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INTRODUCTION  
There is a sudden and sharp rise in the prevalence of diabetes in India. This rise cannot be explained on the basis of ethnic susceptibility or due to increasing urban stress. There has been an adequate medical evidence suggesting that diabetes is an immune-inflammatory disorder thereby implicating environmental factors, particularly faulty nutrition (both in early intrauterine life and infancy). Malnutrition, if it continues unchecked will have its deleterious effects on every tissue of the human body among which the most vulnerable being B-cells in the pancreas and the endothelial cells in the blood vessels. Both coronary artery disease and diabetes have a common etiopathogenic factor which is faulty nutrition producing oxygen free radicals thereby causing oxidative stress. Diabetes and its complications are difficult to be managed once developed, both therapeutically and economically. Therefore an attempt should be made at the primary prevention of diabetes rather hat trying to treat it once it is developed. Nutritional interventions based on certain clinical and experimental observations have shown to have helped not only the disease management but also succeeded in primary prevention of diabetes. Diabetic Association of India has given certain important guidelines for primary prevention of diabetes and its complications evolving nutritional strategies, eye, kidney, and foot care which are aimed at education the primary care physicians. These guidelines are particularly very useful in developing countries because most of the diabetes management is done by the primary care physicians.  
   

  Importance is given to proper nutrition mainly because its adverse effect may start from first day of life in the mother’s womb and continues all through life. Phases of life at high stress i.e. early adolescence, pregnancy and lactation or elderly with poor nutrition are all associated with higher prevalence. Any lapse at any time leaves its mark to increase further susceptibility. In contrast, proper nutrition not only prevents the disease but all its complications involving eye, kidney, heart, foot, nerves and brain.

Studies at All India Institute of Diabetes have shown diet has shown diet has an important role in development of diabetes and its complications. It has been noted that use of refined vegetable oils and deficiency of omega-3 fatty acid found in fish and flax seed are important risk factors for diabetes and its complications. Following guidelines are incorporated taking the above data into consideration.
 
       
 

a)

Total calories: As majority of the population in the urban areas lead sedentary lives with low physical activity 25-30 calories/kg. body weight which for a healthy adult doing normal activity will mean 1800-2200 calories/day. This may be slightly less for females. Some addition is needed for these doing extra physical activity.  
  b) Proteins: As per the W.H.O. recommendations, proteins should provide 0.8 gms/kg body weight. For an average Indian we really need about 60 gms of proteins. This works out to 1 kg/body weight. As our diet is mainly lactovegetarian, milk becomes an important part of the diet. Please see this is included in the diet. Rest of the proteins can come from cereals, pulses and vegetables.  
  c) Fats: Fats have an important role in development of diabetes. Deficiency of omega-3 fatty acids can easily be corrected by giving small supplements of fish oil (2-3 capsules of fish oil/day or 2-3 helpings of fish per week). For vegetarians the alternative is given in point no. 3 of diet guidelines.  
  d) Carbohydrates: On an average Carbohydrates should provide 6065% of total calories. This should come from natural sources. Please take care to avoid simple sugars. Instead complex carbohydrates such as grains, vegetables, pulses should be taken in the required quantam.  
   
  Detailed diet guidelines are given below:  
  1. Omit all cooking oils in use at present namely:
Safflower, Sunflower, Corn, Til, or Groundnut oil or Vanaspati.
 
  2. Instead use a small quantity (3-4 teaspoonful per person per day or half kg per month per person) of any one (or combined) from ghee, coconut oil. In India we have used them for centuries without any harm.  
  3. Avoid use of non-vegetarian items (Eggs, Chicken, Lamb, Pork, Beef or Cheese etc.) It is advisable to take fish regularly (2-3 helpings/weeks) but avoid taking fried fish. Vegetarians can take flax seed, Methi seeds or Green Leafy vegetables. Encourage use of Urad dal and Rajmah instead of Beasan and Bengal gram (Channa).  
  4. Unlike others foods of animals origin, it is necessary for Indians to take some Milk/Surds/Yoghurt (about ½ liters per day). Our diet is mainly vegetarian. We need many important nutrients like Calcium, Phosphorus, Vitamin A, D and Proteins present in Milk.  
  5. Avoid refined processd foods or those containing preservatives; this means that biscuits, cakes, bakery products or other maida preparations like pizza, Roomali Roti or white bread must be avoided. Avoid fried foods.  
  6. Avoid Alcohol, Tobacco in any form.  
  7. Avoid taking Desserts, Sweets dishes. Instead take fresh fruits. Diabetics also need to take 2-3 fruits daily. One of these must be an Orange or Sweet lime. It is better to take whole fruit rather than fruits juice. All fruits including Mango or Banana can be taken by diabetics.  
  8. Patients with high blood pressure or swelling on feet or congestive heart failure should avoid taking excessive salt or salty preparations (Pickles, Chutney, Papad etc.), bakery products, Preserved food in tins and cans.  
  9. You are advised to take vitamins and fish oil supplements as prescribed. These help to prevent diabetes and heart disease.  
  10. Caution; be exercised while using the use of sweetening agents marketed under various trade names. There are some reports suggesting Aspartame may increase chances for some cancers.  
  11. Rice, Potatoes and other root vegetables can easily be consumed by a diabetic, keeping count of their calories.  
 

  1. Detection at Initial Diagnosis.  
    All newly detected cases must have:  
      a) BP  
      b) Urine Routine  
      c) Blood Urea  
      d) S. Creatinine estimation  
   
  2. All newly detected cases found to have “Macro” albuminuria in Routine urine analysis need not be checked for micro albuminuria.  
      Yearly check up of:
    a) BP
    b) Routine urine
    c) Micro albuminuria if urine routine shows no macro albuminuria
    d) If micro albuminuria is present repeat 3 times at monthly interval after correcting extraneous causes like urinary infection
 
       
  4. If “macro” albuminuria present, do 24 hours urine albumin excretion, blood urea, S. Creatinine and S. Protein estimation. If any abnormality is detected, refer to a kidney clinic.  
  5. If BP is elevated at yearly or other check up, or microalbuminuria present then do Doppler, USG of kidney and then start ACE-Inhibitors.  
  6. Target BP 125/75 in sitting position.
(Or Mean arterial Pressure less than 92)
 
  7. If ACE-I contraindicated due to cough-then AT2 blocker.
If ACE-I & AT2 blocker contraindicated for reason of Double Renal Artery steosis, other anti hypertensives with same Target BP.
 
  8. If micro albuminuria persistently +ve. Then protein restriction diet to 0.8 gm/kg body wt per day.  
 

  Diabetic Foot Problem is a serious complication of diabetes requiring hospitalization which invariably results in a loss of toe or limb. It causes tremendous hardships to individuals with diabetes and his family. It handicaps them physically, socially and economically.  
   
  Prevention:
  Following subjects may be at high risk for developing foot lesions:
  1. Diabetes uncontrolled for a long time
  2. Elderly Persons
  3. Presence of neuropathy
  4. Presence of ischemia
  5. History of previous ulceration
  6. Amputation of toe
  7. Presence of retinopathy and neuropathy
  8. Illiterate patients
 
     
  Prevention Programme  
  Daily inspection of feet is necessary. Because of loss of sensation a diabetic may not notice an ulcer. Pressure point areas like ball of the big toe, heel, outer aspects of the feet need to be inspected every day. Due to poor vision it may be difficult to inspect the foot properly. Use of a mirror placed on the ground is helpful. Family members should also take active interest in respecting the foot whenever possible. Family physician should make it a point to examine the foot of the patients on each visit.  
   
  Overcome Dryness: Automatic neuropathy affects sweating mechanism leaving the foot very dry. Dry skin is vulnerable to cracks and fissures as it loses its suppleness. This can be best overcome by application of petroleum jelly, coconut oil or cold cream to the sole of the foot including inter digital area. We have noticed consumption of vegetable oils increases the dryness of the foot resulting in cracks and fissures. Consumption of fish oil and correcting nutrition reverses the dryness. Details of nutrition are given in the nutritional guidelines.  
   
  Careful pedicure: Diabetics tend to injure their toes in the process of cutting their nails because of impaired sensation and poor vision. Great care needs to be taken while cutting the nails and they may need the help of someone else to cut their nails.  
   
  Avoid walking bare surgery: It is a common practice in India to shave corns or callus on the sole of the foot with the help of a shaving blade. This is dangerous in a diabetic because of impaired sensation. Unknowingly he might cut deeper leaving a raw area and a possibility of infection creeping in. This job should be left to the doctor concerned or podiatrist.  
   
  Avoid walking bare foot: Walking bare foot is harmful because of loss of sensation and inability to feel hot or cold. Soft slippers are recommended.  
   
  Shoes should be comfortable and well padded. Socks should always be worn. New shoes should be gradually broken in over a few days.  
   
  If a foot problem does occur it should be detected early. Foot problem should be treated with great caution by bed rest, appropriate dressing, correct footwear and antibiotics as suggested by the doctor.