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”
Hypoglycemia or low sugar is one of the nightmares of the patients and the doctors alike. High and low sugars may both present with sweating , confusion and sometimes even unconsciousness.
The commonest causes being taking too much of insulin or some medicines or forgetting to take food, too intense an exercise, consuming alcohol and some tumors of the pancreas.
Generally sweating, shaking of the hands, irritation, craving for food, beating fast of the heart, headache, stomach pain (gastritis) and clouding of consciousness. The body tries to correct the levels itself by an in built mechanism.
For the elderly adults low sugar manifests as confusion, delirium and drowsiness. Tremors and sweating are rare for the elderly with low sugar levels.These can mimic those with a fit or stroke and is, for that strange reason, often misdiagnosed.
For some people the body fails to recognize the features of low sugar. This is dangerous as very low levels are needed for the body to recognize it thereafter. This is called unawareness.
What can be done?
If low sugar happens, drink a can of orange juice or chew on some dry raisins or put some sugar into your mouth. If glucose tablets are available, that is a good option. Chocolates are not a good solution for low sugars as the fat content in chocolates delay the fast rise in sugar. Check your sugar level after 15 minutes and if still low, repeat the above. Get to nearest hospital and get this corrected if needed.
Categories of hypoglycemia:
• Documented hypoglycemia: typical symptoms of hypoglycemia and when the plasma glucose is ≤70 mg%.
• Severe hypoglycemia : An event which requires active assistance of a person to administer glucagon or carbohydrate or adopt any other resuscitative measure.
• Asymptomatic hypoglycemia: An event that is not accompanied by typical symptoms but the plasma glucose ≤70 mg%.
• Probable symptomatic: An event during which hypoglycemic symptoms are not documented with a plasma glucose determination, but presumed to be ≤70 mg%.
• Relative hypoglycemia: An event during which the diabetic patient reports typical symptoms of hypoglycemia, and interprets those as indicative of hypoglycemia, but the plasma glucose is ≥ 70mg%.
While driving if low sugar is encountered, drive off the road, put on distress signals, turn off the car, pull down the windows, remove the key from the ignition, take some sugar or orange juice immediately.( you must have a stock of this in the car always) . The brain takes some time to recover from the low sugar and impulsive driving may be initiated leading to accidents. Always check sugar levels before a long drive, break the journey in between long drives and carry an ID mentioning your diabetic status and contact numbers.
Sometimes hospitalization is also needed in serious cases.
The impact low sugars can have on life is very dramatic. For example, developing this while attending an interview or while at the exams or at an important meeting or while driving, can change the course of ones` life. People may then become introverts avoiding social functions for fear of low sugar. They are often mistaken for drunken behavior as well.
There are those without diabetes , those with diabetes and those with pre diabetes, who are neither normal nor diabetic. Those belonging to this group can be prevented from progressing to frank diabetes by following advice from their health care providers.
Who is at risk for developing Pre Diabetes?
• All adults with a BMI ≥ 25 kg/m² who are physically inactive and / or have first degree relatives with diabetes.
• Those who have high blood pressure .
• Those who have an A1c >5.7% .
• Those women delivered baby >9lb
• Those who have acanthosis nigricans( thickened velvety skin at the nape of the neck. This indicates there could be diabetes)
How to diagnose ?
American Diabetes association(ADA) stated that Impaired fasting glucose(IFG) patients have fasting plasma glucose levels between100 mg/dL and 125 mg/dL.For those with impaired glucose tolerance(IGT), 2 hour post glucose levels between 140 mg/dL and 199 mg/dL are significant.
Both IFG and IGT both are at high risk of developing diabetes Mellitus type 2 and atherosclerotic disease cardiovascular disease, retinopathy ( affecting the eyes) and nephropathy ( affecting the kidneys). Most of the time people are reluctant to check for sugar and unfortunately find themselves being diagnosed with diabetes when they present with the dreadful complications such as a stroke, or a heart attack, or blindness or a kidney failure.
It has been shown in various studies that the pre diabetes stage lasts for approximately 7-12 years before onset of clinical diabetes ( when the patient is diagnosed with diabetes)
The silver lining:
If diagnosed with pre diabetes, steps can be taken to prevent the progression to frank diabetes by lifestyle changes such as diet, exercise and increased physical activity and for those with high risk ( as among those with the above mentioned risk factors) medicines such as metformin or pioglitazone or acrabose are used.
Why is pre diabetes important?
The risk of developing an eye problem or heart problem is as high as person with diabetes getting a second heart attack or eye problem. There are more pre diabetes cases than diagnosed diabetes cases around the world.
Diabetes Risk assessment score:
18 – 44 years score 0
45 -64 years score 5
65 years or older score 9
2. Body mass index (BMI)
If BMI is > 25 score 5
If BMI < 25 score 0
3. If a woman who has had a baby weighing more than nine pounds (4 kg) at birth
Yes score 1
No score 0
4. Sibling with diabetes
Yes Score 1
No score 0
5. Parent with diabetes
Yes score 1
No score 0
6. under 65 years of age and do not practice regular exercise at all, or I do it less than three times per week
Yes score 1
No score 0
Total scores and interpretation
If score is 10 or more the risk of developing diabetes is high
If score is between 3 and 9, the risk is intermediate
If score is less than 2, the risk is low
Basic steps while reading a nutrition label:
- Look at the serving size and servings per container. The label will describe the values for a serving. So, If one takes twice the serving, the values should be doubled.
- Look at the calories per serving and the calories from fat. If the commodity contains < 40 cals, it is of low calorie, if <100 cals, it is of a moderate calorie, if <400 cals it is of high calories. Too much of calories will lead to obesity.
- Look for the nutrients to limit- total fat, cholesterol and sodium- these are linked to heart disease, high blood pressure and some cancers. While using canned food, rinse off the liquid as it contains a lot of sodium.
- Get enough of dietary fiber, vitamin A, Vitamin C and calcium. Usually on reading carefully, the calcium content in skimmed milk or full fat milk is the same. But, in yoghurts, the calcium will vary. Look for fiber 3 g and more.
- Look for hidden sugars- for example,high fructose corn syrup. Look for substances ending in -ol or –ose. They are sugars. Remember that 5 g of sugar is the same as a level spoonful of sugar.
- The footnote is the same in all labels. This shows the percentage daily values for an average American who is moderately active. He will need 2000 Kcals a day. For a more active American, 25000 Kcals or more may be needed. The values against each of the main nutrients are mentioned. This label will not change with the food.
- Look for % DV ( Daily value) of 20% and above for nutrients that are good and 5% and below for those which are to be limited.
• The top of the label describes a standard serving size and how many servings a package contains — critical information for interpreting the rest of the numbers on the label.
• A bottle of sweetened ice tea may only have 75 calories per serving. But if that bottle contains two and a half servings and you drink the whole bottle, you’re consuming 225 calories.
• Serving sizes are based on standard measures agreed upon by the USDA and the FDA. One serving of cereal is 3/4 cup, for instance. A single serving of macaroni and cheese is a cup. Most all of the information that follows on the nutrition label is based on that serving size, from calories to grams of fat. So it’s essential to know what a serving is, and to know how much you actually eat.
Phrase Definition ……………and………..What they actually mean
No fat or fat-free Contains less than 0.5 g of fat for each 100 g/ml
Lower or reduced fat Contains at least 25% less fat for each 100 g than original
Low fat Contains less than 3 g fat for each 100 g or 1.5 g for each 100 ml
Low in saturated fat Contains no more than 1.5g for each 100g or 0.75g for each 100ml
Lite or light Contains 25% less kilojoules than the original or comparative product
Sugar free Contains less than ½ g sugar for each 100g
Reduced sugar Contains at least 25% less sugar for each serving than the original product
No added sugar Sugar in any form has not been added as an ingredient
Unsweetened No sugar or sweetener has been added
No preservatives added Contains no added chemicals but may contain natural preservatives
Low sodium Contains less than 120 mg sodium for each 100g
No salt or salt-free Contains 5 mg or less of sodium for each 100g
High fiber Contains between 4.8 g– 6g or more fibre for each 100g
Lean Equal to or less than 10% of total fat
Extra lean Equal to or less than 5% of total fat
Low chole ol Contains 20 mg for each 100g or 10 mg for each 100 ml
• Foods can only be labeled as ‘low in energy’ if it contains no more than 170 kJ for each 100 g of solid food or 80 kJ for each 100 ml of liquids.
• Foods can only be labeled as ‘high in energy’ if it contains 950 kJ for each 100 g of solid food or 250 kJ for each 100 ml of liquids.
• Food labels can no longer appear to be endorsed by a health practitioner (for example medical doctor, dietitian etc), or be associated with testimonials like ‘Mrs X has lost 20 kg by using product Y’.
The use of terms such as ‘healthy’, ‘wholesome’ or ‘nutritious’ is banned.
• Food labels are no longer allowed to state or imply that the product can cure any medical condition.
• Foods that were previously advertised as ‘no sugar added’ or ‘sugar free’ will be banned if the product contains any type of sugar form or derivative such as honey, molasses, sucrose, sugar, fruit juice concentrate, high-fructose corn syrup.
A second phase of regulations is planned and will define food advertising that is targeted at children, the glycemic index and foods that are non-essential for a healthy diet.
Did you Know?
• Fortified, enriched, added, extra and plus actually means that the nutrients such as minerals and fiber have been removed and vitamins have been added while processing. Look for 100% wheat or low sugar cereals.
• Fruit drinks may have little or no real fruit with lots of sugar. Look for 100% fruit juices.
• Natural – may have started with natural ingredients, but while processing will lose the “natural” component.
Food labels are meant for adults and not for children. Please remember that children may need > 2000 Kcals or < 2000 Kcals depending on their level of activity or whether they are boys or girls. Children however will benefit from looking at the calories per serving, the fats per serving, the fibers per serving and make good choices. Most of the children will need food containing more calcium and iron.
What is diabetes?
Diabetes Mellitus ( there is diabetes Insipidus, which is caused by over production of dilute urine due to disorder of pituatary gland ) is a condition caused by either a relative or absolute deficiency of Insulin( produced by the beta cells of the pancreas) which results in increased glucose levels. Type 1 diabetes is when there is an absolute absence of insulin caused by some genetic problems or a destruction of pancreas by some viruses or unknown causes. Type 2 diabetes is caused when there is either not enough insulin to meet the demands or when the insulin is blocked from acting.
Type 1 is usually seen in young people, but can be seen in adults as well. This is less common when compared to type 2 diabetes. There is no treatment yet as successful and effective as insulin injection for those with type 1 diabetes. Research is going on to establish the efficacy of islet cell transplantation and stem cell therapy , but with mixed results.
Type 1 is caused by environmental and genetic factors. Destruction of the pancreatic beta cells by a viral fever can also cause diabetes. Type 2 is caused by poor lifestyle and resulting obesity.
Certain medicines also can worsen the glucose tolerance. Long term steroid administration, anti psychotic medication, hormones are some of the well known offenders.
Who are to be tested?
- Any person who is above the age of 45 years,
- Those who has a family history of diabetes, high blood pressure , high cholesterol levels, heart attack at an young age
- Those with kidney disease
- Those with unexplained weight loss in spite of good appetite
- Those with increased thirst and urination out of proportion to the environmental changes
- Those with problems with eye sight
- Those with waist sizes above 88 cm for men and 80 cms for women ( this differs from race to race)
- Those who experience long time for healing of small cuts and wounds
- Those with polycystic ovarian disease( small water filled swellings on ovaries seen in young women which can lead to hair growth on face, obesity, irregular menstruation and sometimes infertility)
- women who have had diabetes during pregnancy( gestational diabetes)
- Those recurrent urinary infections or boils on skin
- Unexplained weakness
The extent of the epidemic
In today`s world things are moving at a fast pace and often we all struggle to keep pace. This leads to unnecessary mental stress, lack of sleep, improper food intake, smoking, alcoholism or other recreational drug abuse, fast food and intake of large quantities of sweetened beverages in the form of fizzy (carbonated) drinks. This habit coupled with lack of exercise or activity has led to the gigantic proportions at which Diabetes is becoming an epidemic. The arrival of fast food( which unfortunately is very tasty and presentable!), processed food, high calorie food have caught on with the young generation in a big way and the parents do not mind as it is readily available and keeps the children happy and content! Large portion size, eating in front of the TV, eating more at night and lack of adequate physical activity are important factors.
The main culprits
Automation of chores such as having a remote for almost everything- opening and closing the gates, controlling the television, controlling the music system, the air-conditioners, the blinds of the windows, the watering of the garden, switching on the lights and even cooking has made us all so dependant as well as lazy! We even resort to ordering food or things from the market through the phone rather than walk. How many of us prefer to take the stairs than the lift or the escalator? How many of us prefer to walk rather than drive the car even for short errands? The boom of the computer age has worsened the matters by encouraging the children to play games, study, acquire knowledge, socialize, watch movies all within the confines of their rooms leading to an absence of activity outside in the fresh air and leading to another threat, OBESITY. Of course, they may be exercising their hands, eyes and rain, but that alone is not enough!
It has become so bad that if one does not have these “modern diseases” such as high blood pressure or diabetes, one is labeled abnormal!
Let us sit and recollect that the previous generation ( not so long ago) had mostly naturally available food, had plenty of oily food, had enough of sweets made with sugar or ghee, did not use additives or flavoring agents and still were happy and almost disease free. They used to work hard and walk where possible. Medicines were so few those days and so also were the medical facilities. They used coconut oil, there was almost no taboo food and stress was much less.
We have reached a stage where the inevitable cannot be avoided, but it can be delayed by a sensible lifestyle.
BMI ( body mass Index) >25, fat in diet< 30%, Saturated fat < 10%, increased fiber, physical activity 150 minutes per week. If any one of these goals can be achieved the incidence of diabetes can be lessened by as much as 20%! It is time we started something drastic to grab Diabetes by its roots.
Testing for diabetes
Fasting blood sugar >7.0 mmol/L or 126 mg/dL ( this means a fasting period of 8-10 hours)
A post prandial blood sugar of > 11.1 mmol/L or 200 mg/dL ( 2 hours post meal- some doctors advise an hour and half)
HbA1C of >6.5% ( this test gives an average of 3 months sugar readings)
Please be aware that the fasting and post prandial can be misleading depending on what the patient ate, but the HbA1C will give the overall picture.
Please note that a glucometer checks the glucose level on the capillary blood ( at the finger tips) and in the traditional method, blood is taken from the blood vessel at the hospital or clinic. There will be a difference between the different meters at the same time and also a difference between the reading taken from the finger tip and the blood vessel.
The HbA1C is done every 3 months to assess how one is progressing, but it can be done once in 6 months if the control is excellent.
There is a pre diabetes state: if the fasting sugar reading is between 5.6-6.9 mmol/L( 100-125 mg/dL) the patient is labeled as having impaired fasting glucose. If the 2 hour post meal sugar is between 7.8-11 mmol/L(140-199mg/dL) the patient is labeled as having impaired glucose tolerance. If the HbA1C is between 5.7-6.4%, the patient is labeled as having pre diabetes. This means you are not yet a diabetic, but may become one. Usually life style changes are all that matter at this stage. Some doctors prescribe medicines at this stage depending on other factors such as body weight, age, BMI and associated diseases.
Other tests to be done:
Urine sugar estimation is not done these days as much as it used to be done long back. It has become unreliable to monitor diabetes control only on urine sugar levels.
Type 1 diabetics are diagnosed by checking some markers in the blood ( GAD 65, ICA, IAA and C peptide) which will not be normally seen in the blood. This is released by the destruction of the cells producing insulin, the beta cells. C peptide shows how much insulin is being produced by the pancreas.
Other tests of the blood to assess kidneys, liver, lipid profile, urine for protein, check for eyes, heart, feet are to be done periodically to make sure Diabetes has not affected any of these organs.
The eyes ( causing blindness), heart ( attacks ), brain ( strokes or paralysis), kidneys( kidney failure), feet ( numbness or inability to feel or differentiate between hot and cold sensation) and erectile dysfunction in males or infertility among males or females.
Diabetes is the commonest cause of preventable blindness and the commonest cause of amputation ( cutting away an extremity) due to non traumatic causes