Hygiene is the foundation of health. This communication proposes the concept of glycaemic hygiene, defined as "conditions and practices that help to maintain health, and prevent the development of diabetes mellitus and its complications". Glycaemic hygiene is relevant at the level of the person, the physician and the community. Aspects such as personal hygiene, food hygiene, physical activity hygiene, mental/ emotional hygiene and dental hygiene must be optimized to ensure good health individuals. Skin hygiene, vaccine hygiene and environmental hygiene are equally important in diabetes care. Physicians should ensure pharmacological hygiene, language hygiene and information hygiene to foster good diabetes self-care and management.
Keywords: Diabetes mellitus, Diabetes prevention, Persons centred care.
The World Health Organization (WHO) defines hygiene as "conditions and practices that help to maintain health and prevent the spread of diseases".1 Hygiene, therefore, is a way of life which extends far beyond mere medical aspects of life. It includes every behaviour and practice that is associated with the preservation of health. Traditionally, hygiene has focused only on prevention of infectious disease. The epidemiology of disease, however, is changing, and non-communicable diseases are now the biggest threat to our health. Therefore, it makes sense to address these challenges to our well-being.
Modern concepts of hygiene, thus, have expanded to encompass mental, social, sleep and information hygiene as well.2 An inclusive definition has been proposed for hygiene, describing it as "conditions and practices that help to maintain health and prevent the development or spread of diseases". On the same lines the term 'Endocrine [and metabolic] hygiene', has also been conceptualized, as the "conditions and practices that help to maintain health and prevent the development of endocrine and metabolic diseases".2 With this contextual background, in this opinion piece, we propose, define and delineate another aspect of hygiene, termed as glycaemic hygiene.
Glycaemic hygiene is defined as "conditions and practices that help to maintain health, and prevent the development of diabetes mellitus and its complications". The term 'glycaemic hygiene' includes a wide spectrum of activities and targets, all related to achieving optimal health outcomes. We discuss the concept of glycaemic hygiene as a 3x3 rubric, designed to facilitate understanding, sharing and practice. Glycaemic hygiene can be practiced at three levels-non-diabetes, prediabetes and diabetes-by three groups of stakeholders, i.e., the people living with diabetes/ prediabetes, the physician, and the community (including family) (Table).
Levels of Adoption
A. Individual level: at individual level, glycaemic hygiene can be practiced at all levels of glycaemia:
1. Non-Diabetes: Glycaemic hygiene encompasses both non-pharmacological and pharmacological interventions, related to both the gluco-centric domain, and comprehensive self-care. For the 'healthy' person who wishes to prevent dysglycaemia, hygiene is of utmost importance. Activities include Personal hygiene that will help to prevent infections, food hygiene (adopting a healthy balanced diet) that ensures optimal body weight and reduces the risk of developing insulin resistance and diabetes in future, adequate physical activity hygiene (an active lifestyle of sports, games and exercise), and mental/emotional hygiene (ability to effectively cope up with daily stress while being able to avoid substance abuse). Avoidance of alternative therapy of unknown nature, that can disturb glucose metabolism, is also a part of glycaemic hygiene.
2. Pre-Diabetes: Persons with prediabetes provides us with a window of opportunity, which must be utilized to ensure prevention of disease or delay its progression. The role of glycaemic hygiene is of utmost importance here. Enhanced focus on the above discussed personal, food, physical activity and emotional hygiene components must be buttressed by adequate dental and pharmacological hygiene. Prevention and management of periodontitis is an important intervention which must not be forgotten. For people with prediabetes and other cardiovascular task factors, pharmacological therapy may be indicated as a means of ensuring control. Drugs which are able to correct gluco and lipo-toxicity, as well as reduce weight in obese people, without stretching beta cell reserves, are preferred. The word hygiene, rather than treatment, may help improve acceptance of therapy aimed at optimizing overall metabolic control and preventing diabetes. An example would be suggesting the use of metformin, dapagliflozin or empagliflozin as a metabolic hygienic measure.
3. Diabetes: For people living with diabetes, glycaemic hygiene takes on a much wider meaning. Apart from the various components of hygiene discussed in the above two sections, there is a need to stress more on personal hygiene to prevent skin and soft tissue infections, dental hygiene to prevent periodontitis and worsening of glycaemic control, and skin hygiene to allows for safe administration of insulin and other injectable drugs. Two more domains deserve mention here: vaccination hygiene becomes all the more important for promotion of health as increase in morbidity and mortality has been established due to COVID-19 amongst the people living with diabetes, and environmental hygiene ensures adequate compliance to biomedical waste guidelines while disposing of insulin and related ancillaries.
B. Physician level
'Glycaemic hygiene' is a phrase that deserves to be used more and more often by health care professionals. Many patients baulk at the thought of "treatment" or "drug therapy", especially "permanent" medication. Prescribed interventions can be positioned as hygiene- oriented measures designed to achieve and maintain "normal" glucose, and thereby ensure good health. The necessity of lifestyle modification can be equated to the adoption of social distancing measures, including face masks. Thus, lifestyle modification is projected as a hygienic, rather than a medically-imposed restrictive measure. The analogy of other hygienic activities, such as washing hands, wearing masks, or keeping a safe distance, encourages acceptance of diabetes self-management behaviour in a non-threatening manner. Newer drug classes have now been developed for use in both glycaemic and non-glycaemic indications. GLP1RA (Glucagon-like peptide-1 receptor agonists) and SGLT2i (Sodium-glucose co-transporter-2 inhibitors)3,4 can be termed as interventions which offer not only glycaemic, but comprehensive metabolic hygiene, to the patient.
C. Community Level
Diabetes is not only a disease of the affected individual but a syndrome which impacts the family, other care givers, and the society at large. The society is a major determinant of health care-related behaviour, and of health outcomes. Popularizing the concept of glycaemic hygiene in the community, through social marketing, will help improve diabetes related health literacy and reduce diabetes distress. Changing one's lifestyle is always difficult, but support from family members and peer group helps navigate the journey of life with diabetes. Policy makers should be encouraged to draft policies that offer facilities and opportunities for healthy eating, safe and enjoyable physical activity, adequate means for relaxation, and avoidance of substance abuse, to all the citizens. Glycaemic hygiene should also include, in its ambit, information hygiene: the responsibility of ensuring correct information, and preventing misinformation regarding diabetes.5
The importance of salutogenic language in health care is well known.6,7 Approaching diabetes care and prevention, through the prism of glycaemic hygiene, and using it in daily conversation, should help foster a positive attitude towards diabetes management. All stakeholders mentioned above — individuals, physicians and the community — must take the onus of promoting conditions and practices that help to maintain health, and prevent the development of diabetes mellitus and its complications. This in turn, should be able to promote better acceptance and adherence to therapy, and finally improve health outcomes.
1. World health Organization. Hygiene. Health Topics. 2020. https://www.afro.who.int/health-topics/hygiene. Accessed 23 Apr 2021.
2. Kalra S, Gupta Y, Sahay R. Endocrine hygiene. Indian J Endocrin Metab. 2016; 20:134-36.
3. Kalra S, Baruah MP, Sahay RK, Unnikrishnan AG, Uppal S, Adetunji O. Glucagon-like peptide-1 receptor agonists in the treatment of type 2 diabetes: past, present, and future. Indian J Endocrin Metab. 2016; 20:254.
4. Kalra S. Sodium glucose co-transporter-2 (SGLT2) inhibitors: a review of their basic and clinical pharmacology. Diabetes Ther. 2014; 5:355-66.
5. Kalra S, Kumar A. Quinary prevention: Defined and conceptualized. J Pak Med Assoc. 2019; 69:1765-6.
6. Antonovsky A. Health, Stress and Coping. San Francisco: Jossey Bass; 1985.
7. Kalra S, Baruah MP, Sahay R. Salutogenesis in type 2 diabetes care: a biopsychosocial perspective. Indian J Endocrinol Metab. 2018; 22:169-72. Vol