Lifestyle Diseases




Options for dealing with obesity and diabetes

Dubai Healthcare City-based specialists shed light on key issues surrounding obesity and diabetes. Middle East Health speaks to Dr Naji Torbay Khoury, Specialist in Endocrinology, The Weight Care Clinic, Dubai Healthcare City, and Dr Alaeddin Saghir, Consultant Endocrinologist Diabetologist, Abu Hammour Medical Centre.

 

Middle East Health: What are the most effective strategies to combat obesity?

Dr Khoury: Calorie-restricted diets are effective in inducing weight loss if the patient is compliant. For more than 60 years the generally accepted principle of gcalorie restrictionh has directed the methodology when weight loss is intended. As such, the Basal Metabolic Rate (BMR) of the subject is calculated using one of the available formulas. If the individual is planning to engage in a physical activity programme, the amount of expected extra calories estimated as a result of this activity are added to those in the BMR. To the resulting total, some 500 calories are extracted and the final dietary prescription formulated. Typically calories are distributed among the three macronutrients in a proportion of 50-60% carbohydrates, 20-30% fat and some 20% protein. The most important disadvantage of this method is that it is unsustainable and from studies done in the 70fs we know that once they are discontinued the majority of subjects regain their original weight in a very short period of time.

Middle East Health: Please explain how diet plays a role in controlling weight in a person with diabetes?

Dr Khoury: Over the past 18 years we have been following a challenging principle of emacronutrient restrictionf based on the extensively-tested hypothesis that insulin- resistant patients respond better to a low carbohydrate, non-ketogenic (LCNK) diet; we first diagnose the insulin status of the individual and proceed accordingly to prescribe either a carbohydrate-restricted diet or a fat-restricted diet if insulin dynamics are normal. Our diets are easy to follow, sustainable and most important, instructing to the patient: the patient learns and tests in his own body the effects of the regulated macronutrient and once he stops dieting, he is able to control his future weight because he knows what in the food is making him gain weight. We generally advise the patient to increase his daily physical activity because it enhances weight loss.

Middle East Health: In your practice, when is bariatric surgery an option?

Dr Khoury: We follow the generally accepted guidelines and indications for bariatric surgery. According to the clinical practice guidelines published by the AACE [American Association of Clinical Endocrinologists] updated 2013, bariatric surgery is advisable for: .

  • Patients with a BMI .40 kg/m2 without coexisting medical problems and for who bariatric surgery would not be associated with excessive risk should be eligible for 1 of the procedures.
  • Patients with a BMI .35 kg/m2 and 1 or more severe obesity-related co-morbidities, including T2D, hypertension, hyperlipidaemia, obstructive sleep apnea (OSA), obesity-hypoventilation syndrome (OHS), Pickwickian syndrome (a combination of OSA and OHS), non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH), pseudotumor cerebri, gastroesophageal reflux disease (GERD), asthma, venous stasis disease, severe urinary incontinence, debilitating arthritis, or considerably impaired quality of life, may also be offered a bariatric procedure. Patients with BMI of 30-34.9 kg/m2 with diabetes or metabolic syndrome may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long term data demonstrating net benefit.
  • There is insufficient evidence for rec-ommending a bariatric surgical procedure specifically for glycemic control alone, lipid lowering alone, or cardiovascular disease risk reduction alone, independent of BMI criteria.

Middle East Health: What is a typical medical obesity treatment programme, especially because obesity is frequently accompanied by medical conditions like type 2 diabetes and hypertension, among others?

Dr Khoury: Co-morbid conditions are associated with the obesity state and therefore specific medical therapies are imperative. Obese hypertensive patients are effectively treated with either an ACE (angiotensin-converting enzyme) or an ARB (angiotensin receptor blocker). In severe cases combination therapy with a diuretic or a CCB (calcium channel blockers) is mandatory. As they follow the prescribed diet and lose weight, blood pressure control becomes simpler. Basic to the medical treatment of the obese diabetic is the use of Metformin, an oral antidiabetic drug, along with a specific kind - LCNK (low carbohydrate non ketogenic diet), of diet. If there is a need for further control, further medical advice is given. The majority of patients get under control especially if they are compliant with the diet. We rarely recur to insulin therapy and try to avoid it because of the substantial weight gain it induces. The obese women with PCO ( polycystic ovary syndrome) respond very well to the LCNK diet and metformin therapy, and any concomitant hyperandrogenima or infertility disorder are frequently corrected. The obese with secondary respiratory difficulty and sleep apnea improve significantly as weight loss ensues. Finally the self-image and psychological suffering frequently found in the obese subject is substantially recovered as he loses weight and regains confidence in himself.

Middle East Health: Typically, common health consequences of being overweight and obese are cardiovascular diseases, musculoskeletal disorders and diabetes, but in your practice in the UAE, what are the most prevalent complications?

Dr Saghir: In my opinion, and as far as I have noticed during my experience in Dubai, diabetes is the commonest health consequence of overweight and obesity in UAE. Actually obesity represents a “new health challenge” in the UAE. I would like to mention here the report of the International Diabetes Federation (IDF) in November 2013, which confirmed that UAE is ranked 15th worldwide in the prevalence of diabetes, with 18.98% of the UAE population living with diabetes. This is expected to rise to 21.4% by 2030. These statistics indicate that the region has high risk factors for diabetes, mostly related to rising obesity rates and physical inactivity. Approximately 75% of people in the UAE are obese or overweight, the UAE’s population is approximately 3.4 million and of those, around 425,000 people from the ages of 20 to 79 in the UAE are currently diagnosed as having diabetes. That figure is expected to rise to approximately 501,000 in 2030.

Middle East Health: What advances in treatment of obesity-related diabetes has the UAE witnessed over the past several years?

Dr Saghir: During the past decade, many weight management programmes have been proposed in the UAE to resolve the issue of obesity-related diabetes. But these programmes, as well as the medical treatment for obesity have proved ineffective; 95% will regain their excess weight after two years. During the past two years, two surgical procedures have been proposed to treat obesity, namely, gastric banding and gastric bypass. These procedures provide alternatives for obese patients and are often the only resort for very obese patients complicated with type 2 diabetes. Actually gastric banding can result in a loss of more than 50% of the patient’s excess weight, while the gastric bypass procedure can result in the loss of 66% of the excess weight.

Middle East Health: The World Health Organization refers to the global epidemic of overweight and obesity – “globesity”; where does the UAE stand globally with regards obesity?

Dr Saghir: Regarding obesity, the UAE is ranked 5th in the world, with an average adult weighing approximately 76 kg, about 14 kg heavier than the global average of 62 kg, according to a team of European researchers who recently published their research in BMC Public Health. The USA ranked number one as the heaviest nation with an average adult weight of 81.9 kg. Kuwait stands at No. 2 in the world with 77.5 kg, followed by Qatar at No. 3 (76.9 kg) and Bahrain at No. 8 (73.5 kg).

MEH: Can you provide some of the more recent approaches to weight loss and give the pros and cons?

Dr Saghir: Diet and eating plans are the first approach to lose weight, as it is affordable for all people, but as demonstrated in the review of Mann et al- 2007, there is no evidence to support significant weight loss through dieting. In fact, two thirds of people weighed more after the diet than they did at baseline. Physical activity is the second most common approach, and the four main types of physical activity are aerobic, musclestrengthening, bone strengthening, and stretching. It is also easy and affordable for most people, except for older people who may have health issues such as a heart problems or chronic diseases like diabetes, joint issues or high blood pressure. Approved weight-loss medicines might be an option for some people, and they might be suitable for adults who cannot lose weight by dieting and physical activity. But most of these medicines have major side-effects and may be harmful to the cardiovascular system. Weight-loss surgery might be an option for people who have extreme obesity when the above treatments have failed. Results are positive and the weight loss target is soon achieved, but the surgery can be risky, and lifelong medical follow-up is needed after surgery.

Date of upload: 16th May 2014

                                  
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