Dr Russell Drummond, in conversation with Shalini Sharma, explains modern approaches to managing weight and blood glucose levels.
Diagnosing obesity
Obesity can be determined a number of ways, ranging from very high- tech machines that can precisely quantify the amount of fat and lean tissue in the body to the simple weight scale that you find at home. The two most common ways of detecting obesity in your doctor’s office is by obtaining a height and weight to calculate body mass index (BMI) and using a tape measurer to determine waist circumference.
Thresholds for meeting criteria for obesity based on BMI and waist circumference vary. This is because obesity is defined as the amount and/or distribution of excess weight one carries that directly contributes to chronic diseases such as Type 2 diabetes, obstructive sleep apnea, and cardiovascular disease. For example, if you are a
woman in the United States or of European heritage, obesity is defined as a BMI greater
= 30 kg/m² or a waist circumference > 88 cm (a similar threshold for a man this would be a waist circumference > 102 cm).
On the other hand, peoples from South and Southeast Asia manifest type 2 diabetes and cardiovascular risk at lower body weights than European populations. The World Health Organization has attempted to identify appropriate parameters of obesity in Asian populations, citing data that risk for chronic diseases increases past a BMI threshold of 25 kg/m². Probably more important for South Asians is the waist circumference, indicative of central obesity. Current consensus holds that central obesity is present in an Asian woman with a waist circumference greater than 80 cm (or 90 cm in an Asian man).
Risks associated with obesity
Metabolic risks associated with obesity have traditionally been high levels of cholesterol and triglyceride, blood pressure, and blood sugars (leading to prediabetes and type 2 diabetes). More recently, disrupted sleep cycle (changing work shifts, limited sleeping time) and obstructive sleep apnea have also become identified as contributing to worsened weight gain, diabetes control, and increased rates of cardiovascular events.
In addition to the comorbid conditions mentioned above, obesity is commonly associated with esophageal reflux, degenerative arthritis of weight bearing joints, infertility, and recent studies have confirmed its importance in increased cancer risk. This is primarily for cancers in women, such as breast and endometrial cancers.
Psychosocially, people who were obese are more likely to be depressed, to earn less in the market place, to experience discrimination, and are less likely to be married.
Obesity may also have an adverse impact on other diseases such as multiple sclerosis and worsens outcomes in patients who are undergoing transplants.
Understanding the weight of the matter
Obesity remains one of the most significant modifiable risk factors for chronic diseases such as Type 2 Diabetes, hypertension, and cardiovascular disease. Every unit increase in body mass index (BMI) above 25 correlates with a higher risk of developing these conditions.
In pregnancy, excess weight poses additional challenges – it can reduce fertility and increase the risk of gestational Diabetes, hypertensive disorders, and complications requiring operative delivery, such as cesarean section.
The good news is that weight loss, achieved through various dietary interventions, can lead to marked improvements. In fact, in people with established type 2 Diabetes or hypertension, losing weight can lead to remission by reducing the fat content in organs like the liver and pancreas, thereby restoring their normal function.
The EndoBarrier device
The EndoBarrier is an innovative, minimally invasive device that offers many of the benefits of bariatric surgery without the need for invasive procedures. This 60- centimeter, semi-permeable liner is endoscopically placed at the pylorus and extends into the small intestine. It mimics the effects of a gastric bypass by preventing food from contacting the upper part of the small intestine, thereby reducing calorie absorption.
Key Benefits:
- Non-surgical placement via endoscopy (no general anesthesia required)
- Temporary device (typically removed after 9 to 12 months)
- 10 to 20 per cent total body weight loss achievable
- Improved glycemic control in patients with type 2 Diabetes
- Potential Diabetes remission and reduction in blood pressure
The EndoBarrier is particularly helpful for patients who are not eligible for or prefer to avoid traditional bariatric surgery. It represents a promising step forward in managing obesity-driven metabolic disease.
What is hypoglycaemia?
Hypoglycaemia (low blood glucose level) is defined as blood sugar level of <70mg/dL or lower. Our brain can use only glucose as a fuel unlike other tissues which can use fatty acids as an alternative source of fuel. So, when acute hypoglycaemia occurs, after the initial warning symptoms which indicate the urgent demand for sugar, the brain just shuts down leading to unconsciousness and coma or even death.
Hypoglycaemia is relatively more common in people with Type 1 Diabetes or those taking medications like sulfonylureas, insulin and in the elderly. It occurs frequently in people with erratic food habits, variable physical activity patterns, and in those who consume alcohol. It
is important to understand the causes, symptoms and treatment of hypoglycaemia not only for people with Diabetes but also for their care givers and family members.
Recurrent hypoglycaemia could occur in people with underlying medical conditions like kidney or liver impairment, gastrointestinal diseases like mal-absorption or gastro paresis (slowing of intestinal motility).
Hypoglycaemia without Diabetes
Although often associated with Diabetes treatment, hypoglycaemia can occur in non-diabetic individuals as well. Causes include:
- Medications (e.g., quinine, pentamidine)
- Critical illnesses like sepsis, liver, or kidney failure
- Rare endocrine disorders, such as insulinoma
Insulinoma
Insulinomas are rare tumors of the pancreas that lead to inappropriate, excessive insulin production. They occur in approximately 0.7 – 4 people per million each year and can be difficult to diagnose.
Diagnosis involves:
- Laboratory glucose tests (not finger- prick or sensor readings)
- Measurement of insulin and C-peptide during a fasting state (typically 15 hours)
- Advanced imaging techniques for tumor localization
Treatment options:
Surgical removal of the tumor (laparoscopic, robotic, or open procedures) Medical therapies such as:
- Diazoxide (reduces insulin secretion)
- Octreotide or Lanreotide (somatostatin analogues)
- Everolimus (for more aggressive or inoperable cases)
Reactive and nocturnal hypoglycaemia
Reactive hypoglycaemia often occurs two to four hours after eating and is more common in people with insulin resistance or those who’ve had bariatric surgery.
Symptoms include sweating, dizziness, hunger and paleness
Nocturnal hypoglycaemia (low blood glucose during sleep) is a common concern in individuals with Type 1 Diabetes.
Prevention strategies include:
- Using continuous glucose monitoring (e.g., Freestyle Libre) to track nighttime glucose trends
- Choosing ultra-long-acting insulins like Tresiba (degludec), which have a more stable profile than glargine (Lantus)
- Adjusting insulin doses appropriately, generally between 0.5 – 1 unit/kg body weight per day, with half as basal insulin
Hypoglycaemia without diabetes can be dangerous. Persistent low blood glucose in non-diabetic individuals can impair brain function and increase the risk of cardiac arrhythmias. Depending on the cause, it can impact daily functioning and even become life-threatening.
To the readers of Diabetes Health, I’d like to emphasise two core messages:
- Prevention is better than cure. Maintaining a healthy lifestyle through balanced diet, regular exercise, and mindful habits is the foundation for long-term metabolic health.
- Type 2 Diabetes is not a life sentence. Thanks to studies like DIRECT, we now know that type 2 Diabetes can go into remission with intensive dietary changes. Patients on an 800-calorie diet for eight weeks experienced significant weight loss and restored metabolic function proving that remission is possible.
The landscape of Diabetes care is rapidly evolving. Tools like the EndoBarrier, combined with modern diagnostics and treatment strategies for hypoglycaemia, give patients more control over their health than ever before. Through education, innovation, and proactive care, we can shift the focus from managing disease to restoring wellness.
