DR. GANGADHAR CHATTERJEE

JR II

DEPT. OF BIOCHEMISTRY

GRANT GOVT. MEDICAL COLLEGE & JJ HOSPITAL, MUMBAI

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OVERWEIGHT & OBESITY''abnormal or excessive fat accumulation that presents a risk to health'‘

HOW TO MEASURE

difficult to develop one simple index in children and adolescents--undergo a number of physiological changes as they grow.

Depending on the age, different methods available:

For children aged 0-5 years

The WHO Child Growth Standards

WHO Global Database on Child Growth and Malnutrition, 0-5 years.

For individuals aged 5-19 years

Growth reference data for 5-19 years

Global school-based student health survey (GSHS)

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For Adults

Most commonly used measure for overweight and obesity is the Body Mass Index (BMI) –

• a simple index to classify overweight and obesity in adults.

• defined as the weight in kilograms divided by the square of the

height in meters (kg/m2).

Other approaches to quantifying obesity

anthropometry (skinfold thickness)

densitometry (underwater weighing)

CT or MRI

electrical impedance.

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The WHO definition is:

a BMI greater than or equal to 25 is overweight

a BMI greater than or equal to 30 is obesity.

BMI

most useful population-level measure of overweight and obesity , same for both sexes and for all ages of adults.

considered a rough guide - may not correspond to the same degree of fatness in different individuals.

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JUST THE FACTS! According to WHO:

As of 2013 :

Worldwide obesity has nearly doubled since 1980.

In 2008, more than 1.4 billion adults, 20 and older, were overweight.

Of these over 200 million men and nearly 300 million women were obese.

35% of adults aged 20 and over were overweight in 2008, and 11%

were obese.

65% of the world's population live in countries where overweight and

obesity kills more people than underweight.

More than 40 million children under the age of five were overweight in

2011.

Obesity is preventable

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LOW AND MIDDLE INCOME COUNTRIES

According to WHO there is a “double burden” of disease

Countries that are developing are still having issues of infectious disease and under-nutrition

There is also an increase of chronic disease related to obesity…especially in urban settings

Causes inadequate prenatal care, lack of infant and child nutrition and eating high fat and high sugar foods

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2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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India : Double Burden of Disease

Under nutrition due to Poverty 30 % below BPL

Over nutrition and Obesity 5-7% MIG and HIG Urban area

Most productive group of the country- Academic/ Planner/ Research/ Administrator/ professional

SHOULD BE GIVEN PRIORITY

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Author Year of Study

Country/State

Criteria used

Prevalence of over-weight (M/F)

Prevalence of obesity (M/F)

Gopinath et.al 1994 Delhi BMI>25 21.3% (M)33.4% (F)

INA

Singhal et al 1998 Jaipur BMI>25 14.6% (M)6.6% (F)

INA

Asthana et al 1997 Varanasi BMI>25 30.2% (F) INA

Chadha et al 1997 Delhi BMI>25 20.7 (M)32.6% (F)

INA

Obesity Trends in India : Recent studies: Adults

Author Year of Study

Country/State

Criteria used

Prevalence of over-weight (M/F)

Prevalence of obesity (M/F)

Singh et.al 1999 5 Cities BMI>23BMI>25BMI>27

50.9% (F)

Vasanthanani 2000 Coimbatore BMI>30 36.0% (M)

Mohan et al 2000 Chennai BMI>25 38.0% (M)33.1% (F)

Easwaran et al 2001 Coimbatore BMI>25BMI>24

65.0% (M)65.0% (F)

Gupta et al 2002 Jaipur BMI>27 24.5% (M)30.2% (F)

NFHS-II 1998-99

India BMI>25 8.6% MIG27.2 HIG

Obesity Trends in India : Recent studies

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OBESITY TRENDS IN INDIA : RECENT STUDIES CHILDREN

S.No Author Name State/country

Prevalence of obesity

1.* Umesh Kapil etal, 2001

Delhi (India)

8% boys 6% girls

2.** Vedavati S etal, 1998

Chennai, India

6% obese

1.* Indian Pediatrics, 2002 May, 17: 449-452

2.** Indian Pediatrics, 2003 Aug, 40: 775-779.GC,GGMC

OBESITY TRENDS IN INDIA : RECENT STUDIES CHILDREN

S.No Author Name State/country

Prevalence of obesity

3.* A.K.Gupta etal, 1985-86

India 7.94% boys6.90% girls

4.** Ramachandran A etal, 2000

India 3.6% boys 2.7% girls

3.* Indian Pediatrics, 1990, Apr, 27 333-337

4.** Diabetes research and Clinical Practice 2002; 57 185-190.GC,GGMC

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CAUSE OF OBESITY

Simple equation…when you eat more than you use.It is stored in your body as “fat”.

Causes

Global shift in how we eat

Western diet of processed food

Higher sugar, fat and calories in what we eat

Less nutrients

Reduced intake of vitamins and minerals

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COMPONENTS OF ENERGY INTAKE AND EXPENDITURE

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HORMONES, NEUROPEPTIDES, DRUGS THAT AFFECTS FOOD BEHAVIOR

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ENERGY IMBALANCEEFFECTS IN THE BODY

Excess energy is stored in fat cells, which enlarge or multiply.

Enlargement of fat cells is known as hypertrophy, whereas multiplication of fat cells is known as hyperplasia.

With time, excesses in energy storage lead to obesity.

Fat cells

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FAT CELL ENLARGEMENTHYPERTROPHY

Enlarged fat cells produce the clinical problems associated with obesity, due to the following:

• The weight or mass of the extra fat• The increased secretion of free fatty acids

and peptides from enlarged fat cells.

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Complement factors : factor-D, adipisin

Hormones:

Leptin

Adiponectin

Resistin

Cytokines:

TNF-α

IL-6

Substrate:

Free fatty acid

Glycerol

Enzymes:

Aromatase

11-β-HSD-1

Others:

PAI-1

Angiotensinogen

RBP-4

FACTORS RELEASED BY THE ADIPOCYTE THAT CAN AFFECT PERIPHERAL TISSUES

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MORTALITY AND MORBIDITYASSOCIATED WITH OBESITY

The effects of excess weight on mortality and morbidity recognized for more than 2,000 years.

Hippocrates -- recognized that “sudden death is more common in those who are naturally fat than in the lean.”

Today, obesity is increasing rapidly. Research shows that many factors related to obesity influence mortality and morbidity.

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MORTALITYWEIGHT, FAT DISTRIBUTION, AND ACTIVITY

The following factors have been shown to increase mortality in individuals:

• Excess body weight• Regional fat distribution• Weight gain patterns• Sedentary Lifestyle

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MORTALITYEXCESS BODY WEIGHT

Mortality associated with excess body weight increases as the degree of obesity and overweight increases.

It is estimated that 280,000 to 325,000 deaths a year can be attributed to obesity in the United States, more than 80% of these deaths occur among individuals with a BMI greater than 30 kg/m2.

Regional fat distribution can contribute to mortality.

This was first noted in the beginning of the 20th century.

Obese individuals with an android (or apple) distribution of body fat are at a greater risk for diabetes and heart disease than were those with a gynoid distribution (pear).

Android fat distribution results in higher free fatty acid levels, higher glucose and insulin levels and reduced HDL levels. It also results in higher blood pressure and inflammatory markers.

MORTALITYREGIONAL FAT DISTRIBUTION

Android Gynoid

In addition to overweight and central fatness, the amount of weight gain after ages 18 to 20 also predicts mortality.

The Nurses’ Health Study and the Health Professionals Follow-up Study showed that a marked increase in mortality from heart disease is associated with increasing degrees of weight gain.

MORTALITYWEIGHT GAIN

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Sedentary lifestyle is another important component in the relationship of excess mortality to obesity.

A sedentary lifestyle increases the risk of death at all levels of BMI.

Obese men with a high level of fitness had risks of death that were not different from fit men with normal body fat.

MORTALITYSEDENTARY LIFESTYLE

MORBIDITY ASSOCIATED WITH

OBESITY

Overweight affects several diseases, although its degree of contribution varies from one disease to another.

Additionally, the risk of developing a disease often differs by ethnic group, and by gender within a given ethnic group.

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Obstructive sleep apnea

Osteoarthritis

Cardiovascular disorders

Gastrointestinal disorders

Metabolic disorders

Endometrial, prostate and breast cancers

Complications of pregnancy

Menstrual irregularities

Psychological disorders

Individuals who are obese are at a greater risk of developing:

MORBIDITY ASSOCIATED WITH OBESITY

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CARDIOVASCULAR DISORDERSASSOCIATED WITH OBESITY

Hypertension

Stroke

Coronary Artery Disease

Obese individuals are at a greater risk of developing these cardiovascular disorders:

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HYPERTENSION

Hypertension (HTN) is the term for high blood pressure.

Hypertension is identified when a blood pressure is sustained at ≥140/90 mmHg.

High blood pressure is referred to as the “silent killer,” since there are usually no symptoms with HTN.

Some individuals find out that they have high blood pressure when they have trouble with their heart, brain, or kidneys.

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HYPERTENSIONTHE DANGERS

• The heart to get larger, which may lead to heart failure.• Small bulges (aneurysms) to form in blood vessels. • Blood vessels in the kidney to narrow, which may lead to kidney failure.• Arteries in the body to harden faster, especially those in the heart, brain,

kidneys, and legs. This can cause a heart attack, stroke, kidney failure, or can lead to amputation of part of the extremities.

• Blood vessels in the eye to burst or bleed. This may cause vision changes and can result in blindness.

Failure to find and treat HTN is serious, as untreated HTN can cause:

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HYPERTENSION

Blood pressure is often increased in overweight individuals.

Estimates suggest that control of overweight would eliminate 48% of the hypertension in Caucasians and 28% in African Americans.

Overweight and hypertension interact with cardiac function, leading to thickening of the ventricular wall and larger heart volume, and thus to a greater likelihood of cardiac failure.

J La State Med Soc .2005; 157 (1): S42-49.

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HYPERTENSION PREVALENCE IN THE OVERWEIGHT

0

5

10

15

20

25

30

35

Males Females

BMI < 25BMI > 25 & < 27BMI > 27 & <30

Prev

alen

ce o

f H

TN

Age-adjusted prevalence of hypertension in

overweight U.S. adults

14.9

22.1

27.0

15.2

27.7

32.7

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STROKE

A stroke occurs when the blood supply to part of the brain is suddenly interrupted by a blocked vessel or when a blood vessel in the brain bursts.

Once their supply of oxygen and nutrients from the blood is cut off to the brain cells, they die.

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STROKE

Sudden numbness or weakness, especially on one side of the body

Sudden confusion or trouble speaking or understanding speech

Sudden trouble seeing in one or both eyes

Sudden trouble with walking, dizziness, or loss of balance or coordination

Sudden severe headache with no known cause

The symptoms of a stroke include:

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STROKEThere are two forms of stroke: ischemic and hemorrhagic.

Ischemic stroke occurs when an artery to the brain is blocked.

Overweight and obesity increase the risk for ischemic stroke in men and women.

With increasing BMI, the risk of ischemic stroke increases progressively and is doubled in those with a BMI greater than 30 kg/m2 when compared to those having a BMI of less than 25 kg/m2.

Hemorrhagic strokes occur when a blood vessel in the brain erupts.

Overweight and obesity do not increase the risk for hemorrhagic strokes.

J La State Med Soc .2005; 156 (1): S42-49.

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CORONARY ARTERY DISEASECoronary artery disease (CAD) is a type of atherosclerosis that occurs when the arteries supplying blood to the heart muscle (coronary arteries) become hardened and narrowed.

This hardening and narrowing is caused by plaque buildup.

As the plaque increases in size, the insides of the coronary arteries get narrower, and eventually, blood flow to the heart muscle is reduced.

This is critical because blood carries much-needed oxygen to the heart.

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CORONARY ARTERIESBLOOD FLOW

When the heart muscle is not receiving the amount of oxygen that it needs, one of two things can happen:

• Angina• Heart Attack

AnginaThis is the chest pain or discomfort that occurs

when the heart is not getting enough blood.

Heart attack This is what happens when a blood clot develops at the site of the plaque in a coronary artery.

The result is a sudden blockage, which may block all or most of the blood supply to the heart

muscle. Because cells in the heart muscle begin to die when they are not receiving adequate amount of oxygen, permanent damage to the heart muscle

can occur if blood flow is not quickly restored.

I

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CORONARY ARTERY DISEASE

Over time, CAD can weaken the heart muscle and contribute to:

• Heart Failure• Arrhythmias

Heart FailureIn this condition, the heart can’t pump blood

effectively to the rest of the body. Heart failure does not mean that the heart has

stopped nor does it mean that it is about to. It means that the heart is failing to pump

blood the way that it should.

Arrhythmias Arrhythmias are changes in the normal beating rhythm of the heart. They can be

either faster or slower than normal. Some arrhythmias can be quite

serious.

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CORONARY ARTERY DISEASE

Obesity is associated with an increased risk for CAD.

Abdominal fat distribution is believed to be related as well.

Data from the Nurses Health Study illustrated that women in the lowest BMI but highest waist-to-hip circumference ratio had a greater risk of heart attack than those in the highest BMI but lowest waist-to-hip circumference ratio.

Regional fat distribution appears to have a greater effect on CAD risk than BMI alone.

J La State Med Soc .2005; 156 (1): S42-49.

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GASTROINTESTINAL DISORDERSASSOCIATED WITH OBESITY

Obese individuals are at greater risk of developing these gastrointestinal disorders:

Colon Cancer

Gall stones

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COLON CANCER

Colorectal cancer is a term used to refer to cancer that develops in the colon or the rectum.

The colon (a.k.a. the large intestine) is about 5 feet long and its role in the digestive system is to continue to absorb water and mineral nutrients from food. Once this process of absorption is complete, waste matter (feces) remains.

The rectum is the final 6 inches of the digestive system. Feces are passed from the large intestine to the rectum, to exit the body through the anus.

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COLON CANCER

Colorectal cancer is the second leading cause of cancer-related deaths in the U.S.

It is estimated to cause about 55,170 deaths during 2006.

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COLON CANCERFINDINGS RELATING TO OBESITY

Colon cancer has been shown to occur more frequently in people who are obese than in people who are of a healthy weight.

An increased risk of colon cancer has been consistently reported for men with high BMIs.

Women with high BMI are not at increased risk of colon cancer.

There is evidence that abdominal obesity may be important in colon cancer risk.

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GALLBLADDER DISEASE

Cholelithiasis is the primary hepatobiliary pathology associated with overweight.

Cholelithiasis is a condition characterized by the presence or formation of gallstones in the gallbladder or bile ducts.

Normally, a balance of bile salts, lecithin, and cholesterol keep gallstones from forming. However, if there are abnormally high levels of bile salts or, more commonly, cholesterol, then stones can form.

.

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GALLSTONESFINDINGS RELATED TO OBESITY

Obesity appears to be associated with the development of gallstones.

More cholesterol is produced at higher body fat levels.

Approximately 20 mg of additional cholesterol synthesized for each kg of extra body fat.

High cholesterol concentrations relative to bile acids and phospholipids in bile increase the likelihood of precipitation of cholesterol gallstones in the gallbladder.

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GALLSTONESFINDINGS RELATED TO

OBESITY

In the Nurses’ Health Study, when compared to those having a BMI of 24 or less,

• Women with a BMI > 30 kg/m2 had a 2-fold increased risk for symptomatic gallstones.• Women with a BMI > 45 kg/m2 had a 7-fold increased risk for symptomatic gallstones.

The relative increased risk of symptomatic gallstone development with increasing BMI appears to be less for men than for women.

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GALLSTONESFINDINGS RELATED TO OBESITY

Ironically, weight loss leads to an increased risk of gallstones-- because of the increased flux of cholesterol through the biliary system.

Diets with moderate levels of fat that trigger gallbladder contraction and subsequent emptying of the cholesterol content may reduce the risk of gallstone formation.

Bile acid supplementation can be used to lower ones risk for gallstone formation.

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METABOLIC DISORDERSASSOCIATED WITH OBESITY

Obese individuals are at greater risk of developing these metabolic disorders:

Diabetes Mellitus

Dyslipidemia

Liver Disease

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DIABETES MELLITUS

Type 2 diabetes mellitus (DM) is strongly associated with overweight and obesity in both genders and in all ethnic groups.

The risk for Type 2 DM increases with the degree and duration of overweight in individuals.

The risk for Type 2 DM also increases in individuals with a more central distribution of body fat (abdominal).

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OBESITY AND TYPE 2 DMIN THE UNITED STATES

Among people diagnosed with Type 2 diabetes, 55 percent have a BMI

≥ 30 (classified as obese), 30 percent have a BMI ≥ 25 or ≤30

(classified as overweight), and only 15 percent have a BMI ≤ 25

(classified as normal weight).

Adapted from: http://www.obesityinamerica.org/trends.html

BMI < 25BMI > 25 or BMI < 30BMI > 30

15%

30%55%

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DIABETES MELLITUSFINDINGS RELATED TO

OBESITY

The Nurses’ Health Study demonstrated the curvilinear relationship between increasing BMI and the risk of diabetes in women:

• Women with a BMI below 22 kg/m2 had the lowest risk of DM• At a BMI of 35 kg/m2, the relative risk of DM increased 40-fold or 4,000%

The Health Professionals Follow-up Study demonstrated a similar relationship between increasing BMI and the risk of diabetes in men:

• Men with a BMI below 24 kg/m2 had the lowest risk of DM• At a BMI of 35 kg/m2, the relative risk of DM increased 60-fold or 6,000%

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DIABETES MELLITUSFINDINGS RELATING TO WEIGHT LOSS

Weight loss reduces the risk of developing diabetes.

In the Health Professionals Follow-up Study, a weight loss of 5-11 kg decreased the relative risk for developing diabetes by nearly 50%.

Type 2 DM was almost nonexistent with a weight loss of more than 20 kg (44 lbs) or in those with a BMI below 20.

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DYSLIPIDEMIA

Dyslipidemia is defined as abnormal concentration of lipids or lipoproteins in the blood.

As BMI increases, there is an increased risk for heart disease.

This is because a positive correlation between BMI and triglyceride (TG) levels has been demonstrated.

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DYSLIPIDEMIAFINDINGS RELATED TO

OBESITY

An inverse relationship between HDL cholesterol and BMI has been noted.

This relationship may be more important than the relationship between BMI & TG levels.

Low level of HDL carries more relative risk for developing heart disease than do elevated triglyceride levels.

Central fat distribution also plays an important role in lipid abnormalities.

Excessive body fat in the abdominal region leads to increased circulating triglyceride levels.

HDL

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LIVER DISEASE

Nonalcoholic fatty liver disease (NAFLD) is the term given to describe a collection of liver abnormalities that are associated with obesity.

In a cross-sectional analysis of liver biopsies of obese patients, it was found that the prevalence of steatosis, steatohepatitis, and cirrhosis were approximately 75%, 20%, and 2% respectively.

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LIVER DISEASEFATTY LIVER

Steatosis is the term for “fatty liver” and it is not actually a disease, but rather a pathological finding.

Most cases of fatty liver are due to obesity.

Other causes of fatty liver include:• Diabetes• Certain drugs• Intestinal bypass operations• Starvation• Protein malnutrition• Alcoholism

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LIVER DISEASEFATTY LIVER

A gradual weight reduction can help to reduce the enlargement of the liver due to fat, and it can normalize the associated liver test abnormalities.

It is important to limit the amount of alcohol consumed in the diet. Alcohol can decrease the rate of metabolism and secretion of fat in the liver.

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Obstructive sleep apneaOsteoarthritis

Endometrial, prostate, and breast cancersComplications of pregnancy

Menstrual irregularitiesPsychological disorders

OTHER DISORDERSASSOCIATED WITH OBESITY

Obese individuals are at greater risk of developing these metabolic disorders:

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OBSTRUCTIVE SLEEP APNEA

Obstructive sleep apnea is caused by repetitive upper airway obstruction during sleep as a result of narrowing of the respiratory passages.

Patients having the disorder are most often overweight with associated peripharyngeal infiltration of fat and/or increased size of the soft palate and tongue.

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OBSTRUCTIVE SLEEP APNEACommon complaints are loud snoring, disrupted sleep, and excessive daytime sleepiness.

Individuals with sleep apnea suffer from fragmented sleep and may develop cardiovascular abnormalities because of the repetitive cycles of snoring, airway collapse, and arousal.

Because many individuals are not aware of heavy snoring and nocturnal arousals, obstructive sleep apnea may remain undiagnosed.

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OBSTRUCTIVE SLEEP APNEAFINDINGS RELATING TO OBESITY

Obstructive sleep apnea affects around 4% of middle-aged adults.

Individuals having a BMI of at least 30 are at greatest risk for sleep apnea.

Weight loss has been shown to improve the symptoms relating to sleep apnea.

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OSTEOARTHRITIS

Osteoarthritis (OA) is the most common type of arthritis

40 million Americans currently have osteoarthritis.

It is a degenerative disease which frequently leads to chronic pain and disability.

For individuals over the age of 65, it is the most disabling disease.

Currently, only the symptoms of OA can be treated; there is no cure.

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OSTEOARTHRITIS FINDINGS RELATING TO OBESITY

The incidence of OA is significantly increased in overweight individuals.

OA that develops in the knees and ankles is probably directly related to the trauma associated with the degree of excess body weight.

Osteoarthritis in other non-weight bearing joints suggests that there must be some component of the overweight syndrome responsible for altering cartilage and bone metabolism, independent of the actual stresses of body weight on joints.

Areas of the body most commonly affected by OA

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CANCERFINDINGS RELATING TO OBESITY

Overweight and obesity are associated with an increased risk of:

esophageal, gallbladder, pancreatic, cervical, breast, uterine, renal, and prostate cancers.

Obesity and physical inactivity may account for 25 to 30 percent of several major cancers, including--- colon, breast (postmenopausal), endometrial, kidney, and cancer of the esophagus.

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ENDOCRINE CHANGES

Changes in the reproductive system are among the most common.

Irregular menses and frequent anovular cycles are common.

Rates of fertility may also be reduced.

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ENDOCRINE CHANGESASSOCIATED WITH OBESITY

Increased cortisol production

Insulin resistance

Decreased sex hormone-binding globulin in women

Decreased progesterone levels in women

Decreased testosterone levels in men

Decreased growth hormone production

Common hormonal abnormalities associated with obesity

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PSYCHOLOGICAL DISORDERSASSOCIATIONS WITH OBESITY

Obesity is associated with an impaired quality of life.

Higher BMI values are associated with greater adverse effects.

When compared to obese men, obese women appear to be at a greater risk for psychological dysfunction.

This may be due to the societal pressure on women to be thin.

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PSYCHOLOGICAL DISORDERS

WEIGHT LOSS

Intentional weight loss has been consistently associated with improved quality of life.

Severely obese patients who lost 43 kg through gastric bypass demonstrated improved quality of life scores to such an extent that their post-weight loss scores were equal to or even better than population norms.

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IN CONCLUSION

Diabetes mellitus

Hypertension

Gallbladder Disease

Liver Disease

Cancer

Coronary Artery Disease

Cerebrovascular disease (stroke)

Endocrine Changes

Psychosocial Function

Obstructive Sleep Apnea

Osteoarthritis

The following conditions have been found to be associated with obesity:

These diseases have been found to be associated with increased metabolic

activity (secretion) of fat cells in obesity

These diseases have been found to be associated with increased fat mass

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WHAT ABOUT CHILDREN?

When children are overweight, they are more likely to be overweight and obese as adults.

How can children avoid being obese?

• This starts as soon as we are born….

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HEALTHY STARTSBefore we are born

Mothers who:• Normal BMI during pregnancy• Eat healthy and exercise moderately • Gain 11.5-16 kg • Prenatal care

When we are babies

• Study shows babies weaned before 4 months gained more weight than recommended

• According to WHO: Breastfeed for at least 6 months exclusively and beyond if possible

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CHILDHOOD OBESITY

Rates of childhood obesity are alarming

Problem is worldwide

Estimated in 2010, 42 million children under age 5 are considered overweight

Tripled in past 30 years

• Age 6-11 6.5% to 19.6% • Age 12-19 5.0% to 18.1%

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CHILDHOOD OBESITY Genetic Link

• Multifactorial condition related to sedentary lifestyle, too much good intake and choice of foods actually alter genetic make-up, creating higher risk of obesity

Behavioral

• Children will more likely choose healthier foods if they are offered to them at young ages and in the home

Environment

• In homes where healthy food is not available, or the food choices are not healthy, Obesity can occur .

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CHILDHOOD OBESITY

Why does this matter?

• Premature death• Developing heart disease at younger ages• Developing diabetes type 2 at younger ages

What can be done?

• Childhood obesity is preventable• Role of the schools • Role of health care professionals

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WHO STRATEGY WHO Strategy for preventing overweight and obesity

Adopted by World Health Assembly in 2004 and WHO Global Strategy on Diet, Physical Activity and Health

Four objectives• Reduce risk factors of chronic disease• Increase awareness and understanding• Implement global, regional, national policies

actions plans• Monitor science and promote research

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GLOBAL RECOMMENDATIONS ONPHYSICAL ACTIVITY FOR HEALTH

5–17 years old

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GLOBAL RECOMMENDATIONS ONPHYSICAL ACTIVITY FOR HEALTH

GLOBAL RECOMMENDATIONS ONPHYSICAL ACTIVITY FOR HEALTH

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AHA GUIDELINES FOR HEALTHY DIETS

Protein: 15-20% of calories not excessive (50-100g/d) proportional to carbohydrate and fat

Carbohydrates: ~55% of calories Minimum of 100g/d

Fat: ~30% of calories, <10% sat fat

Protein foods should not contribute excess total fat, sat fat or cholesterol

Diet should provide adequate nutrients and support dietary compliance

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FRUITS AND VEGETABLES

WHO states:

• Fruits and vegetables need to be part of the daily diet to prevent disease such as obesity and noncommunicable disease

The statistics are startling Lack of enough fruits and vegetables cause

• 19% of GI deaths• 31% of Ischemic heart disease• 11% of stroke

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HOW MUCH FRUIT IS ENOUGH?

WHO recommends at least 400 gms of fruit and vegetables each day…

This will prevent chronic disease related to overweight and obesity

• Heart disease• Diabetes• Cancers

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OBESITY DRUGSAppetite suppressants

Noradrenergic (Schedule IV)

• Phentermine (Adipex, Fastin)• Diethylpropion (Tenuate)

Noradrenergic (Schedule III)

• Benzphetamine (Didrex)• Phendimetrazine (Bontril)

Serotonergic

• Fenfluramine, dexfenfluramine

Mixed Noradrenergic & Serotonergic

• Sibutramine (Meridia)

Nutrient absorption reducers

Lipase inhibitor

• Orlistat (Xenical)

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SIBUTRAMINE (MERIDIA)Contraindicated:

CAD, CHF, cardiac arrhythmias or stroke

Side Effects:

hypertension, arrhythmia, tachycardia

pulse and BP should be checked before treatment and every 2 weeks in the 1st 3 months and every 1-3 months thereafter

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SIDE EFFECTSCommon

• Headache• Dry mouth• Constipation• Insomnia

Stop treatment in patients who experience:• an increase in heart rate of 10 beats/min • an increase in either SBP or DBP of >10 mmHg in 2 consecutive

visits

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ORLISTATLipase inhibitor that reduces fat absorption by ~30% resulting in reduction in energy intake

Inhibits digestion of dietary triglycerides, decreases absorption of cholesterol and lipid-soluble vitamins

Side EffectsGI side effects due to inhibition of fat absorption

• pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting

Multivitamin recommended because of reduction in absorption of fat soluble vitamins (esp. A & E)

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SURGERY2001 -- 47,000

2002 -- 63,000

2003 -- 98,000

NIH Criteria:

Well informed and motivated patient

BMI>40 or

BMI>35 with co-morbidities

Mortality: 1-2%

Effectiveness: >50% excess weight loss at 14 years

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ESSENTIAL UNDERSTANDINGS It is well known that obesity is preventable. It is caused by eating more than we need…so how can we prevent obesity?

Each of us can…according to WHO• Have a balance of energy and healthy weight• Limit how much fat we eat…we need to eat

some..but not too much. • Increase fruits and vegetables• Limit sugars• Increase exercise to at least 30-60 minutes per day

on most days!

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Reversing the obesity epidemic is a shared

responsibility. Social and environmental changes

are influenced by the efforts of many…

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ACKNOWLEDGEMENT

WORLD HEALTH ORGANISATION

CDC, ATLANTA, USA

Ministry of health and family welfare, New Delhi

All India Institute of Medical Sciences, New Delhi

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THANK YOU