Multidisciplinary Approach to the Management of Obesity

By Lalita Kaul, PhD RDN

There is an obesity crisis in America. It is also becoming a global problem, with increased prosperity enjoyed by many developing countries. Because of this, many books have been written on this topic. But none presents a nice, concise, multidisciplinary approach to the problem as this book by Dr. Lalita Kaul. Author has been able to convey the basic information in a simple manner, useful for both medical personnel and lay public.

The clinical consequences of obesity are profound and far reaching. Beginning with prevalence in various ethnic groups, successive chapters deal with causes, health risks, and the management of obesity. Chapter 13 summarizes the treatment for quick reference. The appendices contain valuable information including the caloric content of many commonly used foods, nutritional assessment forms, food diary, ways to measure your servings, and behavior modification strategies. The appendix on calories in fast foods is a true eye-opener. Did you know a Big Mac has 570 calories and 35 gm of saturated fat, only beaten by the Burger King Whopper with 640 calories and 41 gm of fat? No wonder they are called the "coronary diet." Finally, there are healthy, delectable low-fat recipes for your daily use, including a variety of delicious Indian recipes.

All chapters are well written, fully researched, and clearly organized with a lot of practical information on how to handle the problem from infancy to old age. The many tables and diagrams are useful adjuncts. And there is an extensive list of references at the end. The chapters dealing with obesity in children are particularly informative since therein lies the root of the problem. Also, there is an ample discussion on the biology of obesity (genes, hormones, metabolic pathways, etc). Bariatric surgery, now gaining momentum in the United States of America, has been given some importance. Book also discusses obesity in getting COVID and vitamin-D deficiency. In short, this book answers some of the questions we always ask, "Why we eat what we eat? What happens to all that we eat?" and "What can we do to end this epidemic?" and more. Overall, this is a very useful handbook for medical students, residents, nurses, practicing physicians, and the lay public.

• Language: English
• Publisher: Fulton Books, Inc.
• Release date: Nov 30, 2023
• ISBN: 9798887312194

Book preview

Table of Contents

Title

Copyright

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 13

References

Appendices

About the Author

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Multidisciplinary Approach to the Management of Obesity

Lalita Kaul, PhD RDN

Copyright © 2023 Lalita Kaul, PhD RDN

All rights reserved

First Edition

Fulton Books

Meadville, PA

Published by Fulton Books 2023

Library of Congress Control Number: 2005924374

ISBN 979-8-88731-218-7 (paperback)

ISBN 979-8-88982-188-5 (hardcover)

ISBN 979-8-88731-219-4 (digital)

Printed in the United States of America

To Kavita whose continuous support and encouragement sustained me in completion of this book.

Acknowledgments

I am grateful to my family for their love, support, and encouragement, without which this project would not come to fruition:

My late husband, Dali.

My late parents, Aruna and Zind Lal.

My brothers, Maharaj, Raj, and Vinod.

My daughter, Kavita.

I am also grateful to my extended community, including my patients, students, and colleagues. I have learned so much from all of them.

Disclaimer

The opinions presented in this book are the opinions of the authors and are based on her research and personal and professional experiences. The book should not be used to diagnose or treat an illness. Individuals should consult physicians / health-care professionals.

Every effort has been made to ensure the accuracy of the information presented in this book. However, due to the constant and rapid development in medical technology, neither the authors nor the publisher can accept any legal or other responsibilities for the errors, accuracy, and omissions that may have occurred at the time of publication.

Preface

Nutrition is becoming a primary force in preventive medicine, and clinical research has implicated nutritional factors in a number of the most prevalent diseases in the United States. Some of these include coronary heart disease, non-insulin-dependent diabetes mellitus, cancer, arteriosclerosis, and alcohol-induced cirrhosis. In addition, dietary habits are associated with prevention and treatment of diseases, including obesity, low birth weight, and osteoporosis.

Until recently, obesity was considered to be a rather benign condition not necessarily requiring treatment. This attitude has gradually been changing as the prevalence of the condition has increased remarkably and the health risks have been recognized. In the United States, the costs to the society of obesity have been estimated to be 68.8 billion dollars.

A sedentary lifestyle and the variety of tasty, rich, and cheap foods available in the United States make Americans particularly vulnerable to weight gain. It is now clear that obesity is, to some extent, biologically determined and that approximately 25% to 40% of the tendency toward obesity is caused by genetics. This leaves a great portion of the variance attributable to environment, and therefore, much can be done to improve this condition.

Persuading people to eat a healthier diet for obesity prevention or treatment is one of the greatest challenges to medical and public health care among providers. Each year physicians see 70 percent of all adults in the United States, who represent an immediately available resource for physicians to encourage health promotion and disease prevention. Yet there exist numerous incongruities between physicians’ actions regarding dietary recommendations and the recommended guidelines, despite the population-wide potential for modifying dietary risk factors for various diseases.

Barriers to successful physician-delivered dietary counseling by physicians in both the US and Canada have included lack of training in nutrition, lack of time, lack of support staff with nutrition training, and reimbursement concerns. Additional factors include beliefs about the effectiveness of intervention, concerns about patient response and compliance, knowledge about risk factors, and perceived unpalatableness of certain diets. Survey data have revealed that physicians who feel prepared and competent to offer dietary counseling are more likely to be willing to intervene around dietary practices to provide dietary counseling to their patients. Although physicians are thought by many to be in an advantageous position to promote healthy lifestyle, few physicians place emphasis on diet. Medical educators have felt that improving the nutrition education of physicians would increase the inclusion of nutrition in patient care. However, having the knowledge does not necessarily guarantee appropriate nutrition related patient care.

Lalita Kaul

Washington, DC

Chapter 1

Introduction

More than half of the US population is overweight (BMI > 25 kg/m2) or obese (BMI > 30 kg/m2), providing physicians, nurses, and dietitians more an opportunity to work with this medical problem. Obesity is a chronic condition and should be treated as such. A standard model may not help every obese patient because there are often many complex issues (hereditary factors, the environment, and psychological factors) that differ between patients [1, 24, 30, 70].

Successful treatment of obesity seldom requires that the individual return to their ideal body weight. Permanent loss of as little as 5% body weight can result in substantial, long-term improvements in health. Therefore, the focus of obesity treatment should be on the permanent maintenance of a realistic lower body weight rather than a rapid weight loss to ideal level.

Most of the physicians have much of the information needed to assess whether weight management intervention is warranted.

Approach to the Overweight/Obese Patient

Baseline information—examination/office records

Height and weight—this is a means for rapidly assessing the patient’s potential need for intervention. The first step is to have the patient’s body mass index (BMI).

Although seldom measured in an office setting, the waist circumference is a reasonable indicator of abdominal (high-risk) fat and will further help characterize the patient’s health risk from obesity. The presence of obesity or overweight with a waist circumference > 102 cm (40 inches) in men or 88 cm (35 inches) in women suggests the need for treatment, especially in the presence of obesity-related health problems.

Blood pressure measurement may be a routine part of an office visit, but if not taken with an appropriate (large) cuff, the reading may be falsely elevated. Given the prevalence of obesity, it is not unreasonable to have large blood pressure cuffs available in most health-care settings.

The availability of these routine measures should assist the health-care providers in determining whether or not to discuss the issue of overweight or obesity with their patient.

Discussing the problem—making it easier for the patient

Physicians who are familiar with obesity evaluation and treatment may perceive that there is little time to intervene during a brief office visit. Another concern is that mentioning the patient’s weight may cause the patient to withdraw or respond negatively. Physicians are uniquely positioned, however, to provide weight and nutrition intervention. Patients who receive effective messages from their physicians are more likely to follow through on recommended changes in lifestyle. For example, in less than one minute, the physician can point out that lifestyle changes (improved eating habits, increased physical activity) can help in the management of diabetes, hypertension, or lipid disorders. The smoking cessation model is a good example of how focused and clear messages given by physicians to patients repeatedly over time can result in significant benefits with modest efforts. If the patient is receptive, a referral can quickly be made to a dietitian or other health professional with expertise in weight management.

If a physician is to be effective in intervening to help the obese patients, he/she must be sensitive to the communication issues with these patients. Creating a supportive medical environment for the obese patients can make communication easier. For example, having available larger examining gowns, weighing scales, blood pressure cuffs, and examining tables may be appropriate if the physician sees a significant number of obese patients.

The physician’s office staff may need to be educated regarding sensitivity and privacy issues. These issues include location of the scale and references to a patient’s weight by the staff. Both the office staff and the physician need to have empathy for the obese patient and to communicate with the patient in an unbiased and supportive manner.

Medical history relevant to obesity

Medical conditions that are affected by obesity (diabetes, dyslipidemia, hypertension, sleep apnea, etc.) can be a good starting point for discussion of weight-related issues. Documenting blood pressure, blood lipid, and glucose concentrations should be standard data collection for obesity management. Degenerative joint disease is clearly aggravated by being overweight and should be noted. Perhaps the most commonly overlooked complication of obesity is obstructive sleep apnea. Patients should be asked about excessive daytime sleepiness and related symptoms. Spouses often can provide important clues regarding the diagnosis of sleep apnea. Referral to a sleep-disorder specialist can be extremely helpful, as the treatments for sleep apnea are remarkably effective.

Medications predisposing to weight gain (steroids, antidepressants, thiazolidinediones, some antihistamines and anticonvulsants) should be assessed because beginning weight management programs may be fruitless depending upon the medication.

A family history of obesity and obesity-related medical problems can assist in prognosticating obesity-related health complications.

A brief consideration that secondary causes of obesity (Cushing’s syndrome, psychiatric disturbances) may be present is usually warranted. Excluding secondary causes of obesity is generally a straightforward process that can be addressed by a directed history and physical examination. A long duration of overweight and positive family history of obesity makes it unlikely that a secondary cause exists. Exogenous corticosteroids and tricyclic antidepressants are the more common medications resulting in unwanted weight gain, and weight loss is more difficult if these medications are continued. Physical signs that would indicate a secondary cause of obesity, such as Cushing’s syndrome, should be sought. The absence of a positive family history of obesity is unusual and should prompt a more thorough search for secondary causes, including emotional disturbances.

Even if there are medical indications for obesity treatment, it is important to assess whether the patients are ready to change their lifestyle in attempts to deal with the issue. Only if they are willing to try is a further effort on the health-care provider’s part likely to be helpful.

If the patient is willing to work with treatment, a review of the patient’s goals and expectations are warranted. Unrealistic goals can lead to disappointment for all involved. Additional information that can help in developing a program include the pattern of weight gain, including inciting events, the response to previous weight-loss attempts, as well as the patient’s eating pattern and activity habits.

Physical examination

The physical examination is largely directed toward searching for clues of secondary causes of weight gain (physical stigmata of Cushing’s syndrome or hypothyroidism) and documenting complications of obesity or obesity-related diseases. A careful examination of the skin and cardiovascular system is most likely to yield clues to the patient’s condition.

Laboratory evaluation/tests

In routine clinical practice, assessment of blood glucose (diabetes), cholesterol, triglycerides and HDL-cholesterol (dyslipidemia), and liver function tests (steatohepatitis) will provide the needed information to assess the most common health-related issues.

Chapter 2

Prevalence of Obesity

The United Stated is experiencing substantial increase in overweight and obesity (as defined by a BMI > 25 for adults) that cut across all ages, racial and ethnic groups, and genders. According to self-reported measures of height and weight, obesity (BMI > 30) has been increasing in every state of the nation.

Facts:

On average, one out of every three adults are obese, which is about 36% of the population. (Harvard 2020)

The age-adjusted prevalence of obesity in adults from 2017–20 was 42.4%. (Centers for Disease Control and Prevention, 2020)

By 2030, an estimated 20% of the world’s population will be obese.

About 18.5% of children ages two to nine are considered obese in the United Stated. (Centers for Disease Control and Prevention, 2019)

Obesity does not just affect people in the United States. People in many countries experience obesity, and it is becoming a global epidemic.

Facts:

An estimated five hundred million adults in the world are obese.

If unaddressed, an estimated one billion adults will be obese by 2030.

More than 25% of UK adults are obese.

44% of women in Saudi Arabia are obese.

Obesity in United States of America

Non-Hispanic African American women experience the highest rates of obesity in USA at 59%. (Harvard, 2020)

Obesity rates are higher in Hispanic, Mexican American, and non-Hispanic black population than they are for Caucasians. (Harvard, 2020)

The South and the Midwest have the highest obesity prevalence. (Center for Disease control and Prevention, 2019)

All US states and territories have an obesity rate of at least 20%. (Centers for Disease Control and Prevention, 2019)

Obesity prevalence by sex

Overall, adult obesity rates are higher for women. (National Center for Health Statistics)

Four out of five African American women are overweight or obese. (Office of Minority Health, 2018)

Three out of four Latina or Hispanic women are overweight or obese. (Centers for Disease of Control and Prevention, 2018)

Obesity rates for men are highest for middle-income groups. (Centers for Disease Control and prevention, 2020)

Obesity rates for non-Hispanic white, non-Hispanic Asian, and Hispanic women are highest for lowest-income groups. (Centers for Disease Control and Prevention, 2020)

Obesity prevalence by age

In the United States, obesity is more prevalent among adults than youths. (National Center for Health Statistics, 2015–2016)

Childhood obesity is rising globally, with 43% overweight and obese children under the age of five (Harvard, 2020)

One in six children ages two to nineteen are obese (National Health and Nutrition Examination Survey)

Obesity is more prevalent among six to nineteen years old than in two to five years old. (National Center for Health Statistics)

The cost

The medical care costs of obesity are almost $150 billion per year in the United States. (Centers for Disease Control and Prevention, 2020)

States with the most obese populations

These states have the highest prevalence of obesity, with rates over 35%:

Alabama

Arkansas

Iowa

Kentucky

Louisiana

Mississippi

Missouri

North Dakota

West Virginia

Obesity and COVID-19

More than nine hundred thousand adults with COVID-19 hospitalizations occurred in the United States between the beginning of the pandemic and November 18, 2021. Models estimate that 30% of these hospitalizations were attributed to obesity.

Nearly half of US adults gained on excess pounds during the first year of the pandemic, making a national obesity crisis even worse, a new study shows.

Those who report weight gains were more likely to have gained weight if they were overweight before the pandemic (just over two times more likely), had children at home (1.39 times), had depression or anxiety (1.25 times), or checked body weight within the last six months (1.32 times).

Coping with stress

Stress during an infectious disease outbreak can sometimes cause changes in sleep or eating patterns, increased use of alcohol and tobacco, or worsening of chronic health problems.

Over time, health education can help individuals with obesity improve their overall health. And if they result in even modest weight loss, there are health benefits, such as improvements in blood pressure, blood cholesterol, and blood sugars. And with a healthy BMI, the risk of severe illness from COVID-19 is reduced.

People with obesity are more likely than normal weight people to have other diseases that are independent risk factors for severe COVID-19, including heart disease, lung disease, and diabetes. They are also prone to metabolic syndrome.

Body mass index (BMI) is a strong independent risk factor for COVID-19. The impact extends to 42% people who are obese. According to Genentech researchers, 77% of 17,000 patients hospitalized with COVID-19 were overweight (29%) or obese (48%). The rate of COVID-19 hospitalizations begins to rise as soon as someone enters overweight category. People with obesity are vulnerable to severe COVID-19. It begins with fat in the abdomen which pushes up on the diaphragm with severe COVID-19, which causes lungs to restrict airflow. The blood of obese people also has an increased risk of developing clots. They have impaired immunity, chronic inflammation. All this can worsen COVID-19. BMI remains as strong independent risk factor for severe COVID-19, according to several studies that adjusted for age, sex, social class, diabetes, and heart.

Immunity also weakens in people with obesity, in part because fat cells infiltrate the organs where immune cells are produced and stored, such as the spleen, bone marrow, and thymus. Immune tissues are lost in exchange for adipose tissue, making the immune system less effective in either protecting the body from pathogens or responding to a vaccine.

The problem is not only fewer immune cells but less effective ones. Beck’s studies of how obese mice respond to the influenza virus demonstrated that key immune cells called T cells don’t function as well in the obese state, she says. They make fewer molecules that help destroy virus-infected cells, and the corps of memory T-cells left behind after an infection, which is key to neutralizing future attacks by the same virus, is smaller than in healthy weight mice.

Beck’s work suggests the same thing happens in people. She found that people with obesity vaccinated against flu had twice the risk of catching it as vaccinated, healthy-weight people. That means trials of vaccines for SARS-CoV-2 need to include people with obesity, she says, because coronavirus vaccines may be less effective in those people.

Beyond an impaired response to infections, people with obesity also suffer from chronic, low-grade inflammation. Fat cells secrete several inflammation-triggering chemical messengers called cytokines, and more come from immune cells called macrophages that sweep in to clean up dead and dying fat cells. Those effects may compound the runaway cytokine activity that characterizes severe COVID-19. This causes a lot of tissue damage, recruiting too many immune cells, destroying healthy bystander cells.

The severity of COVID-19 in people with obesity helps explains the pandemic’s disproportionate toll in some groups. In American Indians and Alaska Natives, for example, poverty, lack of access to healthy food, lack of health insurance, and poor exercise opportunities combine to cause increased obesity.

Obesity and low vitamin D increases risks for heart attacks and severe COVID-19

Recent studies show that having low levels of vitamin D is associated with increased risk for high blood pressure, heart disease, and severe consequences of COVID-19.

A review of many studies shows that having blood levels of hydroxy vitamin D below 30 ng/mL is associated with increased risk for both getting COVID-19 and suffering severe consequences of that infection. Another study reviewed more than forty studies and showed that adequate vitamin D reduced the frequency and severity of COVID-19 infections and hospital admissions and lowered the death rate. Several studies show that vitamin D deficiency has been associated with increased death rate from COVID-19.

The most dependable test to diagnose vitamin D deficiency is a blood test hydroxy vitamin D. Symptoms of a deficiency include feeling tired all the time, being depressed, bone fractures, dental disease, loss of hair, and frequent infections and colds.

The most recent studies suggest that you should take vitamin D pills to raise blood levels above 30 ng/mL, and most people can do this by taking 1,000 IU pills each day. There is no evidence that higher doses of vitamin D offer greater protection from COVID-19 than moderate doses. Blood levels higher than 60 ng/mL can cause serious tissue damage.

Vitamin D strengthens your immune system

Vitamin D helps your immune system to fight off the effects of COVID-19. Doctors are treating severe COVID-19 with dexamethasone, which has a similar steroid structure to that of vitamin D. COVID-19 can kill by causing an overactive immune system called cytokine storm, and vitamin D helps to reduce cytokine storm by decreasing the production of T helper cells and inflammatory cytokines and by increasing anti-inflammatory cytokines.

Vitamin D deficiency is associated with other risk factors for severe COVID-19, such as obesity, diabetes, older age, or darker skin.

How common is vitamin D deficiency?

About 42% of North Americans have low levels of vitamin D, including 82% of African Americans and 70% of Hispanics. One needs to get vitamin D from sunlight exposure, the foods that you eat, or vitamin D pills. Foods that contain some vitamin D include cold-water fish such as salmon, herring, sardines or mackerel, and red eat, liver, and egg yolks. Many North Americans get enough vitamin D in the summer but need pills or fortified foods in the winter months. In warmer weather, you can usually get enough vitamin D with ten to twenty minutes of sunlight exposure of a small area of three to five times a week.

Overdose of vitamin D

You cannot be poisoned by Vitamin D through sun exposure or diet alone, but vitamin D poisoning can occur when people take high-dose supplements for an extended time. Unless your doctor prescribes higher doses, you should not take more than 2,000 IU/day. Vitamin D is harmless in the body when it is bound to vitamin D receptors and carrier proteins. However, having extra vitamin D floating in your system overwhelms vitamin D receptors to cause a marked increase in calcium to be absorbed from your gut, removed from your bones to cause high blood calcium levels that can bind to and damage every cell in your body.

High blood calcium levels from excess vitamin D can cause bone loss, brittle bones, and bone pain. People who took high doses of vitamin D (4,000 and 10,000 IU/day) for three years lost far more bone than those who took the recommended 400 IU/day. High levels of vitamin D also cause low levels of vitamin K2, with resultant loss of bone. Vitamin K2 helps to keep calcium in bones.

After several months of having high blood calcium levels and having no symptoms at all, you can develop kidney failure and not even know it. You may develop nausea, vomiting, diarrhea, constipation, or muscle weakness. You can also develop high blood pressure, kidney stones, or calcium in your arteries to increase risk for a heart attack. Since vitamin D accumulates in and is released very slowly from fat, it can take month for blood levels of vitamin D to return to normal.

Recommendations from Gabe Mirkin, MD

I think that everyone should get a blood test for hydroxy vitamin D, particularly in the winter months when your levels are likely to be lowest. During this pandemic, you should not let blood levels of hydroxyvitamin D drop below 20 ng/mL, and most recent papers now recommend 30 ng/mL or more. Unless your doctor recommends higher doses, you should not try to get levels much higher than 30 ng/mL, since very high levels can harm you.

If your blood levels of hydroxy vitamin D are below 30 ng/mL, take vitamin D3 pills of at least 1000 IU/day for one to two months. If your blood levels of vitamin D do not return to normal, check with