Obesity

OBESITY

Obesity is defined as an abnormal growth of the adipose tissue due to an enlargement of fat cell size(hypertrophic obesity)or an increase in fat cell number(hyperplastic obesity)or a combination of both.

Central obesity is defined as waist circumference ≥ 90 cm in males and ≥ 80 cm in females. +Any two of the following-Increased triglycerides ≥ 150 mg/dl (1.70 mmol/L)-reduced HDL cholesterol <40 mg/dl in males and < 50 mg/dl in females.-raised blood pressure systolic bp ≥ 130 mm Hg and diastolic bp ≥ 85mm Hg.-raised fasting plasma glucose ≥ 100 mg/dl.

Or treatment for previously diagnosed any of the above condition.

Classification BMI(kg/m2)

Risk of Co-morbidities

Underweight <18.5 Low (Risks are increased in other areas)

Desirable 18.5-22.9

Average

Overweight 22.9-29.9

Mildly Increased

Obese >30.0

Class 1 Obesity

30.0-34.9

Moderate

Class 11 Obesity

35.0-39.9

Severe

Class 111 (morbid obesity)

>40.0 Very severe

Obesity is primarily driven

by individual decisions, and

the way society influences them

Human biology - genetics plays a part but does not pre-destine us to be obese

Culture/Individual psychology - it is difficult to break habituated unhealthy eating patterns, especially when common to those around us

The food environment - there has also been a huge increase in the quantity of quick convenience foods, which tend to be high in saturated fat, salt and sugar.

The physical environment - our lives have become increasingly sedentary. For e.g. last two decades have seen marked reduction in school walking.

RISK

FACTO

RS

RELATIVE RISK OF HEALTH PROBLEMS ASSOCIATED WITH OBESITY

Greatly increased(relative risk >>3)

•Diabetes•Gall bladder diseases•Hypertension•Dyslipidemia•Insulin resistance•Sleep apnea•Breathlessness

Moderately increased

(relative risk 2-3)

•Coronary heart disease •Osteoarthritis (knees)•Hyperuricemia and gout

Slightly increased(1-2)

•Cancer(breast cancer in postmenopausal women, endometrial cancer, colon cancer)•Reproductive hormone abnormalities•Polycystic ovarian syndrome•Infertility•Low back ache•Increased anesthetic risk•Foetal defect arising from maternal obesity.

DETERMINANTS OF CHILDHOOD OBESITY

Unhealthy nutrition- Spurred by advertisements, social networks, peer pressures, and availability of low cost calorie dense food.

Physical inactivity-Lack of green spaces, steady pressure on children to perform well in academics, gradual erosion of playtime by television and internet.

Socio-economic status-In developing countries childhood obesity is more prevalent in affluent society.

Socio-cultural factors-Myths like ‘Fat child is healthy child’, shortened duration of breast-feeding, early introduction of fatty complementary food in diet.

Sleep-Shortened sleep duration, obesity and insulin resistance are inter-related.

Genetic factors-Is responsible for 30%-50% of childhood obesity and adiposity.Syndromes like prader-willi syndrome, Cohen syndrome, achondroplasia.

Obesity in Asian Indians (2003-2005)Variables Urban RuralMean BMI (kg/m²) 24.8 21.9BMI >30 kg/m² 13.0 2.0BMI >23 kg/m² 65.4 31.8High WC (cm) 38.6 7.7BMI, Body mass index, WC, Waist circumferenceUnpublished data based on a study funded by American Associationof Physicians of Indian Origin and Texas A & MUniversity, TX, USA, 2003-2005

HORMONE DISORDERS CAUSING OBESITY

Growth hormone deficiency-

Associated with visceral obesity, and increases in the ratio of fat to lean body mass

Cushing’s syndrome-

Striae, easy bruising, and central fat distribution accompany gluco-corticoid excess.

Hypothyroidism-Increased fatigue, excessively dry skin, constipation, cold intolerance, poor scholastic performance, and short stature.

NEURO-ENDOCRINOLOGY OF WEIGHT REDUCTION

Leptin (is secreted from adipocytes in

proportion to adiposity)

Adiponectin(is secreted exclusively by

adipose tissues)

Acts on hypothalamus to inhibit feeding behaviour, decrease insulin secretion, and increases metabolic rate

Its levels increases 2 fold before a meal and decreases to trough levels within 1 hr after eating.It is decreased in type 2DM, obesity and metabolic syndrome.

Ghrelin-is a hormone secreted by stomach

Levels rises with fasted state and decreases with feeding.

CONSEQUENCES OF OBESITYIncreased adiposity can lead to both immediate and long term complications.Insulin resistance almost always accompanies obesity and is directly proportional to amount of adiposity.

Pubertal development- with increase in average body fat, the age of puberty for boys and girls decreases. Lower age of menarche for obese girls.Blount’s disease- in younger children and is characterized by abnormal growth of the medial aspect of proximal tibial epiphysis which causes progressive varus angulations of the leg below the knee and is often bilateral.Gastro-intestinal problems- elevated concentrations of liver enzymes, Fatty liver.Respiratory problems- obese children have lower peak expiratory rates. Even in the non-asthmatics, obese children demonstrate more severe bronchial hyper-reactivity after exercise.Sleep disorders- snoring, and obstructive sleep apnoea syndrome.Impaired glucose tolerance and diabetes mellitus- IGT is defined as fasting glucose more than 100mg/dl or a 2h post-oral glucose load level between 140-200 mg/dl.Hypertension- Mostly attributed to obesity, as obese children and adolescents have higher prevalence rates for hypertension than leaner childrenHyperlipidemia- high total serum cholesterol, LDL cholesterol and triglycerides and low HDLEarly atherosclerosis-fatty streaks are present in the aorta by the age of 10yrsand in the coronary arteries by age of20yrs.Psychosocial problems- low self esteem, difficulty in peer group relationships.Childhood obesity commonly leads to adult obesity.

TREATMENT AND

MANAGEMENT

Primary interventi

on

Moderate calorie restriction.(to achieve a 5-10% loss of body weight in 1st yr)Moderate increase in physical activity.Change in dietary composition.

Secondary

intervention

Drug therapy is required to treat the metabolic syndrome associated with obesity.There is a definite need for treatment that can modulate the underlying mechanism of metabolic syndrome as a whole and thereby reduce the impact of all the risk factors and the long term metabolic and cardiovascular consequences.

Cut down on salt and sugar.

Do not skip meals

Do not eat while reading, watching TV, playing video games.

Eat little at dinner.

Walk after night meals.

Avoid foods high in saturated fat and cholesterol.

Take fruits in between meals for snacking.

Take at least 7-10 glasses of water every day.

Use skimmed milk instead of full fat milk.

AVOID

•Alcoholic drinks.•Butter , margarine•Cakes, pancakes, cookies, doughnuts, pastries etc.•Candies, chocolates, cream, cheese.•French fries, potato chips, pizza, pasta, burger, snacking food.•Jams, jellies, sugar and syrup.•Ice cream, ice milk, sherbets, soda drinks.

DIET

Diets high in carbohydrate and low in fat results in increased hepatic lipogenesis and increased triglycerides.

High fat diet causes less satiety than high carbohydrate diets and such diets may promote over eating

The main emphasis should be on a diet which provides sufficient dietary caloric restriction while providing adequate protein to ensure ideal growth.

Refined sugars and diet rich in fructose should be

avoided.

Very low energy diets with a restricted energy intake of 600 to 800 kcal per day with 1.5-2.5g of high quality protein per kilogram of ideal body weight , carbohydrates 20-40 g per day and multivitamins .

EARLY YEARS(UNDER 5S)Preschool children should be physically active at least for 180 minutes.All under 5s should minimize the time spend being sedentary for extended periods except for sleeping.

CHILDREN AND ADOLESCENTSAll children and young people should engage in moderate to vigorous intensity physical activity for at least 60 minutes and up to several hours every day. -Vigorous intensity activities, including those that strengthen muscle and bone should be incorporated at least thrice a week.-They should minimize the time spend being sedentary for extended periods.

ADULTS AND OLD AGE-Adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes (2½ hours) of moderate intensity activity in bouts of 10 minutes or more – one way to approach this is to do 30 minutes on at least 5 days a week. Alternatively, comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week or a combination of moderate and vigorous intensity activity. -Adults should also undertake physical activity to improve muscle strength on at least two days a week. -All adults should minimize the amount of time spend being sedentary for long.

PHYSICAL

ACTIVITY

MYTHS AND FACTS ASSOCIATED WITH OBESITY

Myth 1-People only become obese and overweight because they do not engage in weight loss efforts including physical activity and have unhealthy eating habits.

Myth 2-Obesity is only prevalent in developed countries that foster indulgent lifestyles, with poor diets and and lack of exercise like USA and UK.

Fact-Weight loss and management efforts require a balanced combination of behavioural change and medical/scientific evaluation and intervention. In addition hormonal disorders can contribute to obesity

Fact-In economically advanced advanced regions of developing countries, prevalence rates of obesity may be as high as high as rates in industrialized countries. rising obesity rates in developing countries may be due to societal changes such as greater food consumption.

Myth 3-Once committed to a weight loss regimen, obese individuals should attempt to lose a large amount of weight as quickly as possible.

Myth 4-Weight gain in women over time is healthy and part of a natural aging process.

Fact-Fast weight loss (more than 3 pounds per week) or loss of large amount of weight- can increase the risk of developing gallstones. maintaining a balanced regimen is the right approach.

Fact-Although metabolism may change over time, weight gain of more than 20 pounds is not a normal part of the maturation process and may actually increase the women’s risk of obesity-related risk.

Myth 5-Osteo-arthritis only develops when an individual gains a large amount of weight over a short time period.

Fact-Timing is not a major factor in the development of osteo-arthritis.for every 2 pound of weight, the risk of developing arthritis is increased by 9-13%.

Myth 6-Fat children are healthy....with age ‘baby fat’ will go away

Fact-50-70% of obese children remain obese adults.

Myth 7-Heart diseases start at old age

Fact-Hardening and blockage of arteries starts at 11yrs in boys and 15 yrs in girls.

Myth 8-A fat child is otherwise healthy.

Fact-28% of urban children have syndrome X, one step away from diabetes and 2 steps away from heart disease.

Fact-Time on TV, internet and studies leave little time for play. Even during physical activity class many children do not participate.

Myth 9-All children are doing required physical activity

Ammonium carb-Fat patients with weak heart.Women who are tired and weary and takes cold easily.Leads a sedentary lifestyle.Dry coryza-stoppage of nose-at night-can only breathe through mouth-danger of suffocation.Sadness with disposition to weep, timidity, disgust with life, heedlessness, weakness of memory, great absence of mind.Chilly patient < wet stormy weather ; washing> warmth.

Ammonium muriaticum-Body is fat and legs are thin with large buttocks.Full of grief but cannot weep. Irritability and disposition to be angry.Feets get very cold in the evening in bed.

MANAGEMENT

HOMOEOPATHIC

Antium crudum-Children and old people who have a tendency to grow fat with coated white tongue.Belching and great eructations of ingesta.bloating after eating.Cold and callous excrescenses.Patient is aggravated from extremes of temperature.

Calcarea carbonicum-Sweating on the forehead which wets the pillow while sleeping.Fair, fat, flabby are the red lined symptom.Great sensitiveness to cold damp air.

Capsicum-Person who are weak of lax fibre.the digestion is poor and suffer from myalgia.Have burning pains still doesn’t like cold.Old people who have exhausted their vitality.Home-sickness.>from heat Carlsbad-

Action on liver, treatment of obesity and diabetes.Self satisfied, very talkative, good humored. Discouraged and anxious about domestic duties. Absent minded, heedless, forgets names.Sensitive to cold air. sweats more easily.> Motion and open air.

Calotropis gigantea-Helps in reducing the obesity, without reducing the weight i.e. flesh would decrease but the muscle would become more firm.There is great heat in stomach.

Ferrum metallicum-Obesity with anaemia, puffy face with pitting of flesh. Delicate girls, fearfully constipated with low spirits.< cold weather. > warm weather.Great lassitude and weakness.

Graphitis-Obesity in females with delayed menstruation.Fair, fat , chilly constipated people.

Kali carbonicum-Older fat people characterized by sweat, backache and weakness.Dark haired person with lax fiber and inclined to be fat.

Esculentine-Great fat reducer. Can be alternated with phytoline.Should be given in mother tincture.

Fucus vesiculosus-Given when calcarea carb fails.Indigestion, obstinate constipation, flatulence.To be given in tinctures.

Phytolacca berry- One of the best remedies in weight reduction and corpulence reduction

Phytoline-Great fat reducer. Recommended when the patient is having difficulty in walking, sitting, palpitation, dyspnoea on least exertion, nausea, eructations.Given in mother tincture.

Thyroidinum-Excessive obesity. Acts best in pale patients.Is a powerful diuretic and helps in myx-odema and various types of oedema.

COMPILED BY-

Dr Neena Mehan(Head, Deptt. of Medicine)

Dr Pavneet Kaur (Intern 2013-2014 Dr B R Sur Homoeopathic Medical College, Hospital and Research Centre)