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   Table of Contents - Current issue
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April-June 2021
Volume 12 | Issue 2
Page Nos. 111-238

Online since Wednesday, March 31, 2021

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EDITORIAL  

Impact of bariatric surgery on body composition and metabolic profile in obese patients with diabetes: A commentary Highly accessed article p. 111
Rajeev Chawla
DOI:10.4103/jod.jod_24_21  
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REVIEW ARTICLES Top

Inhaled glucagon: A new hope for severe hypoglycemia in type 1 diabetes Highly accessed article p. 114
Salva Fatima Heba, Uzma Parveen, Sara Sana Ayesha Khanum, Maaria Gulnaaz, Maimuna Tabassum, Syeda Batool Safiyya
DOI:10.4103/jod.jod_26_20  
Until now injectable glucagon was the only available treatment used in the management of severe hypoglycemia wherein glucagon had to be prepared in several steps before administration. This method of delivery of injectable glucagon being cumbersome and unappealing for a wide majority of the patients had led to a search for an alternative route of drug delivery. Intranasal (IN) glucagon now serves an efficient, safe, easy to administer, and a favorable substitute to glucagon injections. This ready-to-use device stands in clear contrast to overcome the limitations associated with the currently available glucagon preparations, which has emerged a key advancement in the management of severe hypoglycemia in adolescents and children with type 1 diabetes. IN glucagon is now being developed and studied in other countries as well to meet the unmet need for an easy and convenient glucagon administration. This review covers the basic information of nasal glucagon, trials on nasal glucagon in children’s and adults, and its potential uses, limitations, and future scope in practice.
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Nitrosodimethylamine impurities in metformin drug products: Physician insight p. 120
Chetan Doshi, Rajkumar Malayandi, Gajanan Namjoshi, Pramod Kadam, Dhananjay Mule
DOI:10.4103/jod.jod_60_20  
Metformin is a high-dose antidiabetic drug and most widely used first-line therapeutic agent for the management of type 2 diabetes mellitus (T2DM). Medicines regulatory agencies discovered contamination of genotoxic nitrosamine impurity in certain medications containing angiotensin receptor blocking (ARB) agents. This resulted in screening for nitrosamine impurities in a number of probable drug products. In November 2019, the Singapore government withdrew metformin drug products, due to the contamination of nitrosamine impurity, called nitrosodimethylamine (NDMA). The regulatory agencies from different geographies started investigation and subsequently, many products withdrew from the international market due to the presence of an unacceptable limit of NDMA in metformin tablets. Both pharmaceutical companies and regulatory agencies responded to mitigate this emerging issue. USV Private Limited (USV) has adopted a proactive quality risk management program to investigate the presence of genotoxic impurities in metformin products. The presence of NDMA impurities were tested in 425 batches of drug substances and drug products. Threshold toxicological concern (TTC) of all the batches was found to be ≤30 ng/day, when compared to the regulatory limit of 96 ng/day. Hence, USV metformin products are safe and can be continuously prescribed for the management of T2DM.
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A review on ethanobotanical survey of medicinal plants available in North-East India against microbes involved in diabetic foot ulcer p. 128
Nayan Talukdar, Karabi Das, Indrani Barman
DOI:10.4103/jod.jod_45_20  
Diabetes mellitus is one of the most common chronic metabolic disorders, which are occurring across the globe with several complications affecting different systems of the body. One of the most devastating complications of diabetes mellitus is a diabetic foot ulcer. With the global occurrence of 6.3%, diabetic foot ulcers are commonly caused due to the severe infections caused by multidrug-resistant microorganisms such as Staphylococcus aureus, Klebsiella species, Enterococcus, Pseudomonas aeruginosa, Escherichia coli, and Proteus species and filamentous fungi such as Candida sp and Fusarium solani. Till date, medicinal plants have been traditionally used to treat several human infections. There are plants such as Santalum album, Jasminum officinale, Bergenia ciliata, and Cinnamomum tamala, which have variable antimicrobial activities. They are potentially active against microorganisms such as S. aureus, P. aeruginosa, E. coli, Klebsiella sp., and Proteus sp., which are commonly found in several human infections. Further investigations can be done to introduce the effect of various medicinal plants that can act against the microorganisms associated with diabetic foot ulcers and inhibit their growth. Northeast India being a large reservoir of diverse medicinal plants can be explored for the discovery of newer antibacterial bioactive molecules that can inhibit the growth of such microorganisms, thereby developing nature-based treatment methods which will reduce the high cost of treating diabetic foot ulcers.
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ORIGINAL ARTICLES Top

Admission hyperglycemia and its implications on outcome in patients attending medical intensive care units at Assiut University Hospital p. 134
Lobna F El Toony, Mona H El Zohri, Aml A Abo Elghait
DOI:10.4103/jod.jod_28_18  
Background: Admission hyperglycemia is defined as any blood glucose (BG) level greater than 140 mg/dL (>7.8 mmol/L) in critical care unit (CCU) according to American Diabetes Association 2015. Stress hyperglycemia is related to multiple factors and can lead to insulin resistance and high hepatic glucose output. Aim: To determine the frequency, in-hospital mortality, and length of stay in a cohort of patients with admission hyperglycemia in unselected acute medically ill patients admitted to medical intensive care units (ICUs) (medical ICU and CCU) attending Internal Medicine Department, Assiut University Hospital, Assiut, Egypt, and to evaluate whether admission hyperglycemia or other comorbid conditions are responsible for outcome of critical ill patients. Subjects and Methods: This prospective, observational study involved 170 patients admitted at ICU unit of Internal Medicine Department at Assiut University Hospital between July and December 2016. Measurement of BG on admission to ICU was as following: normoglycemic if less than 140 mg/dL and hyperglycemic if more than 140 mg/dL. Then, follow up BG every 8h till either discharge or death or maximum 4 days in addition to fasting, postprandial BG, HbA1C, complete blood count and kidney function tests, serum sodium, serum potassium, arterial blood gases, and acute physiologic assessment and chronic health score were carried out. Results: This study included 170 patients, 35.3% were normoglycemic and 64.7% were hyperglycemic, which were further subdivided into 43% known diabetics, 14.1% stress hyperglycemia, and 7.6% newly discovered diabetics. Percentage of survivors was 72.9% versus non-survivors, which was 27.1%. Median hospital stay for all patients was 6 (4–28) days with in-hospital mortality of 46 (27.1%) patients. It was noticed that frequency of non-survivors was higher in patients with hyperglycemic versus that of survivors. Conclusion: Stress hyperglycemia and diabetes were independent predictors for in-hospital mortality in patients with admission hyperglycemia attending ICU.
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Prediction and risk factor analysis of obesity-related proteinuria among individuals with metabolic syndrome p. 140
Syed Vaziha Tahaseen, P Kiranmayi, Marni Rakshmitha, Bezawada Anusha
DOI:10.4103/jod.jod_37_20  
Objective: In the present modern era of time, poor and frantic lifestyle has led to an enumerate increase in the number of people with obesity and metabolic syndrome (MS). Epidemiological studies have shown the incidence of chronic kidney disease (CKD) risk factors in individuals with obesity and MS; despite the nonclear evidence on the existing potential risk factors, it became important to reassess existing potential risk factors that are involved in disease progression and its further complications. The strongest risk factor of CKD, albumin-to-creatinine ratio (ACR) recognized as a marker of MS and obesity. This study was carried out to identify the association of obesity (body mass index [BMI]) as a risk factor for albuminuria and to observe the dependence and association with albuminuria of each critical and basic factor of MS. Design: We conducted the potential risk factor analysis on 913 subjects, including 398 females and 515 males, from various diabetic hospitals of Vijayawada, Andhra Pradesh from early 2013 to June 2015. The medical records of the patients followed up; the anthropometric measurements and clinical parameters were retrospectively collected. The total subjects were categorized as subjects with and without MS as per National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPIII) and the subjects with BMI more than 30 kg/m2 were defined as obese according to WHO classification. Results: Student’s t test analysis indicates a significant difference for ACR with mean values of 39.5 ± 44.8 and 18.4 ± 24.3 (P < 0.0001) in subjects with MS and without MS, 43.4 ± 48.3 and 36.7 ± 42.5 (P < 0.02) in obese and nonobese subjects, respectively. Chi-square analysis showed a significant association (P < 0.05) between MS and ACR and correlation analysis manifested significant association (P < 0.01) between ACR and FBS, TG, B.P, and Age in subjects with MS. The subjects with high prevalence of albuminuria exhibited significant association with an odds ratio (OR) of 1 (referent) 1.9 (95% CI, 1.34–2.58, P = 0.0002), 1.5 (95% CI, 1.11–1.96, P = 0.0082) for FBS >110 mg/dL, and TG > 150 mg/dL, respectively. Although the subjects with obesity showed no correlation with albuminuria, the risk for albuminuria was 1.5 times (95%CI 1.03–2.40, P = 0.03) higher among obese male subjects compared to obese female subjects. Conclusion: Our study strongly supports that albuminuria is highly prevalent among the subjects, with MS showing a significant positive association between obesity (BMI) with albuminuria in males only.
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Renoprotective effects of teneligliptin: An observational study p. 146
Prabhat Agrawal, Ashish Gautam, Apoorva Jain, Nikhil Pursnani, Manjula S, Krishna Kumar M
DOI:10.4103/jod.jod_42_20  
Aim: The aim of this study was to validate the potential of teneligliptin in managing type 2 diabetes mellitus (T2DM) with renal impairment and to evaluate its effect on renal parameters in Indian subjects. Patients and Methods: The prospective observational study included 86 subjects aged >40 years with suboptimal control of T2DM (HbA1c >7.5). The demographic details of the selected subjects were recorded. The patients were continued on existing oral hypoglycemic agents (OHAs) and antihypertensives. The following clinical and anthropometric parameters were measured at baseline, 4 months, 8 months, and 12 months during the treatment using 20 mg of teneligliptin per day: HbA1c, eGFRs, UACR, FBG, and PPBG levels. Comparisons of anthropometric and laboratory parameters were carried out using analysis of variance (ANOVA) and t test for normal data, Kruskal–Wallis for nonnormal data, and chi-square test for counts data. Results: The mean age of the subjects was 54.28 ± 6.8 years and the male-to-female ratio noted was 1:0.65. The mean values of FBG (mg/dL ± SD) at 4, 8, and 12 months were found to be statistically significant (P < 0.001, 117.12 ± 30.51, 109.69 ± 43.66, and 113.16 ± 56.93, respectively). t test carried out for PPBG indicated that the levels at respective intervals were significantly reduced as opposed to baseline (P < 0.05). The difference in HbA1c (%) across baseline, 4, 8, and 12 months was found to be statistically significant (P < 0.001) and the mean levels noted were 8.09 ± 2.26, 7.57 ± 1.84, 6.95 ± 1.80, and 6.46 ± 1.81, respectively. The difference in UACR across different intervals was found to be statistically significant (P < 0.001) and the corresponding mean UACRs (mg/g ± SD) noted were 417.21 ± 182.87, 291.82 ± 98.30, 296.84 ± 109.48 and 284.18 ± 103.26. Conclusion: Teneligliptin monotherapy is well tolerated with a persistent reduction in HbA1C and significant improvement in renal function.
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Assessment of acute complications of diabetes mellitus using clinical records of diabetic patients in Adama Hospital Medical College, Oromia Regional State, Ethiopia p. 151
Tigist Tilaye, Bayissa Chala
DOI:10.4103/jod.jod_27_20  
Background: Diabetes mellitus (DM) is one of the emerging public health problems in developing countries. Patients with acute complications of the disease frequently seek care in hospital emergency departments. However, the magnitude of acute complications of DM has not been studied at facility levels. This study was aimed at assessing the prevalence and associated risks of acute complications of DM at health facilities. Materials and Methods: Hospital-based cross-sectional study design was used. The source of population was medical records of DM patients and the study population was medical records of DM patients admitted to Adama Hospital Medical College. A total of 200 medical records of patients in AHMC medical ward were used to extract patients’ medical information concerning DM and associated factors. Moreover, DM-related pretested semi-structured questionnaires were developed and administered to 200 active DM patients following their treatment during December 2018 of data collection. Results: The proportion of diagnosed acute complications of DM among patients in this study was 146(73%) while 54(27%) did not present acute complication of DM. The history of acute complication associated with diabetic ketoacidosis (DKA) accounted for 133(66.5%) while hyperglycemic hyperosmolar state (HHS) was 21(10.5%) but 46(23%) did show neither DKA nor HHS. From this study of clinical record, the proportion of acute complication of DM with DKA was higher among type I DM patients than type II patients. However, the proportion of HHS was relatively low in type I DM and high in type II DM patients. Conclusion: The prevalence of acute complications of DM was 146(73%) and 67(85.9%) and 79(64.8%) in type I and type II DM, respectively. Moreover, the proportion of acute complication of DM with DKA was higher among type I DM patients than type II patients. Strengthening of health education both at health facilities and general population is important.
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Frequency and predictors of hypoglycemia in Type 2 diabetes: A population-based study p. 157
Nesma Ali Ibrahim
DOI:10.4103/jod.jod_48_20  
Background: Hypoglycemia presents a barrier to optimum diabetes management; however, data are limited on the frequency of hypoglycemia incidents outside of clinical trials. Aim: The aim of the present study was to investigate the frequency of self-reported hypoglycemic events in patients with Type 2 diabetes mellitus (T2DM) and to define factors that predict a higher risk of hypoglycemia. Materials and Methods: A sample of 1500 patients with T2DM were recruited in this prospective, observational study, selected at random from a validated community population, attending the outpatient clinic of diabetes, Ain Shams University Specialized Hospital. Eligible patients were followed up for 12 months and were instructed on the use of a diary to record hypoglycemic events. Ordinal logistic regression was performed to identify potential predictors of hypoglycemia. Results: Of a total of 1347 patients with data available for the present analysis, 583(43.28%) had experienced hypoglycemia. The participants experienced a total of 3816 hypoglycemic events during the study period, which amounts to 2.83 events (95% CI 2.74, 2.92) per patient per year. Of those who experienced hypoglycemia, 13(2.23%) recorded severe events and 125(21.44%) had evidence of impaired awareness of hypoglycemia. Patients who had experienced hypoglycemic events were elder and have higher body mass index, longer duration of diabetes, and higher HbA1c than those who had not experienced hypoglycemia, the difference was significant (all P < 0.05). Also, they were on insulin therapy, have diabetes complications, used to have irregular meals, and do not practicing exercise when compared with patients who had not experienced hypoglycemia (all P < 0.05). No significant difference was found based on gender (P = 0.25) between patients who experienced and those had not experienced hypoglycemia. Conclusions: Hypoglycemia is a frequent adverse effect in patients with T2DM, and particular attention is warranted in elder, obese patients with poor control and longer duration of diabetes. The presence of diabetes complications, insulin therapy, and unhealthy life style are also predictors of hypoglycemia.
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A descriptive cross-sectional study on medication adherence of oral antidiabetic agents in diabetes mellitus patients and an overview on clinical pharmacist’s role in medication adherence in government headquarters hospital Tiruppur p. 164
Royal Frank Prathap, Maneesha Suresh, Malavika Maliakkal Rajeev, Jim Cherian Saji, Singaravadi Ezhilmaran Bharanidharan, Ganesan Vellaichamy
DOI:10.4103/jod.jod_57_20  
Aim and Objectives: In this study, the level of adherence to medications and factors influencing nonadherence to oral antidiabetic medications among patients with type 2 diabetes mellitus was assessed. This study also ascertained the clinical pharmacist role in improving medication adherence. Materials and Methods: This is a descriptive cross-sectional study based on prospective analysis of data collected from 150 cases in the general medicine department at the secondary care Government Headquarters Hospital, Tiruppur, Tamil Nadu state, India. The study was carried out over 6 months duration, from March 2019 to August 2019. Results: In the study, of 150 patients 60% were adherent, while 40% showed low adherence. Apparently, the subjects aged below 50 years showed 100% adherence and age group of 80–89 showed the least adherence of 12.5%. Out of 83 (55%) males and 67 (45%) females enrolled in the study, 50 (60.24%) of the former and 40 (59.70%) of the latter were found to be adherent. The rate of nonadherence in married and unmarried population was found to be 40.71% and 30%, respectively. Patients who had graduated from college/university showed 100% adherence whereas, the illiterate patients showed the least adherence of 32%. Moreover, the subjects who had their onset in the age between 20–29 years were 100% adherent and the least adherence of 33% were shown by subjects with onset age between 70–79. Patients with monotherapy were more adherent (77.8%) to the therapy when compared to the patients who were on polytherapy (43.6%) and the patients with diabetic complications showed 40% of adherence and the patients without any complications showed 86.15% of adherence. Eventually, the patients who did not experience any side effects showed good adherence (79.2%) compared to the ones with side effects who showed poor adherence (20.8%) to the therapy. Finally, the adherence among the patients who never consumed alcohol was found to be 69.9% whereas, patients who consumed alcohol everyday was found to be only 33.3%. Conclusion: Majority of the patients were found to be adherent towards oral antidiabetic agents; thus, influence of clinical pharmacist in adherence was evident in this study. The major barriers for medication adherence found were being older age, having low level of education, late onset of disease, presence of side effects and complications, polytherapy, and consumption of alcohol.
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Clustered metabolic approach using HbA1c, BP, and aortic augmentation index in type 2 diabetes as a tool for risk stratification p. 172
Shubhaa Chawla, Siddhant Trehan, Aastha Chawla, Shalini Jaggi, Rajeev Chawla
DOI:10.4103/jod.jod_61_20  
Materials and Methods: Functional vascular age in 2000 patients was assessed using cardiac risk profiler (vascular profiler-genesis), over a period of 3 years and 3 months between October 2016 and January 2020. The cardiovascular interpretations generated were used for the measurement of central arterial stiffness. The metabolically healthy groups were compared with the metabolically nonhealthy groups for the relevance of the triple co-association of HbA1c, arterial stiffness, and hypertension in screening the patients in regular standard care. The mean age of the patients was 53 years. Mann–Whitney test was used for the statistical analysis. Results: The mean age was 53.3 ± 12 years. HbA1c was <7% and >7% in 530 and 1470 patients, respectively. The lipid profile in comorbid scenario (n = 2000 [M = 1170 and F = 830]) revealed mean LDL-C mg/dL values of< 100, 100–150, >150 in 1380, 520, and 100 patients, respectively. A total of 1000 patients had the duration of diabetes <5 years, 380 patients were between 5 and 10 years, and 620 patients had been diabetic for>10 years, respectively. Arterial stiffness markers-Ankle Brachial Index and Carotid-Femoral Pulse Wave Velocity (CFPWV) were assessed and cluster analyses was performed using the metabolically healthy (HbA1c <7 and aortic augmentation index @ HR75 < 14 and nonhypertensive n = 50) as compared to the metabolically unhealthy cohort (HbA1c >7 and aortic augmentation index @ HR75 > 14 and with known hypertension (n = 230). The difference in the triple co-association of HbA1c (glycemic status), hypertensive status, and arterial stiffness was statistically significant when compared between the metabolically healthy (n = 50) vs. the metabolically nonhealthy cohort all across (n = 230) (P = 0.0457)Conclusion: The clustered metabolic marker approach is a tool to identify and stratify patients with diabetes based on the metabolic risk to prevent complications and possibly improve outcomes.
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Utility of an Internet-based short message service in the care of children and adolescents with type 1 diabetes mellitus p. 176
Nikhil Lohiya, Hemchand Krishna Prasad, Sherlin White, Bala Prasanna, Thangavelu Sangalalingam, Nedunchelian Krishnamoorthy
DOI:10.4103/jod.jod_65_20  
Objective: To evaluate the impact of an internet-based intervention system and a short message service (SMS) using cellular phones on the diabetes care and glycemic control in children and adolescents with type 1 diabetes mellitus (DM). Materials and Methods: Observational study in children with type 1 DM on basal bolus regimen. After administering diabetes care education children were divided in 2 groups, group I received timely SMS on diabetes care and group II did not. At the end of 3 months detailed data of diabetes care was recorded. Analysis was done using Statistical Package for the Social Sciences. Results: In a total of 42 children, group I (21) who received the SMS and group II (21), completed the follow-up period of 3 months were included in the study. There was marginal improvement in glycosylated hemoglobin in group I (from 9.2 ± 1.7 to 8.8 ± 1.2); and a minimal increase observed in group II (from 8.8 ± 1.8 to 9.4 ± 1.9) (P > 0.05). The percentage of capillary blood glucose (CBG) values below and above the target range, mean CBG, frequency of self-monitoring blood glucose, significantly improved compared to the control group (P < 0.05). Conclusion: SMS-based education program lead to a significant improvement in self-monitoring blood glucose frequency, diabetes self-care and marginal increase in glycemic control.
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Autoimmunity in south Indian children with recently diagnosed type 1 diabetes mellitus p. 182
Sridevi A Naaraayan, Raghavan V Dhakshayani, Rema Chandramohan
DOI:10.4103/jod.jod_73_20  
Background: Type 1 diabetes mellitus is known to be associated with autoimmunity and hence autoantibodies. The primary objective of this study was to determine the prevalence of glutamic acid decarboxylase 65 (GAD) antibody in patients with newly diagnosed type 1 diabetes mellitus. Materials and Methods: This cross-sectional study was done in a government-run pediatric tertiary care center in South India from 2015 to 2017 and included 125 patients with newly diagnosed type 1 diabetes mellitus. Demographic and clinical data were captured and GAD antibody was detected by the ELISA technique and a titer of above 1.0 IU/mL was considered positive. Results: The prevalence (95% confidence interval) of GAD 65 antibody was found to be 79.2% (71%–86%). Glycated hemoglobin level was significantly higher in GAD negative when compared to GAD positive patients (P < 0.05). Conclusion: Type 1 diabetes mellitus is associated with high prevalence of autoantibodies in the current era.
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Diabetes Educational intervention in Society to Improve (DESI) quality of life p. 186
Rishi Shukla, Deepak Yagnik, Neha Agarwal, Manisha Gupta, Bhasker Ganguli, Sangeeta Shukla, Anurag Bajpai
DOI:10.4103/jod.jod_78_20  
Background: Diabetes self-management education (DSME) is globally recognized as an integral part of diabetes management and in majority of the developed countries, it is delivered by trained diabetes educators. Unfortunately, in India, it is still not considered an essential part of diabetes management. Materials and Methods: A self-structured diabetes education program, of a 75-min duration, was developed over a period of six months. To assess the knowledge, before and after the implementation of the education program, a validated questionnaire, Diabetes Knowledge Questionnaire 24 (DKQ24) was used. Results: A total of 50 patients (34 males; 74%) were recruited in the study. The mean age of the study participants was 54.98 ± 12.02years, with a mean duration of diabetes 12.34 ± 8.76years and mean HbA1c 8.1 ± 1.49%. A statistically significant (P < 0.05) improvement in the proportion of correct responses (14 out of 24 questions; 58.3%) was seen after the implementation of the DSME program. Conclusion: There is limited research available in India on DSME. To meet the need of a structured diabetes education program in India, we have evolved one such program (duration of 75 min) within a period of six months. We anticipate this program to have enough potential in developing countries in the long run.
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Prioritization matrix for the diabetes prevention and control program: A concept paper p. 191
Vinod K Ramani
DOI:10.4103/jod.jod_63_20  
Introduction: The narrated NCD program is being implemented by KHSDRP in collaboration with the World Bank, New Delhi. This pilot project will involve NCD education and mobilization at the community level, provision of screening, and treatment services at the primary health-care level and strengthening diagnostic, specialist treatment services at the secondary and tertiary levels of care. This paper lists the activities of the diabetes component of the NCD program, and the prioritization matrix describes weighting of the important criteria. Materials and Methods: “Precede-Proceed” planning model is the better fit for our Diabetes Program. The prioritization matrix will enable weighting of each criterion against another (comparing each row heading consecutively with all the column headings), in order to decide upon its importance. Results: The matrix shows that awareness activities, beneficiary enumeration, mobilization of beneficiary, and behavior change interventions are the important criteria for this health promotion program. Discussion: The matrix shows that a large proportion of the budget should be invested in field-related activities for the success of the Program. Conclusion: Prioritization matrix enables the examination of all potential opportunities in a Program, by ranking the opportunities by two characteristics: importance and changeability. It systematically compares the choices through selection, weighting, and application of criteria.
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Intervention of a personalized low-carbohydrate diet to reduce HbA1c level and weight in patients with Type 2 diabetes using seed-based flour as replacement for high-carbohydrate flour and foods p. 196
Banshi Saboo, Sanjeev Phatak, Pratap Jethwani, Rohan Patel, Dhruvi Hasnani, Dharmendra Panchal, Smita Shah, Vaishnavi Raval, Roma Dave, Anurag Mishra
DOI:10.4103/jod.jod_74_20  
Background: Globally, 425 million individuals were living with diabetes in 2017, and the numbers are expected to rise to 693 million by 2045. India, with more than 72 million people with type 2 diabetes mellitus (T2DM) in 2017, was reported to have the second largest population of individuals living with T2DM (https://www.diabetesatlas.org/upload/resources/previous/files/8/IDF_DA_8e-EN-final.pdf). The traditional Indian diet is heavily dependent on carbohydrates, and this acts as an obstacle for diabetes control. Carbohydrate restriction is associated with improvements in glycemic control and a reduction in the risk of the worsening of the disease and its complications. Objective: We investigate the real-world effectiveness of personalized carbohydrate reduction by using seed-based flour (sunflower seeds, pumpkin seeds, watermelon seeds, soya, and flaxseeds) with high-carbohydrate grain-based flour in the food along with remote health coach support for patients on the high glycated hemoglobin (HbA1c) levels and weight loss of patients. Materials and Methods: This study is a nonrandomized outpatient intervention focusing on adults with T2DM. With their consent, patients were enrolled from four clinics across Gujarat, Ahmedabad. The key inclusion criteria focused on patients with Hba1c between 7 and 10 with a body mass index more than 25 kg/m2 from 21 to 60 years of age. The key exclusion criteria were patients with advanced renal, cardiac, or liver dysfunction, pregnancy or planned pregnancy, historical ketoacidosis problems, and patients on SGLT2 inhibitors or pre-mix insulin. The intervention was personalized carbohydrate restriction. Patients were advised to avoid high-carbohydrate food categories such as grains, sugars, and high-carbohydrate fruits. They were advised to take seeds and nuts-based flour, nonstarchy vegetables, sprouts, and berries family fruits. Patients were also provided with recipes and options for all meals of the day. No restriction was made on the intake on nonstarchy vegetables. Patients were also provided with Diahappy Health’s Health coach to constantly provide remote support to resolve queries and doubts through phones. Duration of Study: For each participant, the study was carried out for 12 weeks at a stretch. Benefits: The study demonstrates an average 2.34% drop in HbA1c levels in participants who completed the program. There was also an average weight drop of 9 kg achieved in the participants.
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Spectrum of diabetic lesions: An autopsy study p. 201
Shailesh Vartak, Amrita Neelakantan, Urmi Chakravarty-Vartak, Khushboo Mutha
DOI:10.4103/jod.jod_71_20  
Background: The aim of our study was to study the gross morphological changes, histopathology, prevalence, and characteristics of pathological lesions in various organs in patients of diabetes mellitus; to determine the contribution of diabetes to mortality; and to study complications of diabetes mellitus in the cases studied. Materials and Methods: Ours was a descriptive cross-sectional study of a five-year duration carried out at a tertiary care hospital. A complete medical autopsy was done of all the cases; all organs were examined grossly and microscopically, and their details were recorded. Results: A total of 137 patients with diabetes were studied at autopsy. Overall, 32.8% of the patients with diabetes were in the age group of 61–70 years, with a female:male ratio of 1.2:1. The highest frequency of deaths was due to diseases of the cardiovascular system (39%), whereas both septicemia and diseases of the respiratory system followed as a close second (37%). Overall, 10.94% patients died due to diseases of the central nervous system. Conclusion: The global burden of diabetes mellitus is increasing worldwide, and it is necessary to have an improved understanding of its etiology, pathogenesis, and pathophysiology to focus therapeutic and research efforts appropriately to reduce its effects on lives and economies.
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Impact of bariatric surgery on body composition and metabolism among obese Asian Indians with prediabetes and diabetes p. 208
Sundaramoorthy Chandru, Thyparambil Aravindakshan Pramodkumar, Rajendra Pradeepa, Saravanan Jebarani, Y D Meher Prasad, Raj P Praveen, Jagannathan Sathish Babu, Ranjit Mohan Anjana, Viswanathan Mohan
DOI:10.4103/jod.jod_102_20  
Background: The aim of this study was to evaluate the changes in body composition, central obesity (visceral and liver fat), and pro-inflammatory markers after bariatric surgery in obese Asian Indians with prediabetes and diabetes. Materials and Methods: This is 1-year follow-up study of 30 obese patients (BMI of 30–40 kg/m2) with prediabetes and diabetes who underwent bariatric surgery at tertiary diabetes center in South India. HbA1c, adiponectin, liver enzymes, ferritin, and high-sensitivity C-reactive protein (hs-CRP) were tested before surgery and at 6 and 12 months postoperatively. Body composition analysis and ultrasound hepatic fat grading were done before and at 6 and 12 months’ post-surgery. Results: The baseline HbA1c were 8.3 ± 1.8% which reduced to 6.1 ± 0.8% at 12 months. The percent body fat, visceral fat area, and slim lean mass reduced significantly at 12 months compared with baseline (P < 0.001). Hepatic steatosis and liver enzymes also significantly reduced at 12 months compared with baseline. hs-CRP and ferritin significantly reduced (P < 0.05) at 12 months post-op [2.9 ± 2.8 mg/L, 39 ± 29 ng/mL] compared with baseline [7.5 ± 3.5 mg/L, 61 ± 44 ng/mL], respectively. Serum adiponectin levels significantly increased from 26.4 ± 1.4 to 67 ± 3.5 ng/mL after the surgery. Conclusion: Bariatric surgery is effective in reducing total body fat and visceral fat area, hepatic steatosis with an improvement in liver enzyme levels after bariatric surgery. hs-CRP, ferritin, and adiponectin also significantly improved following surgery.
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Non-alcoholic fatty liver disease in Asian Indian adolescents and young adults: Prevalence and its associated risk factors p. 218
Thaharullah Shah Mehreen, Ranjani Harish, Rajan Kamalesh, Ranjit Mohan Anjana, Viswanathan Mohan
DOI:10.4103/jod.jod_104_20  
Background: Non-alcoholic fatty liver disease (NAFLD) is the most common form of chronic liver disease in the youth. The aim of the study was to conduct a metabolic risk factor profiling of NAFLD in adolescents and young adults in Chennai city in south India. Materials and Methods: The study participants included adolescents (n = 188) and young adults (n = 201). Ultrasonographic examination of the abdomen was done using a high-resolution B mode ultrasonography system. Based on the intensity of echogenicity, various grades of fatty liver were classified. Anthropometry, fasting plasma glucose, serum insulin, total cholesterol, triglycerides, and HDL and LDL cholesterol were estimated. χ2 analysis was performed to compare frequencies and t-tests on continuous or measurable data. Odds ratio (OR) was used as an indicator for strength of association. Results: From the total of 389 study participants, 70 had NAFLD which includes 48 with grade I, 21 with grade II, and one participant with grade III NAFLD. About 80% of the participants with NAFLD were adults (≥20 years) and more males were affected (70%) than females (30%). Generalized obesity was present in 90% of the participants with NAFLD. After adjusting for age and gender, obesity [OR: 5.88; 95% confidence interval (CI): 2.53–13.69; P-value: <0.001] and hyperglycemia [OR: 4.20; 95% CI: 1.75–10.08; P-value: <0.001] were significantly associated with NAFLD. Conclusion: With the higher prevalence rates of NAFLD noted in the study participants, prevention modalities should be adopted in the community by reducing obesity, healthy diet, and increased physical activity.
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COMMENTARY Top

Cardiovascular safety of hydroxychloroquine: Brief appraisal of data p. 224
Anil Pareek, Shashank Joshi, Ashok K Das, Ravi Tejraj Mehta
DOI:10.4103/jod.jod_64_20  
Hydroxychloroquine (HCQ), widely used in rheumatology since decades and in type 2 diabetes (T2D) since 2014, has garnered special attention in the current pandemic caused by SARS-CoV-2. HCQ appears to be effective in early COVID-19 and prophylaxis, and more studies are ongoing; its efficacy in severe disease is unclear. Few studies evaluating usage of HCQ in patients hospitalized with COVID-19 have raised concerns about the cardiovascular safety of HCQ, particularly QT-prolongation. It is important to understand the distinct clinical settings where HCQ is being used and appraise the data on cardiac effects of this commonly used drug. Although COVID-19 is an acute pro-arrhythmogenic state, HCQ is extensively used in patients with chronic inflammatory conditions such as rheumatoid arthritis, lupus, and T2D. In these indications, data from clinical studies, real-world experiences, and exhaustive pharmacovigilance database inspires confidence and suggests the cardiac side-effects of HCQ to be rare in frequency. The physicians and patients using HCQ in approved indications at recommended doses need to be reassured of its clinical importance and risk-benefit profile.
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CASE REPORT Top

Recurrent and complicated urinary tract infection in type 2 diabetes: Case series p. 228
Rahul R Kotalwar, Gaurish M Karande, Vedavati B Purandare, Hrishikesh S Deshmukh, Ashootosh M Pakale, Ambika Gopalakrishnan Unnikrishnan
DOI:10.4103/jod.jod_56_20  
Urinary tract infection (UTI) is a common infection in patients with type 2 diabetes (T2DM). We present a case series of recurrent and complicated UTI requiring hospitalization in people with T2DM. Recurrence of UTI, especially when severe or complicated, causes multiple renal and extra renal complications and even death if not intervened early. Recurrent UTI is often caused by resistant pathogens in people with long duration of diabetes and uncontrolled glucose levels. In recurrent and complicated/severe UTI, empirical broad-spectrum antimicrobial therapy and early urological intervention will help early recovery and helps to prevent complications.
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SHORT COMMUNICATION Top

Psychological impact of COVID-19 on teens belonging to a social media group p. 232
K Geethika Sai, Ramesh Jalaja, Anandakumar Amutha, U Venkatesan, Ranjit Mohan Anjana, Ranjit Unnikrishnan
DOI:10.4103/jod.jod_77_20  
Aims: To evaluate the psychological impact of COVID-19 on teens in a small WhatsApp group from Chennai. Materials and Methods: The study population comprised of teenagers, aged 12 to 20 years, who belong to a WhatsApp group. The questions were framed and developed based on the transitional impact scale which has high test–retest reliability. Through the WhatsAppgroup, the teens were informed about the survey. Those who were willing to participate were provided the website link to fill the questionnaire. Fisher’s exact tests were used to assess differences in proportions wherever applicable. Results: Among the 320 participants, 16.7% of them were boys and 83.3% were girls, and the mean age of boys and girls was 16.2 ± 2.1years and 15.6 ± 1.8 years, respectively. More than 40% of teens expressed that they often felt stressed out. Teens of both the genders reported getting irritated by small normal things (34.1%), thought they were helpless (32.8%), sometimes they felt like a burden to people around them (27.8%), and 36.9% reported feeling lonely or left out often. Regarding usage of electronic devices, 47.7% of girls and 58.5% of boys were always on any one of the electronic devices like mobiles, tabs, laptops, television, etc. Similarly, more than 50% of the boys and 60% of the girls slept 6–8h during this pandemic situation. Conclusion: This study shows that this life-changing transitional event has made a massive impact on the daily routine of these teenagers. Parents, health care professionals, and educators have to make sure that the teens come to terms with the current realities of the situation and to make use of the government support programs.
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LETTER TO EDITOR Top

Do we require better classification of diabetes in pregnancy? p. 237
Jethwani Pratap, Lata Jethwani, Shalini Jaggi, Banshi Saboo
DOI:10.4103/jod.jod_90_20  
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