Intermittent Use of Continuous Glucose Monitoring: A New Paradigm in Treatment of Type 2 Diabetes.

OBJECTIVES: To suggest how continuous glucose monitoring (CGM) may be used intermittently in individuals with type 2 diabetes (T2D). MATERIALS AND METHODS: The use of CGM is largely in those with type 1 diabetes (T1D), in whom it makes sense to use CGM continuously as CGM provides a valuable tool to not only adjust their insulin doses but also to match it with their diet, physical activity, and other lifestyle modifications. In the case of T2D, however, especially for those not on insulin, the use of CGM may not be needed on a continuous basis. The use of CGM on an intermittent basis is rarely discussed in the literature. This article tries to provide clinical situations where CGM can be used intermittently. RESULTS: Intermittent use of CGM defined as the "use of CGM once in 2 or 3 months or a fixed frequency," and may be useful in several situations in those with T2D. We suggest the following indications for the intermittent use of CGM in T2D-newly diagnosed patients where treatment is being started, uncontrolled diabetes where treatment is being altered, starting intensive lifestyle modification, during infections, during preoperative control, in children and adolescents with T2D, as a motivational tool to improve behavioral modification, after metabolic surgery, and in patients on steroids, apart from other indications. CONCLUSION: Intermittent use of CGM in T2D can be useful in special situations and can also be cost saving particularly in resource-constrained regions of the world.

Carbohydrate profiling & glycaemic indices of selected traditional Indian foods.

Background & objectives: Consumption of high glycaemic index (GI) food is associated with a high risk for diabetes. There is a felt need to understand the GI of common Indian traditional foods using standard GI protocols. The present study was aimed to analyse the carbohydrate profile of common traditional Indian food preparation and to determine their GI using standardized protocols. Methods: Twelve food preparations made of millets, wheat, maize and pulses were evaluated for nutrient composition including detailed carbohydrate profiling and tested for GI in healthy volunteers using standard methodology. Capillary blood glucose responses for the test foods containing 50 g available carbohydrates were recorded and compared to the reference food (50 g glucose). GI was calculated from the incremental area under the curve (IUAC) for the test and reference foods. Results: Available carbohydrate content of the food preparations ranged between 13.6 and 49.4 g per cent. Maize roti showed the highest total dietary fibre (7.5 g%). White chick pea 'sundal' showed highest resistant starch content (3.95 g%). Amongst the 12 test foods, five fell in the high GI category (finger millet balls, sorghum, pearl millet and maize roti), four in the medium GI category (sorghum idli, wheat dosa, methi roti and adai) and three in the low GI category (broken wheat upma, white peas sundal and white chick peas sundal). Interpretation & conclusions: Merely being a whole grain-based food does not qualify for a lower GI. The method of processing, food structural integrity and preparation could influence the GI. The type and quality of fibre are important than the quantity of fibre alone. Judicious planning of accompaniments using low GI legumes may favourably modify the glycaemic response to high GI foods in a meal.

Remission of Type 2 Diabetes: How, When, and for Whom?

Type 2 diabetes (T2DM) is conventionally considered a progressive disorder, with most patients requiring increasingly intensive therapy to control hyperglycemia over time. Recently, there has been a major paradigm shift towards trying to reverse T2DM. Emerging evidence suggests that remission of T2DM is feasible in a subset of patients. Identification and careful selection of candidates for remission are crucial for the success of these programs. Among various dietary strategies, low-calorie diets (LCDs) and low-carbohydrate diets (LCBDs) have been demonstrated as being effective in facilitating remission of T2DM in a targeted population within a clinical setting. Remission with LCBDs may be maintained in the absence of weight loss, however, long-term evidence is limited and remission may not be maintained without long-term carbohydrate restriction, which poses major challenges. In very low-calorie diets (VLCDs), weight loss of 15 kg or greater and maintenance of weight loss is the main driver and predictor of remission. However, most individuals with T2DM were unable to maintain remission beyond 2 years, despite being on VLCDs. More data are required on the long-term sustainability of remission in an ethnically diverse population like Asian Indians with T2DM who have less obesity and hence less weight to lose. Moreover, "re-reversal" or "relapse" of diabetes can occur in a large percentage of individuals who discontinue the dietary restrictions. Hence, regular follow-up by a multi-disciplinary team to ensure sustainability of the lifestyle modification is crucial to the maintenance of remission of T2DM.

Temporal changes in diabetes prevalence and achievement of care goals in urban South Asia from 2010 to 2016 - The Center for Cardio-metabolic Risk Reduction in South Asia Study.

AIM: Achievement of treatment targets among individuals with diabetes remains suboptimal in many parts of the globe. We aimed to assess changes in diabetes prevalence and achievement of diabetes care goals in South Asia using two consecutive cross-sectional population-based surveys. METHODS: Two representative samples of South Asian adults were recruited using identical methods from Chennai, Delhi, and Karachi in 2010-11 (n = 16,288; response rate-94.7%) and 2015-16 (n = 14,587; response rate-94.0%) through the Center for Cardio-metabolic Risk Reduction in South Asia (CARRS) Study. Quality of care goals were defined as HbA1c <53 mmol/mol (7.0%), blood pressure (BP) control: <140/90 mmHg, lipid control: LDL cholesterol <2.56 mmol/l (100 mg/dl), and self-reported non-smoking. RESULTS: Weighted prevalence of self-reported diabetes increased by 9.0% [13% (95%CI: 13-14) to 15% (14-15)] while that of newly diagnosed diabetes decreased by 16% [6.1% (5.7-6.6) to 5.1% (4.6-5.6)]. There were improvements in achieving glycaemic (25% to 30%, p = 0.002) and lipid (34% to 45%, p < 0.001) goals, but no notable improvements in BP control or smoking status. The proportion of individuals with self-reported diabetes meeting more than one target also increased. CONCLUSIONS: Diabetes prevalence continues to grow among urban South Asians and large gaps still exist in the attainment of treatment targets. Concerted policy, systemic, clinical and individual efforts are needed to close these care gaps.

Real Time Flash Glucose Monitoring: Now a Reality in India.

Tight glycemic control has been recognised as the cornerstone of modern diabetes management. Until recently, glycated hemoglobin (HbA1c) was the only reliable tool for measuring glycemic control, but it is not an ideal metric as it is retrospective, unable to pick up hypo- and hyperglycemic excursions and prone to interference by conditions such as anemia and hemoglobinopathies. The advent of continuous glucose monitoring systems is a giant leap in diabetes management as it enables visualisation of glucose trends over periods of time, helping in identification of hypo- and hypoglycemic events and enabling appropriate treatment decisions to be made. The recent launch of the real-time patient CGM in India is a further step in the right direction as it will empower patients to take control of their diabetes by providing them information on their glucose levels and trends in real time.

Diabetes in Pre-independence India: Rediscovering a Forgotten Era.

Around 300- 400 AD, ancient Indian physicians described a condition akin to diabetes mellitus which was called "Madhumeha". Sushrutha and Charaka, are also credited with describing two types of diabetes which would roughly correspond to type 1 diabetes and type 2 diabetes. However, little is known about the history of diabetes in India between the first and 19th century AD. A thorough search of literature revealed a large number of publications on diabetes from India in the 1800s and early 1900s, mostly from Calcutta and the Madras Presidency, suggesting that the prevalence of diabetes was high in these two places. Building on the observations made by a number of English physicians, Chunilal Bose in 1907 suggested the link between diabetes and lifestyle in India. Amazingly, India did not have to wait long after the discovery of insulin by Banting and Best at Toronto in 1921, to get its own supply. Around this time, Dr. J.P. Bose, eminent physician and diabetologist from Calcutta made remarkable contributions to the study of diabetes in India. He was also the first to describe the dramatic effects of insulin administration to children with type 1 diabetes in India. All these facts have remained largely forgotten which prompted the authors to delve deep into the history of diabetes in pre-independence India. This has led to the unearthing of several pearls of knowledge which are presented in this article as a fitting tribute to the 100th year of Insulin Discovery.

New and Unique Clusters of Type 2 Diabetes Identified in Indians.

Type 2 diabetes (T2D), the most common form of diabetes, is recognized as being a heterogenous disorder, and presents a universal threat to health. In T2D, the pathophysiology and phenotype differ significantly by ethnicity, particularly among Asian Indians, who are known to have the 'Asian Indian phenotype', which makes them more susceptible to develop T2D than white Caucasians. The recent subclassification of T2D into different subtypes or clusters, which behave differently with respect to clinical presentation and risk of developing complications is a remarkable development. Five unique "clusters" of individuals with diabetes were described in the Scandinavian population [Severe Autoimmune Diabetes (SAID), Severe Insulin Deficient Diabetes (SIDD), Severe Insulin Resistant Diabetes (SIRD), Mild Obesity-related Diabetes (MOD) and Mild Age-Related Diabetes (MARD)]. For the first time in India, identification of clusters of diabetes was done on 19,084 individuals with T2D, using 8 clinically relevant variables (age at diagnosis, BMI, waist circumference, HbA1c, triglycerides, HDL cholesterol and fasting and stimulated C-peptide). Four replicable clusters were identified [SIDD, MARD, IROD (Insulin Resistant Obese Diabetes) and CIRDD (Combined Insulin Resistant and Deficient Diabetes)], two of which were unique to the Indian population (IROD and CIRDD). Clustering of T2D helps i) to accurately subclassify diabetes into different subtypes, ii) plan therapies based on the pathophysiology, iii) predict prognosis and prevent diabetic complications and iv) helps in our approach to precision diabetes. Further studies would help us to refine the usefulness of these clusters of T2D particularly in the Indian population, with respect to selection of appropriate therapies and hopefully in the prevention of complications of diabetes.

Fibrocalculous Pancreatic Diabetes.

PURPOSE OF REVIEW: Fibrocalculous pancreatic diabetes (FCPD) is an uncommon form of diabetes occurring in underprivileged developing countries of the world. We attempt to review the latest evidence on epidemiology, secular trends, etiopathogenic mechanisms, and treatment modalities of FCPD with particular reference to studies from the past decade. RECENT FINDINGS: There has been little new data on FCPD over the past decade even from countries where it was considered to be prevalent. There appears to be a decline in prevalence of the condition of late. There is also some evidence to show that the condition develops due to as yet unknown environmental influences acting on a background of genetic susceptibility. FCPD is a severe form of diabetes and may be a premalignant condition. FCPD deserves more attention than it currently receives, because of its unique clinical features and management strategies, and its propensity to develop pancreatic adenocarcinoma.

Assessment of quality of minor millets available in the south Indian market & glycaemic index of cooked unpolished little & foxtail millet.

BACKGROUND & OBJECTIVES: : Millets are widely marketed as healthier alternatives to white rice (WR). This study was conducted with two aims: firstly, to look at the nature and quality of minor millets available in the Chennai market and secondly, to estimate the glycaemic index (GI) of unpolished forms of the two most widely available minor millets, i.e. little (LM) and foxtail millet (FXM). METHODS: : A market survey was conducted of 100 food stores in four zones of Chennai, south India. Morphological features of market millet samples were compared with that of unpolished millets under stereo-zoom microscope, and the claims declared on the pack were evaluated. A consumer perception survey was conducted among 20 minor millet-consuming female homemakers. Finally, the GI of unpolished LM and FXM was evaluated using a validated protocol in 12 healthy volunteers. RESULTS: : Forty eight brands of minor millets were available, with LM and FXM being the most common. Most of the millet samples were identified as highly polished grains using stereo-zoom microscope. The product labels were misleading and showed no scientific backing for claims mentioned on the label. Most participants (12 of 20) were unaware of the fact that millets can also be polished like rice. Both LM and FXM exhibited high GI (88.6±5.7 and 88.6±8.7, respectively). INTERPRETATION & CONCLUSIONS: The availability and knowledge regarding unpolished millets was low. Both LM and FXM exhibited high GI. Hence, substituting millets for WR might be of limited benefit considering the glycaemic property in the prevention and management of chronic non-communicable diseases such as T2DM.

Reproducibility and construct validity of a food frequency questionnaire for assessing dietary intake in rural and urban Asian Indian adults.

BACKGROUND AND OBJECTIVES: To evaluate the reproducibility and construct validity of the Madras Diabetes Research Foundation FFQ (MDRF-FFQ) with biomarkers for its use in epidemiological settings in India. METHODS AND STUDY DESIGN: The MDRF-FFQ was administered to 500 participants representing rural and urban areas of 10 Indian states, twice at an interval of 12 months. Reproducibility was assessed using intra cluster correlation coefficients (ICC). Construct validity of carbohydrate and fat intake was assessed using baseline serum lipids by regression analysis. RESULTS: Reproducibility as measured by ICC was 0.50-0.77 for saturated fatty acids (SFA) and energy in urban and 0.61-0.72 for protein and SFA in rural areas. The ICC for food groups was 0.53-0.77 for whole grains, fruits and vegetables in urban and 0.50-0.89 for animal foods and whole grains in rural areas. After adjusting for potential confounders, carbohydrate intake was positively associated with serum triglycerides (TG) (ß [SE]: +2.3 [0.72] mg/dL; p=0.002) and inversely with high density lipoprotein cholesterol (HDL) (ß [SE]:-0.48 [0.12], p<0.001), while dietary fat and SFA (% Energy) were positively associated with HDL, low density lipoprotein (LDL) and total cholesterol and inversely with TG. CONCLUSIONS: The MDRF-FFQ can be considered as a reliable and valid tool to measure the long-term dietary exposure in respect of macronutrient intakes in Indian populations despite diverse dietary practices.

Adoption of Gla-100 in India and its Impact on Insulin Usage Patterns.

Fueled by perceptions regarding Indian dietary patterns and premixed insulin's claim to fame of providing dual fasting and post-prandial control, there was a greater inclination towards using premixed insulins in clinical practice until the last decade. However, the advent of insulin glargine 100 U/mL (Gla-100) opened up a new dimension in insulin therapy landscape in India. The data from the last 5 years reveal that Gla-100 has gained more traction among Indian clinical practitioners. Basis evidences that have emerged from various clinical studies, this present review elaborates on certain key issues which have helped Gla-100 carve its own niche and effected a progressive shift in insulin prescription pattern in India.

A Pilot Study Evaluating the Effects of Diabetes Specific Nutrition Supplement and Lifestyle Intervention on Glycemic Control in Overweight and Obese Asian Indian Adults with Type 2 Diabetes Mellitus.

BACKGROUND AND OBJECTIVES: Medical nutrition therapy plays a crucial role achievement of optimal glycemic control in individuals with diabetes. This study aims to evaluate the effects of diabetes specific nutrition supplement (DSNS) along with lifestyle intervention in overweight and obese adults with Type 2 Diabetes Mellitus (T2DM). METHODS: A total of 120 overweight or obese individuals aged 30 - 65 years with T2DM, were randomly allocated to intervention (IG, n=60) and control (CG, n=60) groups in this 12-week study. All participants received dietary counselling with diet chart of 1400 kcal/day and recommendations for physical activity. DSNS was included in the dietary regimen adjusted within the daily calorie recommendations for intervention group. All participants were followed up monthly for anthropometric, biochemical and clinical assessments. Continuous glucose monitoring was performed during the initial 2 weeks and last 2 weeks of the study in a sub- sample using Flash Glucose Monitoring device to study glycemic excursions. Data was analyzed for the differences between intervention vs. control group using linear models. RESULTS: Compared to the control group, the intervention group showed significant reduction in glycosylated haemoglobin (IG: -0.95% vs. CG: -0.48%; p=0.020) and fasting blood glucose (IG: -18.47 mg/dL vs. CG: 1.34mg/dL; p=0.03) as well as a greater reduction in postprandial plasma glucose (IG: -29.77mg/dL vs. CG: -2.64mg/dL; p=0.053). There was also a significant reduction from baseline in incremental Area under the Curve (iAUC) (p=0.01) in the intervention group (Δ -22 mg) compared to the control group (Δ -7.9 mg) with a corresponding reduction in the Mean Amplitude of Glycemic Excursion (MAGE) (P=0.04). There was no difference between groups in body weight, waist circumference, blood pressure, and lipid profile. None of the subjects in the study reported serious adverse events. CONCLUSION: This pilot study showed that a diabetes specific nutritional supplement was useful in improving glycemic control and reducing glycemic response in overweight and obese Asian Indian adults with T2DM.

Cashew Nut Consumption Increases HDL Cholesterol and Reduces Systolic Blood Pressure in Asian Indians with Type 2 Diabetes: A 12-Week Randomized Controlled Trial.

Background: There is increasing evidence that nut consumption decreases the risk of cardiovascular disease. However, there are few data on the health effects of cashew nuts among adults with type 2 diabetes (T2DM). Objective: The study aimed to investigate the effects of cashew nut supplementation on glycemia, body weight, blood pressure, and lipid profile in Asian Indians with T2DM. Methods: In a parallel-arm, randomized controlled trial, 300 adults with T2DM [mean ± SD age: 51 ± 9.3 y; body mass index (BMI; in kg/m2): 26.0 ± 3.4; 55% male] were randomly assigned to receive advice to follow a standard diabetic diet (control) or similar advice plus 30 g cashew nuts/d (intervention) for 12 wk. The macronutrient composition of the prescribed diabetic diet was 60-65% energy from carbohydrates, 15-25% from fat, and the rest from protein. Differences between groups in changes in anthropometric and biochemical variables were analyzed using linear models with robust variance estimation under an assumed independence working correlation. Results: Participants in the intervention group had a greater decrease in systolic blood pressure from baseline to 12 wk than did controls (-4.9 ± 13.7 compared with -1.7 ± 11.6 mm Hg; P = 0.04) and a greater increase in plasma HDL cholesterol compared with controls (+1.7 ± 5.6 compared with +0.1 ± 4.6 mg/dL; P = 0.01). There were no differences between the groups with respect to changes in body weight, BMI, blood lipid, and glycemic variables. Plasma oleic acid concentrations and self-reported dietary intake of nuts, oleic acid, and monounsaturated fatty acids suggested excellent compliance with the nut consumption. Conclusion: Cashew nut supplementation in Asian Indians with T2DM reduced systolic blood pressure and increased HDL cholesterol concentrations with no deleterious effects on body weight, glycemia, or other lipid variables. This study was registered at the clinical trial registry of India as CTRI/2017/07/009022.

Diabetes in South Asians: Phenotype, Clinical Presentation, and Natural History.

PURPOSE OF REVIEW: South Asia is one of the epicenters of the global diabetes pandemic. Diabetes in south Asians has certain peculiar features with respect to its pathophysiology, clinical presentation, and management. This review aims to summarize some of the recent evidence pertaining to the distinct diabetes phenotype in south Asians. RECENT FINDINGS: South Asia has high incidence and prevalence rates of diabetes. The progression from "pre-diabetes" to diabetes also occurs faster in this population. Pancreatic beta cell dysfunction seems to be as important as insulin resistance in the pathophysiology of diabetes in south Asians. Recent evidence suggests that the epidemic of diabetes in south Asia is spreading to rural areas and to less affluent sections of society. Diabetes in south Asians differs significantly from that in white Caucasians, with important implications for prevention, diagnosis, and management.

Are excess carbohydrates the main link to diabetes & its complications in Asians?

Dietary carbohydrates form the major source of energy in Asian diets. The carbohydrate quantity and quality play a vital function in the prevention and management of diabetes. High glycaemic index foods elicit higher glycaemic and insulinaemic responses and promote insulin resistance and type 2 diabetes (T2D) through beta-cell exhaustion. This article reviews the evidence associating dietary carbohydrates to the prevalence and incidence of T2D and metabolic syndrome (MS) in control of diabetes and their role in the complications of diabetes. Cross-sectional and longitudinal studies show that higher carbohydrate diets are linked to higher prevalence and incidence of T2D. However, the association seems to be stronger in Asian-Indians consuming diets high in carbohydrates and more marked on a background of obesity. There is also evidence for high carbohydrate diets and risk for MS and cardiovascular disease (CVD). However, the quality of carbohydrates is also equally important. Complex carbohydrates such as brown rice, whole wheat bread, legumes, pulses and green leafy vegetables are good carbs. Conversely, highly polished rice or refined wheat, sugar, glucose, highly processed foods such as cookies and pastries, fruit juice and sweetened beverages and fried potatoes or French fries are obviously 'bad' carbs. Ultimately, it is all a matter of balance and moderation in diet. For Indians who currently consume about 65-75 per cent of calories from carbohydrates, reducing this to 50-55 per cent and adding enough protein (20-25%) especially from vegetable sources and the rest from fat (20-30%) by including monounsaturated fats (e.g. groundnut or mustard oil, nuts and seeds) along with a plenty of green leafy vegetables, would be the best diet prescription for the prevention and management of non-communicable diseases such as T2D and CVD.

Pregnancy outcome of gestational diabetes mellitus using a structured model of care : WINGS project (WINGS-10).

AIM: To evaluate the impact of a structured model of care (MOC) prepared for resource-constrained settings, on the pregnancy outcomes of Asian Indian women with gestational diabetes mellitus (GDM). METHODS: Pregnant women were screened under the Women in India with GDM Strategy (WINGS) MOC for GDM using the International Association of Diabetes and Pregnancy Study Groups criteria. Women with GDM went through a structured MOC that included medical nutrition therapy (MNT), regular physical activity (PA); and insulin when indicated. Fasting blood glucose and post-prandial blood sugar were monitored every 2 weeks. The pregnancy outcomes of women with GDM who underwent the MOC were compared with those without GDM. RESULTS: Under the MOC, 212 women with GDM were followed through pregnancy, of whom 33 (15.6%) required insulin and 179 (84.4%) were managed with MNT and PA. The maternal and neonatal outcomes of women with GDM were similar to the non-GDM women: there were no significant differences in pregnancy complications such as cesarean section, macrosomia, pre-eclampsia, oligo/polyhydramnios, preterm delivery, neonatal death, fetal distress, hyperbilirubinemia and low birthweight. CONCLUSION: Implementation of a structured MOC for women with GDM helped achieve pregnancy outcomes similar to those without GDM.

Clinical research training and capacity building for prevention and control of non-communicable diseases: A programme in India.

BACKGROUND.: Non-communicable diseases (NCDs)-a term which includes diabetes, cardiovascular disease, cancers, chronic respiratory diseases, and mental illness-are now the major cause of death in India and pose healthcare and economic challenges. There is an urgent need for enhanced clinical research training and capacity building for NCD prevention and control in India. METHODS.: We describe a multi-pronged approach funded in part by the US National Institutes of Health Fogarty International Center, which was initiated in 2001, to train Indian present and future scientists/doctors in NCD prevention and control. The approaches used were annual national seminars, intensive training courses, in-house workshops, short-term training sessions in the USA and monthly video conferences. RESULTS.: During 2001-2016, a total of 3650 undergraduate, postgraduate and faculty from medical colleges and institutes from almost all states in India and several neighbouring countries participated in seminars and other capacity-building workshops held at the Madras Diabetes Research Foundation, Chennai and at six other medical colleges; 883 delegates participated in the in-house workshops, 463 in the intensive interactive sessions; 244 in workshops on advanced techniques in genomics; and 37 in short-term training sessions held in the USA. CONCLUSION.: Through this unique capacity-building programme, more than 5000 individuals representing faculty and students from various medical colleges and research institutes across, and beyond, India, underwent training in the prevention and control of NCDs.

Use of Freestyle Libre ProTM Flash Glucose Monitoring System in Different Clinical Situations at a Diabetes Centre.

Flash Glucose Monitoring (FGM) is a newly introduced Glucose Monitoring system. FGM provides both graphical representation of qualitative and quantitative changes in glucose levels occurring over 14-day period collapsed into single modal day graph as well as day by day graphs. In this report, we present our experience with FGM in different clinical situations. In our experience FGM is an extremely useful clinical tool for detection of glucose variability, hyperglycemia and hypoglycemia. It can also be used as an effective educational tool when the data from FGM is shared with the patient. This helps in motivating the patient in achieving better glycemic control.