Case Study: Assessing the relationship between depression, obesity, and HbA1c levels

Summary

With careful assessment, it can be found that diabetic patients who are noncompliant with their treatment, as evident by rising HbA1c levels, are usually also depressed. Lack of energy, appetite, concentration and motivation are some of the significant factors, which can lead to missing their office visits. Keeping a low profile, lacking in physical activity, and generally leading a sedentary lifestyle all contribute to these patients’ obesity. Diabetic patients tend to have a larger appetite, and easy access to fast food with lots of calories increases their fat intake, consequently increasing their HbA1c levels.

Doctors can monitor their noncompliant patients through their symptoms and lab results. We can also assess patients’ depression using the PHQ-9 scale. Patients with a score of 10-14 on the PHQ scale are candidates to be considered for antidepressant drugs or psychotherapy.

Criteria for selection of patients in this study:

  • Age 18 to 80 years
  • Male or female
  • Suffering from diabetes mellitus
  • Comorbidities like obesity, depression
  • Patients with other comorbidities were also included, such as those with hypertension, CAD, chronic kidney disease, and COPD

Modality of treatment used:

  • Diet counseling
  • Obesity counseling
  • Common antidepressants (SSRIs, Bupropion)
  • Smoking and alcohol counseling

Background

While practicing as a physician in India, I came across many patients who were extremely noncompliant, not only with the antidiabetic treatment, but also with office visits. While working here in the U.S. on the Healthcare Effectiveness Data and Information Set, I saw a rising trend in HbA1c levels, which in turn were affecting patients’ hearts, kidneys, eyes and other vital organs at a very young age. When I searched further into the patients’ clinical history and spoke to them, I learned that most of them were not happy with their life or work, and some of them had cultivated habits of eating too much and leading sedentary lifestyles. Patients were not concerned with their diabetic status, did not follow any dietary restrictions, had no physical exercise, developed cravings for food, and ate more than their requirements. Patients started avoiding the things they used to enjoy doing most. In addition, a particular bad circumstance or situation in a patient’s family created a low disposition or feeling that the patient could not escape. This would become a vicious cycle of feeling depressed, increasing BMI or obesity, and deteriorating diabetic status in the form of rising HbA1c levels.[s2If !is_user_logged_in()]…

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Case Presentation

I saw most patients presenting with complaints of low energy, polyuria, joint pains, occipital headache with high blood pressure, blurring of vision, constipation, numbness, tingling in their hands and feet, and sexual dysfunction. Upon physical examination, some patients had high blood pressure, above 140/90, BMI (body mass index) >30, and neurological examinations showed stocking-and-glove sensory loss. We performed an in-house Ankle-Brachial Doppler study where some patients were found to have peripheral vascular disease.

Investigations

Patients underwent minimum basic and highly specific investigation related to the diagnosis and its outcome. The investigations included a complete blood count, lipid panel, glycosylated hemoglobin (HbA1c) test, and an Ankle-Brachial Doppler study.

Treatment

Patients were on antidiabetic drugs, preferably 500 to 1000 mg of Biguanide (Metformin) based on their requirement. This drug was given preference against sulfonylureas (due to the side effect of heavy weight gain), because it helps in reducing BMI. People with HbA1c levels above 10% were started on a combination of NPH and regular human insulin.

A hypertensive patient was given Angiotensin Converting Enzyme (ACE) inhibitors to take care of microalbuminuria, if present, as well.

Some patients with depression were started on pharmacotherapy – one Bupropion tablet (anti-obesity and anti-depression) daily. This treatment was contraindicated in patients with seizure disorder.

All patients with depression were given psycho-counseling at every visit. The frequency of counseling was adjusted based on patients’ presentation and improvement.

Counseling was modified into verbal forms, as well as in scripts, which were handed to patients at every visit.

The following counseling was given:

  1. Diet counseling with more emphasis on a vegetarian diet with raw and lightly cooked green, leafy vegetables and carrots, and lesser amounts of potatoes, fruit and raw vegetable salads.
  2. Regular exercise, starting from 20 minutes and gradually increasing to 30 minutes, with an emphasis on brisk walking and jogging outdoors or on a treadmill.
  3. Psycho-counseling with an emphasis on a positive way of living, positive attitude, reading books by great authors, helping others, community work, praying daily, and going to a place of worship at least once a week to offer their prayer.
  4. Being compliant with medication and office visits.

Outcome and Follow-Up

The combination of pharmacotherapy and psychotherapy induced positive change in many patients.

We saw outcomes in the form of these Primary Endpoints:

  • Decrease in HbA1c levels to normal (at or below 6)
  • Decrease in body mass index (ideally less than 30)
  • PHQ-9 scale = 0

And Secondary Endpoints in the form of:

  • Positive attitude
  • Increased physical activity
  • Diet restricted to 4 or 5 small meals of home-cooked food, with fruit and vegetable salad
  • More compliant with treatment
  • Regularly going to work—some were even promoted and received an increase in their salaries
  • Avoiding all smoking and alcohol

Follow-up was decided based on their assessment. We continued monthly office visits, because any patient with diabetes and hypertension has to be monitored and given medication based on their physical examination and blood tests. Modification of patients’ lifestyles drastically reduced their drug dosage, and most of them required only a single drug.

We drafted our study in such a way that it was not only a learning environment for us, but it created a real change in our patients’ minds and bodies in the direction of healthy living.

Discussion

Today, the major causes of morbidity and mortality in the United States are obesity and diabetes. There is increased evidence from several studies documenting weight gain leading to obesity and its association with an increased risk of type 2 diabetes. People undergoing intentional weight loss reduce their risk, as opposed to overweight people who will more likely develop diabetes. Each year, both obesity and diabetes incur huge healthcare costs.

Comparatively, less than 20% of American adults who are attempting to lose weight are following medical advice to get regular physical exercise and decrease their intake of calories. (1) Every individual should take part in at least 150 minutes per week of physical activity. All physicians and health professionals should do regular counseling to promote a balanced diet and physical exercise for decent weight loss and optimal health. (1)

During the 1990s, epidemics of obesity and diabetes developed among US adults. Our current findings indicate that most US adults (>56%) are overweight, about 1 in 5 is obese, and 7.3% have diabetes. In this study, the prevalence of undiagnosed diabetes was 2.7%. (2)

Recent data collected found an increase in the plasma concentration of TNF-alpha (tumor necrosis factor) and Interleukin-6 (IL-6) – inflammatory mediators in insulin-resistant type 2 diabetes and obesity. Scientists came up with two propositions: first, that an increase in the intake of glucose and micronutrients might be responsible for oxidative stress and inflammatory changes, and second, that an increase in TNF-alpha and IL-6 might be responsible for suppressing insulin signal transduction. Therefore, inflammation in β-cells leads to β-cell malfunction, which, in addition to insulin resistance, leads to type 2 diabetes. (3)

There is a growing prevalence of type 2 diabetes, heart disease, and some cancers related to excess weight gain. A predisposition to abdominal obesity is found to be more prevalent in Eastern Europe, Latin America, and Asia. This may lead to metabolic syndrome and impaired glucose tolerance.

Lifestyle changes can lead to weight loss and reduce the incidence of diabetes and hypertension. The WHO issued objectives for developing countries regarding school meals and healthy living. (4) Also, nutritional intervention studies performed on animals and humans suggest that the ingestion of isoflavones present in soy protein and lignans present in flaxseed improves glucose control and insulin resistance. In research on human subjects with or without diabetes, soy protein also appears to moderate hyperglycemia and decrease body weight, hyperlipidemia, and hyperinsulinemia, supporting its beneficial effects on obesity and diabetes. (5)

Learning Points/Take Home Messages

As one grows older and starts earning for his or her family, he or she becomes so engaged that they lose their healthy physical activity and start gaining weight. They may be eating less, but everything starts being deposited and gets converted to fat. Less physical activity and slow weight gain starts a vicious cycle, which may induce other illnesses like high blood pressure, type 2 diabetes, etc. It is very important to understand that we must do a daily 30 minutes of exercise and eat a balanced diet. There is no shortcut to healthy living.

About The Author

sarkarDr. Rajesh Sarkar is a Clinical Research Associate with Florida Family Physician and a permanent member of the Indian Medical Association. After completing his MBBS, he did DNB in Medicine, Post graduate certificate course in Psychiatry and Psychosexual medicine and Industry program in Clinical Trial Research and Administration from India. Later he joined the University of California, Santa Cruz to complete a post-graduate course in Clinical Trial Design and Management. He was working with Telome Health Inc., doing research on DNA telomere length in average healthy American population and its shortening (Length of Telomere) associated with different kinds of cancer.
anita sarkar1

Dr. Anita Sarkar, MBBS Lady Harding Medical College
Post Doctorate Certification In HIV/AIDS . Presently working on Breast Cancer and Cervical Cancer in young women.

 

 

References (click to show/hide)

  1. Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, 2001. Ali H. Mokdad, PhD; Earl S. Ford, MD, MPH; Barbara A. Bowman, PhD; William H. Dietz, MD, PhD; Frank Vinicor, MD, MPH; Virginia S. Bales, MPH; James S. Marks, MD, MPH. JAMA. 2003;289(1):76-79. doi:10.1001/jama.289.1.76.
  2. The Continuing Epidemics of Obesity and Diabetes in the United States. Ali H. Mokdad, PhD; Barbara A. Bowman, PhD; Earl S. Ford, MD, MPH; Frank Vinicor, MD, MPH; James S. Marks, MD, MPH; Jeffrey P. Koplan, MD, MPH. JAMA. 2001;286(10):1195-1200. doi:10.1001/jama.286.10.1195.
  3. Inflammation: the link between insulin resistance, obesity and diabetes. Paresh Dandona ,Ahmad Aljada, Arindam Bandyopadhyay. Division of Endocrinology, Diabetes and Metabolism, State University of New York at Buffalo and Kaleida Health, 3 Gates Circle, Buffalo, NY 14209, USA.
  4. Obesity and Diabetes in the Developing World — A Growing Challenge. Parvez Hossain, M.D., Bisher Kawar, M.D., and Meguid El Nahas, M.D., Ph.D. N Engl J Med 2007; 356:213-215. January 18, 2007. DOI: 10.1056/NEJMp068177 http://www.nejm.org/toc/nejm/356/3/
  5. Beneficial role of dietary phytoestrogens in obesity and diabetes1,2. Sam J Bhathena and Manuel T Velasquez. Am J Clin Nutr December 2002 vol. 76 no. 6 1191-1201. http://ajcn.nutrition.org/content/76/6/1191.short – aff-1

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One Comment

  1. Dr. Valluri Ramarao
    Posted Sep 2015 at 1:09 pm | Permalink

    Good article on present day practice cases of DM,HTN and obesity is a common associates .we come across problem with depression.. It’s nice to draw relationship with A1C.We come across many cases of menopausal women with hypothyroidism and depression.in the past many such cases are treated with thyroxin with good outcome PHYSICIAN NEED TO KEEP AN EYE ON DEPRESSION WITH ANY CHRONIC DISEASE FOR EFFECTIVE OUTCOME. .

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