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Very simple problem which leads to very complex situations

Diabetes is a hot topic in today’s healthcare industry. With urbanization and industrialization, man’s traditional lifestyle has flipped in ways with which his constitution is unable to cope.

Dr Kashif Rizvi of New Mowasat Hospital, in this interview to the Arab Times, talks in detail about the syndrome and offers valuable insights into the causes and complications of the disease. He also disabuses some misconceptions about the disease: it is not so much obesity as it is inactivity that is the actual villain.

Question: Could you start with the basics? What are the types of diabetes and what causes it?
Answer: Diabetes mainly is of two types. Type 1 and Type 2. Type 1 is a relatively constant disease in terms of its incidence, because it is caused by what we call autoimmunity, the body’s defense system attacks its own tissues in the pancreas, and the body is unable to produce insulin. So you have to be treated with insulin.

The epidemiology or the incidence or prevalence of this Type 1 Diabetes is constant, because it is an easily diagnosable and identifiable condition. And it’s managed by insulin. The problem now that countries like Kuwait and virtually the whole world is facing is with Type 2 Diabetes. Type 2 Diabetes is a very simple problem but it leads to very complex situations.
The problem arises from the modern, industrial world. So, it’s a relatively new disease. It has always existed but in small numbers. But for the last 50 to 60 years, there has been almost an epidemic, great rise in the incidence of Type 2 Diabetes.

It is mainly driven by factors of urbanization, as populations moved into big cities in pursuit of their sustenance from an economic perspective. This urbanization coupled with industrial revolution and affluence, where people get more resources, led to an environment which we refer to as obesogenic, or an environment which is conducive to becoming overweight. This obesogenic environment is a result of bombardment of information which creates this fast food environment. You drive around and you see the logos of various fast food joints, you can drive through. They create a sense of convenience and also create a sense of family around them by installing climbing frames, slides or monkey houses adjacent to these outlets of food. As a result they become synonymous with a day out, fun evening or something like that.

In addition to that there is also general availability of food which is very easy to access, and there is an emphasis on starch-based foods like bread and Rice. In addition in Kuwait we have a culture which revolves around food, because food is not eaten just for nutritional purposes, but it is also eaten for entertainment, socializing and eaten at times to combat boredom. It is eaten for celebration. So there is many aspects of consumption of food. So you have this obseogenic environment where you have this easy availability of energy and decrease of energy consumption. For example, you don’t have any pavement, public pathways or parks or places where people can go and exercise. It is not easy to walk because the traffic is such. It’s a car-based society. The nature of the weather another factor that contributes to a sedentary lifestyle.

So once you have someone with the right genetic makeup, moving to an environment of obesogenic situation, then the stage is set for the creation of Type 2 Diabetes. There is more energy in your body than you can burn. Now, this affects all ages. There are studies that show that the number of hours spent in front of the TV is directly proportional to childhood obesity. So, we have faced it across the board in school age, youngsters, adolescents and older age groups, and all aspects of the society, whether it is Kuwaitis, expatriates or any faction.

Q: Is there any particular ethnic group that is known to be more prone to the disease? If yes, why is it so?
A: It affects the Indian or the South Indian people more, because they are genetically more programmed to store energy. We call this the Thrifty Gene Hypothesis. Their genes are probably designed to store energy, because they are hard working people by nature as peasants and people working in the fields. So through centuries and generations they are programmed to conserve energy. So, when they move to an environment like Kuwait and that doesn’t apply anymore because there is an abundance of food.

So little change in the environmental factors coupled with genetic factors and excess storage of energy causes a central obesity. This is a very key message: you don’t have to be overweight, but when your waist circumference increases so that you have to buy a pair of bigger trousers then the risk begins. So gradually, insidiously it creeps up on you. Your waist circumference increases because of the collection of fat inside your abdomen which is blocking the paths of action of insulin. This creates insulin resistance.

This insulin resistance then leads to a lot of insulin in the body. This in turn leads to the disequilibrium of the cholesterol profile when the bad cholesterol tends to rise and the good cholesterol tends to decline.

This then creates plaque or lumps in the arteries and that makes them stiffer, which with retention of salt, contributes to high blood pressure. So all these factors I alluded to trigger a cycle of symptoms. High energy storage, less physical activity, increase of fat deposition in the abdomen, rise in cholesterol, blood pressure and gradually it also leads to increase in blood glucose level.

However, because the sugar in blood is not rising as high as in Type 1 Diabetes, where there is no insulin, there are usually no symptoms produced. Because of the paucity of symptoms, because there is no symptoms from high blood pressure, no symptoms from cholesterol, no symptoms from sugar, which has just risen above normal. So the patient believes that he is still completely normal.
In the UK we refer to them as the missing million. There are one million people with diabetes, and there is another one million who have it but don’t know about it. The same thing applies in Kuwait. There are a lot of people who have it but don’t know about it, and hence the need for regular checks and increased awareness. Take an increase in waist circumference or a feeling lethargy as symptoms.

Sometimes there are symptoms like increase in thirst, excessive urination, especially at night, and sometimes you could also lose a little bit of weight. But these are not present in everybody.
So this whole syndrome of Type 2 Diabetes is a collection of problems of inactivity, obesogenci environment, abundance of food, consumption of energy dense foods, and quartet of problems of increased waist, high blood pressure, increased cholesterol and increased sugar. Unfortunately a 5th very dangerous component is added by many in the shape of smoking. It then sets about damaging the body’s organs.

Q: Which organs of the body are most vulnerable to the diabetes?
A: Diabetes causes two types of damages: one is the small blood vessels, which are found in the eyes, kidneys and in the feet, and it all happens quietly so you don’t know until the damage is done. The other is the big blood vessels which are supplying the heart and the brain. You become vulnerable to heart attacks and stroke. So, it starts as a simple situation and poses a severe threat to your health causing morbidity or mortality. It can disable you or kill you as well. That’s why it’s very important to raise public awareness and tackle the root causes of this issue. So you have to engage with the people, give regular education, create public transport systems and create facilities for people to exercise. The problem is caused by lack of movement.

Secondly, the emphasis should move from consumption of energy dense foods, which means that there is a lot of energy in a small amount of food, a burger for example, to a salad in which the energy is distributed evenly and has a low glycemic index. So, change in the habits of an individual which are permanent must be started. Stop consuming fast foods or energy dense foods, and make yourself active. In America there was this Diabetes Prevention Project, which found from studies that if you moved for 30 minutes for five days a week, you will have the same effect on diabetes that most tablets would do. So movement coupled with this lifestyle alteration of your dietary pattern, plus the recognition of the silence of the syndrome. You should know that this disease comes without symptoms and hence you have to go to a clinic regularly and get yourself checked.

By adhering to such simple changes in life, you can lead and healthy life. To summarize, Type 1 Diabetes is a distinct entity, accounting for around 10 percent of diabetics. The vast number of diabetics falls under the Type 2 category, which is a product of the urbanization and industrialization, which has led to easy availability of low cost, energy dense fast food, and also decreased consumption of energy due to automation of life and non availability of any public places to exercise. This then creates Type 2 Diabetes which is combination usually of blood pressure, raised cholesterol, increased waist circumference and raised sugar. In addition smoking is at times a dangerous add on. They are in most cases clinically silent. So they don’t show any symptoms but pose a threat to your eyes, kidneys and feet and which you are at great risk if getting heart attack and stroke, especially if you are a smoker. Smoking confers an extra burden and in fact triggers heart attack in most cases.

So our approach is to create more centers in which you have a multi disciplinary team approach to look at all these problems and then in a structured manner, see alteration of lifestyle, moving away from energy dense foods to low glycemic foods with more of vegetables and protein based foods. Walking and movement for 30 minutes a day is also important, in addition to regular surveillance and if required medical intervention.

Q: What have you been doing to fight the disease in Kuwait?
A: We created the first diabetes management center ‘in the private sector here in Kuwait, which is based on the multi-disciplinary approach, a team approach, a holistic management of all issues related to diabetes, which is a very complex disease in itself.

We are successfully completing now the second year, where we provide evidence based internationally recognized protocols for the management of diabetes and all its complications.
We also hold regular contact with Dasman Diabetes Institute. We in fact cooperated quite robustly in the International Diabetes Day celebrations, and created public awareness campaigns. So, we try to fulfill the community obligations, where we try to raise awareness within the Kuwaiti citizens and expatriates alike. We believe that this condition affects the whole strata of the society. All economic backgrounds, and all people.

I am also member of the Diabetes UK, American diabetes association, association of British clinical diabetologists (ABCD) and Endocrine Society in the UK.

Q: Doctor you said about how increase in waist circumference is an indication of risk. But all of us tend to put on weight around our waist as we age. So, is there an ideal waist size for every age group?
A: That’s a very valid question. Yes, international bodies have various criteria. Firstly, it has to be measured in a proper manner, between the umbilicus and the hip, because people tend to believe they are still the same and tend to move the tape a little up or down. Then, as I said, various bodies have various criteria to decide the safe circumference. There are many criteria including the ethnic background. But generally speaking, if your waist as a man is over 40 inches, and as a woman is over 34 inches, then you would like to get assessed. It is an indication, not that they have a problem. Because it depends on the genetic makeup and ethnicity profile and so on. There are diagnostic criteria which strictly look at the waist circumference based on ethnicity. It’s different for the Japanese people, for the Caucasian people and so forth. But if your waist as a man is above 40 inches, and as a woman is above 34 inches, then it’s best to get checked. Waist circumference is a very important indication of what’s going on inside the body.

The key point is that in Kuwait Type 2 Diabetes is amongst the highest in the world. But it is a bit skewed because we don’t have a robust data collection mechanism, although the Dasman Institute is now collecting across the board. So we can’t have a fair assessment of the percentage. Going by the clinical criteria of waist circumference and other observable indications, we can say that it’s going up. It is amongst the highest in the world in all age groups.

In Kuwait, we can believe a waist circumference in men of more than 40 inches and women 34 inches could trigger the need to be assessed for this syndrome. Therefore, you can look at three criteria to detect risk. Body Mass Index, which is called BMI, is more than 30, and waist in a man is more than 40 and woman is more than 34.

Q: How do you measure BMI?
A: BMI is the calculation of weight in kilos divided by height in meters squared.

Q: What are the chances of a person showing all these risk characteristics, waist over 40, a BMI above 30 and so on, being normal?
A: The chances hugely depend on two things. One is the genetic background. If you don’t have a family history of Type 2 Diabetes you have an advantage. But you have to remember that somebody has to start the family history. Secondly, if you are inactive, then your chances of risk are higher.

Inactivity is mostly coupled with obesity. But it need not be the other way round. An obese person can be very active. But their risk will go up the moment they become inactive. And there will be a threshold when even active, obese people will get the syndrome. So, it’s basically inactivity coupled with the obesogenic environment which I have alluded to.

Reference: Arab Times