What an unusual statement you may wonder. Perhaps some of you have heard this statement or a variant of it – your intestine has gone to sleep, you have an ileus or your gut is not working properly.

The small intestine does not like being ‘handled’ by human hands. Whenever you have an open abdominal operation, be it a colon, stomach, small intestine, bladder or kidney operation, there is a significant likelihood that your small intestine will ‘go to sleep’ for a variable period of time. In response to the surgical insult of being handled or being operated on, the intestine will not function. The lack of small intestinal function is called ileus. During this period the abdomen will swell because the secretions from your mouth, stomach and duodenum will not be absorbed. On top of that if you also eat / drink, then the swelling can get worse and you will experience nausea and vomiting. In most instances, the treatment for an ileus is to insert a tube into the stomach via your nose (a nasogastric tube or NG tube) and set up an intravenous infusion (IVI). The NG tube decompresses your stomach of air and liquid while the IVI keeps you hydrated. How long an ileus lasts varies. At the present moment there are no special medicines that can prevent an ileus from occurring or shorten the duration of an ileus.

Gum chewing has been suggested as a means of reducing the duration of ileus. A recent meta-analysis of all the published data on the effect of gum chewing on ileus duration was published by researchers in the University of Amsterdam (Dig Surg 2008; 25: 39 – 45). There were 5 randomised control trials involving a total of 158 patients. The pooled data showed that the gum chewing group had significantly shorter time to passing flatus (gas) and defaecation compared to the non-gum chewing group. The analysis could not show that gum chewing had a significant influence on the total days spent in hospital.

Ileus can be prolonged if there is underlying infection in the abdominal cavity or abnormal electrolytes level in the blood. When infections and abnormal blood electrolytes are excluded, then we need to ensure that there isn’t an underlying mechanical obstruction or poor blood supply to the intestine. If everything has been excluded then the best and only thing to do is ‘be patient’.

For the patient and relatives, it is almost counter intuitive to not give medicine and do nothing. It is difficult for them to comprehend that we just wait and there is no magic medicine to solve the problem. With fluid support, the ileus will resolve in about 5 to 7 days (sometimes shorter). Occasionally an ileus can last for two to three weeks. In such instances the patient needs to be supported with intravenous nutrition.

Sometimes masterly inaction in medicine is actually doing something. If you want to chew a gum or two while you are waiting, it won’t hurt and maybe just might help.

Obesity is reaching an epidemic proportion worldwide. Being obese is associated with increased risk of developing type II diabetes mellitus (DM) and cardiovascular disease (CVD). Previous studies of obesity have shown that individuals who have a selective excess of intra-abdominal (visceral) fat will be at a substantially higher risk of being insulin resistant and have a cardiovascular risk profile. In the body, fat tissue is a store for excess energy. The theory is that when extra energy is deposited as visceral fat and in ectopic depots such as the liver and skeletal muscle, this leads to an increased risk of DM and CVD. If the extra energy is deposited in subcutaneous depots and / or burned within the mitochondria in the liver and skeletal muscle, the individual, though obese, will be protected from these diseases. So can we find these people with metabolically benign obesity?

A study from University of Tubingen, Germany, examined a total of 314 individuals who underwent magnetic resonance (MR) tomography to measure total, visceral and subcutaneous fat, and proton MR spectroscopy to measure fat in the liver and skeletal muscle. The insulin sensitivity was estimated from oral glucose tolerance test. The intima-media thickness [IMT, it is used as an early marker of atherosclerosis (hardening of the artery)] of the common carotid artery (artery to the brain) was measured with ultrasound (Arch Intern Med 2008; 168: 1609 – 1616). There were 4 groups of individuals identified and assessed: normal weight [body mass index (BMI) < 25.0], overweight (BMI 25.0 – 29.9), obese insulin sensitive (OIS) (BMI ≥30, placement in the upper quartile of insulin sensitivity) and obese insulin resistant (OIR) (BMI ≥30, placement in the lower 3 quartiles of insulin sensitivity). Compared with the normal weight group, the overweight and obese groups have higher total body and visceral fat. Within the obese group of individuals, ectopic fat in the skeletal muscle and especially the liver and IMT values were lower in the OIS group when compared to the OIR group. The OIS group has higher insulin sensitivity than the OIR group. Interestingly, the insulin sensitivity and IMT values between the OIS group and normal weight group were not statistically different.

So is there a simpler way of identifying the metabolically benign obese people? Has no one made this observation until now because the MR machine was only invented recently? In 1956, a French clinician with a large obesity practice, published his clinical observations. In his practice, Dr Jean Vague observed that there were 2 predominant types of obese people: an upper-body, central abdominal obesity type which he called android and a lower-body, gluteal-femoral (buttocks and thighs) type which he called gynoid. He reported that patients with the upper-body, central abdominal form of obesity were prone to cardiovascular and metabolic complications such as hypertension, coronary artery disease and diabetes when compared to those having the lower-body, gluteal-femoral type. The designations android and gynoid applies to both men and women. These observations by Dr Vague seems to have gone unnoticed until the 1980s when large Scandinavian epidemiologic studies showed that CVD and death were related to the central body fat phenotype, as assessed by a high waist to hip ratio.

If you do not have an MR machine and do not know how to perform the oral glucose tolerance test, get a tape and measure your waist and hip circumference. Perform a simple mathematical calculation and you will have a rough idea if you have an android type or a gynoid type of habitus.

Even if you are a metabolically benign obese person, it would be wise not to think that you are in the clear and continue to eat as much as you want. In medicine, we are dealing with probabilities. We do not deal with absolute certainty like in rocket science. Thus, it is still a good idea for you to be normal weight rather than overweight or obese!

Overweight and obese individuals have an increased risk of developing metabolic and cardiovascular diseases when compared to normal weight individuals. However, recent studies indicated that an individual’s cardiovascular disease (CVD) risk may depend on the body size and metabolic profile. Among obese individuals, there is a subgroup who are metabolically healthy and appear resistant to the development of the adiposity-associated cardiometabolic abnormalities that increase the CVD risk. Similarly, a subset of normal weight individuals also showed cardiometabolic abnormalities often associated with being overweight and obese. So what percentage of normal weight individuals has increased CVD risk?

The prevalence and correlates of body mass index (BMI) and cardiometabolic groups were assessed in 5,440 participants of the National Health and Nutrition Examination Surveys (NHANES) 1999 – 2004 (Arch Intern Med 2008; 168: 1617 – 1624). The definition of normal weight, overweight and obese individuals was BMI < 25.0, 25.0 – 29.9 and > 30.0, respectively. Metabolically healthy individuals have 0 or 1 cardiometabolic abnormalities and metabolically abnormal individuals have ≥ 2 cardiometabolic abnormalities. Cardiometabolic abnormalities included raised blood pressure; elevated levels of triglycerides, fasting plasma glucose and C-reactive protein; raised homeostasis model assessment of insulin resistance value and low level of high-density lipoprotein (HDL) cholesterol level. The study found that among US adults, 30.1% of normal weight men and 21.1% of normal weight women were metabolically abnormal. In the overweight group, 51.2% of men and 43.0% of women were metabolically abnormal. Seventy point eight percent of obese men and 64.6 % of obese women were metabolically abnormal. The independent correlates of cardiometabolic abnormalities among normal weight individuals were older age, lower physical activity levels and larger waist circumference. If you were overweight or obese, the correlates for metabolically healthy individuals were younger age, non-Hispanic black race, higher physical activity levels and smaller waist circumference.

Even if you are normal weight, you can still have an increased CVD risk. Irrespective of whether you are normal weight, overweight or obese, physical activity levels do play an important role in determining your health risk. If you have a good level of physical activity, you are less likely to become overweight or obese. If you exercise regularly, you reduce your CVD risk. If you want to be healthy, you have to exercise and watch those waist lines!