C ASE DISCUSSION

Dr. Al k a
M.D. 1st Year Nutrition and Dietetics
Preliminary Data
• Name- Deepanshu
• Age- 25 Years
• Gender- Male
• Marital status: Unmarried
• Address- SVSU
• Occupation- Student
• Chief complaint/present illness:
Increase body weight Since 2 Years
k/c/o Alcoholic fatty liver since 1 Year and Hypothyroidism since 2 months.

History of Chief Complaint: Patient was suffering from increased weight since
childhood, but before 3 years his weight was increased rapidly & reached up to
120 Kg but then in starting of year 2020 he reduced his weight by 90 Kg with
the dietary modifications, made changes in his lifestyle and started proper yoga
asanas and exercise.
But after 6 months he was back to his earlier lifestyle i.e. eating more non -veg
diet, disturbed sleeping habit and faulty lifestyle, his weight was increased
rapidly again and because of the consumption of more alcohol and meat products
he was suffered from alcoholic fatty liver before 1 year. He reduced the intake of
alcohol before 6 months and now there is a improvement in his condition of fatty
liver disease.
• History of Past illness: Hypertension , before 1 year
Not a case of Diabetes mellitus, Asthma, Epilepsy.
• History of Past treatment: Pt. was on allopathy medications before 3
months
• Family History: Father is Diabetic and he is also obese.
 Personal History

• Bowel – Normal
• Diet : Mixed Diet
• Appetite – Increase
• Micturition – Normal In frequency
• Tongue- Coated
• Color of Tongue-Whitish pink
• Sleep – So und sleep (6 hours)
• Thirst – More( 5-6 Litres of water/day)
• Addiction – Not now (alcohol and smoking 6 months earlier)
• Habit: Coffee ; 3 times in a day
Nutritional History :
• Diet: Mixed diet ( Non-veg : 4-5 times in a week)
• Timing and frequency of meal & beverages: 5-6 times in a day and
more in frequency. And Cold drinks 4-5 times in a week with junk food.
(200-250 ml in quantity at one time)
• He is taking more junk foods and less nutritive meal.
Physical History Activity:

• Previous physical activity: Earlier He was doing yoga and gym regularly
for 2 hrs before 1 year
• Current physical history: Sometimes he is doing walk or running with a
mild intensity.
 Time or duration: 2 times in a week or sometimes once in a week.
 He is no longer engaged in routine physical exercise since last year
because of his faulty lifestyle and wrong sleeping pattern.
Vital signs and Anthropometric measurements:
Height – 170Cm
Weight – 108 Kg
BMI – 42.1Kg/m 2
B.P – 130/90mmHg
Pulse – 75bpm
RR – 17cycles/min

7
• Mid upper arm circumference: 16.8 inch or 42.67cm (NR: 23.31-24.80 cm)

• Chest Circumference: 48.2 inch or 122.43 cm (NR: 71-105 cm in adult

male )

• Waist Circumference: 49.6 inch or 125.94 cm (NR: 94cm or 37 inch)

• Hip Circumference: 46 inch or 116.84 cm (NR: 94-105cm)

• Waist-Hip ratio: 1.07 ( NR: According to WHO, 0.9 or less for male )

• Thigh Circumference: 25.2 inch ( NR: B/w- 21-23 inch)

 General Physical Examination:

Appearance – Looks appropriate for age and obese

Expression - Normal
Built: Obese
Mouth- Hygenic
Icterus – absent Tongue- Coated
Pallor- absent Lips: Blackish
Cyanosis- absent Hairs- Black
Eyes- Normal
Clubbing- absent
Nose- Normal
Oedema- Absent Ear- Normal
Evaluation
Obesity focused history
• A complete history should include:

1. Childhood weight history

2. Prior weight loss efforts and results
3. Complete nutrition history
4. Sleep patterns
5. Physical activity
6. Associated past medical histories like cardiovascular, diabetes, thyroid, and
depression
7. Surgical history
8. Medications which can promote weight gain
9. Social histories of tobacco and alcohol use
10. Family history
Physical Examination for Obesity:
• BMI
• Waist circumference
• Complete Physical examination Should be done and should include body mass
index (BMI) measurement, weight circumference, body habits and vitals.
• Obesity focus findings like acne, hirsutism, acanthosis nigerians, buffalo hump, fat
pad distribution, irregular rhythms, gynecomastia, hypoventilation, pedal edema,
stasis dermatitis, and gait abnormalities can be present.
 BMI:
• BMI = calculated as weight (kg)/height
(m)2
• Helps to classify weight status & risk
of disease
• BMI provides an estimate of body fat and
is related to disease risk.
• Lower BMI thresholds for overweight and
obesity have been proposed for the Asia-
Pacific region since this population appears
to be at risk for glucose and lipid
abnormalities at lower body weights.
Classification of obesity on the basis of BMI

•Underweight: less than 18.5 kg/m2

•Normal range: 18.5 kg/m2 to 24.9 kg/m2

•Overweight: 25 kg/m2 to 29.9 kg/m2

•Obese, Class I: 30 kg/m2 to 34.9 kg/m2

•Obese, Class II: 35 kg/m2 to 39.9 kg/m2

•Obese, Class III: more than 40 kg/m2

Waist Circumference

• Used to assess – excess abdominal

fat, surrogate for visceral adipose
tissue
• Independently associated with
T2DM, CVD Procedure.
Anthropometric Measurements
• Anthropometric measurements are a series of quantitative measurements of the
muscle, bone, and adipose tissue used to assess the composition of the body.
• The core elements of anthropometry are height, weight, body mass index (BMI), body
circumferences (waist, hip, and limbs), and skin fold thickness.
• Equipments used:
1. Weight scale
2. Stadiometer
3. Knee caliper
4. Skin fold calipers
5. Tape measure
6. Infantometer to measure the recumbent length.
 Stadiometer
Skin fold caliper
Knee Caliper

Tape Measure Infantometer

Classification of weight status & disease risk
General Laboratory Investigations done during
obesity:
• Complete blood count
• Urinalysis
• Fasting lipid levels:
 Triglycerides
 Low-density lipoprotein (LDL) cholesterol
 High-density lipoprotein (HDL) cholesterol
 Non-HDL cholesterol
• Thyroid stimulating hormone
Laboratory
Investigation:
Obesity
Physiology of Energy metabolism:

• Energy balance of the body is maintained by – Laws of

thermodynamics –
Energy intake = energy expenditure
• Regulation of energy balance is coordinated in the hypothalamus –
Which receives afferent signal that indicate nutritional status in short
term – stomach hormone Ghrelin which falls immediately after eating
& rises gradually after it to suppress satiety & signals for the next meal
• For long term – Adipose tissue hormone Leptin increases with
growing fat mass-hypothalamus responds by altering activity of certain
neurotransmitters & pathways which Influences the energy balance.
How Body responses to over nutrition
• Under & over nutrition availability brings alterations in complex regulatory
pathways to adapt.
• In response to over nutrition – BMR increases – extra energy is consumed
for increasing fat storage
• Due to high insulin state in the form TGs in adipose tissue but may
accumulate in liver & skeletal muscle
• In absence of proper hypothalamic regulation – loss of response to satiety
signals with loss of adaptive changes in energy expenditure = results in
weight gain
Structure of Adipose tissue

• Earlier it was just storage organ for triacylglycerol.

• But it is considered as a metabolically dynamic organ that is the primary site of
storage for excess energy but it serves as an endocrine organ capable of
synthesizing a number of biologically active compounds that regulate metabolic
homeostasis.
• Composed not only of adipocytes, but also of other cell types called the stroma-
vascular fraction, comprising blood cells, endothelial cells, pericytes and adipose
precursor cells among others.
Types of adipose tissue
Secretions by adipose tissue
Introduction:
• Obesity is a state of excess adipose tissue mass.
• Form of altered energy – metabolic malnutrition syndrome.
• Obesity is the excessive or abnormal accumulation of fat or adipose tissue
that impairs health via its association to the risk of development of
diabetes mellitus, hypertension and hyperlipidaemia .
• Overweight and obesity are defined as abnormal or excessive fat
accumulation that presents a risk to health. A body mass index (BMI) over
25 is considered overweight, and over 30 is obese. - WHO
Pathophysiology
• Association of genetics and obesity is already well established by
multiple studies. FTO gene is associated with adiposity.
• Leptin is an adipocyte hormone which reduces food intake. Cellular leptin
resistance is associated with obesity.
• Adipose tissue secretes adipokines and free fatty acids causing systemic
inflammation which causes insulin resistance and increased triglyceride levels,
which subsequently contributes to obesity.
• Obesity can cause increased fatty acid deposition in the myocardium
causing left ventricular dysfunction. It has also been shown to alter the
renin-angiotensin system causing increasing salt retention and elevated
blood pressure.
• Besides total body fat, the following also increase the morbidity of obesity:
1. Waist circumference (abdominal fat carries a poor prognosis)
2. Fat distribution (Body Fat Heterogeneity)
3. Intra-abdominal pressure
4. Age of onset of obesity
The Gut-Brain Axis
Gut- Brain
Axis &
obesity
Epidemiology
• In adults, WHO defines ‘overweight’ as a BMI of 25.0 to 29.9 and ‘obese’ as
a BMI ≥ 30.0. Obesity is further classified into three severity levels: class I
(BMI 30.0-34.9), class II (BMI 35.0-39.9) and class III (BMI ≥ 40.0) .
• The prevalence of excessive weight gain has doubled worldwide since 1980,
and about a third of the global population has been determined to be obese or
overweight
• The prevalence of obesity also varies with socioeconomic status, with slower
rates of BMI increase in high-​income and some middle-income countries.
• In low- and middle-income countries, rates of overweight and obesity are
rising especially in urban areas. In China, one study based on 12,543
participants monitored over 22 years revealed that the prevalence of age-
adjusted obesity rose from 2.15% to 13.99% in both sexes, going from 2.78
to 13.22% in female and from 1.46 to 14.99% in male
Etiology:
• Obesity can result from increased energy intake, decreased energy
expenditure or a combination of both.
• Excess accumulation of body fat is the consequence of environmental and
genetic factors, social factors and economic conditions also represent
important influences.
• Recent increases in obesity cases can be attributed to a combination of
excess caloric intake & decreasing physical activity.
• The susceptibility to obesity is polygenic in nature and 30-50% of the
variability in total fat stores is genetically determined.
Clinical Features:
• Obesity has major adverse effects on health. The increased mortality from
obesity is primarily due to CVD, hypertension, gall bladder disease,
diabetes mellitus and several types of cancer i.e. cancer of esophagus,
colon, rectum, pancreas, liver etc.
• Obesity is also associated with an increased incidence of gastro esophageal
reflux, osteoarthritis, gout, back pain , depression etc.
• Hypogonadism in men and infertility in both sexes are prevalent in obesity,
in women this may be associated with hyperandrogenism( polycystic
ovarian syndrome).
Causes of Obesity:
Risk Factors of Obesity:
• Type 2 diabetes
• High blood pressure
• Heart diseases
• Stroke
• Sleep apnea
• Osteoarthritis
Correlation of Obesity with Hypothyroidism :

Sanyal, D., &

Raychaudhuri, M. (2016).
Hypothyroidism and
obesity: An intriguing
link. Indian journal of
endocrinology and
metabolism, 20(4), 554–
557.
https://doi.org/10.4103/22
30-8210.183454

Figure 1: Interrelationship between obesity and thyroid dysfunction. REE: Resting energy expenditure, AITD:
Autoimmune thyroid disease, NIS: Sodium iodide symporter, TRH: Thyrotropin ‑releasing hormone, TSH: Thyroid
stimulating hormone
Correlation of Obesity with CVD
MANAGEMENT
Aim:

• Reduce the weight with naturopathic, yogic and intervention.

• Relieve from the risk factors associated with obesity i.e. Hypothyroidism and
hypertension.
• To reduce the mental and physical fatigue.
• To improve the physical strength.
Title and Author Journal & Year Intervention Conclusion

Meta-analysis of the The American The daily doses used Flaxseed significantly
effects of flaxseed journal of clinical in the flaxseed reduced circulating
interventions on nutrition interventions included total and LDL-
blood lipids. in this meta-analysis cholesterol
Pan An et al
2009 ranged from 20.0 to concentrations.
50.0 g/d (median Flaxseed contains a
dose: 38.0 g) for more large amount of
than 2 week. fiber .Dietary soluble
fiber has been proven
to have cholesterol-
lowering effects,
causing significant
decreases in total and
LDL cholesterol .
Title and Author Journal and Year Intervention Conclusion

Flaxseed (Linum Nutrients, 2020 Flaxseed was Flaxseed

Usitatissimum L.) administered for 10 supplementation was
Supplementation in weeks at a dose of well-tolerated and
resulted in a consistent
Patients Undergoing 28 g/d. and significant
Lipoprotein decrease in total
Apheresis for Severe cholesterol and low-
Hyperlipidemia—A density lipoprotein
Pilot Study (LDL) levels. The
median (and range)
Kanikowska D et al. percentage decrease
was 11.5% and 7.3% for
cholesterol and LDL-C
Title and Author Journal and Year Intervention Conclussion

Chia induces Nutricion Consumption of 35g of Consumption of chia

clinically discrete Hospitalaria , 2015 chia flour/day for 12 for 12 weeks promotes
weight loss and weeks. significant reduction in
weight and waist
improves lipid circumference. And
profile only in observed a reduction in
altered previous total cholesterol and
values. VLDL-c and an
Luciana Tavares increase in HDL-c.
Toscano et al.
Title and Author Journal and Year Intervention Conclussion

A Pilot Study on IOSR Journal of Local mud pack for 30 The findings of the
Impact of Dental and Medical mins. and cold study indicate that
Naturopathic Sciences . abdominal pack 45-60 the designed
mins.
Treatment Protocol 2016 Swedish Massage to
Naturopathic
on Abdominal abdomen and hip area( treatment protocol
Obesity Patients. 15-20 mins) can help in reducing
Dr. Kinjal et al. Cold hip bath( 12-18 C) weight, reduce body
for 10-15 mins. mass index and
Steam bath 10-15 mins. decreases the waist
For one week. circumference
significantly among
both men and
women.
Title and Author Journal and Year Intervention Conclussion

Integrated Yoga and Journal of Ayurveda A 6 week IYN protocol The case report shows
Naturopathy and Integrative was given to a 50-year- remarkable changes in
module in Medicine. old male participant MetS status after
with metabolic following a 6 week IYN
management of syndrome( obesity, intervention.
Metabolic hypertension and The results showed
Syndrome: A case hypothyroidism) . reduction in weight
report. (97.9 kgs to74.6 kgs),
Apar Saoji et al. total cholesterol (192
mg% to 145 mg%),
triglycerides (153 mg%
to 90 mg%), TSH (6.90
mIU/ ml to 3.052
mIU/ml)
Title and Author Journal and Intervention Conclusion
Year
Effect of Udvartana The Journal of Udvrtana (a The study has
(Powder Massage) Alternative and massage done with shown Udvartana
On Obesity. Complementary powder in opposite has resulted in
Vinayaka Medicine. direction) by Kola significant change in
Venkatappa et al. 2014 kulatthadi Churna weight in obesity
for seven days. patients. ( weight
40-45 mins/ day. was reduced from
84.7 to 81.8)
Title and Author Journal and Year Intervention Conclussion

Effect of short-term Int J Basic & The subjects of the Reduction in the body
naturopathy and Clinical study group underwent weight, BMI and
yoga intervention on Pharmacol,2020 10 days of improvement in serum
naturopathic and yogic lipid profile and serum
anthropometric interventions. thyroid profile
variables, lipid Naturopathic in case group subjects
profile and thyroid treatments included compared to control
profile in obese hydrotherapy, mud group suggest that
hypothyroid therapy, fasting naturopathy and yoga
patients: a therapy and diet have therapeutic and
randomised modification. The yogic protective
controlled trial intervention was effects in the
a 50 minutes yoga management of obese
Shetty GB et al. session per day for 10 hypothyroid patients
days which
included asanas,
pranayama and
Title and Author Journal and Year Intervention Conclusion

Effect of Open access Body points are: Hegu Body acupuncture in

Acupuncture on Macedonian journal (LI4), Quchi (LI11), combination with diet
Body Weight of medical sciences, Liangmen (ST21), restriction was found
Tianshu (ST25), to be effective for
Reduction and 2015 Zusanli (ST36), weight loss and also
Inflammatory Fenglong (ST40), reduction of the
Mediators in Neiting(ST44), inflammatory
Egyptian Obese Sanyinjiao(SP6), reactions. Acupuncture
Patients. Daheng (SP15), could be used as a
Laila Ahmed Abou Neiguan (PC6), synergistic treatment
Ismail et al. Taichong (LR3), option for obesity
Guanyuan (CV4) and control.
Zhongwan (CV12).
Acupuncture sessions
was done twice weekly,
each session was 30
minutes for 3 weeks.