A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

How To Manage Your Diabetes After Delivery

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

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Please Don't Sugar Coat It, I Am Diabetic!

Introduction

The chronic metabolic disease is characterized by an inability of the pancreatic cells to produce insulin, or the body&#39;s inability to use the produced insulin. This results in elevated blood glucose levels (hyperglycemia) that can cause complications, such as vascular damage, stroke, cardiovascular disease, <a href="https://www.merisehat.pk/disease/chronic-kidney-disease">chronic kidney disease</a>, neuropathy, and hypertension.

&nbsp;

As per the International Diabetes Federation&#39;s (IDF) latest figures, approximately 537 million adults worldwide are suffering from diabetes<a href="#accordion">[1]</a>. This translates to roughly 1 in 10 people. In Pakistan, the figures have risen 70% since 2019, with diabetes accounting for 400,000 deaths in 2021. The increasing disease prevalence is blamed on rising levels of obesity and the lack of physical activity among Pakistanis.&nbsp; 
&nbsp;

Diabetes management strategies which includes self-care practices such as eating healthy, self-monitoring blood glucose, staying compliant with prescribed medications, and exercising regularly can help maintain glucose levels within range. Furthermore, this can prevent the development of complications and improve the overall quality of life. 
&nbsp;

However, in Pakistan, people face several barriers to the implementation of these self-care practices. Poor knowledge about diabetes, its complications, diet planning, and hypoglycemia management contributes to poor diabetes control<a href="#accordion">[2]</a>.&nbsp;

&nbsp;

Understanding diet plans for Type 2 diabetic patients

Glucose is a form of sugar that the cells use for fuel. However, in diabetes the cells are unable to use the glucose, causing it to build up in the blood. The resulting hyperglycemia is damaging to the vessels and organs. Therefore, keeping the blood glucose levels within a normal range is important.&nbsp; 
&nbsp;

Carbohydrates are a main source of glucose and form a major part of the food we eat. Therefore, doctors recommend limiting carbs when making meal plans for diabetics. Moreover, other food groups such as fats, proteins, and fiber are also taken into consideration when creating diet plans for diabetics. 
&nbsp;

According to the American Diabetes Association (ADA)<a href="#accordion">[3]</a>.&nbsp;the following are the goals of nutrition therapy for adults with diabetics: 
&nbsp;

1. To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes to improve overall health and: 
&nbsp;

<ul>
	<li>achieve and maintain body weight goals</li>
	<li>attain individualized glycemic, blood pressure, and lipid goals</li>
	<li>delay or prevent the complications of diabetes 
	&nbsp;</li>
</ul>

2. To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness, and ability to make behavioural changes, and existing barriers to change 
&nbsp;

3. To maintain the pleasure of eating by providing nonjudgmental messages about food choices, while limiting food choices only when indicated by scientific evidence 
&nbsp;

4. To provide diabetics with the practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods

&nbsp;

Typically, diabetics should consume 5-6 small meals, spaced evenly throughout the day. The meals should contain: 
&nbsp;

<ul>
	<li>Non-starchy vegetables (broccoli, carrots, cauliflower, mushrooms, and greens such as cabbage, spinach, and rocket)</li>
	<li>High-fiber fruits (apples) and cereals (porridge)</li>
	<li>Whole grains such as brown rice, whole wheat chappati, brown pasta, whole wheat bread, quinoa, and oatmeal</li>
	<li>Lean protein sources such as eggs, fish, skinless chicken, turkey, lentils, and beans</li>
	<li>Dairy products such as low-fat milk, yoghurt, low-fat cheese</li>
	<li>Healthy fats such as olive oil, nuts, avocados 
	&nbsp;</li>
</ul>

While non-starchy vegetables can be eaten in unlimited quantities, lentils, beans, and chickpeas are often advised to be taken in a serving size of 3/4 cup cooked. For grains such as rice, corn, noodles, and porridge, a 1/2 cup is recommended. Whereas, for chapati or brown bread, 1 is the preferred serving size.&nbsp; 
&nbsp;

The following methods are often employed to create meal plans for diabetics: 
&nbsp;

1. Counting Carbs - For type 2 diabetics, limiting carbs ensures that their blood glucose levels remain within range. Moreover, it can help overweight individuals lose weight and contribute to better health outcomes. Whereas in type 1 diabetics, since they are on insulin therapy, the risk of hypoglycemia needs to be avoided. A registered dietician can help teach individuals to measure food portions through food labels and calculate the carbohydrate content. Moreover, people can then learn to calculate the carbs in each meal and snack, and adjust their insulin dose accordingly. 
&nbsp;

2. Glycemic Index (GI) - Glycemic index assigns carbohydrate-containing foods a number depending on how much it increases one&#39;s blood sugar. Diabetics opt for foods or meals with a low GI. 
&nbsp;

The three categories of GI values are:

<ul>
	<li>Low GI: 1 to 55</li>
	<li>Medium GI: 56 to 69</li>
	<li>High GI: 70 and higher 
	&nbsp;</li>
</ul>

Examples of low GI foods include carrots (GI=47), apples (GI=38), and peas (GI=48). White bread (GI=70) and white rice (GI=58) are considered high GI foods. Therefore, they are avoided by diabetics. However, GI values are not indicative of a food&#39;s nutritional value. For example, 1 cup of whole milk has a low GI value, but high-fat content, which isn&#39;t recommended for diabetes. 
&nbsp;

3. Diabetes Plate Method - Calculating carbs for every meal is not always feasible. Therefore, some people follow the plate method to reach their nutrition goals. The plate method ensures that one gets enough protein, vegetables, and fruits, while limiting the carb intake.&nbsp; 
&nbsp;

A 9-inch dinner plate is divided as follows:

<ul>
	<li>Half of the plate is filled with non-starchy vegetables.&nbsp;</li>
	<li>One-quarter of the plate is filled with lean protein such as eggs, tofu, turkey, lentils, or chicken.</li>
	<li>One quarter is filled with high-carb foods such as rice, pasta, potatoes, fruit, and grains.</li>
</ul>

Moreover, with the meal, people can go for water or a low-calorie drink.&nbsp; 
&nbsp;

<h4>"Poor diabetes control can lower your heart rate variability. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan </a>and get your reading today!"</h4>

<ul>
	<li>Both type 1 and type 2 diabetics should avoid or limit the following foods:</li>
	<li>packaged and processed foods</li>
	<li>refined grains such as rice, white bread, pasta</li>
	<li>fried foods</li>
	<li>sugary foods such as candies, bakery products, cakes</li>
	<li>alcoholic beverages and sugary drinks such as sodas</li>
	<li>sweetened products</li>
	<li>salty food such as chips, canned soups</li>
</ul>

&nbsp;

Serving size varies for different foods. For example, for diabetics, the recommended serving size for chicken, meat, and fish is 1 ounce. Moreover, 1/2 cup of grains such as rice and corn are recommended. However, when using cups as a measuring size, it is important to stick to a standard measuring cup.&nbsp; 
&nbsp;

Since measuring cups or spoons are not always available, there is an easier guide to estimate the serving size using fingers and hands<a href="#accordion">[4]</a>.&nbsp;

Fist = 1 cup or 1 medium fruit

The palm of hand (no fingers) = 3 ounces of lean protein such as fish, meat, or chicken

Cupped hand = 1-2 ounces of nuts or pretzels

Thumb (tip to base) = 1 ounce of meat or cheese

Thumb tip (tip to 1st joint) = 1 tablespoon (mostly for fats)

Fingertip (tip to 1st joint) = 1 teaspoon

&nbsp;

The following is a sample menu and is meant for general information. It is not a replacement for expert opinion. A dietician or diabetologist should always be consulted for a diet plan to ensure adequate disease management and calorie intake. 
&nbsp;

<h5>Breakfast:</h5>

1/2 cup high fiber cereal/porridge with low-fat milk

or

1 slice of brown bread/chapati with 2 egg white/1 boiled egg

1 cup unsweetened tea or coffee

&nbsp;

<h5>Lunch:&nbsp;</h5>

1 whole wheat chapati/brown bread/1/2 cup rice

vegetables/salad

1-ounce lean meat/lentils

1 medium fruit

1 cup green tea or unsweetened tea/coffee

&nbsp;

<h5>Dinner:&nbsp;</h5>

1 whole wheat chapati/brown bread/1/2 cup rice

vegetables/salad

1-ounce lean meat/lentils

1 medium fruit

1 cup green tea or unsweetened tea/coffee

&nbsp;

<h5>Snack options:&nbsp;</h5>

1-ounce low-fat cheese

4 whole grain crackers

1 medium fruit

1 cup of low-fat milk

4 tbsp peanut butter

1/2 cup corn

&nbsp;

<h5>Fruit Juice Intake: Is it Allowed?</h5>

There has been a lot of debate on whether fruits are better than fruit juices for diabetics. As a rule, fruits are preferred over fruit juice, as it has higher fructose (sugar) and low fiber content. And also, a greater number of calories.&nbsp; 
&nbsp;

As 2014 study assessed the intake of fruit juice and its effect on the risk of type 2 diabetes. Although sugar-sweetened fruit juice increased the risk of type 2 diabetes, 100% fruit juice did not cause the same effects<a href="#accordion">[5]</a>. However, diabetics should practice caution and consult with a nutritionist before adding fruit juices to their diet plans.&nbsp;

&nbsp;

Conclusion

There is no diabetes-specific diet. Instead, several methods can be employed to ensure adequate calorie intake and prevent disease progression. These include counting carbs, focusing on the glycemic index, and the plate method. When creating meal plans, it is important to take into consideration a person&#39;s individual needs and be culturally sensitive to the food practices practised in the area.&nbsp; 
&nbsp;

Lifestyle changes such as dietary habits are a major aspect of improving patients&#39; disease knowledge and disease management. Therefore, it is important to educate patients on food practices that can help them manage their disease better.&nbsp; 
&nbsp;

Key Points

<ul>
	<li>Diabetes is characterized by elevated blood glucose levels that can be damaging to the body&#39;s vessels and organs. The resulting hyperglycemia can cause complications such as stroke, cardiovascular disease, recurrent infections, hypertension, and vision loss.</li>
	<li>A healthy and balanced diet can help maintain blood glucose levels within the normal range and prevent complications of diabetes.</li>
	<li>For diabetics, a healthy meal consists of lean proteins, whole grains, non-starchy vegetables, fruits, and low-fat foods. 5-6 small meals, spaced out over a day, should be consumed daily.&nbsp;</li>
	<li>An experienced dietician and diabetologist should be sought for diabetic meal plans. They may recommend carb counting, glycemic index diet, or the plate method.</li>
</ul>

&nbsp;

[1].International Diabetes Federation, 2021. With 1 in 4 adults living with diabetes, Pakistan has highest diabetes prevalence in the world. s.l.:s.n.

[2].Bukhsh, A. et al., 2020. Type 2 Diabetes Patients' Perspectives, Experiences, and Barriers Toward Diabetes-Related Self-Care: A Qualitative Study From Pakistan. Frontiers in endocrinology, Volume 11.

[3].American Diabetes Association, 2021. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes. Diabetes Care, 44(1).

[4].Canadian Diabetes Association, 2014. Handy portion guide.

[5].Xi, B. et al., 2014. Intake of fruit juice and incidence of type 2 diabetes: a systematic review and meta-analysis. PLoS One, 9(3).

Nimrah H. Sattar

Madeeha Syed

This article or video has been vetted and verified by Meri Sehat’s specialists. It contains citations and research from validated sources.

What Is The Ketogenic Diet?

Overview

We know that there are three macronutrients in our diet that provide all the energy and nutrition we need to sustain our body&rsquo;s normal structures and functions. In a perfect world where everyone opted for a balanced diet, we would consume adequate quantities of these macronutrients. However, in reality a standard diet consists mostly of carbs (50 percent) with some fats (35 percent) and proteins (15 percent) thrown in.&nbsp; 
&nbsp;

Ketogenic diet

Keto is a low-carb, gluten-free and a low-to-moderate protein diet. It is very similar to the Paleo diet and Atkins diet.&nbsp;

In order to understand how a ketogenic diet works, we first need to establish how our body normally produces energy. Glucose is the main source of energy and is obtained mainly from carbs. Normally, a ketogenic diet comprises 75 percent fat, 20 percent of protein and only five percent of carbohydrates. But there are several renditions so you are allowed to switch these percentages around based on your daily needs.&nbsp;

Now where does your body generate the energy it needs if you eliminate carbs to such an extreme extent? It turns out that the body switches to metabolising fat for this purpose and conducts this via a process called &lsquo;Ketosis&rsquo;.&nbsp; 
&nbsp;

Fats are broken down into ketones and these ketones provide all the energy you need. This is where the name &lsquo;ketogenic&rsquo; is derived from &mdash; Keto for &lsquo;ketones&rsquo; and genic for &lsquo;producing&rsquo;. This primes your body to burn fat as a primary source of energy, which is why it&rsquo;s so well-known and widely used for <a href="https://merisehat.pk/article/five-myths-about-weight-loss">losing weight</a>.&nbsp;&nbsp;

It&rsquo;s important to note that our body is a living organism and there&rsquo;s no switch that can make it perform a different activity within a matter of minutes or even days. It will take your body a few days to adjust to employing fats as your primary energy resource and during that time you will feel all the negative impacts of having low glucose stores, including decreased focus, brain fog, nausea, vomiting, and irritability. This phase is commonly known as the &lsquo;keto flu&rsquo;.&nbsp; 
&nbsp;

Let&rsquo;s see some of the claims the proponents of the ketogenic diet make and how much weight they actually hold:&nbsp;

For Weight Loss: This is the main application of the keto diet and is a huge part of the current trend. Once your body gets used to burning fat for your daily needs it will also go ahead and burn your local fat stores. This helps shave off those few extra inches in a very short amount of time.&nbsp;

Another reason why this works for weight loss is the high fat content of your diet leads to satiety. Basically, this means you don&rsquo;t feel any cravings and also feel fuller for longer periods.&nbsp;

However, it is not good for long-term weight loss, and once you go back to your usual eating habits, you will quickly gain those extra pounds back. Putting your body through this kind of metabolic stress is also not advisable because it&rsquo;s very hard to sustain over a long period of time for many people.&nbsp; 
&nbsp;

For The Brain: Anecdotal evidence shows people feel sharper and more focused. Then again, some of them have also reported experiencing brain fog while observing a ketogenic diet.&nbsp; There is no clinical evidence for either of these claims. 
&nbsp;

This is actually well researched.&nbsp;

<ul>
	<li>Ketogenic diet works well for people who are either prediabetic or have Type 2 diabetes. This makes sense because people whose insulin doesn&rsquo;t work are constantly at risk of having high blood sugar levels. And a lifestyle of eating processed food doesn&rsquo;t help either. These are therefore classified as foods with a high glycaemic index &ndash; which essentially means that they raise your blood sugar very fast.&nbsp;</li>
	<li>People on keto achieve better insulin sensitivity over time. Simply because the diet gives the body less glucose to work with, enabling it to function optimally.&nbsp;</li>
	<li>It&rsquo;s also been found effective for heart disease, Alzheimer&rsquo;s, Parkinson&rsquo;s, certain sleep disorders, polycystic ovarian syndrome (PCOS), and metabolic syndrome.&nbsp;</li>
	<li>Cutting out carbs also helps control acne breakouts.&nbsp; 
	&nbsp;</li>
</ul>

For Childhood Epilepsy: This is what the ketogenic diet originally gained popularity for back in the 1920s and 1930s. Before new anticonvulsant medications and therapies were developed, children with epilepsy would fast in order to control their seizures. Keto replaced this successfully. One in seven kids benefit from a ketogenic diet.&nbsp;

Evidence-based science has established that children with refractory epileptic seizures experience seizures less frequently if they opt for keto.&nbsp; 
&nbsp;

For Cancers: Ketogenic diet has shown some promise when it comes to treating certain types of cancers, but the research is so far inconclusive.&nbsp; 
&nbsp;

There are some disadvantages to keto, including:

<ul>
	<li>Nutritional deficiencies&nbsp;</li>
	<li>Formation of kidney stones</li>
	<li>Frequent urination</li>
	<li>Increased thirst</li>
	<li>High levels of LDL (bad cholesterol)</li>
	<li>Increased incidence of certain cancers</li>
	<li>Constipation</li>
	<li>Indigestion</li>
	<li>Inconvenient and unsustainable over a long period of time</li>
	<li>Low blood sugar (hence the mental fog during the initial days)</li>
	<li>Tougher workouts (since you don&rsquo;t have glucose readily available for energy anymore)&nbsp;</li>
	<li>Keto flu: weakness, irritability, headaches, bad breath, and fatigue</li>
	<li>Dry mouth&nbsp; 
	&nbsp;</li>
</ul>

Bottom Line

The ketogenic diet is great for short-term weight loss if you are otherwise healthy. But, it&rsquo;s very tough to successfully carry out since it requires a drastic switch from a normal diet. Lack of conclusive research and knowledge means we don&rsquo;t know everything that might go wrong (or right!) on this diet. Safe to say, anyone planning to go on this diet needs to exercise a certain level of personal discretion.&nbsp;

Dr. Safia Mehmood

Iqra Mazhar

Is Keto Diet Safe For People With Diabetes?

In recent years, there has been a significant surge of interest in exploring different weight loss regimes, specifically following high-protein diets. One such high-protein diet is the <a href="https://www.merisehat.pk/article/what-is-the-ketogenic-diet">ketogenic diet</a>, or simply the keto diet, which is a diet rich in proteins and fats. Initially, the ketogenic diet was primarily proposed to reduce the frequency of epileptic seizures in children, but it has since gained popularity for weight loss. While there is evidence of short-term results with the keto diet, the verdict on its long-term benefits is still inconclusive. However, unlike other low-carb diets that center around protein, the ketogenic diet focuses mainly on fat.

&nbsp;

Understanding The Advantages Of Keto Diet In Diabetes

In 2008, researchers conducted a 24-week study to determine the effects of a low-carbohydrate diet on people with diabetes type 2 and obesity. The study concluded that people who followed the ketogenic diet saw a significant improvement in the glycemic index compared to those following a low-glycemic diet<a href="#accordion">[1]</a>. Patients following a ketogenic diet also saw a significant reduction in the use of medication. Another study conducted in 2013 reported that participants on a ketogenic diet showed improvements in their blood sugar levels and were also able to taper off insulin requirements compared to other diets<a href="#accordion">[2]</a>. Similarly, the ketogenic diet outperformed a low-fat diabetes diet, and the participants showed better weight loss and control of HbA1c in another study<a href="#accordion">[3]</a>.&nbsp;

Although it may seem unlikely that a high-fat diet focuses on weight loss, the ketogenic diet is different and can potentially change the way your body stores and uses energy. The ketogenic diet is high in fat and low in carbs. Instead of sugar, your body converts fat into energy in the keto diet. As mentioned earlier, the diet was initially considered for the treatment of epilepsy in the 1920s, but the effects were later also studied for type 2 diabetes<a href="#accordion">[4]</a>. The ketogenic diet improves blood sugar levels and reduces the need for insulin. However, as with any other diet, there are risks associated with the keto diet as well. Thus, it is important to discuss the possibility of starting the keto diet with your doctor before making any drastic changes to your current diet plan.&nbsp;

&nbsp;

Diabetes is of 2 types: diabetes type 1 and diabetes type 2.&nbsp;

<ul>
	<li>In type 1 diabetes, the body is incapable of producing insulin, and the patient has to rely on medication for life. This condition is less common and is typically diagnosed during childhood.&nbsp;</li>
	<li>In diabetes type 2, which has a more common presentation of the two, the body either does not produce enough insulin to meet the body&rsquo;s needs, or the insulin produced does not work effectively in lowering blood glucose levels.&nbsp;</li>
	<li>Pre-diabetic people have higher than normal blood sugar levels&nbsp;and are at a higher risk of developing diabetes type 2 if they do not take precautionary lifestyle and dietary measures.&nbsp;</li>
	<li>Gestational diabetes is described as diabetes that develops when you are pregnant. This type of diabetes generally resolves after giving birth. Though, it places you at a higher risk of developing type 2 diabetes.&nbsp;</li>
</ul>

&nbsp;

<h4>"Good diabetes control can increase your heart rate variability. Head on over to the <a href="https://www.merisehat.pk/page/sehat-scan/" target="_blank">sehat scan</a> and get your reading now!"</h4><h4> </h4>

Unlike other low-carb diets, the keto diet aims to force your body to use a different type of fuel. And instead of relying on sugar that comes from carbohydrates, for example, fruits, vegetables, legumes, and grains, the diet relies on ketone bodies. This is a type of fuel that the liver produces using stored fat. While burning fat sounds like an ideal way to lose weight, getting the liver to make ketone bodies is a tricky process.&nbsp;

<ul>
	<li>The diet requires that you restrict your intake of carbohydrates to 20 to 25 grams per day.&nbsp;</li>
	<li>Typically, reaching the state of ketosis takes a few days.&nbsp;</li>
	<li>If your diet is too high in protein, it can also interfere with ketosis.&nbsp;</li>
</ul>

In many cases, people with type 2 diabetes are overweight and a high-fat diet may seem unhelpful. The goal of a ketogenic diet is to train the body into using fat instead of carbohydrates or glucose. On the ketogenic diet, most of the energy comes from fat and only a small amount comes from carbohydrates. However, there are some ground rules. A diet high in fats doesn&rsquo;t mean that you should load up on saturated fats. It is recommended that your diet is rich in heart-healthy fats to maintain overall health. Some healthy foods that you can eat on a ketogenic diet include:&nbsp;

<ul>
	<li>Eggs&nbsp;</li>
	<li>Fish&nbsp;</li>
	<li>Cottage cheese&nbsp;</li>
	<li>Avocado&nbsp;</li>
	<li>Olives&nbsp;</li>
	<li>Nuts&nbsp;</li>
	<li>Seeds</li>
	<li>Olive oil&nbsp;</li>
	<li>Nut butter&nbsp;</li>
</ul>

&nbsp;

Foods To Be Eaten In Moderation

<ul>
	<li>Berries -&nbsp;1 cup or less</li>
	<li>Plain, Greek yogurt -&nbsp;1 cup or less</li>
	<li>Cottage cheese -&nbsp;1/2 cup or less</li>
	<li>Nuts and peanuts -&nbsp;1&ndash;2 ounces&nbsp;or 30&ndash;60 grams</li>
	<li>Flaxseeds or chia seeds -&nbsp;2 tablespoons</li>
	<li>Dark chocolate (at least 85% cocoa) -&nbsp;30 grams or less</li>
</ul>

&nbsp;

Foods To Avoid

<ul>
	<li>Bread&nbsp;</li>
	<li>Pasta&nbsp;</li>
	<li>Cereal&nbsp;</li>
	<li>Corn and other grains&nbsp;</li>
	<li>Potatoes, sweet potatoes</li>
	<li>Milk&nbsp;</li>
	<li>Fruits excluding berries&nbsp;</li>
	<li>Juices, sodas, and sweetened teas</li>
	<li>Desserts, candies, ice cream, and other baked goods</li>
</ul>

&nbsp;

When you eat carbs, your body&rsquo;s digestive system breaks down the carbohydrates and turns them into sugars that enter your bloodstream. The more sugar there is in your bloodstream, the more insulin your body needs to break down the sugar for energy. Insulin signals the cells to use the sugar for energy and energy storage. Moreover, the pancreas releases glucagon when the cells of your body begin to use the blood sugar. The two hormones, insulin, and glucagon work together to ensure that you have enough energy. If you have diabetes, then this means that your body is not using the insulin properly or cannot make or is not making enough insulin.

Hence, for people with diabetes type 2, it is recommended to control carbohydrate intake because it turns to sugar, and having it in large quantities can cause spikes in blood sugar levels. However, the ketogenic diet has the potential to decrease the levels of blood glucose. Your doctor will determine the number of carbs you should have based on your needs, current BMI, etc. Studies have shown that some people experience reduced blood sugar by switching to a diet high in fat.

Diabetes affects about 10 percent of the American population. Whereas in Pakistan, 17.1% of the population is estimated to be living with diabetes. This makes a total of 19 million adults in Pakistan who are at risk of the life-threatening complications of diabetes making it a pertinent public health issue<a href="#accordion">[5]</a>.&nbsp;

&nbsp;

Other than the standard keto diet, there are 3 other variations of the diet: the cyclical ketogenic diet, the targeted ketogenic diet, and the very low-carb diet.&nbsp;

<ul>
	<li>On the cyclical ketogenic diet, you can eat 100 to 150 grams of clean carbs once or twice a week.</li>
	<li>With the targeted ketogenic diet, you can follow the same rules as a regular keto diet but the time you eat carbs is fixed. It is suggested to consume carbs before or after a workout.&nbsp;</li>
	<li>The very low-carb diet, as the name suggests, allows you to eat very small quantities of carbs, high fat, and moderate protein. However, compared to the standard keto diet that allows only 50 grams of carbs a day, this diet allows you to eat 100 to 150 grams of carbs daily. However, this may not help you reach a state of ketosis.&nbsp;</li>
</ul>

&nbsp;

After reading this article, you may be wondering how a diet that focuses on fat makes it good for you. Especially, considering the fact that many people with diabetes also have obesity. While this question is completely reasonable, the keto diet is about redefining our understanding of fat. For years, people have focused on low-fat foods, milk, and yogurt thinking that fats are the root cause of all our health concerns, including obesity. However, the situation is more complex.&nbsp;

A recent study indicates that focusing on reducing total fats leads to harmful habits such as increased consumption of refined carbohydrates and added sugars. Moreover, it also leads to avoiding nutrient-dense foods, such as nuts, seeds, vegetable oils, and avocados. We all need fat to keep ourselves healthy and only recently researchers have started shifting from anti-fat foods to encouraging high-fat foods. In simpler words, fat is an important source of energy. It helps our bodies absorb essential vitamins and minerals, helps our muscles move, and enables blood to clot. Thus, science shows that a diet high in fat can be healthy, whereas eating low-fat diets can actually be harmful in the long run because of overconsumption of carbs and processed foods.&nbsp;

&nbsp;

<ul>
	<li>It is important that you speak with your doctor before you start a keto diet. Speaking with your doctor is a rule that should be followed before starting any diet.&nbsp;</li>
	<li>A keto diet can be helpful for diabetics who want to lose weight and lessen the need for medications. However, for others, it might even make diabetes worse. The diet isn&rsquo;t a magic weight loss pill, and there is currently limited information on the long-term effects of a keto diet.&nbsp;</li>
	<li>Moreover, be cautious when transitioning from the keto diet to adding carbs back to your diet. Sudden high consumption of carbs can cause your blood sugar levels to spike, and cause you to gain weight.</li>
</ul>

&nbsp;

[1] Westman, E.C., Yancy, W.S., Mavropoulos, J.C., Marquart, M. and McDuffie, J.R., 2008. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & metabolism, 5(1), pp.1-9.

[2] Paoli, A., Rubini, A., Volek, J.S. and Grimaldi, K.A., 2013. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. European journal of clinical nutrition, 67(8), pp.789-796.

[3] Saslow, L.R., Mason, A.E., Kim, S., Goldman, V., Ploutz-Snyder, R., Bayandorian, H., Daubenmier, J., Hecht, F.M. and Moskowitz, J.T., 2017. An online intervention comparing a very low-carbohydrate ketogenic diet and lifestyle recommendations versus a plate method diet in overweight individuals with type 2 diabetes: a randomized controlled trial. Journal of medical Internet research, 19(2), p.e5806.

[4] Meira, I.A., Romão, T.T., do Prado, H.P., Krüger, L.T., Pires, M.E.P. and da Conceição, P.O., 2019. Ketogenic diet and epilepsy: What we know so far, Front. Neurosci-Switz.(13), 5.

[5] Akhtar, S., Nasir, J.A., Abbas, T. and Sarwar, A., 2019. Diabetes in Pakistan: a systematic review and meta-analysis. Pakistan journal of medical sciences, 35(4), p.1173.Akhtar, S., Nasir, J.A., Abbas, T. and Sarwar, A., 2019. Diabetes in Pakistan: a systematic review and meta-analysis. Pakistan journal of medical sciences, 35(4), p.1173.

Staff Writer

Ismail Munir

Can Gestational Diabetes Be Reversed?

The International Diabetes Federation (IDF) estimates that by 2030 an estimated 783 million adults will be living with <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2">diabetes</a>&nbsp;<a href="#accordion">[1]</a>.&nbsp;According to the latest figures, the prevalence of diabetes has steadily increased in low- and middle-income countries. With a 70% increase since 2019, Pakistan has the highest diabetes prevalence in the world<a href="#accordion">[1]</a>. Moreover, an estimated 11 million adults have Impaired Glucose Tolerance (IGT); thus, increasing their risk of <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2">type 2 diabetes</a>&nbsp;<a href="#accordion">[1]</a>. However, researchers have not only reported an increase in cases of type 2 diabetes but also gestational diabetes mellitus (GDM).&nbsp; 
&nbsp;

The true prevalence of gestational diabetes in Pakistan remains unclear due to varying risk factors and diagnostic criteria. A cross-sectional study conducted across hospitals in Karachi and Hyderabad found a prevalence of 11.9%<a href="#accordion">[2]</a>. Another study conducted at The Indus Hospital in Karachi reported a 17.7% prevalence of GDM<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

Understanding Gestational Diabetes

Gestational diabetes develops due to a combination of beta cell dysfunction and increased insulin resistance during pregnancy. The resulting hyperglycemia is detrimental to both maternal and fetal health. Complications such as neonatal hypoglycemia, stillbirth, macrosomia, shoulder dystocia, breathing difficulty, and maternal preeclampsia can occur.&nbsp; 
&nbsp;

Although maternal blood glucose levels return to normal after birth, approximately half of the women with gestational diabetes go on to develop type 2 diabetes<a href="#accordion">[4]</a>. Moreover, there&#39;s a two in three chance that Gestational Diabetes Mellitus (GDM) can return in future pregnancy<a href="#accordion">[5]</a>. However, proper antenatal and post-natal care can ensure that one&#39;s GDM stays reversed and their glucose levels remain within target.&nbsp;

&nbsp;

Gestational diabetes typically develops during the second trimester and is diagnosed between 24 to 28 weeks of pregnancy. Depending on the diagnostic criteria, doctors may conduct the following tests for diagnosing GDM: 
&nbsp;

<ul>
	<li>Initial Glucose Challenge Test - Patients drink a 50g glucose solution; after one hour, blood glucose levels are checked. Measurements &gt;140mg/dl point to a high risk of gestational diabetes. It is often followed by an oral glucose tolerance test to confirm a diagnosis of gestational diabetes. 
	&nbsp;</li>
	<li>Oral Glucose Tolerance Test (OGTT) - Patients must present in a fasting state for the test. After drinking a 100g glucose solution, samples are drawn every hour for a total of 3 hours. Diagnosis is based on blood glucose levels in fasting state, 1-hour, 2-hour, and 2-hour post glucose solution.&nbsp; 
	&nbsp;</li>
</ul>

The International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2010 criteria recommends a one-step approach<a href="#reference" target="_blank">6</a>. Blood samples are drawn in a fasting state, and then 1- and 2-hours after drinking a 75g glucose solution (OGTT). While most women are screened during the second trimester, those at high risk may undergo screening at their first prenatal visit.&nbsp; 
&nbsp;

Non-modifiable risk factors of GDM include a family history of diabetes, increasing maternal age (&gt;25years), and a history of GDM. Although these cannot be controlled, several modifiable risk factors also exist for gestational diabetes. These include obesity, polycystic ovary syndrome, prediabetes, diet, and physical activity.&nbsp; 
&nbsp;

Antenatal interventions are aimed at making women aware of the risks associated with gestational diabetes and ways to control the modifiable risk factors of the disease. Moreover, they should be made aware of their blood glucose level targets. 
&nbsp;

<h5>Blood Glucose Monitoring</h5>

Using a glucose meter or sensor, pregnant women with GDM should daily test their fasting, pre-meal, 1-hour postprandial, and bedtime glucose levels. According to the American Diabetes Association (ADA), pregnant women with gestational diabetes should maintain their blood glucose levels within the following range<a href="#accordion">[7].</a>

<ul>
	<li>Fasting plasma glucose levels: less than 95mg/dl</li>
	<li>1-hour postprandial glucose levels: less than 140mg/dl</li>
	<li>2-hour postprandial glucose levels: less than 120mg/dl 
	&nbsp;</li>
</ul>

<h5>Dietary Changes</h5>

A certified dietician can help ensure that the mother reaches her caloric requirements and achieves a healthy weight gain during pregnancy. Women are mostly advised to eat 3 small-sized meals and three to four healthy snacks during the day. Moreover, a bedtime snack is recommended to help keep fasting blood glucose levels within range.&nbsp; 
&nbsp;

The recommended nutrition plan for women with GDM should contain a minimum of 175 g of carbohydrate, a minimum of 71 g of protein, and 28 g of fiber. Sugar and saturated fats are mostly limited.&nbsp; 
&nbsp;

<h5>Physical Activity</h5>

Regular exercise can help keep blood glucose levels within normal and combat insulin resistance. Recommended physical activity for pregnant women includes aerobic exercises like walking and swimming. 30 minutes of exercise for 3-5 days a week is often considered adequate. However, one should consult their doctor before starting any form of exercise during pregnancy.

&nbsp;

<h5>Insulin</h5>

If dietary changes and physical activity are unable to maintain blood glucose levels, doctors may prescribe insulin injections to pregnant women. Insulin is the first choice in gestational diabetes due to its safety profile and inability to cross the placenta. Metformin and sulfonylureas are contraindicated due to adverse outcomes in the fetus. However, with daily insulin injections, it is important that women are made aware of the risks of hypoglycemia.&nbsp;

&nbsp;

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Since blood glucose levels and insulin resistance decrease drastically after birth, it is important to re-evaluate a woman&#39;s insulin requirement. Most women do not require further treatment with insulin. However, blood glucose levels are checked the day after birth.&nbsp; 
&nbsp;

The American Diabetes Association recommends the following for postpartum care of gestational diabetes<a href="#accordion">[7]</a>.

<ul>
	<li>Using the 75g oral glucose tolerance test, screen women at 4-12 weeks postpartum</li>
	<li>Lifelong screening for type 2 diabetes or prediabetes every 1 to 3 years</li>
	<li>If women are found to have prediabetes, they should seek an experienced diabetologist that can advise lifestyle interventions and any diabetes medicines if needed.</li>
	<li>Psychosocial assessment of women should also be included in postpartum care 
	&nbsp;</li>
</ul>

According to research, diets consisting of &#39;high refined grains, fats, oils and fruit juice&#39;, &#39;high nuts, seeds, fat and soybean; low milk and cheese&#39;, and &#39;high added sugar and organ meats; low fruits, vegetables and seafood&#39; is associated with an increased risk of gestational diabetes<a href="#accordion">[8]</a>. Therefore, women with GDM are advised to continue with a healthy diet plan following birth. This will reduce their risk of developing gestational diabetes in future pregnancies. 
&nbsp;

Moreover, women with a history of GDM have a 10-fold higher risk of developing type 2 diabetes mellitus than non-GDM women<a href="#accordion">[9]</a>. Lifestyle interventions such as weight loss, healthy diet, daily exercise and/or metformin use can help reduce the progression of the disease. These modifications can further reduce the risk of cardiovascular complications in women with a history of GDM. 
&nbsp;

&nbsp;

The lack of awareness among the general population combined with limited healthcare access is a barrier to the prevention and management of gestational diabetes in low and middle income countries. Moreover, there is no universal consensus on GDM screening. However, multiple diagnostic criteria are available for diagnosing gestational diabetes. Therefore, there is a need for not only general awareness programs but also effective screening tests that can diagnose the condition early on. Preconception diabetes screening can help prevent GDM-related complications and congenital abnormalities. 
&nbsp;

Gestational diabetes can be quite a distressing state for a mother. It is important that family members are involved in providing emotional support to the mother. Psychological counselling might also be beneficial. Moreover, a healthcare professional should review contraceptive options as part of postpartum care as unplanned pregnancies can further increase the risk of complications.&nbsp; 
&nbsp;

<ul>
	<li>Gestational Diabetes Mellitus (GDM) is the most common metabolic disorder of pregnancy and affects both maternal and neonatal health. Common complications include neonatal hypoglycemia, macrosomia, obstructed labor, stillbirth, preterm delivery, increased risk of shoulder dystocia, maternal preeclampsia, and increased risk of type 2 diabetes in both mother and child.&nbsp;</li>
	<li>In women with GDM, blood glucose levels return to normal shortly after birth. However, 50% of women are at risk of developing type 2 diabetes in the future, and 2 in 3 women have a risk of developing GDM in a future pregnancy.</li>
	<li>A healthy and balanced diet, regular physical activity, blood glucose monitoring, and the use of insulin can help maintain blood glucose levels within the normal range in pregnant women with GDM. The American Diabetes Association (ADA) recommends fasting blood glucose levels &lt;95mg/dl, 1-hour postprandial levels &lt;140mg/dl, and 2-hour postprandial levels &lt;120mg/dl during pregnancy.</li>
	<li>4-12 weeks postpartum, women with GDM should undergo testing with 75g-OGTT. Moreover, they should be tested every 1-3 years for risk of type 2 diabetes.&nbsp; 
	&nbsp;</li>
</ul>

[2].Riaz, M. et al., 2019. Frequency of gestational diabetes mellitus using DIPSI criteria, a study from Pakistan. Clinical Epidemiology and Global Health, 7(2), pp. 218-221

[3].Wali, A. S. et al., 2020. High proportion of overt diabetes mellitus in pregnancy and missed opportunity for early detection of diabetes at a tertiary care centre in Pakistan. Pakistan journal of medical sciences, 36(1), pp. 38-43.

[4].CDC, 2021. Gestational Diabetes. [Online]

[5].American Diabetes Association, n.d. Gestational Diabetes - Treatment & Perspective.

[6].Rani, P. R. & Begum, J., 2016. Screening and Diagnosis of Gestational Diabetes Mellitus, Where Do We Stand. Journal of Clinical and Diagnostic Research, 10(4).

[7].American Diabetes Association, 2021. Management of Diabetes in Pregnancy. In: Standards of Medical Care in Diabetes. s.l.:s.n.

[8].Shin, D., Lee, K. W. & Song, W. O., 2015. Dietary Patterns during Pregnancy Are Associated with Risk of Gestational Diabetes Mellitus. Nutrients, 7(11).

[9].Vounzoulaki, E. et al., 2020. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ, Volume 13

Humza Khizer

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Can AI Predict Diabetes?

In 2021, approximately 400,000 deaths in Pakistan occurred due to diabetes<a href="#accordion">[1]</a>. The chronic disease results from a lack of insulin in the body or the cells&#39; inability to use the available insulin. This leads to elevated blood glucose levels which can present as increased thirst, frequent urination, increased appetite, fatigue, recurrent infections, and unexplained weight loss.&nbsp; 
&nbsp;

With 33 million adults suffering from diabetes, Pakistan has the highest diabetes prevalence in the world<a href="#accordion">[1]</a>.&nbsp;However, more than 26.9% of adults are undiagnosed<a href="#accordion">[1]</a>. Thus, putting them at risk of complications such as neuropathy, nephropathy, <a href="https://www.merisehat.pk/disease/hypertension-57">hypertension</a>, vision problem, and cardiovascular diseases. Moreover, the delay in treatment reduces a person&#39;s overall quality of life. This delay in diagnosis and treatment is often blamed on a lack of awareness among the general population. Additionally, many people have limited financial resources and access to adequate healthcare facilities.&nbsp;

According to the International Diabetes Federation, 3 in 4 adults with diabetes live in low- and middle-income countries<a href="#accordion">[2]</a>. Such countries already face multiple healthcare challenges which can make managing chronic conditions such as diabetes more difficult. Therefore, there is a need for improving diabetes care.&nbsp;

&nbsp;

Artificial intelligence is defined as &#39;a branch of computer science that aims to create systems or methods that analyze information and allow the handling of complexity in a wide range of applications<a href="#accordion">[3]</a>.&nbsp;It basically means making a computer perform tasks normally done by humans. Thus, systems or algorithms are equipped with humanistic characteristics of reasoning, analyzing, learning, and generalizing.&nbsp;

&nbsp;

Understanding how to predict diabetes using AI

In recent years, researchers have turned their attention to artificial intelligence (AI) for diabetes management. These newly developed AI-based tools are rapidly becoming an integral part of healthcare due to their portability, low cost, and high efficiency. Using principles of machine learning, researchers have built algorithms that can help predict the risk of developing diabetes and its complications. 
&nbsp;

Several AI-based medical devices are currently in use across the United States, Europe, and Japan. However, most of them are concerned with radiological and diagnostic imaging.&nbsp;&nbsp; 
&nbsp;

Artificial Intelligence can improve and influence three main aspects of diabetes care<a href="#accordion">[3]</a>. 
&nbsp;

<ul>
	<li>Patients with diabetes</li>
	<li>Healthcare professionals</li>
	<li>Healthcare systems 
	&nbsp;</li>
</ul>

Currently, AI technologies focus on blood glucose monitoring, diabetes prediction, lifestyle guidance, monitoring of complications, and diabetes self-management.&nbsp; 
&nbsp;

Chinese researchers developed a risk assessment model for screening post-meal hyperglycemia<a href="#accordion">[4]</a>. The AI-based predictive model used several risk factors, such as age, height, family history, fasting blood glucose, and cholesterol levels to identify those at risk of postprandial hyperglycemia. Thus, replacing the need for an oral glucose tolerance test.&nbsp; 
&nbsp;

Another group of researchers used machine learning algorithms and electronic medical record (EMR) data of patients to predict their risk of developing type 2 diabetes later<a href="#accordion">[5]</a>. Thus, proving that artificial intelligence is feasible for diabetes prediction.&nbsp;

&nbsp;

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In 2018, the U.S Food and Drugs Administration (FDA) approved IDx-DR, an AI-based device for the early detection of diabetic retinopathy. The algorithm analyzes digital retinal images to diagnose people with retinopathy, without the need for an ophthalmologist. However, primary health physicians can refer patients to ophthalmologists for an assessment of the images or ask for a re-evaluation with the device 12 months later. A clinical trial for the AI system reported 92% accuracy levels and 93% specificity levels for the device<a href="#accordion">[6]</a>. 
&nbsp;

AI-based devices have also been developed for image-based screening of diabetic foot ulcers. These tools provide a cost-effective alternative for the detection of diabetic complications. 
&nbsp;

In diabetics, an adequate diet and daily physical activity are essential for maintaining blood glucose levels within the normal range. However, keeping track of one&#39;s dietary habits is not easy. Nor is it feasible to adjust insulin dose for every meal. Artificial intelligence algorithms can combine multiple parameters, such as physical activity, blood glucose measurements, and dietary habits to predict postprandial glucose levels and their metabolic effects. Moreover, based on these parameters they can then adjust one&#39;s insulin dose.&nbsp; 
&nbsp;

Self-management is an integral component of diabetes treatment. However, many patients are unaware of diabetes self-care, and are non-compliant with prescribed treatments and recommended lifestyle changes. Digital platforms, therefore, help increase awareness and help patients become accountable for diabetes care. 
&nbsp;

During a 12-week interventional study, researchers evaluated the use of FareWell, a digital therapeutic, for the management of diabetes. The digital intervention provided health coaching to patients every 2 weeks, aiding healthier lifestyle decisions. At the end of the study, participants reported a significant reduction in HbA1c levels and diabetic medication use. Approximately 92% of the users reported greater confidence in the management of their diabetes<a href="#accordion">[7]</a>.

Moreover, many mobile apps are now available for diabetes management. They can help set reminders for medications, track blood glucose levels, set goals, and provide insights into the patient&#39;s disease progression.&nbsp; 
&nbsp;

In 2021, diabetes was responsible for an estimated USD 966 billion in global health expenditure<a href="#accordion">[1]</a>. The increasing disease burden of diabetes poses further risks for countries facing poverty, lack of resources, high healthcare costs, and lack of healthcare experts. Therefore, prevention and management of diabetes are important for decreasing the disease burden. 
&nbsp;

Type 2 diabetes has a slow disease progression and can take years to show symptoms. Early detection of the disease can decrease healthcare costs by preventing the development of complications. Artificial intelligence allows remote monitoring of the patient&#39;s disease, providing a low-cost and time-effective alternative for diabetes management. Moreover, 50-70% of routine follow-up clinical consults can be replaced with virtual management using artificial intelligence<a href="#accordion">[8]</a>. 
&nbsp;

There are several limitations to the application of artificial intelligence in diabetes, such as data security, low user-friendliness of the apps, technical factors, and lack of access. Nevertheless, these limitations are currently being worked on to ensure that AI helps empower patients to effectively manage their diabetes. 
&nbsp;

<ul>
	<li>Diabetes Mellitus results from either a lack of insulin or the body&#39;s inability to use the available insulin. It can result in complications such as cardiovascular disease, chronic kidney disease, hypertension, vision problems, and skin infections leading to feet/leg amputation.</li>
	<li>Diabetes prevalence has significantly increased in low- and middle-income countries, increasing the disease burden in places already struggling with healthcare management.&nbsp;</li>
	<li>Artificial intelligence can help manage diabetes by helping monitor glucose levels, predicting diabetes, lifestyle guidance, and detecting complications of diabetes.&nbsp;</li>
	<li>Remote monitoring of a patient&#39;s disease progression can reduce the burden on healthcare professionals and provide a low-cost and time-efficient alternative to routine clinical consultations.&nbsp;</li>
</ul>

&nbsp;

[2].IDF Diabetes Atlas, n.d. Diabetes around the world in 2021.

[3].Ellahham, S., 2020. Artificial Intelligence: The Future for Diabetes Care. The American Journal of Medicine, 133(8), pp. 895-900.

[4].Fu, Q. et al., 2014. A Chinese risk score model for identifying postprandial hyperglycemia without oral glucose tolerance test. Diabetes/metabolism research and reviews, 30(4), pp. 284-90.

[5].Mani, S. et al., 2012. Type 2 Diabetes Risk Forecasting from EMR Data using Machine Learning. AMIA Annu Symp Proc., pp. 606-615.

[6].Abràmoff, M. D. et al., 2018. Pivotal trial of an autonomous AI-based diagnostic system for detection of diabetic retinopathy in primary care offices. npj Digital Med.

[7].Berman, M. A. et al., 2018. Change in Glycemic Control With Use of a Digital Therapeutic in Adults With Type 2 Diabetes: Cohort Study. JMIR diabetes, 3(1).

[8].Fagherazzi , G. & Ravaud, P., 2019. Digital diabetes: Perspectives for diabetes prevention, management and research. Diabetes & metabolism, 45(4).

HIV & Diabetes: Is There A Link?

Recently, researchers have discovered the role of the human immunodeficiency virus (HIV) in increasing the risk of diabetes. Moreover, the incidence of diabetes has also significantly increased among <a href="https://merisehat.pk/disease/hiv-61">HIV patients</a>, raising their risk of mortality and morbidity from metabolic disease. 
&nbsp;

Several studies have reported an increased incidence of diabetes in HIV patients. In 2021, French researchers conducted a real-life setting study to identify risk factors of diabetes in people living with <a href="https://merisehat.pk/disease/hiv-61">HIV</a>. The study reported a diabetes prevalence of 9-10% among the infected individuals<a href="http://@accordion">[4]</a>. According to the study, people with HIV developed diabetes at a much younger age.&nbsp;

&nbsp;

Another study, conducted in the United States, found a 3.8% higher prevalence of diabetes among HIV-infected individuals<a href="#accordion">[5]</a>&nbsp;Moreover, similar to the French study, researchers reported diabetes among a younger HIV-infected population, in the absence of obesity.&nbsp;

&nbsp;

Researchers hypothesize that due to the effectiveness of ARTs, people with HIV are now living longer. Thus, increasing their risk of developing chronic diseases such as diabetes. The use of protease inhibitors (PIs) is specifically associated with a five-fold higher rate of hyperglycemia[<a href="#accordion">6]</a>. It causes beta cell dysfunction and decreased insulin sensitivity, both of which contribute to increased incidence of diabetes. Other HIV medications can affect glucose metabolism, leading to insulin resistance. Moreover, inflammation in people living with HIV is considered key to the development of <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes</a>. This may occur from T-cell depletion and co-infection with viruses such as hepatitis C.&nbsp;

&nbsp;

The prevalence of diabetes has drastically risen over the years. In 2021, there was a 16% rise in cases from 2019<a href="#accordion">[1]</a>. As per the IDF Diabetes Atlas, Pakistan currently has the highest national prevalence of diabetes in the world. Several factors are responsible for the surge in cases. These include urbanization, increasing levels of obesity, a sedentary lifestyle, and an ageing population.&nbsp;

&nbsp;

According to the World Health Organization (WHO), an estimated 37 million people suffered from HIV at the end of 2020<a href="http://@accordion">[2]</a>. The virus destroys the body&#39;s immune cells, making the person prone to infections and cancers. Moreover, in the advanced stage, HIV can cause acquired immunodeficiency syndrome (AIDS). This is characterized by the development of infections, various cancers, and severe complications. As of June 2019, more than 24,000 people (14&middot;7%) are registered with the National AIDS Control Program (NACP) in Pakistan<a href="http://@accordion">[3]</a>. This is an increase of more than 4,500 from 2013. 
&nbsp;

Although there is no cure for the virus, the development of effective antiretroviral therapies (ARTs) has resulted in a longer life expectancy among individuals.&nbsp;

&nbsp;

According to the Infectious Diseases Society of America people living with HIV should undergo the following tests at baseline and at 1 to 3 months after starting ART: 
&nbsp;

<ul>
	<li>Fasting Plasma Glucose and/or</li>
	<li>Hemoglobin A1c 
	&nbsp;</li>
</ul>

HbA1c levels of 5.8% or more are considered diagnostic of diabetes in people living with HIV. Moreover, the test should be repeated every 6 months; the goal is to keep the level below 7% for HIV-infected individuals suffering from diabetes.&nbsp;

&nbsp;

Similar to the general population, HIV-infected individuals can follow the following steps to reduce their risk of diabetes: 
&nbsp;

<ul>
	<li>Lifestyle changes such as regular exercise and a balanced diet</li>
	<li>Limiting intake of processed foods, refined sugars, salt, and fat</li>
	<li>Maintain a healthy weight</li>
	<li>Regular blood glucose monitoring, especially prior to and after starting HIV medications</li>
	<li>Quit smoking 
	&nbsp;</li>
</ul>

The appropriate management plan will depend on the individual&#39;s disease status, age, weight, risk of complications, and other factors. Moreover, not all diabetic medications can be given to HIV patients as they can react to ARTs. Therefore, all medications should first be discussed with one&#39;s healthcare provider.&nbsp;

&nbsp;

The significantly high prevalence of diabetes in HIV-infected individuals warrants the need for better screening programs. It is important to modify diabetes screening guidelines with HIV infection as a risk factor for the development of diabetes. Moreover, HIV treatment strategies should focus on reducing the risk of diabetes in these individuals.&nbsp;

<ul><li>The human immunodeficiency virus (HIV) targets the immune system, weakening the body's defenses against certain infections and cancers. An advanced stage is characterized by the development of acquired immunodeficiency syndrome (AIDS).</li><li>Multiple studies have reported an increased incidence of diabetes among people infected with HIV.&nbsp;</li><li>The increased life expectancy due to effective antiretroviral therapies has increased the risk of diabetes in people with HIV.&nbsp;</li><li>Factors such as abdominal obesity, age, hepatitis C co-infection, duration of HIV, longer exposure to ART therapy, and lipodystrophy increase the risk of diabetes in HIV-infected individuals.</li></ul>

[1] International Diabetes Federation, 2021. With 1 in 4 adults living with diabetes, Pakistan has highest diabetes prevalence in the world. s.l.:s.n.

[2] World Health Organization, 2021. HIV/AIDS. [Online]

[3] Ahmed, A., Hashmi, F. K. & Khan, G. M., 2019. HIV outbreaks in Pakistan. The Lancet, 6(7).

[4] Kousignian, I. et al., 2021. Diagnosis, risk factors and management of diabetes mellitus in HIV-infected persons in France: A real-life setting study. PLOS One.

[5] Hernandez-Romieu, A. C. et al., 2017. Is diabetes prevalence higher among HIV-infected individuals compared with the general population? Evidence from MMP and NHANES 2009–2010. BMJ Open Diabetes Research and Care, 5(1).

[6] Sarkar, S., 2019. Diabetes in People Living with HIV. s.l.:s.n.

Is Your Asthma Due To Your Mother’s Gestational Weight Gain?

Gestational weight gain and high BMI (body mass index) affects a majority of pregnant women. There are various factors such as social factors, environmental factors, maternal factors, and energy balance that could contribute to weight gain <a href="https://merisehat.pk/disease/lets-talk-about-sex-during-pregnancy">during pregnancy</a>.&nbsp; 
&nbsp;

Although gestational weight gain (GWG) is a natural response to accommodate a growing fetus, GWG that is either too high or too low contributes to long-term or short-term health complications. This specifically applies for women whose BMI is greater than 25 at the time of their pregnancy. 
&nbsp;

The number of women who experience excessive gestational weight gain while they are pregnant is increasing, irrespective of their socio-economic status. Institute of Medicine, USA, has worked on identifying optimal gestational weight, so healthcare providers can advise pregnant women accordingly<a href="#accordion">[1]</a>.

&nbsp;

Understanding The Impact Of Pregnancy Weight Gain On Childhood Asthma

Extreme gestational weight gain has a significant impact on pregnant women and their health. It increases risk of birth complications, and leads to long-term maternal obesity. 
&nbsp;

Additionally, excessive gestational weight gain is harmful for the child, especially because of increased risk of childhood obesity<a href="#accordion">[2]</a>. There is also enough evidence to link maternal obesity with childhood obstructive lung diseases, e.g., asthma<a href="#accordion">[3]</a>. 
&nbsp;

<h5>GWG And Asthma&nbsp;</h5>

Obesity during pregnancy is directly related to adverse outcomes in children, e.g., higher probability of developing asthma&nbsp; 
&nbsp;

The mechanism to identify this connection is fetal programming. It describes the in-utero exposure that influences gene expression and chronic diseases during childhood. The disease originates from metabolic and psychological adaptations, which are made by the fetus in response to in-utero exposures during critically sensitive developmental phases. Moreover, environmental and genetic factors also play a role in the immune modulatory effects. 
&nbsp;

<h5>The Effects Of BMI</h5>

It&rsquo;s difficult to gauge the effects of the mother&rsquo;s and the child&rsquo;s BMI on childhood asthma. Researchers have investigated the mediating effects of BMI by adding childhood body mass index to their variable models with two or more quantities, and further describing what would reduce the risk. 
&nbsp;

Some studies concluded that birth weight of babies and BMI at the age of eight partially affected childhood asthma due to gestational weight gain. However, other studies found minimal effects on childhood BMI<a href="#accordion">[4]</a>. 
&nbsp;

Another research studied the relationship between maternal pre-pregnancy BMI, gestational diabetes, weight gain, and the risk of wheezing in preschool offspring. The focus was on the growth, infection, and atopic mechanism. 
&nbsp;

The age group of the children in the study was 1-4 years and it was observed that mothers who had a history of asthma, atopy, and pre-pregnancy obesity, had kids at risk of pre-school wheezing.&nbsp; 
&nbsp;

Moreover, whenever the standard gestational weight gain deviated, it increased the risk of preschool wheezing. The results were independent of pre-pregnancy BMI and no difference was seen in mothers with history of atopy or asthma<a href="#accordion">[5]</a>. Additionally, child growth or eczema did not change the results either. 
&nbsp;

An overall higher risk of pre-school wheezing was seen in offspring of mothers with obesity before pregnancy, history of atopy, asthma, and gestational weight gain. Neither of these could be explained by infectious or atopic mechanisms. However, further research might be able to identify what the underlying mechanisms are.

&nbsp;

Childhood asthma is one of the most common chronic respiratory diseases. Considering that the death rate of children by asthma is 0-0.7 per 100,000 around the world, it is a cause for global concern. Moreover, the annual prevalence of asthma in children is 9.5%, which is higher compared to the 7.7% seen in adults<a href="#accordion">[6]</a>. Therefore, new tools have been developed to target preventive strategies, and improve health. 
&nbsp;

Studies suggest that asthma in children is associated with maternal weight gain before and during pregnancy. Moreover, pre-pregnancy weight gain is a global issue; it jumped from 13% to 22% within a decade (1993-2003). Overall, it indicates an increase of 69%.&nbsp; 
&nbsp;

Unfortunately, numerous studies have examined the link between GWG and pre-pregnancy obesity with childhood asthma, and the results remain inconclusive.&nbsp;

&nbsp;

A healthy and balanced diet can help the baby get the required nutrients for a healthy growth. However, the question that is commonly asked is how much extra calories are even normal? Extra calories are helpful and required in some cases, but eating for two is not recommended.&nbsp; 
&nbsp;

However it is important to note that the below caloric add-ons are applicable if a woman&rsquo;s weight is within a normal range and is moderately active. In this case, the recommended daily intake before pregnancy would be about 2,000 calories a day.&nbsp;&nbsp; 
&nbsp;

The caloric intake in pregnant women depends on the time of the pregnancy. For example, slight increase is good enough for the first trimester, which then needs to increase to an additional 300 to 350 calories per day during the second trimester. In the third trimester, an additional 450 to 500 calories per day are needed. If you&#39;re carrying multiple pregnancies, you could need an additional 300 calories per day for each baby. 
&nbsp;&nbsp;

Pregnant women need to consult their healthcare providers to know how much weight they can gain. Women who have the ideal weight according to their BMI should be able to gain 25-35 pounds during pregnancy, whereas underweight women have a margin for 28-40 pounds. Overweight women can gain only 15-25 pounds when pregnant<a href="#accordion">[7]</a>. 
&nbsp;

So, the general rule is that women can gain 2-4 pounds in their first trimester and 1 pound per week for the remaining pregnancy. Besides, women who are expecting twins can gain 35-45 pounds, which makes it an average of 1.5 pounds per week after the usual first trimester weight gain. It is very important for women with twin pregnancy to gain the right weight.&nbsp;

&nbsp;

It is advised that prenatal healthcare providers evaluate maternal weight at every visit. They should also monitor weight goals and provide counselling accordingly. More than 50% of women tend to exceed their weight gain goals and become overweight, which is a serious health hazard. It leads to low birth weight, failure to produce breast milk, cesarean deliveries, and postpartum weight retention. Furthermore, the offspring can also be overweight and suffer from macrosomia. 
&nbsp;

Although gestational weight gain is potentially threatening to women and the offspring, it is a modifiable risk factor. Diet and exercise during pregnancy helps in reducing the extra weight. However, these interventions have not improved neonatal outcomes significantly, and the effects on obese women are also limited. Thus, indicating that its best to achieve a healthy BMI prior to conception.

&nbsp;

[1] Rogozińska, E., Zamora, J., Marlin, N., Betrán, A.P., Astrup, A., Bogaerts, A., Cecatti, J.G., Dodd, J.M., Facchinetti, F., Geiker, N.R. and Haakstad, L.A., 2019. Gestational weight gain outside the Institute of Medicine recommendations and adverse pregnancy outcomes: analysis using individual participant data from randomised trials. BMC pregnancy and childbirth, 19(1), pp.1-12.

[2] Kominiarek, M.A. and Peaceman, A.M., 2017. Gestational weight gain. American journal of obstetrics and gynecology, 217(6), pp.642-651.

[3] Rusconi, F. and Popovic, M., 2017. Maternal obesity and childhood wheezing and asthma. Paediatric respiratory reviews, 22, pp.66-71.

[4] Harskamp-van Ginkel, M.W., London, S.J., Magnus, M.C., Gademan, M.G. and Vrijkotte, T.G., 2015. A study on mediation by offspring BMI in the association between maternal obesity and child respiratory outcomes in the amsterdam born and their development study cohort. PLoS One, 10(10), p.e0140641.

[5] Leermakers, E.T., Sonnenschein-van der Voort, A.M., Gaillard, R., Hofman, A., de Jongste, J.C., Jaddoe, V.W. and Duijts, L., 2013. Maternal weight, gestational weight gain and preschool wheezing: the Generation R Study. European Respiratory Journal, 42(5), pp.1234-1243.

[6] Liu, S., Zhou, B., Wang, Y., Wang, K., Zhang, Z. and Niu, W., 2020. Pre-pregnancy maternal weight and gestational weight gain increase the risk for childhood asthma and wheeze: an updated meta-analysis. Frontiers in pediatrics, 8, p.134.

[7] National Research Council, 2010. Weight gain during pregnancy: reexamining the guidelines.

Could My Child Be Diabetic?

<a href="https://merisehat.pk/disease/diabetes-a-complete-overview">Diabetes</a> is one of the most common diseases on this planet. People all over the world suffer from it. However, the fact that a greater majority of its victims are adults means the prevalence of this disease in children often goes unnoticed. The reason for this negligence is that often many cases of diabetes in children go undiagnosed due to the lack of apparent symptoms. 
&nbsp;

Understanding Diabetes In Children

Diabetes, simply referred to as &lsquo;sugar&rsquo; in Pakistan, is an increase in blood glucose levels due to insulin-related problems. That is, the body is not producing enough insulin, or it could be that the body has completely stopped producing insulin<a href="#accordion">[1]</a>.

How is the production of insulin related to high blood sugar levels? Think of it this way. After a person consumes carbohydrate-containing foods, their body breaks it down into glucose in the stomach, and eventually, the broken-down glucose is sent to the bloodstream for use by the body. Insulin is important because it&rsquo;s the only hormone responsible to break down glucose and allowing other cells of the body to consume it for energy.&nbsp;

When insulin does not function effectively, it may lead to diabetes. The problem is triggered when the production of insulin is hindered greatly to the extent it fails to target all the glucose in the body, or when the biochemical is not produced at all by the body. Either way, it leaves a higher concentration of glucose in the bloodstream.&nbsp;

A third possibility also exists &ndash; that is, the body does produce insulin, but the cells do not react to it in the way they should. This phenomenon is known as insulin resistance and it is commonly found in type 2 diabetes. The result is that the pancreas receives the message about the high blood sugar present in the body and the organ starts producing more insulin, overworking itself until it stops producing insulin altogether. 
&nbsp;

Type 2 diabetes is also known as adult-onset diabetes. Despite the name and its common prevalence in people of older ages, children suffer from this, too, and the numbers keep on increasing due to obesity and inactive lifestyle<a href="#accordion">[1][2]</a>. Especially when the person is overweight and has central obesity (lots of belly fat).

Children with diabetes type 2 mostly get diagnosed during their teens. Thus, it is believed to occur due to the hormonal changes that the body goes through during puberty. Every human is different and their bodies take their own sweet time to understand, accept, and adjust according to these changes. So, naturally, it will be confused in the case of insulin production, too.&nbsp;&nbsp;

With 1 in 4 adults, i.e., 26.7% of people in Pakistan having diabetes, it is safe to assume that the genetics of the country is filled with diabetes. The prevalence of type 2 diabetes is around 11.77% in Pakistan<a href="#accordion">[3]</a>. Simply by extension, it is believed that the instances of diabetes in children would be high too but, unfortunately, there is no robust evidence regarding the number of affected children in Pakistan. 
&nbsp;

Diabetes is a life-altering disease. It can turn out to be very limiting for people of younger age groups with symptoms like increased hunger and thirst, frequent infections, and fatigue.

Adult-onset diabetes is a lot easier to manage because the health and lifestyle changes are much easier to adapt to. On the contrary, the body of children at this age is still developing; consequently, they face multiple issues, including heart diseases, eye problems, and even potential nerve damage.&nbsp;

Unfortunately,&nbsp; these issues also progress faster in children with type 2 diabetes than in type 1, making it harder to control<a href="#accordion">[5]</a>. Children are also known to deal with poor kidney function and bad eyesight.&nbsp;

All of this requires strict control of blood sugar levels, which becomes challenging, especially for parents when children don&rsquo;t cooperate. 
&nbsp;

Obesity is not the only condition related to diabetes. When a person is diagnosed with insulin resistance, they may have several other conditions as well. It is common to experience metabolic syndrome with early age type 2 diabetes. This is characterized by: <ul><li>Increased blood pressure</li><li>Low LDL (high-density lipoproteins)</li><li>High triglycerides</li><li>Increased blood sugar level</li><li>Large waist size </li></ul>

Polycystic ovary syndrome (PCOS) and diabetes go hand-in-hand in girls and women. If a girl is exhibiting symptoms like irregular periods, weight gain, and excess body and facial hair, it&rsquo;s possible that she might have PCOS. Hormonal imbalance is the root cause of PCOS, hence, there is a greater probability that the body stops responding to insulin or produces inadequate amounts of it. And, vice-versa, if the child is diabetic, then they are more susceptible to PCOS than other girls their age<a href="#accordion">[4]</a>. 
&nbsp;

The most ideal approach to managing diabetes is to let the kid in on the action, i.e., make them aware of their condition, inform them how their choices will be different from other kids of their age, and the lifestyle changes they need to incorporate to lead a productive life. This is best done by taking one day at a time rather than unloading the information all at once and overwhelming the child.&nbsp;

Empower them from a young age by letting them make their own choices. For example, let them choose which finger to prick for checking blood sugar levels or decide where they feel comfortable taking their insulin shots. This can be slowly built up as they age. They can be trained into taking care of themselves. As teenagers, they can be taught about carb counting and different ways to maintain their dietary intake for optimum results<a href="#accordion">[6]</a>. 
&nbsp;

When it comes to risk factors of type 2 diabetes in children, they are not too different from those experienced by adults. Some of the common risk factors include:

<ul>
	<li>Obesity</li>
	<li>Age &ndash; Most young patients with diabetes type 2 are diagnosed during their early teens</li>
	<li>Activity &ndash; Sedentary lifestyle has been associated with increased insulin resistance</li>
	<li>Family history</li>
	<li>Mother with gestational diabetes</li>
	<li>Ethnicity &ndash; African American, Asian American and Latino are generally more at risk 
	&nbsp;</li>
</ul>

<ul><li>Type 2 diabetes is getting very common day by day, especially in children, due to a sedentary lifestyle.</li><li>The best approach for type 2 diabetes in children is to allow them to take control of their bodies as well.</li><li>The key to managing it all is weight maintenance, physical activity, and dietary intake.</li></ul>

[1] Gavin ML, ed. What is type 2 diabetes? (for parents) - nemours kidshealth. KidsHealth.

[2] Prevent type 2 diabetes in Kids. Centers for Disease Control and Prevention.

[3] SA, Meo & Zia, Inam & Bukhari, Ishfaq & Arain, Shoukat. (2016). Type 2 diabetes mellitus in Pakistan: Current prevalence and future forecast. JPMA. The Journal of the Pakistan Medical Association. 66. 1637-1642.

[4] Type 2 diabetes in children. Mayo Clinic.

[5] Holland K. Type 2 diabetes in children. Healthline.

[6] Child type 2 diabetes: Symptoms, causes &amp; treatments. WebMD.

Umna Salah

AL SHIFA CLINIC KARACHI

Syed Intisar Hussain

Checking Sugar While Fasting!

You know what they say &ndash; breakfast is the most important meal of the day. But what about when you&#39;re fasting? Well, in that case, your regular breakfast time is your cue to check your blood sugar level! 
&nbsp;

This is especially important if you&rsquo;re a <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetic</a>. Fasting can cause your blood sugar levels to fluctuate, triggering complications such as hypoglycemia or hyperglycemia. Hence, monitoring&nbsp; blood sugar levels while fasting can help your doctor to adjust your treatment plans as needed. 
&nbsp;

So, go get your glucometer ready and let&#39;s dive into the world of checking sugar while fasting! 
&nbsp;

According to the International Diabetes Federation (IDF), an estimated 537 million people worldwide were living with diabetes in 2021<a href="#accordion">[10]</a>.

Also, diabetes was the ninth leading cause of death globally in 2019 and accounted for approximately 6.7 million deaths worldwide in 2021<a href="#accordion">[10][11]</a>.The IDF projects that the number of people living with diabetes will increase to 643 million by 2030 and 783 million by 2045<a href="#accordion">[10]</a>.

In Pakistan, diabetes affects approximately 26% of the population<a href="#accordion">[12]</a>.&nbsp;It is a major cause of morbidity and mortality in Pakistan, with a high prevalence of complications such as diabetic retinopathy, neuropathy, and nephropathy<a href="#accordion">[12]</a>.

&nbsp;

<h5>What Is Blood Sugar Level?</h5>

The term &quot;blood sugar level&quot; describes the amount of glucose in the blood. Glucose is a form of sugar that is the main fuel for the body&#39;s cells. When glucose levels spiral out of control, it can result in two major health issues &ndash; diabetes and metabolic syndrome. 
&nbsp;

<h5>What Is Fasting Blood Sugar Level?</h5>

The quantity of glucose in the blood after a period of fasting is known as the fasting blood sugar level. The test can help you get a timely intervention, especially if you&rsquo;re prediabetic as you&rsquo;ll be able to make lifestyle adjustments to delay the onset of diabetes. 
&nbsp;

<h5>Is It Really Important?</h5>

There are various reasons why it&#39;s crucial for you to check your fasting blood sugar levels: 
&nbsp;

<ul>
	<li>It determines whether your diabetic medication is effective or not. If your fasting blood sugar levels are regularly high, your doctor will adjust your prescription.</li>
	<li>Monitoring your blood sugar levels before a fast helps spot patterns. For instance, if the recorded fasting blood sugar levels are regularly high post-Iftar, it&rsquo;s an indication that you need to change those meals.</li>
	<li>Your doctor can assess the risk of developing diabetic problems, like consistently high fasting blood sugar levels present with an increased risk of cardiovascular disease, neurological damage, and renal disease.</li>
</ul>

This is why your blood sugar levels need to be just right. 
&nbsp;

Normal Blood Sugar Range

According to the American Diabetes Association:

<ul>
	<li>Fasting blood glucose range: 70-99 mg/dL</li>
	<li>2 hours after a meal: less than 180 mg/dL</li>
	<li>A1C level: less than 5.7% 
	&nbsp;</li>
</ul>

However, these blood sugar levels are affected by various factors, including age, weight, and general health. 
&nbsp;

A fasting blood sugar level of 126 mg/dL or greater is considered a cutoff point to identify diabetes. Consult your doctor immediately if you experience symptoms such as frequent urination or excessive thirst, and you have a fasting blood sugar of 126 mg/dL at least.

&nbsp;

NOTE: Remember diabetes is not always indicated by a single high fasting blood sugar level. A second blood sugar test, such as an oral glucose tolerance test or a hemoglobin A1C test, is typically ordered by doctors to confirm the diagnosis. 
&nbsp;

Checking your blood sugar is an easy procedure that can be carried out either at home or at a doctor&#39;s office: 
&nbsp;

1.&nbsp;&nbsp;&nbsp;&nbsp; Wash your hands properly with soap.

2.&nbsp;&nbsp;&nbsp;&nbsp; Place the blood sugar test strips into the glucometer.

3.&nbsp;&nbsp;&nbsp;&nbsp; Use a lancet to prick your finger.

4.&nbsp;&nbsp;&nbsp;&nbsp; Place the blood drop against the test strip in the glucometer.

5.&nbsp;&nbsp;&nbsp;&nbsp; The glucose meter will show your blood sugar level within seconds.

&nbsp;

<h5>Significance Of Fasting Blood Sugar Levels</h5>

High levels of your fasting blood sugar indicate that the body is either not producing enough insulin or not utilizing it well. This may lead to diabetes and other health issues. On the other hand, low fasting blood sugar levels will cause confusion, vertigo, and weariness. 
&nbsp;

Hyperglycemia and Hypoglycemia

Fasting blood sugar levels must be measured to diagnose hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar) in diabetics. 
&nbsp;

High blood sugar levels in diabetics can result in a variety of symptoms, including increased thirst, frequent urination, impaired vision, lethargy, and sluggish wound healing. Long-term effects from hyperglycemia include nerve damage, renal disease, and cardiovascular disease. Consistently high fasting blood sugar readings may be a sign that you need to alter their diabetes medication or make dietary and lifestyle adjustments. 
&nbsp;

Low blood sugar levels in diabetics can result in symptoms including perspiration, shakiness, dizziness, disorientation, and irritability. Hypoglycemia can cause seizures, comas, and even death in extreme circumstances. You may need to adjust your diabetes medication, your food intake, or your level of physical activity if your fasting blood sugar levels are consistently low because it&rsquo;s a sign of not eating enough or exercising too much. 
&nbsp;

Tips for Mangament

A healthy blood sugar level is necessary for your overall well-being. 
&nbsp;

<ol>
	<li>Maintain a nutritious diet: A diet low in processed foods, sugar, and saturated fats, and high in complex carbs, fiber, and protein will help control blood sugar levels.</li>
	<li>Engage in regular exercise: Exercise helps enhance insulin sensitivity, which can help control blood sugar levels. Aim for 150 minutes or more per week of light-moderate intensity exercise.</li>
	<li>Test blood sugar levels often: Checking your blood sugar level regularly helps you keep a track of it and alter your diet and medication accordingly.</li>
	<li>Maintain a healthy weight: Obesity and being overweight are linked to an increased risk of diabetes and other illnesses. Diet and exercise-based weight management can help control blood sugar levels.</li>
	<li>Get adequate sleep: Sleep deprivation can throw off the body&rsquo;s hormonal balance, which can impair how well blood sugar is regulated. Don&rsquo;t be a night owl; sleep for 7-8 hours every night. 
	&nbsp;</li>
</ol>

So, there you have it, folks &ndash; checking your blood sugar levels while fasting is no laughing matter. Remember to stick to a healthy diet, exercise regularly, and get enough rest to keep your blood sugar levels in check. And when in doubt, don&#39;t hesitate to reach out to your healthcare provider for guidance. 
&nbsp;

<ul>
	<li>Blood sugar levels are crucial for your general health and well-being.</li>
	<li>Fasting blood sugar tests, which can provide important details about how effectively your body is metabolizing glucose, is one way to monitor your blood sugar levels. 
	&nbsp;</li>
</ul>

[1] American Diabetes Association. (2021). Standards of medical care in diabetes - 2021. Diabetes Care, 44(Supplement 1), S1-S232. doi: 10.2337/dc21-S000.

[2] American Heart Association. (n.d.). Managing blood sugar with physical activity.

[3] Centers for Disease Control and Prevention. (2020). National Diabetes Statistics Report, 2020.

[4] Mayo Clinic. (2021). Hypoglycemia.

[5] Mayo Clinic. (2021). Blood sugar testing: Why, when and how.

[6] National Institute of Diabetes and Digestive and Kidney Diseases.

[7] National Institute of Diabetes and Digestive and Kidney Diseases. (2021).

[8] Powers, M. A., Bardsley, J. K., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., . . . Vivian, E. M. (2017). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educator, 43(1), 40-53. doi: 10.1177/0145721716689694

[9] World Health Organization. (2021). Obesity and overweight.

[10] International Diabetes Federation. IDF Diabetes Atlas, 10th edn. Brussels, Belgium: IDF, 2021.

[11] World Health Organization. The top 10 causes of death. Updated January 2021.

[12] Pakistan Diabetes Association. About diabetes.

[13] Sabir A, Ohri-Vachaspati P, Singh A, Kern DM, Zhao Y, Crespo NC, et al. Prevalence and correlates of diagnosed and undiagnosed diabetes mellitus and prediabetes in Pakistan: Results from a nationally representative survey. PLoS One. 2020;15(6):e0234451

Arbaz Ansari

Importance Of Hydration During Ramadan For Diabetics!

Muslims around the globe observe Ramadan, an important time when they fast for 29-30 days from dawn until dusk. If fasting is not done safely and properly, Ramadan may cause fasting-related complications, such as hypoglycemia, dehydration, and hyperglycemia. Maintaining hydration is essential for the general health and well-being of diabetics, particularly during Ramadan. The body loses fluids during the fasting period, which causes dehydration. Dehydration can cause headaches, lightheadedness, and lethargy, as well as elevated blood sugar levels in <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetic</a>s.&nbsp; 
&nbsp;

Understanding Importance Of Hydration During Ramadan For Diabetics

To stay hydrated during Ramadan, diabetics need to drink plenty of water and other fluids between Iftar (the evening meal) and Suhoor (the pre-morning meal). It&#39;s important to drink fluids in small amounts regularly throughout the night rather than in large amounts at once. Additionally, consuming foods specifically fruits and vegetables with high water content, such as watermelon, cucumbers, and oranges, can help maintain hydration levels.

Here are some tips on how diabetics can stay hydrated:

<ol>
	<li>&nbsp;Drink Plenty Of Water And Other Fluids: Drink at least eight glasses of water during non-fasting hours between Iftar and Suhoor. Try to consume fluids in small amounts regularly throughout the night rather than large amounts at once.&nbsp;</li>
	<li>&nbsp;Consume Foods With High Water Content: Eating foods with high water content can help maintain hydration levels. Some examples include watermelon, cucumbers, oranges, strawberries, and lettuce.</li>
	<li>&nbsp;Avoid Caffeine And Sugar: Caffeinated and sugary drinks can lead to dehydration, so it&#39;s best to avoid them during Ramadan.</li>
	<li>&nbsp;Use A&nbsp;Humidifier: A humidifier can help maintain moisture levels in the air and prevent dehydration during fasting.</li>
	<li>&nbsp;Monitor Blood Sugar Levels: High blood sugar levels can cause dehydration, so it&#39;s essential to monitor blood sugar levels regularly and adjust medication accordingly.</li>
	<li>&nbsp;Consult With A&nbsp;Healthcare Professional: People with diabetes should consult with their healthcare professional before fasting in Ramadan to ensure it&#39;s safe for them to do so and get personalized advice on how to manage their diabetes and hydration during fasting.</li>
	<li>&nbsp;Avoid Strenuous Exercise: Diabetics are advised to avoid any strenuous exercise, especially before iftar or late in the evening.</li>
</ol>

By following these tips, diabetics will be able to maintain hydration levels during fasting in Ramadan and prevent complications linked with dehydration. 
&nbsp;

While dehydration is a cause for concern, overhydration can also be a possible complication in diabetics. In rare cases, excessive consumption of water can lead to overhydration. This can result in hyponatremia (low blood sodium levels), which can be troublesome for diabetics. As a result, it&#39;s crucial to regulate fluid intake and refrain from overindulging.

Dehydration from inadequate water intake can result in elevated blood sugar levels. On the other hand, hyponatremia from overhydration can result in convulsions or even a coma<a href="#accordion">[1]</a>. 
&nbsp;

In conclusion, diabetics are advised to take precautions to avoid dehydration during Ramadan. It&#39;s important to drink fluids regularly in small amounts, consume foods with high water content, and avoid overhydration. By following these simple hydration tips, people with diabetes can have a safe and healthy Ramadan while effectively managing their diabetes. 
&nbsp;

[1] Tootee A, Larijan B. Ramadan fasting and diabetes, latest evidence and technological advancements: 2021 update. Journal of Diabetes & Metabolic Disorders. 2021 Jun;20:1085-91.

Syeda Qurat-ul-Ain

However, if you are diabetic and pregnant or have developed gestational diabetes during pregnancy, you would have probably noticed the &lsquo;extra&rsquo; care showered at every stage &ndash; during pregnancy, labor, and then birth. But, as your diabetes team and the antenatal team must have told you, it doesn&rsquo;t end here. And you should be expecting a similar routine once the baby is born. 
&nbsp;

Understanding the managment of Diabetes after delivery

<ul>
	<li>Gestational diabetes affects around 17 million pregnancies worldwide.<a href="#accordion">[1]</a></li>
	<li>A majority of women with gestational diabetes develop transient hyperglycemia during pregnancy.</li>
	<li>It is a significant risk factor for permanent or future glucose intolerance or type 2 diabetes postpartum. Pregnant women with gestational diabetes are 50% more likely to develop diabetes within 5 years post-delivery.<a href="#accordion">[2]</a></li>
	<li>Recommendations for postpartum follow-up visits include care continuing throughout the first year after delivery.</li>
	<li>Early diagnosis and intervention help reduce long-term complications, such as retinopathy, neuropathy, and cardiovascular disease. 
	&nbsp;</li>
</ul>

<ul>
	<li>Based on NICE guidelines, women with gestational diabetes should be tested for type 2 diabetes after giving birth. The recommended time for this screening is between 6-13 weeks postpartum. The American Diabetes Association suggests a similar recommendation, but their time frame is slightly narrower, advising the screening to be done between 6-12 weeks postpartum.<a href="#accordion">[3]</a></li>
	<li>If a woman didn&#39;t have a postpartum screening or received a negative result in the first year after giving birth, she should undergo screening at least every 3 years for a total of 10 years after the pregnancy.<a href="#accordion">[4]</a></li>
	<li>If a woman&#39;s initial screening test shows a positive result for diabetes, it is essential for her to repeat the test at least 6 months after giving birth to confirm the diagnosis. This confirmation step should be taken regardless of the type of initial test used &ndash; hemoglobin A1C, fasting plasma glucose, or oral glucose tolerance test.<a href="#accordion">[4]</a></li>
	<li>Repeat testing is advised if a woman was screened using the hemoglobin A1C test within the first 6 months postpartum. This is because the A1C test may not provide accurate results during this period. 
	&nbsp;</li>
</ul>

Additionally, the accuracy of the A1C test can be affected in women with renal failure, anemia, certain hemoglobinopathies, and those who have recently received blood transfusions.<a href="#accordion">[4]</a> 
&nbsp;

<ul>
	<li>Despite recommendations, one-third of affected women reportedly don&rsquo;t have postpartum screening.<a href="#accordion">[5]</a>&nbsp;Although attendance rates vary from country to country, it&rsquo;s generally poor.</li>
	<li>Women visiting hospital-based clinics are twice as likely than those visiting community clinics to go ahead with postpartum glucose testing.<a href="#accordion">[5]</a></li>
	<li>Emotions, like feeling afraid or stressed out from adjusting to a new baby, or being diagnosed with diabetes also contribute to it.</li>
	<li>Studies in Australia and Canada found that postpartum reminders increased the screening rate to 50-60%.<a href="#accordion">[5]</a> 
	&nbsp;</li>
</ul>

The comprehensive postpartum visit is usually scheduled between 4 and 6 weeks postpartum. Culturally, women and newborns are allowed 40 days post-delivery to recover and adjust to their bodies and environment.

In Pakistan, too, the tradition is to provide the new mother with relief from household work, and additional family support for 40 days. The period is also known as chilla.

A recent study found that this cost-effective, community-based practice is actually a sustainable intervention for maternal mental health with lower symptom severity among prenatally depressed women.<a href="#accordion">[6]</a>

While this timing should be individualized, today 23% of employed women go back to work within 10 days postpartum, with 22% more women resuming their roles between 10 and 40 days.<a href="#accordion">[7]</a> 
&nbsp;

In the case of gestational diabetes, your blood sugar levels are most likely to return to normal after labor. 90% of the time, it does. So, any diabetic medication you&rsquo;ve been prescribed by your doctor (including insulin) may be stopped at that time.

However, it may also be the case that you already had diabetes and were taking medications for it before your pregnancy. Or perhaps your pregnancy uncovered existing diabetes that you weren&rsquo;t aware of. Also, there&rsquo;s this increased risk of developing type 2 diabetes later in life or having gestational diabetes in future pregnancies if you have it now. The point is, diabetes continues after delivery in 2-3% of all women. If you fall into this category, you may be asked to carry on with your treatment.

Your blood sugar levels need to be checked regularly. However, studies indicate an average rate of &lt;50% completion of postpartum glucose screening to detect pre-diabetes or diabetes.<a href="#accordion">[8]</a> 
&nbsp;

Screening is important because:

<ul>
	<li>If you are pre-diabetic, screening allows you to adopt a targeted lifestyle and effectively reduce your risk of developing type 2 diabetes later on.</li>
	<li>If you&rsquo;re already diagnosed with type 2 diabetes, targeted intervention again can help reduce your risk of developing end-organ injury.</li>
	<li>Further, in case of future pregnancies, you can reduce your risk of complications, like hypertension, congenital malformations, preterm delivery, and neonatal morbidities, with optimized blood glucose levels. 
	&nbsp;</li>
</ul>

Regular appointments with your healthcare team are a sure thing. DO NOT skip them. In fact, do your preparations before an appointment to get the most out of this opportunity.

<ul>
	<li>Write down your worries and concerns that you need to discuss with your doctor or questions to get the desired information. Don&rsquo;t be shy to ask anything you don&rsquo;t understand.</li>
	<li>Make sure you have your list of medications and your blood sugar results with you.</li>
	<li>Your doctor may order more tests. They may modify your medications or advise you on some lifestyle changes. Take notes if you want to remember the instructions and what to anticipate next. 
	&nbsp;</li>
</ul>

Note: If you have a history of gestational diabetes, it&rsquo;s recommended to have a 2-hour glucose tolerance test at 6 weeks and then at least every 3 years after your baby is born. 
&nbsp;

Post-delivery, it&rsquo;s only natural that you prioritize taking care of your baby. However, this period is also one of the most important times to engage with your diabetes care team and manage the condition.

Your body has gone through so many changes, all of which impact your blood sugar. The delivery process, whether you have a c-section or vaginal delivery, will also affect your recovery period and, hence, your diabetes management. 
&nbsp;

Unlike common misconceptions, glucose targets are necessary to prevent hypoglycemia while regular screenings help monitor for diabetes complications after a pregnancy.

<ul>
	<li>Low carbs are recommended for general diabetes management. However, according to the American Diabetes Association, you should consume at least 120 g of carbs daily while breastfeeding. This is because your glucose may drop to dangerously low levels while breastfeeding as milk production requires high levels of energy, including glucose. Make sure to have access to snacks.</li>
	<li>Half of your plate should be filled with green vegetables.</li>
	<li>Choose whole grain carbs, like oats, brown rice, wholewheat pasta, and high-fiber biscuits. They&rsquo;re also rich in vitamins.</li>
	<li>Opt for beans and fish for your protein intake rather than red or processed meats.</li>
	<li>Reduce fried and processed foods.</li>
	<li>Avoid sweetened drinks and food items.</li>
	<li>Water is best for hydration. Cut down on your caffeine; stick to 300 mg or less per day.</li>
	<li>If you&rsquo;re getting enough calories, then breastfeeding is safe for you. While individual calorie intake depends on age, body size, how much you&rsquo;re breastfeeding, and your activity level, it&rsquo;s recommended to consume about 2300-2500 calories in a day.</li>
	<li>If your diabetes is well under control, your breast milk will be the same as someone without diabetes. 
	&nbsp;</li>
</ul>

The rapid fluctuations in your weight during and after pregnancy are normal. The problem starts when you are unable to shed those extra pounds. It puts you at risk of developing diabetes-related complications, including the risk of developing gestational diabetes in the next pregnancy and type 2 diabetes later in life.

Also, if you don&rsquo;t look or feel good due to weight, it may be an added stressor that can take a toll on your mental health. The CDC states that 1 in 8 American women experience postpartum depression, but nearly 30% of them were not even asked about the symptoms of depression during their postpartum visit. <a href="#accordion">[9]</a>

And diabetic people, specifically, are 2-3 times more likely to have depression and 20% more likely to have anxiety than those who are not diabetic.<a href="#accordion">[9]</a> 
(Note: Get screened for postpartum depression at each visit to get treatment as early as possible.) 
&nbsp;

Breastfeeding may help reduce excessive weight gain. However, the option is not available for all. Besides, an exercise routine to manage the weight after recovery from delivery allows slow, steady, and sustained weight loss. 
&nbsp;

Exercise not only promotes weight loss but also improves fitness and boosts energy levels as well. Further, it relieves stress, reduces symptoms of postpartum depression, and promotes better sleep. So, ask your doctor when it&rsquo;s safe to begin exercising again.

<ul>
	<li>A reduction of 0.5-1 kg per week or 7% of body weight in 6 months is considered a safe goal.</li>
	<li>Get at least 30 minutes of exercise every day.</li>
	<li>If you&rsquo;re breastfeeding, drink plenty of fluids throughout the day.</li>
	<li>Ditch the elevator; use stairs.</li>
	<li>Try yoga or Kegels. Go swimming. Join a dance class. 
	&nbsp;</li>
</ul>

You become extremely sensitive to insulin immediately after the placenta and baby are delivered. As such, your target blood glucose levels should be kept between 5 and 10 mmol/L to avoid the risk of hypoglycemia.

If your treatment before pregnancy was metformin, you&rsquo;ll probably be resuming it afterward. The same goes for insulin; if you were taking it before pregnancy, you will need to continue taking it but the type, dosage, and number of injections will have to be reviewed.

In some cases, insulin is started after pregnancy. If you need it, then these doses will be lower than what was being administered during pregnancy. Moreover, they have to be reviewed frequently, particularly during the first month after delivery.

If you&rsquo;re breastfeeding, insulin and metformin are usually the only diabetes medications that are suitable for use. Any other medication will be prescribed once this phase is over.

Your doctor may also need to adjust your medications to treat other diabetes-related issues, like cholesterol and high blood pressure.

In particular, blood pressure evaluation is recommended around 7-10 days postpartum for women with hypertensive disorders associated with pregnancy. For women with severe hypertension, it&rsquo;s important to consult a doctor within 72 hours; some experts suggest 3-5 days. This is important because more than 50% of postpartum strokes occur within 10 days of discharge.<a href="#accordion">[7]</a>

Birth control may also become part of the postpartum plan to prevent unplanned pregnancies in the future. This may include progesterone-only birth control pills since estrogen can affect milk production, a problem if you choose to breastfeed.

Besides, if you have had gestational diabetes and are planning future pregnancies, make sure you haven&rsquo;t developed diabetes since the last one. Also, take folic acid supplements daily for 3 months before trying to get pregnant. 
&nbsp;

Being a diabetic pregnant woman can be a scary notion. That is, managing diabetes in addition to navigating the changing hormones, fatigue, lack of sleep, lack of sexual desire, and other challenges. But, with a few precautions, you can definitely have a happy and healthy pregnancy. And with a little help from your family, friends, and healthcare providers, postpartum diabetes management is possible, too. Make sure you continue all your follow-up medical tests and doctor visits. Also, continue with a healthy and active lifestyle.

[1] Pregnancy as an opportunity to prevent type 2 ... - wiley online library

[2] Gestational diabetes - after the birth. HSE.ie.

[3] Á. Cronin a, a, c, et al. Facilitators and barriers to attending postpartum screening in women with a recent pregnancy complicated by gestational diabetes mellitus: A qualitative study. Public Health

[4] Diabetes after pregnancy recommendations. WPSI.

[5] Postpartum screening for diabetes in women diagnosed with gestational ...

[6] LeMasters K, Andrabi N, Zalla L, et al. Maternal depression in rural Pakistan: The protective associations with cultural postpartum practices - BMC public health. BioMed Central.