Diabetes mellitus (sugar disease) affects more than half a billion people worldwide, but nearly one-half of them don’t know that they have the condition. At the same time, people living with diabetes look after their own care more than 95 per cent of the time, so they need to understand their condition, how to manage it, and keep their knowledge updated, as mentioned by the International Diabetes Federation (IDF).
Over a period of time diabetes causes many health problems like heart disease, eye problems and kidney damage. Foot problems are common consequences of poorly controlled diabetes. A simple ulcer caused by an abnormal foot-ware can progress to a non-healing infection.
Theme of World Diabetes Day 2022
In 2007 the General Assembly of the United Nations designated 14 November of each year as World Diabetes Day – the birthday of Sir Frederick Banting who co-discovered insulin along with Charles Best. The theme for World Diabetes Day 2021-23 is access to diabetes care. In 2022, the campaign focuses on the need for better access to quality diabetes education. Keeping in with the theme and time of the year we are in, I would like to pass on some education regarding the upcoming winter and managing diabetes.
RELATIONSHIP OF WINTER AND DIABETES
Weather extremes (hot or cold) can affect your testing equipment and your medications and can have negative effects on your body’s ability to produce and use insulin. With the beginning of November, the climate in Kashmir valley like other places in the world begins to change. The temperature starts plunging to sub-zero during the nights and in the early hours of the morning. Winters typically start in mid-November forewarn of bone-chilling cold conditions. In Kashmir this is typically called ‘Chillai Kalan’ and people, the healthy and the diseased, have to be prepared to live in.
WINTER & DIABETES CONTROL
People find managing their diabetes mellitus (high blood sugar) during winter more difficult than at other times of the year. Changes in the daily schedule due to less outdoor activities, staying in bed for a little longer in cold mornings of winter, increased eating, excessive screen time and “the winter blues” could play a role in worsening of blood sugar in winters. High sitting time and low step counts is a fact of our winter-oriented behaviour.
NEED OF REGULARITY IN MONITORING
Regular testing of blood glucose cannot be overemphasized. This helps to point out any highs, or lows, and the necessary action to be taken with reference to medicine and the diet. Before testing your blood glucose with a glucometer, it is reasonable to warm up the hands. Wearing gloves or washing hands in warm water, then drying them before testing or warming them up on a warm mug or on a radiator with a towel or thick clothing over it, is practicable. Be vigilant or better to avoid using Kangri.
PREVENTION attacks OF HOSPITALIZATIONS
Global data and our experience show that Diabetics often need hospitalization in extreme weather conditions. The reasons could be many e.g. diabetic foot problems, chest infections, urinary tract infections and ischemic events like heart attacks or strokes. In a study in PLOS ONE Medicine, DM patients had a higher increased risk of acute myocardial infarction (AMI) admissions than non-DM patients during extreme temperatures. AMI (heart attacks) admissions risks among DM patients rise sharply in both high and low temperatures, with a stronger effect in low temperatures, while AMI risk among non-DM patients only increased mildly in low temperatures. Targeted health protection guidelines should be provided to warn DM patients and physicians about the dangers of extreme temperatures.
FLU OR PNEUMONIA IN DIABETICS
Winter being a flu season can be a little dangerous for people with diabetes. A recent study published in May this year in Open Forum Infectious Diabetes found that people with diabetes were nearly 60 percent more likely to be hospitalized for flu-related symptoms than those without diabetes. Serious complications from Covid 19 are also more common in individuals who have diabetes as has been demonstrated by many studies. General precautions as recommended by CDC such as hand washing, wearing a well-fitting mask, especially when there’s high community spread of COVID-19 in your area, and practicing social distancing indoors in public settings should be observed. Be sure you are vaccinated and boosted against COVID-19, and remember to get your annual flu shots of
CDC recommends pneumonia shots (5 yearly) and Influenza shots (yearly). The two big diabetes organizations: the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) — recommend annual flu shots in their practice guidelines for treating all people with diabetes. The vaccine should be taken in early fall as it takes two weeks for them to act.
REDUCING THE RISK OF DEHYDRATION
Like high temperatures of summer due to in-house heating mechanisms (Hamam, heaters, bukharis etc. ) with less liking for water intake, subjects with higher glucose may have a greater likelihood of dehydration. That’s an issue for everybody, but it has a distinct effect on people with diabetes. “When you’re dehydrated, you have higher concentrations of blood sugar, because less blood flows through your kidneys and with less blood flow, your kidneys don’t remove excess sugar from your blood to excrete through your urine leading to a vicious circle. So, be sure to drink plenty of water or sugar-free drinks. Don’t wait until you are thirsty to replenish fluids.
AVOIDING VULNERABILITY TO HYPOGLYCEMIA (LOW BLOOD GLUCOSE)
As we are aware that hypoglycemia (low blood glucose can be more disastrous in minutes than high glucose (hyperglycemia), we should carefully watch symptoms such as sweating, light-headedness, irritability, shakiness, and confusion, You may think it’s the heat and not recognize that your blood sugar levels have fallen to dangerous lows. Patients or caregivers should be aware of the warning signs, try to check (if possible) and keep some carbohydrates or free sugars readily available to eat if there is suspicion. Due to long nights in winter usually the sugars fall in the midnight to early morning since insulin or oral hypoglycemic taken in the evening will continue to work but the dinner or supper meals are likely to finish by 3 to 5 hours after intake. The glucose release from liver or kidney (stores) may not last long and can be of no significance if the patient has concomitant liver or kidney dysfunction.
NEED OF CARE OF SKIN AND FEET
Dry air in the winter, indoor heat, and low humidity levels cause the skin to lose moisture and crack. Cracked skin is more prone to wounds and infections. Self-inspection of feet is very important. Keep checking the web spaces for any fungal infection or maceration. It is advisable to wash your feet with bearable warm water, dry them up with a towel and apply some moisturizer. The kangri, heaters, blowers, Hamam, hot water bottles etc. very commonly used in winter may lead to foot burns and diabetic foot with its consequences in people who have neuropathic feet (loss of sensation). The temperature of these agents should be checked by hand or by the care given to avoid these mishaps. Please be mindful of the fact that people with neuropathy feel their feet (even sometimes hands) numb and like to keep them near the heat constantly. Such people may also not feel the tightness or dampness of shoes (especially while treading in snow-clad conditions) and are thus vulnerable to ischemia or frostbite. Using nylon socks may also lead to ischemia and hence we advise cotton socks and stockings.
MAINTAINING MENTAL STATUS AND MORALE
Winter weather has been linked to depressive disorders as evidence from global data that these conditions are more prevalent in polar regions of the globe. Less sunshine partly linked to Vitamin D deficiency has been incriminated in many psychiatric comorbidities. Besides this, a large section (40-60%) of diabetic subjects are known to have many psychiatric issues, especially depression. Less outdoor activity and money worries during winter can therefore trigger or aggravate mood swings or in some cases depression, which can negatively affect diabetes control. One should spend more time with friends and family, in order to keep stress at bay.
And lastly, it is indispensable to remain in touch with your treating physician and follow for the routine OPD visits wherever possible.
NEED TO MAINTAIN PHYSICAL ACTIVITY
It is wise not to roam around in the cold morning and evening hours. Instead spending some time for exercise before or after lunch hours is logical. Dancing, jumping, indoor aerobics, yoga, climbing the stairs a few times and even a bit of house work will deliver the required benefit. While having the maximum amount of feasible physical activity, do keep eye on your diet Generally speaking people tend to eat more during the winter and due to shorter days there is overcrowding of meals in the afternoon to evening leading to peaking of glucose during these hours. It is necessary to keep a check on the portion of carbohydrate you eat and see if the meal distribution is appropriate. Home cooked meals and raw or partially ripe fruits are preferable for people with diabetes. Those who can count their calorie intake, should get about 45% of their total calories each day from carbohydrates.
NEED T HAVE ADEQUATE SUPPLIES
If your doctor has prescribed insulin, it is necessary to keep it at an appropriate temperature. Insulin kept at room temperature will last approximately one month. Extra supply of unopened insulin is stored at a temperature between 2–8 degree Celsius away from the light. Insulin pumps and glucometers also need to be kept inside rather than leaving them in very cold weather. It is wise to keep an extra supply of other prescribed medicine to avoid any emergency in an unprecedented winter storm. Due to anticipated heavy snow falls and the system breakdowns supplies of all medications especially for blood pressure and heart protections be kept available.
CONCLUSION
“Winter is the time for comfort, for good food and warmth, for the touch of a friendly hand and for a talk beside the fire: it is the time for home.” The saying of a British poet, Edith Sitwell, probably covers the subject of what a diabetic patient needs to manage his diabetes in winter. If you or your loved one has diabetes mellitus, a little more care, and a little more attention becomes all the more important during winter. To enjoy a disease-free winter, diabetic patients must practice caution and follow the diabetes management tips such as Monitoring regularly, maintaining physical activity, understanding changes in diet and drug schedules, care of feet, avoidance of hypoglycemia and hyperglycemia, maintenance of supplies and preventing infections. Glucose levels often rise significantly higher in response to common colds and seasonal flu. Get vaccinated with Flu Shot as soon as it becomes available. The vaccine needs at least two weeks to take full effect, so better to get vaccinated by the end of October. The Pneumococcal vaccine and Haemophilus influenzae vaccines in addition to Covid 19 vaccine may be required.
(Author is a Professor of Endocrinology & Metabolism at Sher-e-Kashmir Institute of Medical Sciences, Soura. Formerly Associate Professor, Department of Endocrinology & Metabolism, AIIMS New Delhi)