OBESITY & DIABETES IN FEMALES 30/06/2007
INTRODUCTION -
Prevalence of Type 2- Diabetes Mellitus in India is showing a Progressively upward trend . Genetic predisposition , inherent ethnicity , obesity , rapid urbanization, high intake of fast foods, and lack of exercise contribute to this rise in India .Out of all these factors, obesity is the major modifiable risk factor for development of Type 2-diabetes. According to ICMR {India Council of Medical Research } in most urban metros 40% to50% of men and Women are overweight. Again according to Diabetic care Asian Indian Study, among urban Type 2-diabetic patints,40% are obese. “All cause” mortality and morbidity increases among the obese diabetic patients.
How is obesity is related to Type 2 diabetes –
Obesity in particular, increased adiposity in the Visceral Compartment {i.e. around waistline } is negatively Correlated With insulin sensitivity. Tissue Sensitivity to insulin declines by about 30-40%, when a person becomes obese (30-40% Over ideal bodyweight.)
Mechanisms by which obesity leads to development of insulin resistance are as follows:-
1. Lipolysis of fat and release of release of free fatty acids from visceral fat is more pronounced than the subcutaneous fat. These free fatty acids interfere with action of cellular levels. lmpaired insulin stimulated glucose transport in skeletal muscle is responsible for insulin resistance.
2. Adipocytes synthesize and secrete biologically active molecules, which are known as adipocytokines. These include tumor necrosis factor –2 (TNF – alpha ), adiponectin, resistin, leptin. TNF-alpha is responsible for increased free fatty acid secretion and impairment of function of insulin at cellular level.
3. Visceral fats release a lot of free fatty acids. These free fatty acids can reach the liver
through portal circulation. In the liver it again interferes with action of insulin on the cells. This causes gluconeogenesis (a process of formation of glucose from
substances which are not carbohydrates, such as proteins or fats).
Diabesity –obesity induced diabetes –
Together, overweight and obesity account for about two-thirds (2/3) of cases of type 2 diabetes. The risk of diabetes begins to rise once the body mass index
{B.M.I =Weight (kg))
(Ht mtr) 2
is greater than 23kg/mtr 2 , and the relative risk is 40-90 fold higher in patients with BMI >40 Kg/mtr 2. Weight gain in adult life is also a significant risk factor. For every 1 kg increase in measured weight, the risk of diabetes is increased by 4.5%. Findings from available research indicate that overweight or obesity was the single most important predictor of diabetes. In addition, lack of exercise, poor diet, current smoking and abstinence from alcohol use were all associated with a significantly increased risk of diabetes in females.
Possible explanations for a greater prevalence of Obesity in females include the following:-
1} Overconsumption , that is eating behaviours that predipose females to consume too much food in relation to energy needs, possibly including physiologically determined disorders of appetite regulation.
2} Metabolic efficiency , for example –physiological factors that predispose females to store relatively more consumed energy at any given level of intake.
3} Low energy expenditure that is, possibly behavioural / sex differences in the ability to offset energy intake through routine or leisure time physical activity; and
4} Less success in voluntary weight control because of, either behavioural or physiological factors.
These explanation are complimentary and may combine to increase the predisposition of females to a positive energy balance.
WOMENT WITH BEARD – Hirsutism, infertility , oligomenorrhea (reduced menstrual flow) may appear in young women, usually in post – menarchal girls, secondary to excessive production of androgens (male hormone ) and estrogens (mostly the former) by multiple cystic follicles in the ovaries. Few decades ago when the etiopathogenesis was not clear the condition was coined as “women with beard “. This condition is now termed as polycystic ovary syndrome (PCOS) or disease (PCOD). PCOS is clinically defined as oligomenorrhea associated with hyperandrogenism. lt has been described poetically as “the thief of women hood “ because women with PCOS seek medical attention for infertility and hirsutism. Women with PCOS have a higher prevalence and a greater degree of hyperinsulinemia and insulin resistance. More than 40% of PCOS patients are obese.
The insulin resistance is disproportionate to the obesity, however. Obese women with PCOS have greater insulin resistance that weight matched control subject or lean PCOS
Patients. This is associated with differences in fat distribution. Even in females with a Non-obese B.MI; a higher waist to hip ratio
{ Waist (midway between lowest rib to highest point of hipbone)
Hip (Highest hip circumference) }
i.e. more that 0.85, is seen in those with PCOS compare to those without PCOS. This is
supported by the higher proportion of visceral adiposity measured by ultrasound in lean
PCOS patients compared to weight, matched control subjects.
Upto 27 % of per-menopausal women with type 2 diabetes also have PCOS.
This is interesting for two reasons.
lt emphasizes the potential severity of the insulin resistance in PCOS and
lt shows that insulin resistance itself does not lead to PCOS in majority of women with type 2 diabetes.
For those women with both PCOS and diabetes, specific therapies can address features of both disease, especially those exacerbated by insulin resistance. Reducing hyperinsulinemia and insulin resistance has been shown to improve the defining features of PCOS- increasing menstrual cyclicity and decreasing hyperndrogenism.
Management of obesity has a salutary effect on menstrual irregularity in obese girls and women. The safest therapy that has shown benefit both in diabetes and PCOS is weight loss. The observation that weight gain often preceded the development of hyperandrogenism and oligomenorrhea led to early approaches to treat PCOS by weight reduction. Researchers through many studies have show that even modest weight loss (10-20%) improves all symptoms of
PCOS in obese patients, acne , hirsutism and menstrual irregularities.
Menopause as a Risk Factor – No risk factor is as specific for women as hormonal status. Menopause, or the permanent cessation of menses resulting from the loss of ovarian function, coincides with an increase in several comorbidities including obesity, diabetes and heart disease. As defined by WHO (world Health Organisation),
Menopause is basically defined as the absence of menses for atleast 1 year. The perimenopause is the period immediately before menopause that is characterized by
Progressive alteration in endocrine and reproductive function.
Menopause evokes several endocrine changes that have a dramatic impact on post-menopausal health. Review of cross –section and longitudinal studies suggest that the menopause transition is associated with an increase in abdominal and visceral adipose tissue accumulation. It has been hypothesized that a portion of the adverse cardiovascular risk associated with metabolic derangement’s resulting in an increase in central obesity resistance.
DIABETES , OBESITY , HEART DISEASE ( CAD ) AND WOMAN –
Diabetes is the single, most powerful risk factor for heart disease (CAD-coronary Artery disease) in women. Women with diabetes have a fivefold increase in cardio
Vascular disease that in women without diabetes. Women with diabetes have been
Found to have twice the risk of M.I (Myocardial infarction –Heart attack) as non-diabetic women of the same age; the risk of M.I in diabetic women equals that of non-diabetic men of the same age. Diabetes cancels the females hormonal (estrogen and progesterone) advantage over males. The higher risk among diabetic women may be partially explained by the “clustering” of multiple factors in diabetic individuals, such as hypertension, smoking and obesity.
Obesity has been shown to be an independent risk for the development of CAD in women. 50% of the CAD occurring in obese women can be attributed to the
Excess weight alone, and even mild to moderate overweight increases the risk of coronary disease in middle aged women.
Obesity has been strongly associated in women with three major risk factors for CAD : Type 2 diabetes, hypercholesterolemia (or rather atherogenic dyslipidemia) and hypertension. Although obese premenopausal women tend to have
“gynecoid” or gluteo –femoral fat distribution (Pear shaped obesity), menopause has been found to promote the development of android or male pattern or Apple shaped obesity. Central obesity (Waist circumference more than 80cm for Indian females) is associated with both higher blood pressure and hyperinsulinemia, which is thought to result in increases in atherogenic lipoproteins, triglycerides and decreases in HDL (good cholesterol).
Evidence suggests that the distribution of body fat may be a more determining factor of cardiovascular risk than absolute weight.The distribution of adiposity as assessed by waist-to-hip ratio is significantly related to coronary atherosclerosis in both females and males and waist-to-hip ratio was significantly greater in females with CAD. Hence females with truncal (android) distribution are at higher risk than those with gynecoid or Peripheral distribution of body fat.
International Diabetes federation (IDF) and the International Association for the study of obesity (IASO) have collaborated to focus on obesity and diabetes. The campaign slogan (for 2004) was “ FIGHT OBESITY , PREVENT DIABETES “.
The purpose of treating diabesity is to lead a good quality of life for future ,” TO ADD LIFE TO YEARS , THAN YEARS TO LIFE “.
DR. KIRAN RUKADIKAR
M.B.B.S ; M.A.A.R.O ; C.W.M ( MUMBAI)
Bariatric physician &
Obesity consultant
Mobile—09371639929 ,
Email—doctor@fromfat2thin.com
Website- www.fromfat2thin.com
Saturday, June 30, 2007
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