There are people who look good when thin, there are others who look good when fat. Generally when type 2 patients are uncontrolled in their sugar control, there is weight loss due to the excess catabolism by glucose.
Increased obesity was observed in all ages, genders, races and educational levels with an increased magnitude among those in their 20`s with some form of college education. One fourth of the children and adolescents between the ages 6 and 17 are overweight!
Effects of being obese
Negative attitudes towards obesity are very common, lead to depression and these people experience discrimination from society. They usually try their level best to find excuses from shying away from exercise such as blaming the sweating, the itching, and the discomfort by rubbing of thighs and increased axillary pad of fat and having rashes between skin folds on the neck, axilla, below the breasts, in the groin and between the thighs. Getting dresses also is a problem though there are some shops that cater only to the oversized.
The risk is deadly!
Control of weight is important to prevent or manage blood pressure, diabetes, joint related problems, cancer of the endometrium and ovaries among women and cancer of the colon, snoring and disturbed sleep patterns( called Obstructive sleep apnoea), gall stones, impotence and even depression.
The impact of obesity
Disease Relative risk in men Relative risk in women
Type 2 diabetes 12.7 5.2
Hypertension 4.2 2.6
Heart attack 3.2 1.5
Colon cancer 2.7 3
Angina 1.8 1.8
Gall bladder disease 1.8 1.8
Ovarian cancer — 1.7
Joint problems 1.4 1.9
Stroke 1.3 1.3
Normally people tend to gain weight with age due to change in their physical activity or small changes in diet. Weight gain can also be seen during pregnancy, menopause, adolescence, just after marriage or among those who stop smoking.
What causes obesity?
All are aware of the sedentary lifestyle- spending more time on the couch or bed. Too much of a dependence on automated chores such as having remote controlled devices for almost every chore at home- such as for opening and closing the gates, the doors, for raising and closing the blinds, for turning on and off the lights , turning on and off the cooking range, even controlling the television, having washing machines and what not!
It is a well known fact that when there is a mismatch between the intake of food and the expenditure of calories, obesity sets in.
Many still to this day blame their genes and poor forefathers for their obesity!
There are some other causes for obesity :
• Cessation of smoking can cause an increased appetite and reduced metabolic rate which can cause a modest raise of weight. (NO! This does not mean smoking is good for weight control!)
• There are medicines such as anti diabetic medicines, anti depressants, steroids in large doses for a long duration and some medicines for treatment of fits which can cause weight gain.
Types of fat
There are two types of fat on a person. They are subcutaneous fat and visceral fat. The former is seen just under the skin and latter seen internally around the organs.
Subcutaneous fat acts like a cushion to protect the body. It acts a storehouse of energy. Excess subcutaneous fat will give the flabby arms and thighs and is easily burned off with exercise than with diet alone.
Visceral fat increases the waist line tightening the internal organs. Thin people also have visceral fat which makes them as prone for diabetes and cardiovascular diseases as much as for obese people. Excess visceral fat is linked to increased triglycerides ( bad cholesterol), reduced High density lipoprotein ( good cholesterol), elevated blood pressure and elevated blood glucose.
Belly fat goes by many names such as beer belly, pot belly, abdominal fat, organ fat or intra-abdominal fat. Visceral fat is located inside the peritoneal cavity packed in between the internal organs as opposed to subcutaneous fat ( found underneath the skin) and intra muscular fat ( found interspersed in skeletal muscle) An excess of visceral fat is known as central obesity and the abdomen protrudes excessively.
Role of fat: Fat serves as a site for storage of energy, fat effects release of fatty acids in response to signals and functions as an endocrine organ
Apple sized, Pear sized, and Lemon on match stick are different ways to describe those overweight or obese.
There are variations of the size of a person with changes in gender and ageing.
In males, there is a greater lean mass, bone mineral mass, muscle mass in arm, reduced fat mass, less limb mass, greater central fat and larger stronger bones ( there are exceptions though)
Among women, after pregnancy there is increased visceral and central adiposity. Subcutaneous fat is more among women
How to measure level of obesity?
There are different methods to measure accurately the quantity of body fat- underwater densitometry, dual energy X ray absorptiometry, total body water estimate and bioelectric impedence.
Body Mass Index (BMI)
BMI is a common term used by the health care team to describe if you are in range for normal weight to height . This is calculated by dividing the weight in kilograms by the square of the height in meters.
BMI does not reflect the regional fat distribution. But, BMI may not be suitable for measuring among the elderly due to reduced lean body mass.
Although Asians have lower BMI than westerners, they have a higher % of body fat. Only 1/5 of the total body fat is located centrally of this ¾ is subcutaneous. Visceral fat usually increases in both sexes.
A person of BMI 25 has a 5 fold risk of developing type 2 diabetes than a person of BMI 22. If the BMI is increased to 30, the risk is increased to 28 times and the risk is increased to 93 times if the BMI is raised to 35 and more.
The common misconception that only visibly over weight and obese people have belly fat needs to be debunked. Waist to hip ratio is a better marker than the weighing scale in knowing how much belly fat one has.
If the waist Hip ratio is <0.8 (males) < 0.75(females) the risk is low
If the waist to hip ratio is 0.96-1.0 (males) or 0.81-0.85 (females) the risk is moderate
If the waist to hip ratio is >1.0 (males) and >0.85 (females) the risk is high
While assessing the treatment options, the healthcare professional has to take into account the expectations, the level of motivation, the activity history, screen for psychiatric disorders and eating disorders. There are so many diets available in the market each one claiming to be better than the other. The same applies to the various health programs each claiming to give better weight reduction than the other competitors. Losing weight can be frustrating to both the clinician and the patient.
How to reduce weight?
Even a 5-10% weight reduction can help to reduce blood pressure, lipids, insulin resistance, prevent joint problems and improve the quality of life and improve the psyche of the patient.
A simple step of reducing just a spoon of sugar a day can help you reduce 500 cals a day!
Though there are many medicines to help reduce weight, remember there are side effects with each. There are herbal medicines as well. Some of the so called weight loss powders have had side effects due to some of the chemicals incorporated in them. But, the silver lining is that there is nothing to beat a controlled food intake, eat sensibly and exercise in some form to burn off more than what you ate. There are just no short cuts to reducing weight. You need essential nutrients and you need a good breakfast. Drink plenty of fluids in the form of water and go for natural unprocessed food.
Doing some stepping or spot jogging exercises while watching television, pilates exercises, Yoga or Tai Chi , doing some aerobics or hula hoops in the confines of your room, can also help to reduce weight. This negates the excuses of not having a good neighborhood for exercising.
Visceral fat deposition can be reduced by losing weight the healthy way, de-stressing by meditation and deep breathing exercises, hydrating well with fluids, taking a healthy diet containing enough of fiber, fruits and vegetables, wheat bran, fish, non roasted nuts, green tea avoiding junk food, fruit punches, alcohol and leading a life which is physically active.
Did you know Ghee and Butter contain essential fatty acids? You may recollect that those in the past generation ( and even today)used to have thick rotis ( made with dough of wheat) with a dash of ghee or butter on them for food in parts of northern India. But, you must also remember that these people used to expend the energy as well. Having such rotis and relaxing on a sofa, in today`s world can be a suicide.
More processed food contains less of vitamin B12.
Read more in the post titled, “Weight loss”
Indications for insulin usage:
- When oral medicines fail to control the sugar in maximum doses
- when there are complications to the eyes, kidney or heart,
- when the sugars are very high,
- when there is pregnancy associated with diabetes,
- when intolerant to oral medicines ,
- when diagnosed with latent auto immune diabetes of adults
- when being planned for surgery.
- If diagnosed with type 1 diabetes.
Insulin preparation: There are 3 main types of insulin based on duration of action- short acting, intermediate acting and long acting. • Short acting insulin acts for a short time and peaks fast. This is why this has to be administered with the main meals at least three times a day. • Intermediate acting insulin acts for close to 10 hours and so needs twice daily dosing • The long acting insulin can last for 16-24 hours and thus, needs one or two shots a day • There are premix insulin which comprise short and intermediate acting insulin in one. • Ultra short acting and ultra long acting insulin preparations are now available. • Non injection forms of insulin are now becoming available- studies are on. Nasal, inhaled forms, patches, pills, oral sprays are all forms being researched into to avoid the needle prick. The doses of insulin are usually tailored by the doctor or nurse initially and then adjusted by the patient depending on the sugar reading. Insulin delivery devices are now- a days by pen devices or by continuous subcutaneous devices. The old method of using a vial and syringe is still present. Insulin can be safely administered if used sensibly. Store the insulin in fridges ( not in the freezer) or in a cool room, lightly shake the pen before use if pre mix insulin and roll the insulin pen between the palms of the hand to prevent injecting cold insulin and inject at different sites each time. The needles are to ideally thrown after each injection( though some can use up to 3 injections with a needle) . Sites for injecting: • The thighs on inner side, the outer side and front side are the most preferred sites. • The abdomen wall can be used- but remember not to inject just around the belly button ( umbilicus) inject any place on the flanks more than two finger breaths on either side of the umbilicus. • The arms are not commonly used in adults. • The buttocks and back are used for small children How to inject: • Have the needles changed before injecting • Roll the insulin between the palms of the hands if insulin is cold. • Select the site for injection. It is not mandatory to wipe the area with a spirit wipe. However, if you do, make sure the alcohol or spirit dries out before injecting. • Feel for any thickening or induration. If present, avoid injecting into that site. • If skin is dark at that site avoid injecting there. • Do not inject into dilated veins on the thigh, if present. • Dial the required dose. • There are people who pinch a fold of skin before injecting. It is not necessary to. • Plunge the needle vertically into the site ( perpendicular to skin and not at an angle). Needles are fine and almost painless • Depress the plunger down. The meter will return to zero. • Count to five slowly and remove the pen. • It is common to see a drop of blood after removing the needle. • There is no need for a vigorous massage as is done after deep intramuscular injections. • Do not inject soon before or after an exercise regime. • Rapid acting ( short acting) insulin can be injected in the abdominal wall. The absorption from the thighs is ideal for intermediate and long acting insulin as the absorption is not so fast. The absorption of insulin is slowest if injected in the buttocks. The arm is not ideal for self injection. • The pen device has a spring device which can get worn out over a period of time, maybe after an year or two. Change the delivery system when this happens. The needles after use are to be discarded in a proper manner after putting them in a sharps container. There are places around the world where the used needles are sold again in a fresh pack thus helping spread of disease such as AIDS, Hepatitis B and Hepatitis C. Side effects of insulin: • Hypoglycemia- low sugar • Allergy to the preservative or type of insulin( this is quite rare these days with the advent of purified and human varieties of insulin) • Weight gain • Thickening of the subcutaneous tissue at injection site • Neuropathy- sometimes insulin can cause nerve pain which can be very depressing. Being started on insulin does not mean the end of the road. It is used by the doctor when the sugar levels are very high to bring I down, or when you are undergoing an operation or when you are pregnant or when you have complications affecting the eyes, kidney or heart. It does not mean that insulin once started remains so for the rest of your life. There are needless insulin delivery systems which are present elsewhere. There are other insulin routes available which had been researched, but fell out of favor due to the less efficiency. . While traveling long distances, use a temperature controlled pouch or ice box for keeping the insulin at a cool temperature. If you party, take a small dose before the party, have a snack before you leave, and have the rapid acting insulin after the dinner .Meet your doctor for advice on the dose. Alcohol intake can cause a delayed hypoglycemia(low sugar) The three main insulin delivery options are a pen, syringe, or pump. There are also a few newer insulin delivery systems, including the jet injector. Here are the pros and cons of each insulin delivery method to help you get started. Most of the insurance companies do not approve of these delivery systems which are new and innovative. The pen delivery system is, of course, approved and effective. Pen, Pump, or Syringe? Here’s a rundown of the three different insulin delivery systems, how they work, and their pros and cons. Insulin Syringe You use an insulin syringe to inject insulin into your body with a very fine needle. Pros: • Flexibility. You can choose from many different brands and types of syringes, and you can use them with just about any kind of insulin. • Cost savings. These work more economical than the latest medicines which could be very costly. • People with very regular schedules and consistent meal patterns can do well using this method. Cons: • Time. You have to be meticulous in loading the syringe, remember to warm the insulin if cold , by rolling the cartridge in the palm three or four times. Before injecting you need to check there is no air bubble, attach the needle, and draw the correct dose of insulin into the syringe. • Dosing mistakes. Sometimes error while loading the dose can lead to problems. Insulin Pen An insulin pen works much like a syringe, but it looks like the type of pen you use to write. Insulin pens come in disposable and reusable versions. • Disposable pens come pre-filled with insulin. • Reusable pens use a cartridge filled with insulin. Pros: • Ease and convenience. Pens are convenient to carry about unlike the insulin which ( and still is) comes in bottles.. To use an insulin pen, you just dial up the insulin dose on the pen. Then you press a plunger at one end to inject the insulin through a needle at the other end. • Memory storage. Insulin pens have a handy memory feature that will remind you how much insulin you took, and when you took it. Cons: • Expense. The disposable pens are costly and the ones which could be reused are more economical. However, the reusable ones may have to be changed once in a year or two as the dose dialer spring may become faulty. • Lack of options. Some types of insulin are not available in pen form. Insulin Pump An insulin pump is a device that’s about the same size as a pager. You wear it on your belt or in a pocket, and it delivers a steady stream of rapid acting insulin to your body 24 hours a day through a needle attached to a flexible plastic tube. Whenever you eat, you press a button on the pump to give yourself an extra boost of insulin, called a bolus. The pump is an option for people with type 1 diabetes who have not reached their target blood sugar level using other delivery methods. It’s also a good option for people with diabetes that have very active lifestyles. It’s not clear whether people with type 2 diabetes benefit from using a pump. However among those with type 2 diabetes, who have failed to achieve good sugar control with maximum doses and have to take multiple doses of insulin instead, this is a convenient option. Pros: • Steady insulin release. The pump releases insulin as if mimicking the pancreas. The dose of insulin used will be quite less as it will be delivering tiny doses at pre fixed times. Only short acting insulin is used in this. Pumps are so efficient that you can use less insulin than you would with a syringe or pen. • Ease of use. You’ll no longer have to give yourself injections of insulin throughout the day–the pump will do it for you automatically. You can also eat whenever you choose. • Better blood sugar control. Because it delivers insulin steadily like your pancreas, the pump helps prevent blood sugar swings. • Ease of monitoring. Your pump can communicate with your glucose monitoring system so you can track your blood sugar over time and make changes to your routine as needed. Cons: • Constant wear. You’re going to be attached to this pump nearly all of the time — even when you sleep. • Risks. You need to be very careful about changing the needle every couple of days because there is a slight risk for infection. You also have to monitor your blood sugar levels, because you may be more likely to have a drop in blood sugar (hypoglycemia) with the pump than with a syringe or pen. If the catheter slips out or the pump fails, you might not get the insulin you need and over time your sugars can increase and you could develop a dangerous complication called diabetic ketoacidosis. • Cost. Pumps are costly and so also are the infusion tubing and reservoir. Some of the new ones come with inbuilt sensors as well which are costly. Insurance companies do not approve of this usually. • The infusion tubing and reservoir have to changed once every three days • Sometimes the tubing gets kinked without delivering the insulin which could cause problems • One has to feed in the carbohydrate consumption at the start to prime the pump. • The insulin will not be delivered if there is air in the tubing or if the insulin remaining in the cartridge is very low. Jet Injector Jet injectors don’t have a needle. Instead, they use very high pressure to push a fine spray of insulin through the pores in your skin. Pros: • Needle-free. If you hate needles, a jet injector is an alternative to the insulin syringe or pen. Cons: • Pain. Though needle less, they can cause more pain in some of those with sensitive skin as the insulin is driven inside the body by sheer force. You have a high concentration of nerves close to the surface of your skin. Trying to push insulin through the skin can hurt more than injecting — especially considering how thin needles are. • Uneven insulin delivery. Because they send insulin into the body through the pores, jet injectors may not always deliver an accurate dose. Other options include an insulin patch. Work closely with your doctor to choose the option that best fits your budget, health needs, and lifestyle. Not all the above are available here in Oman. Afreeza is a powder form of insulin which is an ultra rapid acting insulin. The powder is used by an inhaler called the Dreamboat inhaler. Peak levels are reported in 12-14 minutes of inhalation. This is especially beneficial for those with type 1 diabetes who are dependent on insulin for life and also for those with type 2 who become insulin dependent with failure of the pancreas. Close to 5300 patients have been studied in trails across the world and the results so far are promising, but needs further time to be found effective. This has been found to reduce the post meal sugar levels, fasting levels, have less incidence of hypoglycemia( term used for low sugar levels) , reduced weight gain as when compared to rapid acting insulin. However, this may need to be combined with long acting insulin or with oral medicines as the case may be for a better effect. The side effect so far noted has been a non productive cough ( dry cough) Degludec insulin is a new ultra long acting insulin which is still on research programs to test its efficacy. Though it is being marketed for injection once in 3 days or once a week ( which sounds like sweet music) , the effects of the insulin wear off after a day or two. Which means it is still better to have the shots of insulin daily for better control. The sugar control and episodes of low sugar have not shown any improvement over the insulin preparations available in the market today. Continuous glucose monitoring Continuous Glucose monitoring (CGM) devices are in the market for quite some time. These are small gadgets the size of a pager which help to monitor the sugar levels throughout the day and night. On an average a child between the ages 5 and 14 may have to poke the finger for sugar checking at least 50000 times and about 15000 injections of insulin during that time. This is quite phenomenal and frightening. For people on intensive insulin therapy as among those with type 1 diabetes or among those with frequent dips or spikes in their sugar levels which could be related to either food, alcohol or exercise. These machines detect the glucose level just under skin with the help of sensors. These levels are transmitted to a receiver. Pros: • This will give a constant reading and you can adjust the doses accordingly with the help of the health care provider. If the blood glucose reading is 7 mmol/L or 126 mg/dL, it could mean the sugar is going up or down and that is the reading at that time. The machine gives an arrow mark which will give the trend based on the readings just before.. • The tracings can be downloaded and interpreted • The tracings are given for every day in different color lines for easy interpretation • It also gives the average and how many lows one had experienced in the interim. • Alarms are there which could be programmed into the machine which could go on either when sugar swings too low or too high. Cons: • The cost is quite high • Normally the insurance companies do not approve of this unless in certain cases. • The sensors will have to be changed once in 3-7 days. This is costly • This is to be worn at all times. • May not be feasible for children below the age of 12. • One will have to calibrate the machine from time to time so that the readings are accurate. Needle less devices Frequent puncturing of the delicate skin at finger tips and also the insulin shots which are so frequent especially among those with type 1 diabetes are a cause of frustration. Now-a-days needle free CGM devices are coming out. Some are awaiting patents. There will be sensors, a transmitter and receiver. The signals can be sent to smart phones, computers or even laptops. This can be useful for working mothers who have children at home and can remotely access the sugar levels and send information to make corrective steps. The sensors are to be changed once in 3 days which helps prevent skin irritation. The skin top layer which comprises dead cells is painlessly removed and leaves a small abrasion not visible to the naked eye. The Symphony is one brand making such needle free CGM. Dexcom G4 Platinum is awaiting patents rights. This is sleek and hardly noticeable