Nutrition and Obesity

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Transcript Nutrition and Obesity

Presented by: Dr. A.Nadjarzadeh
Tehran University of Medical Sciences
‫فشارخون‬
‫كم خوني‬
‫ديابت‬
‫اختالالت‬
‫متابوليسمي‬
‫اختالالت‬
‫گوارش ي‬
‫اختالالت‬
‫كبدي‬
‫افسردگي‬
‫چاقي‬
‫برخي‬
‫سرطان ها‬
‫ايمني و‬
‫عفونت‬
‫امراض‬
‫قلب و عروق‬
‫چربي خون‬
‫اختالت كليوي‬
‫پوكي استخوان‬
Environment stimulus
 High fat , energy dense foods
 Palatable, low cost, easily available foods
 Large portion sizes
 Sedentary behavior
 Activity of daily living
 Work-related physical activity
 Which macronutrintes have more effects on obesity?
 Energy density of diet?
objectives
 Describe the components of a successful weight
management program
Diagnosis
 BMI
 Waist circumference
Determination of the skeleton
 r= Ht (cm)/wrist (cm)
Small
Medium
Large
r (men)
r(women)
>10.4
>11
9.6-10.4
10.1-11
<9.6
10.1>
‫منایه های چاقی‬
‫‪BMI ‬‬
‫کم وزن‬
‫‪> 18‬‬
‫‪ 18.5 – 24.9‬طبیعی‬
‫اضافه وزن‬
‫‪25 - 29.9‬‬
‫چاقی درجه ‪1‬‬
‫‪30 – 34.9‬‬
‫چاقی درجه ‪2‬‬
‫‪35 – 39.9‬‬
‫چاقی درجه ‪3‬‬
‫>= ‪40‬‬
WHR
ٌWomen 0.85 =<
Men
0.95 =<
Waist circumfrance:
women 88cm <
>cm 102 men
Energy needs
 BMI and skeleton
 Herris-benedict ( adjusted weight)
 24-hr recall and decrease 500 Kcal
‫انرژي موردنيازروزانه در افراد ‪ 50‬ات ‪ 19‬ساله‬
‫ابفعاليت متفاوت‬
‫كيلوكالري در كيلوگرم وزن بدن در روز‬
‫نوع فعالیت‬
‫خیلي سبك‬
‫مردان‬
‫زنان‬
‫سبك‬
‫سنگین‬
‫خیلي شدید‬
‫‪30‬‬
‫مردان‬
‫‪38‬‬
‫‪35‬‬
‫مردان‬
‫‪41‬‬
‫زنان‬
‫‪37‬‬
‫مردان‬
‫‪50‬‬
‫زنان‬
‫‪44‬‬
‫زنان‬
‫متوسط‬
‫‪31‬‬
‫مردان‬
‫‪58‬‬
‫زنان‬
‫‪51‬‬
Selecting strategy
Depends on the:
 goals of the patient
 his or her health risks
Weight Loss Supplements
“People do not want to make lifestyle changes. They are
looking for the quick fix.”
Realistic weight goals
 0.5-1 kg (1% of BW) per week
 Slow/stop after 24 weeks (plateau effect)
Weight loss program
 Food choice change
 Exercise
 Behavior modification
 Nutritional education
 Psychological support
 Medication
 surgery
Restricted-Energy Diet
 A balanced energy restricted diet
 Nutritionally adequate except for energy
 500-1000 caloric deficit per day
 Increase physical activity
 High CHO (50-55%), protein (15-25%), fat (not more
than 30%)
Extra fiber
 Reduce caloric density
 Promote satiety by delaying stomach emptying time
 Decrease to a small degree the efficiency of intestinal
absorption
 SCFA
blood FFA and hepatic Glc production ,
 Increase of insulin sensitivity
insulin secretion
increase of fat oxidation and decrease of fat store
 Fat
 Sugar
 Alcohol (sparing effect on fat) (habitual use of ethanol
should be a risk factor for obesity)
 Vitamin, mineral supplements (1200 Kcal for women
and 1800 Kcal for men)
Increased
cheeseburger size:
257 more calories
Lifting weights for
1 hour and 30 minutes
burns approximately
257 calories*
*Based on 130-pound person
Exchange System Diets
 Easily manipulated method
 1200 kcal
Milk, skim 2 ex, Veg 3 ex, Fruit 4 ex,
bread 5 ex , meat (lean) 5 ex, fat 3 ex.
‫الگوي واحدهاي رژمي براي درايفت سطوح متفاوت انرژي‬
‫سطوح انرژي ( كيلو كالري )‬
‫غالت‬
‫سبزي‬
‫ميوه‬
‫شير‬
‫كم چرب‬
‫گوشت‬
‫چرب‬
‫چربي‬
‫كم‬
‫‪3200 3000 2600 2200 2000 1800 1500 1200‬‬
‫‪17‬‬
‫‪15‬‬
‫‪13‬‬
‫‪11 9‬‬
‫‪8‬‬
‫‪7‬‬
‫‪6‬‬
‫‪6‬‬
‫‪6‬‬
‫‪6‬‬
‫‪5‬‬
‫‪5‬‬
‫‪5‬‬
‫‪4‬‬
‫‪3‬‬
‫‪6‬‬
‫‪6‬‬
‫‪5‬‬
‫‪4‬‬
‫‪4‬‬
‫‪4‬‬
‫‪3‬‬
‫‪2‬‬
‫‪3‬‬
‫‪3‬‬
‫‪3‬‬
‫‪3‬‬
‫‪3‬‬
‫‪2‬‬
‫‪2‬‬
‫‪2‬‬
‫‪8‬‬
‫‪8‬‬
‫‪7‬‬
‫‪6‬‬
‫‪6‬‬
‫‪6‬‬
‫‪5‬‬
‫‪4‬‬
‫‪13‬‬
‫‪12 10‬‬
‫‪8‬‬
‫‪7‬‬
‫‪6‬‬
‫‪5‬‬
‫‪3‬‬
Others
 Formula diets and meal replacement program
 Commercial programs
 Extreme energy restriction
 Very low calorie diet
VLCD
 Very low calorie diets:200-800 Kcal
 high protein
 12-16 weeks
 rapid weight loss
 BMI above 30, or 27-30 with comorbidities or risk
factors
 Risk of death
VLCD risks
 Cardiac complication
 Potassium loss
 Loss of body protein
 Increase of urinary ketones
 Increase of serum uric acid
 Increase of cholesterol (gallstone)
 Temperature sensitivity
 Hair loss, digestive
Orlistat in primary care
0
Change in
body weight
(%)
Placebo (n=120)
–2
Orlistat 120 mg (n=149)
*p<0.001
–4
–4.3%
–6
*
–8.5%
–8
–10
–10 –4 0 4 8 12 16 20 24 28 32 36 40 44 48 52
Week
Completers: BM14161
STORM – Mean bodyweight changes during weight loss
and108weight maintenance phases over 2 years
Weight loss
106
Weight maintenance
104
102
100
Control
98
96
94
Sibutramine
92
90
88
0
2
4
6
8
10
12
NB: Same diet and exercise for both sibutramine and control
James et al, Lancet 2000
14
16
18
Month
20
22
24
XENDOS
(XENical in the prevention of Diabetes in Obese Subjects)
 3304 obese patients in placebo controlled trial
 4 years duration, multicentre, prospective
 79% patients normal glucose control, 21% IGT
 Orlistat treated group had a 37% relative risk reduction in
developing diabetes compared to placebo at 4 years
 Orlistat assisted weight loss improved significantly other
metabolic parameters (BP, lipids and BMI)
Nondiet approach
 Eat healthfully
 Being attuned to hunger and satiety cues
 Incorporate physical activity
Obesity in children
 Genetic
 Environment
Genetic
 Obese parents, obese children
 Effects of genes on food intake and energy expenditure
Assessment of Overweight in
Children
 1997 Expert Panel


The Maternal and Child Health Bureau, Health Resources and
Services Administration, the Department of Health and Human
Services
PEDIATRICS Vol. 102 No. 3 September 1998, p. e29
 Recommends that BMI be routinely used to screen
children for overweight
 Defined


Overweight as a BMI for age over the 95th percentile
Risk for overweight as a BMI for age between the 85th and 95th
percentile
Obesity and the Metabolic Syndrome in Children and
Adolescents
Criteria for Metabolic Syndrome in Children
 Obesity (instead of waist circumference)
 Obese = z-score >2.0 for BMI
 Moderate Obese = z-score 2.0-2.5
 Severe Obese = z-score > 2.5
 Metabolic values
 TG: > 95th pct
 HDL-C: < 5th pct
 Glucose intolerance following OGTT
 Insulin resistance = [fasting glu]x[fasting plasma insulin]/22.5
Obesity and the Metabolic Syndrome in
Children and Adolescents
 Metabolic Syndrome
 Cluster of metabolic abnormalities associated with insulin
resistance
 Diagnosis of Metabolic Syndrome in Adults
 Three or more of the following:
 Abdominal Obesity


men > 40” waist circumference
women > 35” waist circumference
 Hypertriglyceridemia (>150 mg/dl)
 Low HDL


men < 40 mg/dl
women < 50 mg/dl
 Pre-hypertension (>130/>85 mmHg)
 Pre-diabetes (> 110 mg/dl)
Parent Weight Change as a Predictor of Child Weight Change in
Family-Based Behavioral Obesity Treatment
 Family-based behavioral treatment
 Parenting techniques



Reinforcement
Stimulus control
Environmental restructuring
 Obese parents make similar behavioral changes
Reducing children’s television viewing to prevent
obesity: A randomized controlled trial.
 Many observational studies have found
associations between television viewing and
child/adolescent adiposity.
 Reviewed in AAP’s Policy Statement
 Pediatrics 112:424-430 (2003)
 25% children watch >4hrs TV/day
 BMI of children who watch >4hrs per day significantly
greater than those watching < 2hrs per day
 TV in child’s bedroom significant predictor of
overweight
treatment
 Objectives:
healthy nutritional behavior
increase of physical activity
Not Ideal Body Weight
treatment
 It is based on
age
BMI percentile
comorbidities
 <= 7 years: weight maintenance
but if there is comorbidity and BMI >= 95 centile
Weight reduction is needed.
 > 7 years , BMI>=95 centile: 0.5 kg per month
Weight Loss Supplements
Ephedra Alkaloids and Caffeine Compounds
 Shekelle, et al. reported in 2003 a meta-analysis of
RCTs showing ephedra had a weight loss of 2lb more
per month compared to placebo
 However, they also showed they had a 2.2 to 3.6-fold
increase in adverse events (psychiatric, autonomic,
cardiovascular and gastrointestinal symptoms)
Weight Loss Supplements
Ephedra Alkaloids and Caffeine Compounds
 FDA MedWatch:
 87 reports of ephedra adverse events between June 97
and March 99
 HTN, arrhythmias, MI, stroke and seizures
 10 events led to death
 13 others yielded permanent disability
 9 of the 23 were at the recommended doses in
individuals without cardiovascular risk factors
Weight Loss Supplements
Ephedra Alkaloids and Caffeine Compounds
 Ephedra comprised 0.8% of dietary supplement sales
in 2001
 However, in 2001, they were responsible for 64% of all
herb-related adverse events reported to the U.S. Poison
Control Centers
 Bitter orange and country mallow and other ephedralike substances are in the “Ephdra-free” weight loss
supplements
Weight Loss Supplements
Ephedra Alkaloids and Caffeine Compounds
“Some products, especially those containing stimulants,
can cause short-term weight loss. (Likewise,
amputation of an extremity can cause weight loss.)
But the risk outweighs the benefit.”
- Scott GN, et al. Problems with Weight Loss Products. Pharmacist’s
Letter/Prescriber’s Letter 2006;22:1-3.
Weight Loss Supplements
Ephedra Alkaloids and Caffeine Compounds
 The Good:
 They work
 The Bad:
 They have many adverse events
 The Ugly:
 They can kill
 Ephedra sales banned by the FDA in April 2004
Ephedra Ban Ruled Invalid
 Ephedra Diet Pills
On April 13, 2005 the 2004 Final Rule issued by the
FDA banning Ephedra was overturned by a Federal
Judge (Case No. 2:04CV409 TC). An appeal was filed
on June 13, 2005 however it will take some time for this
case to be decided.
Weight Loss Supplements
Chromium and Ginseng
 Modulate carbohydrate metabolism
 Chromium
 Ginseng
Weight Loss Supplements
Chromium and Ginseng
 Chromium is thought to play a role in carbohydrate
and lipid metabolism
 Chromium deficiency is associated with
hyperglycemia, hyper-insulinemia,
hypertriglyceridemia and low HDL
 Three (small) RCTs of chromium supplements showed
no difference in weight loss when compared to placebo
Weight Loss Supplements
Chromium and Ginseng
 No adverse events at recommended dose of chromium,
but rhabdomyolysis and renal failure have been
reported at super-therapeutic doses (1000mcg vs 200
to 400mcg)
Weight Loss Supplements
Chromium and Ginseng
 Ginseng has preliminary data suggesting that it may
improve glucose tolerance
 No RCTs in humans have shown greater weight loss
with ginseng when compared to placebo
Weight Loss Supplements
Chromium and Ginseng
 The Good:
 They may be safe
 The Bad:
 No good RCTs to show efficacy
 The Ugly:
 Potential renal failure
Weight Loss Supplements
Glucomannan, Psyllium, and Guar Gum
 Increases satiety
 Guar gum
 Glucomannan
 Psyllium
Weight Loss Supplements
Glucomannan, Psyllium, and Guar Gum
 Action: soluble fiber that absorbs water within the gut
causing a fullness sensation
 May improve control of diabetes and hyperlipidemia
(fiber affect)
Weight Loss Supplements
Glucomannan, Psyllium, and Guar Gum
 Glucomannan: 3 (small) RCTs showed dosages of 3 to
4g per day were tolerated and yielded modest weight
loss
 Psyllium: Showed no difference in weight loss in
patients with Type 2 Diabetes (but did improve glucose
and lipid parameters)
 Guar gum: 11 RCTs showed no benefit over placebo
Weight Loss Supplements
Glucomannan, Psyllium, and Guar Gum
 The Good:
 They may be safe
 The Bad:
 No good RCTs to show efficacy, save modest weight loss
with Glucomannan
 The Ugly:

Weight Loss Supplements
Act on Fat Oxidation or Synthesis
 Increase fat oxidation or reduce fat synthesis
 L-carnitine
 Hydroxycitric acid
 Green tea
 Vitamin B5
 Licorice
 Conjugated linoleic acid
 Pyruvate
Weight Loss Supplements
Act on Fat Oxidation or Synthesis
 Hydroxycitric Acid:
 Inhibits mitochondrial citrate lyase, leading to
decreased acetyl coenzyme A production and decreased
fatty acid synthesis
 12-week RCT of mildly overweight women showed nearly
3 lb weight loss at 750mg
 However, a larger study of men and women showed no
difference at 1,500mg dose
Weight Loss Supplements
Act on Fat Oxidation or Synthesis
 Conjugated linoleic acid:
 In mice, reduces fat deposition postulated to be through
increased fat oxidation and decreased triglyceride
uptake in adipose tissue
 12-week RCT of 3.4 to 6.8 g/day showed no change in
BMI and mild to moderate GI symptoms
 May increase insulin resistance
Weight Loss Supplements
Act on Fat Oxidation or Synthesis
 Green tea in one study increased fat oxidation and
thermogenesis; however, study not designed to assess
weight loss
 Licorice reduced body fat mass without change BMI;
however, shown to also have adverse outcomes of
pseudoaldosteronism, hypertension and hypokalemia
Weight Loss Supplements
Act on Fat Oxidation or Synthesis
 Pyruvate at 6g per day had a 2 lb 10oz weight loss
compared to placebo over six weeks
 Vitamin B5 and L-carnitine have not had any trial to
support claims of causing weight loss
WeightActLoss
Supplements
on Fat Oxidation or Synthesis
 The Good:
 They may be safe
 Pyruvate may have weight loss
 The Bad:
 Minimal and sometimes conflicting data to support
weight loss
 The Ugly:
 Conjugated linoleic acid may increase insulin resistance
Chitosan
Weight Loss Supplements
 Block dietary fat absorption
 Chitosan
Chitosan
Weight Loss Supplements
 Blocks fat absorption by binding to negatively
charged fat molecules within the intestinal lumen
 Five RCTs (all by the same investigators) showed
effective weight loss
 However, three other well-designed RCTs (by
different investigators) showed no differences in
weight loss
 No proof of increased fecal fat excretion in healthy
individuals taking Chitosan
Chitosan
Weight Loss Supplements
 The Good:
 They appear be safe
 The Bad:
 Some investigators show effectiveness in poorly
designed studies
 Should note be taken by those allergic to shellfish
 The Ugly:
 Different investigators show no effect of Chitosan on
weight loss
Weight Loss Supplements
Water Elimination
 Increase water elimination
 Dandelion
 Cascara
Weight Loss Supplements
Water Elimination
 Dandelion – diuretic activity
 Cascara – laxative affect
 Neither one studied for effectiveness in weight loss
 Theoretically may have same adverse effects of long
term use of diuretics and laxatives (dehydration and
electrolyte abnormalities)
Water
Elimination
Weight Loss
Supplements
 The Good:

 The Bad:
 No studies to show efficacy
 May have adverse events similar to long-term diuretic
and laxative usage
 The Ugly:

Weight Loss Supplements
Enhancement of Mood
 Enhance mood
 St. John’s wort
Weight Loss Supplements
Enhancement of Mood
 St. John’s wort inhibits serotonin re-uptake
 Increase of serotonin is believed to stimulate the
hypothalamus and produce the feeling of fullness
 No studies to show effectiveness in weight loss
Enhancement
of Mood
Weight Loss
Supplements
 The Good:
 They may be safe
 The Bad:
 No good RCTs to show efficacy
 The Ugly:

Miscellaneous
Other Supplements
Weight
Loss Supplements
 Miscellaneous or unspecified
 Laminaria
 Spirulina (blue-green algae)
 Guggul
 Apple cider vinegar
Miscellaneous
Other Supplements
Weight
Loss Supplements
 Spirulina contains phenylalanine, which is reported to
inhibit appetite
 However, in 1981, the FDA declared it to be ineffective
for weight loss and no studies have since looked at it
for weight loss
 Other substances here have also never been studied for
weight loss
Weight Loss Supplements
Enhancement of Mood
 The Good:
 They may be safe
 The Bad:
 No good RCTs to show efficacy
 The Ugly:
 FDA already declared spirulina ineffective
Weight Loss Supplements
 Increase energy
 Block dietary fat
expenditure
 Modulate carbohydrate
metabolism
 Increase satiety
 Increase fat oxidation or
reduce fat synthesis
absorption
 Increase water
elimination
 Enhance mood
 Other miscellaneous or
unspecified
Healthy Diet
and
Exercise
Evidence-based Resources on Dietary
Supplements for Physicians
 Natural Medicines Comprehensive Database
(www.naturaldatabase.com)
 Natural Standard (www.naturalstandard.com)
 E-pocrates (www.epocrates.com)
 ConsumerLab.com (www.consumerlab.com)
 Fugh-Berman A. The five-minute herb & dietary
supplement consult. Philadelphia: Lippincott
Williams & Wilkins, 2003.
 Rotblatt M, Ziment I. Evidence-based herbal
medicine. Philadelphia: Lippincott Williams &
Wilkins, 2001.
Weight Loss Supplements
 Weight Loss Products: Some of these supplements
promise to stop cravings and burn fat. Others claim to
prevent fat and cholesterol absorption, permitting
weight loss without changes to diet. There is no
evidence supporting the products' effectiveness.
"Effortless" weight loss remedies do not work and are
directly tied to the public health concern about
obesity.
* from Dietary Supplement Enforcement Report by the US FDA, December 18, 2002. (www.fda.gov/oc/nutritioninitiative/report.html)
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comment
or
question?