20 मार्च 2013

we must change diabetes to truly reform health care in India

To truly reform health care in India  we must change diabetes.

As we work to change health care in INDIA  we must recognize the need to dramatically change diabetes.   Twenty-four million Indian  have diabetes at a cost to our nation of an estimated $218 billion for diabetes and pre-diabetes, according to a series of studies recently published in various papers.  Imagine the effects diabetes will have on our health and economy in the future if we don’t take action now. The prevalence and economic burden of undiagnosed and pre-diabetes make the case for the importance of policies that promote early diagnosis and prevention.  About 50 percent of Indian with diabetes aren’t even aware they have the disease.
The numbers associated with pre-diabetes, a precursor to type 2 diabetes, are equally as staggering.  Pre-diabetes affects an estimated 57 million Indian  . The costs stem from the fact that people with the condition have higher rates of medical visits than those with normal blood-sugar levels.  They also seek medical attention more often for issues associated with diabetes, including high blood pressure and metabolic and renal complications. While the rates of undiagnosed diabetes and pre-diabetes are alarming, studies show that type 2 diabetes can be significantly prevented, or at least delayed, by losing weight through diet and regular exercise.  But, even with evidence supporting prevention, our nation isn’t allocating adequate resources.  In 2005, a study by the National Diabetes Program found that the government spent much amount  more on those with diabetes than those without the disease, and only part of that was spent on prevention and health promotion.   Early diagnosis and prevention are good places to start, but we must also take measures to improve diabetes care and management.  The first step to care improvement is to measure the quality of care being delivered in a consistent way.  A recent study (to be published) documents tremendous variability of how care quality is now being measured. Aggressive treatment is another key component of changing diabetes.  Studies show that intensive treatment to reduce blood sugar levels can delay or prevent debilitating and costly complications of diabetes, such as heart disease, stroke, blindness, kidney failure and amputation. Changing diabetes is not a simple task and requires coordination.  Strategies and activities that impact diabetes need to be aligned in order for us to succeed in the fight against this disease.  We must also look at our budget process and make adjustments to more accurately assess the long-term impact of prevention programs.  The current 10-year budget window doesn’t take into account that the value of prevention and improved treatment needs to be assessed over a longer period of time.       To truly reform health care in India  we must change diabetes.

Discovery of insulin

 Discovery of insulin

In the fall of 1920 Dr. Frederick Banting had an idea that would unlock the mystery of the dreaded diabetes disorder. Before this, for thousands of years, a diabetes diagnosis meant wasting away to a certain death. Working at a University of Toronto laboratory in the very hot summer of 1921 Fred Banting and Charles Best were able to make a pancreatic extract which had anti diabetic characteristics.

 They were successful in testing their extract on diabetic dogs. Within months Professor J. J. R. MacLeod, who provided the lab space and general scientific direction to Banting and Best, put his entire research team to work on the production and purification of insulin. J.B. Collip joined the team and with his technical expertise the four discoverers were able to purify insulin for use on diabetic patients. The first tests were conducted on Leonard Thompson early in 1922. These were a spectacular success.

 Word of this spread quickly around the world giving immediate hope to many diabetic persons who were near death. A frenzied quest for insulin followed. Some patients in a diabetic coma made miraculous recoveries.

While insulin is not a cure, this medical discovery has and continues to save millions of lives world-wide. The production of insulin has changed a great deal since 1922. Modern science and technology has made high quality insulin and delivery systems available to diabetic persons.

significance of an eclipse?

What is the significance of an eclipse?

Eclipse  (grahan )are times of the year when the path of the Sun and the Moon intersect with the Nodes of the Moon, Rahu and Ketu. A Lunar eclipse (chandra  grahan )is during the full Moon and the Solar eclipse is during the new Moon.

What is the significance of an eclipse?
Let's first talk about the basic significance of the Sun, Moon and Rahu and Ketu. The Sun and the Moon are what can be called 'personal' planets because they represent our personality more than any of the other planets.
The Sun is the karaka or signficator of the body and our self-expression, while the Moon is the karaka of the mind (not intellect, which is Mercury) and emotions. The nodes of the Moon, Rahu and Ketu, are called chaya grahas or shadowy planets because they are invisible points in space and not actually planets with orbits around the Sun. They are given the full status of planets in Vedic astrology none the less. Their points in space which are always opposite one another travel through the zodiac in reverse direction in an approximately 19 year cycle.

Because the nodes of the Moon are so mysterious and unusual in nature their influences cause abnormal functioning to whatever they aspect. During the eclipse the nodes of the Moon are aspecting both of the personality planets, the Sun and Moon and are cutting off their normal functioning. They create an opening in our psyche for subtle energies to enter. It's therefore the best to only do spiritual practices during eclipses and not anything in the material world of signficance like having a surgery, or signing an important document. We should take a break and do extra spiritual practices and take advantage of the subtle influences of the eclipse time.

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SMBG OF DIABETES - A Doctor Who Understands

SMBG OF DIABETES  - A Doctor Who Understands

Over time I must admit to developing a certain degree of cynicism about researchers and doctors in the medical research field. I get a little jaded and dispirited about the entrenched attitudes in the fields of diabetes research, especially concerning diet.

Recently, in
 SMBG Research, Or the Lack of It, I wrote “There are so many areas of diabetes crying out for research. There are some that have never been studied at all, including those dealing with diet modified by structured testing or similar methods which can lead to minimal medication or insulin needs.”

The paper is written by Dr Lois Jovanovic and includes references to other studies in support. Not a lot of other studies, most are small and some are only obliquely relevant, but at least there is some research happening in the field. It is so pleasant, after years of reading so many doctors ignoring so many patients on this subject, to finally read a paper like this one. They can ignore diabetics like me and dismiss us as unqualified; but Lois Jovanovic is someone who may be harder to ignore.

I think two unique factors make this particular doctor more aware of the close relationship between carbohydrate input and post-prandial hyperglycemia than most doctors. First, she has
 a depth of experience especially in gestational diabetes and pregnancies in patients already diagnosed as type 2. That has led to experience in trying to attain and manage normoglycemia much tighter than the levels usually expected for most type 2s. Her bio, in part reads:

Dr. Jovanovic has authored over 240 articles, including 135 for refereed journals, and 25 books on the topic of diabetes and pregnancy and islet cell transplantation. She serves as an Associated Editor of Diabetes Care and is on the editorial boards of Clinical Pharmacology and Therapeutics and the American Journal of Perinatology and is a contributing editor for the Journal of the American College of Nutrition and special editor for Endocrine Practice, the official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. In addition, Dr. Jovanovic serves on the national board of directors of the Society for Experimental Biology and Medicine.

The purpose of this article is to describe how self-monitoring of blood glucose (SMBG) data is a useful tool for identifying and managing postprandial hyperglycemia (PPHG).

PPHG and postprandial glucose excursions occur frequently in patients with diabetes even when hemoglobin A1C is controlled below 7.0%, and convey increased risk of cardiovascular morbidity and mortality. Consequently, effective management of diabetes must include control of postprandial glucose levels. Postprandial plasma glucose (PPG) depends on the composition of meals, specifically the amount of carbohydrates.

Reduced-carbohydrate diets offer short-term improvements in glycemic control and other metabolic parameters, but await the support of long-term efficacy and safety studies. Glucose profiling and paired-meal SMBG are useful tools for detecting PPHG and glucose excursions. They provide immediate feedback to patients on the effect of foods and meals, thereby allowing appropriate food and medication adjustments to improve postprandial glycemic control.

But that abstract does not give an inkling of the specific recommendations in the full text or the pleasant shock I received when I read this marvellous “To Do” list for guiding dietary recommendations that is included as Table 1:

Educate your patients on the risks associated with high peak-postprandial glucose concentrations (≥150 mg/dL)

Ensure patients understand that postprandial glucose concentrations are determined by the total amount of carbohydrates consumed

•• Encourage patients to measure their carbohydrate consumption

•• Recommend that patients keep a food diary

Remind patients of the benefits of monitoring their blood glucose levels with SMBG and construct a testing plan that optimizes these benefits

•• Have patients determine the best time for postprandial SMBG by testing 45, 60, 75, 90, 105, and 120 minutes after a meal to detect their peak postprandial glucose concentration

•• Using preprandial and postprandial SMBG, together with a food diary, patients can understand how certain foods influence their glucose concentrations

•• If preprandial glucose concentrations are already high, there is no room for carbohydrates in the upcoming meal

Review recent SMBG and food diary data with your patients to help them recognize trends in out-of-target readings

•• Use this information to recommend a specific SMBG testing schedule including number of tests per day and appropriate testing times

•• Have patients meet with a nutrition specialist if they are having trouble identifying or controlling their carbohydrate consumption