75-80% of our population has Vitamin-D values which are considered less than adequate


 SAFES Summit Proceedings-III

 75-80% of our population has Vitamin-D values
which are considered less than adequate

Nikhil Tandon suggests Vitamin D fortified milk for children
and adequate sun exposure during summer

Aggressive treatment of diabetes reduces the risk
of cardiovascular disease - Dr. Abbas Raza

DHAKA (BANGLADESH): Prof. Nikil Tandon from All India Institute of Medical Sciences New Delhi India delivered Prof. Mohammad Ibrahim Memorial lecture during the SAFES Summit 2015 held at Dhaka Bangladesh from February 24-26th 2015. The topic of his presentation was Vitamin-D: South Asian Perspective. He discussed at length Vitamin D deficiency and insufficiency quoting various studies in the region and said that it was a long latency deficiency disease.  This session was chaired by Dr. A.K. Azad Khan from Bangladesh.

Various intervention studies, he said, has proved that Vitamin- D supplements does reduce risk of fracture. One of the studies from Pakistan has reported 13% prevalence of Vitamin D deficiency. He then referred to Rickets’ disease which is also known as post colonial disease. He then referred to various studies on prevalence and predictions of Vitamin D deficiency from Pakistan, India, Sri Lanka, immigrants in UK besides Vitamin Nutrition status in Pakistan in neonates and breast fed children. He pointed out that almost 75-80% of our population has values which are considered less than adequate. The situation is far better in rural areas as regards Vitamin D status. He then talked about Vitamin D status in elderly, Vitamin D and Bone Health. He was of the view that we must try to find out how can we fix this problem and what are the things that we need to change? In fact we do not know much about Vitamin D. He suggested provision of Vitamin D fortified milk for children. It is possible and the kids can be forced to take it. Just like iodized salt has been a success, this too can be a successful intervention.

Emphasizing the importance of changing our behaviour, Prof. Nikhil concluded that we need to understand Vitamin D deficiency. We must ensure skin exposure to sunlight at regular wave length. During the summer, exposing the skin to sunshine twice a day, wear appropriate dress and use sunshine and fortification of food items with Vitamin D is critical and need to be properly evaluated.

Dr. Sarita Bajaj chaired the next session wherein Dr. Abbas Raza from Shaukat Khanum Memorial Cancer Hospital Lahore was the guest speaker whose presentation was on Double-trouble- tackling cardiovascular risk in diabetic subjects. He referred to the mystery in medical knowledge and pointed out that it is the synovial bubble which makes the noise with a cracking sound when we press our fingers. In diabetes micro vascular and macro vascular complications start much before they are noticed. In diabetes, there are certain things which we can change like poor family and one’s fate but there are others which we cannot change like age, gender and family. Some risk factors have chronic diseases like poor diet. We spend lot of money on treatment of cardiovascular diseases, diabetes mellitus but we must think for a while is it the right way to spend money, he asked? Should not we do something else? With smoking, high blood pressure, high cholesterol and obesity, you increase the risk of cardiovascular diseases.

He then referred to the cardio diabetic syndrome, cardio metabolic syndrome, overweight, obesity and pointed out that most often cardiovascular diseases and diabetes come together. Women are affected worse than men. We all know what happens if diabetes is left untreated i.e. serious complications. He highlighted the concept of individualization and said that if we do not treat these patients with diabetes, they die early. A vast majority of the diagnosed people with diabetes are left untreated. At times hyperglycemia is under diagnosed at the time of coronary disease and more than three fourth of patients are severely affected with heart disease. We also know what happens if we do not treat dyslipidaemias. Aggressive treatment of diabetes reduces the risk of cardiovascular disease. Unstable or strong plaque is left and we should try to reduce it. Young people in this part of the world get diabetes early.

Continuing Dr. Abbas Raza said that there are differences in risk assessment, differences in metabolic diseases, difference in habits and difference in complications in diabetics and non-diabetics. In fact it is not one but multiple risk factors. When we are examining a patient, we must look at other risk factors as well. He then gave findings of CARDIP study which enrolled diagnosed Type 2 diabetics within the last six months between the ages of 30-50 years. Almost 72.5% had family history of diabetes, 74% had no history of IHD. About 14% were smokers. Their average BMI was 27.84 and fasting glucose was 175.26. He was of the view that we end up treating more expensive complications if we do not start treatment in time. Retinopathy is a very common complication. There are documented cases of blindness.  Almost 60% of patients have type 2 diabetes.  He advocated multidisciplinary intervention in Type2 diabetes mellitus. He also talked about evidence based medicine and importance of revascularization. One has to keep a balance between treatment and overtreatment. Do not treat diabetes mellitus aggressively to have more complications. It is recommended that every person with type 2 diabetes should be on Low Dose Aspirin therapy. Reduce LDL cholesterol; go for RAS therapy and smoking cessation. Exercise and lifestyle modification are very helpful. One should aim at starting the treatment early, target global risk and treat to lower the risk, Dr.Abbas Raza concluded.

Dr. Asher Fawwad from BIDE Karachi Pakistan was the next speaker whose presentation was on Beta Cell as a central key player in Type 2 diabetes. He talked about the triangle risk of genetic, environmental and behaviour. Insulin resistance and Beta cell dysfunction, he said, are linked. There are many factors which result in progressive decline of Beta cell function. He suggested weight loss and dietary modification. He also talked about maternal nutrition, pre and post conception biochemical factors, breast feeding and post natal catch up growth.  Currently there is increasing interest in novel drugs which will target affected cells, he added.

Dr. A.K. Das from India talked about Individualization of incretin based therapy. He talked at length about Incretin based therapies i.e.  GLPI based and DPP4 based inhibitors. He also pointed out the benefits of Gliptines as well as some adverse effects of these preparations. He then gave comparison of efficacy of various Gleptins. In kidney failure, all drug dosage, he said, have to be modified. Some drugs are not indicated in live diseases. Speaking about Gleptins and cardiac safety, Dr. Das said that they are cardiac friendly. Dr. Rakesh Sahay highlighted the efficacy of combination of Sulfonylurea’s and Metformin. With the use of sulfonylurea’s there has been 0.5 to 2 HbA1c reduction while sulfonylurea’s also reduced the chances of cardiovascular diseases and death. One should avoid the risk of hypoglycaemia. Gliclazid, it was stated, lowers the risk of hpoglycaemia. Use of insulin results in weight gain but like Gliclazid, sulfonylureas has very low risk of weight gain.  Cardiovascular safety of sulfonylureas was also highlighted. Dr. S.R. Aravnd talked about barrier to insulin treatment and mentioned the fear of unknown and psychological phobia. It was stressed that we need to do lot of education if we wish insulin treatment to work. Most patients have fear of hypoglycaemia. Doctors are uncertain to start insulin therapy fearing that the patient will run away. Some feel that too much time is wasted hence they do not teach the patients about the disease as doctors usually do not spend adequate time with the patient. Patients with Gestational Diabetes Mellitus or during surgery, all type 2 diabetics need insulin therapy for a short period. If blood sugar is high, HbA1C is high, early use of insulin offers benefits in coronary artery disease and it also changes the outcome. It is important that one should not wait for too long and start insulin therapy early and never use it as a threat. Make it patient friendly. Deglude, it was sated is useful in elderly and frequent travelers. If fasting blood d sugar is high, continue basal insulin and simple written instructions are always helpful.

Prof. Hajera Mehtab chaired the afternoon session. Dr. Sarita Bajaj discussed Fatty Liver Disease; Associations and impact beyond the Liver. It was pointed out that about 5% of general population was suffering from fatty liver disease and of this 20-30% will eventually develop NAFLD. All these patients have a great risk of developing diabetes mellitus. India has a community prevalence of Fatty Liver Disease between 5-25%. One of the studies showed ultrasound evidence of 32.2% prevalence of Vitamin D deficiency and NAFALD which is a risk factor of cardiovascular diseases. She then talked about predictors for atherogenic process, non-invasive diagnosis and pharmacological treatment.

Seminar on Medical Writing

Pakistan Association of Medical Editors (PAME) organized a seminar on Medical Writing on February 24th in the afternoon which was chaired by Prof. A.K. Das from India. The speakers from PAME included Dr.Fatema Jawad, Shaukat Ali Jawaid, Prof. Sina Aziz and Prof. Mohammad Mubeen. The topics discussed included literature search, how to write references, How to write structured abstract, Introduction, Methods, Results and Discussion in an original article. Later on Dr.Fatema Jawad made a presentation on Publication Ethics. There were over one hundred fifty participants and the presentation aroused lot of lively discussion and interaction with the audience. Summing up the deliberations Prof. A.K. Das commended the speakers for their presentations and said that lot of research was being conducted which is evident from the number of presentations and posters in this conference. However, how many of these posters will eventually get published is a question mark?. Thousands of dissertations are written but no papers out of these dissertations are published, hence the research does not see the light of the day. He referred to the most commonly use phrase Publish or Perish and then stated that we should search and research as to what we have added to the medical literature, he remarked.

During the General Body meeting it was emphasized that SAFES should promote research in diabetes mellitus, endocrine diseases. We have these diseases which are different from the West; hence we need to promote this research in metabolism. Other objectives of SAFES are public education and public advocacy which were highlighted at the Colombo meeting.  The first SAFES Summit was held at Hyderabad in India in 2013. SAFES organized training programmes, CME programmes for GPs on management of diabetes and better use of newer agents. SAFES also came out with smart use of sulfonylureas while Dhaka Declaration has highlighted the management of Gestational Diabetes Mellitus to get better outcome. There was good interaction with various country’s Endocrine Societies and regional countries have come together to improve the treatment of endocrine disorders.  Dr. Tufail pointed out that we had collaborative research in five countries. We are working on exchange programme of young endocrinologists. We should have exchange programme within our countries. We also had a paediatric endocrinology session in the current SUMMIT. Sulfonylurea’s guidelines should be publicized. It has also been decided that GDM will be the theme for the next two years. Since health cost is going up, management strategies should be affordable.