Transcript Document

8 Weeks to Wellness
Lifestyle solutions to help patients focus on wellness
2 types of
people:
CHAMPIONS
and people with
excuses
Obesogenic Overview
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Obesity epidemic
50% of US adults will be obese by 2030
Obesity prevalence in adults in their 40’s and 50’s would
be 60%
Additionally:
• 6 mil to 8.5 mil more people with diabetes
• 5.7 mil to 7.3 mil more cases of heart disease and stroke
• 490,000 to 670,000 additional cancers
• 26 to 55 mil quality–adjusted life years left
• Increase medical expenditures: 48 bil – 66 bil by 2030
(not including lost productivity estimated at 390 bil – 580
bil per year)
The Lancet 2011. 378: p.815-25
How is Weight Loss a
Musculoskeletal Topic?
• All experts agree that obesity, even being
overweight, contributes heavily to all
degenerative disease
WOW!
• Obesity is associated with increased lumbar disc
degeneration
• Significant difference between underweight/normal
weight, overweight/obese patients
• “Mean number of vertebrae with end-stage
degeneration and disc space narrowing of the
lumbar spine”
Jan 30, 2012, Arthritis and Rheumatism
Obesity = Postural Compensation
Obesity as an Inflammatory Disorder
One of the more interesting discoveries of the
past decade has been the recognition that the
adipocyte produces inflammatory cytokines
Obesity, therefore, may be viewed as a low
grade systemic inflammatory disease
Inflammation
• Obesity contributes to inflammation especially in the
joints
• Inflammatory response related to adipose tissue secretes compounds known as cytokines - cell to cell
signaling proteins that are linked to:
a) Excessive weight gain
b) Chronic diseases such as OA
c) Nutrient excess and insulin resistance
Impaired Function and Gait
• Other conditions that excess weight contributes to:
– Bilateral abducted feet – 276% more toed-out compared
with normal weight people
– Plantar faciitis/heel pain – case-controlled study revealed
obese people 5 x more likely to have heel pain than normal
weight counterparts
– Increased back pain
– Decreased lower body flexibility
Riddle DL. Risk factors for plantar faciitis: a matched case-controlled study. J Bone
Joint Sury Am 2003;85(5), p.872-7
Inflammation Increases Bone Loss
• Decreased estrogen leads to increased inflammatory
cytokines and decreased bone density
- Fontova R, et al. J Endocrinol Invest, 2002;24:684-90
• Trends toward greater spinal bone loss were
observed in woman with high cytokine production
- Salamone LM, et al. Calcified Tissue Int, 1998;63(6)
• Among women 10 years past menopause, I1-6 levels
predicted femoral bone loss
- Scheidt-Nave C, et al. J Clin Endocrinol Metab, 2001;86:2032-42
Overweight – Health Impacts
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Cardiovascular disease
Diabetes
Hypertension
Gallbladder
Osteoarthritis
Sleep apnea
Inflammation
Some cancers
R
I
S
K
Not overweight? You may still be “fat”!
• “Normal” weight women with over 30% body fat also had
increased inflammation
• LDL (bad) cholesterol, triglycerides (a type of blood fat)
• “Normal weight obese” women also had higher levels of
inflammatory chemicals than those with both a normal BMI
and lower body fat
American Journal of Clinical Nutrition, Jan. 1, 2007. Vol. 85;pp. 40-45
Midlife Obesity Affects Health Later On
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Weight linked to late-life heart, diabetes, deaths
Overweight or obese adults have increased risk of dying
from heart disease and diabetes later in life, even if they
don’t have cardiovascular risk factors such as high blood
pressure or high cholesterol
Compared with normal-weight, low-risk counterparts, the
obese people in the study also had four times the risk of
hospitalization for heart disease and 11 times the risk of
dying of diabetes
Yan, L.L. The Journal of the American Medical Association, Jan. 11, 2006; vol.
295: pp 190-198. LiJing I. Yan, PhD, MPH, researchers assistant, professor,
department of preventive medicine, Feinberg School of Medicine, Northwestern
University, Chicago; assistant professor, Peking University, Beijing, China. Gerald
Fletcher, MD, cardiologist, Mayo Clinic, Jacksonville, Fla.
‘BMI’ a Bust for Predicting Heart Risk
Body Mass Index may not be useful in
predicting risk from heart disease
• Body Mass Index (BMI) - ratio of weight to height – proved
to be a bust for predicting death from heart disease in an
analysis of 40 previously reported studies involving 250,000
patients with heart disease followed for average of four
years
• Fat vs Fit:
– Intriguing evidence that two alternative tests – measuring waist
circumference or waist-hip ratio – may be better ways to
distinguish between the fit and the fat
Romero-Corral A. The Lancet, Aug. 19, 2006; vol. 368:pp 666-678
Francisco Lopez-Jimenez, et al. “Obesity and the Risk of MI in 27,000 Participants from 52
Countries,” Yusef et al., The Lancet, Nov. 5, 2005
WHR vs BMI may be a better predictor of allcause mortality in older adults
• “WHR, rather than BMI or WC (waist
circumference), appears to be the more
appropriate yardstick for obesity-related risk
stratification of high-functioning older adults,
and possibly all older adults.”
Ann Epidemiol. 2009;19:724-31
Health Risk Based on Waist to Hip Ratio
Male
Female
Health risk based
solely on WHR
= or < 0.90
= or < 0.80
Low Risk
0.90 to 1.0
0.81 to 0.85
Moderate Risk
> 1.0
> 0.85
High Risk
Waist Circumference
Female
> 35 in.
Male
> 40 in.
Ford ES, Giles WH, Dietz WH (2002). Prevalence of metabolic syndrome among US adults: Findings
from the third National Health and Nutrition Examination Survey. JAMA 287(3):356-359
Abdominal Fat Leads to Inflammation
Conclusion: Data suggests that excessive
abdominal visceral fat contributes to increased
plasma IL-6, which, in turn, is strongly associated
with all-cause and cause-specific mortality in
older persons with OLD
Am J Clin Nutr 2012, 96:526-26
Belly Fat Deadly Even with Low BMI
• Large population-based study from
epidemology research program, American
Cancer Society in Atlanta:
– Risk of death each year increased with waist size –
the bigger the gut, the greater the risk
– Greater waist circumference increased death risk
from all causes in all BMI groups (even with low
body-fat levels)
Archives Internal Medicine, 170: p1293-1301, 2010
Inflammation – Key Component of
Myofascial Pain Syndrome
Inflammation is associated with
virtually every chronic disease
Inflammation is responsible for the
pain and tissue destruction in patients
It’s As Simple As
Carbs - Fist
Protein – Palm
Fats - Thumb
Weight Loss / Body Composition
After
Before
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Am J Clin Nutrition 1996; 64:472S-477S
J Amer Diet Assoc 2001;101(10):1209-1212
J Amer Diet Assoc 2002;102(7):944-955
Amer J Clin Nutr 2003;78:228-35
Data that is:
- Calibrated
- Validated
- Reproducible
- Non-invasive
- Allows tracking of
weight as muscle
vs. fat vs. water
Weight Loss Does Not Always Lead to
Better Performance
“Weight and BMI do not evaluate body
compartments, therefore, do not reveal if
weight changes result in loss of fat free
mass or gain in fat mass”
J. Amer. Diet Assoc. 2002; 102(7): 944-55
“BIA allows for fat-targeted weight loss
and/or muscle-targeted weight gains”
Dr. Rob, 2012
Body Compositon: A three year study on aging
at Tufts University determined that body
composition (muscle mass) is the most
important factor in determining how healthy we
will be in our later years
BIA Testing
Conducting the BioImpedance Analysis
Introduction and Interpretation of BIA
Step 1: Connect the electrodes
that leads to the patient
“RED TOWARDS THE HEAD”
434
RJL
BIA
BIA Electrodes and the Tetra-polar System of
Measurement
•
The tetra-polar system uses two driving
electrodes and two sense electrodes to provide
an accurate measurement of whole body
impedance.
BioElectric Impedance Analysis
1) Body Composition (%
body fat)
2) Fluid Distribution
(dehydration status)
3) Tissue Health (overall
cell health) Phase angle
4) Basal Metabolic Rate
5) Daily Energy Expenditure
“SUMMARY:
The phase angle can be
considered a global
marker of health, and
future studies are
needed to prove its
utility in intervention
studies”
Curr Opin Clin Nutr Metab Care. 2005
May;8(3):311-7. PMID:15809535
Phase Angle Positively Correlates with
Cell Membrane Integrity
Three n-3 polyunsaturated fatty acids eicosapentoenoic acid, docosapentenoic acid, and
decosahexaenoic acid were positively correlated
with phase angle.
Vanderjagt, D. et al. Phase angle correlates with n-3 fatty acids and cholesterol in
red cells of Nigerian children with sickle cell disease. Lipids in Health and Disease.
2003; 2:2
Phase Angle
• Phase angle – an indicator of cellular health and
integrity
• What causes the phase angle to increase:
A. An increase in BCM relative to fat-free mass
B. An increase in FFM relative to body weight
C. Improving hydration of FFM
Core BIA Interpretation
Was there a change in weight; if so, how
much of it was accounted for by fat pounds?
Was there a change in total body water?
• If reduced, by how much?
• Related to menstrual cycle?
What happened to the fluid distribution?
Advanced BIA Interpretation
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Weight in pounds
Fat-free mass pounds
Fat pounds
Body cell mass (ATM) %
Change in total body water (L) amount
ICW/ECW ratio and liters
Phase angle
BIA
Date: 31-Dec-11 8-Jan-12 15-Jan-12 22-Jan-12 29-Jan-12 5-Feb-12 12-Feb-12 20-Feb-12 26-Feb-12 5-Mar-12
12-Mar-12
19-Mar-12
68.00
Height:
Weight:
Age:
68.00
189.00
33
68.00
188.00
33
68.00
185.40
33
68.00
185.20
33
68.00
183.40
33
68.00
182.40
33
68.00
181.40
33
68.00
181.20
33
68.00
181.20
33
68.00
179.40
33
68.00
175.80
33
Resistance:
396.0
380.0
370.0
369.0
364.0
360.0
358.0
355.0
354.0
352.0
347.0
175.40
33
343.0
Reactance:
65.0
62.0
65.0
65.0
69.0
67.0
67.0
64.0
64.0
64.0
67.0
63.0
Ideal/desired wt:
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
Actual BMI:
28.74
28.59
28.19
28.16
27.89
27.73
27.58
27.55
27.55
27.28
26.73
26.67
Actual phase:
9.3
9.3
10.0
10.0
10.7
10.5
10.6
10.2
10.2
10.3
10.9
10.4
Actual BMR:
1943
1968
2037
2041
2101
2097
2105
2085
2089
2097
2151
2124
% actual FAT:
22.0
19.6
17.4
17.2
15.8
14.9
14.2
13.7
13.5
12.5
10.4
9.5
Wt actual FAT:
41.6
36.9
32.2
31.8
29.0
27.1
25.8
24.7
24.4
22.5
18.2
16.6
Wt actual BCM:
81.8
82.7
85.3
85.4
87.9
87.5
87.7
86.8
87.0
87.1
88.9
87.7
Wt minimum
BCM:
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
Wt actual ECM:
65.6
68.4
67.9
67.9
66.5
67.7
67.9
69.7
69.8
69.8
68.7
71.1
Wt maximum
ECM:
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
Liters actual
TBW:
50.1
51.5
52.2
52.3
52.6
53.0
53.1
53.4
53.5
53.6
53.8
54.3
Liters actual ICW:
33.8
34.2
35.3
35.4
36.4
36.2
36.3
35.9
36.0
36.0
36.8
36.3
Liters actual
ECW:
16.3
17.2
16.9
16.9
16.3
16.8
16.8
17.5
17.5
17.5
17.0
18.0
Change in Weight?
Loss or Gain
Did it come from FAT?
Did it come from WATER?
BIA
Date: 31-Dec-11 8-Jan-12 15-Jan-12 22-Jan-12 29-Jan-12 5-Feb-12 12-Feb-12 20-Feb-12 26-Feb-12 5-Mar-12
12-Mar-12
19-Mar-12
68.00
Height:
Weight:
Age:
68.00
189.00
33
68.00
188.00
33
68.00
185.40
33
68.00
185.20
33
68.00
183.40
33
68.00
182.40
33
68.00
181.40
33
68.00
181.20
33
68.00
181.20
33
68.00
179.40
33
68.00
175.80
33
Resistance:
396.0
380.0
370.0
369.0
364.0
360.0
358.0
355.0
354.0
352.0
347.0
175.40
33
343.0
Reactance:
65.0
62.0
65.0
65.0
67.0 = 67.0
64.0
189
13.6 lbs
69.0 – 175.4
64.0
64.0
67.0
63.0
Ideal/desired wt:
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
Actual BMI:
28.74
28.59
28.19
28.16
27.89
41.6 –27.73
16.6 =25
27.58 lbs27.55
27.55
27.28
26.73
26.67
Actual phase:
9.3
9.3
10.0
10.0
10.7
10.2
10.2
10.3
10.9
10.4
Actual BMR:
1943
1968
2037
2041
2105not 2085
2101FAT 2097
Use
Pounds,
%
2089
2097
2151
2124
% actual FAT:
22.0
19.6
17.4
17.2
15.8
14.9
14.2
13.7
13.5
12.5
10.4
9.5
Wt actual FAT:
41.6
36.9
32.2
31.8
29.0
27.1
25.8
24.7
24.4
22.5
18.2
16.6
Wt actual BCM:
81.8
82.7
85.3
85.4
87.9
87.5
87.7
86.8
87.0
87.1
88.9
87.7
Wt minimum
BCM:
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
Wt actual ECM:
65.6
68.4
67.9
67.9
66.5
67.7
67.9
69.7
69.8
69.8
68.7
71.1
Wt maximum
ECM:
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
Liters actual
TBW:
50.1
51.5
52.2
52.3
52.6
53.0
53.1
53.4
53.5
53.6
53.8
54.3
Liters actual ICW:
33.8
34.2
35.3
35.4
36.4
36.2
36.3
35.9
36.0
36.0
36.8
36.3
Liters actual
ECW:
16.3
17.2
16.9
16.9
16.3
16.8
16.8
17.5
17.5
17.5
17.0
18.0
154.00
10.5
154.00
10.6
FAT in Pounds
Does it equal the total
WEIGHT change?
If not, you investigate…
TOTAL BODY WATER in Liters
Did the Total Body WATER change?
BIA
Date: 31-Dec-11 8-Jan-12 15-Jan-12 22-Jan-12 29-Jan-12 5-Feb-12 12-Feb-12 20-Feb-12 26-Feb-12 5-Mar-12
12-Mar-12
19-Mar-12
68.00
Height:
Weight:
Age:
68.00
189.00
33
68.00
188.00
33
68.00
185.40
33
68.00
185.20
33
68.00
183.40
33
68.00
182.40
33
68.00
181.40
33
68.00
181.20
33
68.00
181.20
33
68.00
179.40
33
68.00
175.80
33
Resistance:
396.0
380.0
370.0
369.0
364.0
360.0
358.0
355.0
354.0
352.0
347.0
175.40
33
343.0
Reactance:
65.0
62.0
65.0
65.0
69.0
67.0
67.0
64.0
64.0
64.0
67.0
63.0
Ideal/desired wt:
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
Actual BMI:
28.74
28.59
28.19
28.16
27.89
27.55
27.28
26.73
26.67
Actual phase:
9.3
9.3
10.0
10.0
10.7
10.2
10.2
10.3
10.9
10.4
Actual BMR:
1943
1968
2037
2041
2101
41.62097
– 16.62105= 25 2085
lbs
2089
2097
2151
2124
% actual FAT:
22.0
19.6
17.4
17.2
15.8
13.5
12.5
10.4
9.5
Wt actual FAT:
41.6
36.9
32.2
31.8
29.0
24.4
22.5
18.2
16.6
Wt actual BCM:
81.8
82.7
85.3
85.4
87.9
87.0
87.1
88.9
87.7
Wt minimum
BCM:
58.5
58.5
58.5
58.5
58.5
Wt actual ECM:
65.6
68.4
67.9
67.9
Wt maximum
ECM:
69.9
69.9
69.9
Liters actual
TBW:
50.1
51.5
Liters actual ICW:
33.8
Liters actual
ECW:
16.3
189 –27.73
175.427.58
= 13.627.55
lbs
10.5
14.9
10.6
14.2
13.7
27.1 Pounds,
25.8
24.7 %
Use FAT
not
87.5
87.7
86.8
50.1 – 54.3 = 4.2 L
58.5
58.5
58.5
58.5
58.5
58.5
58.5
66.5
67.7
67.9
69.7
69.8
69.8
68.7
71.1
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
52.2
52.3
52.6
53.0
53.1
53.4
53.5
53.6
53.8
54.3
34.2
35.3
35.4
36.4
36.2
36.3
35.9
36.0
36.0
36.8
36.3
17.2
16.9
16.9
16.3
16.8
16.8
17.5
17.5
17.5
17.0
18.0
TOTAL BODY WATER in Liters
Did the Total Body WATER change?
Did it effect the INTRACELLULAR
Water compartment?
PERCENTAGE vs. LITERS?
BIA
Date: 31-Dec-11 8-Jan-12 15-Jan-12 22-Jan-12 29-Jan-12 5-Feb-12 12-Feb-12 20-Feb-12 26-Feb-12 5-Mar-12
12-Mar-12
19-Mar-12
68.00
Height:
Weight:
Age:
68.00
189.00
33
68.00
188.00
33
68.00
185.40
33
68.00
185.20
33
68.00
183.40
33
68.00
182.40
33
68.00
181.40
33
68.00
181.20
33
68.00
181.20
33
68.00
179.40
33
68.00
175.80
33
Resistance:
396.0
380.0
370.0
369.0
364.0
360.0
358.0
355.0
354.0
352.0
347.0
175.40
33
343.0
Reactance:
65.0
62.0
65.0
65.0
69.0
67.0
67.0
64.0
64.0
64.0
67.0
63.0
Ideal/desired wt:
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
154.00
Actual BMI:
28.74
28.59
28.19
28.16
27.89
27.73
27.58
27.55
27.55
27.28
26.73
26.67
Actual phase:
9.3
9.3
10.0
10.0
10.7
10.5
10.6
10.2
10.2
10.3
10.9
10.4
Actual BMR:
1943
1968
2037
2041
2101
2097
2105
2085
2089
2097
2151
2124
% actual FAT:
22.0
19.6
17.4
17.2
15.8
14.9
14.2
13.7
13.5
12.5
10.4
9.5
Wt actual FAT:
41.6
36.9
32.2
31.8
29.0
27.1
25.8
24.7
24.4
22.5
18.2
16.6
Wt actual BCM:
81.8
82.7
85.3
85.4
87.9
87.5
87.7
86.8
87.0
87.1
88.9
87.7
Wt minimum
BCM:
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
58.5
Wt actual ECM:
65.6
68.4
67.9
67.9
66.5
67.7
67.9
69.7
69.8
69.8
68.7
71.1
Wt maximum
ECM:
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
69.9
Liters actual
TBW:
50.1
51.5
52.2
52.3
52.6
53.0
53.1
53.4
53.5
53.6
53.8
54.3
Liters actual ICW:
33.8
34.2
35.3
35.4
36.4
36.2
36.3
35.9
36.0
36.0
36.8
36.3
Liters actual
ECW:
16.3
17.2
16.9
16.9
16.3
16.8
16.8
17.5
17.5
17.5
17.0
18.0
Fluid distribution?
Basic BIA Interpretation
1st
2nd
3rd
4th
Weight in pounds
Fat pounds
Total body water liters
Intracellular and Extracellular water
• % and Liters
Intracellular
Water
Generally represents
nutrient status
More is better!
Extracellular
Water
Generally represents
toxin status
Less is better!
The FIRST SIGN of FAILING HEALTH is a shift of fluid from the inside
of the cell to the outside of the cell
Associated with Decreased ICW
•
•
•
•
Reduction in BCM
Inadequate cell membrane
Osmotic gradient due to ineffective electrolytes
Stress, inflammation, oxidative stress
Associations with Increased ECW Liters
• Increased body fat levels
• Defects in cell fluid regulation
• Toxins-chemicals, metabolic waste, infections,
foreign antigens, dysbiosis, altered liver
detoxification pathways
• Inflammatory process
• Catabolic reactions (sarcopenia)
• Fluid dysfunctions
• Lymphatic congestion concerns
BIA
5-compartment
model
Lean tissue
(BCM) is 73%
water,
fat tissue
is 10% water
Water in fat is
calculated as
extracellular
water.
Body
Cell
Mass
FAT
FREE
MASS
Extracellular
Mass
Metabolic Tissues
Muscles & organs
Males 66% age 20
Intracellular Water
Females 61% age 20
Extracellular Water
Bone Tissue
Males ≤ 16%
Clinical pearl –
obese patients
will have more
ECW
FAT MASS
Fat
Females ECM ≤ 22%
5-Compartment Model
TOTAL
BODY
WATER
Body Composition
• Fat mass:
– Total adipose tissue of the patient
– Includes VAT and subcutaneous tissue
• Fat free mass:
– Body cell mass:
• Mass of all metabolically active tissues, including muscle and
organ tissues
• Muscle mass should remain constant or even increase under
optimal circumstances
• Remember, it takes 3 X longer to accumulate BCM than to
deplete it
Persistent Organic Pollutants
DETOX
Fat Loss
Patients!
Weight Loss May Push
Toxins Into Bloodstream
“Serum concentrations of most POPs were higher in
those with long-term weight loss”
Int J Obes (Lond). 2010 Sep 7.
Exercise
Quit Smoking
9 Fruits and
Veggies
Lose Weight
Take
Supplements
What fits your schedule better: Exercising 1 hour each day,
or, being DEAD 24 hours each day?