1. Malnutrition and Obesity Whitney Hegedus MS RD CSO LDN CNSC St. Jude Children’s Research Hospital

2. Objective The Learner will… The Learner will… Understand the definition of malnutrition Understand the definition of malnutrition Understand how obesity is defined Understand how obesity is defined Understand the prevalence of obesity in the United States Understand the prevalence of obesity in the United States Understand potential micronutrient deficiencies among the obese population Understand potential micronutrient deficiencies among the obese population

3. What Is Obesity A life-long, progressive, life-threatening, costly, genetically related, multi-factorial disease of excess fat storage with multiple co-morbidities ASMBS.org

4. Malnutrition Any disorder of nutrition status including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism or over nutrition Any disorder of nutrition status including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism or over nutrition Therefore obesity is a form of malnutrition Therefore obesity is a form of malnutrition ASPEN – Board of Directors and Standards Committee

5. Malnutrition Historically, thought that micronutrient deficiencies were rare in Western countries because of the relatively low cost and ample food supply Historically, thought that micronutrient deficiencies were rare in Western countries because of the relatively low cost and ample food supply Many people consume food that is of poor nutritional quality however high in calories, fat, salt and/or sugar Many people consume food that is of poor nutritional quality however high in calories, fat, salt and/or sugar Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutrition deficiencies in morbidly obese patients: a new form of malnutrition? Part A: Vitamins. Obes Surg; 2008:18:870-976.

6. Measuring Obesity Measuring Obesity Determined by height and weight Determined by height and weight Body Mass Index (BMI) Body Mass Index (BMI) BMI = weight (kg)_____ height (m) x height (m) height (m) x height (m)

7. BMI Chart < 18.5 Underweight 18.5-24.9Healthy Weight 25.0-29.9Overweight 30.0-34.9Class I Obesity 35.0-39.9Class II Obesity >40.0Class III Obesity (Morbid Obesity)

8. BMI to Weight Examples A person 65” would have the following BMIs Weight (lbs)BMI (kg/m 2 ) Classification 10517Underweight 13022Healthy Wt 16527Overweight 19532Obesity I 23537Obesity II 26544Obesity III

9. Prevalence and Trends in Obesity Among US Adults 2009-2010 69.2% American adults are considered overweight (BMI >25) 69.2% American adults are considered 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 is no significant change in the prevalence of obesity; however all percentages did increase When compared to the 2003-2008 data there is no significant change in the prevalence of obesity; however all percentages did increase 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. JAMA. 2012;307(5):doi:10.1001/jama.2012.39.

10. Prevalence of High Body Mass Index in US Children and Adolescents, 2009-2010 Ages 2-19 for both sexes and all ethnicities 31.8% considered overweight 31.8% considered overweight BMI >85 th percentile on CDC BMI Growth Charts BMI >85 th percentile on CDC BMI Growth Charts 16.9% considered obese 16.9% considered obese BMI >95 th percentile on CDC BMI Growth Charts BMI >95 th percentile on CDC BMI Growth Charts 12.3% of children and adolescents have a BMI >97 th percentile 12.3% of children and adolescents have a BMI >97 th percentile Ogden CL, Caroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307(5):dio:10.1001/jama.2012.40.

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

12. Actual Cause of Death In 2000 In 2000 435,000 deaths attributed to smoking (18.1%) 435,000 deaths attributed to smoking (18.1%) 400,000 deaths attributed to poor diet and physical inactivity (16.6%) 400,000 deaths attributed to poor diet and physical inactivity (16.6%) Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA. 2004;291:1238-1245.

39. Prevalence and Trends in Obesity Among US Adults 2009-2010 69.2% American adults are considered overweight (BMI >25) 69.2% American adults are considered 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 is no significant change in the prevalence of obesity; however all percentages did increase When compared to the 2003-2008 data there is no significant change in the prevalence of obesity; however all percentages did increase 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. JAMA. 2012;307(5):doi:10.1001/jama.2012.39.

40. Original Question If obesity is a form of malnutrition, what excesses or deficiencies should be evaluated, monitored and/or treated? If obesity is a form of malnutrition, what excesses or deficiencies should be evaluated, monitored and/or treated? Most research reporting micronutrient deficiencies in obese patients are the result of presurgical evaluations of bariatric patients Most research reporting micronutrient deficiencies in obese patients are the result of presurgical evaluations of bariatric patients

41. Study 1 Aim to assess concentrations of vitamins A, B1, B2, B6, folate, B12, C, D and E in morbidly obese patients compared to the concentrations in a healthy control group Aim to assess concentrations of vitamins A, B1, B2, B6, folate, B12, C, D and E in morbidly obese patients compared to the concentrations in a healthy control group Aasheim ET, Hofso D, Hjelmesaeth J, Birkeland KI, Bohmer T. Vitamin status in morbidly obese patients: a cross- sectional study. Am J Clin Nutr. 2008;87:362-9.

42. Participants WomanMen Control (n=30)Patient (n=76)Control (n=28)Patient (n=34) Age (y)39 ± 1141 ± 1139 ± 1141 ± 10 BMI (kg/m 2 )23 ± 345 ± 725 ± 345 ± 7 Smoker [ n(%)]124410 Systolic BP (mm Hg)117 ± 9136 ± 18122 ± 13142 ± 21 Diastolic BP (mm Hg)80 ± 784 ± 1881 ± 1087 ± 13

43. Vitamin Concentrations in Morbidly Obese Patients and Healthy Controls WomanMen VitaminControl (n=30)Patient (n=76)Control (n=28)Patient (n=34) A µmol/L1.9 ± 0.51.7 ± 0.42.3 ± 0.61.9 ± 0.4 B1 nmol/L99 ± 19125 ± 34106 ± 17151 ± 37 B2 nmol/L20 ± 720 ± 925 ± 1421 ± 7 B6 nmol/L46 ± 2429 ± 3058 ± 3139 ± 33 Folic Acid nmol/L16 ± 416 ± 816 ± 513 ± 3 B12 pmol/L307 ± 98303 ± 69368 ± 116331 ± 97 C mmol/L74 ± 1448 ± 1863 ± 1548 ± 14 D nmol/L54 ± 2240 ± 1659 ± 2034 ± 15 E µmol/L26.6 ± 4.928 ± 6.929.4 ± 9.526.8 ± 6.1 E (lipid standardized)5.0 ± 0.74.3 ± 0.85.0 ± 0.84.0 ± 0.7

44. Results Significant differences were noticed in 6 out of the 9 vitamins examined Significant differences were noticed in 6 out of the 9 vitamins examined Obese patients had significantly lower mean serum concentrations of vitamins A, B6, C, D and lipid standardized vitamin E Obese patients had significantly lower mean serum concentrations of vitamins A, B6, C, D and lipid standardized vitamin E A range of 11-38% of obese patients were considered to have inadequate vitamin B6, C, D and lipid standardized vitamin E A range of 11-38% of obese patients were considered to have inadequate vitamin B6, C, D and lipid standardized vitamin E The obese patients had a higher concentration of B1 compared to the healthy control group The obese patients had a higher concentration of B1 compared to the healthy control group

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

46. Study 2 Study design was to investigate the vitamin and trace mineral levels of patients before and after laparoscopic gastric bypass Study design was to investigate the vitamin and trace mineral levels of patients before and after laparoscopic gastric bypass Madan AK, Orth WS, Tichansky DS, Ternovits CA. Vitamin and trace mineral levels after laparoscopic gastric bypass. Obes Surg. 2006; 16:603-606.

47. Design Total Number of Patients per Vitamin Level VitaminNumber of Patients Preoperatively Vitamin A55 Vitamin B1259 Vitamin D-2558 Zinc69 Iron64 Ferritin67 Selenium59 Folate62

48. Results Abnormal Levels (n%)Deficient Levels (n%) Vitamin A11%7% Vitamin B1213%5% Vitamin D2540% Zinc30%28% Iron16%14% Ferritin9%6% Selenium58% Folate6%2%

49. Discussion Having excess weight does not imply appropriate vitamin and trace mineral levels Having excess weight does not imply appropriate vitamin and trace mineral levels Poor nutrition habits of morbidly obese patients may make them more susceptible to lower levels of vitamins and minerals Poor nutrition habits of morbidly obese patients may make them more susceptible to lower levels of vitamins and minerals

50. Conclusions Consideration should be given to testing vitamin and trace minerals on any morbidly obese patients Consideration should be given to testing vitamin and trace minerals on any morbidly obese patients Other paper conclusions were specific to gastric bypass surgery Other paper conclusions were specific to gastric bypass surgery

51. Overall Conclusions When evaluated, obese patients presented with abnormal and deficient levels of several vitamin and trace minerals When evaluated, obese patients presented with abnormal and deficient levels of several vitamin and trace minerals

52. Considerations Weight loss patients Weight loss patients Intentional and Unintentional Intentional and Unintentional Nutrition support patient Nutrition support patient EN and PN EN and PN Children Children

53. Questions