Corresponding Author: Dr. Anuj Maheshwari, MD, FIACM, FICP, FACP, FACE,
FRCP(London) Professor & Head, General Medicine, BBD University,Lucknow-226022, India
Biography : Dr. Anuj Maheshwari is a General Physician and Diabetologist in Vikas
Nagar, Lucknow and has an experience of 21 years in these fields. Dr. Anuj
Maheshwari practices at Sri Hari Kamal Diabetes Heart Clinic in Vikas Nagar,
Lucknow. He completed MBBS from Motilal Nehru Medical College in 1991, MD -
General Medicine from King Georges Medical College, Lucknow University in 2000
and FIACM from Indian Association Of Clinical Medicine in 2013. He is a member
of Indian Medical Association (IMA).
Lean type 2 diabetes can be identified with low body massindex(BMI) with raised waist hip ratio in presence of type 2 diabetes mellitus.
They are difficult to be identified until they are not met with complications. Although,
it is much lesser prevalent in Indian population than caucasians, but it’s impact
is stronger. 15 % western world population is lean type 2 diabetes mellituswhen 55% is obese. In India it is 3.5 percent only when 63 percent are with their
ideal bodyweight. It involves greater risk as Indian tends to develop similar cardiovascular
risks at lesser BMI what others develop on being obese because of peculiar
phenotype which includes abdominal adiposity and much higher fat content at any
BMI. Dietary pattern with higher
carbohydrates intake and lack of physical activity further complicates the
outcome. Although it is more commonly seen in those diagnosed in old age but in
India, as occurrence of type 2 diabetes has been predated a decade, so lot of
youngsters are getting type 2 diabetes mellitus at lower or normal BMI. They
are not typically similar to those in rest of the world. They do not carry the
benefits of being lean type 2 diabetic like high HDL cholesterol and low
occurrence of coronary artery disease (CAD).
Conspicuously lean type 2 diabetes routinely presents with
peripheral neuropathy, high incidence of retinopathy with markedly lesser
incidences of hypertension, nephropathy and CAD as co morbidities. Severe basal
hyperglycemia is seen with no or least weight gain even when it is treated.
They are characterized with high level of glucokinase in circulation and hyperactive
metabolic state in liver which is responsible for excess utilization of insulin
in its first pass. Their lesser weight is accredited of fast carbohydrate
metabolism and characterized with high C-peptide level without
. Contrary to this, Indian lean type 2 diabetic is a peculiar
phenotype that carries all risks of obesity at normal or lower body weight with
hyperinsulinemia progressing gradually towards poor beta cell reserve. Lean
type 2 diabetes is supposed to be associated with malnutrition but Indian type
2 lean diabetes has no relation with malnutrition.
Because of its unique characteristics of abdominal adiposity
with higher insulin resistance with
characteristic dyslipidemia, Indian phenotype poses different challenges of
management. Of course they should be differentiated from Type 1 Diabetes
Mellitus and Latent Autoimmune Diabetes of Adult (LADA). Despite being lean
type 2 diabetic, they are slow metaboliser of carbohydrate with slow disposal rate
of glucose, low level of adipokines, high level of leptin and triglycerides
presenting with impaired insulin secretion and insulin resistance together.
Apart from this they poses serious management challenges impending
cardiovascular risks because of higher content of abdominal adiposity with
visceral fat at any level of BMI. Increased waist circumference with high waist
hip ratio at any level of BMI is important marker of this peculiar phenotype
which is attributed of certain genetic factors.
Same level of glucose challenge causes higher glycemic level
in asian Indians than Caucasians. An important management challenge arises when
glycoselated hemoglobin i.e. HbA1c is not only primarily contributed by post
prandial hyperglycemia when it is reaching closer to target but actually in
Indians type 2 diabetics, post prandial glycemia continues to remain of primary
importance to be controlled together with basal hyperglycemia when HbA1c is far
away from target. Therefore management requires lot of focus on post prandial
correction in Indian phenotype. High carbohydrate content of food is an
important cause. Apart from this few environmental factors like increasing
physical inactivity, insomnia, stress, fast food challenges apart from existing
challenges of high carbohydrate diet, play significant role in making type 2 DM
management complex in Indian phenotype.
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