Category: General

One of the most devastating complications of diabetes is diabetic kidney disease. Around 40 % of people with type 2 diabetes can develop kidney disease. By stricter definitions of kidney disease, even up to 60-70 % of people with diabetes can have some impairment in kidney function. Many who develop kidney disease progress to kidney failure, dialysis and transplantation. Is it inevitable? Can we prevent it?

There are many things a person can do to prevent the development and progression of kidney disease.

• Excellent blood glucose control (HbA1c < 6.5 %)
• Good blood pressure management (BP< 130/80 mm Hg)
• Managing LDL to less than 70 mg/dl or 100 mg/dl according to risk
• Reduce weight
• Stop smoking
• Avoiding the use of medicines that can cause kidney damage
• ACE inhibitors/ARB: this includes medicines like Ramipril, Perindopril, Telmisartan, Olmesartan, etc., which can be used in people with diabetes to delay the progression of kidney disease.
• SGLT2 inhibitors include medicines like Empagliflozin, Dapagliflozin, and Canaglifliozin. These can delay the progression of kidney disease to kidney failure.
• GLP-1 receptor agonists like Semaglutide, Dulaglutide and Liraglutide can not only control blood glucose but also delay kidney and heart disease.
• Finerenone: a new drug which can be very effective in people with diabetes to control the worsening of kidney disease.

So, check with your doctor to understand if you are at risk of kidney disease. Understand the medicines and methods to prevent the disease from progressing.

Author
Dr. Mathew John MD, DM

Most patients need to take medicine to control their blood glucose levels. As the number of drugs increases, patients also become more confused about the timing of the medicine in relation to food. To avoid confusion, we will limit this discussion to oral medication. We will look at insulin and other injectables in the future.

Some medicines are given before food to maximally act when blood glucose is at its peak. Others, like Metformin, are given after food to minimise gastric problems. Oral semaglutide’s absorption and action are best only when consumed on an empty stomach.

Author
Dr. Tittu Oommen MD, DM

People with diabetes often ask us if they should consume fish oils or omega-3 supplements in addition to their regular diet. Fish oil is mainly obtained from specific parts, such as the liver of fatty fish like mackerel, salmon, tuna, and herring. It is a rich source of omega-3 fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Most commercial omega-3 supplements contain EPA and DHA.

Omega 3 has powerful antioxidant properties. Since many of the complications, including heart disease, stroke, kidney disease and retinopathy, involve oxygen-free radical-related damage, omega 3 was believed to reduce the risk of these complications. However, scientific studies involving a large number of people with diabetes have shown that Omega 3 does not improve glucose levels. Omega 3 reduces the level of triglycerides in the blood. However, there is no significant scientific evidence that it reduces the risk of heart disease or stroke. Eicosapent Ethyl (Vascepa, Biosia) is a prescription medication used to reduce the risk of heart disease in people with diabetes. However, this is not the same as commercial omega-3 supplements.

The American Heart Association recommends two servings (approximately 170 g) of fish, particularly fatty fish, per week to help reduce heart disease and stroke risk. This should be a part of a healthy diet. However, there is no recommendation for the regular use of omega-3 supplements. Omega 3 supplements may reduce triglyceride levels in those with a high risk of heart disease.

So, if you have diabetes
1. Take a healthy meal with at least two servings of fish weekly
2. Consider the use of prescription drugs containing Eicosapent ethyl if your physician recommends the same
3. There is no reason why everyone with diabetes should use an omega-3 supplement

Author
Ms Sreekutty S, MSc

Metformin is the most commonly used medicine for treating people with diabetes. You will unlikely find anyone with type 2 diabetes who has not used Metformin at least once. But is it harmful or banned anywhere in the world?

Metformin reduced average blood glucose by 40-50 mg/dl and HbA1c by around 1.5 -2 %, depending on when it is used. It does cause mild weight loss, especially in people who are overweight. Further, it does not produce low glucose ( hypoglycemia). Scientific studies on people with diabetes who are overweight have shown that metformin use is associated with a reduced risk of heart disease.

Metformin is one of the safest medicines and can be used even in children ( approved for ages > 10 years) and pregnancy. Metformin may cause mild gastric irritation and constipation. It may rarely cause altered taste. Long-term use of Metformin, especially in vegetarians, may lead to a deficiency in Vitamin B12. Since Metformin, like most medicines, is excreted by the kidneys, the doses should be discontinued with eGFR of less than 30 ml.

Metformin does not have any adverse effects on the kidneys or heart.
Metformin is currently studied for its effects on increasing lifespan and its impact as an anticancer medicine. So

1. Metformin is a safe drug
2. You can use Metformin if your doctor prescribes the same
3. It is not banned anywhere in the world

Author
Dr. Mathew John MD, DM

Most people will lose some weight if they follow a calorie deficit diet. Persistent calorie deficits produce 5-15 % weight loss at the end of 3-6 months, but most of the weight comes back soon. Studies have shown that at the end of 1 year, less than 50 % of people can keep their weight loss.

Weight loss can trigger many mechanisms by which people can put back weight. As people lose weight, the basal metabolic rate also reduces to a rate which is less than that predicted by their new weight. This means that people find it difficult to lose weight further with the same calorie deficits. This is called metabolic adaptation, and this limits further weight loss and promotes weight regain.  Furthermore, as a person loses weight, there is a change in appetite-regulating hormones like Ghrelin and Leptin which leads to increased appetite that limits further dietary caloric restriction. Further, there is a “weight set point” (postulated) for an individual. Once there is weight loss with diet, there is a tendency for the body to come back to its original weight.

Studies have shown that by using weight loss medicines like Semaglutide and Tirzepatide, more patients can keep their weight down and prevent weight gain than just following a diet restriction alone. It reduces the appetite and signals the brain to limit the food intake. So, once you lose weight with a diet, it is not easy to keep it down.

Just like diabetes and hypertension, obesity is also a disease. Obesity results in various other diseases that may eventually become fatal. Appropriate treatment of obesity can lead to reduced weight and improvement in complications like diabetes, hypertension, fatty liver disease and sleep apnea. Just like diabetes, where we use medicines in addition to lifestyle changes, people with obesity will also require medicines if weight is not manageable with diet and lifestyle changes.

People with obesity and multiple other diseases like sleep apnea, uncontrolled diabetes, fatty liver, and hypertension have a poor quality of life and reduced lifespan due to these diseases. Although diet is an integral part of weight management, and an initial weight loss is produced by diet, weight regain is a rule rather than exception. Scientific studies have shown that medicines are able to produce additional weight loss on top of medicines, sustain weight loss over long term and reduce risk of complications.

Currently we have medicines like Liraglutide (3 mg), Semaglutide (2.4 mg), Tirzepatide and Orlistat approved for weight loss. So, anyone with obesity and other associated disorders would benefit from using these anti-obesity drugs under medical supervision. On a similar note, people with higher degrees of weight gain and related diseases also will benefit from bariatric surgery. Bariatric surgery has been shown to prolong the lifespan and reduce the risk of diseases like diabetes, hypertension, sleep apnea, fatty liver, and heart disease.

So, anti-obesity medicines and bariatric surgery are not short cuts to weight loss, but an essential part of managing people with obesity.

When we see people who have put on excess weight, most people attribute it to a “ lack of willpower”. Is it so? Will just an effort to change diet or increase in exercise lead to sustained improvement?

Obesity is a complex medical condition influenced by various factors, including genetics, environment, and lifestyle. Various aspects of food consumption, appetite and satiety are linked to abnormalities in brain circuits and hormones. These include hormones like Ghrelin which stimulates hunger, and others like GLP-1, Cholecystokinin, Leptin and Amylin, which leads to satiety. People with obesity have energy expenditure different from that of people who are not obese.

So, despite our efforts to control the intake of high-calorie food and exercise, it is essential to address the various abnormal physiological changes that drive obesity. While making healthy choices is vital, it is not as simple as “trying harder” or having more willpower.

It is a common belief (wrong) that people with obesity have to bring down their weight to “ ideal: body weight to reap all the benefits of weight loss. It is disheartening to see that many people give up weight loss efforts if they are unable to achieve it.

Although more significant weight loss may result in more benefits to the body, even losing > 2.5 % of weight can improve blood glucose and triglycerides. More considerable reductions ( say >10 %) would lead to improvements in sleep apnea and fatty liver. Significant weight loss ( > 15 kg loss ) can lead to remission of diabetes in many people with shorter disease duration. People who have undergone bariatric surgery and lost significant weight have seen improvements in heart disease and risk of death.

Further, regular physical activity and calorie restriction will have benefits beyond weight loss. Regular exercise can improve mood, reduce the risk of falls and joint problems, reduce heart attacks, strokes and cancers and also improve sleep.

So, if you are a person with obesity and starting a weight loss program, congratulate yourself for every kilogram lost!

Obesity is a complex health issue in which weight gain has reached the point where it poses significant health risks. It is now a worldwide public health problem, affecting all ages and socio-economic groups. According to WHO estimates over 4 million people die each year as a result of being overweight or obese. Obesity is closely related to several other chronic diseases, including heart disease, hypertension, type 2 diabetes, sleep apnea, certain cancers, joint diseases, and more.

Professional organization like the American Medical Association and World Health Organization considers obesity as a disease. This makes obesity more than just a lifestyle disorder. It results from a combination of causes and individual factors such as behaviour and genetics. Behaviours can include physical inactivity, dietary patterns, medication use, and other exposures. Obesity occurs due to increased accumulation of fat which cannot always be attributed to eating too many calories or lacking physical activity. Individuals with obesity can have abnormalities in metabolic pathways, disordered signalling for hunger, satiety (the feeling of fullness), and fullness. So, obesity is not just the consumption of excess food, it is much more.

Considering obesity as a disease will help physicians and patients take it more seriously. Therefore, management of obesity requires a multifaceted approach targeting changes in lifestyle, nutrition, mental health, and environment. Just like we would approach a doctor to treat blood pressure or diabetes with lifestyle or medicines, obesity should also be treated by an endocrinologist with lifestyle changes, nutrition, and medicines.

Many people are not ready to act on their excess body weight, since they feel it is not a serious issue. Many consider it just a cosmetic issue with some disturbance in their psychological well-being because of their looks!

However, obesity is a serious medical condition that can lead to a variety of health problems. It can include metabolic problems like diabetes, hypertension, high cholesterol levels and high uric acid. People who are obese are at an increased risk of heart attacks, stroke, and heart failure. Obesity is a risk factor for various cancers like breast cancer, endometrial cancer, prostate, and colonic cancer. 4-8% of all cancers can be attributed to obesity.

 It can lead to fatty liver disease which could progress to cirrhosis and liver cancer. Obesity-associated MASLD ( Metabolic dysfunction-associated steatotic Liver  Disease ) is the leading cause of liver dysfunction and transplantation. Sleep apnoea and gastroesophageal reflux are also related to obesity. Certain mechanical problems like osteoarthritis of the knee and ankle and plantar fasciitis. In addition, obesity can be associated with depression, mood disorders and eating disorders.

It is very important to understand that higher weights are associated with more disabilities and diseases. So, obesity is much more than a mere cosmetic issue.