Work in Chennai, India: May to July, 1998

When Diabetes Spectrum associate editor Karmeen Kulkarni asked me to document my recent work experiences in Chennai, India, she echoed my son's words that I should chronicle my 2-month visit.

With a trip to India planned to visit my family, I decided to include a work experience, too. Being a registered dietitian working in the areas of diabetes education and lactation consulting, I felt that I had information and skills that I could share with clinics in Chennai.

I arranged to work with three hospitals. The first, Devaki Hospital, was a general hospital that provided a mixed bag of cases. I would have the privilege of working under the aegis of the famous Dr. Thomas J. Cherian, who has always been very encouraging. The second center was a diabetes hospital, the Dr. Ambedkar Institute of Diabetes (Government Kilpauk Medical College), where I was to work with Dr. A. Sundaram and Dr. C.R. Anand Moses. The third location was a maternal and child care medical center called the Dr. E.V. Kalyani Medical Center. The obstetrics and gynecology consultant, Dr. Gita Arjun interviewed me and identified some of the areas where my skills in lactation management would be welcome.

Long before I left for India, I began collecting literature, tools, and kits used in diabetes and lactation education in India. I contacted organizations and people who I believed could help me build such an inventory. All of those I contacted, including Dr. Kamakshi Sundaram, Dr. Sunil Jhangiani, Dr. Ram Mohan, Dr. Gopal Srinivasan, Dr. C. Sivakumaran, and many others, were most generous. Before long, I had a suitcase filled with a wide array of items ranging from blood testing kits to Supplemental Nursing System kits for lactation support.

Given current travel restrictions, all this was causing me some sleepless nights. I knew that having such items as a box of syringes without authenticating paperwork could provoke an interrogation from Customs. I recontacted the three centers where I was to work, and each sent letters stating that the tools and equipment I was carrying were being accepted as donations for the centers. These letters would serve to clear me through Customs.

On arrival and after a few days with my family, I presented my credentials at the initial interviews and then set up half-day schedules or hours as needed in each center. On the mornings when I went to the Diabetes Center, Dr. Sundaram would have patients lined up for me to have both a group session and one-on-one counseling sessions. In the maternity hospital, on the other hand, I was asked to come around 1:30 p.m., when I could teach problem-solving techniques in breastfeeding management to multiple staff shifts.

I was given outlines of areas of need in each center. I then set about creating a rapport with the staff of each center to assure them that I was going to be part of the team rather than a censorious judge or tattletale.

The attitude of staff at all three locations was very upbeat, and this motivated me even further to share as much as I could in a meaningful way. Time was the most limiting factor, and often an actual working session with a patient was the main method used to convey teaching approaches, problem-solving techniques, or even updated information to staff. After a few sessions, I was able to observe how the information I taught staff was being relayed to patients. I wanted to make sure that the information was put into practice accurately and appropriately.

While there, I also visited various supermarkets to get an appreciation of the local foods and prices, since many patients were stressed economically, and nutrient deprivation was often a primary contributing factor to sickness and malaise. However, during these supermarket trips, I could not escape the plethora of ads showing changing trends of food consumption from simple home-cooked fare to widespread use of processed foods, carbonated drinks, and candies that are high in calories, fat, sugar, or salt. These two factors together helped explain the two ends of the spectrum that ranged from very thin people with diabetes to overweight people with diabetes.

It was easy to see that asking an indigent population to include high-priced vegetables or fruits every day (for vitamin C content) would be neither practical nor affordable. However, asking patients to sprout mung dahl (an excellent source of vitamin C) for a couple of days and eat those sprouts as often as possible would probably result in more success.

While there, I drew up a sample eating pattern to help identify problem areas and suggest modifications. Although there is no one standard eating pattern for all people, a rough meal plan can help to illustrate where the main problems are for the clients with diabetes.

People in India usually get up very early and have coffee or tea with milk and sugar. Sugar substitutes are neither easily available nor affordable for indigent clients. A little later, they may eat meals as shown in Table 1.

However, any of these meals could omit vegetables, lentil gravy, and yogurt due to food costs or other reasons and could become just a starch dish coupled with a condiment. Accompaniments to the meal could include a sweetened drink and a couple of fruits whenever possible. This would drop the fat and protein levels further, and the carbohydrate content of the day's meal could be as high as 80%. One can see how this could have ramifications of consistently elevated postprandial blood glucose levels, especially if no further intervention measures were used.

Meals can also be high in fat and salt when food costs are not a constraining factor and when restaurants are used for the lunch or dinner meal. A booklet on the Asian Indian-Pakistani cuisine published by the Diabetes Care and Education Practice Group of The American Dietetic Association refers to these high-fat starches as an important category to be taken into account in planning Indian diets.

I found some hospital cafeterias serving coconut chutneys as accompaniments with a starch food such as uppuma or khichdi to patient populations. What does this mean for patients with diabetes? Whether the diet was rich in variety or sparse due to economic constraints, items high in saturated fats and oils called for recipe and diet modifications in view of heart disease implications. I showed the staff some methods to empower patients to become aware of their rights as consumers. They could request cafeterias to serve accompanying side dishes like channa (split pea) chutney or a thicker legume gravy.

When total calories consumed is below required levels, one may argue that a higher fat content may help in increasing the caloric level. But fats, if saturated, can take their own toll on the body's metabolic resources, and hydrogenated fats and butter were often used. One meal could supply 4­8 servings or more of starch, little or no vegetables, and fried, high-fat accompaniments.

This was an area in which I found the most challenges and many possible solutions. I emphasized the importance of having a variety of food sources in a meal. Increasing legume and bean dishes (India is one of the world's largest producers of beans), increasing vegetables wherever affordable, incorporating better cooking methods, and maintaining blood glucose records were some of the steps I suggested.

We know that often many patients progress to complications, and building a basic information base on disease management was a first step to prevent that. A rough assessment indicated to me that the need for a stronger information base seemed to correlate directly to the economic levels and educational background of the patients. It also synchronized with poor follow-up on medications. The latter was often due to economic constraints in buying prescription medicines.

I started out mornings with finger prick tests, and then reviewed with patients the previous day's meals and general lifestyle. This was a useful teaching tool. Every day, I demonstrated some exercises for the patients in the waiting rooms. By the end of my trip, I was gratified by patients who came back on follow-up visits with questions about foods or enthusiastic reactions to their new weight loss or just the power of feeling in control by gaining a better understanding of their disease.

On the public education front, I ran sessions for school kids and teachers of the Sarawathi Kendra, a subsidiary of the nonprofit organization C.P. Pamaswami Aiyar Foundatio, on incorporating healthy meals and snacks into school life. Because this was a special education school, parents wanted to know connections between the types of food eaten and behavior problems. We discussed methods to combat the soda and candy craze and the changing diets of school kids. I was given access to helpful software and had the satisfaction of being able to develop multilingual handouts catering to these special needs.

The C.P. Pamaswami Environmental Education Program was another especially gratifying experience that allowed me to visit villages and work with rural farmer groups, women, and school children. The materials I developed and carried were warmly received and appreciated, bringing to mind the famous Shakespeare line that giving blesses he who gives as much as he who takes.

I feel quite fortunate to have been able to evoke this sense of contentment from every visit I made, and I conclude by encouraging my colleagues seek out similar experiences.

Padmini Balagopal, RD, MD, CDE
Wayne, Pa.

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