Malnutrition and Malnutrition and ObesityObesity

Whitney Hegedus MS RD CSO Whitney Hegedus MS RD CSO LDN CNSCLDN CNSC

St. Jude Children’s Research St. Jude Children’s Research HospitalHospital

ObjectiveObjective

The Learner will…The Learner will… Understand the definition of Understand the definition of

malnutritionmalnutrition Understand how obesity is definedUnderstand how obesity is defined Understand the prevalence of obesity in Understand the prevalence of obesity in

the United Statesthe United States Understand potential micronutrient Understand potential micronutrient

deficiencies among the obese deficiencies among the obese populationpopulation

What Is ObesityWhat Is Obesity

A life-long, progressive, life-A life-long, progressive, life-threatening, costly, genetically threatening, costly, genetically related, multi-factorial disease related, multi-factorial disease of excess fat storage with of excess fat storage with multiple co-morbiditiesmultiple co-morbidities

ASMBS.org ASMBS.org

Malnutrition Malnutrition

Any disorder of nutrition status Any disorder of nutrition status including disorders resulting from a including disorders resulting from a deficiency of nutrient intake, impaired deficiency of nutrient intake, impaired nutrient metabolism or over nutrition nutrient metabolism or over nutrition

Therefore obesity is a form of Therefore obesity is a form of malnutrition malnutrition

ASPEN – Board of Directors and Standards CommitteeASPEN – Board of Directors and Standards Committee

MalnutritionMalnutrition

Historically, thought that micronutrient Historically, thought that micronutrient deficiencies were rare in Western deficiencies were rare in Western countries because of the relatively low cost countries because of the relatively low cost and ample food supplyand ample food supply

Many people consume food that is of poor Many people consume food that is of poor nutritional quality however high in nutritional quality however high in calories, fat, salt and/or sugarcalories, fat, salt and/or sugar

Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutrition deficiencies in morbidly obese Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutrition deficiencies in morbidly obese patients: a new form of malnutrition? Part A: Vitamins. patients: a new form of malnutrition? Part A: Vitamins. Obes SurgObes Surg; 2008:18:870-976. ; 2008:18:870-976.

Measuring ObesityMeasuring Obesity

Determined by height and Determined by height and weightweight

Body Mass Index (BMI) Body Mass Index (BMI)

BMI = BMI = weight (kg)_____ weight (kg)_____

height (m) x height (m)height (m) x height (m)

BMI ChartBMI Chart

< 18.5 < 18.5 UnderweightUnderweight

18.5-24.918.5-24.9 Healthy Weight Healthy Weight

25.0-29.925.0-29.9 OverweightOverweight

30.0-34.930.0-34.9 Class I ObesityClass I Obesity

35.0-39.935.0-39.9 Class II ObesityClass II Obesity

>40.0>40.0 Class III Obesity (Morbid Class III Obesity (Morbid Obesity)Obesity)

BMI to Weight ExamplesBMI to Weight Examples

A person 65” would have the following BMIsA person 65” would have the following BMIs

Weight (lbs)Weight (lbs) BMI (kg/mBMI (kg/m22) Classification) Classification105105 1717 UnderweightUnderweight130130 2222 Healthy WtHealthy Wt165165 2727 OverweightOverweight195195 3232 Obesity IObesity I235235 3737 Obesity IIObesity II265265 4444 Obesity IIIObesity III

Prevalence and Trends in Prevalence and Trends in Obesity Among US Adults Obesity Among US Adults

2009-20102009-2010 69.2% American adults are considered 69.2% American adults are considered

overweight (BMI >25)overweight (BMI >25) 35.9% considered obese (BMI >30)35.9% considered obese (BMI >30) 6.3% considered morbidly obese (BMI >40)6.3% considered morbidly obese (BMI >40)

When compared to the 2003-2008 data there When compared to the 2003-2008 data there is no significant change in the prevalence of is no significant change in the prevalence of obesity; however all percentages did increaseobesity; however all percentages did increase

Flegal KM, Caroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass Flegal KM, Caroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index amount US adults, 1999-2010. index amount US adults, 1999-2010. JAMAJAMA. 2012;307(5):doi:10.1001/jama.2012.39.. 2012;307(5):doi:10.1001/jama.2012.39.

Prevalence of High Body Mass Prevalence of High Body Mass Index in US Children and Index in US Children and Adolescents, 2009-2010Adolescents, 2009-2010

Ages 2-19 for both sexes and Ages 2-19 for both sexes and all ethnicitiesall ethnicities

31.8% considered overweight31.8% considered overweight BMI >85BMI >85thth percentile on CDC BMI Growth Charts percentile on CDC BMI Growth Charts

16.9% considered obese16.9% considered obese BMI >95BMI >95thth percentile on CDC BMI Growth Charts percentile on CDC BMI Growth Charts

12.3% of children and adolescents have a 12.3% of children and adolescents have a BMI >97BMI >97thth percentile percentile

Ogden CL, Caroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index Ogden CL, Caroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. among US children and adolescents, 1999-2010. JAMAJAMA. . 2012;307(5):dio:10.1001/jama.2012.40. 2012;307(5):dio:10.1001/jama.2012.40.

Leading Cause of DeathLeading Cause of Death

CDC announced in 2004 that unless CDC announced in 2004 that unless current trends are reversed poor current trends are reversed poor diet and physical inactivity will soon diet and physical inactivity will soon become the leading cause of death become the leading cause of death in Americain America

Actual Cause of DeathActual Cause of Death

In 2000In 2000 435,000 deaths attributed to 435,000 deaths attributed to

smoking (18.1%)smoking (18.1%) 400,000 deaths attributed to poor 400,000 deaths attributed to poor

diet and physical inactivity (16.6%)diet and physical inactivity (16.6%)

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. United States, 2000. JAMAJAMA. 2004;291:1238-1245. 2004;291:1238-1245..

Prevalence and Trends in Prevalence and Trends in Obesity Among US Adults Obesity Among US Adults

2009-20102009-2010 69.2% American adults are considered 69.2% American adults are considered

overweight (BMI >25)overweight (BMI >25) 35.9% considered obese (BMI >30)35.9% considered obese (BMI >30) 6.3% considered morbidly obese (BMI >40)6.3% considered morbidly obese (BMI >40)

When compared to the 2003-2008 data there When compared to the 2003-2008 data there is no significant change in the prevalence of is no significant change in the prevalence of obesity; however all percentages did increaseobesity; however all percentages did increase

Flegal KM, Caroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass Flegal KM, Caroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index amount US adults, 1999-2010. index amount US adults, 1999-2010. JAMAJAMA. 2012;307(5):doi:10.1001/jama.2012.39.. 2012;307(5):doi:10.1001/jama.2012.39.

Original QuestionOriginal Question

If obesity is a form of malnutrition, If obesity is a form of malnutrition, what excesses or deficiencies should what excesses or deficiencies should be evaluated, monitored and/or be evaluated, monitored and/or treated?treated?

Most research reporting Most research reporting micronutrient deficiencies in obese micronutrient deficiencies in obese patients are the result of presurgical patients are the result of presurgical evaluations of bariatric patients evaluations of bariatric patients

Study 1Study 1

Aim to assess concentrations of Aim to assess concentrations of vitamins A, B1, B2, B6, folate, B12, C, D vitamins A, B1, B2, B6, folate, B12, C, D and E in morbidly obese patients and E in morbidly obese patients compared to the concentrations in a compared to the concentrations in a healthy control grouphealthy control group

Aasheim ET, Hofso D, Hjelmesaeth J, Birkeland KI, Bohmer T. Vitamin status in morbidly obese Aasheim ET, Hofso D, Hjelmesaeth J, Birkeland KI, Bohmer T. Vitamin status in morbidly obese patients: a cross-sectional study. patients: a cross-sectional study. Am J Clin NutrAm J Clin Nutr. 2008;87:362-9. . 2008;87:362-9.

ParticipantsParticipants

Woman Men

Control (n=30)

Patient (n=76)

Control (n=28)

Patient (n=34)

Age (y) 39 ± 11 41 ± 11 39 ± 11 41 ± 10

BMI (kg/m2) 23 ± 3 45 ± 7 25 ± 3 45 ± 7

Smoker [ n(%)] 1 24 4 10

Systolic BP (mm Hg)

117 ± 9 136 ± 18 122 ± 13 142 ± 21

Diastolic BP (mm Hg)

80 ± 7 84 ± 18 81 ± 10 87 ± 13

Vitamin Concentrations in Vitamin Concentrations in Morbidly Obese Patients and Morbidly Obese Patients and

Healthy Controls Healthy Controls Woman Men

Vitamin Control (n=30)

Patient (n=76)

Control (n=28)

Patient (n=34)

A µmol/L 1.9 ± 0.5 1.7 ± 0.4 2.3 ± 0.6 1.9 ± 0.4

B1 nmol/L 99 ± 19 125 ± 34 106 ± 17 151 ± 37

B2 nmol/L 20 ± 7 20 ± 9 25 ± 14 21 ± 7

B6 nmol/L 46 ± 24 29 ± 30 58 ± 31 39 ± 33

Folic Acid nmol/L 16 ± 4 16 ± 8 16 ± 5 13 ± 3

B12 pmol/L 307 ± 98 303 ± 69 368 ± 116 331 ± 97

C mmol/L 74 ± 14 48 ± 18 63 ± 15 48 ± 14

D nmol/L 54 ± 22 40 ± 16 59 ± 20 34 ± 15

E µmol/L 26.6 ± 4.9 28 ± 6.9 29.4 ± 9.5 26.8 ± 6.1

E (lipid standardized)

5.0 ± 0.7 4.3 ± 0.8 5.0 ± 0.8 4.0 ± 0.7

ResultsResults

Significant differences were noticed in 6 out Significant differences were noticed in 6 out of the 9 vitamins examined of the 9 vitamins examined

Obese patients had significantly lower mean Obese patients had significantly lower mean serum concentrations of vitamins A, B6, C, D serum concentrations of vitamins A, B6, C, D and lipid standardized vitamin Eand lipid standardized vitamin E

A range of 11-38% of obese patients were A range of 11-38% of obese patients were considered to have inadequate vitamin B6, C, considered to have inadequate vitamin B6, C, D and lipid standardized vitamin E D and lipid standardized vitamin E

The obese patients had a higher concentration The obese patients had a higher concentration of B1 compared to the healthy control groupof B1 compared to the healthy control group

Conclusion Conclusion

Morbidly obese Norwegian patients Morbidly obese Norwegian patients may have lower circulating may have lower circulating concentrations of several vitamins concentrations of several vitamins including vitamin B6, C, D and lipid-including vitamin B6, C, D and lipid-standardized vitamin Estandardized vitamin E

Study 2Study 2

Study design was to investigate the Study design was to investigate the vitamin and trace mineral levels of vitamin and trace mineral levels of patients before and after laparoscopic patients before and after laparoscopic gastric bypassgastric bypass

Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after laparoscopic gastric bypass. laparoscopic gastric bypass. Obes SurgObes Surg. 2006; 16:603-606. . 2006; 16:603-606.

Design Design Total Number of Patients per Vitamin Level

Vitamin Number of Patients Preoperatively

Vitamin A 55

Vitamin B12 59

Vitamin D-25 58

Zinc 69

Iron 64

Ferritin 67

Selenium 59

Folate 62

ResultsResultsAbnormal Levels (n

%)Deficient Levels (n

%)

Vitamin A 11% 7%

Vitamin B12 13% 5%

Vitamin D25 40% 40%

Zinc 30% 28%

Iron 16% 14%

Ferritin 9% 6%

Selenium 58% 58%

Folate 6% 2%

Discussion Discussion

Having excess weight does not imply Having excess weight does not imply appropriate vitamin and trace appropriate vitamin and trace mineral levelsmineral levels

Poor nutrition habits of morbidly Poor nutrition habits of morbidly obese patients may make them more obese patients may make them more susceptible to lower levels of susceptible to lower levels of vitamins and mineralsvitamins and minerals

ConclusionsConclusions

Consideration should be given to Consideration should be given to testing vitamin and trace minerals testing vitamin and trace minerals on any morbidly obese patientson any morbidly obese patients

Other paper conclusions were Other paper conclusions were specific to gastric bypass surgery specific to gastric bypass surgery

Overall ConclusionsOverall Conclusions

When evaluated, obese patients When evaluated, obese patients presented with abnormal and presented with abnormal and deficient levels of several vitamin deficient levels of several vitamin and trace mineralsand trace minerals

Considerations Considerations

Weight loss patientsWeight loss patients Intentional and Unintentional Intentional and Unintentional

Nutrition support patientNutrition support patient EN and PN EN and PN

ChildrenChildren

Questions Questions