TUs. A full load of banked leave may only be used once every four (4) years.
TUs. It has been predicted that in the year 2030 366 million subjects worldwide will suffer from diabetes mellitus24. These are crude estimates, however, that have not taken into account the increase in overweight and obesity; hence, actual numbers may even be much higher. Genetic factors are without doubt of major significance in the development of obesity and type 2 diabetes mellitus. However, because the human genome does not change over just decades, genetic predisposition cannot explain the explosive increase in obesity and type 2 diabetes mellitus of recent years. Environmental and social factors, like a lack of physical exercise and high caloric intake, are more likely explanations for the epidemic. A chronic im- balance between energy intake and energy expenditure eventually leads to obesity. In obese and obese type 2 diabetic patients, insulin resistance is of paramount pathoge- netic significance21,25. Insulin resistance not only impairs glucose homeostasis, but is also associated with hypertension26-28, dyslipidaemia29-31 and abnormalities in coagulation and fibrinolysis32,33, conditions that are independent cardiovascular risk factors34-38, seen in both obesity and type 2 diabetes. In addition, insulin resistance in (severely) obese type 2 diabetic patients makes it often difficult to achieve adequate glycaemic regulation. Sooner or later, insulin therapy will be instituted because normalisation of plasma glucose levels cannot be achieved with oral blood glucose-lowering agents alone. Insulin, however, induces weight gain39, which in turn aggravates insulin resistance, thus requiring higher doses of insulin: a vicious circle has arisen. Furthermore, insulin therapy can also induce or aggravate already existing hyperinsulinaemia, which could be an independent cardiovascular risk factor37,38,40,41, although the relation may be week42. Weight reduction improves insulin resistance and its associated metabolic features (hy- pertension, dyslipidaemia, hyperglycaemia)43,44. In obese patients this will lead to a lower risk for associated co-morbid conditions (Table 2). It has also been demonstrated that lifestyle intervention programmes (often combinations of behaviour therapy, diet therapy and exer- cise) in overweight and obese patients reduces the number of patients that develop type 2 diabetes mellitus45,46. In severely obese type 2 diabetic patients weight loss is, in fact, the only reasonable therapeutic approach. By reducing insulin resistance, glyca...
