All you need to know about Obesity and Diabetes

Wait a second...have a look at your body! What’s the first thing that comes to your mind when you look at your body? Do you have a specific self image? Do you find yourself too thin or too fat to fit in certain types of clothes or your old clothes? Do you want to have a fit body like many of them have it on the screen?

Along with these questions there are another set of questions that are a part of it like do you have a lot of hunger pangs nowadays? Do you fall in obese category for your age and height? At such an early age you have such high blood sugars? Are you on Insulin because your average sugars (HbA1c) is 13.6? Are you a way too scared of Insulin?

These questions summarise the lifestyle diseases that have now become a part of our life. Yes, true I am talking about the most common among all of us is Obesity and Diabetes. I have an experience of more than 4 years of freelancing giving diets to patients where most of the cases are for Weight loss/fat loss from the body and more than 2 years working completely with a Diabetologist where I see a lot of patients with Diabetes and other complications associated with it. Here from my experience I found out that most of the Obese patients have developed type 2 Diabetes.

Here we discuss a lot more about Obesity and Diabetes and as well as the interlink between the both. Both are mostly affected and linked together due to Unhealthy and bad lifestyles. And hence nowadays we find that every second patient is either Overweight/Obese or Diabetic or both. I find myself very privileged that I can help everyone improve their lifestyle and live a happy and fit lifestyle.

What is Obesity?

Obesity has become the most emerging global health concern and challenge with an increasing prevalence in both developed and developing countries. The world wide prevalence of Obesity has nearly tripled in the last 40 years. Obesity rates have been on the rise in India as well, ranging from 11.8 % to 31.3 % in different parts of India in 2015. Global obesity rates are showing a steady increase and the magnitude of the challenge it poses can be judged from the fact that the World Health Organization has included obesity in its list of global noncommunicable disease targets.

Obesity is a metabolic condition. The association between obesity and cardiovascular diseases (stable coronary disease, acute myocardial infarction, heart failure, cardiac arrhythmias, and sudden cardiac death) is well established. In addition, the association of obesity with hypertension, diabetes mellitus, dyslipidaemias, and sleep apnea syndrome also increases the incidence of cardiovascular disorders.

Several national surveys have reported an increasing trend in the prevalence of obesity in India. It has been reported that obesity affects more than 135 million individuals in India. The nationwide population based ICMR- INDI8.AB study conducted in 2015 revealed that the prevalence of generalised obesity (BMI more than 25 kg per meter square) in different parts of India ranged from 11.8% (Jharkhand) to 31.3% (Chandigarh). Obesity is more prevalent among the urban population than the rural population in India. It is more prevalent among women than in men. The prevalence rates of obesity in India are influenced by various factors such as age, gender, place of residence, and socio economic status.

A study shows that in obese patients, a sustained weight loss of 5-10% has been shown to improve hypertension, dyslipidemia, insulin resistance, and diabetes. The strategies for weight loss comprises diet and lifestyle modification, pharmacotherapy, and surgery.

Obesity is diagnosed based on BMI (Body Mass Index) which is calculated as a ratio of weight in kg and height in metre square. BMI cut offs differ based on country specific guidelines established. In India, a BMI of 23 kg/m2 and above is considered as overweight, and a BMI of 25 kg/m2 and above as obesity. Before the latest revised BMI, BMI of 25 kg/m2 and above was considered overweight and BMI of 30 kg/m2 and above was considered as obesity. Another way of measuring obesity is by measuring waist circumference. If the waist circumference is greater than 80 cm in a woman or greater than 90 cm in a man, they are considered to have abdominal obesity. Woman with a body fat percentage of over 40 and men with the body fat percentage over 28 are also considered obese.

Excessive fat accumulation in the body specially the parts of the body like thighs, abdomen, shoulder, chest area, hip region etc poses health risk. There are two kinds of fat namely subcutaneous and visceral fat. Subcutaneous fat is mostly below the skin while visceral fat is around the organs. Subcutaneous fat is usually harmless wild visceral fat is associated with numerous diseases. The body stores energy by building subcutaneous fat. In order to get rid of built up subcutaneous fat, one must burn energy / calories. I usually recommend aerobic activities to burn the subcutaneous fat and calories, that include walking, running, cycling, swimming, other movement based activities that increase the heart rate. Visceral fat can be lost by having a healthy meal with low carbs, more soluble fibre, more protein and limiting sugar and alcohol intake. Aerobic activities help in getting rid of visceral fat too.

Don’t you feel this ???

Don’t we or most of us feel that our generation is much more overweight than what our parents and grandparents were at our age?? They were much slimmer than us and worked really hard and did not indulge in any junk food, in fact ate simple nutritious meals. I wonder and feel that the next generation must not be much more overweight than we are…

Factors associated with Obesity Development

The exact cause of Obesity is not clearly known, but in most cases, it can be attributed to excess energy consumption (dietary intake) relative to energy expenditure (energy loss through metabolic and physical activity). However the etiology of obesity is complex, and it has been linked to an increasing maternal age, lack of sleep, endocrine disturbances, microorganisms, epigenetics, pharmaceutical iatrogenesis, and intrauterine and intergenerational effects. The prevalence of obesity is influenced by consumption patterns, urban developments and lifestyle habits.

Causes of obesity:

Primary Causes:

● Genetic causes

● Monogenic disorders: Melanocortin-4 receptor mutation, leptin deficiency, proopiomelanocortin deficiency.

● Syndromes: Prader-willi, Bardet-biedl, Cohen, Alstrom, Froehlich.

Secondary causes:

● Neurologic: Brain injury, Brain tumor, Consequences of cranial irradiation, hypothalamic obesity

● Endocrine: Hypothyroidism, Cushing syndrome, Growth hormone deficiency, Pseudohypoparathyroidism.

● Psychological: Depression, eating disorders.

● Drug induced: Tricyclic antidepressants, oral contraceptives, anti psychotics, anticonvulsants, glucocorticoids, Sulfonylureas, Glitazones, Beta-blockers.

Obesity may result from a complex interplay between biological, psychosocial, and behavioural factors, including genetic make up, socio economic status, and cultural influences.

Obesity and associated health risks:

● Diabetes Mellitus leading to complications like eye problems, neuropathy, kidney problems.

● Cardiovascular/ Heart diseases like high Triglycerides, high cholesterol, etc.

● Hypertension (High blood pressure)

● PCOS (Poly cystic ovarian syndrome) and infertility in women

● Many more...

Economic burden due to obesity:

Obesity has negative economic consequences in the long term. It often results in a decreased earning potential and is associated with a higher health care cost which places an economic burden on the society. It has been reported that obesity is associated with increases in annual health care costs of 36% and medication costs of 77% compared with being of average weight.

Mortality:

Every 5- unit increase in BMI above 25kg per meter square results in an increase of 29% of overall mortality, 41% in vascular mortality and 210% in diabetes related mortality.

Causes of weight gain:

An important factor to keep in mind is the nature of the weight gain which may be medical or Lifestyle babase. Medical factors known to contribute to obesity include genetic factors, hormonal disturbances, side effects or due to medication such as oral steroids, or psychological factors which can cause binge eating or stress eating. Lifestyle Causes of obesity include imprudent diet, lack of physical activity, migration (change in society, country, socioeconomic strata), inadequate sleep, long working hours, and so on.

Fad diets:

Individuals battling obesity often look out for quick fixes most of which involve quick internet searches for solutions. These solutions often come in forms of fad diets, which are usually poorly sourced and rarely evidence-based. The most common factor among fad diets is the severe restriction of one or more food groups, and amplification of a single good food group. These diets are difficult to follow long-term and may be implicated in future health challenges.

Nowadays people want results fast. They want to have a fast weight loss/fat loss by any means. They do not think of anything else, not even their health. They want easy to do and follow things and also do not want to pay a Dietitian/Nutritionist. They find easy help and steps via google and start following it without understanding that what suits one person may not suit another. These fad diets do give quick results and are much cheaper too, and you may lose your weight and see the results but you will land up with low energy, low stamina, a lot of deficiencies and low health and fitness. Also there are 100% chances of gaining those shed weight back. Fad diets like keto too has same results and one cannot follow it for a long period of time. I really want people to understand that anything that is fast and quick will not stay with you for a long time and you will only get benefits for a period of time from it. So why not have a healthy weight loss with a good healthy balanced diet and healthy lifestyle by being much more active, each passing day.

My experiences:

Sharing my personal experience with the patient following fad diets is that the patient came to me after following the intermediate fasting for almost more than one and a half years. The patient was obese as well as diabetic. I found out that the patient was feeling so weak and did not have any energy to do the daily chores. After following the fad diet for almost many months where the patient only had food twice a day but could eat as much as the patient wanted. The patient saw that there was a reduction in the sugar levels but at the same time when we did the 3 months average test of HbA1c it was found that the patient had a very high average of the sugars, due to eating all the junk and binging that the patient could do only in the two meals which not only lead to increase in the weight but also increase the average sugars of the patient. Not only the sugars and the weight but the other medical condition that the patient developed Cardiovascular disease (heart disease) which led to an increase in the cholesterol and triglycerides levels. The patient was monitored and the diet was entirely changed and the patient was put on a healthy balanced meal i.e., eating small and frequent meals a day with high proteins and high fibre diet.

Another example is of a college going girl who completely followed a fad diet from the internet, where she had only soups and salads a day, some days only fruits, some days only on liquids. Following this diet for a few days she not only felt weak and dizzy, but also could not concentrate on her studies. She started having a lot of hair loss along with a headache every evening. By the end of two weeks she did not have energy to even travel in the train. When she came to me and started complaining about of hair loss, dizziness, and a lot of weakness and fatigue, it was found out that she did not eat macronutrients such as carbohydrates, proteins, fats, foods rich in calcium and iron etc. in correct proportion and the amount needed to sustain, since so many weeks due to which she developed a lot of deficiencies of minerals and vitamins which she could have got from the Macro nutrients like carbohydrates, proteins and fats when eaten in the right and moderate amounts. Following this diet she not only had a fast weight and fat loss from the body but she lost all the muscles as well as became highly deficient in Calcium, Iron, B complex vitamins and many other vitamins and minerals which are the source of many macronutrients rich foods. The patient was counselled by me and was given a healthy balanced meal to prevent the deficiencies and to gain back the stamina and energy which she had lost and to have a healthy weight according to the height. The patient was also put on a high protein diet by increasing proteins in the meals by protein supplement once a day. The patient also had an irregular, scanty menstrual cycle this month. The patient was started on folic acid, B12 medicine prescribed by the physician and also diet rich in it too.

Prevention of Obesity

● Prevention is better and easier than treating obesity.

● Some important prevention mantras for obesity are to watch what you eat, exercise regularly and sleep well.

● It is important to track your weight and waist circumference through the process.

● Eat at regular intervals and small portion sizes.

● Consume plenty of vegetables and 1-2 fruits per day.

● Include protein in every meal. Protein foods are dals, pulses, milk and Milk products and non veg food like fish, chicken, egg.

● Go slow on visible fats like cooking oils, ghee, butter, cream. Use as little as possible for your regular cooking. Avoid fried foods, high fat gravies and only items.

● Consume fats from natural foods like nuts (Almonds, Pistachios, Walnuts, Cashews).

● Avoid highly processed foods like fruit juices, bakery products, ready to eat snacks, sweets, mithais, etc.

● Avoid refined foods such as refined wheat flour (maida), white rice, poha (rice flakes that are made from white rice), semolina, etc. Other refined foods which should be monitored are ready to eat products made from substances mentioned like biscuits, cookies, cakes, etc.

Exercise

This is an important component of lifestyle medication. It helps to achieve fitness, which is the crucial factor for good health as it is critical for maintaining muscle mass. And losses which feel good hormones are secreted post exercise and they improve the quality of life.

I always tell my patients you must always love your body and try to keep it healthy and fit and always think before you dump any food into it, whether it is good for your body and health or no?

DIABETES MELLITUS

What is Diabetes Mellitus?

Diabetes Mellitus is a metabolic disease where in blood Sugars remain high due to either inadequate insulin or insulin resistance (insulin becoming ineffective in its action). There is no cure but it can be managed with diet and Lifestyle modifications. In many cases, patients may require medications or insulin. Right selection of foods help to maintain not only blood Sugars but also weight and blood lipids (cholesterol and triglycerides).

Symptoms of Diabetes:

● Increased Thirst

● Frequent urination (from Urinary tract infection or kidney problems)

● Extreme Hunger

● Unexplained weight loss

● Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there is not enough available insulin)

● Fatigue

● Irritability

● Blurred vision

● Slow healing of wounds

● Nausea

● In some cases even unexplained weight gain

● Tingling, pain, or numbness in the hands/feet

Types of Diabetes Mellitus:

● Type 2 Diabetes Mellitus - A chronic condition that affects the way the body processes blood sugar (glucose). In Type 2 Diabetes Mellitus, the body either does not produce enough insulin, or it resists insulin.

➔ It is the most common type and usually occurs in Adulthood due to bad and unhealthy lifestyle, poor diet control, Obesity, Hereditary etc.

➔ Most of the patients with Diabetes fall under this category.

➔ It can be managed with regular treatment and by following the Diet and exercise regularly without fail.

➔ If Type 2 Diabetes Mellitus is managed well with Diet and exercise you can further prevent the high dose medicines and even Insulin.

● Type 1 Diabetes Mellitus - Type 1 Diabetes was previously known as juvenile diabetes,is a form of diabetes in which very little or no insulin is produced by the pancreas.

➔ These are the patients who are usually on Insulin all the time.

● Gestational Diabetes - Gestational diabetes is a form of high blood sugar affecting pregnant women. Those who develop gestational diabetes are at a higher risk of developing type 2 diabetes later in life.

➔ In most cases, there are no symptoms. A blood sugar test during pregnancy is used for diagnosis.

➔ Treatment strategies include daily blood sugar monitoring, a healthy diet, exercise and monitoring the baby.

➔ If blood sugars are very high during pregnancy then medication is required and usually Diabetologists directly start on Insulin so that the sugars are controlled sooner for the well being of the baby.

● Juvenile Diabetes - Juvenile Diabetes is a chronic condition in which the pancreas produces little or no insulin. It typically appears in Adolescence age.

➔ Treatment can help, but this condition cannot be cured and requires a medical diagnosis and patients are usually on Insulin.

➔ It is chronic and can last for years or be lifelong and in some critical conditions needs emergency care.

➔ From my experience in treating children with Juvenile Diabetes cannot always live life to the fullest as cannot completely enjoy their childhood as they have to take care of their meals all the time, and as well as on insulin have to take it on time and insert needles into their body always.

➔ They often cannot play to the fullest as many of them face low blood sugars while playing and may even faint if immediate care is not given.

➔ They often have headaches and their studies are also hampered with fluctuating sugars and regular appointments with the doctors.

● The above 4 are the most common types of Diabetes. Other types include Diabetes LADA, Diabetes MODY, Double Diabetes, Type 3 Diabetes, Steroid Induced Diabetes, Brittle Diabetes, Cystic Fibrosis Related Diabetes (CFRD) ETC.

SMBG CHART

● Self Monitoring Blood Glucose Chart (SMBG) is a must for all the patients to keep a record of their sugars which I usually give and explain to all my patients. Patients are asked by the Diabetologist to check their sugars a number of times a day to give us an idea about their fluctuating sugars and to make the necessary changes in their diet and medicine.

● Sometimes this gives us the clear idea if the patient is having brittle diabetes where the sugars are never under control despite the change in their medicine and diet.

● It gives us the clear idea of when the patient's sugars are dropping and the patient is going into Hypoglycemia.

● With this data the necessary Insulin and medicine dose can be changed and a clear idea of patients fasting and postprandial (post meal - after 2 hours sugars) can be tracked.

INSULIN

● Insulin acts as a replacement for or supplement to the body’s Insulin.

● Insulin is often given to patients to control their blood sugar levels and to remain healthy and mostly given to Type 1 Diabetic patients. Insulin can however can cause weight gain at the start of the course and taking too much insulin can lead to hypoglycemia.

● Previously Insulin were available in the vial form but now Insulin Pens are available which are very handy to use and can be carried along too.

● The patients who are on Insulin for a long period of time are first checked for lipohypertrophy, as these are lumps that are caused with insertion of needle at the same very place all the time.

● Patients are asked to change the needle every second day and different points where insulin can be taken, Insulin rotation, Insulin time profile, Insulin storage (cold and dark place), Usage of Insulin, Hypoglycemia, is all well explained to the patients by us and regular follow up checks for them in every visit.

Factors related to weight gain in Insulin – treated patients with Type 2 Diabetes are :

1)The factor Attenuation of insulin- evoked satiety has an effect on enhanced hunger and increased food intake which leads to weight gain.

2) Frequent Hypoglycemic episodes factors have an effect on defensive snacking which leads to weight gain.

3)The factor when there is excessive reliance on insulin to normalize glucose readings has an effect on false sense of freedom to eat which ultimately leads to weight gain.

● The simple mechanism is Insulin acts on the Central nervous system in the brain which impairs satiety signals in the stomach which leads to overeating and thus leading to weight gain.

● The MNT includes diet which is rich in foods which has low to moderate glycemic index and load which in turn reduces glycemic spikes, a diet rich and mix in combination of proteins to promote satiety and diet rich in MUFA (Monounsaturated Fatty Acids) which improves heart health.

● Sometimes in a diet to increase protein completely individualized and depending on the sugars , work profile individualized meal replacement or a protein supplement therapy helps to improve HbA1c and cardiometabolic parameters as well as reduction in weight and BMI.

● American Dietetic Association (ADA) recommends Medical Nutrition Therapy (MNT) for individuals using fixed daily insulin doses results in improved glycemic control and for improved outcomes such as reduction in A1C.

Proper diet for diabetes

There is nothing like a separate diet for diabetes. It is based on the same principles of daily food intake, with greater emphasis on certain foods and less emphasis on other foods. Also, in a diet for a person with diabetes there is an emphasis on freshly cooked homemade foods, rather than highly processed, ready to eat homemade foods (like chakli, chiwda etc) or ready to buy foods.

Meal timings

It is important for an individual with diabetes to eat at regular intervals to avoid spikes of valleys in blood sugar management. This is especially important for individuals who are on only Lifestyle management programs and/or use pharmacological therapy.

Features for diet in diabetes

● Emphasize protein foods: Try to include a protein source in every meal that you eat. Proteins come from dals, sprouts, milk and Milk products, non-veg foods like fish, chicken, egg .

● Choose carbohydrates from complex sources - eat whole grains like wheat, millets (jowar, bajra), brown rice, potatoes and sweet potatoes in limited quantities rather than their refined counter parts like maida (refined wheat flour) , Suji (semolina) rice, poha (rice flakes) etc.

● Eat plenty of non root vegetables, green leafy vegetables, gourds, beans etc in the form of salads, raitas, subzis (cooked vegetables).

● Eat 1-2 fruits a day with emphasis on less sweet fruits such as apple, pear, pomegranate, peach, plum.

● Include nuts and oilseeds in your diet like peanuts, almonds, and pistachio.

● Use a limited amount of oil while cooking. Preferably use a combination of oils for cooking.

● Avoid foods which have sugar, jaggery, honey, sago (sabudana), refined wheat flour (maida).

● Use plate method to serve food, where 1/4th portion of the plate each consists of raw vegetables ( may include like salads, raita, koshimbir ) , cooked vegetables (may include any sabzi, tarkari, bhaji), proteins (may include dals, sprouts, non-vegetarian foods or dairy products such as paneer, curd) and carbohydrates (may include roti, phulka, pulao,biryani etc).

● One must keep oneself well hydrated as well.

● Bedtime meals are necessary in most of the patients with diabetes.

Exercise for diabetes

Regular physical activity is important in management of blood sugars. Simple exercises like regular walking for 30 to 60 minutes per day helps to manage sugar levels. Along with control of blood glucose, physical activity has many other benefits such as improved heart health, bone health, better muscle mass, and most importantly exercise leads to the secretion of endorphins (feel good/happy hormones). Diabetics who experience hypoglycemia must have a small snack before exercise and consult their Physician and Dietician for the same before doing any rigorous exercise.

What is Hypoglycemia?

For people with diabetes, low blood sugar (hypoglycemia) occurs when there's too much insulin and not

enough sugar (glucose) in the blood. Several factors can cause hypoglycemia in people with diabetes, including taking too much insulin or other diabetes medications, skipping a meal, or exercising harder than usual.

Hypoglycemia treatment

If a patient feels anxiety,excessive hunger, fatigue, weakness, headache, fast heartbeat, dizziness, shakiness, blurry vision etc, then first check your sugars on a glucometer. If it is 70 mg/dl or low then quickly have 4 tsps of sugar or glucose powder or any simple carbohydrate. Wait for 10 minutes and then check again if it is normal then have a small snack and if it is still low then repeat the procedure. If the sugar remains normal more than twice than consult your doctor or hospital immediately.

Foods you can have in Hypoglycemia

15-20 grams of simple carbohydrates like glucose powder, sugar, fruit, aerated drinks like Pepsi,Cola, Parle-G biscuits etc.

What is Diabetic coma?

A dangerously low blood sugar (Hypoglycemia) or high blood sugar (hyperglycemia) can lead to diabetic coma. A diabetic coma is a life threatening diabetes complication that causes unconsciousness. If left untreated can lead to coma.

What you need to know from my experience:

Here I share my own experience with an old man aged 67 years, had his last meal that is dinner around 7:30 pm and had a walk before sleep. He did not have anything at bedtime as a meal. Around 5 am he started feeling dizzy and was not able to sleep. He just laid down and after some time started feeling shakiness in his both hands and legs and started having a headache too. He did not have any sweet next to his bed nor could he get anything sweet from the kitchen to have it as instructed by the doctor. Also his relatives were in another room and he could not cry out to them for help. After a certain time he became unconscious. Around 7:30 am his relative came to the room and called him but he did not answer. His relative quickly checked his heart beat and sugar on the glucometer and found out that his heart was beating but fasting sugars had dropped down to 45 mg/dl. As he was unconscious they could not give him orally, so the best way was to rub the glucose powder on his teeth. Rubbing glucose powder on the teeth was really helpful as he became conscious and was given glucose powder mixed with water again to have and again after sometime was given a small fruit to eat.

My views and experiences:

The main reason which I found out for both Obesity and Diabetes is that these are the people who skip their breakfast daily either they have no time to cook and are in hurry for work or get up late and have their lunch directly. I want to discuss the point here is that people are now changing their lifestyle and this is not at all good and better for the health. People remain awake till late night where they tend to eat a lot of junk when they are awake after dinner adding a lot of calories. From the patients I have met and have and when asked about their home recall most of them binge on high calorie foods like Chips, marble cakes, soft drinks etc. late night and tend to get up late and miss their breakfast. This lifestyle has not only affected their health leading them to gain weight but also their family. The more of junk food has not only led to increase in fat and weight but also lifetime long diseases like Diabetes, high cholesterol, high triglycerides levels etc. at a very young age. This has also led to Heart attacks occurring to young people where they tend to have a lot of high stress due to work and also binge on a lot of junk food and have a bad lifestyle.

One of the most common examples of the working population gaining weight is a peak time of hunger around 5 to 7 pm in the evening when they leave. It is when not only them but most of us are very hungry as the gap between the two major meals that is lunch and dinner is a lot more. So the working population in a hurry when they leave the office usually tend to buy the most attractive and easy options available from the hawkers outside their office main gate. It usually consists of Vada Pav, Mendu vada, chinese bhel etc. Also nowadays when the working population travels a lot more by metro trains, specially in Mumbai I have found out that there are Jumbo Vada Pav and Dominos at every start and end point of Metro. They have come up with most easy to have and also budget friendly for everyday evening snacks and hence again tend to eat a lot of junk and oily foods. The hawkers do use the same oil again and again which affects the quality of oil and hence the risk of developing diseases has increased.

High Diabetes Risks:

High Diabetes can cause Retinopathy affecting retina of the eye, high diabetes also affects kidney causing diabetic nephropathy, and also high diabetes causes diabetic neuropathy presenting numbness, itching or tingling in the legs but can also be pains and can cause cardiovascular risks other medical disorders. Diet control challenges may affect the overall Diabetes Management. Medical Nutrition Therapy (MNT) can play an integral role in overall Diabetes Management.As there can be Diabetes complications, Risk of Hypoglycemia, Weight gain, Antihyperglycemic Medication burden. Some of the established treatments in Type 2 Diabetes have been associated with weight gain.

THE LINK BETWEEN OBESITY AND DIABETES:

Obesity as a risk factor for diabetes:

Obesity is a major risk factor for the development of Type 2 Diabetes Mellitus. It has been reported that adults with a BMI of 40kg per meter square or higher have an increased risk of Diabetes than those with normal weight. It is well established that an increase in the prevalence of overweight and obesity results in an increased prevalence of type 2 Diabetes Mellitus among different races and ethnicities. It is important to note that even a modest weight gain increases the risk of developing diabetes. In overweight nd obese indiviadual, gradual deterioration of glucose tolerance over several years eventually results in type 2 Diabetes.

Pathogenesis of Type 2 Diabetes Mellitus in obese individuals

Insulin resistance and hyperinsulinemia:

● Insulin resistance is believed to be the first step in the development of type 2 diabetes Mellitus in obese patients, followed by hyperinsulinemia. Hyperglycemia develops due to the failure of Beta cells to produce sufficient insulin.

● The mechanism of development of insulin resistance in obese individuals is when altered levels of adipocytokines, increase circulating free fatty acids and altered body fat distribution results in Insulin resistance.

● The more recent twin cycle hypothesis proposed by Taylor et al. explains the role of muscle, liver and pancreas in the development of type 2 diabetes mellitus in obese individuals as explained in the figure below:

Insulin resistance and hyperinsulinemia are frequently seen in overweight and obese individuals, and are the best known predictors of type 2 diabetes mellitus.

THE BENEFICIAL EFFECTS OF WEIGHT REDUCTION IN DIABETES PREVENTION AND THERAPY

● As most people with type 2 diabetes mellitus are overweight or obese, weight reduction plays a major and important role in the prevention and management of type 2 diabetes mellitus.

● In the diabetes prevention program , a weight reduction of approximately 7% achieved through lifestyle modifications was associated with a 58% reduction in the risk of developing type 2 diabetes mellitus in obese, prediabetic individuals with impaired glucose tolerance. In contrast, metformin alone reduced the risk only by 31%.

● Another study demonstrated that each 1 kg of weight loss in the first year after the diagnosis of diabetes was associated with 3-4 months of prolonged survival. A weight loss of 10 kg increased the life expectancy by 35%.

The various beneficial effects of weight loss in diabetes prevention and therapy are as follows:

● Reduces risk of development of diabetes in prediabetic individuals

● Improved cardiovascular disease risk factors

● Prolonged survival or increased life expectancy

● Decreased need for antihyperglycemic, antihypertensive, and lipid-lowering medications

● Improved overall fitness

● Alleviation of depression symptoms

● Reduced HbA1c levels

● Remission or reduced severity of obstructive sleep apnea

MANAGEMENT OF OBESITY AND DIABETES

The treatment of obesity and diabetes is closely linked to weight loss, which can be achieved by different means, including lifestyle intervention (by diet and exercise), bariatric surgery, and pharmacotherapy. Lifestyle interventions remain the mainshow of weight loss and diabetes programs; bariatric surgery and pharmacotherapy are recommended only when lifestyle interventions alone do not yield sufficient weight loss and when sugars are not in control.

LIFESTYLE INTERVENTIONS

Exercise

● Exercise is an important element of every lifestyle intervention

● Aerobic exercise is the best method to reduce fat mass and to control sugars

● An increase in physical activity helps reduce intra-abdominal fat, increases lean mass, decreases depression, and improves glucose tolerance, insulin sensitivity, and physical fitness.

● All scientific guidelines recommend at least 150 minutes of moderate aerobic exercise per week , along with three weekly sessions of resistance training to increase muscle strength.

● However, it is difficult to adhere to intensive lifestyle interventions over a long period of time.

Diet

● A low to moderate fat , moderate carbohydrates, high fiber, high protein diet provides an additional benefit when combined with an exercise regime.

● Also this type of diet has beneficial metabolic effects and it also delays the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes mellitus.

● However, adherence to the selected diet is imperative for successful weight reduction, controlling of blood sugars, and reduction of cardiac risk factors.

● It is very important that you consult a Qualified Dietitian/Nutritionist to get a proper healthy balanced diet plan for yourself, as she is the best person to plan a diet for you keeping in mind your sugars, activity pattern, height, ideal body weight, home recall, lipid profile or any other medical conditions so that you live a healthy,active and fit lifestyle always by keeping your medical parameters under normal range.

Bariatric Surgery

Bariatric surgery is indicated for obese patients with a BMI of more than 40 kg per meter square or those who have a BMI of more than 35 kg per meter square along with type 2 diabetes mellitus or other major comorbidities. However it is associated with a substantial perioperative morbidity or mortality. Acute perioperative complications, such as hemorrhage, anastomotic leak, infection, and pulmonary emboli can occur in upto 10% of patients undergoing bariatric surgery.

YOU DEFINITELY NEED TO KNOW THIS:

I was working at Saifee Hospital in Mumbai, a few years back when the world's heaviest woman Eman Ahmed who was 500 kgs and lived in Egypt was bought for a bariatric surgery at Saifee Hospital. She had a rare genetic disorder which made her obese in extreme. I got the privilege to work and plan the diet for her along with my colleagues. She was our special guest and patient and hence we took every care and made everything possible and necessary for her. She already had multiple medical conditions because of her weight. She went through a surgery where she was reduced to 340 kg after treatment and Laparoscopic Sleeve Gastrectomy surgery at Saifee Hospital, Mumbai. Her treatment was led by Dr Muffazal Lakdawala. We planned the clear liquid diet for her as a protocol given by Dr. Mufazzal before and after the surgery. Eman died on Monday, a week after celebrating her 37th birthday in Abu Dhabi. The cause of her death was confirmed as various heart diseases and kidney dysfunction and was confirmed by officials from Burjeel Hospital, Abu Dhabi. According to the doctors, a hormone called leptin which comes from fat tissue and tells the brain when fat stores are being depleted. In Eman's case, the docking station in the brain that leptin plugged into, seemed to be very defective. Due to this defect, her leptin didn't send its signal. Because of this, from early life, Eman's brain perceived that she was constantly starving. That led her to constantly seek food, store it avidly in her body as fat and conserve energy. The gene identified as the cause of Eman's obesity is a homozygous missense variant in the LEPR gene. This variant has been previously detected in one other individual in a research setting by the Personalized Diabetes Medicine Program, University of Maryland School of Medicine. However, in Eman's case, this has assumed pathological consequences leading to her obesity. Ahmed's happens to be the only one in the world with this gene defect causing obesity. Although there was no specific cure to her condition, she underwent a few surgeries to lose weight. New drugs were developed to curb her dangerous situation which even helped her lose 300 kg post her operation.

Pharmacotherapy

● Pharmacotherapy for obesity management is indicated when (a) an individual’s BMI is greater or equal to 30 kg per meter or (b) the BMI is greater or equal to 27 kg per meter square and the patient has at least one obesity-related comorbidity (example type 2 Diabetes Mellitus, hypertension, or hyperlipidemia).

● The medications approved by the Food and Drug Administration (FDA) for long-term management of obesity that are available in India include lorcaserin (a selective serotonin 2C ( 5-HT) receptor agonist) and orlistat(a pancreatic lipase inhibitor).

My experience here with a patient is:

A lady patient with BMI 37 kg per meter square , also diabetic was started on medicine which helped her in controlling sugars as well as showed a fast weight loss as well along with diet and exercise. The patient with that medicine developed Urinary tract infection (UTI) and hence the medicine had to stop. After that the patient did not lose weight as fast as it was with the medicine prescribed earlier.

Hence drugs must be taken in supervision of the physician and must be monitored from time to time in regular follow ups by the doctor. A Nutritionist/Dietitian is not allowed to prescribe certain kinds of drugs.

From the current research and studies it is found out that Lifestyle interventions for patients who are obese and with impaired glucose tolerance improved overall morbidity and mortality risk and increased life expectancy by an average of 1.44 years. Lifestyle intervention should remain a strong focus in the treatment of glucose intolerance and type 2 Diabetes as patients in the initial treatment group in the study experienced fewer cardiovascular disease events, fewer microvascular complications as well as fewer cardiovascular disease – specific and overall deaths.