Transcript Pharmacological Approach - e

ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΙΑΣ
Άσκηση και Παχυσαρκία
Κριτική Θεώρηση των Προγραμμάτων Απώλειας
Βάρους
Σακκάς Γεώργιος PhD
Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού
Άδειες Χρήσης
• Το παρόν εκπαιδευτικό υλικό υπόκειται σε άδειες
χρήσης Creative Commons.
• Για εκπαιδευτικό υλικό, όπως εικόνες, που υπόκειται
σε άλλου τύπου άδειας χρήσης, η άδεια χρήσης
αναφέρεται ρητώς.
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Χρηματοδότηση
• Το παρόν εκπαιδευτικό υλικό έχει αναπτυχθεί στα πλαίσια
του εκπαιδευτικού έργου του διδάσκοντα.
• Το έργο «Ανοικτά Ακαδημαϊκά Μαθήματα Πανεπιστημίου
Θεσσαλίας» έχει χρηματοδοτήσει μόνο τη αναδιαμόρφωση
του εκπαιδευτικού υλικού.
• Το έργο υλοποιείται στο πλαίσιο του Επιχειρησιακού
Προγράμματος «Εκπαίδευση και Δια Βίου Μάθηση» και
συγχρηματοδοτείται από την Ευρωπαϊκή Ένωση (Ευρωπαϊκό
Κοινωνικό Ταμείο) και από εθνικούς πόρους.
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Σκοποί ενότητας
• Ο σκοπός της παρούσας ενότητας είναι η
ανασκόπηση των προγραμμάτων απώλειας
σωματικού βάρους καθώς επίσης και η
κρητική τους θεώρηση.
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Περιεχόμενα ενότητας
Weight-loss Approaches
• Surgical (χειρουργικές)
• Pharmacological (φαρμακολογικές)
• Behavioral (συμπεριφοράς)
• Nutritional Supplements (συμπληρώματα
διατροφής)
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Surgical Approach
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Criteria for Bariatric Surgery
In 1991 the NIH recommended
criteria for patients selection for
bariatric surgery
• Patients seeking therapy for
first time should consider a
non-surgical approach
Patients with
• BMI >40 (νοσηρή παχυσαρκία)
after failing medical therapy
• or with BMI between 35-40
with high risk conditions such
as life threatening
cardiopulmonary problems or
diabetes mellitus after failing
medical therapy
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Criteria for Bariatric Surgery
• Patients should be selected
by a team of expert:
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medical
surgical
psychiatric
nutritional
exercise
• Patients need to :
– be motivated,
– be well informed,
– have realistic weight loss
expectations
– be committed to long-term
follow-up after surgery
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Bariatric Approach
• Bariatric (Βάρος + Ιατρική) Operations are
– Restrictive (περιοριστικές) (limiting the amount of food
ingested)
– Malabsorptive (δυσαπορροφητικές) (limiting the amount of
nutrient absorbed)
• or
– Combination
• The choice of procedure is guided by:
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Patients’ BMI
Age
Comorbidity
The cost of the operation
Patient’s and Surgeon’s choice
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Jejunoileal Bypass (JIB) – 1st method
Παράκαμψη Δωδεκαδακτύλου
• Malabsorptive technique
• Λεπτό έντερο (2.8μέτρα) αποτελείται
από το δωδεκαδάκτυλο, τη νήστιδα
και τον ειλεό
• JIB = Παράκαμψη της Νήστιδας
(σύνδεση Δωδεκαδακτύλου με το
τέλος του Ειλεού)
• Joining the proximal jejunum to the
distal ileum, bypassing a large
segment of the nutrient-absorbing
small bowel
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Roux-en-Y Gastric Bypass (RYGB) – 2nd
method
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The name is derived from the surgeon
that first described it (César Roux)
and the stick-figure representation
that looks like the letter Y
Construction of a small gastric pouch
(σάκος) of 30mL or less
Transection of the stomach
Narrow gastroenterostomy
Lengthening of the Roux limb to 100150 cm
Side effects: stomach wall has the
tendency to stretch and the stoma to
enlarge
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Complication for RYGB
• Mortality rate is 0.5%
• Early complications (επιπλοκές)
• Anastomotic leak (1.9%)
• Pulmonary embolism (0.6%)
• Wound infection (2.9% laparoscopic
vs 6.6% open operation)
• Late complications
• Incisional hernia (0.5% laparoscopic
vs 8.6% open oper.)
• Stenosis of the gastrojejunal
anastomosis (4.7% in 2.5 years)
• Bowel obstruction (3.2% in 2.5
years)
• Gallstone formation (32%)
• Malnutrition
• Low levels of: iron, vitamin B12,
vitamin D and Calcium
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Vertical Banded Gastroplasty (VBG) – 3rd method
Γαστρικός Ρυθμιζόμενος Δακτύλιος
• 14 cm3 vertical gastric pouch
• Polyporopylene band acting as
the stoma
• Prevention from stretching
Laproscopic Adjustable Gastric Banding (LAGB)
• To correct the changes in stoma diameter with
the passage of time the band was modified by
adding an inflatable silicone band around the
uppermost part of the stomach
• The correction is done by the laparoscopic
method usually at the doctor’s office based on
weight loss and appetite
• Requires 5-6 visit the first year and 2-3 visits
the second year
• This is the most widely used method in EU
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Complication for LABG
• Mortality rate is 0.05%
• Early complications
– Wound infection (2.9%)
• Late complications
– Gastric prolapse or band slippage (ρήξη ή μετακίνηση
του ελαστικού σφιγκτήρα)
– Herniation of stomach around the band, resulting in
an enlarged gastric pouch and partial or complete
gastric occlusion (5%)
– Port and tubing problems (προβλήματα στην συσκευή
ρύθμισης του σφιγκτήρα) – require surgical repair
– Removal of the adjustable bands due to: failed weight
loss, band erosion, esophageal dilation, or dysphagia
(3-6%)
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Outcomes from Bariatric Surgery
• The majority of the patients
loose the 50% of their excess
weight during the first year
– If you are 1.75m and 75kg your
BMI is 25 and if you are 150kg
your BMI is 48
– meaning you have 75 kg excess
weight, to loose 50% of your
excess weight means to loose
35-40 kg
• Weight loss average 0.7 to 1 kg
per week for the first 2 years of
surgery
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Outcomes from Bariatric Surgery
• 17% of the patients lost less than
50% of the excess weight in 5 years
– this is considered as “insufficient
weight loss”
• After RYGB or LAGB surgery
patients experience:
– 75% resolution of diabetes
– 74% improvement of dyslipidemia
– 94% resolution of obstructive sleep
apnea
– 55% resolution of hypertension
– 100% improvement of asthma
– 76% resolution of
gastroesophageal reflux
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Bariatric Surgery & Extra Skin
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Pharmacological Approach
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Pharmacological Approach
• Sibutramine and Orlistat are the most
used drug for treating obesity
• Sibutramine (Meridia): Inhibitor of
the re-uptake of serotonin,
norepinephrine and dopamine;
increase the satiety-producing effects
of serotonin – decrease hunger
– Side-effects: anorexia nervosa,
hepatic/renal impairment, coronary
disease, arrhythmias
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Pharmacological Approach
• Sibutramine and Orlistat are the
most used drug for treating obesity
• Orlistat (Xenical): decrease the
absorption of dietary fat by
inhibiting enzymes (lipases) which
are necessary for the breakdown
and absorption of fat
– Side-effects: chronic malabsorption
syndrome, diarrhea
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Behavioral Approach
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Behavioral Approach
• Behavior-modification programs in obesity
– Modify eating habits
– Increase physical activity
– Promoting better health
• This system provides appropriate rewards
when patients exhibit the desire behavior
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Modify Eating Habits
• Keep a dietary intake log
• Eat breakfast
• Eat small and frequent meals
• Do not eat junk food (fast food)
• Cut down alcohol consumption
• Do not eat 3 hours before you go to sleep
• Avoid high calories food (deserts, cakes etc)
• In 18 wk of therapy, patients achieved 9.9kg
weight loss but only the 66% of these patients
maintained this weight after 52 wk
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Increase Physical Activity and
Promote Better Health
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Walk every day for half to one hour
Take the elevator from the 1st floor
Park your car one block away
Park your car on the distant spot
Play team games with your friends
Take a dog for a walk – is your personal trainer
• In a 30 months trial, patients with increased physical
activity levels lost more than 5 kg vs 1kg in those that
they did not advice to increase physical activity
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Nutritional Supplements
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Nutritional Supplements
• Providing Nutrients
– In hypocaloric diets (decrease energy intake)
• Stimulating Weight Loss
– Diminishing hunger
– Increasing resting metabolic rate
• Information about Dietary Supplements can be found in:
– www.cfsan.fda.gov, www.ods.od.nih.gov, www.nas.org,
www.eatright.org/public/conferencesAndEvents/92_supplguide.
cfm, www.iom.edu, www.naturaldatabase.com
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Nutritional Supplements
• Terminology- Ορολογία
– DRI: Dietary Reference Intake (αναφορά διαιτολογικής κατανάλωσης)
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Composition of diets for schools, prisons, hospitals or nursing homes
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Industries developing new food stuffs
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Healthcare policy makers and public health officials
– RDA: Recommended Dietary Allowances (προτεινόμενηεπιτρεπόμενη διαιτολογική κατανάλωση)
– AI: Adequate Intake (επαρκείς κατανάλωση)
– UL: tolerable Upper Levels (ανώτερα επιτρεπόμενα όρια κατανάλωσης)
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Dietary Supplements for Achieving
Nutrient Adequacy
• Nutrient-containing dietary supplements contains essential
nutrient that might be low or lacking in reducing diets (very low
calories diet<800 - 500 calories, low calories diet 1200-1500
calories)
• These are:
– multivitamins (100% RDA)
– Calcium, Iron, Vitamin C
– B complex
– Vitamin D + Calcium
– Electrolytes
– Potassium (K)
– Protein and amino acid complex
– Formulated food
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Dietary Supplements for Stimulating
Weight Loss
• Stimulate or enhance weight loss (for those in diet) by
altering body functions (anorectic effect or increase energy
output)
• Dietary supplements are regulated as FOODS and the law
generally assumes that are safe unless proven
otherwise…..
• Some of those supplements might interact with other
medication
• Some of the ingredients are unknown or uncharacterized
• Some are contaminated
• Do not use them during: Pregnancy, Lactation, or
immediately before surgery
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Ephedra (Ma huang)
• Supplements contain Ephedra,
psedo-epherda have shown:
– Sort term (< 6 months) efficacy –
it works!
– Adverse Events: nausea, vomiting
psychiatric symptoms, autonomic
hyperactivity, palpitations
– Concerns: seizure, stroke,
myocardial infraction, deaths
• Sale prohibited in the US since
April 2004
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Grapefruit - Bitter Orange – Citrus Aurantium
Seville orange, sour orange, green orange, neroli oil,
kijitsu
• It has been suggested that it is the “ephedra substitute”
• Contains α & β agonist activity including synephrine and
octopamine
• Synephrine (oxidrine) is a sympathomimetic amine
structurally similar to epinephrine
• Increase blood pressure – special caution is recommended in
those with hypertension, CVD, glaucoma
• Some of the compounds in Citrus are inhibiting cytochrome
P, which will increase the serum levels of many drugs
• There are not adequate evidence for efficacy
• There are not enough evidence for side effects
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Chromium Picolinate
• Chromium + Picolinic Acid
• Studies have shown a small but
significant reduction in body weight
of approximately 200gr / week
• No adverse reactions have been
reported
• Further research is needed
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Conjugated
(συγκολλημένα)
Linoleic Acid (CLA)
• In animals reduce body fat and
increase lean body mass
• In humans CLA consumption
does not show the same results
• No evidence for weight
reduction
• Instead there are evidence that
increase hepatic size and
increase insulin resistance
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Chitosan
• Chitosan is produced by Chitin which is
found in the exoskeleton of lobsters and
other shellfish
• It claims that reduce fat absorption from the
diet and therefore could reduce body
weight
• Studies have shown that NO-EFFECT at all
• Some gastrointestinal symptoms have been
reported
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Green Tea
• Green tea contains several
polyphenolic components
known as catechins
• Catechins increase fat utilization
from the mitochondria and exert
an antioxidant effect
• In humans reduce LDL, body fat
and visceral fat in 12 weeks of
supplementation
• Reduces Iron body levels
• Further studies are needed
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Other Dietary Supplements
• Little evidence of benefit for
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Garcinia bambogia
glucomannan,
Guar gum
B-hydroxymethylbutyrate
Pyruvate
Yarba mate
Yohimbe
• Some GI problems in Guar gum
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Calcium Supplements
• The data are inconsistent
• In animals Ca supplementation
reduce body fat
• In humans in randomized double
blind placebo controlled studies Ca
did not effect body weight
• No adverse reactions
• Further studies are needed to
establish whether Ca supplements
or dairy products can increase
weight loss in Low-calories diet
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Summary
• Bariatric Surgery is the most effective way for
loosing weight (when all other ways have failed)
• Obesity-medication have many side-effects
• In very low-calories diet, it is very important to
take nutrient supplements to improve the
nutritional status and avoid malnutrition
• There are not enough evidence to support that
dietary supplements enhance weight reduction
and promote health
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ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΙΑΣ
Τέλος Ενότητας