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Made by:
Raúl Bustos Hernáiz

LESSON 1: Basic Principles in relation to body composition as a:
method to evaluate changes in EB

 Introduction
 Energy Balance and Body Composition Definitions
 Body composition methods
o -Direct
o -Indirect
 Applications
 Dual X-Ray absorptiometry (DXA)
 Selected bibliography

Energy Balance: The difference between energy intake and energy expenditure
Basal metabolism is the minimum level of energy that the cells needs to survive

The difference between RMR and BMR

Basac metabolic rate (BMR) is the amount of energy expended daily at rest, and the
resting metabolic rate(RMR) is in a neutrally temperate environment while in the post-
absorptive state
What does it mean body composition?
Type and number of components in the body (water, muscle, fat, bone...)
The way that the different components are distributed in the body (proportion)
How can you measure body composition?
1. Direct method. Chemical analysis using body and organs from dead animals
2. Indirect methods.

 -Anthropometry (skin folds and body circumferences).

 -Hydrostatic weighing
 -Bio-electrical impedance
 -Air displacement (BOD-POD)
 -Dual X Ray absorciometry (DXA)
 -Computer tomography (CT)
 Magnetic Resonance Imaging (MRI)

BI COMPARTIMENTAL MODELS (hydrostatic weighting)
Two type of tissues: Fat tissues and fat free mass tissues

It is a limited model


Three tissues: Body fat, body water content and rest of solids


Four tissues: body fat, water, proteins and minerals

For body proteins: Neutron Activation Analysis

For bone mineral content: DXA

Skin fold thickness and body circumferences

It’s the most commonly used field technique (easy to apply and economic)

It measures the subcutaneous fat mass and the body circunferences of one or more points of
the body

With the data you cant calculate: Body density, percentage of body fat, lean mass


It is based on the attenuation of the ionic radiation through the body structures.

It depends on: thickness and composition of the material that is trespassed

Maximum: Bone tissue

Minimun: Regions full of air


 Low radiation and high precision

 Reliable technique and highly valid
 Analysis of different body regions
 Safe and easy procedure: operator and patients
 3-c or 4-c technique


Utiliza irradiaciones ionizantes

Asume constante el contenido de agua de la masa magra (73%)

Endurecimiento de los rayos x por la atenuación que sufren al atravesar tejidos de

diferentes grosores

Interferencias causadas por la ropa

Existencia de diferentes marcas DEXA

LESSON 2 Positive energy balance: overweight, obesity,

diabesity and vigorexia
 Introduction
 Obesity: An Epidemic of the 21st Century
 When can we consider someone overweight/obese?
o -BMI
o -%BF
 Diabesity
 Vigorexia –Muscle Dysmorphia
 References

An excessive accumulation of fat mass in the body a as consequence of a prolonged an
sustained period of tie with a positive energy balance

What are the causes? (three theorys)

1. Our energy intake is bigger than in the past but we don’t increase the energy expenditure in
the same proportion

2. Same energy intake than in the past but we have disminished the energy expenditure

3. The energy intake is lower than in the past but we disminished our energy expenditure even


1. According to BMI.

Advantages: Easy to calculate, economic and non-invasive

Disadvantages: Low accuracy for special populations (Active people)

2. According to %BF

Through various techniques (anthropometry, DXA, ct…)

Advantages: Precision, precise for active people

Disadvantages: Expensive, irradiation, different populatios should have different levels

Not all types of obesity are the same: Body fat

distribution is even more important than total fat
mass or percentage of fat. Visceral fat located in
the central part of the trunk increases the risk of
cardiovascular disease

Associated conditions of obesity: Hypertension

 Cardiovascular diseases
 Hiper-lipidemia
 Non-insulin dependent diabetes (NIDD)
 Ictus
 Mood disorders
 Sleep disorders
 Nutrition disorders
 Gout
 Osteo-arthritis
 Cancer (various types)

Diabesity is so-named because of the close association of obesity and diabetes (type2). Obesity
typically comes first and type 2 diabetes comes later. This leads many to conclude that obesity
causes diabetes.

Elevated blood glucose levels and insulin resistance are two key aspects as visceral fat mmass

Diabesity could be consider as the new 21st century social epidemic, it is predicted to be 1 out
3 in 2050 in the USA

Clinical trials show that as little as 5% weight loss is enough to prevent most obese subjects
with impaired glucose tolerance developing type 2 diabetes


Is an anxiety disorder that causes a person to have a distorted view of themselves about their
appearance. It should start when you are an teenager or a young adult.

BBD can seriously affect daily life, often affecting work, social life and relationships

A person with it may:

 Compare always with other people

 Spend a long time in front of a mirror
 Become distressed by a particular area of their body
 Feel anxious when around other people and avoid social situations
 Excessively diet and exercise


It is a disorder in which a person becomes obsessed with the idea that he/she is not muscular

It is not considered as a formal disease if not as a mental disorder as anorexia nervosa

It is manifested by:

1. Extreme physical activity

2. A high and compulsive energy intake

Some of them also use steroids

However, not all the body-builders should be consider bigorexics, in the same way that not all
the dancers are anorexics.

Bigorexia might be related to an altered serotonin concentrations.

1 in 10 men in gyms in UK believed to have bigorexia

LESSON 3 Negative energy balance: Malnutrition, underweight

status, anorexia/manorexia and bulimia
 Introduction: the double burden of malnutrition
 The underweight status
 Anorexia Nervosa
 Bullimia

Malnutrition. When a person diet has an imbalance of the essential nutrients that the body
need s to remain healthy (special role for the immune systems)

Malnutrition could result in under-nutrition or over-nutrition

1/3 person in the world suffer from deficiency in essential nutrients. 3 most common are:

 Vitamin A (blindness in children)

 Iron (fatigue, infection, risk of hemorraging)
 Iodine (Thyroid gland)

Key concepts (WHO)

1. Malnutrition: Excess & defect

 In adults 1.9B overweight (>600m obese)

 In adults 462m are underweight (too thin for height)

2. In children

 Stunted: too short for age (>156m)

 Wasted: too thin for height (50m)


1. 156 million children are stunted

2. There are 41 million overweight children in the world, 10 million more than 2 decades ago

3. Wasting still threatens the lives of 50 million children around the world

A BMI lower than 18.5 g/m2 is usually refered to as underweight

Stunted growth is a reduced growth rate in human development. A

primary manifestation of malnutrition in early childhood. Once
established, stunting and its effects typically become permanent

Stunted children may never regain the height lost as a result of stunting,
and most children will never gain the corresponding body weight. It also
leads to premature death later in life because vital organs never fully develop during childhood


Decreases immune and non immune host defences, more probabilities of infectious diseases.

People who suffers underweight is not only about gross caloric intake if not intake and
absorptions of other vital nutrients

You also can be underweight with the possibility of intake good food (Anorexa nervosa and

Is an eating disorder characterized by refusal to maintain a healthy body weight, and an
obsessive fear of gaining weight due to a distorted self image. It is a serious mental illness that
has one of the highest mortality rates of any psychiatric disorder

The condition largely affects young adolescent women with between 15 and 19 years old
making up 40% of all cases. Recently a new term for men, manorexia, has appear

Possible signs of anorexia nervosa

 Rapid dramatic weight loss

 Russell´s sign: scarring of the knuckles by the gastric acids due to induce vomiting
 Lanugo
 Obsession with calories and fat content
 Fear of gaining weight
 Rituals: cuts food into tiny pieces
 Purging using laxatives, diet pills…

Possible causes

It has seen that the initial weight loss such as dieting may be the triggering factor in developing
AN in some cases

Socio-cultural studies have highlighted the role of cultural factors, as the promotion of
thinness as the ideal female

In women, being grossly underweight car result in amenorrhea and possible complications
during pregnancy. It can also cause anemia, hair loss and osteoporosis.

Is a disease and a type of eating disorder. It is when a person wants to starve (morir de
hambre) his or herself. People who have it feel that they are fat and want to be skinny. If they
eat a lot they try to take it back by vomiting, exercising or using drugs


Vomit can burn the person´s mouth, throat or teeth. The inmmune system is weakened, and a
person can get muscle or heart problems

Opposited to bygorexia, anorexia nervosa has been study for many years and is already
recognize as a disease, as a probe, many scientific studies has been published until date.

Do athletes have an increased risk of AN/bulimia?

Disordered eating occurs because:

1. Dieting and restrictive eating

2. Abnormal eating behaviour
3. Clinical eating disorders

The prevalence of these disorders are increased in elite athletes due to the perceived
performance improvements, perception of the paradigm of appearance and sociocultural
pressures for thinness or an “ideal” body

Athletes most at risk are for example, bodybuilders or who practise rhythmic gymnastics.

In addition to dieting, personality factors, early start of specific training, injuries, coaching
behaviour… are important risk factors

LESSON 4 Adipose Tissue Regulation

 Brief history AT as an endocrine organ
 Leptin and PA
 Adiponectin and PA
 Resistin and PA
 Ghrelin and PA
 Satiety cascade & appetite: eating behaviors
 Cross-talk between skeletal muscle and adipose tissue: a link with obesity?
 Irisin an PA
 Exercise as a poly-pill for chronic diseases

Adipose tissue produces and releases numerous proteins and substances with autocrine (same
cell) , paracrine (near the releasing cell) and endocrine( to the bloodstream) functions

2. ADIPOQUINES (Hormones secreted by adipose tissue)


It regulates body fat depots by their effects on metabolism and appetite. It also helps in
growth, reproduction, immune system, glucose metabolism and bones; metabolic
neuroendocrine hormone

Main function: Through its effects on metabolism and appetite

The problem of that hormone in obese subjects is the lost of sensibility at the hypothalamus

Relationship between leptine and exercise

1 hour aerobic. NO significant changes

Marathon, road cycling. Decrease in leptine levels

There is controversy because the reduction of fat mass storages or this change is due to the
training effect “per se”

Factors that influence leptine secretion: fasting, food, gender, time of the day and others

Main factor that regulated leptine is final energy balance


Leptin levels are directly and indirectly affected by physical activity

The intensity and duration of exercise and its effects on leptine level are mediated by the

Changes have to be before, during and after the exercise bout including 24-48 hours later


It is produced exclusively by adipocyte

Plasma adiponectin levels are found to be lower in obese subjects than in lean subjects.
Women have 40% higher circulating levels of adiponectin than men, because androgens
appears to have an inhibitory effect on adiponectin.

Low adiponectin levels are found to be a predictor of the later development of type 2 diabetes
and myocardial infarction.

We have seen negative correlations between:

1. Plasma adiponectin levels and BMI

2. Circulating adiponectin, insulin resistance, visceral fat and metabolic syndrome


1. Insulin sensitizing
2. Anti-atherogenic (Anti-inflammatory)
3. Angiogenic (anti-bodies formation)
4. Anti-tumour
5. Decrease free fat acids (FFA)

Two receptors

Receptor 1 (AdipoR1): Skeletal muscle

Receptor 2 (AdipoR2): Liver


In the liver it activates AMPK. This made a decrease in hepatic glucose output.

In skeletal muscle through adipoR1 cause glucose uptake and fatty acid oxidation


1. Adiponectine circulating concentrations exceeds the concentration of any other known

2. Less adiponectine , more BMI
3. It seems likely to be an adipose tissue derived factor which is secreted in higher
amounts when adipose tissue is accumulated
4. In healthy subjects adiponectin protects against the development of insulin resistance
and atherosclerosis

Adiponectin and exercise

Training without a weight loss has not been found to increase plasma adiponectin levels


Resistin levels increase with obesity and type 2 diabetes.

It increases LDL in human liver. AS a result, the liver is less able to clear “bad” cholesterol.
Researches has linked resistin with inflammation and energy homeostasis

2. 4 VISFATIN (Adipomyoquine)

It is present in visceral adipose tissue.

When more visfatin you have, less possibilities of having type 2 diabetes



Is a peptide hormone produced in the gastrointestinal tract.

When the stomach is empty, ghrelin is secreted. When the stomach is stretched, secretion
stops. It acts on hypothalamic brain cells both to increase hunger

Ghrelin and leptin receptors are found in the same place in the brain

Circulating ghrelin concentrations rise before eating and fall afterward (more strongly in
response to protein and carbohydrate than to lipids)

Secreted by the stomach Secreted by fat cells
You´re hungry, you should eat Stop eating, you are full


Restraint: A tendency for individuals to restrict their food inake in order to control their body

o Flexible: A graduated approach where forbidden foods can be eaten in limited

o Rigid: An all or nothing approach to dieting

Trait disinhibition: A tendency to overeat because others are eating, due to the presence of
palatable foods and due to negative effect.

o Internal: Eating in response to anxiety

o External: The presence of other eating

Hunger: The extent to which sensations to hunger are perceived, and the extent to which such
feelings evoke eating episodes

o Internal locus: Feeling so hungry because my stomach is empty (ghrelin)

o External locus: I am observing another people eating


Orexigenic properties. Appetite-stimulating

Anorexigenic properties. Appetite-inhibiting

Blood redistribution during exercise may be
important for suppressing ghrelin.

Overall, changes in appetite-regulating

hormones appear to be intensity-dependent like
appear in the table at the left


Type 2 diabetes, cardiovascular diseases, colon cancer, breast cancer, depression and another
defines a diseasome of physical inactivity

Physical inactivity appears to be an independent and strong risk factor for accumulation of
visceral fat, which again is a source of systemic inflammation

In response to muscle contractions, skeletal muscle releases myokines into the circulation. It
activates AMPK to increase glucose uptake and fat oxidation. In the liver increase glucose
production during exercise and lipolysis in the adipose tissue

The AMPK has emerged as an important integrator of signals that control energy balance
through the regulation of multiple biochemical pathways, as the uptake of glucose, the B-
oxidation of fatty acids and the biogenesis of glucose transporter.

It energy-sensing capability can be attributed to its ability to detect fluctuations in the

AMP:ATP ratio. During muscle stimulation, AMP increases while ATP decreases.

AMPK integrates stress responses such as exercise as well as nutrient and hormonal signalas to
control food intake, energy expenditure and substrate utilization at the whole body level

Cross talk between skeletal muscle and adipose tissue:

1. Myoquines like AMPK

2. Myoquines like IRISIN
It transformate white cells into brite cells
Brite fat-> regulates our corporal temperature. It has anti-diabetic and anti-obesity
White fat -> Bad fat
If you increase your irisin levels, your body weight is going to be lower.
Long term effect of exercise on irisin regulation is lack

LESSON 5 Objective measurement of energy expenditure

 Definitions

 Measurement of energy expenditure / physical activity

 Measurement of low energy expenditure: sedentarism

 The metabolic equivalent (MET)

 Calories

 Active Video Games-EXERGAMES

 E-Sports

 Counting energy expenditure vs. energy intake


Is the sum of all energy process in the body, both the production of energy as ell as the use of

Energy expenditure can be expressed in terms of oxygen. The term aerobic means with oxygen
and anaerobic means without oxygen

Each liter of O2 consumed by the individual is associated with an energy expenditure of

approximately 5 kcal

Energy expenditure

In biology, energy cames form carbohydrates lipids and proteins, which release energy when
reacted with oxygen in respiration. The actions requires certain energy, that is the energy

Physical activity

Includes any bodily movement produced by the skeletal muscles that results in a substantial
increase over resting energy expenditure

Leisure-time physical activity

The average person has 3-4 hours of free leisure time per day


Is a form of leisure-time physical activity that is usually performed repeatedly over an

extended period of time with an objective like fitness, health or performance.


Is a form of physical activity that involves competition

How can we evaluate energy expenditure and/or physical activity?

a) Reference methods: Direct(heat lost) and indirect(gas exchange) calorimetry, and

isotopes (double labelled water)
b) Objective methods: pedometer, accelerometers, arm band, heart rate monitoring
c) Subjective methods: questionnaires, interviews, direct observation and diaries
d) Other Indicators

Is sedentary the opposite of active?

The WHO says; Recent decades we have seen a change in the lifestyle, reducing our energy
expenditure at work besides a change in the diet that results in a deterioration of peoples

How can we evaluate sedentarism?

a) Number of hours devoted to sedentary activities

b) Hours of sleeps
c) Hours of extra-curricular physical activity, training
d) Others (soda, fast food visits, food portions)

In the USA, the risk of being overweight increase by a 34% when children spend 2 or more
hours per day watching TV


Is a physiological concept expressing the energy cost of physical activities as multiples of
resting metabolic rate (RMR)

It is defined as the ratio of metabolic rate during a specific physical activity to a reference rate
of metabolic rate at rest

Set by convention to 3.5 mlO2 kg min

1 MET is considered as the resting metabolic rate obtained during quiet sitting. MET values of
physical activities range from 0,9 (sleeping) to 18 (running at 17.5 km/h)

It is defined as the energy needed to increase the temperature of 1 gram of water by 1ºC.
About 4.2 joules

Ok, now we know how to count the cost of physical activity, lets see the other part of the

Do we really know what we eat? Is the labelling good enough?

Is really hard to know exactly how many kcal we are eating (per portion, per 100 g, per bag…)

LESSON 6 The physical activity (II): Metabolic Fitness and the

optimization of the fat oxidation during the exercise
 Metabolic syndrome (MS)

 Muscle Metabolic Fitness (MMF)

 Metabolic fitness (MF)

 Fat oxidation

 Metabolic flexibility

 The TOFI and the FOTI

 Metabolically healthy obese phenotype: fit but fat

Lifestyle related diseases is increasing globally and this development is explained in part by
increased inactivity, a sedentary behaviour and a low aerobic fitness.

Do we know really the new concepts that are appearing today?



Is a combination of medical disorders that increase the risk of developing cardiovascular

disease and diabetes. There are three mayor definitions:

By the WHO:
It requires the presence of one of:

 Diabetes mellitus
 Impaired glucose tolerance
 Impaired fasting glucose or insulin resistance

And any two of the following:

 Blood pressure: 140/90 mmHg

 Dyslipidemia
 Obesidad
 Microalbuminuria

By the American Heart Association

Requires at least three of the following:

1. Elevated waist circumference

2. Elevated triglycerids
3. Reduced HDL cholesterol
4. Elevated blood pleasure
5. Elevated fasting glucose

By the international diabetes federation

1. You have central obesity

Any two of the following:

 Raised triglycerids
 Reduced HDL cholesterol
 Raised blood pressure
 Raised fasting plasma glucose

Note: If BMI is >30 kg/m, central obesity can be assumed and waist circumference does not
need to be measured


Max. muscle mitoc. Oxidative capacity / max muscle oxygen uptake capacity


Is not well defined, but most often it is associated with blood lipid profile, blood pressure and
insulin sensitivity.

Positive changes in some metabolic variables were observed in all individuals after training.
The ability to oxidize fats during exercise is also used to study the metabolic fitness

Nowadays it is well known that just at the moment that a person start to exercise fat oxidation

How do we know which substrate are we using? The respiratory quotient.

RQ= Volume of C02 production/Volume of Consumed 02

RQ=1 (Mainly glucose consumption)

Rq= 0,7 (preferential fat oxidation)

If RQ is >1 means that C02 production can´t be compensated by the inhaled 02 (Anaerobic

During resting, one of the most influential factor on the RQ is the diet

If the person is in the fasting situation, the RQ tends to be close to 0-7(saving glucose
disposals), but if the subject is the post-pandrial situation a higher amount of glucose is oxidize
to avoid the glucose blood levels to increase too much

In the 90s one of the most controversial debates in exercise physiology was related with the
Cross over concept that tried to determine the equilibrium between fat and carbohydrate use.

G. Brooks vs Coggan, Tripton

2.4 What is fat max?

Fat oxidation reaches its maximum level at the intensity when appears fat max. If we follow
increasing this intensity, the contribution of fat decreases

In normal people it occurs in the range of 40—65% of VO2 max

One of the main adaptations in terms of substrate oxidation is a curve displacement up-words
and right-words (Fat max goes to the right)

There are many factors that influence fat oxidation during exercise:

Duration, Fitness Level, Intensity, muscle mass, V02 max, gender, fat mass, glycogen storages

2.5 What is metabolic inflexibility?

Impaired ability to transition between predominant lipid (postprandial) or carbohydrate

(prandial) oxidation in skeletal muscle

This is important because the inability to increase reliance upon fat oxidation may be related
to the pathogenesis of obesity.

Las mitocondrias de los músculos de los obesos OXIDAN mejor que las mitocondrias de los
sujetos controles que tienen un nivel de fitness similar

Las mitocondrias de los músculos de los diabéticos OXIDAN mejor que las mitocondrias de los
sujetos controles

3. Summary
Resting RER seems to predict the ability to oxidaze fat during exercise (FatMax)

Obese (and also diabetics) does not seems to have a reduced ability to oxidaze fat during
exercise while fasting

Thus, the metabolic inflexibility theory should be modified using data only from studies that
matched their subjects according to fitness levels (VO2max).

Fat oxidation needs further research in order to be confirmed as a useful metabolic fitness


Foti is the body fat person but he has a good healthy

Tofi is a slim person but he has a bad healthy. He has fat in the visceral organs.

Tofi has more probability of dead thatn foti in relation with cardiovascular disease

Better been in shape but fat, than thin but with a bad health

3.2 The metabolically healthy obese (MHO)

Some obese persons do not develop at short term the metabolic complications of obesity that
are thought to be causally linked to cardiovascular events or premature mortality.

In the EEUU 10% of adults have obese BMI and are healthy compared with who are metabolic
unhealthy and have a normal BMI who are 8%

26% of adults hve normal BMI and are healthy, whereas 21% have obese BMI and are

Conclusion: Compared with metabolically healthy normal-weight individuals, obese persons

are at increased risk for adverse long-term outcomes even in the absence of metabolic
abnormalities, suggesting that there is no healthy pattern of increased weight.

The nutrition: The importance and contribution of the fat
content in the diet. The Miracle Diets: Atkins Diet, Ketogenic
Diets, South Beach Diet
 Introduction: typical diet distribution
 Dietary fat importance
 The Miracle Diets:
o Low fat diet: The Ornish Diet
o Low CH – High Fat Diet: Ketogenic diets
o Low CH – High Protein Diet: Atkins Diet / Dukan Diet
o South Beach Diet

The most common diet distribution is:

- Carbohydrates (55-60%)

- Proteins (15-20%)

- Fats (25-30%)

Until 50s a high fat diet was recommended. At 70s a fat reduction was consider as a way to
prevent heart diseases.

At 90 was set up as a 25-30% of dietary intake

Who is Walter Willett?

Is the second most cited author in clinical medicine.

His best study follow 121700 female registered nurses since 1970s to asses risk factors for
cancer and cardiovascular diseases

A eight-year study of 49000 postmenopausal women investigate link between low fat diet and

In 1998, an interesting scientific debate start… 9 chapters


1st chapter: Dr Willet. Diets high in fat are not the primary cause of excess body fat.

2nd chapter: George Bray and Popkin. If you reduces fat you will reduce your body weight

3rd chapter: Willet. Chapter 2 is based on short-term studies. Total energy intake determines
body fat accumulation Saturated and trans fats should be replacing by poliinsaturated and
monoinsatured fats. Thanks of these trans-fats were legally avoided

What does it mean (Trans fat)?

Trans fat is the common name for unsaturated fat with trans-isomer fatty acids. Trans fats may
be mono or polyunsaturated but never saturated

The process of hydrogenation adds hydrogen atoms to unsaturated fats, eliminating double
bonds and making them saturated fats

The consumption of trans fats increases the risk of coronary heart disease

4rd chapter. Astrup: A reduction in dietary fat without intentional restriction of energy intake
causes weight loss

5th chapter. Astrup. Low fat diet to treat the obesity

6th chapter. Willet. Dietary fat is not a major determinant of body fat

7th chapter. Astrup. Dietary fat is a major player In obesity but not the only one

Astrup agreed(A) with Willet in some points and disagreed (D) in others:

1. Meta-analisis of randomized trial is the highest ranking level of scientific evidence (D)

2. In the long term. Subjects without help will gradually return to the high fat diet eaten by
their family and friends (A)

Conclussion of Arne Astrup editorial:

Total dietary fat intake should be reduced to under 30% of energy

American paradox (less dietary fat – more obesity)

8th Chapter. Replacing saturated fats by poliinsaturated is the best option to prevent CHD

9th chapter. Reduce dietary fat in long-term may be an important strategy for weight

Low fat vegetarian diet with less than 10% of calories from fat, 15-20% from protein, 70-75%
from carbohidrates.

No animal products except eggs.

All nuts, seeds, avocado, chocolate, olive and oils are eliminated except a small amount of
canola oil.

Also prohibits caffeine. Allows a moderate intake of alcohol and salt.

There is no restriction on calorie intake.


It replaces bad carbs and bad fats with good carbs and good fasts (It is not a low carb-diet)

Good carbs vs bad carbs

Bad carbs are those that the body digest quickly (high glycemic
index) and good carbs are unprocessed food like vegetables,
beans, and whole grain (low glycemic index)


LOW GI (55 OR LESS) Most fruits and vegetables, legumes,

whole grains, meat, eggs, milk, nuts, fructose..

MEDIUM GI (56-69) whole wheat products, basmati rice, sweet potato, sucrose

HIGH GI (70 OR MORE) Baked potatoes, watermelon, white bread, ost white rices, corn flakes,
cereals, glucose


It replaces trans-fats and saturated fats by unsaturated fats and omega-3 fatty acid which
contribute to HDL cholesterol.
The diet excludes the fatty portions of red meat and poultry

This diet is divided in 3 phases:

Phase 1 (First two weeks). It eliminates all sugars, processed carbohydrates, fruits, and some
vegetables. Its purpose is to eliminate the hunger cycle and a significant weight loss

Phase 2 continuoes as long as the dieter wishes to lose weight. It re introduces most fruit and
vegetables and some whole grains as well.

Phase 3. Is the maintenance phase and lasts for life. There is no specific list of permitted and
prohibited foods.

The body produce ketones when blood glucose decrease (fasting situation), an increase of the
glucagon levels produce the increase in the lipolysis and thus a rise in the FFA.

In the fasting continue Acetil CoA produce in the liver by the oxidation of FA is transformed
into “acetoacetate”

These two intermediates plus the acetone are named ketonic bodies which in fasting situation
are used by many peripheriacal tissues.

Once we eat again and the blood glucose rise, the “ketonic state” is broken

In 1951, Livingstone informed that thanks to the KD 54% of his patients maintain their
symptons under control and almost 26% reduce them

There are 3 main types of KD: the most used LCT, the less used MCT (often produces intestinal
problems) , and a mix KD for kids

Kd maintain the ratio of FAT/CH from 2:1 to 5:1

Lipid profil we see a favourable response to KD in cardiovascular risk factors (LDL, HDL…) most
likely due to the weight loss.


Noakes has claimed that high blood cholesterol is not a contributing factor to heart disease.

High in good quality saturated fats and no more than 50 g of carbohydrates per day

Who should bant? Obese, high blood pressure, type 2 diabetes, hypertension,

What is the RMR?

Paleo is low on carbs, the revolution goes even lower, and includes dairy in its eat-your-fill-list
a no no for paleoites


Hydrates, protein and fat in a balanced ratio (40-30-30)


It is based on a CH restriction and an unlimited intake of protein and fat that results in an
important weight loss without feeling any hunger


Induction. Two weeks. Most restrictive. Body enter in a state of ketosis

Ongoing weight loss. An increase in carbohydrate intake

Pre maintenance. Carbohydrates are increased in 10 grams each week, the key goal is to find
the Critical Carbohydrate Level for Maintenance, this is the maximum number of
carbohydrates you can eat each day without gaining weight

Lifetime maintenance. This phase is intended to carry on the habits acquired in the previous

2.7 DUKAN DIET. Low CH, high protein

More than 10 million copies are selled around the world

Its based on a list of over 100 allowed foods.

The diet is based on a list of over 100 allowed foods


The attack phase. 3 kg in 2-7 days. Eat as much as they want of 72 protein-rich fods

The cruise phase. Addition of 28 specific vegetables. 1 kg of weight loss per week.

The consolidation phase. During this time, fruit bread, cheese and starchy foods are
reintroducen in two meals a week

The stabilization phase: protein day once a week, eating oat bran every day and maing a
commitment to “take the stairs”.


It uses dietary supplements called: protein suppliers. During the weight loss phase only
vegetables and shakes are allowed. Then other type of foods are reintroduced


Consists mainly of meat, fish, vegetables, fruit, roots and nuts; and excludes grains, legumes,
salt, refined sugar and processed oils

In the same line “El mono Obeso” talks about the human evolution and the appearance of the
opulence diseases

1. What is perfectly known is that diet only involve one of the two major components of the
energy balance: the energy intake

2. If a wrong diet and lifestyle is present, it can temporary work, but when the diet is stopped
and the subject returns to the original lifestyle and diet, the chances of relapse are enormous

3. In the long term, behaviour modifications of diet and lifestyle are needed to succeed

4. Due to the changes in the nutritional habits, the energy intake is not what we eat, we are
also what we drink

5. No matter which diet you use, at the end the “hipocaloric” content will determine your
weight loss


Dieta cetogénica. En deportes de alta intensidad se mantienen los valores

En deportes de fuerza máxima estos valores no se mantiene


Ketone bodies are a good fuel for the muscle

 There is not enough evidence to recommend ketone body supplementation to athletes

 Ketone bodies are now sold as supplements and products often contain pretty wild

Lean and obese subjects increment the oxidation of fat as a consequence of a high fat load

LESSON 8 Pharmacology and drugs related to the energy

 Drug Management of Obesity —Efficacy versus Safety
 Anti-obesity medication
o -Anorexic drugs (suppression of the appetite or increase satiety)
o -Drugs to interfere with the body's ability to absorb specific nutrients in food
o -Drugs to increase body metabolism
o -Others (new, supplements & products)

In Europe EMEA (European Medicines Agency) approve o deny new drugs, in EEUU it´s done by
the FDA

The process involves several steps

1. Testing the drug on animals or in medical labs

2. The drug is tested for safety and effectiveness in humans (clinical trials)
3. Once approved, an company may manufacture and market the drug product to
provide a safe low cost alternative to the public

Depending on the action mechanism

1. Anorexic drugs (suppression of the appetite)

2. Drugs to interfere with the body’s ability to absorb specific nutrients in food

3. Drugs to increase body metabolism
4. Others

Catecholamines and their derivatives are the main tools used for this

Also, drugs blocking the cannabinoid receptors may be a future strategy for appetite

They act at the central nervous system liberating or involving nor-adrenaline and thus altering
the transmission of nerve impulses through neurotransmitors regulation

They exerts its behavioural effects by modulating several key neurotransmitters in the brain,
including dopamine, serotonin, and nor adrenaline

a. Amphetamine (increase metabolism)

b. Metanphetamine

c. Fenmetracine

They were banned in the 70s because they cause addiction and abuse.

They act on the agonist of the serotonin receptors and inhibit their absorption

1. Fenfluramine
2. Dexfenfluramine (Redux)

Both drugs were withdrawn in 1997 after report of heart valve disease and pulmonary
hypertension, including cardiac fibrosis

3. Selective inhibitors of serotonin re-uptake (Fluoxetine (Prozac) paroxetine and


The most famous is Sibutramine. It was approbed for the treatment of obesity in 1997. It was
sold under a variety of brand names including Reductil, Meridia and Sibutrex

This pill was prohibited in January 2010 because in patients with cardiovascular disease and
type 2 diabetes showed an increased risk of cardiovascular events, such as stroke.

Another famous was Rimonabant. Is an inverse agonist for the cannabinoid receptor CB1. Its
main effect is reduction in appetite. On 2009 was withdrawn.

Lorcaserin (Lorqess) has serotorgenic properties and is a weightloss drug. It has less adverse-
effects than the others

The most famous drug is Orlistat (Alli in spain). Its prevent the absorption of fats from the
human diet. Although the benefits are not impactant (2-3 kg more in a year)

It has side effects like fecal incontinence or bowel movements. Are not bought without a


Nowadays, only Orlistat and now Liraglutide(analogue of the GLP-1 that secretes intestine in
response to the presence of food) are used as anti´obesity drugs in spain

Liraglutide has seen to reduce a 9% of weight more in one year

Since 2012, a number of new drugs have become available, like the mediators of the gut-brain
axis, which is involved in appetite regulation

Apart from amphetamine, ephedrine is used as an stimulant, appetite suppressant and is

associated with anesthesia. It has side effects like tachycardia, nausea, insomnia, panic,

In the market, there are many other products not recognize as legal drugs but used as
nutritional supplements and/or weight loss products.



Is the indigestible portion of plant foods having two main components, soluble that is
fermented in the colon into gases, and insoluble that is metabolically inert easing defecation

It is believed to have satiety effects.

Glucomannan has been sold like the effects of fiber, but the FDA has not approved any
products with it.


Is an stimulant of the central nervous system. It has diuretic properties. The overdose of it can
cause fidgeting, anxiety, excitement…

Green tea has thermogenic properties similar to the ephedrine (reduce nutrients absorption
and activates lipolysis); same properties like chitosan or bionarval


It is a compound that is required for the transport of fatty acids from the cytosol into the
mitochondria during the breakdown of lipids. Highest concentrations of it are found in red
meat and dairy products.

It is found in two ways, L-carnitine and D-carnitine that is biologically inactive

Although L-carnitine has no scientific evidence to show that it improves weight loss. Like side
effects are hyperactivity, insomnia or nausea

What about performance?

Only three legal supplements have received significant attention over the years: creatine,
carnitine and sodium bicarbonate.

Current anti-obesity drugs aim to reduce food intake by either curbing appetite or suppressing
the craving for food but they almost always have dangerous side effects

Emerging knowledge on the role of the hypothalamus is enabling by managing peripheral

tissue output and it regulates higher brain functions, it can facilitate the discovery of new
agents that are more effective and with lower risk to fight against metabolic disorders such as

LESSON 9 Bariatric surgery and its consequences

 Introduction
 Bariatric surgery (BS)
 Surgical indications and techniques
 Physiology of the gastric bypass
 Efficacy vs. safety. Complications & benefits
 Adjustable gastric band & intra-gastric balloon
 Esthetic treatments for fat reduction

Bariatric surgery is the term encompassing all of the surgical treatments for morbid obesity


Any gastric bypass procedures leads to a market reduction in the functional volume of the
stomach, accompanied by an altered physiological response to food

A gastric bypass first divides the stomach into a small upper pouch a much larger, lower
remnant pouch and then re-arranges the small intestine to allow both pouches to stay
connected to it

The resulting weight loss, markedly reduces co-
morbidities. The long term mortality rate of gastric
bypass patients has been shown to be reduced by up to

However, complications are common and surgery-related death occurs within one month in
2% of patients

Who needs a gastric bypass?

Who was no other choice.

1. People who have a body mass index (BMI) of 40 or higher

2. People with a BMI of 35 or higher with one or more related co-morbid conditions

An increasing number of these operations are now performed by limited access techniques,
termed laparoscopy(small incisions)

Benefits include shortened hospital stay, reduced discomfort, shorter recovery time and
minimal risk on incisional hernia. Nowadays is the most commonly employed gastric bypass

Variations of the gastric bypass:

-Gastric bypass,Rouxen-Y(proximal)

-Gastric bypass,Rouxen-Y(distal)

-Loop Gastric bypass("Mini-gastricbypass")

-Bilio Pancreatic Diversion with Duodena lSwitch

The gastric bypass reduces the size of the stomach by well over 90% (1000 ml to 150 ml)

Is usually formed from the part of the stomach which is least susceptible to stretching. That
prevengs any significant long-term change in volume. When the patient ingest food, the wall of
the stomach pouch stimulates nerves telling the brain that the stomach is full

Changes in circulating hormone levels (ghrelin) after gastric bypass have benen hypothesized
to produce reductions in food intake and body weight in obese patients

It is important that the person only eat at mealtimes (5 meals daily)


Since 7% for laparascopic procedures to 14.5% for open incisions operations, during the 30
days following surgery

Contraside effects

1. Infection of the incisions

2. Hemorraghe.
3. Others. Bowel obstruction, anastomotic ulcer.

Nutritional deficiencies of calcium, iron, zinc or protein malnutrition

Emotional disorders. Many have depression in the following months due to change in the role
food plays. Energy levels in the period net will be low


During the surgery and after the weight loss.


Gastric Bypass makes a weight loss of 565 to 80% of excess body weight and reduces co-
morbid conditions:

 Hiperlipidemia
 Hipertension
 Obstructive sleep apnea
 Type 2 diabetes

Meta-analysis demonstrated in patients participating in exercise a mean of 3.62 kg greater

weight loss


Is an inflatable silicone device that is placed around the top portion

of the stomach in order to treat obesity. Complications usually
comes after three years requiring re-operation. It is also reversible

It is not usual for a person to gain weight after having a bad


It may be an option for bariatric patients who prefer less invasive

and reversible surgery.

Compared with gastric bypass, adjustable gastric banding has lower weight loss efficacy, but
also leads to fewer serious adverse effects.


The silicone balloon is placed and filled with liquid (600 ml) so it partially
fills the stomach and creates a feeling of fullness. The maximum time a
balloon can be left in place is 6 months before be removed

The risk of intestinal obstruction is much bigger after that time

In Brasil 323 with BMI 43kg/m2 lost an average of 48% of their excess weight.

2.1 The liposuction (cosmetic surgery) that removes fat from many different sites on the
human body. The safety of the technique relates in the amount of tissue removed and the kind
of anesthesic, also the patient´s health

Large quantites are more than 5 litres

It is done in men in abdomen and flanks, and in women in abdomen and thighs.

Fat is removed via a cannula (a hollow tube) and aspirator (a suction device). They are
categorized by the amount of fluid injection and by the mechanism in which the cannula works

1. Suction-assisted liposuction (SAL)

Is the standard method. A small canula is inserted through a small incision. The surgeon pushes
it carefully through the fat layer breaking up the fat cells

2. Power-assisted liposuction (PAL)

Used a cannula with mechanized movement, so that the surgeon does not need to make as
many manual movements

3. Ultrasound-assisted liposuction (UAL)

Are more risk of seromas (pockets of fluid). Is a good choice for working on more fibrous areas,
like the upper back or male breast area. There is slightly less blood loss.

4. Other techniques (TCAL, EUAL, WAL…)


 Allergic reaction to medication or material used during surgery

 Infection
 Damage to the skin (including necrosis)
 Contour irregularities:
o Thrombo embolism and fat embolization (low risk)
o Fluidimbalance

Other aesthetic treatments for fat reduction are:


3.1 Cryolipolysis is a medical device used to destroy fat cells. IT causes cell death of
subcutaneous fat tissue without apparent damage to the overlying skin

3.2 Ultrasound The new technology focuses the ultrasound frequencies to only target fat cells
in the body and essentially melts away the fat.

3.3 Cavitation (ultrasound) Waves at a frequency rate (35-40 khz) produce fat tissue

3.4 Mesotherapy. Employs multiple injections of pharmaceutical and homeopathic

medications and other ingredients into the subcutaneous fat Physicians have expressed
concern over the efficacy of mesotherapy, arguing that hasn’t been studied enough. Recently
it has been banned by the French National Agency of Health for being dangerous for human

3.5 Slimming creams

Those creams have ingredients that when applied on the skin encourages it to increase the
circulation, getting rid of toxins and excess water

The truth is that there are no scientific proof that cellulite creams are effective with it.

Cellulite Is a storage pattern of superficial fat. But is not the result of toxins (is the natural
anatomic contour characteristic of many women`s thighs and buttocks) It is unrelated to
weight gain or loss.

The only one that has been minimally probed is retin-a (tretinoin) for the acne treatment

LESSON 10 Appropriate physical activity intervention strategies

for weight loss and prevention of weight regain for adults.
ACSM Position Stand.
 Main reasons to perform a weight loss program
 Guidelines for an optimal and safe weight loss
 Contraindication of a severe diet
 Main goal of a diet
 Genetic vs. lifestyle
 Summary


1.1 What are the main reasons to perform a weight loss program?

 Health: Obesity has been associated with chronic diseases and health conditions such
as heart disease, diabetes, cancer..
 Because of the increased risk of bariatric surgery including anesthesia
 The subects are unable to perform at work
 Esthetic issues

Obesity is associated with premature death. Life expectancy is reduced by 6.5 years comparing
BMI of 40-45 kg/m2 to normal weight people.

The reduction is bigger when BMI is 45-50 (9), 55-60(10) and 60-65(14)

1.2 What does it means a “healthy diet”?

In 2001 ACSM says:

Guidelines for an optimal and safe weight loss

1. Those that are nutritionally equilibrated and complete

2. Those that maximize fat loss and minimize the fat free mass loss

Guidelines and recommendations for an optimal and safe weight loss

It is recommend to know that:

1. Prolonged fasting that severely restrict the energy intake are scientifically non desirable and
can be dangerous from a medical point of view.

2. Diets and prolonged fasting that seriously restrict the energy intake normally result ingreat
loss of water, electrolytes, minerals… with a minimum fat loss

3. Moderate energy restrictions (500-1000 kcal less than needed) results in a lower water,
electrolytes, minerals and fat free mass losses and are less prone to cause bad nutrition

4. Dynamic exercise of the bigger muscles helps to maintain the FFM, including lean mass and
bone mass, and helps to maximize weight loss. The weight loss that results of an increased
energy consumption is mainly due to fat loss

5. The sustained weight loss should not exceed 1kg per week, including an exercise program
and also an eating behaviour modification program

6. To maintain the benefits, a whole life compromise is needed, maintaining appropriate

nutritional habits and a regular physical activity

Summary of an optimal and safe weight loss

1. Energy intake should not be lower than 1200 kcal/day in adults including variety of foods

2. Including suitable food for the costumer

3. Producing a negative energy balance of aprox 500-1000 kcal per day less than needed (max
1 kg per week)

4. Behavioral modification techniques are needed to maintenance positive nutritional habtis

5. A regular physical activity program(aerobic) is needed

6. Nutritional habits and active lifestyle need to be maintained

1.3 Why not a diet with less than 1200 kcal?

 Glucose levels while fasting are markedly reduced in obese

 In non-diabetic this type could result in a glucose intolerance
 Urine ketonic bodies are found to appear after many hours
 Hiperuricemia is common in people fasting
 Reduction of urine excretion of uric acid.
 Elevated levels of electrolyts in urine during fasting
 Increased risk of dizziness and weekness
 Increased excretion of potassium


Two studies

1st. Minnosota trial demonstrate that a 45% reduction in daily calories (24 weeks) produce at
week 12 a reduction of 11.5 kg which only 5.3 were fat. After 24 weeks another 4.1 kg (15.6k
total) were lost and only 2.8 kg were fat (8.1 kg total)


2st. A moderate restriction (500-1000 kcal day) after 8 weeks a mean of 6.4 kg were obtained
of which 89% were FM and only 11% were FFM


Other similar studies has put similar results (79-21/68-32)

When weight loss occurs an increase of HDL is present.

Including physical activity in the weight loss program normally produce an increase in the
energy expenditure and collaborate in the maintenance or increase of the FFM while the FM is

1.4 What is more important in order to lose weight? Diet or exercise?

It is true that diet induces bigger weight loss than exercise alone and produces higher
reductions in systolic blood pressure, total cholesterol and blood glucose levels

It is true that exercise alone can also produce weight loss even in the absence of caloric

The best combination is DIET + EXERCISE

Low calorie diet + 30’/d exercise

The real question is not what is more effective way to lose weight if not How should I perform
a healthy weight loss?

1.5 Is diet an important issue in the athletes?

The use of rapid weight loss and frequent weight fluctuation among athletes have been
considered a problem for years. A high proportion of athletes are using extreme weight-
control methods.

The most urgent needs are: develop sport-specific educational programs for athletic trainers,
modifications to regulations and research related to minimum percentage body fat and
judging patterns.

And after a success weight loss… what´s next?

Thus, a weight loss program should not be just a plan to lose weight, it should include
behavioural changes.

Knowing that:

1. Maintaining the appropriate weight loss is a whole-life task

2. Miracle diets are normally ineffective
3. Regular physical activity is needed

1.6 Can genetic risk associated with complex diseases be offset by behavioural changes?

Almost 50% of the risk of those with the highest risk of developing CVD can be reduced by a
favourable lifestlye