Peepal Tree School organised a chai pe charcha on ‘Understanding Diabetes ‘ on 17-Dec-23. The keynote speaker was Dr Subodh Pandit, a surgeon who ran his own hospital in Devlali, Nasik for 30 years. Dr Pandit believes that healthcare’s real role is in prevention, not cure. Vegan breakfast of poha, sprouts, fruits and green tea was arranged for all participants. Here are notes on the workshop:
Understanding Diabetes, Part 1
Any action, whether physical or chemical, requires energy. Even when you sleep, your body is at work. The heart muscles are pumping. Your brain is regulating the body temperature. Your back muscles work every hour to change your sleep position and keep the spinal cord lubrication in place.
So where do these body parts get the energy from? Glucose. It is the energy currency of the body. It goes to every part of the body through the bloodstream. Glucose is a potent fuel, one gram of glucose delivers around 4 kilocalories. (Note: A lot of us drop the kilo and just call these calories.).Your body just has one teaspoon (5 g) sugar in your blood for all these energy transfers. To put it in perspective, you have around 5 liters of blood flowing in your system, so you have around 1 g per liter of sugar. The human mind does not comprehend small numbers very well, so we multiply this by 100 to change units to mg per deciliter.
The body maintains sugar levels in a band of typically around 80 to 150 mg per dl. Diabetes is when your blood sugar levels are consistently above the upper limits. Doctors usually treat HbA1C as the holy grail of sugar tests. This parameter tells you the 3 month average level of sugar in the body. A value of less than 5.5% is considered normal, beyond that you are part of the group of 12 cr diabetic Indians.
Like with any currency, there are problems when sugar demand and supply doesn’t match. When there are supply issues, the body draws from its reserves and continues delivering that 5 g. But you can also have demand issues. What happens in such cases? You build reserves. The glucose is first converted to glycogen. Glycogen is transient energy. Your body has about 500 g of glycogen stored in your muscle and about 100 g in your liver. Glucose converted to glycogen stays in that form for a max of 48 hours. It then gets converted to fats. Your body has about 10 kg of fat reserves. This is enough to survive 20 days without eating.
The glucose transfer from blood to brain and muscle happens through the simple process of diffusion, albeit in the presence of some transport regulators. But for other organs you need something special to get the glucose into the cell’s furnace. And that something special is insulin. Insulin is produced in an organ called the pancreas, a huge organ, the size of your hand. Even then surgeons at times have problems locating the pancreas as it lies hidden behind the stomach. The pancreas’ main function is to produce the enzymes that break down food into digestible form. The main components of food are carbohydrates, proteins and fats. The pancreas secretes amylase, lipase, protease, which digest the above three food types. The pancreas also neutralises the acidity of the food that enters the small intestine from the stomach.
But from a sugar transfer point of view, we will concentrate on insulin manufacture, which takes up only 1% floor space in our body’s pancreas factory. You can think of insulin as the key that opens the cell’s glucose gate locks. When you eat food, there are some weight sensor equivalents in the stomach and the lower part of the small intestine, which tell the body that it is time to let the insulin into the blood. Once a cell has had its quota of sugar, it puts an additional latch on the glucose gates, which now even insulin cannot open. The pancreas is capable of producing 200 units of insulin a day. Most of us use only 100 a day. Once insulin enters the bloodstream it remains active for 30 minutes.
Let’s move on to the roles of the food components. Proteins are the bricks of the body – to use a pun, you can call them the body builders. Excess of proteins in your diet can lead to kidney damage. Fats, apart from energy storage function, also are used as building material. The cell walls are membranes constructed from fats. Our entire brain is built from cholesterol, which is nothing but fat. And fats also help in absorbing vitamins and proteins. Carbohydrates have only one role in the body – which is to feed the cell furnaces. Or in other words – carbs are only meant to be used as fuel.
Compared to the rest of Southeast Asia, Indian food tends to be large on carbs. This is possibly because of our farming ancestry, where we saw most people work in fields in activities which required calories. If we track Indian appetite over the years, there has been a calorie fall. From a range of 2500 to 3,000 about a century ago, we are around 1500 to 2000 now. But given our sedentary lifestyles, even this is too much. This excess of carbs ends up as fat, typically around the belly. Fats also start lining up the blood vessels.
Your body’s initial reaction is to dilate the vessels to let the blood flow be maintained. This results in a temporary drop of blood pressure. But as the body gets used to the new normal, it ends up upping the pressure delivered by its pumps – high BP. To excrete the extra sugar from the body, more water is used – so more frequent urination is also a symptom of diabetes. If the blood sugar levels continue to remain high, you may end up being blind, having your foot amputated and going to hospitals multiple times a week for dialysis.
Though sugar levels can be controlled by drugs like metformin, the better solution is to control through food. So what should be the ideal food balance? You need to start your planning with protein, because traditional vegetarian diets lack that the most. About a quarter of your calories should come from protein, another quarter from fat – and about half from carbs. That’s about 400 cal per day from protein, 400 from fats and 800 from carbs. If you weigh around 65 kg, then your daily intakes need to be around 100 g of protein, 130 g of fat and 200 g of carbohydrates.
Dr Pandit had an interesting way for doing the calorie math – using grocery bills. Look at your monthly ration bill – and you can get a fair idea of what calories your family is inputting every month. Let’s say you have 4 adults in the family. Average person eats about 2 kg of food per day. So our family has eaten 8 * 30 = 240 kg of food in a month. Here’s an example:
2 kg of sugar,
5 kg of cooking oil,
5 kg of dal
10 kg of rice
30 kg of atta,
80 kg of fruits
80 kg of vegetables.
So here’s your family’s monthly intake:
Carb in grains: 4 g * 40,000 = 160,000 cal
Carb in fruits and vegetables: 0.5 * 160,000 = 80.000 cal
Fats: 9 g * 2000 = 18,000 cal
Protein: 4 g * 2000 = 8,000 cal
Caveat: we have underreported fats and proteins because fruits and vegetables will also yield some amount of fats and proteins.
Total of 266,000 cal for the family. About 66,000 per person. Divide by 30, you get a daily calorie intake of around 2200. Your family is clearly overeating. And the culprit here is the atta and the rice. (We have for the purposes of this example, assumed that your family does not eat any biscuits, bread and cake. If they do, the carb calories add up to even more.)
So one clear way forward – reduce the carbs. Sagar Shah, who runs a digital marketing firm, is an expert on diets. He talked of his own experience. One low hanging fruit is to take away all the processed plastic packed food from your diet. Most of it is sugar and wheat. Wheat is the most genetically engineered crop in the world – and is now 100% carb. So is sugar. Sugar is also the fastest to digest. 1 hour after you have eaten that biscuit, the stomach is empty again as the biscuit sugar is already in the stream. Fats and proteins take more time to digest and hence you don’t feel hungry for at least 4 hours.
Now what do carbs need to be substituted by? We want about 133,000 cal coming in from non-carbs. Of these, proteins are the most critical. And to digest proteins you also need fats. The good news is that most foods that are high on protein are also decent on fats. For the non veg eater, eggs are the best source of proteins. Two eggs with a little carb is a balanced breakfast. For vegetarians, we need to increase the use of dals – maybe in the form of sprouts. It takes 5 cups of sprouts to deliver the same proteins as 1 egg. We also need to have more nuts. Almonds are used by vegans as a milk substitute. It is a nut which has almost 0% carbs.
We need to change our vegetable mix to reflect more of the leafy stuff like spinach, which have higher proteins in them. The added advantage of having more leafy stuff raw is that you also get carbs with fibre. On the subject of fibre, when you switch your carb source from wheat to jowar, bajra and ragi, you also add 30% fibre to your diet. And fibre is a good jhadoo for your gastrointestinal tract. If your job involves travel, you can find it more challenging to eat healthy. Sanjeev, 31st batcher from Joka, who currently heads Bharat Forge, had a very interesting practice to share. He carries his own food when he travels.
We had a long discussion on meal timings. Dr Pandit is clear that there should be total abstention between meals. 6 hour gaps between meals help. And a gap of at least 2 hours between dinner and sleep. We discussed fasting. The fast recommended is a 36 hour fast, with only water to be consumed during the fasting period. You can fast once a week, but it is recommended that you should fast once a month.
For managing sugar demand, the only solution is exercise. 1 hour of walking will consume around 200 calories of energy. That is so much less getting converted to fat. This walking can be part of your commuting too. Btw, if you do one hour of cycle commuting, you consume 300 calories. Ensure that your car is parked a 30 minutes walk away from your destination. You can then walk through the park instead of tearing your hair on finding parking. Walking after meals is a good idea, but should be done about half an hour after you finish the meal. Yoga, unfortunately, does not burn calories. It’s good for flexibility. If you want to use Yoga for some calorie burning, prefer the surya namaskar and kapalbhati.
Dr Pandit recommends at least one hour of exercise every day. His definition of exercise being anything that makes your resting heart rate increase by more than 15%. But his advice: take up the exercise challenge in such a way that you can follow that routine for the rest of your life. A simple self health check is to stand in front of a full length mirror sans clothes and check if all izz well. An even simpler health check is body weight. Get onto the scales once a month. The thumb rule is that if you are fit, you weigh around 1 kg per inch of height. I am 69 inch tall – and I weigh around 67 kg. (Note: I like this thumb rule :-)) Any weight which is too far away from this norm is a signal of something wrong in your diet, exercise or infective status.
Understanding Diabetes, Part 2
Here is a bullet pointed cheatsheet notes used by Dr Subodh Pandit.
What is diabetes?
Diabetes is characterised by increased sugar levels. Insulin level increases by 3 times before the sugar level increases.
How does insulin act?
All cells have insulin receptors, to which the insulin produced by the pancreas gets attached. When glucose enters the bloodstream it attaches to the receptors, which opens the doors for the cells for entry of the glucose-receptor. In case the receptors are saturated, the sugar, though present in the blood, is unavailable for utilisation, this is insulin resistance.
In type 2 diabetes, insulin binds to the receptor normally, but the signal is not sent into the cell. The cells do not take up glucose and the resulting high blood glucose levels cause organ damage over time. The only tissues which use free glucose are the brain, the skeletal muscles and the liver, which converts extra sugar to glycogen and fat.
How is insulin obtained?
Insulin is produced by the beta cells of the pancreas at the rate of 0.25-1.5 units/hr. 1 unit metabolises 12-15 gms. of glucose. Pancreas stores roughly 200 units of insulin .
Energy requirement decides the amount of insulin to be produced. Extra insulin produced is taken to the adipose tissues where the glucose is stored as glycogen.
Apart from utilisation of glucose what are the other actions of insulin?
Normally the insulin produced is sufficient for carbohydrate metabolism. Increased insulin causes:
a. Increased fat deposition in tissues, fatty liver, blood vessels, pancreas itself and fat tissues, especially around the waist.
b. Increased Blood Pressure.
c. Increased sodium retention by kidneys.
d. Decreased libido
Why is food required by the body?
Food gives the energy which is essential for functions of the body. The Gastrointestinal system utilises 10% of the calories eaten for its digestion. Total calories burned without activity is 1300-2000 calories. Walking normally burns 30-40 cals per 1000 steps. During sleep we burn 40-50 cals/hr.
How many calories are produced by food?
Carbohydrates give 4 kcals/gm. This is the only food used by the brain, central nervous system and muscles during exercise
Fats provide 9 kcals/gm. Fats are needed for absorption of proteins, vitamins and minerals. Fats also help in cell building.
Proteins provide 4 kcals/gm. They constitute 16% of body weight, essential for the development of muscles, antibodies. Essential for immunity.
In addition food contains water, which is 60% of body weight, calcium for bones, zinc for immunity, iron to carry oxygen and vitamins (13 in number) which are essential to carry out all functions of the body.
Carbohydrates and protein are digested in 1-2 hours and fat takes 4-6 hrs.
What happens to the extra calories?
Extra Carbohydrates gets converted to glycogen and stored in the liver, for 48-72 hours. After that the extra glycogen gets converted to fat and gets stored in the adipose tissues.
Extra proteins are not stored but thrown out as nitrogenous waste which is nephrotoxic. Finally, the end product of all foods is directly/indirectly glucose.
Why is increased glucose harmful to the body?
- Increased blood sugar is excreted via urine, as the sugar gets dissolved in the water of urine. This leads to higher reabsorption of water from the tissues which results in
– decreased blood volume, which decreases the B.P.
– increased sugar to the brain, resulting in swelling of the brain which results in coma or haemorrhage
– increased urination
- Chronically increased sugar results in increased insulin whose function is to deposit fat all over the body especially blood vessels which can lead to a heart attack or stroke.
– peripheral vascular disease resulting in non-healing ulcers in 16% of diabetics leading to amputation in 16% of non-healing ulcer patients.
– affect the kidneys by affecting the smaller vessels
– decreased vision
Management of increased glucose
– Increased utilisation by exercise or medicines
– Calories restricted diet.
– Since our diet is carbohydrate dominated it should be a low carbohydrate and low fat diet with adequate proteins
– Fasting
– Bariatric surgery
Guidelines for diet
Low carbohydrate and fat with adequate proteins
Avoid foods with high glycemic index
Rice GI 70, wherein 150 g provide roughly 200 cals
Wheat GI is …, wherein 150 g provide roughly 170-180 cals
Potatoes GI 96
Result will be gauged by the decreasing weight
Foods with extremely low carbohydrate content are chicken, fish, mushrooms and almonds.
Fruits to avoid are mangoes, banana, grapes, watermelon, pineapple and dried fruits
Fruits in moderation are apples, papaya, peach, guava, strawberries, oranges, kiwi, and chikoo
Vegetables with moderate proteins are
Sprouts 5.6 g/cup
Peas 8.6g/cup
Potatoes 4.6g/cup
Mushrooms 4g/cup
Spinach 6g/cup
Broccoli 0.37g/cup
Nuts highest in proteins
beans, 2 g/cup
peanuts 9.6 g/ ¼ cup
almonds 7g/ ¼ cup
Cashews 5g/ ¼ cup.
Cauliflower and broccoli 5g/cup
Pistachios 6 g/ ¼ cup
Yoghurt 10g/100 g
Timing of meal: Try to eat 3 meals with spacing of 6-8 hrs between meals
Proteins requirement is 1-1.5 gm/kg of body weight
Fat requirement is around 2 gm/kg
Carbohydrates requirement is 2.5-3 g/kg
SUMMARY
Exercise compulsorily. Exercise increases demand for glucose.
Low carbohydrate with high protein diet (in moderation).
Prioritise proteins
No fast foods AT ALL.
Supplement by fasting
Check weight regularly. Use plate method for major foods
There is NO HOLIDAY from diet and exercise.
Hi Guys,
Next chai pe charcha is on ‘Understanding Diabetes ‘.
Sun, 17-Dec 0830 to 1000 hrs.
Venue: Peepal Tree School, Pimple Nilakh
Who would benefit? Folks who are on diabetes medication.
The keynote speaker is Dr Subodh Pandit, a surgeon who ran his own hospital in Devlali, Nasik for 30 years. Dr Pandit believes that healthcare’s real role is in prevention, not cure. We will have peer discussions where participants will share their own experiences in managing diabetes. Vegan breakfast is being arranged. Would strongly recommend that if you want to attend, do that with your spouse. Please DM me if you are interested in attending.
Attendance list
- Mayank Agarwal
- Mahesh Dabi
- Shridhar Karandikar
- Sudhir Krishna
- Mithil Gulhane
- Asha Pandit
- Subodh Pandit
- Atul
- Pinki
- Anant Joshi
- Jyoti Joshi
- Sanjeev
- Nisha
Understanding Diabetes
Breakfast meet – Sun, 16-Dec 0830 to 1000 hrs.
Venue: Peepal Tree School, Pimple Nilakh
Who should attend: Junta on Diabetes / BP medication. Spouse also expected to join
Number of Couples Attending – 10
Program:
0830 – Fasting sugar test
0840 – Participant Introductions over Breakfast
0900 – Dr Subodh Pandit Talk on Human Anatomy
0930 – Q and A
0945 – Reflections
0955 – Discussion on Action Points
1000 – HBA1C Tests / Sugar PP Tests
Note: Testing is optional.
Breakfast Menu:
Smoothie
Fruit Salad
Poha and Sprouts
Green Tea
Booklet to be printed – 4 A5 sheets on Dr Pandit’s Notes for the session.