1. Chapter 6 Obesity and Healthy Weight Management

2. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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. 3 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Body Mass Index (BMI)  Body mass index (BMI) = kg/m 2 —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

4. 4 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. (*BMI ≥30, or ~30 lb overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Obesity Trends* Among U.S. Adults BRFSS, 2007

5. 5 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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)

6. 6 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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

7. 7 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Current 1 cup juice (2 oranges equivalent) and 1 liter (8 oranges) versus 1950s and previous times: 4 oz juice glass (1 orange)

8. 8 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Increased sugar from carbonated soft drinks (soda pop); front L to R: 20 oz plastic bottle, 6 oz traditional bottle, sugar of 1 liter soda pop

9. 9 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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 reduced fat-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. 10 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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 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. 11 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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. 12 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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. 13 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Hormonal Connections  Times of awakening found with decreased leptin (hormone related to satiety); may explain increased weight with “swing shifts”  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 T 3 and T 4 hormones) with decreased metabolic rate  Deficiency of growth hormone leads to increased body fat

14. 14 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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) Elevated CRP and interleukin-6 (IL-6) Reduced anti-inflammatory hormone: adiponectin Reduced anti-inflammatory hormone: adiponectin  Clot formation  Free-radicals

15. 15 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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)

16. 16 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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)

17. 17 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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 (1500 kcal depending on portions and choices); 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

18. 18 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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

19. 19 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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)

20. 20 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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

21. 21 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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

22. 22 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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

23. 23 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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) 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 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

24. 24 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Roux-en-Y Gastric Bypass Bariatric Surgery  Surgery creates a Y-shaped reconstruction between the stomach and middle portion of the small intestine (jejunum)  Stomach reduced in size by stapling off the lower portion  Potential complications:  Mortality resulting from surgical intervention  Dumping syndrome because pyloric sphincter bypassed  Rhabdomyolysis (Koffman et al., 2006)  Hyperinsulinemic hypoglycemia due to increased incretin hormonal levels (Goldfine et al., 2007)  After a decade post-surgery: myelopathy, a pathologic spinal cord disease (Juhasz-Pocsine et al., 2007)  Long-term malnutrition despite supplementation with vitamins and minerals

25. 25 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Specific Nutritional Complications of Roux-en-Y  Iron-deficiency anemia  Folate deficiency (increased risk of neural tube defects, or spina bifida, with pregnancy)  Vitamin B 12 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 D 3 (the active form), decreased l-lysine (an amino acid)

26. 26 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Distal Gastric Bypass Biliopancreatic Diversion (DBP) and Duodenal Switch (DS)  Most severe malabsorptive procedure  Linked with protein-calorie malnutrition in up to 10% of individuals experiencing 80% weight loss  Increased gallbladder disease with rapid weight loss; cholecystectomy (removal of gallbladder) often performed at time of DBP-DS procedure in anticipation of need

27. 27 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Long-Term Effectiveness of Bariatric Surgery  Stomach stapling procedures found with increased expansion of remaining stomach portion leading to regain of lost weight  Persons with Prader-Willi syndrome generally have poor outcomes (Scheimann et al., 2008)  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)

28. 28 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 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)

29. 29 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Nutritional Deficiency Symptoms; Monitor After Bariatric Surgery  Osteoporosis—advise regular DXA scans  Hair loss—may be zinc deficiency or other deficiency: biotin, iron, vitamin D, lysine  Impaired vision in daytime—may be vitamin A deficiency  Involuntary movements of the eyeball, double vision, loss of balance, muscle loss or tingling/weakness, memory loss—vitamin B 1 deficiency