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Chapter 6

Chapter 6. Obesity and Healthy Weight Management. Health Problems with Weight and Obesity. Medical problems associated with the metabolic syndrome: Hypertension Dyslipidemia (high triglycerides and low HDL) Gout Polycystic ovary syndrome Diabetes Early cardiovascular disease

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Chapter 6

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  1. Chapter 6 Obesity and Healthy Weight Management

  2. Health Problems with Weight and Obesity Medical problems associated with the metabolic syndrome: Hypertension Dyslipidemia (high triglycerides and low HDL) Gout Polycystic ovary syndrome Diabetes Early cardiovascular disease Certain forms of cancer Inflammatory conditions Cholelithiasis (gall stones) Osteoarthritis Sleep apnea

  3. Estimating Caloric Needs • Harris Benedict equation for BMR: • Women: BMR = 655 + ( 4.35 x weight in pounds ) + ( 4.7 x height in inches ) - ( 4.7 x age in years ) • Men: BMR = 66 + ( 6.23 x weight in pounds ) + ( 12.7 x height in inches ) - ( 6.8 x age in year ) • Activity Factors for Total Energy Needs: • little or no exercise: BMR x 1.2 • light exercise/sports 1-3 days/week: BMR x 1.375 • moderate exercise/sports 3-5 days/week: BMR x 1.55 • hard exercise/sports 6-7 days a week: BMR x 1.725

  4. Body Mass Index (BMI) Body mass index (BMI) = kg/m2—see Appendix; concept developed >100 years ago by mathematician Quetelet BMI 19-25 = ideal body weight (IBW) BMI 26-29 = indicator of the metabolic syndrome BMI ≥30 = 20% overweight; class I obesity BMI ≥35: class II obesity BMI ≥40 = 30% overweight; class III obesity or “extreme obesity” BMI <19 = underweight BMI <16 = severe anorexia; generally necessitates hospitalization

  5. Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007 (*BMI 30, or about 30 lb overweight for 5’4” person) 1998 1990 2007 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

  6. Rates About 65% U.S. adults with BMI 25 per NHANES data About 30% with classes I and II obesity About 5% with extreme obesity (class III)

  7. Causes and Theories of Obesity Kilocalorie imbalance Sedentary lifestyles—old-time lumberjacks required 3500 to 5000 kcal/day; most adults now need about 2000 kcal/day Increased intake of sugar-based beverages Larger food portions

  8. Snack-size chips: traditional 1 oz size bag on left

  9. FYI Impact of Diet Quality Monounsaturated fats (oleic acid) increase daily energy expenditure; saturated fats (palmitic acid) lower energy expenditure (Kien and Bunn, 2008); the difference is as much as 275 kcal (Kien et al., 2005) Omega-3 and polyunsaturated fats related to reducedfat-cell size; saturated fat increases fat-cell size and number (Garaulet et al., 2006) Inclusion of a variety of high-fiber foods promotes cellular metabolism via inclusion of vitamins and minerals

  10. FYI Role of Eating Habits Increased chewing of foods related to smaller waist size (Murakami et al., 2007) Young children in the U.S. who eat less often in the day consume larger portions; by toddler age self-regulation of kilocalories based on need is less effective than in infancy (Fox et al., 2006) Obese women have been found to have a higher intake of carbohydrates; obese men have higher intake of fat (Duvigneaud et al., 2007) Avoidance of dehydration improves insulin resistance and promotes use of insulin (Schliess and Haussinger, 2003)

  11. FYI A Canadian study found preschool children were half as likely to be overweight if they did not drink sweetened beverages (Dubois et al., 2007) Two or more hours of watching television increased odds of overweight adolescents by 50%(Fleming-Moran and Thiagarajah, 2005) Typical portions in a college setting were found to be significantly larger than 2 decades previous (Schwartz and Bryd-Bredbenner, 2006) Monosodium glutamate (MSG) related to increased appetite and obesity in rats; increased fiber intake and physical activity found to counter this effect (Diniz et al., 2005)

  12. Physiologic Influences on Obesity Genetic predisposition with the thrifty gene appears to enhance weight gain; hyperinsulinemia found with the metabolic syndrome is lipogenic (creates fat) and inhibits lipolysis (impairs fat breakdown) Hyperinsulinemia decreases kilocalories available for daily physical energy needs with enhanced body fat storage and increases hunger due to interference with leptin’s role in appetite regulation and increased need for food as a reward system due to altered dopamine levels(Lustig, 2006) Insulin inhibits weight loss among those persons with obesity; lean tissue (muscle) is insulin resistant; adipose (body fat) tissue is insulin sensitive (Sebert et al., 2005)

  13. Hormonal Connections Increased cortisol production related to lack of deep REM sleep and skipping meals (cortisol associated with excess weight, especially central obesity) Hypothyroidism (low levels of T3 and T4 hormones) with decreased metabolic rate Deficiency of growth hormone leads to increased body fat (less growth hormone as we age)

  14. Hormones Affecting Appetite Leptin—lowers appetite Cholecystokinin—protein intake promotes production and promotes satiety Ghrelin—produced by the stomach; related to increased appetite

  15. Other Adverse Impacts from Adipocytokines Hormones related to obesity promote insulin resistance, heart disease, and cancer by increased Inflammation Elevated CRP and interleukin-6 (IL-6) Reduced anti-inflammatory hormone: adiponectin Clot formation Free-radicals

  16. Prevention of Obesity Is the Key Begin in infancy with appropriate weight gain during pregnancy and breastfeeding Develop positive food habits in childhood emphasizing goals of the MyPyramid and Dietary Guidelines Encourage high-fiber foods and slow-paced eating for satiety and goal of reduced food portions Avoid rewarding and comforting with food—promote alternatives such as flowers, card of thanks, praise Drink water or seltzer water or other sugar-free beverages Try diluting juice with seltzer, as done in Europe Include regular physical activity on most days, including physical education in schools; discourage excess sedentary behaviors (e.g., excess television, computer use)

  17. Calories Count 3500 kcal = 1 lb body fat Reduction of 500 kcal/day = 1 lb/week loss Alternative: increase physical activity for equivalent of 500 kcal/day May want to do combination low-cal + increased activity Advise maximum of 1- to 2-lb/week weight loss for long-term success and maintenance of lean muscle mass Individual needs vary because of metabolic differences (e.g., thrifty gene, amount of muscle mass, medication effects)

  18. Weight-Loss Tips Plan must be individualized per lifestyle and food habits—no “one diet fits all” Emphasize satiety through chewing more; reduce pace of eating Include fiber in meals for “fullness” (e.g., people have been known to eat ½ gal of ice cream at a sitting, but never ½ gal beans) Include some unsaturated fats (take as long as 4 hr to leave the stomach) Include the minimum number of servings from the MyPyramid Food Guidance System: this approach is healthful and likely to be successful Legumes can substitute for some grains for goal of increased fiber with trace minerals and B vitamins

  19. Set Realistic Weight Goals Desirable weight goals are achievable weight goals Desirable weight goal may not be IBW per the BMI A weight loss of 10 to 15 lb often will normalize blood glucose in a person with diabetes A weight loss of 10% is significant; a weight loss of 15% is considered very significant; permanent weight loss of >15% seldom occurs Slow, sustained weight loss of ½ lb/week is most likely to be permanent weight loss and preserve muscle mass Persons needing to gain weight rarely gain more than ½ to 1 lb per week

  20. Popular Weight-Loss Strategies

  21. Calorie-Control Approaches Exchange lists for weight management—aimed at kilocalorie restriction MyPyramid—minimum number of servings promotes modest kilocalorie restriction while promoting good nutritional intake for general health needs Food labels—guidelines provided at 2000 kcal can be an appropriate level for active adults with high kilocalorie needs; guidance based on macronutrient intake can be modified (e.g., 1500 kcal at 200 g CHO, 60 g PRO, and 50 g fat)

  22. The Low-Fat Approach Rationale: 9 kcal/g fat versus 4 kcal/g carbohydrate and protein Volume-wise: ½ cup sugar = 400 kcal versus ½ cup fat = more than 1000 kcal Drawbacks: food companies increase sugar in fat-free foods (i.e., some fat-free products have more kilocalories than their original low-fat versions) People assume if a food has no fat, it has no kilocalories (e.g., 1 L soda pop = 0 g fat) but actually has more than 400 kcal

  23. Variations of the Low-Fat Approach Low-fat with additional focus on high-fiber foods or “good carbohydrates” Point system—Weight Watchers™ Lower points for foods high in fiber and low in fat Moderate-fat with high fiber Therapeutic Lifestyle Changes (TLC) diet

  24. The Low-Carbohydrate Approach Rationale: insulin causes weight gain Problems Most low-carbohydrate diets are extremely low (less than 50 g carbohydrate per day) The high protein includes high-fat foods, and usually no distinction is made between saturated and unsaturated fats No solid evidence exists that insulin causes weight gain, but no solid evidence exists that it does not RDA for carbohydrate set at 130 g minimum

  25. Variations of the Low-Carbohydrate Approach Moderate-carbohydrate intake with high-fiber foods, high lean-protein sources, and emphasis on unsaturated fats The low glycemic index (GI) diets Partially misleading because GI charts take into account only foods eaten alone, not as part of a meal

  26. Non-Dieting Approaches Focus on hunger and satiety to base food intake Behavior modification: Avoidance of high-risk foods (those that prompt excess intake without satiety) Decreased pace of eating to promote satiety Consistency of mealtimes and food choices Avoidance of starve-binge cycles

  27. Role of Physical Activity in Weight Management Burns kilocalories Increased metabolic rate for up to 24 hr with aerobic forms; long-term increase in metabolic rate with increased muscle mass from anaerobic exercise Can increase the number and function of mitochondria Can improve hormonal balance Improved mood can promote better food choices

  28. Aerobic versus Anaerobic Exercise Aerobic—form of exercise requiring increased oxygen; goal of at least 30 minutes on most days; weight loss may require 60 minutes Walking, running, dancing, cycling, cross-country skiing, most sports Anaerobic “without air”—contributes to weight loss via increased muscle mass; muscle pain associated with increased levels of lactic acid (excess pain associated with rhabdomyolysis and kidney failure) Weight lifting Combination aerobic and anaerobic Evidence suggests this is most effective approach for weight loss Hill climbing

  29. Obesity Medications Orlistat—potent inhibitor of intestinal lipases; side effects include diarrhea and potential nutritional deficiencies, especially of fat-soluble vitamins, decreased absorption of many prescriptions Meridia—appetite suppressant; can be prescribed short-term only Buproprion (Wellbutrin)—an antidepressant Topamax—not FDA approved for weight loss Controversial supplement: conjugated linoleic acid (CLA)

  30. Surgical Interventions Approved for class III obesity or class II with high mortality risk Gastric banding Least invasive and reversible; associated with 47% weight loss (Spivak et al., 2005) Stomach stapling Bariatric surgery Reduces stomach size to volume of about ¼ cup (micropouch procedure involves 1 tbsp volume) and bypasses a portion of the small intestine for decreased absorptive area

  31. Gastric Bypass

  32. Specific Nutritional Complications of Roux-en-Y Iron-deficiency anemia Folate deficiency (increased risk of neural tube defects, or spina bifida, with pregnancy) Vitamin B12 deficiency or pernicious anemia with concerns of permanent nerve damage Osteoporosis from decreased calcium absorption and altered metabolism of vitamin D Thiamin deficiency caused by excessive vomiting with potential for neuropathy, dry beriberi with memory impairment, heart failure, Wernicke’s encephalopathy (triad of inattentiveness, ataxia, or impaired muscle coordination, and paralysis of eye muscles) Hair loss caused by varied nutritional deficiencies: Biotin deficiency, decreased ferritin level, decreased vitamin D3(the active form), decreased l-lysine (an amino acid)

  33. Long-Term Effectiveness of Bariatric Surgery Stomach stapling procedures found with increased expansion of remaining stomach portion leading to regain of lost weight Increased ghrelin levels after 3 months of bariatric surgery promote increased appetite, despite reduction in stomach size (Garcia-Unzueta et al., 2005) Weight gain occurs over the long-term Evidence indicates only modest decrease in long-term mortality (Shah et al., 2006)

  34. Nursing Concerns Related to Bariatric Surgery Explain specific adverse health outcomes prior to irreversible bariatric weight loss procedures Rather than saying there are vitamin and mineral deficiency concerns, be specific (e.g., “B vitamin deficiency can cause irreversible nerve damage”) Support those who have had bariatric surgery Reinforce the need for small, frequent meals, avoidance of liquids with meals to prevent the dumping syndrome Reinforce the need for regular medical follow-up for those persons who have had bariatric surgery (e.g., review s/s to observe related to neurodegeneration and B vitamin deficiency, especially with emesis)

  35. Study Guide • Health Problems associated with Obesity • What is BMI based on? • What region has the highest rate of obesity? • Theories of Obesity (pg 217) • Kilocalorie imbalance • Diet Quality & Eating Habits • Altered Metabolism • Hormones • Genetics/Gender Differences • How does insulin affect lypolysis and lypogenesis? • Obesity prevention

  36. Study Guide (cont.) • How many calories needed to lose 1lb? • What is a safe/healthy amount of weight to lose/week? What is the best amount of weight to lose in 1 week? Why? • How much weight would a diabetic need to lose to help reduce glucose levels? • How do fat & fiber help with weight loss? • Theories Behind Weight Loss Strategies • Calorie Control Approach • Low Fat Approach • Low Carbohydrate Approach • Non-Dieting Approaches

  37. Study Guide (cont.) • Benefits of Exercise • Distinguish between anaerobic and aerobic exercise • Who are surgical Interventions appropriate for? • Distinguish between gastric banding, stomach stapling and bariatric surgery

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