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.
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
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 = <
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
Weight Loss Supplements
“People do not want to make lifestyle changes. They are looking for the quick fix.”
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
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
<= 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
Weight Loss Supplements
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
Ephedra Alkaloids and Caffeine CompoundsEphedra Alkaloids and Caffeine Compounds
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
Ephedra Alkaloids and Caffeine CompoundsEphedra Alkaloids and Caffeine Compounds
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.
Ephedra Alkaloids and Caffeine CompoundsEphedra Alkaloids and Caffeine Compounds
Weight Loss Supplements
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 Alkaloids and Caffeine CompoundsEphedra Alkaloids and Caffeine Compounds
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.
Weight Loss Supplements
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
Chromium and GinsengChromium and Ginseng
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)
Chromium and GinsengChromium and Ginseng
Weight Loss Supplements
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
Chromium and GinsengChromium and Ginseng
Weight Loss Supplements
The Good:They may be safe
The Bad:No good RCTs to show efficacy
The Ugly:Potential renal failure
Chromium and GinsengChromium and Ginseng
Weight Loss Supplements
Increases satietyGuar gumGlucomannanPsyllium
Glucomannan, Psyllium, and Guar GumGlucomannan, Psyllium, and Guar Gum
Weight Loss Supplements
Action: soluble fiber that absorbs water within the gut causing a fullness sensation
May improve control of diabetes and hyperlipidemia (fiber affect)
Glucomannan, Psyllium, and Guar GumGlucomannan, Psyllium, and Guar Gum
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
Glucomannan, Psyllium, and Guar GumGlucomannan, Psyllium, and Guar Gum
Weight Loss Supplements
The Good:They may be safe
The Bad:No good RCTs to show efficacy, save modest
weight loss with GlucomannanThe Ugly:
Glucomannan, Psyllium, and Guar GumGlucomannan, Psyllium, and Guar Gum
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
Act on Fat Oxidation or SynthesisAct on Fat Oxidation or Synthesis
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
Act on Fat Oxidation or SynthesisAct on Fat Oxidation or Synthesis
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
Act on Fat Oxidation or SynthesisAct on Fat Oxidation or Synthesis
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
Act on Fat Oxidation or SynthesisAct on Fat Oxidation or Synthesis
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
Act on Fat Oxidation or SynthesisAct on Fat Oxidation or Synthesis
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
Weight Loss SupplementsThe Good:
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
Weight Loss Supplements
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)
Water EliminationWater Elimination
Weight Loss SupplementsThe Good:
The Bad:
No studies to show efficacy May have adverse events similar to long-term
diuretic and laxative usageThe Ugly:
Water EliminationWater Elimination
Weight Loss Supplements
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
Enhancement of MoodEnhancement of Mood
Weight Loss SupplementsThe Good:
They may be safeThe Bad:
No good RCTs to show efficacyThe Ugly:
Enhancement of MoodEnhancement of Mood
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
Weight Loss SupplementsThe Good:
They may be safeThe Bad:
No good RCTs to show efficacyThe Ugly:
FDA already declared spirulina ineffective
Enhancement of MoodEnhancement of Mood
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)