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Cutting Edge: Episode 9

Dec 24 | 4:30 PM

In this episode, Dr. Mahadev Desai discusses the benefits of intermittent fasting, the review suggests that intermittent fasting may have a beneficial effect on improving anthropometric and cardiometabolic outcomes. Dr. Desai also talks about the American Diabetes Association’s updates on clinical recommendations for 2022.

[Music] good evening it's a little too late in the evening but we are glad that you were able to join us today i'm dr naveed and uh we have with us dr madhav desai a senior consultant physician from amdapad hello good evening everyone uh welcome to the ninth episode of cutting edge and if you remember in our fifth episode of cutting edge we had reported for the first time that there is a new variant of concern is emerging just two days back that means today is the exact one month when in south africa on 24th november a new variant of was reported and within two days only the who technical committee gathered and gave the name omicron in fact we had also run the quiz and what would be the expected name of this because these variants are given name according to the greek alphabet and to our surprise it was omicron that was decided now practically everybody knows about omicron people called omicron some people call it oh micron and one of my person yesterday said sir what happened to that oh my god variant i said what is oh my god varian and i realized that what he meant was omicron and so within one month only everybody has become so much aware but maybe people like us who are not very media savvy or who do not see much of the tv or the electronic media really we not know much that is how we thought that will start with the updates about the omicron and within less than 30 days now practical is the talk of the town india recorded the first case of omicron variant infections on second december from and 114 patients have already recovered and that's a good story part it but worldwide the number of co-micron cases are increasing and in usa the omicron now accounts for almost 73 percent of the cases which was only 13 percent before two weeks and one percent before three weeks so that's how it spreads and in uk also sixty percent of the cases are of omicron variety and it has surpassed the delta variant and the hospitalizations are also increasing and the silver lining is that the country where it originated have started reporting lesser number of cases in of africa there were 27 000 cases reported on a daily basis but it has dropped to 15 000 cases on tuesday so let's hope that india also does not witness the big surge like one which is presently going on usa where as it is shown here by the new york times that the omicron has surpassed the delta and now we say in fact today the u.s has recorded more than two lake cases and the uk also and there are more than 90 000 cases are definitely occurring on a day-to-day basis and the number of dates reported in england had been 24 but as for today's figures they are 26 dates have been attributed to the new variant so we only pray that we do not get the big spike that we saw about the delta uh waves views in april and may and in india in india the number of cases as we saw about the delta variant was so this was the story of the delta variant in april may and now we can see that total number of cases india is reported around less than ten thousands and let's hope that it doesn't go up like the us and uk but we are lacking in the last time also we are almost a one month behind the you can ussr so we'll have to be very careful and make sure that we remain the committee appropriate behavior all the time and take all the vaccines those who have not received and the experts speculate that because india had the good third immunity as well as the natural infection mediated immunity that is why we are expected to have less such of the cases as well as the less hospitalization and deaths but that remain to be proved and let's hope that it doesn't turn out to be only wishful thinking we move on to the next story that is about the this is probably the first time a drug which has been approved has been voluntary withdrawn by the company and the drug is none other than the republic forcing dipaglifocine has been approved in typhon diabetes in european in so the astrazeneca has withdrawn the nepali depoglyphosin for the first time after introduction in less than two years time and in european union the dipaglyphosin which is an sglt2 inhibitor was introduced as a type one medicines with certain criteria that all type 1 patients who had an bmi of more than 27 kg per meter square or who had even spite of the high dose of insulin that glucose were not on target were approved for the type 1 diabetes the depoglyphosin and it was never approved in usa even today but this is the only drug oral drug which has been approved other than the insulin in european union but after some time that means last week only the astrazeneca has started withdrawing this drug and they've given litter to all the healthcare professionals as well as they have informed the mhra that is the medicine and healthcare products regulatory agency with their agreement they have withdrawn the drug and it's no longer available to treat typhoon diabetes patients and the reasons they have ascribed that it's not a safety concern but they say that it's we know that diabetic ketoacidosis is more common in try for diabetes and in patients who are receiving hdlt2 inhibitors the diabetic ketogenic can occur even at a lesser glucose levels normally diabetic ketosis occurs when the blood glucose levels are in excess of 300 milligram but in patients with uh patients who are receiving diabetes as you alt inhibitors the ketoacidosis can occur even at the blood glucose levels 200 or 250 and that is called eu glycemic diabetic ketoacidosis so the reason kept forward by the astrazeneca company is that because of this decay warning diabetes is spawning in type 1 which are more predisposed the company has to put a black triangle over the product leaflet and that is why it might confuse with the professionals as well as the patients about that this is some drug which can cause ketosis in all the patients and that may be the reason that the patients who really need it the type one type two diabetic patients who are having a chronic heart failure or following ckd now depot glyphosate is one of the first drug to be used over and above metformin so the company thought that because of this black triangle labeling there might number of type 2 diabetic patients may not take the advantage of the drugs and that is why they have voluntary withdrawn but this has not gone well with the patients who have been receiving this drug in large numbers in uk and that is why there have been a large protest but as of now in type 1 diabetes the dipaglyphosin which was available as 5 milligram template is no longer available we'll say more about it as the time comes then there's a third story that is about the visceral fat we know that obesity itself as a risk factor for the many cardiovascular problems and diabetes and we also know that there are two types of obesity the subcutaneous fat as well as the visceral fat visceral fat is the one which is around the organs as well as in the liver and this particular paper appeared in the on 20th december in midscape and here the 605 youth from age from 10 to 23 years at cincinnati children's hospitals in ohio have been enrolled in the study out of which 236 individuals were having a healthy weight while 224 persons were obese and 145 had type 2 diabetes we can have diabetes even between the age of 20 and 23 too so the visceral fat was essays by the dexa scan the exascan is a dual energy x-ray absorptiometry one which we use for bone mineral density for osteoporosis in india we routinely use this particular machine so here the whistle fat was assessed by dexa scan and also they need to study what is the effect on the cardiovascular disease and there is a sub clinical sign in the form of carotid femoral pulse wing velocity is one kind of topper studies when the carotid fungal pulse velocity was compared with the quantity of the whistle fat as just by dexa scan and what they found was that the persons who had healthy weight right the subunit right was not linked to that stiffness the persons who were obese or persons with diabetes there the subcutaneous fat as well as the visceral fat was going showing an additional increase in the actual stiffness so in the youth with the healthy weight the visceral fat supplements fat or base circumference are not significantly affected but actually once if you want to see the exact amount of fat then we should go for mri but it's very expensive and may not be possible each and every case so nexus can is relatively inexpensive and even a simple weight side examination the from waist hip ratio is also good enough to know about the subclass as well as the physical fat the point to be learned from this study is that whenever the young patients come if they are overweight or obese we should keep the documentation of their waist hip ratio and we should also go for the exascan for documenting the visceral fat because that itself is a marker and if you have the carotid pulse femoral will all velocity studies are available then we can judge the stiffness of the vessels and that can be a foreigner of the cbd risk factor so something we should learn from this then very interesting study we know that libodopa is one of the cornerstone of treatment for parkinson's disease the problem with liverpool treatment is that liver dopa is very slowly absorbed and most of the drug is metabolized in the peripheral blood by the carboxylase and that is why most of the time we have to give levodopa with carbidopa the problem with liverpool is an excellent drug as long as the drug is in good concentration in the blood but the moment the blood levels fall the patients get the phenomena what is called off phenomena so there is honor phenomena going on in parkinson's patients and in all phenomena patient literary freezes right to overcome that the this particular study is carried out this in fact is a meta-analysis of five randomized control studies by of almost 5000 parkinson's patients and here the drug uses liver dopa in 25 to 84 milligram in the inhaler form the name given is cvt-301 here the levodopa's patients are asked to inhale the levodopa and the parallel group that is the placebo group has been given the electrode powder the electrodes powder as the placebo and they were also asked to inhale these powers and the duration of studies in the entire five rcts were anything from 39 days to 12 months what they found was that the most of the patients who were on liver pain healers had were on on state rather than the offspring that means they have maintained the labor upon levels and their most of their activities are just fine their water function has also improved they use this code for this and look at the p value the significance of these values between the patients who received levodopa inhalers and the blessing boss is almost four zeros and one so that's highly significant so whether it's a motor function whether they are on on phenomenon or their self-reporting of the overall improvement all had a p value of almost four zero and one so that's something absolutely remarkable and that is why the researchers suggest that really in next few days next four years the liverpool may become the standard root is the inhaler root and because it's a much better preferred treatment than the oral because of the less fluctuations which is what bothering most of the parkinson's patients and the side effects profile was also very few mainly the respiratory symptoms or the nausea but they were no better than the no worse than the placebo so levodopa in inhaler form may be one of the treatment will expect in the near future then another important study we know that most of our hypertension patients would require eventually two drugstore drugs or four drugs and most of the other therapies chronic illnesses like diabetes also we start with the combination therapies so this particular study is called the cortex studies here four antihypertensive medicines were given in quarter dose one-fourth of the reusable toes compared with the monotherapy of one drug which is generally used as one of the saturn's that is the earbuds atom erb saturn in 150 milligram as the control group and other group which is the intervention group where four drugs are given irb saturn in the one for those that is 37.5 milligram the amyloid in 1.25 milligram indapami which is a diuretic in 0.625 milligram and bisoprolol is a beta blocker selective beta blocker in 2.5 milligram so there were two arms or 591 patients were taken with a mean age of around 59 plus minus 12 years and 60 percent males and they were randomized to receive either a single pill containing four drugs as i said airway saturn amlodipine indap mi and visceral or a single pill which is indistinguishable from the quadrupole pill and what they study what the primary outcome was what is the difference in the blood pressure when it is undetermined not in office but then the patient is moving around in the community at 12 weeks and they also had another parallel subgroup analysis of 417 patients were studied for the same effect for one year to see the long-term effect of the four drugs combinations and after 12 weeks the percentages of patients requiring additional blood pressure medications in the intervention group that means those who receive the folder combinations were 15 against the persons who are receiving the group who receiving the invasion alone were 40 and the systolic blood pressure lowering was also 6.5 6.9 millimeter compared to the intervention group which is again the p value is 0.0001 and the higher percentage of patients achieving the standard blood pressure control was 76 percent against the 58 percent so again the p value is highly significant so the anti hypothesis therapy may be next time probably or when the next time the guidelines change they may come out with the only therapy for the mta person to begin with the idea is that these four drugs work in a different mechanism actions and lesser the drugs lesser will be the side effects plus they will have the synergistic effect which are probably more than the individual drugs when given uptrackity and those 417 patients who were recruited for the long term follow-up there also the blood pressure had fallen by 7.7 millimeter lower and the control group versus the the intervention group there was a significant difference and the mean alternate diabetic blood pressure was also reduced in the group which received the fourth quarterback drugs so maybe the multiple drugs combinations will be the order of the day in the time to come so that's about the first round of stories yeah and there have been questions and maybe we will take up later on one of the question was equipotent dosages it's not a universal normally what they tried is the one-fourth of the those that normally that receive so that is why they call it in quadruple quadrat quartet trial and it is just first a trial composition and maybe uh we'll have different kinds of combinations or maybe we take different drugs in a different at a separate time but the idea was that the four drugs in a one-fourth dose may be a better option than the monotherapy as per the studies reasons so i'll move on to the next yes i will start with the next this is a very interesting story in the form that and pro is carry also that we know that our usage of plastic has gone very high right and this particular paper has come in the american chemical society journals of environment science and technology on 22nd december and here the researchers have estimated the plastics in the fecal matter right and we they have given the name microplastics microplastics are the quantity of plastic in the size of less than five millimeter right and usually we get the plastic water bottles or we get the food in the plastic containers and that is why they studied the and that research hypothesis question was that this plastic itself might produce intestinal inflammations and they may change the gut microwave and other issues of digestions and what they studied was the what is the effect of this micro plastics which is recovered in the stool in the inflammatory bowel disease that is mainly the ulcerative colitis and the crohn's disease these are the two inflammatory bowel diseases uh incidentally the incidences of implementary bowel diseases are also on rise we do not know whether it is related to the use of plastics or not but that was the research question and they took the fecal samples of 50 healthy people and 52 people with a known diagnosis of implemented bowel disease confirmed by the biopsies and from the china and they analyzed the characteristics of microplastics in the fecal matter difficult samples and the what they found was that the amount of micro plastics in the persons with inflammatory bowel disease in their fickle the 41.5 items per gram per dm that is what they say that is almost 1.5 times higher than the fecal content of the persons who were healthy so then in all they could find out different types of micro plastics almost 15 types of micro plastics and they were all different chemical names they are all latin for us but the point is that microplastics are something that might be one of the either the ecological factor or the trigger for the inflammatory bowel disease and they could find the severity of the inflammatory bowel disease with the content of the microplastics in the stool uh we do not know it's a very small study but what we can do at our end is you all of us who are treating the infirmity bible disease patients at least we can tell them to stop using and see whether there is effect on their exacerbations or they need less number of the medicines whether it's steroids or salicylates or whatever medicines we are using so at least that is what we can start doing from ray itself that all our ibd patients we ask them to cut down their usage of plastics or start using instead of water bottles they are the stainless steel or copper water and something to see whether it has an effect on their ibd exact services or remissions next another very interesting story and that is about the use of acetone acetazolamide we know all those who of our patients or friends who have to undertake the high altitude journeys whether it's a monster or whether it's a layla attack they would always ask us about what precaution we should be taking and we always prescribe them acetazolamide we know that it's a carbonic anhydrase drug and it has a stimulant effect on the respiratory system respiratory center and that is how it reduces the hypoxia at a high altitude and it is known to reduce the high altitude illness many of the symptoms of high altitude illness and acute mountain sickness and it's a standard drug which we use it but up till now we have not allowed our copd patients to take up this journey because it's clear contraindications that truly they are the ones who are most vulnerable to not only acute mountain illness but even high altitude pulmonary edema and such serious illnesses so this particular study appeared two days back in new england journal of medicine and here the researchers have designed two different trials which ran parallelly with the same type of protocol in one trial they were copd patients right which were 176 patients and one group was treated with acetonite 375 milligram and again they have an interesting dosages they give 125 125 milligram in the morning and 250 milligram in the night something probably we have been using only 125 milligram or 250 milligram uh up till now but 125 milligram in the morning and 250 milligram at night so that at night time we need the more stimulations of the respiratory center and correct the hypoxemia so this was tried and all the patients who are enrolled whether it's a placebo group or the study group were taken to a height of 3100 meters and they had established one clinic at the 3100 kilometers with all the facilities oxygenations and drugs and everything and under the supervision of pulmonologists they were all analyzed for what symptoms they developed and whether they needed hospital oxygen or they needed other treatment for the acute mountain illness and the second trial was 345 healthy low lenders those who stayed at the low lands were also asked to take the drugs and also to observe for two days in the same clinic so two two parallel trials were conducted and the primary outcome in the trial one was the incidence of composite endpoint of altitude related adverse health effects and acute mountain sickness severe hypoxemia requiring interventions and in primary outcome the second trial which are all the healthy persons or only about the questionnaires they ask about whether they had different types of symptoms with the nausea or headache uneasiness and any of the acute mountain illness uh mountain sickness symptoms uh were asked to them and they recorded and the results were that in the first trial that is the trial of patients who are at copd 76 percent receiving 68 out of 90 that is they sing the placebo and 42 out of it is 49 percent receiving acetosilamide experienced some symptoms so patients of copd are bound to have some symptoms when they incline to 3100 meters that comes around more than 10 000 feet uh but those who had acetazolamide their level of symptoms severity of the symptoms were statistically significant than those who did not receive the acid reservoir and very importantly whenever we want to see the efficacy of any particular drug or any particular investigation we always see how many number of patients required to treat that is called nmt or number needed to treat so if you want to prevent one illness related to the high altitude in patients with copd all that you do is treat four patients that's a very very highly significant or encouraging results and in the same way in the trial two the number of number needed to treat was 10 that's also not bad see we have many drugs where the number needed is around 25 30 still we use it here the number needed to trade to prevent an illness is only 10 so one out of 10 will be benefited which is a huge number so in healthy individuals also almost 54 out of 170 receiving the placebo had symptoms and 38 out of 175 also had symptoms uh statistically obviously they were not very significant that is why the number nutrient also has gone up but all in all the acetozolamide works better whether it's a healthy volunteers or these copd patients and that is what we also observe and this trial has confirmed that the beneficial role of acetosal amide in patients who have to climb then very interesting story which is the probably the now talk of the time and the talk of the town we know that so many people have undertaken intermittent fasting and there are different types of intermittent fasting and this particular paper appeared in the jama on 17th of december and here the researchers have analyzed that there is a huge data and they have analyzed 11 meta analysis the every analysis is properly of one study itself one metal analysis is coming off fewer studies and they've analyzed 11 meta analysis which has and then 30 rcts randomized controlled trials of 130 times and what they studied was a different types of intermittent fasting in the adults and they had taken the period so what they studied was the different types of intermittent fasting we have dr dhiran ganjala with us for the expert comment about the infinite fasting i'll finish with what i have to say and then we'll call him he's already there so there are four different types of intermittent fasting which were studied one was the zero calorie alternative fasting that means on one day patient would be taking low calories and on the next day he would take his normal diet that was called zero calorie alternative fasting second type of intermittent fasting was modified alternative fasting in which person would take on one day and think up to 40 percent of his calorie or 600 calorie maximum and the sake secondly he would take his regular diet that is called modified alternative fasting or matf the third which is probably the most popular in most of the people who do this intermittent fasting is five to two that means on five days whether it's a consecutive or intermittently five days the person would have his regular diet and today he would be fasting again consuming around 600 calories no more than that and the fourth is the time restricted eating which person would not eat for 12 hours and then you do it for his regular diet for 12 hours that is called time restricted eating these are the four different types of intermittent fasting going on there are so many other types also but this particular meta-analysis these four types of intermediate fasting were studied and the outcomes also there are large number of outcomes this study is very exhaustive and what they found the result was that they modified alternative fasting uh and the five to two that means five days regular diet and 2 day fasting actually the best results as far as the weight loss is concerned almost most of the participants lost 5 percent of the weight loss that was the desired primary outcome in them and the measurements whether it's a body mass index or whether the blood glucose levels or triglydes or ldl they were all better off in these particular two types uh unlike the other types the time restricted eating or the alternate zero were not as good as these two particular types of the uh and overall as i said the last line if you can read the modified alternative uh fasting as well as the five to two diet have the best effective right and we have dr dhiran ganjawala he is a very good personal friend he is by profession he is a pediatric orthopedic surgeon but is also a good reader and he himself had had many talks about this intermittent fasting and he also he himself is one of the one who had observed intermittent fasting so let us hear from him about his comments about the intermittent fasting and its fact on the overall weight loss as well as the other parameter metabolic parameters dr dingo ganjuala welcome you and please have a process yeah so basically uh first of all thank you very much for asking me to share my views about intermittent fasting i tried intermittent fasting before two years at that point my body mass index was 24 so according to indian standard i was overweight but not obese but still i wanted to bring it down to 22 to 23. so uh i had various options already i was walking two hours in a day almost two hours in a day sometimes uh like three hours so there was no question of increasing the exercise so i thought of various options and at that point i came across a book of jason fung and i read about this intermittent fasting that if you really want to uh reduce weight then probably this is the best method because it reduces the insulin sensitivity and that is probably one of the reason of obesity so i tried that and it really worked like say i lost almost one kilogram every week and in six weeks i was able to achieve my target and after that i continued that and during that period i would just like to emphasize that a lot of people say that what about the weakness i ran uh around 10 half marathon during that period so basically it does not lead to that that much weakness also yes initial few days are difficult because it demands a lot of uh willingness or like say the will power sorry i would say willpower but it's not that difficult so anyone who wants to try it should try it and uh probably i i have not seen uh a great side effect also so it's really a very effective method thank you you said about the jason fung so what are the different types of intermittent fasting suggested by jason fung and which according to what kind of intermittent fasting you went for okay okay yeah that's that's very important question so i used to do it uh 16 by eight so in a window of eight hours i was eating so that comes to lunch then one tea at 4 or 5 p.m and then dinner so after dinner then no breakfast the first thing which i take is the lunch so i did needed that 16 hour fasting eight hours uh eating so that was the pattern which i did but your experience or comments from the book about the five to two or the alternate day fasting okay yes author says that even like at present my wife is doing slightly more strenuous and she's eating only one sunday so that comes to 22 hours fasting and two hours of eating and that is also very effective but that depends like how much weight loss you want to carry out in my case it was not a great amount of weight loss i was expecting or or like targeting so 16 by 8 really worked then there is they say 36 hours fasting so i have tried that also and again it's effective so there is no question about the efficacy the only thing is it's all about your willpower which is are you still observing the intermittent fasting right now or not only once a week once a week right because most of the studies say that the short-term gain is always there but the long-term benefits are yet to be proven on the simple reason that there is a metabolic adaptations the initially it is the liver which is main response polygon which they call it a metabolic switch that the metabolic switch is in the form of losing the fat and conserving and that is why probably it's a works best for the weight loss but overall and maybe it is very difficult to sustain that kind of lifestyle for most of the people who are as you said not motivated by themselves so maybe that is the reason that this intermittent fasting is not getting enough of the result that it should be otherwise logically if you cut down your calories by whatever means it should work yes so it's not basically like say when i was eating two times there was i don't think that there is a calorie restriction because i was eating everything no doubt i was avoiding sweets but otherwise like if you look at the quantity i'm sure that i was consuming 2 000 calories so it's not probably the calories which is the only reason there is something more beyond that which is responsible for this weight loss right and that is exactly what they say that is probably the lever that undergoes the metabolic switch and the insulin sensitivity that improves and that will also help in the energy balance so thank you a doctor genjawala and it was pleasure having you and we'll call you again for the common topics thank you so much yeah thank you yeah thanks we move on to our next story again very interesting story and that is about ram decibel no there is one drug ruling which has had a roller coaster ride in this pandemic uh when it came it came with the big hue and cry and probably we have got the something that what people saw that is probably something that is the elixir of life and it will save the life and we also witnessed that the there were so many of the people waiting for rem received and as if ram destroy is the only one which is going to save us then there so many papers came that ram distributes no better than placebo than there were the results that probably just could only in the hospitalized patients and so the of course uh remedies for has been co in the hospitalized patient we have enough data but this particular paper appeared before yesterday and in the new england journal of medicine here the type of patients were enrolled were the non-hospitalized patients or very early patients of having the rtbc are positive and the symptoms in less than seven days and what they tried was the whether the early ram decibel can prevent the progression to severe covet 19 infections hospitalization and death that was the research questions and they enrolled 562 patients 279 received ram decibel and 283 received placebo and the dose of ram receiver that was employed here was only three day course of rendezvous 200 milligram on day one 100 milligram on day two and 100 milligram on day three so over 400 milligram we used to give 500 to 600 milligrams when the patients were treated in the hospitals and the they also had the criteria was that the patients have to have one conditions one particular character is either they are more than 60 years of age or they have one comorbid conditions like diabetes or obesity or hypertension and that was the criteria for receiving the rem recipe and what they found in the study was the md suggested the hospitalizations occurred in two patients in the ram decision group while 15 patients in the non placebo group had to be hospitalized uh so the p value was significant and the total of 246 patients in ram decibel group and 21 of the 252 in i means 4 of 246 in the rendezvous group and 21 of 252 in the placebo group had covered related medical illnesses for which they had to go to the hospital for in the next 40 at four weeks so of course there were no patient the death in either group but the adverse events occurred in almost the same number of patients so ram decibel was not having any adverse effects in the patients the idea of giving gram discipline early is that as we say most of the antiviral drugs work better when we catch the patients in the very early the viral replicating period of the illness and this again proves that if at all vo2 is ramdas here we should be selecting the right patient in the form of the patients who are eligible for it in the form of persons who are more than 60 years or having comorbid conditions and we have to give them early if we want to prevent them hospitalizations or the complications like going to icu or ventilator so among hospitals patients there were at high risk of covet a three-day course of rdb has definitely acceptable safety profile and resulted in 87 percent lower risk of oscillation than placebo so we invited dr sunil mehta who is one of the leading physicians and who had worked very hard along with the team of hcg hospitals in ahmedabad and let us have his opinion about the use of ram recive in the second particular phase of the very delta variant infections in along april may when we treat this with large number of patients who require hospitalizations and reimbursement treatment so let's hear from dr sunil mehta what he has to say about his experience about the use of ram decision my experience of receiving is quite good ever since when recipe was available to the general public we started using in all our patients we saw about 9 000 patients in opinion about 2000 plus patients where i beated our care in our hospitals and most of them were given ram distributor unless there was a specific contraindications initially we were using 700 milligrams 200 for the first day and remaining 100 milligram daily nowadays they have changed the dose to 400 milligram 200 for the first day and remaining two on the second and the third day this is how they are using it now but our experience was that the ram recipe has worked beautifully well in most of the patients as far as the symptomology was concerned the fever went down very fast the oxygen requirement was minimum or probably not there in people who were timely used ram decimate and subsequently the admission in icsu were also quite less compared to those who are not given this benefit of the ram recipe [Music] six days or seven days of symptoms then results are fantastic there are no major side effects of patients and those who are bottling high created level though it was initially mentioned as a contraindication but we have our experience that the c from created level went on proving after the use of brand decimal that was the striking feature which we observed in our patients of embracement so overall our experience of rem decision was excellent okay that was really very important and reassuring thing that ram desi has have a very high safety profile and of course what we have to take this paper with a pinch of salt in that sense that ram device is still in injectable form and now at least two new drugs have already been approved for the early part of the coveted 19 infections and that is the monopyravir as well as the one drug that is called the pacsflow weed has also been recently approved so we need to see the when of course we don't expect any head to head trial with all the three different drugs but the malnupira as well as the another drug is also there in our armamentarium for the early part of the covet 19 infections so we move on to our top story and that is about the american diabetes association standard of care 2022 release and usually the american diabetes association which is the premier institute for all the diabetes related guidelines or suggestions or practice uh suggestions that come from and practically for the whole year we will be using these guidelines as a standard or what we can say the rule of thumb and this particular guideline just came before two days and here they have made many good changes from what we have been following as a treatment for diabetes and first and foremost thing was that up till now we were screening all patients with diabetes for uh all normal persons who screened for diabetes the age was 40 right the only people who had obesity were screened earlier but in this particular this year's guidelines they will lower down the age for screening to 35 years that is one second in pregnancy up till now we were only advocating the screening for diabetes only past if there were no pre-existing diabetes then usually we were for only after the 20 weeks or 24 weeks of gestation but here less than 15 weeks of gestation the all pregnant women should be screened for the diabetes that is gdm and also that if they are at the time of conceiving also if they have a high risk or family history then they should be screened or at least the first internal visit whatever may be the first entitled visit they should be screened for diabetes that is very very important and whenever we are suspecting type 1 diabetes then we should subject them to antibody testing this is also this year's new recommendations that all suspected typhoon diabetes should be offered an antibody screening then again depending on the comorbidities right that should be an individualized care if the patients had comorbidities in the form of cbd then we have to add our patients have any complications then accordingly we should go for the individualization of the treatment we don't have to fix algorithm for a treatment that is accepted and inbuilt they have got a new inbuilt four pillars strategy in which the complications risk reductions including the management of blood pressure blood pressure lipids are also given importance along with the glucose management diabetes management is no longer a glucose glucocentric but it should have the good control of blood pressure lipids as well as the benefit to the kidney and cardiovascular disease have to be kept in mind whenever a selected drug or the overall therapy whether it's an antihypertensive medicine or anti-diabetic medicines we should be looking at the cardiovascular and kidney benefit of this therapy then another important part is the pharmacological algorithm which includes not only the patient's weight the risk of hypoglycemia we select a drug in a particular group of patients if they are more risk at risk of hypoglycemia we should avoid drugs like this sulfonylurea group of drugs which are known to cause hypoglycemia and the weight also is important drugs like bioglitasms who increase the weight should be avoided or if the patients are overweight you should go for the hdlt2 inhibitors which have a way along with the anti-hyperglycemia effects also the weight reduction effects and the cost of therapy the first time it is also included the cost is equally important because we know from our practical experience that if you don't take into the cost then patients are likely to not take the drugs for a longer period and that still cause more complications then there was a special section entitled obesity and weight management for the prevention and treatment of type 2 diabetes and again we know that oral sel glp 1 drugs is coming in the indian market also in january probably and that is called the sema glutam sema glutathione up till now we have only injectable glp one agonist drugs and that is the whether it is a lira glue type and many other drugs but sema glutathione is the first orally acting glp one agonist drugs and which is not only approved for the treatment of diabetes also approved for the obesity treatment so the semi glutamine treatment is also added this year right and especially we know that in this kovid time we have so many nuanced diabetic patients not only because of the use of steroids but otherwise also we had patients all of us have treated new onset diabetes because of the covalent fractions maybe it is the infection also involving the pancreatic beta cells uh we don't know the exact etiology but new onset diabetes is known in kovid time and may be these drugs are going to be useful and also they've added the management of non-alcoholic fatty liver disease liver particularly has been given now importance or the mechanism of the drugs as well as at a target organ for because we know that those patients who do not have the history of hepatitis b or c infections or alcohol consumption probably nafld is one of the leading cause of cirrhosis of liver in the time that we see in our group of patients so nafld should be tricked for the risk factors and it is one of the metabolic disease which is a foreigner for the cirrhosis of liver and the another important is the management hypertension and the diagnosis of hypertension up till now we are waiting for many number of readings before labeling somebody is hypertensive but this particular recommendation suggests that any patient who has at least one reading of the severe hypertension right then the blood pressure anti-hypertensive treatment should be started and the blood pressure targets should also be individualized up till now uh there came a period when we used to bring down the blood pressure lower the better then came that less less than 140 less than 90 should be the target of blood pressure for all diabetic reasons but now they said individualizing the patients can tolerate the drug maybe we try to achieve anything systolic between 120 and 113 dash between 17 80 millimeters and don't just be happy with only 149 years of target blood pressure then security management the chronic kidney disease management in diabetic patients have been separated from the other microscopic complications uh and have been given many new updates are there then the retinopathy neuropathy and food care they are also part of the microvascular complications are combining what sections and again very important thirst is given to the use of newer technology when it comes to the diabetes the glucose readings and the continuous glucose monitoring that is cgm and particularly in cgm itself also we try to see what is called tir or timing range that means if the patient's overall glucose readings if you see and if that glucose readings remains between 70 and 140 that is called time in range how many number of hours the patient remain in tir how many how many times the patients reading were above tir or below tir so that technology has to be utilized for a better smooth control of the glucose overall because it's not only the hypoglycemia or hyperglass but the fluctuations that is called the glycemic variability also has to be attended to get the best out of the management of the diabetes so these are all the standard and we had requested dr bansi sabu i am not sure whether he is available today he has joined in and we are really um he is the president of the research society of diabetes in india and very leading researchers and has so many papers he and his team about the diabetes and it will it's really a pleasure to have dr bansi sabu with us or his comments about the newer ada release this week it says marriage season and you are busy and otherwise also you're very busy and if your spare time that's really good for us and our audience and we want your comments about the ada 2022 new release of the set of recommendations sir first of all thank you dr madhave for giving me this invitation and i'm really very happy to be with you and your comments which i was listening about the american diabetic restoration guideline which is recently introduced uh two very important thing which you talked about just now that they have reduced the ease instead of 40 now 35 is the age for screening for everyone but just for that viewers the icmr and indian guidelines we are talking that in india as we asians are at higher risk of developing diabetes we recommend screening for everyone who is above the age of 30. so that's what indian guideline and that is since last five years we are recommending more than 30. recently me along with dr anuprisha have published a paper that in india rather from 30 we should come down to 25 so americans are moving from 40 to 35 and we are thinking that whether we should do for everyone from 30 to 25 so that's one very important information which i thought i must share with everyone yes definitely all those who are at the higher risk of developing diabetes with the family history we also have our indian diabetes risk score and those who qualify with higher risk they should be screened every year even whatever the age they could have it could be in a pediatric case also the last one the second we were talking about the diabetes in pregnancy that we also call hyperglycemia and pregnancy before that we were talking about only about gdm so a gdm criteria is typical when we are having hyperglycemia at 20th to 24 we but now ada is also recommending that even it should be done for earlier week and even at the first entire visit but just again for the audience audience everyone to know that in indian dipsy guideline rssdi guideline and icmr guideline we recommend for every female even at first antenatal visit because we are trying to see for hyperglycemia pregnancy and we found to have more hyperglycemia pregnancy impaired glucose tolerance during pregnancy time and that's the reason that it's our recommendation is for everyone and that since almost like five years dipsy guideline is there in india which is again accepted by indian council of medical research so these are the two important points which is the change in the guideline from american life negotiation but one very important change which they had thought of that we are since years talking about the metformin should be the first choice of therapy for all diabetes still it is considered as a first choice of therapy but now they are recommending that even instead of metformin if there is a conditions like established cardiovascular disease or a heart failure even before metformin the sglt2 inhibitor or even patient with obesity or primary the problem is obesity even glp1 can be considered as a first line even before the metformin also already sglt2 was in 2019 european society of cardiology had given the choice that before metformin even the patient who is first time detected with established cardiovascular disease in diabetes i think before starting the patient on metformin sglt2 inhibitor should be given so the same recommendation which was esd had endorsed in 2020 and now in 2022 uh the guideline ada is also recommending the same now one more recommendation in pharmacotherapy they had put that patients to whom we put on insulin therapy after three oral anti-diabetic agents are failed instead of giving them only insulin it is better to put them on insulin in glp together so i mean that's strong recommendation of glp if you have not used in first three drugs and putting the patients on insulin it's better to combine both the things together because that will help further weight loss it will not require most of these patients may not require the prandtl insulin and the sugar can be controlled and as there is internationally basal insulin and glp1 analog is in co-formulation is also available so that can be also initiated and it can be intensified according so that's again and very important as you were talking rightly that in tectosis action the headphone that uses of continuous glucose monitoring should be more frequently as for type 1 it was already recommended since years but now for type 2 diabetic also because now we are moving from indus medicine to the precise medicine you know from each and every person and each and every person have different diet every day the diet is different every day the pending sugar will be different and better to them control with a continuous glucose monitoring because then you can monitor them with glycemic variability how much they have and as you rightly talked about time in raise that more than 70 percent of the time they should be in time in range between 70 to 180 so that's a strong recommendation had come from ada in technology section also so these are some of the important issue other than you had already talked about the ctd microscope complications and all other aspects of newer aspect but as american diabetic association all over the world we all looked upon it that this is the guideline what is new in it what are the things where they are recommending and then we always we know that we are indians are different we are at much higher risk than what americans have and we develop diabetes even at lower bmi we have higher cardiovascular disease risk also as they have recommended this time those patients who can't be achieved with highest dose of statin with ldl cholesterol less than 70 it is better to put them on pcsk or htmi early instead of that delaying these therapy so i mean again intensive lipid lowering as there are four pillars other than hypertension glucose control lipids uh the molecules which will decrease the cardiovascular disease like sglt2 and glp1 analog this is what a therapy which should be offered to a diabetic patient for prevention of complications i mean this is all we are moving i mean we i will not say that we are moving rather we are glucocentric but we will continue to be glucocentric but along with that we should be more focusing on prevention of complication and that is from the day of diagnosis itself you should try to prevent the complication from day one so our glucocentric approach along with prevention complication uh preventing complication approach should be continued or are type 2 diabetic patients and again we indian should more focus on prevention of diabetes how lifestyle measures can help our patients or the person with diabetes or somebody who is at the risk of developing diabetes how we can prevent the diabetes because we develop diabetes at almost one or two decades early so that's a really a something which is a serious problem in our country yes sir yeah i was just reminded when you were talking that really india our guidelines had talk of cost uh much earlier than this time only the led has come out with the cost but we already had to talk about the emphasize about the cost of therapy efd and that f is for financing condition because 70 percent of our patients are out of pocket expenses we are always very conscious when we are writing the medication that what is the cost of therapy with overall cost if it is high then again compliance will be significantly poor for the person who is taking the medication ah thank you very much dr bansi in spite of your busy schedule and the function you are involved your spare time and enlighten us thank you very much and we would like to have you again again and again right and thank you so much and thank you sir thank you please thank you sir yeah thank you one of the readers wanted uh the viewers wanted to know whether kv can we not use insulin obviously insulin is the first drug right to be used but because it's an injectable one most of the patients don't want it and but the there's a clear-cut guideline the patients who are an hb1c more than nine percent or patients who are symptomatic have to be offered insulin but in the earlier part when the patient's hb1c is not iron if he's not willing for insulin then only the question of the oral anti-diabetic drugs would come otherwise insulation is logically the first choice have to be offered and there have been studies when if the patients have received insulin in the first five years they have remained uh in normal glucose levels for a much longer period that used to be called the molecular memory or metabolic or legacy effect and it's known well known that you have to very aggressive in the first five years of the diagnosis of diabetes and uh that's definitely there so i think with that we come to the end of our stories and it's a time for quiz what do you mean thank you sir so for those who've joined us new uh we have three questions out of the stories that we covered today uh they have abcd options so uh type in the correct option either a b c or d in the comment section and the first person to get the right answer uh netflix will get in touch with you uh for uh for a price from our site um so we can have the first question uh so we'll give you a couple of uh minutes and y'all can put in the put in your right answer in the comment section most accurate measurement for visceral fat is uh done with a ct scan mri scan dexa scan or 3d body scanner i think we've got a couple of right answers so we can move to the next question uh same thing again uh y'all can uh you can put on your uh answer in the comment section uh we'll wait for a minute and then we'll uh go to the next slide i think we can go to the last question for today okay in treatment of parkinson's disease inhaled liver dopa helps to improve memory sensory impairment motor fluctuations or behavioral issues i think most of the people who have answered have given the correct answers motor fluctuations the only phenomenon which is troubling the most of the patients of the parkinson's have been benefited with the inhaled liver power so thank you very much thank you sir um just give us a couple of minutes and the team will come up with the right answer uh the right people uh who won the prizes uh okay so we do have the uh winners here so for question number one we have dr samya singh uh for question number two we have dr shri priya and for question number three we have dr aashiq bhatt uh so someone from team netflix will get in touch with you for your prices uh very soon in this coming week yeah so one of the doctors asked whether intermittent fasting can be recommended early diabetes definitely definitely because the very mechanism of intermittent fasting is the insulin sensitivity improvement so definitely it can be only thing is the patient is on drugs which cause hypoglycemia you have to be very careful about giving the intent fasting what kind of fasting and what that you have to take so we stop here but remember it's a new way new year eve is coming and the omicron threat is also very much there so we have to have most of the states have now imposed the night curfew as per the today's evening news so we have to be very careful we must have the appropriate behavior as we always say and we must avoid the gathering and we should remain stay fit stay healthy and go for the vaccinations and boosters as in when they come and with that we wish you the very best and we'll meet for the next friday or an interesting updates of the all the stories uh interesting stories of this year and thank you all good night take care thank you

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dr. Mahadev Desai

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Dr. Mahadev Desai

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