KOCHI:Obesity is a condition where there is an excess accumulation of fat in the body. Obesity is medically defined as a body mass index of above 30 kg/m2 with a waist circumference more than 40 inches in a male and 35 inches in females. Diabetes is a condition when a person has fasting glucose above 120, postprandial sugars above 200 or HBA1C above 6.5. But what if the two factors occur together in a person and make him/her a Diabesity patient.
Worldwide 415 million people are afflicted with diabetes and about 600 million with obesity. Together they are responsible for another malady that is fatty liver causing non-alcoholic steatohepatitis (NASH). About 12% cases may progress to cirrhosis. At my hospital, I was religiously documenting the BMI of my diabetic patients and I found that over 60% patients had a BMI of above 25 and at least 20% per cent patients had a BMI over 30.
The former qualifies as overweight and latter as obese. Therefore, when I choose a treatment I have to tackle both these issues. To begin with, I would opt for a simple metformin regimen and ask for a review after two months. If the sugars remain like fasting glucose above 130 and postprandial above 220 mg/dl, then I would opt to add an SGLT-2inhibitor gliflozins. Among these, some are particularly targeted for obese diabetic patients. For example, canaglilozin 300 mg may achieve up to 8 kilos weight loss in 8 months time along with a drastic reduction in sugar levels as these class of drugs excrete sugar via urine.
Other molecules empagliflozin and dapagliflozins work equally well. The second class of drugs recommended is injectables for obese diabetic patients. These include GLP-1 agonist injections like liraglutide. This molecule was originally approved for use in diabetic patients with dosage upto 1.8 mg. Recently, however, it was approved for use in non-diabetic obese patients in 3 mg dosage.
We also have once a week dulaglutide injection which has the same effects. Next major advance in GLP1 therapy is sumaglutide.GLP 1 injections reduce up to 7 kilos in 7 months and for those who desire more weight loss the 3mg dose is there.
However, sometimes weight loss is not enough. The fasting and postprandial sugars need to be controlled along with Hba1c. Here we have the latest insulins like degludac(36 hours acting) along with analogue insulins like aspart, lispro and glusine. Conventional basal insulin has come out with a more sophisticated concentrated glargine at 300 units per ml.
All these mean lesser jabs for insulin injections at lesser doses. For example, in certain patients I have been able to reduce insulin doses from 100 units daily to about 40 units of degludac-aspart along with a GLP 1 injection achieving optimal glucose control and weight loss. More exciting combinations like degludac-liraglutide in one injection pen are on the anvil.
Do we really have a potent weap on against diabetes and obesity?
We do. As we use the latest therapeutics in our fight against diabetes and obesity. But nothing can beat an individual leading a healthy lifestyle with a nutritious balanced diet. Forty minutes of exercise and fibre-protein diet must be our daily mantra. An average Indian must have a BMI below 25. Its not an unachievable dream, but a possible reality.
Dr Joseph K Joseph
Consultant, Internal medicine and preventive health VPS Lakeshore Hospital, Kochi
( The views expressed by the author are his own)