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Prabal Kumar,1 Shashikiran Umakanth,2 Emanuele Marzetti,3,4 Sanjay Kalra,5,6 Girish N1 1Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India; 2Department of Medicine, Dr. TMA Pai Hospital, Manipal Academy of Higher Education, Manipal, Karnataka, India; 3Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy; 4Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica Del Sacro Cuore, Rome, Italy; 5Department of Endocrinology, Bharti Hospital, Karnal, India; 6University Center for Research & Development, Chandigarh University, Mohali, IndiaCorrespondence: Girish N, Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India, Tel +91 9886782114, Email girish.n@manipal.edu; girish_darsana@yahoo.co.inBackground: The prevalence of sarcopenia is concerningly high in long-term care settings (LTCS); yet, no exercise programs specifically targeting older adults living in residential care are available.Objective: The goal of the present study was to co-design and validate a program named Reablement Strategies targeting Sarcopenia (ReStart-S) for older long-term care residents.Design: Cross-sectional study with an exploratory phase.Settings: LTCS in Udupi, Karnataka, India.Participants: Sarcopenic older adults diagnosed using Asian Working Group for Sarcopenia 2019 criteria.Material and Methods: The program was designed using a four-step intervention mapping technique involving systematic progression after completing each step. The steps included 1) identifying the appropriate exercise-based intervention for sarcopenia, 2) determining objectives and expected outcomes, 3) seeking expert views through a Delphi consensus approach, and 4) assessing the feasibility of ReStart-S program among older adults living in LTCS.Results: A comprehensive literature review appraised existing exercise programs for managing sarcopenia. A workshop held with six older adults and one caretaker, decided on morning exercise sessions, recommended 2– 7 days/week. The results of the review and workshop were compiled for the Delphi process that had seven experts from 5 countries, achieving a 71% response rate after four rounds. In the last step, a pilot study on eight LTCS residents, two males and six females with a mean age of 78.3 ± 8.3 years, was conducted and the program was found to be feasible.Conclusion: The ReStart-S program for managing sarcopenia among older adults residing in LTCS incorporates evidence from the literature and the engagement of older adults, caregivers, and experts, making it a contextually appropriate intervention. Our study also provides researchers and healthcare professionals insight into co-designing an intervention program for vulnerable older adults. Finally, the program evaluation indicates that a full-scale trial testing the efficacy of the ReStart-S program is feasible.Keywords: reablement, sarcopenia, intervention mapping, older adults, long-term care settings

Sanjay Kalra,1 Nitin Kapoor,2 Jeevan Joseph,3 Abhishek Arun,4 Supratik Bhattacharyya,5 Siba Prasad Dalai6 1Endocrinology Department, Bharti Hospital, Karnal, Haryana, India; 2Endocrinology Department, Christian Medical College, Vellore, Tamil Nadu, India; 3Endocrinology Department, Vimala Hospital, Ettumanoor, Kerala, India; 4Endocrinology Department, Vishudh Diabetes Clinic, Lucknow, Uttar Pradesh, India; 5Endocrinology Department, Apollo Sugar Clinic, Kolkata, West Bengal, India; 6Endocrinology Department, IMS & SUM Hospital, Bhubaneshwar, Odisha, IndiaCorrespondence: Sanjay Kalra, Bharti Hospital, BRIDE Kunjpura Road, Model Town, Near State Bank of India, Sector 12, Karnal, Haryana, 132001, India, Tel +91 98960 48555, Fax +91 124-407 8652, Email brideknl@gmail.comPurpose: The study aimed to evaluate the effect of Vidaslim®, meal replacement on weight, body mass index (BMI), waist circumference (WC), hip circumference (HC), and other cardiometabolic parameters and to see the impact of timing of Vidaslim meal replacement on the level of weight loss achieved.Methods: In a prospective, observational study, male and female subjects with obesity based on inclusion and exclusion criteria were administered Vidaslim (60 g in 200 mL water) once daily as a meal replacement (lunch or dinner) for 16 weeks.Results: A total of 107 subjects (mean age 34.09± 8.26 years) were included in the study. There was a significant reduction in weight by 13.4 kg (p=0.0001), BMI by 5.5 kg/m2 (p=0.00001), WC by 3.7 inches (p=0.0001), and HC by 4.5 inches (p=0.0001) at the end of 16 weeks. Statistically significant reductions were noted in heart rate, fasting blood glucose, postprandial blood glucose, lipid profile (p=0.0001 for all), and systolic blood pressure (p=0.002) at 16 weeks. A significant change in hunger (p=0.0001), appetite (p=0.014), mood (p=0.021), sleep quality (p=0.0001), and general well-being (p=0.013) was observed at the end of 16 weeks. Replacing lunch or dinner with Vidaslim resulted in a significant reduction in weight (− 9.8 kg versus − 14.3 kg, respectively; p=0.0001 for both) compared to replacing breakfast (− 3 kg, p=0.205) with Vidaslim over 16 weeks. No subject reported any side effects post–Vidaslim intervention.Conclusion: The medical nutrition therapy, Vidaslim, was found to be an effective and safe meal (lunch or dinner)-replacement strategy and brought a significant reduction in weight, WC, and HC over 16 weeks in overweight and obese individuals.Keywords: food supplement, overweight, anthropometric, cardiometabolic, meal replacement, blood glucose

Parag Shah,1 Sanjay Kalra,2 Yogesh Yadav,3 Nilakshi Deka,4 Tejal Lathia,5 Jubbin Jagan Jacob,6 Sunil Kumar Kota,7 Saptrishi Bhattacharya,8 Sharvil S Gadve,9 KAV Subramanium,10 Joe George,11 Vageesh Iyer,12 Sujit Chandratreya,13 Pankaj Kumar Aggrawal,14 Shailendra Kumar Singh,15 Ameya Joshi,16 Chitra Selvan,17 Gagan Priya,18 Atul Dhingra,19 Sambit Das20 1Department of Endocrinology, Gujarat Endocrine Centre, Ahmedabad, Gujarat, India; 2Department of Endocrinology, Bharti Hospital & B.R.I.D.E, Karnal, Haryana, India; 3Department of Endocrinology, MAX Super Specialty Hospital, Dehradun, Uttarakhand, India; 4Department of Endocrinology, Apollo Hospital & Dispur Polyclinic and Nursing Home, Guwahati, West Bengal, India; 5Department of Endocrinology, Apollo Hospital, Mumbai, Maharashtra, India; 6Department of Endocrinology, CMC Hospital, Ludhiana, Punjab, India; 7Department of Endocrinology, Diabetes and Endocrine Clinic, Berhampur, Orissa, India; 8Department of Endocrinology, OeHealth Diabates & Endocrinology Centre, Delhi, Delhi, India; 9Department of Endocrinology, Excel Endocrine Centre, Kolhapur, Maharashtra, India; 10Department of Endocrinology, Visakha Diabates & Endocrine Centre, Vishakhapatnam, Andhra Pradesh, India; 11Department of Endocrinology, Endodiab Clinic, Calicut, Kerala, India; 12Department of Endocrinology, St.John’s Medical College & Hospital, Bangalore, Karnataka, India; 13Department of Endocrinology, Endocare Clinic, Nashik, Maharashtra, India; 14Department of Endocrinology, Hormone Care & Research Centre, Ghaziabad, Uttar Pradesh, India; 15Department of Endocrinology, Endocrine Clinic, Varanasi, Uttar Pradesh, India; 16Department of Endocrinology, Endocrine and Diabetes Clinic, Mumbai, Maharashtra, India; 17Department of Endocrinology, Ramaiah Memorial Hospital, Bangalore, Karnataka, India; 18Department of Endocrinology, IVY Hospital, Chandigarh, Punjab, India; 19Department of Endocrinology, Bansal Hospital, Sri Ganganagar, Rajasthan, India; 20Department of Endocrinology, Endeavour Clinic, Bhubaneshwar, Orissa, IndiaCorrespondence: Sanjay Kalra, Kunjpura Road, Model Town, Near State Bank of India, Sector 12, Karnal, Haryana, 132001, India, Tel +9215848555, Email brideknl@gmail.comAbstract: 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.Keywords: corticosteroids, insulin, steroid-induced hyperglycemia, steroid-induced diabetes, stress hyperglycemia, diabetes

Nitin Kapoor,1,2 Rakesh Sahay,3 Sanjay Kalra,4 Sarita Bajaj,5 Arundhati Dasgupta,6 Dina Shrestha,7 Guru Dhakal,8 Mangesh Tiwaskar,9 Manisha Sahay,10 Noel Somasundaram,11 Ravinder Reddy,12 Saptarshi Bhattacharya,13 Vijaya Bhaskar Reddy,14 Vijay Viswanathan,15 Dharini Krishnan,16 Manash Baruah,17 A K Das18 1Department of Endocrinology, Christian Medical College, Vellore, Tamil Nadu, India; 2Non Communicable Disease Unit, The Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; 3Department of Endocrinology, Osmania MedicalA30 College, Hyderabad, Telangana, India; 4Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India; 5Department of Medicine, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India; 6Department of Endocrinology, Rudraksh Superspecialty Hospital, Siliguri, West Bengal, India; 7Department of Endocrinology, Hospital for Advanced Medicine and Surgery (HAMS), Kathmandu, Nepal; 8Department of Medicine, Khesar Gyalpo University of Medical Sciences, Thimphu, Bhutan; 9Department of Diabetology, Shilpa Medical Research Centre, Mumbai, Maharashtra, India; 10Department of Nephrology, Osmania Medical College and Osmania General Hospital, Hyderabad, Telangana, India; 11Department of Endocrinology, National Hospital of Sri Lanka, Colombo, Sri Lanka; 12Department of Gastroenterology, CARE Super Specialty Hospital & Transplant Centre, Hyderabad, Telangana, India; 13Department of Endocrinology, Max Superspeciality Hospital, Delhi, India; 14Department of Endocrinology, Government General Hospital, Pondicherry, India; 15Department of Medicine, M.V. Hospital for Diabetes & Prof M Viswanathan Diabetes Research Centre, Chennai, Tamil Nadu, India; 16Department of Food, Nutrition and Dietetics, Laksha Hospitals, Chennai, Tamil Nadu, India; 17Department of Endocrinology, Excel Care Hospitals, Guwahati, Assam, India; 18Department of Medicine, JIPMER, Puducherry, IndiaCorrespondence: Sanjay KalraBharti Hospital, Kunjpura Road, Model Town, Near State Bank of India, Sector 12, Karnal, Haryana, 132001 Tel +91 9896048555Email brideknl@gmail.comAbstract: Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.Keywords: diabesity guidelines South Asia, medical nutrition therapy South Asia, nutrition therapy for obesity, nutrition therapy for diabetes, diabetes, obesity and diabesity

Sanjay Kalra,1,2 Ambika Gopalakrishnan Unnikrishnan,3 Manash P Baruah,4 Rakesh Sahay,5 Ganapathi Bantwal6 1Department of Endocrinology, Bharti Hospital, Karnal, India; 2Department of Endocrinology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India; 3Department of Endocrinology and Diabetes, Chellaram Diabetes Institute, Pune, Maharashtra, India; 4Department of Endocrinology, Excel Hospitals, Guwahati, India; 5Department of Endocrinology, Osmania Medical College, Hyderabad, Telangana, India; 6Department of Endocrinology, St. John’s Medical College and Hospital, Bangalore, Karnataka, IndiaCorrespondence: Sanjay KalraBharti Hospital, Kunjpura Road, Karnal, 132001 Haryana, IndiaTel +919896048555Email brideknl@gmail.comAbstract: Metabolic flexibility is the ability to efficiently adapt metabolism based on nutrient availability and requirement that is essential to maintain homeostasis in times of either caloric excess or restriction and during the energy-demanding state. This regulation is orchestrated in multiple organ systems by the alliance of numerous metabolic pathways under the master control of the insulin-glucagon-sympathetic neuro-endocrine axis. This, in turn, regulates key metabolic enzymes and transcription factors, many of which interact closely with and culminate in the mitochondrial energy generation machinery. Metabolic flexibility is compromised due to the continuous mismatch between availability and intake of calorie-dense foods and reduced metabolic demand due to sedentary lifestyle and age-related metabolic slowdown. The resultant nutrient overload leads to mitochondrial trafficking of substrates manifesting as mitochondrial dysfunction characterized by ineffective substrate switching and incomplete substrate utilization. At the systemic level, the manifestation of metabolic inflexibility comprises reduced skeletal muscle glucose disposal rate, impaired suppression of hepatic gluconeogenesis and adipose tissue lipolysis manifesting as insulin resistance. This is compounded by impaired β-cell function and progressively reduced β-cell mass. A consequence of insulin resistance is the upregulation of the mitogen-activated protein kinase pathway leading to a pro-hypertensive, atherogenic, and thrombogenic environment. This is further aggravated by oxidative stress, advanced glycation end products, and inflammation, which potentiates the risk of micro- and macro-vascular complications. This review aims to elucidate underlying mechanisms mediating the onset of metabolic inflexibility operating at the main target organs and to understand the progression of metabolic diseases. This could potentially translate into a pharmacological tool that can manage multiple interlinked conditions of dysglycemia, hypertension, and dyslipidemia by restoring metabolic flexibility. We discuss the breadth and depth of metabolic flexibility and its impact on health and disease.Keywords: metabolic flexibility, DBCD, insulin resistance, prediabetes, diabetes, microvascular and macrovascular complication

Yashdeep Gupta,1 Bharti Kalra,2 Manash P Baruah,3 Rajiv Singla,4 Sanjay Kalra2 1Department of Medicine, Government Medical College and Hospital, Chandigarh, India; 2Bharti Hospital, Karnal, Haryana, India; 3Excel Center, Guwahati, Assam, India; 4Saket City Hospital, New Delhi, India Abstract: Gestational diabetes mellitus (GDM) is associated with an increased risk of complications for both mother and baby during pregnancy as well as in the postpartum period. Screening and identifying these high-risk women is important to improve short- and long-term maternal and fetal outcomes. However, there is a lack of international uniformity in the approach to the screening and diagnosis of GDM. The main purpose of this review is to provide an update on screening for GDM and overt diabetes during pregnancy, and discuss the controversies in this field. We take on debatable issues such as adoption of the new International association of diabetes and pregnancy study groups criteria instead of the Carpenter and Coustan criteria, one-step versus two-step screening, universal screening versus high-risk screening before 24 weeks of gestation for overt diabetes, and, finally, the role of HbA1c as a screening test of GDM. This discussion is followed by a review of recommendations by professional bodies. Certain clinical situations, in which a pragmatic approach is needed, are highlighted to provide a comprehensive overview of the subject. Keywords: pregnancy, guidelines, IADPSG, GDM, Carpenter and Coustan criteria