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Nutrition and Obesity

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Title: Nutrition and Obesity


1
Nutrition and Obesity
  • Presented by Dr. A.Nadjarzadeh
  • Tehran University of Medical Sciences

2
(No Transcript)
3
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

4
  • Which macronutrintes have more effects on
    obesity?
  • Energy density of diet?

5
objectives
  • Describe the components of a successful weight
    management program

6
Diagnosis
  • BMI
  • Waist circumference

7
Determination of the skeleton
  • r Ht (cm)/wrist (cm)

r (men) r(women)
Small gt10.4 gt11
Medium 9.6-10.4 10.1-11
Large lt9.6 gt10.1
8
????? ??? ????
  • BMI 18 gt ?? ??? 9.24 5.18
    ????? 9.29 - 25 ????? ??? 9.34 30
    ???? ???? 1 9.39 35 ???? ???? 2
    gt 40 ???? ???? 3

9
WHR
?Women 0.85 lt Men 0.95 lt Waist
circumfrance women 88cm lt
gtcm 102 men
10
Energy needs
  • BMI and skeleton
  • Herris-benedict ( adjusted weight)
  • 24-hr recall and decrease 500 Kcal

11
Energy needs
  • Overweight and obese women
  • TEE
  • 448-7.95age(yr)PA(11.4wtkg619htm)
  • PA1 (sedentary) , 1.16 (low active)
  • PA 1.27(active) , 1.44 (very active)

12
????? ?????????????? ?? ????? 50 ?? 19 ????
???????? ??????
????????? ?? ??????? ??? ??? ?? ??? ??? ??????
31 30 ???? ??? ????? ????
38 35 ??? ????? ????
41 37 ????? ????? ????
50 44 ????? ????? ????
58 51 ???? ???? ????? ????
13
Selecting strategy
  • Depends on the
  • goals of the patient
  • his or her health risks

14
Weight Loss Supplements
  • People do not want to make lifestyle changes.
    They are looking for the quick fix.

15
Realistic weight goals
  • 0.5-1 kg (1 of BW) per week
  • Slow/stop after 24 weeks (plateau effect)

16
Weight loss program
  • Food choice change
  • Exercise
  • Behavior modification
  • Nutritional education
  • Psychological support
  • Medication
  • surgery

17
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)

18
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

19
  • 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)

20
Lifting weights for 1 hour and 30 minutes burns
approximately 257 calories
Increased cheeseburger size 257 more calories
Based on 130-pound person
21
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.

22
????? ??????? ???? ???? ?????? ???? ?????? ?????
???? ????? ( ???? ????? ) 1200 1500 1800 2000 2200 2600 3000 3200
6 7 8 9 11 13 15 17 3 4 5 5 5 6 6 6 2 3 4 4 4 5 6 6 2 2 2 3 3 3 3 3 4 5 6 6 6 7 8 8 3 5 6 7 8 10 12 13 ???? ???? ???? ??? ?? ??? ???? ?? ??? ????
23
Others
  • Formula diets and meal replacement program
  • Commercial programs
  • Extreme energy restriction
  • Very low calorie diet

24
VLCD
  • Very low calorie diets200-800 Kcal
  • high protein
  • 12-16 weeks
  • rapid weight loss
  • BMI above 30, or 27-30 with comorbidities or risk
    factors
  • Risk of death

25
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

26
Orlistat in primary care
27
STORM Mean bodyweight changes during weight
loss and weight maintenance phases over 2 years
108
Weight loss
Weight maintenance
106
104
Expected weight gain 2kg/year
102
100
Control
98
Body Weight (Kg)
96
94
Sibutramine
92
90
88
NB Same diet and exercise for both sibutramine
and control
Month
James et al, Lancet 2000
28
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)

29
Nondiet approach
  • Eat healthfully
  • Being attuned to hunger and satiety cues
  • Incorporate physical activity

30
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31
Obesity in children
  • Genetic
  • Environment

32
Genetic
  • Obese parents, obese children
  • Effects of genes on food intake and energy
    expenditure

33
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

34
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35
(No Transcript)
36
Obesity and the Metabolic Syndrome in Children
and Adolescents Criteria for Metabolic Syndrome
in Children
  • Obesity (instead of waist circumference)
  • Obese z-score gt2.0 for BMI
  • Moderate Obese z-score 2.0-2.5
  • Severe Obese z-score gt 2.5
  • Metabolic values
  • TG gt 95th pct
  • HDL-C lt 5th pct
  • Glucose intolerance following OGTT
  • Insulin resistance fasting gluxfasting
    plasma insulin/22.5

37
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 gt 40 waist circumference
  • women gt 35 waist circumference
  • Hypertriglyceridemia (gt150 mg/dl)
  • Low HDL
  • men lt 40 mg/dl
  • women lt 50 mg/dl
  • Pre-hypertension (gt130/gt85 mmHg)
  • Pre-diabetes (gt 110 mg/dl)

38
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

39
Reducing childrens television viewing to prevent
obesity A randomized controlled trial.
  • Many observational studies have found
    associations between television viewing and
    child/adolescent adiposity.
  • Reviewed in AAPs Policy Statement
  • Pediatrics 112424-430 (2003)
  • 25 children watch gt4hrs TV/day
  • BMI of children who watch gt4hrs per day
    significantly greater than those watching lt 2hrs
    per day
  • TV in childs bedroom significant predictor of
    overweight

40
treatment
  • Objectives
  • healthy nutritional behavior
  • increase of physical activity

Not Ideal Body Weight
41
treatment
  • It is based on
  • age
  • BMI percentile
  • comorbidities

42
  • lt 7 years weight maintenance
  • but if there is comorbidity and BMI gt 95
    centile
  • Weight reduction is needed.
  • gt 7 years , BMIgt95 centile 0.5 kg per month

43
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)

44
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

45
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
    ephedra-like substances are in the Ephdra-free
    weight loss supplements

46
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. Pharmacists Letter/Prescribers
    Letter 2006221-3.

47
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

48
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. 204CV409
    TC).  An appeal was filed on June 13, 2005
    however it will take some time for this case to
    be decided.

49
Weight Loss Supplements
Chromium and Ginseng
  • Modulate carbohydrate metabolism
  • Chromium
  • Ginseng

50
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

51
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)

52
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

53
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

54
Weight Loss Supplements
Glucomannan, Psyllium, and Guar Gum
  • Increases satiety
  • Guar gum
  • Glucomannan
  • Psyllium

55
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)

56
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

57
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

58
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

59
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

60
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

61
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

62
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

63
Weight Loss Supplements
Act 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

64
Weight Loss Supplements
Chitosan
  • Block dietary fat absorption
  • Chitosan

65
Weight Loss Supplements
Chitosan
  • 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

66
Weight Loss Supplements
Chitosan
  • 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

67
Weight Loss Supplements
Water Elimination
  • Increase water elimination
  • Dandelion
  • Cascara

68
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)

69
Weight Loss Supplements
Water Elimination
  • The Good
  • The Bad
  • No studies to show efficacy
  • May have adverse events similar to long-term
    diuretic and laxative usage
  • The Ugly

70
Weight Loss Supplements
Enhancement of Mood
  • Enhance mood
  • St. Johns wort

71
Weight Loss Supplements
Enhancement of Mood
  • St. Johns 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

72
Weight Loss Supplements
Enhancement of Mood
  • The Good
  • They may be safe
  • The Bad
  • No good RCTs to show efficacy
  • The Ugly

73
Weight Loss Supplements
Miscellaneous Other Supplements
  • Miscellaneous or unspecified
  • Laminaria
  • Spirulina (blue-green algae)
  • Guggul
  • Apple cider vinegar

74
Weight Loss Supplements
Miscellaneous Other 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

75
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

76
Weight Loss Supplements
  • Increase energy expenditure
  • Modulate carbohydrate metabolism
  • Increase satiety
  • Increase fat oxidation or reduce fat synthesis
  • Block dietary fat absorption
  • Increase water elimination
  • Enhance mood
  • Other miscellaneous or unspecified

Healthy Diet and Exercise
77
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.

78
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)
79
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