Doctor's Heart Series Chapter 3 : Normal Weight Obesity(Skinny Fat) in South Asians
The importance of Metabolic effects in South Asians..
It was mid-September month; during the training internship, I was posted in the Intensive Care Unit at an urban County Hospital in India. It was a busy morning; the Hospital was very busy, the shift change, senior doctors, and sign-out regarding the patient. Patients were assigned admitted overnight. The people seeking care are primarily from the poor socioeconomic class. That morning Hospital was bustling, looking at the patients on stretchers on hallways, holding saline bags by families next to them. I was signed out on a patient about to be admitted that morning.
To give the backdrop, the County Hospital was an infirmary built around 1851 to serve then British units next to the Railway station, later became a county teaching Hospital after independence in 1947. The Hospital had the imprint of British leftover buildings, one will find in most cities throughout India. There were probably 20 beds, but another ten were waiting on stretchers in the hallways. Hardly any space between the patient rooms, only by small curtains, the broken beds, paint off walls, patients' families on the floor, the wailing sounds of the families who lost loved ones; it had the typical hospital smell of chlorine bleach. The resources are limited, and most of the medications and injections were given by junior doctors. Patients are wheeled in and wheeled out doing the tests or downgraded or upgraded to the floor.
Let's go back to the patient I was about to admit that morning, unable to obtain history due to altered mentation. He was brought in by a passerby from Central Railway Station. He was admitted to the ICU (intensive care unit) from the Emergency room due to unresponsiveness. He was a middle-aged gentleman, average height, and normal weight; most south Asians fit into this category. He was found to have a significant elevation of blood sugars and was in DKA (Diabetic ketoacidosis) and unresponsive. This is the most frequent complication of Insulin-dependent Diabetes Mellitus (people on Insulin). The body cannot produce enough insulin and excess sugar in the blood vessels. Due to lack of insulin production, excessive glucose starts converting into ketones in the Liver. The body needs energy as glucose cannot be utilized due to lack of Insulin; it has a mechanism to turn into ketones for fuel. This is the exact mechanism of the keto diet (when less carbohydrate is consumed, the body energy sources to ketones, mild versions doesn't change in physiology). However, when the entire conversion of glucose to ketones from the breakdown of free fatty acids and lipolysis( fat cells break down) due to lack of Insulin, dehydration and rapid breathing ensues due to severe acidosis(excessive ketones). Due to extreme dehydration, the treatment is to replenish fluids, electrolytes, and Insulin. High rate of mortality if not treated within 24-48 hrs.
We started treatment immediately; time is of the essence. The patient was critical; he received fluids, electrolytes, insulin as per protocol (needs closely monitoring with blood work); however, due to the critical illness on presentation and severity of the condition. We lost the patient. I was still naive and new to the medical world as a trainee; losing any patient is a gut-wrenching experience, especially for some treatable conditions. It was almost 20 years ago; I remember the whole thing like it happened yesterday.
One thing that popped out from the entire scenario was average Asian with a normal Body Mass Index(height to weight ratio), male fifty-something with severe uncontrolled diabetes on insulin. His body morphology was average Indian male with normal weight. As I had a heart attack myself (Normal BMI), I realized the nature of extensive disease carried by South Asians, something ubiquitous but very hidden. As I review more literature and studies, Metabolic diseases are rampant in South Asians and growing exponentially.
What is Metabolism?
Metabolism is the energy required to keep cells and tissue alive. The digestion of foods consumed releases various hormones especially Insulin to make sure the glucose is available for each cell in the body. The hormone Insulin released from the pancreas is the gatekeeper for glucose metabolism. Insulin works like a key to let glucose inside the cell; it also helps to store excess sugar as fat and produces many inflammatory changes. Other hormones, leptin and ghrelin, play a significant role in Obesity(too scientific).
“Studies show lean individuals with the metabolic disease had higher mortality than non-lean individuals.”
Normal Weight Obesity is excess fat around the visceral organs(abdominal fat) or also called skinny fat. Most South Asians are very lean yet carry chronic diseases like diabetes, heart disease and die younger. Some studies even suggested that as high as 30 % metabolic disease (carrying significant visceral adiposity). Individuals don’t have to be physically obese to have metabolic disease.
Mechanisms and understanding the disease process…
Persistent Insulin secretion due to excess eating(refined sugars/processed foods) → Overtime development of Insulin resistance(Insulin not recognized by cells for consumption of glucose) → Pancreas produce excess amount of Insulin to overcome resistance → Excess insulin helps in forming visceral fat → Increased Inflammatory markers → Lipogenesis(abnormal cholesterol) → Atherosclerosis(Plaque build-up)/Fatty Liver/ Diabetes…
The reasons still unknown why Asians have a disproportionate effect on the metabolic stress-causing worsening visceral fat(fat around organs and belly) accumulation. The data suggests the disease process does start early in life, carry to middle age, finally converts into Diabetes(elevated blood sugars), Atherosclerotic heart disease, and other co-morbidities; some include life-threatening heart attack. The definitive evidence of Intracellular lipids(cholesterol in cells) prohibiting glucose uptake and thus causing worsening insulin resistance is a possible hypothesis responsible for this inflammatory cascade. I have attached a picture below showing the plethora of changes before developing chronic diseases. Metabolic Syndrome (MetS) is characterized by elevated triglycerides, low HDL, increased waistline, elevated blood pressure, high fasting glucose, which is the hallmark of most south Asians.
“Studies show insulin resistance can promote accelerated atherosclerosis and cause heart disease in the young without a diagnosis of Diabetes.”
One of the biggest reasons in south Asians is excessive consumption of simple carbohydrates(rice, wheat, sweets, refined sugars, etc.) An adaptation of the wrong side of the western diet(fast food joints Etc, you know what I am implying). This puts undue pressure on the insulin-producing pancreas. Initially, the pancreas works excessively to meet the demand and keep the body normoglycemic (average blood sugar level). As pancreatic fatigue and failure set in, diabetes ensues.
The aims of this review are to define the diagnostic criteria for normal-weight metabolic disease syndrome and to examine the risks associated with this condition in order to promote preventive measures and early treatment for affected individuals.
Diagnosis :
Few of the diagnostic tests discussed are easy to obtain, and most get through yearly physical examinations. South Asians have a higher chance of metabolic disease irrespective of their size and shape.
Start with Waist to Hip Ratio
The test is easy to measure and, if abnormal, can be worked up towards diagnosing metabolic syndrome. People with waist to hip ratio more than 0.8 for women and 0.9 in men shown to have excessive abdominal fat(visceral adiposity).
How to Measure Your Waist to Hip Ratio
Measure at the smallest point. Wrap a tape measure around your waist at the smallest point, usually around your belly button. ...
Measure your hips. Next, wrap the tape measure around your hips at the widest part. ...
Divide. ...
Record your ratio.
Oral Glucose tolerance testing with insulin
A simple test can be measured at the lab called glucose tolerance test at 0hr, 1 hr, 2 hr, 3 hr (Normally done in pregnancy). The glucose challenge typically involves 75g of glucose ingestion and checking the body's response to the glucose uptake called impaired glucose tolerance. This test is a positive marker for metabolic disease and insulin resistance. There are multiple surrogate markers; however, this is the easiest to start.
“The one-hour post glucose challenge with blood sugar elevation >155 mg/ dl has shown the future risk of diabetes”.
Visceral Adiposity / Body Fat Analysis :
Most weight scales at home or the diagnostic centers can provide body fat percentage if the Body fat percentage is> 25% in men and 35 % in women, chance of increased visceral adiposity (There are different scales able to gauge the amount of fat in individuals). DEXA scan is the best test to check and measure for Visceral fat percentage(Body fat).
Lipid profile(more information in future sessions):
Looking at the Lipid profile (cholesterol test), the importance of Non-HDL Cholesterol should be emphasized; the studies suggest having stricter control of Non-HDL Cholesterol, a disease affinity marker (<130). The higher number represents the worsening of plaque-building Cholesterol.
Solutions:
Being mindful about the health and importance of insulin in metabolic activity. The key is to avoid refined and processed foods and stick to low glycemic index foods (foods low in simple sugars). Nutrition is another subject very dear to me (I will do detailed episodes in the future). Muscles absorb more than 60% of glucose. Physical activity and toning up the muscles, especially big groups of muscles, have shown tremendous improvement in metabolic health. I am still here and writing up this blog because possibly my physical activity(running) helped sustain the life-threatening injury and complete recovery. Plenty of restful sleep and stress management, as discussed.
Conclusion :
The widespread heart disease in the south Asian population and normal weight Metabolic Obesity(fat) raises some important questions. Insulin resistance and lipogenesis (abnormal cholesterol) are cornerstones in the development of atherosclerosis(plaque build-up). Therefore, metabolic health is paramount in preventing chronic disease and maintaining healthy wellbeing. My continuous goal in this journey is to make aware of simple diagnostic tools to better control health and take a path towards disease free-living and longevity.
Suman Manchireddy MD FACP FHM, Internal Medicine, Leesburg, VA.
Email : Care@ReliantMD.com
Disclaimer: This is purely informational and educational purposes only, seek medical advise prior to starting any testing or treatment regimen. The data presented here is researched extensively and has been condensed for a broader audience.