Diabetes is one of the major health problems now-a -days affecting large number of populations worldwide. According to World Health Organisation (WHO) by 2025, 300 million people will be suffering from Diabetes. Amongst of all the well known factors that cause diabetes, Obesity is the major risk factor and the most important which has reached epidemic proportion in all the developing countries including India. The increasing onset of diabetes can thus be accredited to the global epidemic of Obesity. Sedentary lifestyle, less physical activity, changing food habits are the major reasons of the substantial increase of this dual epidemic obesity and diabetes. This should be taken as a major concern as this could lead to other fatal conditions like Coronary health disease, cardiovascular disorder, diabetes cardiomyopathy etc…
Diabetes and Obesity are so much interdependent that to describe this a new term has been coined DIABESITY. As the name explains this term is used to describe the combined adverse health effects of obesity and diabetes mellitus (DM). It can be further defined as Metabolic Dysfunction or Metabolic Syndrome caused by decreased ability or total inability of the pancreas to produce insulin which results in Insulin Resistance of Difficulty in secretion of insulin. Both insulin resistance and decreased insulin secretion is seemed very early in the obese patients results in diabetes or worsening it.
The Interdependence Obesity and Diabetes - Enemy Within
A strong relationship between Obesity and the prevalence of diabetes has been reported in a number of studies. Researches have proved that an increase in the overall fat, especially visceral as well as ectopic which means a person who is carrying more weight around their abdomen are more insulin resistant. Excessive storage of fat in obese people leads to the release of excessive fatty acids results in insulin resistance and hyperglycemia It is estimated that around 60-90% of all the patients with Type II Diabetes are obese (BMI >30 kg/m2) or overweight (BMI >25 kg/m2). There are many tools to make sure if a person is obese or overweight. To measure obesity, doctors, use different tools like BMI Body Mass Index, Waist Hip ratio (WHR), Waist Circumference (WC). BMI is the commonly used tool to measure Obesity which can be calculated as Your weight in kilograms divided to your height in meter squared. According to WHO a person whose BMI is more than 25 is obese, BMI more than 30 has Class 1 obesity, BMI more than 35 Class II Obesity, BMI 40 or above comes under morbid obesity which need to treated immediately before it manifests into metabolic syndrome.
In India, the body fat percentage is significantly higher than the Europeans and Americans having similar BMI and blood glucose levels. It has been accepted that the high prevalence of hyperinsulinemia and high risk of Type II Diabetes in Indians is a result of low muscle mass and excess body fat. The risk of having Type II Diabetes increases if a person has BMI more than 25 kg/m2. studies have also proven that in middle aged Indians the risk of developing Type2 Diabetes is more if their BMI >23kg/m2. Prolonged duration of obesity could definitely worsen their resistance to insulin resulting in type 2 DM. So, the patients who are carrying extra weight are advised to increase their physical activity, change their lifestyle and dietary and behavior modifications to lose weight. Preventing Obesity can prevent Diabetes.
The Diabetes/Metabolic Surgery - How Bariatric Surgery cure Diabetes/ Metabolic Syndrome
Diabetes is a metabolic disorder caused by decreased ability or total inability of the tissues to utilize carbohydrates due to insufficient or inability to produce insulin. The medical management of Type 2 DM consists of lifestyle modifications and specific glucose-lowering medications. In few cases this approach is beneficial but when a person has BMI more than 32.5 along with other comorbidities the approach through medication, physical activity & lifestyle changes cannot promise sustained results for “Diabesity”, in that case Bariatric Surgery gives a new life to the person with promising results by curing diabetes and losing weight.
Clinical studies have indicated that circulating bile acid (BA) concentration increases after bariatric surgery, according to it, the increased circulating BA concentrations after bariatric surgery – independently of calorie restriction and body-weight loss – contributes to improve insulin sensitivity, incretin hormone secretion, and postprandial glycemia, leading to the permanent control of Type-2 diabetes. The study also shows BA along with gut micro biota also plays a vital role in controlling hyperglycemia condition post-surgery.
The effect of bariatric surgery on glycemia might vary between different bariatric surgical procedures out of which RYGB(Gastric Bypass) has proven to be a gold standard in weight loss procedures. This procedure combines both restrictive and mal-absorptive elements to limit the size of the stomach and the amount of nutrients and calories absorbed which helps to reduce faster and cure Diabetes. In that case, the major drive for weight loss is the post-operative establishment of a state of profound negative energy balance, leading to the long-term restoration of peripheral insulin sensitivity. The sustained reductions in energy intake post-surgery primarily depends upon the reduction of hunger & early satiety, This is due to either early post-prandial distention of a reduced-capacity of upper gastrointestinal pouch sending satiety signals through the vagal pathways, or to the modulation of hunger and satiety signaling networks in subcortical brain areas regulating energy intake. This mechanism involves post-prandial secretion of satiety-inducing gut peptides such as glucagon-like peptide 1 (GLP-1), peptide YY (PYY) and oxyntomodulin (OXM), combined with a diminished secretion of orexigenic hormones such as ghrelin and possibly altered leptin signaling in the hypothalamus & thus help achieving early feeling of fullness. This early satiety need regulation of calorie intake along with medicine or insulin dosage alteration.
Role of Diet After Bariatric Surgery
There is a need to adjust anti-diabetic drug dosages in the postoperative period in order to prevent hypoglycemia. Before surgery a very low calorie diet (VLCD) is advice to reduce the liver volume so medicine dosage monitoring is also very important both pre surgery & post-surgery. Study shows that patient having HbA1c levels <6.5 have better DM control & better weight loss than patient having higher HbA1c levels. Diet & Lifestyle changes are recommended for sustainable results post-operative.
After surgery 50% intake of Diabetic drug should be advice along with perfect proportion of carbohydrates to Proteins is recommended to avoid hypoglycemia so diet in liquid phase like: dal soup, vegetable soup, chicken soup, curd, milk, buttermilk, protein powder & Fruit smoothies are advice to control hypoglycemia.
The main motive of diet for a Diabetic person is to avoid sugar spikes. Once, the patient resume to his normal diet which includes adding of Complex Carbohydrates, resistant starch, protein along with proper fiber intake in diet along with the proper monitoring of blood sugar levels twice in a day is advisable. Moreover anti-diabetic drugs adjustment with blood sugar variation is strongly recommended. Portion size reduces due to surgery so carbohydrates must be added in every meal along with protein foods like oats, quinoa, and brown rice with protein like dal, legumes, curd, egg chicken or Paneer. Frequent & small meals are advisable to avoid hypoglycemia. To reduce glycemic load of food low GI food is preferred like adding of vegetable in chapatti (like spinach, fenugreek leaves) or Veg. rice or steamed sprouts are the best choices. According to carb counting technique, to avoid sugar spikes & hypoglycemia, total distribution of carbohydrates for whole day is planned prior. Distribution of carbs for main three meal should be between 30- 45gm & for short two meal 15- 20gms thus the total intake must not be more than 120-150gm for a day. The main motive is to achieve less sugar spikes which will be better for diabetic control along with best weight-loss results. Protein is the preferred food macronutrient post-surgery to avoid lean muscle mass loss. So total recommended dosage can varies from 1.2-1.5gm of IBW. Fats are also important as it plays a role in lowering the GI of food. The total intake is not more than 15-20% of the total calorie intake. Fiber rich food is advisable which must be rich in both soluble & non soluble fiber. Total intake recommended must be 25gm of 1000calorie/ day. Macronutrients play an important role in controlling diabetic condition but few micronutrients also help in controlling Sugar spikes or Insulin resistance like zinc & selenium. Thus diet as a whole is important even post-surgery to delay the Remission of Type 2 Diabetes. Life style changes and behavior modification with physical activity is important for the management of sustainable weight loss and diabetes. a
According to the International Diabetes Federation by 2045 around 629 million people globally will be affected by Diabetes and around 438 million people aged between 20-64 years will be affected by it. Obesity and Diabetes have become the major health problems in India as well as globally and both are closely linked. Urbanization has fueled it up. The rising prevalence of obesity is associated with Type 2 DM which in combination further leads to major health problems like Coronary health disease, Mental Illness, Depression, Endometrial Cancer, GERD, PCOS, Infertility and are endless. Obesity is a burden on society which has the potential to destroy nations. It need serious attention and medical intervention.