Introduction and Objective: Cardiac autonomic neuropathy (CAN), a common complication of type 2 diabetes (T2D), has limited non-pharmacologic options. This pilot study assessed whether supervised Suryanamaskar, a yoga-based practice, improves autonomic function, glycemic control, and mental health in T2D with CAN. Methods: This pilot report presents interim findings from a 6-month prospective, real-world study conducted at four centers in India. Eighty adults with type 2 diabetes (T2D) and confirmed cardiac autonomic neuropathy (CAN) were enrolled between March 2023 and October 2025. Participants were assigned to: (a) intervention group (n=47) receiving supervised Suryanamaskar (5 sessions/week) plus standard care, or (b) control group (n=43) receiving standard care. Both groups continued guideline-based lifestyle management. CAN was assessed using standard autonomic tests; secondary outcomes included HbA1c, lipids, liver enzymes, WHO-QOL BREF, and HADS/BDI scores. Ethics approval and written consent were obtained. Results: Valsalva ratio improved in the intervention group (1.32 ± 0.15 to 1.38 ± 0.17, p=0.081) with no change in controls; E:I ratio increased (1.13 ± 0.08 to 1.17 ± 0.09, p=0.069) in the intervention group but remained unchanged in controls. CAN reversion was seen in 25.5% of the intervention group versus 7% in controls (p=0.029; RR 3.64, 95% CI 1.13-11.73). No significant changes were observed in HbA1c, BP, lipid profile, or liver enzymes; glycemic neutrality was maintained. The intervention group showed significant reductions in HADS (14.1 ± 3.6 to 11.3 ± 3.2, p=0.002) and BDI (18.7 ± 5.2 to 14.5 ± 4.8, p=0.001), with no changes in controls. WHO-QOL BREF scores improved (58.3 ± 7.5 to 61.0 ± 8.1, p=0.058) in the intervention group, though not statistically significant. Conclusion: In this pilot cohort, supervised Suryanamaskar alongside standard care led to modest improvements in autonomic function and significant benefits in mental health, with glycemic stability maintained. Disclosure S. Samajdar: None. B. Saboo: None. A. Modi: None. H. Hirani: None. S. Mukherjee: None. B. Saboo: None. S. Joshi: None.

Introduction and Objective: BMI significantly influences type 2 diabetes (T2D) management and treatment outcomes. LANDMARC is a 3-year study on people with T2D (PWT2D) in India. This sub-group analysis evaluated BMI-specific glycemic control and outcome. Methods: Evaluable participants were stratified into four BMI categories: underweight, normal, overweight, and obese. Data on macrovascular and microvascular complications, cardiovascular (CV) risk factors, insulin dosing, and glycemic assessments were collected and analyzed across 7 visits (V) over 36 months. Results: Out of 6234 eligible participants, 6203 were evaluable. BMI groups showed slight variations in macrovascular complications with no specific trends in new complications. Microvascular complications were lowest in underweight group and showed marginal differences among other BMI groups. The obese category had a higher percentage of PWT2D (58.57%) with CV risk factors, including hypertension, and dyslipidemia. Insulin dosing varied by BMI; overweight and obese PWT2D required higher basal and prandial insulin doses. Mean HbA1c was >8% at baseline across BMI groups and reduced to <7.5% by V7. Initial higher FPG and PPG levels decreased to near normal by V7 across all BMI groups. Glycemic control improved in all BMI groups at each V (Table). Conclusion: BMI impacts T2D complications and glycemic control, emphasizing the need for BMI-tailored management. Disclosure S. Joshi: None. H. Thacker: Speaker's Bureau; Current; Sanofi. Speaker's Bureau; Ended; Bayer India, GlaxoSmithKline India, Novo Nordisk, Sun Pharmaceutical Industries Ltd. A. Das: Speaker's Bureau; Current; Sanofi. Speaker's Bureau; Ended; Novo Nordisk. N. Rais: Speaker's Bureau; Current; Sanofi. Funding Sanofi (DIREGL08112)

The United Nations Organization (UNO) has proposed achieving specific Sustainable Development Goals (SDGs), including poverty, hunger, health, education, equality, climate change, and the need for sustainable development, while protecting the planet Earth from environmental degradation. The expert group of the International College of Nutrition aims to emphasize the merits of sustainable diets and traditional plant based foods for the primordial prevention of cardio-metabolic Diseases (CMDs) and other chronic diseases in this review, to achieve these goals. A narrative review was conducted to identify articles related to cardiovascular diseases (CVDs), obesity, diabetes, and cancer, using databases from the World Health Organization (WHO), Google Scholar, MEDLINE (PubMed), Web of Science, and EBSCO, along with additional secondary sources and a search of grey literature. Opinions of experts were also sought, and views of all authors were obtained as outlined in this document. It seems that education, in particular health education and motivation, apart from cultural factors, are crucial for achieving total health, and the SDGs of the UNO. The prevalence of unhealthy behaviours and risk factors for most of the CMDs and other chronic diseases is rapidly increasing in low- and middle-income countries, due to the ongoing economic development, leading to rapid changes in diet and lifestyle. There is some decline in cardiovascular disease (CVD) mortality in high-income countries due to education and learning of preventive strategies, resulting in a reduction in mortality due to these diseases. However, CMDs and cancer remain the significant causes of morbidity and mortality. During and after World War II, food scarcity persisted from 1940 to 1965 in most countries, accompanied by a low risk of cardiovascular disease (CVD) and diabetes. The rapid increase in industrialization and urbanization has been linked to environmental degradation on planet Earth, a decline in fertile, healthy soil, and sustainable, functional farming practices, resulting in a decrease in the production of nutritious foods. These alterations in food availability are associated with an increased production of unhealthy, energy rich foods and Western-type dietary patterns, which in turn increased the risk of non-communicable diseases (NCDs). The health of the planet and its people is at risk. There is a deterioration in the global standard of natural systems that support life on Earth, which is exacerbating energy, food, and water insecurity, and increasing the risk of disease, disaster, displacement, and conflict. Recent advice about the safe corridor on the planet can enhance research on planetary boundaries and Earth-system aspects of the SDGs. It appears that poverty, lack of education, and inadequate health education and motivation, possibly due to ineffective policies by national and local governments, are significant determinants of the increased risk of these diseases. In urban areas of lower and middle-income countries, as well as in immigrant populations in high-income countries, CMDs and other chronic diseases are significantly higher than they are in some of the high-income populations. Improvements in soil and the promotion of functional farming, along with an emphasis on the food industry, are urgently needed to support plant-based, low-animal food traditional food diets. Traditional foods are feasible and affordable in every country. The use of high-protein substitutes for animal-derived foods, such as soybean products such as tofu and tempe, millets, beans, lentils, peas (400 g/day), green vegetables, fruits, and nuts (400 g/day), as well as vegetable oils, low-fat dairy products, and culinary spices, with low meat (sea-foods) may be beneficial in promoting health and preventing NCDs. Health education and promotion of healthier lifestyles and behaviours during the preconception period, in utero life, and the postnatal development and infancy stages may lead to healthy eating patterns, contributing to primordial prevention of NCDs. A wild-type omega-6/3 diet rich in flavonoids, folate, and other nutrients, along with other interventions may mitigate epigenetic risk variations at the individual level across all subgroups, from the preconception period to the elderly stages. These findings may necessitate revisions to the existing guidelines proposed for sustainable functional farming and sustainable plant based diets. Eating 400 g/day of vegetable, fruits, and nuts and another 400 g/day of whole grains, with spices (20-50 g/day) and meat as condiment (50 g/day), along with 30-50 g/day of vegetable oils, can prevent CMDs and other chronic diseases, and promote health to serve the SDGs of the UNO. Cohort studies and randomized trial in each country may be necessary to confirm the role of our advice in the prevention of diseases.

The management of type 2 diabetes (T2D) has entered a new era with the advent of advanced incretin-based therapies. Therapeutic agents such as semaglutide and tirzepatide have demonstrated exceptional efficacy in improving glycemic control, inducing substantial weight loss, and reducing cardiometabolic risk, thereby redefining therapeutic expectations. Yet, dulaglutide retains a distinct role supported by its strong cardiovascular evidence base. The REWIND trial remains the only GLP-1 receptor agonist study to show a statistically significant reduction in major adverse cardiovascular events (MACE) in a predominantly primary prevention population, with durable benefit sustained over more than five years of follow-up. Comparative trials highlight that while tirzepatide and semaglutide deliver superior reductions in HbA1c and body weight, dulaglutide offers proven cardiovascular safety, favourable tolerability, and high persistence in real-world analyses. Its once-weekly, fixed-dose regimen requires no titration and is accessible across diverse healthcare systems in low- and middle-income countries, including those constrained by cost or resources. The SURPASS-CVOT established tirzepatide’s non-inferiority to dulaglutide for cardiovascular outcomes, reaffirming dulaglutide as an established comparator with robust outcome data. This narrative review collates evidence in this regard and argues that dulaglutide should be viewed not as superseded but as complementary offering a pragmatic balance of efficacy, safety, and accessibility that supports equitable cardiometabolic care worldwide.

Background:Obesity plays a pivotal and modifiable role in the development and progression of type 2 diabetes mellitus (T2DM). Clinicians increasingly use lower doses of liraglutide (1.2 mg and 1.8 mg) to achieve clinically meaningful weight loss while maintaining effective glycemic control in people with T2DM and obesity. In this meta-analysis, we compared the efficacy and safety of liraglutide 1.2 mg and 1.8 mg in this population. Methods:We systematically searched PubMed, the Cochrane Central Register of Controlled Trials, LENS, ClinicalTrials.gov, and the Virtual Health Library (VHL) for randomized controlled trials published in English up to 30 September 2024. We included trials with 24-52 weeks of treatment that evaluated liraglutide at doses of 1.2 mg or 1.8 mg against placebo or glucose-lowering therapies (GLTs). Comparators included insulin, sulfonylureas, dipeptidyl peptidase-4 inhibitors (DPP-4i), sodium-glucose cotransporter-2 inhibitors (SGLT2i), other glucagon-like peptide-1 receptor agonists (GLP-1RAs), and oral antidiabetic drugs (OADs). We assessed changes in body weight and HbA1c as efficacy outcomes and evaluated the occurrence of nausea and vomiting as safety outcomes. Two reviewers independently extracted data and assessed study quality using PRISMA guidelines and the Cochrane Risk of Bias 2 tool. Results:We included 25 RCTs comprising 10,593 participants. Liraglutide 1.2 mg (8 studies, 3,455 participants) produced a mean weight reduction of -1.24 kg versus GLTs, -0.75 kg versus placebo, and -2.46 kg versus OADs. Liraglutide 1.8 mg (22 studies, 8,259 participants) achieved significantly greater weight loss of -2.30 kg versus GLTs, -1.93 kg versus placebo, and -2.81 kg versus OADs. When compared with oral semaglutide, exenatide, dulaglutide, lixisenatide, and albiglutide, liraglutide showed comparable efficacy. For glycemic control, liraglutide 1.2 mg reduced HbA1c by -0.24% versus OADs, while liraglutide 1.8 mg reduced HbA1c by -0.26% versus GLTs. Liraglutide 1.2 mg showed a numerically lower incidence of nausea and similar rates of vomiting compared with other GLP-1RAs. Conclusion:Liraglutide 1.2 mg and 1.8 mg doses improve weight and glycemic outcomes with a favourable safety profile, supporting its role as an effective therapeutic option for comprehensive management of T2DM with comorbid obesity.

Obesity in India is rising rapidly, with higher body fat at lower BMI and younger age compared to Western populations, leading to earlier onset of type 2 diabetes and cardiovascular disease in a resource-constrained health system. Protocols for obesity care therefore need to address region-specific challenges and ensure culturally acceptable, feasible treatment options. The Obesity and Metabolic Surgery Society of India (OSSI) and the Endocrine Society of India (ESI) jointly developed India-specific obesity management protocols using a modified Delphi consensus. A protocol development team generated 73 statements based on literature review and expert experience. Seventy-eight experts (38 OSSI, 40 ESI) participated; 100

Aims:To evaluate the efficacy and safety of dapagliflozin plus pioglitazone versus comparators on metabolic control and hepatic steatosis in adults with type 2 diabetes mellitus (T2DM), with or without metabolic dysfunction-associated steatotic liver disease (MASLD). Methods:We conducted a systematic review and meta-analysis of randomized and observational studies in PubMed, Embase, Cochrane Central, Scopus, Web of Science with a search updated through January 2026, following peer review. Eligible studies enrolled adults with T2DM with or without MASLD, receiving dapagliflozin plus pioglitazone in comparison with standard care or monotherapy, or as pooled-arm exploratory estimates. The primary outcome was glycemic control (HbA1c and fasting and postprandial glucose levels). Secondary outcomes included body weight, insulin resistance indices, related liver outcomes (liver fat content, NAFLD activity score [NAS], and steatohepatitis resolution), liver enzymes, non-invasive fibrosis indices, lipid parameters, and safety outcomes. Results:Thirteen studies (n = 1411) met the inclusion criteria. Dapagliflozin-pioglitazone significantly improved glycemic control, with a reduction in HbA1c (mean difference -0.49%; 95% CI -0.64 to -0.34), and Fasting Blood Glucose (-11.96 mg/dL; 95% CI -16.30 to -7.62) and Post-Prandial Glucose (-21.54 mg/dL; 95% CI -30.84 to -12.24). Hepatic outcomes also improved, with reductions in liver fat content (standardized mean difference -0.42; 95% CI -0.61 to -0.22) and NAS (standardized mean difference -0.39; 95% CI -0.56 to -0.22), and higher rates of steatohepatitis resolution (risk ratio 1.48; 95% CI 1.13-1.92). Certainty of evidence was moderate for glycemic and steatosis outcomes and low for histological endpoints. Conclusions:Dapagliflozin-pioglitazone combination therapy was associated with improvements in glycemic control and non-invasive markers of hepatic steatosis in adults with T2DM, with or without MASLD, while maintaining a favorable safety profile. Certainty of evidence was moderate for metabolic and steatosis outcomes and low for histological endpoints. Given the predominance of surrogate hepatic endpoints and limited biopsy-confirmed data, these findings should be interpreted with appropriate caution. Systematic review registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=1117019, identifier CRD420251117019.

Mineralocorticoid receptor antagonists (MRAs) are important pillars in the treatment of heart failure (HF), chronic kidney disease (CKD), and diabetic kidney disease (DKD). MRAs share complementary pathways with sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in patients with cardiovascular-kidney-metabolic (CKM) syndrome. Combination therapies of MRA with SGLT2i and GLP-1RA are showing promising results in CKM than individual therapies. Further, the unique action of MRAs in antagonizing MR receptors and aldosterone, implicated in the pathophysiology of several conditions, is paving the way for clinical trials and promising results in these therapeutic areas. Disease-specific biomarkers such as UACR and eGFR are increasingly being used to individualize treatment with MRA. Utilizing MRA-specific biomarkers may open the path for precision medicine and further treatment individualization.

BACKGROUND:Imeglimin is a novel oral glucose-lowering agent targeting mitochondrial dysfunction. While randomized trials demonstrate its efficacy, real-world data in diverse populations remain limited. We evaluated the effectiveness, safety, and utilization patterns of imeglimin in Indian adults with inadequately controlled type 2 diabetes (T2D). MATERIALS AND METHODS:This prospective, multicenter, observational cohort study enrolled adults with T2D newly initiated on imeglimin across 11 Indian centers. Participants were followed for 6 months. The primary outcome was the change in HbA1c from baseline. Effectiveness was analyzed in a complete-case cohort using linear mixed-effects models to adjust for covariates, while safety was assessed in all participants with at least one post-baseline evaluation. FINDINGS:The baseline cohort included 736 participants (mean age 52.4 years, mean baseline HbA1c 9.8%). Imeglimin was predominantly prescribed as an add-on therapy (84.6%), most frequently alongside three or more other agents (57.9%). In the complete-case cohort (n = 337; 46% of baseline), adjusted mean HbA1c decreased by 1.28% (95% CI -1.41 to -1.14) at 3 months and 2.27% (-2.41 to -2.13) at 6 months (p <0.001). Greater reductions were significantly associated with higher baseline HbA1c. Adverse events were reported in 9.9% of the safety cohort (n = 573), most commonly mild gastrointestinal symptoms (5.2%). Hypoglycemia occurred in 1.2%. Two cases of lactic acidosis were reported, though causality with imeglimin was not established. CONCLUSION:In routine clinical practice, the initiation of imeglimin among Indian adults with T2D was associated with clinically meaningful reductions in HbA1c, fasting plasma glucose, and postprandial glucose over a 6-month period, alongside a favorable safety profile. These real-world findings support the clinical utility and tolerability of imeglimin as an effective therapeutic option for glycemic management in this population. Future randomized controlled trials with extended follow-up are warranted to establish definitive causal treatment effects and evaluate long-term clinical outcomes.

Introduction and Objective: The prevalence of peripheral arterial disease (PAD) among individuals with diabetes mellitus is two to seven-fold higher than those without DM. Individually, DM and PAD are contributors to high atherosclerotic cardiovascular disease (ASCVD) risk. Put together, they amplify the risk of mortality and mortality due to ASCVD. We conducted a systematic review and meta-analysis to assess the efficacy of Semaglutide in this population. Methods: Databases (PubMed, EMBASE, Cochrane Central, Scopus) were systematically searched for relevant studies after registration (CRD420251182802). Both randomized and non-randomized studies were included. Binary outcomes were reported as relative risk (RR) for binary outcomes, with 95% confidence intervals and I² statistic for heterogeneity. Results: A total of 4 studies (2 RCTs, 1 post-hoc analysis of an RCT, 1 propensity score matched observational study) with 10,776 patients were included. Gangrene was the most frequently reported limb adverse event in both groups (p=0.219). Semaglutide was associated with a significantly lower risk of major adverse limb events (RR 0.76 [95% CI 0.64-0.91], where the outcome was reported as time to event, HR 0.75 [95% CI 0.65-0.86] I2=0%) Conclusion: Semaglutide is associated with a significantly lower risk of adverse limb events in patients with DM and PAD however, additional RCTs are required to further corroborate this evidence Disclosure P. Deshmukh: None. M. Amaanullah: None. S. Agarwal: None. D. Gutta: None. S. Shah: None. S. Joshi: None. V. Deshmukh: None.

Obesity is a global health crisis affecting developing nations, including India. The management of obesity continues to evolve with newer drugs, metabolic and bariatric surgery and endoscopic interventions, requiring family physicians and specialists to adapt their clinical practice accordingly. There is an urgent need for a standardized algorithm to diagnose, stage, and treat obesity. The Endocrine Society of India (ESI) and the Obesity Surgeons Society of India (OSSI) appointed a steering committee to develop an evidence-based algorithm for managing patients with obesity in India. This was put to vote by 80 specialists (38 from OSSI and 42 from ESI) in a physical meeting. A proposed stage-wise algorithm based on Edmonton Obesity Staging System, Asian definition of obesity, and resources in India, received 100

Despite revolutionizing diabetes care globally, continuous glucose monitoring (CGM) adoption in India remains limited, as a result of several economic, infrastructural, clinical, and sociocultural concerns. This narrative review aims to map unmet needs and propose practical, context-specific solutions. Continuous use of CGM remains the preferred approach for optimal glucose management and achieving long-term metabolic advantages, providing insights for proactive, data-driven, and preventive diabetes care. However, main barriers to CGM uptake include limited awareness among people with diabetes and healthcare providers, high costs, lack of reimbursement, limited device availability beyond major cities, and economic, infrastructural, and sociocultural access inequities across urban and rural populations. The psychological burden from frequent alarms, data fatigue, and stigma with noticeable or intrusive devices add to these challenges. Addressing these barriers necessitates a multifaceted strategy involving affordable, climate-adapted devices, interoperable digital ecosystems, India-specific reimbursement models, and robust educational infrastructure. The emergence of cost-effective CGM devices with a range of advanced features, such as predictive glucose algorithms and personalized pattern identification, is pivotal to this effort. These innovations improve clinical outcomes and quality of life by simplifying the user experience, addressing challenges, such as alarm fatigue while translating complex data into actionable insights, facilitating widespread CGM adoption in India. This review examines why the uptake of continuous glucose monitoring (CGM) is poor in India, despite its advantages observed in people with diabetes. It discusses typical challenges, including high costs, inadequate infrastructure beyond major cities, and limited awareness among patients and healthcare providers. This review also emphasizes the importance of optimizing the current CGM solutions for people with diabetes to monitor their glucose levels, reduce stress, and help with better diabetes management. It further highlights the need for improved training for healthcare providers and care teams and patient-centred education. By combining enhanced technology, supportive health systems, and practical policies, this review outlines strategies to make CGM more accessible and useful for people with diabetes across India.

Hyperglycaemia in pregnancy (HIP), encompassing gestational diabetes mellitus (GDM) and diabetes in pregnancy (DIP), is increasingly recognized as an early marker in the life-course trajectory of noncommunicable diseases (NCDs). In developing countries such as India, a substantial proportion of women enter pregnancy with preexisting metabolic risk factors, limiting the preventive impact of antenatal-only screening strategies. To propose an India-specific framework for prevention of HIP through preconceptional metabolic optimization, aligned with the life-course approach endorsed by the International Federation of Gynaecology and Obstetrics (FIGO) and supported by FOGSI. This position statement synthesizes global evidence, epidemiological data and DIPSI experience to develop a pragmatic framework for preconceptional screening, risk stratification and intervention using both globally accepted diagnostic standards and context-specific approaches. DIPSI recommends opportunistic preconceptional screening using standard diagnostic criteria for nonpregnant adults, including fasting 75 g OGTT and HbA1c, while permitting nonfasting glucose testing for initial risk identification in resource-constrained settings. Women are stratified into normoglycaemia, prediabetes and pregestational diabetes. Core interventions include lifestyle modification, micronutrient optimization, pharmacological management where indicated and family- and couple-centric counselling. Selective use of self-monitoring and continuous glucose monitoring is recommended. Integration into existing health systems with differentiated urban and rural strategies is emphasized. Preconceptional care represents the earliest, most effective and most equitable opportunity to prevent GDM and future NCDs. A simplified, scalable, woman- and family-centred approach can interrupt the intergenerational cycle of metabolic disease.

Introduction and Objective: Type 2 diabetes mellitus (T2D) is a global health challenge requiring innovative treatments. This study assessed the three-year outcomes of Digital Twin (DT)-enabled intervention in achieving sustained T2DM remission (HbA1c <6.5% without medications for ≥3 months) compared to standard care (SC). Methods: The analysis included 233 DT participants who completed three years. The DT intervention utilized AI-driven models to deliver personalized lifestyle recommendations for nutrition, physical activity, and sleep through a mobile application. Key metrics included reductions in HbA1c levels, body weight, HOMA2-IR, HOMA2B and T2D medication use. Continuous variables were analyzed with paired t-tests. Results: Mean age and diabetes duration were 45.8 ± 8.5 and 3.8 ± 2.6 years. Out of the initial 233 DT participants, 209 completed a minimum of six months of the intervention, qualifying them for remission evaluation. Of these, 53.6% (112/209) achieved sustained remission at three years versus 0% in SC (p<0.001). Significant changes (p<0.0001) from baseline to three years in DT participants included HbA1c (from 9.0± 1.9, 95% CI 8.8-9.2 to 6.8 ± 1.2, 95% CI 6.6-6.9), body weight (from 78.4 kg ± 14.5 to 75.3 kg ± 14.7), BMI (from 27.2 ± 4.4 to 26.0 ± 4.4), waist circumference (from 97.6 cm ± 11.2 to 87.4 cm ± 15.7), HOMA2-IR (from 1.9 ± 0.9 to 1.8 ± 0.8), and HOMA2B (from 51.3 ± 30.4 to 88.0 ± 43.4). The SC participants showed minimal HbA1c change (8.5 ± 1.9 to 8.3 ± 1.8) (p=0.403). Conclusion: These findings underscore the potential of DT as a transformative tool in diabetes management, with significant correlations observed between reductions in A1c, body weight, and HOMA2IR. Further research is needed to validate these results in diverse populations and extended follow-up periods. S. Joshi: Advisory Panel; USV Private Limited, Marico, Glenmark Pharmaceuticals, Franco Indian, Twin Health, Biocon, Zydus Lifesciences. Speaker's Bureau; Abbott, Novo Nordisk, MSD. M. Dharmalingam: None. A. Vadavi: None. P. Shamanna: None. A. Keshavamurthy: None. L. Shah: None. S. Damodharan: None. S. Murthy: None. M. Thajudeen: None. M. Mohamed: None. Twin Health