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