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MRCOG ( UK ) inspection @ Max Shalimarbagh .

My views on Air Pollution!

New researches and publications. October to December 2023.

How To Reverse Type 2 Diabetes ??

Can we ????

An original experience based article.


In today's writing , I will unravel a topic that affects millions worldwide – Type 2 Diabetes (T2D).

While the term "reversal" is often used in the context of this condition, it's essential to understand that reversing doesn't necessarily mean CURING .

Instead, it refers to reaching and maintaining blood sugar levels within the normal range without the need for medication.

Why diabetics like me need to do this ???

Type 2 diabetes increases the risk for the majority of the chronic diseases that we face. It is the largest cause of surgical amputations, renal failure, blindness and many other conditions.


Let's dive in!

1. Understand the Basics :

Type 2 Diabetes is a condition where your body doesn't tolerate sugars and refined carbohydrates properly, leading to high blood sugar levels.

2. The Power of Diet :

Low-Carb Diets:

Reducing carbohydrate intake can significantly lower blood sugar and insulin levels.

Limit Sugars and Processed Foods.

Minimize the intake of sugary beverages, sweets, and highly processed foods.

Consider Intermittent Fasting.

Some people find success in managing their blood sugar levels through intermittent fasting.

Always consult with a healthcare professional before trying a new diet regimen.

3. Move More :

Physical activity helps the muscles use glucose more effectively, reducing the load on the pancreas and helping regulate blood sugar levels.

Aim for 30 minutes of moderate intensity activity most days of the week.

Even walking is great to start.

Mix Cardio and Strength.

Both aerobic exercises (like walking and cycling) and strength training can be beneficial.

4. Maintain a Healthy Weight:

Losing even a small amount of weight can make a significant difference.

If you're overweight, start with a goal of losing 5-10% of your current weight.

5. Medications and Regular Monitoring :

Lifestyle changes work but they may take time. It's essential to
regularly monitor.

Keep track of your blood sugar levels as advised by your doctor.

Stay on Medications:

Don't stop any medications without discussing with your healthcare provider.

6. Sleep and Stress:

Both inadequate sleep and chronic stress can negatively affect blood sugar levels.

Aim for 7-9 hours of sleep a night and adopt stress-reducing techniques that work for you.

7. Stay Informed and Supported:

Joining a local or online diabetes support group can provide you with additional resources, experiences, and a sense of community.

In Closing :

While the possibility of reversing T2D is promising, it's essential to remember that everyone's journey is unique.

What works for one person might not work for another.

Always consult with your healthcare provider before making significant changes to your lifestyle or treatment plan.

Weight Reduction :

Are you tired of constantly counting
calories, cutting down on fat, and still seeing no significant weight loss?

Well, it might not be your fault.

For decades, we've been told that weight loss is simply a matter of consuming fewer calories than we burn, but emerging science suggests there's more to the story.....much more.

The Insulin Factor :

We all know insulin controls our blood sugar .
Recent studies have been shining a light on
insulin, a hormone that plays a central role in regulating blood sugar levels.

A high-
carbohydrate diet, including those ...low fat
options that we thought were good for us,
causes an insulin spike, storing those calories as "fat" rather than burning them as energy.

Essentially, it's not just about the calories we consume but about how those calories are processed and stored in our bodies.

So insulin plays a major part to store glucose in muscles in different forms which can be used when the human body needs them in emergent and urgent conditions .

The Atkins Diet trumps all the best options !!!

What is " Atkins " ?

Interestingly, a comparative study of
popular diets showed that the Atkins diet-
an extremely low carb plan resulted in the
most weight loss. Surprisingly, the success
wasn't merely due to calorie restrictions;
instead, it significantly altered insulin
levels, thus affecting how the body stores
or burns calories.

An simple idea about Atkins Diet ...

The Atkins diet is split into 4
different phases:

Phase 1 (induction): Under 20 grams of carbs per day for 2 weeks. Eat high-fat, high-protein, with low carb
vegetables like leafy
greens. This kick-starts the weight loss.

Phase 2 (balancing):
Slowly add more nuts, low carb vegetables, and small amounts of fruit back to your diet.

Phase 3 (fine-tuning):
When you're very close to your goal weight, add more carbs to your diet until weight loss slows down.

Phase 4 (maintenance):
Here you can eat as many healthy carbs as your body can tolerate without regaining weight.

The Artificial Sweetener
Trap :

Think whether opting for 'sugar-free' or zero calorie options will save you? A big NO.

Think again.

Artificial sweeteners like aspartame and
sucralose can actually increase insulin
levels. This means even though you're
consuming fewer calories, your body might store more fat! Now acdays they are proclaimed " carcinogens by WHO.

Sleep Matters !!!

Really!!!!

We often overlook the importance of a
good night's sleep. Sleep deprivation and
conditions like sleep apnea not only lead to
a groggy day but can also severely impact
your insulin sensitivity, putting you at risk for weight gain and type 2 diabetes.

The Stress Connection :

Both acute and chronic stress can wreak
havoc on your insulin levels. Chronic
stress, in particular, has been linked to
increased cortisol levels, which also results
in insulin resistance. So, if your job is stressing you out, it might also be padding your waistline.

Sneaky Obesogens : ( no such term exists in medical text...)

Another emerging field of study focuses on
"obesogens"-environmental toxins that
can alter our metabolism and fat storage
These chemicals are found in a multitude
of everyday items, from food packaging to
personal hygiene products.

Obesogens like
BPA, PFAS compounds, and certain pesticides could be secretly contributing to
your weight gain.

The Inevitability of Aging :

Let's face it...our metabolism changes as
we age.

Increased insulin resistance is a
part and parcel of the aging process, and it
can make weight management more challenging as we get older.

We all agree to this .. I mean people on otherside of 40 .

Wrapping Up !!!!

It's time we looked beyond the calorie
equation to truly understand the multifaceted mechanisms that contribute to
weight gain.

Dieting is not just about eating fewer calories . It's also about eating the
right kind of calories and understanding how various lifestyle factors like sleep and
stress influence our weight.

So, if you are struggling to shed those
pounds, perhaps it's time to pay attention
to your insulin levels and other overlooked
factors that might be sabotaging your
weight loss journey.

Finally I have been a big enthusiast behind knowing how to loose weight .. .though I myself has been completely unsuccessful.

My two elder brothers and a younger has been highly successful. Me , my sister's and others have been highly unsuccessful.

So my advice is ...do not lose hope ...continue trying!!!! ❤️❤️

10 publications recently.

Our recent international publication.

2023 s new publication.

Dr. Kishalay Datta - Winner of Indian Achievers' Award 2022 Dr. Kishalay Datta Achiever’s Success Story Thank you for reading this post, don't forget to subscribe! With a vision to serve the needy in their need of hour, Dr. Kishalay Datta proudly stands with all his endeavors With over 15 years of experience in Emergency Medicine and a total experience of ...

My Story : in

INDIAN ACHIEVERS FORUM. Link ....is below .

https://www.iafindia.com/dr-kishalay-datta/

Achiever's Success Story

With a vision to serve the needy in their need of hour, Dr. Kishalay Datta proudly stands with all his endeavors

With over 15 years of experience in Emergency Medicine and a total experience of 28 years, Dr. Kishalay Datta, has worked in various medical colleges of India and in various hospitals that include some premier hospitals and trauma centres globally. He has worked in hospitals of USA, Australia, middle east countries etc. Dr. Datta holds a post graduate degree in Emergency Medicine with many Fellowships and diplomas in allied healthcare specialties. After working across institutions that are present globally, he returned to India, as he wanted to stay closer to his parents, his family members, culture and had a strong desire to contribute to his motherland.

Thank you for reading this post, don't forget to subscribe!

He has been providing post graduate training and education to number of medical students and also has been mentoring them across Max hospitals located in several places of Delhi India, for the past twelve years. He has been guiding young doctors with deep insights into the current medical education system and is helping them achieve their career goals. He is also the author of much popular book ” A guide to Mechanical Ventilation “. He has contributed to numerous chapters in leading books of Emergency Medicine. He is also the editor of leading Indian journals of Emergency Medicine. Mr. Datta also has more than 100 national and international research papers published in his field.

Dr. Datta currently serves as the Director of Emergency Medicine, in Max Hospital, Shalimar Bagh and practices his trade there. His Emergency Medicine department is also considered to be one of the best in pan Indian scenario. Through his experience and expertise, he is also guiding India’s Emergency Medicine field and perspectives into a better direction in coming future. Dr. Kishalay Datta is a man with an optimistic approach in all circumstances and envisions to help people with the goal of a more robust and self-reliant India.

Shall we still continue with HbA1c as a marker for Diabetes???

IMPORTANT CAUSES OF LOW HbA1c LEVELS:-

1.Genetic Hemoglobin Disorders such as sickle cell anemia and thalassemia can cause falsely low HbA1c.

2.Conditions that Decrease or Destroy Red Blood Cells such as blood loss, donation, or transfusion can falsely decrease HbA1c levels despite possibly elevated blood glucose.

3.Hemolysis that can occur in infections, autoimmune diseases, tumors, and as a side effect of some drugs also decreases HbA1c.

4.Hypersplenism is another condition that destroys red blood cells and decreases HbA1c.

5.Excessive alcohol consumption can decrease HbA1c levels despite elevated blood glucose because it may interfere with the binding of glucose to hemoglobin. It also may have an effect by lowering blood glucose levels.

6.HbA1c can be lower in chronic liver disease.
it may be a combination of abnormal red blood cell turnover and function (e.g., anemia and iron overload) and viral infection.

7.HbA1c can be lower in the second trimester of pregnancy.

8.Drugs and Supplements:-Any drug which causes the rupture or destruction of red blood cells can potentially lower HbA1c by increasing the proportion of younger cells in the blood. Dapsone, ribavirin, antiretroviral, and sulfonamide drugs have all been reported to reduce the HbA1c in this manner.

Hydroxyurea is used for the treatment of some leukemias and sickle cell disease. This drug can significantly reduce the number of blood cells and causes a decrease in HbA1c levels.

Chronic use of aspirin has been reported to falsely decrease HbA1c.
However, aspirin can also modestly, in a way that is not clinically relevant, increase HbA1c levels in some cases.
Vitamin E can decrease the binding of glucose to hemoglobin, falsely decreasing HbA1c.

HbA1c is less reliable than blood glucose measurement in conditions like postpartum state, HIV on ART and Iron deficiency anemia.

As newer modalities/ tests come into fore , maybe we are on the process of discarding this marker !!

New Chapter in new Book ! Continuing my efforts....

Monkeypox is a viral zoonotic disease seen in Central and West Africa . It resembles smallpox in appearance . Outbreaks are recently reported from North America and Europe.

Monkeypox is caused by monkeypox virus,
a member of the Orthopoxvirus genus in
the family Poxviridae.

Monkeypox typically presents clinically
with fever, rash and swollen lymph nodes and may lead to a range of medical complications.
Monkeypox is usually a self limited disease with the symptoms lasting from 2 to 4 weeks. Severe cases can occur.

In recent times the case fatality ratio has been around 3-6%.
Monkeypox is transmitted to humans through close contact with an infected
person or animal or with material contaminated with the virus .

Monkeypox virus is transmitted from one person to another by close contact with lesions ,body fluids, respiratory droplets
and contaminated materials such as clothes.

The incubation period of monkeypox is
usually from 6 to 13 days but can range from
5 to 21 days .

The infection can be divided into two periods:

The invasion period (lasts between O-5
days) : characterized by fever, intense
headache lymphadenopathy , back pain, myalgia
and intense asthenia .

Lymphadenopathy is a distinctive feature of monkeypox compared
to other diseases that may initially appear
similar to it like (chickenpox, measles, smallpox).

The skin eruption usually begins within 1- 3 days of appearance of fever. The rash tends to be more concentrated on the face and extremities rather than on the trunk .It
affects the face and palms of the hands and soles of the feet . Also
infected are oral
mucous membranes ,
genitalia , conjunctivae, as
well as the cornea.

The clinical differential diagnosis includes other rash illnesses, such
as chickenpox , measles ,bacterial skin infections, scabies ,syphilis, and medication
associated allergies.

Lymphadenopathy during
the prodromal stage of illness can be a clinica
feature to distinguish monkeypox from
chickenpox or smallpox.

If monkeypox is suspected , health workers should collect an appropriate sample and have it transported safely to a laboratory with
appropriate testing facilities.

Polymerase chain
reaction (PCR) is the preferred laboratory test
given its accuracy and sensitivity.

The clinical presentation of monkeypox
resembles that of smallpox, a related
orthopoxvirus infection which has been
eradicated.

Smallpox was more easily
transmitted and more often fatal as about 30% of patients died . The last case of
naturally acquired smallpox occurred in 1977
and in 1980.

Smallpox was declared to have
been eradicated worldwide after a global
campaign of vaccination and containment. It
has been 40 or more years since all countries,
ceased routine smallpox vaccination with
vaccinia based vaccines .

Whereas smallpox no longer occurs naturally,
the global health sector remains vigilant in the
event it could reappear through natural
mechanisms like laboratory accident or deliberate
release .

To ensure global preparedness in the event of reemergence of smallpox, , newer
vaccines diagnostics and antiviral agents are
being developed . These may also now prove
useful for prevention and control of monkeypox.

Therapeutics :

Clinical care for monkeypox should be fully
optimized to alleviate symptoms ,manage complications and prevent long-term
sequelae .

An antiviral agent
known as " tecovirimat " that was developed for
smallpox was licensed by the European
Medical Association (EMA) for monkeypox in
2022 .

It is not yet widely available for patient care.

Tecovirimat should
deally be monitored in a clinical research
context .

Vaccination against smallpox was demonstrated through several observational
studies to be about 85% effective in
preventing monkeypox .

Thus, prior smallpox
vaccination may result in milder illness .

Evidence of prior vaccination against smallpox
can usually be found as a scar on the upper
arm.

At the present time the original (first-
generation) smallpox vaccines are no longer
available to the general public .

Some
laboratory personnel or health workers may
have received a more recent smallpox vaccine
to protect them in the event of exposure to
orthopoxviruses in the workplace .

A still newer vaccine based on a modified
attenuated vaccinia virus (Ankara strain) was
approved for the prevention of monkeypox in 2019 . This is a two-dose vaccine for which availability remains limited .

Smallpox and
monkeypox vaccines are developed in
formulations based on the vaccinia virus due
to cross-protection afforded for the immune
response to orthopoxviruses .

Prevention :

Raising awareness of risk factors and
educating people about the measures they
can take to reduce exposure to the virus is the main prevention strategy for monkeypox.

Scientific studies are now underway to assess
the feasibility and appropriateness of
vaccination for the prevention and control of
monkeypox .

Some countries have, or are
developing, policies to offer vaccine to
persons who may be at risk such as laboratory
personnel, rapid response teams and health
workers.

Reducing the risk of human to human transmission,
surveillance and rapid identification of new cases is critical for outbreak containment.

During human monkeypox outbreaks, close
contact with infected persons is the most
significant risk factor for monkeypox virus
infection .

Health workers and household
members are at a greater risk of infection.

Health workers caring for patients with suspected or confirmed monkeypox virus
infection, or handling specimens from them,
should implement standard infection control
precautions If
selected to care for the patient.

"2 new case reports " April 2022.

FODMAP DIET :

FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) is a condition where we have trouble digesting certain carbohydrates which can cause symptoms like bloating, gas,constipation, diarrhoea, and vomiting.

The culprit carbohydrates are oligosaccharides, disaccharides,
monosaccharides, and polyols.

The FODMAP carbohydrate's certain sugars may cause
intestinal distress. These carbohydrates causes irritable bowel syndrome
(IBS) and/or small intestinal bacterial overgrowth (SIBO).

FODMAPs are types of
carbohydrates found in certain foods, including wheat and beans.

Studies have shown strong links between FODMAPs and digestive
symptoms like gas, bloating, stomach pain, diarrhea, and constipation.

FODMAP or fermentable oligosaccharides ,
disaccharides, monosaccharides, and polyols are short chain carbohydrates that
are poorly absorbed in the small intestine and
are prone to absorb water and ferment in the colon.

They include short chain
oligosaccharide polymers of fructose (fructans) and galactooligosaccharides (GOS,stachyose, raffinose), disaccharides (lactose),monosaccharides (fructose), and sugar
alcohols (polyols), such as sorbitol, mannitol,
xylitol, and maltitol.

12 most FODMAPs are naturally present in food and the human diet,
but the polyols may be added artificially in
commercially prepared foods and beverages.

FODMAPs cause digestive discomfort in
some people. The reasons are hypersensitivity to luminal distension, and a proclivity to excess water retention and gas
production and accumulation, but they do not cause intestinal inflammation. In fact,naturally occurring FODMAP may cause minimal digestive discomfort because they produce beneficial alterations in the human intestinal flora .

These short chain carbohydrates (lactose,
fructose and sorbitol, fructans and polyols)
behave similarly in the human intestine.

Firstly, being
small molecules and either poorly absorbed or
not absorbed at all, they drag water into the
intestine via osmosis.

Secondly, these
molecules are readily fermented by colonic
bacteria. So upon malabsorption in the small intestine they enter the large intestine where
they generate gases (hydrogen, carbon
dioxide and methane).

The dual actions of
these carbohydrates cause an expansion in
volume of intestinal contents, which stretches
the intestinal wall and stimulates nerves in the
gut. It is this stretching that triggers the
sensations of pain and discomfort that are
commonly experienced by irritable bowel sufferers.

The FODMAP concept was first published in
2005 as part of a hypothesis paper,by Monash University, Melbourne.

In this paper, it was proposed that a collective
reduction in the dietary intake of all
indigestible or slowly absorbed, short chain
carbohydrates would minimise stretching of
the intestinal wall and thus produce less gas , distension and constipation.

FODMAP DIET PLAN :

A FODMAP diet might help to improve
short term digestive symptoms in adults with a irritable bowel but its long
term use can have negative effects because it causes a detrimental impact on the gut
flora. This diet plan should only be used for short periods of time and
under the advice of a specialist.

More studies are needed to evaluate its
effectiveness in children with irritable bowel.

There is only a little evidence of
its effectiveness in treating functional
symptoms in inflammatory bowel disease. More studies are on to assess
the need and true impact of this diet on health.

In addition, the use of a low FODMAP diet without medical advice can lead to serious health risks, including nutritional deficiencies
and vitamin deficiencies and other nutritional diseases.

FODMAP foods :

Vegetables: alfalfa, bean sprouts, green beans, bok choy, capsicum (bell pepper),carrot, chives, fresh herbs, choy sum,cucumber, lettuce, tomato, zucchini, the green parts of leeks and spring onions.

Fruits: orange, grapes, melon,apples

Protein: meats, fish, chicken, eggs, tofu .

Dairy: lactose free milk, lactose free
yoghurts, hard cheese

Breads and cereals:
rice, crisped rice, maize or corn, potatoes, quinoa, besan and breads made
with their flours alone;

However, oats and
spelt are relatively low in FODMAPs

Biscuits (cookies) and snacks: made with flour of cereals listed above.


FODMAP ingredients added to food (such as onion, pear, honey, or polyol artificial sweeteners)

Nuts and seeds. almonds , pumpkin seeds, cashews or pistachios

Beverages: coffee, tea, alcohol.

"A LOW FODMAP" diet consists in the global restriction of all fermentable carbohydrates mentioned in above list .

"So it's practically impossible to maintain a FODMAP diet .Almost everything edible falls in this category. "

A low FODMAP diet is only recommended for managing patients with
irritable bowel syndrome and can reduce
digestive symptoms of IBS including bloating
and flatulence.

A low FODMAP diet is highly restrictive in various groups of nutrients, can be impractical
to follow in the long term and may add an
unnecessary financial burden.

So what to eat and what not to eat 🤔 should be decided by the individual only .

Bengali's have always been fascinated by foods causing gas and bloating. Every Bengali household pretends to be very knowledgeable about the above gastrointestinal conditions. 😉. So beware of FODMAP s.

I recommend " nutritious and comfortable " food and not gaseous ones . Do not be a gas balloon !!!

Happy Eating guys 😊!!

Diabetes and Insulin : when to start ?

Insulin should generally be initiated where
A1C is >7% after 2 to 3 months of intensive dual oral anti diabetes drug therapy.
The preferred regimen for insulin initiation in Type 2 diabetes mellitus is ideally once daily basal insulin.

In addition to timely initiation,rapid titration of the dose is indispensable for successful insulin therapy.

Insulin therapy will often need to be started on urgent basis ,if the initial fasting plasma glucose is greater than 250 or the
HbA1c is greater than 10%. It is commonly done in hospital therapy and after control, patients are generally returned to their oral therapy.

People with type 2 diabetes may require insulin when their meal plan, weight loss, exercise and antidiabetic drugs do not achieve targeted blood glucose (sugar) levels.

Diabetes is an auto immune progressive
disease and the body may require insulin injections to compensate for declining insulin production by the
pancreas in every year of its presence.

Prandially less than 140 mg/dL (7.8 mmol/L) is normal. 140 to 199 mg/dL (7.8mmol/L and 11.0 mmol/L) is diagnosed as prediabetes. 200 mg/dL (11.1 mmol/L) or higher after two hours suggests diabetes.

Glycemic treatment should be stepwise with swift introduction of successive interventions after treatment failure with other measures like diet , exercise and oral drugs (i.e., A1C ≥7.0%).

Hypoglycemia ( sugar < 60 mg / dl ) risk is very low among type 2 diabetic patients just starting insulin therapy, making NPH insulin the most cost effective drug.

Several clinical trials established that insulin therapy reduces microvascular and macrovascular complications related to DM. That's the main aim of insulin therapy . Though DM starts with lack of insulin , many cases are seen where insulin resistance develops. Insulin is not the treatment for end stage DM as thought .

Insulin has no upper dose or limit ; our glycemic goals should be controlled by using adequate insulin doses, which might be sometimes very high crossing even 100 IU of insulin or more per day .

Also it must be known that a minority of patients achieve A1C < 6.5 even with intensive insulin dosing patterns.

So we must remember that initiation, control and intensification of insulin therapy is not at all that simple and straight forward.

So an algorithm is needed for every individuals started on insulin. A good idea of different types of insulin , dosing patterns is needed for better control.

Insulin available in market are ultra short , short / regular , NPH , and long acting ones. These different insulins have different patterns and time of action , different absorption times and modes of actions .
Ultra short and short have a span of maximum 6 hours while long acting has work life of 24 hours or more . So depending on times of action , doses have to be adjusted which may be thrice or once daily.

Newer insulins have a tendency to mimic natural endogenous insulin action , but we all know in Type 2 DM , the patients have more of insulin resistance rather than insulin lack. So copying natural pattern of insulin secretion would be better in Type 1 DM.

When should we start insulin?

DM is an auto immune disease( immune system works against our own body cells instead of helping to overcome) with destruction of beta cells in pancreas. Over years insulin tend to decrease to bare minimum ( 12 years or more ) and needs to supplement insulin externally grows.

Insulin is a hormone needed for various functions of the body in addition to control blood sugar.

So we conclude that there is no unequivocal answer to the above question.

"When" to start ..... is difficult to say and expertise and experience based !!!!

Studies say that, more opinionated answer was when there was a failure to control blood sugar by two oral glucose lowering medications.

Traditionally “final step” in DM management was insulin after 10 to 15 years of the disease. Both patients and physicians are often reluctant to start insulin because of fear of injections, hypoglycaemia and weight gain.

Furthermore “ psychological insulin resistance “ was seen among many due to permanence of using injections ,restrictiveness, low self efficacy, personal failure, costs and illness severity.

So treatment with insulin is often delayed and denied by many years in majority of patients till date .

Insulin in general produces rapid control of blood sugar. Intense treatment with it maintains beta cells function of pancreas compared to oral agents , and had improved treatment satisfaction and quality of life . The combination of long acting basal insulin or NPH insulin or twice long acting insulin has to tailored by your doctor only for early benefits and not by you .

So combinations of several insulins or single insulin to target blood glucose close to 100 mg / dl or lowering A1C < 7 % must be monitored under medical supervision only , till the dose of insulin has stabilised.

Further which insulin is better than other ( discussions between patients while receiving treatment of DM ) should be answered by your doctor only and not by a nutritionist .

The regular biphasic insulin and combination with long acting ones or a single insulin has to be decided by an endocrinologist or a DM specialist only .

What are the drawbacks of insulin therapy ?

As insulin is a anabolic hormone , body weight may increase by 5 to 7 kgs with increase of size . Libido may decrease . You may find your waist and chest has increased. Also your tummy 😅.

Furthermore , increasing doses and better control may lead to “hypoglycaemia” due to lack of proper meals and timings of dose .

Take Home Message:

1. No upper limit for insulin dose .

2. Can be started at anytime of treatment phase of DM ,mainly when A1c > 7%. The disease is due to lack of insulin .

3. Better control of DM can be achieved. Lesser A1C . Don’t be scared to start , if your doctor suggests. Please do not give your opinion regarding when to start.

4. Newer insulins are better and combinations are better than single monotherarapy with insulin.

5. Higher doses means longer period of DM .
Combinations with oral drugs are Ok . Has to be taken under supervision.

6. Look for weight gain and look for complications of DM.

7. Take care of small infections , cuts or abrasions of foot , hands and sole .

8. Patients acceptance for 3 injections per day or a single injection a day has to be carefully considered when initiating the insulin treatment.

9. It would be difficult to control A1 c > 8.5 % with single insulin mono therapy , so experts are needed for initiation of treatment with different types of insulin or oral agents or in combination.

10. There can be minimisation of adverse effects of insulin therapy like hypoglycaemia and weight gain by combination with metformin tablets. Combination would lead to reduced insulin doses , easier dose titration and improved compliance.

11.As DM is a auto immune disease insulin therapy will be more intensified as years roll bye . We should not be thinking why such increasingly higher doses are needed as time rolls on . The main aim of insulin therapy is to prevent micro vascular complications in your kidneys , eyes , brain and heart ( strokes and heart attack, cataract and kidney failures) .Such complications cannot be controlled by only diet and exercise only . We need to take insulin via injections with oral drugs to survive uncomplicated DM life.

12. Different types of insulin are not better than each other . But guidelines are …. use newer forms of insulin. Ask your doctor and go for it . It will do no harm.

Finally a doctor must also take into consideration the “ price factor “ while treating with insulin.

13 . Treatment with " continuous insulin pumps" has a better insulin control in some patients but problems of insulin therapy remains ; Compliance is a factor as continuous finger pricking for blood sugar levels are needed to be done .

14 . Nasal spray insulin has not lived upto its standards.

We need to remember the disease Diabetes Mellitus is due to problems of " insulin " secreted by pancreas. So we need insulin in whatever forms to be healthy .