Appendix
Appendix 1
Appendix 1a
Persons at high risk for diabetes
- All persons manifesting any of the following signs and symptoms: polyuria, polydipsia, polyphagia, weight loss in spite of adequate food intake, undue tiredness and fatigue, tingling or numbness in the extremities, burning feet, generalised pruritus, pruritus vulvae, balanitis, delayed wound healing, impotency, premature cataracts, visual disturbances. Although diabetes has many and varied signs and symptoms, these, in my opinion are the commonest in people with diabetes.
- All persons with a family history of diabetes.
- All obese patients, especially those with central obesity as measured by the waist measurement.
- All adult patients with tuberculosis, including atypical presentations, recurrent infections, non-healing ulcers.
- Patients with atherosclerosis and its complications, especially those with premature macrovascular disease.
- All patients with high blood pressure and lipid abnormalities.
- All women with a bad obstetric history, recurrent fetal wastage, and those who give birth to large weight babies.
- Persons who were large weight babies; very low birth weight babies may also be predisposed to diabetes.
- Persons who show an acute rise in the blood glucose levels at time of physical (myocardial infarction, cerebrovascular accidents, acute infections, trauma, etc.) or mental stress.
- Persons taking drugs which are known to increase blood glucose levels like steroids, thiazide diuretics, oral contraceptives, beta-blockers, phenytoin sodium, etc.
- People with obstructive sleep apnea.
Appendix 1b
Glucose Tolerance Test (GTT)
Procedure
- The person to be tested must be on their usual diet, exercise and routine schedule for at least 3 days prior to the test. It is felt that the person should be taking around 300gms. of carbohydrates daily during these days. This should not be a problem as most traditional diets do contain this amount of carbohydrates. It is essential that the patient be told about this need for taking a normal diet for a few days prior to the test. Many people starve themselves before the test. They are so afraid of being diagnosed as a diabetic that they feel that by not eating properly for a few days before the test, the blood glucose levels will decrease and they will be found to be non-diabetic. It is obvious that this should never be done. Firstly, starving oneself before the test usually results in an abnormal result. Secondly, and more important., the very idea of doing the test is to correctly diagnose diabetes so that if it be present, then adequate measures can be taken to optimally control it. It is better not to test than to try and vitiate the results!
- The test should be carried out in the morning after fasting for at least 8 -10 hours; Some amount of water can be taken as there is no adequate proof that this would interfere with the test.
- Blood is collected in the fasting state. After this, glucose is given to the patient. It may be mixed with as much water as is necessary so that the mixture is not so sweet that it causes nausea and the, patient vomits. A dash of lemon may be added to make the drink more palatable. The glucose solution should be ingested within 4-5 minutes.
- The amount of glucose used is 75 gms of anhydrous glucose (for children the dose is 1.75 gms of glucose per kg of body weight upto a maximum of 75 gms.). If glucose monohydrate (which is the form of glucose most commonly available in the market) is used, 82.5 gms. must be administered.
- The person must rest throughout the test. After the glucose is taken, the patient must remain seated for the duration of the two hours when the second sample will be collected. This should be made very clear to the patients when they are going for this test. Often, the patient takes the glucose and then goes out, does some work and then returns in time for the second sample. This is not correct if one is aiming for an accurate result.
- Smoking should not be permitted during the test.
- Whilst interpreting the test results, one must know whether the patient is taking any medications as many drugs are known to affect the blood glucose levels.Ask the patients if they are suffering from any illness or did so in the near past and their level of activity. The age of the patient may not be relevant to the diagnosis of diabetes but would definitely be needed whilst planning any treatment.
- Blood is collected 2 hours from the start of glucose ingestion.
Appendix 1c
Measurement Of The Waist Circumference
To measure waist circumference, locate the top of the right iliac crest. Place a measuring tape in a horizontal plane around the abdomen at the level of the iliac crest. Before reading the tape measure, ensure that tape is snug but does not compress the skin and is parallel to the floor. Measurement is made at the end of a normal expiration.
Diagnostic waist measurements according to country/ethnic group.
Appendix 2
Appendix 2a
BMI Charts
Appendix 3
Appendix 3a
The Omega-6 and Omega-3 content of the commonly used edible oils
| Omega - 6 | Omega - 3 | W6 / W3 | |
|---|---|---|---|
| Sunflower | 49 | 0.3 | 163 |
| Safflower | 73 | 0.5 | 146 |
| Sesame | 40 | 0.5 | 80 |
| Corn | 57 | 0.8 | 71 |
| Groundnut | 28 | 0.8 | 35 |
| Ricebran | 33 | 1.6 | 34.6 |
| Palm | 9 | 0.3 | 30 |
| Soyabean | 52 | 5 | 10.4 |
| Olive oil | 7 | 1 | 7 |
| Rapeseed | 22 | 10 | 2.2 |
| Ghee (Cow) | 1.6 | 0.5 | 3.2 |
| Ghee Buffalo | 2 | 0.9 | 2.2 |
| Mustard / Rape | 13 | 8.6 | 1.5 |
| Coconut | 1.8 | -- | -- |
| Flaxseed | 16 | 57 |
Appendix 4
Table on Calories spent on various activities and sports
| Activity | Calories Spent Per Minute |
|---|---|
| Lying down, sleeping, sitting, Standing, strolling (1 mile per hour) playing cards, knitting, sewing, darning, desk work, car driving, electric typing, using calculators, etc. | 1 to 1.25 |
| Level walking (2 miles per hour), level bicycling (5 m.p.h.), horse-backriding (walking speed), playing musical instruments like the piano, playing billiards and snooker, golf using a power cart to move around, manual typing, bartending, auto, T.V. and radio repair. | 2.5 to 4 |
| Walking at 3 m.p.h., cycling at 6 m.p.h. Volleyball ( 6 man noncompetitive). Horse riding 9 sitting to trot), playing golf with lugging around the golf bag, sailing (handling small boats), badmintion (social doubles), cleaning windows, energetic musician. | 4 to 5 |
| Walking at 3.5 m.p.h., cycling at 8 m.p.h.. table tennis, golf (carrying clubs), dancing (at a pace of a dance like the foxtrot), Badminton (social singles), tennis (social doubles), any callisthenics, painting walls, light carpentry (hobby). | 5 to 6 |
| Walking at 4 m.p.h., cycling at 10 m.p.h., roller skating, horse riding (trot), gardening (digging). | 6 to 7 |
| Walking at 5m.p.h., cycling at 11 m.p.h., badminton (competitive), tennis (social singles), light downhill skiing, water skiing. | 7 to 8 |
| Logging at 5 m.p.h., cycling at 12 m.p.h., basketball, vigorous downhill skiing, carrying loads of around of 36 kgs. | 8 to 10 |
| Running at 5.5 m.p.h., cycling at 13 m.p.h., playing squash (social level), handball (social level), vigorous game of basketball. | 10 to 11 |
| NOTE: The calories given above are basically for a person weighing around 70 kg. People who weight less than this may spend relatively less calories in carrying out similar activities whilst who are more than this weight spend that much more calories. There may also be a gender difference. | |
Appendix 5
Incretin Mimetics
| Property | DPP-IV Antagonists | GLP-1/agonists |
|---|---|---|
| Route of administration | Oral | Subcutaneous |
| Mode of action | Inhibit peptide hormone metabolism by DPP-IV enzyme, thus a) Enhance insulin secretion b) Inhibit glucagon secretion c) Improve ß-cell function |
Enhancement of endogenous incretin hormone effects, thus a) Enhance insulin secretion b) Inhibit glucagon secretion c) Improve ß-cell function d) Slow gastric emptying e) Induce satiety and weight loss |
Sitagliptin | Exenatide |
| Dosing schedule | 100mg/day can be taken with or without food. |
Therapy initiated at 5 mcg per dose administered twice daily at any time within the 60-minute period before the morning and evening meals (or before the two main meals of the day, approximately 6 hours or more apart). Not to be administered after a meal. Based on clinical response, the dose can be increased to 10 mcg twice daily after 1 month of therapy. Each dose should be administered as a SC injection in the thigh, abdomen, or upper arm. The pen should be discarded 30 days after first use, even if some drug remains in the pen. |
| Glycemic control | More dominant effect on postprandial levels, although some effect on fasting levels also seen. | Most dominant effect appears related to controlling postprandial hyperglycemia. |
| Adverse effects | Diarrhea; gas; headache; indigestion; nausea; sore throat; stomach upset; stuffy or runny nose; vomiting; weakness.anorexia and early satiety are notable. |
Nausea, vomiting, anorexia, thus not recommended in patients with severe gastrointestinal disease. No hypoglycemia when used as monotherapy. |
| Contra-indications |
Need for dosage adjustment based upon renal function. Avoid if possible in patients using digoxin. |
Not recommended for use in patients with end-stage renal disease or severe renal impairment (creatinine clearance <30 mL/min). Not recommended in patients with severe gastrointestinal disease. |
Appendix 6
Appendix 6a
Diabetes Patients Who Should Receive Insulin
Patients not optimally controlled with OHA use.
Insulin should be considered in diabetics with significant complications like ischemic heart disease, CVA, peripheral artery disease, significant retinopathy, nephropathy and neuropathy, hepatic complications such as viral hepatitis.
Any patient with an acute problem like several infection, injury, any metabolic catastrophe, etc., should receive insulin.
Patients with tuberculosis often do better with insulin.
Any Type 2 patient who manifests ketosis for whatever reason.
Diabetes patients undergoing most surgical procedures, especially those requiring general anesthesia, and where the patient will be on intravenous fluids for any significant period of time should be stabilized on insulin.
Pregnant women with diabetes, if not "tightly" controlled with diet alone, must be managed with insulin.
Any patient, even if optimally controlled with OHA's who shows evidence that may contraindicate the use of these oral agents, must be shifted to insulin.
Many underweight patients and those with significant symptoms would do better with insulin therapy, possibly in combination with small doses of sensitisers.
Patients with INSULIN-REQUIRING diabetes, even though they are not prone to ketosis, should be identified and their management supplemented with insulin to get the best possible control.
Appendix 6b
Patients Who Should Use Analog Insulins
Rapid acting analogs
- Patients exhibiting high postprandial glycemia with late hypoglycemia.
- Brittle diabetes.
- In the elderly and in children.
- In those with erratic eating habits.
- Perioperative period.
- Sick day therapy.
- Renal and hepatic dysfunction where one sees low fasting blood glucose levels with high postprandial blood glucose values and the fear of late hypoglycemia.
- People on RT and other tube feeds.
- Significant variations in bioavailability in the same patient on a day to day basis.
Long acting analogs
May have a special role to play in those clinical situations where a steady basal level of insulin is required.
Appendix 7
Appendix 7a
Drugs that may cause false-positive results in urine glucose tests
- Aminosalicylic acid
- Ascorbic acid
- Cephalosporins
- Chloral hydrate
- Chloramphenicol
- Isoniazid
- Levodopa
- Methyldopa
- Nalidixic acid
- Nitrofurantoin
- Penicillin G in large doses
- Phenazopyridine
- Probenecid Salicylates
- Streptomycin
- Tetracyclines
NOTE: This is not a complete list.
Appendix 7b
Drugs that may cause glycosuria
- Ammonium chloride
- Asparaginase
- Carbamazepine
- Corticosteroids
- Dextrothyroxine
- Lithium carbonate
- Nicotinic acid (large doses)
- Phenothiazines (long-term)
- Thiazide diuretics
- Amikacin.Amphotericin-B
- Bacitracin
- Gentamicin
- Gold preparations
- Kanamycin
- Neomycin
- Netilmicin
- Penicillin
- Phenylbutazone
- Polymyxin B
- Streptomycin
- Sulfonamides
- Tobramycin
- Trimethadione
NOTE: This is not a complete list.
Appendix 7c
A Partial list of commonly used drugs and medications which can affect the results of estimating plasma glucose levels.
- Acetaminophen
- Alcohol Arginine
- Benzodiazepines
- Beta-adrenergic blockers
- Chlorthalidone
- Clofibrate
- Corticosteroids
- Dextrothyroxine
- Diazoxide
- Epinephrine
- Ethacrynic acid
- Furosemide
- Lithium
- MAO inhibitors
- Nicotinic acid (large doses)
- Oral contraceptives
- Phenolphthalein
- Phenothiazines
- Phenytoin
- Thiazide diuretics
- Triamterene
Appendix 7d
Factors that interfere with GHB (HbA1c) Test Results
Hemoglobin Variants and Derivatives: Genetic variants (e.g. HbS trait, HbC trait) and chemically modified derivatives of hemoglobin (e.g. carbamylated Hb in patients with renal failure, acetylated Hb in patients taking large amounts of aspirin) can affect the accuracy of GHB measurements. The effects vary depending on the specific Hb variant or derivative and the specific GHB method.
Shortened Erythrocyte Survival: Any condition that shortens erythrocyte survival or decreases mean erythrocyte age (e.g., recovery from acute blood loss, hemolytic anemia) will falsely lower GHB test results regardless of the assay method used. GHB results from patients with sickle cell disease or thalassemia must be interpreted with caution given the pathological processes, including anemia, increased red cell turnover, transfusion requirements. Alternative forms of testing such as glycated serum protein (fructosamine) should be considered for these patients.
Other factors: Vitamins C and E are reported to falsely lower test results, possibly by inhibiting glycation of hemoglobin; vitamin C may increase values with some assays. Iron-deficiency anemia is reported to increase test results. Hypertriglyceridemia, hyperbilirubinemia, uremia, chronic alcoholism, chronic ingestion of salicylates, and opiate addiction are reported to interfere with some assay methods, falsely increasing results. High concentrations of fetal hemoglobin can lead to false raised levels.
Diabetes during pregnancy, commonly referred to as gestational diabetes, may falsely increase or decrease HbA1c.