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Title: (THE%20GRANDEST%20OF)%20GRAND%20ROUNDS


1
(THE GRANDEST OF) GRAND ROUNDS
  • RAHIL The Fattest Man (At Heart) Alive SHAIKH,
    MD
  • Northeast Iowa Family Medicine
  • November 12th, 2014

2
Sponsors
3
Chief Complaint
  • 29 year old male whos chief complaint is being
    too fat.

4
HPI
  • Has been fat and getting fatter for the last 12
    years
  • Associated with increased dietary intake and
    decreased exercise
  • Worsened by having an income and being allowed to
    buy his own food

5
PMH, PSH, FH, SH
  • PMH includes median and ulnar nerve irritation
    bilaterally
  • PSH includes dental surgery to remove extra tooth
    at age 12
  • FH includes HTN, DM, CAD, CVA, and cancer
  • SH includes stressful job working long hours,
    living at home with wife (but never seeing her),
    never smoker, no alcohol, no drugs (he does
    distribute plenty of drugs though)

6
Review Of Systems
  • Fatigue takes anywhere from three to eight
    alarms in the morning to wake up on work days
    has little energy for more than one strenuous
    activity in the day would sleep for 10 hours /
    day if he could
  • Polyphagia gets hungry a lot, has many food
    cravings

7
Review Of Systems
  • Dyspnea with exertion walking up one flight of
    stairs or running more than one minute causes SOB
    (he does claim to be able to walk on the
    elliptical for up to one hour without too much
    trouble though it sounds like hes lying)

8
Medications/Allergies
  • Acetaminophen, ibuprofen, naproxen, metaxalone
    all as needed, every 2 months
  • NKDA, but does complain of seasonal allergies and
    being allergic to mammograms

9
Physical Examination
  • Normal except for being strikingly handsome,
    having an obese belly, and having an odd affect
  • Height 173 cm, weight 100 kg, BMI 33.4

10
Labs
  • CMP normal
  • TSH normal
  • HbA1c 4.7
  • Fasting lipid panel total cholesterol 210,
    triglycerides 90, HDL 42, LDL 150
  • UA and urine microalbumin normal

11
Assessment Plan
  • 29 year old male with diagnoses of obesity and
    hyperlipidemia. Whats the plan?
  • ?
  • ?
  • ?

12
FOOD ADDICTION (and the great fatty sugary debate)
13
What Causes Us To Be Fat?
14
What Causes Us To Be Fat?
  • Are we what we eat?
  • Our diets are filled with processed cra---err,
    food
  • Everywhere we look, we see advertising for fast
    food, junk food, and fatty and sugary foods
  • But, isnt it as simple as calories in minus
    calories out?

15
Calories
  • A calorie is a unit of energy
  • How many calories we use up during the day makes
    up our basal metabolic rate (BMR)
  • My own BMR based on my sex, age, height, weight,
    and activity level is 2500 calories / day

16
Calories
  • A BMR of 2500 means that it takes 2500 calories
    coming in from my diet to maintain my weight and
    offset the requirements of energy that my body
    needs which is 2500 calories
  • Eating less calories than this will cause me to
    lose weight and eating more calories than this
    will cause me to gain weight
  • Or will it?

17
Calories
  • Is a calorie a calorie?
  • Is equivalent to
    ?
  • Both are 500 calories
  • Do they affect our body the same way?

18
Sugar Processing
  • No
  • The fiber in the salad slows down the processing
    of the natural sugars and doesnt lead to the
    sugar high as seen with processed (fake) foods
    like the Big Mac
  • The fast intake of sugars in processed food
    forces the pancreas to release insulin and forces
    the liver to take in more sugar than it can
    handle

19
Sugar Processing
  • Normally the liver converts sugar to glycogen for
    storage, to be released in between meals and
    during the fasting night state
  • However, processed food sugar, usually high
    fructose corn syrup (HFCS) causes the liver to
    get overloaded and convert the sugar into not
    just glycogen, but also fat LOTS OF FAT

20
Sugar Processing
  • This is how processed sugar, in a simplified way,
    makes us fat its missing the fiber to help us
    digest it properly!

21
Sugar Processing
  • On top of that, fiber does another thing that
    fructose has a hard time doing on its own
    increasing satiety
  • The brain has a hard time knowing its full when
    processed sugars are taken in by themselves (i.e.
    leptin resistance increases) with the fiber
    still present, this does not happen
  • So when we eat processed sugars by themselves,
    our brains dont know weve taken in enough
    calories to be full!

22
Drank
  • And on top of that again, things like pop (a.k.a.
    soda, fizzy drank, sugary goodness) also contain
    not just HFCS, but also salt, which promotes
    thirst and thus makes you want to drink even more!

23
Evolution Of Man (And Wo-Man)
24
Low Fat?
  • In the 1970s people started to notice obesity as
    a health problem
  • The leading cause of obesity was thought to be
    fat
  • You eat fat, you get fatmakes sense, right?
  • Therefore, policies came into effect that pushed
    the food industry to adopt low fat varieties of
    their food

25
Low Fat?
  • Taking some of the fat out of food though made it
    taste terrible
  • How to get the food to taste better now?
  • You guessed it sweet sweet SUGAH BABY
  • Cane sugar that was processed and had its fiber
    stripped from it was a start
  • The corn industry also learned how to make a
    cheap viable corn syrup alternative to sweeten
    foods

26
Sugar
  • Its not fat thats the biggest enemy in the
    obesity epidemic, its sugar!
  • Doesnt it make sense? Weve reduced our fat
    consumption (and proportions of bad transfats,
    etc.) but obesity rates have climbed to epidemic
    proportions

27
Obesity Trends Among U.S. AdultsBRFSS, 1985
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
28
Obesity Trends Among U.S. AdultsBRFSS, 1986
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
29
Obesity Trends Among U.S. AdultsBRFSS, 1987
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
30
Obesity Trends Among U.S. AdultsBRFSS, 1988
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
31
Obesity Trends Among U.S. AdultsBRFSS, 1989
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
32
Obesity Trends Among U.S. AdultsBRFSS, 1990
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
33
Obesity Trends Among U.S. AdultsBRFSS, 1991
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
34
Obesity Trends Among U.S. AdultsBRFSS, 1992
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
35
Obesity Trends Among U.S. AdultsBRFSS, 1993
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
36
Obesity Trends Among U.S. AdultsBRFSS, 1994
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
37
Obesity Trends Among U.S. AdultsBRFSS, 1995
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
38
Obesity Trends Among U.S. AdultsBRFSS, 1996
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519
39
Obesity Trends Among U.S. AdultsBRFSS, 1997
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
40
Obesity Trends Among U.S. AdultsBRFSS, 1998
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
41
Obesity Trends Among U.S. AdultsBRFSS, 1999
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
42
Obesity Trends Among U.S. AdultsBRFSS, 2000
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 20
43
Obesity Trends Among U.S. AdultsBRFSS, 2001
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
44
Obesity Trends Among U.S. AdultsBRFSS, 2002
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
45
Obesity Trends Among U.S. AdultsBRFSS, 2003
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
46
Obesity Trends Among U.S. AdultsBRFSS, 2004
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 25
47
Obesity Trends Among U.S. AdultsBRFSS, 2005
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
48
Obesity Trends Among U.S. AdultsBRFSS, 2006
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
49
Obesity Trends Among U.S. AdultsBRFSS, 2007
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
50
Obesity Trends Among U.S. AdultsBRFSS, 2008
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
51
Obesity Trends Among U.S. AdultsBRFSS, 2009
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
52
Obesity Trends Among U.S. AdultsBRFSS, 2010
(BMI 30, or 30 lbs. overweight for 5 4
person)
No Data lt10 1014
1519 2024 2529
30
53
Obesity Trends Among U.S. AdultsBRFSS, 1990,
2000, 2010
(BMI ?30, or about 30 lbs. overweight for 54
person)
2000
1990
2010
No Data lt10 1014
1519 2024 2529
30
54
Obesity
55
Obesity
  • We know that being obese can lead to multiple
    medical conditions, including HTN, DM, HLD, CAD,
    CVA, PVD, metabolic syndrome

56
Obesity
  • People have long considered a lack of willpower
    as the main constituent to obesity
  • Its not just lack of exercise thats
    contributing to our obesity epidemic its
    mostly what were eating, and the main culprit is
    sugar
  • Obviously bad fats and lack of exercise dont
    help, but sugar is the silent cause that most
    people dont consider

57
Metabolic Syndrome
  • What is it?
  • Its a syndrome of high blood pressure, insulin
    resistance, and high cholesterol (in our office
    we call these symptoms the trifecta and we bill
    that badboy a 99214, yeahhh boi)
  • Actually, in reality, were not writing for
    metabolic syndrome a lot do you see a lot of
    charts with it written in the Major Problem List?

58
Metabolic Syndrome
  • How are insurance companies paying for a
    diagnosis of metabolic syndrome?

59
(No Transcript)
60
Metabolic Syndrome
  • Ask The Expert

61
Metabolic Syndrome
  • American Heart Association and National Heart,
    Lung, and Blood Institute (NHLBI) definition of
    metabolic syndrome - at least 3 of elevated waist
    circumference
  • 102 cm (40 inches) or higher in men
  • 88 cm (35 inches) or higher in women
  • elevated triglycerides 150 mg/dL (1.7 mmol/L) or
    higher or on medication
  • reduced HDL cholesterol or on medications
  • lt 40 mg/dL (1.03 mmol/L) in men
  • lt 50 mg/dL (1.3 mmol/L) in women
  • elevated blood pressure 130/85 mm Hg or higher or
    on medication
  • elevated fasting glucose 100 mg/dL (5.6 mmol/L)
    or higher or on medication

62
Metabolic Syndrome
  • International Diabetes Federation definition of
    metabolic syndrome requires both central obesity
    defined as waist circumference at least
  • 94 cm for Europoid men or 80 cm for Europoid
    women
  • 90 cm for South Asian and South-East Asian men or
    80 cm for South Asian and South-East Asian women
  • 85 cm for Japanese men or 90 cm for Japanese
    women
  • and any 2 of 4 other factors
  • serum triglyceride level 1.7 mmol/L (151 mg/dL)
    or higher (or specific treatment for this
    abnormality)
  • serum high-density lipoprotein cholesterol level
    lt 1.03 mmol/L (40 mg/dL) in men or lt 1.29 mmol/L
    (50 mg/dL) in women (or specific treatment for
    this abnormality)
  • systolic blood pressure 130 mm Hg or higher,
    diastolic blood pressure 85 mm Hg or higher, or
    treatment of previously diagnosed hypertension
  • fasting plasma glucose 5.6 mmol/L (100 mg/dL) or
    higher, or previously diagnosed type 2 diabetes

63
Metabolic Syndrome
64
Metabolic Syndrome
  • Biggest complication of metabolic syndrome?
    Coronary artery disease
  • Treat metabolic syndrome by eating less sugar and
    exercising (both of which promote weight loss!)

65
Metabolic Syndrome Sugar
  • Processed sugar ? increased fat ? increased waist
    lines, increased blood pressure, insulin
    resistance and increase in lipids (especially
    VLDL as a byproduct of the liver trying to
    metabolize fructose in HFCS)
  • Sugar and metabolic syndrome are inextricably
    linked

66
AHA Recommendations
  • The AHA states that American on average consume
    20 teaspoons of sugar per day
  • Their recommendations for added sugars are no
    more than 6 teaspoons (100 calories) per day for
    women and 9 teaspoons (150 calories) per day for
    men
  • 1 teaspoon of sugar 4 grams of sugar 16
    calories of sugar

67
Sugar
  • Natural sugars like lactose and fructose are
    found in milk and fruit

68
Sugar
  • Are all sugars bad for you?
  • No, its the simple sugars that are broken down
    quickly that arent as good for you as the
    complex carbohydrates that take effort to break
    down
  • In effect, you use up calories to break down
    calories, resulting in no excess weight gain over
    time

69
Sugar
  • We dont actually need sugar to survive at
    least, added, processed sugars (we do need
    carbohydrates for energy obviously)
  • Added sugars add calories to our diets and add
    zero nutrients absolutely nil

70
Sugar
71
Sugar
72
Sugar
  • Ever noticed that on nutrition labels, the
    daily value for sugar is not listed? As everyone
    looks at their labels, I say BOOOM
  • Most items would be well above the 100 daily
    recommended mark the percentage is not listed
    for a reason

73
Food Corporations
74
Diet Drank?
  • What about diet versions or calorie free
    versions of our favorite beverages?

75
Diet Drank?
  • Studies are starting to show that diet pop can be
    just as bad as regular pop, or maybe even worse
  • Partly it has to do with our bodies developing an
    impaired ability to predict caloric content of
    food (and thus leading to increased intake)

76
Diet Drank?
  • The psychology behind it is if I saved myself
    150 calories by not drinking the regular pop, why
    not go for a slice of pizza instead of a wrap?

77
Diet Drank?
  • Partly it has to do with hormonal imbalance
  • Artificial sweeteners are much more sweeter than
    regular sugar as we ingest it, our bodies think
    real calories are on the way and insulin is
    pumped out of the pancreas

78
Diet Drank?
  • Any sugar in the blood will then go straight to
    the liver to be converted toFATTY STUFFS
  • The sugar will also be uploaded into the fat
    cells directly by insulin because fat cells are
    sensitive to insulin longer than other types of
    cells

79
Diet Drank?
  • Dietary Intake and the Development of the
    Metabolic Syndrome The Atherosclerosis Risk in
    Communities Study by Lutsey et al., 2008,
    followed 9514 people for 9 years and those that
    drank artificially sweetened beverages were found
    to have a 34 greater risk of developing
    metabolic syndrome
  • This study also references the Framingham study
    for showing similar findings

80
Diet Drank?
  • Diet Soda Intake and Risk of Incident Metabolic
    Syndrome and Type 2 Diabetes in the Multi-Ethnic
    Study of Atherosclerosis (MESA) by Nettleton et
    al., 2009, showed that those people that drank
    artificially sweetened beverages were found to
    have a 36 greater risk of developing metabolic
    syndrome

81
Diet Drank?
  • There are studies coming out that show the
    association between diet pop and depression and
    diet pop and cancer (although the latter is also
    being linked to sugar in general)

82
Diet Drank?
  • Consumption of artificially and sugar-sweetened
    beverages and incident type 2 diabetes in the
    Etude Epidemiologique aupres des femmes de la
    Mutuelle Generale de lEducation Nationale
    European prospective Investigation into Cancer
    and Nutrition cohort by Fagherazzi et al., 2013,
    showed an association (not causation) between
    both artificially and sugar-sweetened beverages
    and type 2 diabetes

83
Is Sugar Addictive?
  • Intense Sweetness Surpasses Cocaine Reward by
    Lenoir et al., 2007, that showed that rats, when
    given a choice, preferred saccharin over IV
    cocaine

84
Is sugar addictive?
  • This is a Bhupinder on no sugar

85
Is sugar addictive?
  • This is a Bhupinder on sugar

86
Is Sugar Addictive?
  • Were evolutionarily built to enjoy sugar (well,
    most of us)sugar is indeed addicting

87
SoWhat The Heck Do We Eat Now?
  • There are more than half a million grocery store
    items out there, and a whole bunch of them
    contain sugar we wont be getting rid of them
    overnight
  • So how do we counsel our patients?

88
SoWhat The Heck Do We Eat Now?
  • 12 year old girl presents with her parents to
    find out what to do about her weight and rising
    blood pressure

89
Counselling
  • Should we quit added, processed sugars cold
    turkey like tobacco and alcohol or go slow?
  • It depends on the person!
  • Having a full detox works for a few people, but
    most have to make slower changes in their lives
    in regards to sugar addiction

90
Counselling
  • First step portion sizes!
  • We used to have reasonable portion sizes until
    everything was supersized, now what used to be
    supersized is our norm and whats supersized now
    is

91
(No Transcript)
92
Counselling
93
Counselling
94
Counselling
  • Second step stop the pop
  • By far contains the most and most useless
    calories out of all the sugary foods
  • This is poison

95
Counselling
  • Third step eat real food
  • If your grandparent couldnt recognize it, its
    probably not good for you
  • By far the single biggest and most important
    variable in the fight against obesity real food
    a.k.a. not fake, processed material that we
    mistake for food
  • Cook

96
Counselling
  • Fourth step recognizing that exercise is
    crucial, but not enough
  • Burning off 2 thin mint cookies would take 20
    minutes of running
  • Eating the right foods though helps the food
    partially burn itself off, just by eating it
    (think, celery), so you dont have to spend all
    the time youre not eating in the day trying to
    exercise it off!
  • Have a standing work station with a chair
    available if needed

97
Counselling
  • Fifth step have cheat days if you need them
    depriving yourself completely may cause you to
    relapse and bingelike this guy

98
Practical Approach to Maximize Satiety and
Achieve Meaningful Weight Loss and Weight
Management
1.Individualized balance of Carbs / Fats /
Protein for sustained adherenceFocus on FOOD
Right Fats (mono- and poly- unsaturated, omega
3s) Right Carbs (high fiber, low glycemic
index, complex) Right Protein (plant, marine,
and lean animal sources) 2.Limit or eliminate
sugar, high fructose corn syrup, and refined
starches and snack foods 3.Reduce or eliminate
all calories from beverages 4.Smaller portions,
low energy density, high nutrient density
5.Consider book-keeping of calories, points,
etc. 6.Drink (and eat) water 7.Exercise for
life 8.Get adequate sleep
99
Detox
  • Most people who have given up on sugar from
    processed foods and go back to it, even for a few
    bites, claim to have headaches, dizziness, even
    nausea others have GI upset and diarrhea

100
Conclusions
  • 1. Sugar is the devil
  • 2. Im fat
  • 3. Lets all go to Popeyes for a residency retreat

101
Conclusions
  • Obesity and metabolic syndrome are truly
    epidemics, not only in this country, but now all
    across the world
  • Its said that the current generation of children
    will be the first generation of children not to
    live longer than their parents did
  • Reports claim that this is the first time in
    human history that there are more obese people
    than starving people in the world

102
Conclusions
  • Not only is fat and a lack of exercise
    contributing obesity and metabolic syndrome, but
    the main culprit might very well be sugar, which
    is likely the villain behind food addiction
    (which was the topic of this talk if you remember)

103
Case
  • Back to our casewhat is our 29 year old obese,
    now hyperlipidemic male planning on doing to
    improve his diet, his physical activityand his
    life?
  • Stay tunedfor JAUCH

104
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