Chapter 6 Obesity and Healthy Weight Management. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Health Problems

Chapter 6Chapter 6

Obesity and Healthy Obesity and Healthy Weight ManagementWeight Management

2Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Health Problems with Health Problems with Weight and ObesityWeight and Obesity

Medical problems associated with the metabolic Medical problems associated with the metabolic syndrome: syndrome: HypertensionHypertension Dyslipidemia (high triglycerides and low HDL)Dyslipidemia (high triglycerides and low HDL) GoutGout Polycystic ovary syndromePolycystic ovary syndrome DiabetesDiabetes Early cardiovascular disease Early cardiovascular disease Certain forms of cancerCertain forms of cancer

Inflammatory conditionsInflammatory conditions Cholelithiasis (gall stones)Cholelithiasis (gall stones) OsteoarthritisOsteoarthritis Sleep apneaSleep apnea


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

Body mass index (BMI) = kg/mBody mass index (BMI) = kg/m22——see Appendix; see Appendix; concept developed >100 years ago by concept developed >100 years ago by mathematician Queteletmathematician Quetelet BMI 19-25 = ideal body weight (IBW)BMI 19-25 = ideal body weight (IBW) BMI 26-29 = indicator of the metabolic syndromeBMI 26-29 = indicator of the metabolic syndrome BMI BMI ≥≥30 = 20% overweight; 30 = 20% overweight; class I obesityclass I obesity BMI BMI ≥35: ≥35: class II obesityclass II obesity BMI BMI ≥≥40 = 30% overweight; 40 = 30% overweight; class III obesity or class III obesity or

“extreme obesity”“extreme obesity” BMI <19 = underweightBMI <19 = underweight

BMI <16 = severe anorexia; generally BMI <16 = severe anorexia; generally necessitates hospitalizationnecessitates hospitalization


(*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. AdultsObesity Trends* Among U.S. AdultsBRFSS, 2007BRFSS, 2007


RatesRates

About 65% U.S. adults with BMI About 65% U.S. adults with BMI 25 per 25 per NHANES dataNHANES data

About 30% with classes I and II obesityAbout 30% with classes I and II obesity About 5% with extreme obesity (class III)About 5% with extreme obesity (class III)


Causes and Theories of ObesityCauses and Theories of Obesity

Kilocalorie imbalanceKilocalorie imbalance Sedentary lifestyles—old-time lumberjacks Sedentary lifestyles—old-time lumberjacks

required 3500 to 5000 kcal/day; most adults required 3500 to 5000 kcal/day; most adults now need about 2000 kcal/day now need about 2000 kcal/day

Increased intake of sugar-based beveragesIncreased intake of sugar-based beverages Larger food portionsLarger food portions


Current 1 cup juice (2 oranges equivalent) Current 1 cup juice (2 oranges equivalent) and 1 liter (8 oranges) versus 1950s and and 1 liter (8 oranges) versus 1950s and previous times: 4 oz juice glass (1 orange)previous times: 4 oz juice glass (1 orange)


Increased sugar from carbonated soft drinks Increased sugar from carbonated soft drinks (soda pop); front L to R: 20 oz plastic bottle, 6 (soda pop); front L to R: 20 oz plastic bottle, 6 oz traditional bottle, sugar of 1 liter soda popoz traditional bottle, sugar of 1 liter soda pop


FYI Impact of Diet QualityFYI Impact of Diet Quality

Monounsaturated fats (oleic acid) increase daily Monounsaturated fats (oleic acid) increase daily energy expenditure; saturated fats (palmitic acid) energy expenditure; saturated fats (palmitic acid) lower energy expenditure lower energy expenditure (Kien and Bunn, 2008(Kien and Bunn, 2008)); the difference ; the difference is as much as 275 kcal is as much as 275 kcal (Kien et al., 2005)(Kien et al., 2005)

Omega-3 and polyunsaturated fats related to reducedOmega-3 and polyunsaturated fats related to reducedfat-cell size; saturated fat increases fat-cell size and fat-cell size; saturated fat increases fat-cell size and number number (Garaulet et al., 2006)(Garaulet et al., 2006)

Inclusion of a variety of high-fiber foods promotes Inclusion of a variety of high-fiber foods promotes cellular metabolism via inclusion of vitamins and cellular metabolism via inclusion of vitamins and mineralsminerals


FYI Role of Eating HabitsFYI Role of Eating Habits

Increased chewing of foods related to smaller Increased chewing of foods related to smaller waist size waist size (Murakami et al., 2007)(Murakami et al., 2007)

Young children in the U.S. who less often in the Young children in the U.S. who less often in the day consume larger portions; by toddler age self-day consume larger portions; by toddler age self-regulation of kilocalories based on need is less regulation of kilocalories based on need is less effective than in infancy effective than in infancy (Fox et al., 2006)(Fox et al., 2006)

Obese women have been found to have a higher Obese women have been found to have a higher intake of carbohydrates; obese men have higher intake of carbohydrates; obese men have higher intake of fat intake of fat (Duvigneaud et al., 2007)(Duvigneaud et al., 2007)

Avoidance of dehydration improves insulin Avoidance of dehydration improves insulin resistance and promotes use of insulin resistance and promotes use of insulin (Schliess and (Schliess and Haussinger, 2003)Haussinger, 2003)


FYIFYI

A Canadian study found preschool children were A Canadian study found preschool children were half as likely to be overweight if they did not drink half as likely to be overweight if they did not drink sweetened beverages sweetened beverages (Dubois et al., 2007)(Dubois et al., 2007)

Two or more hours of watching television Two or more hours of watching television

increased odds of overweight adolescents by 50%increased odds of overweight adolescents by 50% (Fleming-Moran and Thiagarajah, 2005)(Fleming-Moran and Thiagarajah, 2005)

Typical portions in a college setting were found to Typical portions in a college setting were found to be significantly larger than 2 decades previous be significantly larger than 2 decades previous (Schwartz and Bryd-Bredbenner, 2006)(Schwartz and Bryd-Bredbenner, 2006)

Monosodium glutamate (MSG) related to Monosodium glutamate (MSG) related to increased appetite and obesity in rats; increased increased appetite and obesity in rats; increased fiber intake and physical activity found to counter fiber intake and physical activity found to counter this effect this effect (Diniz et al., 2005)(Diniz et al., 2005)


Physiologic Influences on ObesityPhysiologic Influences on Obesity

Genetic predisposition with the thrifty gene appears to Genetic predisposition with the thrifty gene appears to enhance weight gain; hyperinsulinemia found with the enhance weight gain; hyperinsulinemia found with the metabolic syndrome is metabolic syndrome is lipogeniclipogenic (creates fat) and (creates fat) and inhibits inhibits lipolysislipolysis (impairs fat breakdown (impairs fat breakdown)) Hyperinsulinemia decreases kilocalories available for daily Hyperinsulinemia decreases kilocalories available for daily

physical energy needs with enhanced body fat storage and physical energy needs with enhanced body fat storage and increases hunger due to interference with leptin’s role in increases hunger due to interference with leptin’s role in appetite regulation and increased need for food as a reward appetite regulation and increased need for food as a reward

system due to altered dopamine levelssystem due to altered dopamine levels (Lustig, 2006)(Lustig, 2006)

Insulin inhibits weight loss among those persons with Insulin inhibits weight loss among those persons with obesity; lean tissue (muscle) is insulin resistant; obesity; lean tissue (muscle) is insulin resistant; adipose (body fat) tissue is insulin sensitive adipose (body fat) tissue is insulin sensitive (Sebert et al., (Sebert et al., 2005)2005)


Hormonal ConnectionsHormonal Connections

Times of awakening found with decreased leptin Times of awakening found with decreased leptin (hormone related to satiety); may explain (hormone related to satiety); may explain increased weight with “swing shifts”increased weight with “swing shifts”

Increased cortisol production related to lack of Increased cortisol production related to lack of deep REM sleep and skipping meals (cortisol deep REM sleep and skipping meals (cortisol associated with excess weight, especially central associated with excess weight, especially central obesity)obesity)

Hypothyroidism (low levels of THypothyroidism (low levels of T3 3 and Tand T44 hormones) hormones)

with decreased metabolic ratewith decreased metabolic rate Deficiency of growth hormone leads to increased Deficiency of growth hormone leads to increased

body fatbody fat


Other Adverse Impacts Other Adverse Impacts from Adipocytokinesfrom Adipocytokines

Hormones related to obesity promote Hormones related to obesity promote insulin resistance, heart disease, and insulin resistance, heart disease, and cancer by increasedcancer by increased InflammationInflammation

• Elevated CRP and interleukin-6 (IL-6)Elevated CRP and interleukin-6 (IL-6)• Reduced anti-inflammatory hormone: adiponectinReduced anti-inflammatory hormone: adiponectin

Clot formationClot formation Free-radicalsFree-radicals


Prevention of Obesity Is the KeyPrevention of Obesity Is the Key

Begin in infancy with appropriate weight gain during Begin in infancy with appropriate weight gain during pregnancy and breastfeedingpregnancy and breastfeeding

Develop positive food habits in childhood emphasizing Develop positive food habits in childhood emphasizing goals of the MyPyramid and Dietary Guidelinesgoals of the MyPyramid and Dietary Guidelines

Encourage high-fiber foods and slow-paced eating for Encourage high-fiber foods and slow-paced eating for satiety and goal of reduced food portionssatiety and goal of reduced food portions

Avoid rewarding and comforting with foodAvoid rewarding and comforting with food——promote promote alternatives such as flowers, card of thanks, praisealternatives such as flowers, card of thanks, praise

Drink water or seltzer water or other sugar-free beveragesDrink water or seltzer water or other sugar-free beverages Try diluting juice with seltzer, as done in EuropeTry diluting juice with seltzer, as done in Europe

Include regular physical activity on most days, including Include regular physical activity on most days, including physical education in schools; discourage excess sedentary physical education in schools; discourage excess sedentary behaviors (e.g., excess television, computer use)behaviors (e.g., excess television, computer use)


Calories CountCalories Count

3500 kcal = 1 lb body fat3500 kcal = 1 lb body fat Reduction of 500 kcal/day = 1 lb/week lossReduction of 500 kcal/day = 1 lb/week loss Alternative: increase physical activity for Alternative: increase physical activity for

equivalent of 500 kcal/day equivalent of 500 kcal/day May want to do combination low-cal + increased May want to do combination low-cal + increased

activityactivity Advise maximum of 1- to 2-lb/week weight loss for Advise maximum of 1- to 2-lb/week weight loss for

long-term success and maintenance of lean long-term success and maintenance of lean muscle massmuscle mass

Individual needs vary because of metabolic Individual needs vary because of metabolic differences (e.g., thrifty gene, amount of muscle differences (e.g., thrifty gene, amount of muscle mass, medication effects)mass, medication effects)


Weight-Loss TipsWeight-Loss Tips

Plan must be individualized per lifestyle and food habitsPlan must be individualized per lifestyle and food habits——no “one diet fits all”no “one diet fits all”

Emphasize satiety through chewing more; reduce pace of Emphasize satiety through chewing more; reduce pace of eatingeating

Include fiber in meals for “fullness” (e.g., people have been 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 known to eat ½ gal of ice cream at a sitting, but never ½ gal beans)beans)

Include some unsaturated fats (take as long as 4 hr to leave Include some unsaturated fats (take as long as 4 hr to leave the stomach)the stomach)

Include the minimum number of servings from the Include the minimum number of servings from the MyPyramid Food Guidance System (1500 kcal depending MyPyramid Food Guidance System (1500 kcal depending on portions and choices); this approach is healthful and on portions and choices); this approach is healthful and likely to be successfullikely to be successful

Legumes can substitute for some grains for goal of Legumes can substitute for some grains for goal of increased fiber with trace minerals and B vitaminsincreased fiber with trace minerals and B vitamins


Set Realistic Weight GoalsSet Realistic Weight Goals

Desirable weight goals are achievable weight goalsDesirable weight goals are achievable weight goals Desirable weight goal may not be IBW per the BMIDesirable weight goal may not be IBW per the BMI A weight loss of 10 to 15 lb often will normalize blood A weight loss of 10 to 15 lb often will normalize blood

glucose in a person with diabetesglucose in a person with diabetes A weight loss of 10% is significant; a weight loss of 15% is A weight loss of 10% is significant; a weight loss of 15% is

considered very significant; permanent weight loss of considered very significant; permanent weight loss of >15% seldom occurs>15% seldom occurs

Slow, sustained weight loss of ½ lb/week is most Slow, sustained weight loss of ½ lb/week is most likely to be permanent weight loss and preserve muscle likely to be permanent weight loss and preserve muscle massmass

Persons needing to gain weight rarely gain more than ½ to Persons needing to gain weight rarely gain more than ½ to 1 lb per week1 lb per week


Calorie-Control ApproachesCalorie-Control Approaches

Exchange lists for weight management—aimed at Exchange lists for weight management—aimed at kilocalorie restrictionkilocalorie restriction

MyPyramid—minimum number of servings MyPyramid—minimum number of servings promotes modest kilocalorie restriction while promotes modest kilocalorie restriction while promoting good nutritional intake for general promoting good nutritional intake for general health needshealth needs

Food labels—guidelines provided at 2000 kcal Food labels—guidelines provided at 2000 kcal can be an appropriate level for active adults with can be an appropriate level for active adults with high kilocalorie needs; guidance based on high kilocalorie needs; guidance based on macronutrient intake can be modified (e.g., 1500 macronutrient intake can be modified (e.g., 1500 kcal at 200 g CHO, 60 g PRO, and 50 g fat)kcal at 200 g CHO, 60 g PRO, and 50 g fat)


The Low-Fat ApproachThe Low-Fat Approach

Rationale: 9 kcal/g fat versus 4 kcal/g Rationale: 9 kcal/g fat versus 4 kcal/g carbohydrate and proteincarbohydrate and protein

Volume-wise: ½ cup sugar = 400 kcal versus Volume-wise: ½ cup sugar = 400 kcal versus ½ cup fat = more than 1000 kcal½ cup fat = more than 1000 kcal

Drawbacks: food companies increase sugar in Drawbacks: food companies increase sugar in fat-free foods (i.e., some fat-free products have fat-free foods (i.e., some fat-free products have more kilocalories than their original low-fat more kilocalories than their original low-fat versions)versions)

People assume if a food has no fat, it has no People assume if a food has no fat, it has no kilocalories (e.g., 1 L soda pop = 0 g fat) but kilocalories (e.g., 1 L soda pop = 0 g fat) but actually has more than 400 kcalactually has more than 400 kcal


Role of Physical Activity in Role of Physical Activity in Weight ManagementWeight Management

Burns kilocaloriesBurns kilocalories Increased metabolic rate for up to 24 hr Increased metabolic rate for up to 24 hr

with aerobic forms; long-term increase in with aerobic forms; long-term increase in metabolic rate with increased muscle metabolic rate with increased muscle mass from anaerobic exercisemass from anaerobic exercise

Can increase the number and function of Can increase the number and function of mitochondria mitochondria

Can improve hormonal balanceCan improve hormonal balance Improved mood can promote better food Improved mood can promote better food

choiceschoices


Aerobic versus Anaerobic ExerciseAerobic versus Anaerobic Exercise

Aerobic—form of exercise requiring increased oxygen; goal Aerobic—form of exercise requiring increased oxygen; goal of at least 30 minutes on most days; weight loss may of at least 30 minutes on most days; weight loss may require 60 minutesrequire 60 minutes Walking, running, dancing, cycling, cross-country skiing, most Walking, running, dancing, cycling, cross-country skiing, most

sportssports Anaerobic “without air”—contributes to weight loss via Anaerobic “without air”—contributes to weight loss via

increased muscle mass; muscle pain associated with increased muscle mass; muscle pain associated with increased levels of lactic acid (excess pain associated with increased levels of lactic acid (excess pain associated with rhabdomyolysis and kidney failure)rhabdomyolysis and kidney failure) Weight liftingWeight lifting

Combination aerobic and anaerobicCombination aerobic and anaerobic Evidence suggests this is most effective approach for weight Evidence suggests this is most effective approach for weight

lossloss Hill climbingHill climbing


Surgical InterventionsSurgical Interventions

Approved for class III obesity or class II Approved for class III obesity or class II with high mortality riskwith high mortality risk Gastric bandingGastric banding

• Least invasive and reversible; associated with 47% Least invasive and reversible; associated with 47% weight loss (Spivak et al., 2005)weight loss (Spivak et al., 2005)

Stomach staplingStomach stapling Bariatric surgeryBariatric surgery

• Reduces stomach size to volume of about ¼ cup Reduces stomach size to volume of about ¼ cup (micropouch procedure involves 1 tbsp volume) and (micropouch procedure involves 1 tbsp volume) and bypasses a portion of the small intestine for bypasses a portion of the small intestine for decreased absorptive areadecreased absorptive area


Roux-en-Y Gastric BypassRoux-en-Y Gastric BypassBariatric SurgeryBariatric Surgery

Surgery creates a Y-shaped reconstruction between the Surgery creates a Y-shaped reconstruction between the stomach and middle portion of the small intestine (jejunum)stomach and middle portion of the small intestine (jejunum)

Stomach reduced in size by stapling off the lower portionStomach reduced in size by stapling off the lower portion Potential complications:Potential complications:

Mortality resulting from surgical interventionMortality resulting from surgical intervention Dumping syndrome because pyloric sphincter bypassedDumping syndrome because pyloric sphincter bypassed RhabdomyolysisRhabdomyolysis (Koffman et al., 2006)(Koffman et al., 2006)

Hyperinsulinemic hypoglycemia due to increased incretin Hyperinsulinemic hypoglycemia due to increased incretin hormonal levelshormonal levels (Goldfine et al., 2007)(Goldfine et al., 2007)

After a decade post-surgery: myelopathy, a pathologic spinal After a decade post-surgery: myelopathy, a pathologic spinal cord disease cord disease (Juhasz-Pocsine et al., 2007)(Juhasz-Pocsine et al., 2007)

Long-term malnutrition despite supplementation with vitamins Long-term malnutrition despite supplementation with vitamins and mineralsand minerals


Specific Nutritional Specific Nutritional Complications of Roux-en-YComplications of Roux-en-Y

Iron-deficiency anemiaIron-deficiency anemia Folate deficiency (increased risk of neural tube defects, or Folate deficiency (increased risk of neural tube defects, or

spina bifida, with pregnancy)spina bifida, with pregnancy) Vitamin BVitamin B1212 deficiency or pernicious anemia with concerns deficiency or pernicious anemia with concerns

of permanent nerve damageof permanent nerve damage Osteoporosis from decreased calcium absorption and Osteoporosis from decreased calcium absorption and

altered metabolism of vitamin Daltered metabolism of vitamin D Thiamin deficiency caused by excessive vomiting with Thiamin deficiency caused by excessive vomiting with

potential for neuropathy, dry beriberi with memory potential for neuropathy, dry beriberi with memory impairment, heart failure, Wernicke’s encephalopathy (triad impairment, heart failure, Wernicke’s encephalopathy (triad of inattentiveness, ataxia, or impaired muscle coordination, of inattentiveness, ataxia, or impaired muscle coordination, and paralysis of eye muscles)and paralysis of eye muscles)

Hair loss caused by varied nutritional deficiencies:Hair loss caused by varied nutritional deficiencies: Biotin deficiency, decreased ferritin level, decreased vitamin DBiotin deficiency, decreased ferritin level, decreased vitamin D33

(the active form), decreased l-lysine (an amino acid)(the active form), decreased l-lysine (an amino acid)


Distal Gastric Bypass Biliopancreatic Distal Gastric Bypass Biliopancreatic Diversion (DBP) and Duodenal Switch (DS)Diversion (DBP) and Duodenal Switch (DS)

Most severe malabsorptive procedureMost severe malabsorptive procedure Linked with protein-calorie malnutrition in Linked with protein-calorie malnutrition in

up to 10% of individuals experiencing 80% up to 10% of individuals experiencing 80% weight lossweight loss

Increased gallbladder disease with rapid Increased gallbladder disease with rapid weight loss; cholecystectomy (removal of weight loss; cholecystectomy (removal of gallbladder) often performed at time of gallbladder) often performed at time of DBP-DS procedure in anticipation of needDBP-DS procedure in anticipation of need


Long-Term Effectiveness Long-Term Effectiveness of Bariatric Surgeryof Bariatric Surgery

Stomach stapling procedures found with Stomach stapling procedures found with increased expansion of remaining stomach increased expansion of remaining stomach portion leading to regain of lost weightportion leading to regain of lost weight

Persons with Prader-Willi syndrome generally Persons with Prader-Willi syndrome generally have poor outcomes have poor outcomes (Scheimann et al., 2008)(Scheimann et al., 2008)

Increased ghrelin levels after 3 months of bariatric Increased ghrelin levels after 3 months of bariatric surgery promote increased appetite, despite surgery promote increased appetite, despite reduction in stomach size reduction in stomach size (Garcia-Unzueta et al., 2005)(Garcia-Unzueta et al., 2005)

Weight gain occurs over the long-termWeight gain occurs over the long-term Evidence indicates only modest decrease in long-term Evidence indicates only modest decrease in long-term

mortality mortality (Shah et al., 2006)(Shah et al., 2006)


Nursing Concerns Related Nursing Concerns Related to Bariatric Surgeryto Bariatric Surgery

Explain specific adverse health outcomes prior to Explain specific adverse health outcomes prior to irreversible bariatric weight loss proceduresirreversible bariatric weight loss procedures Rather than saying there are vitamin and mineral deficiency Rather than saying there are vitamin and mineral deficiency

concerns, be specific (e.g., “B vitamin deficiency can cause concerns, be specific (e.g., “B vitamin deficiency can cause irreversible nerve damage”)irreversible nerve damage”)

Support those who have had bariatric surgerySupport those who have had bariatric surgery Reinforce the need for small, frequent meals, avoidance of Reinforce the need for small, frequent meals, avoidance of

liquids with meals to prevent the dumping syndromeliquids with meals to prevent the dumping syndrome Reinforce the need for regular medical follow-up for those Reinforce the need for regular medical follow-up for those

persons who have had bariatric surgery (e.g., review s/s to persons who have had bariatric surgery (e.g., review s/s to observe related to neurodegeneration and B vitamin observe related to neurodegeneration and B vitamin deficiency, especially with emesis)deficiency, especially with emesis)


Nutritional Deficiency Symptoms; Nutritional Deficiency Symptoms; Monitor After Bariatric SurgeryMonitor After Bariatric Surgery

Osteoporosis—advise regular DXA scansOsteoporosis—advise regular DXA scans Hair loss—may be zinc deficiency or other Hair loss—may be zinc deficiency or other

deficiency: biotin, iron, vitamin D, lysinedeficiency: biotin, iron, vitamin D, lysine Impaired vision in daytime—may be vitamin A Impaired vision in daytime—may be vitamin A

deficiencydeficiency Involuntary movements of the eyeball, double Involuntary movements of the eyeball, double

vision, loss of balance, muscle loss or vision, loss of balance, muscle loss or tingling/weakness, memory loss—vitamin Btingling/weakness, memory loss—vitamin B11

deficiencydeficiency

Documents

Chapter 6 Obesity and Healthy Weight Management. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Health Problems