overview of nutrition & health€¦ · define the components of body weight and methods of...
TRANSCRIPT
11/5/2014
1
WEIGHT MANAGEMENT
NUTR 2050 Nutrition for Nursing Professionals
Mrs. Deborah A. Hutcheon, MS, RD, LD
Lesson Objectives At the end of the lesson, the student will be able to:
1. Define the components of body weight and methods of assessment.
2. Distinguish between hyperplasia and hypertrophy, white and brown adipose
tissue, android & gynoid fat distribution and their relationship to health.
3. Delineate the potential causes and health consequences of underweight,
overweight, and obesity.
4. Discuss the three components of energy expenditure and factors that might
influence each.
5. Define the three key components of a successful weight management program.
6. Explain the role of diet (total kcals & distribution of kcals) in weight
management.
7. Explain the role of exercise in weight management.
8. Define the three mechanisms of action for pharmaceuticals used in weight
management.
Role of Adipose Tissue
Location: subcutaneous fat vs. visceral fat
Composition: primarily fat (85% of adipocyte).
Adipocyte = Fat Cell
Hypertrophy vs. Hyperplasia
White Adipose vs. Brown Adipose
11/5/2014
2
Role of Adipose Tissue
Fat Distribution
• Android (“apple-shaped”): truncal-abdominal fat
• Androgens ↑ lipoprotein lipase (LPL) action in central abdomen.
• Most common in men
• Highest association with health risks.
• Gynoid (“pear-shaped”): gluteofemoral fat
• Estrogen ↑ lipoprotein lipase (LPL) action in
gluteofemoral region.
• Most common in women
• Fat harder to lose from this region as lower
body less active in releasing fat from storage.
Complications of Obesity
11/5/2014
3
Matarese L et al. Nutr Clin Pract. Online October 2014.
Calorie Balance
1 Pound Fat = 3500 kcals
(+ kcal per day x 7 days = 1# wt gain)
(+ kcal per day x 7 days = 2# wt gain)
Calorie Balance or Diet Quality?
Lustig DA et al. JAMA. May 16, 2014:E1-E2.
11/5/2014
4
Energy Needs
Total Energy Expenditure (TEE) is the sum of…
1. Basal Metabolic Rate (BMR)…~1200 kcal/day (70%)
2. Thermic Effect of Food…~200 kcal/day (10%)
3. Thermogenesis…~600 kcal/day (30%)
Factors Affecting BMR
Calculating Energy Needs
11/5/2014
5
Calculating Energy Needs 1. Calculate Basal Metabolic Rate
Men: Weight _______# X 11 = ________kcal from BMR
Women: Weight ______# X 10 = _______kcal for BMR
2. Account for Physical Activity
30% - 75% (use table 8.2 to determine your activity level)
BMR ________ X .30 = _________kcal for Physical Activity
3. Dietary Thermogenesis: 10% of total needs
(BMR_____ + PA needs_____) X .10 = ____thermogenesis
BMR + PA needs + Thermo needs =
TOTAL CALORIES
Weight Management Position of ADA
“It is the position of the American Dietetic
Association that successful weight
management to improve overall health for
adults requires a lifelong commitment to
healthful lifestyle behaviors emphasizing
sustainable and enjoyable eating practices
and daily physical activity.”
Source: Seagle SD, Denny S, Gee M, Leman C, Nisevich PM, Myers E. Position of the
American Dietetic Association: weight management. J Am Diet Assoc. 109:330-346; 2009.
Weight Management Position of ADA
“It is the position of the American Dietetic Association
that successful weight management to [purpose]
improve overall health for adults requires a
lifelong commitment to [1.] healthful lifestyle
behaviors emphasizing sustainable and enjoyable
eating practices and [2.] daily physical activity.”
Source: Seagle SD, Denny S, Gee M, Leman C, Nisevich PM, Myers E. Position of the
American Dietetic Association: weight management. J Am Diet Assoc. 109:330-346; 2009.
11/5/2014
6
A Good Weight Management Program
Purpose: Improve overall fitness & health
Focus: Healthful weight vs. normal BMI range
Time & Amount: Set realistic goals & objectives!!!
Should be REALISTIC & INDIVIDUALIZED!
Components:
1. Healthy Eating Practices
2. Daily Physical Activity (Exercise & NEAT)
3. Lifestyle Modification
Benefits of Weight Loss
For the obese, loss of 5% to 10% of initial body
weight may improve health risks and severity of
comorbities associated with excessive body weight.
Reversal of Type II Diabetes
Improved Blood Pressure
Easier Ability to Move
How Do I Lose Weight?
1 pound weight = 3500 calories
Normal Use of Nutrient Stores
1. Glycogen
2. Protein
3. Fat—spares protein catabolism
Rapid Weight Loss (Starvation) ← AVOID THIS!
Utilization of protein then fat, reduced BMR
Gradual, Steady Weight Loss ← THIS IS THE GOAL!
Reduction in fat stores with limitation to loss of protein, sustained BMR
11/5/2014
7
Safe Weight Loss Guidelines
1 pound body weight = 3500 kcal
BMI 27 to 35: 0.5 to 1.0 lb per week (less 250 to 500 kcal)
BMI>35: 1.0 to 2.0 lb per week (less 500 to 1000 kcal)
Alternate between weight loss (6 months) &
weight maintenance (6 months).
Restricted Energy Diets
• Nutritionally adequate, except for energy.
• At least 1200 kcal/day
• CHO (45% to 65% kcal): veggies, fruit, beans, whole grains
• Protein (10% to 20%): lean meat, dairy, legumes, nuts
• Fat (20% to 30%): unsaturated fatty acids
• Distribute total caloric intake throughout the day.
• Promote portion control, meal spacing, water intake, PA.
• Avoid “empty” calories (i.e. simple sugar, added fat & alcohol).
Vital Component of Exercise
• Helps to balance LBM & BMR with weight loss.
• Most variable component of energy expenditure.
• Crucial in the prevention of weight regain.
• Combine aerobics with resistance training.
• Any benefit to “spot reduction?
Recommendations for Adults:
1. Health Benefits: 30 minutes 5 days per week
2. Substantial Health Benefits: 60 minutes 5 days per week
11/5/2014
8
Vital Component of Exercise
Source: http://www.choosemyplate.gov/food-groups/physicalactivity_calories_used_table.html
Pharmaceutical Management
Approved for use by the FDA for 12+ weeks.
Candidates: BMI 30+ or BMI 27+ w/co-morbidities
Success determined by:
1. Loss of 5% x 6 months
2. Co-morbid conditions have improved.
Pharmaceutical Management Positive Arguments
1. Obesity is an incurable disease and should be treated as such
by controlling symptoms (not curing) with medication.
2. Medications can help “kick start” weight loss efforts.
3. Meds can be part of a comprehensive treatment program.
Negative Arguments
1. Meds are of no real value in maintaining long-term wt loss.
2. Risks of medications outweighs the little benefits.
3. Tend to be a “quick fix” for people with a “quick fix” mentality.
4. Despite theory of use in conjunction with comprehensive
treatment program, it tends to be a stand-alone therapy.
11/5/2014
9
Pharmaceutical Management Mechanism of
Action Medication Caveats
Pancreatic
Lipase Inhibitor
Orlistat
(Alli or Xenical)
• <30% kcals from fat
• Take with meal
• 200-300 kcal/day
• 5-7# loss x 1-2 years
Decrease
Appetite &
Increase Satiety
Lorcaserin (Belviq)
Phentermine-
Topiramate (Qsymia)
Naltrexone (Contrave)
• ~6-20# loss x 1 year
• Must demonstrate
benefit by 12 weeks or
discontinue
Diuretic/Laxative • Risk: dehydration,
metabolic imbalance
Pharmaceutical Management
Cunningham JW et al. Clin Cardiol. Sept 15, 2014.
Bariatric Surgery Candidacy (NIH Guidelines since 1991)
1. Morbidly Obese
100# over IBW OR BMI > 40 OR BMI > 35 + comorbities
2. Documented failure of comprehensive non-
surgical weight loss
3. Good surgical candidate
4. Between ages of 14 and 75
5. Clearance by healthcare team
6. Commitment to follow post-surgery diet
11/5/2014
10
Classification of Procedures
1. Restrictive: decrease amount of food that enters GI tract
(Gastric Banding and Gastric Sleeve)
2. Restrictive & Malabsorption: decrease amount of food
that enters GI tract and decreases absorption
(Roux-en-Y Gastric Bypass, BPD-DS)
Classification Procedure
Restrictive Gastric Banding & Gastric Sleeve
Primarily Restrictive & Partially Malabsorptive
Roux-en-Y Gastric Bypass (RYGB)
Primarily Malabsorptive & Partially Restrictive
Biliopancreatic Diversion with
Duodenal Switch
Laparoscopic Adjustable Gastric Band (LapBand®)
Video: http://www.realize.com/adjustable-gastric-band/how-it-works
11/5/2014
11
Laparoscopic Sleeve Gastrectomy
Video: http://www.realize.com/sleeve-gastrectomy/how-it-works
Roux-en-Y Gastric Bypass
Video: http://www.realize.com/gastric-bypass/how-it-works
Bariatric Surgery Dietary Modifications
Stage 1: Clear Liquids (7-10 days)
Stage 2: Full Liquids (2 to 4 weeks)
Stage 3: Pureed/Blended (3 to 4 weeks)
Stage 4: Soft (by week 12)
Stage 5: Regular (800 kcals/day)
11/5/2014
12
Bariatric Surgery Dietary Modifications
• Consume small frequent meals—high protein, low CHO.
• Chew foods 25 to 30 time before swallowing.
• No beverages 30 minutes before, with meals, or up to 60
minutes after meal.
• Drinking only water or sugar-free beverages.
• No carbonated or alcoholic beverages.
• No smoking.
• Sugar free foods—no simple sugars.
• No straws for drinking.
Nutrition After Bariatric Surgery New stomach size: 1 oz to 2 oz (vs. 40 oz)
• Eat small frequent meals—no single large meals
• Encourage continual fluid (water) intake
Emphasis of High Protein Foods: monitor for s/s pro malnutrition
Vitamin/Mineral Supplementation
• Daily MVI with 100% RDI for most vitamins and minerals and 200%
RDI for major B-complex vitamins
• Vitamin B12: 500 micrograms orally or 1000 mcg IM monthly
• Folate: 400 micrograms daily
• Calcium: 1000 to 2000 mg CALCIUM CITRATE with 1000 to 2000
IU vitamin D-3
• Iron (elemental): 65-80 mg
Bariatric Surgery Comparison
Source: http://www.realize.com/surgery-comparison
11/5/2014
13
Bariatric Surgery Risk vs. Benefit General Complications
• Bloating of pouch, N/V, infection
• Malabsoprtion/Malnutrition
• Dumping Syndrome
• Leak at suture or staple lines
• Blood Clots and Bleeding
• Ulceration and Blockage
• Hair loss—lack of dietary
protein
• Wt regain (5%-10%) x 10 yrs
General Benefits
• Reduction in 30% to 40%
initial body weight
• Maximum weight loss:
60% to 80%
• Weight loss plateau: 18 to
24 months after surgery
• Improvement of
comorbidities
• Improvement of self-image
& psychological factors