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Community pharmacy
Chapter 6:
Nutrition
• Is defined as a function of the living plants and
animals, consisting of the taking in and
assimilation of material through chemical
changes ( metabolism) where by tissue is build up
and energy liberated.
• The successive stages of the metabolism are
digestion, absorption, assimilation and excretion.
Digestion is preceded by mastication and
deglutition in man.
• excretion is effected by expiration, perspiration,
urination, and defection. Not all the materials
involve in human metabolism can be synthesized
by the body. Therefore, these essential material-
nutrients must be provided by the diet.
• Food is a composite mixture of substances
including proteins, carbohydrates, fats, vitamins
and minerals. Where as nutrition signifies a
dynamic process in which the food that is
digested absorbed and assimilated, is used for
nourishing the body.
• The word nutrition comes from the Latin “
nutrire ” which means to breast feed or nurse.
No clear distinction has yet been made between
the food and nutrients.
Classification of foods
• The dietary constituents of food include
proteins, fats, carbohydrates, vitamins,
minerals and water. A complete food should
contain all these factors. Proteins, fats, and
carbohydrates are considered as proximate
principles and a long with water they form the
main bulk of food.
• Food have been classified on the basis of their
predominant functions:
1. Energy yielding foods: these foods are rich in
carbohydrates and fats. Ex : sugar, honey, jellies.
2. Body building (anabolic food). Ex: meat, liver,
fish, milk, eggs.
3. Protective foods: these items are rich in
proteins, vitamins, and minerals. Ex : milk, egg,
green vegetables.
• The important functions of food are: provision
of energy, body building and repair, and the
maintenance and regulation of tissue functions
Proteins
• Proteins are complex organic nitrogenous
compounds. They are composed of carbon,
hydrogen, oxygen, nitrogen and sulphur in
varying amounts.
• Some of the also contain phosphorus, iron and
other elements. Proteins provide about 24
amino acids of which eight are essential fro
human for normal synthesis of different
proteins in the body and for maintaining
nitrogen balance in the adults.
• As the human body cant synthesize them in
sufficient quantity they must be supplied from
the dietary proteins. The quality of dietary
protein is closely related to its pattern of
amino acids.
• Protein from milk and eggs have pattern of
amino acids which are considered most
suitable for human consumption.
• Proteins have an important role in the
consumption of all tissues including body
fluids such as blood.
• They are required for building ,repair, and
maintenance of the body tissues, and for the
biosynthesis of plasma proteins, hemoglobin,
antibodies, enzymes, and hormones.
• They are also responsible for the cell mediated
immune response and the bactericidal activity
of leucocytes.
• Proteins can also serve as source of energy
but under normal condition human body
doesn’t utilize them for this purpose.
• Proteins in our diet are generally obtained
from 2 important sources:
1. Animal source: egg, meat, fish, beef, milk
2. Vegetable source: cereal, nuts, fruits
• The proteins obtained from milk, eggs, and
meat generally of higher biological value
than the proteins from vegetable source.
•
• Growing children need more proteins in the
term of body Wight since new tissues laid
during growth. Proteins needs of women
during pregnancy and lactation are also
greater.
• Deficiency of proteins: proteins calorie
malnutrition ( PMC) is the most prominent
form of the protein deficiency. It occurs
frequently among infants and adults children
among 1-3 years of age. it is not only
responsible for childhood morbidity and
mortality but it may also lead to permanent
impairment of physical and mental growth of
• The two terms used to describe PCM:
1. Marasmus: it is chronic condition resulting
from the deficiency of total energy intake.
Consequently, the individual reserves of
protein end energy are depleted.
2. Kwashiorkor: it is common in patients who
have adequate caloric intake but relative
protein deficiency and who are catabolic
usually with trauma, infection of burns.
• Treatment of PCM: essentially comprises of
adequate diet, treatment of infections and
measures to prevent relapse.
• In most cases 3-5 gm of food quality
protein/kg/day will suffice the child's needs.
After deworming and treating other infections
it may take about 3 months to obtain a
complete cure of PCM.
• Prevention of PCM: a number of measures are
essential for prevention on PCM in the
developing countries .these include
1. health education: measures directed to
pregnant and lactating women, their
education toward health consciousness,
breast feeding, family planning, nutrition,
and food requirements of the family and
growing children.
2. Specific protection of infants and children:
this can be achieved by timely immunization
and provision of protein and calorie rich
food like milk, eggs, and fresh foods where
ever possible
3. Early diagnosis, treatment, and
rehabilitation: these can be achieved by
periodic surveillance, proper treatment of
diarrhea and worm infections, development
of supplementary feeding programs and
follow up care in case of hospitalized
children.
Fat
• Are concentrated source of energy and thus
form an essential part of out diet. They
improve the palatability of food and are
required for the absorption of vitamins
A,D,E,K.
• Dietary fats are derived from both animals
source like milk, vegetable oils, and nuts.
• Animal fats are in general poor source of
essential fatty acids abut they are good source
of retinol and cholecalciferol, where as the
vegetable oils except coconuts oil are rich
sources of essential fatty acids
• Essential fatty acids include linoleic, linolenic
and arachidonic acids. They are active in
promotion of growth as well as in the
maintenance of the dermal integrity.
• Their deficiency may lead to some abnormal
skin conditions. Diet rich in EFAs also reduce
blood cholesterol.
• The nutritional significance of fats has
increased due to its influence on cholesterol
levels in the blood.
• A high blood level of cholesterol is one of the
predisposing factors for the development of
atherosclerosis leading to CHD.
• Fatty acids are classified into saturated and
unsaturated fatty acids. Fatty acid of animal
origin is saturated where as those present in
groundnut oil, sesame oil, safflower oil and
sunflower oil are mostly ply unsaturated fatty
acids.
• Hydrogenated vegetables fats contain high
proportion of saturated fatty acid.
• The consumption of unsaturated fatty acids in
diet can control the rise in blood cholesterol.
Its now considered that the daily of fats
should not account for more than 15-20% of
the total calories in the diet and these should
include some amount of vegetable fats which
contain unsaturated fatty acids.
% of fatty acids contain of commonly used
vegetable oils
Vegetable oil Saturated
fatty acid
Mono
Unsaturated
fatty acids
Poly
Unsaturated
fatty acids
Sunflower oil 8 27 65
Corn oil 08 27 65
Soybean oil 14 24 62
Butter 60 37 3
• Blood fats are found in various forms but only
two of these cholesterol and triglycerides are
important from the point of view of health. In
general plasma cholesterol higher than 200
mg/ 100 ml +the age of person in years and
plasma triglycerides level exceeding 150/100
ml required medical attention. An excessively
high quantity of the fat in the blood vessel
likely to get deposit on the wall of the blood
vessels and make them narrow.
• This narrowing of blood is called
atherosclerosis . The narrowing of coronary
arties may lead to decreased like angina and
MI which may be fatal unless treated
immediately and cared for life time.
• Hydrogenation: converts the liquid oils into
semi solid and solid fat which are commonly
known as “ vanaspti” and are popular cooking
medium in our country.
• Helps in maintaining the quality of the
vegetable oils even in hot and humid climates,
but in drastically reduces the contents of EFAs
• Refined oils: refining of vegetables oils is done
by treatment with steam and alkalies. It
renders them free from unpleasant odor and
color and improve the taste. However, refining
reduce the EFAs content of vegetable oils.
• Invisible fats: fats like butter, ghee, vegetable
oil “ visible fats” As their daily intake can be
estimates. On the other hand, fat present in
various foods items like cereals, pulses, nuts,
meat, eggs, vegetables, milk cant be
quantities and hence they are called “invisible
fats”
Obesity
• Represent an imbalance between energy
intake and out put resulting in a surplus of
energy which is converted to fat and stored as
adipose tissue.
• Individuals whose weight is 10-20% above the
desirable weight for their age, gender and
frame are defined as over weight. When the
weight exceeded 20 %more than the
desirable weight, a person is regard as above
• The association of obesity with increased
morbidity and mortality is well known.
Hypertension, diabetes, gall bladder disease,
gout, osteoarthritis, flat feet, coronary
arteriosclerosis are frequently associated with
obesity.
• There is unexplained increase in the incidence
in certain types of cancer ( breast, gall bladder,
colon…) in obese individuals.
• Obesity also presents special hazards in
pregnancy and surgical patients.
Balancing one's weight
• Gaining or losing weight is simply a question
of balancing food calories with the body's
need for calories. One kg of fat is equal to
about 7500 kcal. Thus, if you have 500 kcal
every day above what your body needs, you
will gain 0.5 kg in a week. On other hand, if
you intake 500 kcal below your needs, you will
lose about 0.5 kg in a week.
•
• Fat deposition occurs when caloric intake exceeds
caloric output. ,modern living conditions contribute
to the obesity problems because of several factors:
1. Family pattern of rich, high caloric foods
2. Good appetite , likes to eat may dislike fruits and
vegetables.
3. Ignorance of caloric value of foods
4. Skipping breakfast, coffee break with high calorie
intake
5. Pattern of living: secondary occupation, riding to
work, little exercise, tend to watch more than
participating
6. Emotional outlet: eats to overcome worry,
boredom
7. Many social events with rich foods, frequent
eating in restaurants.
8. Lower metabolism with increasing age , but
failure to reduce intake.
9. Influence by pressure of advertising for many
high calorie food.
Treatment
• Specific weight reducing agent and hormones
(ex: thyroid) singly or in combination are
either ineffective or hazardous and have no
place in the treatment of obesity.
• drug like fenfluramine have limited value a s
anorexigenic. Juvenile onset obesity is often
very difficult to treat, possibly because of
unknown metabolic disorder and it is
important to institute a therapeutic
programme as early as possible.
• Any programmed of weight loss of more than
a few pounds should be directed by a
physician. If a weight losing programmed is to
be successful, the individual must be
convinced of the rewards that will come
better health, slimmer figure, more energy.
• Although a low calorie diet is used only so
long as the weight to be lost. Each obese
person must be convinced that he needs to
modify his life time eating habits. If he fails to
do this, he will gain back all pounds he has
lost.
Diet
• Is the most important factor in the
management of the obesity. Preventive
education about diet should be started during
the early, at the time when eating habits are
being established. The motivation to reduce
the caloric intake to normal level is difficult to
achieve in patients with long standing
overeating patterns. Diets that claim to offer
was weight reduce by reliance on certain
special food or unusual combinations of food
not only are invalid but may actually be
harmful
• There are a number of basic points to be
considered in planning a diet for an obese
patient:
1. calories: in order to loss weight, it is necessary
to decrease the intake below the caloric
requirements. An intake of 500 kcal/day less
than the required calories should lead to an
average weight loss of approximately 0.5
kg/week. The number of calories/ day to
prescribe for a patient varies with age
occupation, any urgency to loss weight.
• A daily caloric intake of 800-1200 kcal is
satisfactory for the modest reducing diet.
complications of rapid weight reducing are
largely associated with severs or prolonged
caloric restriction and occur most commonly
in patients who were obese as children.
• Weakness, postural hypotension, metabolic
acidosis, hyperuricemia, ulcerative colitis,
mental depression, and some times even
suicidal thoughts also occur.
2. protein: a protein intake of about 1 g/kg
should be maintained.
3.Carbohydrates and fat: to keep the calories, fat
must be decreased. After the proteins
requirements have been met. The remaining
calories may be supplied as half carbohydrates
and half fat.
4. Vitamins and minerals: can be used to supply
the average daily maintenance requirements
during the time of weight reduction
Low calories diets: foods to be distributed into
regular meals during the day
Source 800 kcal 1600 kcal
Bread, enriched
white or whole grain
½ slice 2 slice
Fruits, un sugared
(1/2 cup)
3 servings 3 servings
Fats and oils , butter none 6 tsp
Starch, potato, … None 3 servings
Meat, fish any but
fried
4 oz 6 oz
Carbohydrates
• Are the main source of energy to the human
body.
• They consist of starch, sugars, and cellulose.
Cereals and roots and tubers used as
vegetables are rich in starch and account for
the most of dietary carbohydrates.
• Cane sugar and glucose are pure
carbohydrates. Cellulose is the fibrous
substance lining fruits, vegetables and in
fibers.
• Should provide 50-70% of total caloric intakein
diet
• Dietary fiber has not been considered an
important component of human diet probably
because it has no nutritional value. Most of
the fiber is removed from the cereals by
milling, while peelings, boiling reduce the
same in vegetables and fruit.
• Of the late there has been a reawakening of
interest about useful role in dietary fiber. a
wide range of diseases like constipation,
colonic cancer, CHD, appending and gall stone
have been associated with the deficiency of
the dietary fiber.
Energy metabolism
• Energy is required for:
1. Basal metabolism ( maintaining life)
2. Voluntary exercise and activity
3. Additional need such as growth.
• Energy is derived from the oxidation of
carbohydrates, fats, and proteins in the diet.
We measure the energy value of the food or
the energy needs of the body in unit called
calories or joules. The calorie or the joule is
measure of heat
• Calorie: one large calorie ( kcal) is the amount
of heat required to raise the temperature of
100 g of the water by 1C. In nutrition the large
calorie is always used. It is 1000 times as great
as the small calorie unit used in chemistry or
physics.
• Joule: the international unit of energy is joule.
It is defined as the amount of heat needed to
raise the temperature of 240 g of water by 1 C
• 1 kcal = 4.184 kilojoules
• The energy value of food is measured in the
laboratory by an instrument called a bomb
calorimeter.
• Ex: carbohydrates: 4 kcal/gram, Fat: 9
kcal/gram, Protein: 4 kcal/gram.
• Thus if we know the carbohydrate, fat and
protein contents of food or diet, we can
calculate the calorie value.
• Energy needs of the body: the body used
glycogen, sugars, fatty acids, glycerol and
amino acids to supply energy.
• The breakdown of these substances required
numerous steps and is a very complex
process.
• The rate of breakdown depends upon the
total daily energy requirement: the basel
metabolism, the amount of voluntary activity,
the influence of food and the need of growth.
• Basel metabolism: account for more than ½
the energy requirement for most people. Its
include the involuntary activity of the body
while at rest but awake
• The basal metabolism can be measured as
basel metabolism rate(BMR). The following
conditions are observed:
1. The individual is a wake but laying quietly in
comfortable room.
2. He is in the post absorptive state( he has had
no food for 12-16 hours).
3. The body temperature is normal
4. He is not tense or emotionally upset.
• The BMR is then measured by indirect
calorimeter, which is the measurement of
oxygen consumption and carbon dioxide
production arising from the combustion of
specific nutrients. It is based on the fact that
the amount of energy expended is always in
direct relationship to the amount of oxygen
utilized in the combustion of various food
componants
• In clinical practice, BMR can be estimated
accurately by measuring O2 consumption of the
patient for two 6 min periods under basel
condition thus:
• O2 consumption/hour= average O2
consumptionx10
• 1L of O2 = 4.825 kcal/hour
• Convert O2 consumption/hour into kcal/hour
• BMR=( Kcal/hour)/surface area = Kcal/m2/h
• Surface area =obtained from the nanogram
• Several factors affect the BMR: these include
body size, muscle tissue, growth, age, thyroid
state and climate..
• Voluntary activity: increases the energy
requirement considerably. When calculating
the person's energy needs the BMR may have
to be doubled for a very active person. Under
most normal life includes mainly light exercise
( office workers, teachers), moderate exercise
( nurses) of heavy exercise ( manual laborers
• Useful table based on the type f activity, age
and weight are available to help one
determine quickly the needs of the
individuals.
Classification of overweight and obesity
Classification BMI Disease risk
Under weight <18.5
Normal 18.5-24.9
Over weight 25-29.5 High
Obese
Class 1 30-34.9 Very high
Class 2 35-39.9 Very high
Extreme obesity
Class 3
=>40 Extreme high
Disease risk: DM 2, hypertension, CVD for men >40 inches and
women>35 inches
Medications that can cause weight gain
Medication Possible alternative
Corticosteroids NSAIDs, acetaminophen
Anti diabetic ( sulfonylurea, insulin,
thiazolodione)
Biguanides
Anticonvulsants gabapentin,
carbamazepine, valopric acid
Lamotrigine
Alpha- adrenergic blocker( clonidine,
prazosin)
doxazosin
Hormonal contraceptives Barrier methods
Pharmacological treatment options
available in USA
Class/ Drug Usual dose
Lipase inhibitor
Orlistate
Alli: 60 mg 1x3 with each fat containing
meal
Xenical: 120 mg 1x3 daily 1 hour after
each fat containing meal
Sympathomimetics
Phentermine 15-37.5 mg/day given in 1-2 divided dose,
before or 1-2 hours after breakfast
Phendimetrazine Capsule: 105 mg 1x1 daily before
breakfast
Complementary and alternative medicine
Herb Dose Effectiveness rating Common A/E
Bitter orange 975 mg/day Insufficient
evidence
Increase in Bp,
tachycardia, CV
toxicity
St. john's wort Not available for
obesity, range from
300-1200 mg/day
Not available GI discomfort ,
diarrhea, insomnia
Chitosan 1-5 g/day Insufficient
evidence
GI upset, nausea,
flatulence,
constipation
References
1. A text book of community: new age, chapter
5, rakesh saini, 2012
2. Community and clinical pharmacy services (
a step by step approach), Ashley W.ellis,
chapter 13 (obesity: weight management
services), 2013.

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  • 2. • Is defined as a function of the living plants and animals, consisting of the taking in and assimilation of material through chemical changes ( metabolism) where by tissue is build up and energy liberated. • The successive stages of the metabolism are digestion, absorption, assimilation and excretion. Digestion is preceded by mastication and deglutition in man. • excretion is effected by expiration, perspiration, urination, and defection. Not all the materials involve in human metabolism can be synthesized by the body. Therefore, these essential material- nutrients must be provided by the diet.
  • 3. • Food is a composite mixture of substances including proteins, carbohydrates, fats, vitamins and minerals. Where as nutrition signifies a dynamic process in which the food that is digested absorbed and assimilated, is used for nourishing the body. • The word nutrition comes from the Latin “ nutrire ” which means to breast feed or nurse. No clear distinction has yet been made between the food and nutrients.
  • 4. Classification of foods • The dietary constituents of food include proteins, fats, carbohydrates, vitamins, minerals and water. A complete food should contain all these factors. Proteins, fats, and carbohydrates are considered as proximate principles and a long with water they form the main bulk of food.
  • 5. • Food have been classified on the basis of their predominant functions: 1. Energy yielding foods: these foods are rich in carbohydrates and fats. Ex : sugar, honey, jellies. 2. Body building (anabolic food). Ex: meat, liver, fish, milk, eggs. 3. Protective foods: these items are rich in proteins, vitamins, and minerals. Ex : milk, egg, green vegetables. • The important functions of food are: provision of energy, body building and repair, and the maintenance and regulation of tissue functions
  • 6. Proteins • Proteins are complex organic nitrogenous compounds. They are composed of carbon, hydrogen, oxygen, nitrogen and sulphur in varying amounts. • Some of the also contain phosphorus, iron and other elements. Proteins provide about 24 amino acids of which eight are essential fro human for normal synthesis of different proteins in the body and for maintaining nitrogen balance in the adults.
  • 7. • As the human body cant synthesize them in sufficient quantity they must be supplied from the dietary proteins. The quality of dietary protein is closely related to its pattern of amino acids. • Protein from milk and eggs have pattern of amino acids which are considered most suitable for human consumption. • Proteins have an important role in the consumption of all tissues including body fluids such as blood.
  • 8. • They are required for building ,repair, and maintenance of the body tissues, and for the biosynthesis of plasma proteins, hemoglobin, antibodies, enzymes, and hormones. • They are also responsible for the cell mediated immune response and the bactericidal activity of leucocytes. • Proteins can also serve as source of energy but under normal condition human body doesn’t utilize them for this purpose.
  • 9. • Proteins in our diet are generally obtained from 2 important sources: 1. Animal source: egg, meat, fish, beef, milk 2. Vegetable source: cereal, nuts, fruits • The proteins obtained from milk, eggs, and meat generally of higher biological value than the proteins from vegetable source. •
  • 10. • Growing children need more proteins in the term of body Wight since new tissues laid during growth. Proteins needs of women during pregnancy and lactation are also greater. • Deficiency of proteins: proteins calorie malnutrition ( PMC) is the most prominent form of the protein deficiency. It occurs frequently among infants and adults children among 1-3 years of age. it is not only responsible for childhood morbidity and mortality but it may also lead to permanent impairment of physical and mental growth of
  • 11. • The two terms used to describe PCM: 1. Marasmus: it is chronic condition resulting from the deficiency of total energy intake. Consequently, the individual reserves of protein end energy are depleted. 2. Kwashiorkor: it is common in patients who have adequate caloric intake but relative protein deficiency and who are catabolic usually with trauma, infection of burns.
  • 12. • Treatment of PCM: essentially comprises of adequate diet, treatment of infections and measures to prevent relapse. • In most cases 3-5 gm of food quality protein/kg/day will suffice the child's needs. After deworming and treating other infections it may take about 3 months to obtain a complete cure of PCM. • Prevention of PCM: a number of measures are essential for prevention on PCM in the developing countries .these include
  • 13. 1. health education: measures directed to pregnant and lactating women, their education toward health consciousness, breast feeding, family planning, nutrition, and food requirements of the family and growing children. 2. Specific protection of infants and children: this can be achieved by timely immunization and provision of protein and calorie rich food like milk, eggs, and fresh foods where ever possible
  • 14. 3. Early diagnosis, treatment, and rehabilitation: these can be achieved by periodic surveillance, proper treatment of diarrhea and worm infections, development of supplementary feeding programs and follow up care in case of hospitalized children.
  • 15. Fat • Are concentrated source of energy and thus form an essential part of out diet. They improve the palatability of food and are required for the absorption of vitamins A,D,E,K. • Dietary fats are derived from both animals source like milk, vegetable oils, and nuts. • Animal fats are in general poor source of essential fatty acids abut they are good source of retinol and cholecalciferol, where as the vegetable oils except coconuts oil are rich sources of essential fatty acids
  • 16. • Essential fatty acids include linoleic, linolenic and arachidonic acids. They are active in promotion of growth as well as in the maintenance of the dermal integrity. • Their deficiency may lead to some abnormal skin conditions. Diet rich in EFAs also reduce blood cholesterol. • The nutritional significance of fats has increased due to its influence on cholesterol levels in the blood.
  • 17. • A high blood level of cholesterol is one of the predisposing factors for the development of atherosclerosis leading to CHD. • Fatty acids are classified into saturated and unsaturated fatty acids. Fatty acid of animal origin is saturated where as those present in groundnut oil, sesame oil, safflower oil and sunflower oil are mostly ply unsaturated fatty acids. • Hydrogenated vegetables fats contain high proportion of saturated fatty acid.
  • 18. • The consumption of unsaturated fatty acids in diet can control the rise in blood cholesterol. Its now considered that the daily of fats should not account for more than 15-20% of the total calories in the diet and these should include some amount of vegetable fats which contain unsaturated fatty acids.
  • 19. % of fatty acids contain of commonly used vegetable oils Vegetable oil Saturated fatty acid Mono Unsaturated fatty acids Poly Unsaturated fatty acids Sunflower oil 8 27 65 Corn oil 08 27 65 Soybean oil 14 24 62 Butter 60 37 3
  • 20. • Blood fats are found in various forms but only two of these cholesterol and triglycerides are important from the point of view of health. In general plasma cholesterol higher than 200 mg/ 100 ml +the age of person in years and plasma triglycerides level exceeding 150/100 ml required medical attention. An excessively high quantity of the fat in the blood vessel likely to get deposit on the wall of the blood vessels and make them narrow.
  • 21. • This narrowing of blood is called atherosclerosis . The narrowing of coronary arties may lead to decreased like angina and MI which may be fatal unless treated immediately and cared for life time. • Hydrogenation: converts the liquid oils into semi solid and solid fat which are commonly known as “ vanaspti” and are popular cooking medium in our country. • Helps in maintaining the quality of the vegetable oils even in hot and humid climates, but in drastically reduces the contents of EFAs
  • 22. • Refined oils: refining of vegetables oils is done by treatment with steam and alkalies. It renders them free from unpleasant odor and color and improve the taste. However, refining reduce the EFAs content of vegetable oils. • Invisible fats: fats like butter, ghee, vegetable oil “ visible fats” As their daily intake can be estimates. On the other hand, fat present in various foods items like cereals, pulses, nuts, meat, eggs, vegetables, milk cant be quantities and hence they are called “invisible fats”
  • 23. Obesity • Represent an imbalance between energy intake and out put resulting in a surplus of energy which is converted to fat and stored as adipose tissue. • Individuals whose weight is 10-20% above the desirable weight for their age, gender and frame are defined as over weight. When the weight exceeded 20 %more than the desirable weight, a person is regard as above
  • 24. • The association of obesity with increased morbidity and mortality is well known. Hypertension, diabetes, gall bladder disease, gout, osteoarthritis, flat feet, coronary arteriosclerosis are frequently associated with obesity. • There is unexplained increase in the incidence in certain types of cancer ( breast, gall bladder, colon…) in obese individuals. • Obesity also presents special hazards in pregnancy and surgical patients.
  • 25. Balancing one's weight • Gaining or losing weight is simply a question of balancing food calories with the body's need for calories. One kg of fat is equal to about 7500 kcal. Thus, if you have 500 kcal every day above what your body needs, you will gain 0.5 kg in a week. On other hand, if you intake 500 kcal below your needs, you will lose about 0.5 kg in a week. •
  • 26. • Fat deposition occurs when caloric intake exceeds caloric output. ,modern living conditions contribute to the obesity problems because of several factors: 1. Family pattern of rich, high caloric foods 2. Good appetite , likes to eat may dislike fruits and vegetables. 3. Ignorance of caloric value of foods 4. Skipping breakfast, coffee break with high calorie intake 5. Pattern of living: secondary occupation, riding to work, little exercise, tend to watch more than participating
  • 27. 6. Emotional outlet: eats to overcome worry, boredom 7. Many social events with rich foods, frequent eating in restaurants. 8. Lower metabolism with increasing age , but failure to reduce intake. 9. Influence by pressure of advertising for many high calorie food.
  • 28. Treatment • Specific weight reducing agent and hormones (ex: thyroid) singly or in combination are either ineffective or hazardous and have no place in the treatment of obesity. • drug like fenfluramine have limited value a s anorexigenic. Juvenile onset obesity is often very difficult to treat, possibly because of unknown metabolic disorder and it is important to institute a therapeutic programme as early as possible.
  • 29. • Any programmed of weight loss of more than a few pounds should be directed by a physician. If a weight losing programmed is to be successful, the individual must be convinced of the rewards that will come better health, slimmer figure, more energy. • Although a low calorie diet is used only so long as the weight to be lost. Each obese person must be convinced that he needs to modify his life time eating habits. If he fails to do this, he will gain back all pounds he has lost.
  • 30. Diet • Is the most important factor in the management of the obesity. Preventive education about diet should be started during the early, at the time when eating habits are being established. The motivation to reduce the caloric intake to normal level is difficult to achieve in patients with long standing overeating patterns. Diets that claim to offer was weight reduce by reliance on certain special food or unusual combinations of food not only are invalid but may actually be harmful
  • 31. • There are a number of basic points to be considered in planning a diet for an obese patient: 1. calories: in order to loss weight, it is necessary to decrease the intake below the caloric requirements. An intake of 500 kcal/day less than the required calories should lead to an average weight loss of approximately 0.5 kg/week. The number of calories/ day to prescribe for a patient varies with age occupation, any urgency to loss weight.
  • 32. • A daily caloric intake of 800-1200 kcal is satisfactory for the modest reducing diet. complications of rapid weight reducing are largely associated with severs or prolonged caloric restriction and occur most commonly in patients who were obese as children. • Weakness, postural hypotension, metabolic acidosis, hyperuricemia, ulcerative colitis, mental depression, and some times even suicidal thoughts also occur.
  • 33. 2. protein: a protein intake of about 1 g/kg should be maintained. 3.Carbohydrates and fat: to keep the calories, fat must be decreased. After the proteins requirements have been met. The remaining calories may be supplied as half carbohydrates and half fat. 4. Vitamins and minerals: can be used to supply the average daily maintenance requirements during the time of weight reduction
  • 34. Low calories diets: foods to be distributed into regular meals during the day Source 800 kcal 1600 kcal Bread, enriched white or whole grain ½ slice 2 slice Fruits, un sugared (1/2 cup) 3 servings 3 servings Fats and oils , butter none 6 tsp Starch, potato, … None 3 servings Meat, fish any but fried 4 oz 6 oz
  • 35. Carbohydrates • Are the main source of energy to the human body. • They consist of starch, sugars, and cellulose. Cereals and roots and tubers used as vegetables are rich in starch and account for the most of dietary carbohydrates. • Cane sugar and glucose are pure carbohydrates. Cellulose is the fibrous substance lining fruits, vegetables and in fibers. • Should provide 50-70% of total caloric intakein diet
  • 36. • Dietary fiber has not been considered an important component of human diet probably because it has no nutritional value. Most of the fiber is removed from the cereals by milling, while peelings, boiling reduce the same in vegetables and fruit. • Of the late there has been a reawakening of interest about useful role in dietary fiber. a wide range of diseases like constipation, colonic cancer, CHD, appending and gall stone have been associated with the deficiency of the dietary fiber.
  • 37. Energy metabolism • Energy is required for: 1. Basal metabolism ( maintaining life) 2. Voluntary exercise and activity 3. Additional need such as growth. • Energy is derived from the oxidation of carbohydrates, fats, and proteins in the diet. We measure the energy value of the food or the energy needs of the body in unit called calories or joules. The calorie or the joule is measure of heat
  • 38. • Calorie: one large calorie ( kcal) is the amount of heat required to raise the temperature of 100 g of the water by 1C. In nutrition the large calorie is always used. It is 1000 times as great as the small calorie unit used in chemistry or physics. • Joule: the international unit of energy is joule. It is defined as the amount of heat needed to raise the temperature of 240 g of water by 1 C
  • 39. • 1 kcal = 4.184 kilojoules • The energy value of food is measured in the laboratory by an instrument called a bomb calorimeter. • Ex: carbohydrates: 4 kcal/gram, Fat: 9 kcal/gram, Protein: 4 kcal/gram. • Thus if we know the carbohydrate, fat and protein contents of food or diet, we can calculate the calorie value. • Energy needs of the body: the body used glycogen, sugars, fatty acids, glycerol and amino acids to supply energy.
  • 40. • The breakdown of these substances required numerous steps and is a very complex process. • The rate of breakdown depends upon the total daily energy requirement: the basel metabolism, the amount of voluntary activity, the influence of food and the need of growth. • Basel metabolism: account for more than ½ the energy requirement for most people. Its include the involuntary activity of the body while at rest but awake
  • 41. • The basal metabolism can be measured as basel metabolism rate(BMR). The following conditions are observed: 1. The individual is a wake but laying quietly in comfortable room. 2. He is in the post absorptive state( he has had no food for 12-16 hours). 3. The body temperature is normal 4. He is not tense or emotionally upset.
  • 42. • The BMR is then measured by indirect calorimeter, which is the measurement of oxygen consumption and carbon dioxide production arising from the combustion of specific nutrients. It is based on the fact that the amount of energy expended is always in direct relationship to the amount of oxygen utilized in the combustion of various food componants
  • 43. • In clinical practice, BMR can be estimated accurately by measuring O2 consumption of the patient for two 6 min periods under basel condition thus: • O2 consumption/hour= average O2 consumptionx10 • 1L of O2 = 4.825 kcal/hour • Convert O2 consumption/hour into kcal/hour • BMR=( Kcal/hour)/surface area = Kcal/m2/h • Surface area =obtained from the nanogram
  • 44. • Several factors affect the BMR: these include body size, muscle tissue, growth, age, thyroid state and climate.. • Voluntary activity: increases the energy requirement considerably. When calculating the person's energy needs the BMR may have to be doubled for a very active person. Under most normal life includes mainly light exercise ( office workers, teachers), moderate exercise ( nurses) of heavy exercise ( manual laborers
  • 45. • Useful table based on the type f activity, age and weight are available to help one determine quickly the needs of the individuals.
  • 46. Classification of overweight and obesity Classification BMI Disease risk Under weight <18.5 Normal 18.5-24.9 Over weight 25-29.5 High Obese Class 1 30-34.9 Very high Class 2 35-39.9 Very high Extreme obesity Class 3 =>40 Extreme high Disease risk: DM 2, hypertension, CVD for men >40 inches and women>35 inches
  • 47. Medications that can cause weight gain Medication Possible alternative Corticosteroids NSAIDs, acetaminophen Anti diabetic ( sulfonylurea, insulin, thiazolodione) Biguanides Anticonvulsants gabapentin, carbamazepine, valopric acid Lamotrigine Alpha- adrenergic blocker( clonidine, prazosin) doxazosin Hormonal contraceptives Barrier methods
  • 48. Pharmacological treatment options available in USA Class/ Drug Usual dose Lipase inhibitor Orlistate Alli: 60 mg 1x3 with each fat containing meal Xenical: 120 mg 1x3 daily 1 hour after each fat containing meal Sympathomimetics Phentermine 15-37.5 mg/day given in 1-2 divided dose, before or 1-2 hours after breakfast Phendimetrazine Capsule: 105 mg 1x1 daily before breakfast
  • 49. Complementary and alternative medicine Herb Dose Effectiveness rating Common A/E Bitter orange 975 mg/day Insufficient evidence Increase in Bp, tachycardia, CV toxicity St. john's wort Not available for obesity, range from 300-1200 mg/day Not available GI discomfort , diarrhea, insomnia Chitosan 1-5 g/day Insufficient evidence GI upset, nausea, flatulence, constipation
  • 50.
  • 51. References 1. A text book of community: new age, chapter 5, rakesh saini, 2012 2. Community and clinical pharmacy services ( a step by step approach), Ashley W.ellis, chapter 13 (obesity: weight management services), 2013.