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Transcript
ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΙΑΣ Άσκηση και Παχυσαρκία Κριτική Θεώρηση των Προγραμμάτων Απώλειας Βάρους Σακκάς Γεώργιος PhD Τμήμα Επιστήμης Φυσικής Αγωγής και Αθλητισμού Άδειες Χρήσης • Το παρόν εκπαιδευτικό υλικό υπόκειται σε άδειες χρήσης Creative Commons. • Για εκπαιδευτικό υλικό, όπως εικόνες, που υπόκειται σε άλλου τύπου άδειας χρήσης, η άδεια χρήσης αναφέρεται ρητώς. 2 Χρηματοδότηση • Το παρόν εκπαιδευτικό υλικό έχει αναπτυχθεί στα πλαίσια του εκπαιδευτικού έργου του διδάσκοντα. • Το έργο «Ανοικτά Ακαδημαϊκά Μαθήματα Πανεπιστημίου Θεσσαλίας» έχει χρηματοδοτήσει μόνο τη αναδιαμόρφωση του εκπαιδευτικού υλικού. • Το έργο υλοποιείται στο πλαίσιο του Επιχειρησιακού Προγράμματος «Εκπαίδευση και Δια Βίου Μάθηση» και συγχρηματοδοτείται από την Ευρωπαϊκή Ένωση (Ευρωπαϊκό Κοινωνικό Ταμείο) και από εθνικούς πόρους. 3 Σκοποί ενότητας • Ο σκοπός της παρούσας ενότητας είναι η ανασκόπηση των προγραμμάτων απώλειας σωματικού βάρους καθώς επίσης και η κρητική τους θεώρηση. 4 Περιεχόμενα ενότητας Weight-loss Approaches • Surgical (χειρουργικές) • Pharmacological (φαρμακολογικές) • Behavioral (συμπεριφοράς) • Nutritional Supplements (συμπληρώματα διατροφής) 5 Surgical Approach 6 Criteria for Bariatric Surgery In 1991 the NIH recommended criteria for patients selection for bariatric surgery • Patients seeking therapy for first time should consider a non-surgical approach Patients with • BMI >40 (νοσηρή παχυσαρκία) after failing medical therapy • or with BMI between 35-40 with high risk conditions such as life threatening cardiopulmonary problems or diabetes mellitus after failing medical therapy 7 Criteria for Bariatric Surgery • Patients should be selected by a team of expert: – – – – – medical surgical psychiatric nutritional exercise • Patients need to : – be motivated, – be well informed, – have realistic weight loss expectations – be committed to long-term follow-up after surgery 8 Bariatric Approach • Bariatric (Βάρος + Ιατρική) Operations are – Restrictive (περιοριστικές) (limiting the amount of food ingested) – Malabsorptive (δυσαπορροφητικές) (limiting the amount of nutrient absorbed) • or – Combination • The choice of procedure is guided by: – – – – – Patients’ BMI Age Comorbidity The cost of the operation Patient’s and Surgeon’s choice 9 Jejunoileal Bypass (JIB) – 1st method Παράκαμψη Δωδεκαδακτύλου • Malabsorptive technique • Λεπτό έντερο (2.8μέτρα) αποτελείται από το δωδεκαδάκτυλο, τη νήστιδα και τον ειλεό • JIB = Παράκαμψη της Νήστιδας (σύνδεση Δωδεκαδακτύλου με το τέλος του Ειλεού) • Joining the proximal jejunum to the distal ileum, bypassing a large segment of the nutrient-absorbing small bowel 10 Roux-en-Y Gastric Bypass (RYGB) – 2nd method • • • • • • The name is derived from the surgeon that first described it (César Roux) and the stick-figure representation that looks like the letter Y Construction of a small gastric pouch (σάκος) of 30mL or less Transection of the stomach Narrow gastroenterostomy Lengthening of the Roux limb to 100150 cm Side effects: stomach wall has the tendency to stretch and the stoma to enlarge 11 Complication for RYGB • Mortality rate is 0.5% • Early complications (επιπλοκές) • Anastomotic leak (1.9%) • Pulmonary embolism (0.6%) • Wound infection (2.9% laparoscopic vs 6.6% open operation) • Late complications • Incisional hernia (0.5% laparoscopic vs 8.6% open oper.) • Stenosis of the gastrojejunal anastomosis (4.7% in 2.5 years) • Bowel obstruction (3.2% in 2.5 years) • Gallstone formation (32%) • Malnutrition • Low levels of: iron, vitamin B12, vitamin D and Calcium 12 Vertical Banded Gastroplasty (VBG) – 3rd method Γαστρικός Ρυθμιζόμενος Δακτύλιος • 14 cm3 vertical gastric pouch • Polyporopylene band acting as the stoma • Prevention from stretching Laproscopic Adjustable Gastric Banding (LAGB) • To correct the changes in stoma diameter with the passage of time the band was modified by adding an inflatable silicone band around the uppermost part of the stomach • The correction is done by the laparoscopic method usually at the doctor’s office based on weight loss and appetite • Requires 5-6 visit the first year and 2-3 visits the second year • This is the most widely used method in EU 13 Complication for LABG • Mortality rate is 0.05% • Early complications – Wound infection (2.9%) • Late complications – Gastric prolapse or band slippage (ρήξη ή μετακίνηση του ελαστικού σφιγκτήρα) – Herniation of stomach around the band, resulting in an enlarged gastric pouch and partial or complete gastric occlusion (5%) – Port and tubing problems (προβλήματα στην συσκευή ρύθμισης του σφιγκτήρα) – require surgical repair – Removal of the adjustable bands due to: failed weight loss, band erosion, esophageal dilation, or dysphagia (3-6%) 14 15 Outcomes from Bariatric Surgery • The majority of the patients loose the 50% of their excess weight during the first year – If you are 1.75m and 75kg your BMI is 25 and if you are 150kg your BMI is 48 – meaning you have 75 kg excess weight, to loose 50% of your excess weight means to loose 35-40 kg • Weight loss average 0.7 to 1 kg per week for the first 2 years of surgery 16 Outcomes from Bariatric Surgery • 17% of the patients lost less than 50% of the excess weight in 5 years – this is considered as “insufficient weight loss” • After RYGB or LAGB surgery patients experience: – 75% resolution of diabetes – 74% improvement of dyslipidemia – 94% resolution of obstructive sleep apnea – 55% resolution of hypertension – 100% improvement of asthma – 76% resolution of gastroesophageal reflux 17 Bariatric Surgery & Extra Skin 18 Pharmacological Approach 19 Pharmacological Approach • Sibutramine and Orlistat are the most used drug for treating obesity • Sibutramine (Meridia): Inhibitor of the re-uptake of serotonin, norepinephrine and dopamine; increase the satiety-producing effects of serotonin – decrease hunger – Side-effects: anorexia nervosa, hepatic/renal impairment, coronary disease, arrhythmias 20 Pharmacological Approach • Sibutramine and Orlistat are the most used drug for treating obesity • Orlistat (Xenical): decrease the absorption of dietary fat by inhibiting enzymes (lipases) which are necessary for the breakdown and absorption of fat – Side-effects: chronic malabsorption syndrome, diarrhea 21 Behavioral Approach 22 Behavioral Approach • Behavior-modification programs in obesity – Modify eating habits – Increase physical activity – Promoting better health • This system provides appropriate rewards when patients exhibit the desire behavior 23 Modify Eating Habits • Keep a dietary intake log • Eat breakfast • Eat small and frequent meals • Do not eat junk food (fast food) • Cut down alcohol consumption • Do not eat 3 hours before you go to sleep • Avoid high calories food (deserts, cakes etc) • In 18 wk of therapy, patients achieved 9.9kg weight loss but only the 66% of these patients maintained this weight after 52 wk 24 Increase Physical Activity and Promote Better Health • • • • • • Walk every day for half to one hour Take the elevator from the 1st floor Park your car one block away Park your car on the distant spot Play team games with your friends Take a dog for a walk – is your personal trainer • In a 30 months trial, patients with increased physical activity levels lost more than 5 kg vs 1kg in those that they did not advice to increase physical activity 25 Nutritional Supplements 26 Nutritional Supplements • Providing Nutrients – In hypocaloric diets (decrease energy intake) • Stimulating Weight Loss – Diminishing hunger – Increasing resting metabolic rate • Information about Dietary Supplements can be found in: – www.cfsan.fda.gov, www.ods.od.nih.gov, www.nas.org, www.eatright.org/public/conferencesAndEvents/92_supplguide. cfm, www.iom.edu, www.naturaldatabase.com 27 Nutritional Supplements • Terminology- Ορολογία – DRI: Dietary Reference Intake (αναφορά διαιτολογικής κατανάλωσης) • Composition of diets for schools, prisons, hospitals or nursing homes • Industries developing new food stuffs • Healthcare policy makers and public health officials – RDA: Recommended Dietary Allowances (προτεινόμενηεπιτρεπόμενη διαιτολογική κατανάλωση) – AI: Adequate Intake (επαρκείς κατανάλωση) – UL: tolerable Upper Levels (ανώτερα επιτρεπόμενα όρια κατανάλωσης) 28 Dietary Supplements for Achieving Nutrient Adequacy • Nutrient-containing dietary supplements contains essential nutrient that might be low or lacking in reducing diets (very low calories diet<800 - 500 calories, low calories diet 1200-1500 calories) • These are: – multivitamins (100% RDA) – Calcium, Iron, Vitamin C – B complex – Vitamin D + Calcium – Electrolytes – Potassium (K) – Protein and amino acid complex – Formulated food 29 Dietary Supplements for Stimulating Weight Loss • Stimulate or enhance weight loss (for those in diet) by altering body functions (anorectic effect or increase energy output) • Dietary supplements are regulated as FOODS and the law generally assumes that are safe unless proven otherwise….. • Some of those supplements might interact with other medication • Some of the ingredients are unknown or uncharacterized • Some are contaminated • Do not use them during: Pregnancy, Lactation, or immediately before surgery 30 Ephedra (Ma huang) • Supplements contain Ephedra, psedo-epherda have shown: – Sort term (< 6 months) efficacy – it works! – Adverse Events: nausea, vomiting psychiatric symptoms, autonomic hyperactivity, palpitations – Concerns: seizure, stroke, myocardial infraction, deaths • Sale prohibited in the US since April 2004 31 Grapefruit - Bitter Orange – Citrus Aurantium Seville orange, sour orange, green orange, neroli oil, kijitsu • It has been suggested that it is the “ephedra substitute” • Contains α & β agonist activity including synephrine and octopamine • Synephrine (oxidrine) is a sympathomimetic amine structurally similar to epinephrine • Increase blood pressure – special caution is recommended in those with hypertension, CVD, glaucoma • Some of the compounds in Citrus are inhibiting cytochrome P, which will increase the serum levels of many drugs • There are not adequate evidence for efficacy • There are not enough evidence for side effects 32 Chromium Picolinate • Chromium + Picolinic Acid • Studies have shown a small but significant reduction in body weight of approximately 200gr / week • No adverse reactions have been reported • Further research is needed 33 Conjugated (συγκολλημένα) Linoleic Acid (CLA) • In animals reduce body fat and increase lean body mass • In humans CLA consumption does not show the same results • No evidence for weight reduction • Instead there are evidence that increase hepatic size and increase insulin resistance 34 Chitosan • Chitosan is produced by Chitin which is found in the exoskeleton of lobsters and other shellfish • It claims that reduce fat absorption from the diet and therefore could reduce body weight • Studies have shown that NO-EFFECT at all • Some gastrointestinal symptoms have been reported 35 Green Tea • Green tea contains several polyphenolic components known as catechins • Catechins increase fat utilization from the mitochondria and exert an antioxidant effect • In humans reduce LDL, body fat and visceral fat in 12 weeks of supplementation • Reduces Iron body levels • Further studies are needed 36 Other Dietary Supplements • Little evidence of benefit for – – – – – – – Garcinia bambogia glucomannan, Guar gum B-hydroxymethylbutyrate Pyruvate Yarba mate Yohimbe • Some GI problems in Guar gum 37 Calcium Supplements • The data are inconsistent • In animals Ca supplementation reduce body fat • In humans in randomized double blind placebo controlled studies Ca did not effect body weight • No adverse reactions • Further studies are needed to establish whether Ca supplements or dairy products can increase weight loss in Low-calories diet 38 Summary • Bariatric Surgery is the most effective way for loosing weight (when all other ways have failed) • Obesity-medication have many side-effects • In very low-calories diet, it is very important to take nutrient supplements to improve the nutritional status and avoid malnutrition • There are not enough evidence to support that dietary supplements enhance weight reduction and promote health 39 ΠΑΝΕΠΙΣΤΗΜΙΟ ΘΕΣΣΑΛΙΑΣ Τέλος Ενότητας