The following is a verbatim transcript of a webinar conducted with Dr Sanjay Kalra in 2024. The transcript has been lightly edited for clarity.
Transcript:
I’m an endocrinologist. We deal with hormones, and you know, there are hormones which help you in learning as well. Dopamine, serotonin. These are some examples. So for the past one hour at least, my dopamine has been on fire learning new things about CVD risk assessment. But there are other hormones as well. Not all hormones are happy, like dopamine and serotonin. There are some hormones which can be maladaptive, and one of them is NT-proBNP, something that we’ve been speaking about today.
Let me talk about my practice. I work in a private hospital in India. Now you see, when you read the American guidelines, you would tend to assume, or the American guidelines, you would tend to assume that everybody with diabetes is very well behaved. They’re all chronic patients. So they come in when diabetes is diagnosed, they stick around to the same healthcare system, like in Ireland, or perhaps the same healthcare provider as well. And they behave very well throughout life. As, of course, diabetes progresses as they become more and more mature, or they become older, they need more medications, more treatment, more investigations as well.
But where I work, some of our patients are chronic, others are acute. So we have a relatively higher percentage of patients with symptoms. The symptoms may be of hyperglycemia, they may be of complications, such as atherosclerotic cardiovascular disease or heart failure. And accordingly, our management changes.
There is something known as Maslow’s Hierarchy of Needs. This comes from Maslow, who was a behavioural psychologist. So what he said is that at the very outset, everybody needs… everyone needs food, clothing, shelter; basic needs for survival. Once you’ve got those, then you move on to searching for love and affection, a sense of belonging. And after that, you search out for self-esteem. So for example, if you’re not doing well in practice, you haven’t got your degree or your fellowship, you’re not going to dream of becoming the president of the ADA. The president of the ADA is something that comes to your mind only after you’ve gone through the basics of this pyramid.
The same thing happens in diabetes as well. Some of our patients come in with very basic needs. They just need symptomatic control. And like I said, a relatively larger percent of our patients are like that in India. Once you’ve taken care of the symptoms, then they want glucometabolic control. They’ll say, “Doc, my HbA1c is 7.1, why don’t you bring it down to 6.4?” If you’ve done that, then it’s only after that that they say, “Can you help me prevent heart disease? Can you help me prevent kidney disease?” So as you evolve in this Maslovian Hierarchy of diabetes needs, you tend to rely more and more upon investigations so that you can predict the future and you can pre-empt the future. That’s what we’ve been trying to do with NT-proBNP.
In countries like India, we have multiple challenges, and one of the challenges is speaking the same language with our patients. We have 800+ languages. Every 50 km the language changes, the food changes, and I serve a group of patients who speak maybe seven or eight different dialects, three or four different languages. The same is true for Dr. Ameya Joshi, who’s from Mumbai, logged in with us today. So to communicate the same thing to them in different languages can be challenging, and it helps us a lot if we have one single number that we can convey.
And that’s the good thing about NT-proBNP. You can use numbers and you can use concepts from Indian philosophy to help convey. Patients will ask you, “Why do I need one more test? As it is, you’re doing so many tests for me.” Now in India and perhaps in other countries, a lot of people like predicting their future. They go to astrology to get their future predicted. Though of course we have songs which tell us that during COVID, all our astrologers went on leave. Nobody dared to predict the future while COVID was going on.
We tell our patients that we have something called medical astrology, biomarker astrology. Whether you are born in Capricorn or Venus or Aries that may or may not predict your personality. No comments on that. But some biomarkers like NT-proBNP, hormones like NT-proBNP can actually predict your medical future. They can tell you the risk of future CVD events. When you convey this to the patient, the patient actually feels very happy. You can empower your patient by telling him or her that a simple number is all that you need to remember. You don’t need to get into the complexities of what the heart does and what hormones are.
Another concept we use from our philosophy is that of karma. Now karma is an English word now; it’s present in all the English dictionaries. In Indian languages like Sanskrit and Hindi, karma can be past tense, present tense, and future tense. Karma is what we did yesterday. Supposing I did not take care of my glucose, that influences my today, it influences my state of health today. It’s like glycemic memory… glycemic legacy, or metabolic memory. So we use the word metabolic karma. You can also use the word cardiovascular karma.
No point in crying over spilled milk, but you tell your patient that if you have an NT-proBNP today of, let’s say 125 or 250 or 600, that is your karma today. But we can take action, if we know where we are standing today, we can prevent bad karma from happening tomorrow. So this is a very proactive approach from our philosophy. We use this concept to talk about BNP baggage. Whatever baggage, whatever weight you are carrying of NT-proBNP… BNP, that can be lightened. You can shed the bad karma today and you can achieve a happier karma today… tomorrow.
There are people, however, in a gray zone. So in my practice, I tend to use the word a hundred, the number hundred quite… more frequently, because it’s much easier to remember, much easier to remind your patients about, as compared to 125. But still, NT-proBNP is a very simple, a very sensible method, of helping us communicate risk with our patients.
We tell them that if the NT-proBNP is more than 125, we should sort of become more aggressive in medication. I can do it myself. I can use the SGLT2 inhibitors, the other drugs, I can go for guideline or based medical therapy. I might wish to refer to a cardiologist. If it’s between 100 and 125, we should retest early, maybe within six months, depending upon symptoms. And if it’s below 100, then you can kind of relax. You’re in good karma. You’re in a safe zone.
The most important people, the most important people in my hospital for conveying this message are the phlebotomists and the diabetes educators. They use these concepts of medical astrology, of medical karma, metabolic karma, and they’re able to communicate these concepts, these numbers in a very non-threatening manner. In a very salutogenic; ‘salus’ means ‘health’ in Latin, in a very salutogenic manner to our patients. And my paramedical staff are indispensable. Without them, I would not be able to work. I would not be able to handle all the load that I have to.
We use many concepts in our laboratory. These are examples of some pictures that we use, some charts that we have in our hospital. We talk about heartbreak. It’s not the emotional kind of a heartbreak, it’s the endocrine, or cardiovascular heartbreak that you can have if you have a heart failure. Some numbers are better if they are bigger, but other numbers are better if they are less, like NT-proBNP. And we talk about speed as well. There’s a difference between speed and velocity. Too much of speed can be dangerous for your life when you’re driving; NT-proBNP means that your heart is working a bit harder than it should, so it might get tired. Let’s bring it back to normal.
We have Dr. Amaya with us here and recently one of his abstracts has been accepted at ESD. He screened 318 patients, asymptomatic, and he found that 120 of them had an elevated NT-proBNP. That’s 37.5%. We do the same in our practice and we find that the NT-proBNP number helps us in informing the patient and in creating a situation where shared decision making… decisions can be taken. In my OPD, roughly 15% of all patients, of all asymptomatic patients, have a high NT-proBNP, and we refer all our high-risk patients to the neighbouring cardiology center. And there 50% of their patients, the asymptomatic ones, have a high NT-proBNP. The very fact that we are able to do this number helps us in telling the patient whether he should stick to us or whether we should involve the cardiologist. And it’s not just about informed decision making, shared decision making between the patient, his or her caregiver, and myself, we also involve the cardiology team in this.
VAT is something that you’re all familiar with. I remember going to Ireland once and they put lots and lots of that on whatever shopping I had done. Value added tax. But NT-proBNP is different. It is a Value Added Therapy. So it actually adds a lot of value to our treatment and type 2 diabetes. It helps us become better at preventive diabetology. We are able to prevent disease, we are able to prevent disability, and we are actually able to reduce costs. So that is what I like about this hormone. In endocrinology, we say that dopamine, serotonin are happy hormones. NT-proBNP is not a happy hormone, but that’s wrong actually. If you use NT-proBNP in the right manner, it will make your patients happier because you’ll be able to prevent them from getting into trouble. Thanks.
