A combination of a healthy diet and exercise can get rid of the extra kilos and decrease the risk of developing diabetes

My patients have been complaining of weight loss or weight gain since the circuit breaker was initiated. Those who have lost weight were very concerned that they had an illness of sorts. Some of them had lost substantial weight – 5-8kg. We did the necessary and made sure there were no sinister causes. So, what had happened to my patients who lost substantial weight? Well, I figured out that they had change in lifestyle; there was a change in diet with eating and cooking more at home. Those who previously travelled extensively had stopped eating and drinking on planes, and had to give up entertaining or being entertained. All this resulted in a healthier diet; cooking at home involved healthier ingredients, produce and oils. The other big change is exercise.

With so much time on our hands and working from home, most of my patients ended up doing more exercise. Some started with walking, graduated to running and high intensity interval training. The gyms were closed and so quite a few ended up with cycling. There  was also a lot of online yoga, Pilates and aerobics being done. Underneath all these changes in lifestyle, there were also mental changes. There is loss with all that has happened – loss of liberty, loss of travel, loss of connection, loss of relationships, economic loss. And some of the losses would be only realised somewhere in the future. With such loss, a grief reaction was inevitable and there would be denial, anger, bargaining, sadness and finally acceptance. Some of my patients, without realising it, had slipped into depression or a milder form of it called dysthymia.

These were all characterised by weight loss, insomnia, loss of drive, loss of pleasure and libido with depressed mood. Some felt hopelessness with loss of focus and concentration as well. As we move into a lull phase of the pandemic in our nation, we still have to contend with the economic losses and unemployment ahead, with possibility of resurgence of the virus at any time. The prior losses, current bleakness and future potential losses have been instrumental in affecting our mental state. What about those who had gained weight? The majority had increased their intake for various reasons and had not matched it with exercise. One of the biggest drivers of ill health in today’s world is being overweight and obesity. We use body mass index (BMI) of 25 and above for overweight and 30 and above for obesity. For Asians, we actually found that we are worse off at those criteria and we use 23 and above for overweight and 27 and above for obesity.

Our local obesity rate is about 10 per cent of our population. Depot for fat cells The biggest enemy in our battle is the presence of visceral fat. Visceral fat is also known as “belly” fat and is different from fat on your thighs and buttocks. The visceral fat is actually deposited in the omentum – an apron that surrounds our intestines. The omentum is actually the transparent skin that gives the meat sausage its shape. It is also the biggest depot for fat cells. This fat is different because it generates cytokines; these are proteins that are generated by the immune system. You may have heard of the role of cytokines in desperately ill Covid-19 patients undergoing a “cytokine storm”. We know that these cytokines, including proteins named interleukins, tumour necrosis factor, adiponectin and leptin,  are powerful drivers of insulin resistance and inflammation and ultimately leading to an increased risk of diabetes, hypertension, heart disease, stroke and even cancer.

How does one know that he or she has visceral fat? A simple tape measure of the waist circumference around the navel and a measurement of 80cm and above for women or that of 90cm and above for men is indicative. So, how did we know all this? In 1986, there were more than 100,000 patients in Da Qing with prediabetes and they were subjected to diet, exercise and combination of both for six years. The outcome was that those who did nothing went on to develop diabetes, while those who went on a diet reduced their chance of diabetes by 31 per cent, those who exercised by 46 per cent and those who did both diet and exercise by 42 per cent. In the same year, a study of more than 40,000 nurses over the next eight years by Harvard showed that women with obesity, a high waist-to-hip ratio and a waist circumference of 92cm and above were more 11 times more likely to develop diabetes.

So, what do we have to do about visceral fat? We have to make sure our sugar levels do not spike as our insulin levels will also mirror such a spike to get rid of the sugar. The insulin works like a key and opens all the cell doors in your body so that the sugar load in your blood will move into cells to burn for energy. Avoid a sugar spike The main driver of visceral fat formation is actually the high insulin level. So in this case a sky high level of insulin is the “bad boy”. Hence, we have to eat carbohydrates that don’t give us a sugar spike.  These include healthier options such as cooked oatmeal as opposed to instant oatmeal, glass noodles, Japanese noodles like soba and udon and Italian pastas. The ones to avoid are white rice, white bread, potato and yellow noodles. Fruits are also high in sugar and these include pineapple, mango, melons, banana, grapes, lychee and longans. The idea then is to eat carbohydrates that turn slowly to sugar.

These are called Low Glycemic Index (GI) foods. Hence, the quality of the carbohydrates and the amount of the carbohydrates also matters. When you factor both quality and quantity of the carbohydrates you get something called Glycemic Load (GL). When you attach a glucose monitor onto your arm that measure your blood sugar levels every 15 minutes for a period of two weeks, we get nice graphs of your sugar peaks and troughs. When you annotate these beautiful graphs with the foods you eat, you get something called a Glycemic Response (GR). We have analysed patients with such graphs using machine learning tools software and found some interesting findings. We found that sometimes what you think is healthy may not be so. I used to eat oatmeal with blueberries every morning and thought that was extremely healthy. It turned out that it spiked my blood sugar sky high.

I have a patient whose sugar spiked through the roof every time he ate any kind of bread including wholemeal. The message is clear, each individual’s GR is different; pretty much like a thumbprint. You may have to attach a glucose monitor to find out. The final analysis is that we think that there are certain foods that you are eating and these are likely to be your favourite, and hence frequently consumed, foods that are really affecting your GR and making you pile on visceral fat. You can boil all this down to an adage: there are foods you want to eat, there are foods you should eat, but ultimately you have to figure out which foods you can eat.