Diabetes sucker paunch and its knockout effect

Struggling to make ends meet around your waist? It is time to adopt a dietary budget, start counting those calories on your dinner plate and also get those running sneakers out of the shoe-storage box.

In simple words: don’t just leave your trousers (or skirts) to do the heaving and stretching, and start sweating it out yourself. Excess abdominal fat has now been confirmed to be directly associated with type 2 diabetes risk in both young and middle-aged individuals.

The problem with excess abdominal fat is that the outer layer of flab that we can see and feel is literally just like the tip of the iceberg. The bulk of this excess fat gets deposited and stored deep inside the abdominal cavity, especially on organs like liver and pancreas. These fat deposits end up disrupting our entire metabolic cycle, making us susceptible to a battery of metabolic, endocrinal and cardiovascular disorders, including diabetes. As a result, experts point to a bulging paunch as one of the sure-shot external signs of consistent spike in blood glucose levels and a serious warning for the onset of full-blown type 2 diabetes.

Waist side story

Until three years ago, Bibin JE, a 38-year-old quality health safety and environment project co-ordinator with a private oil and gas firm in the United Arab Emirates, weighed 136kg and was suffering from a horde of adverse lifestyle health conditions, including high blood sugar levels. He was following an unhealthy diet pattern and finding it difficult to control his expanding 40-inch waistline and reduce his body weight.

“I used to be extremely erratic with my diet,” Bibin told Happiest Health. “I had to go on frequent site visits, often in the deep desert. Once I returned to the base camp or home, I used to hog on anything and everything that was within my reach, and then crash for the day.”

Some of the early signs of trouble that he sensed, apart from his bulging tummy, were frequent urination, bouts of fatigue and black patches on the skin at the back of his neck. Such patches — mainly found on skinfolds in the neck and armpit region – are a common health marker for insulin resistance that could lead to diabetes. Medically it is called acanthosis nigricans. Because of insulin resistance, the insulin produced in the body is unable to effectively break down glucose in the bloodstream, leading to type 2 diabetes.

Bibin’s worst fears were confirmed when a routine medical examination revealed high blood glucose levels and an early fatty liver condition.

“My blood glucose levels on that particular day were just above 130 mg/dl, which technically is prediabetes, but my Hba1c test result was close to 7 per cent, indicating that I might need medication,” Bibin said. “The fatty liver diagnosis came as a double whammy.”

His doctor left him with two options: lifetime medication or reining in his lifestyle at the earliest. Bibin chose the latter and started following a strict diet and workout regime. After adopting a sustained diet pattern and workout regime since 2019, Bibin now (as of June 2022) weighs 99kg and has reduced his waistline to about 36 inches. He says his sugar levels have been normal for some time and his fatty liver condition has also improved considerably.

“I make it a point to exercise regularly, and have stopped eating processed food,” Bibin said. “I opt for more vegetarian and lean meat (chicken and fish) these days, and prefer to eat during the day. For dinner, I usually have a green apple. If occasionally I get a craving for biriyani, I ensure that’s my only heavy meal of the day and also work out more to burn off the extra calories.”

Paunch-tantra of diabetes

Fat gets stored under the skin as subcutaneous fat, which is comparatively less harmful. Excess fat also gets stored near our organs in the abdominal region as visceral fat and impacts our cardiovascular and metabolic health, leading to conditions like obesity and diabetes.

Dr V Mohan, chief diabetologist at Dr Mohan’s Diabetes Specialities Centre and president, Madras Diabetes Foundation, told Happiest Health in an online interaction that excess visceral fat or intra-abdominal fat is directly associated with chronic inflammation and is one of the main triggers for type 2 diabetes.

“It is well known that obesity – particularly central obesity, that is fat in the abdominal area – is associated with diabetes,” Dr Mohan said. “When you have excessive fat around the abdomen, most of it would be visceral fat (which is fat inside the abdomen), while some of this would be subcutaneous fat (which is outside the abdomen, below the skin).”

Dr Mohan said visceral obesity is extremely detrimental to overall health since it not only considerably increases the risk of type 2 diabetes but also triggers hypertension and heart disease.

In an online interaction with Happiest Health, Dr Alka Kanaya, professor of medicine and principal investigator of the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort study group, University of California San Francisco, said that a larger waist girth was an indicator of excess fat around the abdominal visceral organs, intestines and in the liver, as well as fat under the skin, which could lead to diabetes.

“Fat that is deposited in the liver and around the visceral organs has more adverse effects on the metabolism of glucose and lipids,” Dr Kanaya said. “In the MASALA study, we have shown how having more fat in the liver and around the visceral organs is strongly associated with worsening glucose tolerance and type 2 diabetes development over time.”

Tummy trouble: Visceral fat and insolent insulin

Visceral fat that gets stored in the pancreas, liver and intestines is often referred to as ectopic fat and could disrupt the normal metabolic cycle. It is also responsible for triggering and aggravating an array of internal conditions ranging from blood pressure to diabetes and even liver cirrhosis.

According to Dr Mohan, excess ectopic fat in the abdomen meant excess fat in liver, which would eventually trigger an inflammatory condition called steatohepatitis in the liver. The inflammation would lead to insulin resistance, making the already available insulin secreted in the body unable to properly break down the glucose content in the blood. He said since there is excess fat deposition in the liver and abdominal cavity, the pancreas also won’t be able to escape from excess fat accumulation on it, which will hamper insulin secretion itself.

“When this occurs, the secretion of insulin also gets reduced,” Dr Mohan said. “With both these defects – that is, decreased insulin secretion and insulin resistance — the stage is set for the development of diabetes by elevation of blood glucose levels.”

Get your fats right, curb your carb enthusiasm

Ironically, most people believe that they gain body weight by eating food rich in fat content. But it has been proven that weight gain and excess fat is a direct result of consumption of calorie-rich — especially carbohydrate-rich — food. It is the excess calories ingested through food that eventually get converted into fat and stored as either subcutaneous or visceral fat inside the body.

“Effects of type 2 diabetes are lifestyle induced, and maintaining a consistency in our diet is the key to keep them under control,” Simi Thomas, dietician at NutriDietz, Kochi, Kerala, told Happiest Health. “Diet patterns would differ for each person, and it should be a balanced one, on the basis of dietary requirements, availability and also a bit of personal preferences to ensure that it is consistent and sustainable for the person to follow.” A practising dietician for more than 15 years, she said a carbohydrate-rich diet pattern combined with lack of physical activity was the main reason behind the present boom in diabetes and obesity.

When it comes to diabetes and obesity, the main dietary concern has always been carbohydrates, especially processed food items laced with simple carbohydrates instead of whole or complex carbohydrates that are rich in fibre content.

“Yes, carbohydrate intake has to be controlled for both diabetes control and weight loss,” Thomas said. “I always insist that these conditions could be properly addressed by ensuring that we take proper portions of food according to individual requirements.” She said that fiber-rich carbohydrates could be included in the diet in moderation for basic energy requirements along with food containing adequate proteins and fat.

According to the American Diabetes Association (ADA), it is carbohydrate intake that primarily impacts our blood glucose levels. Plus, the association says, a balanced diet of protein, fat and carbohydrates is essential to combat diabetes.

The carbohydrates and sugar content in our diet gets broken down into glucose, and this serves as the main source of energy for our body for various activities. Carbohydrates and sugar-rich food are high in calorie content (unit of energy generated from food after digestion). If total calorie intake is more than the energy requirement, the excess glucose gets stored in the liver and also gets converted and stored as fat in adipose tissues for later use.

Insulin also has a major role to play in this process as it is basically glucose metabolism happening here.

If the body is forced to store excess fat internally due to high calorie diet and there is no physical activity on a regular basis, the excess unused fat starts getting deposited on the liver and pancreas, leading to serious health issues including fatty liver, diabetes and obesity. The bulging waistline is also an indicator of this excess fat deposition inside the abdominal cavity.

Android apple or gynoid pear?

The fat distribution pattern in our body is generally divided into two categories, android and gynoid fat distribution, depending on where the excess fat ends up getting stored inside the body.

Apart from dietary choices, an array of genetic, metabolic and cardiovascular conditions also plays a major role in excess fat storage in the body. The people in whom the excess fat gets deposited around the abdominal region and upper body are classified under android fat distribution or central obesity category. According to a research article published in the Frontiers of Physiology journal in September 2019, people with android fat distribution are generally considered to be at a higher risk of getting diagnosed with cardiovascular and metabolic conditions, including diabetes.

“Abdominal fat is definitely an indicator — especially among middle-aged people — of the risk of developing diabetes,” Dr Satish Chander Wasoori, endocrinologist, Paras Hospital, Gurugram told Happiest Health. “Diabetes is a metabolic disease and that’s why it could be made to go in remission through dietary and lifestyle management.” He said that Indians generally tend to develop type 2 diabetes early on in life (by the age of 40) — unlike Caucasians or any other ethnic group — because of this excess abdominal fat.

Android fat distribution is also considered to be more common among males than in females, especially among South Asians. Ironically, people with android pattern of fat storage are often referred to as apple-shaped because of external appearance due to excess fat from waist upwards, especially near their abdomen and under the chest.

“Most of the times when we conduct ultrasound scans on people with excess abdominal fat, we find conditions like grade one fatty liver and also fat deposits on pancreas,” Dr Wasoori said. This further leads to insulin resistance and diabetes.

Gynoid fat distribution, on the other hand, is when excess fat storage occurs on the hips, thighs, buttocks and lower portion of the body. People with gynoid pattern of fat storage are considered pear-shaped and are at lesser risk from obesity-triggered cardiovascular and metabolic disorders against those with android fat distribution, since fat deposition is not concentrated in the abdominal region.

Link between abdominal fat and diabetes

The May 2019 edition of ADA’s Diabetes Care carried an article dissecting the link between body composition, especially abdominal fat, and diabetes risk among South Asians. The study was conducted by analyzing and comparing data of 2,615 participants included on the basis of MASALA and Multi Ethnic Study of Atherosclerosis (MESA) cohort study group data involving participants from white, African American, Chinese American, Hispanic and South Asian ethnic groups. It was pointed out that apart from genetic conditions, body composition (mainly excess fat storage) was responsible for making South Asians highly susceptible for diabetes and cardiovascular complications compared with the rest and required healthy lifestyle alterations.

“Yes, the key is lifestyle changes to prevent both excess fat deposition and diabetes, and this starts in childhood and adolescence,” Dr Kanaya said. “We know that South Asians have more rapid progression to diabetes, often ten years in advance of other groups.”

Dr Kanaya said this was a strong validation that evolutionary and genetic reasons are also responsible for South Asians being more prone to developing type 2 diabetes. “Diabetes is the leading risk factor for cardiovascular diseases among South Asians,” she said. “So, controlling diabetes will be highly effective in controlling cardiovascular diseases also.”