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Iqra Mazhar

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Importance Of Insulin In Diabetic Care

Ismail Munir

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The Foot Care Guide For Diabetic Patients

Introduction

Diabetes foot problems are quite common as, according to the American Diabetes Association, 1 in 5 people with diabetes seek hospital care for it<a href="#accordion">[1]</a>. However, that doesn&#39;t mean everyone with diabetes has diabetic feet. 
&nbsp;

You won&#39;t succumb to diabetic feet if you give your feet all the attention they deserve. It&rsquo;s all the more imperative if your blood sugar levels are continually out of range.&nbsp; 
&nbsp;

In short you need to be proactive while taking care of your feet to avoid diabetic foot or any other complications. 
&nbsp;

Understanding the Foot Care for Diabetic Patients

To understand the correlation between diabetes and foot problems, you first need to have a clear idea about what diabetes really is.&nbsp; 
&nbsp;

<h5>Understanding Diabetes&nbsp;</h5>

Diabetes mellitus, or diabetes for short, is a metabolic disorder that causes high blood sugar levels, which is referred to as hyperglycemia.&nbsp; 
&nbsp;

The reason for diabetes is either absolute or relative deficiency of insulin, or&nbsp; insulin resistance. Insulin is the hormone released by pancreas that helps to maintain a normal level of the blood glucose levels by ensuring glucose uptake in the liver and muscles after a meal.&nbsp; 
&nbsp;

There are 3 different types of diabetes:

1. Type 1 Diabetes Mellitus: This type of diabetes has an autoimmune basis, which means that the body&#39;s own immune cells start attacking the pancreas resulting in absolute deficiency of insulin. The reason behind this autoimmune destruction of cells in the pancreas that produce insulin remains unclear<a href="#reference" target="_blank">2</a>. This type of diabetes affects both children and young adults.

2. Type 2 Diabetes Mellitus: Almost 90-95% of individuals with diabetes have this type of diabetes. It occurs when cells in the body become unresponsive to insulin and the sugar levels peak in the blood resulting in hyperglycemia<a href="#accordion">[2]</a>. 
&nbsp;

3. <a href="https://merisehat.pk/disease/diabetes-gestational">Gestational Diabetes</a>: Some women experience this type of diabetes during pregnancy. Their placenta makes hormones that block insulin from functioning<a href="#accordion">[2]</a>.&nbsp; 
&nbsp;

If left untreated, all three types of diabetes result in blood sugar levels beyond the normal range, which ultimately damages multiple sites in the body like the kidneys, eyes, nerves, and other organs<a href="#accordion">[2]</a>.&nbsp; 
&nbsp;

Some common symptoms of diabetes include<a href="#accordion">[2][3]</a>: 
&nbsp;

<ul>
	<li>Increase in thirst&nbsp;</li>
	<li>Increase in hunger&nbsp;</li>
	<li>Increase in frequency of urination&nbsp;&nbsp;</li>
	<li>Weight loss (individuals with gestational diabetes would have increased weight gain during pregnancy)</li>
	<li>Blurry vision&nbsp;</li>
	<li>Sores that heal slowly or do not heal&nbsp;</li>
	<li>Fatigue&nbsp;</li>
	<li>Numbness or tingling in hand or feet&nbsp;</li>
	<li>Dry or itchy skin 
	&nbsp;</li>
</ul>

Now back to the initial question: how can diabetes cause foot problems? So, diabetes damages the nerves, a condition called diabetic neuropathy. As a result, you may experience pain, tingling, and burning sensation in your affected foot. If the nerve damage is extensive, you may feel nothing at all.&nbsp; 
&nbsp;

While the idea of having an area of skin being pain free may sound great, not being able to have any sensation in any region of your body is far from great. The dangers associated with not being able to sense anything are so serious that it can even cost you losing the affected part through amputation, that is, surgically removing the affected limb. 
&nbsp;

As an individual with diabetic neuropathy, you may not feel a stone or pebble underneath your sole; you won&rsquo;t even feel a blister or if your foot&rsquo;s sore. When these lesions are not treated early on, they can either become the portal of entry for bacteria and other microorganisms causing infection or they can result in ulcer formation due to delayed healing of the skin<a href="#accordion">[4]</a>. 
&nbsp;

Slow healing in diabetic individuals is because the blood vessels supplying the periphery become very narrow which reduces the amount of blood flowing in the leg and foot. This impedes the healing process and infections of the feet often take too long to heal or at times may not heal at all. When an infection doesn&#39;t resolve, it progresses to gangrene (death of a body tissue due to inadequate blood perfusion or due to a serious bacterial infection)<a href="#accordion">[4]</a>.&nbsp; 
&nbsp;

Once gangrene or ulcers form in the foot, treatment&nbsp; options include removing the dead tissue and treating existing infections. In extreme cases amputation of the involved part, such as the toe, foot, or part of the leg is the only option<a href="#accordion">[4]</a>.

Therefore, in order to prevent the loss of a part of your limb, precautions should be taken and foot care needs to be maximized. Controlling blood sugar levels is the only way to prevent diabetic foot<a href="#accordion">[4]</a>. In case a foot problem develops, a foot specialist or a podiatrist needs to be consulted immediately<a href="#accordion">[4]</a>. 
&nbsp;

Nerve damage eventually leads to diabetic foot if not treated. The following risk factors increase the risk of developing diabetic neuropathy<a href="#accordion">[3]</a>: 
&nbsp;

<ul>
	<li>High blood sugar levels that are difficult to manage</li>
	<li>Having a long history of diabetes with blood sugar levels beyond normal ranges</li>
	<li>Being overweight</li>
	<li>Having hypertension (increased blood pressure</li>
	<li>Having high levels of cholesterol</li>
	<li>Being more than 40 years of age 
	&nbsp;</li>
</ul>

There are some measures that you can take to prevent nerve damage<a href="#accordion">[3]</a>:&nbsp;

<ul>
	<li>Maintain healthy blood sugar levels&nbsp;</li>
	<li>Quit smoking since smoking reduces the blood perfusion to the feet</li>
	<li>Use medications as prescribed by the doctor&nbsp;</li>
	<li>Become physically active&nbsp; 
	&nbsp;</li>
</ul>

You need to be consistent with your foot care regimen as it is the only way to prevent foot problems in diabetes. There&#39;s no denying that managing diabetes can get quite overwhelming with trying to maintain your blood sugar levels, going for doctor&#39;s appointments, taking medications, staying active along with eating healthy; and there is a chance that your feet get neglected in the process. 
&nbsp;

However, incorporating foot care into your daily routine will help reduce the risk of developing diabetic feet<a href="#accordion">[3]</a>. Remember, persistence is the key!&nbsp;

Here&#39;s a list of tips that you can follow to ensure that your feet stay healthy: 
&nbsp;

<ul>
	<li>
	<h5>Inspect Your Feet Daily</h5>
	</li>
</ul>

You need to regularly check your feet for any signs of bruises, scar marks, blisters, swelling, sores, calluses, or any change in color of the skin or nail. You can use a mirror to inspect the part of your feet that isn&#39;t visible to you or, if you don&#39;t find it convenient, ask a family member to help you or consult a doctor<a href="#accordion">[3]</a>. The earlier you detect any sore or blister, the easier it is to treat and vice versa.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Don&#39;t Walk Barefoot&nbsp;</h5>
	</li>
</ul>

Always wear slippers at home and shoes outdoors and never walk barefoot even in your house. This is to prevent injuries to the feet. Moreover, make sure that your shoes have no pebbles or any other object that can cause any injury to your feet<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Wash Your Feet Daily With Warm Water&nbsp;</h5>
	</li>
</ul>

Do not use hot water to wash your feet as it will cause skin&nbsp; dryness; instead, use warm water. Also, don&#39;t soak your feet. Just wash them properly and dry them right after<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Moisturize Your Feet</h5>
	</li>
</ul>

Diabetic individuals, especially those who have dry feet, are no strangers to cracks on their feet. The trick is to keep your feet moistened. However, make sure not to apply lotion or moisturizing cream between the toes as it can result in infection<a href="#accordion">[3]</a>&nbsp;and keep the application limited to the heel of the foot.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Choose The Right Shoes&nbsp;</h5>
	</li>
</ul>

Wear shoes that are the right size, not too tight or too loose. It would not only be difficult to walk, but would also increase the chances of developing foot problems. Most importantly, make it a habit to wear socks with your shoes<a href="#accordion">[3]</a>. 
&nbsp;

<ul>
	<li>
	<h5>Properly Trim Toenails</h5>
	</li>
</ul>

Try to cut your nails gently straight across and smooth them with a nail file. Avoid cutting your nails too deep as it may cause a break in the skin and become a space for an infection to set in<a href="#accordion">[3]</a>.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Keep The Blood Flowing&nbsp;</h5>
	</li>
</ul>

To maintain perfusion in the feet, put your feet up while sitting and don&#39;t stand or hang your legs for too long. This is also for women with gestational diabetes as they need proper perfusion in their lower limbs (leg area). Wiggle your toes multiple times in a day to maintain perfusion<a href="#accordion">[3]</a>. 
&nbsp;

<ul>
	<li>
	<h5>Do Not Miss Your Doctor&#39;s Visit&nbsp;</h5>
	</li>
</ul>

Visit your doctor every year or as scheduled for your diabetes. Get your feet properly examined by a feet specialist, more so if your healthcare provider is suspecting diabetic neuropathy. 
&nbsp;

Stay vigilant and if you notice any of the symptoms listed below, consult a healthcare provider immediately to either treat or prevent diabetic foot<a href="#accordion">[3]</a>: 
&nbsp;

<ul>
	<li>Pain in the legs and cramping in the thighs and calves during physical activity&nbsp;</li>
	<li>Inability to sense temperature, pain, or touch over the skin of your foot&nbsp;</li>
	<li>Tingling, painful, and burning sensation in your feet&nbsp;</li>
	<li>Dry skin with cracks</li>
	<li>Thick, yellow toenails&nbsp;</li>
	<li>Signs of fungal infection, such as athlete&#39;s foot&nbsp;</li>
	<li>Any sign of sore, blister, or ulcer anywhere on the foot 
	&nbsp;</li>
</ul>

Conclusion

Diabetes is a very common metabolic disorder and it is associated with a constellation of signs and symptoms. Moreover, the damage caused by diabetes is also widespread as it involves many organs of the body. Diabetic neuropathy affecting the foot is another dreaded complication of diabetes that can cause the diabetic individual to lose sensation over the affected area. It can progress to diabetic foot, which can result in amputation and loss of limb. Optimization of feet care and maintenance of healthy blood sugar levels can prevent the development of this condition.&nbsp; 
&nbsp;

Key Points

<ul>
	<li>Diabetic foot is one of the common complications of diabetes yet the most dreaded.</li>
	<li>Diabetes causes nerve damage in the peripheries and this is often due to high blood sugar levels that are not managed.</li>
	<li>Nerve damage causes the foot to lose sensation, and blisters, sores, or minor injuries go unnoticed; it&rsquo;s dangerous because these points can become the site of entry for bacteria and result in infection.&nbsp;</li>
	<li>Infection in diabetic foot is often difficult to treat which then progresses to gangrene and ulceration</li>
	<li>Amputation remains the last resort to protect the infection from progressing throughout the body.</li>
	<li>Maintaining normal blood sugar levels and adopting a healthy foot care regimen are the only ways to prevent diabetic foot.&nbsp;</li>
</ul>

[1] Diabetes Foot Care. WebMD. es/caring-feet. Published 2022.

[2] Watson S. Diabetes: Symptoms, Causes, Treatment, Prevention, and More. Healthline.

[3] CDC.

[4] Problems D, Health N. Diabetes & Foot Problems | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases.

Nawal Adnan

AL SHIFA CLINIC KARACHI

Syed Intisar Hussain

This article or video has been recorded by a subject / domain specialists with a proven track record of excellence in their area. 

O’ Sweet Kidney Of Mine!

This is surely not an article on how cannibalism is good. I mean there shouldn’t be any articles on “how cannibalism is good”, right? Rest assured, the information summoned here, is related to the sugary stuff and its effects on your health. So, get ready as you’re in for a treat, no pun intended!

Understanding Diabetic Nephropathy

Nephropathy is the progressive deterioration of the kidney&rsquo;s function. Diabetic nephropathy, then, refers to the deterioration of the kidney as a result of longstanding or complicated diabetes<a href="#accordion">[5]</a>. As the disease progresses and reaches the final stage, it is termed as kidney failure or end-stage renal disease (ESRD)<a href="#accordion">[2]</a>.&nbsp;

According to the CDC reports, diabetes is the most common cause of ESRD. In 2011, there were around 26 million diabetic people in the U.S., and more than 200,000 people with ESRD were either going through chronic renal dialysis or had kidney transplant<a href="#accordion">[2]</a>.&nbsp;

&nbsp;

There are essentially two types of diabetes:&nbsp;

1. Type I (Inherited or Juvenile)&nbsp;

2. Type II (Adapted)

&nbsp;

Type I diabetes is the most likely of the two types of diabetes to progress into ESRD, the fifth and last stage of diabetic nephropathy, while patients who develop type II diabetes mellitus may present with albuminuria (the presence of albumin protein in the urine) at the time of diagnosis.

However, diabetic nephropathy in type I diabetes develops over the course of 15-20 years after the diagnosis. This difference in the timeline is because it&rsquo;s difficult to pinpoint the precise onset of type II diabetes. It&rsquo;s identified only when the kidney&rsquo;s structural and functional changes occur due to diabetes, causing proteinuria and hypertension the hallmarks of diabetic nephropathy<a href="#accordion">[1]</a>. 
&nbsp;

<ul>
	<li>Ethnic Groups: Some groups of the population, such as&nbsp;African Americans, Native Americans, and Mexican Americans, are more at risk than others. Researchers have noted familial clustering (occurrence of the disease within some families in excess of what would be expected from the occurrence in the population) in these cases, which indicates that genetics also play a vital role in developing nephropathy<a href="#accordion">[1]</a>.&nbsp;</li>
	<li>Blood Sugar Level: The high levels of blood sugar associated with diabetes damage the kidney through various pathways. The damage is mostly directed toward&nbsp;the blood vessels that are responsible to filter the blood in order to make urine.</li>
</ul>

&nbsp;

Diabetic nephropathy has a high morbidity and mortality rate&nbsp;mainly because of other issues due to diabetes<a href="#accordion">[1]</a>:

<ul>
	<li>Chronic Kidney Disease (CKD): As of now, diabetic nephropathy is the leading cause of CKD in the United States as well as other Western societies<a href="#accordion">[6]</a>.&nbsp;</li>
	<li>Hypertension: Like CKD, hypertension (commonly known as high blood pressure) is also believed to be both a cause of and a result of the damage that is done by the disease. An individual suffering from uncontrolled hypertension progresses toward&nbsp;stage V diabetic nephropathy faster than those who don&rsquo;t have high blood pressure<a href="#accordion">[2]</a>.&nbsp; 
	&nbsp;</li>
</ul>

On the basis of the clinical presentation, doctors have broken down this kidney disease into 5 stages, depending on the glomerular filtration rate (GFR) which is essentially the rate at which the kidneys filter the blood. GFR is basically a representation of the effectiveness of the kidney function in percentage. The stages are as follows<a href="#accordion">[3]</a>:

Stage 1: The kidney is damaged; however, the kidney function is normal and a GFR of 90% or above is seen.

Stage 2: The kidney faces some degree of damage and a GFR of 60&ndash;89% is observed.

Stage 3: Mild to severe loss of kidney function is recorded with a GFR of 30&ndash;59%.

Stage 4: This stage refers to the severe loss of function and a GFR of 15&ndash;29%.

Stage 5: Kidney failure and a GFR of under 15% defines stage 5. 
&nbsp;

Diabetic nephropathy is always a cause for alarm if the individual has diabetes mellitus as a comorbidity along with a history of the following<a href="#accordion">[1]</a>:

1. Foamy urine

2. An unexplained proteinuria

3. Diabetic retinopathy, i.e., diabetes affecting the visual sense

4. Fatigue and foot edema because of hypoalbuminemia, i.e., decreased levels of albumin protein)

5. Hypertension

6. Coronary artery disease

&nbsp;

Diabetic nephropathy sounds dangerous, and rightfully so! However, there are ways to lower the risk<a href="#accordion">[4]</a>:&nbsp;

<ul>
	<li>Keep up with regular checkups; an annual appointment with a healthcare team helps with diabetes management, hence, helping avoid complications like diabetic nephropathy, retinopathy, and neuropathy.&nbsp;</li>
	<li>Take antidiabetic drugs with utmost efficiency. When it&rsquo;s impossible to resist chocolate cake, tiramisus, or maybe some soft succulent, and sweet gulab jamuns, why hold back on the medicines that actually allow devouring these delicacies in moderation? There is no doubt that medication can be very effective and may even help prevent diabetic nephropathy.&nbsp;</li>
	<li>Manage blood pressure as it increases the risk of kidney disease<a href="#accordion">[3]</a>. Moreover, take care while taking nonprescription pain relievers (e.g., aspirin) and nonsteroidal anti-inflammatory drugs (e.g., naproxen and ibuprofen) as they can lead to kidney damage in case of diabetic nephropathy.&nbsp;</li>
	<li>Also try to maintain a balanced body mass index<a href="#accordion">[3]</a>.&nbsp;</li>
	<li>Another crucial thing to take care of&nbsp;to avoid diabetic nephropathy and its complications is smoking. The solution is pretty simple: don&rsquo;t smoke. Cigarette smoking is responsible for damaging the kidneys and can even make existing kidney damage worse<a href="#accordion">[3]</a>.</li>
</ul>

&nbsp;

A doctor advising medical intervention will discuss the best drug according to the severity of the disease. Therapeutic agents for glycemic (sugar) control in diabetic patients, who have developed kidney disease as well, include<a href="#accordion">[3]</a>:

<ul>
	<li>Dipeptidyl Peptidase Inhibitors, e.g., Sitagliptin</li>
	<li>Alpha-Glucosidase Inhibitors, e.g., Acarbose</li>
	<li>Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors, e.g., Canagliflozin</li>
	<li>Glucagon-like peptide-1 (GLP-1) Receptor Agonists or Incretin Mimetics, e.g., Dulaglutide&nbsp;</li>
	<li>Amylin Analogs, e.g., Pramlintide</li>
	<li>Nonsteroidal, Selective Mineralocorticoid Receptor (MR) Antagonists, e.g., Finerenone&nbsp; 
	&nbsp;</li>
</ul>

It may take months or years for complications of diabetic nephropathy to develop. Whatever the reason, whether it was non-compliance on your part or whether it was due to the fact that the disease was already in its advanced stages, it is important to know the current status of your condition so that it can be treated accordingly before it develops into the following complications<a href="#accordion">[4]</a>:

1. Fluid Retention: Fluid retention can cause swelling in the arms and legs, hypertension, or even cause pulmonary edema, whereby fluid builds up in the lungs.

2. Hyperkalemia: Hyperkalemia is an increase in potassium levels in the blood and it can lead to abnormal heart rhythms.

3. Cardiovascular Disease: Another major complication is cardiovascular diseases which, in turn, can lead to stroke.

4. Diabetic Retinopathy: Uncontrolled diabetic nephropathy can also damage the blood vessels of the retina, the light-sensitive tissue at the back of the eye, and cause diabetic retinopathy.

5. Blood Loss: It will lead to a reduced number of red blood cells to transport oxygen, a condition known as anemia

6. Bone And Mineral Disorders: Since the kidneys are losing their ability to function properly, it will affect the level of calcium and phosphorus in blood.

7. Miscellaneous Conditions: Some other conditions caused due to diabetic nephropathy are foot sores, erectile dysfunction, diarrhea, damaged nerves and blood vessels, and pregnancy complications. 
&nbsp;

Dialysis or a kidney transplant is used as the last resort, i.e., if the kidneys are damaged beyond repair, then the patient may need dialysis on a regular basis - at least until they can get a transplant - to survive<a href="#accordion">[3]</a>.

&nbsp;

Additionally, the doctor may give some instructions regarding their diet to avoid an unfortunate event<a href="#accordion">[3]</a>:

<ul>
	<li>Water: Water is definitely essential; however, excess fluid can increase the risk of swelling and hypertension.</li>
	<li>Sodium: An excessive intake of sodium can raise blood pressure pathologically.</li>
	<li>Protein: A drawback of kidney disease is the consumption of too much protein can lead to a buildup of waste products in the blood, putting unnecessary pressure on the kidneys</li>
	<li>Phosphorus: Phosphorus is found in high quantities in dairy products. A high level of phosphorus can weaken the bones and again put excessive pressure on the kidneys.</li>
	<li>Potassium: People with kidney disease reportedly have a higher level of potassium than a healthy adult; too much and/or too little&nbsp;potassium is bad for the neurons. 
	&nbsp;</li>
</ul>

Diabetes takes away a person’s integrity slowly and bit by bit. However, with due management and precautionary methods, it can be kept at bay and the patient can live a fairly decent life filled with heavenly desserts (in moderation of course)!

<ul>
	<li>Nephropathy is the progressive deterioration of the kidney&rsquo;s function. Diabetic nephropathy, by extension, is the deterioration of the kidney due to long-standing or complicated diabetes.</li>
	<li>According to the CDC reports, diabetes is the most common cause of ESRD.</li>
	<li>In 2011, there were around 26 million diabetic people in the U.S., and more than 200,000 people with ESRD were either going through chronic renal dialysis or had undergone a kidney transplant.</li>
	<li>There are essentially 5 stages of diabetic nephropathy; ESRD is the fifth and last stage.</li>
	<li>Some groups, such as African Americans, Native Americans, and Mexican Americans are at a high risk of developing diabetic nephropathy.</li>
	<li>Researchers have noted familial clustering, which means that genetics play a vital role in developing nephropathy.</li>
	<li>Diabetic nephropathy is one of the most prominent long-term complications when it comes to morbidity and mortality of a diabetic person.</li>
	<li>Hypertension is an inevitable threat posed by diabetes. It is also a major reason why diabetic nephropathy develops in the first instance.</li>
	<li>The damage is mostly directed towards the blood vessels responsible to filter the blood to make urine.</li>
	<li>If the kidney&rsquo;s structural and functional changes occur due to diabetes, it results in proteinuria and hypertension, which are the hallmarks of diabetic nephropathy.</li>
	<li>Diabetic nephropathy is an alarming condition given the patient also has diabetes mellitus as a comorbidity.</li>
	<li>Do not skip regular checkups. An annual appointment with the healthcare team is necessary since it sheds light on how well the person can manage diabetes, and thereby, avoid complications like diabetic nephropathy, retinopathy, and neuropathy.</li>
	<li>Moreover, take nonprescription pain relievers (e.g., aspirin) and nonsteroidal anti-inflammatory drugs (e.g., naproxen and ibuprofen) as prescribed by the doctor since their side effects often include kidney damage.</li>
	<li>Cigarette smoking is responsible for damaging the kidneys and can even make existing kidney damage worse.</li>
	<li>Kidney disease is categorized into 5 stages, depending on the glomerular filtration rate.</li>
	<li>In Stage 1, the kidney is damaged; however, the kidney function is normal and a GFR of 90% or above is seen.</li>
	<li>In Stage 2, the kidney faces some degree of damage&nbsp;and a GFR of 60&ndash;89% is observed.</li>
	<li>Stage 3 is when there is mild to severe loss of kidney function and a GFR of 30&ndash;59%.</li>
	<li>Stage 4 refers to the severe loss of function and a GFR of 15&ndash;29%.</li>
	<li>Stage 5 is defined by kidney failure and a GFR of under 15%.</li>
	<li>The doctor may suggest a medical intervention to discuss the treatment options according to the severity of the disease.</li>
	<li>Complications of diabetic nephropathy include fluid retention, diabetic retinopathy, and hyperkalemia.</li>
	<li>If a person has diabetic nephropathy, then they need to keep a check on their intake of sodium, phosphorus, and water specifically.</li>
</ul>

[1] Diabetic nephropathy - statpearls - NCBI bookshelf.

[2] Diabetic nephropathy (kidney disease). Diabetic Nephropathy (Kidney Disease) | Johns Hopkins Medicine.

[3] Diabetic nephropathy: Symptoms, stages, causes, and treatment. Medical News Today.

[4] Diabetic nephropathy (kidney disease). Mayo Clinic.

[5] EmmaHook. Diabetic nephropathy (kidney disease). Diabetes UK.

[6] Gross JL, de Azevedo MJ, Silveiro SP, Canani LH, Caramori ML, Zelmanovitz T. Diabetic nephropathy: Diagnosis, prevention, and treatment. American Diabetes Association.

Arbaz Ansari

Medilink Consultant clinic

Saad Ullah Siddiqui

Best Exercises For Diabetics In Ramadan!

Fasting during Ramadan is one of the five pillars of Islam. The holy month is a time of spiritual reflection that is meant to develop a sense of gratitude and discipline, encouraging self-improvement and knitting the community closer.

For all its benefits, though, we know Ramadan can be challenging for diabetic people. However, one trick to managing these blood sugar spikes is regular exercise.

Oh no, don&rsquo;t worry! These are not high-intensity activities. The following exercises can easily be integrated into a daily routine without causing excessive strain or fatigue<a href="#accordion">[1][2]</a>: 
&nbsp;

Understanding Best Exercises For Diabetics In Ramadan

<ul>
	<li>
	<h5>Walking</h5>
	</li>
</ul>

Walking is an excellent low-impact exercise for <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetics </a>as it not only improves blood sugar control but also reduces the risk of heart disease. You can go out for a walk before Suhoor or after Iftar when your body has sufficient energy to fuel the activity.

&nbsp;

<ul>
	<li>
	<h5><a href="https://merisehat.pk/article/yoga-a-life-changing-approach">Yoga</a></h5>
	</li>
</ul>

Yoga is a gentle, cost-effective form of exercise that&rsquo;s more famous for improving body flexibility. But do you know it helps your body manage stress levels, too? It really does! So, if you&rsquo;re struggling to cope mentally and/or physically, then this is for you! Yoga during Ramadan will improve your blood circulation, lower blood pressure, manage insulin levels, and even help you maintain a healthy weight.

&nbsp;

<ul>
	<li>
	<h5>Tai Chi</h5>
	</li>
</ul>

Tai chi is an ancient Chinese practice involving slow movements and deep breathing. It is an effective way for people with type 2 diabetes to manage their blood glucose and A1C levels. Additionally, this form of meditation is known to improve balance and reduce nerve damage, although more research is required in this regard.

&nbsp;

<ul>
	<li>
	<h5>Swimming</h5>
	</li>
</ul>

Swimming during Ramadan helps cool down the body temperature and, consequently, reduces the loss of fluid through sweating. Also, it&rsquo;s a full-body workout, so it will leave you feeling more energetic and focused to go about your daily tasks. Moreover, it doesn&rsquo;t matter if you are at risk of gestational diabetes, young or elderly, or have hypertension or heart conditions; the exercise is ideal for everyone who&rsquo;s tackling diabetes in Ramadan without exhausting their bodies.

NOTE: Make sure to inform the lifeguard about your medical condition before taking a dip.

&nbsp;

<ul>
	<li>
	<h5>Cycling</h5>
	</li>
</ul>

Cycling is yet another exercise that doesn&rsquo;t put excessive pressure on your joints. It can be done indoors or outdoors, whichever is more convenient or suits your condition best. According to recent research, nearly half of the people with type 2 diabetes also have arthritis. Factors like diabetic neuropathy and obesity only make you more susceptible to suffering from joint pain. Cycling helps you keep up with your fitness goals while fasting. 
&nbsp;

<ol>
	<li>Begin slowly, especially if you haven&#39;t been physically active in a while. Do a 5-minute warm-up before exercising. Similarly, finish off with a 5-minute cool-down after exercising.</li>
	<li>Check blood sugar levels before and after exercise to understand how your body responds to it.</li>
	<li>Make sure your blood sugar is less than 250 mg/dl before exercising.</li>
	<li>Wear a medical alert ID band and carry a cell phone in case of emergency.</li>
	<li>Avoid exercising in extremely hot or cold temperatures.</li>
	<li>Always listen to your body. If you feel dizzy or short of breath, stop immediately.</li>
</ol>

NOTE: Always consult with a doctor before starting an exercise program to ensure it&#39;s safe and suitable for your condition<a href="#accordion">[3]</a>. 
&nbsp;

Fasting during Ramadan can make it challenging for diabetic people to maintain a regular exercise routine. Remember, it&rsquo;s okay to modify physical activities to suit your body&rsquo;s needs during this time. Some strategies include adjusting the timing and intensity of exercise, staying hydrated, and monitoring blood glucose levels closely. Consulting with a healthcare professional before starting any exercise program during Ramadan is essential. 
&nbsp;

[1] Grey H. The best 10 exercises if you have diabetes. Healthline.

[2] Migala J, By. 6 great exercises for people with diabetes. EverydayHealth.com.

[3] Team CC. 5 best exercises for people with diabetes. Cleveland Clinic.

Sarah Mhowwala

Humza Khizer

Best Regimens For Diabetics During Ramadan

<a href="https://merisehat.pk/disease/diabetes-type-1-and-2">Diabetes</a> management during Ramadan is essential to avoid any health complications. This includes taking your medications as prescribed by your doctor and monitoring your blood sugar levels regularly. But more importantly, it involves being aware of the signs of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) and taking appropriate action when necessary. 
&nbsp;

Fasting Tips  for Diabetics

<ol>
	<li>Consult With A Healthcare Professional: Consult your doctor to determine if fasting is safe for you. Yes, fasting during Ramadan is a religious obligation, but it doesn&rsquo;t mean neglecting your health. 
	&nbsp;</li>
	<li>Monitor Blood Sugar Levels: Monitor your blood sugar levels regularly, especially during the fast. Inform your doctor if you notice any spike in these readings. 
	&nbsp;</li>
	<li>Stay Hydrated: Dehydration can cause blood sugar levels to rise, so make sure to drink plenty of water after Iftar/before Suhoor. 
	&nbsp;</li>
	<li>Consume Low Glycemic Index Foods: The glycemic index is a scale that measures how quickly foods raise blood sugar levels. </li>
</ol>

 
Foods with a high GI are digested quickly and cause a sudden spike in blood sugar levels, whereas foods with a low GI are digested more slowly and do not cause a sudden spike in blood sugar levels. 
&nbsp;

So, do yourself a favor and fill your plate with: 
&nbsp;

<ul>
	<li>Non-starchy vegetables, such as spinach, broccoli, and carrots</li>
	<li>Whole grains, such as brown rice, quinoa, and whole-wheat bread</li>
	<li>Lean protein, such as fish, chicken, and tofu</li>
	<li>Healthy fats, such as nuts, seeds, and avocado 
	&nbsp;</li>
</ul>

And at the same time, as tempting as they appear to be during Ramadan, keep away from high glycemic foods, such as: 
&nbsp;

<ul>
	<li>Sugary drinks, such as soda, juice, and sports drinks</li>
	<li>Processed snacks, such as chips and crackers</li>
	<li>White bread and pasta</li>
	<li>Fried foods, such as fried chicken and fries</li>
	<li>High-fat meats, such as bacon and sausage 
	&nbsp;</li>
</ul>

<ol start="5">
	<li>Do Not Skip Meals: Your body is already low on essential nutrients due to fasting. Skipping your dinner after Iftar or your Sehri can lead to hypoglycemia during the day.</li>
</ol>

&nbsp;

<ol start="6">
	<li>Break The Fast With A Balanced Meal: Have a balanced meal at Iftar that includes low glycemic index foods, protein, and healthy fats. 
	&nbsp;</li>
</ol>

Nutrient Content Guidance

<h5>Nutritional Recommendations:</h5>

<ul>
	<li>Carbohydrates: Consume 40-50% of daily calories from low-glycemic, high-fiber, whole grain sources</li>
	<li>Protein: Consume 20-30% of daily calories from lean meat, legumes, pulses, and vegetable protein sources.</li>
	<li>Fat: Consume less than 35%, with saturated fat intake under 7%. Choose healthier cooking methods, such as grilling, baking, and steaming.</li>
</ul>

&nbsp;

<h5>Lifestyle Recommendations:</h5>

<ul>
	<li>Hydration: Drinking enough water at Iftar helps overcome dehydration from fasting.</li>
	<li>Physical Activity: Staying active promotes overall health.</li>
	<li>Sleep: Maintaining a regular sleep schedule helps avoid sleeping longer than usual. 
	&nbsp;</li>
</ul>

Balanced and Healthy Meal Plan

Normally, a person should consume 1500 calories per day. This is how you can manage your meal plans: 
&nbsp;

Suhoor: 450-600 kcal/Meal

&bull; Omelette, 2 egg

&bull; Roti, 1 small

&bull; Milk/Lassi, 1 glass

&bull; Salad (tomatoes/onions), 1 small bowl

&bull; Water, 2 glasses 
&nbsp;

Iftar Snack: 150-240 kcal/Meal

&bull; Fruit, 1

&bull; Water/unsweetened drinks, 2 glasses

&nbsp;

Iftar Meal: 500-750 kcal/Meal

&bull; Chicken roast, 1 palm size

&bull; Daal/lentil curry, 1 cup

&bull; Vegetable curry, 1 cup

&bull; Cooked brown rice, &frac34; cup

&bull; Dahi baray, 1 small bowl

&bull; Salad

&bull; Water/unsweetened drinks, 2 glasses

&nbsp;

Post-Iftar Healthy Snack: 150-300 kcal/Meal

&nbsp;&bull; Fruit, 1 piece

&bull; Milk-based dessert (e.g., kheer, ras malai made with sweetener), 1 small

&bull; Water/unsweetened drinks, 2 glasses 
&nbsp;

Note: This is what a diabetic person can eat on average during Ramadan. Your diet can vary based on your daily calorie goals. 
&nbsp;

As a diabetic person, you need to take extra care of your health during Ramadan. Make sure to take meds as prescribed by your doctor and monitor your blood sugar levels regularly to stay fit while fasting during Ramadan. What&rsquo;s more, you can ask your doctor to refer a registered dietitian who can develop a personalized nutrition plan that meets your individual needs. 
&nbsp;

[1] CARB counting and diabetes. Carb Counting and Diabetes | ADA.

[2] IDF clinical practice recommendations for managing type 2 diabetes in

[3] Author links open overlay panelMohamed Hassanein a, a, b, et al. Diabetes and ramadan: Practical guidelines. Diabetes Research and Clinical Practice.

Insulin And Postpartum

The postpartum period refers to the time after you give birth. Your hormonal levels will be fluctuating as your body recovers from the physical and emotional toll of the pregnancy. You&rsquo;ll probably be overwhelmed by all sorts of emotions during this period.

Besides mood, these changes can affect your blood sugar regulation, particularly if you had gestational diabetes. However, you can have postpartum diabetes even if you did not have gestational diabetes. 
&nbsp;

Around 2-10% of all pregnant women in the US have gestational diabetes<a href="#accordion">[1]</a>. The condition often shows up during the middle of pregnancy when the placenta produces hormones that prevent the body from efficiently using insulin. Consequently, glucose concentrates in the blood rather than being absorbed by the cells.

The best thing to do after the diagnosis of gestational diabetes is to look after yourself as much as possible. It&rsquo;s crucial to monitor blood glucose during labor and birth. While eating healthy and staying active during pregnancy can help control blood sugar levels, you may need to take insulin as well to control your blood sugar levels and avoid complications, like preeclampsia and birth defects, for you and your baby. 
&nbsp;

Insulin can be injected via pen or syringe and it&rsquo;s generally safe to use as prescribed by your doctor. Using too much insulin or skipping a meal, however, may cause hypoglycemia which can be dangerous for both you and your baby.

Note: If you have type 1 or type 2 diabetes, refer to a professional doctor before getting pregnant as uncontrolled gestational diabetes is not safe for your baby. Moreover, several diabetes tablets are not safe to be taken during pregnancy so your doctor can guide you regarding insulin injections<a href="#accordion">[2]</a>. 
&nbsp;

Understanding the importance of insulin in pregnancy

If you were diagnosed with gestational diabetes, it&rsquo;s important that you get tested for diabetes after delivery. Your doctor will order regular glucose checking for a few days after delivery, usually before breakfast and two hours after meals, to ensure your glucose levels are within the normal range. An oral glucose tolerance test is recommended 6-12 weeks after birth<a href="#accordion">[2]</a>. 
&nbsp;

If your blood glucose level is:

<ul>
	<li>Normal &ndash; Get checked every three years</li>
	<li>Pre-Diabetes &ndash; Get checked every year; talk to your doctor about minimizing your risk of diabetes</li>
	<li>Diabetes &ndash; Consult your doctor and set up a treatment plan 
	&nbsp;</li>
</ul>

The symptoms of gestational diabetes usually disappear in the postpartum period as blood sugar levels return to normal after labor and any medications, including insulin, will be stopped after your baby is born. But it&rsquo;s also possible that it progresses to type 2 diabetes. Around 50% of women with gestational diabetes develop type 2 diabetes<a href="#accordion">[1]</a>. 
&nbsp;

Getting checked helps because type 2 diabetes presents few symptoms during the early stages of the disease. With a timely diagnosis, you can prevent or delay the development of type 2 diabetes by continuing with your treatment, eating healthily, and avoiding a sedentary lifestyle.

Note: For future pregnancies, make sure to inform your healthcare team about your history of gestational diabetes. 
&nbsp;

According to the American Diabetes Association, breastfeeding can help you manage your diabetes<a href="#accordion">[3]</a>.

For the baby, breastfeeding for the first six months at least means a reduced risk of developing type 1 diabetes, obesity leading to type 2 diabetes, and other health issues like eczema and respiratory disease. For the mother, benefits include a lower risk of developing health conditions like breast and ovarian cancers and type 2 diabetes in addition to a quicker recovery after birth. 
&nbsp;

That said, is it safe to take insulin while breastfeeding your newborn? Yes, it is<a href="#accordion">[3]</a>. This is because insulin molecules are large enough to not pass through the breast milk to the baby.

However, the dose needs to be adjusted accordingly after the pregnancy and, again, during breastfeeding. Ideally, the blood sugar level while breastfeeding should be between 90 and 180 mg/dL.

These levels may drop during breastfeeding, a condition known as hypoglycemia, so you should eat before each session to keep the glucose levels stable. And check your blood glucose levels every time before and after nursing. 
&nbsp;

<ul>
	<li>Gestational diabetes goes away soon after birth in the majority of cases. This is because of a drop in pregnancy hormones and the insulin resistance associated with them.</li>
	<li>If you have had gestational diabetes or are at risk of postpartum diabetes, you should monitor your blood sugar regularly during the postpartum period.</li>
	<li>Breastfeeding may help reduce insulin and blood sugar levels after birth.</li>
	<li>If you started taking insulin during pregnancy, it may be stopped after childbirth. But, depending on your blood glucose levels, you may have to restart insulin again.</li>
	<li>If you were taking insulin before pregnancy, you will most probably continue to do so. However, the dosage and the type of insulin may be reviewed by your doctor.</li>
	<li>Lifestyle recommendations may further help prevent developing type 2 diabetes. 
	&nbsp;</li>
</ul>

[1] Gestational diabetes. Centers for Disease Control and Prevention.

[2] Department of Health &amp; Human Services. Diabetes - gestational. Better Health Channel.

[3] Diabetes and breastfeeding. Diabetes and Breastfeeding | ADA

Shermeen Zuberi

Ramadan: A Blessing For Diabetics

Ramadan is regarded as one of the holiest months of the Islamic calendar. Muslims all over the world fast from daybreak until dusk, abstaining from all food and beverages. For Muslims everywhere, this is a period of introspection and self-discipline. However, people with <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes </a>may worry about how fasting might impact their health at this time. Contrary to common perception, if done properly and under medical guidance, fasting during Ramadan can be helpful for diabetics. 
&nbsp;

Benefits for Diabetics

For diabetics, fasting during Ramadan can be quite beneficial. One of the most significant benefits is that fasting can help control blood glucose levels, specifically for those with type 2 diabetes. When a person fasts, the body burns stored glucose for energy, which can help in reducing blood sugar levels. Moreover, fasting improves <a href="https://merisehat.pk/article/insulin-dose-and-timings">insulin </a>sensitivity, making it easier for the body to use insulin to regulate blood sugar levels. 
&nbsp;

Fasting during Ramadan has an immense amount of positive effects on overall health. It has been shown to improve cardiovascular health, boost brain function, and promote weight loss. Apart from that, fasting can also help reduce inflammation in the body, which has been linked to many chronic diseases. 
&nbsp;

Fasting during Ramadan should be done safely and under medical supervision, specifically for those with diabetes. People with type 1 diabetes who take insulin should consult with their healthcare provider to adjust their insulin dose and meal plan to avoid hypoglycemia (low blood sugar). Those with type 2 diabetes, who take oral medication or insulin, may also need to adjust their medication schedule to prevent hypoglycemia. Monitoring blood glucose levels regularly during fasting is crucial to ensure blood sugar levels stay within a safe range<a href="#accordion">[1]</a>. 
&nbsp;

Diabetics should schedule an appointment with their diabetologist at least 6-8 weeks before the start of Ramadan so their diabetes is stable<a href="#accordion">[1]</a>.&nbsp;Furthermore, this gives them a chance to discuss any change in dosage, warning signs of hypoglycemia, meal plans for Ramadan, and any other queries with their doctors. 
&nbsp;

Nutrition Management

Another important aspect for diabetics during Ramadan is planning meals. During Ramadan, Muslims typically consume two meals: sehri (eaten before dawn) and iftari (eaten at sunset). The large gaps between meals can cause their blood glucose levels to fluctuate. Therefore, it is important to eat a well-balanced and nutritious meal at both times. 
&nbsp;

Diabetics should aim to consume foods that are low in sugar and carbohydrates and high in fiber, protein, and healthy fats. It is also important to stay hydrated by drinking plenty of water and other non-sugary fluids between iftar and sehri.

Ramadan also offers an opportunity for diabetics to reflect and focus on their spiritual well-being. By fasting, diabetics can feel a sense of solidarity with fellow Muslims and strengthen their faith. They can also use this time to practice mindfulness, gratitude, and other spiritual practices that can help improve their overall well-being. 
&nbsp;

Although fasting during Ramadan can be challenging for diabetics, with proper management and care, it can also be a blessing. Fasting can help control blood glucose levels, improve insulin sensitivity, and have positive effects on overall health. By working with healthcare providers, carefully monitoring blood sugar levels, and planning nutritious meals, diabetics can still participate in the spiritual and cultural traditions of Ramadan while maintaining their health and well-being. 
&nbsp;

[1] Diabetes And Ramadan – Guidance For Fasting During The Holy Month. Diabetes And Ramadan – Guidance For Fasting During The Holy Month | Hull University Teaching Hospitals NHS Trust 2016.

Staff Writer

Diabetic Retinopathy

Diabetic retinopathy is essentially a complication of pre-existing diabetes that affects your eyes.&nbsp;At the early stage of the disease, diabetic retinopathy may exhibit no symptoms. In some cases, it may show mild vision disturbances. However, it can eventually cause blindness, a complication that can develop in anyone who has a pre-existing diagnosis of diabetes.

The development of this complication doesn&rsquo;t depend on the type of diabetes you have. It is subjective to how long you have had the condition and how efficiently you can manage your blood sugar level.

According to a systematic review and meta-analysis of 59 population-based studies, the global prevalence of diabetic retinopathy is estimated to reach 160.5 million by 2045. It also revealed that Hispanics and Middle Eastern people who have diabetes are at a higher risk of developing diabetic retinopathy as compared to Asians<a href="#accordion">[1]</a>. 
&nbsp;

Understanding Diabetic Retinopathy

The retina is essentially the layer of cells at the back of the eye, which is sensitive to light and responsible for converting it into electrical signals. These signals are then sent to your brain, turning them into the images you see in front of your eyes.

The retina needs a healthy and continuous blood supply to do its job. This is delivered by a network of tiny blood vessels. If your blood sugar level is constantly high, it can damage these blood vessels in 3 main stages: 
&nbsp;

<h5>1. Background Retinopathy</h5>

At this stage, tiny bulges or microaneurysms develop in the blood vessels of your retina. These may or may not leak a small amount of blood.

Even though it does not affect your sight, the condition puts you at a higher risk of developing vision issues. If both eyes are affected, the probability of your eyesight worsening is even higher. 
&nbsp;

<h5>2. Pre-Proliferative Retinopathy</h5>

This stage is a bit more severe. There may be bleeding into the retina, which means there is a high risk that vision will be affected. 
&nbsp;

<h5>3. Proliferative Retinopathy</h5>

New blood vessels and scar tissue have developed on your retina at this stage. These new blood vessels are weaker in structural integrity and, therefore, significant bleeding can occur. It can also cause retinal detachment &ndash; your retina pulls away from the back of the eye.

The risk of losing your vision is highest at this stage. Treatment only stabilizes the vision; it does not restore your vision.

Diabetic retinopathy does not exhibit symptoms in its early stages. However, later on, you may develop:

<ul>
	<li>Floaters (small dark spots) or streaks in your vision</li>
	<li>Blurred or distorted vision</li>
	<li>Pain or pressure in either one or both eyes</li>
	<li>Poor night vision</li>
	<li>Seeing colors as faded or color blindness</li>
	<li>Blank spots in your vision 
	&nbsp;</li>
</ul>

An eye doctor or an ophthalmologist diagnose diabetes-related retinopathy based on the following factors<a href="#accordion">[2]</a>:

<ul>
	<li>Visual Acuity or how clear your eyesight is</li>
	<li>Intraocular Pressure to rule out the possibility of glaucoma</li>
	<li>Eye Muscle Function, i.e., how well you can move your eyes</li>
	<li>Peripheral Vision or the vision from the side of your eyes</li>
	<li>Pupil Response, i.e., how well your pupils react to light 
	&nbsp;</li>
</ul>

Furthermore, eye drops are used to dilate pupils to allow your doctor to confirm the presence of:

<ul>
	<li>Abnormalities in the blood vessels, optic nerve, or retina</li>
	<li>Cataract</li>
	<li>Changes in the internal eye pressure</li>
	<li>Growth of new blood vessels</li>
	<li>Retina swelling</li>
	<li>Scar tissue</li>
</ul>

The eye drops and the bright lights can feel uncomfortable. Sometimes, the eye drops can cause an increase in ocular pressure, especially if you&rsquo;re a high-risk patient. 
&nbsp;

Your doctor will suggest a treatment plan based on the following factors:

<ul>
	<li>Age</li>
	<li>Medical history</li>
	<li>General health</li>
	<li>Type of diabetic retinopathy and how severe it is</li>
	<li>HbA1c</li>
</ul>

If the disease is mild or moderate, your doctor may want to wait and observe, especially if your vision is intact. You may not need any further treatment during this time. However, doctors advise eye exams every 2-4 months in some cases to monitor the progression of the disease. 
&nbsp;

Depending on your condition, the following treatment modalities can be used to help alleviate the symptoms<a href="#accordion">[2]</a>:

<ul>
	<li>
	<h5>Injections</h5>
	</li>
</ul>

Your doctor may inject medications, like anti-vascular endothelial growth factor or corticosteroids, into the vitreous of the affected eye. It is meant to stop the growth of new blood vessels and decrease fluid buildup. 
&nbsp;

<ul>
	<li>
	<h5>Laser Surgery</h5>
	</li>
</ul>

Laser is preferred in case of swelling in the retina or neovascularization. The treatment works by shrinking abnormal blood vessels or repairing the leaking vessels. 
&nbsp;

<ul>
	<li>
	<h5>Vitrectomy</h5>
	</li>
</ul>

A vitrectomy is an eye surgery to treat clouded vision due to leaking blood vessels. During the procedure, your surgeon will make a small cut or incision in the eye to repair the blood vessels and remove the scar tissue. 
&nbsp;

Important!

Diabetics can prevent diabetes-related retinopathy by making lifestyle changes, such as exercising, taking medications as prescribed by their doctor, and quitting smoking.&nbsp;

At the same time, it&rsquo;s crucial to monitor and manage blood sugar and blood pressure to avoid any disease complications. Also, do NOT skip your eye checkups. 
&nbsp;

Diabetic retinopathy can lead to serious eye conditions as well, including<a href="#accordion">[4][5]</a>: 
&nbsp;

<ul>
	<li>
	<h5>Diabetic Macular Edema (DME)</h5>
	</li>
</ul>

1 in 15 diabetic people develops DME4. The fluid from the blood vessels in your retina leaks into the macula, a part of the retina that&rsquo;s important for sharp and central vision. As a result, it causes blurry vision. 
&nbsp;

<ul>
	<li>
	<h5>Vitreous Hemorrhage</h5>
	</li>
</ul>

The newly-formed blood vessels bleed into the clear, jellylike substance that fills the center of your eye. If it&rsquo;s light bleeding, you might see a few floaters only. However, when the blood fills the vitreous cavity in critical cases, it can block your vision completely.

It should be noted that the vitreous hemorrhage, on its own, usually doesn&#39;t cause any permanent vision loss. The blood often drains from your eye in a few weeks or months, and your vision returns to its previous clarity unless your retina is damaged, too. 
&nbsp;

<ul>
	<li>
	<h5>Retinal Detachment</h5>
	</li>
</ul>

The abnormal blood vessels stimulate the growth of scar tissue, which pulls the retina away from the back of the eye. This can cause spots floating in your vision, flashes of light, or severe vision loss. 
&nbsp;

<ul>
	<li>
	<h5>Glaucoma</h5>
	</li>
</ul>

Neovascularization occurs at the front part of your eye (iris) and essentially interferes with the normal flow of the fluid out of the eye. This leads to increased pressure in the eye that can damage the optic nerve carrying images from your eye to your brain. 
&nbsp;

<ul>
	<li>
	<h5>Blindness</h5>
	</li>
</ul>

Diabetic retinopathy, macular edema, glaucoma, or a combination of these conditions can cause complete vision loss. 
&nbsp;

Even though anyone can develop diabetic retinopathy, the risk is higher if you:

<ul>
	<li>Have uncontrolled blood sugar levels</li>
	<li>Have high blood pressure (hypertension)</li>
	<li>Have high cholesterol</li>
	<li>Are pregnant</li>
	<li>Smoke regularly</li>
	<li>Have diabetes for a long time 
	&nbsp;</li>
</ul>

Note: If a woman conceives with diabetes as a comorbidity or a healthy woman develops gestational diabetes then they are automatically at a higher risk for developing diabetic retinopathy. 
&nbsp;

Someone can be the apple of your eye, but you can&rsquo;t look at them if you don&rsquo;t care for yourself. Poor management of diabetes leads to poor vision. So,&nbsp; make sure you see your doctor to get your eyes checked. 
&nbsp;

Key Takeaways

<ul>
	<li>Diabetic retinopathy is a complication of your pre-existing diabetes that affects your eyes.</li>
	<li>At the early stage of the disease, diabetic retinopathy may exhibit no symptoms. In some cases, it may show mild vision disturbances. However, it can eventually cause blindness.</li>
	<li>The risk is higher if you have uncontrolled blood sugar levels or high blood pressure.</li>
	<li>If your retina is damaged, your vision may not return to its previous clarity.</li>
	<li>The abnormal blood vessels stimulate the growth of scar tissue, which pulls the retina away from the back of the eye.</li>
	<li>The increased pressure damages the optic nerve that carries images from your eye to your brain.</li>
	<li>Diabetic retinopathy, macular edema, glaucoma, or a combination of these conditions can cause complete vision loss.</li>
</ul>

[1] Global Prevalence of Diabetic Retinopathy and Projection of Burden through 2045: Systematic Review and Meta-analysis.

[2] Diabetes-related retinopathy: Symptoms, treatment & causes. Cleveland Clinic.

[3] Diabetic retinopathy. Diabetic Retinopathy | Johns Hopkins Medicine.

[4] Diabetic retinopathy. National Eye Institute.

[5]Diabetic retinopathy. Mayo Clinic. February 21, 2023.

Insulin Dose And Timings

<a href="https://merisehat.pk/article/the-importance-of-a-checkup-before-ramadan-for-diabetic-patients-using-insulin">Insulin </a>is an important hormone that regulates the body&#39;s blood sugar levels. It is created by the pancreas and converts glucose into usable energy for the body. Doctors often prescribe insulin injections to diabetics struggling to maintain good blood sugar levels. Like all medications, it&rsquo;s important to follow the doctor&rsquo;s instructions to take insulin shots at the right time and with the right amount of insulin. 
&nbsp;

Understanding Insulin Dose And Timings

The dose of insulin that a person requires during a day depends on a series of factors, including:

<ul>
	<li style="text-align:justify">Diabetes Type:<a href="https://merisehat.pk/disease/diabetes-type-1-and-2"> Type 1 diabetics </a>usually require insulin injections several times a day. On the other hand, <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">type 2 diabetics</a> may be able to control their blood sugar levels with oral medications or an oral medication and insulin combo.</li>
	<li style="text-align:justify">Insulin Resistance: People who have type 2 diabetes require a higher dosage than people with type 1 diabetes. </li>
	<li style="text-align:justify">Weight And Body: The dose also depends on a person&#39;s weight and body composition. </li>
	<li style="text-align:justify">Exercise Routine: Diabetics who are active throughout the day usually require less insulin than those who&rsquo;re not.</li>
	<li style="text-align:justify">Nutrition: People who consume high amounts of carbohydrates need a high dose of insulin to control their blood sugar levels.</li>
	<li style="text-align:justify">Other Drugs: It&rsquo;s important to discuss any additional medications with the doctor as they can influence the amount of insulin required by the body. 
	&nbsp;</li>
</ul>

According to the type of insulin, the following are some basic recommendations for when an insulin injection should be scheduled throughout the day<a href="#accordion">[3][4]</a>:

<ul>
	<li style="text-align:justify">Rapid-Acting Insulin: This kind of insulin begins to function within 15 minutes and usually lasts 2-4 hours. It is usually consumed 15 minutes before meals to reduce the spike in blood sugar that follows meals. This type of insulin is frequently used with longer-acting insulin.</li>
	<li style="text-align:justify">Short-Acting Or Regular Insulin: This kind of insulin begins to function in 30 minutes and lasts 3-6 hours. It is usually consumed 30-60 minutes before meals to reduce the spike in blood sugar that follows meals.</li>
	<li style="text-align:justify">Intermediate-Acting Insulin: It takes 1-2 hours to begin working and lasts 12 hours. In other words, it covers the insulin needs for half a day or overnight. It is usually combined with short-acting or rapid-acting insulin.</li>
	<li style="text-align:justify">Long-Acting Insulin: It begins to function within 2-4 hours and lasts for up to 24 hours. It is usually taken once daily, for instance, it can be recommended first thing in the morning or before bed to control sugar levels all day. Depending on the type of diabetes, it may be used with rapid-acting or short-acting insulin. 
	&nbsp;</li>
</ul>

<ul>
	<li style="text-align:justify">While fasting, some individuals may need to take less insulin while others may need to take more before or after meals.</li>
	<li style="text-align:justify">During Ramadan, insulin timing may also need to be changed. To ensure that basal insulin coverage is sufficient during the fasting hours, for instance, individuals who typically take long-acting insulin in the morning may need to take it at night.</li>
	<li style="text-align:justify">It&#39;s crucial to carefully monitor blood sugar levels, particularly during the first few days of fasting when insulin requirements might be unpredictable.</li>
	<li style="text-align:justify">Refrain from overindulging at iftar. This may reduce the need for extra insulin<a href="#accordion">2</a>.</li>
</ul>

NOTE: Always consult a doctor who can guide you about insulin dosages during Ramadan. 
&nbsp;

[1] Humulin R, Novolin R (insulin regular human) dosing, indications, interactions, adverse effects, and more. Humulin R, Novolin R (Insulin Regular Human) Dosing, Indications, Interactions, Adverse Effects, and More n.d.

[2] Pathan MF, Sahay RK, Zargar AH, Raza SA, Khan AA, Ganie MA, Siddiqui NI, Amin F, Ishtiaq O, Kalra S. South Asian Consensus Guideline: use of insulin in diabetes during Ramadan. Indian journal of endocrinology and metabolism. 2012 Jul;16(4):499.

[3] Common brands and various types of insulin for diabetics. WebMD.

[4]  The 6 types of insulin: A complete guide - goodrx.

Syeda Qurat-ul-Ain

Usage Of Insulin Pens And Pumps During Ramadan

The month of Ramadan is upon us and Muslims worldwide rejoice for it&rsquo;s officially the month of blessings! And unless you&rsquo;re exempted, you&rsquo;ve probably begun preparing for a month of fast and spiritual growth.

But, how do you fast if you&rsquo;re a diabetic? There&rsquo;s no denying that it can be a bit difficult as compared to fasting by otherwise healthy individuals. Then again, given the medical advancements, it is actually possible for you to successfully fast and keep your blood sugar levels under control.

Read on to find out for yourself! 
&nbsp;
<quillbot-extension-portal></quillbot-extension-portal>

Understanding Usage Of Insulin Pens And Pumps During Ramadan

Using insulin pens during Ramadan is a practical option. They are a great choice for those who are fasting because they are portable and simple to use. The price of insulin pens differs based on the brand and style of the pen.

In Pakistan, the two common insulin pen types are NovoRapid FlexPen and Levemir FlexPen.

<ul>
	<li style="text-align:justify">Levemir FlexPen: It is a long-acting insulin pen that can help control blood sugar levels throughout the day.</li>
	<li style="text-align:justify">NovoRapid FlexPen: It is a rapid-acting insulin pen. It is usually taken before meals because it takes 10-20 minutes to lower your blood sugar levels.</li>
</ul>

NOTE: Change your injection site regularly. 
&nbsp;

Another choice for controlling <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes </a>during Ramadan is insulin pumps. They are especially helpful for those who need to administer insulin frequently or who struggle to control their blood sugar levels with insulin syringes.

The price of insulin pumps differs in Pakistan based on the type and features of the device. 
&nbsp;

Also accessible in Pakistan are patch devices, which can be attached to your skin to administer insulin through a tiny catheter.

&nbsp;

Managing diabetes during Ramadan requires careful planning and monitoring of blood sugar levels. Insulin pens and pumps are convenient and effective options for diabetics who are fasting during Ramadan.

However, it is essential to consult a healthcare professional before making any changes to insulin doses or medication schedules.&nbsp; Also, if you&rsquo;re concerned about hypoglycemia or low blood sugar levels during Ramadan, make sure to keep a supply of quick-acting carbohydrates, such as glucose tablets or juice, to avoid hypoglycemia. 
&nbsp;

[1] Ali S, Davies MJ, Brady EM, Gray LJ, Khunti K, Beshyah SA, Hanif W. Guidelines for managing diabetes in Ramadan. Diabetic Medicine. 2016 Oct;33(10):1315-29.

[2] Nawaz MS, Rafique HS, Malik T, Wahab MU, Chughtai AU, Nawaz MS, Butt MD. CURRENT TRENDS AND AVAILABILITY OF INJECTABLE THERAPY IN PAKISTAN FOR MANAGEMENT OF DIABETES MELLITUS. International Journal of Pharmacy & Integrated Health Sciences. 2023 Mar 1;4(1).

Diabetic Medications And Your Kidneys

According to a study, nearly 40% of patients with type 2 diabetes have diabetic kidney disease, which may lead to kidney failure, cardiovascular disease, and premature death. Native Americans, Hispanics, and Black people are at greater risk of developing diabetes, kidney disease, and kidney failure than Caucasians<a href="#accordion">[8]</a>.

Chronic kidney disease cannot be reversed. However, careful control of medical conditions that cause it, like diabetes and high blood pressure, can prevent kidney function from worsening.

It&rsquo;s usually recommended that a person with type 1 diabetes begins screening for diabetic nephropathy five years after their diagnosis. Whereas, type 2 diabetics are advised screening at the time of diagnosis only<a href="#accordion">[1]</a>. This is because people with type 2 diabetes are often unaware that they have it and the unchecked excess sugar in their blood has already started damaging their kidneys.

Besides diet, exercise, and lifestyle changes to control diabetes and high blood pressure &ndash; a known risk factor for kidney disease &ndash; patients are prescribed medications to prevent or delay kidney dysfunction. 
&nbsp;

Understanding The Impact Of Diabetic Medications On Kidneys

Here are some commonly prescribed medications for diabetic patients and how they affect kidney health<a href="#accordion">[6]</a>: 
&nbsp;

<ul>
	<li>
	<h5>Metformin</h5>
	</li>
</ul>

Some brand names for this include Glucophage, Riomet, Glumetza, and Fortamet.

This is the first-line medicine for most people who are recently diagnosed with type 2 diabetes. It&rsquo;s usually taken twice a day.

Common side effects include diarrhea and nausea. However, they subside when the medicine is taken with food.

While metformin is generally safe for diabetic people, people with severe kidney disease should not take metformin. When the kidneys are significantly compromised, metformin can lead to lactic acidosis<a href="#accordion">[9]</a>. The pill should also be stopped if there&rsquo;s a severe infection with low blood pressure, the person develops acute heart failure, becomes dehydrated, or any surgery is scheduled.

&nbsp;

<ul>
	<li>
	<h5>Sulfonylureas</h5>
	</li>
</ul>

Some brand names for this include Amaryl (glimepiride), Glucotrol (glipizide), and Micronase (glyburide).

Another common medicine to treat type 2 diabetes, sulfonylureas are meant to stimulate insulin production. While all sulfonylurea drugs have an equal effect on blood glucose levels, they differ in how often they should be taken, their interaction with other drugs, and their side effects.

A drawback is hypoglycemia (low blood sugar), which presents as sweating, hunger, confusion, anxiety, and shaking. It needs to be treated immediately by eating fast-acting carbs (e.g., glucose tablets, fruit juice, or candy) or the person can pass out.

While most diabetics don&rsquo;t react to sulfonylureas, they should be used with caution by those with kidney disease as they may accumulate in the body and cause hypoglycemia. Patients with kidney failure should avoid glimepiride<a href="#accordion">[5]</a>.

&nbsp;

<ul>
	<li>
	<h5>Dipeptidyl Peptidase-4 (DPP-4) Inhibitors</h5>
	</li>
</ul>

Some of the brand names for this include Januvia (sitagliptin), Onglyza (saxagliptin), Tradjenta (linagliptin), Nesina (alogliptin), and Galvus (vildagliptin).

DPP-4 improves A1C (average blood glucose levels over 2-3 months) without causing low blood glucose by preventing the breakdown of GLP-1 and GIP, naturally-occurring hormones that are responsible for reducing blood glucose levels. The medication is generally well-tolerated.

DPP-4 inhibitors do not cause changes to body weight or low blood sugar, although, in rare instances, pancreatitis, joint pain, and severe skin reactions have been reported. The dosage should be adjusted according to the kidney function of the patients as they are not extensively cleared by the kidneys.

&nbsp;

<ul>
	<li>
	<h5>Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors</h5>
	</li>
</ul>

Some of the brand names for this include Invokana (canagliflozin), Jardiance (empagliflozin), Farxiga (dapagliflozin), and Brenzavvy (bexagliflozin).

The mechanism of this newer class of medications is reducing glucose reabsorption in the kidneys. In other words, it increases the excretion of glucose in urine to lower blood sugar. As a result, it improves blood glucose, decreases blood pressure, and promotes weight loss.

SGLT2 inhibitors may have side effects, like UTIs, genital yeast infections, and dehydration. Some medicines in this class may cause the patient to be prone to bone fracture. They can also increase the risk of infection in the perineum, which can be fatal in both men and women. Another rare but serious issue is diabetic ketoacidosis, a medical emergency wherein ketone levels in the blood become elevated even if the blood glucose level is not that high.

According to the American Diabetes Association, patients with type 2 diabetes who also have chronic kidney disease are possible candidates for SGLT2 inhibitors<a href="#accordion">[2]</a>. In addition to cardiovascular benefits, especially in patients with heart failure, SGLT2 inhibitors slow the progression of diabetic kidney disease<a href="#accordion">[4]</a>.

&nbsp;

<ul>
	<li>
	<h5>GLP-1 and Dual GLP-1/GIP Receptor Agonists</h5>
	</li>
</ul>

Some of the brand names for this include Byetta (exenatide), Bydureon (exenatide extended-release), Victoza (liraglutide), Trulicity (dulaglutide), Adlyxin (lixisenatide), and Rybelsus (semaglutide).

These drugs potentially suppress glucagon and increase insulin release post-meal. They are usually only recommended if even the highest dose of one or two diabetic medicines has failed to control blood sugar, especially if the patient is overweight or struggling to lose weight with other medications. Some of these agents also prevent heart disease<a href="#accordion">[3]</a>.

However, they can have side effects like diarrhea, vomiting, pancreatitis (rarely), and gallbladder disease.

Individuals with abnormal kidney function should avoid exenatide and lixisenatide, besides exercising caution when taking dulaglutide and liraglutide.

&nbsp;

<ul>
	<li>
	<h5>Meglitinides</h5>
	</li>
</ul>

Some of the brand names for this include Prandin (repaglinide) and Starlix (nateglinide).

Someone allergic to sulfonylureas may be prescribed meglitinides as they work similarly. An added advantage is that they are more efficient and quicker than sulfonylureas.

In the case of advanced kidney disease, they may lower the blood sugar too much and, therefore, are not recommended for everyone<a href="#accordion">[2]</a>.

&nbsp;

<ul>
	<li>
	<h5>Insulin</h5>
	</li>
</ul>

The earlier the patient begins insulin therapy, the better they can manage their diabetes over time. The dose can be adjusted according to the individual&rsquo;s needs to reduce the risk of side effects, such as low blood sugar and weight gain.

Insulin is considered safe to use in case of kidney disease, irrespective of the stage of the disease. Firstly, insulin doesn&rsquo;t rely on kidneys for its elimination from the body, which means there&rsquo;s no risk of accumulation or other adverse effects on kidneys in individuals with impaired kidney function. Secondly, by enabling precise blood sugar control, it not only helps manage diabetes but also prevents complications which include kidney damage. Thirdly, diabetes may cause cardiovascular disease that can impact kidney health, and insulin can reduce that risk of complication by helping manage diabetes.

It is important to note here that insulin can be used at any stage of kidney disease, including end-stage renal disease, when the other medications are not as effective. 
&nbsp;

FDA recently approved a drug, Kerendia (finerenone), to minimize the risk of decline of kidney function and kidney failure in addition to cardiovascular disease in adults with chronic kidney disease associated with type 2 diabetes<a href="#accordion">[7]</a>. 
&nbsp;

Diabetic kidney disease aka Diabetic Nephropathy is a serious condition and can even prove life-threatening. Without treatment, it can lead to the accumulation of toxins and waste products in the body, eventually causing kidney failure and hemodialysis.

In general, diabetes medicines are not inherently bad for the kidneys. However, some medications for diabetes need to be used with caution or adjusted in individuals with existing kidney disease or impaired kidney function.

When it comes to choosing the best diabetes medication for individuals with kidney disease, it is essential to consider the stage of kidney disease and the overall health of the individual. A healthcare professional may prescribe more than one kind at a time or a combination of pills and insulin injections to achieve the best result.

Regular follow-ups with doctors are necessary. Managing diabetes and kidney disease often requires a multidisciplinary approach. The healthcare team may include endocrinologists, nephrologists, dietitians, and other specialists who work together to develop a tailored treatment plan, monitor progress, and adjust medications and interventions as needed. 
&nbsp;

[1] Diabetic nephropathy (kidney disease). Mayo Clinic. October 19, 2021.

[2] Cherney K. List of common diabetes medications. Healthline. March 13, 2023.

[3] What are my options for type 2 diabetes medications? Oral and Injectable Diabetes Medications | ADA.

[4] Samar Hafida M. Type 2 diabetes: Which medication is best for me? Harvard Health. November 5, 2020.

[5] Kean M. Ask the expert: Diabetes drugs for people with kidney disease. Healthline. March 9, 2023.

[6] Type 2 diabetes: Treatment (Beyond the Basics). UpToDate.

[7] Center for Drug Evaluation and Research. FDA approves drug for chronic kidney disease. U.S. Food and Drug Administration.

[8] Henderson R by E. Drug combinations may help to slow the progression of diabetic kidney disease. News. June 16, 2022.9. Common diabetes drug found safe for most diabetics with kidney disease. Johns Hopkins Medicine Newsroom. June 5, 2018.

Nearly 463 million people in the world are diagnosed with diabetes, out of which nearly 150-200 million people need insulin therapy for their health<a href="#accordion">[1]</a>.

If you have type 1 diabetes, you&rsquo;ll have to inject insulin on a regular basis to use glucose from meals and, basically, to survive. This is because your pancreas is no longer making any insulin or producing an insufficient amount of the hormone.

If you have type 2 diabetes, your body may be producing insulin, but due to the fact that you&rsquo;re overweight or inactive, it may not be utilizing the hormone properly. This is called insulin resistance. You may need insulin shots to help your body control high blood glucose levels or hyperglycemia.

About 5-10% of pregnant women develop gestational diabetes<a href="#accordion">[4]</a>&nbsp;If you have gestational diabetes, you may need to inject insulin as well to manage your blood glucose levels until the baby is born. 
&nbsp;

Understanding the importance of Insulin

Understanding the role of insulin therapy as part of diabetes treatment becomes a whole lot easier when you understand how the hormone typically works and what happens when you get diabetes. 
&nbsp;

<ul>
	<li>
	<h5>Regulating Blood Sugar Levels</h5>
	</li>
</ul>

When you eat or drink, your body breaks down the carbs into glucose, which is the primary source of energy for your body. This glucose enters the bloodstream, signaling the pancreas to release insulin. Insulin helps the blood sugar to enter the cells where it can be used as an energy source.

It also helps the blood sugar to be stored in the liver as glycogen for later use; in case of low insulin levels between meals, the liver releases this stored sugar, ensuring the blood sugar levels are within a narrow range. 
&nbsp;

As a result, the blood sugar levels in the bloodstream decrease and, accordingly, the insulin levels decrease, too.

The problem arises when there&rsquo;s a lot of blood sugar in the bloodstream. The pancreas either has difficulty keeping up with the rising blood sugar levels or the cells stop responding to all the insulin, which is why you need therapy. 
&nbsp;

<ul>
	<li>
	<h5>Preventing Diabetic Complications</h5>
	</li>
</ul>

Untreated high blood glucose can lead to various complications. This includes nerve damage, blindness, foot ulcers, kidney damage, heart disease, and stroke. There is lots of insulin in the bloodstream, too, instructing the liver and muscles to take up the excess blood sugar; when their capacity is full, the extra blood sugar is sent to fat cells and is stored as body fat, resulting in weight gain and increasing the risk of type 2 diabetes. Insulin therapy is crucial to managing blood sugar levels to reduce the risk of developing these life-threatening complications and also to maintain overall better health. 
&nbsp;

<ul>
	<li>
	<h5>Correcting Insulin Deficiency</h5>
	</li>
</ul>

Your body&rsquo;s immune system may mistakenly destroy the insulin-producing cells in the pancreas if you have type 1 diabetes. This leads to a complete deficiency of insulin. Some individuals with type 2 diabetes struggle when they don&rsquo;t have enough insulin or when other treatment options (e.g., oral medications) are not effective in controlling blood sugar. Insulin treatment supplements or replaces natural insulin with the aim to achieve normal blood glucose levels. 
&nbsp;

<ul>
	<li>
	<h5>Meal Scheduling</h5>
	</li>
</ul>

A lot of factors, including lifestyle and weight, influence your insulin therapy. Planning meals helps because you can then determine your insulin regimen (insulin pump therapy or multiple injections every day) according to the amount of carbohydrates you consume in a meal. It gives you the liberty to enjoy a varied diet along with better glycemic control. 
&nbsp;

<h5>Other Functions Of Insulin</h5>

Insulin is also involved in<a href="#accordion">[2]</a>:

<ul>
	<li>Modification of enzyme activity and the subsequent reactions in the body</li>
	<li>Management of the synthesis of lipids</li>
	<li>Uptake of potassium and amino acids by cells and regulate DNA replication and synthesis of proteins</li>
	<li>Management of the breakdown of lipids and proteins because of changes in fat cells</li>
	<li>Regulation of the excretion of sodium and fluid volume of urine</li>
	<li>Building muscle post-injury or sickness</li>
	<li>Enhance the memory 
	&nbsp;</li>
</ul>

Important!

<ul>
	<li>Starting insulin therapy can be frightening. Consult your doctor to know more about the type of insulin you need. Make sure you know how, when, and where to inject insulin, and also how to rotate your injection sites.</li>
	<li>Always keep a proper record of your insulin dose and your blood glucose levels.</li>
	<li>Insulin should be stored correctly for usage. Extreme (hot and cold) temperatures damage insulin.</li>
	<li>Proper disposal of syringes, lancets, pen needles, and cannulas is important.</li>
	<li>Inform a doctor if you need help adjusting your insulin doses. This change may be due to changes in diet, increased or decreased exercise, illness, medication, weight loss or weight gain, etc.</li>
	<li>Contact a doctor if you have any problems taking insulin or if you notice any side effects. 
	&nbsp;</li>
</ul>

Insulin is an important hormone that controls how tissues and cells absorb energy. Insulin shots are effective in counteracting the effects of insulin resistance or deficiency. While people with type 1 diabetes have to inject insulin for the rest of their lives, the majority of people with type 2 diabetes may not need it<a href="#accordion">[3]</a>. Regular blood sugar monitoring and close communication with healthcare providers are essential for optimizing insulin therapy and achieving optimal diabetes management. 
&nbsp;

[1] Buse JB, Davies MJ, Frier BM, Philis-Tsimikas A. 100 Years on: The impact of the discovery of insulin on clinical outcomes. BMJ Open Diabetes Research &amp; Care