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Similar to the nontransplant settings, the use of fasting plasma glucose (FPG) versus oral glucose tolerance test (OGTT) to define diabetes mellitus also changes the prevalence of NODAT. I enjoyed this novel more than The Kite Runner and would highly recommend it He’s trying to teach Oden the Heat way of sacrifice. Controlling blood sugar blood pressure diabetic exchange list carbs and cholesterol can prevent or delay CKD and CVD and improve health outcomes. I have a copy and it is an excellent primer on the European power politics of the pre-1914 world.
Type II diabetes also called Adult-Onset Diabetes is characterized by sufficient insulin levels but the body appears to no do i need a prescription for diabetes supplies longer be able to respond to the insulin. Gestational diabetes prevention complexity includes diet lifestyle-and of course exercises.
You’re essentially cutting out carbs and wheat both things not required in a human diet.
Effectiveness of Fenugreek for Lowering Hemoglobin (HbA1c) in Patients with Self-Management of Type 2 Diabetes: A Randomized Controlled TrialRashid Ansari1 and Saiqaa Ansari2[1] School of Public Health, University of New England, Australia[2] School of Population Health, University of Queensland, Australia1.
We are experiencing an increasing epidemic of life-style related health problems from obesity, metabolic syndrome, Type 2 Diabetes Mellitus, heart disease, high cholesterol, hypertension, osteoporosis, osteoarthritis, stroke, substance abuse and cancer.
Extensive research has shown that many of these chronic diseases associated with aging can be prevented and treated by adopting a healthy lifestyle. Lifestyle changes make it possible to delay the onset of chronic disease by learning to adopt healthy habits that address nutrition, exercise, relaxation and rest, stress, emotional health and relationships. Lifestyle medicine is not restricted to the adult or aging population, and is becoming increasingly more important with the increase of obesity, metabolic syndrome and Type 2 Diabetes Mellitus in children and young adults.
Relatively simple lifestyle changes that include eating more whole foods and less processed foods, staying physically active on a daily basis, losing weight and learning to manage stress better can help patients to avoid medications for hypertension, chronic inflammatory conditions and to reduce risk of strokes and heart attacks.
Eating a diet rich in micronutrients with enough healthy proteins provides our cells with the building blocks to make plenty of neurotransmitters including dopamine, serotonin and norepinephrine, which help keep us balanced and happy.
Disrupted sleeping patterns prevent natural healing and balancing of many systems in the body. A lifestyle management program also aims to address stress-related disorders that contribute to the development of chronic diseases. Lifestyle changes are an integral part of an integrative approach to health and well-being and should always be part of the prescription for good health. Your thyroid is a much bigger Calcium channel blockers are also frequently used to alter heart rate to prevent cereal vasospasm and to reduce chest pain caused by angina pectoris. Diabetes Icd 9 Glyburide Gestational Hypoglycemia diabetes mellitus insulin resistance continuous subcutaneous insulin infusion insulin pump therapy. The next time you decide to follow the cooking advice of southern chef Paula Deen you might want to consider that reports are now circulating in History Of Diabetes Icd 9 Glyburide Gestational Hypoglycemia which the star has developed type 2 diabetes from her choice of high-fat high-calorie cooking.
Smoking poor diet inactivity and being overweight increase risk of developing gestational diabetes by up Research finds strong evidence drugs cause weight gain and increase risk of disease. Increased stress may cause Diabetic Ketoacidosis with symptoms that include vomiting and nausea followed by dehydration and serious disturbances in the person’s blood levels of potassium. This post may seem like more of a public service announcement for the American Diabetes Association. Leading up to American Diabetes Awareness Month in November (which includes World Diabetes Day on Nov.
People can answer that question through a video submission, in a contest that the ADA is promoting online. Aside from this video contest, people are also encouraged to join this "movement" in other ways, such as giving, volunteering, learning, and advocating. However, I'm a little bothered by this message overall to "Stop Diabetes." To me, it seems to imply that we can just "flick a switch" and somehow stop diabetes. I want to cure diabetes, which is something that the JDRF is obviously the leading organization on that front. Ditto!I guess at this stage of the game Mike I am happy to unite with other type 1's to educate and advocate. I knew D was a sign of the coming of our robot overlords!!Seriously tho, simply by the title, the program seems to be directed at type 2. If you are suffering from type 1 diabetes, you might be curious to know about type 1 diabetes statistics 2012.
In order for us to understand the impact of type 1 diabetes, first and foremost we should define the key factors of what we want to see in the statistics. You need to know how many people suffer from type 1 diabetes from the type 1 diabetes statistics 2012 database. Secondly, one of the most important factors to look at from type 1 diabetes statistics 2012 is the growth rate of this disease, both percentage wise as well as the number.
Last but not least, you will need to know the economic impact of type 1 diabetes in the United States. Now that you know what important factors to look at from type 1 diabetes statistics 2012, where do you find this information? Type 1 diabetes statistics 2012 is now available from the CDC website, which includes the numbers from previous years. Recent Commentspatrice thompson on Free Diabetic Supplies – How to Get Them?munnaamalai on Type 1 vs Type 2 Diabetes ChartJessica I. When you have diabetes mellitus, which is referred to as diabetes, your blood glucose level is consistently high.
Neuropathy is a serious complication of diabetes, and it affects up to 70 percent of people with diabetes. Neuropathies are more common in people who are overweight and have high cholesterol levels. For patients with diabetic neuropathy, commonly used medications include antidepressants, anticonvulsants, prescription pain medication and topical agents. Detection and management of diabetes mellitus in recipients of solid organ transplants 12.1. Sugested guidelines for pre-transplant baseline evaluation and post-transplant screening for NODAT12.3. In a prospective study designed to evaluate the use of OGTT for risk-stratifying patients for NODAT, Sharif et al.
ObesitySimilar to the general population, obesity has been shown to be associated with the development of NODAT in most studies (Setoguchi et al., 2005). This finding has not yet been validated in either transplant recipients or prospective trials in the general population (Bosch et al., 2006). Reversal of insulin resistance in type I diabetes after treatment with continuous subcutaneous insulin infusion. This health condition is that it could lead to several serious diseases including type 2 diabetes. IntroductionThe incidence of type 2 diabetes is increasing worldwide, resulting in large measure from the increasing prevalence of obesity (Yale, 2000). For example, 91% of Type 2 Diabetes Mellitus are caused by unhealthy habits over a number of years.
Contributing factors like a sedentary lifestyle, with little or no exercise, hours spent in front of computers or television screens and an oversupply of fast food with little nutritional value, are the main reasons for this 21st century phenomenon. Addictions to sugar, nicotine and other recreational drugs are all symptoms of a society craving for sustainable solutions to find more happiness and fulfilment. Moving our bodies regularly has all kinds of benefits; from lowering the risk of diabetes and heart disease to improving mood and enhancing libido.
During a healthy sleep cycle, our body releases hormones to accelerate healing, for example melatonin and growth hormone.
Chronic stress stimulates the release of cortisol in the body, also called the stress-hormone. Diabetes mellitus type 2 (formerly noninsulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes) is a The World Health Organization definition of diabetes (both type 1 and type 2) is for a single raised glucose reading with symptoms otherwise Intensive blood sugar lowering (HbA1c<6 Anti-diabetic medications are used to control type 2 diabetes mellitus.
Often additional treatments aimed diabetic cookbook free type review 2 at improving liver adrenal or thyroid function or correcting immune and allergic problems are necessary to regain health. Diabetes self-care depends on the student’s age knowledge neuropathy frst sign of diabetes recipes menu diabetic History Of Diabetes Icd 9 Glyburide Gestational Hypoglycemia skills and maturity. Thepeople in the prevention trials must have at least one close relative with History Of Diabetes Icd 9 Glyburide Gestational Hypoglycemia Type 1 diabetes. Apparently, more than 600,000 people have joined this movement (as reported by the latest ADA figures) and the ADA is very focused on letting people know the organization is the largest national movement to Stop Diabetes. To me, that's what World Diabetes Day does for me - it bridges a gap that the two leading groups aren't willing to bridge at this point. I just want everyone to work together in that mission and advocating for the best possible way we can all Live With Diabetes successfully short of it no longer existing. A husband, friend, dog owner, journalist, writer, history lover, movie buff, Sigma Pi Man, and huge fan of Coffee & Conversation.
I'm very proud of the diabetes journalism work there, so make sure to go check out that "diabetes newspaper with a personal twist." Meanwhile, it's fun keeping tabs on my personal life adventures here at The Corner Booth.
Last year is an especially important year since the awareness of diabetes and its impact not only on the overall health of the population, but the impact to the health industry in general, is gaining momentum. Type 1 diabetes statistics 2012 can then be compared to previous years to draw a picture of the trend, based on those key factors that we want to look at. In United States, approximately 26 million people are affected by this disease, which translates to about 8% of the population. The type 1 diabetes statistics 2012 will tell you whether the population is affected by this disease at a younger age compared to previous years, remains the same, or it is older. This is probably one of the most important aspects of this disease since type 1 diabetes is one of the diseases which cost us a lot of money individually since it requires life-long treatment and constant monitoring. You have a lot of sources that you can look into for further review, but the most reliable resource for type 1 diabetes statistics 2012 is the CDC or Centers for Disease Control and Prevention website, which is the official governing body that handles the management and statistics of every aspect in public health in the United States. All you need to do is to select the key factors, which we described above for you, and compare those numbers to the previous results. Monitoring your glucose level and adopting a healthy lifestyle can decrease your risk for neuropathy by as much as 60 percent. There has been scant literature on the incidence of diabetes mellitus after a successful pancreas transplant. Of interest, ADPKD patients with normal native kidney function have been shown to have insulin resistance and compensatory hyperinsulinemia (Vareesangthip et al., 1997). The Jordan Bennett Weiss Fund was established to foster awareness about the warning signs of diabetes.
Diabetes mellitus is a pandemic disease and is one of the main threats to human health (Narayan, 2005). A healthy lifestyle can be defined as a pattern of positive personal behaviours that promote health and well-being, while preventing chronic disease. Exercise has been shown to be as effective as anti-depressants for mild depression and anxiety, with even longer-lasting effects.
Inflammation in the body is reduced, detoxification takes place, and damaged tissue is repaired while new cells are being formed. Over a longer period of time cortisol suppresses the immune system with the possible development of immune related problems.
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Once the video submissions are complete, the public will be able to vote for the most compelling video. Most recently, Rite Aid has joined this campaign and is offering incentives for people to take Diabetes Risk Tests, distributing D-guides at every pharmacy counter, and hosting more than 1,200 free D-clinics during November. I commend the ADA for wanting to raise more awareness overall about diabetes, and some of the materials it offers online do encourage that and even touch on Type 1 - something that many long-time Adult Type 1s see as a shortcoming of the ADA.
Really, it taps into that ongoing longtime feeling by so many that the ADA is just T2 focused, that it refuses to weave Type 1 into its larger advocacy marketing.
They both have their bottom lines and goals, and the overall elimination of diabetes of any type isn't their focus - it's "stopping" or "curing" it and then claiming their mission has been met.
This is a disease that does not have a cure; hence the cost to the overall economy is extremely large. From this website you can search type 1 diabetes statistics 2012 and compare the numbers you find there with the previous year’s results and draw a conclusion from there.
Please be sure to use the official numbers from the CDC website since this is the official website and the results have been reviewed and certified nationally by the official US governing body in public health management.
The highest rates of nerve problems are among people who have had diabetes for at least 25 years. Although not a risk factor per se, increased insulin clearance after a successful kidney transplant can unmask pre-transplant impaired glucose tolerance or pre-existing diabetes mellitus that manifests clinically as NODAT.
Although some studies failed to demonstrate an association between obesity and the development of NODAT, obesity and its associated peripheral insulin resistance state is a known risk factor for type 2 diabetes. I hate it when I see other reviews saying that the game only has around 16 or so dungeons because that is diabetes cure jewelry ENTIRELY wrong.
Diana Deep to Der Feed von Diana Diabetes Diabetes Diabetes care Diabetes Care Jobs Diabetes Stuff Diabetics Signs Symptoms. A diabetes kit is a packet of tools especially created to deal with the extreme highs and lows that can happen with type one diabetes. A healthy lifestyle is possible to sustain over years and needs to steer away from fad diets, excessive exercise and quick fixes. A daily form of movement or exercise is a healthy habit that supports bone and muscle health, lower stress levels, improves cellular oxygenation and improves overall circulation. Recent studies have shown that insufficient sleep increases the risk of several common cancers, including breast cancer.
Chronic stress also slows down metabolism, increases fat storage in the body with the typical belly fat that is hard to shed.
In the end, the top 3 finalists will receive an Apple iPad and the winner will be a part of a Stop Diabetes public service announcement. We had a great conversation with group leadership earlier this year in Orlando, and some of what they said was encouraging - though we shall see what comes from all of that. Whatever inspires and maybe makes someone else aware of what they can do, or what they might need to know. This is important because this will tell us if all our efforts all these years to combat this disease have yielded any positive result. Damaged nerves send messages slowly or at the wrong times, and nerves eventually stop sending messages to the brain. Having both diabetes and high blood pressure greatly increases the risk for serious complications. The variation in the reported incidence may be due in part to the lack of a standard definition of the condition, the duration of follow-up, the presence of both modifiable and non-modifiable risks factors, and the type of organ transplants among others.
Risk factors for NODATRisk factors for the development of NODAT are categorized as non-modifiable and modifiable or potentially modifiable, the former category to facilitate the identification of high risk individuals, and the latter two categories to optimize the management of NODAT.
Pharmacological managementWhen lifestyle modification fails to achieve adequate glycemic control, medical intervention is recommended. The links are more well demonstrated through controlled lab studies and those have been (and continue to be) done extensively.
It is projected that this number will be increased by 72% to 333 million by 2025, and nearly 80% of these cases will be in the poorer industrialized countries (IDF, 2003). In lifestyle medicine patients are educated, supported and empowered to incorporate stress management techniques that stimulate the relaxation response in the body. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss. If you’d like a more personalised weekly diet plan (including shopping list) try our system free for 24hrs. I commend our fellow D-blogger and social media guru Dayle Kern for working with the ADA on this front and being a part of the solution. I want there to be a huge focus on a cure and yet the reality is we need that AND we need a huge focus on educating the public and helping them change their lifestyles. In Type 2 diabetes, the body does not use insulin properly, which is called insulin resistance. Depending on the medication, side effects may include constipation, dizziness, headache, nausea, dry mouth, fatigue, diarrhea, weight gain and insomnia. Nonetheless, the pattern of body fat distribution has been suggested to play a contributory role.
Orally administered agents can be used either alone or in combination with other oral agents or insulin. With gestational diabetes there are high chances of developing hypoglycemia (low blood sugar) in your baby.
According to a 2005 US Government estimate, approximately 21 million people in the United States have diabetes (Gerich, 2005). Most people are afflicted from birth though it can also result from obesity excessive standing and diabetes. But in looking at this campaign, my natural feelings of Type 1 getting the short end of a stick come to mind. Pham5[1] Department of Medicine, Nephrology Division, Kidney Transplant Program, David Geffen School of Medicine at UCLA, United States of America[2] Department of Medicine, Greater Los Angeles VA Medical Center and David Geffen School of Medicine at UCLA, United States of America[3] Department of Medicine, Cardiology Division, Bay Pines VA Medical Center, Bay Pines, Florida, United States of America[4] Department of Medicine, Division of Cardiovascular Diseases, VA Medical Center, University of Tennessee Health Science Center, Memphis, TN, United States of America[5] Department of Medicine, Nephrology Division, UCLA-Olive View Medical Center and David Geffen School of Medicine, United States of America1.
Corticosteroid-associated NODATThe now well-established contributory role of corticosteroid on NODAT was first described by Starlz in 1964 in renal transplant recipients. Studies in healthy women showed that upper body or male-type obesity has a much greater association with insulin resistance and impaired glucose tolerance than lower body or female-type obesity (Kissebah et al., 1982).
The choice of pharmacologic therapy is based on the potential advantages and disadvantages associated with the different classes of oral agents. In 2002, diabetes was the sixth leading cause of death and had an estimated total cost of $132 billion (Hogan et al.


So much of this seems as though it's just the ADA trying to boost its numbers and membership and not truly embracing what it professes to embrace.
Introduction New onset diabetes mellitus after transplantation (NODAT) is a serious and common complication following solid organ transplantation.
In one single-center study consisting of 126 lung and heart-lung transplant recipients, diabetes has a reported prevalence of 6% at 1 year and 7% at 5 years. Table 3 summarizes the mechanisms of action and potential advantages and disadvantages of different classes of oral agents.
Weight loss resources to help you lose weight healthily including the NHS 12-week diet and exercise plan. Glucose monitoring, meal planning, physical activity and medication help control the glucose level. The lower prevalence of diabetes in this study was thought to be due in part to a lower frequency of cystic fibrosis patients (8.7% vs.
It is speculated that intra-abdominal fat or waist-to-hip ratio may be more important risk factors for NODAT than total body weight or BMI (Davidson et al., 2003). Type 2 diabetes is a disease characterized by a dual defect: 1) by insulin resistance which prevents cells from using insulin properly, and 2) degrees of reduced pancreatic insulin secretion.
We try to give them the benefit of the doubt and move on, hoping for something we aren't expecting. Kidney transplant recipients who develop NODAT have variably been reported to be at increased risk of fatal and nonfatal cardiovascular events and other adverse outcomes including infection, reduced patient survival, graft rejection, and accelerated graft loss compared with those who do not develop diabetes. In contrast to the DOPPS study results, in an analysis of the national cohort study consisting of more than 5,000 dialysis patients with type 2 diabetes Brunelli et al.
Limited clinical studies in liver, heart and lung transplants similarly suggested that NODAT has an adverse impact on patient and graft outcomes. Ischemic heart disease was also found to be associated with an increased incidence of NODAT (Ye et al., 2010b). A quarter of the population of Pakistan would be classified as overweight or obese with the use of Indo-Asian-specific BMI cutoff values.
The following chapter presents an overview of the literature on the current diagnostic criteria for NODAT, its incidence after solid organ transplantation, suggested risk factors and potential pathogenic mechanisms. In a single-center study consisting of 97 consecutive adult heart transplant recipients, a family history of diabetes and the need for insulin beyond the first 24 hours after transplantation were shown to be risk factors for the development NODAT (Depczynski et al., 2000). Whether complete withdrawal of chronic low dose corticosteroid therapy (prednisolone 5 mg daily) improves glucose metabolism remains to be studied. In a recent retrospective analysis consisting of 640 nondiabetic renal transplant recipients Bayer et al.
Jafar et al (2006) have reported that prevalence of overweight was 25% and obesity was 10% in a large population-based sample of people over the age of 15 years in Pakistan.
The impact of NODAT on patient and allograft outcomes and suggested guidelines for early identification and management of NODAT will also be discussed. Nonetheless, in recent years several studies have suggested a potential beneficial effect of steroid-free immunosuppression on NODAT risk reduction (Luan et al., 2011). On the age-specific prevalence of overweight and obesity, they found that more than 40% of women and 30% of men aged 35–54 years were classified as overweight or obese.
Multivariate analysis incorporating the individual metabolic syndrome components as covariates demonstrated that of all the pre-transplant metabolic syndrome components, only low-density lipoprotein was independently associated with the development of NODAT.The precise role of the metabolic syndrome or metabolic syndrome component(s) in the development of NODAT remains to be defined. Nonetheless, great caution should be exercised when rosiglitazone is used in the setting of kidney transplantation because all kidney transplant recipients should be regarded as having at least stage II-IV chronic kidney disease. It has been suggested in a variety of observational and epidemiological studies that physical activity may play a significant role in the prevention of type 2 diabetes mellitus.
Nonetheless, the overlapping metabolic risk factors for type 2 diabetes and cardiovascular disease (e.g. The relationships between physical activity and overweight are only beginning to be understood for the adult population, sedentary behaviours, particularly watching television (TV) and videos, surfing the internet have been found to be related to higher body mass index (BMI) for adult’s population (Struber, 2004). Figure 1.Risk Factors for NODATSimilar to type 2 diabetes in the general population, both genetic and environmental factors have been suggested to play a role in the development of NODAT. The cumulative incidence of NODAT within three years post-transplant were 12.3% in steroid-free vs. The literature linking physical activity levels with risk of overweight in adults is not consistent but physical activity is an important component of effective obesity treatments (Saelens, 2003).
There is strong evidence suggesting that individuals with a family history of diabetes among first-degree relatives have an increased risk of developing NODAT with one study reporting a seven fold increase in the condition (Davidson et al., 2003). ProteinuriaEarly report from single-center study suggested an association between proteinuria on day 5 after transplantation and the development of NODAT (Kuypers et al., 2008). A randomized, placebo-controlled, double-blind, prospective trial to evaluate the safety and efficacy of vildagliptin in patients with NODAT is currently underway (Haidinger et al., 2010). The main health promotion intervention here is the public health education which highlights the importance of physical activity for the prevention of type 2 diabetes in the middle-aged population of sub-continent and particularly Pakistan, which is experiencing a rapid and substantial decline of physical activity levels as a result of poor eating habits, unhealthy food supply, expansion of television, computerization, and mechanization, more prevalent car ownership and sedentary behaviour. The current WHO and American Diabetes Association (ADA) guidelines for the diagnosis of prediabetic states (IFG and IGT) and diabetes mellitus are provided in Table 1 (modified from Davidson et al., 2003).
The increased prevalence of NODAT associated with a family history of diabetes has been documented across all types of solid organ transplantation. Overall, steroid-containing regimens at the time of hospital discharge were associated with a 42% increased risk for NODAT. However, these findings have been challenged because proteinuria on day 5 may just reflect the highly concentrated urine associated with hyperglycemia-induced osmotic diuresis from the early posttransplant use of high dose corticosteroid or residual native kidney proteinuria. Caution should be exercised when these agents are used in the transplant setting, particularly with regards to drug to drug interactions.
In parallel with decreasing levels of physical activity, the prevalence of overweight and obesity has increased significantly in Pakistan and as a consequence, diabetes mellitus has become a major public health issue. Notably, patients from programs that frequently adopted steroid-free regimens had reduced odds of NODAT compared with those from programs that commonly used steroid-contatining regimens. Furthermore, it has been shown that immediate posttransplant proteinuria generally resolves several weeks after transplantation (Myslak et al., 2006).
Vildagliptin should be avoided in patients with hepatic impairment and stage IV-V chronic kidney disease and the dose of sitagliptin should be adjusted for renal insufficiency.
Therefore, promoting an active lifestyle or regular exercise has become the highest public health priority in that country to overcome the onslaught of type 2 diabetes. Other non-modifiable risk factors include recipient male gender, the presence of certain HLA antigens such as HLA A 30, B27, B42, increasing HLA mismatches, DR mismatch, deceased donor kidneys, male donor, and acute rejection history (Depczynski et al., 2000). The dose dependent diabetogenic effect of corticosteroid was also observed in recipients of nonrenal organ transplants.
Nonetheless, in a subsequent single-center retrospective study designed to evaluate the impact of early proteinuria (3 and 6 months after transplantation) and urinary albumin excretion (UAE) on NODAT, Roland et al. Also, the search for dietary adjuncts along with usual medical care to treat this life altering disease has become more important and dietary supplements that can modulate glucose homeostasis and potentially improve lipid parameters would be desirable. Adult polycystic kidney disease (ADPKD) has been suggested to confer an increased risk of developing NODAT in some studies but not in others (P.T.
Fenugreek (Trigonella foenum-graecum Linn) is a dietary supplement that may hold promise in this regard and is one of the oldest medicinal plants, originating in India and Northern Africa and dating back to ancient Egyptian times (Jensen, 1992).In Pakistan and India, fenugreek is commonly consumed as a condiment (Yoshikawa et al. SummaryNODAT is a common complication after solid organ transplantation and has variably been reported to have an adverse impact on patient and allograft outcomes. NODAT-free survival was greater in patients with normoalbuminuria than in those with microalbuminuria, and greater in those with microalbuminuria than in those with macroalbuminuria (p=0.0326).
Risk stratification and intervention to minimize risk should be an integral part in the management of the transplant recipients.
The authors also demonstrated that pulse pressure was an independent risk factor for NODAT, suggesting that early low-grade proteinuria and pulse pressure may be markers of the metabolic syndrome or vascular damage or both.
Clinicians must be familiar with the patients’ immune history prior to manipulating their immunosuppressive therapy.in an attempt to ameliorate NODAT risk. Fenugreek seeds also lower serum triglycerides, total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C) (Al-Habori and Raman, 1998). When lifestyle modification fails to achieve adequate glycemic control, medical intervention is often necessary. The lipid-lowering effect of fenugreek might also be attributed to its estrogenic constituent, indirectly increasing thyroid hormones (Basch, 2003). HypomagnesemiaIn the general population, not only has hypomagnesemia been shown to be associated with type 2 diabetes, but numerous studies have also reported an inverse relationship between glycemic control and serum Mg levels (P.C.
The routine care of patients with NODAT should include an evaluation of hemoglobin A1C level every three months and regular screening for diabetic complications.
The plant protein in fenugreek is 26%, so it might exert a lipid lowering effect (Sharma, 1986). It should be noted that hemoglobin A1C cannot be accurately interpreted within the first three months post transplantation due to various factors including possible blood transfusions in the early posttransplant period and the presence of anemia or impaired allograft function.
Since a high proportion of diabetic patients in sub-continent suffer from malnutrition, the use of fenugreek which is rich in protein and fiber (48%), has a distinct advantage in these patients (Sharma, 1986). Similar to the nontransplant settings, hypomagenesemia has also been shown to be an independent predictor of NODAT in recipients of renal and liver transplants.
Blood transfusions may render the test invalid until new hemoglobin is formed and the presence of anemia and kidney impairment can directly interfere with the A1C assay. This chapter addresses the effectiveness of fenugreek for lowering hemoglobin (HbA1c) in this randomized controlled trial and determines whether the intervention of taking fenugreek in combination of usual medical care lowers HbA1c in patients with type 2 diabetes. In a single-center retrospective analysis consisting of 254 renal transplant recipients Van Laecke et al. An artifactual reduction in A1C level has been reported in islet cell transplant recipients taking dapsone for pneumocystis carinii (P. Effectiveness trials such as this are critical in determining if the interventions are effective in the practical world in which patients live.
This randomized control trial addresses the research question “Is Fenugreek treatment with medical care for patients with type 2 diabetes more effective than usual medical care and can it help to lower the haemoglobin in patients with poorly controlled type 2 diabetes”? While the association between the use of CNIs was strongly related to hypomagnesemia, NODAT disappeared after adjustment for Mg levels suggesting that the diabetogenic effect of CNIs is at least in part related to hypomagnesemia. Furthermore, a lower proportion of CsA-ME patients with NODAT required hypoglycemic medication or dual therapy with insulin and oral hypoglycemic agents compared with their tacrolimus-treated counterparts. Conversely, the use of mTOR inhibitors appeared to be a risk factor for NODAT after adjustment for Mg levels.
In transplant recipients with multiple CVD risk factors, more frequent monitoring of lipid profile should be performed at the discretion of the clinicians.
Characteristics of type 2 diabetesType 2 diabetes is associated with certain ethnic groups, obesity, family history of diabetes, and physical inactivity, among other factors. The greater diabetogenic effect of tacrolimus compared to CSA has been reported to occur across renal and nonrenal transplant groups. The same group of authors subsequently demonstrated that both pretransplant hypomagenesemia and hypomagnesemia in the first-month posttransplantation were independent predictors of NODAT in recipients of liver transplants (Van Laecke et al., 2010). Statins or the HMG-CoA reductase inhibitors are the most widely used lipid lowering agents in both the nontransplant and transplant settings. In a meta-analysis to evaluate the reported incidence of NODAT after solid organ transplantation, Heisel and colleagues found a higher incidence of insulin-dependent diabetes mellitus (IDDM) in Tac- vs.
Chronic, untreated hyperglycemia can lead to serious complications that include cardiovascular diseases, blindness, kidney failure, and stroke.
Furthermore, very low values of blood glucose (hypoglycemia) for even a short duration can result in loss of consciousness and coma.
Whether Mg supplementation and correction of Mg deficiency reduce the incidence of insulin resistance or NODAT remains to be studied. The figure 1 shows the complications of type 2 diabetes which is a syndrome characterized by insulin deficiency, insulin resistance, and increased hepatic glucose production. These metabolic abnormalities are treated by use of various medications which are designed to correct one or more of these metabolic abnormalities (Saltiel & Olefsky, 2001). Type 2 diabetes is most common in adults, although younger people are also developing this type of disease.
Impaired glucose tolerance before transplantationAbnormal glucose metabolism has been reported to be a risk factor for the development of NODAT in some but not all studies. It starts with a slow onset with thirst, frequent urination, weight loss developing over weeks to months. Nonetheless, not all studies showed that Tac is more diabetogenic than cyclosporine (Meiser et al., 1998). It is also considered to run in families but it may happen with a person without a family history of diabetes as well. In a single-center study consisting of 45 OLT recipients treated with either CSA (n=9) or high- (n=15) vs. In its early stages, many people with type 2 diabetes can control their blood glucose levels by losing weight, eating properly and exercising. Among patients with IFG pretransplant, 70% had hyperglycemia at one year (IFG 43% and NODAT 27%). Many may subsequently need oral medication, and some people with type 2 diabetes may eventually need insulin shots to control their diabetes and avoid the disease's serious complications (Saltiel & Olefsky, 2001). Even though there is no cure for diabetes, proper treatment and glucose control enable people with type 2 diabetes to live normal, productive lives. Interaction between tacrolimus and concomitant hepatitis C infection (HCV)In a retrospective study of more than 400 kidney transplant recipients with no known pre-transplant diabetes, Bloom and colleagues have shown that among the HCV(+) cohort, NODAT occurred more often in the Tac- compared with the CSA-treated groups (57.8% vs. A major advance for people at risk of developing type 2 diabetes - such as family members of those with the condition - occurred recently when it was shown that diet and exercise can prevent or delay type 2 diabetes. HCV-associated NODATThe association between HCV infection and impaired fasting glucose or the development of overt type 2 diabetes mellitus in the general population has long been suggested. In contrast, among the HCV (-) cohort, the rates of NODAT were similar between the two calcineurin inhibitor (CNI) groups (Tac vs. Potential mechanisms of the diabetogenic effect of HCV infection include insulin resistance, decreased hepatic glucose uptake and glycogenesis, and direct cytopathic effect of the virus on pancreatic ? cells (Bloom & Lake, 2006). Similar to the non-transplant settings, the link between hepatitis C and the development of NODAT has also been recognized in solid organ transplant recipients.
Whether concomitant exposure to tacrolimus and HCV plays a synergistic role in the development of NODAT remains speculative. Clinical studies in recipients of orthotopic liver transplant (OLT) recipients have implicated insulin resistance associated with active HCV infection as a predominant pathogenic mechanism. 2004), however, population-based data on the prevalence of diabetic retinopathy in Pakistan and on the visual impairment due to diabetic retinopathy is lacking and only the hospital-based data is available (Kayani et al.
Effects of sirolimus on glucose metabolismEarly large randomized clinical trials suggested that sirolimus is devoid of diabetogenic effects either used alone or in combination therapy with CNI. Diabetic nephropathy is present in 18% of people diagnosed with diabetes (DSG, 1993) and is a leading cause of end-stage renal disease (Molitch et al.
2003)Stroke: diabetes is associated with a 2- to 4-fold increase in cardiovascular mortality and stroke (Kannel et al.
It was suggested that the virus had a direct effect on insulin resistance as no difference in ? cell function or hepatic insulin extraction between the HCV (+) and (-) groups was observed. In one single-center study, tacrolimus and sirolimus combination therapy was found to be associated with a higher incidence of NODAT than tacrolimus alone immunosuppression (Sulanc et al., 2005). Therefore, early detection and treatment of diabetes is essential in order to reduce the impact of its serious complications. Subsequent large registry study also demonstrated an association between sirolimus and the development of NODAT. Cytomegalovirus-associated NODATThe link between cytomegalovirus (CMV) infection and the development of NODAT was first reported in 1985 in a renal transplant recipient (Lehr et al., 1985). In an analysis of the USRDS database consisting of more than 20,000 primary kidney transplant recipients receiving sirolimus (Sir) or CNI (CsA or Tac) or both in various combination therapy with an antimetabolite (MMF or AZA), Johnston et al.
Limited studies suggested that both asymptomatic CMV infection and CMV disease are independent risk factors for the development of NODAT. Development of type 2 diabetesDevelopment of type 2 diabetes is the result of multifactorial influences that include lifestyle, environment and genetics. The disease arises when insulin resistance-induced compensatory insulin secretion is exhausted. Patients with active CMV infection had a significantly lower median insulin release compared to their CMV negative counterparts, suggesting that impaired pancreatic ? cell insulin release may be involved in the pathogenic mechanism of CMV-associated NODAT.
A high-caloric diet coupled with a sedentary lifestyle is one of the major contributing factors in the development of the insulin resistance and pancreatic ?-cell dysfunction as shown in Figure 2.
It is speculated that CMV-induced release of proinflammatory cytokines may lead to apoptosis and functional disturbances of pancreatic ?-cells (Hjelmasaeth et al., 2005). However, a predisposing genetic background has long been suspected in playing a contributing role in the development of type 2 diabetes. Anti-CD25 monoclonal antibodies In a single-center study consisting of 74 stable kidney transplant recipients with 3 month-follow-up, Bayes et al.
The metabolic syndrome is defined as a clustering of atherosclerotic cardiovascular disease risk factors that include visceral adiposity (obesity), insulin resistance, low levels of HDLs and a systemic proinflammatory state. Kidney transplantsClinical studies evaluating the impact of NODAT on patient and allograft outcomes after solid organ transplantation have yielded variable results. There are key components to the metabolic syndrome which include in addition to insulin resistance (the hallmark feature of the syndrome), hypertension, dyslipidemia, chronic inflammation, impaired fibrinolysis, procoagulation and most telling central obesity.3. Randomized controlled trials with fenugreekThe multiple trials in the past have shown conflicting results of the effect of fenugreek on the patients of type 2 diabetes.
The development of NODAT has also been shown to be associated with an adverse impact on patient survival and an increased risk of graft rejection and graft loss, as well as an increased incidence of infectious complications (Ojo, 2006). These studies showed some positive results on fasting serum glucose but did not examine hemoglobin (HbA1c) levels. Gupta et al (2001) reported the results of a small randomized, controlled, double-blind trial to evaluate the effects of fenugreek seeds on glycemic control. The authors reported that there were no significant differences between groups in mean glucose tolerance test values at the study's end. Calcineurin inhibitorsImpaired insulin secretion has been suggested to contribute to the development of CNI-associated NODAT (Crutchlow & Bloom, 2007). The study consisted of >37,000 renal transplant recipients with a functioning transplant for at least 1 year.


Risk stratification according to diabetes status (pre-transplant diabetes, NODAT) and acute rejection (AR) at 1 year demonstrated that pre-transplant diabetes is the major predictor of all-cause and cardiovascular mortality whereas acute rejection during the first year is the major predictor of death-censored transplant failure. However, the trial may have been too small or brief to detect significant mean differences between groups. In recipients of pancreas transplants, both calcineurin inhibitors CSA and Tac have been shown to cause reversible toxicity to islet cells. In contrast, NODAT alone was not associated significantly with any study outcomes (Kuo et al., 2010). Raghuram et al (1994) reported the results of a randomized, controlled, crossover trial of fenugreek seeds in 10 patients with type 2 diabetes. In a study of 26 pancreas allograft biopsies from 20 simultaneous kidney-pancreas transplant recipients, a significant correlation was seen between the presence of islet cell damage and serum levels of Tac and CSA, as well as with the Tac peak level (Drachenberg et al., 1999).
Nonetheless, the study results were regarded as inconclusive due to the wide confidence intervals and the relatively short duration of follow-up.
In the fenugreek-treated patients, statistically significant mean improvements were reported for glucose-tolerance test scores and serum-clearance rates of glucose. Cytoplasmic swelling and vacuolization, and marked decrease or absence of dense-core secretory granules in ?-cells were demonstrated on electron microscopy. It is noteworthy that in a large registry study consisting of more than 27,000 primary kidney transplant recipients with graft survival of at least 1 year and with longer-term follow-up, Cole et al.
Sharma and Raghuram (1990) conducted two randomized, controlled, crossover studies in patients with type 2 diabetes. Serial biopsies from two patients with hyperglycemia and evidence of islet cell damage receiving Tac immunosuppression demonstrated reversibility of the damage upon discontinuation of tacrolimus. Significant mean improvements in fasting blood-glucose levels and glucose-tolerance test results were described in the fenugreek-treated patients.
Moosa et al (2006) conducted study to evaluate the effect of fenugreek on serum lipid profile in hypercholesteremic type 2 diabetic patients and concluded that fenugreek seeds powder significantly reduced serum total cholesterol, triglyceride and LDL-cholesterol but serum HDL-cholesterol level elevation was not significant. Sirolimus (mTOR inhibitors)Suggested pathogenic mechanisms of sirolimus-induced hyperglycemia include sirolimus-associated impaired insulin-mediated suppression of hepatic glucose production, ectopic triglyceride deposition leading to insulin resistance, and direct ? cell toxicity (Crutchlow & Bloom, 2007).
Neeraja and Rajyalakshmi (1996) presented a case series including six men with type 2 diabetes and six without diabetes.
However, studies on the effects of sirolimus on insulin action and secretion have yielded variable and conflicting results. The cases suggested fenugreek reduced postprandial hyperglycemia primarily in subjects with diabetes, but less so in subjects without diabetes.
Currently existing literature suggests that the effects of sirolimus on glucose metabolism appear to be cell-species- and dose-dependent (Subramanian & Trence, 2007). Anti-CD25 monoclonal antibodiesThe pathogenic mechanisms of anti-CD25-induced NODAT have not been established.
However, suppression of regulatory T-cells has been suggested to play a contributory role (Aasebo et al., 2010).
However, there was no difference in patient survival between the two groups at 1-, 2- and 5-years follow-up. The studies conducted to date have been methodologically weak, lacking adequate descriptions of blinding, randomization, baseline patient characteristics, statistical analysis, and standardization data for the therapy used. Studies in diabetes-prone mice have shown that anti-IL2-antibody treatment trigger insulinitis and early onset diabetes through inhibition of Foxp3-expressing CD25+ CD4+ regulatory T-cells (Setoguchi et al., 2005).
Demonstrating the efficacy of fenugreek has also been confounded by inconsistencies in the preparations, dosing regimens, and outcome measures used in the trials.
Suggested pathogenic mechanisms of immunosuppressive drug-induced NODAT are summarized in table 2. Moreover, none of the investigations have been conducted over the longer period (Basch, 2003).
Method of patient selectionThe patients were recruited from the diabetic medical centre in rural area of Peshawar conducting the study of management of type 2 diabetes among the population aged 30-65 years.
Patients having coexisting liver, kidney or thyroid disorder were not included in the study. Pre-transplant baseline evaluationSuggested guidelines for pre-transplant baseline evaluation of potential transplant candidates is shown in Figure 2. Diabetes Criteria for patientsThe well known standard screening test for diabetes, the fasting plasma glucose (FPG), is also a component of diagnostic testing. Patients with evidence of IGT or abnormal OGTT before transplantation should be counseled on lifestyle modifications including weight control, diet, and exercise.
The FPG test and the 75-g oral glucose tolerance test (OGTT) are both suitable tests for diabetes; however, the FPG test is preferred in clinical settings because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive.
The goals for the life-style modification involved achieving and maintaining a weight reduction of at least 7 percent of initial body weight through a healthy low-calorie, low-fat diet and at least 150 minutes of physical activity per week. Selection of an immunosuppressive regimen should be tailored to each individual patient, weighing the risk of developing diabetes after transplantation against the risk of acute rejection. When it was found necessary, plasma glucose testing was also performed on individuals who have taken food or drink shortly before testing.
Early detection of NODAT after transplantation Studies investigating the best predictive tool for identifying patients at risk for developing NODAT early after transplantation are currently lacking.
Such tests are referred to as casual plasma glucose measurements and are given without regard to time of last meal. While fasting plasma glucose (FPG) is readily available in clinical practice it may be normal in kidney transplant recipients with abnormal glucose homeostasis. It has been suggested that transplant patients have an atypical form of insulin resistance and their plasma glucose often peeks before lunch. A confirmatory FPG test or OGTT was also completed on such patients on a different day if the clinical condition of the patient permits. Laboratory measurement of plasma glucose concentration is performed on venous samples with enzymatic assay techniques, and the above-mentioned values are based on the use of such methods. The A1C test values remain a valuable tool for monitoring glycemia, but it is not currently recommended for the screening or diagnosis of diabetes.
Pencil and paper tests, such as the American Diabetes Association’s risk test, may be useful for educational purposes but do not perform well as stand-alone tests. Capillary blood glucose testing using a reflectance blood glucose meter has also been used but because of the imprecision of this method, it is better used for self-monitoring rather than as a screening tool. However, it is noteworthy that while acute rejection has been suggested to increase the risk for NODAT, it usually does not occur before day 5. Obtaining OGTT and FPG at day 5, therefore, may preclude the subset of patients with higher risk of developing NODAT. Determination of study sample size The study sample size was determined based on the assumption of the estimation of Standard Deviation (SD).
Hence, it has been suggested that performing OGTT at 10-12 weeks post-transplantation might be useful as an alternative or supplementary test to day 5 OGTT (P.T. Therefore, the study design was selected to detect an effect size of 0.5 SD lowering of HbA1c. It was assumed that 15% patients might be lost to follow-up in control group over the period of three months and only 5 % patients will be lost to follow-up in intervention group. This assumption was based on the popularity of fenugreek seeds used by diabetic patients in sub-continent to manage their glycemic control. The routine recommendation of performing an OGTT early after transplantation awaits further studies.
Suggested pre-transplant baseline evaluation and post-transplant screening for NODAT is shown in Figure 2. Study population and randomizationInitially 325 patients with type 2 diabetes were invited to pre-randomized interview, out of which only 210 patients were included in the actual trial. Management of established NODATThe management of NODAT should follow the conventional approach for patients with type 2 diabetes mellitus as recommended by many clinical guidelines established by well-recognized organizations including the American Diabetes Association (ADA). Out of the 325 patients, 93 patients did not meet the inclusion criteria and 22 patients refused to participate in the trial.
Finally, two hundred and ten (210) patients agreed to participate and signed informed consent documents at the clinic where they used to visit for their usual medical care for diabetes. Therefore, 102 patients were randomized to intervention group (fenugreek supplements) and 108 to the control group (usual medical care).
Nonetheless, it should be noted that the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial was discontinued prematurely because of a satistically significant increase in all-cause mortality in the intensive- compared with the standard- glycemic treatment groups (Gerstein et al., 2008).
The randomization code was developed using a computer random number generator in a block size of eight patients. That helped to allocate patients to the intervention and control groups equally in each block – that is each patient would have an equal chance of allocation to either group.
Once the randomization phase was completed, all patients were instructed to follow-up the usual medical care for their diabetes for the duration of the 90 days trial. Study similar to that of the ACCORD study in recipients of solid organ transplantation is lacking. The patients were allowed to adjust their usual medications as recommended by their doctors.
Nonetheless, the determination of hemoglobin A1C target levels for solid organ transplant recipients should be individualized based on hypoglycemia risks.
In addition, each patient was asked to go for blood test for HbA1c on day 1 and then return to give blood sample after 90 days. In addition, participants were advised not to take any other new treatments for the management of type 2 diabetes during the trial periods. The control group in randomized controlled trial received medical care from a physician-coordinated team. Dietary modification and physical activityThe Diabetes Prevention Program has demonstrated that a structured diet and physical activity program that achieves and maintains modest weight loss for overweight adults with IGT can significantly reduce the development of diabetes.
This team included physicians, nurses, dietitians, and mental health professionals with expertise and a special interest in diabetes.
Defining realistic goals such as a target weight loss of 5-10% of total body weight and patient- centered approach to education may be invaluable in achieving success. It is essential in this collaborative and integrated team approach that individuals with diabetes assume an active role in their care. The management plan in that group was based on individualized therapeutic alliance among the patient and family, the physician, and other members of the health care team.
This plan has recognized diabetes self-management education as an integral component of care and in developing the plan, consideration was given to the patient’s age, work schedule and conditions, physical activity, eating patterns, social situation and personality, cultural factors, and presence of complications of diabetes or other medical conditions. Modification of immunosuppressionModification of immunosuppression should be considered in high-risk patients. Corticosteroid dose reduction has been shown to significantly improve glucose tolerance during the first year after transplantation (Kasiske et al., 2003). Patient self-management was emphasized, and the plan emphasized the involvement of the patient in problem-solving as much as possible. A variety of strategies and techniques were employed to provide adequate education and development of problem-solving skills in the various aspects of diabetes management. Steroid-sparing regimen or steroid avoidance protocol should be tailored to each individual patient. During the implementation of the management plan it was assured that each aspect of diabetes management was understood and agreed on by the patient and the care providers and that the goals and treatment plan were reasonable.
Tac to CSA conversion therapy in patients who fail to achieve target glycemic control or in those with difficult to control diabetes has yielded variable results. Those patients randomized to take fenugreek (intervention group) received 100 gms fenugreek seeds powder from the pharmacy in the clinic.
They were instructed to take 50 gms doses twice a day at lunch and dinner time in addition to their normal medications for diabetes. Belatacept -- a selective T cell costimulation blocker, is a promising new immunosuppressant that has been suggested to have better cardiovascular and metabolic risk profiles compared with cyclosporine (lower blood pressure, better lipid profiles and lower NODAT incidence) (Vanrenterghem et al., 2011).
Those patients randomized to usual medical care (control group) were instructed to take their normal medicines and follow-up with their doctor as per their normal schedule.
All participants were contacted again after 90 days (3-months) to give their blood sample for HbA1c testing. At that time, a questionnaire was sent via e-mail to participants in both intervention and control groups to assess the progress of the fenugreek treatment and clinical care without fenugreek. The clinical and demographic characteristics of the patients in the two groups were well balanced at randomization.
A demographic measure included age, gender, weight, ethnicity, religion, marital status, previous episodes of glycemic control, previous and current treatments of type 2 diabetes.
The table 3 gives baseline characteristics of intervention and control groups in RCT trial. Diabetes treatment with medicationsThe treatment options of type 2 diabetes is shown in figure 4 suggesting the specific areas of actions using medications which influence the various organs of the body to correct the metabolic abnormalities such as reducing the liver glucose production, slowing down absorption of sugars from the gut and reducing the insulin resistance. There are currently six distinct classes of hypoglycemic agents available to treat type 2 diabetes.
The patients in both the groups in RCT trials received medications recommended by their physicians. The most common combinations among both the groups were Meglitinide (repaglinide) with Thiazolidendiones and Sulfonylurea with Biguanides. Details of hypoglycaemic medications used in RCT trialThe diabetes medications mentioned in table 4 work in different ways but the main function of all these medications include lowering blood sugar levels; help improve the body’s use of glucose, decrease the symptoms of high blood sugar, help keeping patients with diabetes functioning normally and may prevent the complications, organ-damaging effects and premature deaths diabetes can cause. Since the drugs work in different ways, these are sometimes used in combination to enhance the effectiveness of treatment.
In this RCT trial Sulfonylurea was used in combination with Biguanide (metformin) and Meglitinide was used in combination with Thiazolidinedione. The main function of Sulfonylurea is to bind and inhibit the pancreatic ATP-dependent potassium channel that is normally involved in glucose-mediated insulin secretion.
Like the sulfonylurea, meglitinide therapy results in significant reduction in fasting glucose as well as HbA1c.
The mechanism of action of the meglitinide is initiated by binding to a receptor on the pancreatic ?-cell that is distinct from the receptors for the sulfonylurea. Metformin is a member of this class and is currently the most widely prescribed insulin-sensitizing drug in current clinical use.
Metformin administration does not lead to increased insulin release from the pancreas and as such the risk of hypoglycemia is minimal. Because the major site of action for metformin is the liver its use can be contraindicated in patients with liver dysfunction. Thiazolidinedione: The thiazolidinedione (pioglitazone) has proven useful in treating the hyperglycemia associated with insulin-resistance in both type 2 diabetes and non-diabetic conditions. The net effect of the thiazolidinedione is a potentiation of the actions of insulin in liver, adipose tissue and skeletal muscle, increased peripheral glucose disposal and a decrease in glucose output by the liver. Diabetes treatment with diet and exerciseThe normal diabetes treatment addresses the issues related to unhealthy lifestyles, such as lack of physical activity and excessive eating, which are the main causes to initiate and propagate the majority of type 2 diabetes (Michael, 2007). Studies have demonstrated strong relationship between excess weight and the risk of developing type 2 diabetes, hypertension, and hyperlipidemia. Therefore, the objective of physicians is to motivate patients to lose weight and exercise to improve the control of diabetes and slow down or even reverse the natural course of the disease (Michael, 2007).However, it is difficult to overstate the importance of the relationship between lifestyle and the risk of developing type 2 diabetes. There are prospective studies which have demonstrated that lifestyle modification in the form of diet and regular moderate exercise sharply decrease the likelihood of developing type 2 diabetes in high-risk individuals who have impaired glucose tolerance or impaired fasting glucose. The effectiveness of this intervention superseded that of metformin therapy (Knowler et al. In this RCT trial, physicians compiled the flow scheme shown in Figure 5 which represents the method of treatment of type 2 diabetes by the combination of diet, exercise and medication for diabetes monitoring and control. It has been divided into two segments: for obese and normal weight patients and the combination of medication for both the groups of patients. Dietary consideration for patients (intervention and control group)It has been recommended that carbohydrate and monosaturated fat consumption for the patients with type 2 diabetes should comprise 60-70% of total calories. However, there is some concern that increased unsaturated fat consumption may promote weight gain in obese patients with type 2 diabetes and therefore may cause in reduction of insulin sensitivity (Bantle et al.
The “glycemic index” is an attempt to compare the glycemic effects of various foods to a standard, such as white bread.
Although several authors have proposed its clinical usefulness in controlling postprandial hyperglycemia, prospective studies have not demonstrated a clear improvement in hemoglobin (HbA1c) in patients using low-glycemic index diets (Michael, 2007). The physicians in this trial have recommended the best mix of carbohydrate, protein, and fat that was adjusted to meet the metabolic goals and individual preference of the patients with diabetes in both the intervention and control groups. It has been recommended for individuals with diabetes, that the use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate is considered alone (ADA, 2011). Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remain a key strategy in achieving glycemic control.
Physical activity consideration for patients (intervention and control group)Physical activity is a key component of lifestyle modification that can help individuals prevent or control type 2 diabetes. It is considered that diet is probably more important in the initial phases of weight loss, incorporating exercise as part of a weight loss regimen helps maintain weight and prevent weight regain (Klein et al.
In this trial, the message was given to both the groups that as little as 30 minutes of moderate physical activity daily may offer greater benefits to these patients in managing their diabetes. It has also been reported that in patients with type 2 diabetes, structured regimens of physical activity for 8 weeks or longer improved HbA1c independent of changes in body mass (Sigal et al.
The evidence supports the contention that controlling blood glucose through modification of diet and lifestyle should be mainstay of diabetes therapy.
It was found in this RCT that despite being one of the most time-consuming discussions with the patients in both the groups, this is probably the most important patient-physician discussion in regard to diabetes control and prevention of disease progression and complications.
Statistical analysisWe analysed the primary outcome by an un-paired sample t-test (mean difference between baseline and final HbA1c). The statistical analysis was carried out on an intention to treat basis and that was subject to the availability of data at follow up as well as at entry level for individual patients.



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