Diabetes Mellitus Prevention

Time edited：2018/05

     I.         What is DM (Diabetes Mellitus)?

  DM is a metabolic disease characterized by the rise of blood glucose and caused by deficiency of insulin secretion and (or) its function. DM is a chronic and life-time disease, which severely affects one‘s health.  The typical DM’s symptoms are ‘three-mores and one-less’, i.e. polyuria, polydipsia, polyphagia and weight loss.

   II.         Diagnostic Criteria of DM^{[i][ii][iii][iv]}

  Diagnosis of DM is determined by clinical symptoms, including polyuria, polydipsia, polyphagia and weight loss. Or other indicators like Fasting Plasma Glucose (FPG), Plasma Glucose (PG) level at random time , 2-hour PG value during OGTT (Oral Glucose Tolerance Test) and HbA1c. If there’s symptoms such as three-mores and one-less (polyuria, polydipsia, polyphagia and loss of weight) exist, and PG level at any time is ≥ 11.1 mmol/L (200 mg/dl), it should be diagnosed as DM. Meanwhile, if FPG level is ≥ 7.0 mmol/L (126 mg/dl), or 2-hour PG level is ≥ 11.1 mmol/L (200 mg/dl) during OGTT, it should be diagnosed as DM, too. Or A1C values ≥ 6.5 % (48 mmol/mol). All the values of the tests as mentioned above refer to venous plasma glucose level. Fast means no other caloric intake in previous at least 8 hours; random time means any time within a day, and has no relation with last meal and food intake; OGTT is a test that 75 g of glucosum anhydricum dissolved in water, taken orally with in 5 minutes. HbA1c is glycated haemoglobin which indicates long period plasma glucose changes.

ADA(American Diabetes Association) criteria for diagnose of diabetes

 III.         Exercises of DM patients

    Exercises for DM patients must be done as directed by medical staff.

1.     Principle : Personalized, moderately and frequently.

2.     Types of exercises :

  According to the patients’ body situations, ages, exercise habits, etc., it is advised to do aerobic exercises that can train whole body muscles, such as walking, Tai Chi, climbing stairs, riding bicycles, swimming, etc. For the elder patients who have low mobility, massage or stretching exercise are the alternative choices.

3.     Exercise intensity :

    Exercise intensity should take individual’s physical status and exercise level into account. Medium-intensity exercises is recommended. Targe heart rate zone should be within 50%-75% of the highest individual heart rate. The scale of rating of perceived exertion (RPE) should be 12 or 13. Another east way to distinguish medium-intensity is when patients feel a little tired or tired during exercise. Patients of Type 1 DM should avoid high intensity and long exercises. Patients of Type 2 DM can take low intensity, high frequency and longer exercises.

Table 1. Target heart rate zone^[v]

*highest heart rate = 220 – age

    For example, for a 40-year-old person, the estimated maximum age-related heart rate would be calculated as 220 - 50 years = 180 beats per minute (bpm). The 50% and 70% levels would be:

50% level: 180 x 0.50 = 90 bpm, and

70% level: 180 x 0.70 = 126 bpm

Ways to measure the heart rate.

    To measure the heart rate while exercising, patients need to stop exercising briefly. Patients can measure the pulse through neck, wrists, or chest. It is recommended to use wrists. Patients can feel the radial pulse on the artery of the wrist in line with the thumb, Placing the tips of the index and middle fingers over the artery and press lightly. Do not use the thumb. Take a full 60-second count of the heartbeats, or tale for 30 seconds and multiply by 2. Start the count on a beat, which is counted as “zero.”

Table 2. The Borg Rating of Perceived Exertion^[vi]

9. corresponds to "very light" exercise. For a healthy person, it is like walking slowly at his or her own pace for some minutes

13. on the scale is "somewhat hard" exercise, but it still feels OK to continue.

17. "very hard" is very strenuous. A healthy person can still go on, but he or she really has to push him- or herself. It feels very heavy, and the person is very tired.

19. on the scale is an extremely strenuous exercise level. For most people this is the most strenuous exercise they have ever experienced.

4.     Exercise frequency :

   Patients of Type 1 DM should exercise on daily basis, combined with diet control and insulin therapy as a routine treatment. For obese patients of Type 2 DM, exercise at least 5 days every week to achieve the purpose of losing weight through high caloric consumption. 

5.     Exercise duration:

    At least 30 minutes of medium-intensity exercise every day to keep healthy. During medium-intensity exercise, the exercise duration of patients should be around 20 minutes. After half to one month of training without any adverse event, the duration can slowly increase to around 40~60 minutes. Interval exercise is suitable for patients with poor health. For example, walk for two minutes and rest for two minutes repeatedly for the total duration around 10~20 minutes.

6.     Which DM patients are not fit for exercises?

                                 i.         DM patients with ketoacidosis, hypoglycemia ( < 4.4 mmol／L) or significant hyperglycemia(＞14 mmol／L);

                               ii.         DM patients with nephropathy, retinal hemorrhage or infected; DM patients with diabetic foot or having a blood test recently.

                              iii.         DM Patients with uncontrolled hypertension, unstable angina or recently have history of myocardial infarction (MI).

                              iv.         DM Patient with acute infection.

7.     What should DM patients be careful with during exercise?

                                 i.         Physical training must be combined with dietary control and drug therapy.

                               ii.         Be persistent.

                              iii.         Properly adjust training based on the variation of personal health condition, climate, weather, and surrounding condition.

                              iv.         Warm-up for 5-10 minutes before exercise. Relaxing and stretching your muscle for 5-10 minutes after exercise.

                                v.         If patients experience low blood glucose symptoms such as faint, night sweat, lack of strength, even unconsciousness, etc., stop exercise right away, and replenish carbohydrates.

                              vi.         Patients should not have symptoms such as dizziness or chest pain. During exercise, patients should be careful when being short of breath breathe.  

                            vii.         Having appropriate extra meal If patients are going to have long and extensive exercises such as outgoing, mountain climbing.

                           viii.         Changing positions slowly to avoid gesture hypotension during exercise.

                              ix.         Making any Movements gently and slowly, and avoid intensive activity  and suddenly change of gestures.

                                x.         If patient having concurrent medications like b-blockers (atenolol or metoprolol etc.), It is suggested that using Rating of Perceived Exertion (RPE) to determined exercise intensity (which is around 9~11) rather than using target heart rate  zone (Heart rate).

                              xi.         If there is any injury of patients’ foot or other parts of body, see a doctor immediately.

                            xii.         For long-term DM patients, patients can get different type of nerve damage and loss feeling of toes or even feet. In order to avoid infection, checking feet before exercises, wearing suitable shoes and protective soft socks, and checking, washing feet every day. 

                           xiii.         Ｗays to Avoid hypoglycemia during exercise:

a.     Monitoring blood glucose before exercise.

b.     Lower insulin dosage before exercise (determined by doctor) or increase intake of carbohydrate.

c.     Avoid Exercise time during insulin peak time, i.e. exercising 1~2 hours after meal.

d.     When exercising, DM patients should be accompanied by other people and prepare some candies just in case.

 IV.         What are the risk groups for DM?

    Nine categories of people are risk for getting DM. During early stages of DM, there are no obvious symptoms. So when diagnosed as DM, patients may already have various levels of complications. It is recommended that high risk group people check FPG and PG after meal at regular intervals such as every half a year. Early diagnosis, early treatment. It is helpful to prevent and reduce the occurence of various complications. 

    Nine high risk group of people:

1.     People with abnormal FPG (5.6～7 mmol/L) or impaired glucose tolerance 2-hour post-meal (7.8～11.1 mmol/L).

2.     People with family history of DM. For example, people whose parents, siblings or other relatives have history of DM, and the average rate of these people getting DM are two times more than the people who do not have family history of DM.

3.     Obese people, especially those who have figure as ‘big belly but slim legs’, these people are not only at risk getting DM, but also usually combined with other complication such as hypertension and (or) dyslipidemia.

4.     People who have already suffered from hypertension, dyslipidemia or premature coronary heart diseases.

5.     Women had increased PG during their past pregnancy or gave birth to a larger baby (with weight of more than 4 kg).

6.     People had low birth weight (< 2500 g) or with relatively lower weight than normal infants during their infancy stage.

7.     People whose age are more than 45 and do not participate any physical activities for a long period. The older people become, the chance of morbidity of DM are greater. The chances are apparent rising up after 45 years old and reaching peak at 60 years old.

8.     Smoking, having less physical activities, living a high pressure life style and having long period of anxiety.

9.     Long term using of medicines affecting glucose metabolism, such as glucocorticoids, diuretics, etc.

Other concerns:

  If routine physical examination shows that the FPG level is more than 5.6 mmol/L, OGTT should also be checked. Because in the early stage of DM, only test the FPG level will misdiagnose half the patients who may already had DM. The misdiagnose result from the FPG will be normal but only the OGTT value will increase.

   For early diagnosed DM patients,  when the intensive life style modification fails to control the plasma glucose, should start the initial pharmacological therapy under the instruction of a physician.

   V.         How to prevent DM?

1.     Learn more about DM.

2.     Diet control.

3.     Regularly appropriate exercise

4.     Quit smoking, alcohol

5.     Maintain psychological health. 

 VI.         Which groups need a routine physical examination?

  Routine physical examination. Early diagnose of DM, Early treatment.

The following are people who need increased routine DM examination:

1.     Age ≥ 45 years old, with body mass index (BMI) (weight (kg) /height^2 (m)) ≥ 24.

2.     With family history of DM.

3.     With dyslipidemia.

4.     With hypertension.

5.     Pregnant women whose age ≥ 30 years old.

6.     With history of gestational diabetes.

7.     Women who gave birth to fetal giant (birth weight ≥ 4kg).

8.     Women who have polycystic ovarian syndrome.

9.     Do not participate in physical activities for a long period of time.

10.  People having special medicines, such as glucocorticoids, diuretics, etc.

VII.         What should patient need to know about diet?

   The treatment of DM needs a multiple way, including diet, exercise, drug therapy, great patient education and compliance, regularly plasma glucose monitoring.  The above five ways of DM treatment of is ‘Five Key Points’. Diet control is the essential basis to treat DM. Through dietary treatment, the burden of insulin β cell can be alleviated, and also loss weights, thus reducing other complications. Moreover, a balanced, reasonable diet can not only guarantee the normal physiological and daily activity requirements, but also facilitate the recovery of DM as well.

  The key points of diet:

1.     Weighing diet. DM patients should follow the recommended dietary allowance instructed by physicians or dietitians and under normal circumstances, patients should not increase or reduce the quantity of diets.

2.     If feeling hungry, DM patients can slightly adjust the dietary structure, and it’s better to eat brown rice as main meal or eat vegetables which contains low calorie, high fiber and high satiety value.

3.     Sufficient calcium, chromium and zinc supplement. Example for foods contains high calcium : milk, beans, and seafoods. Foods with high chromium : yeast, mushrooms, beef, livers. Foods with high zinc : brown rice, beans, seafoods, red lean meat, livers, and mushrooms.

VIII.         How to correctly taking the drugs to treat DM? 

1.     Should follow the instruction of a physician. DM is a complicated disease, which can not be treated through just buying drugs from pharmacy store without appropriate professional guides.

2.     Shouldn't stop drug therapy including oral drugs or injection drugs once the plasma glucose value is back to normal. DM is a chronic disease that requires long term treatment and cannot be cured easily. DM needs to be carefully controlled. Normal or stable plasma glucose within a short period does not mean a full recovery.

3.     Don’t  frequently change drugs. Most drugs need half a month to one month to reach the maximum plasma glucose reducing effect. 　

4.     Only adjust the dose of drugs under the instruction of a physician, don’t  change any dose by one’s self just because the plasma glucose becomes normal.

5.     Don’t trust any advertisement blindly.

6.     Don’t overusing insulin.

7.     Don’t believe any exaggerate claim that traditional Chinese medicines  can fully cure DM forever.

8.     Don’t having the medicines blindly without professional guidance.

9.     Don’t miss the indicated time given by a physician to take the drugs . Even the same antiglycemic drugs taken at different time will cause different efficacy.

10.  There is no therapy can fully cure DM forever around the world now.

 IX.         Should a DM patient eat fruits?

Many DM patients believe that they should not eat any fruits. Actually, fruits are not horrible. In the contrary, there is a large quantity of vitamins, cellulose and minerals in them, which are beneficial for DM patients. The important thing is correctly eat the fruits in a right way. Belows are five “shouldn’t” when a  DM patient are going to eat fruits: 

1.     Shouldn’t eat fruits when plasma glucose level is not under controlled (FPG > 7.8 mmol/L).

2.     Shouldn’t eat fruits before or after meals. Generally speaking, before or after meals in half an hour, the plasma glucose level will influctuate dramatically.

3.     Shouldn’t eat fruits contain sugar more than 44%. The fruit contains lowest sugar is watermelon (4%). It is fine to eat some watermelon without excess one’s calorie intake plan.

4.     Shouldn’t eat fruits without reducing intake of regular meals. For example, 200 grams of orange or apple equal to 25 grams of regular meals. In general, when lunch controlled at 50 grams or 75 grams, a slice of watermelon, an apple or other fruits can be eaten.

5.     Shouldn’t eat fruits without regular checks of the plasma glucose level.

   X.         What should DM patients know about self-management?

1.     Learn the knowledge about DM treatment, and build their confidence in overcoming the diseases.

2.     Learn how to check their plasma glucose level by themselves. For example, leaning how to use urine glucose test strips and know the urine glucose test strips color chart.

3.     Know details about the diet therapy. Having meals and calculate the intake calories according to the personalized plan. Don’t be a picky eater. Go on a light and diversity diet, which is a low fat, low sugar, sodium-restricted and high fiber diet.

4.     Carefully observe the effect and adverse reactions when taking antiglycemic drugs.

5.     Pay attention to skin cleansing, especially cleansing of feet, mouth, genital area to prevent infection. If there is symptoms including inflammation, pain and trauma, patients should consult a physician as soon as possible.

6.     Avoid psychological trauma and overwork.

7.     If feeling hypoglycemic symptoms including fatigue, hunger, Palpitation or sweating, it is recommended to drink little amount of sugar water and consult a physician as soon as possible if the symptoms still remain for a long period.

 XI.         Dietary therapy of DM^{[vii][viii][ix]}

    According to the American Diabetes Association (ADA) nutritional guidelines, which do not give specific total dietary compositional targets except for the following recommendations that are in large part similar to the recommendations for the general population.

1.     A diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged

2.     A variety of eating patterns (Mediterranean, low fat, low carbohydrate, vegetarian) are acceptable.

3.     Fat quality is more important than fat quantity. Saturated and trans fats contribute to coronary heart disease (CHD), while monounsaturated and polyunsaturated fats are relatively protective. Saturated fats (eg, in meats, cheese, ice cream) can be replaced with monounsaturated and polyunsaturated fatty acids (eg, those found in fish, olive oil, nuts). Trans fatty acid consumption should be kept as low as possible.

4.     Protein intake goals should be individualized but not lower than 0.8 g/kg body weight per day (the recommended daily allowance). Patients should be encouraged to substitute lean meats, fish, eggs, beans, peas, soy products, and nuts and seeds for red meat.

5.     Fiber intake should be at least 14 grams per 1000 calories daily; higher fiber intake may improve glycemic control.

6.     A reduced sodium intake of 2300 mg per day with a diet high in fruits, vegetables, and low-fat dairy products is prudent. For individuals with hypertension, further reduction in sodium may be necessary.

7.     Foods containing sucrose may be substituted for other carbohydrates or covered with insulin or insulin secretagogue medications, although care should be taken to avoid excess calorie intake.

8.     Sugar, alcohols, and non-nutritive sweeteners are safe when consumed within daily levels established by the US Food and Drug Administration (FDA). When calculating carbohydrate content of foods, one-half of the sugar alcohol content should be counted in the total carbohydrate content of the food.

  It is recommended that before starting any form of supplementary nutrition therapy, consulting a physician first. 

Reference:

[i] Follow-up Report on the Diagnosis of Diabetes Mellitus. (2003). Diabetes Care, 26(11), pp.3160-3167.

[ii] Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997; 20:1183.

[iii] American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33 Suppl 1:S62.

[iv] American Diabetes Association. 2. Classification and Diagnosis of Diabetes. Diabetes Care 2017; 40:S11.

[v] Cdc.gov. (2018). Target Heart Rate and Estimated Maximum Heart Rate | Physical Activity | CDC. [online] Available at: https://www.cdc.gov/physicalactivity/basics/measuring/heartrate.htm [Accessed 21 May 2018].

[vi] Cdc.gov. (2018). Perceived Exertion (Borg Rating of Perceived Exertion Scale) | Physical Activity | CDC. [online] Available at: https://www.cdc.gov/physicalactivity/basics/measuring/exertion.htm [Accessed 21 May 2018].

[vii] Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2013; 36:3821.

[viii] Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 2002; 25:148.

[ix] Inzucchi, S., Bergenstal, R., Buse, J., Diamant, M., Ferrannini, E., Nauck, M., Peters, A., Tsapas, A., Wender, R. and Matthews, D. (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55(6), pp.1577-1596.