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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

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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

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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.

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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

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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.

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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

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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

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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.

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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

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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

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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)

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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

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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