Barocrinology.

The authors propose "Barocrinology", a novel terminology in medical literature, to comprehensively describe the rapidly expanding field of obesity medicine. This new term highlights the need to appreciate the role of endocrine physiology in the evolution of obesity, insights into its complications and changes in the hormonal milieu following weight loss therapies, including bariatric surgery. This term would not only reduce the stigma associated with obesity in affected individuals but also give them a better appreciation of its biological origin rather than self-criticism. This paper also undermines the importance of a multi-disciplinary approach needed in this field for achieving practical and sustainable goals, individualized to each person.

A Prospective Validation Survey to Assess Usage of Premix Insulins in Management of Diabetes with Respect to the Recommendations Enlisted in Indian Guidelines.

OBJECTIVE: Widely used in the management of diabetes, the premix insulin therapy is influenced by several patient preferences and physician choices. The present survey aims to provide specific recommendations based on published data for appropriate management of T2DM with premix insulins. METHODS: We administered an online questionnaire where the respondent physicians were requested to go-through the published India specific and international guidelines before the survey. The respondents were requested to answer the electronic survey based on their clinical experiences with patients having diabetes. RESULTS: Overall, 1408 doctors participated in the survey. Majority of physicians preferred a premix insulin regimen for initiation. Short-term therapy with premix insulins in insulin-naive T2DM patients with symptomatic hyperglycemia and/ or glucotoxicity was strongly recommended by 40.7% physicians. Initiation of insulin early in the course of T2DM was recommended by 58.7% of physicians in cases where glycemic goals were not achieved by non-insulin drugs. Premix insulin analogues were preferred over human premix insulins by more than half of participating physicians (52.2%). Premix insulin analogues were preferred over basal insulins by 49.8% of physicians. Nearly half (44.5%) of the physicians recommended initiation of twice daily premix analogues over once daily basal insulins to achieve recommended glycemic targets. Around forty two percent (41.9%) physicians strongly believed that twice daily/thrice daily premix insulin analogues provide comparable glycemic control and safety to basal plus regimen with additional benefit of simplicity. During Ramadan premix insulin analogues were recommended over human premix by 46.5% physicians in view of improved safety and flexibility of dosing. SUMMARY: Majority of Indian physicians concur with the recommendations of INCG 2017 guidelines. Premix insulins were preferred for insulin initiation. IDegAsp was preferred over other premix insulins by majority of physicians. Twice daily premix insulins were recommended for intensification.

Colesevelam in the management of type 2 diabetes.

Colesevelam is a bile acid sequestrant, approved for the management of both dyslipidaemia and type 2 diabetes. This review discusses the potential for the use of colesevelam in the management of type 2 diabetes. Expert opinion suggests possible indications where colesevelam may add value as a glucose lowering agent. It also highlights the limitations of the drug, and precautions that must be observed while using it.

Oncocrinology.

Oncocrinology is the science which studies the complex bi-directional relationship between cancer and the endocrine system, including pathophysiological links, clinical presentation and the impact of cancer treatment and endocrine therapy. This review describes the vast spectrum of the complex, multifacted relationship between the endocrine system and malignancy. It also includes the endocrine aspects of anti-cancer treatment, and the need for oncovigilance with endocrine therapy.

Initiation of basal bolus insulin therapy.

Most practice guidelines recommend the use of longacting or pre-mixed insulin at the initiation of insulin therapy in type 2 diabetes, especially in patients not achieving glycaemic goals. Nonetheless, there are some specific indications where basal bolus insulin is the preferred regimen for insulin initiation. These include the "5S" situations - 'Severe' hyperglycaemia, 'Symptomatic' diabetes, 'Sick' diabetes (acute or chronic comorbidity), 'Special' situations (pregnancy, childhood, adolescence) and 'Secondary' diabetes (pancreatic, drug-induced, endocrine disorders). This review describes a practical approach to initiation and follow up of basal bolus insulin regimens.

Sweet Cravings in Diabetes: Desserts that are not so Sinful.

Desserts form an important and integral part of South East Asian cuisines and are often associated with festive eating and celebrations. Since most desserts are high in caloric content and contain refined carbohydrates and saturated or trans-fats, their consumption poses obvious challenges in diabetic individuals. Meals should not only meet the biological needs of an individual but should also be palatable, appealing and retain their hedonistic aspects of taste, smell and visual appeal. While remaining within the principles of medical nutrition therapy, desserts can be incorporated into meals with use of whole grains, low fat dairy or yoghurt, fruits, vegetables and pulses as their primary ingredients. Intake of free sugars can be minimized by using non-nutritive sweeteners, soluble fiber, condiments and spices. In this article, we focus on ways to encourage healthy eating among diabetics while still retaining pleasurable foods such as desserts.

Difficult diabetes: the 7d approach.

This communication describes a 7D approach to the assessment and management of 'difficult' or refractory type 2 diabetes. It lists 7 aspects of care, which may contribute to refractoriness of hyperglycaemia, and classifies them according to a bio-psychopharmacological triad. The biomedical aspects to be addressed include diagnosis of the type of diabetes and exclusion of comorbid disease. Psychosocial factors of importance include establishing effective dialogue with the patient, ensuring discipline in daily lifestyle, and minimizing diabetes related distress. Pharmacological factors which may cause difficulty in management pertain to inappropriate choice of drug or delivery device. A simple 7D checklist of factors which may lead to uncontrolled hyperglycaemia and indicate need for insulin therapy is also presented. The bio-psychopharmacological 7D approach serves as a simple, yet comprehensive, learning tool to help improve diabetes care.

Person, Patient, Public, Peers: the four pillars of physician practice.

More often than not, the root cause of unsatisfactory diabetes care can be traced to in appropriate communication. In this brief article, we share the four pillars of communication that a successful physician should be able to address: person, patient, public and peers. A good physician should be able to understand herself or himself, communicate with patients and the society at large, and handle professional relationships. This quadruple helps us identify our strengths and shortcomings and facilitates attempts at self-improvement, so as to improve the quality of our life.

The Lipo- Phenotypic Screening Tool for Familial Hypercholesterolaemia.

Familial hypercholesterolaemia (FH) is a common disorder of lipid metabolism. However, it is rarely diagnosed in time, leading to a high burden of preventable cardiovascular (CV) morbidity. The authors describe a lipophenotypic screening tool, which can be used by clinicians to screen for FH. This simple construct is based on history, physical examination, lipid profile and non-invasive cardioimaging. Structured as a bidirectional three column rubric, this tool should be able to improve clinical skills and teaching related to FH.

Management of prediabetes.

Prediabetes is an intermediate stage of hyperglycaemia, characterized by impaired fasting glucose, impaired glucose tolerance and/ or an HbA1c ranging from 5.7-6.4%. Prediabetes is associated with an increased risk of progression to overt diabetes and increased risk of cardiovascular disease. Several intervention studies have demonstrated that onset of diabetes can be prevented or delayed with intensive lifestyle modification and oral antidiabetic agents including metformin, thiazolidinediones and alpha-glucosidase inhibitors. Prediabetes management should focus on lifestyle modification and multiple risk factor management. In cases at high risk, use of oral antidiabetic agents may be considered.

Glucocrinology.

Diabetes is a complex syndrome, with multiple pathophysiologic connections. While the vasculometabolic aspects are certainly important, current discourse tends to ignore the endocrine facets of diabetes. We propose the term 'glucocrinology', to define the study of medicine that relates to the relationship of glycaemia with the endocrine system. Glucocrinology includes in its ambit, endocrinopathies that may cause secondary diabetes, coexist with metabolic syndrome, precipitate hypoglycaemia, lead to refractory hyperglycaemia, or simply coexist with diabetes. The concept also covers the role of endocrinotropic drugs in unmasking latent diabetes, worsening hyperglycaemia, or managing diabetes in specific situations, as well as antidiabetic drugs in modulating endocrine disease. Highlighting glucocrinology as a distinct field will enhance the quality of diabetes care, by making it more holistic, comprehensive and clinically oriented. This article will be followed by gland-specific reviews of glucocrinology.

Subcutaneous insulin administration in infants and toddlers.

Management of diabetes in infants and toddlers requires the administration of multiple subcutaneous insulin injections and frequent monitoring of blood glucose. However, there are significant unique challenges in managing insulin injections in this age group due to unpredictable eating and activity patterns, less subcutaneous fat, increased risk of hypoglycaemia, and the child's inability to communicate symptoms and comprehend the need for insulin. Insulin pumps and pen devices are preferable to insulin syringes. Injection should be administered with smaller and finer gauge needles and care should be taken to ensure correct injection technique to avoid inadvertent intramuscular injection. In this article, we highlight some of these challenges and summarize the strategies to optimize insulin administration in infants and toddlers.

IDEA Group Consensus Statement on Medical Management of Adult Gender Incongruent Individuals Seeking Gender Affirmation as Male.

Gender-affirming hormone therapy (GAHT) is the most frequent treatment offered to gender-incongruent individuals, which reduces dysphoria. The goal of therapy among gender-incongruent individuals seeking gender affirmation as male is to change their secondary sex characteristics to affect masculine physical appearances. GAHT greatly improves mental health and quality of life among gender incongruent individuals. India-specific guideline for appropriate care for gender-incongruent individuals is almost absent. This document is intended to assist endocrinologists and other healthcare professionals interested in gender incongruity for individuals seeking gender affirmation as male. A safe and effective GAHT regimen aims to effect masculinising physical features without adverse effects. In this document, we offer suggestions based on an in-depth review of national and international guidelines, recently available evidence and collegial meetings with expert Indian clinicians working in this field. Clinicians represented in our expert panel have developed expertise due to the volume of gender incongruent individuals they manage. This consensus statement provides protocols for the hormone prescribing physicians relating to diagnosis, baseline evaluation and counselling, prescription planning for masculinising hormone therapy, choice of therapy, targets for monitoring masculinising hormone therapy, clinical and biochemical monitoring, recommending sex affirmation surgery and peri-operative hormone therapy. The recommendations made in this document are not rigid guidelines, and the hormone-prescribing physicians are encouraged to modify the suggested protocol to address emerging issues.

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.

Diabetes Insipidus: A Pragmatic Approach to Management.

Diabetes insipidus (DI) is a disorder of water balance characterized by polyuria and polydipsia. It can occur due to genetic and acquired causes that affect the secretion or action of arginine vasopressin (AVP) or antidiuretic hormone (ADH).Markedly increased thirst and urination are not only quite distressing but also increases the risk of volume depletion and hypernatremia in severe situations. A careful diagnosis of the type of DI and its etiology is based on careful clinical evaluation, measurement of urine and serum osmolality, and water deprivation test. Management includes the correction of any water deficit and the use of specific pharmacological agents, including desmopressin, thiazides, and amiloride.

An Expert Opinion on "Glycemic Happiness": Delineating the Concept and Determinant Factors for Persons with Type 2 Diabetes Mellitus.

The importance of the psychological impact of diabetes is globally well-documented. Evidence suggests that there is a high level of psychosocial burden of diabetes in India. Moreover, there is a lack of relevant knowledge among the patients and caregivers regarding the psychological impact of diabetes and how to cope with it, as compared to the majority of other countries. "Happiness of the patient" is an essential component of diabetes management, which potentially affects the treatment outcome, treatment adherence, self-care, and lifelong management of diabetes. Although several validated tools and scales exist for measuring psychological outcomes both in patients and physicians, tools to assess "happiness in diabetes care" are still lacking. With this background, an expert group meeting was held in India in September 2019, involving nine expert diabetologists and endocrinologists across the country to discuss the concept of "glycemic happiness". This article summarizes the expert opinion on the factors affecting psychological outcomes in diabetes, introduces the concept of glycemic happiness, describes available scales and tools to measure general happiness, and delineates the five sets of questionnaires developed with questions that may help correlate with "glycemic happiness". The questionnaires are based on a five-point Likert method. The experts also discussed and decided upon the study design for a proposed observational survey to assess glycemic happiness of persons with type 2 diabetes mellitus (T2DM) based on the developed five sets of questionnaires. Given the huge burden of diabetes in India, the introduction of the concept of glycemic happiness will help in the optimization of diabetes care in the country.

Individualizing Time-in-Range Goals in Management of Diabetes Mellitus and Role of Insulin: Clinical Insights From a Multinational Panel.

Diabetes mellitus is a global health concern associated with significant morbidity and mortality. Inadequate control of diabetes leads to chronic complications and higher mortality rates, which emphasizes the importance of achieving glycemic targets. Although glycated hemoglobin (HbA1c) is the gold standard for measuring glycemic control, it has several limitations. Therefore, in recent years, along with the emergence of continuous glucose monitoring (CGM) technology, glycemic control modalities have moved beyond HbA1c. They encompass modern glucometrics, such as glycemic variability (GV) and time-in-range (TIR). The key advantage of these newer metrics over HbA1c is that they allow personalized diabetes management with person-centric glycemic control. Basal insulin analogues, especially second-generation basal insulins with properties such as longer duration of action and low risk of hypoglycemia, have demonstrated clinical benefits by reducing GV and improving TIR. Therefore, for more effective and accurate diabetes management, the development of an integrated approach with second-generation basal insulin and glucometrics involving GV and TIR is the need of the hour. With this objective, a multinational group of endocrinologists and diabetologists reviewed the existing recommendations on TIR, provided their clinical insights into the individualization of TIR targets, and elucidated on the role of the second-generation basal insulin analogues in addressing TIR.

Clinical practice recommendations for the detection and management of hyperglycemia in pregnancy from South Asia, Africa and Mexico during COVID-19 pandemic.

The human coronavirus disease 2019 (COVID-19) pandemic has affected overall healthcare delivery, including prenatal, antenatal and postnatal care. Hyperglycemia in pregnancy (HIP) is the most common medical condition encountered during pregnancy. There is little guidance for primary care physicians for providing delivery of optimal perinatal care while minimizing the risk of COVID-19 infection in pregnant women. This review aims to describe pragmatic modifications in the screening, detection and management of HIP during the COVID- 19 pandemic. In this review, articles published up to June 2021 were searched on multiple databases, including PubMed, Medline, EMBASE and ScienceDirect. Direct online searches were conducted to identify national and international guidelines. Search criteria included terms to extract articles describing HIP with and/or without COVID-19 between 1st March 2020 and 15th June 2021. Fasting plasma glucose, glycosylated hemoglobin (HbA1c) and random plasma glucose could be alternative screening strategies for gestational diabetes mellitus screening (at 24-28 weeks of gestation), instead of the traditional 2 h oral glucose tolerance test. The use of telemedicine for the management of HIP is recommended. Hospital visits should be scheduled to coincide with obstetric and ultrasound visits. COVID-19 infected pregnant women with HIP need enhanced maternal and fetal vigilance, optimal diabetes care and psychological support in addition to supportive measures. This article presents pragmatic options and approaches for primary care physicians, diabetes care providers and obstetricians for GDM screening, diagnosis and management during the pandemic, to be used in conjunction with routine antenatal care.

Cardiometabolic vigilance in COVID-19 and resource husbandry in resource-challenged times: Clinical practice- based expert opinion.

BACKGROUND AND AIMS: The ongoing pandemic of coronavirus disease 2019 (COVID-19) is rapidly evolving, thereby posing a profound challenge to the global healthcare system. Cardiometabolic disorders are associated with poor clinical outcomes in persons with COVID-19. Healthcare challenges during the COVID-19 pandemic are linked to resource constraints including shortage of Personal Protective Equipment's (PPE), laboratory tests and medication. In this context, a group of clinical experts discussed the endocrine and cardiology vigilance required in times of COVID-19. Further, the group proposed certain resource husbandry recommendations to be followed during the pandemic to overcome the constraints. METHOD: The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists, Consultant Physicians and cardiologists from India. The panel thoroughly reviewed existing literature on the subject and proposed expert opinion. RESULTS: The expert panel put forward clinical practice-based opinion for the management of cardiometabolic conditions including diabetes mellitus and hypertension. As these conditions are associated with poor clinical outcomes, the expert panel recommends that these persons be extra-cautious and take necessary precautions during the ongoing pandemic. Further, experts also provided appropriate, affordable, available and accessible solution to the resource constraint situations in times of COVID-19 pandemic. CONCLUSION: The clinical expert opinion put forward in this article will serve as a reference for clinicians treating diabetes and cardiovascular disease during the COVID-19 pandemic.

Challenges in Women with Diabetes During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has created significant challenges for healthcare systems across the world. The disease seems to infect men and women in equal numbers, though trends suggest that men have greater morbidity. This has been attributed to differences in immunological response, expression of angiotensin-converting enzyme 2 (ACE2), prevalence of comorbidities, and health-related behaviours, such as smoking. However, this cannot be taken to mean that women are somehow protected. Advanced age, smoking, diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease have emerged as the leading contributors to increased morbidity and mortality from the disease. Women with diabetes form a vulnerable group as they often receive suboptimal diabetes care and support, even though they have a high burden of comorbidities and complications. While there are challenges in healthcare delivery during the pandemic, cardiometabolic care cannot be compromised, which calls for exploring new avenues of healthcare delivery, such as telemedicine. Pregnant women with diabetes should continue to receive quality care for optimal outcomes, and the psychological health of women also needs special consideration. The management of hyperglycaemia during COVID-19 infection is important to reduce morbidity and mortality from the infection. The gendered impact of outbreaks and quarantine goes beyond biomedical and psychological aspects, and the socioeconomic impact of the pandemic is likely to affect the long-term care of women with diabetes, which creates an urgent need to create effective policies and interventions to promote optimal care in this vulnerable group.