Defining and Diagnosing Obesity in India: A Call for Advocacy and Action.

The prevalence of overweight and obesity has more than doubled since 1980, and it is predicted that around two-thirds of the global burden of the disease will be attributed to chronic non-communicable diseases. Developing countries are experiencing a more dramatic rise in the prevalence of obesity in recent years. As per National Family Health Survey-5 (NFHS-5), one in every four Indians is now having obesity. It has been reported that being overweight and obese is a significant problem among different socioeconomic spectrums of men and women in India, especially among the elderly, people residing in urban regions, and diverse socioeconomic strata. There is an urgent need to identify obesity as a chronic disease requiring immediate attention, mandating timely screening, timely treatment, and economical ways of achieving and managing weight loss across the country. In this review, the authors have discussed various aspects of overweight and obesity and critically appraised the current status of obesity in India, its public health implications, the significance of screening, the role of BMI and other parameters in diagnosing obesity, and the need for treatment and cost-effective prescriptions.

Healthcare Practitioners' Perspective of Prevailing Awareness on Diabetes Complications: A Questionnaire-Based Pan-India Study.

The increasing prevalence rate of diabetes mellitus (DM) and the associated long-term complications warrant a need to improve awareness of DM-related complications in the Indian population. Our questionnaire-based pan-India study (April 2021-March 2022) aims to capture the observations of healthcare practitioners (HCPs) on the prevailing level of knowledge and awareness regarding diabetes among their patients. We refer to this as the 90:90:90 program. It aims to achieve 90% awareness, 90% screening and detection of diabetes and prediabetes, and 90% achievement of effective treatment and control. A structured questionnaire was circulated to 1800 HCPs using Google Forms (Google, Mountain View, CA) and Zoom poll questions (Zoom Video Communications, Inc., San Jose, CA) during 125 symposiums. About half (48.6%) of the HCPs observe that less than 40% of their patients are aware of the risk factors of diabetes, and less than 60% of the patients were aware of its cardiovascular complications. About 92-95% of the HCPs recommend screening for diabetes in adults over 30 years of age and suggest the inclusion of a blood glucose estimate as a fifth vital to be tested during doctor visits. Less than 40% of patients fail to achieve the treatment goal, possibly due to lack of adherence, access to medicines, and financial constraints. Therefore, spreading awareness of DM complications and early screening for DM among adults (>30 years) could help achieve better management and treatment outcomes.

Bariatric Triage: Weight Loss As A Tool For Therapeutic Decision Making.

This communication highlights how early weight loss can be used as a technique for triage in persons who have undergone bariatric surgery, and as a tool for therapeutic decision making. Weight loss is a target for obesity medicine, but can also be used to plan further treatment strategies and interventions. In this manner, early weight loss is similar to HbA1c (glycated haemoglobin) which is a diagnostic tool, a monitoring device, a therapeutic target, and also a technique to decide intensity of treatment in diabetes.

Fluid Imbalance in Geriatrics: The Need for Optimal Hydration.

In the elderly, increased morbidity and mortality are often linked to fluid and electrolyte imbalances due to age-related physiological changes, hence monitoring and maintaining healthy hydration levels is important for the geriatric patient population. Patients recuperating from an illness at home maybe likely to neglect proper fluid intake and energy management, which hampers their timely recovery. In elderly patients with concurrent illnesses and therapies, dehydration is a common condition that often remains unnoticed despite persistent disease symptoms. Oral nutritional supplements such as scientifically formulated oral rehydration therapies (ORTs) have been recommended in such cases. These supplements can be further suggested by nutritional counseling, diet modification, nursing interventions, and educating the patients. The main aim of this review is to generate a greater understanding of the fluid intake requirements for the elderly, thus contributing to the prevention of the negative effects of dehydration. This review comprehensively highlights the need for treatment, recovery from illness to supportive care to address a patient's needs. Maintaining an optimal hydration level aids the efficacy of therapy in elderly patients. Hospitalized patients are considered to be at risk of dehydration, whereas patients at home completely ignore the need for fluid and energy management, leading to hospital readmissions and delayed recovery. Guidelines are available for treating, managing, and maintaining ideal hydration levels, these are considered to be imperative in managing elderly patients with chronic illnesses.

Prevalence of Hearing Loss in Type 2 Diabetes Mellitus and Its Association with Severity of Diabetic Neuropathy and Glycemic Control.

OBJECTIVES: This study assessed the prevalence of hearing loss (HL) in patients with type 2 diabetes mellitus (T2DM) and its relationship with the presence and severity of diabetic neuropathy. MATERIALS AND METHODS: Patients between the ages of 30 and 60 years (both ages inclusive) with T2DM were recruited and divided into three groups. Group I included patients without neuropathy. Group II had patients with mild neuropathy. Group III had patients with moderate and severe neuropathy. After informed consent hearing threshold was assessed using pure tone audiometry (PTA). RESULTS: Of the 200 patients recruited, the prevalence of HL was overall 81%. The prevalence was 66.7% in group I, 80.9% in group II, and 87.6% in group III (p = 0.009). Among patients with moderate to severe neuropathy (group III), 33.3% had clinically significant HL (CSHL) (p = 0.015). Age, gender, presence of neuropathy, and severity of neuropathy were associated with an increased risk of developing HL. CONCLUSION: Among patients with diabetes, age, nephropathy, and neuropathy were associated with HL. The severity of HL worsened with the worsening severity of neuropathy and increase in glycated hemoglobin (Hba1c) levels. Patients with moderate to severe neuropathy might benefit from screening for HL.

The etiopathogenesis and management of obesity: The quintessential quincunx.

This communication uses the quincunx, i.e, a quadruple surrounding a central point, to create a model that describes the etiopathogenesis, as well as informs the management strategy of obesity. With the energy fulcrum (mismatch between energy intake and expenditure) at its centre, the model lists two external influencers-the physical environment and psychosocial environment, and two internal influencers- the hypothalamo-bariatric axis and the endocrine system, to explain the etiopathogenesis of obesity. Genetics factors are included with the hypothalamo-bariatric axis. The same model can be used to explain the five pillars of management: lifestyle and nutritional modification at the centre, along with environmental optimization, behavioural therapy, baro-thalamic modulation, and endocrine optimization.

Expert Opinion on the Diagnosis and Management of Male Hypogonadism in India.

Male hypogonadism (MH) is a clinical and biochemical syndrome caused by inadequate synthesis of testosterone. Untreated MH can result in long-term effects, including metabolic, musculoskeletal, mood-related, and reproductive dysfunction. Among Indian men above 40 years of age, the prevalence of MH is 20%-29%. Among men with type 2 diabetes mellitus, 20.7% are found to have hypogonadism. However, due to suboptimal patient-physician communication, MH remains heavily underdiagnosed. For patients with confirmed hypogonadism (either primary or secondary testicular failure), testosterone replacement therapy (TRT) is recommended. Although various formulations exist, optimal TRT remains a considerable challenge as patients often need individually tailored therapeutic strategies. Other challenges include the absence of standardized guidelines on MH for the Indian population, inadequate physician education on MH diagnosis and referral to endocrinologists, and a lack of patient awareness of the long-term effects of MH in relation to comorbidities. Five nationwide advisory board meetings were convened to garner expert opinions on diagnosis, investigations, and available treatment options for MH, as well as the need for a person-centered approach. Experts' opinions have been formulated into a consensus document with the aim of improving the screening, diagnosis, and therapy of men living with hypogonadism.

Addendum 1: Forum for Injection Technique and Therapy Expert Recommendations, India.

With the emerging complexities in chronic diseases and people's lifestyles, healthcare professionals (HCPs) need to update their methods to manage and educate patients with chronic lifestyle disorders, particularly diabetes. The insulin injection technique (IIT), along with various parameters, must also be updated with newer methods. Forum for Injection Technique and Therapy Expert Recommendations (FITTER), India, has updated its recommendations to cover newer ways of detecting hypoglycaemia and lipohypertrophy, preventing needlestick injuries (NSIs), discouraging the reuse of insulin needles and encouraging good disposal. FITTER, India, is also introducing recommendations to calculate insulin bolus dose. These updated recommendations will help HCPs better manage patients with diabetes and achieve improved outcomes.

Monitoring Endocrine Nursing in South Asia (MENSA).

Background: South Asian countries face the colossal challenge of tackling the massive burden of diabetes and other endocrine disorders. These patients grossly outnumber the specialists trained to deal with these conditions. A trained cadre of diabetes specialist nurses (DSN) and endocrine specialist nurses (ESN) might help bridge this gap. Exploring the perception of DSN/ESN among South Asian doctors will help to understand their role, responsibilities and future prospects. Methods: One hundred and seventy-four endocrinologists from South Asia participated in an online survey on their perception of DSNs and ESNs. Results: Out of the 174 respondents, 61 (35%) were currently working with DSN/ESN, 79 (45.4%) had worked in the past and 131 (75.2%) were willing to start recruiting or employ additional DSN/ESN in the future. The majority considered that the primary function of DSN and ESN is to educate on diabetes (n = 86, 96.6%) and endocrine disorders (n = 34, 57.6%), respectively, followed by anthropometry and initial work-up. Only a small minority felt they could write independent follow-up prescriptions (nurse-led clinics) [DSN - 16 (18%) and ESN - 3 (5.1%)]. Graduation with a certificate course in diabetes and basic endocrinology was considered a sufficient qualification by 68 (39.1%) respondents. Endocrinologists from countries other than India were more willing to recruit ESN/DSN in the future (89.7% vs 72.4%; P < 0.03) and approve a nurse-led clinic (62.1% vs 29.7%; P < 0.03). Upon multiple logistic regression, working in countries other than India was an independent predictor of future willingness to work with DSN/ESN (odds ratio (OR): 4.48, 95% confidence interval (CI) 1.09-18.43, P = 0.03). Conclusion: DSN and ESN could facilitate the management of healthcare-seekers with diabetes and endocrine disorders. A certification course to train nurses on diabetes and basic endocrine disorders following graduation could be helpful. Major hindrances in creating a regular cadre of DSN/ESN were limited opportunities for career progression and lack of additional remuneration for services.

Strategies for appetite suppression: A key player in the management of diabetes and obesity.

People with diabetes and/ or obesity are advised to curtail their calorie intake in order to improve their glycaemic control and reduce their weight. However, many patients complain of an inability to manage their appetite and thereby find it difficult to control their calorie intake. Dysregulated appetite leads to glycaemic swings, and creates a challenge for metabolic management. Moreover, short term non-structured methods to suppress appetite often can cause a rebound excess of food intake, which can even overshoot more than the baseline intake. This article shares the non-pharmacological heuristics and hacks to help suppress and optimize appetite which can be used in day-to-day clinical practice.

Asian Best Practices for Care of Diabetes in Elderly (ABCDE).

The elderly population with diabetes is diverse with the majority experiencing a decline in physical and mental capabilities, impacting the entire diabetes management process. Therefore, a need for geriatric-specific guidelines, especially for the Asian population, was identified and subsequently developed by an expert panel across government and private institutions from several Asian countries. The panel considered clinical evidence (landmark trials, position papers, expert opinions), recommendations from several important societies along with their decades of clinical experience and expertise, while meticulously devising thorough geriatric-specific tailored management strategies. The creation of the ABCDE best practices document underscores and explores the gaps and challenges and determines optimal methods for diabetes management of the elderly population in the Asian region.

South Asian Working Action Group on SARCOpenia (SWAG-SARCO) - A consensus document.

The South Asian population is rapidly ageing and sarcopenia is likely to become a huge burden in this region if proper action is not taken in time. Several sarcopenia guidelines are available, from the western world and from East Asia. However, these guidelines are not fully relevant for the South Asian healthcare ecosystem. South Asia is ethnically, culturally, and phenotypically unique. Additionally, the region is seeing an increase in non-communicable lifestyle disease and obesity. Both these conditions can lead to sarcopenia. However, secondary sarcopenia and sarcopenic obesity are either not dealt with in detail or are missing in other guidelines. Hence, we present a consensus on the screening, diagnosis and management of sarcopenia, which addresses the gaps in the current guidelines. This South Asian consensus gives equal importance to muscle function, muscle strength, and muscle mass; provides cost-effective clinical and easy to implement solutions; highlights secondary sarcopenia and sarcopenic obesity; lists commonly used biomarkers; reminds us that osteo-arthro-muscular triad should be seen as a single entity to address sarcopenia; stresses on prevention over treatment; and prioritizes non-pharmacological over pharmacological management. As literature is scarce from this region, the authors call for more South Asian research guided interventions.

Faith healers and diabetes care in South Asia: Fighting together, moving forward.

Faith healing has been prevalent in the South Asian society since time immemorial. This is often coupled with alternative and complementary systems of medicine and attract a large proportion of people belonging to different sects, religions, and organizations. Though based on blinded trust, it does address the psychosomatic component of chronic disorders and hence does make the patient feel better. In this article the authors highlight the significant role of modern medicine in patients with certain endocrine and systemic disorders but also explore futuristic options to utilize these different systems in amalgamation for the better control and treatment of endocrine disorders like diabetes.

Management of Glucocorticoid-Induced Hyperglycemia.

Glucocorticoids are potent immunosuppressive and anti-inflammatory drugs used for various systemic and localized conditions. The use of glucocorticoids needs to be weighed against their adverse effect of aggravating hyperglycemia in persons with diabetes mellitus, unmask undiagnosed diabetes mellitus, or precipitate glucocorticoid-induced diabetes mellitus appearance. Hyperglycemia is associated with poor clinical outcomes, including infection, disability after hospital discharge, prolonged hospital stay, and death. Furthermore, clear guidelines for managing glucocorticoid-induced hyperglycemia are lacking. Therefore, this consensus document aims to develop guidance on the management of glucocorticoid-induced hyperglycemia. Twenty expert endocrinologists, in a virtual meeting, discussed the evidence and practical experience of real-life management of glucocorticoid-induced hyperglycemia. The expert group concluded that we should be proactive in terms of diagnosis, management, and post-steroid care. Since every patient has different severity of underlying disease, clinical stratification would help understand patient profiles and determine the treatment course. Patients at home with pre-existing diabetes who are already on oral or injectable therapy can continue the same as long as they are clinically stable and eating adequately. However, depending on the degree of hyperglycemia, modification of doses may be required. Initiating basal bolus with correction regimen is recommended for patients in non-intensive care unit settings. For patients in intensive care unit, variable rate intravenous insulin infusion could be temporarily used, but under supervision of diabetes inpatient team, and patients can be transitioned to subcutaneous insulin once stable baseline assessment and continual evaluation are crucial for day-to-day decisions concerning insulin doses. Glycemic variability should be carefully monitored, and interventions to treat patients should also aim at achieving and maintaining euglycemia. Rational use of glucose-lowering drugs is recommended and treatment regimen should ensure maximum safety for both patient and provider. Glucovigilance is required as the steroids taper during transition, and insulin dosage should be reduced subsequently. Increased clinical and economic burden resulting from corticosteroid-related adverse events highlights the need for effective management. Therefore, these recommendations would help successfully manage GC-induced hyperglycemia and judiciously allocate resources.