1. Diabetes & Heart Care Clinic Dr.R.Ravindranath M.D. Consultant in Cardiac & Diabetic Care H2, Turnbulls Road , 1 st Cross street, On Chamiers road (Next to Canara Bank) Nandanam, Chennai – 600 035 Phone: Clinic 24355368 , Residence 42112244 , Mobile 9381047102 The loser is the winner

3. and views too !

5. Even when I stop still, my body parts keep moving Paunch sliding, heart palpitating and chest heaving At times I feel difficult even to talk I really wonder how long I can walk. Many a shopping arcade I am in and out in search of a pair Pants I see all - none fit at all, I return panting in despair Ego asks me to get at least a slack or shirt Evenings pass by as I return home ditheringly hurt. My aching feet, having their arches totally flat Ask for a supporting pair of shoes before I return to my flat As the shoe racks are empty, even the fastidious salesman becomes tedious Swears he to me, “Nowhere you can get your footwear in the entire radius.” Dr.R.Ravindranath M.D. (Gen. Med.), F.C.C.P., F.R.S.H. (London) Consultant in Diabetes & Cardiac Care travails of an Obese * ‘ Trying’ to be at ease

6. Matters still turn worse when I go with meters of cloth Sarcastically tells the sartorial, “With all my skill I cannot clothe” As he has stopped making pants for elephants Decades ago when he was working under circus tents. When I go to a hotel, my diet plan goes a-bust As I see a tempting menu, my resolution goes to dust At the nearby gym, I try out the treadmill However hard I run, my body does not share my mind's goodwill Back at home, during the festival of lights My family refuses me any sweets, putting up fights They drag me to a doctor, who advises me to go on a diet But looking at my stout self, I loudly cry and can't keep quiet. At parties nobody asks me to dance Discreetly conveying I am too big for my pants People living nearby say 'Neighbors envy, owner's pride' Because I could pass through the door only by my side.

7. Things seem to settle a little at last When I make up myself to go on a fast Even at the nearby 'McDonalds', I could not go for a dip As my doctor kept me on a liquid diet, only a sip. All the constant teasing and frustration around Finally made me look at myself round and round My 'doc' strictly forbids my favorite chocolate cake He tells me listen up man, your life is at stake. To avoid all these, I try to bring down my bane Quickly and completely before I go insane I will be Mr. Handsome, a man, really a man I won't prey, only pray as much as I and you too can! Dr.R.Ravindranath M.D . Consultant in Diabetes & Cardiac Care

9. Introduction : Time for a change Throughout much of recorded history, people struggled to get enough food to eat. Today, many people in the world, remain undernourished. However, a good majority of us face the opposite situation: we are overweight and find it difficult to lose the unwanted kilos. This is a major public health issue because being overweight can lead to serious health problems. Every year in India, about 300,000 adults die from causes related to excess body weight. We cannot change our genetic make-up, but the good news is that we can make a difference in two of the key factors that contribute to premature death: cigarette smoking and eating habits. Individually, in our communities, and as a country, it is time for us to make a comparable change in the way we eat. This type of change is needed in order to address the epidemic of Obesity .

21. Contributing Factors Energy Imbalance When the number of calories consumed is not equal to the number of calories used Weight Gain: Calories Consumed > Calories Used Weight Loss: Calories Consumed < Calories Used No Weight Change: Calories Consumed = Calories Used Looking back at the energy balance scale , weight gain is a result of extra calorie consumption, decreased calories used (reduced physical activity) or both. Personal choices concerning calorie consumption and physical activity can lead to energy imbalance.

25. Complications and Consequences

28. Health Consequences Type 2 Diabetes What is it? Type 2 diabetes used to be called adult-onset diabetes or non insulin-dependent diabetes. It is the most common type of diabetes in India. Type 2 diabetes is a disease in which blood sugar levels are above normal. High blood sugar is a major cause of early death, heart disease, kidney disease, stroke, and blindness. How is it linked to overweight? More than 80 percent of people with type 2 diabetes are overweight. It is not known exactly why people who are overweight are more likely to suffer from this disease. It may be that being overweight causes cells to change, making them less effective at using sugar from the blood. This then puts stress on the cells that produce insulin (a hormone that carries sugar from the blood to cells) and makes them gradually fail. What can weight loss do? You can lower your risk for developing type 2 diabetes by losing weight and increasing the amount of physical activity you do. If you have type 2 diabetes, losing weight and becoming more physically active can help you control your blood sugar levels. Losing weight and exercising more may also allow you to reduce the amount of diabetes medication you take.

29. Health Consequences Heart disease and stroke What is it? Heart disease means that the heart & circulation (blood flow) are not functioning normally. If you have heart disease, you may suffer from a heart attack, congestive heart failure , sudden cardiac death , angina (chest pain), or abnormal heart rhythm . During a stroke , Blood and oxygen do not flow normally to the brain, possibly causing paralysis or death. Heart disease is the leading cause of death, and stroke is the third leading cause. How is it linked to overweight? People who are overweight are more likely to suffer from high blood pressure , high levels of triglycerides (blood fats) and LDL cholesterol (a fat-like substance often called the &quot;bad cholesterol&quot;), and low levels of HDL cholesterol (the &quot;good cholesterol&quot;). These are all risk factors for heart disease and stroke. In addition, people with more body fat have higher blood levels of substances that cause inflammation . Inflammation in blood vessels and throughout the body may raise heart disease risk. What can weight loss do? Losing 5 to 15 percent of your weight can lower your chances for developing heart disease or having a stroke. If you weigh 200 pounds, this means losing as little as 10 pounds. Weight loss may improve your BP, triglyceride, and cholesterol levels; improve how your heart works and your blood flows ; and decrease inflammation throughout your body.

30. Health Consequences Cancer What is it? Cancer occurs when cells in one part of the body, such as the colon, grow abnormally or out of control and possibly spread to other parts of the body, such as the liver. Cancer is the second leading cause of death in the world. How is it linked to overweight? Being overweight may increase the risk of developing several types of cancer, including cancers of the colon, esophagus, and kidney. Overweight is also linked with uterine and postmenopausal breast cancer in women. Gaining weight during adult life increases the risk for several of these cancers. Being overweight also may increase the risk of dying from some cancers. It is not known exactly how being overweight increases cancer risk. It may be that fat cells make hormones that affect cell growth and lead to cancer . Also, eating or physical activity habits that may lead to being overweight may also contribute to cancer risk. What can weight loss do? Avoiding weight gain may prevent a rise in cancer risk. Weight loss, and healthy eating and physical activity habits, may lower cancer risk.

31. Health Consequences Sleep apnea What is it? Sleep apnea is a condition in which a person stops breathing for short periods during the night. A person who has sleep apnea may suffer from daytime sleepiness, difficulty concentrating, even heart failure and sudden death . How is it linked to overweight? The risk for sleep apnea is higher for people who are overweight. A person who is obese may have more fat stored around his or her neck. This may make the airway smaller . A smaller airway can make breathing difficult, loud (snoring), or stop altogether. In addition, fat stored in the neck and throughout the body can produce substances that cause inflammation . Inflammation in the neck may be a risk factor for sleep apnea. What can weight loss do? Weight loss usually improves sleep apnea. Weight loss may help to decrease neck size and lessen inflammation.

32. Health Consequences Osteoarthritis What is it? Osteoarthritis is a common joint disorder . With osteoarthritis, the joint bone and cartilage (tissue that protects joints) wear away. Osteoarthritis most often affects the joints of the knees, hips, and lower back. How is it linked to overweight? Extra weight may place extra pressure on joints and cartilage, causing them to wear away . In addition, people with more body fat may have higher blood levels of substances that cause inflammation . Inflammation at the joints may raise the risk for osteoarthritis. What can weight loss do? Weight loss can decrease stress on your knees, hips, and lower back, and lessen inflammation in your body. If you have osteoarthritis, losing weight may help improve your symptoms.

33. Health Consequences Gallbladder disease What is it? Gallstones are clusters of solid material that form in the gallbladder. They are made mostly of cholesterol and can sometimes cause abdominal or back pain. How is it linked to overweight? People who are overweight have a higher risk for developing gallbladder disease and gallstones. They may produce more cholesterol, a risk factor for gallstones . Also, people who are overweight may have an enlarged gallbladder, which may not work properly. What can weight loss do? Weight loss, especially fast weight loss (more than 1 kilo per week) or loss of a large amount of weight can actually increase your chance of developing gallstones. Modest, slow weight loss of about 1/2 to 2 pounds a week is less likely to cause gallstones.

34. Health Consequences Fatty liver disease What is it? Fatty liver disease occurs when fat builds up in the liver cells and causes injury and inflammation in the liver. It can sometimes lead to severe liver damage, cirrhosis (build-up of scar tissue that blocks proper blood flow in the liver), or even liver failure. Fatty liver disease is like alcoholic liver damage, but it is not caused by alcohol and can occur in people who drink little or no alcohol. How is it linked to overweight? People who have diabetes or &quot;pre-diabetes&quot; (when blood sugar levels are higher than normal but not yet in the diabetic range) are more likely to have fatty liver disease than people without these conditions. And people who are overweight are more likely to have diabetes. It is not known why some people who are overweight or diabetic get fatty liver and others do not. What can weight loss do? Losing weight can help you control your blood sugar levels . It can also reduce the build-up of fat in your liver and prevent further injury. People with fatty liver disease should avoid drinking alcohol.

35. Metabolic Syndrome A high waist circumference can be one sign of a condition called Metabolic Syndrome Although most people have never heard of it, this syndrome is quite common; it affects about one out of every five adults in India. Metabolic Syndrome often progresses to type 2 Diabetes and treating the syndrome can help prevent this form of diabetes. If you think you may have Metabolic Syndrome, it is important to discuss the possibility with your doctor so that you can undergo the appropriate diagnostic tests. Treatments for Metabolic Syndrome involve basic lifestyle changes, such as losing weight, eating a healthier diet, and increasing your activity level. Your doctor can help you develop a specific plan for making the necessary changes.

36. Metabolic Syndrome ( Syndrome X ) A person has Metabolic Syndrome if they have at least 3 of the 5 conditions listed in the table below Aim for 20-pound loss/year* Replace white bread with brown bread, whole grains, cereals Weight loss Increase soluble fiber High blood sugar after fasting 110 mg/dL or greater Raise omega-3 fatty acids Aim for 20-pound loss/year Replace soda, juices with seltzer, water, diet soda Limit: 2 drinks/day for men; 1 drink/day for women Eat fish twice/week Weight loss Reduce simple carbohydrates Limit alcohol High triglycerides level 150 mg/dL or greater Aim for 20-pound loss/year 30 minutes of moderate activity 5 days a week Replace cookies, candy, cakes with unsalted almonds, walnuts, peanuts Stop smoking Weight loss Increased physical activity Cut carbohydrates, eat more monounsaturated fats Low HDL (good) cholesterol Men: 40 mg/dL Women: less than 50 mg/dL Aim for 20-pound loss/year Salt shaker off the table; no salt when cooking Get at least 5 servings/day Get 3 glasses of skim milk, low-fat yogurt, cheese/day Weight loss Reduced salt intake More fruits and vegetables Low-fat dairy products High blood pressure 130/85 mm Hg or greater Cut 250 calories a day*; lose 1/2 pound a week; aim for losing 20 pounds in a year 30 minutes of moderate activity 5 days a week Weight loss Increased physical activity Abdominal obesity (measured by waist circumference) Men: > 40 inches Women: > 35 inches Practical Suggestions Treatment Condition

37. Childhood Obesity

40. Childhood Obesity Health problems for kids Few health problems are observed in obese children. But they may develop conditions that cause problems later in life, such as high blood pressure. They may also suffer from 'sleep apnoea '. When this happens, soft tissue in the throat blocks the airways during sleep. This can stop their breathing for up to a minute. This process can happen hundreds of times a night, leading to cardiovascular disease, memory problems, headaches and fatigue. Some obese children may develop type II diabetes . Normally this condition only starts much later in life. When it strikes, the body stops being able to process sugar properly and the cells are starved of energy. Type II diabetes cannot be cured , but it can be treated. It may lead to complications such as nerve damage, heart disease, kidney disease and blindness. Children with this condition will have to live with it all their lives, increasing the chance of complications.

42. Childhood Obesity What Treatments Are Available? Our feelings of hunger are controlled by a part of the brain called the 'hypothalamus' . This takes its cue from a number of different chemical messengers, or hormones, circulating in our blood. New drugs Current weight-loss drugs are mainly amphetamine based . They increase the amount of nor-adrenaline and dopamine hormones in the blood, lowering hunger levels. However, they are not suitable for long-term use and side effects can include high blood pressure, anxiety and restlessness. Lifestyle changes What is required is a complete change in lifestyle . More exercise, a healthier balanced diet and realistic expectations can help make the change permanent. To become more healthy doesn't require huge weight loss.

45. Advice on Childhood Obesity Can giving kids food as a reward cause obesity? Using food as a reward is never a good idea because your child will learn to value certain 'treat' foods and may turn to food for comfort. Use non-food rewards instead – they don't need to be large material rewards. One of the best motivators is praise! Should I tell my child off for being fat? Your child may already feel upset about their weight. Telling them off will only make them feel worse and may add to the problem if they then turn to food for comfort. Don't single out your child as the one with the problem. The whole family can make healthy changes to their lifestyle. Is it worth forbidding fattening foods? Forbidding certain foods can make them seem more attractive. Teach your child about the health value of foods, particularly those that are rich in vitamins and nutrients. Make your home a healthy food zone. Fill up the fruit bowl instead of buying biscuits and crisps. Your child is likely to model themselves on your behavior, so choose healthy food options whenever possible.

46. Advice on Childhood Obesity Should I offer my child a choice of food? Research has shown that when there is more choice available we tend to eat more. Even the sight or smell of tempting food can override the body's natural mechanism of regulation so we eat when we're not hungry. You might want to offer your child a choice, but keep the options to a minimum. Are 'weight management camps' a good way to treat obesity? They can be . One of the problems is keeping that weight off. If the child comes home and none of the family members have altered their eating habits, improvements may be difficult to sustain. At what age should kids be treated for obesity? Parents of even young children can make sure the family changes to a healthy lifestyle rather than targeting weight loss specifically. Children grow at different rates and many overweight children will 'grow out of it' as they grow taller. Few treatments are targeted at children under the age of seven years. From age eight to 10, a child who is obese should have a medical evaluation to assess the severity of the problem. The older your child is, the less likely they are to grow out of it . A 15-year-old who is overweight is likely to remain so in adulthood.

48. Tips for Parents Ideas and Tips to Help Prevent Childhood Overweight Balancing Calories: Help Kids Develop Healthy Eating Habits Encourage healthy eating habits. Look for ways to make favorite dishes healthier. Remove calorie-rich temptations! Balancing Calories: Help Kids Stay Active Help kids stay active. Reduce sedentary time.

49. What Do I do ?

51. Lowering Health Risks

56. Enter the Doctor

58. Nutrition History Form 100ml

59. Beyond Kilos: The measurements that count Know your Body Mass Index (BMI) What is your waist circumference? Body fat that accumulates in the stomach area (described as &quot;abdominal obesity&quot;) is more of a health risk than body fat that builds up in the buttocks and thigh areas. For this reason, your waistline provides valuable information about your risk for heart disease, high blood pressure, high cholesterol, and type 2 diabetes. Waist circumference 40 inches (100cms) or more in men 35 inches (90cms) or more in women. Too High If

60. Beyond Kilos: The measurements that count Know your Body Mass Index (BMI) Your BMI is based on your height and weight. What is your BMI? Are you overweight or obese? Normal Overweight Mildly Obese Grossly Obese Not everything that counts can be counted, and not everything that can be counted counts - Albert Einstein

62. What is your waist circumference? Body fat that accumulates in the stomach area (described as &quot;abdominal obesity&quot;) is more of a health risk than body fat that builds up in the buttocks and thigh areas. For this reason, your waistline provides valuable information about your risk for heart disease, high blood pressure, high cholesterol, and type 2 diabetes. Doctors consider a waist circumference too high if it is 40 inches or more in men, or 35 inches or more in women.

64. Steps you can take Obesity treatment is not a lesson, but a course to make a new YOU

66. Diet

69. Myths & Realities Myth : Drinking hot water with lime & honey early in the morning helps losing weight? Fact : Early morning body is in post absorptive state & it is a good idea to hydrate the body, which improves metabolism but it has no effect on weight loss. Weight loss is a combined outcome of total caloric intake, macronutrient modulation & level of physical activity. Myth : I have totally stopped sugar in tea/coffee, yet I do not lose weight? Fact : Stopping sugar in tea or coffee or going low on aerated drinks is a good way to reduce your total caloric intake, but this should also be supported with a decreased intake of other refined sugar products which includes biscuits, breads, bakery products, romali roti, naan & fried preparations & a programmed aerobic exercise input. Myth : I have been walking for 6 months but have not achieved weight loss? Fact : It is very important that you understand the essentials of walking. You should be walking as per your Target Heart Rate which is calculated as (220- your Age). Take 60% of the figure obtained. ( e.g. if your age is 30 your target heart rate will be 220-30= 190 multiplied by 60/100, which is = 114 beats per minute or 4 beats per 2 seconds). You should be doing a brisk walk at this target Heart rate for at least 20 minutes. An accumulated physical activity of 60 minutes per day at a desired heart rate will lead to weight loss.

70. Myths & Realities Myth : Can I consume rice or potato if I want to lose weight? Fact : Rice & potato have a higher glycemic response as compared to chapati thus should not be over-emphasized in weight loss diets. They can surely be consumed in restricted amounts. Myth : Do I have to be off chocolates if I wish to lose weight? Fact : Consuming restricted amounts (a small piece) of dark chocolate may add to the flavonoid intake in the diet & may be cardioprotective. It will be a good idea to make them as 'some time' foods instead of 'every day' foods. Myth : Eating behavior has no relationship with the psychological state of the person? Fact : Eating behavior has a direct relationship with your state of mind. Behavior modification is a key to bring about control with regards to undesired eating behavior.

71. Weight watching food priorities 1. Load your diet with plenty of fibrous vegetables & fruits. 2. Get good quality fat containing foods in your diet like flax (alsi), tilseeds, methi seeds, melon seeds and nuts in your diet. 3. Add on the extra bit of protein by consuming soya, pulses, dals, nuts and oil seeds, low fat milk & curds, fish and lean chicken, egg whites. 4. Ensure adequate amount of good quality complex and fibrous sources of carbohydrates like whole pulses, coarse cereals like bajra, ragi, jowar, oatbran, wheat flakes etc. 5. Say NO to all refined starches. Like white breads, naans, romali rotis, bakery buns, pavs etc. 6. Eat 5-6 small frequent meals. 7. Get the exercise vitamin every day (60 minutes of accumulated physical activity - brisk walk, play, is a desirable standard to achieve weight loss).

74. Northern & Southern Region

75. Exercise

76. How Active Are You? Are you active at all ? In-line skating Weight lifting Playing actively with children Playing basketball or soccer Moving furniture Vacuuming Playing singles tennis Playing doubles tennis Hiking Digging a ditch Mowing lawn with hand mower Yard work/ gardening Step aerobics (6- to 8-in steps) High impact aerobics Dancing or tai chi Bicycling (> 14 mph) Bicycling (12 mph) Bicycling (10 mph) Swimming laps (vigorous effort) Swimming laps (light effort) Treading water Jogging (<10 min/mile) Walking or jogging (12 min/mile) Walking a mile in 15-20 min (3-4 mph) Very hard physical activity Hard physical activity Moderate physical activity

80. Weight-loss medications Some medicines are effective in helping obese patients lose weight. The guidelines for people who are candidates for medical therapy for weight loss are those with a: BMI of 30 or more and no risk factors for additional conditions BMI of 27 or more (but less than 30) with one or more obesity-related condition(s) or disease(s) speak with your doctor about the risks and benefits of these medicines.

81. Weight-loss medications

83. Conditions that may prevent weight loss If you have, or think you might have, any of the conditions on this list, or you are taking any of the medications listed, speak with your doctor about measures you should take to manage your weight. Bulimia Carbohydrate craving syndrome Eating Disorders Obstructive sleep apnea Upper airway resistance syndrome Sleep Congestive heart failure Idiopathic hypertrophic cardiomyopathy Heart valve disorders Cardiovascular Hormonal disorders Polycystic ovarian disease Cushing's disease Diabetes Hypothyroidism Hormonal Disorders Condition Category

84. Medications that may cause weight gain Neuroleptics (such as Zyprexa and Risperdal) Schizophrenia Lithium (such as Eskalith and Lithobid) Manic-depressive illness Valproate (such as Depakene) Epilepsy Tricyclic antidepressants (such as Norpramin and Sinequan) Depression Progestins (a component of certain oral contraceptives, such as Lo/Ovral and Ortho-Tri-Cylcen) Contraception Alpha blockers (such as Hytrin, Cardura) Beta blockers (such as Betapace, Blocadren, Tenormin) Methyldopa (Aldoment) High Blood Pressure Antihistamines (such as Claritin, Allegra) Allergies Medication Condition

85. Breaking old habits Many of our choices with respect to the foods we eat, how we eat, and how we exercise (or don't exercise) are unconscious. In other words, we often develop habits as children, or as young adults, and we stick With those habits as we age without giving Much thought to how our choices may affect our health. The goal of this session, is to bring those unconscious choices to light, and to offer reasonable suggestions for new choices and new behaviors that will contribute to better health.

86. 2007 Nov 14

87. Thank you Diabetes & Heart Care Clinic Dr.R.Ravindranath M.D. Consultant in Cardiac & Diabetic Care H2, Turnbulls Road , 1 st Cross street, Nandanam, Chennai – 600 035 Phone: Clinic 24355368 , Residence 42112244 , Mobile 9381047102 We are here for you, to hear from you.