OBESITY GOSSIPS AND HICCOUGHS

RANJINI DATTA HOD, CLINICAL DIETETICS KPC MEDICAL COLLEGE & HOSPITAL

Are We Gaining Too Much Weight!

Overweight is a major

problem, throughout the world Obesity is the second leading cause of preventable deaths in the world (tobacco is the first). People who are obese have much higher risks of many serious health problems than nonobese people.

 Obesity affects every

system of the body and increases the risk of illness from about 30 serious medical conditions like Diabetes Hypertension Obstructive sleep apnea and pulmonary hypertension Heart disease embolism

 Fatty liver disease and nonalcoholic steatohepatitis Gastroesophageal reflux disease Stroke Blood clots, deep venous thrombosis, and pulmonary

Urinary incontinence Osteoarthritis Gallstones Colon cancer

Endometrial cancer
Depression

Why Are We Gaining Weight?

Were eating too

much
Large portions Empty calories

We sit too much We get too little

physical activity

Treatment of Obesity
Diet Physical activity Behavior modification Medication

Surgery

 The first step toward weight loss is to eat less and to exercise more. The goal is not to lose all the excess

weight. Losing even 10% of your weight can significantly lower you risk of developing obesity-related medical problems

Diets
Should consider:
Percentage of

macronutrients Kcal intake Vitamins & Minerals Safety / efficacy of supplements Is the diet sustainable?

Principles of Weight Loss Two assumptions:

1.) Energy expenditure will remain constant or increase. 2.) Dieter will stick with nutritional modifications until desired weight is established.

Dieting Basics
1.Evaluate energy needs 2.Set degree of energy

deficit/ rate of weight loss desired 3.Calculate energy intake needed 4.Decide on macronutrient composition 5.Decide on meal/snack frequency 6.Decide on variety 7.Design weekly menus 8.Moniter and adjust as needed during dieting

Set Degree of Energy Deficit/ Rate of Weight Loss Desired

Your choices: Low calorie diet-> 800 kcal/day Very low calorie diet-< 800 kcal/d Weight maintenance diet-based on current EE Rate of weight loss depends on EE: 7(EE-EI on diet)/3500 = predicted weekly loss, lbs Each 500 kcal/d deficit = 1 lb/wk loss 3500 x lbs per week loss desired/ 7 d = daily diet deficit needed

EE daily diet deficit in kcal = daily kcal allowed on diet Example: I weigh 160 lbs, wish to lose 1 lb/wk: EE = 160 x 16 = 2360 kcal/d Deficit needed = 3500/7 = 500 kcal/d 2360 500 = 1860 kcal/d is the prescribed diet

Caloric Intake and Weight Loss

Determine normal, average caloric intake for weight maintenance. Restrict calories to cause a deficit that will elicit the loss of 1 2 lbs / week (3500 7000 kcals) Example 78 kg female wishes to lose

30 lbs. (105,000 kcals) Currently consumes 2800 kcals Reducing diet to 1800 kcals = 1000 kcal deficit. 7000 kcal deficit / week = 2 lbs Desired weight loss in aprox. 15 weeks

Set Point Theory

Most researchers believe in

the Set Point theory

We all have an internal set

point for body fat and our body does everything it can to maintain that % BF Early in diet, caloric deficit results in weight loss from fat stores being burned and loss of body water from glycogen depletion. Eventually, Hypothalamus detects changes in fat stores and decreases BMR to replenish lost fat

BMR: Caloric restriction w/ no exercise

BMR may be reduced by 45% Repeated bouts of starvation result in faster and more

25

VO2 (rest) L/HR

24 23 22 21 20 19 4 8 12 16 20 24 28 32 Days of food restriction

significant lowering of BMR Loss of LBM further accelerates decrease in BMR

BMR decreased from 122.5 kcals/hr to 105 kcals/hr (420 kcals/day)

Weight Cycling (Yo-Yo effect)

Studies have proven that weight is readily regained at a much faster rate than it was lost.
Animal studies: twice

Enzymatic changes
LPL: activity skyrockets

the time to lose weight on second attempt, 1/3 time to regain it.

when body fat is lost (even more so in obese people) promotes fat storage Leptin: Levels decrease when fat stores diminish increases appetite

We Are Turning To Fad Diets

The Lure of Low-Carb /Ketogenic Diets

Lose weight quickly Body is forced to mobilize fat stores
Less hunger Unlimited amounts of

meat and fat Low-carb foods are flooding the market in the grocery store in restaurants

Low-Carb Menu

Low Carb Diet Claims

Carbohydrate is the cause

of weight gain

too much insulin is released, causing hunger, cravings and weight gain

Low-carb diets cause

weight loss Typical low-carb diet: Initially severely restricts foods with carbohydrate
Fruits, vegetables, milk,

whole grains

Often allows unlimited

meats and fats

Quick Weight Loss

Carbohydrate stored in muscle and liver

Water

Energy

Are Low Carb Diets Harmful?

Lack important nutrients
found in fruits, vegetables,

low-fat dairy products and whole grains

High in cholesterol and

saturated fat May increase risk of heart disease May increase the risk of: Bone loss Kidney stones Gout (painful joint disease) Kidney disease Dehydration and constipation

Low carb diets may hinder the performance of athletes

May run out of energy

too quickly Carbohydrate needed to replenish stored carbohydrate in muscles (glycogen) Low-carb diets may cause dehydration

How Are Carbs Reduced?

Reduce or eliminate flour
Use proteins from soy

beans, wheat, oats, milk, eggs Add fiber

Replace sugar
Sugar alcohols (maltitol)

or sugar substitutes

Reduce the serving size

Evaluating a Low Carb Diet

Low in:
Calcium Fiber Antioxidants,

phytonutrients

High in:
Total fat
Saturated fat Cholesterol

Increasing Your Activity Level

Moderate physical activity, such as walking, helps you lose weight and keep your weight down. At least 30 minutes of exercise a day is recommended. Walking :When walking for weight loss, distance is important, not speedOther activities Riding bicycle or exercise bike and pedal while watching TV or talking on the phone Water aerobics is a popular choice. Start slow. Even weekend chores use calories if you do them the physical way.

Exercise
Exercise can help off set the lowering of BMR Increases in muscle mass = increase in BMR Enzymatic changes that promote lipolysis
Composition of Weight Loss w/ Food Restriction & EXERCISE*
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Days 1-3 Days 11-13 Days 21-24

Water Protein Fat

Daily 0.23 Weight kg Loss

0.82 kg

0.18 kg

1000 kcals/day & 2.5 hrs. of exercise/day*

Hints for Weight Loss Success

:

Food and exercise habits of successful weight losers Follow a reduced calorie, low-fat diet Exercise at least 30 minutes most days Keep a record of what and how much is eaten Eat breakfast every day Check weight weekly

How Medication Can Help You Lose Weight

With one exception, the

medications used to treat obesity work by suppressing the appetite. Appetite suppressants decrease appetite by increasing levels of serotonin or catecholamines, such as norepinephrine. Serotonin and catecholamines are brain chemicals that affect mood and appetite.

The exception, Xenical,

works by disrupting lipase, the enzyme in the intestines that controls absorption of fats. It prevents digestion of about 30% of the fats eaten. These undigested fats are not absorbed, but excreted, thus lowering the calorie intake.

How Medication Can Help You Lose Weight

Meridia
Sibutramine (Meridia) is a

prescription medication approved by the FDA in 1996. It may be recommended for people who are more than 30 pounds overweight. Unlike phentermine, sibutramine is a nonamphetamine appetite suppressant that may also have antidepressant properties.

This drug may increase blood

pressure, so regular monitoring is essential. It affects levels of 2 brain chemicals, serotonin and norepinephrine, which control mood and appetite. In clinical trials, the average weight loss was 5-10% of body weight, when combined with a reduced calorie diet. It may also help to maintain weight loss. Sibutramine may cause serotonin syndrome, a rare but serious condition.

Xenical
Orlistat (Xenical) is a

prescription medication approved by the FDA in 1999. Your doctor may prescribe it if you weigh more than 30% over healthy body weight or have a BMI greater than 30.

Orlistat works in the digestive

system to block the digestion of about 30% of dietary fat eaten. The undigested fat is then eliminated in bowel movements. It also block digestion of the fatsoluble vitamins A, D, E, and K, so a supplement should be taken. The undigested fat will increase in frequency and number ofbowel movements. They may be unable to control or oily in consistency. These effects will be more pronounced if your meals contain more than 30% fat.

Risks and Benefits of Weight-Loss Medications

Benefits
The possible benefits of

Risks
Side effects are especially a

these drugs in the short term include weight loss, which may lower the risk of some obesity-related health problems

concern in patients who may be healthy other than their obesity. Other concerns include the potential for abuse of the drugs (all except Xenical are controlled substances). People taking these drugs often find that their weight loss tapers off after 4 to 6 months. This is usually attributed to development of tolerance,

Surgery in the Treatment of Obesity

Surgical treatment of

obesity is also known as bariatric surgery or weight loss surgery. Surgery is currently the most effective treatment for morbid obesity resulting in durable and sustainable weight loss and accompanying health improvements.

Surgery in the Treatment of Obesity

Criteria for Surgery Weight loss surgery candidates must fulfill all the following criteria:

Body mass index (BMI) greater than 40 or a BMI of at least 35 with obesity-related medical problems such as diabetes, heart disease, hypertension, sleep apnea, or high blood lipids
Previously attempted nonsurgical weight-loss treatments and failed to achieve long-term weight loss Well-informed and motivated for long-term follow-up to achieve substantial weight loss Acceptable medical risks for surgery

Surgery in the Treatment of Obesity

Classifications of Surgery Surgeries for weight loss can be classified as follows: Restrictive procedures that limit the amount of food intake by reducing the size of the stomach Malabsorptive procedures that interfere with absorption of food from the digestive tract

Combined restrictive and malabsorptive procedures

Operative Procedures
Gastric bypass

Roux-en-Y gastric bypass is the most commonly performed weight loss procedure in the United States. This operation both restricts food intake and limits absorption of food. A part of the stomach is closed off, creating a small pouch. This restricts the amount of food that you can eat at one time. Most people find they can eat less than 1 cup of food at a time after the operation. Food must be chewed very well. Overeating or not chewing food finely will result in cramping, nausea, and vomiting.

 Laparoscopic adjustable gastric binding

This is a purely restrictive procedure. It involves placing an inflatable silastic band around the uppermost part of the stomach. This results in a smaller upper stomach pouch and a narrow opening between the upper and lower parts of the stomach. This induces and early feeling of fullness and thereby decreases food intake

 Biliopancreatic diversion

Biliopancreatic diversion (BPD) is a malabsorptive procedure with some restrictive component. A part of the stomach is removed and the remaining part is attached directly to the small intestine near its end. BPD is used much less often than Roux-en-Y because it has a greater risk of complications.

 Vertical banded gastroplasty

Vertical banded gastroplasty (VBG, stomach stapling) is a restrictive procedure that traditionally was done by applying bands or staples to the stomach. This procedure is rarely performed today due to the high failure rate.

Benefits and Risks of Weight-Loss Surgery

Benefits of weight-loss surgery

Weight loss: Most patients begin to lose weight right

away. Some gain some of the weight back, but most are able to keep the weight off for long periods In general, combined restrictive and malabsorptive procedures (like gastric bypass) are more successful than restrictive procedures (like adjustable gastric banding) at promoting weight loss.

 Improved health: Most obesity-related medical

conditions improve drastically after surgery, especially diabetes, sleep apnea, and hypertension. After surgery mortality rate is reduced and improvements are seen in many of the health risks associated with obesity. Overall, quality of life, self image, and mobility are reported to be better. People who undergo one of these procedures are much more likely to reach their goal and keep weight off if they also adopt a plan of healthy eating and regular exercise.

Risks of weight-loss surgery

"Dumping syndrome" -

Patients experience nausea, abdominal cramping, and diarrhea after eatingsugar Narrowing or ulcer formation or leak at the stomach to intestine connection Blood clot in the leg Incisional hernia

Malabsorption arise if

patients with gastric bypass do not take supplemental vitamins, iron, and calcium. Vitamin deficiencies (A, B-12, D, E, and K) Deficiencies of vitamin B-12, folate, and iron can cause anemia. Mineral deficiencies may lead to osteoporosis and other bone disorders


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