DIET,
OBESITY AND METABOLIC DISEASE

INTRODUCTION

Obesity has emerged as a
pervasive public health problem in the last decade. The disorder manifests as
the abnormal or excessive fat accumulation in adipocytes after an excessive
calorie ingestion through consumption of food that exceeds the body’s metabolic
necessities for growth and development and may impair the health of the
individual. The overweight and obesity can be diagnosed by checking the Body
mass index (BMI), which is a simple index of weight-for-height. It is defined
as a person’s weight in kilograms divided by the square of his height in meters
(kg/m2) (WHO, 2016). A person with BMI greater than or equal to 25
is inferred to be overweight and one with a BMI greater than or equal to 30 is
classified to be obese. The fundamental reason for this is the imbalance
between calorie intake and calorie expended by an individual. WHO database show
that, the prevalence of obesity globally was about 13% of the world’s adult
population (11% of men and 15% of women) in 2016 and that of metabolic syndrome
(MS) is estimated to be between 20-25% and is associated with a two-fold
increase in the risk of coronary heart disease, cerebrovascular disease, and a
1.5-fold increase in the risk of all-cause mortality. The
frequency of obesity got nearly triple folded since 1975, arguably making it
the most serious global epidemic. In 2016, more than 1.9 billion adults, who
were 18 years and older and 41 million children under the age of 5 were
overweight or obese (WHO, 2016). Globalization has deeply affected people and
the way they live and eat. It has brought forth a need and urge to consume high
calorie diets from fast food chains. Researches that were conducted on the
possible outcomes and health hazards which includes obesity and other metabolic
disorders, has proved that it is time to start limiting the intake and focus
more on an everyday healthy diet. The prevalence of the metabolic syndrome and
cardiovascular disease is expected to rise along with the global obesity
epidemic, therefore a greater emphasis should be given to effective early
weight-management to reduce risk in pre-symptomatic individuals with large
waists (Thang S Han, 2016).

OBESITY,
CARDIOVASCULAR DISEASES AND METABOLIC SYNDROME

A person can be diagnosed if he
has metabolic syndrome if any 3 among increased waist circumference (?102 cm in
men and ? 88 cm in women elevated triglycerides (?150 mg/dl), reduced HDL
cholesterol (<40 mg/dl in men and < 50 mg/dl in women), elevated blood pressure (?130/85 mm Hg or on treatment for hypertension), or elevated glucose (?100 mg/dl) is present. The discovery of multiple products released from adipocytes, such as non-esterified fatty acids (NEFAs), inflammatory cytokines, PAI-1, adiponectin and leptin has helped to build the understanding of the relation between obesity and metabolic risk factors. NEFAs are formed by lipolysis of adipose tissue triglycerides. The greater the amount of fat in adipose tissue, the more the amount of NEFAs released will be. Excessive influx of non-esterified fatty acids leads to insulin resistance in the muscles and increases the triglyceride content of the liver (fatty liver) (Scott M. Grundy, 2004). The production of cytokines such as TNF?, IL-6 is increased in obese persons and this interferes with the action of insulin to suppress lipolysis. High PAI-1 levels in obese persons due to abnormal abdominal adipose tissue or fatty liver, along with the high plasma fibrinogen observed in such persons contributes to a prothrombotic state. Low levels of adiponectin deprive obese patients the anti-inflammatory and antiatherogenic properties necessary to fight against metabolic syndrome. The most frequently observed component of metabolic syndrome is abdominal obesity (when the waist circumference is 102 cm or more in men or 88 cm or more in women). Metabolic syndrome also known as Dysmetabolic syndrome or syndrome X is a major public health challenge and is becoming more frequent due to the increased obesity rates among adults in the past three decades. It may become the principal risk factor for heart disease overtaking smoking which is currently the major risk factor.     DIETARY CHANGES Carbohydrates, fats, and proteins, which are the baseline nutrients are the basis of all life activities. They form the carbon skeleton of various functional molecules, and provide energy through oxidative decomposition. The main aim of nutrition is preventing and treating nutritional deficiencies. However, when nutrition is disproportionate, the body faces the problems of absorption and storage. Over nutrition, can not only affect health but also cause many ailments such as diabetes, cardiovascular diseases, obesity, hyperlipidaemia and hypertension. Dietary changes in the past 30 years are predominantly characterized by increased consumption of animal products, refined grains and sugars, due to the increased availability of low-cost food and drinks, which are often low in nutritional value and high in energy and sugar. Citing an example, global per capita food consumption was 2358 kcal per capita per day in the year 1965, and increased to a 2655 in 1985 and a shocking 2940 kcal per capita per day in 2015. It is expected to reach 3050 kcal per capita per day by 2030. Furthermore, calories of different materials are not the same depending on the metabolic pathways, like protein requires a higher energy to get metabolize than fats and carbohydrates. As many countries started to experience rapid economic growth changes to food choice and availability brought about by urbanization was inevitable, causing overnutrition. These conversions are also fuelled by reductions in prices of low-quality foods that are high in energy and increases in gross domestic product, which are indicative of higher family income and greater purchasing power. Fast food has been linked to obesity, cardiac and metabolic disease for a number of reasons, including high calorie content, huge portion sizes, high amounts of processed meat, very refined carbohydrates, sugary beverages, unhealthy fats, and unhealthy levels of salt and sugar. The presence of overweight and obesity is directly linked to the prevalence of metabolic syndrome, cardiovascular disease and type 2 diabetes. This relationship is one of cause (overweight/obesity) and effect (metabolic disease). Therefore, if added sugar consumption promotes body fat gain relative to other macronutrients, this is a second and indirect pathway by which high sugar diets may contribute to the development of metabolic disease (Kimber L. Stanhope 2015).   ADDED SUGARS Added sugar at commonly-consumed levels does not have a huge effect on the weight gain as per, but big on the development of metabolic disease as we devour sugar treats almost every day in variant forms. Sugar is not simply a source of extra calories. It is a direct contributor to the development of metabolic disease. But some sugars pose a greater threat compared to their counterparts. Excessive fructose ingesting especially in combination with surplus energy intake does have adverse effects on metabolic health, comparing glucose and fructose, glucose can be metabolized by all the body's tissues, but fructose can only be metabolized by the liver in any significant amount. Moreover, fructose from added sugars leads to higher ghrelin levels also known as "hunger syndrome", reduced satiety, insulin resistance, fat gain in the abdominal region, increased triglycerides and blood sugar and small, dense low-density lipopolysaccharides compared to similar number of calories from glucose. This knowledge and understanding will be more effective in slowing our epidemics of metabolic disease.   OBESITY MANAGEMENT Obesity management is expensive and, along with diabetes, obesity is a disease that needs to be defused. Medical costs rise progressively as BMI increases and are expected to continue to rise in the next 15 years. Obesity shortens life span and affects the function of many organ systems. Mortality results from several diseases that are associated with obesity, including diabetes, chronic kidney disease, gastrointestinal disease, and cardiovascular disease and maintaining weight loss is often difficult or unsuccessful. The first and foremost thing to manage obesity is to control the diet and to consume appropriate foods. According to a study by Prof George Bray MD, the energy intake should be reduced by 500 kcal/day below energy requirements or must use a dietary plan that has 1200–1500 kcal/day for women or 1500–1800kcal/day for men (increased by a further 300 kcal/day for each sex if weight exceeds 150 kg) (Prof George Bray MD, 2016). Even though, obesity is highly preventable, the measures taken to control it is not as effective as it is needed to be. When it cannot be prevented, treatment on various levels must be indicated. Physical activity, provides only a small effect on weight reduction, still, it is an important part of obesity management by conservation of the fat-free mass during severe weight loss and additionally it helps to encourage weight maintenance. It increases cardiorespiratory fitness. Physical activity counselling includes advice on both habitual physical activity in everyday life and structured supervised exercise. Exercise prescription must focus on a gradual increase to levels that are safe for the patient. The prescription should be tailor made for each patient. Dietary Prescriptions and dietary modifications should be custom made. Moreover, it can be used to help the patient identify insights and beliefs about cognition (emotional eating behaviour) and behaviour (eating habits). The management of eating disorders also appears as an imperative before reduction in energy intake. Weight maintenance would need spasmodic treatment with formula diet or drug remedies. Pharmacotherapy should be considered as part of an all-inclusive strategy of disease management. It can help to prevent the development of obesity co-morbidities (e.g. hypertension, type II diabetes mellitus). Current drug therapy is suggested only for patients with a BMI ? 30 kg/m2 along with an obesity-associated disease (e.g. hypertension or type II diabetes mellitus). Medicines should be used according to their licensed warnings and restrictions. Whether the therapy is useful or not should be evaluated by the first 3 months and treatment should be sustained only if weight loss achieved is considered reasonable (approximately 5% weight loss in people without and 3% in patients with diabetes). Progresses in waist circumference reduction should be used as alternative, more genuine indicator for accomplishment. Treatment should be discontinued in non-responders. One of the approved available drugs for weight management in Europe is Orlistat, which is a triglyceride lipase inhibitor and it decreases fat absorption by 30%. It contributes a modest effect to the lifestyle intervention when paired with hypocaloric low-fat diet. Several other drugs are currently tested in clinical trials for weight management worldwide. Soon such medicines are hoped to help bridge the gap between existing treatment options and needs of the patients. Bariatric surgery, when used in carefully selected patients is the most effective measure for inducing substantial weight loss. It is a part of a lifelong weight management programme and might have a follow-up of medical complications. Current evidence points to chief benefits in terms of prevention of type II diabetes, cardiovascular risk reduction and cancer reduction (mostly in women), and suggests increased longevity. The most frequently used surgical techniques now are adjustable gastric banding, sleeve gastrectomy, Roux-en-Y gastric bypass, biliopancreatic diversion or combined operations such as biliopancreatic diversion with duodenal switch. Proper communication with the patient is essential regarding the risk-benefit ratio and an experienced multidisciplinary team including the surgeon should cautiously access the selection of the right patient for the procedure.   RECOMMENDATIONS Strategies to address the global obesity epidemic require sustained, population-wide intercessions and policy approvals designed to improve diet and upsurge physical activity using a multilevel systems approach. Battling obesity requires synchronized efforts from the international community, governments, industries, health-care providers, schools and universities, urban planners, agricultural and service sectors, the media, communities and individuals. The agricultural and service sector can put forth nutritional and agricultural policies, which can be powerful instruments for preventing obesity if they are aligned with evidence-based national dietary goals. Legislation for removal of trans fats from the food supply is an important factor and it should be enacted along with replacing partially hydrogenated oils with oils that include omega-3 fatty acids. This initiative should be supported by government regulation, which could include inducements for the production and use of oils that are healthier, but this approach would require the agricultural and food industry sectors to work together. Implementation of taxes on unhealthy foods and beverages must be indorsed by the government, as well as the design and execution of food pricing policies, such as agricultural subsidies, should stress the need to increase availability and affordability of fruits, vegetables, legumes, nuts and whole grains. The governments should also encourage use of public transportation and bicycles by providing incentives including discounted transportation fares, and secure bicycle parking along with implementing taxes.  Voluntary actions and regulations (labelling calorie and nutrient content of foods) made by industry could be beneficial policies for improving diet quality both nationwide and worldwide. Growth in food marketing and advertising, has created major shifts in food demand as marketing leads people especially children to increase their consumption of advertised products. For this reason, the WHO recommends that governments and industry decrease the advertising and marketing of unhealthy foods and to improve the school meal programmes and policies related to vending machines are influential tools to address childhood obesity along with nutritional education about healthy diet and education about active lifestyles. Make sure to deliver educational pamphlets to parents for informed dietary choice. Public-health messages about healthy diet and lifestyle need to reach far and wide and this can only be possible with the help of the mass media and public service campaigns, like Change4Life in England, which aims in supporting people to make healthier choices about activity and food.       CONCLUSION Obesity has become an international public health issue that affects the HALYs, risk of morbidity, and raises health economics in countries all over the world. An individual does not become obese acutely, it is likely that the risk factors exist considerably long before evident indications of the metabolic syndrome and cardio vascular disease are expressed. Some individuals carry the risk from a very early age because of childhood obesity, while others do not reflect it until later in life. Therefore, it becomes matter of importance to provide risk inhibition to pre-symptomatic individuals.   Proper awareness must be spread to the public, to eradicate any lingering myths and misconceptions regarding the risk factors of obesity, how two calories are not the same and how diet and added sugars affect metabolism.   Social inequalities and stigmatization resulting in discrimination is very high for the obese patients. Reducing weight stigma and access promotion to healthier lifestyle options are the two vital points in management of the weight. The contemporary trends are suggesting a co-responsibility which is shared by both the society and the obese individual as it is hard to assess the accountability of an individual for obesity or future weight gain. REFERENCES   Brady, G., Frühbeck, G. Ryan, et al. (2016). D Management of Obesity. The lancet, 387(10031), pp. 1947-1956 Fao.org. (2017). 3. 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