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Fulltext A Case of Severe Lactation Ketoacidosis in a Nondiabetic Mother on a Ketogenic Diet

Borhan MK, Vethakkan SR, Sarvanandan T, Paramasivam SS

JCEM Case Rep, 2023 Nov;1(6):luad134.
PMID: 37954835 DOI: 10.1210/jcemcr/luad134

Lactation ketoacidosis is a rare yet severe metabolic emergency that has been reported in breastfeeding mothers. Reduced carbohydrate intake during breastfeeding has been reported as a common trigger for ketoacidosis. We report the case of a 31-year-old mother without diabetes who presented with life-threatening lactation ketoacidosis after following a ketogenic diet while exclusively breastfeeding her newborn baby. She was managed in the intensive care unit with dextrose and insulin infusion to reverse ketoacidosis. With prompt treatment, the patient's ketoacidosis resolved within 24 hours, and she was discharged well 3 days later. We further discuss the underlying increased metabolic demand in lactating women that puts them at risk of ketoacidosis, underlining the importance of early recognition of lactation ketoacidosis and nutritional education for lactating women.
Fulltext Risk Prediction and Management of Chronic Kidney Disease in People Living with Type 2 Diabetes Mellitus

Ooi YG, Sarvanandan T, Hee NKY, Lim QH, Paramasivam SS, Ratnasingam J, et al.

Diabetes Metab J, 2024 Mar;48(2):196-207.
PMID: 38273788 DOI: 10.4093/dmj.2023.0244

People with type 2 diabetes mellitus have increased risk of chronic kidney disease and atherosclerotic cardiovascular disease. Improved care delivery and implementation of guideline-directed medical therapy have contributed to the declining incidence of atherosclerotic cardiovascular disease in high-income countries. By contrast, the global incidence of chronic kidney disease and associated mortality is either plateaued or increased, leading to escalating direct and indirect medical costs. Given limited resources, better risk stratification approaches to identify people at risk of rapid progression to end-stage kidney disease can reduce therapeutic inertia, facilitate timely interventions and identify the need for early nephrologist referral. Among people with chronic kidney disease G3a and beyond, the kidney failure risk equations (KFRE) have been externally validated and outperformed other risk prediction models. The KFRE can also guide the timing of preparation for kidney replacement therapy with improved healthcare resources planning and may prevent multiple complications and premature mortality among people with chronic kidney disease with and without type 2 diabetes mellitus. The present review summarizes the evidence of KFRE to date and call for future research to validate and evaluate its impact on cardiovascular and mortality outcomes, as well as healthcare resource utilization in multiethnic populations and different healthcare settings.
The Use Of Prednisolone 2.5 mg Daily During Ramadan Fasting In Patients With Adrenal Insufficiency

Mok ML, Farook NS, Hee NKY, Sarvanandan T, Lim QH, Lim LL, et al.

Clin Endocrinol (Oxf), 2024 Dec 11.
PMID: 39660808 DOI: 10.1111/cen.15176

BACKGROUND: A previous study had established the safety and preserved of quality of life in patients with adrenal insufficiency (AI) who received prednisolone 5 mg once daily at sahur (predawn) during Ramadan fasting. It has been postulated that a lower dose of prednisolone between 2 and 3 mg may be sufficient for glucocorticoid replacement in this group of patients. This study aimed to assess the safety and effect on quality of life in patients with AI given prednisolone 2.5 mg during Ramadan fasting.
METHODS: Patients with AI on twice-daily hydrocortisone, who had low or moderate risk of adrenal crisis and intended to fast, were recruited. Patients were given prednisolone 2.5 mg once daily taken at sahur(predawn) and Ramadan education was given. Weight, sleep duration, physical activity, biochemical parameters and quality of life measurements (SF-36 questionnaire) were analysed at the end of Ramadan and compared against the patient's own baseline readings before the start of Ramadan.
RESULTS: A total of 16 patients (10 men, median age 60 [50.3, 68] years) were recruited. All patients were on 15-20 mg of hydrocortisone (in divided doses) before Ramadan, and intended to fast. Five of the participants had type 2 diabetes with low IDF-DAR risk category. 18.7% of the participants were unable to complete all 29 days of fasting. Up to 62.5% of the participants reported at least one adverse event. There was a statistically significant reduction in weight (median: -1.6 [-2.5, -0.3] kg, p
Fulltext Are the 2009 Institute of Medicine gestational weight gain recommendations applicable in a contemporary South-East Asian pregnancy cohort? Results of a prospective analysis

Tai YT, Khoo JK, Lim QH, Lim LL, Paramasivam SS, Ratnasingam J, et al.

PLoS One, 2025;20(1):e0316837.
PMID: 39761286 DOI: 10.1371/journal.pone.0316837

Gestational Weight Gain (GWG) modulates pregnancy outcomes and long-term offspring metabolic health. The 2009 Institute of Medicine (IOM) GWG recommendations have largely been validated in Caucasian and mono-ethnic East Asian cohorts. Asians are at higher metabolic risk at a lower body mass index (BMI), and this has prompted the World Health Organization (WHO) to identify lower BMI cut-offs for risk evaluation amongst Asians. This prospective observational cohort study aimed to determine if 2009 IOM GWG thresholds are applicable in a contemporary multi-ethnic South-East Asian cohort. We recruited 875 mothers from an urban Malaysian tertiary clinic during screening for gestational diabetes mellitus (GDM) from 2014-2021. Data collected included measures of insulin-sensitivity, total GWG (maternal weight at delivery-self-reported pre-gravid weight), and neonatal anthropometrics (birthweight and skinfold-thickness measured with Harpenden calipers). BMI was stratified by Caucasian (overweight ≥25kg/m2, obese ≥30kg/m2) as well as Asian (overweight ≥23kg/m2, obese ≥27.5kg/ m2) cut-offs, and patients categorized by 2009 IOM GWG reference ranges. The cohort comprised 67% Malay-, 23% Chinese- and 10% Indian-descent mothers with a high prevalence of overweight/obesity (Asian cut-offs 56.9% vs Caucasian 44%). When Asian BMI cut-offs were deployed, excessive GWG incidence increased (34.1% → 40.6%) whilst inadequate GWG declined (30% → 24.8%) (p<0.05). Upon multivariate-analysis (adjusting for age, parity, race, GDM, insulin-sensitivity, baby-gender) excessive GWG categorized with Caucasian BMI cut-offs was significantly associated with increased risk of macrosomia (adjusted odds ratio (aOR) 8.65, 95% confidence interval (CI) 1.07-70.01), Neonatal-Fat-Mass (NFM) >90th centile (aOR 2.14, 95% CI 1.02-4.45) and Sum-of-Skinfold Thickness (SSFT) >90th centile (aOR 3.88, 95% CI 1.77-8.51). Excessive GWG by Asian cut-offs was also associated with increased risk of SSFT >90th centile (aOR 5.75, 95% CI 2.35-14.10). Inadequate GWG by both Caucasian and Asian BMI cut-offs was associated with Small-for-Gestational-Age (SGA) status (aOR 4.30, 95% CI 2.48-7.45 and aOR 3.66, 95% CI 2.13-6.30 respectively). In conclusion, the 2009 IOM GWG recommendations, using either Caucasian or regional Asian BMI cut-offs, are applicable in a contemporary Malay majority South-East Asian cohort in terms of predicting abnormal neonatal adiposity. Importantly, the association with neonatal adiposity is independent of increased maternal insulin resistance characteristic of Asians.