Management of Obesity
| Obesity In Type 2 Diabetes - Dr K B Nihalani*, Dr J P Shembalkar*** Ex-Professor and Head, ** Lecturer, Department of Endocrinology, T. N. M. C & B.Y.L. Nair Charitable Hospital, Mumbai. |
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| Obesity and genetic susceptibility along with other factors play a great role in causation of Type 2 diabetes. Patients with high waist hip ratio and BMI have 15% higher risk of developing Type 2 diabetes over a 13 years period. Abdominal fat increases insulin resistance and leads to hyperinsulinaemia. This could either be due to increased insulin production by the pancreas or decreased degradation by the liver. These abnormalities in insulin secretion can be taken as predicators of Type 2 diabetes.
Plasma proinsulin levels are also high in Type 2 diabetics which correlate with increased cardiovascular morbidity and mortality. Type 2 diabetics are divided into obese and non-obese and in both dietary management is a starting point in management diabetes. Designing A Diet For Obese Type 2 Diabetic Patients Dietary histories are to be taken carefully in obese patients as they often underestimate their food intake. Dietary recommendations should be based on current weight, eating habits and lifestyle of the individual patient. Factors like age, occupations, degree of hyperglycaemia and other medical disease like hypertension should also take into consideration. The target of and dietary program should be to achieve and acceptable BMI between 20-25. This target can be achieved over a period of 3-6 months depending on the original weight. The rate of weight reduction should not be too rapid. They should be advised to restrict 500 K cal per day so that there is weight loss of 2 kg per month. Along with total calories restriction, the composition of total diet is important. High carbohydrate and low fat diet has many advantages in diabetics. Along with it high soluble fibre intake is advisable. This leads to less tendency to overeat. The overall diet of obese diabetic should be planned as follows:
Exercise Exercise has acute and long term effect which are potentially beneficial in diabetic patients. It not only reduces weight but also increases insulin sensitivity and produces less atherogenic lipid profile. Simple advice to every patient is to walk for an extra 30-60 minutes daily. More strenuous exercise should be taken after cardiac evaluation. Sulphonylureas They have represented the backbone of the Type 2 diabetics therapy for the last 30 years. They can act only when the beta-cells of pancreas can secrete endogenous insulin. Sulphonylurea act by enhancing insulin secretion by stimulation beta-cells of pancreas. They do not have extra pancreatic effect. Clinical efficacy of all second generation sulphonylurea are equal. They usually are well tolerated. Approximately 20% have one episode of hypoglycaemia in 6 months. Role Of Metformin Metformin is useful as first line drug for obese Type 2 diabetics. It decreases blood-glucose levels in Type 2 diabetic patients primarily by an increase in glucose utilisation. It decreases hepatic glucose output. These actions are because of the increased sensitivity to insulin. It does not stimulate insulin secretion. Metformin also has been shown to impair glucose absorption from the intestine leading to reduced PPBS. It has modest effect on lowering lipids. Other small beneficial effect is on fibrinolytic activity and platelet aggregation. Dose: 0.5 – 2.5 g/day in divided doses. Drug of choice either alone or with sulphonylurea for obese Type 2 diabetics who are IR with relatively mild hyperglycaemia. Alpha – Glucosidase Inhibitor Delays carbohydrate absorption in gut by selectivity inhibiting disaccharidase in intestines. OHA Failure If there is no response to the sulphonylurea treatment for 30 days since the start of the treatment, it is called as primary failure. Primary failure is usually due to incorrect use of drug. If OHA failure is after period of therapeutic success then it is called as secondary drug failure. |
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