Diabetic Diet Zone

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Burton Rochelson MD Chief of Maternal Fetal Medicine and Obstectrics at
NS/LIJ Healthcare System
www.DrMDK

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Women At Risk For Developing Type II Diabetes (Non-Insulin Dependent) After Developing Gestational Diabetes in Pregnancy

Developing Gestational Diabetes during pregnancy carries a 15 to 60 percent chance of developing Non-Insulin Dependent (Type II) after pregnancy within a 5 to15 year period of time.  It is important to determine the significant risk factors that lead to Type II diabetes as this disease has reached epidemic proportions around the world.  From 1994 to 2002, the incidence of gestational diabetes doubled to now involve 7 percent of pregnancies.  This has an increased  maternal and neonatal morbidity which includes but is not limited to elevated blood pressure, preeclampsia, eclampsia, placental abruption, maternal kidney disease, increased susceptibility to premature delivery, increased incidence of C-sections, uterine infection, bacteria in the blood, maternal death, fetal macrosomia (large infant) hypoglycemia of the infant, prematurity of the lungs even late in the third trimester, increased risk or neonatal infection, hyperbilirubenemia, intrauterine fetal death, and perinatal mortality.  

By knowing the risk factors that lead to a higher incidence of gestational diabetes, there is hope to be able to prevent them before, during, or after the pregnancy in order to reduce the complications mentioned above associated with the immediate problems with gestational diabetes.

When patients are diagnosed with Non-insulin dependent diabetes, there are a host of complications and risk factors that occur:  increased risk of heart, peripheral vascular, kidney, eye, and neurologic diseases such as heart attacks, angina, pain in legs when walking (claudication , kidney failure,  blindness, stroke, transient ischemic attack, loss of balance when walking and unable to feel feet due to peripheral nerve damage.

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Several  studies show three factors  that lead to highest risk for women developing Type II diabetes after having gestational diabetes in pregnancy:

1) BMI  (Basal Metabolic Index) > 27

Patients have a 4 to 8 fold chance of developing Type II diabetes whose BMI is greater than 27

2) Developing gestational diabetes before 24 weeks gestation

Patients who develop gestational diabetes after 24 weeks have less chance of developing Type II diabetes.  The fetal placenta is responsible for abnormal glucose intolerance after 24 weeks  

3) Use of insulin to control the blood sugars in pregnancy

Insulin  use in pregnancy means  the mother has less ability to produce an adequate amount of insulin during stress (excessive sugar loads, viral or bacterial infections, ect.)

Measures must be in place to prevent, reduce, and or treat each risk factor.

Regarding prevention, reduction, or treating a BMI of greater than 27 requires a comprehensive approach  involving  psychological, environmental, nutritional, and exercise.

1)  Eating minimal amounts of calories is noted to increase longevity. This is because obesity leads to chronic diseases such as cancer, hypertension, heart disease, diabetes, and arthritis. One must learn to eat frequent small meals. Eating 5 to 7 small meals throughout the day will increase the metabolism by 10 to 12 percent. Increasing the portion of protein and reducing the amount of carbohydrates will reduce insulin demand that is needed to metabolize sugars in the body.  Patients must reduce breads, pasta, and sweets.  Patients must increase fiber intake, brown rice, sweet potatoes, nuts, and non-starchy vegetables.

2) Exercise. One must engage is some form of exercise 30 minutes to 1 hour a day.  Swimming, walking, riding bicycles, stationary bicycle, treadmill, weightlifting, rowing, stair climber, etc, are examples of exercises that will build muscle and help increase the uptake of sugars into muscle which in turn decreases the demand for insulin and reduces glucose resistance.   Increase in one pound of muscle leads to an increase of 50 calories a day being burned.   

3) Supplements  known to increase glucose utilization in diets.

a. Cinnamon

b. Bitter melon

c. Cane sugar

d. Alpha Lipoic Acid

e. Chromium Piccolinate

In summary, Type II diabetes leads to serious illness and disease left untreated.   Gestational Diabetes during pregnancy predicts a high incidence of developing Type II Diabetes within a few years.  Knowing the risk factors that lead to Type II diabetes after Gestational Diabetes and the ways to reduce or prevent these factors from occurring, will help to reduce the incidence of this detrimental disease.

Foot Care in Diabetes Management

Diabetes is a metabolic disorder which occurs due to unbalanced insulin secretion by the pancreas. Diabetes can be categorised into two types: Type 1(when insulin secretion is less or almost none than the normal value) and Type 2(when insulin is secreted more than the required or normal range).

Foot ulcers are one of the most common indications of diabetes. Thus, foot care is one of the utmost and significant strategies in diabetes management.

Research has shown that Peripheral neuropathy and poor circulation in diabetes results in foot ulcers. Serious complications can result in gangrene and amputation of foot or leg. Thus doctors recommend gentle care of foot in both paediatric and elderly diabetic patients.

Patients with Diabetic foot ulcers can be classified into three categories, depending upon the level of risk: Low risk patients, Moderate risk patients and High risk patients.

Low risk patients have no past history of ulcer and have at least one pulse per foot. They have equal to or more than one of ten sites insensible to monofilament testing. Also, no foot distortion or physical or visual damage is observed.

In moderate-risk patients, both pulses in either foot can be lost. They have equal to or more than two sites insensible to monofilament testing. Foot distortion or wrap may be seen. Sometimes, patient is also unable to see or reach foot.

In high-risk patients, neuropathy is observed as pulses can be totally lost .Calluses formation leading to entire foot damage or amputation may be seen.

Foot Care Management in Diabetics in-turn depends upon: risk category, foot status and metabolic control.

For high-risk patients, visual foot inspection, by a physician or trained staff, to identify foot problems is recommended at every visit. Visual inspection involves examination of skin for wound, corns, sores, cracks, pustules or any unusual condition. Assessment of footwear for wavering lines, foreign substances, breathable materials, abnormal wearing patterns and improper fitting. For low-risk patients, visual inspection is advised atleast once in a year.

After the Visual Inspection, a Medical record is usually prepared by Physicians enclosing the details of physical assessment, including risk-assessment, results of visual inspection and guidance provided to patients for preventive care.

The Diabetes Quality Improvement Project (DQIP) is a joint initiative to improve diabetes care and the quality of life for diabetics. DQIP practices a set of eight Quality measures for diabetes, one of which stipulates that “an annual foot exam for adults with diabetes” should be documented and recorded. Several public organizations (the Department of Defense, the Health Care Financing Administration, the Indian Health Service, and the Veterans Health Administration) and private establishments (the American Diabetes Association Provider Recognition Program and the National Committee for Quality Assurance) are using some or all of the DQIP measures

Physician Guidelines as available for Management of Active ulcer or foot infection entails the following:

Not to allow patients with an open plantar ulcer walk out in their own shoes, weight relief should be provided

Prescription/Advising therapeutic footwear as per the patient condition

Frequent assessments

Patient education

Providing referrals of Specialists if required.

Attachment of labels and stickers specifying risk-level on OPD cards.

Patient Education entails the following instructions:

Daily wash of feet using mild soap and warm water

Drying of feet after wash-no rubbing, only pat drying.

Everyday examination of feet-doing check for blisters, sores, redness, corns, warmness etc.

Proper Care of toenails

Precautions during exercise

Protection of feet via socks and shoes-as advised by physician.

Thus,a dedicated effort from both Doctors and Patients can help in preventing foot complications in Diabetes.

Related Diabetes Management Articles

Could You be at Risk? American Diabetes ociation “Sounds the Alert” on March 25th — ADA’s 20th Annual American Diabetes Alert® Day

Could you have diabetes? One in five Americans have a high risk of developing type 2 diabetes, or may even already have diabetes. Because people can live for years without knowing they have diabetes, the American Diabetes ociation (ADA) is issuing an urgent call-to-action for Americans to learn their risk for type 2 diabetes during the 20th Annual American Diabetes Alert Day. Awareness about diabetes can lead to early detection and treatment, which may help prevent type 2 diabetes or devastating complications ociated with diabetes such as heart disease, stroke, blindness, kidney disease, and amputation.

On American Diabetes Alert Day, held annually on the fourth Tuesday in March, the ADA encourages people who are overweight, physically inactive, or over the age of 45 years to take the Diabetes Risk Test, which asks seven simple questions about weight, age, lifestyle and family history – all potential risk factors for type 2 diabetes. People scoring 10 points or more are at a high risk for diabetes and are encouraged to speak with their health care provider. The Diabetes Risk Test, in English or Spanish, is available by calling the ociation toll-free at 1-800-DIABETES (1-800-342-2383) or by visiting www.diabetes.org/alertnews.

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