DIABETES MELLITUS

INTRODUCTION

Diabetes Mellitus is a group of metabolic disorder characterized by hyperglycaemia associated with abnormalities in carbohydrate, fat and protein metabolism resulting in chronic complications.

It is a serious and economically devastating illness that is reaching epidemic proportions in both industrialized and developing countries and poses a major threat to public health in the 21^st century. Diabetes was the fifth leading cause of death in the US in the year 2000. Diabetes is associated with an increased incidence of stroke, heart failure, new-onset blindness, limb amputations, End-Stage Renal Disease (ESRD), birth complications and sexual dysfunction. Persons with diabetes often have associated Cardio Vascular Disease (CVD) risk factors including hypertension, dyslipidaemia, and obesity.

Diabetes is one of the leading causes of morbidity and mortality due to specific microangiopathy and the associated macroangiopathy. It is the leading cause of blindness and visual impairment in adults in the western hemisphere and the risk of cardiovascular disease is two to five times in persons with diabetes, as compared to normal adults. For the purpose of rational management, it is appropriate to classify diabetes as the following.

• Type 1 (also called Insulin-Dependent Diabetes Mellitus or IDDM),
• Type 2 (also called Non-Insulin-Dependent Diabetes Mellitus or NIDDM).

Other specific types of diabetes are :

• Genetic defects of b-cell function (eg.MODY)
• Genetic defects in insulin action
• Diseases of the endocrine pancreas
• Endocrinopathies
• Drug or chemical induced
• Infections
• Gestational Diabetes Mellitus (GDM)

Gestational Diabetes Mellitus

Defined as any degree of glucose intolerance that has its onset or is first detected during pregnancy.

• Occurs in approximately 2% - 4% of pregnant women, generally during the second or third trimester.
• Occurrence of GDM increases future risk for developing type 2 diabetes.

CHART 1: DIFFERENCE BETWEEN TYPE 1 AND TYPE 2 DIABETES

Characteristics	Type 1	Type 2
Other names	Previously : insulin-dependent diabetes mellitus (IDDM) : juvenile-onset diabetes mellitus	Previously : non-insulin-dependent diabetes mellitus (NIDDM): adult onset diabetes mellitus
% of diabetic population	5-10%	90%
Age of onset	Usually <30 yr, peaks at 12-14 yr, rare before 6 months, some adults develop type 1 during the fifth decade	Usually >40 yr, but increasing prevalence among obese children.
Pancreatic function	Usually none, although some residual C-peptide can sometimes be detected at diagnosis, especially in adults	Insulin present in low, "normal", or high amounts
Pathogenesis	Associated with certain HLA types; presence of islet cell antibodies suggests autoimmune process	Defect in insulin secretion, tissue resistance to insulin; ↑ hepatic glucose output.

CHART 1: continued

Family history	Generally not strong	Strong
Obesity	Uncommon unless "overinsulinized" with exogenous insulin	Common (60-90%)
History of ketoacidosis	Often present	Rare, except in circumstances of unusual stress (eg.infection)
Clinical presentation	Moderate to severe symptoms that generally progress relatively rapidly (days to weeks): polyuria, polydipsia, fatigue, weight loss, ketoacidosis	Mild polyuria, fatigue, often diagnosed on routine physical or dental examination
Treatment	Insulin Diet Exercise	Diet Exercise Oral antidiabetic agents and insulin

PREVALENCE

The prevalence of diagnosed diabetes has increased dramatically over the past 40 years both in the US and worldwide. In 1985, there were approximately 30 million people with diabetes worldwide; by 1995, this number had escalated to 135 million and by 2025, it is projected that there will be an increase in the incidence of diabetes, affecting 300 million people. Most of the expected increase will be in type 2 diabetes, which accounts for >90% of cases of diabetes, while the incidence of type 1 diabetes is anticipated to remain stable. By 2025 the countries with largest number of people with diabetes will be in India (>57 million, prevalence 6%), China (>37 million, prevalence 3.4%), and the United States (>21 million, prevalence 8.9%).

REVIEW OF MANAGEMENT OF DIABETES

Three methods of treatment are available for diabetic patients: diet alone, oral hypoglycaemic drugs, and insulin. Approximately 50% of new cases of diabetes can be controlled adequately by diet alone, 20-30% will require insulin. Regardless of aetiology, the type of treatment required is determined by the circulating plasma insulin concentration. In clinical practice the age and weight of the patient at diagnosis are closely related to the plasma insulin and usually indicate the type of treatment required.

Fig 1: Long-term treatment of diabetes

DIETARY MANAGEMENT

Dietary measures are required in the treatment of all diabetic patients to achieve the overall therapeutic goal: i.e. normal metabolism. The aims of dietary treatment are the following.

• Abolish symptoms of hyperglycaemia.
• Reduce overall blood glucose and minimize fluctuations.
• Achieve weight reduction in obese patients to reduce insulin resistance, hyperglycaemia and dyslipidaemia.
• Avoid hypoglycaemia associated with therapeutic agents

(Insulin, sulfonylureas).

• Avoid weight gain associated with therapeutic agents

(Insulin, sulfonylureas, thiazolidinediones).

• Avoid 'atherogenic' diets or those, which may aggravate diabetic complications

(e.g. high protein intake in nephropathy).

TYPES OF DIABETIC DIET

Two basic types of diet are used in the treatment of diabetes: low-energy, weight-reducing diets and weight maintenance diets.

Low-energy, weight-reducing diets

Dietary prescriptions, which cause a daily deficit of 500kcal, provide a realistic diet and induce a weekly weight loss of around 0.5kg. Rapid weight reduction may provoke loss of lean body tissue, and care must be taken in the elderly to avoid the omission of essential nutrients, vitamins and minerals. Caloric restriction is essential for the obese diabetic patient treated with insulin and most oral agents, to try to minimize the weight gain, which these can promote. In such individuals, the omission of snacks between meals is often necessary.

Weight maintenance diets

These are necessary for individuals with a normal Body Mass Index (BMI) and should be high in carbohydrate and low in fat, with particular attention being paid to the type of fat ingested.

ORAL DRUG TREATMENT OF TYPE 2 DIABETES MELLITUS

The main stay of treatment for patients with type 2 diabetes who fail diet therapy are the oral antidiabetic agents. There are 5 classes of oral antidiabetic agents available in the United States: Sulfonylureas, biguanides, alpha-glucosidase inhibitors, thiazolid-inediones and non-sulfonylurea secretagogues. They have differences and similarities with respect to their pharmacology and role in diabetes.

The oral antidiabetic drug classes differ in their sites and mechanisms of action to lower plasma glucose. The sulfonylureas and non sulfonylurea (non-SU) Secretagogues primarily work in the pancreas to stimulate insulin release. The biguanides primarily work in the liver to decrease glucose production. The alpha-glucosidase inhibitors primarily work in the small intestine to slow carbohydrate absorption. The thiazolidinediones (TZDs) primarily work in the peripheral tissues and act as insulin sensitizers.Chart 2 lists the mechanism and site of action for each class of drugs.

Chart 2

The oral antidiabetic agents also differ in their effects on the patient's lipid profile. Sulfonylureas, non-SU secretagogues, and alpha-glucosidase inhibitors do not appreciably affect the lipid profile. Biguanides can improve the complete lipid profile, whereas TZDs can improve some lipid levels while adversely affecting the others. Chart 3 lists the effects the oral antidiabetic agents have on lipid profile.

Chart 3

Sulfonylureas

Sulfonylureas are classified as first and second-generation agents based on when they became available. The generations differ in their potency, Pharmacokinetics, and safety. The second-generation agents are more potent and in general have better pharmacokinetic and safety profiles. The first-generation agents include acetohexamide, chlorpropamide, tolazamide, and tolbutamide. The second-generation agents include glimepiride, glipizide, and glyburide. It is well known that sulfonylureas (available since 1954) lower plasma glucose primarily by increasing the release of insulin from functioning pancreatic b-cells. One concern with these agents is the loss of efficacy over time, which may be related to the potential to exhaust b-cell function. Because these agents increase plasma levels of insulin, they may cause of hypoglycaemia. The addition of other antidiabetic agents can further increase the risk of hypoglycaemia.

Biguanides

Metformin (available since 1995) is the only biguanide available in the United States. It is in the same class of drugs as phenformin, which was available but was removed from the United States and European markets in the 1970s because of its association with lactic acidosis. The long-term benefit of metformin was shown in the United Kingdom Prospective Diabetes Study, (UKPDS). Metformin has several mechanism of action, but its primary mechanism for lowering plasma glucose is to decrease hepatic gluconeogenesis. To a smaller extent, it also improves insulin sensitivity of peripheral tissues. Recent studies suggest that metformin may reduce the risk of cancer in diabetic patients.

Alpha-glucosidase Inhibitors

The alpha-glucosidase inhibitors (available since 1996) include acarbose and miglitol. These agents decrease the rate of ingested carbohydrate absorption in the small intestine. They act as competitive, reversible inhibitors of alpha-glucosidases (hydrolase enzymes found in the brush border of the small intestine), and alpha-amylase (found in the pancreas). Inhibition of these enzymes slows digestion of carbohydrates, which results in slower absorption and a reduction in postprandial plasma glucose levels.

TZDs (Thiazolidinediones)

TZDs (available since 1997) include pioglitazone and rosiglitazone. These agents act primarily to improve insulin sensitivity of muscle and adipose tissue. To a lesser extent, these agents decrease hepatic glucose production. TZDs are selective and potent agonists for the proxisome proliferator-activated receptor-gamma (PPARg) nuclear receptors. The action of these agents requires the presence of insulin. A study by found rosiglitazone to decrease the proinsulin-insulin ratio in patients with type 2 diabetes mellitus, indicating an improvement in b-cell function.

Non-SU Secretagogues

The non-SU secretagogues include repaglinide (which is a member of the meglitinide family) and nateglinide (which is a derivative of d-phenylalanine). Like the sulfonylureas, the non-SU secretagogues (available since 1998) lower plasma glucose by increasing the release of insulin from functioning pancreatic b-cells. The mechanism is exactly same as the sulfonylureas, except the non-SU secretagogues bind to different receptors on the b-cells. Unlike SU, non-SU secretagogues have a very short half-life and duration of action, so they stimulate insulin secretion for brief periods. Therefore, they are dose with meals and are most helpful in decreasing postprandial hyperglycaemia. The quick "on and off" helps to decrease the incidence of hypoglycaemia compared to SU.

EFFICACY

All 5 classes of oral antidiabetic agents lower fasting plasma glucose and A1c, but they do so to different extents. Chart 5 lists the efficacy in lowering fasting plasma glucose and A1c for the 5 classes of antidiabetic agents.

In general, sulfonylureas, biguanides, and non-SU secretagogues lower fasting plasma glucose and A1c to a similar extent.

Chart 5

Insulin

Insulin is required for treatment of all patients with IDDM and many patients with NIDDM. No single standard exists for patterns of administration of insulin, and treatment plans vary from physician to physician and, with a given physician, for different patients. Three treatment regimens will be described: Conventional, Multiple subcutaneous injections (MSI), and Continuous subcutaneous insulin infusion (CSII). MSI or CSII is required in intensive treatment schedules designed to protect against complications. Conventional insulin therapy involves the administration of one or two injections a day of intermediate-acting insulin such as Zinc insulin (Lente insulin) or Isophane insulin (NPH) with or without the addition of small amounts of regular insulin.

Insulin is considered the most effective treatment for lowering extremely high glucose. This is important because inhibition of glucotoxicity may be beneficial in preserving functional b-cell mass. Oral agents do not work as quickly or lower glucose enough to effectively address glucotoxicity in many patients.

Insulin therapy may actually protect against endothelial damage. Observational and interventional evidence consistently indicates that glycaemic control with insulin therapy in the hospital setting can improve clinical outcomes. demonstrated that the unfavourable long-term prognosis for myocardial infarction could be improved by insulin treatment.

CHART 6: CONVENTIONAL (STANDARD) PREPARATIONS OF INSULIN ( Tripathi KD 2003)

Type	Appearance	Onset (hr)	Peak (hr)	Duration (hr)	Can be mixed with
Short Acting
Regular (soluble) insulin	Clear	0.5-1	2-4	6-8	All preparations
Prompt Insulin Zinc Suspension (amorphous) or semilente	Cloudy	1	3-6	12-16	Regular, Lente preparations
Intermediate Acting
Insulin zinc Suspension or Lente (ultra: Semi: 7:3)	Cloudy	1-2	8-10	20-24	Regular, semilente
Neutral Protamine Hagedorn (NPH) or Isophane Insulin	Cloudy	1-2	8-10	20-24	Regular
Long Acting
Extended Insulin Zinc Suspension (Crystalline) or Ultralente	Cloudy	4-6	14-18	24-36	Regular, semilente
Protamine Zinc Insulin (PZI)	Cloudy	4-6	14-20	24-36	Regular

PATIENT EDUCATION IN DIABETES

Pharmacists Role

Pharmacists in all practice settings are in a key position to start providing care to people, who have diabetes or are at risk of developing it, or to expand and improve their care. Pharmacy programs for patients with diabetes involve activities ranging from identifying and referring at-risk patients, to supporting American Diabetes Association - recognized multi-disciplinary diabetes care programs.

Pharmacists can help identify patients with diabetes through screening and should target patients at high risk, people with a family history of the disease, and women with a history of gestational diabetes or who delivered a baby weighing more than nine pounds. Patient education should be provided immediately after diagnosis, at a second stage at which time a patient assessment can be performed, and at a third stage during which patients can receive continuing education to reinforce concepts and motivational boost. One of the pharmacist's most important roles is the referral of patients to the other members of the diabetes care team. Although the role of the pharmacist in monitoring diabetes is not well defined, it might include such things as ascertaining whether physician visits and testing to assess long-term glycaemic control.

The pharmacist can play an important role in diabetes care by screening patients at risk for diabetes, assessing patient health status and adherence to standards of care, educating patients to empower them to care for themselves, referring patients to other health care professionals as appropriate, and monitoring outcomes. Providing diabetes management services requires communication skills, and a commitment of time, effort, and resources. Pharmacists who obtain training in diabetes management reap rewards in professional satisfaction and financial reimbursement.

Patient involvement is paramount for the successful care of diabetes. Patients require education and information about a wide range of subjects. The following areas are to be considered for patient education.

1. The disease

• Signs and symptoms

1. Hyperglycaemia

• Signs, symptoms and treatments

1. Hypoglycaemia

• Signs, symptoms and treatments

1. Exercise

• Benefits and effect on blood glucose control

1. Diet
2. Insulin therapy

• Injection technique
• Types of insulin
• Onset and peak actions
• Storage
• Stability

1. Urine testing

• Glucose
• Ketones

1. Home blood glucose testing

• Technique
• Interpretation

1. Oral hypoglycaemic agents

• Mode of action
• Dosing
• Need for multiple therapies

1. Foot care
2. Management during illness
3. Cardiovascular risk factors

• Smoking
• Hypertension
• Obesity
• Hyperlipidaemia

1. Regular medical and ophthalmologic examinations

The patient must be involved in the decision making process and must learn as much about the disease and associated complications as possible. Emphasis should be placed on the evidence that indicates complications can be prevented or minimized with glycaemic control and management of risk factors for cardiovascular disease. Recognition of the need for proper patient education to empower them into self-care has generated certification in diabetes education.

CONCLUSION

The current approach to management of drug therapy in patients with type 2 diabetes is to begin insulin therapy if a combination of two oral agents fails to provide adequate glycaemic control. For every 10 units of insulin administered, an average of 1 kg of weight may be gained. This weight gain, associated with the lipotrophic effect of insulin, promotes greater insulin resistance in patients with severe disease. The result of escalating doses of insulin is a perpetual cycle of weight gain and uncontrolled diabetes. With the advent of the newer oral agents, combination therapy may delay insulin use in patients who traditionally would require insulin early in the course of the disease. Reasonable combinations of oral agents based on mechanism of action include sulfonylurea plus metformin, sulfonylurea plus an alpha-glucosidase inhibitor, sulfonylurea plus glitazone, repaglinide plus metformin, glitazone plus metformin, insulin plus metformin, and insulin plus glitazone. The frequency and timing of glucose monitoring should be individualized for each patient. The optimal frequency of self-monitoring of blood glucose in patients with type 2 diabetes is not known, but monitoring should be performed often enough to facilitate reaching treatment goals. Efforts should be made to substantially increase appropriate use of self-monitoring, providing both the patient and the practitioner with substantial information necessary to achieve glycaemic goals. When possible, sulfonylureas should be prescribed as initial therapy in non-obese patients since they are less expensive than the newer oral agents. Metformin is an excellent initial agent for obese patients (i.e., those greater than 120 percent of ideal body weight) or as add-on therapy in patients whose disease is not controlled with sulfonylurea therapy. An alpha-glucosidase inhibitor or glitazone may be an alternative to a sulfonylurea or metformin as add-on therapy in patients with uncontrolled disease or significant renal dysfunction.

As health care providers with knowledge of the illness, its treatments, and monitoring tools, pharmacists are vital members of the diabetic health care team in both the outpatient and the inpatient settings. Clinical pharmacists in all practice settings are in a key position to start providing care to people, who have diabetes or are at of developing it, or to expand and improve their care.

Important U.S. Laws and Regulations

Important U.S. Laws and Regulations

Helpful guidelines for foreign students studying in the U.S.

Social Security Numbers
A Social Security number (SSN) is a nine-digit identification number assigned by the U.S. government. All U.S. citizens have unique Social Security numbers, which they provide to employers for tax purposes. If you are temporarily visiting the United States and do not plan to work off campus, you do not need an SSN. If you desire to work off campus, however, you may need an SSN. The first step in determining whether you'll need an SSN is to establish your visa classification. According to the Social Security Administration, visa holders classified as F-1, J-1, Q-1, Q-2, and M-1 who perform work tied to their studies or closely connected to the purpose of their visit are not subject to Social Security tax and do not need an SSN.
Driver's Licenses
If public transportation is not available in the city where your school is located, you may need a driver's license. All states require you pass a vision test, a written exam, and a driving test. Regulations pertaining to the issuance of driver's licenses to international students vary by state. For example, international students living in Ohio must present to the Bureau of Motor Vehicles a valid passport; visa; I-94 card, I-20, IAP-66, or I-9; and proof of six-month residency in Ohio. Contact the governing department that oversees the issuance of driver's licenses in your state to find out how to obtain a license.
Alcohol Regulations
The age at which U.S. residents may legally consume alcohol is 21. Underage drinking is a crime, and punishment can include fines, suspension of driver's license, court-ordered community service, and incarceration. To show proof of legal drinking age, most people present a driver's license. If you do not have a driver's license, you can present an identification card, which is available from the local license office.
Classified Information
Your visa classification will be provided by the Department of Homeland Security. You can use your classification status to determine the circumstances under which you're required to have a Social Security number.

F-1	foreign student
J-1	exchange visitor
M-1	vocational student
Q-1	admitted to the United States to participate in a cultural exchange program
Q-2	visitor under the Irish Peace Process Cultural Training Program Act

Understanding American Cultural Values

Understanding American Cultural Values

Five attributes of Americans that are often misunderstood

Shared history and geography often give rise to the perceptions that become incorporated into a nation's identity. Although America's communal history is relatively short, many U.S.-born citizens inherently display values that are rooted in historical events. As with any culture, Americans have distinguishable values that international students should try to understand so they can successfully adjust. While there are many American perceptions and behaviors that are worthy of discussion, the focus of this article is on five attributes of Americans that sometimes result in confusion or even clashes with members of outside cultures.
1. Equality - Considered important enough to be written into the U.S. Declaration of Independence, this concept has given rise to some of the nation's deepest beliefs, aspirations, and rights. Although it is not always achieved, Americans strive for equality. We commonly use the first names of our elders, professors, and lawyers—a lack of deference to age and authority that is commonly mistaken for disrespect or laziness by foreigners. Similarly, our sensitivity to disparity and unfairness causes us to be outraged when someone receives special privilege due to their family's wealth or notoriety.
2. Hard Work - Americans believe that through hard work and human endeavor, one can improve their status in life. Values such as thriftiness, hard work, and ingenuity go back to a time when pioneers began settling the western United States. There was so much land and so many opportunities, but it was dangerous and difficult. These conditions led to an adopted mentality of "work hard or perish" that has withstood the test of time and been passed down through generations.
3. Directness/Transparency - Americans are often perceived (sometimes negatively) as bold, especially in their professional dealings. One theory about this phenomenon is that, because the earliest U.S. citizens had vastly different backgrounds, languages, and expectations, they adopted a very direct approach so as to avoid misunderstandings. This characteristic can be seen as overbearing or rude in certain contexts.
4. Time-focused - Punctuality is another American quality that was likely transmitted from our northern European ancestors who resettled in the 1800s. Time-focused societies think that people who show up late are being disrespectful or unprofessional. Americans believe in deadlines and sticking to the agenda.
5. Individualism - This is also most likely rooted in America's history of immigrants who left families and support systems behind to start a new life. They needed to rely on themselves in order to be successful and thus became independent minded. Many Americans believe that this individualism translates directly to the freedoms outlined by the U.S. Declaration of Independence—the right to "life, liberty, and the pursuit of happiness." While the dogged pursuit of happiness can be viewed as childish or foolish in some cultures, Americans cherish the right to live according to one's own ideas of success and satisfaction.
Understanding the history behind common American values helps to put them into perspective. Schools can help their incoming foreign students by matching them up with a cultural mentor—another student from the local culture—who can explain the cultural roots of the American qualities that are often difficult to understand.

DEALING WITH HOME SICKNESS

Dealing with Homesickness While Away at College in the U.S.

There's a lot to do before leaving home to study in the United States. Unfortunately, many international students simply don't have time to prepare for the emotional impact that comes with entering an entirely different culture.
Homesickness is very common among international students, so if you find yourself feeling displaced or lonely, know that you are not alone and try to be patient. While there's no specific time limit, rest assured that those feelings will eventually pass. In the meantime, use these guidelines to start taking an active part in adjusting to your new surroundings.
Identifying Homesickness
Homesickness is a feeling or feelings that occur naturally when a person experiences a sudden change in environment or routine. It can manifest as vague sadness or uncertainty, anxiety, change in sleeping/eating patterns, feelings of isolation, inability to concentrate, and/or a desire to stay in close contact with people from home. For some people, these feelings pass quickly and for others it takes longer, but identifying homesickness is often the first step in resolving it.
Taking Actions
As difficult as it might seem at first, making an effort to meet new people can help tremendously when dealing with homesickness. Opportunities for positive social interaction at your new university can include:

• Visiting your international student union
• Attending sporting events
• Signing up for campus activities
• Checking out local music and arts venues
• Joining clubs and groups

With practice, you'll find it easier to make friends and get involved. Look to teachers, advisors, RAs, and other international students for tips on what's happening around campus.
Making Room for It All
Studying in the United States will put plenty of physical space between you and your home, but it's also important to distance yourself psychologically—at least for now. Try to focus on creating new routines and setting bigger academic goals. For starters, try to speak English exclusively, and limit phone calls and/or e-mail communication with friends and family back home to one day a week.
At the same time, you don't want to lose your connection to the familiar altogether; in fact, maintaining close friendships and keeping a few personal items from home within reach can help lift your spirits on those not-so-great days. Remember that by exploring other cultures you are not abandoning your own—you may even be surprised to learn that you're not missing out on much back home. You're simply allowing yourself to grow academically and gain experiences that will shape you for a brighter future..

AIR TRAVEL TIPS FOR F1 STUDENTS

This post will help you understand the flight booking process and provide you with some air travel tips. Cheap flight ticket from India to USA might not be the best always.

1. Find a travel companion to the same university from your departing city.
2. Book flights together (India to USA), if not get same connecting flight from second flight (if you have connections).
3. Search for best airfare deal not the cheapest airfare (don’t just ask one travel agent)
4. After you ding the lowest priced ticket through travel agent, then shop online (or vice versa).
5. Negotiate to get the lowest air fare to US
6. One way fare is about 70% to 80% value of round trip fare.
7. Register for frequent flyer account with the airline which you plan to book ticket.
8. Provide the frequent flyer number to travel agent while issuing the ticket.
9. Don’t forget about registering for frequent flyer account. After accumulating 25,000 miles, you can get 1 round trip ticket within US.
10. Find baggage allowance.
11. You may have to pay $50 for second suitcase
12. Some airlines will allow students to carry 2 checked bags for free (23kgs or 50 lbs each)
13. Avoid certain airlines (know for poor customer service and frequently delayed flights)
14. Lowest fare doesn’t always provide best flight connections and options.
15. First time travelers ask for Window seat. If you are tall, ask for aisle seat.

Flight Connections

1. Most likely you will have to get connecting flight within US before you reach your final destination.
2. Universities located in Major cities will have direct flight from India (Mumbai to New Jork) or direct entry from second connecting flight.
3. Port of entry in US will be the first city where you land (not your final destination)
4. You have to clear Immigration and Custom procedures before boarding the next flight within US
5. Allow atleast 3 hours between connecting flight, that will give enough time to clear customs and immigration procedures.
6. You will have to take your suitcase and clear customs and check the bags-in for local domestic connection.
7. If you miss the connection, don’t panic.
8. Airline will get you on the next flight to your destination.
9. Have some US Dollars in hand and atleast $1 bill to make phone calls.
10. Find a way( phone or email) to inform the party who will be waiting to pick you from the airport, if there is a flight delay.

 

General tips for INDIAN STUDENT

General Tips:

Ok, so you have finally made it to the land of your dreams!! But you dont wanna make a bad impression do you? So here are a few tips to help you begin your life in America on the right note.

1) Guess what's the first thing Americans notice about us desis? Surprise!!....THE SMELL!
FACT: Most desis smell horrible to Americans.We smell of fried food and curry coz most of us cook at home and do not care to shower and change before we go out. Keep your clothes away from the kitchen, in a closet. Use a deodorant. Change before you go out. And for heavens sake dress decently when you go out. I've seen desis go shopping in malls in the raggediest of outfits.

2) Ok, so now you smell good...you think you're COOL.... Next thing to remember, Americans are very friendly people. So you will see total strangers greeting you or smiling at you. Return the smile or greeting. Question: How're you doin? Answer: How're you doin or Doing Good. how about yourself. When americans ask you how you are doing,they do not expect a lengthy answer. Its just a polite greeting. If you want to be cool, you'd say "Whats up"...and expect a "Not much".

3) Try to speak clearly. Many Americans can't understand what you are saying because of your bad pronunciations or because you speak too fast. Try to smoothen out those rrrr's. Also try not to use your native tongue when there are people of other nationalities around. And stop nodding your head like a bobblehead when you agree with something! It realllly looks funny to non-Indians!!

4) Hold doors open for people. Its common courtesy here to hold the door open for people who are following you through a doorway.

5) Don't be cheap. Always tip cab drivers, waiters, hair dressers etc. Don't do things like stealing carts from the local store to bring home your grocery.
All stores have a return policy . Don't misuse it! For example, don't buy a camera coz your friends are coming, and return it to the store after they leave as you don't need it anymore!

6) Most desis are secure in their own community. They don't make efforts to meet people from other communities. Don't be shy...go out, meet people. Some of my best friends are Americans and other international students.

7) Never ask another person how much money he makes or other such personal questions. Americans value their privacy a lot. Don't be too inquisitive. Also, keep a good distance when you speak to people. Its called "personal space". At least an arms length.

8) Use "thank you" and "please" a lot. For example if a host asks you if you would like more coffee, don't say Yeah!. Say "Yes please" or "please". "Yeah" will do if you are with close friends !

9)Don't dig your nose in pubic! Its disgusting! Also, you may be caught on camera as many places in the US have security cameras! Always wash your hand before leaving a restroom. Do not litter. As you may have noticed, there are plenty of dust-bins all over America. So don't throw stuff on the ground.
10) Professors prefer to be called "Professor His Name" or "Doctor His Name" rather than just Sir.

11) DO NOT use any illegal means in exams. Do not copy each other's assignments!
If caught, you will not only bring a bad name to the Indian community, you will also be in deep shit! Americans value honesty. Do not try to cheat the system. YOU WILL GET CAUGHT.

12) Finally, try to blend into the American way of life. The best part is you don't have to give up being an Indian to live here. The greatest thing about America is its tolerance. Most people who come here will never go back because of the high quality of life and the freedom to be who you are.
So stop complaing, stop judging Americans by your values and morals. If you want to stick to your traditions and values, nobody is stopping you.

All of us need to work toward fighting the 'desi stereotype'. We Indians already have a good impression in America as far as academics is concerned. We need to extend that to all walks of life.

Above all, have fun! America is THE PLACE to realize all your dreams. Work hard, live life to the fullest and believe me, you will never go back!

HOW TO BECOME SUCCESSFUL STUDENT IN USA

8 Things to remember to be successful student in the US University

You are all set to leave India & pursue your higher education in the US. All bags are packed and you are ready to go. Your mind is cluttered with all sorts of questions about the journey you are going to embark. How are you going to manage it all alone? Is the education system similar to that of India’? and so on. There is no cookie cutter formula to be a successful student in the US, but we have 8 suggestions which if followed, we feel, will make your experience a more memorable one, if not easier. We will break this blog into 2 parts & below are 4 of those suggestions
Cleanse your mind … at the airport terminal:
There is a reason why America is known as the land of opportunities- It is because people over there follow their passion. And you are about to become one of them … you have burnt the midnight oil to get where you are right now & there are a million students who would love to have your visa stamped passport. So take a deep breath & feel good about what you have achieved so far … you are about to begin a very exciting adventure … So before you board your flight, our sincere advice to you is to dump all the useless gyaan (you know what I’m talking about;) ) about life in the US, which you got from your friends & relatives who have never been to the US & have heard it from their friends & relatives who also have never been to the US, in the garbage can at the airport terminal.
Do not have any pre-conceived notions about what life in the US is … go with an empty mind which is ready to absorb & learn … remember, studies will just be a small subset of your education. Follow your passion & success will follow (all right .. I did take that last line from 3 Idiots)
Learn to listen to others:
To survive in the cut throat competitive Indian education system, it is natural to adopt an attitude where a student is always voicing his/her opinions, so that he/she may stand out among others. In order to be successful, one of the first things you will have to do is let go of that habit & start practicing the art of listening. For those of you, who already do that, further hone that skill. You will be amazed by the quantity of information you can assimilate, just by being an attentive listener. It is always beneficial to learn new views and perspectives, especially in a new country and this will surely help you in the long run.

STOP cramming & START understanding:
Partly due to the nature of India’s educational system, more importance is given to the quantity of information one can regurgitate on the answer sheet than on the knowledge which a student possess. In the US, things are the opposite. Thorough understanding of a concept is far more important than just knowing it. More stress is given on the Why and How rather than on the What. To every Why there is a Why Not? So when you make your course selection, choose the subjects which genuinely interest you otherwise, you will end up not far from what you were as a student in India.
No Cheating:
Once you leave the motherland for US, please relinquish your habits of cheating & copying from others. If you have spent your engineering years copying journals from your seniors and keeping chits in your socks during exams, dump this habit with the useless gyaan which I described above. There is zero tolerance for plagiarism & if proven guilty, not only do you get immediately suspended but that blot stays with you for rest of your life (YES … I mean it trickles into your professional life also)