Dyslipidemia is an important etiologic factor in the development of cardiovascular disease (CVD),... more Dyslipidemia is an important etiologic factor in the development of cardiovascular disease (CVD), which is a leading cause of death worldwide As CVD begins in childhood, and as dyslipidemia is an important risk factor for CVD, screening and treatment of dyslipidemia in ...
JPMA. The Journal of the Pakistan Medical Association, 2018
This article describes a Seven Sinful Sisters and Smart Solutions (FIVE S) concept, which lists s... more This article describes a Seven Sinful Sisters and Smart Solutions (FIVE S) concept, which lists seven contributory factors of diabetes, and seven potential solutions to help prevent its spread. The Seven Sinful Sisters include Sugar, Salt, Saturated fat, Spirits (alcohol), Sitting time (sedentary life style), Steroids (including other drugs) and Stress. Seven Smart salutogenic Solutions are use of Self-restraint, Small size portions, Spices (nutrition -based remedies, including sugar and salt substitutes), Slimnastics (a synonym for aerobic exercise), high Spirit (a positive attitude), health Sleep/Siesta, and enjoyment of Sunday (or Stress management).
The kidney is important in the context of diabetes not only because it is involved in normal gluc... more The kidney is important in the context of diabetes not only because it is involved in normal glucose homeostasis, but also because it is one of the most important end organs to be involved in diabetes complications. Glomeruli are the meeting point of both microvascular, or renal; and macrovascular, or cardiovascular, health in diabetes. Sulfonylureas are effective glucose-lowering drugs. While a sulfonylurea-based glucose-lowering strategy is nephro-safe and nephro-protective, this aspect of sulfonylurea pharmaco-biology has not been highlighted earlier. In this editorial, we discuss current preclinical and clinical trial evidence regarding the performance of modern sulfonylureas at the glomerular battlefield.
Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endoc... more Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endocrine and metabolic health, and are used to prevent and manage disease. Endocrine and metabolic function influence participation and performance in sports activity. The Bhubaneswar Declaration, released on the occasion of the Endocrine Society of India Conference, resolves to promote the science of sports endocrinology. The authors commit to optimize endocrine health in sports persons, encourage safe use of sports to promote health, and prevent misuse of endocrine interventions in sports.
JPMA. The Journal of the Pakistan Medical Association, 2018
Optometric or visual acuity assessment is an essential part of ophthalmologic examination. Visual... more Optometric or visual acuity assessment is an essential part of ophthalmologic examination. Visual acuity measurement serves as a tool for screening of ophthalmic disorders, as well as diagnosis and monitoring of refractive errors and other causes of reduced acuity. Persons with diabetes may experience situations which impair visual acuity, or which impact the utility of refractive visual acuity assessment. This communication shares guidance as to when and when not to perform visual acuity charting in persons with diabetes.
The Shrimad Bhagavad Gita enlightens everyone on how to cope up with various situations in life. ... more The Shrimad Bhagavad Gita enlightens everyone on how to cope up with various situations in life. It uses the conversation between Lord Krishna and Arjuna to highlight initial negative coping mechanisms exhibited by the latter. It goes on to showcase positive coping skills suggested by Lord Krishna and implemented by Arjuna. The Bhagavad Gita, through this "case-based methodology," teaches us how to cope with a demanding situation. Diabetes is a lifestyle disease, which warrants a thorough change in one's lifestyle, including changes in basic activities such as diet and exercise. This brief communication utilizes the teachings of Bhagavad Gita to help in coping with illness, especially chronic illness such as diabetes. The article cites verses from the Bhagavad Gita to show how one may cope with the stress of illness such as diabetes.
Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally man... more Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally managed in India. Thus, innovative comprehensive approaches that can concomitantly improve their detection, prevention and control are warranted. UDAY, a 5-year initiative, aims to reduce the risk of diabetes and hypertension and improve management by implementing a comprehensive intervention programme in the two selected study sites, Sonipat and Visakhapatnam (Vizag). It has a pre-post evaluation design with representative cross-sectional surveys before and after intervention. Within these two sites, urban and rural subsites each with a total population of approximately 100 000 people each were selected and a baseline and postintervention assessment was conducted deploying five surveys [among general population (including body measurements or biosamples), patients, healthcare providers including physicians and pharmacists, health facilities], which will determine the knowledge levels about...
Diabetes therapy : research, treatment and education of diabetes and related disorders, 2018
A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or ad... more A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin (A). Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) (A). Typically, patients with T1DM will require initiation with multiple daily injections at the time of diagnosis. This is usually short-acting insulin or rapid-acting insulin analogue given 0 to 15 min before meals together with one or more daily separate injections of intermediate or long-acting insulin. Two or three premixed insulin injections per day may be used (A). The target glycated hemoglobin A1c (HbA1c) for all children with T1DM, including preschool children, is recommended to be < 7.5% (< 58 mmol/mol). The target is chosen aiming at minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications (B). For patients prone to glycemic variability, glycemic control is best evaluated by a...
JPMA. The Journal of the Pakistan Medical Association, 2017
The International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR)... more The International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance, has recently published practical guidelines on the management of diabetes and Ramadan .The risk stratification categorizes all persons wishing to fast into three groups, based upon potential risk. In spite of evidence to the contrary, all persons using premixed insulin are categorized as having high risk. In this article, we present data from randomized controlled trials, and discuss the placement of premixed insulin in the risk stratification framework.
JPMA. The Journal of the Pakistan Medical Association, 2018
Some women may wish to fast during pregnancy or lactation, for religious or spiritual reasons. Th... more Some women may wish to fast during pregnancy or lactation, for religious or spiritual reasons. This may pose a dilemma to the obstetric care provider, who has to balance the need for maternal and foetal wellbeing with the wishes and needs of the mother. This communication describes a pragmatic, shared decision making, based on patient centred approach to this challenging clinical situation. It highlights simple clinical and investigation based clues which allow obstetric risk stratification of women in pregnancy or lactation. This clinical and laboratory based assessment allows appropriate decision making regarding fasting, while keeping foeto-maternal safety paramount.
Diabetes distress - commonly encountered as a part of life with diabetes mellitus - can be effect... more Diabetes distress - commonly encountered as a part of life with diabetes mellitus - can be effectively managed by coping skills training. Systematic assessment and documentation of the existing coping skills (and lack thereof) is a pre-requisite for planning such coping skills training. A six-item tool, the GlucoCoper - which assesses two negative (resistance, blame) and four positive (acceptance, optimism, planning and action) coping mechanisms - was administered to English-literate adult participants with type 2 diabetes (T2DM) at an endocrine centre in India. Each item was graded on a 10-point Likert scale. The GlucoCoper was administered to 338 participants. The tool demonstrated high internal validity. Total score on the GlucoCoper correlated with fasting and postprandial glucose. The GlucoCoper is a valid tool which can be used to assess and rate coping in persons with T2DM. It has potential in helping plan, deliver and monitor coping skills training in persons with diabetes d...
Diabetes is epidemic worldwide and places a huge burden on healthcare systems. The majority of th... more Diabetes is epidemic worldwide and places a huge burden on healthcare systems. The majority of the cost of type 2 diabetes (T2D) is related to hospitalization and the management of complications, and these also have a negative impact on the individual's quality of life. The Berlin Declaration is a global call for early action for the identification of high risk individuals, prevention of T2D and the prevention of complications in those with T2D, through prevention, early detection, early control and early access to the right multidisciplinary interventions. This should empower people to take action to prevent T2D and its complications.
JPMA. The Journal of the Pakistan Medical Association, 2017
This paper describes the seminal Berlin Declaration, released in December 2016, and draws inspira... more This paper describes the seminal Berlin Declaration, released in December 2016, and draws inspiration from it to ensure early prevention, early detection, and early control of diabetes, and provide early access to the right interventions for diabetes care. Discussion focuses on actions which primary care physicians can take in their individual practices to help achieve the goals laid down in Berlin Declaration. Collective efforts, involving simple, achievable and measurable interventions, will facilitate fulfillment of the Berlin Declaration's aims and objectives.
JPMA. The Journal of the Pakistan Medical Association, 2017
This article discusses a comprehensive approach to the management of diabetes distress. It mentio... more This article discusses a comprehensive approach to the management of diabetes distress. It mentions the screening and diagnosis of diabetes distress, and discusses its etiopathogenesis, investigations and management strategies in detail. The management of diabetes distress, termed as diabetes therapy by the ear, is based upon four pillars: strengthening of self-care skills, optimization of coping skills, minimizing change-related discomfort, and utilization of external support. The article describes coping skills training and change-related discomfort mitigation in detail.
JPMA. The Journal of the Pakistan Medical Association, 2018
The vital signs are an integral part of clinical methods. In diabetes, determination of plasma gl... more The vital signs are an integral part of clinical methods. In diabetes, determination of plasma glucose can be taken as the fifth vital sign. The sixth vital sign is well being, which can easily be measured by two item questionnaires designed to assess distress, depression and coping skills. This sign is essential for the screening and follow up of persons living with diabetes, as it provides an idea of quality of care, helps plan therapeutic interventions, and serves as a surrogate for prognosis or outcome. Inclusion of the sixth vital sign reflects the relevance of the bio-psychosocial model of health to diabetes care. .
International guidelines recommend using local trimester-specific normative data for TSH (thyroid... more International guidelines recommend using local trimester-specific normative data for TSH (thyroid stimulating hormone). However, there are no unified Indian data for the same. This review collates recently published data from various Indian centres and discusses the state of trimester-specific TSH ranges in the country. The authors describe the strengths and limitations of available data, and support the need for pan-India data. To ensure effective screening and action, harmonized research is necessary to establish national normative data for TSH in India.
Diabetes research and clinical practice, Jan 26, 2018
Diabetes is a major global epidemic and places a huge burden on healthcare systems worldwide. The... more Diabetes is a major global epidemic and places a huge burden on healthcare systems worldwide. The complications of type 2 diabetes (T2D) and related hospitalizations are major contributors to this burden, and there is strong evidence that the risk for these can be reduced by early action to identify and prevent people at high risk of T2D and ensure tight glycemic control in those with established disease. In response to this, the Berlin Declaration was developed by four working groups of experts and ratified by healthcare professionals from 38 countries. Its aim is to act as a global call to action for early intervention in diabetes, in addition to providing short-, medium- and long-term targets that should be relevant to all nations. The Berlin Declaration focuses on four aspects of early action, and proposes actionable policies relating to each aspect: early detection, prevention, early control and early access to the right interventions. In addition, a number of treatment targets...
For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armame... more For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.
Dyslipidemia is an important etiologic factor in the development of cardiovascular disease (CVD),... more Dyslipidemia is an important etiologic factor in the development of cardiovascular disease (CVD), which is a leading cause of death worldwide As CVD begins in childhood, and as dyslipidemia is an important risk factor for CVD, screening and treatment of dyslipidemia in ...
JPMA. The Journal of the Pakistan Medical Association, 2018
This article describes a Seven Sinful Sisters and Smart Solutions (FIVE S) concept, which lists s... more This article describes a Seven Sinful Sisters and Smart Solutions (FIVE S) concept, which lists seven contributory factors of diabetes, and seven potential solutions to help prevent its spread. The Seven Sinful Sisters include Sugar, Salt, Saturated fat, Spirits (alcohol), Sitting time (sedentary life style), Steroids (including other drugs) and Stress. Seven Smart salutogenic Solutions are use of Self-restraint, Small size portions, Spices (nutrition -based remedies, including sugar and salt substitutes), Slimnastics (a synonym for aerobic exercise), high Spirit (a positive attitude), health Sleep/Siesta, and enjoyment of Sunday (or Stress management).
The kidney is important in the context of diabetes not only because it is involved in normal gluc... more The kidney is important in the context of diabetes not only because it is involved in normal glucose homeostasis, but also because it is one of the most important end organs to be involved in diabetes complications. Glomeruli are the meeting point of both microvascular, or renal; and macrovascular, or cardiovascular, health in diabetes. Sulfonylureas are effective glucose-lowering drugs. While a sulfonylurea-based glucose-lowering strategy is nephro-safe and nephro-protective, this aspect of sulfonylurea pharmaco-biology has not been highlighted earlier. In this editorial, we discuss current preclinical and clinical trial evidence regarding the performance of modern sulfonylureas at the glomerular battlefield.
Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endoc... more Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endocrine and metabolic health, and are used to prevent and manage disease. Endocrine and metabolic function influence participation and performance in sports activity. The Bhubaneswar Declaration, released on the occasion of the Endocrine Society of India Conference, resolves to promote the science of sports endocrinology. The authors commit to optimize endocrine health in sports persons, encourage safe use of sports to promote health, and prevent misuse of endocrine interventions in sports.
JPMA. The Journal of the Pakistan Medical Association, 2018
Optometric or visual acuity assessment is an essential part of ophthalmologic examination. Visual... more Optometric or visual acuity assessment is an essential part of ophthalmologic examination. Visual acuity measurement serves as a tool for screening of ophthalmic disorders, as well as diagnosis and monitoring of refractive errors and other causes of reduced acuity. Persons with diabetes may experience situations which impair visual acuity, or which impact the utility of refractive visual acuity assessment. This communication shares guidance as to when and when not to perform visual acuity charting in persons with diabetes.
The Shrimad Bhagavad Gita enlightens everyone on how to cope up with various situations in life. ... more The Shrimad Bhagavad Gita enlightens everyone on how to cope up with various situations in life. It uses the conversation between Lord Krishna and Arjuna to highlight initial negative coping mechanisms exhibited by the latter. It goes on to showcase positive coping skills suggested by Lord Krishna and implemented by Arjuna. The Bhagavad Gita, through this "case-based methodology," teaches us how to cope with a demanding situation. Diabetes is a lifestyle disease, which warrants a thorough change in one's lifestyle, including changes in basic activities such as diet and exercise. This brief communication utilizes the teachings of Bhagavad Gita to help in coping with illness, especially chronic illness such as diabetes. The article cites verses from the Bhagavad Gita to show how one may cope with the stress of illness such as diabetes.
Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally man... more Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally managed in India. Thus, innovative comprehensive approaches that can concomitantly improve their detection, prevention and control are warranted. UDAY, a 5-year initiative, aims to reduce the risk of diabetes and hypertension and improve management by implementing a comprehensive intervention programme in the two selected study sites, Sonipat and Visakhapatnam (Vizag). It has a pre-post evaluation design with representative cross-sectional surveys before and after intervention. Within these two sites, urban and rural subsites each with a total population of approximately 100 000 people each were selected and a baseline and postintervention assessment was conducted deploying five surveys [among general population (including body measurements or biosamples), patients, healthcare providers including physicians and pharmacists, health facilities], which will determine the knowledge levels about...
Diabetes therapy : research, treatment and education of diabetes and related disorders, 2018
A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or ad... more A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin (A). Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) (A). Typically, patients with T1DM will require initiation with multiple daily injections at the time of diagnosis. This is usually short-acting insulin or rapid-acting insulin analogue given 0 to 15 min before meals together with one or more daily separate injections of intermediate or long-acting insulin. Two or three premixed insulin injections per day may be used (A). The target glycated hemoglobin A1c (HbA1c) for all children with T1DM, including preschool children, is recommended to be < 7.5% (< 58 mmol/mol). The target is chosen aiming at minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications (B). For patients prone to glycemic variability, glycemic control is best evaluated by a...
JPMA. The Journal of the Pakistan Medical Association, 2017
The International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR)... more The International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance, has recently published practical guidelines on the management of diabetes and Ramadan .The risk stratification categorizes all persons wishing to fast into three groups, based upon potential risk. In spite of evidence to the contrary, all persons using premixed insulin are categorized as having high risk. In this article, we present data from randomized controlled trials, and discuss the placement of premixed insulin in the risk stratification framework.
JPMA. The Journal of the Pakistan Medical Association, 2018
Some women may wish to fast during pregnancy or lactation, for religious or spiritual reasons. Th... more Some women may wish to fast during pregnancy or lactation, for religious or spiritual reasons. This may pose a dilemma to the obstetric care provider, who has to balance the need for maternal and foetal wellbeing with the wishes and needs of the mother. This communication describes a pragmatic, shared decision making, based on patient centred approach to this challenging clinical situation. It highlights simple clinical and investigation based clues which allow obstetric risk stratification of women in pregnancy or lactation. This clinical and laboratory based assessment allows appropriate decision making regarding fasting, while keeping foeto-maternal safety paramount.
Diabetes distress - commonly encountered as a part of life with diabetes mellitus - can be effect... more Diabetes distress - commonly encountered as a part of life with diabetes mellitus - can be effectively managed by coping skills training. Systematic assessment and documentation of the existing coping skills (and lack thereof) is a pre-requisite for planning such coping skills training. A six-item tool, the GlucoCoper - which assesses two negative (resistance, blame) and four positive (acceptance, optimism, planning and action) coping mechanisms - was administered to English-literate adult participants with type 2 diabetes (T2DM) at an endocrine centre in India. Each item was graded on a 10-point Likert scale. The GlucoCoper was administered to 338 participants. The tool demonstrated high internal validity. Total score on the GlucoCoper correlated with fasting and postprandial glucose. The GlucoCoper is a valid tool which can be used to assess and rate coping in persons with T2DM. It has potential in helping plan, deliver and monitor coping skills training in persons with diabetes d...
Diabetes is epidemic worldwide and places a huge burden on healthcare systems. The majority of th... more Diabetes is epidemic worldwide and places a huge burden on healthcare systems. The majority of the cost of type 2 diabetes (T2D) is related to hospitalization and the management of complications, and these also have a negative impact on the individual's quality of life. The Berlin Declaration is a global call for early action for the identification of high risk individuals, prevention of T2D and the prevention of complications in those with T2D, through prevention, early detection, early control and early access to the right multidisciplinary interventions. This should empower people to take action to prevent T2D and its complications.
JPMA. The Journal of the Pakistan Medical Association, 2017
This paper describes the seminal Berlin Declaration, released in December 2016, and draws inspira... more This paper describes the seminal Berlin Declaration, released in December 2016, and draws inspiration from it to ensure early prevention, early detection, and early control of diabetes, and provide early access to the right interventions for diabetes care. Discussion focuses on actions which primary care physicians can take in their individual practices to help achieve the goals laid down in Berlin Declaration. Collective efforts, involving simple, achievable and measurable interventions, will facilitate fulfillment of the Berlin Declaration's aims and objectives.
JPMA. The Journal of the Pakistan Medical Association, 2017
This article discusses a comprehensive approach to the management of diabetes distress. It mentio... more This article discusses a comprehensive approach to the management of diabetes distress. It mentions the screening and diagnosis of diabetes distress, and discusses its etiopathogenesis, investigations and management strategies in detail. The management of diabetes distress, termed as diabetes therapy by the ear, is based upon four pillars: strengthening of self-care skills, optimization of coping skills, minimizing change-related discomfort, and utilization of external support. The article describes coping skills training and change-related discomfort mitigation in detail.
JPMA. The Journal of the Pakistan Medical Association, 2018
The vital signs are an integral part of clinical methods. In diabetes, determination of plasma gl... more The vital signs are an integral part of clinical methods. In diabetes, determination of plasma glucose can be taken as the fifth vital sign. The sixth vital sign is well being, which can easily be measured by two item questionnaires designed to assess distress, depression and coping skills. This sign is essential for the screening and follow up of persons living with diabetes, as it provides an idea of quality of care, helps plan therapeutic interventions, and serves as a surrogate for prognosis or outcome. Inclusion of the sixth vital sign reflects the relevance of the bio-psychosocial model of health to diabetes care. .
International guidelines recommend using local trimester-specific normative data for TSH (thyroid... more International guidelines recommend using local trimester-specific normative data for TSH (thyroid stimulating hormone). However, there are no unified Indian data for the same. This review collates recently published data from various Indian centres and discusses the state of trimester-specific TSH ranges in the country. The authors describe the strengths and limitations of available data, and support the need for pan-India data. To ensure effective screening and action, harmonized research is necessary to establish national normative data for TSH in India.
Diabetes research and clinical practice, Jan 26, 2018
Diabetes is a major global epidemic and places a huge burden on healthcare systems worldwide. The... more Diabetes is a major global epidemic and places a huge burden on healthcare systems worldwide. The complications of type 2 diabetes (T2D) and related hospitalizations are major contributors to this burden, and there is strong evidence that the risk for these can be reduced by early action to identify and prevent people at high risk of T2D and ensure tight glycemic control in those with established disease. In response to this, the Berlin Declaration was developed by four working groups of experts and ratified by healthcare professionals from 38 countries. Its aim is to act as a global call to action for early intervention in diabetes, in addition to providing short-, medium- and long-term targets that should be relevant to all nations. The Berlin Declaration focuses on four aspects of early action, and proposes actionable policies relating to each aspect: early detection, prevention, early control and early access to the right interventions. In addition, a number of treatment targets...
For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armame... more For decades, sulfonylureas (SUs) have been important drugs in the antidiabetic therapeutic armamentarium. They have been used as monotherapy as well as combination therapy. Focus on newer drugs and concerns about the risk of severe hypoglycemia and weight gain with some SUs have led to discussion on their safety and utility. It has to be borne in mind that the adverse events associated with SUs should not be ascribed to the whole class, as many modern SUs, such as glimepiride and gliclazide modified release, are associated with better safety profiles. Furthermore, individualization of treatment, using SUs in combination with other drugs, backed with careful monitoring and patient education, ensures maximum benefits with minimal side effects. The current guidelines, developed by experts from Africa, Asia, and the Middle East, promote the safe and smart use of SUs in combination with other glucose-lowering drugs.
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Papers by Sanjay Kalra