Obesity, diabetes, and the metabolic syndrome; a broad spectrum of disease.

Patient with the metabolic syndrome

Courtesy: James Heilman MD

Wikimedia Commons

When a patient visits a doctor with classic symptoms of diabetes (excessive thirst, urination and loss of weight) the patient often reports the symptoms have been present for a week or two when in reality the patient has been in the pre-diabetic phase of the disease for years.

Although there are few if any symptoms in the pre-diabetic phase of disease and these patients generally have normal blood glucose levels, they have high circulating blood insulin levels, sometimes up to ten times higher than normal. Insulin is the hormone that regulates the body’s blood glucose level, and is produced by the pancreas. In obesity the fat cells block insulin from reaching the proper target cells and those cells from properly utilizing the insulin. This is called insulin resistance. Increased secretion of insulin by the pancreas to keep the glucose level normal causes the pancreas (an enzyme rich organ) to work overtime to control the blood glucose but in so doing releases some of its other enzymes into the circulation. If the scenario persists a chain reaction is set up resulting in a increased production of triglycerides (fat in the blood) an elevation in LDL (bad cholesterol) and reduction in HDL (good cholesterol). There is also production and release of inflammatory mediators, (substances produced by cellular reactions) and associated with release of pancreatic enzymes. These inflammatory mediators can promote heart disease and liver disease. Elevated insulin level also has an effect on the kidney that results in elevated blood pressure.  So it is not unusual for the patient that is seen by the doctor for the first time with symptoms of type 2 diabetes mellitus (T2DM) will also have high blood pressure. In these patients the silent metabolic effects of obesity and pre-diabetes have been present for a long period.  And if abdominal obesity, high blood pressure, high blood glucose, and abnormal triglycerides and cholesterol exist together they fit definition of the metabolic syndrome.

The metabolic syndrome is a constellation of conditions that include central obesity, diabetes, high blood pressure, and derangements of cholesterol (good and bad). The syndrome was first described in 1988. When present together these finings form a perfect storm for the development of heart disease, strokes, and kidney disease. Body fat is thought to be essential for the condition to exist, although in certain ethnic populations visible obesity is not always apparent nevertheless the majority of persons are visibly obese. It is the fat within organs and surrounding organs (visceral fat) rather than fat directly under the skin (subcutaneous fat) that drives the metabolic derangement.¹ This explains why of removal of subcutaneous fat with procedures such as liposuction has limited effect in the treatment of T2DM (only subcutaneous fat is removed with the procedure). The metabolic syndrome is associated with T2DM, cardiovascular disease, strokes and kidney disease.  The good new is that a prudent diet and increased levels of exercise can mitigate the effects of the syndrome and its complications. But when diet and exercise is not enough medications will be needed to control glucose, blood pressure, and cholesterol. There is more good news however! There is a possibility of remission (slowing or reversing the disease) in newly diagnosed diabetics. This will be posted in the next discussion.

1- Int J Obes Relat Metab Disord 1995, 19:846–850

Obesity commentary

After posting on obesity and some of its consequences, I’ve received mixed responses (on and offline) with feedback like... “informative and interesting” implying, politely, that they read the piece but were not moved to further comment. What I was hoping for is commentary from persons that have a vested interest in the topic, skin in the game if you will, to give their opinion or tell their story on some aspects of the points raised.  Although there is not a lot of glamor in the topic (obesity and its consequences) it is a public health concern. But equally important is the fact (as made in one of the post) that there are many solicitations out there that try to market weight loss to improve body image and improve social life in a quick - painless – way without the discipline needed for true sustained weight loss and a healthier lifestyle. These methods often do not have the science to back them and are often misleading. The next post will be on the metabolic syndrome.  This is a constellation of conditions including obesity, hypertension (high blood pressure), diabetes, and derangements of cholesterol (good and bad). These conditions when present together form the perfect storm for the development of heart disease, kidney disease and stroke.

On treating obesity and diabetes with herbal preparations

I am often surprised when I receive advertisements – online - clearly targeting the obese population that offer to reduce weight over a short period of time and without significant diet or exercise. The ads describe some fat altering diet supplement that can be purchased, and there is some urgency to purchase, as the offer is usually time limited. And accompanying the ad there is often a before and after photo over a very short period (weeks) demonstrating a dramatic change in body image. I often wonder who would have such expectation of – weight loss and improvement in body image over such a short period? And what of the complications of obesity that are not obvious in the body image photos? In these ads there is little or no mention of any of the complications associated with obesity such as diabetes rather just the focus on the before and after image.  Should health consequences of being overweight or obese be mentioned in weight loss ads?

Obesity is linked to type II diabetes mellitus (DM).  Data obtained form the NHANES (National Health and Nutrition Examination Survey) collected over a five-year period studied a large population (over twenty-one thousand) with diabetes. Over 80% of patients with DM had a BMI (body mass index – a measure of body fat using height and weight) over 25% placing them in the overweight category, and 50% had BMI of over 30% placing them in the obese category¹.  In obese individuals the body’s production and sensitivity to insulin (the hormone secreted by the pancreas that regulates blood sugar levels – glucose) can be altered and either you don’t produce enough or there may be resistance to insulin.  Even if you take insulin (exogenous) obesity can alter the way the body reacts to it, and if there is resistance to insulin higher levels may be needed to keep the blood glucose level under control. DM related complications are quite serious. They affect every organ in the body. The most well known complications are kidney disease – leading to dialysis, cardiovascular disease – leading to heart attacks and strokes, and the effects on the circulatory system leading to limb loss; these are a few of the most serious complications. Knowing the significance of DM’s consequences it is hard to believe that obesity, which is linked to DM, is not taken as seriously as it should be by those individuals who are obese and at risk for DM?  Lifestyle modification (the foundation of the treatment of obesity) includes diet, and exercise.  And healthcare providers should repeatedly reinforce this to their patients. Lifestyle modifications alone have been documented to significantly reduce weight and reduce the risk of developing diabetes, and if medications are ultimately needed for treatment of DM they should be administered by a knowledgeable healthcare professional in addition to the lifestyle modifications.

Would you attempt to treat DM yourself with herbal medications without the guidance of a healthcare professional? Lately I have been paying attention to online ads that promote the treatment of DM using herbal preparations. I am not sure where the science is that documents the efficacy and safety of these products - I have not found it in peer review journals. But a disease such as DM should be monitored under the supervision of a healthcare professional, and not self treated with online mail order preparations that have not been properly been evaluated by regulatory agencies. At very least these preparations will probably not provide the desired effect and at worst they may even do harm. So please, consult your healthcare professional about these and other alternative medications. If one were to attempt to use a supplement for DM and glucose control (and I am not advocating this) how would you monitor the efficacy of the preparation? This leads into a discussion about monitoring blood glucose levels, and the over all periodic evaluation required when dealing with DM or any other chronic disease.

1- JAMA 2006 April 5, 295 (13) 1549.