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WEIGHT MANAGEMENT: DEFINING ‘MORBID OBESITY’NIC

E defines morbid obesity ‘for the purposes of the guidance’ as:A BMI either equal to or greater than 40 kg/m2, or between 35 kg/m2 and 40 kg/m2 in the presence of significant comorbid conditions that could be improved by weight loss.Other authorities use a broader definition. According to Balsiger et al:Patients have morbid obesity when they are 100% or greater above ideal body weight (IBW), are at least 100 lb above IBW or have a BMI of over 35. A strictly weight-based definition is not appropriate, however, and a better definition of morbid obesity includes patients who have direct, weight-related serious morbidity, such as mechanical arthropathy, hypertension, type 2 diabetes, lipid related cardiac disease, and sleep apnoea.
People suffering from morbid obesityIn 1998, an estimated 0.6% of men and 1.9% of women in England and Wales had a BMI of 40 kg/m2 or more – this is equivalent to 124 000 men and 412 700 women. People with a BMI >35 have a rate of mortality at any given age double that of someone with a BMI of 20-25.*55/312/5*

STRIKE BACK AGAINST HEART ATTACK: HOW TO SURVIVE A HEART ATTACK

Your chances of living to talk about your heart attack increase greatly if you listen when your body is trying to tell you something. Although some heart attacks occur without any symptoms at all, any one of the following symptoms is a ‘strong warning that you are probably having a heart attack:(i) Uncomfortable pressure —not necessarily pain — in yourhest, most often experienced as a deep central discomfort (or feeling of fullness or squeezing) below the breastbone. This kind ofcrushing pain or heaviness in the middle of the chest is the mostcommon symptom of a heart attack (About a quarter of patients how-ever will not experience this sensation). If it lasts more than a few minutes, or if it subsides when you rest but increases with activity, that increases the likelihood that what you are experiencing is a restriction of blood flow to the heart muscle.(ii) Chest pain that radiates to the jaw, neck, back, shoulder or arm. In some patients, the pain is experienced primarily, or even exclusively, in other locations. (iii) Chest discomfort that’s accompanied by light-headedness, nausea, sweating or shortness of breath.Chest pain is unlikely to be a heart attack if it is — “Stabbing” pain that can be localized to one small spot on the chest (about the size of a coin). For instance, a feeling as if a pencil is being poked into the chest for an instant.Pain/discomfort that lasts for less than 30 seconds.Pain that is felt exclusively” in the region of the heart itself (that is the left side of the chest).If you experience any of the main symptom syndromes, immediately call for an ambulance to take you to a hospital, then take half a tablet of soluble aspirin (even if you already are on an aspirin regimen), either chewing it or allowing it to dissolve under your tongue. This self-administered aspirin therapy can in itself cut the risk of death by 40 per cent!Though an ambulance is often the fastest and safest way to get to a hospital, a friend or relative can sometimes drive you there faster. Delay in seeking expert medical attention is the most critical risk factor when a heart attack is taking place: a delay of even one to two hours can mean the difference between a small heart attack and a big one or even the difference between life and death. Doctors today have powerful drugs to dissolve the clots in the arteries that are causing heart muscle to die. But they work best if they are administered within an hour after the first symptoms begin; after six hours, they make little difference as most of the damage is irreversible by then. That is why cardiologists say, “Time is Muscle.” So, don’t stop to rationalize away the warning symptoms you’re experiencing as something else.    More don’ts:Don’t waste time going to your family doctor’s clinic or to a small nursing home. What you need is a hospital with an 1CCU (Intensive Cardiac Care Unit) which is geared to provide specialized emergency care.(Ideally, you need to practise Early Cardiac Care: if you are at known risk for heart disease, get to know and keep a list of hospitals in your areas of residence and/or work, in advance. Also keep a list of phone numbers: ambulance services, friends, relatives).Don’t try to drive yourself to the hospital, or to go by foot, cab, bus or train.And remember:Youth is no guarantee against a heart attack. Even if you are in your 20s, a long episode of chest pressure needs to be promptly evaluated by an expert to exclude the possibility of a heart problem, even a heart attack.Many heart attacks occur in those without any of the traditional risk factors for heart disease. So even if you have no history of high blood cholesterol or hypertension, do not ignore prolonged episodes of chest discomfort.Some heart attacks are signalled by atypical symptoms, which may fun the gamut from heartburn to sudden, recurrent vomiting. Complaints that arise with activity and subside with rest often also serve as early warning signs of a heart attack.*54\332\2*

MAIN FOOD SOURCES OF FAT: DIETARY FAT

The major food sources of fat in the Australian diet as determined by the CSIRO Division of Human Nutrition. The personal pattern of fat intake will need to be considered when advising individuals about eating for fat loss.

What is dietary fat? Dietary fats or triglycerides are made up of three fatty acids joined together by a glycerol molecule. Oils are fats in liquid form and these have the same energy value (i.e. 9kcal/g) as ‘hard’ fats. Hence all fats and oils have been generally thought to have the same effect on body fat storage, although there is now some controversy about this. In terms of other health issues such as blood cholesterol level, the type of fat is known to be more important. Fatty acids in foods can be divided into two major categories: saturated and unsaturated. Within the unsaturated category, there are also two major classes: monounsaturated and polyunsaturated.

Fats in food contain a mixture of all types of fatty acids but in different proportions. For example, com oil contains around 14 per cent saturated, 32 per cent monounsaturated and 52 per cent polyunsatured oil and butter contains about 52 per cent saturated, 23 per cent monounsaturated and 1 per cent polyunsaturated fat. It’s a common misconception that only animal fats are saturated. Most plants and oils contain some saturated fat and in coconut and palm kernel oil, the saturated fats are the dominant ones (based on the fatty acid of greatest concentration).

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WEIGHT LOSS: DEFINING BULIMIA NERVOSA

The DSM-III-R, published in 1987, substantially improved the definition of bulimia, largely because physicians had had time to study many more Patients with the condition. The revised definition reads as follows:

Diagnostic criteria for bulimia nervosa

A. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a

discrete period of time).

B. A feeling of lack of control over eating behavior during the eating binges.

C. The person regularly engages in either self-induced vomiting, use of laxatives or

diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain.

D. A minimum average of two binge eating episodes a week for at least three months.

E. Persistent over-concern with body shape and weight.

 

One subtle but significant change appears in the very name given to the illness: from bulimia to bulimia nervosa. Such a change, never made lightly, was the result of intense debate by experts on both sides of the Atlantic.

When the disorder first attracted notice, experts focused attention on the single symptom of bulimia-”ox hunger,” or uncontrolled bouts of overeating. Bulimics resemble anorexics in many ways, especially in their attitudes about body shape and weight. The main difference, however, is that a bulimic’s weight is more likely to fluctuate-sometimes wildly-yet on the average it tends to stay within the normal range. An anorexic, by contrast, falls considerably below even a minimal normal weight.

Different experts proposed a variety of terms to identify these patients. A British physician, Gerald Russell, introduced the term bulimia nervosa in 1979. The name identifies more than just the symptom of overeating and helps forge a link with anorexia nervosa. Of course, you can’t please all the people all the time, especially when those people are doctors. The controversy over the name continues.

The first criterion in the DSM-IH-R attempts to define an eating binge. Even so, the definition is somewhat vague: What exactly constitutes “a large amount of food”? How rapid is “rapid”? And what qualifies as a “discrete period of time”?

Actually, this vagueness is purposeful and has its advantages. It grants physicians some leeway in applying the standard to different patients.

“Rapid” simply suggests that the food is consumed quickly. A normal person might eat a normal meal in, say, half an hour. At a formal dinner she might eat a larger amount of food, but that dinner might stretch out over the entire evening. In contrast, a bulimic will often gorge herself as quickly as she can, sometimes eating a day’s worth of food within fifteen minutes.

“Discrete time” sidesteps the need to specify the period over which the patient eats. This is an improvement over the 1980 version of the DSM, which stated that the binge usually takes “less than two hours.” True, most binges occur within that time, but I treat patients who get home from work around six o’clock and begin eating whatever they can find. When that’s gone they send out for pizza. Finally, around ten o’clock they make a bee-line for the convenience store, where they buy as much ice cream and as many cookies as they have money for, then dash home and continue eating. These people qualify as bulimics, even if their eating binge doesn’t quite match the original guideline.

The second criterion makes the crucial point that the bulimic feels her eating behavior is out of control. In this way she resembles alcoholics or drug addicts who also can’t control their behavior. Her lack of control produces strong feelings of shame and inadequacy. To compensate she goes to extreme lengths to regain mastery, but as we have seen, such actions just perpetuate the vicious cycle.

The third criterion identifies the flip side of binge eating: weight control through extraordinary means. The authors of these revised guidelines felt that purging or other similar behavior was such a cardinal feature of the syndrome of bulimia that it deserved a listing of its own. The guideline also helps differentiate between bulimics, who tend to be of normal weight, and people who just overeat. This latter group may be overweight, a problem that requires a different therapeutic approach.

The fourth criterion specifies that the pattern of bingeing and purging must reach a certain severity before medical intervention becomes necessary. By stating the frequency with which binges occur and by indicating that the behavior must persist for a certain period of time, the DSM-IH-R helps differentiate those people with a severe disorder from those who might binge only occasionally. The actual figures (at least two episodes a week for three months) are useful but somewhat arbitrary.

The last criterion, addressing the bulimic’s distorted attitudes about her body, appeared in the manual only after a lot of wrangling. Some physicians felt that bulimics showed their “over-concern” about the body simply through the extraordinary measures they use to control weight. Surely, they argued, self-induced vomiting by itself reflects over-concern about the effect of food; another criterion would just be redundant.

However, other experts felt that the extreme importance bulimics (and anorexics, for that matter) attach to body shape and weight is an essential feature of the illness. In fact, without evidence of these distorted attitudes, some physicians are reluctant to enter a diagnosis of bulimia, choosing to classify the problem as a type of depression or some other variety of disturbed eating.

Almost all of the people I see for bulimia express concern about body shape to one degree or another. If a patient doesn’t appear to have these attitudes, I attribute their absence to my inability to perceive them, or to the patient’s skillful ability at disguising them.

The 1980 criteria stated that depressed mood was an essential component of the illness. The new version drops that requirement. Many patients do have depressive symptoms. The strong association between eating disorders and depression suggests a possible link somewhere in the brain: The cause of one may be the cause of the other. In the past, some experts thought of eating disorders as just one subtype of depression.

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GET YOUR BODY MOVING: RUNS TO READ— AND LOST 68 POUNDS

Rebecca Harding wasn’t always an exercise buff. In fact, the 49-year-old Salt Lake City woman used to shy away from most physical activity because she was too ashamed of her size. Now, she’s an avid runner, sometimes going out twice a day. And she’s 68 pounds lighter.

What transformed this former couch potato into a fitness fanatic? She credits Books on Tape.

“I was always much heavier than I wanted to be,” Rebecca says. “As a teenager, I was 30 pounds overweight.” Through marriage and three pregnancies, she continued to gain. By age 35, she weighed 204 pounds.

All the while, Rebecca’s self-esteem plummeted. She began avoiding social events, and even dreaded grocery shopping, for fear that she’d run into someone she knew who’d notice how much she had gained. “All I wanted to do was stay home and eat,” she says. “The more I ate, the worse I felt about myself. The worse I felt about myself, the more I ate.”

Rebecca’s turning point came the day she waited in a hospital emergency room with one of her sick children. “A nurse asked me when my baby was due,” she said. “I was mortified. I wasn’t pregnant.” she says. “Then and there, I made up my mind to slim down.”

Out went the junk food and fast food, replaced by healthful choices such as whole-grain cereals for breakfast, salads for lunch, and skinless chicken breast—stir-fried in lemon juice instead of oil—for dinner.

For exercise, Rebecca joined a walking group in her neighborhood. As she got trimmer and fitter, she went out on her own, graduating to jogging and eventually to running.

Rebecca enjoyed the faster pace of her workouts, but she missed the companionship of her walking-group buddies. To keep herself from getting bored, she decided to listen to Books on Tape while she ran. “I had used the tapes occasionally while I was driving, and I enjoyed them immensely,” she explains.

She began borrowing tapes from her local library and listening to them during her workouts. “I told myself that I could play them only when I was running,” she says. “If I got really caught up in a particular tape, I’d run twice in one day just to finish it.”

That may explain why she was able to lose 68 pounds in just 8 months. Fifteen years later, she maintains her weight at 136 pounds. And she continues to eat healthfully and run daily, always with her Books on Tape in tow.

“Just recently, I ran to a tape of The Horse WhispererRebecca says. “Later, when I drove my route to measure it, I couldn’t believe how far I had gone. Almost 9 miles up a steep hill—and in the rain. I hadn’t even noticed because I was so into the tape.”

WIN NING ACTIO N

Catch up on your reading while you work out. Listen to ^ Books on Tape, available at most libraries, while you run, walk, or do other types of exercise. The stories will keep your mind occupied, and you’ll finish your workout before you know it. In fact, you may even find yourself looking forward to your next session. A word of caution, however: If you live in an area where there’s lots of traffic, you may want to leave your headphones at home. You need to know what’s going on around you, for safety’s sake.

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