Dr. Fathi Neana discusses metabolic syndrome and its impact on the musculoskeletal system. Metabolic syndrome is reaching epidemic proportions and is associated with obesity, diabetes, gout, and other conditions that can cause surgical difficulties and complications. Intermittent fasting is presented as a potential strategy for correcting metabolic abnormalities and managing conditions associated with metabolic syndrome like type 2 diabetes.

1. Dr. fathi Neana
Chief of Orthopaedics
Dr. Fakhry & Alrajhy hospital
Saudi Arabia
November 24, 2016
Metabolic syndrome
and
Intermittent fasting
(IF)

2. 1- Metabolic syndrome reached an epidemic
2- Impact on the musculoskeletal system
Obesity – DM - Uric a – etc
Host A – B – C
Surgical difficulties & complications
3- Masks fallen down and truths rapidly prevails
Era of communications
& evidence based medicine
4- Friends & colleagues requisite
The Metabolic Syndrome
Why this presentation

3. DM and the musculoskeletal system
Conditions more frequently in DM
Diabetic cheiroarthrophaty (stiff hand
synd)
Trigger finger (flexor tenosynovitis)
Dupuytren’s contracture
Carpal tunnel syndrome
Adhesive shoulder capsulitis (frozen
shoulder)Calcific shoulder tendonitis
Reflex sympathetic dystrophy (
shoulder-hand syndrome)
Diabetic osteoarthrophaty or Charcot's
or neuropathic arthropathy
Conditions Sharing Risk Factors of DM
Diffuse Idiopathic Skeletal
Hyperostosis (DISH)
Gout/ Pseudo gout
Osteoarthritis
The Metabolic Syndrome
Impact on the musculoskeletal system
Obesity and the musculoskeletal system
Musculoskeletal conditions associated
with obesity
OA (knee, hip, hand)
Low Back Pain
Diffuse idiopathic skeletal hyperostosis
(DISH)
Gait disturbance
Soft tissue conditions (for example,
carpal tunnel syndrome, plantar
fasciitis)
Osteoporosis ?
Gout
Fibromyalgia
Connective tissue disorders (rheumatoid
arthritis) .

4. Co-occurrence of several known
cardiovascular risk factors
Type 2 Diabetes
Central Obesity
Atherogenic dyslipidemia
Hypertension
These conditions are interrelated
and share underlying mediators,
mechanisms and pathways
The metabolic syndrome
Insulin Resistance syndrome - Syndrome X - Deadly quartet - Reaven’s
syndrome

5. Abdominal obesity
Plus
two other components
Elevated BP
Low HDL
Elevated TG
Impaired fasting glucose
Metabolic Syndrome
Definition
The International Diabetes Federation

6. Intermittent fasting (IF)
Simplified View of Insulin Action
Graphic originally published at
http://weightology.net/weightologyweekly/?page_id=
319
Recently attracted attention
Because
1- Its potential for correcting metabolic
Abnormalities
2- Better adherence than other
methods

7. Sugar (fructose)
Insulin
resistance
+
Obesity
Leptin
resistance
-> failure to
suppress
ghrelin
-> hunger ->
more eating
->> obesity

9. Leptin, ghrelin, and weight loss
Normally Insulin 8 Leptin (satiety) 7 Ghrelin (huger)
Obesity Hyperglycemia
Hyperinsulinemia
Insulin Resistance
Hyperleptinemia
Leptin Resistance
TG
Ghrelin
Unsuppressed
->> Hunger ->> More eating ->> Obesity
Hyperinsulinemia
Insulin Resistance
Hyperleptinemia
Leptin Resistance
Ghrelin
Unsuppressed
->> Hunger ->> More eating ->> Obesity
HyperglycemiaObesity

10. Four protocols
for preventing DM in KSA and the Gulf
Dr. Mohammad Jamil Alhabbal
Encourage
• Breast feeding
• Camel milk consumption
Control
• Consumption of high sugar drinks (HFCS)
• Bleaching agents used in wheat flour and other
foods

11. Intermittent fasting (IF)
Leptin, ghrelin, and weight loss
• Cortisol
– Stress hormone
• Leptin
– controls satiety
• Ghrelin
– Sparks hunger
• Thyroid
– Controls metabolic rate
Intermittent Fasting
eliminates hunger & cravings
IT reduces or normalizes ghrelin (the
hunger hormone) -> less appetite
EAT PROTEIN BEFORE CARBS
We know the amount of certain nutrients
But the order in which you eat them matters too
Blood sugar levels were about 29 percent lower after 30 minutes, 37 percent lower after
60 minutes, and 17 percent lower after 120 minutes after starting their meal
High Sugar (esp fructose) turning off the body's appetite-control system (insulin and leptin signaling)
-> huger -> more eating -> gaining weight

12. Effect of intermittent fasting and refeeding on insulin action in healthy men
Nils Halberg, Morten Henriksen, Nathalie Söderhamn, Bente Stallknecht, Thorkil Ploug, Peter Schjerling, Flemming Dela
Journal of Applied Physiology Published 1 December 2005 Vol. 99 no. 6, 2128-2136 DOI: 10.1152/japplphysiol.00683.2005
We mimicked the fluctuations in eight healthy young men [25.0 ± 0.1 yr (mean ± SE);
body mass index: 25.7 ± 0.4 kg/m2] by subjecting them to intermittent fasting every
second day for 20 h for 15 days.
This study was undertaken to test the hypothesis that 14 days of intermittent fasting
and refeeding improves insulin-stimulated glucose disposal.
Fasting every second day increased the insulin sensitivity approximately sevenfold
according to the homeostatic model assessment (2) and decreased the incidence of
diabetes (32).
We found a decrease in circulating leptin after 8–20 h of fasting

13. Intermittent fasting (IF)
Better adherence than other methods
1- ‘Alternate day fasting’ (ADF)
Every other day (EOD) fasting
2- ‘Fasting two non-consecutive days per
week’
3- ‘Modified fasting regimes’
(allow water - coffee or tea. limiting caloric
intake < 20%)
4- The Warrior diet (1 large meal per day)
5- Variations (different combinations of EOD
and the Warrior diet
‘Normal eating’
Resumed on non-fasting days

14. • Is it dangerous to go without food?
• Won’t health suffer if we aren’t eating
regular meals?
• I need to eat regularly otherwise my body
goes into starvation mode
Intermittent fasting (IF)
Frequently asked questions

15. Fasting
Religious Reasons
Ramadan
a 4-week period of food and fluid
abstinence between the hours
from sunrise to sunset
the length of the fast may vary from 10
to 19 hours each day
Fasting
Recall History
Human history
we were not regular meal eaters. We followed a
more episodic pattern of intake (intake does not
refer to a set period of time, as habitual pattern )

16. Fasting
Watch, observe and read the
natural life

17. Fasting was a regular part of the Messenger's life.
He would fast every Monday and Thursday.
He would also fast the 13th, 14th and 15th of each month
When the Messenger (peace and blessings be upon him)
was not fasting he was on
“intermittent fasting”
eating only once a day
(The Warrior diet )
The Prophetic Diet: The Perfect New Year’s Resolution
Moutasem Atiya on 30 December 2013

18. Timeline of Tissue Breakdown
36-48 hours before significant amounts of protein start being broken down

19. 19
>1980
Since the low-fat guidelines came
out, the prevalence of obesity has
skyrocketed reaching an epidemic
This graph shows that the obesity
epidemic started full-force at the
same time the low-fat advice was
peaking.
The type 2 diabetes epidemic
followed soon after.
Insulin Resistance 92% of type 2
diabetes

20. Diagnosed Diabetes in the US: 2008
http://apps.nccd.cdc.gov/brfss/list.asp?cat=DB&yr=2008&qkey=1363&state=All
4 – 6% 6 – 8% 8 – 10% 10 – 12%
CDC BRFSS: Self-Reported Diabetes: 8.2% Nationwide

21. The Metabolic Syndrome
Insulin
Resistance
Hypertension
Type 2 Diabetes
Disordered
Fibrinolysis
Complex
Dyslipidemia
TG, LDL
HDL
Endothelial
Dysfunction
Systemic
Inflammation
Athero-
sclerosis
Visceral
Obesity
Adapted from the ADA. Diabetes Care. 1998;21:310-314;
Pradhan AD et al. JAMA. 2001;286:327-334.
Insulin
Resistance

22. Gelfand EV et al, 2006; Vasudevan AR et al, 2005
* working definition
Global cardio metabolic risk*

23. Metabolic syndrome and
Cardiovascular Disease
Musculoskeletal complications in
diabetes mellitus
Obesity and Musculoskeletal
complications
Cardio metabolic Syndrome

24. LOW FAT MESSAGE ABANDONED
No link between heart disease
and Total fat, Saturated fat and
Dietary cholesterol
A.C.C - A.H.A 2015
USDGAG JAMA 2 – 2016
PROCESSED FOODS IS
THE CULPRIT
Sugars, Non fiber carb
and Transfats
Effect is worse by
Smoking , Alcohol,
Addiction
Cardiovascular Disease (CVD) risk
Why
There is Essential fatty and amino acids
But No essential carb or sugar
(Glycogen, Fat, Protein)

25. 25
A diet low in saturated
fat 'will not prevent
heart disease or
prolong life'

26. A healthy eating pattern limits
Trans fats - Added sugars - Non fiber Carbohydrates - Sodium
Harmful Effects of Sugar
(NB: Non fiber Carb rapidly
absorbed)
1- Lipoprotein Oxidation & Glycation
2- Hyper insulinemia syndrome
Metabolic syndrome
-> Insulin resistance (type 2 DM)
-> increased triglycerides VLDL
->Cholesterol (small dense LDL type B
particles)
3- State of chronic inflammation

27. Harmful Effects of Sugar
HFCS (High-fructose corn syrup) is found in almost all types
of processed foods and drinks
Sugar: toxic, addicting, and deadly
As a general recommendation, keep total fructose
consumption below 25 grams per day, including that from
whole fruit
body can safely metabolize six teaspoons of added sugar per
day.

28. •An average American consumes about 22 teaspoons sugar per day
•The human body is not made to consume excessive amounts of sugar,
especially fructose
1- classic metabolic syndrome)
• It is actually a hepatotoxin and is metabolized directly into fat
leading to chronic metabolic dysfunction (classic metabolic syndrome)
These include weight gain, abdominal obesity, decreased HDL and
increased LDL, elevated blood sugar, elevated triglycerides, and high
blood pressure
2- feeds” the cancer cells
•One study found that fructose is readily used by cancer cells to
increase their proliferation – it “feeds” the cancer cells, promoting
cell division and speeding their growth, which allows the cancer to
spread faster
Harmful Effects of Sugar

29. 3- Gaining weight
by turning off the body's appetite-control system
(insulin and leptin signaling)
It fails to stimulate insulin, which in turn fails to suppress ghrelin, "the hunger
hormone," which then fails to stimulate leptin "the satiety hormone."
Causing more eating and develop insulin resistance
4- increases uric acid levels - risk for heart & kidney
disease
uric acid level can now be used as a marker for fructose toxicity.
the safest range of uric acid is between 3 to 5.5 milligrams per deciliter.
uric acid level higher than this, means risk to the negative health
impacts of fructose
Harmful Effects of Sugar
• Cortisol
– Stress hormone
• Leptin
– controls satiety
• Ghrelin
– Sparks hunger
• Thyroid
– Controls
metabolic rate

30. 5- Overloads and damages the liver
The effects of much sugar or fructose likened the effects of alcohol
Non-alcoholic fatty liver disease (NAFLD).
The same disease from excessive alcohol intake can be caused by excessive
sugar (fructose) intake.
Dr. Lustig explained the three similarities between alcohol and fructose:
•The liver metabolizes alcohol the same way as sugar
as both serve as substrates for converting dietary carbohydrate into fat. This
promotes insulin resistance, fatty liver, and dyslipidemia
•Fructose undergoes the Maillard reaction with proteins. This causes
superoxide free radicals to form, resulting in inflammation – a condition that
can be also caused by acetaldehyde, a metabolite of ethanol
•Fructose can directly and indirectly stimulate the brain's "hedonic
pathway," creating habituation and dependence, the same way that ethanol
does
Harmful Effects of Sugar

31. 6- Other diseases linked to metabolic syndrome include
Type 2 diabetes
Heart disease
Hypertension
Polycystic ovarian syndrome
Lipid problems
Dementia
Alzheimer's disease
A powerful connection between a high-fructose diet and risk of developing Alzheimer's
disease, through the same pathway that causes type 2 diabetes.
Alzheimer's and other brain disorders may be caused by the constant burning of glucose for
fuel by the brain.
(low fat & cholesterol diet )
Harmful Effects of Sugar

32. 32
The typical atherosclerotic plaque comprises of the lipid core and the fibrous cap, and is the most
commonly classified histologically by the American Heart Association
1- Endothelial damage & permeability
2- Small dense particles LDL type B
(Caused by)
1- Chronic inflammation)
2- Insulin – Leptin resistance
(Diet too high in sugars + Obesity)
Treat the cause is the logical
thinking
1- Anti-inflammatory lifestyle
2- Control
Insulin - Leptin resistance
Hyper insulinemia – Hyper leptinemia
Diet too high in sugars & Obesity

33. Intermittent fasting (IF)
Interventional strategy
where in individuals are subjected to varying periods of fasting.

34. Timeline of Tissue Breakdown
Intermittent fasting
Fasting Period
(8 h glucose & glycogen) ---- fat –--- (36 - 48 hours protein)
Fasting for 14+ hours force the
body to burn body fat when
blood sugar or carbs drop
Rapid loss of fat by fasting 14 to
20 hours per day
(even without ex & dietary
regimes)
Progress slowly, don’t jump
straight into 24-36 hour fasts 36-48 hours before significant amounts
of protein start being broken down

35. Intermittent fasting (IF)
A 2014 review have
shown
fasting improves
indicators of health
Blood pressure
Insulin sensitivity
Inflammation—cellular
responses to stress
Reduce the risk of chronic
diseases - cancer
LIMITATIONS
Intermittent fasting not studied
in children
the elderly
the underweight
and could be harmful in this population
fast for periods of time greater than 24 hours
should be monitored by a physician, as changes
to the gastrointestinal system or circadian
rhythm can occur
. fasting is unlikely to have much effect on
conditions other than obesity, such as aging or
other chronic condition
unless combined with moderate calorie
restriction and plant-based diet such as the
Mediterranean diet.[7]

36. Bariatric Life vs. Bariatric Surgery
How does Bariatric surgery work ?
1- GIT effects
2- Loss of subcutaneous fat mass
3- Acute profound caloric reduction (Surgically Enforced Fasting)
(No Cure)
Insulin
Drugs
Low fat diet
(Cure)
Bariatric surgery
(Fasting)
Very low carb diet
Type 2
Diabetes

37. Intermittent Fasting vs Dieting regime
Alternating periods of eating & not eating VS. Regular eating less than normal
Better adherence than other methods
Instead of trying to create a deficit of 300-500 kcal/day
(dieting regime)
you are making deficits of 1500-2000 kcal a couple days a
week

38. Bariatrics is Surgically Enforced Fasting
All of the benefits of bariatric surgery accrue because of the fasting.
Studies show that fasting is actually superior to surgery in both
weight loss and reduction in blood sugars.
Patients scheduled for bariatric surgery underwent a period of fasting immediately prior. This would burn a lot of
the liver fat. The smaller liver makes surgery easier, especially with the newer laparoscopic techniques.
Comparing the effects of the fasting with the surgery right after, fasting was clearly superior in terms of weight
lost (7.3kg vs 4kg) and reduction in blood sugars.

39. Likelihood of Complications: 10% For Early Complications,
15.3% For Late Complications
List of Potential Complications: All 20 Possible
Complications
vary widely depending on the experience of your
surgeon and your behavior before and after
surgery.
•Bleeding (also called “Hemorrhage”)
•Blood clots or blood clot symptoms (also called
“thrombus”)
•Bowel function changes
•Bowel obstruction (also called an “internal
hernia”)
•Dumping syndrome
•Dehydration
•Dyspepsia (indigestion)
•Gallstones
•Gastro esophageal reflux disease (GERD)
•Hypoglycemia (low blood sugar)
•Incision(al) hernia
•Intolerance to certain foods
•See our Bariatric Diet section for details.
•Kidney stones
•Leaks ( including gastrointestinal leaks and
staple line leaks )
•Nausea and vomiting
•Nutritional deficiency, especially iron and
calcium.
•See our Bariatric Vitamins .
•Organ injury during surgery
•Stenosis/Stricture
•Marginal Ulcer
•Wound infection
For a complete list and comparison of
complications relating to all types of bariatric
surgery, see our Bariatric Surgery
Complications page
Bariatric Life vs. Bariatric Surgery

40. International Journal of Obesity
(26 December 2014)
Fasting for weight loss: an effective strategy or latest dieting trend?
A Johnstone
Obesity epidemic
Search for dietary strategies that
(i) prevent weight gain
(ii) promote weight loss
(iii) prevent weight regain

41. International Journal of Obesity
(26 December 2014)
Fasting for weight loss: an effective strategy or latest dieting trend?
A Johnstone
There is some long-term success with
gastric surgical options
But
1- Invasive interventions
2- Post-operative risk of death
due to early complications
3- Long term late complications
SO
there is still a requirement for effective
dietary interventions
1- Promote long-term adherence
2- Sustained beneficial effects
Such dietary interventions
need to be
1- Palatable and satiating
2- Meet minimal nutritional requirements
3- Promote loss of fat and preserve lean body mass
4- Ensure long-term safety
5- Simple to administer and monitor
6- Widespread public health utility
(Intermittent fasting)
Is that option
achieving weight loss and maintenance

42. 1- Intermittent fasting forces your body to burn more fat
The less blood sugar in your body = The more fat you will burn
John Rowley, Wellness Director for the International Sports Science Association
2. Intermittent Fasting increases your energy & metabolism
adrenaline (or norepinephrine) cause more energy, more alert and focused, it forces your body to
burn fat (mainly the belly, thighs & hips) like the Geico caveman
3. Intermittent Fasting naturally increases HGH (Human Growth Hormone)
HGH is a fat burning hormone help maintain your muscle mass while fasting
4. Intermittent Fasting eventually eliminates your hunger & cravings
IT reduces or normalizes ghrelin (the hunger hormone) -> less appetite.
4 reasons why fasting (14+ hours per day)
help you burn fat faster than the average diet regimes

43. • Decreases chances of cancer risk
.
• less likely to become diabetic
• Improves cognitive function
• less likely to suffer from cardiovascular disease
• Reduces inflammation
• Helps you live longer
• Protects from the effects of Alzheimer's & Parkinson's diseases
7 More benefits of intermittent fasting

44. Patient compliance & willness
POP cast
vs
Patient Education
Beriatric surgery
vs
Intermittent fasting