009.) Criteria and Classification of Hyperglycaemia First
Detected in Pregnancy. Stephen Colagiuri, Maicon-
* This “walk in test” is recommended by Diabetes In Falavigna, Mukesh M. Agarwal, Michel Boulvain,
Pregnancy Study Group India.(DIPSI). Edward Coetzee, Moshe Hod, Sara Meltzer, Boyd
Metzger, Yasue Omori, Ingvars Rasa, Maria Inês,
(Balaji v, Balajimadhuri, Anjalakshi C, Cynthia A, Arthi Veerasamy Seshiah, David Simmons, Eugene Sob-
T, Seshiah V, Diagnosis of gestational diabetes melli- ngwi, Maria Regina Torloni, Hui-xia Yang. DRCP. 103
tus in Asian-Indian Women. Indian Jounal of Endocri- (2014) 364-372 )
nology and Metabolism, year 2011, Volume :15, Issue
:3, page no:187-190.) A “Single Step Procedure” to diagnose GDM is also
recommended by WHO -2013
* Diagnosis of GDM with 2-h PG ≥ 140 mg/dl and
treatment is worthwhile with a decreased macroso- (Ref - WHO/NMH/MND/13.2)
mia rate, fewer emergency cesarean sections, seri-
ous perinatal morbidity and may also improve the Disadvantage of two-step procedure
women’s health-related quality life.
This two-step procedure is cumbersome & also the
(Crowther CA, Hiller JE, Moss JR, et al. Effect of treat- phenomenon of “No show” occurs as the woman
ment of gestational diabetes mellitus. N Engl J Med has to visit the antenatal clinic or laboratory in a
2005; Vol. 352, No. 24, 2477-86.) fasting state.

(Gayle C, Germain S, Marsh MS, et al. Comparing 20-29% of screen positive women did not return for
pregnancy outcomes for intensive versus routine an- the diagnostic test.
tenatal treatment of GDM based on a 75 gm OGTT
2- h blood glucose (>140 mg/dl). Diabetologia.2010; (Luiz Guilherme Kraemer de Aguiar ,Haroldo Jose de
Vol. 53, Suppl. No. 1, S435.) Matos, Marilia de Brito Gomes. Diabetes Care 2001:
24: 954-5. )
(Jitendra Singh et al .Prevalence of Gestational Diabe-
tes Mellitus (GDM) and Its Outcomes in Jammu. JAPI (V Seshiah, V Balaji, Madhuri S Balaji, CB Sanjeevi,
(59): April 2011. ) A Green GestationalDiabetes Mellitus in India. JAPI
52, 2004. 707-11)
(V Seshiah, V Balaji, Madhuri S Balaji, ArunaSekar,
C B Sanjeevi, Anders Green: One step procedure for Indian subcontinent: medium to low resource set-
screening and diagnosis of gestational diabetes mel- tings serving ethnic populations at high risk
litus. J ObstetGynecol India 2005. Vol. 55,No.6: No-
vember/December: 525-529 2 hour value after 75g OGTT in fasting or non fasting
state.Value > 140 is GDM

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TARGET BLOOD GLUCOSE LEVELS during INTRA UTERINE PERIOD and continue through
out life from early childhood.
(Balaji V, Balaji MS, Seshiah V, Mukundan S, DattaM. (Tuomilehto J. A paradigm shift is needed in the pri-
Diabetes Res ClinPract. 2006 Aug;73(2):223-4. ) mary prevention of Type 2 DM, Prevention of DM,
John Wiley & sons limited, 153-165; 2005)
(V. Seshiah, AK Das, Balaji V, Shashank Joshi, MN
Parikh, Sunil Gupta for DIPSI. GDM- Guidelines. JAPI GDM offers an important opportunity for the
vol 54, 2006, 622-28) development, testing and implementation of clinical
strategies for diabetes prevention and NCD.
(Oded Langer.Maternal glycemic criteria for insulin
therapy in GDM.Diabetes care, vol 21 (2), August 1998. (Thomas A Buchanan, Anny Xiang, Siri L Kjos, Rich-
B91-98.) ard Watanabe. “What is gestational diabetes?” Dia-
betes Care 30(2): S105-111, July 2007)
* Birth weight between2.5 and 3.5 Kg
Screening strategy
(Vinod K Paul, Ashok K Deorari, Meharban Singh.
Management of Low Birth Weight Babies. In: IAP The current practices for testing for hyperglycaemia
Textbook of Pediatrics. 2nd ed. A. Parthasarathy, ed- in pregnancy (hip) in the medical college institutions
itor.Jaypee publications, 2002, p60.) in india

* Prevalence of diabetes during pregnancy in women ( J. Evid. Based Med. Healthc., pISSN- 2349-2562,
according to their birth weights eISSN- 2349-2570/ Vol. 4/Issue 19/April 06, 2017
Hema Divakar1, Shelly Dutta2, Uday Thanawala3 )
(David J Pettitt et al, Diabetes Care, Vol 21(2), Aug
1998; B138-141) * A Simpler Solution…..

* The goal is to obtain newborn babies birth weight In future clinical practice, simpler and more cost- ef-
appropriate for gestational age [To avoid both SGA fective strategies that do not require performing an
and LGA babies] OGTT on most pregnant women may be developed.

(Lois Jovanovic. American Diabetes Association’s (International Association of Diabetes & Pregnancy
Fourth International Workshop – Conference on Ges- Study Groups (IADPSG) Recommendations on the di-
tational Diabetes Mellitus: Summary and Discussion. agnosis and classification of hyperglycemia in preg-
Diabetes Care. 1998; 21 (2): B131 - B137 ) nancy. IADPSG Consensus panel, Diabetes Care 33
(3), 2010 )
* Impact of our Diabetes In Pregnancy Awareness
And Prevention [DIPAP] Project on Birth Weight * “A single-step procedure with a single glucose val-
of New born babies [DIPSI Criteria] ue” to diagnose abnormal glucose tolerance in preg-
nancy is rational, cost-effective and causes negligible
Total Number of pregnant women followed-up = 8731 inconvenience to the expectant mother.

This single initiative of achieving birth weight of in- (Gestational Diabetes Mellitus- Indian Guidelines.
fants appropriate for gestational age, would have sig- Journal of Indian Medical Association (JIMA) Novem-
nificant positive effect on the overall health of the ber 2009, 107 (11); 799- 806 )
family and the community.
* We should not let the best come in the way of the
(Data from Diabetes In Pregnancy Awareness & Pre- good Most complicated problems in this universe has
vention (DIPAP) PROJECT a simple solution - Albert Einstein

FEMALE GENDER: THE KEY TO DIABETES PREVEN- ONE Test with 75gm of oral glucose
TION? – LiseKingo irrespective of last meal timing

It starts with a healthy pregnancy ONE Value to diagnose GDM

Maternal health – The link to the NCD epidemic 2hr PG> 140 mg/dl.
ONE Target 2hr PPG < 120mg/dl.
(Seshiah v, Balaji V. Primordial Prevention: maternal
health and diabetes. 2013. Future medicine, Diabetes (Nielsen et al. BMC Pregnancy and Childbirth (2017)
Manage. (2013) 3(4), 1-9 ) 17:255 DOI 10.1186/s12884-017-1429-y )

Prevention of Diabetes

Preventive measures against Type 2 DM should start

Cardio Diabetes Medicine

594 Prevention of Non-Communicable Diseases - Whom to Focus?

* Factors influencing timely initiation and completion
of gestational diabetes mellitus screening and diag-
nosis - a qualitative study from Tamil Nadu, India

Karoline Kragelund Nielsen1,2* , Thilde Rheinländer1
, Anil Kapur3 , Peter Damm4 , Veerasamy Seshiah5
and Ib C. Bygbjerg1

Conclusions:

Minimising and aligning complex stepwise processes of
prenatal care and GDM screening delivery and attention
to the factors influencing it are important for further
improving and expanding GDM screening and related
services, not only in Tamil Nadu but in other similar low
and middle income settings. This study stresses the
importance of guidelines and diagnostic criteria which
are simple and feasible on the ground.
Public Health Priority (For Primordial prevention of
Diabetes)

The timely action taken now in screening all pregnant
women for glucose intolerance, achieving euglyce-
mia in them and ensuring adequate nutrition may
prevent in all probability, the epidemic of diabetes
and CVD.

(Diabetes Res ClinPract. 2012 Sep;97(3):350-8. doi:
10.1016/j.diabres.2012.04.024. Epub 2012 Jun  )

Seshiah V Member Technical Advisory group on
GDM, inistry of Health Govt of India.

(Krishnaveni V etal. Intrauterine exposure to maternal
diabetes is associated with higher adiposity and in-
sulin resistance and clustering of cardiovascular risk
markers in Indian children.

GDM Is the Mother of Non Communicable Diseas-
es.-Seshiah

References:

Wing Hung Tam, Ronald Ching Wan Ma, Xilin
Yang, Gary Tin Choi Ko, Peter Chun Yip Tong, Clive
Stewart Cockram, Daljit Singh Sahota, Michael Scott
Rogers, Juliana Chung Ngor Chan - Pediatrics De-
cember 2008, volume122/issue65

(Lucas A (1991) Programming by early nutrition in
man. In: Bock GR, Whelan J (eds) The childhood en-
vironment and adult disease. John Wiley and Sons,
Chichester (UK), pp 38 - 55 )

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Cardio Diabetes Medicine 2017 595

“Medical Nutritional Therapy in Gestational Diabetes”

DR.MEENAKSHI BAJAJ

PG.DND., M.Sc., C.D.E., R.D., CCN (U.S.A).,(PhD).,
DIETICIAN, Tamil Nadu Govt. Multi Super Specialty Hospital,Chennai

Introduction: Nutrition Therapy During a Pregnancy with
Diabetes Strives to Achieve Three Important
Gestational diabetes mellitus” (GDM) is defined as Goals
carbohydrate intolerance with onset or recognition
during pregnancy1.GDM is associated with perinatal 1. Minimize blood glucose excursions and maintain
morbidity and mortality in the current pregnancy, risk glucose values within target goal ranges before and
of the mother developing type 2 diabetes, and of in- after meals.
tra-uterine programming of the developing fetus with
subsequent expression of disorders in later life. 2. Provide a calorie intake that is neither inadequate
nor excessive and will achieve an appropriate for
Lifestyle change is an essential component of man- gestational weight gain without maternal ketosis.
agement of GDM and may suffice for the treatment
for many women. Medical nutrition therapy (MNT) 3. Ensure adequate, and safe, nutrients for maternal
reduces pregnancy and perinatal complications and and fetal health.
brings glycemic control 2
Weight Gain During Pregnancy
Pregnant women who are diagnosed with gestation-
al diabetes mellitus (GDM), should be referred to a The expected weight gain during pregnancy is 300–
registered dietitian (RD) for MNT. Individualized MNT 400 g per week and total weight gain is 10–12 kg by
is important in helping pregnant women with GDM term.
achieve and maintain normal glycemic levels and
appropriate weight gain, while meeting essential nu- Nutrition Interventions For Pregnancy With
trients for pregnancy to promote positive maternal Diabetes
and fetal outcomes3.
MNT includes nutrition assessment, patient interview,
Nutrition Therapy For Diabetes And clinical data, blood glucose records, food history,
Pregnancy exercise pattern, psychosocial and economic condi-
tions when developing an individualized meal plan.
Nutritional therapy guidelines include achieving op-
timal body weight and starting a prenatal meal plan Nutrition assessment is organized under five cate-
before attempting conception. gories

AIM:  As preventive medicine starts before birth, to These are: Food/Nutrition-Related History; Anthro-
provide adequate calorie and nutrients to meet the pometric Measurements; Biochemical Data, Medical
maternal and fetal demands, provide energy intake Tests, and Procedures; Nutrition-Focused Physical
for appropriate weight gain, and avoid excessive Findings; Client History
weight gain, decrease the risk of hypoglycemia and
avoid postprandial hyperglycemia, avoid ketonemia Food or Nutrition-Related History 4
and ketonuria, prevent obesity, impaired glucose tol-
erance and type2diabetes in the offspring. Dietary history includes a thorough review of usu-
al food intake, pattern of intake (timing, meals and
snacks) and previous history of diet adherence. Edu-
cational knowledge, such as nutrition and meal-plan-

Cardio Diabetes Medicine

596 “Medical Nutritional Therapy in Gestational Diabetes”

ning skills, barriers to dietary compliance, such as Guidelines for carbohydrate intake for
lack of family support, daily schedule or economic preexisting diabetes and GDM are discussed
issues, etc. Macronutrient (especially carbohydrate below:
and fiber) and micronutrient dietary intake. Vitamin
and mineral supplement use (prenatal and non-pre- The amount and distribution of calories and carbohy-
natal) or use of natural remedies, such as herbs or drates are individualized and based on the woman’s
alternative therapies. Food allergies or intolerances food preferences, blood glucose records, plasma
glucose responses, outcome measures and physical
Medications: Prescription (diabetes-related, non-dia- activity level.
betes-related); over the counter medications
MNT for GDM primarily involves a carbohydrate-con-
Use of alcohol, tobacco, caffeine or other substances trolled meal plan to achieve and maintain normo-
& Exercise pattern: Type, frequency, duration glycemia. Monitoring carbohydrate by choices, ex-
changes, carbohydrate counting, glycemic index and
Screening for other nutrition risks (e.g., eating dis- glycemic load remains a key strategy in achieving
orders, pica, adolescence, low literacy, low income, glycemic control5
psychosocial issues), language, cultural background,
ethnic or religious beliefs should be taken into con- CHO’s ideally to be distributed throughout the day
sideration in 3 small to moderate sized meals and 2-4 snacks.
Single large meals with large percentage of simple
Nutritional plan includes Calorie allotment, carbohydrates are not preferred.
distribution & carbohydrate intake
The most difficult blood glucose level to manage is
The meal pattern should provide adequate calories the post breakfast value, because of the insulin resis-
and nutrients to meet the needs of pregnancy.Calorie tance associated with higher hormone levels seen in
requirement depends on age, activity, pre-pregnancy the early morning hours & may improve with splitting
weight and stage of pregnancy. in two halves of equal portion & consuming at 2-hour
gap, peaking of plasma glucose is high with break-
GDM: Macronutrient Requirements fast (Dawn phenomenon) than with lunch and dinner.

For normal-weight and underweight women with An initial food plan would suggest the following car-
GDM, caloric intake is assessed by weight gain and bohydrate ranges for each meal and snack:An eating
avoidance of starvation ketosis. Unless a woman plan including foods with a low GI may improve post
begins pregnancy with depleted body reserves, en- meal glucose readings; however, the first nutrition
ergy needs do not increase in the first trimester. An therapy intervention is to control the total amount
additional 300 kcals/day are suggested during the and distribution of carbohydrate.
second and third trimester for increases in maternal
blood volume and increases in breast, uterus and * Breakfast - 10-15% of Total Energy Intake (TEI)
adipose tissue, placental growth, fetal growth, and
amniotic fluids. * Mid-Morning snack - 5-10% of TEI

First trimester- 30kcal/kg Ideal Body Weight(IBW). * Lunch - 20-30% of TEI

Second & Third trimester- 30kcal/kg IBW + 300kcal/ *Evening Snack - 5-10% of TEI
day.
* Dinner - 20-30% of TEI
TheDietary Reference Intakes for all pregnant wom-
en, including those with GDM, recommends a mini- * Bed time Snack 5-10 % of TEI
mum of 175g carbohydrate (CHO), a minimum of 71g
protein (or 1.1g per kg per day protein) and 28g fiber3 On sick days associated with morning sickness, the
diet restrictions need to be more flexible.
Obese GDM
Due to the continuous fetal draw of glucose from
Weight loss diets are in general not recommended the mother, maintaining consistency of times and
during a pregnancy. amounts of food eaten are important to avoidance
of hypoglycemia. Evening snack is a must to prevent
If pre - pregnancy BMI >30kg/m2 -25kcal/kg Present nocturnal hypoglycemia accelerated starvation
Body Weight (PBW)
If insulin therapy is added to MNT, maintaining carbo-
hydrate consistency at meals and snacks becomes
a primary goal.

GCDC 2017

Cardio Diabetes Medicine 2017 597

Insulin to Carbohydrate Ratio disorders, and impaired intellectual development.

The pre-meal insulin dose is calculated by insu- Mercury-contaminated fish
lin-to-carbohydrate ratio.Prandial or mealtime insulin
must match the amount of mealtime carbohydrate to Fish containing high levels of methyl-mercury, a
keep glucose levels in the target range before and potent human neurotoxin that readily crosses the
after eating. placenta and has the potential to damage the fetal
nervous system should be avoided. Prefer fresh lake
Choose where possible carbohydrate from low Gly- water fish to other sources.
cemic Index (GI) sources. Substituting low–glycemic
load foods for higher–glycemic load foods may mod- Lactation
estly improve glycemic control5
Breast-feeding is recommended for infants of women
Vitamin and Mineral Recommendations with preexisting diabetes or GDM. Lactating women
have reported fluctuations in blood glucose related to
Adequate calcium, iron, folate, vitamin D, and mag- nursing sessions, often requiring a snack containing
nesium intakes are especially important in pregnancy. carbohydrate before or during breast-feeding.
400 μg /day of folic acid from fortified foods and /or
a supplement, as well as food folate from a variety of Lactating type 2dm calorie requirement being total
foods, is recommended for the prevention of neural calories provided in the 3rdtrimester + 200kcals/day,
tube defects and other congenital abnormalities. not <1800kcals/day.

Fiber and whole grains. Protein recommendations being +18gm/day for first
6 months and +25gms/day for following 6 months.
Recommendations for fiber intake for people with di-
abetes are like the recommendations for the general Provide adequate fluid, calcium& lactogogue rich diet.
14g/1000 kcals of TEI.
Long-term therapeutic consideration:
Non-nutritive sweeteners.
All patients with prior to GDM should be educated
The use of products that are classified as Generally regarding lifestyle management that reduces insulin
Recognized As Safe (GRAS) are acceptable during resistance that is including maintenance of normal
pregnancy in moderation. body weight by MNT and physical activity.

Stevia has recently received GRAS status; however, Summary of Nutrition Recommendations
there is little specific research on the use of stevia Gdm6
during pregnancy. Saccharin crosses the placenta
and hence unsafe during pregnancy. The primary goals of nutrition therapy for diabetes
during pregnancy are excellent glycemic control
* Non-Caloric/ Non-Nutritive Sweeteners- (Approved
by FDA)6 appropriate weight gain, and a nutrient-rich eating
pattern. Food plans should be culturally appropriate
* Acesulphame K PL * Avoid in Renal Failure / Hy- and individualized to consider the patient’s body hab-
perkalemia its, weight gain, and physical activity and be modified
as needed throughout pregnancy to achieve treat-
* Aspartame PL *Moderation (Avoid in Phenyl Keton- ment goals.
uria)
Conclusion
* Saccharin PL *Avoid as it crosses the placenta.
Medical nutrition therapy is a form of “Natural thera-
* Neotame PL *?? py with no side effects”. Taking care of women with
GDM by adequate nutrition advise and achieving
* Sucralose PL *Safe euglycemia in them is likely to prevent obesity and
glucose intolerance in their offspring.
* PL *-Pregnancy & Lactation,

Alcohol

No amount of alcohol consumption can be consid-
ered safe during pregnancy. Alcohol use during preg-
nancy increases the risk of alcohol-related birth de-
fects, including growth deficiencies, facial abnormal-
ities, central nervous system impairment, behavioral

Cardio Diabetes Medicine

598 “Medical Nutritional Therapy in Gestational Diabetes”

Energy First trimester- 30kcal/kg IBW. Second trimester- 30kcal/kgIBW+300kcal/day.
Obese – If pre-pregnancy BMI >30kg/m2 -25kcal/kg Present Body Weight& Re-
striction of CHO to 35-40% in Obese GDM.

Carbohydrates Minimum 175g/day is given to –prevent starvation ketosis. Carbohydrate percent-
age is individualized. Avoid hypo caloric diets to prevent IUGR

Sucrose and caloric USFDA approved sweeteners for pregnancy in moderation only.Avoid Saccharin.
sweeteners

Fiber 20-35g dietary fiber/day from a variety of food sources.

Protein +10g above RDA

Fat Percentage based on nutritional assessment and treatment goals

Sodium No benefit in alleviating gestational hypertension

Vitamins and minerals Ferrous iron-30mg/day, Folic acid – 400ug/day (to rule out Pernicious anemia
before supplementation), Calcium and magnesium requirement is increased. In
case of high risk pregnancies like low birth weight, Multiple Gestation and sub-
stance abuse, use of prenatal vitamins is necessary. Women with low gravid,Zinc
supplementation is essential.

Alcohol and caffeine Alcohol- not advisable. Caffeine- moderate usage is acceptable

References

1. Seshiah V, Balaji V, Balaji MS. Scope for prevention of diabetes ‘focus
intrauterinemilieu interieur’. J Assoc Physician India.2008;56:109-13

2. Morampudi S, Balasubramanian G, Gowda A, Zomorodi B and Patil AS,
TheChallenges and Recommendations for Gestational Diabetes Mellitus
Care in India: A Review. 2017, Front. Endocrinol. 8:56.

3. American Diabetes Association: Management of diabetes in pregnancy.
In Standards of Medical Care in Diabetes Diabetes Care, 2016; Volume
39 (Suppl.1): S94–S98.

4. American Diabetes Association: Nutrition Therapy Recommendations for
the Management of Adults with Diabetes, Diabetes Care,2013, Volume
36, S:3821-S3842

5. American Diabetes Association: Standards of medical care in diabetes:
2012. Diabetes Care, Volume 35 (suppl.1) S:11-S63

6. American Diabetes Association: Nutrition recommendation and interven-
tions for diabetes (Position Statement). Diabetes Care,2008, 31 (Supp
l): S61-S78,2008.

GCDC 2017

Cardio Diabetes Medicine 2017 599

Medical Nutrition Therapy in
Heart Failure

DR.MEENAKSHI BAJAJ

PG.DND., M.Sc., C.D.E., R.D., CCN (U.S.A).,(PhD).,
DIETICIAN, Tamil Nadu Govt. Multi Super Specialty Hospital,Chennai

Introduction Therapy for HF Box 1

Medical Nutritional Therapy (MNT) is an integral com- Treat hypertension, Encourage smoking cessation
ponent of diabetes prevention, management and self Treat lipid disorders, Encourage regular exercise
- management education. It is defined as “nutritional
diagnostic, therapy, and counselling services for pur- Discourage alcohol intake, illicit drug use
pose of disease management.”
Control metabolic syndrome
All individuals with diabetes should receive individual-
ized medical nutrition therapy (MNT), preferably pro- Referral to a registered dietitian is needed for (Med-
vided by a registered dietitian RD who is knowledge- ical Nutrition Therapy) MNT which can lead to im-
able and skilled in providing diabetes MNT. There is proved dietary pattern and quality of life, decreased
not a one-size-fits-all eating pattern for individuals oedema and fatigue, more optimal pharmacological
with diabetes there is no single ideal dietary distri- management, and fewer hospitalizations. (3)
butionof calories among carbohydrates, fats, and
proteins for people with diabetes, macronutrient dis- The RD provides MNT, which includes assessment,
tribution should be individualized while keeping total a nutrition diagnosis, and interventions
calorie and metabolic goals in mind1.
Nutrition Intervention & Objectives(4,5)
As many as 50% of patients with type 2 diabetes may
develop heart failure (HF)2. Diseases of the heart can * Lessen demands on the heart and restore hemo-
be caused by CHD, previous heart attack, history of dynamic stability.
cardiomyopathy, chronic obstructive pulmonary dis-
ease, severe anaemia, excessive alcohol consump- * Prevent cardiogenic shock, thromboembolism, and
tion, or low thyroid function. renal failure.

Advanced HF is a multifactorial metabolic syndrome * Maintain target Blood Pressure.
that can lead to cardiac cachexia. It is defined as in-
voluntary weight loss of at least 6% of non-oedema- * A significant reduction in systolic blood pressure in
tous body weight during a 6-month period. those at increased risk for cardiovascular disease is
a novel strategy to prevent HF (3)
Aggressive therapy to halt progression of the various
risk factors can have a major impact on controlling * Eliminate or reduce oedema.
or curing HF.
* Avoid distention and elevation of diaphragm, which
reduces vital capacity. Avoid overfeeding in cachexic
patients to prevent refeeding syndrome.

* Attain desirable BMI and WHR to decrease oxygen
requirements and tissue nutrient demands.

* Replenish lean body mass (LBM) when needed

Nutrition Assessment

Determination of body weight. Altered fluid balance

Cardio Diabetes Medicine

600 Medical Nutrition Therapy in Heart Failure

complicates assessment of body weight in the pa- For persons with hypertension, the DASH diet is rec-
tient with HF. Weights should be taken before eating ommended with adequate potassium, calcium, and
and after voiding at the same time each day followed magnesium.Sodium intake less than 2 g/d to im-
by evaluation of Body Mass Index 4 prove clinical symptoms and quality of life (3).

Waist circumference; waist to hip ratio (WHR) A one-size-fits-all sodium restriction is not possible.
The HF stage, amount of oedema present, overall nu-
Dietary assessment for: SFA, -fatty acids, omega-3 tritional status, and medications must be taken into
fatty acids, fibre, sodium, alcohol, sugar and phyto- consideration. There is consensus that high sodium
nutrients intake (above 3 g/day) is contraindicated for HF.

Anorexia • Nausea, abdominal pain and feeling of Table 1 Sodium and Salt Measurement Equivalents
fullness • Constipation • Malabsorption • Malnutrition (4)
• Cardiac cachexia • Hypomagnesemia • Hyponatre-
mia Sodium chloride is approximately 40% (39.3%) so-
dium and 60% chloride.
MNT in Hf(4,5)
To convert a specized weight of sodium chloride to
Nutrition education to promote behaviour change is its sodium equivalent,
a critical component of MNT.
multiply the weight by 0.393.
Patients with HF often tolerate small, frequent meals
better than larger, infrequent meals because the lat- Sodium also is measured in milliequivalents (mEq).
ter are more tiring to consume, can contribute to
abdominal distention, and markedly increase oxygen To convert milligrams of sodium to mEq, divide by
consumption. the atomic weight of 23.

In assessing energy needs for patients with heart fail- To convert sodium to sodium chloride (salt), multi-
ure, most of studies indicate that use of indirect cal- ply by 2.54.
orimetry best determines energy needs. (3)The energy
needs of patients with HF depend on their current dry Millimoles (mmol) and milliequivalents (mEq) of so-
weight, activity restrictions, and the severity of the dium are the same.
HF. If patient is obese, a calorie-controlled diet can be
recommended. Caloric reduction must be monitored For example:
carefully to avoid rapid body protein catabolism
1 tsp of salt = approximately 6 g NaCl
Appropriate daily intake of protein for clinically sta-
ble patients,HF patients have significantly higher pro- 6096 mg NaCl * 0.393 = 2396 mg Na (approx. 2400
tein needs than those without HF (3).Protein restriction mg)
warranted in case of raise in Blood Urea Nitrogen.
2396 mg Na/23 = 104 mEq Na
For dyslipidemia or atherosclerosis, a heart-healthy
diet low in SFAs, trans fatty acids, and cholesterol 1 g Na # 1000 mg/23 = 43 mEq or mmol
and high in fibre, whole grains, fruits, and vegetables
is recommended. 1 tsp of salt = 2400 mg or 104 mEq Na

A vegan pattern may be helpful with five to six small Patients with HF are at risk for thiamine defeciency
meals daily. Beans, cabbage, onions, cauliflower, and because of poor food intake; use of loop diuretics,
Brussels sprouts may cause heartburn or flatulence; which increases excretion; and advanced age. Thia-
avoid if needed. mine supplementation (e.g., 100mg/day) can improve
left ventricular ejection fraction and symptoms.
Whole grains cut the risk for HF while eggs and high-
fat dairy products contribute to it, according to the A multi-vitamin/mineral containing B12 or a combina-
ARIC study Add soluble fiber to the diet from apples tion of B6, B12 and folate could be recommended in
or oat bran. Patients. This level of B12 supplementation (200-500
mcg daily), given with other vitamins/minerals, has
Pistachios, sunflower kernels, sesame seeds, and been shown to have beneficial clinical heart failure
wheat germ are high in phytosterols; use often. outcomes (3).

Patients with HF are at increased risk of developing
osteoporosis. Caution must be used with calcium

GCDC 2017

Cardio Diabetes Medicine 2017 601

supplements because they may aggravate cardiac and cakes
arrhythmias. It remains unclear if vitamin D supple-
mentation truly is needed in HF patients Salted Buttermilk, most cheese spreads and chees-
es, salted butter
Magnesium deficiency is common in patients with
HF because of poor dietary intake and the use of Carbonated beverages & Proprietary /Energy Drinks
diuretics.The practitioner should encourage patients
with heart failure (HF) to consume at least the Dietary Soy sauce, salad dressing, chilisauce, ketchup, bar-
Reference Intake (DRI) for magnesium through food becue sauce, and monosodium glutamate (MSG)
and/or supplements. Low levels of magnesium may
be present in patients with heart failure and irregular Add fresh herbs, spices, and salt-free seasoning
heart rhythms may occur(3). blends in cooking and at the table (Lemon, mint,
corianderleaves).
Fish consumption and fish oils rich in omega-3 fatty
acids can lower elevated triglyceride levels and may Table 2 FOOD LABELING GUIDE FOR SODIUM(4)
prevent atrial Librillation in HF patient. However, fur-
ther studies are needed. Sodium-free Less than 5 mg per stan-
Very low sodium dard serving; cannot con-
Routine use of nutritional supplements is not recom- Low sodium tain any sodium chloride
mended for patients with heart failure with preserved Reduced sodium
ejection fraction. (3) Light in sodium 35 mg or less per standard
serving
Standard fluid restrictions are to limit total fluid in-
take to 2000 ml daily. When patients are severely de- 140 mg or less per stan-
compensated, depending on fatigue or shortness of dard serving
breath., a more restrictive fluid intake (1000 to 1500
ml daily) may be warranted for adequate diuresis. At least 25% less sodium
per standard serving than
Limit caffeine only if needed. The evidence is not de- in the regular food
fenitive in this area.
50% less sodium per stan-
Chronic alcohol ingestion may lead to cardiomyopa- dard serving than in the
thy and HF. If alcohol is consumed, intake should not regular food
exceed one drink per day for women and two drinks
per day for men.

Enteral feeding, use a low-sodium product and in-
crease volume gradually.

With total parenteral nutrition, ensure adequate in-
take of all micronutrients as well as macronutrients.

Tips For Lowering Sodium In The Diet

Choose More OftenFresh fruits and vegetables, fresh
lean poultry, fish, and lean meat,egg white rather than
canned or processed types
Rice and hot cereals cooked without salt.

Cut back on

Extra Salt, Salt on the dining table, salted chips, nuts,
papads, savouries & popcorn

Instant, ready to heat and eat rice, gravies,cereal
mixes, instant noodles, instant soup mixes, canned
foods and preserved foods which usually have added
salt.

Cut back on baked foods- pizza, burgers, biscuits

Cardio Diabetes Medicine

602 Medical Nutrition Therapy in Heart Failure

GCDC 2017

Cardio Diabetes Medicine 2017 603

Unsalted, without added No salt added during
salt, or no salt added processing; the product
it resembles is normally
processed with salt

Lightly salted 50% less added sodium
than is normally added;
product must state “not a
low-sodium food” if that
criterion is not met

Cardio Diabetes Medicine

604 Medical Nutrition Therapy in Heart Failure

NUTRITION CARE PLAN(5)

Table 3 NUTRITION MANAGEMENT(4,5)

1.Lose to or maintain appropriate weight

2.Dash Dietary PatternRestricted sodium diet 2 gm/

day (Visible & Invisible Sodium)3.Mediterranean diet

pattern In-

creased use of whole grains, fruits(provided ade-

quate glycemic control), vegetables

Increase dietary fibre to 25–30 g/day or more

Add omega-3 fats from food sources

Add fresh fruits and vegetables

4.Limit fluid to urine output plus obligatory losses

5.Potassium restriction or excess based on the di-
uretic used if any.

6.Magnesium supplementation

7.Thiamine supplementation

8.Avoid tobacco

9.Increase physical activity as tolerated

10.Avoid alcohol

11.CoQ10 for those on statin drugs

References

1. Lifestyle Management Diabetes Care 2017;40(Suppl.1): S33–S43

2. American Diabetes Association: Standards of Medical Care in Diabetes
2017 ;40, (Suppl.1): S:1- S131

3. Yancy et al. Heart Failure Focused Update J a C C A u g u s t 8, 2 0
17 V O L 7 0, No.6, 2 017: 7 7 6– 803 2017ACC/AHA/HFSA

4. L. Kathleen Mahan, Medical Nutrition Therapy for Cardiovascular Disease,
CD, Janice L. Raymond, Krause’s Food & The Nutrition Care Process, St.
Louis, Missouri, Elsevier, Fourteenth Edition 2017,33:668-676

5. Sylvia Escott-Stump, Cardiovascular Disorders, avid Troy, Nutrition and
Diagnosis-Related Care, Philadelphia, Lippincott Williams & Wilkins,
Seventh edition 2012: Section 6, 357 -360.

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Cardio Diabetes Medicine 2017 605

Primary Prevention of Type 2 Diabetes
Make In India

Ambady Ramachandran, Chamukuttan Snehalatha,
Arun Nanditha, Arun Raghavan

India Diabetes Research Foundation and
Dr. A. Ramachandran’s Diabetes Hospitals, Chennai, India

Summary Fasting Glucose (IFG) and/or Impaired Glucose Tol-
erance (IGT). It is also predicted that this number is
Primary prevention of type 2 diabetes is shown to likely to grow to 63.3 million by 2040, indicating the
be feasible and is a major step in preventing the ris- presence of a large pool of persons with the poten-
ing prevalence of diabetes. India, which has a large tial to convert to diabetes. In addition to the need to
population with diabetes and also a large number of manage the large number of persons suffering from
people with prediabetes, has to implement primary the disease, there is an urgent need to curb the rising
prevention programmes at community level. Several incidence of diabetes. The major step towards this
studies in India have proved that conversion to dia- goal would be implementation of primary prevention
betes from prediabetes can be reduced, either by the of diabetes among the people at risk of developing
use of lifestyle modification or by use of small doses the disease (1).
of metformin. Several challenges exist in translating
the research findings into real world practices which Studies from different parts of the world and in peo-
includes social, economic, availability of sufficient re- ple of different ethnic origin have conclusively shown
sources and lack of facilities for large scale screening the possibility of preventing diabetes in people with
to identify those at high risk. Awareness on diabetes high risk by lifestyle modification or by use of phar-
and its complications is generally poor among the macological agents such as metformin (2).
public. Therefore, education of the general popula-
tion by camps, group lectures and by the mass media India can claim that it has contributed very import-
is required. ant pioneering observations on the practicality, meth-
odology, insight into the mechanism of prevention
There is also a lack of adequate national health care modalities and also on innovative and pragmatic
budget for preventive care. Therefore support of the methods of translating the research findings to the
governmental, non-governmental, national and inter- use of public at large (3). It is well known that T2D
national agencies are required to promote preventive develops because of the interaction of genetic and
endeavours at national level. environmental risk factors. The recent epidemic of
the disease is attributed to changes in environmen-
Introduction tal risk factors caused by socio-economic transition,
resulting in adverse biological profile favouring early
Primary prevention of type 2 diabetes (T2D) will be a expression of diabetes.
major step in preventing the relentless increase in the
global prevalence of diabetes. More than 80% of the A few pioneering studies from India (3,4) shown in
people affected with diabetes live in the developing the Table have proven that T2D is preventable among
countries and therefore the highest health care and Asian Indians, despite having several adverse biolog-
economic burden are seen in these countries (1). Of ical characteristics. These include increased adiposity
the total 415 million adults with diabetes in 2015, In- despite having relatively lean Body Mass Index (BMI),
dia has 69.2 million and holds the second position susceptibility to develop diabetes at a young age, in-
among the countries with the largest number of peo- creased insulin resistance, lean muscle mass and a
ple with diabetes. Moreover, India also has 36.5 mil-
lion people with prediabetes consisting of Impaired

Cardio Diabetes Medicine

606 Primary Prevention of Type 2 Diabetes Make In India

Table: Randomized, controlled diabetes prevention studies in India

Study ( Year ) Primary Outcome Other Major Observations

Indian Diabetes Prevention Cumulative incidence of diabetes (%) • T2D is preventable in Asian Indians

Programme -1 (2006) Control: 55.0 with high risk for diabetes (IGT and/or
IFG), despite the presence of several

LSM: 39.3 adverse features such as high insulin

Metformin: 40.5 resistance.

LSM + Metformin: 39.5 • Asian Indians with IGT, with non-obese
BMI and young age respond to LSM.

Relative risk reduction (%) • Metformin in small doses (500 mg/
day) had a similar effect as the LSM,
LSM: 28.5 but combining LSM with metformin did
not improve the effectiveness.
Metformin: 26.4
• Iimprovement in other cardiometabolic
LSM+ Metformin: 28.2 variables, such as lipid profile.

• The beneficial effects of primary pre-

vention strategies occur due to improve-

Indian Diabetes Prevention Cumulative incidence of diabetes (%) ment in insulin sensitivity and favorable
Programme-2 (2009) changes in beta cell function.

LSM + Placebo: 31.6 • Higher insulin resistance and /or lower

LSM + Pioglitazone: 29.8 beta cell secretion at baseline predis-
posed to the adverse outcome.

Relative risk reduction (%) • A time-related deterioration in the beta
cell function occurred with persistant

No additional benefit by adding pi- IGT.

oglitazone • Low adiponectin concentration was a

strong independent predictor of future

diabetes .

• Moderate LSM reduced diabetes risk
among Asian Indians independent of
weight loss.

• The most powerful predictor of diabe-
tes was HbA1c baseline.

• LSM produces the best preventive im-
pact among the Asian Indians with high
risk for diabtes.

• LSM produces the best preventive im-
pact among the Asian Indians with high
risk for diabtes.

GCDC 2017

Cardio Diabetes Medicine 2017 607

Indian SMS Study (2013) Cumulative incidence of diabetes (%) • First examples of a clinical outcome

Control: 27.4 using mobile technology and mobile
health in the field of prevention of T2D.

Intervention: 18.5 • Mobile phone messaging was found

Relative risk reduction (%) to be practical and affordable to deliver.

Intervention : 36.0 • Early improvement in glucose toler-
ance (NGT in 6 months) significantly
reduced the risk of development of di-
abetes. Persons who reverted to NGT
in the first 6 months had the highest
probability of remaining free of diabe-
tes at the end of 2 years. The RRR in
people who reverted to NGT was 75%
when compared with the remaining par-
ticipants.

• Development of Diabetes was asso-
ciated with deterioration in beta cell
function. Beta cell function showed
significant improvement in those who
reverted to NGT.

• Persons who had Hypertriglyceridemic
Waist Phenotype (HTWP), a combination
of elevated waist circumference (WC)
(> 90cms in men) and hyper triglyceri-
demia (fasting serum triglycerides > 150
mg/dl), had higher risk of developing
diabetes during the study period.

• Elevated levels of serum Retinol
binding protein-4 (RBP-4) and Gamma-
glutamyl Transferase (GGT) were also
useful predictors of incident diabetes.
Presence a HTWP can be used as a
biomarker for T2D.

• Beneficial effects of lifestyle interven-
tion were the result of increased compli-
ance to healthy diet principles advised,
independent of physical activity.

Diabetes Community Life- Cumulative incidence of diabetes (%) • Relative Risk Reduction varied by type

style Improvement Program Control: 34.9 of prediabetes.

(D-CLIP) (2016) Intervention: 25.7 • The reduction was higher in older peo-
ple, male or obese.

Relative risk reduction (%) • 72% of the participants required met-
formin for reducing the risk of diabetes.

Intervention : 32.0

Cardio Diabetes Medicine

608 Primary Prevention of Type 2 Diabetes Make In India

high degree of familial aggregation. The two Indian Diabetes Prevention Programmes
mentioned above have shown that T2D can be pre-
The Indian Diabetes Prevention Programme-1 vented in persons having high risk of developing the
(IDPP-1) (5) disease, by consistent LSM focused on improved
physical activity and healthy diet. It has also been
The Indian Diabetes Prevention Programme-1 (IDPP- shown that the beneficial changes were associated
1) was the first pioneering community based, ran- with improved dietary habits, independent of chang-
domized, controlled trial from India conducted by es in body weight.
Ramachandran et al which showed the feasibility of
primary prevention of diabetes using lifestyle modifi- Such programmes required trained personnel and
cation (LSM) or use of small doses of metformin. The constant contact with the study participants and
study was done in 531 participants with persistent therefore were labor intensive, costly and had not
IGT, who were younger and had lower BMI than the been widely implemented even in high-income coun-
participants in the western studies. The study groups tries. At present, there is an urgent need to translate
were 1) control with standard advice 2) LSM of mod- the findings from the clinical trials into community
erate intensity 3) treatment with metformin (250 mg level programs using cheaper and widely accessible
twice daily) 4) a combination of LSM and metformin methods of communication for motivating people to
therapy. In a median follow up of 30 months, the adhere to the preventive strategies.
rate of conversion to diabetes was high in the control
group (18.3% per year). All 3 modes of intervention In an attempt to use more economical and scalable
resulted in equal relative risk reduction of approx- methodology to reach larger number of people even
imately 29%. LSM is the preferred strategy as it is in remote parts of the country, novel methodologies
safe and acceptable to the participants. No additional such as use of information technology (IT), telemed-
benefit of combining LSM with metformin was noted. icine and short messaging services (SMS) through
The mechanism by which the incidence of diabetes mobile phones have been tested for their effective-
was reduced in persons with IGT was by improving ness for education and motivation of participants in
the beta cell function and by reducing insulin resis- prevention of non-communicable diseases. Mobile
tance. More importantly, the beneficial changes in technology is becoming widely available, popular and
basic pathophysiology occurred without significant comparatively cheaper.
weight reduction.
The Indian SMS Study (7)
The Indian Diabetes Prevention Pro-
gramme-2 (IDPP-2) (6) The Indian SMS study in 537 participants with IGT
was undertaken in 2009, with the objective of eval-
The Indian Diabetes Prevention Programme-2 (IDPP- uating whether tailored, mobile phone messaging
2) was the second, community based, placebo-con- encouraging lifestyle changes could reduce incident
trolled, 3-year prospective study in another cohort of T2D compared with standard lifestyle advice given
407 participants with persistent IGT, to test whether only at baseline. This was a collaborative study be-
a combination with pioglitazone would enhance the tween India Diabetes Research Foundation (IDRF)
efficacy of LSM. Persons with IGT were randomized and the Department of Medicine, Imperial College,
either to a LSM and 30 mg of pioglitazone or LSM London, UK and was funded by the UK India Ed-
and a placebo groups. At the end of 3 years, the ucation and Research Initiative. This two year inter-
results showed that there was no additional benefit vention study was conducted in men with persistent
in adding pioglitazone to LSM. The cumulative inci- IGT, who were randomized to the control group with
dence of diabetes in the placebo (31.6%) and piogli- standard lifestyle advice only at baseline and the in-
tazone (29.8%) were similar. Therefore it was evident tervention group who received motivational text mes-
that in Asian Indians, addition of pioglitazone did not sages on various aspects of healthy lifestyle at least
enhance the effectiveness of LSM. It appears that 3 times per week. The participants were followed up
the maximum possible effect on the pathophysiology at 6 monthly intervals with anthropometric and bio-
was produced by LSM and no additional improve- chemical investigations. At the end of the study, the
ment could occur by adding an insulin sensitizer. The cumulative incidence of T2D was significantly lower
effectiveness of LSM was evident from the fact that in the intervention group than in the control group.
the conversion rate of IGT to diabetes was only 32%, There was a 36% relative risk reduction among the
as against 55% in the control group observed in the participants who were motivated using the SMS.
IDPP-1.
The study was the first to prove the effect of mobile
technology or mobile health in primary prevention of

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Cardio Diabetes Medicine 2017 609

diabetes. In addition to this major observation, sev- incidence of T2D and improving the behavior, psy-
eral ancillary studies have resulted in a wealth of in- cho-social, clinical and biochemical measures at 24
formation on the possible biomarkers for detection months compared with the control arm. The K-DPP is
of people developing diabetes. a collaborative programme with Monash University,
Australia and uses a cluster randomized controlled
Mobile phone messaging was shown to be a prac- design of a culturally, tailored and group based life
tical and affordable method for education and rein- style intervention programme. The data was collected
forcement of lifestyle principles to the participants in by home visits and the data collectors were given
the prevention programme. It is a cost-effective and training prior to commencement of the programme in
practical method which can be used in developed accordance with the WHO STEPS training guide and
and developing countries for large scale prevention protocol. Participants in the control arm were provid-
programmes. ed with health education booklets which detailed the
primary prevention strategies. The intervention arm
The Diabetes Community Lifestyle Improve- had multiple level, multifaceted, culturally adapted
ment Program (D-CLIP)(4) training. The mode of delivery was peer led small
group sessions with support of peer leaders. Small
The Diabetes Community Lifestyle Improvement Pro- group sessions were also conducted periodically. The
gram (D-CLIP) was a 3 year, randomized, controlled, peer leaders met the participants in person at regular
translation trial in 578 overweight/obese Asian Indian intervals. The 24 months programme has been com-
adults with isolated IGT (iIGT), isolated IFG (iIFG) or IF- pleted and the publication results are awaited.
G+IGT conducted in Chennai, India. Participants were
randomized to 2 arms, control arm which received mHealth in prevention of diabetes(4)
standard care advice and the intervention group
which received aggressive LSM training through A large prospective, parallel group cohort study in
once weekly classes regarding diet and exercise India by Pfammater and coworkers had addressed
modeled on the basis of the US Diabetes Prevention the utility of mHealth intervention to improve diabe-
Programme (DPP). This study used a stepwise inter- tes risk behaviors using text messages. This study
vention approach in which metformin was added to was started in 2011 by Arogya World in association
LSM when needed. During the first 4 months training, with Nokia Life and also supported by other orga-
changes in blood glucose were tested and metformin nizations from multiple sectors in India and US, by
500 mg twice daily was added for the participants, if implementing diabetes prevention through mHealth
they were considered to be at high risk of converting programmes. The objective was to see whether dia-
to diabetes ie, if they had IFG+IGT or IFG+HbA1c > betes risk behaviors improved, indicated by improved
5.7% (39 mmol/mol). OGTTs were performed annually, use of fruit, vegetables and fat intake and exercise
measurement of BP and anthropometry were done as the indicators. The duration of the follow up was
every 6 months. The primary outcome was diabetes 6 months. The researchers used 56 mobile text mes-
incidence diagnosed based on a single annual OGTT sages to motivate improvement in health behavior
or the semiannual fasting plasma glucose test. The and awareness of diabetes. The control group had
relative risk reduction (RRR) of diabetes was 32% in only telephonic contact at baseline and at 6 months
the intervention vs control group. It was shown that interview while the intervention group received fre-
the RRR varied by the type of prediabetes, and was quent text messages on lifestyle parameters over the
stronger in older participants (> 50 years), male or study period. This large programme had sensitized
obese. A significant observation was that 72% re- one million consumers who received multiple mes-
quired metformin in addiction to lifestyle and the sages on healthy living habits. The results showed
effectiveness was the least among iIFG. that the m-Health intervention was feasible and was
effective in assessing diabetes related health behav-
The Kerala Diabetes Prevention Programme iors in a low/middle income country.
(K-DPP) (4)
Impact of health education in rural India (4)
A group based peer support programme for preva-
lence of diabetes was conducted in Kerala, South It has been shown that education at personal level
India. This Kerala Diabetes Prevention Programme can improve the knowledge regarding the risk fac-
(K-DPP) is the first implementation trial to evaluate tors for diabetes and associated complications. A
a peer led group based life style intervention pro- short community based study in rural Southern In-
gramme among individuals at high risk of develop- dia, in 703 village inhabitants, using trained trainers,
ing diabetes in rural India. The aim is to reduce the showed that culturally appropriate educational ses-

Cardio Diabetes Medicine

610 Primary Prevention of Type 2 Diabetes Make In India

sions on lifestyle factors and relaxation breathing risk of developing T2D. These studies have shown
techniques brought about improvement in health the feasibility of preventing diabetes with LSM and/
seeking behavior. In 7 months period, the interven- or by use of metformin. LSM is found to be practi-
tion helped to reduce blood glucose levels in indi- cal and safe. In order to translate the research find-
viduals with prediabetes and diabetes. It was also ings at national level, support of the government,
encouraging to note that the intervention improved non-governmental agencies, research organizations
dietary intake, and obesity parameters. This study such as American Diabetes Association (ADA), IDF,
showed that even short term health education had WHO and World Diabetes Foundation (WDF) are re-
preventive effects on youth as well as adults. quired. Use of telemedicine, mHealth and training of
lay health educators and community health workers
Several community based diabetes prevention and has to be taken up on a large scale. There is also an
management programmes have been initiated in In- urgent need for help from funding agencies such as
dia both in urban and rural setting. the WDF and IDF to encourage these translational
research projects.
A large medical education programme for children
and adolescents conducted by the Diabetes Foun- Highlights
dation of India, focused on primary prevention with
the aim of creating awareness about diabetes, obe- India has a high prevalence of type 2 diabetes (T2D)
sity, lipid disorders and heart diseases. The MARG and prediabetes.
(Path) programme was funded by the World Diabe-
tes Foundation, Denmark. This programme reached Several Indian Primary Prevention Programmes have
large numbers of children, parents and teachers in 3
cities in Northern India over a period of 3 years. At demonstrated that T2D is preventable in people with
baseline, the knowledge on health care and health high risk for diabetes.
seeking behavior was poor and following the inter-
vention, scores improved even in the children. Despite having several biological characteristics, Indi-
ans respond well to lifestyle modification (LSM).
Challenges
Education of the public on healthy living habits has
Several challenges and barriers exist in the imple- shown rewarding results.
mentation of prevention programmes. These include
economic constraints, socio-cultural problems, poor Use of mHealth and other mass media programmes
health seeking behavior, screening for high risk are promising in large scale management of diabetes
population and lack of knowledge and skills. Sever- and also in conducting preventional studies.
al patient related barriers, societal barriers related to
diabetes management and barriers related to medical Acknowledgement
profession have been identified. The Indian studies
have also shown methods to face these challenges We acknowledge Mrs. Mary Simon for helping in
and have set examples for developing countries to preparation of the chapter and Mrs. L.Vijaya for sec-
carry out similar programmes. A mismatch of national retarial assistance.
health care budget and health care burden, especially
due to the epidemic of non- communicable diseases References
poses a huge challenge to the country.
1. IDF Diabetes Atlas, 7th ed. International Diabetes Federation, 2015. www.
To promote primary prevention of diabetes, there is idf.org/diabetes atlas
a need to improve nutrition and enhance physical
activity. These require major behavioral changes in 2. Nanditha A, Ma RC, Ramachandran A, Snehalatha C, Chan JC, Chia KS,
the community and several hurdles including social, Shaw JE, Zimmet PZ. Diabetes in Asia and the Pacific: Implications for
political, economic and administrative in nature have the Global Epidemic.Diabetes Care. 2016;39:472-85.
to be overcome to achieve the goals.
3. Ramachandran A, Snehalatha C, Samith A Shetty, Nanditha A. Primary
Conclusion Prevention Trials in Type 2 Diabetes. Chapter-4 Global Health Perspectives
in prediabetes and Diabetes Prevention. Editor. Michael Bergman. World
Primary prevention of diabetes is of paramount im- Scientific Publication. 2014; P.No. 49 – 74.
portance in developing countries such as India. Sev-
eral groups have worked and implemented primary 4. Ranjani H, Weber MB, Venkat Narayan KM, Mohan V. Real life diabetes
prevention programmes mostly in people at high prevention initiative in India. Chapter-13 Global Health Perspectives in
prediabetes and Diabetes Prevention. Editor. Michael Bergman. World
Scientific Publication. 2014; P.No. 281 –315.

5. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V.
The Indian Diabetes Prevention Programme shows that lifestyle modifica-
tion and metformin prevent type 2 diabetes in Asian Indian subjects with
impaired glucose tolerance (IDPP-1). Diabetologia 2006; 49: 289– 297.

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Cardio Diabetes Medicine 2017 611

6. Ramachandran A, Snehalatha C, Mary S, Selvam S, Kumar CK, Seeli AC
et al. Pioglitazone does not enhance effectiveness of lifestyle modification
in preventing conversion of impaired glucose tolerance to diabetes in Asian
Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2).
Diabetologia 2009; 52: 1019– 1026.

7. Ramachandran A, Snehalatha C, Ram J, Selvam S, Mary Simon, Nanditha
A, Samith A Shetty, Godsland IF, Chaturvedi N, Majeed A, Oliver N, Toum-
azou C, Alberti KG, Johnston DG. Effectiveness of mobile phone messaging
in prevention of type 2 diabetes by lifestyle modification in men in India:
a prospective, parallel-group, randomized controlled trial Lancet Diabetes
Endocrinol 2013; 1: 191–19

Cardio Diabetes Medicine

612 Medical Nutrition Therapy in Chronic Kidney Disease

Medical Nutrition Therapy in
Chronic Kidney Disease

DR.MEENAKSHI BAJAJ

PG.DND., M.Sc., C.D.E., R.D., CCN (U.S.A).,(PhD).,
DIETICIAN , Tamil Nadu Govt. Multi Super Specialty Hospital,Chennai

Introduction : ican Diabetes Association’s (ADA’s) Standards of
Medical Care in Diabetes, 2011
Chronic kidney disease (CKD) is one of the most
prevalent complications of diabetes, and patients As there is not an ideal percentage of calories from
with diabetic kidney disease(DKD) have a substan- carbohydrate, protein, and fat for all people with
tially higher risk of cardiovascular disease and death diabetes (B); therefore, macronutrient distribution
compared to their non-diabetic CKD counterparts. In should be based on Individualized assessment of
addition to pharmacologic management strategies, current eating patterns, preferences, while keeping
nutritional and dietary interventions in DKD are an total calorie and metabolic goals in mind (4) Since CKD
essential aspect of management with the potential is a hypercatabolic phase in order to preserve lean
for ameliorating kidney function decline and prevent- muscle mass the calorie requirements are increased
ing the development of other end-organ complica- from the baseline.
tions(1).
Carbohydrates from sugars should be limited to less
Diabetes‐related diet and lifestyle modification is of than 10% of energy intake, and it is also suggest-
benefit across the Chronic Kidney Disease (CKD) ed that higher polyunsaturated and monounsaturat-
spectrum. Dietary modification contributes to CKD ed fat consumption inlieu of saturated fatty acids,
prevention; minimising disease progression in early trans-fat, and cholesterol are associated with more
CKD; blood glucose management and malnutrition favorable outcomes (1).
prevention in dialysis (CKD 5) and risk factor man-
agement for optimal graft survival in transplant re- As patients with advanced DKD progressing to end-
cipients (2). stage renal disease may be prone to the “burnt-out
diabetes” phenomenon (i.e.,spontaneous resolution
Accordingly, the 2012 KDIGO guidelines recommend of hypoglycemia and frequent hypoglycemic epi-
the following lifestyle changes to lower BP and im- sodes),further studies in this population are particu-
prove long-term cardiovascular and other outcomes larly needed to determine the safety and efficacy of
in non-dialysis– dependent CKD patients(3): dietary restrictions in this population.

• Achieve or maintain a healthy weight with a body Hypoglycemia
mass index in the range of 20–25 kg/m.2
Glucose is the preferred treatment for hypoglyce-
• Lower salt intake to <90 mmol (<2 g) per day of so- mia, ingestion of 15–20 g of glucose is an effective
dium, which corresponds to 5 g of sodium chloride, treatment.
unless contraindicated.
On the contrary in patients on Peritoneal Dialysis de-
• Follow an exercise program pending on the dialysate glucose concentration and
volume, energy from glucose can provide 120–1200
Optimal Mix of Macronutrients kcal per day. Absorption of PD dialysate glucose may
increase the requirement of hypoglycaemic agents
ADA does not endorse any single meal plan . If weight maintenance is the desired therapeutic
or specified percentages of macronutrients, and the
term “ADA diet” should no longer be used (3). Amer-

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Cardio Diabetes Medicine 2017 613

outcome, then dietary advice to compensate for di- tiative (KDOQI) clinical practice guidelines for diabe-
alysate energy by reducing energy from food is sug- tes and CKD recommend a dietary protein intake at
gested. the lower end of the normal range (0.8 g/kg body
weight/day), as an achievable goal for minimising
Advanced CKD progression. Due to possible increased risk
of malnutrition, care should be taken when advising
The optimum level of protein intake in practice would protein restrictions below 0.8 g/kg body weight (2)
require a compromise between efficacy and achiev-
ability of protein restriction in a population who are A higher dietary protein intake(>1.2g/kg of body
already likely to be following other dietary restrictions weight/day)is advised among diabetic end-stage re-
relating to diabetes and CVD. The National Kidney nal disease patients receiving maintenance dialysis
Foundation/Kidney Dialysis Outcomes Quality Ini- to counteract protein catabolism,dialysate aminoacid
and protein losses,and protein-energy wasting (1Nu-
trients ,2017(1)

Cardio Diabetes Medicine

614 Medical Nutrition Therapy in Chronic Kidney Disease

Advanced Nutrition and Dietetics in Diabetes,(2)

* While guidelines recommend dietary sodium re- ple providers, several strategies may be implemented
striction to less than 1.5–- 2.3g/day, excessively low that enhance its successful implementation (1).
sodium intake may be associated with hyponatremia
as well as impaired glucose metabolism and insulin Diabetes education should aim to be inclusive of an
sensitivity (1) individual’s renal dietary adaptations and lifestyle re-
strictions and address the patient’s issues relating to
* Fluid restrictions in patients with CKD is individual- balancing both conditions. It should also focus on
ised based on excretory and obligatory losses. helping patients to recognise, understand and ad-
dress their body signals in relation to both diabetes
* When nephropathy is advanced, the diet should and dialysis and teach people how to convey these
reflect the need for phosphorus and potassium re- signals to the relevant healthcare professional (2).
striction, with the use of phosphate binders (5).
Chronic, low‐grade inflammation is implicated in the
* Potassium levels should be monitored while admin- pathogenesis of diabetes. Inflammation, confounded
istering ARBs (3). by protein energy malnutrition (PEM) is common in
the dialysis population and is consistently linked to
* Potassium restriction based on Serum Potassium increased morbidity and mortality. Interrelated and
values. In case of hyperkalaemia, hyperphosphate- concurrent conditions associated with both inflam-
mia to follow a potassium, phosphorous restricted mation and PEM, such as poor appetite, hyper ca-
diet if required leaching of vegetables, rice may be tabolism, nutrient losses via dialysis, oxidative stress,
required. hyperphosphatemia, uraemia and fluid overload have
led to the term ‘malnutrition‐inflammation complex
* Look for hyperuricemia in CKD and add on a further syndrome’ (MICS) (2)
restriction of purine restricted diet.
Food fortification methods and nutritional supple-
* Non-Nutritive Sweeteners (U.S Department of ments should be considered to help combat malnu-
Health and Human Services, 2015) trition and meet nutritional requirements. In dialysis
patients, intra‐dialytic parenteral nutrition can be con-
* Sucralose 5 mg/kg body weight/day (Acceptable sidered if food fortification and other nutrition sup-
Daily Intake) Acesulfame K Contraindicated in Hyper- port routes are unsuccessful (2)
kalaemia Adherence to nutritional guidelines may be
challenging among DKD patients who bear multiple
concurrent comorbidities resulting in complex med-
ication regimens and recommendations from multi-

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Cardio Diabetes Medicine 2017 615

Nutrients,2017(1)

Post Renal Transplantation

In the absence of robust studies to inform the nutritional management of diabetes in kidney trans-
plant recipients, general population advice for diet in diabetes prevention and cardiovascular protection in
high risk groups should be followed (2)

Cardio Diabetes Medicine

616 Medical Nutrition Therapy in Chronic Kidney Disease

References

1. Gang Jee Ko 1,2, Kamyar Kalantar-Zadeh 1,3,4 ID , Jordi Goldstein-Fuchs
5,6 and Connie M. Rhee 1, Nutrients 2017, *Dietary Approaches in the
Management of Diabetic Patients with Kidney Disease9, 824

2. Advanced Nutrition and Dietetics in Diabetes, First Edition. Edited by
Louise Goff and Pamela Dyson. © 2016 John Wiley & Sons, Ltd. Published
2016 by John Wiley & Sons, Ltd

3. Georgi Abraham, KN Arun etal Supplement to Journal of The Association
of Physicians of India Published on 1st of Every Month 1st February, 2017
Management of Hypertension in Chronic Kidney Disease: Consensus State-
ment by an Expert Panel of Indian Nephrologists

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Cardio Diabetes Medicine 2017 617

The Role of Lifestyle Modification in The Prevention of
Diabetes and Cardiovascular Disease

Prof. Dr. Anand Moses MD, FRCP Dr. S. Charles Bronson

Emeritus Professor MBBS, D.Diab.(MMC), MRi,
The TN Dr MGR Medical University, Chennai Diabetologist,
Formerly Director and Professor, Institute of Diabetology,
Institute of Diabetology, Stanley Medical College & Hospital,

Madras Medical College & R.G. Govt. General Hospital, Chennai Chennai.

Diabetes – the epidemic: Furthermore, diabetes, per se, is considered as a
‘coronary heart disease risk equivalent’ by some au-
In recent years, diabetes mellitus (DM) has emerged thorities11-13 while others differ on this concept.
as a major public health problem throughout the
world, with the number of people suffering being in Therefore, we must be able to grasp the concept that
hundreds of millions. India has the second highest ‘diabetes mellitus’ is not an isolated disorder, but
number of diabetes patients in the world, next only to rather it is part of a continuum, that is, the so-called
China. An estimated 69.2 million people have diabe- “Glycaemic continuum” which extends through the
tes in India. In terms of those with impaired glucose spectrum of IFG, IGT, DM and CVD.
tolerance (IGT), India tops the world with about 36.5
million people with IGT.1 The importance of weight management:

Diabetes and cardiovascular disease: Weight gain and obesity are known to be associat-
ed with an increased incidence of insulin resistance
DM is a significant cause of cardiovascular (CV) mor- (IR) and T2DM. The Diabetes Prevention Program
bidity and mortality. The Framingham Heart Study (DPP) done in the United States has revealed that in
showed that the diabetes patient has a two to four those at risk of developing diabetes, a reduction in
times increased risk of developing myocardial infarc- body weight by 7% decreases the risk by about 58%.
tion, stroke,2,3 congestive cardiac failure,2,4 peripheral This reduction was higher than the reduction in risk
arterial disease2,5 and increased mortality due to cor- achieved with metformin therapy (31%).
onary heart disease.2,3
Further, weight loss also helps to prevent CVD by
In the prediction of the progression from prediabetes reducing blood pressure (BP) and triglycerides (TGL)
to type 2 diabetes mellitus (T2DM), IGT has a high- which are risk factors for CVD.
er sensitivity than that of ‘impaired fasting glucose’
(IFG).6,7 Aucott et al showed, in a systematic review, that los-
ing weight (intentional weight loss) by T2DM patients
Further, as seen in the Funagata Diabetes Study, IGT can decrease their risk of mortality by about 25%.
also is a risk factor for cardiovascular disease (CVD). Wing and co-workers showed that in overweight and
The Funagata study also pointed out that IFG, unlike obese individuals with T2DM, modest weight losses
IGT, is not a risk factor for CVD.7,8 Any degree of of about 5 to 10% produced significant improvements
glucose intolerance following a glucose challenge is in CVD risk factors. Greater weight losses produced
associated with atherosclerotic CV disease, mortality greater decrease in the risk factors of CVD. The
and morbidity.7,9 magnitude of weight loss at 1 year was found to be
strongly associated with improvements in glycaemic
However it is noteworthy that Haffner et al had level, BP, TGL and HDL cholesterol, but not in LDL
shown in a subgroup analysis of the Scandinavian cholesterol (LDL-C) levels.
Simvastatin Survival Study population, that in those
patients with IFG who received simvastatin, signifi- Professional expert group guidelines thus recom-
cant reduction in major cardiovascular events and mend a reduction in body weight in overweight in-
mortality were observed. 7, 10 dividuals for the prevention as well as management

Cardio Diabetes Medicine

618 The Role of Lifestyle Modification in The Prevention of
Diabetes and Cardiovascular Disease

of T2DM and CVD. The NICE [National Institute for Diet also plays an important role in the prevention
Health and Care Excellence] guidelines recommend of T2DM. The caloric content of food is more import-
an initial weight loss target of 5 to 10%; ADA [Amer- ant than its macronutrient content, in achieving and
ican Diabetes Association] recommends to achieve maintaining the recommended weight loss by an in-
and maintain a minimum of 7% weight loss, RSSDI dividual.
[Research Society for the Study of Diabetes in India]
recommends a 5 to 10% reduction in body weight. In prospective epidemiological studies, the glycaemic
index and the glycaemic load of the food were asso-
It is noteworthy that any unintended weight loss ciated with an increased risk of T2DM in both sexes.
needs to be differentiated from intentional weight Diets which contain high starch, low-fibre and with a
loss through the efforts of the patient. This is be- high ‘starch-to-cereal fibre ratio’ are associated with
cause unintentional weight loss may be an adverse an increased risk of T2DM.
indicator pointing towards poor management of dia-
betes, poor compliance and poor glycaemic control. Consumption of dietary fibre reduces the risk of
diabetes and research evidence strongly supports
Diet: this. For example, in the Finnish Diabetes Preven-
tion study (Finnish DPS), consumption of ≥ 15g / 1000
Diet is one of the cornerstones in the treatment of kcal of fibre in the diet reduced the risk of diabetes.
DM. Dietary recommendations for patients with dia- Thus, professional guidelines recommend increasing
betes focus on glycaemic control and reducing the the intake of dietary fibre to reduce the risk of de-
risk of developing the co-morbidities of diabetes & veloping diabetes. Diets high in fibre content reduce
the risk of CVD and other complications of diabe- fasting blood glucose levels and LDL-C levels in pa-
tes. In individuals with diabetes, various patterns of tients with DM. Dietary fibre also seems to be protec-
dietary management have been tried. These include tive against CVD as seen in epidemiological studies.
low-carbohydrate diet, low-glycaemic index diet, low- However, information from randomised controlled
fat diet, very-low calorie diet, etc. trials (RCTs) is insufficient at the present.

Dietary guidelines:

The European Society of Cardiology (ESC) in collaboration with the European Association for the Study of
Diabetes (EASD) has put forward the following recommendations on the macronutrient composition of diet
in regard to the prevention of CVD in patients with diabetes:

Proteins 10-20 % of total energy intake.
In patients with nephropathy, protein intake should be lesser.

Carbohydrates 45-60 % of total energy intake.
Very low carbohydrate diets are not recommended.

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Cardio Diabetes Medicine 2017 619

Fats Total fat intake should not exceed 35% of total energy intake.

Overweight individuals need to consume fats as < 30% of energy intake, to aid
weight loss.

Cholesterol intake should be less than 300mg/day and is to be reduced further if
LDL-C is high.

Intake of n-3 fatty acids is recommended.

Oils rich in monounsaturated fatty acids may provide 10-20% of total energy, con-
sidering that the total fat intake does not exceed 35%.

Polyunsaturated fatty acids may constitute up to 10% of total energy intake.

Saturated and trans-unsaturated fatty acids should be <10% of energy intake. If
LDL-C is elevated, an intake of <8% may be beneficial.

Trans fat intake should be very minimal and should be <1% of total energy intake
and where consumed, it should be from natural sources and not of industrial origin.

Vegetables, fruits Should be part of the diet consumed.

legumes, and

wholegrain cereals

Dietary fibre Intake of fibre should be about 40 g/day, that is about 20 g/1000 Kcal/day. Half
of this should be soluble fibre.

Eating ≥5 servings of fibre-rich vegetables or fruit every day and eating ≥4 servings
of legumes per week will provide the minimum requirements for fibre intake.

Cereals consumed should be whole-grain with high fibre content.

Alcohol Moderate amount of alcohol intake is associated with a lower risk of CVD, in indi-
Coffee viduals with and without diabetes, when compared with non-drinkers (teetotalers)
and heavy drinkers.
Alcohol consumption should not exceed two glasses per day (20g/day) for men
and one glass per day (10g/day) for women

Drinking > 4 cups of coffee per day is associated with a lower risk of CVD in those
with DM. However, boiled coffee without filtering should be avoided as it raises
LDL-C levels.

Cardio Diabetes Medicine

620 The Role of Lifestyle Modification in The Prevention of
Diabetes and Cardiovascular Disease

As per the RSSDI recommendations, a ‘cardio-protective diet’ should include the following:

Higher amounts of the following to be consumed:
Leafy vegetables, coarse grains, vegetable salads, sprouted grams and other food items rich in anti-oxidants
and fibre

Moderate amounts of the following to be consumed:
Low fat milk and milk products, vegetable oils with monounsaturated fatty acids (MUFA) and polyun-
saturated fatty acids (PUFA),
Flesh foods such as fish, chicken without skin, white of the
egg and artificial sweeteners

The following items are to be avoided / restricted :
Sugar, Saturated fats
Foods that are refined, processed, salt-rich, cholesterol-rich and deep-fried
Polished rice
High fructose corn syrup
Alcohol

Total dietary salt intake should be reduced (<5g/day) in population at high risk of hypertension.

Misra and colleagues put forward “Consensus dietary guidelines for healthy living and preven-
tion of obesity, the metabolic syndrome, diabetes, and related disorders in Asian Indians.”
These guidelines recommend the following–

 Reduction in the intake of carbohydrates,
 Preferential intake of complex carbohydrates and low glycemic index foods,
 Higher intake of fiber,
 Lower intake of saturated fats,
 Optimal ratio of essential fatty acids, reduction in trans fatty acids,
 Slightly higher protein intake,
 Lower intake of salt, and
 Restricted intake of sugar. 

On alcohol consumption, the Indian Consensus Guideline points out that most of the studies that recommend
a limited consumption of alcohol have been done in the Caucasian white population. Therefore whether the
same inferences could be applied to the Indian subjects is not clear, as Indians already have a high preva-
lence of fatty liver.
Individuals with elevated serum triglycerides of 500 mg/dl or more, and those with significant liver dysfunc-
tion should not consume alcohol.

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Cardio Diabetes Medicine 2017 621

The Indian Consensus guideline states that regular, physical activity and is not a structured exercise train-
excessive intake of alcohol is harmful to the individ- ing) interventions were associated with lower HbA1c
ual. Until more data are available for Indian subjects, levels only when they were combined with dietary
those who do not consume alcohol should not take management.
alcohol. However, those individuals who are already
taking a small quantity of alcohol need not be dis- The best way to motivate and promote physical activ-
couraged. ity is not well known. However, RCTs have shown that
reinforcement of the activity by healthcare workers
Physical activity and exercise: would be beneficial.

Physical activity plays a significant role in preventing/ Cessation of smoking:
delaying the development of diabetes in those with
IGT. It is also important in achieving and maintaining Active smoking is associated with an increased risk
glycaemic control in IGT and DM. Aerobic exercise of T2DM. Smoking increases the risk of premature
and resistance exercise improve insulin sensitivity, deaths. The leading causes of death due to smok-
plasma glucose levels, blood pressure and plasma ing were CVD, chronic obstructive pulmonary disease
lipid levels and decrease the CV risk. and lung cancer. Further, the cessation of smoking
decreases CVD risk. Therefore, smoking should be
According to the ADA, all children including those avoided. Smokers should be encouraged to quit
with diabetes or prediabetes, should engage in at smoking and should be offered a structured pro-
least 60 minutes of physical activity every day. Chil- gramme including pharmacological therapy. The ADA
dren should be encouraged to engage in 60 min- states that non-smokers should be advised not to
utes or more of moderate-to-vigorous aerobic activity use e-cigarettes, as research data on their short- and
each day, with muscle-and-bone strengthening ac- long-term effects is still not sufficient.
tivities at least 3 days per week. Adults (> 18 years)
should engage in 150 minutes per week of moderate Clinical trials and their inferences:
intensity aerobic physical activity or 75 minutes per
week of vigorous intensity aerobic physical activity or Landmark clinical trials and studies have given us
an equivalent combination of these. Muscle strength- useful information to understand the importance
ening activities should be performed 2 or more days/ of lifestyle modification in the prevention of T2DM.
week. Further, extended sedentary periods should be Some of these are discussed below.
avoided as much as possible. Sedentary periods (>
30 minutes) may be broken by briefly standing, walk- The American DPP randomly assigned participants
ing and doing some light physical activity. Avoided with prediabetes, to receive either metformin (850
extended sedentary periods may help prevent T2DM mg twice a day) or lifestyle intervention or placebo
for those at risk and aid in achieving better glycaemic and measured the incidence of T2DM after an aver-
control for those with diabetes. age follow-up period of 2.8 years. The lifestyle inter-
vention targeted a weight loss of at least 7% of body
The RSSDI recommends moderate physical activity weight and physical activity of at least 150 minutes /
such as walking for at least 150 minutes/ week. The week. Lifestyle intervention reduced the incidence of
RSSDI also recommends 6-8 hours of sleep daily. diabetes by about 58% and metformin reduced the
incidence by about 31%, when compared to placebo.
In a systematic review and meta-analysis by Ump- The lifestyle intervention in DPP was a ‘goal-based
ierre and co-researchers, structured exercise training intervention’, that is, all participants were given the
reduced HbA1c by about 0.67% in those with diabetes same goals in weight reduction and physical activity.
when compared to controls. Structured aerobic exer- But individualization of the methods to achieve these
cises, resistance training and both combined reduced goals was permitted for each participant. An individu-
HbA1c by 0.73%, 0.57% and 0.51% respectively. Struc- alized approach rather than a group-based approach
tured exercise durations of > 150 minutes per week was used in the DPP.
were associated with HbA1c reduction of 0.89% while
those of ≤ 150 minutes per week were associated with The Finnish DPS studied participants with IGT and
reductions by 0.36%. As decrease in HbA1c level is divided them into two groups- the intervention group
associated with long-term reduction in microvascu- and the control group. The subjects in the interven-
lar complications and CV events, long-term exercise tion group received individualized counseling on diet,
regimens that help to improve glycaemic control are physical activity and weight reduction. The mean du-
likely to bring down the vascular complications. Phys- ration of follow-up was 3.2 years. The risk of T2DM
ical activity advice (i.e., advice to patients to increase was found be reduced by 58% in the intervention

Cardio Diabetes Medicine

622 The Role of Lifestyle Modification in The Prevention of
Diabetes and Cardiovascular Disease

group. In the Chinese Da Qing study, the participants or delay the onset of T2DM and consequently its
had IGT. The subjects were assigned to one of the 4 complications like CVD.
groups – Control, Diet only, Exercise only and Diet
plus Exercise. The follow-up period was for 6 years. References:
The Diet only, Exercise only and Diet plus Exercise
groups had 31%, 46% and 42% reductions, respective- 1. International Diabetes Federation. IDF Diabete Atlas, 7 ed. Brussels, Bel-
ly, in the risk of developing T2DM. gium: International Diabetes Federation, 2015. http://www.diabetesatlas.
org
The Diabetes Prevention Program Outcomes Study
(DPPOS) was a follow-up of the DPP where the orig- 2. Fox CS. Cardiovascular Disease Risk Factors, Type 2 Diabetes Mellitus, and
inal metformin group was continued with metformin the Framingham Heart Study. Trends Cardiovasc Med. 2010; 20(3):90-5.
treatment and the original lifestyle group was given doi: 10.1016/j.tcm.2010.08.001.
additional lifestyle modification support. The study
showed that there was a sustained reduction in the 3. Kannel WB, McGee DL. Diabetes and cardiovascular disease. The Fram-
incidence of T2DM by 34% in the lifestyle group and ingham study. JAMA. 1979; 241: 2035-38.
18% in the metformin group at the end of 10 years
since randomisation for the DPP.33 In the follow-up of 4. Kannel WB, Hjortland M, Castelli WP. Role of diabetes in congestive heart
the Finnish DPS and the Chinese Da Qing study, 43% failure: the Framingham study. Am J Cardiol. 1974; 34: 29–34.
reduction at 7 years and 43% reduction at 20 years
respectively were observed in the incidence of T2DM. 5. Brand FN, Abbott RD, Kannel WB. Diabetes, intermittent claudication,
and risk of cardiovascular events. The Framingham Study. Diabetes. 1989;
In the Indian Diabetes Prevention Programme (IDPP), 38:504–509.
the participants were divided into groups. Group 1 was
the control group. Group 2 was given advice on life- 6. Shaw JE, Zimmet PZ, De Courten M, Dowse GK, Chitson P, Gareeboo H,
style modification (LSM), group 3 was treated with et al. Impaired Fasting Glucose or Impaired Glucose Tolerance- What best
metformin (MET) and group 4 received both LSM and predicts future diabetes in Mauritius? Diabetes Care. 1999; 22: 399-402.
metformin (LSM+MET). The median follow-up period
was 30 months. The reduction in risk of diabetes 7. Moses A, Bronson SC, Moses VS. Pharmacotherapy for management of
was 28.5% in the LSM group, 26.4% in the MET group prediabetes. In: Madhu SV, editor-in-chief. RSSDI Diabetes Update 2016.
and 28.2% in the LSM+MET group as compared to New Delhi: Jaypee Brothers medical publishers (P) Ltd. ; 2017. 375 -77.
the control group. These reductions are seemingly
lesser than those observed in the American, Finnish 8. Tominaga M, Eguchi H, Manaka H, Igarashi K, Kato T, Sekikawa A. Im-
and Chinese studies. In the IDPP, the lifestyle advice paired Glucose Tolerance is a risk factor for cardiovascular disease, but
& modification administered were less intense than not Impaired Fasting Glucose – The Funagata Diabetes Study. Diabetes
that given in the DPP and Finnish DPS, and exercise Care. 1999; 22:920–924.
was not supervised. Further, the relatively lesser risk
reduction of T2DM in the Chinese and Indian studies 9. Perry RC, Baron AD. Impaired Glucose Tolerance. Why is it not a disease?
when compared to the American and Finnish studies Diabetes Care. 1999; 22: 883-885.
may also be reflective of and due to the higher inci-
dence of T2DM in the population in these countries. 10. Haffner SM,  Alexander CM,  Cook TJ,  Boccuzzi SJ,  Musliner TA,  Pedersen
TR, et al. Reduced coronary events in simvastatin-treated patients with
Conclusion: coronary heart disease and diabetes or impaired fasting glucose levels:
subgroup analyses in the Scandinavian Simvastatin Survival Study. Arch
Diabetes affects the individual, his family and the Intern Med. 1999; 159:2661-7.
society in terms of physical, emotional, familial, eco-
nomical and socio-cultural stress and burden. India 11. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from
has a higher prevalence of T2DM & IGT and the pop- coronary heart disease in subjects with type 2 diabetes and in nondiabetic
ulation is prone to develop dysglycaemia. Hence, as subjects with and without prior myocardial infarction. N Engl JMed 1998;
for as India is concerned, not only those with predi- 339: 229-34.
abetes & other high risks for developing diabetes,
but also the whole population in general needs to 12. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cho-
be targeted to prevent T2DM and reduce the burden. lesterol in Adults. Executive summary of the third report of the national
Therefore, in such a scenario, a well motivated and cholesterol education program (NCEP) Expert panel on detection, evalu-
sustained lifestyle modification will definitely prevent ation, and treatment of high blood cholesterol in adults (adult treatment
panel III). JAMA. 2001; 285 :2486-97.

13. Rana JS. Is Diabetes really a CHD risk equivalent. Expert Opinion.
2016 Apr 13. American College of Cardiology website. Accessed on
2017 Sep 6. Available from: http://www.acc.org/latest-in-cardiology/arti-
cles/2016/04/12/13/40/is-diabetes-really-a-chd-risk-equivalent

14. Rydén L, Grant PJ, Anker SD, et al. ESC Guidelines on diabetes, pre-diabe-
tes, and cardiovascular diseases developed in collaboration with the EASD:
the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of
the European Society of Cardiology (ESC) and developed in collaboration
with the European Association for the Study of Diabetes (EASD). Eur
Heart J.  2013; 34(39): 3035-87. doi: 10.1093/eurheartj/eht108. Epub
2013 Aug 30.

15. Guess N. Lifestyle issues: Diet. In: Holt RIG, Cockram CS, Flyvbjerg A,
Goldstein BJ, editors. Textbook of Diabetes. 5th ed. Chichester, West Sus-
sex, UK: Wiley Blackwell; 2017. 341-52.

GCDC 2017

Cardio Diabetes Medicine 2017 623

Lifestyle & Noncommunicable Diseases: My ‘Formula of 80’
To Live Up To 80 Years Without A Lifestyle Disease

Dr. KK. Aggarwal

Padma Shri Awardee
National President Indian Medical Association

Noncommunicable diseases (NCDs) are a major and diet, as responsible for more than 90% of the
cause of premature and preventable deaths globally. global risk for acute heart attack viz. abnormal lip-
The World Health Organization (WHO) has identified ids, smoking, hypertension (HT), diabetes, abdominal
four main types of NCDs - cardiovascular diseases, obesity, psychosocial factors, daily consumption of
cancer, chronic respiratory diseases and diabetes - in fruits and vegetables, alcohol and regular physical
its ‘Global Status Report on NCDs 2014’.1 activity. All these nine modifiable risk factors were
found to be similar in all regions of the world, in men
NCDs account for almost 70% of global deaths, ac- and women, the young and the old, except for the
cording to a global survey on assessing national ca- earlier age of occurrence of acute myocardial infarc-
pacity for the prevention and control of NCDs car- tion (MI) in South Asians. 7 This is because South
ried out in 2015 by the WHO. 2 NCDs are no longer Asians had more risk factors at ages younger than
considered diseases of the affluent as most of the 60 years. 8
deaths due to NCDs occur in low- and middle-income
countries. 2 Deaths due to NCDs have been projected More recently, the WHO’s ‘Global Status Report on
to increase to 52 million by the year 2030 from 38 NCDs 2014’ also identified four behavioral risk fac-
million in 2012. 1 Cardiovascular diseases (CVDs) ac- tors (tobacco use, unhealthy diet, physical inactivity
count for most NCD deaths that occur every year (17.7 and harmful use of alcohol) and four major metabol-
million), followed by cancers (8.8 million), respiratory ic risk factors (obesity, raised blood pressure (BP),
diseases (3.9 million) and diabetes (1.6 million). 3 raised blood sugar and raised blood total cholesterol)
that are most commonly implicated in NCDs. 1
NCDs affect people of all age groups, regions and
countries. Although regarded as diseases of older The major risk factors are briefly discussed below.
age, an estimated 15 million of all deaths between
30 and 69 years of age are caused by NCDs. All the Cholesterol
four major NCDs account for more than 80% of all
premature deaths due to NCDs. 3 In the INTERHEART study, the most important risk
factor for acute MI in South Asians was dyslipidemia.
India too is not untouched by this. Due to rapid ur-
banization, India is experiencing an epidemiological 9
transition moving away from a predominantly com-
municable or infectious to a predominantly NCD pat- The dyslipidemia in South Asians is an ‘atherogenic
tern. Modernization, sedentary lifestyles and longev- dyslipidemia’ characterized by high triglycerides, low
ity are the other major contributory factors for the levels of high-density lipoprotein cholesterol (HDL-C)
epidemic of NCDs. 4 NCDs account for over 60% of and increased levels of more atherogenic small,
all mortality in India and almost 55% of these are pre- dense low-density lipoprotein (LDL) particles even
mature mortality. 5 The major factors contributing to with comparatively normal levels of LDL-C. Also, the
NCDs include inappropriate life styles, tobacco use, HDL particles are smaller, dysfunctional and proath-
obesity, inappropriate diet, physical inactivity, alcohol erogenic in South Asians. 9  Atherogenic dyslipidemia
consumption, high blood pressure, air pollution etc. 6  is typically seen in the obese, patients with metabol-
ic syndrome, insulin resistance and type 2 diabetes
The landmark INTERHEART study, conducted in 52 mellitus (T2DM) and is an important risk factor for
countries identified nine factors, all related to lifestyle CVD in these patients. 10,11 The higher prevalence of
atherogenic dyslipidemia in Asian Indians has been

Cardio Diabetes Medicine

624 Lifestyle & Noncommunicable Diseases: My ‘Formula of 80’
To Live Up To 80 Years Without A Lifestyle Disease

attributed to higher physical inactivity, low exercise normal, 25.0 - 29.9 for overweight and >30 kg/m2
and diet that is lacking in polyunsaturated fatty acids for obesity.
(PUFAs). 11
BMI however is increasingly being recognised as a
A target LDL-C level less than 100 mg/dL is recom- poor indicator of body fat percentage, especially in
mended by all guidelines (except American College of the non-obese.
Cardiology/American Heart Association [ACC/AHA])
for the general population without CVD or high risk Waist circumference is a more sensitive measure
of CVD. In high-risk patients with established CVD, of abdominal obesity than BMI and thereby of obe-
diabetes, or lifetime risk of more than 45%, the rec- sity-related health risks. Waist circumference has
ommended LDL-C goal is less than 70 mg/dL. 12   shown stronger associations with CVD and CVD risk
factors.
A one standard deviation (1 mmol/L [38.5 mg/dL])
increase in LDL above the mean of 3.50 mmol/L (135 The consensus statement for diagnosis of obesity,
mg/dL) is associated with an age adjusted relative abdominal obesity and the metabolic syndrome for
risk for coronary heart disease of 1.42 for men and Asian Indians has recommended cut-offs for waist
1.37 for women. 13 circumference and also defined two action levels to
control abdominal obesity.
The 2013 ACC/AHA guidelines on the management
of blood cholesterol focused on reducing the risk Any person with waist circumference above the cut-
of atherosclerotic cardiovascular disease (ASCVD) offs of 78 cm in men and 72 cm in women should
rather than defining any target LDL-C levels. These avoid gaining weight and maintain physical activity to
guidelines did not recommend any specific LDL-C avoid acquiring any of the cardiovascular risk factor.
treatment goals, but identified four groups of pa- A waist circumference that is higher than 90 cm in
tients for whom statin treatment is recommended: men and 80 cm in women should be investigated for
Patients with established clinical ASCVD (coronary obesity-related risk factors and their management.
heart disease [CHD], strokes, or peripheral arterial
disease of atherosclerotic origin); patients with pri- Blood sugar
mary elevation of LDL-C ≥190 mg/dL; patients aged
40 to 75 years with diabetes mellitus (type 1 or 2) and Type 2 diabetes (T2DM) and metabolic syndrome
with LDL-C levels between 70 and 189 mg/dL and have reached epidemic proportions in India. With 69.1
patients without ASCVD or diabetes who are 40 to million cases of diabetes in 2015, India is now second
75 years of age and whose estimated 10-year ASCVD only to China, which has 110 million people with type
risk is ≥7.5%.14  2 diabetes. The ratio of undiagnosed to diagnosed
diabetes is higher in rural compared with urban areas
Abdominal obesity as was evident from the results of the phase I of the
ICMR- INdia DIABetes (INDIAB) Study.
The typical Asian Indian phenotype is the “thin-fat
Indian” i.e. Asian Indians have smaller muscle mass, Around 77.2 million people in India reportedly have
but more body fat than their white or African counter- prediabetes. The Indian Diabetes Prevention Pro-
parts or other Asian ethnic groups. The pattern of fat gramme-1 (IDPP-1) study in persons with IGT showed
deposition in abdomen, ectopic fat deposition (liver, that the progression of IGT to diabetes is high in na-
pancreas) and also low lean mass are more import- tive Asian Indians; 18% per year.
ant determinants of disease risk than body mass.
15, Individuals with higher abdominal fat deposition The Asian Indian phenotype predisposes Indians
are at higher risk of coronary artery disease (CAD), to insulin resistance and type 2 diabetes because
type 2 diabetes and other cardiometabolic risk inde- of genetics and also lifestyle factors of unhealthy
pendently of body mass index (BMI). diet and physical inactivity. The DiabCare India 2011
study showed that type 2 diabetes also develops at
BMI has been traditionally used to evaluate obesi- a younger age in Indians and also at lower levels
ty. Compared to the internationally recommended of BMI.
cut-offs, the cut-offs of normal BMI are narrower
and lower in Asian Indians. The normal BMI cut-off ASCVD is a common complication of type 2 diabetes.
ranges between 18.0-22.9 kg/m2; overweight is be- Any increase in blood sugar levels above the normal
tween 23.0 and 24.9 kg/m2 and obesity is BMI >25 is associated with an increased relative risk for myo-
kg/m2. While the corresponding currently WHO rec- cardial infarction and stroke.
ommended cut-offs of BMI are: 18.5 - 24.9 kg/m2 for
In people without diabetes, the risk of CHD increas-
es 6% for every 1 mmol/L increase (18 mg/dL) in

GCDC 2017

Cardio Diabetes Medicine 2017 625

fasting blood sugar (FBS). A 10% increased risk of to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg,
sudden cardiac death has been observed with each as defined in the JNC 7 identifies persons at future
1 mmol/L increase in FBS. risk of developing hypertension. Intervention at this
stage with appropriate lifestyle modifications can
Boguszewski et al reported a significantly higher avert or delay CVD. JNC 7 also recommended anti-hy-
prevalence of ASCVD in dyslipidemic patients with pertensive drug in prehypertensive individuals, who
FBS between 90 and 99 mg/dL compared to lower also have diabetes or kidney disease, if the lifestyle
levels of the blood sugar. With increase in FBS from modifications did not lower the BP to 130/80 mmHg
90 to 125 mg/dL, a corresponding increase in the or less.
prevalence of ASCVD was also seen.
Smoking
Blood pressure
Smoking increases risk of CVD. Sudden death, MI,
Hypertension (HT) is often called ‘the silent killer’ as CHD, cerebrovascular disease, PAD, HT complica-
it is usually asymptomatic in the early stages. It is tions and poor prognosis following angioplasty or
a significant risk factor for atherosclerosis and also bypass surgery are associated with smoking. Hence,
an independent predisposing factor for heart failure, patients should be encouraged and helped to quit
CAD, stroke, renal disease and peripheral arterial smoking. Quitting smoking may reduce calculated
disease (PAD). CVD risk almost to the same levels as never-smok-
ers.
As per the National Family Health Survey 4 (NFHS-
4) 2015-16, 13.6% men and 8.8% women in India in Smoking is associated with insulin resistance, in-
the age group of 15-49 years are hypertensive. The flammation and dyslipidemia. It increases the risk of
prevalence of hypertension is increasing in both rural developing diabetes, and aggravates the micro- and
and urban areas in India. Nearly 25% of urban and 10- macrovascular complications of diabetes. Although
15% of rural adults are hypertensive, corresponding smoking is known to decrease body weight, it is as-
to a 12-fold and 7-fold increase in urban and rural sociated with central obesity. Smoking also increases
hypertensive population, respectively. Hypertension inflammation and oxidative stress and has direct ad-
accounts for 57% of deaths due to stroke and 24% verse impact on beta-cell function and also impairs
of deaths due to CHD and around 11% of all deaths endothelial function.
in India.
Diet
The hypertensive population in India is estimated to
double from 118 million in 2000 to 213 million by the Dietary modifications can prevent many of the life-
year 2025. style diseases.

This rising trend is multifactorial due to factors such Replacing saturated fats with unsaturated fats re-
as increased life expectancy, life style changes, in- duces the risk of CAD. Diets rich in fiber and com-
creased salt intake and also due to the increased plex carbohydrate and low in fat improve glycemic
awareness and detection of hypertension. A signifi- control, delay absorption of glucose, lower insulin
cant association was found between high salt intake requirement, decrease serum cholesterol and tri-
(>10gms/day) and HT in a study, where 55.46% of glycerides, help to control body weight and also lower
hypertensive study participants had >10gm of daily BP in patients with type 2 diabetes. There is an in-
salt intake. verse association between fruit, vegetable and fibre
consumption and risk for CHD and stroke.  
As per the Seventh Report of the Joint National Com-
mittee (JNC 7) on prevention, detection, evaluation, Cereal products should be eaten in a whole-grain,
and treatment of high BP, the risk of CVD doubles high-fiber form. High consumption of refined car-
with each increment of 20/10 mm Hg in the BP from bohydrates is associated with type 2 diabetes, CAD
a baseline of 115/75 mm Hg. and metabolic syndrome. Intake of sugar and sug-
ar-based beverages should be restricted. Sugar in-
In a meta-analysis of individual data for one million take leads to hypertriglyceridemia, insulin resistance,
adults in 61 prospective studies published in The Lan- metabolic syndrome, diabetes and fatty liver, and
cet, mortality from both ischemic heart disease (IHD) hyperuricemia mostly by increasing body fat and in-
and stroke increased more than 2-folds with every 20 tra-abdominal fat.
mmHg increase in systolic BP or 10 mmHg increase
in diastolic BP between ages 40 and 69 years. Excessive intake of energy from any source should
be avoided to prevent avoid obesity and overweight.
The category of prehypertension, systolic BP of 120

Cardio Diabetes Medicine

626 Lifestyle & Noncommunicable Diseases: My ‘Formula of 80’
To Live Up To 80 Years Without A Lifestyle Disease

One gram of food contains six calories on an average If you are a heart patient, consider 80 mg aspirin and
(9 g in fat, 4 each in carbohydrates and proteins). 80 mg atorvastatin a day.

Sodium intake should also be restricted given its ef- * Keep kidney and lung functions more than 80%.
fect on BP. The AHA/ACC guideline on lifestyle man-
agement to reduce CV risk recommends consump- * Avoid exposure to PM 2.5 and PM 10 levels < 90
tion of not more than 2,400 mg of sodium daily. In mcg/m3.
prehypertension and HT, daily sodium intake should
be further lowered to 1,500 mg as it is associated * Avoid exposure to >80 dB of noise.
with an even greater reduction in BP.
* Take vitamin D through sunlight 80 days in a year.
My Formula of 80 to live up to 80 years
without a lifestyle disease * Do 80 cycles of pranayama (parasympathetic
breathing) in a day with a speed of 4 per minute.
All the major lifestyle disorders or NCDs share com-
mon lifestyle-related risk factors. * Spend 80 minutes with yourself every day (relax-
ation, meditation, helping others etc).
Because these lifestyle diseases share modifiable
risk factors, patients should be advised a common References
lifestyle, which will prevent all lifestyle disorders. In-
stead of advocating a lifestyle for individual disease, 1. Global Status Report on noncommunicable diseases 2014. World Health
these lifestyle modifications should be such that they Organization.
not only prevent heart diseases but also type 2 dia-
betes, hypertension, overweight and obesity, depres- 2. Assessing national capacity for the prevention and control of noncommu-
sion and cancer. nicable diseases: report of the  2015 global survey. World Health Orga-
nization. 2016.
Keeping this in mind, I have devised a ‘Formula of
80’, which I teach and recommend to all my patients. 3. Noncommunicable diseases Fact sheet, World Health Organization
They are evidence-based and as most recommenda-
tions are to keep the values below 90, I have chosen 4. Updated June 2017.
the number 80 as common to all risk factors so that
it is easy for patients to remember. 5. Passi SJ, Akanksha J. Combating non-communicable diseases. Press Infor-
mation Bureau, February 20, 2017.
Here is my Formula of 80 to live up to the age
of 80. 6. Press Information Bureau, Government of India, Ministry of Health and
Family Welfare. January 21, 2017.
* Keep lower BP, LDL ‘bad’ cholesterol levels, rest-
ing heart rate, fasting sugar and abdominal girth lev- 7. Communicable and Non- Communicable Diseases. Press Information Bu-
els all less than 80. reau, Government of India, Ministry of Health and Family Welfare, July
22, 2016. 
* Walk 80 minutes a day, brisk walk 80 min a week
with a speed of 80 steps (at least) per minute  8. Yusuf S, Hawken S, Ounpuu S, et al; INTERHEART Study Investigators.
Effect of potentially modifiable risk factors associated with myocardial
* The less you eat, the more you live. Eat less and infarction in 52 countries (the INTERHEART study): case-control study.
not more than 80 gm or ml of caloric food each meal.  Lancet. 2004;364(9438):937-52.
Follow a healthy diet (high fiber, low saturated fat,
zero trans fat, low refined carbohydrate, low salt, high 9. Joshi P,  Islam S,  Pais P,  et al. Risk factors for early myocardial infarc-
in fruits). Refined carbohydrates are white rice, white tion in South Asians compared with individuals in other countries.
maida (refined flour) and white sugar. JAMA. 2007;297(3):286-94.

* Observe cereal fast 80 days in a year. 10. Bilen O, Kamal A, Virani SS. Lipoprotein abnormalities in South Asians
and its association with cardiovascular disease: Current state and future
* Do not smoke or be ready to shell out Rs. 80,000/- directions. World J Cardiol. 2016;8(3):247-57.
for treatment.
11. Musunuru K. Atherogenic  dyslipidemia:  cardiovascular  risk  and  dietary
* Do not drink alcohol; if you do, do not consume intervention. Lipids.  2010;45(10):907-14.
more than 80 ml per day for men (50% for women) or
80 grams per week. Ten grams of alcohol is present 12. Manjunath CN, Rawal JR, Irani PM, et al. Atherogenic dyslipidemia. Indian
in 30 ml or 1 oz of 80 proof liquor. J Endocrinol Metab. 2013;17(6):969-76.

13. Enas EA, Dharmarajan TS. The Lipid Association of India Expert Consensus
Statement 2016: A sea change for management of dyslipidemia in Indians.
J Clin Prev Cardiol 2016;5(2):62-6.

14. Semmler A, Moskau S, Grigull A, et al. Plasma folate levels are associ-
ated with the lipoprotein profile: a retrospective database analysis. Nutr
J. 2010;9:31.

15. Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardi-
ology/American Heart Association Task Force on Practice Guidelines2013
ACC/AHA guideline on the treatment of blood cholesterol to reduce ath-
erosclerotic cardiovascular risk in adults: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guide-
lines. Circulation. 2014;129(25 Suppl 2):S1-45.

GCDC 2017

Cardio Diabetes Medicine 2017 627

08. Future

1. An Overview of Legal Issues in Hypertensive and Diabetic Patients. - Dr .T.Ravi shankar

2. Susceptible and Prognostic Genetic Factors associated with Diabetic Peripheral Neuropa-
thy: A Literature Review - Dr.VHW Dissanayake

3. Can the Projected World Center of Chronic Disease be Converted to the Worlds Control
Centre of Chronic Disease? - Dr.Alexander Thomas

4. Health Insurance – A Comprehensive Study - Dr. S.Prakash

Cardio Diabetes Medicine