CASTING ENVIOUS eyes at the Rolls-Royces, Bentleys and Mercedes outside the casino and the Hôtel de Paris, the doctors who were meeting in Monte Carlo last week walked briskly past the bars and gaming tables and on to the Grimaldi Conference Centre, where they spent two days discussing insulin-resistance syndrome — also known as the metabolic syndrome.
If Adam and Eve had not disobeyed God and earned His displeasure, the conference would have been unnecessary. Just as thorns and thistles ruined the pre-Eden time when Earth was “pleasant to the sight and good for food”, so today millions of people are destroying their chance of a long and healthy life by eating too much enticing, forbidden food and by being too slothful.
Adam and Eve are not forgotten in Monte Carlo. The sculptor Botero — influenced perhaps by Maillol’s love of well covered women — created in 1981 an overweight, stumpy couple with a tiny apple at their feet. Very different from the figures of Monte Carlo’s famously svelte sunbathers, some of whom are already topping up their tans.
The problems of obesity are not confined to patients who also display insulin resistance and the other risk factors found in insulin-resistance syndrome. Insulin resistance is the condition in which ever higher concentrations of insulin are needed to achieve the same biological effect. The tissues of organs become progressively more insensitive to the action of insulin so that more insulin is required to achieve normal blood glucose levels.
The doctors were debating the best treatments and diets available for all forms of obesity. In fact the obesity depicted by Botero is of the type in which the patient has an over-thick layer of subcutaneous fat evenly distributed all over the body — like a Michelin man. This form of obesity is less dangerous than that which doctors tend to associate with insulin resistance. Once insulin resistance has become established, there is often a redistribution of fat. The limbs may be skinny but there is excessive central fat, so that the abdomen and chest become padded by thick folds of subcutaneous fat. The abdomen is also swollen by pounds of fat that swathe the internal organs and hang from the normally gauzy mesenteric curtains. The mesentery is a fine web of peritoneum which attaches the intestines and other organs to the abdominal wall and carries the blood vessels and nerves.
Problems with insulin resistance are not confined to obesity and have much wider metabolic implications — hence the other term for the condition, the metabolic syndrome. As well as a resistance of the body tissues to insulin, the patient may have high levels of circulating blood insulin, obesity, high blood pressure, abnormal blood fat levels — the combination of high blood pressure and raised triglyceride blood fats is a particularly ominous one — and type 2 diabetes. In women, there is also an association between insulinresistance syndrome and polycystic ovarian syndrome. In the present epidemic of childhood and adolescent obesity, it is found that however the fat is distributed, an overwhelming number of patients are insulin-resistant and potential candidates for type 2 diabetes.
There is a strong familial and racial pattern to insulin- resistance syndrome. It is common in Asia, but in all countries of the world it is increasing. One way of countering it and the ever-increasing numbers of patients suffering from type 2 diabetes that stems from it is to reduce the prevalence of obesity. This may be achieved by reducing the calorie intake, and by increasing exercise. The change doesn’t have to be dramatic; by cutting the calorie intake by 600 a day, and by walking briskly for an extra half mile a day, a dramatic difference may be observed after a year.
Professor Thomas Wadden, from the US, had an interesting observation on the obesity associated with insulin-resistance syndrome. He has found that many of these patients are binge-eaters. Between 15 and 20 per cent of the obese patients who attend his clinic fall into this category. Many of the binge-eaters he treats are also depressed and have a typical depressed patient’s diurnal variation — that is to say they become progressively more jolly as the day wears on. This has an effect on their eating pattern. Although they are hearty eaters at supper time and night-raiders of the fridge, they are anorexic at breakfast and have a very light lunch.
Professor Lars Sjostrom, from Sweden, has been studying insulin-resistance syndrome for more than 30 years, and was therefore one of the first in this field of research. For the past four years he has been plotting the effect of Xenical, coupled with lifestyle changes, on weight loss and the prevention of diabetes in overweight people.
Xenical, manufactured by Roche, is one of only two drugs licensed to treat obesity, (the other is Reductil, manufactured by Knoll AG). Xenical, in the opinion of Professor Sjostrom, is one of the safest drugs in our pharmacopias. It has a good side-effect profile and, if taken regularly, supplements the effects of increased exercise and decreased calories.
Xenical works by inhibiting the absorption of fat from the diet. Weight is lost slowly and steadily throughout the first year, there is some regain of weight after the second year, but those who continue to take it and modify their diet still record a significant weight loss at the end of four years, together with a marked reduction in their waist circumference, a more respectable blood pressure and weight reduction.
Xenical has one disadvantage; if patients do not restrict the amount of fat in their diets, the fat that is not absorbed will be excreted. This alters the nature of the faeces, but the manufacturers are keen to explain that this can’t be described as a side-effect, or even as diarrhoea.
Reducing excess weight is the most important modifiable risk factor in the development of type 2 diabetes — 80 to 90 per cent of people with type 2 diabetes are either overweight or obese. Xenical has proved to be an efficient way of achieving weight reduction providing that the patient is able to persevere, is able to reduce their fat intake and is also prepared to walk that extra half mile a day.
