Should Live Operative workshops be banned?

Should Live Operative workshops be banned?.

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Should Live Operative workshops be banned?

Live Operating workshops as a mode for training of surgeons has recently been in for a lot of criticism and debate as to whether they should be banned or not. The main reason cited has been rare deaths occurring after surgery being performed in a live workshop for demonstration and training. These raises several issues related to patient safety, patient rights, surgeons training, industry involvement and surgical grandiose.
The protagonists of live operative workshops claim that it is one of the important modes of surgical training for surgeons who wish to learn new procedures or new technologies from the masters of the field. In our country, there are few options for training in newer technologies such as laparoscopy as animal right activists have almost banned training on live animals under anaesthesia, which is fairly justified. Other forms of training include didactic lectures, video training, practice on models or simulators. There is no doubt that live surgical workshops ignite the most enthusiasm amongst the surgeons and are attended the most out of all forms of training. Still, this does not justify the conduct of live operative workshops in its present form. Live operative workshops also provide surgeons an opportunity to see how some of the complications can be managed by experts during a live surgery, which generally are never shown on video training modules.
The antagonists of live operative workshops are equally vehement and believe it is unfair for patients to undergo surgery as a demonstration case. It is true that surgeons operate in an unfamiliar environment with an unfamiliar team, which can produce a less than optimal outcome especially in a difficult and a complicated case. This is especially true for a foreign surgeon operating in India. They believe that most live workshops are more of advertising and marketing gimmicks for private hospitals. Though this is not completely true, the motive behind many a workshops is for projection of private hospitals or even departments and individuals. Most of the patients seeking treatment in live operative workshops are poor patients, who otherwise would not afford a regular treatment. Most of these patients are neither aware of their rights, nor would be capable of raising their voice in times of disaster. This raises several ethical questions in the conduct of these workshops.
The current technology of high speed broadband can actually allow live surgeries to be transmitted from the expert surgeon’s centres anywhere in the world, which would take away the many disadvantages of live operative workshops such as patient factors and unfamiliarity of the environment. This would actually be an excellent way of demonstrating live operative procedures and in the future would be one of the best ways to proceed for live surgical workshops. The only challenge is to manage time zones and plan the slots accordingly.
Actually, having organised many live operative workshops and having participated as a faculty to perform live surgeries in a few of them, I believe that live workshops do some good to some of the patients who would otherwise would not have been able to afford high technology surgery using expensive consumables, being performed by the masters. This would definitely not be an argument to carry out live workshops but is an important factor in our country, as most of the patients in live workshops have either free or highly subsidized treatment. Many individual patients have benefited from live workshops.
This would bring the patient rights into focus. All patients undergoing live surgeries in workshops should be counselled thoroughly about the surgery being performed by another surgeon and the postoperative care being taken by the host surgical team. This can create medico-legal issues if thorough counselling and adequate consenting has not been done.
Coming back to the question, whether live operative workshops should be banned? I would say that live operative workshops have benefited many surgeons for training and many patients with their diseases. It is also true that live operative workshops have been banned by a few associations in developed countries. In India, there are very few training opportunities for surgeons to learn newer procedures, newer skills and get exposed to newer technologies. There are only barely available structured and simulator based training centres for surgeons in India. Thus, in my opinion, live operative workshops should not be banned, but should be properly regulated and restricted. I would suggest following 10 steps to be taken by the MCI to regulate live operative workshops:
1. Any live operative workshop should be registered online on the website of MCI, atleast one week prior to the workshop.
2. All the operating faculties must be having a valid MCI registeration, and their certificates should be uploaded on the website. The programme of the workshop should also be uploaded on the website atleast 24 hours prior to the workshop.
3. Any high risk patient ie. ASA grade 3 or 4 or supramajor surgeries having an expected perioperative mortality of more than 1% should not be performed in a live workshop, but should be beamed live on the broadband from the host centre.
4. All patients undergoing surgery in live workshop should be counselled and adequate consent taken.
5. All patients selected for live workshop should be screened through a committee comprising five persons – one host surgeon, one independent expert surgeon, one host anesthetist, one independent expert anesthetist and one physician with 10 years experience.
6. Outcomes of all patients undergoing live surgeries in workshops should also be uploaded on the MCI website, 1 week after the surgery and one month after the workshop.
7. An audit for any complications occurring on any patients in live workshops should be performed by the screening committee and results to be uploaded on the website.
8. Live operative workshops showcase the best surgeons to perform complex tasks. A novice surgeon cannot duplicate these tasks just by watching these master surgeons. The best a live workshop does is to motivate or inspire a surgeon to learn new techniques. It does not actually allow a surgeon to perform such complex tasks without adequate in house training and experience. All live operative workshops can carry such a tagline on its brochure. “Live workshop is a demonstration by experts, and should not be considered a replacement for in-service training of surgeons. Procedures seen here should not be duplicated without adequate training and experience.”
9. All Live workshops should be preceded by a session on selection of patients, indications, contraindications and should be followed by a discussion on complications and outcomes.
10. During difficult steps of the surgery ie during control of a bleed, the operating surgeon should be left alone with muting of the microphone so that he can focus on the problem rather than on the discussion.
With a regulatory framework in place, live operative workshops can actually inspire many surgeons to acquire newer surgical skills and update their skills. This can even benefit many patients who would otherwise not have an opportunity to get a surgery from a master in the field at a highly subsidized rates. The jury is not out yet and the debate would continue……..

Dyspepsia, Irritable Bowel Syndrome (IBS)

What is dyspepsia?

Dyspepsia means indigestion which manifests itself as bloating, abdominal distension or fullness especially after meals, which can also lead to decrease in appetite. This affects a large number of people around the world.

What are the causes of dyspepsia?

This is a very common problem encountered in today’s world, due to sedentary lifestyle and unhealthy eating habits. Unhealthy eating habits include eating large volumes of food at a quick pace without adequately chewing the food, unable to reduce volume of food as age advances, eating fatty, spicy and oily food, eating a lot of fried and sweet food and beverages. Sedentary habits include absence of regular exercises, too much dependence on vehicles and machines for routine use i.e. excessive use of lifts for climbing 1-3 storeys, absence of sporting activities, laziness by nature to walk or perform household activities.

What are the symptoms of dyspepsia?

Symptoms of dyspepsia mainly include upper abdominal bloating or gassy feeling which sometimes can escalate to dull pain and stretching pain in the abdomen. Frequently this is associated with excessive passage of gas as burps, or excessive flatulence or uncommonly as hiccoughs.  Some patients also experience nausea and have to induce vomiting rarely. Dyspepsia may be a manifestation of underlying acid peptic disorder such as gastritis, pylori infection, GERD or even peptic ulcer. Such patients would need to have an upper GI Endoscopy test to rule out organic disorder of this form. Dyspepsia can rarely be due to gallstones or inflammatory bowel diseases (IBD). Once all these disorders are ruled out, such dyspepsia can be labelled as functional dyspepsia.

How can dyspepsia be treated?

Dyspepsia is best treated by altering lifestyle and dietary habits in the long term. Immediate relief can be obtained by antiflatulent agents or prokinetic agents which increase the gastric motility. This agents are available in chewable form which can give instant relief. People are encouraged to walk which also helps in expelling excess gas. Herbal medicines in form of pudinhara may also give some relief.

How can functional dyspepsia be prevented?

The best way to prevent dyspepsia is to change dietary and lifestyle habits. People are encouraged to take consume small meals in divided proportions rather than large meals. They should cut down on excess oil, ghee and butter in their diet. Some people develop such symptoms after consuming sprouts and beans are advised to avoid them or restrict their usage. Excessive spicy food, restaurant food as well as fatty food is best avoided by such people. They are encouraged to pursue an active lifestyle with regular periods of exercise for long term prevention. Overweight persons are advised to loose weight.

What is Irritable Bowel Syndrome (IBS)?

Irritable bowel syndrome (IBS)is a functional disorder of the intestine and is a symptom-based diagnosis. It is characterized by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits. Diarrhoea or constipationmay predominate, or they may alternate (classified as IBS-D, IBS-C, or IBS-A, respectively)

What are the cause of IBS?

As a functional gastrointestinal disorder, IBS has no known organic cause. The most common theory is that IBS is a disorder of the interaction between the brain and thegastrointestinal tract.For at least some individuals, abnormalities in the gut bacterial flora occur, and it has been theorised that these abnormalities result in inflammation and altered bowel function. The stress response in the body involves thesympathetic nervous system, which has been shown to operate abnormally in IBS patients.

How is IBS classified?

IBS can be classified as either diarrhoea-predominant (IBS-D), constipation-predominant (IBS-C), or with alternating stool pattern (IBS-A) or pain-predominant.

How can we make a diagnosis of IBS?

The primary symptoms of IBS are abdominal pain or discomfort in association with frequent diarrhoea or constipation and a change in bowel habits. There may also be urgency for bowel movements, a feeling of incomplete evacuation (tenesmus), bloating, or abdominal. In some cases, the symptoms are relieved by bowel movements.  Up to 60% of people with IBS also have a psychological disorder, typically anxiety or depression.

The Rome III criteria for the diagnosis of irritable bowel syndrome require that patients have had recurrent abdominal pain or discomfort at least 3 days per month during the previous 3 months that is associated with 2 or more of the following:

  1. Relieved by defecation
  2. Onset associated with a change in stool frequency
  3. Onset associated with a change in stool form or appearance

No specific laboratory or imaging test can be performed to diagnose irritable bowel syndrome. Diagnosis involves excluding conditions that produce IBS-like symptoms, and then following a procedure to categorize the patient’s symptoms. Ruling out parasitic infections, lactose intolerance, small intestinal bacterial overgrowth (SIBO), celiac disease and inflammatory bowel disease (IBD) is recommended for all patients before a diagnosis of irritable bowel syndrome is made.

How is IBS treated?

Although no cure for IBS is known, treatments to relieve symptoms exist. These include dietary adjustments, medication, and psychological interventions. Patient education and good doctor–patient relationships are also important.Dietary measures that have been found to be effective include increasing soluble fiber intake. IBS has no direct effect on life expectancy. It is, however, a source of chronic pain, fatigue, and other symptoms, and contributes to work absenteeism.It is common and its effects on quality of life make it a disease with a high social cost.Psychiatric disorders such as anxiety and major depression are common in IBS.

Diet – A diet restricted in fermentable oligo – di and monosaccharides and polyols (FODMAPs) now has an evidence base sufficiently strong to recommend its widespread application in conditions such as IBS andIBD.70% of people benefit from low FODMAP diet for managing IBS when other dietary and lifestyle measures have been unsuccessful. This diet restricts various carbohydrates as well as fructose andlactose, which are poorly absorbed in the small intestine. No evidence indicates digestion of food or absorption of nutrients is problematic for those with IBS at rates different from those without IBS. However, the very act of eating or drinking can provoke an overreaction of the gastrocolic response in some patients with IBS owing to their increased visceral sensitivity, and this may lead to abdominal pain, diarrhoea and/or constipation.

Fiber – Some evidence suggests soluble fiber supplementation (e.g. psyllium/isapgula husk) is effective. It acts as a bulking agent, and for many IBS-D patients, allows for a more consistent stool. For IBS-C patients, it seems to allow for a softer, moister, more easily passable stool.

Laxatives – For patients who do not adequately respond to dietary fiber, osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose can help avoid “cathartic colon” which has been associated with stimulant laxatives.

Medicationsmay consist of:

  • Stool softeners andlaxativesin IBS-C and anti-diarrhoeals (e.g., opiateor opioid analogs such as loperamide, codeine, diphenoxylate) in IBS-D.
  • Serotonin stimulates the gut motility and so agonists can help constipation-predominate irritable bowel, while antagonists can help diarrhoea-predominant irritable bowel.
  • Selective serotonin reuptake inhibitors, SSRIs, frequently prescribed for panic and/or anxiety disorder and depression, affect serotonin in the gut, as well as the brain.
  • Antispasmodicdrugs (e.g., anticholinergicssuch as hyoscyamine or dicyclomine) may help patients, especially those with cramps or diarrhoea.
  • PPIs used to suppress stomach acid production may cause bacterial overgrowth leading to IBS symptoms. Discontinuation of PPIs in selected individuals has been recommended as it may lead to an improvement or resolution of IBS symptoms.
  • Strong evidence indicates low doses oftricyclic antidepressants can be effective for IBS.
  • Rifaximin can be used as an effective treatment for abdominal bloating and flatulence,giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.
  • Domperidone, a dopamine receptor blocker and a parasympathomimetic, has been shown to reduce bloating and abdominal pain as a result of an accelerated colon transit time.
  • Psychological treatment strategies such as cognitive behavioural therapy [CBT], hypnotherapy and/or psychological therapy.Reducing stressmay reduce the frequency and severity of IBS symptoms. Techniques that may be helpful include relaxation techniques such as meditation, Yoga, Pranayama and regular exercise such as swimming, walking, or running.
  • Probiotics – may exert their beneficial effects on IBS symptoms via preserving the gut microbial flora, improving the intestinal transit time, and by treatingsmall intestinal bacterial overgrowth of fermenting bacteria.

Occupational Hazards: “Better Prevented than Cured”

What are Occupational or Professional hazards?

An occupational or a professional hazard is something unpleasant that one may suffer or experience as a result of doing one’s job or profession that can lead to illness or death.

Why are Occupational hazards important?

Occupational or Professional hazards are important, as they are much more common than we think. One estimate suggests that they happen in 80% of people in their working lifetime. Further, these hazards significantly limit the ability of the person to carry out one’s own job and profession due to chronic or acute health problem. This significantly diminishes the productivity not only as an individual, but collectively can hamper the economic growth of a developing country such as India, where a majority of the population is young and is employed or working.

How are Occupational hazards caused?

Occupational or Professional hazards either present in an acute dramatic form such as an accident or an occupational disaster or assumes a more common, but chronic form due to repeated stresses and strains due to particular posture assumed secondary to the requirement of the profession. People are often unaware of these risks, till they develop such problems. Common problems seen today are back pain or neck pains due to cervical or lumbar disc prolapse due to incorrect posture secondary to sedentary work habits combined with lifestyle disorders such as sedentary life, overweight and obesity.

In this article, my focus shall be on the more chronic variety of occupational hazards, for which awareness is the key. The good news is that with small changes in the lifestyle and working habits, these problems can be kept under control. Many of these problems are self-limiting, and over a period of time, with postural modifications, regular exercise and lifestyle changes, these can be managed well. Unfortunately, it so happens that awareness for these problems comes only after we suffer from these problems. My own awareness for such issues happened after I suffered from these hazards myself. Unfortunately, during our professional education, we are never formally taught about these professional hazards and ways and means to avoid them and treat them. Thus I would like to share the two issues I have gone through and managed. Being a surgeon and involved in long surgeries and looking down in open surgeries, for many hours together, for many years now, I developed cervical disc prolapse with pain twice till now. Till I endured it, I never realised these root pains could be so severe and so limiting. Fortunately, with modifications in lifestyle, these could be controlled and the pain vanished in 6 months in the first instance and 9 months in the second. Lifestyle changes required use of regular neck exercises, awareness of posture, short interruptions in the prolonged stressful postures and use of local analgesic gels and occasional sos oral analgesics. Fortunately with the current application of laparoscopic surgery where we look straight at the monitor during the surgery, the neck is not strained. One should always consult a specialist, but one should realise that the solution is no quick fix, but prolonged and persistent changes in lifestyle and regular exercises.

Another issue that I developed, which I found quite common in others as well, was heel pain due to Plantar fasciitis. This is due to prolonged standing especially when we use energy device foot switches, weight of the body is more on one foot, which predisposed to plantar fasciitis. Some modifications in posture including use of sitting posture in some surgeries where possible and with the use of silicon insoles and soft footwear, these health issues could be controlled. Commonly, I see many IT professional and farmers with sedentary lifestyle having many professional hazards due to sedentary lifestyle and prolonged stressful posture. Common problems are back pain, neck pain, indigestion, bloating, constipation and acid reflux. Overweight and Obesity surmount these musculoskeletal pains and disability, and invite more diseases such as hypertension, diabetis, osteoarthritis, sleep apnoea, cardiovascular disease etc.

Which are the Occupations having maximum hazards?

Specific occupational safety and health risk factors vary depending on the specific sector and industry. Construction workers might be particularly at risk of falls, for instance, whereas fishermen might be particularly at risk of drowning. The United States Bureau of Labour Statistics identifies the fishing, aviation, metalworking, agriculture, mining and transportation industries as among some of the more dangerous for workers. Similarly psychosocial risks such as workplace violence are more pronounced for certain occupational groups such as health care employees, police, correctional officers and teachers.

Construction

Construction is one of the most dangerous occupations in the world, incurring more occupational fatalities than any other sector. Falls are one of the most common causes of fatal and non-fatal injuries among construction workers.

Agriculture

Agriculture workers are often at risk of work-related injuries, lung disease, noise-induced hearing loss, skin disease, as well as certain cancers related to chemical use or prolonged sun exposure. On industrialized farms, injuries frequently involve the use of agricultural machinery. Pesticides and other chemicals used in farming can also be hazardous to worker health, and workers exposed to pesticides may experience illnesses or birth defects. Common causes of fatal injuries among young farm worker include drowning, machinery and motor vehicle-related accidents.

Service sector

As the number of service sector jobs has risen in developed countries, more and more jobs have become sedentary, presenting a different array of health problems than those associated with manufacturing and the primary sector. Contemporary problems such as the growing rate of obesity and issues relating to occupational stress, workplace bullying, and overwork in many countries have further complicated the interaction between work and health. Psychosocial workplace exposures were relatively common in this sector.

Mining and oil & gas extraction

Workers employed in mining and oil & gas extraction industries have high prevalence rates of exposure to potentially harmful work organization characteristics and hazardous chemicals.

Healthcare

Healthcare workers are exposed to many hazards that can adversely affect their health and well-being. Long hours, changing shifts, physically demanding tasks, violence, and exposures to infectious diseases and harmful chemicals are examples of hazards that put these workers at risk for illness and injury. Medico legal hazards are real for health care workers, and musculoskeletal hazards due to prolonged stressful postures are on the rise.

Which are the common Workplace hazards?

Although work provides many economic and other benefits, a wide array of workplace hazards also present risks to the health and safety of people at work. These include but are not limited to, “chemicals, biological agents, physical factors, adverse ergonomic conditions, allergens, a complex network of safety risks,” and a broad range of psychosocial risk factors.

Physical and mechanical hazards

Physical hazards are a common source of injuries in many industries. They are perhaps unavoidable in certain industries, such as construction and mining, but over time people have developed safety methods and procedures to manage the risks of physical danger in the workplace. Employment of children may pose special problems. Falls are a common cause of occupational injuries and fatalities, especially in construction, extraction, transportation, healthcare, and building cleaning and maintenance. Machines are commonplace in many industries, including manufacturing, mining, construction and agriculture, and can be dangerous to workers. Many machines involve moving parts, sharp edges, hot surfaces and other hazards with the potential to crush, burn, cut, shear, stab or otherwise strike or wound workers if used unsafely. Various safety measures exist to minimize these hazards, including lockout-tagout procedures for machine maintenance and roll over protection systems for vehicles. The transportation sector bears many risks for the health of commercial drivers, too, for example from vibration, long periods of sitting, work stress and exhaustion. Working in “Confined space” as having limited openings for entry and exit having unfavourable natural ventilation, and which is not intended for continuous employee occupancy. Spaces of this kind can include storage tanks, ship compartments, sewers, and pipelines. Confined spaces can pose a hazard not just to workers, but also to people who try to rescue them. Noise is not the only source of occupational hearing loss; exposure to chemicals such as aromatic solvents and metals including lead, arsenic, and mercury can also cause hearing loss Temperature extremes can also pose a danger to workers. Heat stress can cause heat stroke, exhaustion, cramps, and rashes. Heat can also fog up safety glasses or cause sweaty palms or dizziness, all of which increase the risk of other injuries. Workers near hot surfaces or steam also are at risk for burns. Dehydration may also result from overexposure to heat. Cold stress also poses a danger to many workers. Overexposure to cold conditions or extreme cold can lead to hypothermia, frostbite and trench foot. Electricity poses a danger to many workers. Electrical injuries can be divided into four types: fatal electrocution, electric shock, burns, and falls caused by contact with electric energy. Vibrating machinery, lighting, and air pressure (high or low) can also cause work-related illness and injury. Asphyxiation is another potential work hazard in certain situations. Musculoskeletal disorders are avoided by the employment of good ergonomic design and the reduction of repeated strenuous movements or lifts. Ionizing (alpha, beta, gamma, X, neutron), and non-ionizing radiation (microwave, intense IR, RF, UV, laser at visible and non-visible wavelengths), can also be a potent hazard.

Biological hazards

Many healthcare and Pharmaceutical workers are particularly exposed to the biological hazards. Use of biological warfare also increases the risk of defence personnel to these hazards. These hazards may include diseases from Bacteria, Virus, Fungi, blood-borne pathogens, Tuberculosis and others.

Chemical hazards

Certain industries are more prone to chemical hazards from heavy metals, solvents, petroleum, fumes (noxious gases/vapours), highly-reactive chemicals, Fire, conflagration and explosion hazards.

Psychosocial hazards

Employers in most countries have an obligation not only to protect the physical health of their employees but also the psychological health. Therefore as part of a risk management framework psychological or psychosocial hazards (risk factors) need to be identified and controlled for in the workplace. Psychosocial hazards are related to the way work is designed, organised and managed, as well as the economic and social contexts of work and are associated with psychiatric, psychological and/or physical injury or illness. Linked to psychosocial risks are issues such as occupational stress and workplace violence which are recognized internationally as major challenges to occupational health and safety.

How can we prevent these Occupational hazards?

Professionals advise on a broad range of occupational health matters. These include how to avoid particular pre-existing conditions causing a problem in the occupation, correct posture for the work, frequency of rest breaks, preventative action that can be undertaken, and so forth. According to Joint WHO Committee on Occupational Health, “The main focus in occupational health is on three different objectives:

(i) Maintenance and promotion of workers’ health and working capacity;

(ii) Improvement of working environment and work to become conducive to safety and health and

(iii) Development of work organizations and working cultures in a direction which supports health and safety at work and in doing so also promotes a positive social climate and smooth operation.

In essence, Professional and Occupational hazards are extremely common. An increased awareness is required for the particular profession as to their risk of hazards. Minor modification in Lifestyle goes a long way in preventing these debilitating conditions affecting the professional work in the active workforce of our country. It is more than true for these hazards, “Prevention is a thousand times better than Cure.”

Lifestyle changes can prevent atleast 60% of all Cancers

Are Cancers genetic (hereditary) or environmental in origin?

After sequencing his own genome, pioneer genomic researcher Craig Venter remarked, “Human biology is actually far more complicated than we imagine. Genes are absolutely not our fate. They can give us useful information about the increased risk of a disease, but in most cases they will not determine the actual cause of the disease, or the actual incidence of somebody getting it. Most biology will come from the complex interaction of all the proteins and cells working with environmental factors, not driven directly by the genetic code.”

The fact is, only 5–10% of all cancer cases can be attributed to genetic defects, whereas the remaining 90–95% have their roots in the environment and lifestyle (Fig. 1). The lifestyle factors include tobacco intake, cigarette smoking, diet (fried foods, red meat), alcohol, environmental pollutants, infections, stress, obesity, and physical inactivity and sun exposure. The evidence indicates that of all cancer-related deaths, almost 25–30% are due to tobacco, as many as 30–35% are linked to diet, about 15–20% are due to infections, and the remaining percentage are due to other factors like radiation, stress, physical activity, environmental pollutants etc. Therefore, cancer prevention requires tobacco abstinence, increased ingestion of fruits and vegetables, limited use of alcohol, caloric restriction, exercise, avoidance of direct exposure to sunlight, minimal meat consumption, use of whole grains, use of vaccinations, and regular health check-ups.

Cancer is caused by both internal factors (such as inherited mutations, hormones, and immune conditions) and environmental/acquired factors (such as tobacco, diet, radiation, and infectious organisms.

The role of genes and environment in the development of cancerFig. 1. The role of genes and environment in the development of cancer.The contribution of genetic factors and environmental factors towards cancer risk is 5–10% and 90–95% respectively

Diet

The link between diet and cancer is revealed by the large variation in rates of specific cancers in various countries and by the observed changes in the incidence of cancer in migrating population. For example, Asians have been shown to have a 25 times lower incidence of prostate cancer and a ten times lower incidence of breast cancer than do residents of Western countries, and the rates for these cancers increase substantially after Asians migrate to the West. http://www.dietandcancerreport.org

Most of the cancers have some relationships with diet predominant among them are cancers of the upper aero digestive tract (mouth, throat), oesophagus (food pipe and lungs), stomach, large intestine, and breast cancer in women (Fig. 2).

The role of diet takes special importance in countries like India which are fast moving towards industrialization and westernization. We had a predominantly plant based diet and with the advent of western life style we are moving towards a diet rich in animal proteins. This coupled with other habits like smoking and alcohol will lead to increase in the chronic disease burden especially cancer and cardiovascular diseases. Prompt action has to be taken to spread the message of healthy life style and dietary practices.

The biologically active ingredients of the fruits and vegetables are from the carotenoid family and they have substantial anti-cancer properties. Intervention Studies have tried to get the advantage of eating vegetables through supplementation of beta carotene, the most active ingredient.

Cancer deaths (%) linked to dietFig. 2. Cancer deaths (%) linked to diet.

Heavy consumption of red meat is a risk factor for several cancers, especially for those of the gastrointestinal tract, but also for colorectal, prostate, bladder, breast, gastric, pancreatic, and oral cancers. Long-term exposure to food additives such as nitrite preservatives and azo dyes has been associated with the induction of carcinogenesis. Furthermore, bisphenol from plastic food containers can migrate into food and may increase the risk of breast and prostate cancers. Ingestion of arsenic may increase the risk of bladder, kidney, liver, and lung cancers. Saturated fatty acids, transfatty acids, and refined sugars and flour present in most foods have also been associated with various cancers

Tobacco

Among males, 50% of cancers in the mouth, throat and lungs are caused by Tobacco and alcohol habits. Among women, tobacco related cancers are 15%.

Tobacco use increases the risk of developing at least 14 types of cancer (Fig. 3). In addition, it accounts for about 25–30% of all deaths from cancer and 87% of deaths from lung cancer. Compared with nonsmokers, male smokers are 23 times and female smokers 17 times more likely to develop lung cancer. Tobacco contains at least 50 carcinogens. For example, one tobacco metabolite, benzopyrenediol epoxide, has a direct etiologic association with lung cancer. Curcumin, derived from the dietary spice turmeric, can block the NF-κB (inflammatory pathway) induced by cigarette smoke. In addition to curcumin, several natural phytochemicals also inhibit the NF-κB induced by various carcinogens. Thus, the carcinogenic effects of tobacco appear to be reduced by these dietary agents.

Alcohol

Chronic alcohol consumption is a risk factor for cancers of the upper aerodigestive tract, including cancers of the oral cavity, pharynx, hypopharynx, larynx, and esophagus, as well as for cancers of the liver, pancreas, mouth, and breast (Fig. 3).  In addition to it being a risk factor for breast cancer, heavy intake of alcohol (more than 50–70 g/day) is a well-established risk factor for liver and colorectal cancers. Ethanol is not a carcinogen but is a co-carcinogen. Specifically, when ethanol is metabolized, acetaldehyde and free radicals are generated; free radicals are believed to be predominantly responsible for alcohol-associated carcinogenesis through their binding to DNA and proteins, which destroys folate and results in secondary hyperproliferation.

Cancers that have been linked to alcohol and smoking

Fig. 3. Cancers that have been linked to alcohol and smoking. Percentages represent the cancer mortality attributable to alcohol and smoking in men and women

Obesity

Obesity has been associated with increased mortality from cancers of the colon, breast (in postmenopausal women), endometrium, kidneys (renal cell), esophagus (adenocarcinoma), gastric cardia, pancreas, prostate, gallbladder, and liver (Fig. 4). Of all deaths from cancer in the United States, 14% in men and 20% in women are attributable to excess weight or obesity. Increased modernization and a Westernized diet and lifestyle have been associated with an increased prevalence of overweight people in many developing countries. Studies have shown that the common denominators between obesity and cancer include neurochemicals; hormones such as insulinlike growth factor 1 (IGF-1), insulin, leptin; sex steroids; adiposity; insulin resistance; and inflammation.

Various cancers that have been linked to obesity

Fig. 4. Various cancers that have been linked to obesity.

Infections

Worldwide, an estimated 17.8% of neoplasms are associated with infections; this percentage ranges from less than 10% in high-income countries to 25% in African countries. Viruses account for most infection-caused cancers (Fig. 5). Human papillomavirus, Epstein Barr virus, Kaposi’s sarcoma-associated herpes virus, human T-lymphotropic virus 1, HIV, HBV, and HCV are associated with risks for cervical cancer, anogenital cancer, skin cancer, nasopharyngeal cancer, Burkitt’s lymphoma, Hodgkin’s lymphoma, Kaposi’s sarcoma, adult T-cell leukemia, B-cell lymphoma, and liver cancer.  Infection-related inflammation is the major risk factor for cancer, and almost all viruses linked to cancer have been shown to activate the inflammatory marker, NF-κB. Similarly, components of Helicobacter pylori have been shown to activate NF-κB. Thus, agents that can block chronic inflammation should be effective in treating these conditions.

Various cancers that have been linked to infection

Fig. 5. Various cancers that have been linked to infection.

Environmental pollution

Environmental pollution has been linked to various cancers (Fig. 6). It includes outdoor air pollution by carbon particles associated with polycyclic aromatic hydrocarbons (PAHs); indoor air pollution by environmental tobacco smoke, formaldehyde, and volatile organic compounds such as benzene and 1,3-butadiene (which may particularly affect children); food pollution by food additives and by carcinogenic contaminants such as nitrates, pesticides, dioxins, and other organochlorines; carcinogenic metals and metalloids; pharmaceutical medicines; and cosmetics.

New Picture (5)

Fig. 6. Various cancers that have been linked to environmental carcinogens. The carcinogens linked to each cancer is shown inside bracket.

Radiation

Up to 10% of total cancer cases may be induced by radiation, both ionizing and nonionizing, typically from radioactive substances and ultraviolet (UV), pulsed electromagnetic fields. Cancers induced by radiation include some types of leukemia, lymphoma, thyroid cancers, skin cancers, sarcomas, lung and breast carcinomas. Another source of radiation exposure is x-rays used in medical settings for diagnostic or therapeutic purposes. In fact, the risk of breast cancer from x-rays is highest among girls exposed to chest irradiation at puberty, a time of intense breast development. Nonionizing radiation derived primarily from sunlight includes UV rays, which are carcinogenic to humans. Exposure to UV radiation is a major risk for various types of skin cancers including basal cell carcinoma, squamous cell carcinoma, and melanoma.  A recent meta-analysis of all available epidemiologic data showed that daily prolonged use of mobile phones for 10 years or more showed a consistent pattern of an increased risk of brain tumors. (D. Belpomme, et al. The multitude and diversity of environmental carcinogens. Environ. Res.2007;105:414–429)

Which are the Cancers most affected by lifestyle changes?

Cancer of the head and neck

The main risk factor for these cancers is tobacco and alcohol. A diet rich in green and yellow vegetables has been shown to offer protection against oral cancer. Avoidance of tobacco and alcohol is the most important preventive action against mouth, throat and lung cancers.

Cancer of the Oesophagus

Cancer of the Oesophagus is a serious disease caused mainly by tobacco intake, smoking and consuming very hot and spicy food items over prolonged periods.

Cancer of the stomach

Japanese had the highest rate of stomach cancer of the world and the rates in Japanese migrants have dropped to very low levels as that of Americans when they migrated to the United States. This is clear evidence of the dietary pattern and risk of stomach cancer. The advent of refrigeration has dramatically reduced stomach cancer incidents as it has revolutionized food preservation. Consumption of large amounts of red chillies, food at very high temperatures and alcohol consumption are the main risk factors for stomach cancer in South India.

Cancer of the large intestine

Low Fiber diet as in western diet is directly linked to Colon Cancer. A high fibre diet typically consumed in Asian diet is one of the important factors for low risk of Colon cancer in the Asians. Heavy consumption of red meat can lead to risk of colon cancer. White meat such as that of poultry do not have this risk. There is an international correlation in between the occurrence of large bowel cancer and consumption of red meat.In South India there is a trend towards increasing consumption of red meat and this can lead to increased risk for large bowel cancer.

Cancer of the breast in women

A large number of factors are identified as risk factors for breast cancer. Late age at first pregnancy greater than 30 years, single child, late age at menopause etc are some of them. A high fat diet is also identified as a risk factor. Physical activity is found to be protective for breast cancer. The sudden changes towards affluent life styles have reduced the physical activities to a minimum and increased the consumption of diets rich in fat. High fat diets during the pubertal age and obesity in the post menopausal age are risk factors for breast cancer.

Regular breast self-examination by women themselves is a very good way of detecting breast cancer in early stages. Detecting a cancer when it is in the very early stage can improve the cure rate from breast cancer. Mammography (X-rays of the breast) is another way of detecting breast cancer that cannot be palpated by hand.

Cancer of the uterine cervix

Early age at first intercourse, multiple sexual partners, poor sexual hygiene, repeated child birth etc. are some of the reproductive risk factors for cervical cancer. Improvements in the living standards of women has resulted in a reduction in the incidents of cervical cancer. Regular cervical cytology examination (pap smear) by all women who have initiated sexual activity can prevent the occurrence of cervical cancer. This has been successfully achieved in many European countries.

How can we prevent lifestyle related cancers?

Lifestyle changes can prevent atleast 60% of all Cancers

“Many people believe cancer is down to fate or ‘in the genes’ and that it is the luck of the draw whether they get it,” study author Professor Max Parkin, a Cancer Research UK epidemiologist based at Queen Mary, Universityof London, said in a written statement. “Looking at all the evidence, it’s clear that around 60 percent of all cancers are caused by things we mostly have the power to change.”

These observations indicate that most cancers are not of hereditary origin and that lifestyle factors, such as dietary habits, smoking, alcohol consumption, and infections, have a profound influence on their development. Although the hereditary factors cannot be modified, the lifestyle and environmental factors are potentially modifiable. The lesser hereditary influence of cancer and the modifiable nature of the environmental factors point to the preventability of cancer. The important lifestyle factors that affect the incidence and mortality of cancer include tobacco, alcohol, diet, obesity, infectious agents, environmental pollutants, and radiation.

In the upper aerodigestive tract, 25–68% of cancers are attributable to alcohol, and up to 80% of these tumors can be prevented by abstaining from alcohol and smoking.

Prevention of cancer

The fact that only 5–10% of all cancer cases are due to genetic defects and that the remaining 90–95% are due to environment and lifestyle provides major opportunities for preventing cancer. Because tobacco, diet, infection, obesity, and other factors contribute approximately 25–30%, 30–35%, 15–20%, 10–20%, and 10–15%, respectively, to the incidence of all cancer deaths in the USA, it is clear how we can prevent cancer. Almost 90% of patients diagnosed with lung cancer are cigarette smokers; and cigarette smoking combined with alcohol intake can synergistically contribute to tumour genesis. Similarly, smokeless tobacco is responsible for 400,000 cases (4% of all cancers) of oral cancer worldwide. Thus avoidance of tobacco products and minimization of alcohol consumption would likely have a major effect on cancer incidence.

Infection by various bacteria and viruses (Fig. 5) is another very prominent cause of various cancers. Vaccines for cervical cancer and HCC should help prevent some of these cancers, and a cleaner environment and modified lifestyle behaviour would be even more helpful in preventing infection-caused cancers.

Diet, obesity, and metabolic syndrome are very much linked to various cancers and may account for as much as 30–35% of cancer deaths, indicating that a reasonably good fraction of cancer deaths can be prevented by modifying the diet. Extensive research has revealed that a diet consisting of fruits, vegetables, spices, and grains has the potential to prevent cancer (Fig. 7). The specific substances in these dietary foods that are responsible for preventing cancer and the mechanisms by which they achieve this have also been examined extensively. Various phytochemicals have been identified in fruits, vegetables, spices, and grains that exhibit chemo preventive potential, and numerous studies have shown that a proper diet can help protect against cancer.

Fruits, vegetables, spices, condiments and cereals with potential to prevent cancer

Fig. 7. Fruits, vegetables, spices, condiments and cereals with potential to prevent cancer

Fruits include:

1 apple, 2 apricot, 3 banana, 4 blackberry, 5cherry, 6 citrus fruits, 7 dessert date, 8 durian, 9 grapes, 10 guava, 11 Indiangooseberry, 12 mango, 13 malayapple, 14 mangosteen, 15 pineapple, 16 pomegranate.

Vegetables include:

1 artichok, 2 avocado, 3 brussels sprout, 4 broccoli, 5 cabbage, 6 cauliflower, 7 carrot, 8 daikon, 9 kohlrabi, 10 onion, 11 Tomato, 12 turnip, 13 ulluco, 14 water cress, 15 okra, 16 potato, 17 fiddle head, 18 radicchio, 19 komatsuna, 20 salt bush, 21 winter squash, 22 zucchini, 23 lettuce, 24 spinach.

Spices and condiments include:

1 turmeric, 2 cardamom, 3 coriander, 4 black pepper, 5 clove, 6 fennel, 7 rosemary, 8 sesame seed, 9 mustard, 10 licorice, 11 garlic, 12 ginger, 13 parsley, 14 cinnamon, 15 curry leaves, 16 kalonji, 17 fenugreek, 18 camphor, 19 pecan, 20 star anise, 21 flax seed, 22 black mustard, 23 pistachio,24 walnut, 25 peanut, 26 cashew nut.

Cereals include:

1 rice, 2 wheat, 3  oats, 4 rye, 5 barley, 6  maize, 7  jowar, 8 pearl millet, 9 proso millet, 10 foxtail millet, 11 little millet, 12 barnyard millet, 13 kidney bean, 14 soybean, 15 mung bean, 16 black bean, 17 pigeon pea, 18 green pea, 19 scarlet runner bean, 20 black beluga, 21 brown spanishpardina, 22 green, 23 green (eston), 24 ivory white, 25 multicolored blend, 26 petite crimson, 27 petite golden, 28 red chief.

Fruits and Vegetables

The protective role of fruits and vegetables against cancers that occur in various anatomical sites is now well supported. 75–80% of cancer cases diagnosed in the USA in 1981 might have been prevented by lifestyle changes. According to a 1997 estimate, approximately 30–40% of cancer cases worldwide were preventable by feasible dietary means (www.dietandcancerreport.org). More than 25,000 different phytochemicals have been identified that may have potential against various cancers. These phytochemicals have advantages because they are safe and usually target multiple cell-signalling pathways. Major cancer preventive compounds identified from fruits and vegetables includes carotenoids, vitamins, resveratrol, quercetin, silymarin, sulphoraphane and indole-3-carbinol.

Carotenoids – Various natural carotenoids present in fruits and vegetables were reported to have anti-inflammatory and anti-carcinogenic activity. Lycopene is one of the main carotenoids in the regional Mediterranean diet and can account for 50% of the carotenoids in human serum. Lycopene is present in fruits, including watermelon, apricots, pink guava, grapefruit, rosehip, and tomatoes. A wide variety of processed tomato-based products account for more than 85% of dietary lycopene. The anticancer activity of lycopene has been demonstrated in tumor models as well as in humans.  Other carotenoids reported to have anticancer activity include beta-carotene, alpha-carotene, lutein, zeaxanthin, beta-cryptoxanthin, fucoxanthin, astaxanthin, capsanthin, crocetin, and phytoene.

Resveratrol has been found in fruits such as grapes, peanuts, and berries. Resveratrol exhibits anticancer properties against a wide variety of tumours, including lymphoid and myeloid cancers, multiple myeloma, and cancers of the breast, prostate, stomach, colon, and pancreas.

Teas and Spices

Spices are used all over the world to add flavour, taste, and nutritional value to food. A growing body of research has demonstrated that phytochemicals such as catechins (green tea), curcumin (turmeric), diallyldisulfide (garlic), thymoquinone (black cumin) capsaicin (red chili), gingerol (ginger), anethole (licorice), diosgenin (fenugreek) and eugenol (clove, cinnamon) possess therapeutic and preventive potential against cancers of various anatomical origins. Other phytochemicals with this potential include ellagic acid (clove), ferulic acid (fennel, mustard, sesame), apigenin (coriander, parsley), betulinic acid (rosemary), kaempferol (clove, fenugreek), sesamin (sesame), piperine (pepper), limonene (rosemary), and gambogic acid (kokum).

Catechins

More than 3,000 studies have shown that catechins derived from green and black teas have potential against various cancers.

Curcumin is one of the most extensively studied compounds isolated from dietary sources for inhibition of inflammation and cancer chemoprevention, as indicated by almost 3000 published studies. Diallyldisulfide, isolated from garlic, inhibits the growth and proliferation of a number of cancer cell lines including colon, breast, glioblastoma, melanoma, and neuroblastoma cell lines. Gingerol, a phenolic substance mainly present in the spice ginger (Zingiberofficinale Roscoe), has diverse pharmacologic effects including antioxidant, antiapoptotic, and anti-inflammatory effects. Gingerol has been shown to have anticancer and chemopreventive properties. Diosgenin, a steroidal saponin present in fenugreek, has been shown to suppress inflammation, inhibit proliferation, and induce apoptosis in various tumor cells. Eugenol is one of the active components of cloves. Studies conducted by Ghosh et al. showed that eugenol suppressed the proliferation of melanoma cells.

Wholegrain Foods

The major wholegrain foods are wheat, rice, and maize; the minor ones are barley, sorghum, millet, rye, and oats. Grains form the dietary staple for most cultures, but most are eaten as refined-grain products in Westernized countries. Whole grains contain chemopreventive antioxidants such as vitamin E, tocotrienols, phenolic acids, lignans, and phytic acid. The antioxidant content of whole grains is less than that of some berries but is greater than that of common fruits or vegetables. The refining process concentrates the carbohydrate and reduces the amount of other macronutrients, vitamins, and minerals because the outer layers are removed. In fact, all nutrients with potential preventive actions against cancer are reduced. For example, vitamin E is reduced by as much as 92%.

Wholegrain intake was found to reduce the risk of several cancers including those of the oral cavity, pharynx, esophagus, gallbladder, larynx, bowel, colorectum, upper digestive tract, breasts, liver, endometrium, ovaries, prostate gland, bladder, kidneys, and thyroid gland, as well as lymphomas, leukemias, and myeloma. Intake of wholegrain foods in these studies reduced the risk of cancers by 30–70%. How do whole grains reduce the risk of cancer? Several potential mechanisms have been described. For instance, insoluble fibers, a major constituent of whole grains, can reduce the risk of bowel cancer. Additionally, insoluble fiber undergoes fermentation, thus producing short-chain fatty acids such as butyrate, which is an important suppressor of tumor formation. Whole grains also mediate favourable glucose response, which is protective against breast and colon cancers. Also, several phytochemicals from grains and pulses were reported to have chemopreventive action against a wide variety of cancers.

Observational studies have suggested that a diet rich in soy isoflavones (such as the typical Asian diet) is one of the most significant contributing factors for the lower observed incidence and mortality of prostate cancers in Asia.

Vitamins

Although controversial, the role of vitamins in cancer chemoprevention is being evaluated increasingly. Fruits and vegetables are the primary dietary sources of vitamins except for vitamin D. Vitamins, especially vitamins C, D, and E, are reported to have cancer preventive activity without apparent toxicity.

Exercise/Physical Activity

There is extensive evidence suggesting that regular physical exercise may reduce the incidence of various cancers. A sedentary lifestyle has been associated with most chronic illnesses. Physical inactivity has been linked with increased risk of cancer of the breast, colon, prostate, and pancreas and of melanoma. The increased risk of breast cancer among sedentary women that has been shown to be due to lack of exercise has been associated with a higher serum concentration of estradiol, lower concentration of hormone-binding globulin, larger fat masses, and higher serum insulin levels. Physical inactivity can also increase the risk of colon cancer, most likely because of an increase in GI transit time, thereby increasing the duration of contact with potential carcinogens.

Caloric Restrictions

Dietary restriction, especially CR, is a major modifier in experimental carcinogenesis and is known to significantly decrease the incidence of neoplasms.

Conclusions

A unifying hypothesis is proposed, that all lifestyle factors that cause cancer (carcinogenic agents) and all agents that prevent cancer (chemopreventive agents) are linked through chronic inflammation (Fig.8). The fact that chronic inflammation is closely linked to the tumorigenic pathway is evident from numerous lines of evidence. In summary, this review outlines the preventability of cancer based on the major risk factors for cancer. The percentage of cancer-related deaths attributable to diet and tobacco is as high as 60–70% worldwide.

Carcinogens activate and chemopreventive agents suppress NF-κB activation, a major mediator of inflammation.

Fig. 8. Carcinogens activate and chemopreventive agents suppress NF-κB activation, a major mediator of inflammation.

Are Lifestyle related cancers Curable?

When Lifestyle related cancers are diagnosed at an early stage (Stage 1 & 2), they are eminently curable. However, unfortunately, majority of the cancers are diagnosed at an advanced stage (Stage 3 & 4), and are curable in only a few patients.

How can we  diagnose Lifestyle related Cancers early?

Lifestyle relates cancers can be diagnosed early by regular health checkups in high risk individual. Regular self breast examination, mammography and regular pap smear can diagnose breast and cervical cancers early. In tobacco addicts and smokers, regular examination can identify early cancers. UGI and Colon cancers can be diagnosed early by regular endoscopic assessment in high risk individuals and biopsies to confirm.

Reference:
  1. Cancer is a Preventable Disease that Requires Major Lifestyle Changes. Preetha Anand, Ajaikumar B. Kunnumakara, Chitra Sundaram, Kuzhuvelil B.Harikumar, Sheeja T. Tharakan, Oiki S. Lai, Bokyung Sung, and Bharat B. Aggarwal. Pharm Res. 2008 Sep; 25(9): 2097–2116., Published online 2008 Jul 15. PMCID: PMC2515569

Overweight and Obesity : Proven Health Risks, we all should know…

What is Obesity?

Overweight and obesity are defined as abnormal or excessive fat accumulation in the body that presents a risk to health. Obesity will have a negative effect on health, leading to reduced life expectancy and/or increased health problems. According to WHO, Obesity is one of the most serious public health problems of the 21st century.

Obesity isn’t just a cosmetic concern. It increases risk of diseases and health problems such as heart disease, diabetes and high blood pressure.In 2013, the American Medical Association classified obesity as a disease.

Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat, and/or body water. Both terms mean that a person’s weight is greater than what’s considered healthy for his or her height.

Obesity occurs over time when one eats more calories than use. The balance between calories-in and calories-out differs for each person. Factors that might affect our weight include our genetic makeup, overeating, eating high-fat foods, and not being physically active.

Is Obesity a new disease of the new world?

Hippocrates wrote that “Corpulence is not only a disease itself, but the harbinger of others”. As early as 6th century BC, the pioneer Indian surgeon Sushruta related obesity to diabetes and heart disorders. He recommended physical work to help cure it and its side effects. Thus Obesity is prevalent since the ancient times, but has reached epidemic proportions globally in the 21st century.

What are the causes for Obesity?

Obesity is most commonly caused by a combination of excessive food energy intake, lack of physical activity, and genetic susceptibility, although a few cases are caused primarily by genes, endocrine disorders, medications, or psychiatric illness. In contrast, increasing rates of obesity at a societal level are felt to be due to an easily accessible and palatable diet, increased reliance on vehicles, and mechanized manufacturing.

Diet and Obesity

From 1971 to 2000, obesity rates in the United States increased from 14.5% to 30.9%. During the same period, an increase occurred in the average amount of food energy consumed. For women, the average increase was 335 calories per day, while for men the average increase was 168 calories per day. Most of this extra food energy came from an increase in carbohydrate consumption rather than fat consumption. The primary sources of these extra carbohydrates are sweetened beverages, which now account for almost 25 percent of daily food energy in young adults in America. Consumption of sweetened drinks such as soft drinks, fruit drinks, iced tea, and energy and vitamin water drinks is believed to be contributing to the rising rates of obesity and to an increased risk of metabolic syndrome and type 2 diabetes.

Sedentary Lifestyle and Obesity

A sedentary lifestyle plays a significant role in obesity. Worldwide there has been a large shift towards less physically demanding work, and currently at least 30% of the world’s population gets insufficient exercise. This is primarily due to increasing use of mechanized transportation such as cars and two wheelers, and a greater prevalence of home help or labour saving technology in the home, such as TV, computers, remotes, cell phones etc. In children, there appears to be decline in levels of physical activity due to less walking and outdoor games. In both children and adults, there is an association between television viewing time and the risk of obesity.

Genes and Obesity

A faulty gene, called FTO, makes 1 in every 6 people overeat, a team of scientists from University College London reported in the Journal of Clinical Investigation (July 2013 issue).

Like many other medical conditions, obesity is the result of an interplay between genetic and environmental factors. People with two copies of the FTO gene (fat mass and obesity associated gene) have been found on average to weigh 3–4 kg more and have a 1.67-fold greater risk of obesity compared with those without the risk allele.

Other illnesses

Medical illnesses that increase obesity risk include several rare genetic syndromes as well as some congenital or acquired conditions: hypothyroidism, Cushing’s syndrome, growth hormone deficiency, and the eating disorders: binge eating disorder and night eating syndrome.

Medications

Certain medications may cause weight gain or changes in body composition; these include insulin, sulfonylureas, thiazolidinediones, atypical antipsychotics, anti-depressants, steroids, certain anticonvulsants (phenytoin and valproate), pizotifen, and some forms of hormonal contraception.

Social Class

Among developed countries, levels of adult obesity, and percentage of teenage children who are overweight, are correlated with income inequality.  In undeveloped countries the ability to afford food, high energy expenditure with physical labour, and cultural values favouring a larger body size are believed to contribute to the observed patterns. In the developing world urbanization is playing a role in increasing rate of obesity.

How is Obesity measured?

BMI is usually expressed in kilograms per square metre, resulting when weight is measured in kilograms and height in metres.

BMI (kg/m2) Classification
from up to
  18.5 Underweight
18.5 25.0 Normal weight
25.0 30.0 Overweight
30.0 35.0 Class I obesity
35.0 40.0 Class II obesity
40.0    Class III obesity  
  • BMI ≥ 35 kg/m2is severe obesity.
  • BMI of ≥ 35 kg/m2and experiencing obesity-related health conditions or ≥40–44.9 kg/m2 is morbid obesity.
  • BMI of ≥ 45 or 50 kg/m2is super obesity.

 Pathophysiology

Many hormones and mediators have recently been identified which regulate hunger and satiety, and play an important role in people becoming overweight or obese and in weight loss surgery. Since leptin’s discovery, ghrelin, insulin, orexin, PYY 3-36, cholecystokinin, adiponectin, as well as many other mediators have been studied. The adipokines are mediators produced by adipose tissue; their action is thought to modify many obesity-related diseases.

Leptin and ghrelin are considered to be complementary in their influence on appetite, with ghrelin (hunger hormone) produced by the stomach, modulating short-term appetitive control (i.e. to eat when the stomach is empty and to stop when the stomach is stretched). Leptin is produced by adipose tissue to signal fat storage reserves in the body, and mediates long-term appetitive controls (i.e. to eat more when fat storages are low and less when fat storages are high).

What are the hazards of Obesity?

Obese people are more likely to develop a number of potentially serious health problems, including:

  • High triglycerides and low high-density lipoprotein (HDL) cholesterol – The primary dyslipidemia related to obesity is characterized by increased triglycerides, decreased HDL levels, and abnormal LDL composition.
  • Type 2 diabetes – One of the strongest risk factors for type 2 diabetes is obesity, and this is also one of the most modifiable as it can be partially controlled through diet and exercise.
  • High blood pressure – There are multiple reasons why obesity causes hypertension, but it seems that excess fat tissue secretes substances that are acted on by the kidneys, resulting in hypertension.
  • Metabolic syndrome — a combination of high blood sugar, high blood pressure, high triglycerides and low HDL cholesterol.
  • Heart disease – Obesity carries a penalty of an associated adverse cardiovascular risk profile. Largely as a consequence of this, it is associated with an excess occurrence of cardiovascular disease morbidity and mortality.
  • Stroke – Rising obesity rates have been linked to more strokes among women aged 35 to 54.
  • Cancers, including cancer of the uterus, cervix, endometrium, ovaries, breast, colon, rectum, esophagus, liver, gallbladder, pancreas, kidney and prostate – In 2002, approximately 41,000 new cases of cancer in the USA were thought to be due to obesity. In other words, about 3.2% of all new cancers are linked to obesity
  • Breathing disorders, including sleep apnea, a potentially serious sleep disorder in which breathing repeatedly stops and starts – Obesity has been found to be linked to sleep apnea. Also, weight reduction has been associated with comparable reductions in the severity of sleep apnea.
  • Gastro-oesophageal reflux disease (GERD) and Hiatus Hernia – Patients with obesity commonly have severe heartburn and regurgitation of food due to reflux disease and hiatus hernia
  • Gallbladder disease – Being overweight is a significant risk factor for gallstones. In such cases, the liver over-produces cholesterol, which is then delivered into the bile causing it to become supersaturated.
  • Liver diseases, including Fatty Liver, NASH (Nonalcoholic steatohepatitis) and Liver Cirrhosis
  • Gynecologic problems, such as infertility, PCOD(Polycystic ovarian disease) and irregular periods
  • Erectile dysfunction and sexual health issues.
  • Osteoarthritis – Obesity is an important risk factor for osteoarthritis in most joints, especially at the knee joint (the most important site for osteoarthritis). Obesity confers a nine times increased risk in knee joint osteoarthritis in women. Osteoarthritis risk is also linked to obesity for other joints. Data suggest that metabolic and mechanical factors mediate the effects of obesity on joints.
  • Skin conditions, including poor wound healing, and increased skin infections.

Quality of life

Obese people enjoy an overall lower quality of life. They may not be able to do things they normally enjoy as easily as they’d like, such as participating in enjoyable activities. They may avoid public places. Obese people may even encounter discrimination.

Social issues

Other weight-related issues that may affect quality of life include depression, disability, sexual problems, shame and guilt, social isolation and lower work achievement. Obesity can lead to social stigmatization and disadvantages in employment.

Obesity and Life expectancy

Obesity is one of the leading preventable causes of death worldwide. A BMI above 32 kg/m2 has been associated with a doubled mortality rate among women over a 16-year period. On average, obesity reduces life expectancy by six to seven years, a BMI of 30–35 kg/m2 reduces life expectancy by two to four years, while severe obesity (BMI > 40 kg/m2) reduces life expectancy by ten years. Insurance companies realized the connection between weight and life expectancy and increased premiums for the obese.

Medical management

Obesity treatments have two objectives:

  1. To achieve a healthy weight.
  2. To maintain that healthy weight.

The good news is that even modest weight loss can improve or prevent the health problems associated with obesity.

Counselling for behavioural modification

Intensive behavioural counselling is recommended in those who are both obese and have other risk factors for heart disease. An active lifestyle and plenty of exercise, along with healthy eating, is the safest way to lose weight. Even modest weight loss can improve health. There is a need for a lot of support from family and friends.

Many people find it hard to change their eating habits and behaviours. You may have practiced some habits for so long that you may not even know they are unhealthy, or you do them without thinking. You need to be motivated to make lifestyle changes. Make the behaviour change part of your life over the long term. Know that it takes time to make and keep a change in your lifestyle.

The main treatment for obesity consists of dieting and physical exercise.

Diet

Diet programs may produce weight loss over the short term, but maintaining this weight loss is frequently difficult and often requires making exercise and a lower food energy diet a permanent part of a person’s lifestyle. All types of low-carbohydrate and low-fat diets appear equally beneficial. The heart disease and diabetes risks associated with different diets also appear to be similar. Success rates of long-term weight loss maintenance with lifestyle changes are low, ranging from 2–20%. When dieting, the main goal should be to learn new, healthy ways of eating and make them a part of the daily routine.

Work with your health care provider and dietician to set realistic, safe daily calorie counts that help you lose weight while staying healthy. Remember that if you drop weight slowly and steadily, you are more likely to keep them off. Your dietician can teach you about healthy food choices, healthy snacks, reading nutrition labels, new ways to prepare food, portion sizes and sweetened drinks.

Extreme diets (fewer than 1,100 calories per day) are not thought to be safe or to work very well. These types of diets often do not contain enough vitamins and minerals. Most people who lose weight this way return to overeating and become obese again.

Learn ways to manage stress, rather than snacking. Examples may be meditation, yoga, or exercise. If you are depressed or stressed a lot, talk to your health care provider.

WHO Diet Recommendations to combat obesity :

  • achieve energy balance and a healthy weight
  • limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids
  • increase consumption of fruits and vegetables, and legumes, whole grains and nuts
  • limit the intake of free sugars
  • limit salt (sodium) consumption from all sources and ensure that salt is iodized

 Physical activity

The more you move your body the more calories you burn. To lose a kilogram of fat you need to burn 8,000 calories (1 pound of fat = 3,500 calories). Walking briskly is a good way to start increasing your physical activity if you are obese. Combining increased physical activity with a good diet will significantly increase your chances of losing weight successfully and permanently!

Try to find activities which you can fit into your daily routine. Anything that becomes part of our daily life, weaved into our existing lifestyle, is more likely to become a long-term habit. If you use an elevator, try getting off one or two floors before your destination and walking the rest. One could try the same when driving your car or taking any form of public transport – get off earlier and walk that bit more. If any of your regular shops are within walking distance, try leaving the car at home.

Medications

Two medications, Orlistat and Sibutramine are currently available in India, and have evidence for long term use. Orlistat interferes with fat absorption, whereas Sibutramine is an appetite suppressant. Weight loss with Orlistat and Sibutramine is modest, an average of 2.9 kg at 1 to 4 years. Its use is associated with high rates of gastrointestinal side effects such as diarrhoeas and concerns have been raised about negative effects on the kidneys. Sibutramine is known to get difficulties with getting pregnant in young females. Overall, these medications are not very effective, need to be taken for lifetime and have significant side effects. Thus they should be used for selected patients under medical supervision.

Weight loss Surgery

Weight loss surgery (WLS) is also known as Bariatric Surgery. It comes from the Greek work baros, which means weight.

The most effective treatment for obesity is bariatric surgery. Surgery for severe obesity is associated with long-term weight loss, improvement in obesity related conditions, and decreased overall mortality.

There are two types of bariatric surgeries:

  • Restrictive procedures –These make the stomach smaller. The surgeon may use a gastric band or staples known as gastric sleeve operation, which is currently an effective and popular operation in selected people. After the operation, the hunger comes down significantly due to reduction of the hunger hormone (Ghrelin), and the patient cannot consume more than about one cup of food during each sitting, significantly reducing his/her food intake. Over time, some patients’ stomach may stretch and they are gradually able to consumer larger quantities. 
  • Malabsorptive procedures –Parts of the digestive system, especially the first part of the small intestine (duodenum) or the mid-section (jejunum), are bypassed, called the laparoscopic gastric bypass surgery, which also reduce the size of the stomach. This procedure is generally more effective than restrictive procedures. However, the patient has a higher risk of experiencing vitamin/mineral deficiencies because overall absorption is reduced, and thus need lifelong supplementation of Iron, Vitamin B12 and Calcium.

Bariatric (weight-loss) surgery can significantly reduce the risk of certain diseases in people with severe obesity. These risks include Arthritis, Diabetes, Heart disease, High blood pressure, Sleep apnea, Some cancers and Stroke.

Surgery alone is not the answer for weight loss. It can train a person to eat less, but they still have to do much of the work. They must be committed to diet and exercise after surgery to achieve a long term remission of weight.

Endoscopic options

Endoscopic options such as balloon placement and other newer options are under evaluation. Endoscopic balloon currently can be retained for 6 months and is associated with modest weight loss in the range of 5 – 10 kg over 6 months. This may be useful in elderly patients who are at a high risk for surgery, in selected young patients, and in patients who are going for bariatric surgery, to reduce their risks for surgery.

Childhood Obesity

Obesity in children and adolescents is defined as a BMI greater than the 95th percentile. Childhood obesity is one of the most serious public health challenges of the 21st century, as it has reached epidemic proportions in the 21st century, with rising rates in both the developed and developing world. Changing diet and decreasing physical activity are believed to be the two most important causes for the recent increase in the incidence of child obesity. Because childhood obesity often persists into adulthood and is associated with numerous chronic illnesses, children who are obese are often tested for hypertension, diabetes, hyperlipidemia, and fatty liver. Treatments used in children are primarily lifestyle interventions and behavioural techniques, although efforts to increase activity in children have had little success.