1 st time in India

To keep the members of

diabetes care team abreast with
DSME and DSMS concepts

EDITORIAL BOARD NATIONAL ADVISORY BOARD

Executive Editor President Dr. Brij Makkar, Delhi
Dr. Sunil Gupta, Nagpur Immediate Past President Dr. Vasanth Kumar, Hyderabad
President Elect Dr. Rakesh Sahay, Hyderabad
Associate Editor Secretary General Dr. Sanjay Agarwal, Pune
Dr. Pratap Jethwani, Rajkot Hon. Joint Secretary Dr. Pratap Jethwani, Rajkot
Hon. Treasurer Dr. J. K. Sharma, New Delhi
Editorial Board Vice President Dr. Sujoy Ghosh, Kolkata
Dr. J. J. Mukherjee, Kolkata Vice President Dr. L. Sreenivasamurthy, Bengaluru
Dr. Sanjeev Phatak, Ahmedabad Executive Members Dr. Aravinda J., Bengaluru
Dr. Abhay Sahoo, Bhubaneshwar Dr. Manoj Chawala, Mumbai
Dr. Ajay Kumar, Patna Dr. N. K. Singh, Dhanbad
Dr. Nandita Arun, Chennai Dr. M. Shunmugavelu, TRICHY
Dr. Archana Sarda, Aurangabad Dr. Amit Gupta, Delhi
Dr. Prasanth Sankar, Kerala Dr. Jothydev, Trivandrum
Dr. Saurabh Mishra, Kanpur
Dr. Rakesh Parikh, Jaipur
Dr. Dakshata Padhye, Mumbai
Dr. Anil Virmani, Jamshedpur
Co-opted Members Dr. Vijay Viswanathan, Chennai
Dr. Anuj Maheshwari, Lucknow
Dr. Sunil Gupta, Nagpur
Patrons of RSSDI Dr. H. B. Chandalia, Mumbai
Dr. C. Munichhoodappa, Bengaluru
Dr. Ashok K. Das, Puducherry
Dr. Binode K. Sahay, Hyderabad
Dr. V. Seshiah, Chennai
Scan the QR code to access Dr. P. V. Rao, Hyderabad
full library of IDEJ - Dr. Jitendra Singh, New Delhi
https://usvmed.com/
Dr. V. Mohan, Chennai
Dr. Vinod Kumar, New Delhi
Dr. Sidhartha Das, Cuttack
*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t
 1 st time in India
To keep the members of
diabetes care team abreast with
DSME and DSMS concepts

FOREWORD

Research Society for the Study of Diabetes in India (RSSDI) founded by Prof MMS Ahuja in the year 1972 is the biggest
scientific association of healthcare professionals involved in promoting diabetes education and research in India. RSSDI
is happy to collaborate with USV to support their endeavour to make India the ‘Diabetes care capital of the world’.
Through this collaboration, RSSDI would like to strengthen the cadre of diabetes educators by empowering them with
recent updates in diabetes management helping bridge the gap between the physician and the patient. Today, the rule of
50% is prevailing in terms of awareness, detection, treatment and control in T2DM.Our aspiration is to achieve 90-90-
90-90 i.e.90% of people with diabetes should be made aware, 90% should be detected, 90% of those detected should
be treated, and 90% of those treated should reach their goals.
Indian Diabetes Educator Journal (IDEJ) is the first of its kind in India, and the longest running monthly diabetes educator
journal since April 2015 & continues its endeavour to spread awareness, knowledge and enable healthcare teams to
manage individuals with diabetes and empower them for self-care. RSSDI IDEJ will continue to keep the members of
diabetes care team abreast with concepts of Diabetes Self-Management Education/Support (DSME/S) with a reach of
44000 doctors and diabetes educators digitally.
Medical nutrition therapy is a cornerstone in the management of diabetes. The ‘Hidden Hunger’ which refers to a
deficiency of micronutrients is commonly seen in people with diabetes. This month's IDEJ aims to propagate the
importance of micronutrients in the pathogenesis and management of diabetes and its complications. Understanding
the role of vitamins, minerals, and antioxidants in diabetes management can help diabetes educators to empower
people with diabetes to be able to meet their daily requirements of these essential nutrients.
We sincerely thank our contributors for making this issue delightful reading for our readers. We dedicate this journal to all
the healthcare professionals who are working relentlessly towards making “India–The Diabetes Care Capital of the
World.”

Sincere Regards,

Dr. Sanjay Agarwal

RSSDI Secretary

Disclaimer: This Journal provides news, opinions, information and tips for effective counselling of people with diabetes. This Journal intends to empower your clinic
support staffs for basic counselling of people with diabetes. This journal has been made in good faith with the literature available on this subject. The views and
opinions expressed in this journal of selected sections are solely those of the original contributors. Every effort is
made to ensure the accuracy of information but Hansa Medcell or USV Private Limited will not be held responsible for any inadvertent
error(s). Professional are requested to use and apply their own professional judgement, experience and training and should not
rely solely on the information contained in this publication before prescribing any diet, exercise and medication.
Hansa Medcell or USV Private Limited assumes no responsibility or liability for personal or the injury,
loss or damage that may result from suggestions or information in this book.

*DSME: Diabetes Self-Management Education, DSMS: Diabetes Self-Management Suppor t

Dr. R C Sharma
MBBS, MD (Internal Medicine)
Consulting Physician, Diabetologist & Cardiologist
Dr. R C Sharma Clinic, Indore

Article: Role of Micronutrients in Prevention and Management of Diabetes

Dr. Ramesh Goyal

MD (Medicine), DM (Endocrinology)
Consulting Diabetologist & Endocrinologist, Apollo Hospitals
International Ltd, Ahmedabad

Article: Role of Vitamin D in Type 2 Diabetes and

Diabetic Kidney Disease

Dr. Suresh Sawardekar

MD (General Medicine), Dip & M. H. Sc. in Diabetology,
Consultant Diabetologist, Nanavati Hospital, Mumbai

Article: Prevention of Nutrient Losses from Food

Dr. Vivek Agarwal

MBBS (KGMC), MD (Medicine)
Consultant Diabetologist & Physician, R. R. Diabetes &
Heart Care Centre, Lucknow

Article: Role of Micronutrients in Wound Healing in Diabetic Foot

Dr. Anand M K
MBBS, MD (General Medicine)
Consultant Physician & Asst. Professor, Jubilee Mission
Medical College & Research Institute, Thrissur

Article: Bioavailability of Micronutrients via the Intestinal Microbiome

Dr. Shubhashree Patil

MBBS, D.N.B (General Medicine), D. Diabetology
Consultant Diabetologist & Physician, Diabetes &
Wellness Clinic

Article: Impact of Metformin on Micronutrient Status

Dr. Sushil Patel
MD, FAIIDR PGCD (Boston)
Consulting Diabetologist, Akshar Diabetes Centre, Vadodara

Article: Frequently Asked Questions

Dr. Parth Patel

MD (Family Medicine), FCCS (USA), AFIH, MBA
(Hospital Admin), AHA Instructor
Consultant Diabetologist & Metabolic Physician, V Cure
Hospital, Ahmedabad

Article: Use of Dietary Supplements for Diabetes

Dr. Gayatri Ghanekar

MBBS, MD (General Medicine), DNB (Endocrinology)
Consultant Endocrinologist & Diabetologist, Zen Super Speciality Clinic,
Dombivli

Article: Role of Antioxidants in Diabetes

Dr. Harsha Pamnani

MBBS, MD (General Medicine) (Gold Medallist), DNB
(Endocrinology)
Consulting Endocrinologist, Siddhanta Red Cross Hospital,
Bhopal

Article: How to Incorporate Micronutrients in the Diet?

 Issue No. 98, May 2023

Cover Story: Role of Micronutrients in Frequently Asked Questions

the Prevention and Management of
Diabetes
Dr. R C Sharma
01 Dr. Sushil Patel
16
Role of Vitamin D in Type 2 Diabetes Use of Dietary Supplements for
and Diabetic Kidney Disease

Dr. Ramesh Goyal

04 Diabetes

Dr. Parth Patel

18
Prevention of Nutrient Losses Role of Antioxidants in Diabetes
from Food

Dr. Suresh Sawardekar

06 Dr. Gayatri Ghanekar
20
Role of Micronutrients in Wound Diabetes Educator Tip of the Month
Healing in Diabetic Foot

Dr. Vivek Agarwal

09 Ms. Saili Randive
22
What's Trending? How to Incorporate Micronutrients
Bioavailability of Micronutrients via the
Intestinal Microbiome
Dr. Anand M K
11 in the Diet?

Dr. Harsha Pamnani

26
Impact of Metformin on Micronutrient
Status

Dr. Shubhashree Patil

14 Dia-Games
28
 Cover Story: Role of Micronutrients in the Prevention and
Management of Diabetes

Micronutrients are vitamins and minerals required

Dr. R C Sharma by our body in small dosages for important
MBBS, MD (Internal Medicine)
physiological functions crucial to maintain health.
Consulting Physician, Diabetologist & They play a central part in the body’s metabolism
Cardiologist and maintenance of tissue function and thus may be
Dr. R C Sharma Clinic, Indore
beneficial in diabetes. Though all micronutrients are
essential for the human body, there are certain

micronutrients that need special attention in diabetes. Some micronutrients act as cofactors in glucose metabolic pathways,
pancreatic b-cell function, and the insulin signaling cascade; therefore, their deficiency may play a role in the development of type 2
diabetes.

Calcium (Ca)

Calcium homeostasis plays a role in insulin resistance and secretion. Ca

homeostasis impaired in diabetes contributes to defective cell regulation in
erythrocytes, platelets, and skeletal and cardiac muscles. This affects insulin
secretion and action. Low Ca levels have been shown to increase the risk of CALCIUM
metabolic syndrome and diabetes. On the other hand, some studies have
found increased diabetes risk with high serum Ca levels. A complex
association between Ca levels and the pathogenesis of diabetes is observed.
In individuals with diabetes, uncontrolled blood glucose levels are found to be
associated with low serum Ca levels. But, given the fact that Ca is important
for muscle and bone health, its sufficiency must be ensured due to the
increased risk of fractures and sarcopenia in individuals with diabetes.

Vitamin D (vit D)

Vitamin D insufficiency and deficiency both have been reported in individuals

with diabetes. The role of vit D in insulin secretion and function comprises –
the presence of vit D receptors in human pancreatic b-cells, the detection of
1-a-hydroxylase activity, and insulin gene transcription responsiveness to vit
D in pancreatic b-cells. Pancreatic b-cell dysfunction is observed with vit
D deficiency in animals, which is then restored with supplementation. Many
epidemiologic studies have demonstrated an inverse relationship between
25-hydroxyvitamin D levels and the prevalence of type 2 diabetes. Improved

1
insulin sensitivity has been observed with vit D supplementation among individuals with insulin resistance. In some studies, the
beneficial effect of vit D supplementation on glycemic control in individuals with diabetes has been reported while some suggest no
beneficial effects. However, vit D deficiency is very common among most individuals, let alone individuals with diabetes, and its
sufficiency should be evaluated in routine care.

Magnesium (Mg)

Magnesium acts as a co-factor for the movement of glucose into the cell. It is
also involved in the cellular activity of insulin and carbohydrate metabolism.
Hence, low Mg intake can be considered a risk factor for type 2 diabetes.
Deficiency in Mg also inhibits cellular defenses against oxidation damage
accelerating the progression to diabetes-related complications. Studies have
shown that Mg intake reduces the risk of type 2 diabetes and metabolic
syndrome by alleviation of insulin resistance. Low Mg levels are reported to be
very common among individuals with type 2 diabetes. Mg is also a cofactor in
the downstream actions of the insulin cascade. Given the imperative benefits,
adequate Mg intake is important for both the prevention and management of
type 2 diabetes.

Chromium (Cr)

Chromium is an essential trace element. Dietary Cr acts as a physiological

enhancer of insulin activity and is termed a glucose tolerance factor (GTF). Cr
is involved in increased insulin binding, increased insulin receptor number,
and increased insulin receptor phosphorylation, significantly improving
glucose metabolism in diabetes. An inverse association is also observed
between serum Cr levels and HbA1c levels. Cr also improves oxidative stress
secondary to hyperglycemia. Mild glucose intolerance may require only
200 mg/day of Cr supplementation whereas higher glucose intolerance may
require more.

Zinc (Zn)

Zinc is another vital micronutrient needed for the processing, storage, secretion, and action of insulin in mammalian pancreatic cells
and its deficiency augments cytokine-induced damage in the autoimmune attack, resulting in islet cell destruction in type 1
diabetes. It may contribute to diabetes progression through genetic polymorphisms in the Zn transporter 8 gene and in
metallothionein (MT)-encoding genes associated with type 2 diabetes.

2
Zn reduces cytokine production and partially functions as an antioxidant and its supplementation results in the reduction of reactive
oxygen species production, beneficial in diabetes mellitus. Disturbances in Zn homeostasis are associated with insulin resistance
and diabetes. Diabetes is also responsible for increased urinary loss and decreases in total body Zn. A more profound effect of
decreased Zn levels is found among individuals with type 2 diabetes than individuals with type 1 diabetes. More research is needed
on the impact of serum Zn levels on diabetes and its complications.
While these are certain micronutrients closely associated with diabetes, other micronutrients are also important as a part of overall
well-being. Including diet diversity through whole grains, a variety of vegetables, fruits, nuts, and seeds, can also contribute to
adequate micronutrient intake and is also recommended as part of a lifestyle intervention in the management of diabetes.

Resources:
1. Dubey P, Thakur V, Chattopadhyay M. Role of Minerals and Trace Elements in Diabetes and Insulin Resistance. Nutrients. 2020;12(6):1864. Published
2020 Jun 23. doi:10.3390/nu12061864.
2. Via M. The malnutrition of obesity: micronutrient deficiencies that promote diabetes. ISRN Endocrinol. 2012;2012:103472. doi:10.5402/2012/
103472.

3
 Role of Vitamin D in Type 2 Diabetes and Diabetic Kidney Disease

The prevalence of Diabetes mellitus (DM) and its

Dr. Ramesh Goyal complication of diabetic kidney disease (DKD) is on
MD (Medicine), DM (Endocrinology)
the rise. Moreover, vitamin D insufficiency is
Consulting Diabetologist & Endocrinologist, acknowledged as a global health issue. Also,
Apollo Hospitals International Ltd, Ahmedabad hypovitaminosis D has lately been implicated in the
initiation and development of DM and DKD. There is
mounting evidence that people with DM or DKD
frequently have an inverse vitamin D status.

Vitamin D and type 2 DM (T2DM)

Vitamin D insufficiency is linked to insulin secretion, insulin resistance, and pancreatic b-cell malfunction because vitamin D
receptors in pancreatic b-cells are crucial to the development of T2DM. Through regulating the production and effects of cytokines,
vitamin D administration restores glucose-stimulated insulin secretion and encourages b-cell survival. Calcium concentration and
flux through b-cells have an impact on insulin secretion as well. By controlling intracellular calcium, vitamin D controls the activity of
calbindin, a systolic calcium-binding protein present in pancreatic b-cells, and modulates insulin release that is induced by
depolarization. Parathyroid hormone (PTH), whose level is controlled by vitamin D, is connected to the pancreas production and
secretion of insulin. The expression of insulin receptors is induced by vitamin D, which also controls insulin sensitivity. Vitamin D
improves insulin sensitivity by encouraging the expression of the nuclear receptor fatty acid sensor known as peroxisome
proliferator-activated receptor (PPAR) delta, which is a member of the PPAR family and controls fatty acid levels in skeletal muscle

Vitamin D

Expression of insulin receptor RAAS Activation of insulin gene Inflammation

PPARd Calbindin
Calcium flux through b-cell
PTH

Angiotensin II

Insulin resistance Insulin secretion b-cell dysfunction

Type 2 diabetes mellitus

4
and adipose tissue. While secondary hyperparathyroidism is brought on by secondary vitamin D deficiency, elevated PTH levels are
also linked to diabetes. Additionally, low levels of 1,25-dihydroxy vitamin D [1,25(OH)2D] boost renal-renin production and turn on
the RAAS system. Finally, angiotensin-II hinders glucose absorption by inhibiting insulin's ability to work in vascular and skeletal
muscle tissues. High levels of inflammation decrease glucose control as cytokine-induced apoptosis affects b-cells in the pancreas.
By directly regulating cytokine expression and activity, vitamin D may lessen the consequences of systemic inflammation and
defend against b-cell cytokine-induced apoptosis.

Vitamin D and DKD

Low levels of vitamin D turn on the RAAS system and eventually injure the
VITAMIN D AND KIDNEY FUNCTIONS
renal tissues. Because the RAAS system plays a role in the etiology of DKD, it
is frequently inhibited in people with T2DM. According to a recent meta-
analysis, RAAS inhibitors plus active vitamin D analogs reduced proteinuria by
16% compared to traditional RAAS-blocking medication. According to
multiple studies, people with DKD had considerably lower 25-hydroxyvitamin
D [25(OH)D] plasma levels, which over time caused vitamin D shortage or
insufficiency due to a number of causes, including (i) a decrease in the
number of functioning nephrons, (ii) overexpression of 25-hydroxyvitamin
D-24-hydroxylase (CYP24A1- an enzyme responsible for 25(OH)D and
1,25(OH)2D catabolism) in diabetes individuals causes enhanced degradation of the main vitamin D metabolite, (iii) the cytochrome
P450, family 27, subfamily B, member 1, (CYP27B1- provides instructions for production of an enzyme called 1-a-hydroxylase)
activity is likely lowered as a result of elevated fibroblast growth factor-23 (bone-derived hormone suppressing phosphate
reabsorption and vitamin D hormone synthesis in the kidney) levels, which also result in elevated CYP24A1 transcription, (iv) vitamin
D binding proteins (megalin and cubilin) are a few of the proteins lost in urine that are crucial for maintaining vitamin D homeostasis.
All of these elements contribute to impaired vitamin D homeostasis, a drop in 25(OH)D and 1,25(OH)2D levels, and secondary
hyperparathyroidism.

Resources:
1. Nakashima A, Yokoyama K, Yokoo T, Urashima M. Role of vitamin D in diabetes mellitus and chronic kidney disease. World J Diabetes. 2016;7(5):89-
100. doi:10.4239/wjd.v7.i5.89.
2. Galuška D, Pácal L, Kaňková K. Pathophysiological Implication of Vitamin D in Diabetic Kidney Disease. Kidney Blood Press Res. 2021;46(2):152-161.
doi:10.1159/000514286.

5
 Prevention of Nutrient Losses from Food

Cooking is a culinary skill that enhances the flavor of

Dr. Suresh Sawardekar food. But when food is exposed to heat, light, and
MD (General Medicine), Dip & M. H. Sc. in
oxygen during the process of food preparation, there
Diabetology, may be certain nutrient losses. Cooking also
Consultant Diabetologist, Nanavati Hospital, increases the availability of some phytonutrients,
Mumbai

HOW
TO
PRESERVE NUTRIENTS
WHEN COOKING?
decreases anti-nutrient factors, and improves digestion. Hence, to enjoy
delicious and nutrient-dense food, we must master the art of smart cooking.
Here are some ways in which nutrient losses can occur and some tips to
prevent them.

Washing

Water soluble vitamins like Vitamin B and Vitamin C are easily lost when vegetables comprising these vitamins are soaked and the
soaking water is drained away. Repeated washing of grains like rice and pulses and washing cut vegetables also leads to loss of
nutrients.
Prevention
¢ In order to preserve the water-soluble vitamins and minerals in the vegetables, avoid soaking them beforehand.
¢ Wash the vegetables before chopping them.
¢ Whey, or the leftover water from making paneer, provides an extremely
high-quality protein. It should be had or consumed either plain or with
lime, salt and pepper added for flavor or whey can be added while
kneading the dough for chapati.
¢ Soaking pulses and grains helps reduce anti-nutritional factors like
phytates, tannins, and enzyme inhibitors when the water used to soak is
discarded. This increases the availability and absorption value of
nutrients from these foods.

6
 Boiling

Certain vitamins are heat labile, meaning that too much heat will cause them
to be destroyed. The most unstable of them are thiamine (B1), folate, vitamin
B12, and vitamin C, which are all rapidly destroyed by heat. The maximum loss
of these essential elements occurs during prolonged cooking, higher
temperatures, baking, canning, and dehydration.
Prevention
¢ Cook food for the shortest amount of time necessary.
¢ Steer clear of repeated reheating.
¢ Pressure cooking and steaming are the greatest cooking techniques for retaining nutrients because they speed up the cooking
process and don't require additional water.
¢ When boiling, add the raw vegetable after the water has reached a rolling boil.

Air

Vitamin C oxidizes when exposed to air, which is essentially oxygen. With higher cooking temperatures, longer cooking times, and
chopping or mashing vegetables, oxidative losses rise. Vitamin A is also susceptible to oxidation.
Prevention
¢ The salads should be cut just before serving.
¢ To prevent exposure to air, serve salads and gravies in covered dishes.
¢ Avoid chopping veggies into extremely little pieces since each one will
come into contact with oxygen and lose its vitamins.
¢ Cabbage or green leafy vegetables, if used in salads, must be steamed
or blanched to lower oxalates and microbial growth.

Light

Vitamins including riboflavin (Vitamin B2), vitamin E, and vitamin K are light
sensitive, so sun drying and cooking food in light-exposed pots degrades
these vitamins.
Prevention
¢ Keep food covered in all instances.

7
 Alkaline medium

The cooking medium becomes alkaline when soda is added. It intensifies the color of leafy greens and speeds up cooking, but it
severely depletes them of vitamins B1, B2, B6, C, and K.
Prevention
¢ Avoid using soda when cooking. Instead, add a pinch of sugar to keep the color.

Resource:
1. Salis Sheryl. Smart Cooking. In: Diet in Diabetes Simplified. Vol 2. 2nd ed. Chennai, Tamil Nadu: Notion Press; 2020:85-100.

8
 Role of Micronutrients in Wound Healing in Diabetic Foot

Diabetic foot ulcer (DFU) is a chronic consequence of

Dr. Vivek Agarwal uncontrolled diabetes mellitus and a major cause of
MBBS (KGMC), MD (Medicine)
amputation and prolonged hospitalization. The
Consultant Diabetologist & Physician, R. R. majority of individuals with DFU are malnourished,
Diabetes & Heart Care Centre, Lucknow

which leads to inappropriate metabolic micronutrient status causing

impairment in the wound healing process. Micronutrients play an important
role in the form of trace elements and vitamins and influence the course
followed by the healing wound.

Role of micronutrients in wound healing

Micronutrients Role in wound healing in DFU

Vitamin A Vitamin A contributes to fibroplasia, angiogenesis stimulation, collagen synthesis, and epithelial
differentiation and proliferation. It has a unique ability to reverse the inhibitory effects of
glucocorticosteroids on wound healing.
Vitamin C Vitamin C plays a crucial role in numerous biological processes that contribute to wound healing, including
collagen production, immune system control, and cartilage and bone maintenance.
Vitamin D Vitamin D significantly reduces the ulcer length, width, depth, and erythema rate. It also plays an important
role in bone homeostasis. Moreover, it decreases wound fibrosis.
Vitamin E Vitamin E promotes the generation of fibroblasts and keratinocytes which speeds up the closure of wounds.
Zinc Zinc is a cofactor for several transcription factors and enzyme systems, such as zinc-dependent matrix
metalloproteinase, which play a significant role in wound healing. It promotes wound healing due to its
effects on insulin resistance, inflammation, and oxidative stress.
Magnesium Magnesium plays a significant role in insulin sensitivity and glucose homeostasis. It interacts with ATP in the
processing of collagen formation and is involved in protein formation and tissue development. In addition, it
reduces the risk of developing DFU.
Copper Copper is a crucial cofactor in protein synthesis and collagen formation in wound healing. Thus deficiency of
copper may be a cause for impaired wound healing.
Iron Iron is required for hydroxylation in collagen synthesis. It reduced the risk of developing DFU.

9
Nutrition plays an important role in the wound-healing process in an individual with DFU. Thus, adequate daily nutritional demands
should be provided as part of the best standard care.

Resources:
1. Da Porto A, Miranda C, Brosolo G, Zanette G, Michelli A, Ros RD. Nutritional supplementation on wound healing in diabetic foot: What is known and what
is new?. World J Diabetes. 2022;13(11):940-948. doi:10.4239/wjd.v13.i11.940V.
2. Pena G, Kuang B, Cowled P, et al. Micronutrient Status in Diabetic Patients with Foot Ulcers. Adv Wound Care (New Rochelle). 2020;9(1):9-15.
doi:10.1089/wound.2019.0973.
3. Kulprachakarn K, Ounjaijean S, Wungrath J, Mani R, Rerkasem K. Micronutrients and Natural Compounds Status and Their Effects on Wound Healing in
the Diabetic Foot Ulcer. Int J Low Extrem Wounds. 2017;16(4):244-250. doi:10.1177/1534734617737659.

VITAMINS FOR
WOUND HEALING

10
 What's Trending?
Bioavailability of Micronutrients via the Intestinal Microbiome

Micronutrients, which include vitamins and

Dr. Anand M K minerals, are essential for human health and are
MBBS, MD (General Medicine)
crucial regulators of basic biosynthetic cellular
Consultant Physician & Asst. Professor, Jubilee reactions, including immune and energy functions,
Mission Medical College & Research Institute, growth, bone health, fluid regulation, and other
Thrissur
biological processes.
Micronutrient deficiency is regarded as a global

health issue as it is linked to serious health issues, especially in children, who

are more susceptible to pathogen infections, the development of allergies,
inflammatory diseases as well as delayed physical and mental development.
Numerous findings also show evidence that micronutrient deficiency may
contribute to the progression of some human cancers. The human body
cannot synthesize all necessary micronutrients, which thus need to be
obtained exogenously from three main resources: dietary components, oral
supplements, or synthesis by commensal gut bacteria. Therefore, food
fortification programs and oral supplementation of micronutrients have been
carried out in most countries.
Micronutrient bioavailability is the fraction of a micronutrient that is available to the body for use and storage. Micronutrients are
absorbed through a variety of pathways some of which are specific and can be both active or passive. For example, the absorption of
vitamins A and D takes place by passive diffusion in the small intestine, whereas the absorption of vitamins C and B7 (biotin) is
+
mediated by Na -dependent carriers.

Micronutrients and gut microbiota

The gut microbiome is the community of trillions of microorganisms living in

the gastrointestinal tract, that is known to interact with dietary substances in
a bidirectional manner, affecting both their composition and functional
structure as well as their metabolism and absorption, which in turn affects
their bioavailability. Micronutrients, in particular, can influence the diversity
and makeup of the gut microbiome, having either positive or negative effects
on the host's health. Contrarily, commensal bacteria in the human gut have
the ability to affect nutrient absorption and produce vital vitamins (such as
vitamin K and biotin, among others), possibly having a significant impact on
the micronutrient status.

11
 Micronutrients-gut microbiota interaction

The micronutrient and microbiome relationship is a two-way interaction. On the one hand, micronutrients are consumed by gut
microbes for nutrition and functioning. On the other hand, the gut microbiota facilitates the uptake and absorption of minerals like
iron and calcium and generates substantial amounts of a variety of vitamins, particularly vitamin K and B group vitamins.

Mineral metabolism and intestinal microbiome

The gut microbiota has an impact on how minerals are metabolized. This
MINERALS
includes (i) directly affecting mineral absorption in the gastrointestinal tract
during digestion and (ii) producing a variety of enzymes that are only
produced by colonic microbes and assist in releasing minerals from foods.
Two studies revealed similar findings of a unique beneficial role for a molecule
produced by bacteria C. elegans in promoting the host's iron homeostasis,
bringing a surprising benefit from commensal bacteria to the host. The
dynamic link between the gut microbiota and mineral bioavailability is clearly
demonstrated in bone health. Vitamin D-regulated calcium-binding proteins,
such as calbindin D9k, can help increase calcium active absorption in part.
However, under conditions of low calcium intake, microbiota plays a significant role in calcium bioavailability. Asemi et al. (2013)
found that pregnant women who consumed probiotic yogurt with Bifidobacterium lactis and Lactobacillus acidophilus maintained
serum calcium levels better than those who consumed conventional yogurt. Many studies also show that microbiota may control
bone loss via a variety of mechanisms, including micronutrient bioavailability, in addition, several other studies show the
microbiota's significance in preventing bone loss.

Vitamins metabolism and intestinal microbiome

Some bacterial genera normally adapted to the human gastrointestinal tract

A B1
environment, including Bifidobacterium, Bacteroides, and Enterococcus, are
K well-known to biosynthesize water-soluble B vitamins and vitamin K.
E B2 Magnúsdóttir et al. (2015) systematically evaluated the in silico (experiments
performed by computer) biosynthetic capability of common human gut
D VITAMINS B3 bacteria for the production of eight B vitamins and demonstrated that the
studied gut microbes produced 40-65% of each of those vitamins. Recent
C B5 clinical trials and in vivo research have explained the function of the
microbiota in the host's vitamin balance. For example, several members of
B12 B6
B9 the bacterial phylum firmicutes identified using 16S ribosomal RNA
sequencing of human stool samples, such as clostridia class, clostridia order,
and part of the Ruminococcacus, Coprococcus, Mogibacterium, and Blautia

12
genera, were positively correlated with the vitamin D levels in serum. In a human cohort, butyrate-producing bacteria were
associated with increased expression of the vitamin D receptor protein.
The gut microbiome can variously impact the bioavailability of micronutrients as well as be affected by micronutrient
supplementation, thereby impacting health even in the long run. Although several mechanisms have been proposed, a thorough
study of the microbiome-micronutrient two-way association is significant, as it can shed light on the design of microbiome-based
precision intervention strategies aimed at enhancing overall health and micronutrient status.

Resources:
1. Barone M, D'Amico F, Brigidi P, Turroni S. Gut microbiome-micronutrient interaction: The key to controlling the bioavailability of minerals and vitamins?.
BioFactors. 2022;48(2):307-314.doi:10.1002/biof.1835. https://iubmb.onlinelibrary.wiley.com/doi/full/10.1002/biof.1835
2. H Noushin, B Vincent,W Haiping, T Mirko. Intestinal microbiota as a route for micronutrient bioavailability. Current Opinion in Endocrine and Metabolic
Research. 2021;20:100285.https://doi.org/10.1016/j.coemr.2021.100285. https://www.sciencedirect.com/science/article/pii/
S245196502100082X
3. Ekins S, Mestres J, Testa B. In silico pharmacology for drug discovery: methods for virtual ligand screening and profiling. Br J Pharmacol.
2007;152(1):9-20. doi:10.1038/sj.bjp.0707305.
4. Asemi Z, Esmaillzadeh A. Effect of daily consumption of probiotic yoghurt on serum levels of calcium, iron, and liver enzymes in pregnant women. Int J
Prev Med. 2013;4(8):949-955.
5. Magnúsdóttir S, Ravcheev D, de Crécy-Lagard V, Thiele I. Systematic genome assessment of B-vitamin biosynthesis suggests co-operation among gut
microbes. Front Genet. 2015;6:148. Published 2015 Apr 20. doi:10.3389/fgene.2015.00148.

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 Impact of Metformin on Micronutrient Status

Metformin is typically one of the first-line

Dr. Shubhashree Patil medications for type 2 diabetes mellitus (T2DM),
MBBS, D.N.B (General Medicine), D.
which has a good safety profile and is efficient and
Diabetology affordable. There is plenty of evidence, that the
Consultant Diabetologist & Physician, Diabetes
& Wellness Clinic

usage of metformin is associated with vitamin B12 deficiency. Prolonged use of

metformin may have an adverse effect on the levels of the other
micronutrients too such as vitamins B1, D, folic acid, and magnesium in
addition to upsetting the microbiome.

Nutrients Mechanisms that result in metformin-induced deficiency of nutrients

Vitamin B1 Prevents the body from absorbing thiamine by blocking the human thiamine transporter in the small
(Thiamine) intestine.

Folic acid Folate is an essential co-factor in the conversion of homocysteine (Hcy) to methionine and plays a role in the
purine base synthesis of DNA. Patients with T2DM who use metformin have been reported to have lower levels
of folate and vitamin B12, which normally cause a slight increase in Hcy and an increased cardiovascular
disease risk.

Vitamin B12 Changes in the motility of the small bowel might stimulate bacterial overgrowth.
(Cobalamin) Alterations in levels of intrinsic factor (IF) that cause inactivation or competitive inhibition in the absorption of
vitamin B12.
According to research, metformin lowers the body's stores of chromium and calcium. The uptake of vitamin B12
relies on calcium availability in the body. Calcium-associated vitamin B12-IF complex absorption is inhibited in
the terminal ileum.

Magnesium The Mg2+ (re)absorption in the intestine and kidney is fine-tuned by the TRPM6 channel. TRPM6 gene
expression is reduced in kidney and intestinal cells after long-term metformin use.

14
Moreover, it has been demonstrated that metformin decreases the body's
coenzyme Q10 (CoQ10) levels, raising the risk of heart problems. Given that CoQ10
people with T2DM are already likely to have suboptimal levels of these
micronutrients and that these deficiencies are varyingly linked to diabetic
Folate Vitamin
complications like impaired endothelial, microvascular, vascular, and
B12
neurological function, it may be appropriate to think about supplementation
when necessary to lessen these side effects of metformin. The researchers
Micronutrients Depleted by Metformin
advise that metformin-using individuals with T2DM get vitamin B12
concentrations tested at least annually.

Resources:
1. Wakeman M, Archer DT. Metformin and Micronutrient Status in Type 2 Diabetes: Does Polypharmacy Involving Acid-Suppressing Medications Affect
Vitamin B12 Levels?. Diabetes Metab Syndr Obes. 2020;13:2093-2108. Published 2020 Jun 18. doi:10.2147/DMSO.S237454.
2. Diabetes drug-induced nutrient depletion & solutions: Davis Island's Pharmacy and Compounding Lab: Tampa. Davis Island's Pharmacy and
Compounding Lab | Tampa's Trusted Compounding Pharmacy: We Care. https://davisislandspharmacy.com/drug-induced-nutrient-
depletion/diabetes/. Published November 13, 2018. Accessed March 10, 2023.
3. Bouras H, Roig SR, Kurstjens S, et al. Metformin regulates TRPM6, a potential explanation for magnesium imbalance in type 2 diabetes patients. Can J
Physiol Pharmacol. 2020;98(6):400-411. doi:10.1139/cjpp-2019-0570.

15
 Frequently Asked Questions

1. I am a 59-year-old, and I have been living with

Dr. Sushil Patel diabetes for the past 15 years. Lately, I have started
developing symptoms of numbness and tingling
MD, FAIIDR PGCD (Boston)
Consulting Diabetologist, Akshar Diabetes sensation in my extremities. I am told these are early
Centre, Vadodara signs of diabetic neuropathy. Is there any way that I
can lessen the symptoms through diet?

Ans. The term "neuropathy" is used to describe a number of disorders that

affect the nerves. Long-standing diabetes often results in neuropathy. B
vitamins are renowned for their ability to assist normal nervous system
functioning. It has been observed through studies that the vitamins B1, B6, and
B12 are particularly helpful for managing neuropathy. Thiamine (vitamin B1) is B12
essential for the regeneration of nerves because it helps nerve cells use B6
carbohydrates for energy and defend them from oxidative stress, which B1
normalizes pain perception and lowers hyperexcitability. Pyridoxine (vitamin
B6) protects the sheath that surrounds nerve terminals. It is also essential for
the production of neurotransmitters because it prevents the release of
neurotoxic glutamate and restores the function of sensory nerves. Cobalamin (vitamin B12) significantly and actively contributes to
remyelination and the upkeep of myelin sheaths, which in turn greatly enhances nerve cell survival. Studies have proven that a
vitamin B12 deficiency can lead to neuropathy. Metformin use can also lead to vitamin B12 deficiency. Common food sources of vitamin
B are – eggs, seafood, whole grain cereals, legumes, green leafy vegetables, low-fat dairy products, mushrooms, nuts, and seeds.
2. My 26-year-old son is overweight and has been recently diagnosed with prediabetes. I am taking a lot of efforts to manage his
diet and lifestyle to avoid progression to diabetes. Being a working woman, I use microwaves sometimes to cook and reheat food. Is
this going to be harmful to my son? Will microwave cooking destroy the nutrients in the food?
Ans. The use of microwaves for cooking or reheating is quite common and is
fast and convenient. However, a lot of people worry about its side effects and
its negative impact on the nutritional value of food. But the fact is that all
cooking methods reduce the nutrient value to some extent and microwave
cooking does not do more harm than any other traditional cooking way. Some
studies even show that microwaves generally preserve nutrients better. This
is because the best cooking method to preserve nutrient value is one that
cooks quickly, with the shortest amount of time and the use of liquid.
Microwaving meets these criteria. Also, microwaves are generally safe
because they use electromagnetic waves to heat the food up. The only
precaution you must take for safety is to use only microwave-safe containers and keep the microwave in good condition. Overall, it is
safe, effective, and convenient to use the microwave.

16
3. I am a 32-year-old woman. My husband has had diabetes for the last 3 years. I give him a bowl of moong sprouts as an evening
snack. Does sprouting have any additional benefits in terms of nutritional value?
Ans. The process of sprouting has a myriad of health benefits. Sprouting makes digestion easier. Germination promotes the release
of enzymes that help predigest starch and improve digestion. Sprouted grains and legumes have a higher concentration of vitamin
C, B vitamins, and antioxidants. The bioavailability of vitamins and minerals is also better in sprouted grains, as the process of
sprouting helps to release enzymes that break down antinutritional factors like phytates, which otherwise bind with minerals and
vitamins and make them unavailable for absorption. Sprouting also reduces cooking time, so the automatic retention of nutrients is
better. So overall, they are a powerhouse of nutrition.

17
 Use of Dietary Supplements for Diabetes

Diabetes, especially type 2 diabetes mellitus, is one

Dr. Parth Patel of the most prevalent conditions globally. While
medication, nutritional intervention, and exercise
MD (Family Medicine), FCCS (USA), AFIH,
MBA (Hospital Admin), AHA Instructor are regarded as the primary options for management,
Consultant Diabetologist & Metabolic the use of dietary supplements is becoming popular.
Physician, V Cure Hospital, Ahmedabad Dietary supplements are one type of oral
complementary and alternative medicine therapy. A
dietary supplement is a "product taken by mouth

that contains a dietary element designed to enhance the diet," according to

the Dietary Supplement Health and Education Act (DSHEA) of 1994. These
food components could include "vitamins, minerals, herbs, amino acids, and
other botanicals and substances such as enzymes, organ tissues, glandular,
and metabolites." These supplements come in a variety of shapes and sizes,
including tablets, capsules, soft gels, liquids, powders, and bars. It is crucial to
remember that dietary supplements are not regarded as medications. Rather,
they must be identified as dietary supplements and fall under the general
category of "foods.” The following are some of the most popular supplements.

Common diabetes dietary supplements

Alpha lipoic The antioxidant known as alpha lipoic acid, also known as lipoic acid or thioctic acid, functions similarly to the B
acid (ALA) complex vitamins. When administered intravenously to patients with diabetic neuropathy, ALA can help to
relieve some peripheral neuropathy symptoms and reduce blood glucose levels.
Sources: Liver, spinach, broccoli, brussels sprouts, peas, potatoes, and yeast are foods that contain ALA.
Dosage: 600–1200 mg of a tablet daily
Side effects: Although ALA side effects are uncommon, they could include hypoglycemia (if taken with insulin
or insulin secretagogues), rash, thiamine shortage in vulnerable individuals, and potential interactions with
thyroid medication.

Bitter gourd According to some studies, the bitter gourd's fruit and seeds can lower blood glucose levels via increasing
glucose uptake by tissues, increasing the production of muscle and liver glycogen, enhancing glucose oxidation,
and activating an enzyme called AMPK. AMPK controls fuel metabolism and encourages glucose uptake.
Sources: There are several ways to consume bitter gourd, including as a vegetable, juice, or in pill form.
Dosage: There is no standard dosage schedule due to the various variances in the types of bitter gourd
consumed. However, doses of 50 to 100 ml (about 3-6 tablespoons) have been applied.
Side effects: Eating bitter gourd as a vegetable is probably safe. Bitter gourd allergies can cause a rash, itching,
shortness of breath, and gastrointestinal upset in some people who are sensitive to it. It might interact with
chemotherapeutic treatments, immune system suppressants, and lipid-lowering pharmaceuticals.

18
 Chromium Chromium is a crucial trace mineral required for the metabolism of glucose. It increases the impact of
supplementation insulin in order to work. Chromium is a popular dietary supplement for people with diabetes and those
trying to lose weight, usually in the form of chromium picolinate.
Sources: Dried basil, dried garlic, dried grape juice, broccoli
Dosage: 400–800 g/day of chromium supplementation
Side effects: Thrombocytopenia, hemolysis, renal and hepatic failure, skin reactions, and mood
disturbances may result from excessively high chromium ingestion.

Cinnamon Ceylon and cassia cinnamon are the two varieties. The kind of cinnamon that is supposedly utilized to
supplementation manage diabetes and gastrointestinal pain is ceylon cinnamon. The chemical hydroxychalcone which is
believed to improve insulin activity is the active component of cinnamon.
Sources: Ground cinnamon is frequently sprinkled over food or used as a spice in baking. In addition to
being added to a beverage or food, it also comes in capsule and essential oil form.
Dosage: 1 g (1/2 teaspoon) per day
Side effects: Contact dermatitis and uncommon but probable allergic reactions. Moreover, anyone
receiving insulin or using an insulin secretagogue may experience hypoglycemia. Caution should be taken
when using cinnamon if you have liver disease. High coumarin dosages found in cassia cinnamon may
cause or exacerbate liver damage.

Fenugreek Fenugreek is commonly used in the management of diabetes. Fenugreek seeds are believed to decrease
supplementation gastric emptying and consequently, the digestion and absorption of carbohydrates since they contain fiber.
Moreover, the seeds may decrease triglycerides and cholesterol as they are high in soluble fiber.
Sources: Fenugreek is available as a tea and in capsule form.
Dosage: 5 to 100 g/day
Side effects: Gastrointestinal distress may result from consuming fenugreek seeds or capsules (gas,
bloating, diarrhea). Fenugreek should not be taken by pregnant women since it may trigger uterine
contractions. Fenugreek may interact with drugs that thin the blood.

Gymnema Originating in central and southern India, Gymnema (Gymnema sylvestre) is a woody plant. The herb is also
supplementation known as gurmar, which translates to "sugar destroyer" since chewing the leaves impairs one's ability to
taste sweetness. It involves enhanced glucose absorption and insulin release from b-cells, and it is used to
manage both type 1 and type 2 diabetes.
Sources: A water-soluble extract of Gymnema that is standardized to contain 24% gymnemic acid is
available. Moreover, it can be consumed as tea or in capsule form.
Dosage: Gymnema extract is typically used in doses of 400–600 mg per day, divided as follows: 100 mg
three to four times per day as a capsule and 0.5-1 teaspoon per day as a tea-making powder.
Side effects: If taken combined with insulin or insulin secretagogues, it may cause hypoglycemia. The
capacity to taste sweet or bitter flavors may also be affected.

Resource:
1. Amy P. Campbell; Diabetes and Dietary Supplements. Clin Diabetes. 1 January 2010; 28 (1): 35–39. https://doi.org/10.2337/diaclin.28.1.35

19
 Role of Antioxidants in Diabetes

Diabetes can lead to oxidative stress which can

Dr. Gayatri Ghanekar damage proteins, lipids, and DNA in addition to
MBBS, MD (General Medicine), DNB
triggering the activation of various cellular pathways
(Endocrinology) and is a result of an imbalance between the
Consultant Endocrinologist & Diabetologist, production and buildup of reactive oxygen
Zen Super Speciality Clinic, Dombivli
species. These reactive oxygen species in a higher
concentration in the body with a minimal amount of

antioxidant enzymes lead to oxidative stress. Antioxidants are substances

that can prevent the cells from damage that can be caused by oxidative
stress. Antioxidants can be endogenous (produced by the body) or
exogenous (taken from outside). Both types of antioxidants can aid to rule
out the formation of free radicals by scavenging or encouraging their
breakdown. A few antioxidants are discussed below:

Vitamin E

A lipophilic antioxidant, available in tocopherol and tocotrienol form is a

naturally occurring antioxidant that is believed to aid in the treatment of
hyperglycemia and can prevent microvascular and macrovascular problems
in people with diabetes. Sources include almonds, avocados, leafy greens
(beet, mustard, turnip), peanuts, pumpkin seeds, and sunflower seeds.

Vitamin C

Another powerful antioxidant scavenging free radicals is vitamin C. In

Vitamin C
population-based research, it was shown that regular dietary intake of
vitamin C lowers the risk of type-2 diabetes. Microalbuminuria, erythrocyte
sorbitol levels, and insulin resistance are all significantly improved by vitamin
C due to its antioxidant capacity. Sources are amla, lemon, orange, papaya,
guava, strawberries, and tomatoes.

20
 Alpha lipoic acid (ALA)

Alpha lipoic acid can be used to treat cellular damage brought on by free
radical triggering. It possesses the ability to restore other antioxidants such as
vitamins C, E, and glutathione. ALA is also known to improve glucose
metabolism in people with diabetes. Plasma insulin sensitivity can be
increased by the oral supplementation of ALA. Reactive oxygen species
generated during the peroxidation of lipids can be neutralized by ALA,
protecting the cells from harm. Regular ALA intake lowers hyperglycemia and
complications such as diabetic nephropathy. The body produces ALA
naturally but its intake can be enhanced with dietary supplements and it is
also found in tomatoes, broccoli, and spinach in some amounts.

Selenium

Resources:
1. Suresh V, Reddy A, Muthukumar P, Selvam T. Antioxidants: Pharmacothearapeutic Boon for Diabetes. Antioxidants - Benefits, Sources, Mechanisms of
Action [Internet]. 2021 Sep 8; Available from: http://dx.doi.org/10.5772/intechopen.98587 https://www.intechopen.com/chapters/77150
2. Pasupuleti VR, Arigela CS, Gan SH, et al. A Review on Oxidative Stress, Diabetic Complications, and the Roles of Honey Polyphenols. Oxid Med Cell
Longev. 2020;2020:8878172. Published 2020 Nov 23. doi:10.1155/2020/8878172 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704201/
3. Rajendiran D, Packirisamy S, Gunasekaran K. A Review on Role of Antioxidants in Diabetes. Asian J Pharm Clin Res. 2018; 11, 48-53. Published 1 Feb
2018. https://www.researchgate.net/publication/322930654_A_review_on_role_of_antioxidants_in_diabetes
4. Antioxidants. The Nutrition Source. Harvard T.H. Chain. Updated 2021. Accessed March 10, 2023. Available at https://www.hsph.harvard.edu/
nutritionsource/antioxidants/
5. Selenium. The Nutrition Source. Harvard T.H. Chain. Updated March 2023. Accessed March 21, 2023. Available at https://www.hsph.harvard.edu/
nutritionsource/selenium/#:~:text=Selenium%20is%20a%20component%20of,inflammation%20and%20other%20health%20problems.

21
 Diabetes Educator Tip of the Month

Food Pairings Which Increase

Nutrient Absorption

Contributed by
Food pairing or synergy is the concept of interaction
Name: Saili Randive
between nutrient absorption and bioavailability in
PG Dip Dietetics, CDE the human body. Such interactions can give positive
as well as negative health impacts. However, pairing
foods to obtain potential health benefits can be

practiced with the help of evidence-based studies, which are available for certain active functional components present in the food
we eat for disease prevention and obtaining good health. Below are some of the following beneficial pairings.

Green tea and lemon

Catechins present in green tea are associated with enhanced immunity with
lower incidences of cardiovascular disease and cancer. The addition of lemon
to green tea enhances the absorption of epigallocatechin gallate ten folds
more than it would have if green tea was consumed all by itself.

Turmeric and black pepper

Curcumin is the active ingredient in turmeric, which is known for its anti-inflammatory, anti-cancer, and tumor-protective
properties. Whereas black pepper shows piperine as the active component, when combined synergistically with curcumin, black
pepper enhances the absorption of curcumin 1000 times.

22
 Boiled eggs with salads

Salads with greens are rich in carotenoids like lutein, zeaxanthin,

b-carotene, and a-carotene. Zeaxanthin and lutein are present in egg yolk as
well. Consumption of boiled eggs along with salads containing tomatoes,
green leafy vegetables, and carrots enhances the absorption of carotenoids
3 to 9-fold.

Green leafy vegetables with lemon

Squeezing lemon (vitamin c) on green leafy veggies enhances the absorption

of non-heme iron by increasing its bioavailability, thus helping in combating
iron deficiency anemia.

Yogurt and banana

A combination of prebiotics (food for good bacteria) and probiotics (beneficial

live microorganisms) are known to be beneficial for gut health. The inulin
present in bananas serves as food for the good gut bacteria in yogurt.
Together they help in building immunity, improving digestion, and increasing
the absorption of some minerals as well.

For cardiovascular health

Garlic with fish

Garlic and fish when paired synergistically, improve cardiovascular health
and help in improving immunity levels as well.

23
Tomatoes with olive oil
Tomatoes are rich in carotenoids like lycopene which is fat soluble. Tomatoes
when cooked with olive oil, the absorption of lycopene is enhanced. Lycopene
helps improve serum lipid profile.

For diabetes management

Onion and garlic

Methiin and S-allyl cysteine sulphoxide are the active components found in
onion and garlic which stimulate insulin production from the pancreas and
thus help in regularising blood glucose levels.

Vitamin D and vitamin K supplements

K2
Supplementation of vitamin D and vitamin K aid in decreasing blood glucose
levels, by increasing insulin receptor gene expression and encouraging
D3
insulin release from pancreatic cells, which improves blood glucose
metabolism.
Ca
For cancer protection

Apples with apple peels

Phloridzin, quercetin, chlorogenic acid, and catechin are some of the
phytochemicals found in apples. The apple peel exhibits anticancer
properties. Consuming apples with skin reduces lipid oxidation, lowers
cholesterol, and prevents the growth of cancer cells in cancer patients.

24
Good dietary choices with the synergistic pairing of nutrients enhance one's health holistically by boosting immunity and nutrient
bioavailability.

Resources:
1. Natarajan, T.D., Ramasamy, J.R. & Palanisamy, K. Nutraceutical potentials of synergic foods: a systematic review. J. Ethn. (2019). Food. 6,27.
2. National Center for Biotechnology Information. PubChem Compound Summary for CID 65064, (-)-Epigallocatechin gallate. Accessed Mar. 8, 2023.
3. Shoba G, Joy D, Joseph T, Majeed M, Rajendran R, Srinivas PS. Influence of piperine on the pharmacokinetics of curcumin in animals and human
volunteers. Planta Med. 1998;64(4):353-356. doi:10.1055/s-2006-957450.
4. Hallberg L, Brune M, Rossander L. The role of vitamin C in iron absorption. Int J Vitam Nutr Res Supp. 1989;30:103–8.
5. Fernandez MA, Marette A. Potential health benefits of combining yogurt and fruits based on their probiotic and prebiotic properties. Adv Nutr.
2017;8(1):155S–64S.
6. Morcos NC. Modulation of lipid profile by fish oil and garlic combination. J Natl Med Assoc. 1997;89(10):673.
7. Ahuja KD, Pittaway JK, Ball MJ. Effects of olive oil and tomato lycopene combination on serum lycopene, lipid profile, and lipid oxidation. Nutrition.
2006;22(3):259–65.
8. Corzo-Martínez M, Corzo N, Villamiel M. Biological properties of onions and garlic. Trends Food Sci Technol. 2007;18(12):609–25.
9. Aguayo-Ruiz, J.I., García-Cobián, T.A., Pascoe-González, S. et al. Effect of supplementation with vitamins D3 and K2 on undercarboxylated osteocalcin
and insulin serum levels in patients with type 2 diabetes mellitus: a randomized, double-blind, clinical trial. Diabetol Metab Syndr (2020). 12,73.
10. Wolfe KL, Liu RH. Apple peels as a value-added food ingredient. J Agric Food Chem. 2003;51(6):1676–83.

25
 How to Incorporate Micronutrients in the Diet?

Using the healthy plate method is the easiest way to

Dr. Harsha Pamnani create well-balanced healthy meals that can help
MBBS, MD (General Medicine) (Gold
manage blood glucose levels.
Medallist), DNB (Endocrinology)
Consulting Endocrinologist, Siddhanta Red
Cross Hospital, Bhopal

Fill a quarter of your Fill half of your plate with Fill a quarter of your Add 8 oz. of non-fat or Add 1-2 teaspoons of
plate with brown rice, colorful vegetables like plate with chicken, fish, low-fat 1% milk or 6 oz. heart-healthy fat, such as
sweet potato, whole- broccoli, green beans, lean meat, low-fat of non-fat or low-fat vegetable oil or trans-fat-
grain pasta, bread, corn, spinach, beets, carrots, cheese, tofu, or egg yogurt and a small piece free margarine.
or whole-wheat tortillas. zucchini, or tomatoes. whites. Remove any of fruit.
Prepare them without fat visible fat or skin before
by steaming them. cooking.

Fig 1. Healthy plate by Joslin Diabetes Centre

The recommended healthy plate by Joslin Diabetes Centre is shown in figure 1.

It suggests an individual with diabetes should consume:
¢ Half a plate filled with non-starchy vegetables.
¢ Quarter of a plate containing cereals/whole grains.
¢ Quarter of a plate containing protein sources.
To ensure intake of all micronutrients, one must consume all five food groups
– cereals and grains, pulses and legumes, dairy and its products, fruits,
vegetables, nuts, and oil seeds. Foods belonging to each of these groups
provide individually different micronutrients and hence, a variety of these
foods must be emphasized. For example, different vegetables have varied phytochemicals corresponding to the color of the
vegetable and each of these phytochemicals has diverse health benefits.

26
Important micronutrients in diabetes management and their sources are listed in the table below:

Calcium Milk and its products, sesame seeds, poppy seeds, almonds, ragi, amaranth, edamame, dark green leafy vegetables
Vitamin D Sunlight exposure, mushrooms, egg yolk, and fatty fish
Magnesium Legumes, almonds, peanuts, whole grains
Chromium Whole grains, nuts, vegetables, poultry, egg, lean meat
Zinc Seafood, egg, mushroom, milk and its products, nuts, seeds, legumes

Resources:
1. Joslin Diabetes Centre, Available at https://www.joslin.org/patient-care/diabetes-education/diabetes-learning-center/healthy-plates.
2. Longvah, Thingnganing & Ananthan, Rajendran & Bhaskar, K & Venkaiah, K. (2017). Indian food Composition Tables.

27
 Dia-Games

Multiple choice questions

1. Which of the vitamins are easily lost when vegetables are soaked and washed repeatedly?
a. Vitamin A & E
b. Vitamin B & C
c. Vitamin A & B
d. Vitamin D & E
2. Which of these vitamins helps in the absorption of iron in the body?
a. Vitamin D
b. Vitamin B
c. Vitamin C
d. Vitamin K
3. The best cooking method to reduce nutrient losses is one that……
a. Has minimum cooking time
b. Uses less fluid
c. Uses lesser temperature
d. All of above
4. In which cinnamon a compound called coumarin is present which can be toxic to the liver in large quantities?
a. Cassia
b. Ceylon
5. Turmeric should be paired with which spice for better curcumin absorption?
a. Cumin seeds
b. Fennel seeds
c. Carom seeds
d. Pepper

1. B, 2. C, 3. D, 4. A, 5.D
Answers

28
NOTES

29