The Latest Skinny FAT
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1 The Latest Skinny FAT Christine Kessler MN, CNS, ANP, BC-ADM None Zip Nada Keiner Ingen Никто Aucun Nessuno Disclosures TACKLING A BIG PROBLEM 1
2 Case Studies in Obesity Just look around At work At the mall At Disneyworld.etc Where Are We Now in The Fat Attack? Size of the Problem CDC reports obesity has doubled in adults and nearly tripled in our youth since 1980!! Increasing the risk of: Hypertension Dyslipidemia Type 2 diabetes Coronary heart disease Stroke Gallbladder disease/ fatty liver disease/ pancreatitis Sleep apnea & respiratory issues Cancers (endometrial, breast & colon) Dementia 2
3 Obesity or Overweight? BMI over 30% = obesity BMI over 25 to 29% = overweight BMI controversy Progression the issue? Waist or weight? 3
4 Globesity Obesity in the Young Approximately 17% (or 12.5 million) of children and adolescents aged 2 19 years are obese (up from 5% in 1980) (2011) 4
5 Data derived from Health, United States, 2010: With Special Feature on Death and Dying. NCHS, 2011 What Excessive Adiposity Does Among children ages 2 19, ~ 1 in 3 are overweight & obese (BMI-for-age at or above the 85th percentile) % of all boys % of all girls Overweight adolescents have a 70% chance of becoming overweight adults. Children will be entering adulthood heavier than they ve ever been at any time in human history. Even without further increases in prevalence, the impact of the epidemic will continue to mount for many years to come. - Dr. David Ludwig, director of the childhood obesity program at Children s Hospital in Boston 5
6 SO WHY THE BODY EXPLOSION???? SO WHY THE BODY EXPLOSION? Food quantity or quality? Sedentary lifestyle? Genes? Bugs Adenoviruses? Intestinal microbiata? ALL OF THE ABOVE Quantity & quality 6
7 Quality of our bread? GUT FLORA 7
8 Inherited predisposition Nutrigenentics & Nutrigenomics It Is Illogical to Assume All Individuals are Equally Responsive to Drugs, Foods or Food Components!! 8
9 Obesity is a disease Waist more a problem than weight Location location location 9
10 FATTY LIVER DISEASE The FATTY HEART Brown fat White fat 10
11 Most abundant in babies: Generates non-shivering heat (via TGs) Counters pro-obesity white fat? Same precursors as skeletal musle Inflammation & pro-coagulation Inflammation clotting Notable Adipokines Leptin Pro-satiety but Adiponectin Anti-inflammatory but 11
12 Satiety! What About the Gut? 12
13 Gut Peptides That Regulate Appetite The gut-fat-brain connection Murphy KG, Bloom SR. Gut Peptides That Regulate Appetite, Nature. 2006; 444: Satiety = reward So What Can We Do? 13
14 This Doesn t Work Which diet works best.? Sacks F et al. Comparison of Weight-Loss Diets N Engl J Med 2009; 360: S It Is Illogical to Assume All Individuals are Equally Responsive to Drugs, Foods or Food Components!! 14
15 STOP mindless eating Portion control!! WHAT YOU CAN DO? Stop mindless overeating Consume foods that are low in calories but high in fiber and water Use smaller plates and serving utensils to control portion sizes. Beware of the "clean plate" mentality: visualize how much you're going to eat before you start eating. Avoid all-you-can-eat restaurants and buffets Eat slowly; it takes the brain 20 minutes to sense that you're full. Don't do other activities while you eat, such as watching TV. 15
16 More on Food Fixes - Timing and sequencing food and drink -Fiber (water insoluble/ insoluble) -Nuts (fat/protein) pre meal -Probiotics/yogurt? - Anti-inflammatory diet (yes, no, maybe) More Eating Tips 1. Eat around the plate : protein, fat first delay carbs 2. Fiber, fiber, fiber 3. Drink before or after not during 4. Slooowww it down 5. Don t eat 3 hours before bed 6. Others.. 16
17 Mixed messages So Exercise!!! Why? When? What type? How much? 17
18 CDC 2008 Age-Adjusted Estimates of the Percentage of Adults (>18 yrs) Who Are Physically Inactive Estimates of Leisure-Time Physical Inactivity Source-- Medical Treatment for Obesity Global Market for Treatment of Obesity, Source: MedMarket Diligence, LLC, Report #S835, "Products, Technologies and Markets Worldwide for the Clinical Management of Obesity, " 18
19 Selected Pharmacological Aids Nutrient blockers Orlistat (Xenical, Alli) Starch blockers Central satiety agents SSRIs Sibutramin (Meridia) now GONE! Direct satiety drugs Phentermine.more later Herbal Stimulants Hoodia Others: vitamin D, chromium picolinate, ETHO? Selected Pharmacological Aids Herbal Stimulants Hoodia Sensa vitamin D Niacin-chromium combo ETHO Magnesium, calcium Incretins Biotherapies GLP-1 (liraglutide, exenatide) Amylin E-cannabanoid receptor blockers (no FDA approval) Rimonabant (Acomplia) Taranabant 19
20 The New Anti-obesity Drugs Lorcaserin (Belviq) Serotonin 2c receptor agonist 5-10% weight loss Anti-obesity Drugs in Research Pheneramine & topiramate (Q-nexa) Leptin sensitizers New metreleptin and pramlintide combo Ghrelin blockers Empatic (zonisamide and bupropion combo) Sirtuins (obesity gene manipulators) Most focused on CNS!!! We want to lose weight and feel good about it! Kishore M; Bupropion Plus Zonisamide for Obesity. J Clin Psychiatry 68:8, August 2007 Thomsen, W. J.; Grottick, A. J.; Menzaghi, F.; Reyes-Saldana, H.; Espitia, S.; Yuskin, D.; Whelan, K.; Martin, M. et al. (2008). "Lorcaserin, a Novel Selective Human 5-Hydroxytryptamine2C Agonist: in Vitro and in Vivo Pharmacological Characterization". Journal of Pharmacology and Experimental Therapeutics 325 (2): Fat Apps 20
21 Invasive Intervention BARIATRIC SURGERY Roux-en-Y Gastric Bypass Gastric Banding Gastric Sleeve AHA Statement on Potential Bariatric Surgery Benefits March 17, 2011 The benefits of bariatric surgery may outweigh the risks for some severely obese people, says the AHA (American Heart Association). Specifically, bariatric surgery can lead to improvements in weight-related health problems such as diabetes, high cholesterol, liver disease, high blood pressure, cancer, obstructive sleep apnea and cardiovascular dysfunction. Source: Poirier P, Cornier MA, Mazzone T, et al of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Bariatric Surgery and Cardiovascular Risk Factors: A Scientific Statement From the American Heart Association. Circulation, March 14, 2011 DOI: /CIR.0b013e
22 And there are APPS A Few References Batterham RL, Cowley MA, Small CJ, Herzog H, Cohen MA, Dakin CL, Wren AM, Brynes AE, Low MJ, Ghatei MA, Cone RD, and Bloom SR. Gut hormone PYY(3 36) physiologically inhibits food intake. Nature 418: , Chen C et al. Ghrelin Gene Products and the Regulation of Food Intake and Gut Motility. Pharmacol. Rev. December 1, 61: , 2009 Lutz, T. Hunger and satiety: one brain for two? Am. J. Physiol. Regul. Integr. Comp. Physiol. October 1, 291:R900-R902, Meier U, Gressner A. Endocrine Regulation of Energy Metabolism: Review of Pathobiochemical and Clinical Chemical Aspects of Leptin, Ghrelin, Adiponectin, and Resistin Clin. Chem. September 1, 50: , Wisser A et al. Interactions of gastrointestinal peptides: Grehlin and its anorexigenic antagonists Woods S., Benoit S, Clegg D. The Brain-Gut-Islet Connection. Diabetes December 1, 55:S114-S121, 2005 ckessler@maranatha.net 22
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