• Overweigtht / obese
• Family history of Diabetes
• Stressful lifestyle
• Sedentary lifestyle
• Diabetes in preganancy
• Polycystic Ovary Syndrome (PCOD)

In the above cases we can prevent early onset of diabetes by correction of diet, proper exercise and lifestyle modification along with timely checkups.

Advice on diet and exercise

Due to fast-food & junk-food culture, people are going away from traditional healthy food & adopting wrong dietary habits leading to diabetes & many other disorders.Exercise is an essential step in managing diabetes. Advice on correction of diet and pre-exercise work up for every patient is done

• Diet and insulin therapy
• Self-monitoring of blood glucose
• Management of emergencies (Hypoglycemia, diabetic keto-acidosis) Sick day regime
• Psychological counselling on issues(schooling,employment, marriage, pregnancy)
• CGMS and Insulin pump

• Pre- pregnancy counselling
• Diet and insulin therapy
• Self-monitoring of blood glucose
• CGMS and Insulin pump
• Management during delivery
• Post-partum care of diabetic patients

Studies conducted on diabetic patients show that 155 of patients experience a foot ulcer in their lifetime. It is ow concluded that 15 – 20% of patients with such foot ulcers need an amputation, which can be avoided with proper foot care and constant follow-ups. Also, it is seen that 85% major limb amputations are preceded by a foot ulcer.

The goal of treatment is to help you manage these symptoms, so that they can be treated and arrested at an early stage.

Management

• All patients with diabetes should have their feet inspected at every visit.
• Obtain a history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication).

• The examination should include inspection of the skin, assessment of foot deformities, neurological assessment (10-g monofilament testing), and vascular assessment, including pulses in the legs and feet.
• Screen for decreased sensation in feet, tingling, numbness in feet with the help of instruments as biothesiometer, monofilament.
• Examination of the feet are done to detect deformity, corn, callus, nails swelling of the leg, infections, ulcers, gangrene, etc.

• Scanning for abnormal pressure which can cause ulcers can be detected with the use of podiascan.
• Examination of the pulses can be detected in the peripheral artery by using hand doppler studies & to predict vascular status ankle-brachial index is used.
• Comprehensive foot evaluation each year to identify risk factors for ulcers and amputations.
• Patients who are ≥50 years of age and any patients with symptoms of claudication or decreased or absent pedal pulses should be referred for further vascular assessment as appropriate.

• A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet (e.g., dialysis patients and those with Charcot foot, prior ulcers, or amputation).
• Provide general preventive foot self-care education to all patients with diabetes.
• The use of specialized therapeutic footwear is recommended for high-risk patients with diabetes, including those with severe neuropathy, foot deformities, or history of amputation.

To manage obesity we have a trained dietician who will solve all the queries regarding diet &prescribe an individualized diet according to his/her weight.height & lifestyle.

Continuous Glucose Monitoring System (CGMS)

• It is a device that records glucose level throughout day and night.
• It can provide measurements every 24 hours.
• System used to measure an average blood glucose for up to 3 days, while the person with diabetes continues daily activities at home and work.
• A tiny sterile flexible electrode inserted just under the skin and it measures glucose in interstitial fluid.
• Used for patient empowerment to lead and act upon continuous glucose information.
• It allows to view fluctuations during days and night.
• Provides insights that fingerstick testing and HbA1C can’t provide.

Insulin Pump

• Insulin Pump can closely mimic normal pancreatic insulin delivery.
• Insulin Pump can closely mimic normal pancreatic insulin delivery.
• Delivers insulin through a soft cannula under through skin.
• Replaces injections.

Indications:

1. Patient’s with type 1 Diabetes Mellitus

2. Patient with type 2 Diabetes Mellitus on multiple tablets + insulin with HbA1C > 7%

3. GDM, Type 1/ type 2 during pregnancy or preconception requiring insulin therapy.

4. Patient’s with type 1/ type 2 diabetes mellitus with brittle diabetes, fluctuating blood sugars and repeated hypoglycaemia/ nocturnal hypoglycaemia.

According to International Diabetes Federation (IDF), the number of people with diabetes worldwide is projected to increase from 382 million in 2013 to 592 million by 2035 (Journal Endocrinology, 2015).

Diabetes is an increasing health burden in India. India is the diabetes capital of the world. It is widely accepted fact that 35 – 40% of people show presence of diabetes related complications at the time of diagnosis.

Diabetes is the silent killer.

It causes many diseases related to the heart, cholesterol, nerves, feet, eyes and circulatory system if uncontrolled for a long time. Since prevention is better than cure, a multidisplinary approach is required to control the disease and more important to prevent complications.

Every patient is unique hence the diabetes clinic offers comprehensive medical care for diabetic patients based on their unique requirements. The diabetes clinic offers following services.

Cardiovascular

As CVD is the leading cause of morbidity and mortality for individuals with diabetes and is the largest contributor to the direct and indirect costs of diabetes.

In all patients with diabetes, cardiovascular risk factors should be systematically assessed at least annually.

Risk factors include:

• Hypertension
• Dyslipidaemia
• Smoking
• Family History of Premature Coronary Disease &
• Albuminuria.

Management

• Measuring Blood pressure at every routine visit.
• Targeting Blood pressure for patients with diabetes and hypertension and other disorders.
• Annual ECG evaluation to rule out ischemic heart disease.
• Optimizing glycaemic control for patients by using suitable medications.
• Optimizing elevated lipid profile through intensive lifestyle therapy and medications.
• Encouraging a lifestyle intervention consists of change in dietary pattern & weight loss – if overweight or obese and increased physical activity.
• Screening diabetes distress using validated and appropriate measures & psychosocial problems and other barriers to diabetes self-management such as limited financial, logistical, and support resources.
• Referring to a cardiologist if required.

Retinopathy

Diabetic retinopathy is the most common preventable cause of blindness in diabetic patients.

Frequent high blood sugars in diabetics are associated with damage to the tiny blood vessels in the retina, leading to diabetic retinopathy.

Retina detects light and converts it to signals sent through the optic nerve to the brain.

Diabetic retinopathy can cause blood vessels in the retina to leak fluid or haemorrhage, distorting the vision.

In its most advanced stage, new abnormal blood vessels proliferate on the surface of the retina, which can lead to scarring and cell loss in the retina.

Signs and Symptoms:

• Seeing spots or floaters
• Blurred vision

• Having a dark or empty spot in the centre of the vision

• Difficulty in seeing well especially at night.

Management

• Optimize glycaemic control to reduce the risk or slow the progression of diabetic retinopathy.
• Optimize blood pressure and serum lipid control to reduce the risk or slow the progression of diabetic retinopathy.
• Annual eye examination by an ophthalmologist/ Referral ophthalmologist.

Nephropathy

Diabetic Nephropathy (DN), also known as Diabetic Kidney Disease (DKD) is one of the most important long-term complications of diabetes and the most common cause of end-stage renal disease (ESRD) worldwide. DKD occurs in type 1 & type 2 diabetes mellitus and other secondary forms of diabetes and is defined as structural and functional renal damage manifested as clinically detected albuminuria in the presence of normal or abnormal glomerular filtration rate (GFR).

DKD develops after the initial 10-15 years of disease onset in type 1 diabetes, whereas the onset is not clearly defined in type 2 due to the late diagnosis of diabetes in some patients.

Screening and Diagnosis of Diabetic Nephropathy:

• Screened annually with S. Creatinine and eGFR and Urine Alb:Creat (ACR) Starting 5 years after diagnosis of type 1 diabetes & starting at the diagnosis of type 2 diabetes
• Elevated Urine ACR confirmed > 2 times and not in setting of UIT (Urinary tract infections), acute febrile illness, vigorous exercise, uncontrolled hypertension and heart failure.
  Microalbuminuria: ACR – 3 to 30 mg/ mmol
  Macroalbuminuria: ACR – >300 mg/ mmol

Signs and Symptoms:

• Pedal oedema
• Nausea & vomiting
• Decreased urine
• Inching skin

The treatment goals for Diabetic Kidney Disease (DKD) are to manage glycaemic control, maintain blood pressure and lipid profile, to prevent further cardiovascular events & slow the progression of the renal disease.

Management

• Assessing urinary Albumin: Creatinine ratio with Afinion Analyser in patients with Type 1 & Type 2 diabetes
• Setting and reaching blood pressure goal
• Optimizing glucose control to reduce the risk or slow the progression of diabetic kidney disease.
• Provide nutrition support by developing or maintaining healthy lifestyle habits, which help to maintain Blood pressure and blood glucose levels.
• Screening diabetes distress using validated and appropriate measures & psychosocial problems and other barriers to diabetes self-management such as limited financial, logistical, and support resources.

Neuropathy

Peripheral neuropathy, a result of damage to your peripheral nerves, often causes weakness, numbness and pain, usually in your hands and feet. It can also affect other areas of your body.

Management

• All patients should have annual 10-g monofilament testing to identify feet at risk of ulceration and amputation.
• Assessment for diabetic peripheral neuropathy (DPN) starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter.
• Evaluation for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick sensation (for small-fiber function) and vibration sensation using a 128-Hz tuning fork (for large-fiber function).
• Optimize glucose control to prevent or delay the development of neuropathy in patients with type 1 diabetes and to slow the progression of neuropathy in patients with type 2 diabetes.

Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards.

The overall objectives of DSME are to support informed decision-making, self-care behaviour’s, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life.

Management

• Education of disease
• Education of acute complications like hypoglycaemia and hyperglycaemia & chronic complications like retinopathy, nephropathy and neuropathy.
• Education of social and behaviour change towards healthy lifestyle.
• Education of smoking cessation – Advising all patients not to use cigarettes and other tobacco products and include smoking cessation counselling and other forms of treatment as a routine component of diabetes care.
• Education of immunization advice – By provide routine vaccinations for children and adults with diabetes according to age-related recommendations.
• Education of dental care – As periodontal disease is more severe and may be more prevalent in people with diabetes than in those without.
• Self-management of Blood Glucose (SMBG) and foot care.

Patients with diabetes exhibit anxiety or worries regarding diabetes complications, insulin injections or infusion, taking medications, and/or hypoglycaemia that interfere with self-management behaviour’s and those who express fear, dread, or irrational thoughts and/or show anxiety symptoms such as avoidance behaviour’s, excessive repetitive behaviour’s, or social withdrawal.

Considering re-evaluating the treatment regimen for people with diabetes who present with symptoms of disordered eating behaviour, an eating disorder, or disrupted patterns of eating is crucial.

Effective diabetes management requires adherence to a chronic and complex regimen and, accordingly, nonadherence is the norm rather than the exception. Psychological treatments may be used to improve adherence to the diabetes regimen and, more generally, to develop sustained pro-diabetic lifestyles.

One in every four diabetic patients suffers from recurring problems with depression, anxiety, or eating disorders. These conditions respond well to psychological treatment, and in many cases, relief of distress is associated with improved glycaemic control.

Children and adolescents with diabetes present with psychological problems in different ways than adults and require appropriate psychological care to intervene at their specific developmental level.

The psychologist provides direct services to the patient via promotion of health behaviour’s and treatment of psychological problems, and also provides consultation to the medical team on how to incorporate psychological principles into patient care to enhance clinical outcomes.

Management

• Screening for depression, anxiety, and disordered eating using validated and appropriate measures.
• Screening for diabetes distress using validated and appropriate measures.
• Screening for psychosocial problems and other barriers to diabetes self-management such as limited financial, logistical, and support resources.
• Screening for disordered or disrupted eating using validated screening measures when hyperglycaemia and weight loss are unexplained based on self-reported behaviour’s related to medication dosing, meal plan, and physical activity.