Are laws required to treat diabetes mellitus (diabetics) and obesity (obese people)?

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Editorial, Nov 2014 issue

“At present perhaps Japan is the only country where majority of the people are willingly assisting government by following Metabo law guidelines to shed those extra pounds or to be away from gaining those extra calories.

Diabetes mellitus and obesity have assumed the proportion of unparallel man-made calamity. At present there is no sure shot way to escape the fury of these two. These two arise due to inherent traits in the victim or due to unhealthy dietary regime or some sort of metabolic hitches.  Diabetes, often referred to by doctors as diabetes mellitus, describes a group of metabolic syndromes in which the victim has raised blood sugar level, either because insulin production is scarce, or because the body's cells do not respond properly to insulin, or both. Signature symptoms of diabetes are polyuria (frequent urination), polydipsia (frequent urge for water) and increased hunger bouts (polyphagia); other symptoms are diabetic retinopathy, diabetic neuropathy and diabetic nephropathy. Obesity is a disease where there's a disregulation of eating, just like diabetes is a disease where the system of controlling blood sugar is not functioning properly. As per American Obesity Treatment Associations obesity can be defined as accumulation of excess fat on the body. Obesity is considered a chronic (long-term) disease, like high blood pressure or diabetes. It has many serious long-term consequences for the subject especially if not checked at right step. It sounds threatening to know that obesity is the second leading cause of preventable deaths in the United States, tobacco being the first. Obesity is defined as having a body mass index (BMI) of greater than 30. If situation remains incessant then it would not be comical to think that regulatory bodies world over may revise BMI figure in either direction; either less than 30 (to sound it more dangerous so that tentative subjects, who are predisposed to be obese, could be stopped at overweight stage only) or more than 30 (indicating that change in eating behavior and rapidly changing life style is insurmountable hurdle in obesity treatment). The BMI is a measure of one’s weight relative to her height.

Diabetes is the only disease which allows victim to live for many years despite of gradual decrease in efficiency of major organs (Kidney, Eye, Nervous system, Pancreas). This may further enjoy the title of being called most dreadful among all the known diseases (at least in the segment of non communicable and not infective disorders) because the patients die owing to complications and not directly because of the main cause, that is elevated blood sugar level. Obesity is another disease which has been a conundrum, keeping scientists busy and abuzz all over the world. These two disorders are directly related with feeding behavior and/or genetic susceptibility of subject for these two. Other reasons are not as strong as these two. Diabetes is a common disease, yet every individual needs unique care. The American Diabetes Association has been supporting diabetes research in the academic community for more than half a century, notably contributing to the landscape of diabetes research. In 2013, the Research Program made $35.75 million available for research. This included more than 400 active research projects, with approximately 375 investigators at 145 leading academic research institutions across the U.S1. Because despite of available treatments and measures diabetes does not seem to go away so easily from Indian culture as the habits (compulsory sweets in mean and post meal) are deeply rooted and therefore in near future government may restrict the use of sugar (raw and refined) in commercially available food products to a certain extent. Because if buyers are not controlling their desires then sellers will be brought under the purview of law sooner or latter.

Despite of all the efforts there is not - so - impressive scenario when it comes to management of obesity. Obesity is defined as BMI (body mass index) 30kg\m2 or more. A person with a BMI between 25 and 29.9 are considered over weight but not obese. BMI is a simple index of weight-for-height that is commonly used to classify overweight and obesity in humans. It is also defined as a person’s weight in kilograms divided by the square of his height in meters (kg\m2). As per world health organization (WHO), BMI greater than or equal to 25 is overweight and BMI greater than or equal to 30 is obese. Obesity is a foremost health problem not only in developed nations but also in developing countries. It increases the risk of other diseases like diabetes, cardiovascular ailments, fatty liver and some forms of cancer. Obesity is now so common in various geographies that it is beginning to replace conditions arising from malnutrition and infectious diseases as the most significant contributor to ill health. Obesity is measured using BMI and further evaluated in terms of fat distribution via the waist–hip ratio and total cardiovascular risk factors.  

India is home to world’s third largest pool of obese people. Obesity makes subject an easy victim of diabetes, heart ailments and other disorders associated with life style. About one third of the world population has been found obese in a survey conducted by Institute of health metrics and evaluation.

Looking at increasing number of obese or over wait person, it won’t be an exaggerated statement to say that WHO may shift BMI value to a higher level (presently anybody with a BMI of 30 is considered obese according to internationally followed BMI chart). There cannot be a pill which can address obesity of all origins. Because phenotype is simple (increased fats in body or more precisely specific part of body and giving various types of look as shown below), but reasons might be different. One more concept may be mentioned here obesity may be a terminology which gives a perception of stomach or GIT, but feeding and stop feeding signals arise from nervous system only. It means to address obesity; one cannot overlook neural circuits directly or indirectly involved in obesity.

Years ago Mark Twain said “The only way to keep your health is to eat what you don't want, drink what you don't like, and do what you'd rather not”. The only treatment of obesity with no side effect is Will Power. The most successful treatment of obesity lies in its root cause that is excessive consumption of fatty food and minimum physical exercise; but if victim does reverse of it he will be far away from being obese. No other stuff is as effective as this. Because dietary control, physical activities with or without medication (if medication works then also) demand a strict will control. Much talked, read and done but still there is lot many stuff to be explored and exploited. Olive oil, rice bran oil, corn oil all are in trend but obesity is a disorder with pig headed attitude. Some of the most relevant reasons for obesity (deposition of fats in various regions of the body) or diabetes (because excessive food intake will surely include sweets also) are:

* Increased, economic (especially roadside eateries), easy and stylish availability of high-energy foods,

* Forced use or compelled or peer-pressure enabled use of smart phones (perhaps android is destroying users),

* Tendency to wind-up assignments either at home or office while skipping the meal,

* Fast accepted trends of having lunch and dinner as part of outing on weekends, severe pain while doing exercise to burn fat (as robotic/programmed life style and office modus operandi involving sitting job renders body no more agile),

* Frequent and lavish way of celebrating festivals in India with sweets,

* Frequent partying owing to celebrate silly reasons

* Hassle free loan facilities for purchasing two wheelers so giving up cycling

* Improved adherence to diabetes medications can lead to better health outcomes and reduced costs but according to recent research, diabetics who do not constantly take their medicines as prescribed are 2.5 times more likely to be hospitalized than those who follow their prescribed treatment regimens more than 80 percent of the time. (same is true for obesity, barring the figures)

The rapidly acceptable reasons, inter alia, for obesity is heavy consumption of sugar.

Such is the acceptance of sugar/sweet in Indian culture that even condoms are sold in India in chocolate flavor. (Time to think). Treatment of these two diseases is very difficult especially for obesity owing to following reasons:

* Perhaps the only disease where person has to interrupt his daily assignment (taking meal) fixed by the God, which is a daunting task.

* Preclinical models or clinical designs are not robust enough to analyze and predict real time effect in obese persons.

* Placebo or will power seems to be more effectual than well designed clinical studies.

* With technology spreading and sliding in every household, obesity victim becomes helpless and hapless notwithstanding his willingness to shed those extra pounds.

* Side effects of approved antiobesity molecules led to frequent suspension of marketing authorization by regulatory authorities in one or more part of world.

* Moreover, this is among those rare diseases in which medication alone does not improve the conditions significantly and permanently. Person has to follow strict dietary regimen.

* Treatment and change in food habits are frustrating.

* Treatment involves interplay of at least three major systems of body: Nervous, Endocrine and Digestive systems.

* Though a bit successful, but traditional treatment single drug therapy to treat obesity is not effective impressively because of multiplicity and redundancy of mechanism involved in appetite regulation and energy homeostasis.

* Even treatment is on but ready availability of palatable food with a high fat content is not supporting the therapy.

* Side effects are probably due to the fact that body is being forced to not absorb/assimilate basic building blocks i. e. fatty acids.

* So many chemicals are involved that it seems difficult to completely control the system.

* From the physiology of weight control, it is evident that there are many potential targets for obesity treatment, but there is high degree of redundancy in the system.

* So far there is no proof or success indicating that pharmacological treatment is effective in the absence of changes to diet and lifestyle.

* Intense behavioral interventions are mandatory for effective weight loss and health improvements in obese patients.

Because such is the rate of prevalence of obesity and quite limited options that as soon as a successful antiobesity drug is launched (without side effects) in coming years, people will take it in no time and it will break the record of world’s biggest blockbuster brand Lipitor®. Lipitor® till date is the world’s largest sold drug; becoming the blockbuster brand containing Atrovastatin. There is an urgent need of exploring all the available options to address the menace of this metabolic disorder.


Officially this law is known as the Standard Concerning Implementation Special Health Examinations and Special Public Health Guidance in Japan, more commonly referred as “metabo law,” named after “metabolic syndrome” which is Japan’s official name for obesity. Effective from 2008, this is one of its own kind and really praiseworthy world over. It is now responsibility of local governments and employers to ensure regular checkups of citizens and employees which involve waist measurement too. Waists measuring 33.5 and 35.5 inches are considered at risk for male and female respectively and they are referred to counseling, email and phone monitoring and correspondence, along with motivational support on a compulsory manner. There is strict conformity to these guidelines, people are also self conscious and it is not just a formality or documentation either. Some citizens complained of the embarrassment they felt when exposing their stomachs while being measured, so the government decided to allow patients to remain fully clothed and deduct 1.5 centimeters from their final measurement. The goal is to guarantee that local governments and employers must maintain a minimum of 65% participation in the program and meet specific guidelines. The first goal was a 10% reduction in obesity rates by 2012, with a 25% goal by the year 2015. Over 50 million Japanese are expected to be measured each year. Employers unable to meet the guidelines will be forced to pay nearly 10% higher payments into the national health insurance program. This can equate to millions of dollars for large corporations. The annual waist measurements have prompted some people to crash diet in the weeks leading up to their yearly checkup. Some companies offer their employees free gym memberships or special diet plans. There has also been an increase in the sale of health products related to the Metabo law. At present perhaps Japan is the only country where majority of the people are willingly assisting government by following Metabo law guidelines to shed those extra pounds or to be away from gaining those extra calories. Around the world, Japanese are known, in context of kicking obesity and diabetes, for their walk, stuffing stomach to 80% of hunger, taking meal in small plates, consuming low oil-fat-sugar food (literally a challenge in India), relatively heavy intake of sea foods (research shows that sea vegetables checks absorption of fats in body) and salad (avoid snacks), consuming not more than 48.8 gm of sugar (average), avoiding dessert immediately post meal and for their longer life expectancy (83 years). Another country worth mentioning here for its tough rules to check obesity is Finland.

Following images indicate one of the major steps in the history of soft drink industry. Government of India has spoke to Indra Nooyi, top most authority in Pepsico that they should think over sugar concentration in their products. This might be due to uncontrollable and ever increasing trends (in Indians) of consuming pre- during- or- post- meal soft drinks. This news is few weeks old (August 28, 2014). Another image is a screen shot of video released by Pepsico which shows the benefits of very recently launched new variant of Pepsi. Pepsi True.

This is not launched in India but some other part of the world. Here it is must to mention that this is perhaps first time that one of the biggest brands of the world has added natural sweetening agent Stevia in its product to add sweet taste along with real sugar to decrease calorie intake, and that company is mentioning it very boldly in its commercial too. It is really a welcome move.

Note: The article is not written with malign intention or any ill-will to tarnish image of any company or its products.

2. dainik bhaskar rasrang 6/7/14 sarjna chaturvedi cover story.

- Amit Gangwal