(THE GRANDEST OF) GRAND ROUNDS RAHIL “The Fattest Man (At Heart) Alive” SHAIKH, MD Northeast...

(THE GRANDEST OF)

GRAND ROUNDS

RAHIL “The Fattest Man (At Heart) Alive” SHAIKH, MD

Northeast Iowa Family Medicine

November 12th, 2014

Sponsors

Chief Complaint

29 year old male who’s chief complaint is being too fat.

HPI

Has been fat and getting fatter for the last 12 years

Associated with increased dietary intake and decreased exercise

Worsened by having an income and being allowed to buy his own food

PMH, PSH, FH, SH

• PMH includes median and ulnar nerve irritation bilaterally

• PSH includes dental surgery to remove extra tooth at age 12

• FH includes HTN, DM, CAD, CVA, and cancer

• SH includes stressful job working long hours, living at home with wife (but never seeing her), never smoker, no alcohol, no drugs (he does distribute plenty of drugs though)

Review Of Systems

Fatigue – takes anywhere from three to eight alarms in the morning to wake up on work days; has little energy for more than one strenuous activity in the day; would sleep for 10 hours / day if he could

Polyphagia – gets hungry a lot, has many food cravings

Review Of Systems

Dyspnea with exertion – walking up one flight of stairs or running more than one minute causes SOB (he does claim to be able to walk on the elliptical for up to one hour without too much trouble though – it sounds like he’s lying)

Medications/Allergies

Acetaminophen, ibuprofen, naproxen, metaxalone all as needed, ~ every 2 months

NKDA, but does complain of seasonal allergies and being allergic to mammograms

Physical Examination

Normal except for being strikingly handsome, having an obese belly, and having an odd affect

Height 173 cm, weight 100 kg, BMI 33.4

Labs

CMP – normal

TSH – normal

HbA1c – 4.7%

Fasting lipid panel – total cholesterol 210, triglycerides 90, HDL 42, LDL 150

UA and urine microalbumin – normal

Assessment & Plan

29 year old male with diagnoses of obesity and hyperlipidemia. What’s the plan?

1) ?

2) ?

3) ?

FOOD ADDICTION (and

the great fatty sugary debate)

What Causes Us To Be Fat?

What Causes Us To Be Fat?

Are we what we eat? Our diets are filled with processed cra---

err, food Everywhere we look, we see advertising

for fast food, junk food, and fatty and sugary foods

But, isn’t it as simple as calories in minus calories out?

Calories

A calorie is a unit of energy How many calories we use up during the

day makes up our basal metabolic rate (BMR)

My own BMR based on my sex, age, height, weight, and activity level is ~ 2500 calories / day

Calories

A BMR of 2500 means that it takes 2500 calories coming in from my diet to maintain my weight and offset the requirements of energy that my body needs – which is 2500 calories

Eating less calories than this will cause me to lose weight and eating more calories than this will cause me to gain weight

Or will it?

Calories

Is a calorie a calorie? Is equivalent to ?

Both are ~ 500 calories Do they affect our body the same way?

Sugar Processing

No The fiber in the salad slows down the

processing of the natural sugars and doesn’t lead to the ‘sugar high’ as seen with processed (fake) foods like the Big Mac

The fast intake of sugars in processed food forces the pancreas to release insulin and forces the liver to take in more sugar than it can handle

Sugar Processing

Normally the liver converts sugar to glycogen for storage, to be released in between meals and during the fasting night state

However, processed food sugar, usually high fructose corn syrup (HFCS) causes the liver to get overloaded and convert the sugar into not just glycogen, but also fat – LOTS OF FAT

Sugar Processing

This is how processed sugar, in a simplified way, makes us fat – it’s missing the fiber to help us digest it properly!

Sugar Processing

On top of that, fiber does another thing that fructose has a hard time doing on its own – increasing satiety

The brain has a hard time knowing its full when processed sugars are taken in by themselves (i.e. leptin resistance increases) – with the fiber still present, this does not happen

So when we eat processed sugars by themselves, our brains don’t know we’ve taken in enough calories to be full!

Drank

And on top of that again, things like pop (a.k.a. soda, fizzy drank, sugary goodness) also contain not just HFCS, but also salt, which promotes thirst and thus makes you want to drink even more!

Evolution Of Man (And Wo-Man)

Low Fat?

In the 1970’s people started to notice obesity as a health problem

The leading cause of obesity was thought to be fat

You eat fat, you get fat…makes sense, right?

Therefore, policies came into effect that pushed the food industry to adopt ‘low fat’ varieties of their food

Low Fat?

Taking some of the fat out of food though made it taste terrible

How to get the food to taste better now? You guessed it: sweet sweet SUGAH

BABY Cane sugar that was processed and had

its fiber stripped from it was a start The corn industry also learned how to

make a cheap viable corn syrup alternative to sweeten foods

Sugar

It’s not fat that’s the biggest enemy in the obesity epidemic, it’s sugar!

Doesn’t it make sense? We’ve reduced our fat consumption (and proportions of ‘bad’ transfats, etc.) but obesity rates have climbed to epidemic proportions

Obesity Trends* Among U.S. AdultsBRFSS, 1985

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

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



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



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

2000

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

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

2010

1990

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

Obesity

Obesity

We know that being obese can lead to multiple medical conditions, including HTN, DM, HLD, CAD, CVA, PVD, metabolic syndrome

Obesity

People have long considered a lack of willpower as the main constituent to obesity

It’s not just lack of exercise that’s contributing to our obesity epidemic – it’s mostly what we’re eating, and the main culprit is sugar

Obviously ‘bad’ fats and lack of exercise don’t help, but sugar is the ‘silent’ cause that most people don’t consider

Metabolic Syndrome

What is it? It’s a syndrome of high blood pressure,

insulin resistance, and high cholesterol (in our office we call these symptoms the trifecta – and we bill that badboy a 99214, yeahhh boi)

Actually, in reality, we’re not writing for metabolic syndrome a lot – do you see a lot of charts with it written in the Major Problem List?

Metabolic Syndrome

How are insurance companies paying for a diagnosis of metabolic syndrome?

Metabolic Syndrome

Ask The Expert:

Metabolic Syndrome

•American Heart Association and National Heart, Lung, and Blood Institute (NHLBI) definition of metabolic syndrome - at least 3 of elevated waist circumference

• 102 cm (40 inches) or higher in men• 88 cm (35 inches) or higher in women

•elevated triglycerides 150 mg/dL (1.7 mmol/L) or higher or on medication•reduced HDL cholesterol or on medications

• < 40 mg/dL (1.03 mmol/L) in men• < 50 mg/dL (1.3 mmol/L) in women

•elevated blood pressure 130/85 mm Hg or higher or on medication•elevated fasting glucose 100 mg/dL (5.6 mmol/L) or higher or on medication

Metabolic Syndrome

•International Diabetes Federation definition of metabolic syndrome requires both central obesity defined as waist circumference at least

• 94 cm for Europoid men or 80 cm for Europoid women• 90 cm for South Asian and South-East Asian men or 80 cm for South Asian

and South-East Asian women• 85 cm for Japanese men or 90 cm for Japanese women

•and any 2 of 4 other factors• serum triglyceride level 1.7 mmol/L (151 mg/dL) or higher (or specific

treatment for this abnormality)• serum high-density lipoprotein cholesterol level < 1.03 mmol/L (40 mg/dL)

in men or < 1.29 mmol/L (50 mg/dL) in women (or specific treatment for this abnormality)

• systolic blood pressure 130 mm Hg or higher, diastolic blood pressure 85 mm Hg or higher, or treatment of previously diagnosed hypertension

• fasting plasma glucose 5.6 mmol/L (100 mg/dL) or higher, or previously diagnosed type 2 diabetes

Metabolic Syndrome

Metabolic Syndrome

Biggest complication of metabolic syndrome? Coronary artery disease

Treat metabolic syndrome by eating less sugar and exercising (both of which promote weight loss!)

Metabolic Syndrome & Sugar

Processed sugar increased fat increased waist lines, increased blood pressure, insulin resistance and increase in lipids (especially VLDL as a byproduct of the liver trying to metabolize fructose in HFCS)

Sugar and metabolic syndrome are inextricably linked

AHA Recommendations

The AHA states that American on average consume 20 teaspoons of sugar per day

Their recommendations for added sugars are no more than 6 teaspoons (100 calories) per day for women and 9 teaspoons (150 calories) per day for men

1 teaspoon of sugar = 4 grams of sugar = 16 calories of sugar

Sugar

Natural sugars like lactose and fructose are found in milk and fruit

Sugar

Are all sugars bad for you? No, it’s the simple sugars that are

broken down quickly that aren’t as good for you as the complex carbohydrates that take effort to break down

In effect, you use up calories to break down calories, resulting in no excess weight gain over time

Sugar

We don’t actually need sugar to survive – at least, added, processed sugars (we do need carbohydrates for energy obviously)

Added sugars add calories to our diets and add zero nutrients – absolutely nil

Sugar

Ever noticed that on nutrition labels, the % daily value for sugar is not listed? As everyone looks at their labels, I say “BOOOM”

Most items would be well above the 100% daily recommended mark; the percentage is not listed for a reason

Food Corporations

Diet Drank?

What about ‘diet’ versions or ‘calorie free’ versions of our favorite beverages?

Diet Drank?

Studies are starting to show that diet pop can be just as bad as regular pop, or maybe even worse

Partly it has to do with our bodies developing an impaired ability to predict caloric content of food (and thus leading to increased intake)

Diet Drank?

The psychology behind it is – if I saved myself 150 calories by not drinking the regular pop, why not go for a slice of pizza instead of a wrap?

Diet Drank?

Partly it has to do with hormonal imbalance

Artificial sweeteners are much more sweeter than regular sugar – as we ingest it, our bodies think real calories are on the way and insulin is pumped out of the pancreas

Diet Drank?

Any sugar in the blood will then go straight to the liver to be converted to…FATTY STUFFS

The sugar will also be uploaded into the fat cells directly by insulin because fat cells are sensitive to insulin longer than other types of cells

Diet Drank?

Dietary Intake and the Development of the Metabolic Syndrome – The Atherosclerosis Risk in Communities Study by Lutsey et al., 2008, followed 9514 people for 9 years and those that drank artificially sweetened beverages were found to have a 34% greater risk of developing metabolic syndrome

This study also references the Framingham study for showing similar findings

Diet Drank?

Diet Soda Intake and Risk of Incident Metabolic Syndrome and Type 2 Diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA) by Nettleton et al., 2009, showed that those people that drank artificially sweetened beverages were found to have a 36% greater risk of developing metabolic syndrome

Diet Drank?

There are studies coming out that show the association between diet pop and depression and diet pop and cancer (although the latter is also being linked to sugar in general)

Diet Drank?

Consumption of artificially and sugar-sweetened beverages and incident type 2 diabetes in the Etude Epidemiologique aupres des femmes de la Mutuelle Generale de l’Education Nationale – European prospective Investigation into Cancer and Nutrition cohort by Fagherazzi et al., 2013, showed an association (not causation) between both artificially and sugar-sweetened beverages and type 2 diabetes

Is Sugar Addictive?

Intense Sweetness Surpasses Cocaine Reward by Lenoir et al., 2007, that showed that rats, when given a choice, preferred saccharin over IV cocaine

Is sugar addictive?

This is a Bhupinder on no sugar:

Is sugar addictive?

This is a Bhupinder on sugar:

Is Sugar Addictive?

We’re evolutionarily built to enjoy sugar (well, most of us)…sugar is indeed addicting

So…What The Heck Do We Eat Now?

There are more than half a million grocery store items out there, and a whole bunch of them contain sugar – we won’t be getting rid of them overnight

So how do we counsel our patients?

So…What The Heck Do We Eat Now?

12 year old girl presents with her parents to find out what to do about her weight and rising blood pressure

Counselling

Should we quit added, processed sugars cold turkey like tobacco and alcohol or go slow?

It depends on the person! Having a full detox works for a few

people, but most have to make slower changes in their lives in regards to sugar addiction

Counselling

First step: portion sizes! We used to have reasonable portion

sizes until everything was supersized, now what used to be supersized is our norm and what’s supersized now is…

Counselling

Counselling

Second step: stop the pop By far contains the most and most

useless calories out of all the sugary foods

This is poison

Counselling

Third step: eat real food If your grandparent couldn’t recognize it,

it’s probably not good for you By far the single biggest and most

important variable in the fight against obesity – real food a.k.a. not fake, processed material that we mistake for food

Cook

Counselling

Fourth step: recognizing that exercise is crucial, but not enough

Burning off 2 thin mint cookies would take 20 minutes of running

Eating the right foods though helps the food partially burn itself off, just by eating it (think, celery), so you don’t have to spend all the time you’re not eating in the day trying to exercise it off!

Have a standing work station with a chair available if needed

Counselling

Fifth step: have ‘cheat’ days if you need them – depriving yourself completely may cause you to relapse and binge…like this guy:

1.Individualized balance of Carbs / Fats / Protein for sustained adherence—Focus on FOOD •Right Fats (mono- and poly- unsaturated, omega 3’s)•Right Carbs (high fiber, low glycemic index, complex)•Right Protein (plant, marine, and lean animal sources) 2.Limit or eliminate sugar, high fructose corn syrup, and refined starches and snack foods 3.Reduce or eliminate all calories from beverages 4.Smaller portions, low energy density, high nutrient density 5.Consider book-keeping of calories, points, etc. 6.Drink (and eat) water 7.Exercise for life 8.Get adequate sleep

Practical Approach to Maximize Satiety and Achieve Meaningful Weight Loss and Weight Management

Detox

Most people who have given up on sugar from processed foods and go back to it, even for a few bites, claim to have headaches, dizziness, even nausea; others have GI upset and diarrhea

Conclusions

1. Sugar is the devil 2. I’m fat 3. Let’s all go to Popeyes for a residency

retreat

Conclusions

Obesity and metabolic syndrome are truly epidemics, not only in this country, but now all across the world

It’s said that the current generation of children will be the first generation of children not to live longer than their parents did

Reports claim that this is the first time in human history that there are more obese people than starving people in the world

Conclusions

Not only is fat and a lack of exercise contributing obesity and metabolic syndrome, but the main culprit might very well be sugar, which is likely the ‘villain’ behind food addiction (which was the topic of this talk if you remember)

Case

Back to our case…what is our 29 year old obese, now hyperlipidemic male planning on doing to improve his diet, his physical activity…and his life?

Stay tuned…for JAUCH

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(THE GRANDEST OF) GRAND ROUNDS RAHIL “The Fattest Man (At Heart) Alive” SHAIKH, MD Northeast...

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