Digital Nerve Care Forum: Innovative Healthcare Professionals Education on Neuropathy.

Neuropathy is a common complication of diabetes, rarely detected on time, often deprioritized by treating physicians, and hence rarely managed in time, leading to avoidable complications which can be limb and life-threatening. Despite introducing new diagnostic tests, novel potential bio parameters, and a series of relatively small intervention studies utilizing detailed phenotypic profiling, the management of diabetic neuropathy (DN) and painful DN has remained unchanged due to misdiagnosis. The diagnostic complexity of diabetic peripheral neuropathy (DPN), variation in patient response to treatment, and regulatory pressures to meet data-driven quality metrics for diabetes management all likely contributes to the underdiagnosis and treatment of DPN in clinical practice. Educating the primary healthcare providers and diabetic trainers would help improve the number of diagnosed DPN cases as these practitioners lead public health literacy. The digital nerve care forum (NCF) is an educational initiative created by clinical experts and Procter and Gamble (P&G) health academy. Its primary aim is to generate awareness amongst healthcare practitioners (HCPs) about early diagnosis and timely management of DPN. Since its inception in October 2020, NCF has conducted 143 engagements; 39 neuropathy case puzzles, four interactive case-based discussions, two diagnostic workshops, four mentor-mentee nerve talk shows, two intercountry nerve talk shows, two global neuropathy awareness week initiatives, three nerves of steel (Women's Day special engagements), and 17 NCF times (Newsletters). This online forum is hosted on a global HCP education and upskilling platform, MediSage, which offers these educational resources to HCPs worldwide for free. It has helped create a community of 254, 714 HCPs from 86 countries across six continents supported by 30 neuropathy experts from seven countries. With a repeated viewership of 53% of HCPs engaging continuously, NCF empowers this community to improve diabetic patient care. Activities that increase disease awareness and highlight the importance of diabetic nerve health have been the key objectives behind the several educational programs on NCF. To drive this continuum, these digital programs are now becoming more phygital and impactful than ever. Therefore, earlier detection of DPN in at-risk individuals and those with prediabetes or type 2 diabetes is recommended for better management through optimal intervention and lifestyle changes and to prevent future complications of untreated DPN. How to cite this article: Kalra S, Tiwaskar M, Shrestha D, et al. Digital Nerve Care Forum: Innovative Healthcare Professionals Education on Neuropathy. J Assoc Physicians India 2023;71(10):89-92.

Sexual dysfunction among men with diabetes; a cross-sectional study at a specialised diabetes clinic in Sri Lanka.

BACKGROUND: Male sexual dysfunction in diabetes is often an unrevealed clinical issue. Though many publications report the prevalence, there is limited data on its associations, impact, and health-seeking behaviour. The objectives were to assess the prevalence of male sexual dysfunction, its associations, impact and treatment-seeking among men with diabetes in a selected tertiary care Diabetes Clinic. METHODS: A cross-sectional study was conducted at the Diabetes Clinic, National Hospital of Sri Lanka, from January to September 2020. Men with diabetes aged 18 to 70 years undergoing annual assessment were recruited consecutively. Socio-demographic and clinical information were collected using an interviewer-administered questionnaire. Erectile dysfunction (ED), premature ejaculation, mental health and quality of life were assessed using validated self-administered questionnaires. Cardiovascular autonomic reflex tests and total testosterone levels were performed. Penile colour Doppler ultrasonography was performed on consenting participants with erectile dysfunction. Associations were assessed using the chi-square test or Fisher's exact for dichotomous variables and independent sample t-test for continuous variables. RESULTS: Two hundred and twelve participants were recruited with a mean age of 54.1 (SD = 10.1) years. Erectile dysfunction was present in 168 (79.2%), (mild: 45, mild-moderate: 56, moderate: 26, severe: 41). Premature ejaculation was present in 26 (18.7%). Libido was low among 16%. Sexual dysfunction was not revealed to a health provider by 85.6% despite 60.5% experiencing psychological and/or relationship effects. Out of 18 who sought treatment, only 4 achieved a good response. Mean age (55.4 ± 9.5 vs 48.7 ± 10.6 years, p < 0.001) and duration of diabetes (10.9 ± 7.6 vs 5.8 ± 4.6 years, p < 0.001) were higher while eGFR was lower (73.9 ± 27.7 vs 100.51 ± 28.08 years, p < 0.008) among those with ED compared to those without. Diabetic retinopathy (4% vs 42%, p < 0.001), peripheral neuropathy (17.9% vs 38.4%, p = 0.041) and lower limb arterial disease (0% vs 12.2%, p = 0.04) were associated with ED. Arterial insufficiency was seen among 50% of the participants who underwent penile colour Doppler ultrasonography. CONCLUSIONS: Male sexual dysfunction is a pervasive yet underappreciated problem in diabetes care despite its effect on the individual. Patient and disease characteristics would guide the identification of high-risk individuals for targeted screening in clinical practice.

Trimester-specific thyroid hormone reference data in Sri Lankan women.

Introduction: Regional differences in thyroid hormones are noted, especially during pregnancy. Objectives: Establish reference values for thyroid function tests for Sri Lankan pregnant women and to determine their comparability with regional data; and determine the prevalence of 2. Thyroid Peroxidase (TPO) antibody positivity and 3. Iodine deficiency among pregnant women with uncomplicated clinical history. Methods: A cross-sectional study conducted in antenatal clinics of a tertiary care maternity center recruited a minimum of 56 women in each trimester in a multistep approach to derive an "ideal-reference population"; Participants with clinically manifested thyroid disease, followed by subjects with sonographically abnormal thyroids and finally those at high risk for thyroid disease as shown by positive TPO levels and urine iodine deficiency were excluded in sequence. Thyroid hormones were measured by chemiluminescence in the ideal reference population. Reference ranges were derived using median and 5th and 95th centiles. Results: Final sample included 369 women. TSH reference ranges of the first (n=64), second (n=188) and third (n=117) trimesters were 0.014-2.77mIU/L, 0.31-3.2 mIU/L and 0.34-3.4 mIU/L, respectively. TPO antibody level showed a weak but significant correlation with TSH (r=0.10,p 0.021) in the final sample. No significant association was found between urine iodine and thyroid function tests. Conclusions: TSH reference ranges observed in this study are concordant with the Caucasian reference values more than the regional values. Discrepancies in study methodology, defining and selection of reference population and methods employed in measuring thyroid hormones in different studies may have accounted for these differences.

Apoplexy of Crooke cell tumour leading to the diagnosis of severe Cushing disease; a case report.

BACKGROUND: Patients with Crooke cell tumours present with features of Cushing syndrome or mass effect. There are few reports of patients with Crooke cell tumours presenting due to apoplexy. All of them had silent tumours. Patients with Cushing syndrome caused by Crooke cell tumours have not been reported to present with apoplexy. CASE PRESENTATION: A 35-year-old female presented with sudden onset headache and visual loss for 1 week. She had secondary amenorrhoea for 10 years. There were features of Cushing syndrome including central obesity, multiple monomorphic acne, dorso-cervical and supraclavicular fat pads, hypertension, proximal weakness, pigmentation and refractory hypokalaemia. She was found to have markedly elevated serum cortisol, central hypothyroidism and hypogonadotropic hypogonadism. There was a mass in the sellar region (4.7 cm × 1.9 cm × 5.3 cm) suggestive of a pituitary tumour extending to the suprasellar region. Imaging showed evidence of bleeding and compression of the optic chiasm. She underwent urgent trans-sphenoidal excision of the tumour. Histology was compatible with a pituitary neuroendocrine tumour. There was margination of ACTH reactivity to the cell periphery and ring like positivity in most of the cells in the cytokeratin stain. Features were in favour of a Crooke cell tumour. After surgery she improved gradually and became eucortisolaemic. CONCLUSIONS: This is a unique presentation of an apoplexy of Crooke cell tumour causing Cushing syndrome. Delayed health seeking behaviour of this patient despite severe Cushing disease could have led to this presentation which has not been reported before.

A challenging case of Cushing's disease complicated with multiple thrombotic phenomena following trans-sphenoidal surgery; a case report.

BACKGROUND: Cushing's syndrome occurs due to overproduction of cortisol from adrenal glands. Endogenous hypercortisolemia can occur secondary to adrenocorticotropic hormone (ACTH) dependent as well as independent causes. The presence of non-specific symptoms and signs contributes to a delay in diagnosis. Early identification and prompt definitive management is crucial. It is important to be alert about the post-operative complications including multiple thrombotic phenomena, which can add to the mortality. We report a case of Cushing's disease in a young female managed with trans-sphenoidal surgery, followed by a challenging post-operative period complicated with multiple thrombotic phenomena, ultimately succumbed. CASE PRESENTATION: A 32-year-old Sri Lankan female presented with overt features of Cushing's syndrome and diagnosed to have ACTH dependent Cushing's disease with pituitary microadenoma. She underwent trans-sphenoidal surgery, following which she developed fatal multiple complications including diverticular rupture and ischemic colitis, needing hemicolectomy, followed by a parieto-occipital infarction. CONCLUSION: This case highlights important and aggressive complications associated with Cushing's syndrome giving rise to a challenging post-operative course. Diverticular rupture had been described in association with hypercortisolemia and this case adds to the existing literature. Post-operative ischemic colitis and stroke which contributed to the death of this patient could have been due to the procoagulant state associated with Cushing's syndrome, with a high risk during the immediate post-operative period. This emphasizes the need to consider post-operative thromboprophylaxis in patients undergoing surgery for Cushing's syndrome.

Effectiveness and acceptability of a novel school-based healthy eating program among primary school children in urban Sri Lanka.

BACKGROUND: Obesity rates are rising rapidly in low-middle-income-countries (LMICs). School-based interventions have shown moderate efficacy in improving diet and lifestyle associated with obesity in high-income countries. However, there is little data available on effective interventions suitable for LMICs. We devised a novel program for primary school children including a simple storybook and sticker-based food-diary (FD) and conducted a pilot study to evaluate the acceptability and short-term effectiveness of the program. METHODS: This pre-post intervention study included grade 1 and 2 students from four public schools in Colombo, Sri Lanka. Weight and height were assessed, and participating children self-monitored their diet using sticker-based FDs for one week at baseline (pre-test). The following week, class teachers discussed the storybook, which incorporated the benefits/disadvantages of a healthy/unhealthy diet and lifestyle in classrooms. At the end of the intervention, participating children were self-monitoring their diet again for a week (post-test). A simple scoring system was used to derive a weekly score based on the healthiness of the meals consumed each week (FD-score). The primary outcome of the study was change in eating habits following the story book discussion (post-test FD score - pre-test FD score). Acceptability and effectiveness were also assessed by anonymized feedback questionnaires for parents and teachers. RESULTS: One thousand and forty-two students completed the program. There was an improvement in eating habits of participating children, with FD scores improving by 12% from 51 ± 23 at baseline to 63 ± 24 following the intervention (p < 0.001). Further, when considering BMI category of participants: 69.1% were normal weight (NW), 18.3% underweight (UW), 7.4% overweight (OW) and 5.2% obese (OB). Improvement in eating habits were seen among children of all BMI categories (change in FD-score: UW 13.2%, NW 12.3%, OW 10.4% and OB 12.4% (p < 0.001)). Furthermore,> 90% parents(n = 1028) and > 95% teachers(n = 39) strongly agreed/agreed that the intervention was easy to implement, motivated children and led to an observable improvement in healthy eating. CONCLUSION: This novel program led to an immediate improvement in eating habits and was well accepted by parents and teachers making it a potentially suitable intervention for wider implementation in primary schools in urban Sri Lanka.

Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature.

The coronavirus disease 2019 (COVID-19) pandemic has emerged as one of the greatest challenges faced by humankind in the recent past. People with diabetes and related comorbidities are at increased risk of its complications and of COVID-19-related death. Older age, multi-morbidity, hyperglycaemia, cardiac injury and severe inflammatory response are predictors of poor outcome. The complex interplay between COVID-19, diabetes and the effects of related therapies is being explored. Most patients experience a mild illness with COVID-19, while people with diabetes are at increased risk of severe disease. Optimising glycaemic control and adopting measures to prevent disease spread are critical aspects. The management of mild disease is supportive, while very many immunomodulatory and antiviral therapies are being investigated for the treatment of severe disease. Several of these agents have specific considerations for use in people with diabetes. Since mass population lockdowns are considered a key step in controlling disease spread, it follows that, in addition to the direct vulnerability to severe COVID-19, people with diabetes can be affected by limited access to healthcare, insulin, other medications and blood glucose monitoring equipment. Measures to prevent disease spread at the individual and community level are the key to mitigating the rapidly escalating pandemic, while agents for chemoprophylaxis and vaccines are being explored. People with diabetes should be recognised as a vulnerable group for complicated disease and are at risk during times of disturbed social systems. Strategies are needed to safeguard the health of patients with diabetes during the pandemic. This review summarises the current knowledge and perceived challenges for prevention and management of COVID-19 in people with diabetes.

Endocrine vigilance in COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus responsible for a pandemic that emerged in December 2019. Heterogeneous clinical forms are described from asymptomatic to severe hypoxaemic acute respiratory syndrome with multisystem organ failure. The impact of this coronavirus disease 2019 on the endocrine glands remains unknown. However, the results of previous studies on viruses from the same family allow us to write proposals for patients followed for chronic endocrine diseases. Currently, if these subjects are infected with SARS-CoV-2, they must not stop their treatment. In some cases, hormone replacement doses have to be increased. In case of worsening clinical signs, hormonal biological monitoring must be done. This article will be helpful for improving the management of chronic endocrine diseases that could affect thyroid, adrenals, gonads and pituitary gland functions. Proposals could be applied in COVID-19 infected subjects or in those who have been in contact with COVID-19 infected people.

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.

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.

Case report: rare skeletal manifestations in a child with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (PHPT) is uncommon among children with an incidence of 1:300,000. This diagnosis is often missed in children in contrast to adults where it is detected at a pre symptomatic stage due to routine blood investigations. Etiology of PHPT can be due to adenoma, hyperplasia or rarely carcinoma. CASE PRESENTATION: A 12 year old Sri Lankan girl presented with progressive difficulty in walking since 1 year. On examination she had bilateral genu valgum. Skeletal survey revealed valgus deformity of knee joints, bilateral subluxation of upper femoral epiphysis(SUFE), epiphyseal displacement of bilateral humeri, rugger jersey spine and subperiosteal bone resorptions in lateral aspects of 2nd and 3rd middle phalanges. There were no radiological manifestations of rickets. Metabolic profile revealed hypercalcemia with hypophosphatemia. Intact parathyroid hormone levels were elevated at 790 pg/ml. Vitamin D levels were deficient. She had low bone mineral density with Z score of -3.4. Vitamin D supplementation resulted in worsening of hypercalcemia without reduction in PTH levels. Tc 99 Sestamibi uptake scan showed abnormal tracer retention in left inferior pole of thyroid. A large parathyroid gland was removed with histology favoring parathyroid adenoma. Post operatively she developed hypocalcemia. Bilateral osteotomy was done for SUFE and further surgeries for correction of limb deformities planned. CONCLUSION: PHPT in children is usually diagnosed late when irreversible organ damage has occurred. Children can present with non specific symptoms involving gastrointestinal, musculoskeletal, renal and neurological systems. PHPT can cause disarray in bone and epiphysis in children during pubertal growth spurt. Genu valgum and SUFE are rare skeletal manifestations in PHPT and only 10 cases of genu valgum and 9 cases of SUFE have been reported up to now. So far no cases have been reported on epiphyseal displacement of humeri. Awareness regarding the occurrence of these rare skeletal manifestations especially during puberty is important for early diagnosis to prevent irreversible outcomes.

Outcomes of offspring born to mothers with gestational diabetes.

With the global explosion of Diabetes and obesity at epidemic proportions, keeping Asia at its epicenter, 1 in 7 live births get complicated with hyperglycaemia; either pre-existing Diabetes or Gestational Diabetes. In utero, exposure to an adverse metabolic environment with nutrient excess or deficiencies and toxic metabolites with teratogenic potential, leads to short and long term consequences to the offspring. Multisystemic congenital malformations, macrosomia associated obstetric complications and perinatal metabolic derangements complicate the early neonatal stage. Epigenetic changes taking place during foetal development initiate foetal metabolic programming and create adverse metabolic memory leading to childhood obesity, metabolic syndrome and Diabetes. Hyperglycaemia and poor metabolic parameters throughout pregnancy correlate with adverse offspring outcomes. Novel management strategies targeting near normoglycaemia have achieved marked improvements in rates of perinatal mortality and other adverse outcomes. Therapies for management of Diabetes in pregnancy should be carefully selected upon the safety profile for the offspring.

South Asian consensus guideline: Use of GLP-1 receptor agonists during Ramadan: Update 2016 Revised Guidelines on the use of GLP-1A in Ramadan.

This guidance is an update to the South Asian Consensus Guideline: Use of GLP1RA in Diabetes during Ramadan, published in the Indian Journal of Endocrinology and Metabolism in 2012. A five country working group has collated evidence and experience to suggest guidelines for the safe and rational use of glucagon-like peptide1 receptor agonists during Ramadan. The suggestions contained herewith are based upon recently published evidence as well as available basic pharmacological data.

Update to South Asian consensus guideline: Use of newer insulins in diabetes during Ramadan Revised Guidelines on the use of insulin in Ramadan.

This guidance is an update to the South Asian Consensus Guideline: Use of Insulin in Diabetes during Ramadan, published in the Indian Journal of Endocrinology and Metabolism in 2012. A five country working group has collated evidence and experience to suggest guidelines for the safe and rational use of insulin degludec (IDeg) and insulin degludec aspart (IDegAsp) during Ramadan. The suggestions contained herewith are based on the pharmacokinetic and pharmacodynamics properties of these novel insulins.

Lifestyle patterns and dysglycaemic risk in urban Sri Lankan women.

Specific dietary patterns are associated with the risk of chronic disease. An in-depth understanding more reflective of lifestyle would be possible when assessing the synergistic effects of both diet and physical activity in pattern analysis. In the present study, we examined the biochemical markers of dysglycaemia and cardiometabolic risk in relation to lifestyle patterns using principal component analysis (PCA). Urban women (n 2800) aged 30-45 years were screened for dysglycaemia using cluster sampling from the Colombo Municipal Council area. All the 272 dysglycaemic women detected through screening and 345 randomly selected normoglycaemic women were enrolled. The International Physical Activity Questionnaire and a quantitative FFQ were used to assess physical activity and diet, respectively. Anthropometric measurements, bioelectrical impedance analysis and biochemical estimations were carried out. Lifestyle patterns were identified based on dietary and physical activity data using exploratory factor analysis. PCA was used for the extraction of factors. A total of three lifestyle patterns were identified. Women who were predominantly physically inactive and consumed snacks and dairy products had the greatest cardiometabolic risk, with a higher likelihood of having unfavourable obesity indices (increased waist circumference, fat mass percentage and BMI and decreased fat-free mass percentage), glycaemic indices (increased glycosylated Hb (HbA1c) and fasting blood sugar concentrations) and lipid profile (increased total cholesterol/TAG and decreased HDL-cholesterol concentrations) and increased high-sensitivity C-reactive protein concentrations. For the first time, we report lifestyle patterns and demonstrate the synergistic effects of physical activity/inactivity and diet and their relative association with cardiometabolic risk in urban women. Lifestyle pattern analysis greatly increases our understanding of high-risk behaviours occurring within real-life complexities.

Bruns Garland Syndrome as the first presentation of type 2 diabetes: two case reports and a practical approach to diagnosis.

BACKGROUND: Diabetes is a global health problem causing a significant burden on the healthcare systems both due to the disease itself and associated complications. Diabetic radiculoplexus neuropathies or Bruns-Garland syndrome constitutes a rare form of microvascular complications, more commonly affecting the lumbosacral plexus and, very rarely, the cervical plexus. We describe two Sri Lankan males who presented with diabetic lumbosacral radiculoplexus neuropathy and diabetic cervical radiculoplexus neuropathy as the initial manifestation of diabetes. CASE DESCRIPTION: Case 1: a 49-year-old Sri Lankan hotel chef presented with subacute painful weakness and wasting of the left upper arm for 3 months and weight loss. Left upper limb proximal muscles were wasted with diminished power and reflexes. A nerve conduction study showed comparative amplitude reduction. An electromyogram revealed positive sharp waves, frequent fibrillations, and high amplitude polyphasic motor unit potentials with reduced recruitment in proximal muscles of left upper limb. Case-2: a 47-year-old Sri Lankan carpenter presented with subacute progressive asymmetrical painful weakness and wasting of bilateral thighs for 5 months and weight loss. Lower limb proximal muscles were wasted with reduced power and knee jerks. The nerve conduction study was normal. The electromyogram was similar to case 1 involving both quadratus femoris muscles, which was more prominent on the left side. The work up for an underlying etiology revealed only elevated fasting blood glucose and HbA1c, suggesting a new diagnosis of diabetes associated with neurological symptoms. Patient 1 was diagnosed with diabetic cervical radiculoplexus neuropathy and patient 2 with diabetic lumbosacral radiculoplexus neuropathy. Both showed significant improvement following optimization of glycemic control together with symptomatic treatment and physiotherapy. CONCLUSION: Diagnosis of diabetic radiculoplexus neuropathy requires a comprehensive workup to rule out other sinister pathologies. This case report has a dual importance; it describes diabetic radiculoplexus neuropathy as the very first manifestation of two previously healthy people, giving rise to a new diagnosis of diabetes and, at the same time, reporting on diabetic cervical radiculoplexus neuropathy, which is extremely rare and has never been previously reported in Sri Lanka.

Global Barriers to Accessing Off-Patent Endocrine Therapies: A Renaissance of the Orphan Disease?

CONTEXT: Clinical endocrinology encompasses many diseases requiring long-term drug therapy. Prohibitive pricing of some endocrine drugs classified as essential by the World Health Organization has created suboptimal care of patients with endocrine disorders. EVIDENCE ACQUISITION: This review is based on evidence obtained from several databases and search engines including PubMed, Google, and Google Scholar; reference searches; manual searching for web pages of international regulatory bodies; and the authors' experience from different healthcare settings. EVIDENCE SYNTHESIS: After the expiry of a patent, generic versions with the opportunity for increased availability and a price reduction are expected. There are access barriers worldwide for many off-patent endocrine drugs. The high price is the main issue for several medicines including insulin, hydrocortisone, testosterone, and gonadotropins. This is caused by several factors including the market monopoly due to the lack of registered generics or suppliers limiting the benefit of competition and a complex supply chain. Additionally, the lack of some medicines has been concerning due to market factors such as the relatively small number of patients, making it less attractive for the manufacturers. Commissioning of nonprofit manufacturers and state manufacturing as well as strict price control measures could alleviate this situation. CONCLUSION: Lack of availability and disproportionate price inflation affecting essential off-patent endocrine therapies is common due to several interrelated factors. Global collaboration among healthcare organizations with the support of policymaking bodies might be needed to mitigate this.

Improved food habits and anthropometry among primary school children following a novel healthy eating programme.

OBJECTIVE: Assess longer-term changes in food habits and anthropometry among Grades 1-2 primary school students from four public schools in Colombo, Sri Lanka, following a 3-week programme including a classroom-based motivational storybook discussion and self-monitoring food diary (FD). METHODS: This follow-up study assessed changes from baseline (pre-intervention) BMI z-scores and food habits (increased healthy food-item consumption/decreased unhealthy food-item consumption reflected by an increase in FD score) and parental perceptions (anonymous questionnaires) among 863 students (aged 6-8 years), between 9 and 12 months after completing the programme (November 2019-February 2020). RESULTS: Food habits showed sustained improvement from baseline mean FD score (baseline vs. follow-up: 51 ± 23% vs. 67 ± 22%, p < 0.001), with children from all BMI subgroups (underweight [UW], normal weight [NW], overweight [OW] and obesity [OB]) showing a significant increase in FD scores (ranging from 14.1% to 17.2%, p < 0.001). BMI z-scores increased in children living with UW (-2.85 to -2.21, p < 0.00) and NW (-0.70 to -0.57, p < 0.001), but did not change in children with OW (+1.5 to +1.49, p = 0.83) and OB (+2.85 to +2.21, p = 0.19). Most parents (n = 497, 97.8%) reported satisfaction with programme outcomes. CONCLUSION: This programme led to sustained improvement in food habits among young primary school children from all BMI categories, increase in BMI towards the median among children living with UW and NW, and stabilization of BMI in children with OW and OB, suggesting it as a useful tool for improving nutritional status of young children in low- and middle-income countries (LMIC) facing the double burden of under- and overnutrition.

Influence of quitting smoking on diabetes-related complications: A scoping review with a systematic search strategy.

INTRODUCTION: Smoking in people with diabetes markedly elevates their risk of developing complications and increases the likelihood of cardiovascular mortality. This review is the first to specifically provide evidence-based analysis about the influence of quitting smoking on diabetes-related complications in people with type 2 diabetes. METHOD: The present review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. All human clinical studies assessing the effects of stopping smoking cessation on diabetes-related complications were included. PubMed and Embase were screened until January 2024. References of primary studies and principal peer-reviewed scientific journals in the field were manually screened. RESULTS: We identified a total of 1023 studies. Only 26 met the criteria for eligibility. In general quitting smoking is associated with decreased risks of myocardial infarction and ischemic stroke. Regarding microvascular complications, the strongest evidence for the beneficial effects of smoking cessation is observed in diabetic nephropathy. However, the relationship between smoking cessation and retinopathy, neuropathy, diabetic foot complications and diabetic-related erectile dysfunction, is poorly investigated. CONCLUSION: Quitting smoking offers significant advantages in managing diabetes-related complications, significantly lowering the risks of myocardial infarction, ischemic stroke, and diabetic nephropathy. This underscores the importance of cessation. Providing evidence-based information on the benefits of stopping smoking for people with type 2 diabetes who smoke, can bolster smoking cessation efforts in the context of diabetes management.

Behavioral Therapy for People With Diabetes Who Smoke: A Scoping Review.

BACKGROUND: Tobacco smoking exacerbates diabetes-related complications; its prevalence is notwithstanding substantial. Persons with diabetes face a number of barriers and challenges to quitting such as multiple lifestyle restrictions; tailored interventions are required for smoking cessation. OBJECTIVE: To identify research on behavioral interventions for smoking cessation in diabetes. METHODS: Studies had to be randomized controlled trials, quasiexperimental or systematic reviews. The behavioral interventions included were: the 5As, Cognitive-Behavioral Therapy, Motivational Interviewing, Contingency Management, Health Coaching and Counselling, as compared to standard care. The outcomes were self-reported and/or biochemically verified smoking cessation. CINAHL Complete, MEDLINE Complete, the Cochrane databases of systematic reviews and randomized controlled trials, PsychInfo and PubMed Central were searched until July, 2023. Keywords used included diabetes, smoking cessation and each of the behavioral interventions included. RESULTS: 1615 papers were identified. Three studies on the 5As/brief advice, 4 on Motivational Intervention and 1 on counseling were retained. The results on the 5As and Motivational Interviewing were conflicting. More intensive interventions appear to be more successful in achieving smoking cessation in smokers with diabetes. CONCLUSIONS: Future research should focus on the continued development and evaluation of structured smoking cessation interventions based on the 5As, Motivational interviewing and Cognitive Behavioral Therapy.