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Dr. fathi NeanaChief of Orthopaedics
Dr. Fakhry & Alrajhy hospitalSaudi Arabia
November 24, 2016
Metabolic syndrome
andIntermittent
fasting(IF)
1- Metabolic syndrome reached an epidemic
2- Impact on the musculoskeletal systemObesity – DM - Uric a – etc
Host A – B – CSurgical difficulties & complications
3- Masks fallen down and truths rapidly prevails
Era of communications & evidence based medicine
4- Friends & colleagues requisite
The Metabolic SyndromeWhy this presentation
DM and the musculoskeletal system
Conditions more frequently in DM Diabetic cheiroarthrophaty
(stiff hand synd)Trigger finger (flexor
tenosynovitis)Dupuytren’s contractureCarpal tunnel syndrome
Adhesive shoulder capsulitis (frozen shoulder)Calcific
shoulder tendonitisReflex sympathetic dystrophy
( shoulder-hand syndrome)Diabetic osteoarthrophaty or
Charcot's or neuropathic arthropathy
Conditions Sharing Risk Factors of DM
Diffuse Idiopathic Skeletal Hyperostosis (DISH)Gout/ Pseudo gout
Osteoarthritis
The Metabolic SyndromeImpact on the musculoskeletal system
Obesity and the musculoskeletal system
Musculoskeletal conditions
associated with obesityOA (knee, hip, hand)
Low Back PainDiffuse idiopathic skeletal
hyperostosis (DISH)Gait disturbance
Soft tissue conditions (for example, carpal tunnel syndrome,
plantar fasciitis)Osteoporosis ?
GoutFibromyalgia
Connective tissue disorders (rheumatoid arthritis) .
Co-occurrence of several known cardiovascular risk
factors
Type 2 Diabetes Central Obesity
Atherogenic dyslipidemia Hypertension
These conditions are interrelated and share underlying mediators,
mechanisms and pathways
The metabolic syndromeInsulin Resistance syndrome - Syndrome X - Deadly quartet -
Reaven’s syndrome
Abdominal obesity Plus
two other components Elevated BP
Low HDLElevated TG
Impaired fasting glucose
Metabolic Syndrome Definition
The International Diabetes Federation
Intermittent fasting (IF)
Simplified View of Insulin ActionGraphic originally published at
http://weightology.net/weightologyweekly/?page_id=319
Recently attracted attention
Because
1- Its potential for correcting metabolic
Abnormalities
2- Better adherence than other methods
Sugar (fructose)
Insulin resistance
+ObesityLeptin
resistance
-> failure to suppress ghrelin
-> hunger -> more eating->> obesity
Leptin, ghrelin, and weight lossNormally Insulin 8 Leptin (satiety) 7 Ghrelin (huger)
Obesity Hyperglycemia
Hyperinsulinemia
Insulin Resistance
Hyperleptinemia
Leptin Resistance
TG
Ghrelin
Unsuppressed->> Hunger ->> More eating ->> Obesity
Hyperinsulinemia
Insulin Resistance
Hyperleptinemia
Leptin Resistance
Ghrelin
Unsuppressed->> Hunger ->> More eating ->> Obesity
HyperglycemiaObesity
Four protocolsfor preventing DM in KSA and the Gulf
Dr. Mohammad Jamil Alhabbal
Encourage• Breast feeding
• Camel milk consumption
Control• Consumption of high sugar drinks (HFCS)
• Bleaching agents used in wheat flour and other foods
Intermittent fasting (IF)Leptin, ghrelin, and weight loss
• Cortisol– Stress hormone
• Leptin– controls satiety
• Ghrelin– Sparks hunger
• Thyroid– Controls metabolic rate
Intermittent Fasting eliminates hunger & cravings
IT reduces or normalizes ghrelin (the hunger hormone) -> less
appetite
EAT PROTEIN BEFORE CARBSWe know the amount of certain nutrients
But the order in which you eat them matters too
Blood sugar levels were about 29 percent lower after 30 minutes, 37 percent lower after 60 minutes, and 17 percent lower after 120 minutes
after starting their meal
High Sugar (esp fructose) turning off the body's appetite-control system (insulin and leptin signaling)
-> huger -> more eating -> gaining weight
Effect of intermittent fasting and refeeding on insulin action in healthy men
Nils Halberg, Morten Henriksen, Nathalie Söderhamn, Bente Stallknecht, Thorkil Ploug, Peter Schjerling, Flemming DelaJournal of Applied Physiology Published 1 December
2005 Vol. 99 no. 6, 2128-2136 DOI: 10.1152/japplphysiol.00683.2005
We mimicked the fluctuations in eight healthy young men [25.0 ± 0.1 yr (mean ± SE); body mass index: 25.7 ± 0.4 kg/m2] by subjecting them to intermittent fasting every second day for 20 h for 15 days. This study was undertaken to test the hypothesis that 14 days of intermittent fasting and refeeding improves insulin-stimulated glucose disposal.
Fasting every second day increased the insulin sensitivity approximately sevenfold according to the homeostatic model assessment (2) and decreased the incidence of diabetes (32). We found a decrease in circulating leptin after 8–20 h of fasting
Intermittent fasting (IF)Better adherence than other methods
1- ‘Alternate day fasting’ (ADF)Every other day (EOD) fasting
2- ‘Fasting two non-consecutive days per week’
3- ‘Modified fasting regimes’(allow water - coffee or tea. limiting
caloric intake < 20%)
4- The Warrior diet (1 large meal per day)
5- Variations (different combinations of EOD and the Warrior diet
‘Normal eating’Resumed on non-fasting days
• Is it dangerous to go without food?
• Won’t health suffer if we aren’t eating regular meals?
• I need to eat regularly otherwise my body goes into starvation mode
Intermittent fasting (IF)Frequently asked questions
FastingReligious Reasons
Ramadana 4-week period of food and fluid abstinence between the hours from
sunrise to sunsetthe length of the fast may vary from 10
to 19 hours each day
FastingRecall History
Human historywe were not regular meal eaters. We followed a more episodic pattern of intake (intake does not refer to a set period of time, as habitual pattern )
FastingWatch, observe and read the
natural life
Fasting was a regular part of the Messenger's life.He would fast every Monday and Thursday.
He would also fast the 13th, 14th and 15th of each month
When the Messenger (peace and blessings be upon him)
was not fasting he was on“intermittent fasting”eating only once a day
(The Warrior diet )
The Prophetic Diet: The Perfect New Year’s ResolutionMoutasem Atiya on 30 December 2013
Timeline of Tissue Breakdown
36-48 hours before significant amounts of protein start being broken down
19
>1980
Since the low-fat guidelines came out, the prevalence of
obesity has skyrocketed reaching an epidemic
This graph shows that the
obesity epidemic started full-force at the same time the
low-fat advice was peaking.
The type 2 diabetes epidemic followed soon after.
Insulin Resistance 92% of
type 2 diabetes
Diagnosed Diabetes in the US: 2008
http://apps.nccd.cdc.gov/brfss/list.asp?cat=DB&yr=2008&qkey=1363&state=All
4 – 6% 6 – 8% 8 – 10% 10 – 12%
CDC BRFSS: Self-Reported Diabetes: 8.2% Nationwide
The Metabolic Syndrome
InsulinResistance
HypertensionType 2 Diabetes
DisorderedFibrinolysis
ComplexDyslipidemia
TG, LDLHDL
EndothelialDysfunction Systemic
Inflammation
Athero-sclerosis
VisceralObesity
Adapted from the ADA. Diabetes Care. 1998;21:310-314;Pradhan AD et al. JAMA. 2001;286:327-334.
InsulinResistance
Gelfand EV et al, 2006; Vasudevan AR et al, 2005* working definition
Global cardio metabolic risk*
Metabolic syndrome and Cardiovascular Disease
Musculoskeletal complications in diabetes mellitus
Obesity and Musculoskeletal complications
Cardio metabolic Syndrome
LOW FAT MESSAGE ABANDONED No link between heart disease and Total fat, Saturated fat and Dietary cholesterol A.C.C - A.H.A 2015 USDGAG JAMA 2 – 2016
PROCESSED FOODS IS THE CULPRIT
Sugars, Non fiber carb and TransfatsEffect is worse by Smoking , Alcohol,
Addiction
Cardiovascular Disease (CVD) risk
Why There is Essential fatty and amino
acidsBut No essential carb or sugar
(Glycogen, Fat, Protein)
25
A diet low in saturated fat 'will not prevent heart disease or prolong life'
A healthy eating pattern limitsTrans fats - Added sugars - Non fiber Carbohydrates - Sodium
Harmful Effects of Sugar(NB: Non fiber Carb rapidly
absorbed)
1- Lipoprotein Oxidation & Glycation
2- Hyper insulinemia syndromeMetabolic syndrome
-> Insulin resistance (type 2 DM)
-> increased triglycerides VLDL ->Cholesterol (small dense LDL
type B particles)
3- State of chronic inflammation
Harmful Effects of Sugar
HFCS (High-fructose corn syrup) is found in almost all types of processed foods and drinks
Sugar: toxic, addicting, and deadly
As a general recommendation, keep total fructose consumption below 25 grams per day, including
that from whole fruit
body can safely metabolize six teaspoons of added sugar per day.
• An average American consumes about 22 teaspoons sugar per day
• The human body is not made to consume excessive amounts of sugar, especially fructose
1- classic metabolic syndrome)• It is actually a hepatotoxin and is metabolized directly
into fatleading to chronic metabolic dysfunction (classic
metabolic syndrome)These include weight gain, abdominal obesity, decreased HDL and increased LDL, elevated blood sugar, elevated
triglycerides, and high blood pressure
2- feeds” the cancer cells• One study found that fructose is readily used by cancer cells to increase their proliferation – it “feeds” the cancer cells, promoting cell division and speeding their growth,
which allows the cancer to spread faster
Harmful Effects of Sugar
3- Gaining weightby turning off the body's appetite-control system
(insulin and leptin signaling) It fails to stimulate insulin, which in turn fails to suppress
ghrelin, "the hunger hormone," which then fails to stimulate leptin "the satiety hormone."
Causing more eating and develop insulin resistance
4- increases uric acid levels - risk for heart & kidney disease
uric acid level can now be used as a marker for fructose toxicity.the safest range of uric acid is between 3 to 5.5 milligrams per
deciliter. uric acid level higher than this, means risk to the
negative health impacts of fructose
Harmful Effects of Sugar
• Cortisol– Stress hormone
• Leptin– controls satiety
• Ghrelin– Sparks hunger
• Thyroid– Controls metabolic
rate
5- Overloads and damages the liverThe effects of much sugar or fructose likened the effects of
alcohol
Non-alcoholic fatty liver disease (NAFLD).The same disease from excessive alcohol intake can be caused by
excessive sugar (fructose) intake.
Dr. Lustig explained the three similarities between alcohol and fructose:
• The liver metabolizes alcohol the same way as sugar as both serve as substrates for converting dietary carbohydrate
into fat. This promotes insulin resistance, fatty liver, and dyslipidemia
• Fructose undergoes the Maillard reaction with proteins. This causes superoxide free radicals to form, resulting in inflammation
– a condition that can be also caused by acetaldehyde, a metabolite of ethanol
• Fructose can directly and indirectly stimulate the brain's "hedonic pathway," creating habituation and dependence, the
same way that ethanol does
Harmful Effects of Sugar
6- Other diseases linked to metabolic syndrome include
Type 2 diabetesHeart diseaseHypertension
Polycystic ovarian syndromeLipid problems
DementiaAlzheimer's disease
A powerful connection between a high-fructose diet and risk of developing Alzheimer's disease, through the same pathway that causes
type 2 diabetes.
Alzheimer's and other brain disorders may be caused by the constant burning of glucose for fuel by the brain.
(low fat & cholesterol diet )
Harmful Effects of Sugar
32
The typical atherosclerotic plaque comprises of the lipid core and the fibrous cap, and is the most commonly classified histologically by the American Heart
Association
1- Endothelial damage & permeability 2- Small dense particles LDL type B
(Caused by)1- Chronic inflammation)
2- Insulin – Leptin resistance (Diet too high in sugars + Obesity)
Treat the cause is the logical thinking
1- Anti-inflammatory lifestyle
2- ControlInsulin - Leptin resistance
Hyper insulinemia – Hyper leptinemia
Diet too high in sugars & Obesity
Intermittent fasting (IF)Interventional strategy
where in individuals are subjected to varying periods of fasting.
Timeline of Tissue Breakdown
Intermittent fastingFasting Period
(8 h glucose & glycogen) ---- fat –--- (36 - 48 hours protein)
Fasting for 14+ hours force the body to burn body fat when blood sugar or carbs
drop
Rapid loss of fat by fasting 14 to 20 hours per day
(even without ex & dietary regimes)
Progress slowly, don’t jump straight into 24-36 hour
fasts36-48 hours before significant amounts of protein start being
broken down
Intermittent fasting (IF)
A 2014 review have shown
fasting improves indicators of health
Blood pressure
Insulin sensitivity
Inflammation—cellular responses to stress
Reduce the risk of chronic diseases -
cancer
LIMITATIONSIntermittent fasting not studied
in children the elderly
the underweight and could be harmful in this population
fast for periods of time greater than 24 hours
should be monitored by a physician, as changes to the gastrointestinal system
or circadian rhythm can occur
. fasting is unlikely to have much effect on conditions other than obesity, such
as aging or other chronic conditionunless combined with moderate calorie restriction and plant-based diet such
as the Mediterranean diet.[7]
Bariatric Life vs. Bariatric Surgery How does Bariatric surgery work ?
1- GIT effects2- Loss of subcutaneous fat mass
3- Acute profound caloric reduction (Surgically Enforced Fasting)
(No Cure)
Insulin
Drugs
Low fat diet
(Cure)
Bariatric surgery
(Fasting)
Very low carb diet
Type 2Diabetes
Intermittent Fasting vs Dieting regimeAlternating periods of eating & not eating VS. Regular eating less than normal
Better adherence than other methodsInstead of trying to create a deficit of 300-500
kcal/day (dieting regime)you are making deficits of 1500-2000 kcal a couple
days a week
Bariatrics is Surgically Enforced FastingAll of the benefits of bariatric surgery accrue because of the fasting.
Studies show that fasting is actually superior to surgery in both weight loss and reduction in blood sugars.
Patients scheduled for bariatric surgery underwent a period of fasting immediately prior. This would burn a lot of the liver fat. The smaller liver makes surgery easier, especially with the newer laparoscopic techniques.
Comparing the effects of the fasting with the surgery right after, fasting was clearly superior in terms of weight lost (7.3kg vs 4kg) and reduction in blood sugars.
Likelihood of Complications: 10% For Early Complications, 15.3% For Late Complications
List of Potential Complications: All 20 Possible Complications
vary widely depending on the experience of your surgeon and your behavior before and
after surgery.• Bleeding (also called “Hemorrhage”)
•Blood clots or blood clot symptoms (also called “thrombus”)
• Bowel function changes •Bowel obstruction (also called an “internal hernia”)
• Dumping syndrome• Dehydration
• Dyspepsia (indigestion)• Gallstones
• Gastro esophageal reflux disease (GERD)• Hypoglycemia (low blood sugar)
• Incision(al) hernia
• Intolerance to certain foods • See our Bariatric Diet section for details.
• Kidney stones•Leaks ( including gastrointestinal leaks and staple line leaks )
• Nausea and vomiting•Nutritional deficiency, especially iron and calcium
. • See our Bariatric Vitamins .• Organ injury during surgery
• Stenosis/Stricture• Marginal Ulcer
• Wound infection
For a complete list and comparison of complications relating to all types of
bariatric surgery, see our Bariatric Surgery Complications page
Bariatric Life vs. Bariatric Surgery
International Journal of Obesity(26 December 2014)
Fasting for weight loss: an effective strategy or latest dieting trend?
A Johnstone
Obesity epidemic
Search for dietary strategies that
(i) prevent weight gain
(ii) promote weight loss
(iii) prevent weight regain
International Journal of Obesity (26 December 2014)
Fasting for weight loss: an effective strategy or latest dieting trend?
A Johnstone
There is some long-term success with gastric surgical options
But1- Invasive interventions
2- Post-operative risk of deathdue to early complications
3- Long term late complications
SO
there is still a requirement for effective dietary interventions
1- Promote long-term adherence
2- Sustained beneficial effects
Such dietary interventionsneed to be
1- Palatable and satiating
2- Meet minimal nutritional requirements
3- Promote loss of fat and preserve lean body mass
4- Ensure long-term safety
5- Simple to administer and monitor
6- Widespread public health utility
(Intermittent fasting)Is that option
achieving weight loss and maintenance
1- Intermittent fasting forces your body to burn more fatThe less blood sugar in your body = The more fat you will burn
John Rowley, Wellness Director for the International Sports Science Association
2. Intermittent Fasting increases your energy & metabolism adrenaline (or norepinephrine) cause more energy, more alert and focused, it
forces your body to burn fat (mainly the belly, thighs & hips) like the Geico caveman
3. Intermittent Fasting naturally increases HGH (Human Growth Hormone)
HGH is a fat burning hormone help maintain your muscle mass while fasting
4. Intermittent Fasting eventually eliminates your hunger & cravings
IT reduces or normalizes ghrelin (the hunger hormone) -> less appetite.
4 reasons why fasting (14+ hours per day)
help you burn fat faster than the average diet regimes
• Decreases chances of cancer risk.
• less likely to become diabetic
• Improves cognitive function
• less likely to suffer from cardiovascular disease
• Reduces inflammation
• Helps you live longer
• Protects from the effects of Alzheimer's & Parkinson's diseases
7 More benefits of intermittent fasting
Patient compliance & willness
POP castvs
Patient Education
Beriatric surgeryvs
Intermittent fasting