No Disclosures

No Disclosures Secretary, Association of Surgeons of India, Delhi International Advisor, Society of Laparoscopic Surgeons, USA Associate Editor, Indian Journal of Surgery Vice President, International Society of Colo-Proctology Chairman (Delhi), International Medical Sciences Academy

Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration

Obesity : A 21st Century Problem Brij B Agarwal MS (Gold medalist), FIMSA, FCLS, Dip in Yoga (Gold medalist)

Vice Chairman Professor & Senior Consultant Department of Laparoscopic & General Surgery GRIPMER & Sir Ganga Ram Hospital, Hindustaan (India)

Secretary, Association of Surgeons of India, Delhi International Advisor, Society of Laparoscopic Surgeons, USA Associate Editor, Indian Journal of Surgery Vice President, International Society of Colo-Proctology Chairman (Delhi), International Medical Sciences Academy


Obesity •

WHO has described obesity as the greatest current threat to human health

•

Its rising prevalence is a major burden in terms of morbidity and mortality

•

It impacts HrQoL & life expectancy of patients

•

It leads to tremendous socio-economic burden

•

The complications of obesity and comorbidities, such as hypertension, coronary heart disease, type 2 diabetes mellitus (T2DM), hyperlipidemia, osteoarthrosis, and an increase in cancer risk, are placing growing demand on healthcare resources.

•

A CONSUMERIST LIFE STYLE IS POSING A HUGE RISK TO CIVILIZATION Kopelman PG (2000) Obesity as a medical problem. Nature 404 (6778):635–643 Flegal KM et al (2005) Excess deaths associated with underweight, overweight, and obesity. JAMA 293(15):1861–1867.


The Cambridge Project for Existential Risk • Scientists have identified extinction-level risks to our species •

They come from developments in biotechnology (AI), artificial life, nanotechnology, and worst of them all from extreme effects of anthropogenic climate change


http://cser.org/

http://www.millennium-project.org/millennium/publications.html Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration


Poverty and Obesity Relationship Based on General Trends • Based on a large national study, BMI, an indicator of excess body fat was higher every year between 1986 and 2002 among adults in the lowest income group and the lowest education group, than among those in the highest income and education groups, respectively (Truong & Sturm, 2005) • Wages were inversely related to BMI and obesity in a nationally representative sample of more than 6,000 adults – (Kim & Leigh, 2010) Home Health Care Management Practice. 2007 Dec;20:141-49 Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration

Obesity and Poverty: Are Food Stamps to Blame? • 66% of adults in the United States are overweight, and 32% of Americans are obese • In the United States, the paradoxical relationship between poverty and

overweight exists •

The authors concluded that a diet that consists of more processed, highcalorie foods is significantly more agreeable with a Food Stamp

Programme budget than a diet that meets USFDA recommendations


Home Health Care Management Practice. 2007 Dec;20:141-49

Obesity •

WHO has described obesity as the greatest current threat to human health

•

Its rising prevalence is a major burden in terms of morbidity and mortality

•

It impacts HrQoL & life expectancy of patients

•

It leads to tremendous socio-economic burden

•

The complications of obesity and comorbidities, such as hypertension, coronary heart disease, type 2 diabetes mellitus (T2DM), hyperlipidemia, osteoarthrosis, and an increase in cancer risk, are placing growing demand on healthcare resources

Kopelman PG (2000) Obesity as a medical problem. Nature 404 (6778):635–643 Flegal KM et al (2005) Excess deaths associated with underweight, overweight, and obesity. JAMA 293(15):1861–1867.


The Evolution of the Concept • Since the 1950s, it was believed that obesity is a result of a net positive energy balance Energy expenditure

Energy intake

• “We get fat because we overeat” • However efforts to cure obesity, by eating less or exercising more, have been remarkably ineffective BMJ 2013;346:f1050 doi: 10.1136/bmj.f1050 (Published 17 April 2013) Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration

Calories or carbohydrates? • Increased calories blamed for obesity. • Which calories are to be blamed? Total calories or carbohydrate calories? • Do people get fat because they are eating more, or, do people eat more because the calorie composition of their diet is

promotes fat accumulation, driving an increase in appetite?

BMJ 2013;346:f1050 doi: 10.1136/bmj.f1050 (Published 17 April 2013)


Flaw in the concept • We tend to blame the ignorance of the obese patient and the general public for this failure • However,

there

is

possibility

that

our

fundamental

understanding of the etiology is indeed, incorrect



Energy balance hypothesis?? • Proposed by 2 physicians:- German diabetologist Carl Von Noorden and in early 1900s American researcher Louis Newburg • During the times of World War II, German & Austrian scientists proposed

that obesity is a disorder of hormonal dysbalance • Rejected worldwide after the anti-German sentiment post World War II • Newberg (University of Michigan) said “All obese persons are alike in one

aspect – they literally overeat” • He blamed “perverted” appetite, overindulgence & human ignorance for obesity



Circular Logic – Leads us nowhere Why do we get fat ? Because we’re getting fatter

Because we overeat

How do we know we’re overeating?

• This tells us nothing about the cause of obesity • “Positive energy balance would be a “result”, rather than a “cause” of obesity Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration


Endocrinological Hypothesis • Some “intrinsic abnormality” was at the root of the disorder • 2 distinct hypothesis:– One was the brainchild of Wilhelm Falta, student of Card Von Nordeen. He noted that a “functionally intact pancreas was necessary for fattening” – Held insulin as the culprit for obesity



Lipophilia – Gustave von Bergmann’s (German scientist) theory

– Lipophilia – love of fat – People who are constitutionally predisposed to fatten had adipose tissue that was more lipophilic than that of constitutionally lean individuals



Anarchy • Bauer explained “Like a malignant tumor, pregnant uterus, pregnant breasts or a live fetus, lipophilic tissue seizes on foodstuffs, even in case of under nutrition” • “Anarchy of adipose tissue over the other tissues.”



Circadian Rhythm of Metabolism “It doesn’t mean a thing if it ain’t got that swing.” -Edward Kennedy “Duke” Ellingtone

• Biological clock of the body – like rhythmic music

• Supra-chiasmatic nucleus – central clock, governs the circadian rhythm • Clocks in peripheral tissues exist – Entrained by food

• Neural & hormonal cues synchronize the central & peripheral clocks • Inter & intra-organ asynchrony may contribute to chronic pathologies – obesity, DM, cardiovascular disease Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration

Maury E, Ramsey KM, Bass J. Circ Res. 2010 Feb;106:447-62

A Time to Fast, A Time to Feast


Maury E, Ramsey KM, Bass J. Circ Res. 2010 Feb;106:447-62

Thrifty Genes Hypothesis • Neel proposed a hypothesis to explain the prevalence of

obesity and diabetes in modern society • In our early evolutionary history, genes that promoted efficient fat deposition would have been advantageous, because they allowed their holders to survive at periods of famine

• In modern society, such genes are disadvantageous because they promote fat deposition in preparation for a famine that never comes. Int J Obes (Lond). 2008 Nov;32(11):1611-7 Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration

Drifty genes hypothesis • The genes that predispose us to obesity are neutral and have been drifting over evolutionary time -- so-called drifty genes, leading some individuals to be obesity prone and others obesity resistant

Annu Rev Nutr.2013;33:289-317 Brij B Agarwal (17 Aug 2014), DMA Centenary Celebration

Syndrome X • Syndrome X has been described as a condition in which hyperinsulinemia and insulin resistance are primary features. • Associated characteristics are hypertriglyceridemia, low high density

lipoproteins, and hypertension. • Visceral obesity is very likely a part of this syndrome because of its close relationship with the components of Syndrome X

Reaven GH. Role of insulin in human disease. Diabetes 1988;37: 1595-1607


Shortcomings of obesity and nutrition research • What we want to know, is what causes us to gain weight, not whether weight loss can be induced by both semi-starvation and

carbohydrate restriction. • What can we do about this? It seems we have two choices. • We can continue to examine and debate the past, or we can look forward and start anew. BMJ 2013;346:f1050 doi: 10.1136/bmj.f1050 (Published 17 April 2013)


What can we do about this? •

First- acceptance of the existence of an alternative hypothesis of obesity, or even multiple alternative hypotheses, that adhere to the laws of physics and must be tested rigorously

•

Second is a refusal to accept substandard work.

•

The authors must be brutally honest about their results, possible shortcomings and all reasonable alternative explanations for what they observed.

•

“If science is to progress,” as the Nobel prize winning physicist Richard Feynman said half a century ago, “what we need is the ability to experiment, honesty in reporting results—the results must be reported without somebody saying what they would like the results to have been—and finally—an important thing—the intelligence to interpret the results. BMJ 2013;346:f1050 doi: 10.1136/bmj.f1050 (Published 17 April 2013)



Take Home Message • Historically, evolution has been in nature’s hands • Now, it is largely in our hands & we need to be cautious, using our scientific know-how as responsibly as possible •

The job of today’s young people, or the "Transition Generation," will be to get humanity through the coming

period of chaos, peril, and opportunity


• A massive transition is needed, and the agenda should be created for the generation that will bring about this transition • Much of what needs to be done is not happening • Today's computer models show that we are not adapting quickly enough because we are not thinking ahead


“Life is like a box of chocolates; Doesn’t last very long for fat people”


 Thank You 
