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Obesity

Obesity

BMI               BMI 2      BMI 3

There are people who look good when thin, there are others who look good when fat. Generally when type 2 patients are uncontrolled in their sugar control, there is weight loss due to the excess catabolism by glucose.

Increased obesity was observed in all ages, genders, races and educational levels with an increased magnitude among those in their 20`s with some form of college education. One fourth of the children and adolescents between the ages 6 and 17 are overweight!

Effects of being obese

Negative attitudes towards obesity are very common, lead to depression and these people experience discrimination from society. They usually try their level best to find excuses from shying away from exercise such as blaming the sweating, the itching, and the discomfort by rubbing of thighs and increased axillary pad of fat and having rashes between skin folds on the neck, axilla, below the breasts, in the groin and between the thighs. Getting dresses also is a problem though there are some shops that cater only to the oversized.
The risk is deadly!
Control of weight is important to prevent or manage blood pressure, diabetes, joint related problems, cancer of the endometrium and ovaries among women and cancer of the colon, snoring and disturbed sleep patterns( called Obstructive sleep apnoea), gall stones, impotence and even depression.

The impact of obesity

Disease                                                   Relative risk in men                            Relative risk in women

Type 2 diabetes                                                   12.7                                                          5.2
Hypertension                                                       4.2                                                             2.6
Heart attack                                                           3.2                                                            1.5
Colon cancer                                                         2.7                                                             3
Angina                                                                      1.8                                                           1.8
Gall bladder disease                                            1.8                                                            1.8
Ovarian cancer                                                        —                                                             1.7
Joint problems                                                       1.4                                                          1.9
Stroke                                                                         1.3                                                          1.3

Normally people tend to gain weight with age due to change in their physical activity or small changes in diet. Weight gain can also be seen during pregnancy, menopause, adolescence, just after marriage or among those who stop smoking.
What causes obesity?

All are aware of the sedentary lifestyle- spending more time on the couch or bed. Too much of a dependence on automated chores such as having remote controlled devices for almost every chore at home- such as for opening and closing the gates, the doors, for raising and closing the blinds, for turning on and off the lights , turning on and off the cooking range, even controlling the television, having washing machines and what not!

It is a well known fact that when there is a mismatch between the intake of food and the expenditure of calories, obesity sets in.

Many still to this day blame their genes and poor forefathers for their obesity!

There are some other causes for obesity :

Cessation of smoking can cause an increased appetite and reduced metabolic rate which can cause a modest raise of weight. (NO! This does not mean smoking is good for weight control!)
• There are medicines such as anti diabetic medicines, anti depressants, steroids in large doses for a long duration and some medicines for treatment of fits which can cause weight gain.
Types of fat

There are two types of fat on a person. They are subcutaneous fat and visceral fat. The former is seen just under the skin and latter seen internally around the organs.

Subcutaneous fat acts like a cushion to protect the body. It acts a storehouse of energy. Excess subcutaneous fat will give the flabby arms and thighs and is easily burned off with exercise than with diet alone.

Visceral fat increases the waist line tightening the internal organs. Thin people also have visceral fat which makes them as prone for diabetes and cardiovascular diseases as much as for obese people. Excess visceral fat is linked to increased triglycerides ( bad cholesterol), reduced High density lipoprotein ( good cholesterol), elevated blood pressure and elevated blood glucose.

Belly fat goes by many names such as beer belly, pot belly, abdominal fat, organ fat or intra-abdominal fat. Visceral fat is located inside the peritoneal cavity packed in between the internal organs as opposed to subcutaneous fat ( found underneath the skin) and intra muscular fat ( found interspersed in skeletal muscle) An excess of visceral fat is known as central obesity and the abdomen protrudes excessively.
Role of fat: Fat serves as a site for storage of energy, fat effects release of fatty acids in response to signals and functions as an endocrine organ

Apple sized, Pear sized, and Lemon on match stick are different ways to describe those overweight or obese.

There are variations of the size of a person with changes in gender and ageing.

In males, there is a greater lean mass, bone mineral mass, muscle mass in arm, reduced fat mass, less limb mass, greater central fat and larger stronger bones ( there are exceptions though)

Among women, after pregnancy there is increased visceral and central adiposity. Subcutaneous fat is more among women

How to measure level of obesity?

There are different methods to measure accurately the quantity of body fat- underwater densitometry, dual energy X ray absorptiometry, total body water estimate and bioelectric impedence.

Body Mass Index (BMI)
BMI is a common term used by the health care team to describe if you are in range for normal weight to height . This is calculated by dividing the weight in kilograms by the square of the height in meters.
BMI does not reflect the regional fat distribution. But, BMI may not be suitable for measuring among the elderly due to reduced lean body mass.

Although Asians have lower BMI than westerners, they have a higher % of body fat. Only 1/5 of the total body fat is located centrally of this ¾ is subcutaneous. Visceral fat usually increases in both sexes.
A person of BMI 25 has a 5 fold risk of developing type 2 diabetes than a person of BMI 22. If the BMI is increased to 30, the risk is increased to 28 times and the risk is increased to 93 times if the BMI is raised to 35 and more.
The common misconception that only visibly over weight and obese people have belly fat needs to be debunked. Waist to hip ratio is a better marker than the weighing scale in knowing how much belly fat one has.

If the waist Hip ratio is <0.8 (males) < 0.75(females) the risk is low
If the waist to hip ratio is 0.96-1.0 (males) or 0.81-0.85 (females) the risk is moderate
If the waist to hip ratio is >1.0 (males) and >0.85 (females) the risk is high
While assessing the treatment options, the healthcare professional has to take into account the expectations, the level of motivation, the activity history, screen for psychiatric disorders and eating disorders. There are so many diets available in the market each one claiming to be better than the other. The same applies to the various health programs each claiming to give better weight reduction than the other competitors. Losing weight can be frustrating to both the clinician and the patient.

How to reduce weight?

Even a 5-10% weight reduction can help to reduce blood pressure, lipids, insulin resistance, prevent joint problems and improve the quality of life and improve the psyche of the patient.

A simple step of reducing just a spoon of sugar a day can help you reduce 500 cals a day!

Though there are many medicines to help reduce weight, remember there are side effects with each. There are herbal medicines as well. Some of the so called weight loss powders have had side effects due to some of the chemicals incorporated in them. But, the silver lining is that there is nothing to beat a controlled food intake, eat sensibly and exercise in some form to burn off more than what you ate. There are just no short cuts to reducing weight. You need essential nutrients and you need a good breakfast. Drink plenty of fluids in the form of water and go for natural unprocessed food.

Doing some stepping or spot jogging exercises while watching television, pilates exercises, Yoga or Tai Chi , doing some aerobics or hula hoops in the confines of your room, can also help to reduce weight. This negates the excuses of not having a good neighborhood for exercising.

Visceral fat deposition can be reduced by losing weight the healthy way, de-stressing by meditation and deep breathing exercises, hydrating well with fluids, taking a healthy diet containing enough of fiber, fruits and vegetables, wheat bran, fish, non roasted nuts, green tea avoiding junk food, fruit punches, alcohol and leading a life which is physically active.
Did you know Ghee and Butter contain essential fatty acids? You may recollect that those in the past generation ( and even today)used to have thick rotis ( made with dough of wheat) with a dash of ghee or butter on them for food in parts of northern India. But, you must also remember that these people used to expend the energy as well. Having such rotis and relaxing on a sofa, in today`s world can be a suicide.

More processed food contains less of vitamin B12.

Read more in the post titled, “Weight loss”

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exercise and diabetes

exercise and diabetes

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Benefits of exercising:

  • Improves body posture and balance
  • strengthens the bones and muscles
  • improves collateral blood flow
  • Improves insulin sensitivity
  • improves sugar, blood pressure and lipid levels
  • improves endurance levels
  • increases the HDL, good cholesterol, levels
  • reduces central obesity
  • helps to loosen up the taut muscles
  • improves flexibility of joints
  • psychological well being
  • reduces stress
  • improves lean body mass

You must have heard from doctors to exercise, but probably not knowing how much to exercise or how to exercise. Lifestyle modification which includes diet, physical activity, cessation of smoking and alcohol, all form the cornerstone in management of diabetes mellitus.

American Diabetes association recommends 150 minutes of exercise a week. There are 3 main types of exercise- aerobics, flexibility and resistance training. Aerobic exercises increase the heart rate and breathing rate. These  include jogging, swimming, running, brisk walking, cycling and dancing. Resistance training involves use of weights. Flexibilty exercises include stretching exercises such as gardening, walking, doing household chores and taking the stairs.

Remember the following:

1) do a comprehensive medical check up including the heart, eyes, feet and kidney before starting a program.

2) Do warm up exercises and stretches for 5 minutes before active exercise.  Focus on stretching calves, thighs, neck, low back and shoulder group of muscles. Hold the stretch for 30 seconds. Breathe freely.

3) perform the active exercise for a minimum of 20 minutes( you may have to adjust the time according to your age and ability).

4) cool down for 5 minutes where by the heart rate comes back to the levels before exercise.

5) The maximum heart rate to be achieved is calculated as follows- 220 minus your age is the target heart rate. By exercising you should achieve 60-75% of the target heart rate.

6) Try to take a break half way through the exercise regime especially if doing for an hour. Sugar levels can come down and so it is wise to have half a glass of orange juice or have a couple of dates or half an apple or half a banana.

7) Core muscle group involve the muscles supporting the back and abdomen. These also have to be concentrated upon.

8) Do exercises which improve balance like standing on one leg. You may have to hold on to something for support at the beginning.

Beware of these problems before exercising:
Those with eye problems should not do resistance training with weights and heavy exercises which jar the head as it will cause a bleed within the eyes. Similarly, those with feet problems or heart problems also have to be careful with heavy exercises. Cycling and swimming are more beneficial than jogging among those with feet nerve problems or heart problems.

Check the sugar levels before exercising  and after cooling down.

Remember to hydrate yourself with fluids while exercising. Check sugar levels before exercising. If the levels are low ( 100 mg/dL or <5.5 mmol/L) always take some snack like bread slice or biscuits so that sugar levels do not fall with the exercise. You can have orange juice or plain candy bars if the sugars are low.Likewise, if sugar levels are very high, reduce the levels with insulin shots and proceed for the exercise regime after consulting with the health care provider.

Never inject insulin before exercising

While doing resistance training, remember not to use heavy weights, but use small weights and increase the repetitions. . Sugar levels fall with exercise unless you do a high intensity exercise ( like sprinting) when the sugars will increase.

Walking is still the best exercise, wear appropriate clothes, avoid exercising outdoors during extremes of climate( hot and cold) and don proper footwear.

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Are there any barriers to exercising?

  • If a type 1 diabetic, having high blood sugar levels > 300 mg/dL or having ketones in blood.
  • If type 2 diabetic having high blood sugar or low blood sugar
  • If having an advanced retinopathy ( eye affection in diabetes)- seek consultation with eye specialist before exercising.
  • If having nephropathy ( kidney affection in diabetes) – can affect delivery of oxygen to tissues and increase protein in urine.
  • If having peripheral neuropathy- ( nerves affected by diabetes)- patients will not have any sensation and so can land in problems.
  • If having a heart problem, one is advised not to stress the heart too much

Some common excuses to avoid exercising:

  • shame
  • laziness
  • lack of time
  • poor lighting
  • harsh climatic conditions
  • being overweight and all people are “staring”
  • costs of exercising
  • racial and cultural reasons
  • sweating induced itching of body and mal odour
  • Fear of hypoglycemia

 

 

Gunner Borg devised an exertion scale , a tool that helped define how hard one felt during any particular activity:

  • grade 0      if  feeling nothing at all
  • grade 1      if feeling very weak
  • grade 2     if feeling weak
  • grade 3     if feeling moderately weak
  • grade 4     if feeling somewhat strong
  • grade 5     if feeling strong
  • grade 6     if feeling stronger
  • grade 7    if feeling very strong
  • grade 8    if feeling more difficulty
  • grade 9    if feeling  very difficult
  • grade 10  if feeling extremely difficult

walking to good health 16

walking to good health 17

There are some other forms of exercise which can be used to break the monotony.

  • Running backwards- less problems for joint injury but have to be in a safe environment.
  • Cycle karoke- pedaling on a stationary exercise cycle and singing at the same time. If out of breath, go slow on the cycling. If one can sing well, then increase the tempo of the cycling.
  • Troga- yoga on the treadmill. But the speed of the treadmill should not be more than 3 mph. Be careful of falling.Not recommended for the elderly or with joint problems.
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