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Weight concerns Overweight and obesity

Case M.B. is a 51-year-old female who presents asking for advice on how to lose weight. She is 160 cm tall and weighs 85 kg (body mass index, (BMI) 33). She has been overweight all her life everyone in her family is heavy. She has tried Weight Watchers, the Atkins diet, and several others diets. Sometimes she loses weight, but she always regains it. She wonders whether there's a way for her to really lose weight, or whether it's hopeless at this point in her life. Obesity is one of the most important public health problems in the USA. The combined prevalence of overweight and obesity (defined as BMI greater than or equal to 25) in American adults is 59 .10 The prevalence of obesity (defined as BMI greater than or equal to 30) increased 61 between 1991 and 2000, to almost 20 of all USA adults.10 Strong evidence supports an association between obesity and increased morbidity and mortality. Recent research has linked excessive weight and body fat to a dysmetabolic syndrome, which...

Inflammatory Alterations In Adipose Tissue With Obesity

Subsequent studies demonstrated a second AT-derived cytokine, IL-6, to be elevated in the serum of obese individuals and significantly correlated with FFA levels (69). Interestingly, more than 90 of IL-6 in adipose tissue was produced by nonadipocyte cells. In 2003 two separate laboratories independently reported a key observation concerning the appearance of macrophages in obese adipose tissue (70,71). There was a strong correlation between macrophage numbers with increasing adipocyte cell size (essentially reflecting increasing amounts of adipocyte triglyceride) and obesity. Adipose tissue macrophages were found to secrete several cytokines, including TNF-a and IL-6, as well as bioactive mediators of nitric oxide. These cytokines and other inflammatory mediators produced by macrophages are thought to alter adipocyte metabolism and function, as well as adipokine profile (72,73), and are further discussed later in the TFN-a and IL-6 sections. Future studies (including those in our own...

Dietary Fiber and Cancer Risk

Since the original suggestion by Denis Burkitt that dietary fiber might protect against colon cancer,48 numerous case-control and a few cohort studies have investigated this relationship. Most, but not all, have supported the original hypothesis of a protective role for fiber in the etiology of colon cancer. A recent review reported that 11 out of 17 case-control studies found an inverse relationship between dietary fiber intake and colorectal cancer.49 Another review and meta-analysis (based on 5255 patients with colorectal cancer) also found a significant inverse relationship between dietary fiber and colorectal cancer risk. An overall relative risk of 0.53 comparing those in the highest quintile with those in the lowest quintile was calculated it persisted after controlling for adjustment for other nutrients and for vitamin C and beta-carotene).50 The conflicting results from case-control and cohort studies are difficult to reconcile. Recall bias is a serious limitation in the...

Obesity As A Public Health Problem

Obesity is rapidly becoming the scourge of modern society. Presently, at least 34 of the U.S. population is obese (20 or more above their ideal weight) and more than 55 weigh in excess of ideal.1,2 This represents the highest prevalence ever recorded in the United States.3 Nor is the problem unique to Americans. It is estimated that there are now 250 million obese adults in the world (7 of the total population), with many more overweight.4 At the 1998 International Conference on Obesity, the World Health Organization identified obesity as a worldwide epidemic.5 In industrialized and developing countries alike, obesity ranks as one of the top five global health problems.6 One of the more sobering observations is that obesity is increasing rapidly among children and adolescents. The association between childhood obesity and obesity in adulthood indicates a strong relationship. Analysis by Serdula et al.7 indicates that about one third of obese preschool children become obese as adults,...

Vegetarian Children and Obesity

Body mass index, kg sq m attribute also tends to be present among older vegetarian children and adolescents, although limited research data are available for older children. Lousuebsakul and Sabate21 studied anthropometric data of 870 children aged 7 to 18 years who were attending Seventh-Day Adventist schools in California. One third of them were vegetarian. A vegetarian lifestyle was associated with lower BMI and a decreased tendency to be overweight, especially in adolescent girls. Specifically, age- and height-adjusted analysis showed that vegetarian boys and girls were, on average, 1.4 kg and 1.0 kg, respectively, leaner than their non-vegetarian classmates. Also, BMI values and skinfold measurements were lower among vegetarians. The prevalence of obesity (BMI > 75th percentile of national standards) was lower among vegetarian adolescent girls. In view of the relationship of childhood obesity to adult corpulence,7 the adoption of a vegetarian lifestyle during the school years...

Anthropometry and Change in Body Composition in Obesity

Waist circumference is commonly used to assess change in abdominal obesity. Changes in waist circumference are associated with changes in visceral fat in response to diet and or exercise weight loss (Fig. 5) (35,50,52). It is reported that a 1-cm reduction in waist circumference corresponds to a 4 reduction in visceral fat however, there was a substantial amount of variance (standard deviation 4 ) in this relationship. The variation in this association is in part due to changes in subcutaneous fat and or lean mass that mask the ability of waist circumference to accurately distinguish changes in abdominal tissues. When examining the utility of WHR to estimate changes in body composition, a principal limitation of a ratio score becomes clear. Owing to the nature of ratio scores, changes in the ratio could be due to alterations in the numerator (waist) or the denominator (hip). For example, a reduction in the WHR after an exercise intervention could be due to reductions in the waist...

Potential Explanations For The Antiobesity Effect Of A Vegetarian Diet

While data indicate that vegetarians may weigh less than other population subsets, it does not necessarily follow that it is their avoidance of meat that is responsible. Vegetarians are also more likely to adopt other healthy life-style habits, such as regular exercise and reduced alcohol consumption, that also impact their lack of obesity. There is some evidence, however, that eating more vegetables and abstaining from meat does play a significant role in their leaner profiles. A study by Kahn and others of 79,000 individuals followed for over 10 years showed that the one habit that seemed to prevent the development of abdominal obesity was eating vegetables. Those who consumed 19 or more servings of vegetables per week did not succumb to an increase in central girth, while those who ate meat (beef, pork, or lamb) more that seven times per week did.26 Vegetarian diets can be lower overall in total energy intake. Also, the macronutrient composition and sources of macronutrients tend...

Diabetes And Minerals Vitamins And Dietary Supplements

At present, megadoses of dietary antioxidants, such as selenium, P-carotene, vitamin E, and vitamin C, have not demonstrated cardioprotection in diabetic patients in some clinical trials, such as the Heart Outcomes Prevention Evaluation (HOPE) trial, they have actually been shown to be inferior to certain medications, particularly angiotensin-converting enzyme (ACE) inhibitors (16). Medical nutrition therapy should be individualized according to the metabolic profile, desired goals, and clinical outcomes, in accordance with the usual dietary habits of the patient. Family members of individuals with type 2 diabetes should be encouraged to engage in regular physical activity and dietary management to decrease their risk of developing the disease. 2. The Rotterdam Study (20). This study evaluated the relationship between dietary intake of P-carotene, vitamin C, and vitamin E in 4800 people aged 55-95 years with no history of myocardial infarction. This study demonstrated that P-carotene...

Components Of Energy Expenditure And Their Relevance To Obesity

Total daily energy expenditure (TDEE) varies substantially in humans (42) such that two adults of the same size could have an EE that varies by 1500 kcal d. The largest determinants of TDEE are weight, height, age, and gender (42). Whereas both weight and height are positive determinants of TDEE, age is a negative predictor in adults. Across all ages, TDEE is approx 11 higher in males, after adjustments for body size (42). With the increasing prevalence of obesity, understanding the inherent interindividual variation in TDEE is important. The variability in daily energy requirements is related to the variability in the energy expended in its three major components resting metabolic rate, diet-induced thermogenesis, and activity thermogenesis (Fig. 2).

Energy Expenditure In The Etiology Of Obesity

Cross-sectional studies that compare lean and obese individuals have added little to our understanding of the physiological mechanisms predisposing to weight gain (76). An understanding of the etiology of human obesity demands longitudinal studies to reveal predictors or risk factors. Several studies have prospectively examined these predictors in the Pima Indian population in southwestern Arizona, a population where obesity is extremely prevalent (77) and, therefore, weight gain is common in young adults. In these individuals at least six metabolic parameters have been found to be predictive of weight gain. In particular, related to energy expenditure and relevant to understanding the etiology of obesity, are low metabolic rate, low activity thermogenesis, low sympathetic nervous system activity, and low fat oxidation.

Obesity Epidemic And Health And Cost Consequences

The rate in early 1980s (14.5 based on the second NHANES, conducted in 1976-1980) (8,9). Moreover, none of the major sociodemographic groups of the population has been immune to the epidemic rapid weight gain has been found in both genders, all racial ethnic groups, and all educational levels (5,10) the entire population weight distribution is moving to the right. Figure 1 is a depiction of the shift of the BMI (based on self-reported weight and height) distribution among the US adult population from the early 1990s to the early 2000s. There is another, possibly more disturbing, phenomenon. The distribution is becoming flatter i.e., a smaller proportion of the population is now in the center of the distribution (which is shifting as well), and a larger proportion further out in the right tail, i.e., in the obese range. This picture does little to reveal what is going on at the more extreme end of the weight distribution i.e., in the severe obesity range. Does severe obesity simply...

Food Supply and Dietary Changes

Changes in diet have been implied in the rising obesity and diabetes rates. One intriguing theory focuses on the economics of food supply, noting that the price for foods with higher energy density is much lower than that of less energy-dense foods in terms of price per calorie and that maintaining energy balance is more difficult with foods that have If the price per unit of energy for energy-dense products and for sweetened products is much lower than that for food such as fresh produce, lean meats, and fish, a differential dietary pattern would develop between income groups if people of low income are more sensitive to the price of food (29). The evidence is unclear, although low-income families are less likely to purchase fresh produce and they spend less money on it (34). The secular decline of prices for energy-denser foods and sugars relative to produce or fish would suggest widening gaps in obesity and related chronic conditions (such as diabetes) between populations of...

Morbidity and Mortality Associated With Obesity

Obesity is common and is associated with increased rates of mortality and morbidity. The effect of obesity on mortality risk has been addressed by a large number of studies over the past 20 yr. There are unfortunately a number of important methodological issues that have made it difficult to establish a clear relationship between these variables. For example, smokers weigh less than nonsmokers but have increased mortality related to their smoking, not their reduced weight. People with undiagnosed cancer may lose weight and have an increased risk of mortality that, again, is not related to their reduced weight. In an effort to correct for these factors, many modern studies exclude smokers and first 2- to 5-yr mortality (this period begins when BMI weight is first measured) when looking at the effects of obesity on mortality. When this has been done, there remain some questions about whether mortality rates are increased in overweight individuals (BMI 25-30), but it is clear that...

Costs Associated With Obesity

In addition to the impact of obesity on mortality and comorbid health, there are now a great deal of data demonstrating that obesity is responsible for increased medical costs, job absenteeism, and a reduced quality of life for both adults and adolescents (7,8). Obese individuals have more visits to primary care providers and are the recipients of more diagnostic and specialty services (9). In a study of more than 16,000 Medicare recipients, Daviglus et al. found that individuals who were either obese or severely obese in middle age generated 2020 and 6469 more per year in attributable health care charges than their lean counterparts when they entered the Medicare program at age 65 (10). Other studies have also documented an increase in health care costs associated with increasing weight in people covered by indemnity or preferred provider organization (PPO) health insurance plans, as well as those enrolled in health maintenance organizations (11-13). The net effect of health-related...

Consensus That Addressing Obesity Is Important

As a result of the increasingly compelling data on the growing prevalence of obesity, the adverse effects of obesity on health, and the costs of the condition, a broad consensus has emerged that evaluating patients for obesity should be an integral part of usual clinical care. One of the first groups to provide guidance on this topic was the National Heart, Lung, and Blood Institute (NHLBI) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, which was first published in Obesity Research in 1998 (15). More recently, a comprehensive evaluation of the evidence for screening for obesity in adults was published by the US Preventive Services Task Force (USPSTF) (16) along with recommendations for clinical evaluation (17). This organization, which is relatively conservative and firmly evidence-based, felt that determining BMI in adult patients was justified and that there was fair evidence that high-intensity counseling produces modest,...

Most Clinicians Currently Do Not Address Obesity

Despite the weight of the evidence and the broad consensus, there remains a great deal of clinical inertia against making a diagnosis of obesity and advising patients to lose weight. One study of more than 55,000 ambulatory care visits from the mid-1990s found that physicians reported obesity in only 38 and counseled only one-quarter of their obese patients (27). In another study of more than 12,000 obese adults, only 42 were advised to lose weight, and yet those who were so advised were more likely to try to do so (28). One might think that things have improved over the past 10 yr, but a recent study found that the number of patients who received advice to lose weight was actually lower in 2000 than it was in 1994 (40 , down from 44 ) (29). Physicians feel that there are many barriers to counseling their patients about weight loss. These include insufficient confidence, knowledge, and skills, as well as a perception that there are no effective therapies (30). Physicians seem more...

Defining Obesity Body Mass Index

There is general agreement that BMI, which is the weight adjusted for height, is the best way to initially evaluate patients for obesity. BMI, generally expressed as kg m2, is easily determined using measured height and weight and a table such as the one provided in the NHLBI and North American Association for the Study of Obesity's (NAASO, the Obesity Society) Practical Guide on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (Table 1) (35). An individual patient can then be placed in a risk category based on the BMI (Table 2). A healthy weight is defined as a BMI between 18.5 and 24.9, with overweight being defined by a BMI between 25 and 29.9 and obesity being the appropriate diagnosis when the BMI exceeds 30. The BMI is

Laboratory Evaluation of the Obese Patient

Although one could make a case for obtaining a large number of biochemical tests in the evaluation of an obese patient, a more limited initial screen seems warranted. A fasting sample of blood for glucose total, LDL, and HDL cholesterol and triglyceride levels is clearly indicated. These tests, along with an appropriate history, will provide the information necessary for cardiovascular risk stratification and can be used to rule out diabetes or impaired fasting glucose (25,57). Some have advocated obtaining a glycosylated hemoglobin (HbA1C) level to screen for diabetes. Although this test should be useful in the diagnosis of diabetes, the assay method has not been standardized and at this time there is no widely accepted diagnostic criteria for diabetes based on an HbA1C level. In addition, some have advocated obtaining a fasting insulin level to determine whether insulin resistance is present. Unfortunately, here again, methods for assaying insulin have not been standardized and...

Energy Expenditure and Obesity

Energy expenditure is made up of three components basal metabolic rate (BMR), which can be estimated as resting energy expenditure (REE), which has also been called resting metabolic rate (RMR) thermic effect of food, which makes up only a small fraction of total daily energy expenditure and energy expended in physical activity (EEPA), which is by far the most variable among individuals. Although patients often complain that they have a low metabolic rate, careful studies have conclusively shown that REE is linearly related to lean body mass (72). This means that heavier people have higher REE than thin individuals, and as a result need to eat more on average each day to maintain their higher weight. It is likely that the rise in the prevalence of obesity is the result not only of increased EI associated within the modern food environment, but also of a reduction in the habitual levels of EEPA associated with a modern environment filled with technologies designed to reduce the need...

Increase in Prevalence of Obesity

The National Health and Nutrition Examination Survey (NHANES) III, which was conducted from 1988 to 1994, showed that 59.4 of men and 50.7 of women in the United States are overweight or obese. In the period between the second NHANES survey and the third, the prevalence of obesity rose from 14.5 to 22.5 (7). More recent data has put the figure at 30.5 for obesity and 64.5 for overweight (8). Obesity is also increasing rapidly in other parts of the world (8). Global obesity increased from an estimated 200 million adults in 1995 to more than 300 million in 2000 (9). Childhood obesity has also increased. During the past 30 yr, childhood obesity in the United States has more than doubled (10). As obesity increases, it leads to an increased disease burden (11,12), increased mortality (13), and a shortened life span (14). It brings with it not only an increased incidence of type 2 diabetes, but also of dyslipidemia, hypertension, and cardiovascular disease.

Reductions in Dietary Energy Density as a Weight Management Strategy

Reducing caloric intake is the cornerstone of dietary therapy for long-term healthy weight management. Strategies individuals have typically used include limiting portion sizes, food groups, or certain macronutrients. Although such restrictive approaches can lead to weight loss in the short term, they can result in feelings of hunger or dissatisfaction, which can limit their acceptability, sustainability, and long-term effectiveness. An alternative positive strategy to manage energy intake is for individuals to eat more foods that are low in calories for a given measure of food that is, they are low in energy density (kcal g). Data have shown that people eat a fairly consistent amount of food on a day-to-day basis therefore, the energy density of the foods an individual consumes influences energy intake. Encouraging patients to eat more foods low in energy density and to substitute these foods for those higher in energy density allows them to decrease their energy intake while eating...

Dietary Guidelines

Dietary guidelines are designed to provide advice for healthy individuals regarding diet and related life-style practices to promote healthful eating and reduce the risk of disease.1 Dietary guidelines differ from nutrient standards such as the Reference Dietary Intakes (RDI) and Recommended Dietary Allowances (RDA),2 or food guides such as the Food Guide Pyramid.3,4 Nutrient standards define the reference points for average daily intake of essential nutrients food guides provide a framework for selecting kinds and amounts of foods of different types that together provide a nutritionally adequate diet and dietary guidelines give advice on consumption of types of food or food component related to a public health concern. The guidelines are intended to be population-based recommendations for health promotion and disease prevention. The dietary guidelines concept was first introduced by Atwater over a century ago. He indicated that food production at the time provided a relative excess...

Can Physical Activity Prevent Weight Gain

Close examination of prevalence data indicates the need to focus intervention efforts on the prevention of weight gain. If effective, this will decrease the likelihood of a transition from normal weight to overweight or obesity, and decrease the transition from overweight to obesity. There is some evidence that LTPA can play a significant role in the prevention of weight gain this is mostly likely a result of the increase in energy expenditure resulting from an increase in LTPA. For example, there are data from prospective observation studies that appear to support this hypothesis. Lee and Paffenbarger (9) concluded that participants in the Harvard Alumni Study who reported levels of physical activity consistent with approx 30 min of moderate-intensity physical activity had a lower body weight when compared with individuals reporting lower levels of physical activity. When change in cardiorespiratory fitness is used as a surrogate for change in LTPA, the data reported by DiPietro et...

Applying MI to Obesity Conceptual and Pragmatic Issues

There are several aspects of obesity counseling that pose unique challenges for the MI counselor. First, for pediatric obesity, depending on the age of the patient, the intervention may occur directly with the parent(s), directly with the child, or both. There is some evidence that older obese children do not benefit from the involvement of their parents, whereas parent involvement may be beneficial for younger children (46). However, it is not known at what ages youth and parents should be seen alone versus together. For both youth and adults, the practitioner needs to understand that obesity is not a behavior per se. Therefore, a key task for clinicians is to work with patients to identify what behaviors contribute to their own or their child's weight status and use agenda setting strategies to determine which behaviors they feel are most amenable to intervention (Table 1).

MI Studies Targeting Pediatric Obesity

We identified two studies in which MI was used to intervene in pediatric obesity. The first of these studies, the Healthy Lifestyles Pilot Study, focused on prevention of overweight among children 3 to 7 yr old. The second study, Go Girls, was a multicomponent intervention for overweight African American adolescents aged 12 to 16 that included MI as a key intervention element. The Healthy Lifestyles Study (HLS) (unpublished data) and Go Girls was conducted in 2004-2005 as a partnership of the Centers for Disease Control and Prevention, the American Academy of Pediatrics (AAP), and the American Dietetic Association. The primary aim of the HLS pilot was to examine the feasibility and potential efficacy of pediatrician and dietitian MI counseling for preventing childhood obesity in primary care pediatrics. Study sites were members of the AAP Pediatric Research in Office Settings (PROS) network, which is a practice-based research network established by the AAP in 1986 (55). Fifteen PROS...

MI Studies Addressing Dyslipidemia and Diabetes Dietary Intervention Study in Children

The Dietary Intervention Study in Children (DISC) was a multicenter, randomized controlled trial sponsored by the National Heart, Lung, and Blood Institute to assess the efficacy of dietary counseling to decrease elevated serum lipids (LDL-C). Children with elevated LDL-C entered the initial clinical trial when they were 8 to 10 yr of age (34). As the intervention cohort moved into adolescence, the investigators elected to add an MI-based intervention to renew adherence to the prescribed diet among the original intervention group (there was no control group for this phase). The counselors were primarily masters-level health educators and dietitians who received 18 h of MI training. Each study participant received one in-person MI session and one follow-up session that was conducted either in person or by telephone. Twenty-four-hour recall data from the first 127 youths to complete the two-session protocol indicated that the proportion of calories from fat and dietary cholesterol was...

Hyperphagia and Obesity in 5HT2CReceptor Knockout Mouse

Serotonin modulates numerous autonomic functions. It acts through the activation of a large family of G-protein-coupled-receptor subtypes that are widely expressed throughout the brain. The complexity of this signaling system and the paucity of selective drugs have made it especially difficult to define specific roles for 5-HT-receptor subtypes. Mutant mice lacking functional 5-HT2C receptors have been generated to elucidate the physiological function of this widely expressed receptor (156,157). Unexpectedly, 5-HT2C receptor-deficient mice display substantial overweight as a result of increased appetite. This obesity is characterized by leptin and insulin resistance, impaired glucose tolerance, and increased responsiveness to high-fat feeding. Thus, these mutant mice have established a role for the 5-HT2C receptor in the serotonergic control of feeding and energy expenditure. These findings also demonstrate a dissociation of serotonin and leptin signaling in the regulation of feeding,...

Predictors Of Success In Losing Weight

Most NWCR participants reported that they used diet and physical activity to lose their weight (3). Fewer than 10 of participants lost weight with diet alone and fewer than 2 lost weight with physical activity alone. Somewhat surprisingly, there was no similarity in the types of diets used by the individuals to lose weight. We could find no particular diet that seemed to be used more than others for losing weight in this population. The fact that most of them used physical activity along with diet is interesting, particularly as adding physical activity to food restriction has minimal effects on weight loss (21).

Persistence Sequelae and Costs of Pediatric Overweight

Increased body fatness can occur at any age and may or may not persist. The longer a child is overweight, the more likely it is that he or she will be overweight as an adult. At any point in time the positive predictive value of early obesity increases with the age of the child but never reaches 100 . One of the most significant risks of childhood obesity is that it is a strong predictor of adult obesity and the medical complications associated with obesity in adult life, such as diabetes, hypertension, and hyperlipidemia. Early obesity is also a risk factor for later cardiovascular and metabolic morbidities. Although parental obesity is predictive of child and adolescent obesity, the contribution of parental obesity to this risk ratio diminishes in importance over time in relation to the child's own BMI (16). The tendency for excess weight in childhood and adolescence to persist into adult life has been demonstrated in a variety of studies (27-29). Thus, obesity persisting from early...

Endocrine Causes of Obesity

Many patients are concerned that they have a metabolic or glandular cause for their obesity. This may be a reflection of the frustration that some of these individuals feel over the difficulties that they have had in battling a weight problem over many years. They may be looking for a medical explanation of why they have not succeeded in their goal of losing weight. Endocrine causes of serious obesity are not common. The three most commonly cited are hypothyroidism, Cushing's syndrome, and hypothalamic obesity. To evaluate the patient for hypothyroidism, questions can be asked about cold intolerance, constipation, irregular menses, fatigue, or depression. The presence of easy bruisability, proximal muscle weakness (difficulty getting out of a chair, trouble getting things out of a high cupboard), a change in appearance, or osteoporosis may be signs of hypercortisolism. The patient can be examined for signs of hypothyroidism including bradycardia, cool dry skin, a firm palpable...

Dietary Pattern And Pregnancy Outcome

The first comprehensive study of pregnant vegetarians, including dietary intake, nutritional status and health history, was reported by Hardinge et al. in 1954.2 Although vegans were included in the larger study of which this was a part, none was pregnant consequently, comparisons were made between lacto-ovo-vegetarians (LOVs) and omnivores. There was no difference in height, weight, or weight gained during pregnancy and there were no serious delivery complications in either group. Birth weights and lengths were not significantly different. Dagnelie et al. reported that the proportion of low birth weight among Dutch macrobiotics was more than twice the proportion found in the general population in the Netherlands.10 After excluding those with low birth weight, the mean birth weight in the remaining macrobiotic infants was 200g lower than the Dutch reference.11 The authors found a strong positive relationship between birth weight and the frequency of consumption of dairy products and...

Role Of Allied Health Professionals In Assessment Of The Obese Patient

The evaluation proposed here is extensive. It may be unrealistic to expect a busy clinician to obtain, evaluate, and counsel around all the information that could be discussed with an obese patient. An alternative is to identify individuals with unique skills and specialized resources in the clinical environment who can be brought into service during the evaluation and treatment of these patients. Examples include registered dieticians to assist in evaluation of the diet, exercise physiologists who help with assessing exercise capacity and the safety of initiating an exercise program, psychologists or psychiatrists to help evaluate and treat psychological comorbidities such as depression, pharmacists who have an interest in weight loss medications, and surgeons who have experience in bariatric surgery. If a clinician is interested in taking a more active role in managing obesity in his or her practice it will be useful to identify resources in the community to refer patients to....

Are Nwcr Participants Different From The Average Person Trying To Lose Weight

One potential criticism of the NWCR is that we have just captured people for whom weight loss is easy and that NWCR participants are somehow different from most overweight and obese people who try to lose weight. Although we cannot conclusively determine whether or not this is the case, we do find that the majority of NWCR participants were overweight as children or adolescents and that most have at least one overweight or obese parent. It is generally thought that those with a family history of obesity and those who developed obesity as children may find weight loss to be more difficult than those without a family history of obesity or those who become obese later in life.

Socioeconomic Disparities In Obesity And Diabetes

So far, we have discussed overall trends. At every point in time, obesity and diabetes rates are higher in some populations than in others. Populations with higher rates generally include groups with less education, lower household income, blacks, and Native Americans, but there are some noticeable variations and interactions depending on whether we distinguish between moderate and severe obesity. For example, obesity as defined by a BMI of over 30 has been higher among men than women (although that gap has narrowed noticeably). However, severe obesity (BMI > 40) has been much higher among women for some time, and women also make up the vast majority (close to 85 ) of bariatric surgery patients (15). Table 1 shows descriptive prevalence statistics for obesity, severe obesity, and diagnosed diabetes for men and women and by socioeconomic characteristics. Individuals without health insurance are, on average, 10 yr younger than those with health insurance (partly an effect of...

Digestion absorption and transport of dietary fat

The plasma lipoproteins are a family of globular proteins, each of which consists of a core of neutral lipid (predominantly triglyceride or cholesteryl ester) surrounded by a coat of phospholipid and protein. These particles can be divided into four broad categories (1) chylomicrons, which primarily transport dietary triglyceride and cholesterol (2) very-low-density lipoproteins (VLDL), which primarily transport triglycerides that have been synthesized in the liver Absorption of the fat-soluble vitamins takes place mainly in the proximal jejunum and depends on the proper functioning of the digestion and absorption of dietary fat. The fat content of a typical Western diet is composed mainly of triglycerides accompanied by smaller amounts of phospholipids and sterols. The efficiency of absorption of fat-soluble vitamins parallels that of fat absorption and is affected by the nature of the lipid component of the diet. The stomach is the major site for emulsification of dietary fat. The...

Prostate Cancer Risk Reduction by Dietary Modification

Current scientific and clinical data support a relation between diet and prostate cancer Is there enough evidence for us to be able to advise dietary modifications, such as reduced fat and increased soy protein consumption, and the use of nutritional supplements, for example vitamin E and selenium, to reduce the risk of developing or improve outcomes in prostate cancer Some of the data are conflicting. In the case of the suggested link between dietary fat and prostate cancer, the balance of the prospective data is at odds with laboratory investigations, international comparisons, and case-control studies. The value of case-control studies is limited because of the potential for recall bias and confounding. Moreover, these studies have been conducted in different populations, have often had different inclusion criteria, and included questionnaires varying substantially from one study to another. Cohort studies have also been subject to bias depending on the methods used. Large...

Poor Timing Of Fat Oxidation In Obesity Glucose Induced Fat Inhibition

More than a decade ago, the author's laboratory began to assess substrate competition in type 2 diabetes and obesity from the perspective of whether fat oxidation is appropriately regulated during fasting conditions. Using arteriovenous limb balance methods to assess oxygen and carbon dioxide exchange across the leg, we observed an elevated RQ across the leg after an overnight fast in type 2 DM (20), which denoted a decreased reliance on fat oxidation. Furthermore, there was reduced fractional extraction of fatty acids across the leg in type 2 DM (21). Experimentally, in lean, healthy volunteers, an increase in RQ across the leg was induced by hyperglycemia, even without elevation of insulin or marked suppression of plasma fatty acids an even more pronounced effect was observed in obese, nondiabetic individuals (22). Thus, increased glucose availability was associated with depressed reliance on fat oxidation during fasting conditions. The elevated RQ response was associated with...

Medications For Obesity Treatment Approved Medications

Sibutramine is approved by the Food and Drug Administration for long-term use in the treatment of obesity. Sibutramine has been evaluated extensively in several multicenter trials lasting 6 to 24 mo a meta-analysis of some of these trials is shown in Table 2 (10-13). In a 6-mo dose-ranging study of 1047 patients, 67 treated with sibutramine achieved a 5 weight loss from baseline, and 35 lost 10 or more (14). In a 1-yr trial of456 patients who received sibutramine (10 mg or 15 mg d) or placebo, 56 of those who stayed in the trial for 12 mo lost at least 5 of their initial body weight, and 30 of the patients lost 10 of their initial body weight while taking the 10-mg dose (8). In a third trial in patients who initially lost weight eating a very-low-calorie diet before being randomized to sibutramine (10 mg d) or placebo, sibutramine produced additional weight loss, whereas the placebo-treated patients regained weight (8). The Sibutramine Trial of Obesity Reduction and Maintenance lasted...

Possible Mechanisms Underlying Obesity And Diabetes Trends And Disparities

What are the underlying causes for these trends Among researchers there has been an increasing consensus that changes in dietary and physical activity patterns are driven by changes in the environment and by the changing incentives that people face (1,2). Many factors have been suggested as causes of the obesity epidemic and related health disparities automobiles, television, fast food, computer use, vending machines, suburban housing developments, food portion sizes, and countless others. These are also the same factors that will either simplify or complicate adherence to recommended behavioral changes to maintain weight or manage diabetes. Putting a multitude of isolated data points into a coherent picture is a challenging but necessary task to assess whether proposed solutions are promising or likely to lead us down a blind alley.

Defining Pediatric Overweight and Obesity

What is pediatric obesity The Expert Committee on the Evaluation and Treatment of Childhood Obesity has defined pediatric obesity as excess body weight (adipose tissue) associated with adverse health or psychological outcomes (11). BMI is used to assess the presence or risk of overweight. Children among whom the BMI exceeds the 95th percentile for age and gender are considered overweight. Those whose BMI falls between the 85th and 94th percentile for age and gender are considered at risk for overweight. In this chapter, the term obesity will be used in reference to the clinical condition as defined above, whereas the term overweight will be used in reference to patients, individually or as a group. Although BMI is not an ideal measure of body fatness, it represents a clear advance over reliance on skinfold thickness or other indirect measures of fatness in the clinical environment. Difficulties with reliability make skinfold measurement prone to error, especially as body fatness...

Transgenic And Knockout Animals In Studies Of Food Intake Body Composition And Obesity

In addition to the studies of GH described earlier in this chapter, transgenic and targeted gene-disruption technologies are used to elucidate the mechanisms controlling food intake, body composition, and the pathogenesis of obesity. Within the past few years, the applications of these genetic techniques in whole animals have identified a number of new molecules and physiologic pathways involved in the regulation of body wt, and have led to important new insights into the pathophysiology of eating disorders and obesity. These include the hormone leptin, the short and long forms of the leptin receptor, uncoupling proteins, agouti and agouti-related proteins, melanocortin-recep-tor isoforms, melanin-concentrating hormone, orexin, mahogany, and the proteins responsible for tub and fat, two monogenic mouse models of obesity. These efforts, in addition to characterization of several spontaneous obese mutants, provided a number of novel genetic models in which a single gene or pathway has...

Importance Of Evaluating Obesity In Clinical Practice

Epidemiology of Obesity The prevalence of obesity has increased dramatically over the past 30 yr. From 1985 to 2004, the Centers for Disease Control and Prevention (CDC) determined the prevalence of obesity by self-report across the country through the Behavioral Risk Factor From Contemporary Endocrinology Treatment of the Obese Patient Edited by R. F. Kushner and D. H. Bessesen Humana Press Inc., Totowa, NJ Surveillance System (BRFSS). Despite the fact that self-reported weights underestimate the true prevalence of obesity, the CDC obesity maps ( nccdphp dnpa obesity trend maps ) document a dramatic rise in obesity in every state of the country over the past 20 yr. More accurate composite data on the prevalence of obesity in the United States come from a series of studies that directly measured height and weight in carefully selected, nationally representative samples of adults in the National Health and Nutrition Examination Surveys (NHANES). In the most recent NHANES...

Food Sources and Dietary Intakes

The Second National Health and Nutrition Examination Survey (NHANES II) has been extensively evaluated to determine dietary sources of vitamin E in the United States. Major food groups contribute the following percentages of total vitamin E fats and oils, 20.2 vegetables, 15.1 meat, poultry, and fish, 12.6 desserts, 9.9 breakfast cereals, 9.3 fruit, 5.3 dairy products, 4.5 mixed main dishes, 4.0 nuts and seeds, 3.8 soups, sauces, and gravies, 1.7 (1, 33). Data in Table 2.3 reported as mg a-TE show that fortified cereals are the most concentrated source of vitamin E in the U.S. diet. Other excellent sources are salad and cooking oils, instant breakfast and diet bars, mayonnaise and salad dressings, and peanuts and peanut butter. Figure 2.2 shows the distribution of vitamin E intakes for males and females reported as mg a-TE. The distributions were thought to be skewed by a few individuals with very high intakes. According to these data, 69 of men and 80 of women are below the...

Recast Obesity as a Behavioral Rather than Medical Condition Flip Nexus of Care to Behavioral Professionals

To prevent it, consult a mosquito controller. Documenting the severe medical consequences of obesity can help motivate patients, practitioners, and policy makers to attend to the epidemic. However, despite its numerous and severe physiologic medical sequelae, the origins of obesity (and the recent increase in its prevalence) are largely social and behavioral. This raises questions about our current treatment paradigm. The medical profession has been (perhaps de facto, rather than by design) designated as the primary gatekeeper charged with stemming the epidemic. In the current model, behavioral and nutritional professions have largely been cast as secondary resources as treatment adjuncts. This has considerable implications for how we conceptualize obesity and how we reimburse those who care for it. Given the behavioral origins of the condition, perhaps we should reconsider the nexus of professional responsibility. A model that casts behavioral...

Medications That Cause Obesity

Far more common, however, is weight gain associated with the introduction of medications to treat comorbid illnesses (50). These include antidiabetic medications (sulfonylureas, thiazolidinediones, insulin) as well as a wide range of psychotropic medications. The antipsychotic drugs clozapine, olanzepine, risperidone, and quetiapine have all been associated with weight gain, as well as abnormalities in glucose homeo-stasis (51). A number of antidepressant medications, incuding amitriptyline, mirtazapine, and some serotonin reuptake inhibitors, may promote weight gain in some patients. Other drugs that are used as mood stabilizers including lithium, valproic acid, and carbamazepine can cause weight gain. Finally, the antiepileptic drugs valproate, carbamazepine, and gabapentin can promote weight gain. Historically, psychiatrists and neurologists may have paid little attention to the weight-gaining properties of some of the medications that they prescribed. This is fortunately changing,...


Obesity is a generalized, excessive over-accumulation of fat. It may result from an increase in number or size of adipocytes. Risk Factors Etiology. Parental obesity and family inactivity can predispose to obesity. Feeding babies as a generic response to any crying can lead to obesity. Too much fruit juice in the first year of life has been linked with subsequent obesity. Some syndromes are related to obesity. Presentation. Tall stature may sometimes be seen. Boys may present with increased adipose tissue in the mammary area mistaken for breast development. Abdominal striae are present. A large pubic fat pad gives the appearance of micropenis. Puberty may come early. Associated obesity of the proximal extremities is common. Diagnostic Tests. Body mass index (BMI) > 95 for age sex or > 30 in adolescents is used to define obesity. Treatment. Exercise and a balanced diet are the keystones to effectively managing obesity. Complications. Obese infants and children are at...

Body Mass Index

BMI is the measure commonly used in clinical settings for the identification of individuals at increased health risk. BMI is calculated using an individual's weight in kilograms divided by their height in meters squared. Height and weight are relatively simple measures, but in large studies they are often collected by self-report. Both men and women tend to overestimate their height and underestimate their weight, wherein the overestimation of height is increased with decreasing height, and the extent of the underestimation of weight is increased with increasing weight (13). Accordingly, reports suggest that as many as 41 of men and 27 of women self-report as being overweight or normal weight (13), when in fact they are obese. Race also influences the level of adiposity for a given BMI (16) and may explain why observational studies report very high incidences of obesity-related metabolic disorders despite a very low obesity prevalence when using the Caucasian BMI cut-points in some...

Anti Obesity Drugs

Apart from diet, combination with pharmacological treatment with metformin or with weight-reducing agents has been used when required for further weight reduction. It has been reported that the combination of a low-calorie diet with metformin treatment induced greater reduction of body weight and visceral obesity in women with PCOS compared with a low-calorie diet and placebo treatment (136). Weight-reducing agents have been shown to increase the effect of lifestyle modification in reducing the incidence of type 2 diabetes in obese patients (137), and similar effects have been noted in women with PCOS. Sibutramine treatment alone and in combination with ethinyl estradiol and cyproterone acetate in obese women with PCOS has been found to have positive effects on clinical and metabolic risk factors for cardiovascular disease (decrease in waist-to-hip ratio, blood pressure, triglycerides, and insulin levels) (138). Furthermore, orlistat treatment in obese women with PCOS induced a more...

Dietary sources

All natural sources of vitamin A in the diet are derived ultimately from provitamin A carotenoids. For much of the world's human population, and particularly in parts of the developing world, vegetables and fruits provide the main dietary sources of vitamin A in the form of P-carotene and other provitamin carotenoids. In other parts of the world, milk, butter, cheese and eggs are important dietary sources of vitamin A. The liver of meat animals is a particularly rich source as this organ stores the vitamin for the body's use. Preformed vitamin A is present in animal tissues and in milk as a consequence of the enzymatic conversion of ingested provitamin carotenoids in the intestinal wall of the animal. Dietary preformed vitamin A consists mainly of retinol esterified with long chain fatty acids, particularly palmitic acid. Retinyl esters are also found in processed foods supplemented with vitamin A.

Dietary factors

Dietary factors have been postulated as a means of risk reduction in multiple common malignancies. One Chinese case-control study found a significantly reduced odds ratio for ovarian cancer in women who drank green tea, which was dependent on frequency and duration.43 A US case-control study of women in Hawaii and Los Angeles found a significant reduction in the odds ratio for ovarian cancer in women with the highest quartile of dietary calcium intake compared with the lowest quartile, with a non-significant trend also found with calcium supplement intake.44 Ameta-analysis of five observational studies of beta-carotene intake determined a modest but statistically significant reduction in summary relative risk for ovarian cancer with a diet high in beta-carotene.45 Another study found reduced risk with alpha-carotene and lycopene.46 Case-control data are also available suggesting some protective effect from a diet high in fiber from vegetable sources.47 Information regarding dietary...

Dietary migraine

As mentioned in the introduction to this chapter, anecdotal accounts of dietary initiation of migraine attacks in some individuals have punctuated the scientific literature since time immemorial. Even so, serious doubt exists in the minds of many neurologists as to whether the condition really exists as a clinical entity (e.g. Blau 1992 Sacks 1993) or whether the phenomenon is merely a manifestation of the placebo effect. Socrates said 'Let no one persuade you to give the drug against headache to him who before has not opened his soul to your treatment' (Plato, Charmides). And even when an experiment appears to be carefully controlled, there may be pitfalls Strong (2000), pondering on why some dietary migraine patients claim to get headaches from placebos, pinpointed the control gelatine capsule, composed of animal and vegetable protein, as a possible migraine trigger of subjects, without a blood pressure rise sufficient to account for it. It appears, however, that tyramine ingestion...

Dietary RA

Discovery of the molecular mechanisms of RA action, it was shown that dietary RA could partially substitute for vitamin A, influence hepatic vitamin A levels, and spare whole-body vitamin A stores (Lamb et al., 1974). In view of these observations, we were interested in the effects of chronic RA administration on vitamin A kinetics in rats with low vitamin A status. Using data collected in an in vivo kinetic study done at the same time as that on rats with low vitamin A status (Lewis et al., 1990), parallel models were developed for rats with low vitamin A status with or without RA supplementation (Cifelli et al., 2005). To develop models for individual organs, the forcing function'' option in WinSAAM was applied (Wastney et al., 1999, pp. 123-126) (see earlier discussion). Once all organs were satisfactorily fit for each group, the forcing function was removed and the entire data set was modeled together, allowing for the determination of various kinetic parameters. The final model...

Mediterranean diet

The best data on a diet that prevents recurrent CHD events are from the Lyon Diet Heart Study.51 This study found that the Mediterranean diet, rich in linolenic acid, reduced cardiovascular events in patients who had survived their first heart attack.51 In the study, the treatment group was advised to eat more bread, more vegetables, more fruit, more fish, and less meat, and to replace butter and cream with canola (rapeseed) oil margarine. The treatment group also ate 50 more fruit than the usual care group. The trial was stopped after 27 months because of a 70 relative risk reduction in death in the intervention group. The effect remained significant at 46 months of follow-up.51 The components of the Mediterranean diet include cold-water fish (salmon and halibut), olive oil, low glycemic carbohydrates, plenty of fruits, vegetables (onion and garlic), and nuts, and small amounts of red wine (quercetin), which amounts to a diet composed of 20-25 protein, 30-35 healthy fats, and 45-50...

Diet pills

Both prescription and non-prescription substances are marketed with the promise of helping people to lose weight. According to the NHLBI guidelines, weight-loss drugs should be considered as only part of a comprehensive treatment plan for patients with BMI over 30, or over 27 with accompanying obesity-related disease. Weight-loss drugs should never be used without concurrent lifestyle modification efforts (evidence level B). The two drugs approved by the Food and Drug Administration(FDA) for long-term use are sibutramine and orlistat. Sibutramine is an appetite suppressant, working to promote weight loss by decreasing appetite or increasing the feeling of satiety. Orlistat is a lipase inhibitor it works by reducing the body's ability to absorb dietary fat. Many over-the-counter medications and dietary supplements are marketed with similar promises. Some pose significant health risks Other dietary supplements promoted for weight loss include conjugated linoleic acid,...

Weight Reduction

The BMI is calculated by dividing the weight in kilograms by the square of the height in meters (kg m2). More than half of the adults in the United States are considered overweight, with a BMI of greater than 25 one-third of the adults in the United States are obese, with a BMI greater than 30. Any diet can be effective if there is a deficit of caloric intake relative to caloric expenditure. In patients on diet alone, there is generally a 5-6 reduction in body weight over the first 6 months of treatment, with the weight slowly returning over 12-24 months. Compensatory changes in energy expenditure oppose maintenance of lower body weight. A study comparing low-carbohydrate diets (< 30 g day) with a low-fat, calorie-restricted diet in 132 severely obese patients with a mean BMI of 43 and a high prevalence of diabetes and the metabolic syndrome showed that after 6 months, the 43 patients still on the low-carbohydrate diet lost a mean of 5.8 kg, compared...

Series Preface For Modern Nutrition

We welcome the contribution Vegetarian Nutrition, edited by Joan Sabate with the collaboration of Rosemary Ratzin-Turner. There is a great deal of interest regarding vegetarianism as an alternate dietary pattern. This book discusses that issue in detail and will appeal to nutritionists, dietitians, physicians, students, and professionals in the health sciences and health services arenas.

Anabolic Effector Systems

Neuropeptide Y (NPY) is one of the most potent stimulators of food intake (115-117), and is proposed to be an anabolic effector that induces positive energy balance. NPY is a highly expressed peptide in the mammalian CNS (118,119), and is well conserved across species. Hypothalamic NPY neurons are found primarily in the arcuate (ARC) and dorsomedial nuclei, and in neurons such as the PVN (120-125). Endogenous release of NPY is regulated by energy balance. Specifically, in the ARC, food deprivation, food restriction, or exercise-induced negative energy balance each results in upregulation of NPY mRNA in the ARC and increased NPY protein. Repeated administration of NPY results in sustained hyperphagia and rapid body weight gain (126,127). The response of the NPY system to negative energy balance is mediated, at least in part, by the falls in both insulin and leptin that accompany negative energy balance. Central insulin or The ARC NPY system has received the most experimental attention...

General Therapeutic Measures

Of smoking cessation programmes and antidepressant therapy, if necessary. Lipid-lowering drugs are especially indicated, with the use of HMG-CoA reductase inhibitors. Statins not only decrease cholesterol levels but also exert pleiotropic effects on the vascular wall limiting the inflammatory process within the plaques 1, 13 . Plaque regression with lipid-lowering therapy has been reported in both the aorta and carotids. An LDL cholesterol level less than 100 mg dl should be attained. The incidence of cardiac event may be minimized by appropriate control of heart rate and blood pressure. Diabetic patients should be adequately treated and monitored. Haemoglobin A1c should be less than 7 . Dietary supplementation of vitamin B12 and folic acid should be prescribed, especially in patients with hyperhomocysteinemia 25 . Exercise decreases LDL cholesterol and all patients should maintain a regular exercise regimen. Lastly, the use of anti-platelet drugs may reduce the risk of fatal and...

Stability and bioavailability of vitamins

Certain dietary components can retard or enhance a vitamin's absorption, therefore the composition of the diet is an important consideration. For example, the presence of adequate amounts of dietary fat is essential for the absorption of the fat-soluble vitamins. Carotenoids exhibit low bioavailability relative to vitamin A due to the poor digestibility of fibrous plant material. Other ingested substances such as alcohol and drugs may interfere with the physiological mechanisms of absorption.

Of Lipidlowering Drugs that may Benefit PAD Patients

Patients with the metabolic syndrome have a clustering of many risk factors, such as hypertension, insulin resistance type 2 diabetes mellitus, dyslipidaemia and obesity 11 . Therefore, it not surprising that these patients are at increased risk of developing PAD 15, 28 . The prevalence of the metabolic syndrome in PAD patients in a cross-sectional survey 15 was 58 .

Crc Series In Modern Nutrition

Robert-McComb Childhood Obesity Prevention and Treatment, Jana Par zkov and Andrew Hills Alcohol and Coffee Use in the Aging, Ronald R. Watson Handbook of Nutrition in the Aged, Third Edition, Ronald R. Watson Vegetables, Fruits, and Herbs in Health Promotion, Ronald R. Watson Nutrition and AIDS, Second Edition, Ronald R. Watson Advances in Isotope Methods for the Analysis of Trace Elements in Man, The Mediterranean Diet Constituents and Health Promotion, Antonia-Leda Matalas,

Balancing intake and output

Two models that are useful regarding the proper balance of food types are the Food Pyramid and the New American Plate. The Food Pyramid, developed by the US Department of Agriculture (USDA), illustrates the healthy diet as based on a foundation of plant-based foods, including whole-grain complex carbohydrates and substantial amounts of vegetables and fruits. Meat and dairy products make up a smaller proportion, with fats and sweets being used only sparingly.

Rxr Functional Activities

Include LXR and FXR pathways were also compromised, at least partially, by the absence of RXRa. These effects could not be compensated for by RXRb and RXRg (Imai et al, 2001b Wan et al, 2000a,b). Invalidation of RXRa in the adipose tissue of adult animals resulted in an alteration of preadipocyte differentiation as well as in resistance to induced obesity (Imai et al., 2001a). These results are reminiscent of the observations obtained with PPARg heterozygous mice (Kubota et al., 1999) and with an adipose-specific deletion of PPARg (Imai et al., 2004a), suggesting that most of the effects due to the lack of RXRa expression reflect altered PPARg functions (Imai et al., 2001a). However, the impaired lipolysis observed in these mice might be related to an alteration of LXR RXR heterodimer signaling.

Coronory Heart Disease

Coronary heart disease (CHD) is the major cause of death in most Western countries, and is rapidly becoming a major cause of death in developing countries too. Lopez and Murray1 predicted that, by the year 2020, CHD will be the leading cause of disease worldwide. Differences in the diets consumed by different populations account for much of the observed variation in CHD mortality rates, and the effect of vegetarian diets on CHD is a topic of great interest. Vegetarian diets are defined by what they do not include and can vary enormously in terms of both foods and nutrients. The diets of affluent Western vegetarians are very different from those of poor vegetarians in developing countries. Even within Western countries, vegetarian diets vary substantially according to the degree of exclusion of animal foods and according to whether the diet is followed predominately for ethical or health reasons. In view of this, any discussion of the health effects of a vegetarian diet must take into...

Proglucagon Gene Products

OXM shows a diurnal variation, with the lowest levels being early in the morning and higher levels peaking in the evening (72). Similar to the rest of the anorexigenic peptides, it is released in proportion to food ingestion and calorie intake (71). Raised plasma levels of OXM have been shown to inhibit gastric acid secretion and motility in both humans and rodents. It also stimulates intestinal glucose uptake and decreases pancreatic enzyme secretion in rats. Recent evidence supports an anorexigenic role for OXM in both animals and humans. In animals, central administration of OXM has been shown to acutely inhibit food intake (73,74), and chronic intracerebroventricular (ICV) and IP administration reduces both food intake and weight gain (74,75). The latter is thought to be the effect of reduced food intake as well as increased energy expenditure (75). In humans, Cohen and coworkers (76) demonstrated a significant reduction in hunger scores and calorie intake (in a free-choice buffet...

Possible Risk Factors 1 Homocysteine

Patients with CHD have higher plasma concentrations of homocysteine than controls, and these differences have been observed in both case-control and prospective studies.54-56 Plasma concentrations of homocys-teine are inversely related to the dietary intake of folic acid, vitamin B6, and vitamin B12.57 Typically, vegetarians have relatively high intakes of folate and similar intakes of vitamin B6, as compared with the general population.58 However, vegetarians (and particularly vegans) typically have relatively low intakes of vitamin B12.59 Vitamin B12 is essentially absent from plant foods and is present in small amounts in dairy products (but in somewhat higher amounts in eggs). Therefore, dietary intake of vitamin B12 in vegetarians is low unless they consume large amounts of dairy products and eggs, or regularly consume fortified foods or vitamin supplements. For example, Hokin and Butler60 reported that 73 of vegetarian Seventh-Day Adventist ministers in Australia had low serum...

Gut Adipose Interaction

Gut hormones have been shown to interact with long-term signals from adipose tissue. GLP-1 is known to improving insulin sensitivity and, thereby, glycemic control. In rodents, peripheral administration of PYY3-36 for 4 wk resulted in improved glycemic control reduce body weight and visceral fat (33). Recently, Wynne et al. (77) showed a significant reduction in leptin and an increment in adiponectin, markers of adiposity, associated with reduced body weight in 14 patients who had subcutaneous OXM injections for 4 wk.

Endocannabinoids and Energy Homeostasis

The body's endogenous endocannabinoid system includes two endogenous agonists for cannabinoid-(CB)-1 receptors, anadamide and 2-arachidonoyl-glycerol (2-AG). Both of these endocannabinoids (ECs) are fatty acid signals derived from cell membranes. They exert a coordinated action at multiple tissues to promote increased food intake, lipogenesis, and storage of fat. Endocannabinoids interact with multiple hypothalamic circuits and transmitter systems to stimulate food intake in general, and they also act in reward areas of the brain to selectively enhance intake of palatable foods. Activation of CB1 receptors increases enzyme activity that causes de novo fatty acids to be formed in the liver and circulating lipids to be taken up by fat cells. All these actions are reversed in animals lacking CB1 receptors, and there is growing evidence that activity of the endocannabinoid system is toni-cally increased in animal and human obesity. Acute or chronic administration of selective synthetic...

Vegetarianism And Coronary Heart Disease A Observational Studies

Data on mortality rates in Western vegetarians are available from the early study reported by Phillips et al.76 and from four other cohort studies that included a large proportion of vegetarians. Two of these studies were conducted among Seventh-Day Adventists in California, two among members of the Vegetarian Society and others in Britain, and one among the readers of vegetarian magazines in Germany. A pooled analysis of original data from these five cohort studies was published recently48,52 and included data for 76,000 men and women (of whom 28,000 were vegetarians). Importantly, the vegetarians and the non-vegetarians in each study had a shared interest in healthy living or a similar social religious background. All results were adjusted for age, sex, and smoking, and a random effects model was used to calculate pooled estimates of effect for all studies combined. Further adjustments for body mass index, alcohol consumption, exercise, and education level had little effect on the...

Energy Homeostasis and the Endocannabinoid System

In this chapter we review the endocannabinoid system. It represents a novelly described and quite different kind of intercellular signaling system within the body, and we focus on how it influences energy homeostasis as well as how it might be exploited to treat obesity and its complications. Although synthetic and plant-derived cannabinoids such as A9-tetrahydrocannabinol (A9-THC) have long been recognized to influence food intake, it is only relatively recently that endogenous cannabinoids (endocannabinoids ECs ) generated within the body have been identified, and it is very recently that the scope of their influence on energy homeostasis has started to become revealed, along with potential therapeutic implications.

Modification of the Biochemistry of Domestic Animals

During the evolution of our major species of domestic animals, a significant number of metabolic pathways have been lost by irreparable damage to the genetic information that encodes them. The end products of these pathways must be supplied as essential nutrients in the diet, and there are instances where this source is insufficient for maximum productivity. Genetic engineering now provides the ability to transfer genes encoding these pathways from organisms where the pathways are functional, thus restoring functional biosynthetic capacity to the target species. In order for this to be useful, however, it is necessary to identify substrate or nutrient limitations to important production traits. This is not a simple task, because many production traits are influenced by a variety of different factors depending on the actual husbandry situation, and the identification of these factors requires a detailed knowledge of the physiology of the production trait. Such knowledge is often not...

Digestion and absorption

Digestion commences as soon as the food enters the mouth. Chewing helps to break up large particles of food, whilst also mixing food with saliva, which acts as a lubricant and contains the enzymes salivary amylase and lingual lipase. Lingual lipase has only a minor role in digestion of dietary triglycerides however, salivary amylase plays a major role in digestion of dietary starch. Most of the enzymatic activity of salivary amylase occurs in the stomach, where there is a much longer time for it to interact with the starch. Many patterns of adaptation fall into one or the other of two categories (1) a non-specifically increased absorption of all nutrients, arising ultimately from an increase in the animal's overall nutrient requirements, and with an increase in absorptive surface area as the primary mechanism, and (2) phenomena involving the induction or repression of a specific transport mechanism, depending on the dietary availability or body store of the transported substrate....

The Cysteine Biosynthetic Pathway

The Australian wool industry provides one useful area where this approach might succeed. When sheep are fed a diet that simulates that of the grazing animal, the amino acid cysteine is rate limiting for wool growth. Although cysteine itself is not an essential amino acid for mammals, it can only be synthesized from methionine. Thus, the supply of either methionine or cysteine is essential in the sheep diet. In order to increase the rate of wool growth, it is clearly necessary to increase the supply of one of these two amino acids. However, direct dietary supplementation of these amino acids is not effective as a method of increasing their supply, because the unique features of ruminant digestion ensure that added amino acid is degraded by the resident microflora. In the past, different approaches have been taken to overcome the degradation that occurs. For example, the ruminai degradability of proteins can be reduced by treatment with formaldehyde (23), which prevents ruminai...

Physiological actions of insulin

And liver as a fuel source, thus reserving the supply of glucose as a fuel for other tissues, e.g., brain. During prolonged fasting, fatty acids may also be metabolized by the liver to form ketone bodies. Although the liver cannot use ketone bodies as a fuel source, other tissues are able to utilize them and they may become a major source of fuel in prolonged starvation.

History Of Parasitology

Parasites were thought to be beneficial to humans during the seventeenth and eighteenth centuries. For example, many people believed that lice protected children from disease and leeches were used extensively for blood letting as a cure. For a time, intestinal parasites were thought to help in cleaning the tract of excess food and waste and until recently, the Chinese believed that powdered Ascaris was helpful for medicinal treatment of impotency. In France, the heads of tapeworms (scolices) were once used as weight control measures.

Foods Nutrients Vegetarianism and Coronary Heart Disease

It is likely that the reduction in CHD among vegetarians is, at least partly, due to a lower serum cholesterol concentration caused by a lower dietary intake of saturated fat and cholesterol. Unfortunately, none of the five prospective studies of mortality in vegetarians has complete information on serum cholesterol concentrations in all subjects, therefore, it is currently impossible to investigate whether the difference in CHD between vegetarians and non-vegetarians can be statistically explained by the difference in cholesterol levels. Some data are available, however, on the relationships of various foods to CHD within the cohort studies of vegetarians. Meat intake was strongly positively associated with CHD among male Seventh-Day Adventists in the two large prospective studies in California.49,77 There was also a positive, but weaker, association with meat intake among women in the earlier study,77 but not in the more recent study.49 Eggs, but not dairy products, were also...

Storage And Transport

Vitamin A is obtained from the diet, either as preformed vitamin A (retinyl ester, retinol, and small amount of RA) or as provitamin A (carotenoids) (Fig. 1). In the lumen of the small intestine or in the intestinal mucosa, dietary retinyl esters are hydrolyzed to retinol, through the action of retinyl ester hydrolases (REHs). Provitamin A (mainly in the form of -carotene) absorbed by the mucosal cells is converted to retinaldehyde through the actions of carotene-15,15'-dioxygenase, and this form is further reduced to retinol by retinaldehyde reductase. Within the enterocyte, retinol, independently of its dietary origin, is reesterified by the enzyme lecithin retinol acyl-transferase (LRAT), and retinyl esters are packaged into chylomicrons, together with other dietary lipids. Although LRAT is considered the primary enzyme for esterification of retinoids, LRAT null mice maintain some ability to convert retinol to retinyl esters, supporting the notion that another enzyme, namely...

Constitutive Release of ECs

Research on EC biology is progressing at a rapid rate. One consequence is that exceptions to the general model proposed above have become apparent. For example, although increased intracellular calcium is necessary for EC synthesis and release in most neuronal circuits (40), others appear to be calcium-independent (41,42). More pertinent to this review, although ECs are generally thought to be synthesized and released only when presynaptic neurons become highly activated, there is evidence for constitutive release, in the absence of external stimulation, in both the hippocampus (43) and the arcuate nucleus (ARC) in the hypothalamus (44). In the latter case, neurons in the ARC that synthesize pro-opiomelanocortin (POMC) and that initiate a net catabolic response, including reducing food intake when activated, have been reported to secrete ECs con-

Endocannabinoids And Regulation Of Energy Balance

Early animal studies demonstrated that systemic or oral administration of A9-THC potently increases food intake. Administration of CB1 antagonists, conversely, blocks the orexigenic action of exogenous cannabinoid agonists and also decreases food intake and body weight in laboratory animals (reviewed in ref. 16). Based on these promising observations, considerable research is currently under way to elucidate the mechanisms of action of endocannabinoids and to determine the feasibility of using cannabinoid antagonists to treat obesity and its complications (48,49).

Systemic Corticosteroids

Corticosteroids are potent modulators of the immune system but have low specificity and serious side effects. Their well-known and serious side effects, including osteopaenia, weight gain, hyperglycaemia, hypercholesterolaemia, hypertension, and skin fragility, can occur with modest doses administered over relatively short periods. Despite this they are widely used in solid organ transplantation, where their combination with other immunosuppressive agents enables the use of lower doses of the individual agents with a corresponding reduction in the side effects. However, even when used in combination, the side effects from systemic administration of

Anabolic Steroid Abuse

ID CC A 46-year-old female comes to the medical clinic for an evaluation of weight gain, roundness of her face, and epigastric pain that is relieved by eating (peptic ulcer). PE VS hypertension (BP 145 95) 110 fever. PE moon facies, acne, buffalo hump, truncal obesity, striae, increased facial hair

Vitamin B12 and Homocysteine

Dietary intake of vitamin B12 can be low in both vegetarians and veg-ans.58-60,86 The sources of vitamin B12 in a vegetarian diet are dairy products, eggs, fortified foods (especially meat analogues, soya milks, yeast extracts, and breakfast cereals) and vitamin supplements. If none of these sources of vitamin B12 is regularly consumed, intake of this vitamin will be low and the risk of deficiency will increase. More data are needed on current intakes of vitamin B12 in vegetarians, and on whether this is a determinant of homocysteine and CHD risk in these populations.

How can I prevent a hypo

Prevention is the key to dealing with hypoglycaemia. To keep your blood sugar from falling too low, eat your meals at around the same times each day - never skip meals. Recognise that hunger may be a sign that your blood sugar level is too low, and that you need to take steps to bring it back up to within a normal range. Also, make sure you take your medication as directed, in the correct dosage and at the proper times. Be vigilant about monitoring your blood sugar levels. In this way you will be able to detect low blood sugar, even if you are not experiencing any overt symptoms.

Diabetes Prevention Study

The Diabetes Prevention Study involved 3234 patients with IGT and BMI greater than 24 kg m2. There were three groups for assignment placebo, metformin (850 mg twice daily), or intensive lifestyle changes. The lifestyle modifications included dietary instruction, 150 minutes of exercise weekly, and a calorie-restricted, low-fat diet. These patients were followed for an average of 2.8 years. The study demonstrated a 58 relative risk reduction in progression to diabetes with diet and exercise compared with a 31 relative risk reduction with metformin. The number of patients needed to treat was seven for 3 years for lifestyle modification and 14 for metformin. The metformin seemed to be more effective in the younger patients with higher BMI and higher fasting-glucose levels than in patients more than 60 years of age, who showed the least benefit with the drug (14).

Induction of Allergy to Nonvaccine or Food Proteins

This is a particularly important test when examining the suitability of an adjuvant for inclusion in an oral vaccine, as there could be a reaction to food proteins (23). With the interest in the oral route as a means of stimulating mucosal immunity, there is a possibility that an adjuvant could induce an allergic response to dietary proteins. In this study, both lactalbumin and gluten failed to elicit an IgE response in the presence of the original Freund's Complete or Incomplete Adjuvants (FCA or FIA) in HAM1 CR mice or Dunkin Hartley guinea pigs. On the other hand, the guinea pigs showed increased IgE production after oral administration of ovalbumin or soy bean protein, both unusual proteins in their normal pellet diet. Such tests are valid only if all of the previous toxicity tests are negative. 1. Groups of mice or guinea pigs are fed freely with moistened ovalbumin or lactal-bumin as the main food supply for 24 h. This does not affect their normal weight gain or health....

Clinical Use Of Cb1 Antagonists Sr 141716

The selective CB1 antagonist SR 141716 (rimonabant or Acomplia Sanofi-Synthelabo), when administered to marijuana smokers, caused weight loss in overweight and obese subjects without causing adverse side effects (118). Based on this and the promising studies on animals (reviewed previously), SR 141716 has been used in randomized, double-blind clinical trials to determine its efficacy in treating obesity and related metabolic complications. Several Phase III clinical trials named RIO (Rimonabant In Obesity) were initiated starting in 2001 and included more than 6600 overweight or obese patients with or without comorbidities who were given SR141716 (5 or 20 mg) or placebo for up to 2 yr (119 - 121). All subjects were on a calorie-restricted diet and underwent a run-in period of diet alone prior to being randomized to drug or placebo conditions.

Health Impacts Of Vitamin E

It is generally accepted that oxidative damage at the cellular level is significant to the onset of chronic disease. Since vitamin E is the primary fat-soluble antioxidant in mammalian systems, a logical assumption is that supplementation of the human diet with vitamin E potentially could be significant in prevention and or slowing of the onset of various chronic disease states. This assumption taken together with increasing knowledge about the role vitamin E plays and potential roles other antioxidants available in the food supply might play produced an extremely large body of scientific literature on antioxidants and health. Unfortunately, the body of data does not provide for a clear conclusion on vitamin E and its overall worth when consumed at levels above the recommended dietary allowance (RDA). Diverse opinions about supplemental use of vitamin E remain. The fact remains that the Panel on Dietary Antioxidants and Related Compounds (1), when establishing the DRIs for vitamin E...

Chapter Summary continued

Genomic imprinting refers to differential expression of genes based on chromosomal inheritance from maternal versus paternal origin. The classic examples are the mental retardation syndromes Prader-Willi syndrome (paternal deletion of chromosome 15 with obesity and hypogonadism) and Angelman syndrome (maternal deletion of chromosome 15 producing ataxia and inappropriate laughter characterized as happy puppet).

Epidemiologic and Clinical Studies

Most of the available clinical evidence regarding the effect of dietary fat intake on prostate cancer comes from observational rather than interven-tional studies. A close correlation exists between However, other studies have failed to show an association between prostate cancer and total fat or total saturated fat. A prospective study of 6763 white male Seventh-Day Adventists observed for 21 years failed to find a significant relation between prostate cancer risk and fat-associated food meat or poultry, milk, cheese, and eggs. There was a suggested positive association that was stronger when an individual consumed all four of these dietary items, but overall there was no significant relation between diet and prostate cancer 13 . A further finding of this study was that overweight men had a significantly higher risk of dying from prostate cancer compared with nonobese men (relative risk 2.5). Another cohort study of 7999 men of Japanese ancestry living in Hawaii also found no...

Studies in Seventh Day Adventists

Seventh day Adventists (SDAs) are a conservative Christian denomination dating back to the mid-19th century in the U.S By religious belief, the SDA church proscribes the use of tobacco, alcohol, and pork among church members and recommends, but does not require, that members practice a vegetarian lifestyle. As a consequence, a small number (< 5 ) of SDAs are pure vegetarians, a substantial proportion (40-50 ) practice a lacto-ovo-vegetarian lifestyle (i.e., consume no flesh products but use eggs and dairy products), while the rest consume meat to one degree or another. Due to their avoidance of tobacco and alcohol and their dietary habits, SDAs have received sustained attention from scientists and others interested in evaluating lifestyle and disease relationships. Several studies have been conducted among SDAs in both the U.S. and elsewhere. In this review, the studies among SDAs in the U.S will be separate from the non-U.S. studies.

Tumor Necrosis Factora

Of recent intense study, TNF-a has been at the center of attention as a mediator of obesity. Earlier observations in the literature revealed that adipose tissue expression of TNF-a was positively correlated with insulin resistance in humans (67-69) and that as humans became obese, adipose tissue expression of TNF-a increased (67). It is now known that the vast majority, approx 95 , of TNF-a in adipose tissue of obese individuals is synthesized by macrophages, with only a small percentage released from adipocytes (81). Nonetheless, it is not well understood how these two sources of TNF-a, from both the adipocytes themselves and the infiltrated macrophages, contribute to obesity-associated disease etiology. In general, plasma levels of TNF-a are low and do not correlate with obesity or insulin resistance (69). It is known that one role for TNF-a is for it to stimulate an increase in expression of other proinflammatory molecules, such as IL-6 and MCP-1 (82), as well as to positively feed...

New Adventist Health Study

The mortality studies of SDAs in the U.S. and elsewhere were useful in comparing risk of cancer death with non-SDA populations and for examining the relationship between diet and risk of several fatal cancers. However, the mortality studies were hindered by certain limitations. First, by restricting attention only to fatal outcomes, differences in stage at diagnosis, or differences in survival may have partly explained the differences between SDA and non-SDA populations. Second, in comparing cancer mortality with the general population, the possibility of selection bias may have obscured the true relationship between diet and cancer risk. Therefore, in the early 1970s, a new study of cancer incidence in California SDAs was designed in which risk of newly diagnosed cancers was to be measured and relationships between dietary intake and cancer incidence within the SDA population was to be evaluated. Table 4.1 Age- and Sex-Adjusted Relative Risks for Fatal Cancer Among SDA Age > 35...

Adverse Effects of Longterm Treatment with Antipsychotics

Some side effects may already be apparent during acute treatment but become relevant only during long-term management. These include sedation, weight gain and sexual dysfunctions 105 . As these adverse events are thought to have a negative impact on compliance, they warrant special consideration. The management of chronic side effects of antipsychotics, with the exception of tardive dyskinesia, follows the same principles as have been described in the acute treatment section. Treating manifest tardive dyskinesia is still unsatisfactory prophylactic measures are therefore of utmost importance. Patients have to be examined regularly with regard to incipient tardive dyskinesia. As soon as such symptoms are found, if continuous antipsy-chotic treatment is considered necessary, an attempt to reduce the dose should be the first step. If tardive dyskinesia progresses despite this, treatment must be changed to clozapine or another compound with a low TD risk. Patients with a shorter duration...

Monocyte Chemoattractant Protein1

MCP-1 is hyperexpressed in adipose tissue from obese mice compared with control animals (114). Plasma and adipose tissue levels of this protein are also increased with increasing adiposity BMI (115). Likewise, levels are decreased after weight reduction (115). MCP-1 has also been implicated in type 2 diabetes patients with type 2 diabetes have higher circulating levels of MCP-1 (116). In summary, MCP-1 is a cytokine that is thought to promote macrophage recruitment into AT. The chronically elevated levels of insulin that are often seen with obesity may promote the synthesis and secretion of MCP-1 from adipocytes. Though more research is needed, these higher levels of MCP-1 may then have distinct metabolic effects, possibly contributing to the development of metabolic disease.

Vitamin E and Age Related Eye Diseases

Cataract and age-related macular degeneration (AMD) represent the two most frequent disease states leading to vision loss worldwide. Both diseases usually occur in older adults. Oxidative stress with accumulation of free radical damage to the lens and retina has been considered causative to development of both cataract and AMD. Thus, the role of dietary and supplementary antioxidants, including vitamin E, -carotene, other carotenoids, vitamin C, and selenium, in preventing or slowing such age-related eye diseases has been extensively investigated. The DRI panel (1) in 2000 noted the existence of nine epidemiological studies (138-146) and one clinical intervention study (147) relating vitamin E status and supplementation to risk of cataract. The epidemiological studies were inconclusive, and the intervention study (147) showed no effect at 50mg -T per day.

Plasminogen Activator Inhibitor1

Plasma levels of PAI-1 are elevated with obesity and strongly correlated with visceral adiposity (120). It appears that secretion from AT is increased in obese individuals (121). Interestingly, mice that lack PAI-1 are completely protected against high-fat diet-induced obesity (122). Even ob ob mice, as a model of genetic morbid obesity, are protected (123). This suggests that PAI-1 effects are not limited to clotting but may have other systemic effects. The primary role of PAI-1 is to help maintain vascular homeostasis (127). This protein is actually implicated in the pathogenesis of cardiovascular disease, with plasma levels being a strong predictor of future cardiovascular disease development (128). It will be interesting to follow the results of future studies when it might be determined how PAI-1 contributes to obesity-related pathologies.

P Hydroxydehydrogenase1

Cushing's disease or administration of exogenous glucocorticoids such as prednisone are often associated with increased weight gain, central adiposity, increased food intake, insulin resistance, and in certain individuals, increased likelihood of developing diabetes. However, in general, obese individuals do not have increased circulating levels of cortisol. Interestingly, over the past few years, research has demonstrated that certain enzymes can actually convert inactive cortisol metabolites into active cortisol. One of the first hints that AT was in fact an endocrine organ was its identification as a major site for steroid hormone metabolism (129). Animal experiments have provided insight into the role of 11 HSD-1 in obesity and obesity complications. Adipocyte-specific overexpression of 11 HSD-1 in mice results in increased visceral adiposity and hyperphagia. In addition, these animals develop insulin resistance (132). Interestingly, mice that do not express 11 HSD-1 are resistant...

Combined Radiotherapy and Hormone Therapy

The potential benefits of androgen deprivation have to be balanced against toxicity. Most patients experience hot flushes, fatigue, and impotence of varying degrees, which can impact significantly on quality of life. Other toxicities include loss of libido, weight gain, muscle wasting, and changes in texture of hair and skin. Longer-term concerns include the development of osteoporosis and the possibility that low testosterone levels may predispose to cardiovascular disease. There is no evidence yet that long-term hormone therapy increases non-prostate cancer mortality, but this is being investigated in the meantime, it is sensible to restrict the use of long-term hormone therapy to patient groups in which it has been shown to have an overall survival benefit.

Sedentary Lifestyle Exercise Therapy

Intermittent claudication is a symptom of lower limb peripheral arterial disease. It arises when the blood flow is insufficient to meet the metabolic demands of the leg muscles in ambulating patients. Intermittent claudication is a leveraged disability, as pain increases with walking, patients walk shorter distances, muscle strength erodes, and walking distances continue to decrease. This leads to other negative consequences such as weight gain, hypertension, and diabetes. Overall, patients with claudication have a 60 lower functional capacity than age-matched individuals without the disease (Eldridge and Hossack, 1987).

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Anabolic steroids are made from male hormones and are mistakenly used in tonics to help children gain weight and grow. At first the child may grow faster, but he will stop growing sooner and end up shorter than he would have if he had not taken the medicine. Anabolic steroids cause very dangerous side effects. Girls grow hair on their faces like boys, which does not go away, even when the child stops taking the medicine. Do not give growth tonics to children. Instead, to help your child grow, use the money to buy food.

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Many women who have recently given birth are always interested in attempting to lose some of that extra weight that traditionally accompanies having a baby. What many of these women do not entirely realize is the fact that breast-feeding can not only help provide the baby with essential vitamins and nutrients, but can also help in the weight-loss process.

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