Presented by: Dr. A.Nadjarzadeh Tehran University of Medical Sciences.

Presented by: Dr. A.NadjarzadehTehran University of Medical Sciences

كم خوني

اختالالتمتابوليسمي

افسردگي

ايمني و عفونت

چربي خون

اختالت كليوي پوكي استخوان

امراض قلب و عروق

برخي سرطان ها

اختالالتكبدي

اختالالت گوارشي

ديابت

فشارخون

چاقي

Environment stimulusHigh fat , energy dense foodsPalatable, low cost, easily available foodsLarge portion sizes

Sedentary behaviorActivity of daily livingWork-related physical activity

Which macronutrintes have more effects on obesity?

Energy density of diet?

objectives

Describe the components of a successful weight management program

DiagnosisBMIWaist circumference

Determination of the skeletonr= Ht (cm)/wrist (cm)

r (men) r(women)

Small >10.4 >11

Medium 9.6-10.4 10.1-11

Large <9.6 >10.1

نمایه های چاقیBMI

< کم وزن 18 طبیعی5.18 – 9.24 اضافه وزن25 - 9.29 1 چاقی درجه 30 – 9.34 2 چاقی درجه 35 – 9.39 3 چاقی درجه 40 = <

Energy needsBMI and skeletonHerris-benedict ( adjusted weight)24-hr recall and decrease 500 Kcal

ساله 19 تا 50انرژي موردنيازروزانه در افراد بافعاليت متفاوت

روز در بدن وزن كيلوگرم در روز كيلوكالري در بدن وزن كيلوگرم در كيلوكالري نوع نوع فعاليت فعاليت

3131

3030

سبك سبك خيلي خيليمردان مردان

زنان زنان

3838

3535

سبك سبك

مردانمردان

زنان زنان

4141

3737

متوسط متوسط

مردان مردان

زنان زنان

5050

4444

سنگين سنگين مردانمردان

زنان زنان

5858

5151

شديد شديد خيلي خيليمردانمردان

زنان زنان

Selecting strategyDepends 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 goals0.5-1 kg (1% of BW) per weekSlow/stop after 24 weeks (plateau effect)

Weight loss programFood choice changeExerciseBehavior modificationNutritional educationPsychological supportMedicationsurgery

Restricted-Energy DietA balanced energy restricted dietNutritionally adequate except for energy500-1000 caloric deficit per dayIncrease physical activityHigh CHO (50-55%), protein (15-25%), fat

(not more than 30%)

Extra fiberReduce caloric densityPromote satiety by delaying stomach emptying

timeDecrease to a small degree the efficiency of

intestinal absorptionSCFA blood FFA and hepatic Glc

production , Increase of insulin sensitivity insulin secretion increase of fat oxidation and decrease of fat

store

FatSugarAlcohol (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)

Lifting weights for 1 hour and 30 minutes burns approximately 257 calories*

*Based on 130-pound person

Increased cheeseburger size: 257 more calories

Exchange System DietsEasily manipulated method1200 kcal Milk, skim 2 ex, Veg 3 ex, Fruit 4 ex, bread 5 ex , meat (lean) 5 ex, fat 3 ex.

الگوي واحدهاي رژيم براي دريافت سطوح

متفاوت انرژيكالري ) ( كيلو انرژي كالري ) (سطوح كيلو انرژي سطوح

12001200 15001500 18001800 20002000 22002200 26002600 30003000 32003200

66 77 88 99 1111 1313 1515 1717

33 44 55 55 55 66 66 66

22 33 44 44 44 55 66 66

22 22 22 33 33 33 33 33

44 55 66 66 66 77 88 88

33 55 66 77 88 1010 1212 1313

غالتغالت

سبزيسبزي

ميوهميوهكم كم شيرشير

چربچرب

گوشتگوشتچرب چرب كم كم

چربيچربي

OthersFormula diets and meal replacement

programCommercial programsExtreme energy restrictionVery low calorie diet

VLCDVery low calorie diets:200-800 Kcalhigh protein12-16 weeks rapid weight loss BMI above 30, or 27-30 with comorbidities or

risk factorsRisk of death

VLCD risksCardiac complicationPotassium lossLoss of body proteinIncrease of urinary ketonesIncrease of serum uric acidIncrease of cholesterol (gallstone)Temperature sensitivityHair loss, digestive

Completers: BM14161

*

0

–2

–4

–6

–8

–10

Change inbody weight(%)

Week

–10 –4 0

Placebo (n=120)

Orlistat 120 mg (n=149)*p<0.001

–4.3%

–8.5%

48 524436 403224 282012 1684

MonthMonthJames et al, Lancet James et al, Lancet 20002000

NB: Same diet and exercise for NB: Same diet and exercise for bothboth sibutraminesibutramine and controland control

Bod

y W

eig

ht

(Kg

)B

od

y W

eig

ht

(Kg

)

104104

8888

9090

9292

9494

9696

9898

100100

102102

00 22 44 66 88 1010 1212 1414 1616 1818 2020 2222 2424

106106

108108

ControlControl

SibutramineSibutramine

Weight loss Weight maintenance

Expected weight gain 2kg/yearExpected weight gain 2kg/year

XENDOS (XENical in the prevention of Diabetes in Obese Subjects)

3304 obese patients in placebo controlled trial4 years duration, multicentre, prospective79% patients normal glucose control, 21% IGTOrlistat 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 approachEat healthfullyBeing attuned to hunger and satiety cuesIncorporate physical activity

Obesity in childrenGeneticEnvironment

GeneticObese parents, obese childrenEffects of genes on food intake and energy

expenditure

Assessment of Overweight in Children1997 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 overweightDefined

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 SyndromeCluster of metabolic abnormalities associated

with insulin resistanceDiagnosis 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 treatmentParenting 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 StatementPediatrics 112:424-430 (2003)25% children watch >4hrs TV/dayBMI of children who watch >4hrs per day

significantly greater than those watching < 2hrs per day

TV in child’s bedroom significant predictor of overweight

treatmentObjectives: healthy nutritional behavior increase of physical activity

Not Ideal Body Weight

treatmentIt is based on age BMI percentile comorbidities

<= 7 years: weight maintenance but if there is comorbidity and BMI >= 95

centileWeight reduction is needed.

> 7 years , BMI>=95 centile: 0.5 kg per month

Weight Loss SupplementsShekelle, 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)

Ephedra Alkaloids and Caffeine CompoundsEphedra Alkaloids and Caffeine Compounds


FDA MedWatch:87 reports of ephedra adverse events between

June 97 and March 99HTN, arrhythmias, MI, stroke and seizures10 events led to death13 others yielded permanent disability9 of the 23 were at the recommended doses in

individuals without cardiovascular risk factors


Weight Loss SupplementsEphedra comprised 0.8% of dietary

supplement sales in 2001However, 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



“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.



The Good:They work

The Bad:They have many adverse events

The Ugly:They can killEphedra sales banned by the FDA in April 2004


Ephedra Ban Ruled InvalidEphedra 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.


Modulate carbohydrate metabolismChromiumGinseng

Chromium and GinsengChromium and Ginseng

Weight Loss SupplementsChromium is thought to play a role in

carbohydrate and lipid metabolismChromium 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 SupplementsNo adverse events at recommended dose of

chromium, but rhabdomyolysis and renal failure have been reported at super-therapeutic doses (1000mcg vs 200 to 400mcg)



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



The Good:They may be safe

The Bad:No good RCTs to show efficacy

The Ugly:Potential renal failure



Increases satietyGuar gumGlucomannanPsyllium

Glucomannan, Psyllium, and Guar GumGlucomannan, 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 SupplementsGlucomannan: 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



The Good:They may be safe

The Bad:No good RCTs to show efficacy, save modest

weight loss with GlucomannanThe Ugly:


Weight Loss SupplementsIncrease fat oxidation or reduce fat synthesis

L-carnitineHydroxycitric acidGreen teaVitamin B5

LicoriceConjugated linoleic acidPyruvate

Act on Fat Oxidation or SynthesisAct on Fat Oxidation or Synthesis

Weight Loss SupplementsHydroxycitric 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 SupplementsConjugated 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 SupplementsGreen 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 SupplementsPyruvate 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


Weight Loss SupplementsThe Good:

They may be safePyruvate may have weight loss

The Bad:Minimal and sometimes conflicting data to

support weight lossThe Ugly:

Conjugated linoleic acid may increase insulin resistance


Weight Loss SupplementsBlock dietary fat absorption

Chitosan

ChitosanChitosan

Weight Loss SupplementsBlocks 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

ChitosanChitosan


They appear be safe

The Bad:Some investigators show effectiveness in

poorly designed studiesShould note be taken by those allergic to

shellfish

The Ugly: Different investigators show no effect of

Chitosan on weight loss

ChitosanChitosan

Weight Loss SupplementsIncrease water elimination

DandelionCascara

Water EliminationWater Elimination


Dandelion – diuretic activityCascara – laxative affectNeither one studied for effectiveness in

weight lossTheoretically may have same adverse effects

of long term use of diuretics and laxatives (dehydration and electrolyte abnormalities)



The Bad:

No studies to show efficacy May have adverse events similar to long-term

diuretic and laxative usageThe Ugly:


Weight Loss SupplementsEnhance mood

St. John’s wort

Enhancement of MoodEnhancement of Mood


St. John’s wort inhibits serotonin re-uptakeIncrease of serotonin is believed to stimulate

the hypothalamus and produce the feeling of fullness

No studies to show effectiveness in weight loss



They may be safeThe Bad:

No good RCTs to show efficacyThe Ugly:


Weight Loss SupplementsMiscellaneous or unspecified

LaminariaSpirulina (blue-green algae)GuggulApple cider vinegar

Miscellaneous Other SupplementsMiscellaneous Other Supplements

Weight Loss SupplementsSpirulina contains phenylalanine, which is

reported to inhibit appetiteHowever, 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

Miscellaneous Other SupplementsMiscellaneous Other Supplements


They may be safeThe Bad:

No good RCTs to show efficacyThe Ugly:

FDA already declared spirulina ineffective


Weight Loss SupplementsIncrease energy

expenditureModulate

carbohydrate metabolism

Increase satietyIncrease fat

oxidation or reduce fat synthesis

Block dietary fat absorption

Increase water elimination

Enhance moodOther miscellaneous

or unspecified

Healthy DietHealthy Dietandand

ExerciseExercise

Evidence-based Resources on Dietary Supplements for PhysiciansNatural 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 SupplementsWeight 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. (* from Dietary Supplement Enforcement Report by the US FDA, December 18, 2002. (www.fda.gov/oc/nutritioninitiative/report.html)www.fda.gov/oc/nutritioninitiative/report.html)

Any comment or question?

Presented by: Dr. A.Nadjarzadeh Tehran University of Medical Sciences.

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Transcript of Presented by: Dr. A.Nadjarzadeh Tehran University of Medical Sciences.