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Obesity - an evolving epidemic

by Dr. Henry N. Rajaratnam (consultant physican and Endocrinologist)

Obesity is the deposition of excessive amounts of fat in the body. This deposition depends on the balance between the energy intake, mainly from food, drink and the energy output, usually in the form of physical exercise.

When the intake of calories exceeds the output, the excess calories are deposited as fat. A hereditary and familial tendency for obesity is well-known. The prevalence of obesity is increasing worldwide, including developing countries like Sri Lanka.

Different grades of obesity

Obesity is classified into four grades. Grade 1. Overweight. Grade 2. Mild obesity. Grade 3. Moderately severe obesity. Grade 4. Severe or morbid obesity.

Adverse effects of obesity on the body?

The adverse features of obesity are the severe limitation by the bulk of the individual, making it difficult to get in and out of a car, to shop and even maintain satisfactory hygiene.

Obesity is a chronic disease and needs to be looked after like diabetes or high blood pressure.

It is associated with serious medical conditions like diabetes, hypertension, increased intra cranial pressure, inability to control the passage of urine, on coughing or sneezing (stress incontinence), arthritis of the weight bearing joints, belching and heart burn due to gastro oesophageal reflux, infertility, heart and respiratory failure, episodes of breathing arrest during sleep (sleep apnoea), day time sleepiness and a higher prevalence of cancers of the stomach, breast, colon and prostate.

Many are physically and emotionally abused in the homes school and office. They are often socially isolated and significantly depressed. Finding a marital partner may be difficult.

Lifestyle and behaviour modification

Treatment of obesity includes increasing one's activity by means of exercise and decreasing one's intake by dieting. Low caloric foods instead of high calorie, high sugar, high fat, "fast foods" are recommended.

Usually these measures which are termed "life style modifications" can decrease one's weight when maintained for long periods of time. However the body readjusts its basal energy output downwards to offset the benefit, resulting in a gradual regain in weight. Behaviour modification is also of benefit.

Drugs used in obesity are targeted to either decrease the appetite, decrease absorption of fat from the intestines, facilitate a sense of satisfaction with the meal eaten (early satiety) or increase the energy output by stimulation of the nervous system.

The safety and efficacy of these drugs have not been validated for use over two years and they are not effective in moderately severe and severe obesity. Dietary supplements and nutritional agents are not recommended.

Surgery

Surgery is the only procedure which has been shown to give long term benefit in those with severe obesity. It is also indicated in those with moderately severe obesity who have other complicating diseases such as Asthma, osteoarthritis of the knees, diabetes or heart disease.

The surgery performed is called "Bariatric surgery". It is performed when the response to dieting and exercise is suboptimal. Surgery in fat people has a higher risk than those who are non obese. Surgery involves two aspects.

One aspect is called the "restrictive' method, where the stomach is made smaller so that the person can eat less.

The other is by reducing the absorption of already eaten food, and is achieved by "bypassing" the first part of the intestines, so that only of the food eaten gets into the body. This is called the "malabsorptive" method.

The most effective operation considers both these aspects and a procedure called the "duodenal switch' is a satisfactory one. This involves cutting and removing part of the stomach and bypassing a certain length of intestine.

Contraindications for surgery are

1.Severe medical conditions which increase the risk of surgery such as serious kidney, liver heart or lung disease.

2. Failure to understand the procedure and its consequences.

3. Uncontrolled alcohol or drug abuse.

4. Unresolved depression or other emotional disorder.

5. Refusal to agree for life long follow up.

Relative contraindications are 1. Age below 16 years. 2. Lack of family support.

For children - a laparoscopic procedure (key hole surgery) called "adjustable gastric banding" is available. This only limits the capacity of the stomach to take food, but does not interfere with intestinal flow and function.

Q: Complications of operation

The complications of the operation are like any other abdominal procedure such as wound infection and suture disruption. Special; complications in obese people are vein thrombosis in the legs, clots in the lung and pneumonia due to the immobility.

Complications due to the procedure include deficiencies of minerals and vitamins, low protein levels and hair loss. Excessive skin may be seen as skin folds due to the reduction in weight and may require plastic surgery later. The frequency of stools is usually increased.

Life long supervision by an Endocrinologist, Surgeon, Dietitian and psychologist are required. The patient should be compliant and take all medications prescribed regularly to prevent nutritional deficiencies.

Q: Benefits of the operation?

The benefits of this operation apart from decrease in weight include - full remission of diabetes of adult type, resolution of hypertension, reversal of stress incontinence, relief of gastro oesophageal reflux, asthma, daytime sleepiness and snoring in a large percentage of patients. Sharp improvement in arthritis in weight bearing joints improve mobility remarkably.

Recently a patient weighing 135 Kg underwent gastric bypass surgery at the Nawaloka Hospital. The team consisted of Dr. H. N. Rajaratnam, Physician and Endocrinologist, Dr. M. Ganesharatnam, Surgeon. Dr. S. K. Collure, Surgeon. Dr. (Mrs) K. Balasuriya, Anaesthetist.

The operation consisted of reducing the size of the stomach to reduce the quantity of food taken in (restrictive), and bypassing the upper small intestine by a process called "duodenal switch", which reduces the absorption of food already eaten (mal absorptive).

The operation was successful without any major complications. She had lost 10 Kg of weight about two weeks after surgery. Long term follow up has been arranged. This is the first such Operation done in Sri Lanka.

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shocking WHO disclosure on Measles deaths

"Measles is still a major childhood killer, with over 30 million cases and nearly 900,000 annual deaths in recent years.

These figures are even more shocking given the fact that effective immunisation, which includes vaccine and safe injection equipment, costs just US$ 0.26 and has been available for more than 30 years," said Dr. Bjorn Melghaard, Director of Vaccines and Biologicals, WHO.

Measles accounts for the majority of the estimated 1.6 million annual deaths due to childhood vaccine-preventable diseases. Failure to deliver at least one dose of measles vaccine to all infants remains the primary reason for the high incidence and mortality rates of measles.

The Global Measles Strategic Plan calls on countries to assess progress on measles control, identify reasons for low routine coverage, develop a three to five year plan for measles mortality reduction and fully implement the recommended strategies.

The plan has been developed by UNICEF and WHO in cooperation with the United States Centers for Disease Control and Prevention (CDC), numerous experts worldwide and several other partners. It has the advantage of being a flexible framework that can be adapted to the specific needs and immediate goals of individual countries.

Under the new initiative, WHO and UNICEF will assist affected countries to:

1. Provide a first dose of measles vaccine to all infants.

2. Guarantee a "second opportunity" for vaccination to increase the probability that as many children as possible are immunised and to assure that those immunised are responding to the vaccination.

3. Establish an effective system to monitor coverage and conduct measles surveillance, improve management of complicated measles cases, including vitamin A supplementation.

Near blanket coverage is crucial for containing the disease. "Because measles is so contagious and because a small number of those who are vaccinated do not develop immunity, vaccination coverage levels need to be above 90 per cent to stop measles deaths.

Unfortunately this goal has not yet been achieved in all countries," said Dr. Suomi Sakai, UNICEF's Chief of Immunisation Activities. "But we know we can get there," she added.

Measles, a viral disease, is spread by infected droplets during sneezing and coughing, though direct contact with nasal or throat secretions of infected persons or by touching contaminated objects.

It is predominantly a disease of childhood, causing fever and rash and is sometimes complicated by ear infections, pneumonia, or encephalitis (inflammation of the brain) which can result in convulsions, deafness, mental retardation or death.

In addition to the compelling humanitarian and health reasons, the economic arguments for investing in measles control are convincing. Of all health interventions, measles immunisation carries the highest health return for the money spent, saving more lives per unit than most other health interventions.

In 1999 measles coverage below 50 per centwas reported by 14 countries, most of them in Africa. The list includes Afghanistan, Burkina Faso, Burundi, Cameroon, Congo, Democratic Republic of Congo, Djibouti, Guinea-Bissau, Liberia, Madagascar, Niger, Senegal, Somalia and Togo.

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No legitimate research to prove coconut oil is bad - Dr. D. P. Atukorale

I refer to the question on coconut oil appearing in 'Health' page Daily News of 19.12.2003 where Chandra Piyadasa of Nugegoda.

I am one of the cardiologists who had been maintaining that coconut oil is good for heart patients and those with hypercholesterolaemia, in spite of the fact that, coconut oil has a high concentration of saturated fat.

It is common knowledge that all saturated fats are not the same. There are 'good' saturated fats such as coconut oil which contain medium chain fatty acids (MCFA) and 'bad' saturated fats such as those present in animal products which contain long chain saturated fatty acids (LCFA).

The MCFA in coconut oil and palm oil are not converted into cholesterol in the liver, but are utilised for energy (as in the case of carbohydrates) by the liver.

Good saturated fats containing MCFA present as in coconut, promote better health whereas 'bad' saturated fats such as those present in meat, containing LCFA are converted by your liver into LDL (bad) cholesterol.

It is true

It is true that coconut oil is primarily a saturated fat. What many people don't realise is that there are many different types of saturated fats and all of them affect the body differently.

The degree of saturation and the length of the carbon chain in the fatty acid determine their chemical properties and their effect on our health.

Healthy benefits of coconut oil

Coconut oil has emerged as the premier oil of all times providing health benefits that far surpass those of all other so-called healthy vegetable oils such as olive oil, corn oil, gingelly oil, soya oil, sunflower oil etc.

The type of saturated oil in coconut (which is a plant source) is different from LCFA found in animal products which cause elevation of your LDL (bad) cholesterol. The difference between MCFA (in coconut oil) and LCFA (in animal fats) is dramatic and is fully documented by years of scientific research.

Different effect on the body

As mentioned previously coconut oil (containing MCFA) have a different effect on our body and are broken down and are used immediately for energy production and this almost never ends up as body fat or as deposits in arteries or anywhere else. They provide energy and not fat, unlike LCFA (both saturated and unsaturated) found abundantly in meat and polyunsaturated oils.

No proof

All the criticism that has been aimed at coconut oil is based primarily on the fact that it is a saturated fat and as medical students (in 1958) we were taught by our teachers that all saturated fats increased blood cholesterol. No legitimate research in man however has ever demonstrated, any proof, that consumption of dietary coconut oil ever causes blood cholesterol elevation in man.

Neutral effect

Numerous studies have clearly demonstrated that coconut oil has a neutral effect on cholesterol levels in humans ie coconut oil neither relegates nor decreases the cholesterol level. (Hegsted et al, Am. J. of Clin. Nutrition, 17, 281; Baba. N. 1982, Am. J of Clin Nutrition 35, 678; Greenberger N.J. and Skillman TG, 1962, New Eng J. Med. 280, 1045-58).

The use of MCFA (those found in coconut oil and palm oil) has been found to result in significantly, lower levels of liver cholesterol in man (Kaunitz et al 1959, J. Am. Oil Chem. Soc. 36, 322-325).

Even the ratio of HDL (good) cholesterol to LDL (bad) cholesterol is not change of (Sindi Rani et al, 1993, Ind. Coco. g XXIV (7) 2; Kurup and Rajmohan 1995, proceedings of symposium on coconut and coconut oil in Human Nutrition, 27 March, Coconut Development Board, Kochi, India 1995, p. 35).

Stimulatory effect on metabolism

While coconut oil's direct effect on blood cholesterol in man is neutral, it may indirectly lower LDL cholesterol and increases HDL cholesterol. This is because, coconut oil has a stimulatory effect on our metabolism.

One of the factors that increases cholesterol, is low metabolism and because coconut oil stimulates metabolism it actually protects against high blood cholesterol.

Dietary coconut oil and heart disease

A review of epidemiological and experimental data shows that dietary coconut oil does not lead to coronary artery disease (Kaumitz and Dayrit 1992 Philippine g. of Intl. Medicine 30, 165) when native people change their diet and give up coconut oil in favour of polyunsaturated vegetable oil, their risk of heart disease has been shown to increase (Mendis S. and Kumarasundaram R, 1990, British J. of Nutrition 63, 547; Kurup and Rajmohan 1995, symposium on coconut and coconut oil in Human Nutrition, 27 March, Coconut Development Board, Kochi, India page 35.

Dr. Prior et al showed that island people who eat very high amounts of saturated fat from coconut oil showed no signs of heart disease. But when they migrated to New Zealand and began eating less coconut but more polyunsaturated fats, the incidence of heart disease increased (prior 1.A et al, 1981, Am. g. of Clin Nutrition, 34, 1552).

No evidence

There is no evidence as far as I am aware to support the notion that coconut oil is harmful. Indeed there is strong evidence to show that coconut oil prevents heart disease (Enig. M.G., 1999, 36th session Asia-Pacific Coconut Community).

There is no evidence to support the hypothesis that coconut oil is harmful (Enig MG 1993, Coronary Heart Disease: The dietary sense and Nonsense, Janus Publishers, London, p. 36).

Clotting of blood

Special portion in blood platelets cause clotting of blood when the platelets become sticky. Numerous studies have demonstrated that beef fat, lard, unsaturated vegetable oils including olive oil promote platelet stickiness. Omega 3 fatty acids present in fish oil and fruits and vegetables, are an exception.

Too much of fish oil is bad as it can cause cerebral haemorrhage. Another group of fats that don't promote platelet stickiness is M.C.F.A. (in coconut oil and palm oil) of all the dietary fats. MCFA are the most benign.

In Western countries where vegetable oils are the main source of fat, heart diseases accounts for nearly half of all deaths.

It seems that if you want to protect yourself from heart disease, you should replace polyunsaturated vegetable oils (which contain dangerous trans-fatty acids) with coconut oil.

Coconut oil has been called the healthiest dietary oil on earth. If you are not using coconut oil for your daily cooking and body care needs, you are missing out on one of nature's most amazing health products.

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Recipe for longevity

All mankind and animals wish to live long. But in Sri Lanka when we step out of our homes life is at stake due to environmental pollution and accidents that are taking place daily. The Japanese hold the world record for longevity. They cherish a heritage of fitness and have a traditional trust in herbal diet, and preventive infusion like Green Tea.

Green Tea is long associated with good health and has new scientific evidence to back its claim. Furdue Researcher Dorothy Moore and D. James Moore found that EGCg a compound of Green Teas inhibit an enzyme required for Cancer cell growth and can kill cultured cancered cells with no ill effect on healthy cells.

The Green Tea leaves are rich in this anti cancer compound, although all teas come from the same Botanical source. Green tea differs from Black tea because the way tea leaves are processed after they are plucked.

For Black tea freshly picked leaves are withered indoors and allowed to oxidise, whereas Green tea leaves are not oxidised but are steamed and parched to better preserve the natural active substances of the leaf.

It is very sad that Sri Lanka being the largest producer of Black tea has not advertised the value of Green tea than going in for soft sweetened drinks.

We should be more careful in preparing green vegetable leaves for 'mellums' for our daily diet and not to expose the fire directly to the Green leaves, to get the maximum benefit from it. Spices like pepper, garlic too should be added to the curries.

Exercise is very important for every one, such as walking, gardening etc. till one sweats. Start the day with a glass of water and drink at least six glasses of water a day. Avoid allergic food. Reduce salt and sugar to the maximum.

Smoking is completely prohibited. Little Red wine may be beneficial to be taken only at functions. (Singing strengthens the immune system according to research by scientists at University of Frankfurt in Germany).

Checking of Cholesterol ie. Lipid Profile, Blood Sugar and Blood pressure is very important. Go on a picnic once in a way to avoid stress and strain.

Laughter is the best medicine for relaxation. Last but not the least practice your Religion and meditate daily at least for ten minutes in the morning and evening.

DR. D. N. NILLEGODA, Kadugannawa.

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