~Obesity, Part 8 - Appendix A - Appendix F

APPENDIX A

Weight Loss Drugs

Amphetamine and related sympathomimetic medications are thought to stimulate the release of norepinephrine and/or dopamine from storage sites in nerve terminals in the lateral hypothalamic feeding center, thereby producing a decrease in appetite.

Adrenergic drugs for weight loss include phentermine (Adipex, Fastin, Ionamin); diethylpropion (Tenuate, Tepanil); phendimetrazine (Adipost, Bontril, Plegine, Prelu-2); and benzphetamine (Didrex). These drugs are chemically related to amphetamine. Mazindol (Sanorex, Mazinor) is an isoindole thought to inhibit the reuptake of norepinephrine rather than to cause its release.

Adrenergic weight loss drugs are all classified as controlled substances by the U.S. Drug Enforcement Agency (DEA) due to their tendency to cause dependency and the risk of abuse. All of these drugs are approved by the U.S. Food and Drug Administration (FDA) for short-term use (about 12 weeks) (FDA 1992).

Sympathomimetic appetite suppressants stimulate the central nervous system and elevate blood pressure. Side effects of these drugs include dry mouth, anxiety, insomnia, dizziness and lightheadedness, headache, palpitations, and (rarely) increased blood pressure. Tolerance to the effects of medications in this class usually develops within a few weeks and rebound weight gain may occur after discontinued use of the medication.

Give a physician your complete medical history especially if you have high blood pressure, an overactive thyroid, glaucoma, diabetes, or emotional problems. Inform your physician if you think you are pregnant or if you are breast-feeding. Limit alcohol use. Alcohol can increase unwanted side effects of dizziness. Adipex and other stimulants that work via this mechanism are not recommended for use in children.

Also inform your physician about all medicines used (prescription and nonprescription), especially if you take high blood pressure medicine or MAO inhibitors (e.g., furazolidone, phenelzine, selegiline, tranylcypromine) or any other weight-loss medicine. Decongestants are commonly found in over-the-counter cough and cold medicines.

Orlistat (Xenical) is unique among current obesity drugs in that it does not act directly on the central nervous system. Orlistat inhibits an enzyme (pancreatic lipase) essential to fat digestion. In 2 years of clinical trials, orlistat has produced sustained weight loss similar to that of other single agents.

The most common side effects are intestinal symptoms, including cramping, gas, and diarrhea, particularly in patients who eat high-fat foods against the advice of their physician. It is possible that the desire to avoid these unpleasant side effects might encourage people to eat a diet that is lower in fat, thereby helping them to lose weight.

Sibutramine (Meridia) increases the levels of both serotonin and noradrenaline in areas of the brain that regulate food intake and body weight. It produces 1-year weight loss similar to that of other single agents and reduces some complications of obesity such as those involving blood glucose and lipids. Unlike some other anti-obesity drugs, sibutramine does not reduce blood pressure. The side effects may include dry mouth, lethargy, drowsiness, and insomnia

Obesity is associated with decreased human growth hormone levels. Growth hormone is released by the pituitary gland in response to exercise, deep sleep, hypoglycemia, and ingestion of protein. It stimulates the production of RNA (ribonucleic acid), mobilizes fat deposits, and is a central part of insulin metabolism (Fischbach 1996). Decreased levels of growth hormone are associated with obesity and corticosteroid use. Therapies that boost growth hormone can help facilitate weight loss. The cost of human growth hormone injections is cost-prohibitive for most people.

Most weight loss drugs have side effects that cause many people to discontinue using them before significant results are obtained.

APPENDIX B

Exercise and Diet

The goal of any weight-loss program is to attain better health through improved diet and exercise, in addition to restoring one's metabolic profile to fit that of a 21-year-old.

It is difficult for many overweight individuals to engage in exercise because excess body fat makes them too lethargic to contemplate a consistent exercise program. Additionally, some people just will not exercise. By properly modulating hormone levels, some individuals will feel revitalized enough to become physically active.

Restoring hormones to reflect more youthful profiles will produce some quick fat loss and alleviate depression. Feeling better and seeing real weight reduction can induce many people to improve their diet.

Those who remain hopelessly overweight may not be able to focus on proper diet or exercise, because neither was effective for them in the past. That is why it is so crucial to restore one's metabolic profile to a healthy, youthful level. For most people, this requires proper hormone balance. When there are hormone imbalances, such as too much fasting insulin and/or not enough testosterone, DHEA, thyroid, people gain weight. These age-related hormone imbalances often preclude sustained weight control, despite agonizing diet and exercise programs that are supposed to work!

APPENDIX C
  • The Glycemic Index
  • What Is the Glycemic Index
  • Food Fraud
The Glycemic Index

Much attention is being paid to avoiding foods that have a high glycemic index and glycemic load. The hypothesis is that since high glycemic foods increase production of insulin, avoiding them and eating only low glycemic foods will facilitate fat loss by reducing excess insulin. The problem with obese and severely overweight individuals relying on low glycemic diets is that they are already making too much insulin to achieve meaningful fat loss.

A review of published studies comparing the effects of consuming high as opposed to low glycemic diets on weight loss has yielded mixed results. Many studies indicate that it is healthier to eat lower glycemic index as opposed to high glycemic index foods, especially for diabetics.

A study in the July 2002 issue of the American Journal of Clinical Nutrition challenged the validity of many of the existing published studies showing increased weight loss and other health benefits associated with consuming low glycemic index foods ( Pi-Sunyer 2002). The author's summary about glycemic index and disease follows:
"It has been suggested that foods with a high glycemic index are detrimental to health and that healthy people should be told to avoid these foods. This paper takes the position that not enough valid scientific data are available to launch a public health campaign to disseminate such a recommendation. . . . Presented herein are the reasons why it is premature to recommend that the general population avoid foods with a high glycemic index."
The purpose of this appendix is to provide the reader with the basis for why some people think consuming low glycemic foods is the solution for obesity. For severely overweight individuals, it is at best only a partial solution. This Obesity protocol has meticulously identified the need to correct multiple metabolic disorders in order to achieve significant and sustained fat loss. The failure to correct for even one metabolic imbalance (such as low T3) can render any fat loss program useless.

What Is the Glycemic Index?

Glycemic index refers to the rate blood glucose levels rise after eating food, in comparison with an equivalent amount of pure glucose (sugar) or white bread. Many people are sensitive to carbohydrates even though they have normal fasting glucose levels.
  • Foods with high glycemic indices include corn flakes, instant potatoes, honey, pasta, bread, rice, and potatoes.
  • Food with a low glycemic index include kidney beans, lentils, soy beans, peanuts, butter and haricot beans, blackeye and chick peas, apples, ice cream, milk, yogurt, and tomato soup.
Interestingly, ice cream has a fairly low glycemic index, a result of the fats that tend to slow blood sugar rises. This emphasizes the complexity of the subject of diet. Although ice cream is considered a low-glycemic index food, it is high in calories, carbohydrates, and fats.

Persons who have carbohydrate cravings and food addictions should be particularly aware of the glycemic index. Certain carbohydrates can cause a sudden elevation of glucose in the blood with a sudden rush of energy often accompanied by feelings of dizziness or lightheadedness followed by a "crash." In particular, children may become addicted to the energy rush from snacks and soda. The pattern is often continued into adulthood by substituting coffee and donuts (for breakfast) or by eating cakes and cookies (after dinner).

Get into the habit of stocking your refrigerator with oranges, grapefruit, apples, pears,and berries. These fruits have been shown to reduce disease risk as opposed to refined sugar snacks that cause excessive fat accumulation.

While people seeking to lose body fat try to avoid sucrose and fructose, too often the intense craving for sugar (induced by hyperinsulinemia) results in carbohydrate bingeing.

The food industry misleads the public into thinking that high-glycemic foods are healthy. For instance, orange juice is promoted as a source of folic acid, vitamin C, and calcium. The downside to orange juice is that it induces an acute influx of fructose into the bloodstream that then spikes serum insulin. When an orange is eaten, there is only a gradual release of sugar into the blood. However, once fruits or vegetables are juiced, they become catalysts for insulin overload because of their high concentration of rapidly absorbable sugar.

Carrots have a high-glycemic index, but since their glycemic load is very low, there is nothing wrong with eating carrots. However, once carrots are juiced, the sugar is concentrated into a form that instantly hits the bloodstream and provokes an insulin spike. The moral to this story is to eat high amounts of fruits and vegetables, but avoid their juice. A look at the calorie content of a glass of fruit or vegetable juice confirms their fat-inducing effects. For those persons who are concerned about obtaining adequate folic acid, vitamin C, alpha-carotene, etc., these nutrients can be obtained by eating whole fruits and vegetables and by taking supplements.

As can be seen in this section, foods that were once considered part of a healthy "low-fat diet" have a very high glycemic index and glycemic load. This means that ingesting too many of these types of foods could cause weight gain, even if you think you are eating a healthy diet.

Eating too many high sugar-content foods and beverages causes the release of excess insulin. When evaluating the insulin-elevating effects of foods, two measurements to consider are the "glycemic index" and "glycemic load." The "glycemic index" measures how fast a carbohydrate triggers a rise in circulating blood sugar. The "glycemic load" assesses the impact of carbohydrate consumption, but provides a fuller picture than does the glycemic index alone. Foods that are high in both of these measurements should be reduced.

Comparison of High and Low Glycemic Index Foods

 
High Glycemic Index + High Glycemic LoadLower Glycemic Index + Low Glycemic Load
Food NameGlycemic Index*Glycemic Load*Food NameGlycemic Index*Glycemic Load*
Instant Rice**9124Popcorn728
Baked Potato**8520Watermelon724
Corn Flakes8421Carrot714
Corn Chex8321Ice Cream628
Pretzels8316Oat Bran, raw502
Corn Pops8021Green Peas483
Doughnut7617Grapes437
French Fries7522Orange425
Bread Stuffing7416Apple406
Cheerios7415Strawberries401
Kaiser Rolls7312Fish Fingers387
Bagel7225Apple368
White Bread7021Pear334
Pancakes6739Yogurt, low fat319
Cranberry Juice Cocktail6824Lentil Beans295
FantaŽ Orange Soft Drink6823Peach284
Mars Bar6526Milk273
Rye Bread6520Plum243
Sweet Corn6020Kidney Beans236
Macaroni and Cheese6432Cherries223
Sushi5219Cashew Nuts, salted223
Orange Juice5212Peanuts141
Linguini4823Broccoli----
When eating out, try to avoid eating bread. Ask for a double portion of vegetables in lieu of potato or rice. Cut back on desserts, especially at night. If you have an insatiable sweet tooth (carbohydrate craving), eat dessert in the morning, not at night. Consume higher glycemic carbohydrates in the morning, trying to reduce your intake after 12 noon. While these dietary changes can be difficult to implement, the effects of slowly reducing serum insulin can make this diet modification tolerable in the long run.

*Note that there can be variations of the actual glycemic index/load based on the brand or particular lot of the food/beverage. Glycemic load calculation is based on differing quantities of each food group.

**Some weight-loss physicians allow potatoes and rice as long as an overall reduced glycemic program is followed.

Food Fraud

In spite of the term "low-fat" or "fat-free" appearing on more and more food labels, a record number of Americans are overweight. The problem is that "low fat" often means "high sugar." For example, look at the label of fat-free salad dressings; they are loaded with sucrose or fructose.

Sugar is cheap and is a palatable alternative to oils that add fat calories. For instance, when looking at pasta sauce labels, you will see that the majority of them are loaded with "high fructose corn syrup" or just plain old sucrose. Eating these sugar-fortified sauces with high glycemic pastas and bread can create an enormous insulin spike.

Fruit and vegetable juices feature healthy-looking photographs on their labels, but when looking at the calorie content of these sugar concentrates, you should seek to consume the actual fruit or vegetable in lieu of the juice. Even products that purport to have health benefits such as tea beverages are often loaded with sugar.

Food companies have duped Americans into believing that anything that is low in fat is beneficial. Consumers should carefully read food labels to make sure they are not inadvertently loading up on insulin-spiking sugar calories.

When addressing the problem of high-glycemic diets, there are two obstacles to overcome. First is to cut the craving for sugar; the other is to change eating patterns to reduce intake of high-glycemic foods late in the day. The solution is to regulate insulin secretion in such a way that both late-day carbohydrate craving and excessive calorie intake is reduced.

APPENDIX D
  • Gastric Surgery
  • Risks of Surgery
Gastric Surgery

One of the latest developments in treatment of obesity is the use of surgery to restrict food intake or to interrupt normal digestive function. These techniques are usually reserved for the severely obese, with a body mass index over 40, which corresponds to about 100 pounds overweight.

There are two surgical methods for weight loss: gastric banding and gastric bypass. In gastric banding, the amount of food the stomach can hold is reduced by closing off or removing parts of the stomach. A gastric bypass procedure reduces the digestion and absorption of food by connecting the stomach to the lower part of the small intestine, bypassing the duodenum and some of the jejunum.

Restrictive operations lead to weight loss in almost all patients, although some are unable to adjust their eating habits and fail to lose weight. About 30% of persons undergoing vertical banded gastroplasty achieve normal weight and about 80% achieve some degree of weight loss.

Gastric bypass operations are usually combined with restrictive operations to increase the effectiveness. Patients who have bypass operations generally lose two thirds of their excess weight within 2 years.

Risks of Surgery

In 10%-20% percent of patients who have weight-loss surgeries, follow-up surgeries are required to correct complications. Abdominal hernia is the most common complication requiring follow-up surgery. Less common complications include breakdown of the staple line and stretched stomach outlets.

More than one third of obese patients who have gastric surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss, a person's risk of developing gallstones is increased. Gallstones can be prevented with supplemental bile salts taken for the first 6 months after surgery.

Nearly 30% of patients who have weight-loss surgery develop nutritional deficiencies. Decreased absorption of vitamin B12 can cause anemia, and decreased calcium absorption can cause osteoporosis and metabolic bone disease. These deficiencies can be avoided if vitamin and mineral intakes are maintained.

Gastric bypass operations may also cause "dumping syndrome," in which the stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and occasionally diarrhea after eating, as well as the inability to eat sweets without becoming so weak and sweaty that the patient must lie down until the symptoms pass.

APPENDIX E

Different Causes of Obesity

Obesity is most often attributed to increased intake of calories combined with a decreased output of energy. There are other clinical entities that might be the underlying cause or contributory factors of weight gain (Collins 1981; Healey et al. 1994; Bouchier et al. 1997):
  • Hypothyroidism (low thyroid hormone)
  • Adrenal disease, including adrenal insufficiency, Addison's disease (adrenal deficiency), and Cushing's syndrome (adrenal excess)
  • Pancreatic problems, including diabetes, insulin insensitivity (Syndrome X), and insulinoma (insulin stimulates appetite)
  • Pituitary deficiency, including hypopituitarism (Frolich's syndrome), hyperprolactinemia, and Nelson's syndrome
  • Ovarian problems, including polycystic ovary syndrome (excess androgens, especially testosterone) and postmenopause
  • Inflammation caused by chronic infections, including meningitis, encephalitis, tuberculosis, or syphilis
  • Genetic disorders, such as Klinefelter's syndrome, Prader-Willi syndrome, Laurence-Moon-Biedl syndrome, Alstrom syndrome, Morel syndrome, Morgagni syndrome, Morgagni-Stewart-Morel syndrome, Cohen's syndrome, or Carpenter's syndrome
  • Excess fluid retention from cardiac, liver, or renal failure, nephrotic syndrome, periodic edema, or hyperproteinemia states
  • The use of drugs such as glucocorticoids, tricyclic and heterocyclic antidepressants, monoamine oxidase inhibitor antidepressants, lithium, phenothiazides, sulphonylurea agents, estrogens, and cyproheptadine (Bernstein 1987)
  • Cessation of cigarette smoking and alcohol excess (pseudo-Cushing's) are highly associated with weight gain (Yarnell et al. 2000)
A common cause of obesity in women is Polycystic Ovary syndrome (PCOS). Until recently, PCOS was very hard to diagnose and even harder to treat. With modern ultrasound diagnostic technology and the advent of aromatase-inhibiting drugs and metformin (Glucophage), some physicians have achieved a high degree of success in treating this condition.

Overweight subjects also are uniformly deficient in growth hormone and its cleavage fractions including IGF-1. We believe this to be the result of deficient production of growth hormone releasing factor by the hypothalamus, all of which is related to obesity.

APPENDIX F

Basic Dietary Information
  • Calories
  • Basal Metabolic Rate
  • Calculating the Insulin/Glucose Ratio
Calories

A calorie is the amount of heat energy required to raise the temperature of 1 milliliter of water at a standard initial temperature 1 degree centigrade. Large amounts of energy are released during the digesting of food. A capital letter (K) is often used with "calorie" to denote kilocalories (1000 calories). For practical application, the following are the energy content of each of the categories of food:
  • Carbohydrates contain 4 kilocalories per gram
  • Protein contains 4 kilocalories per gram
  • Fat contains 9 kilocalories per gram
  • Alcohol contains 7 kilocalories per gram
Basal Metabolic Rate

When a body is totally at rest, the amount of energy spent carrying out activities necessary to sustain life (such as respiration, circulation, etc.) is called the basal metabolic rate (BMR). When calculated over 24 hours, the average BMR is:
  • 1680 kcal for the average 70-kg (154-pound) man
  • 1173 kcal for the average 58-kg (127.6-pound) woman
The process of digestion greatly impacts the basal metabolic rate because it requires energy. This energy expenditure is called diet-induced thermogenesis. Fats and carbohydrates increase the BMR by about 5%. An all-protein diet increases the metabolic rate by 25%. A mixed or balanced diet increases the BMR by 10%. However, severely restricting calories reduces the basal metabolic rate, thereby causing fatigue (from a decreased level of overall energy) and eventual weight gain. That is why thyroid hormone replacement is so important in many people who are going to restrict their calorie intake in order to lose weight. Adequate thyroid hormone status maintains the basal metabolic rate.

Calculating the Insulin/Glucose Ratio

We cannot stress enough the role of insulin in causing and, even more important, maintaining obesity. As little as one (1) microUnit of insulin in the blood can inhibit release of fat from storage, no matter how little is eaten! We are often asked how to tell if one is hyperinsulinemic. The simplest method to determine if you are hyperinsulinemic is to have your fasting insulin levels tested. This means you cannot eat anything for 12 hours prior to having your blood drawn. Most people have their blood drawn in the morning and achieve the 12-hour fast by skipping breakfast. Optimal fasting insulin levels are between 0-3.

Another way of assessing serum insulin levels is to have blood drawn for serum glucose and serum insulin levels at the same time. When the results are obtained, multiply the glucose number (reported in milligrams percent) by 0.41 and then subtract 34. The resulting number is what your insulin level should be (reported in microUnits).

0.41 < Glucose (mg%) minus 34 = Insulin (microUnits)

Continued . . .


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