wt.mgt ch 22 ppt edited

Nutrition in Weight Nutrition in Weight ManagementManagement

Chapter 22Chapter 22

Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Body Weight ComponentsBody Weight Components

Lean body mass (LBM)Lean body mass (LBM)– Skeletal muscles, water, bone, and essential fat Skeletal muscles, water, bone, and essential fat

in internal organs, bone marrow, and nerve in internal organs, bone marrow, and nerve tissuestissues

– Higher in men than in womenHigher in men than in women

– Increases with exercise; decreases with ageIncreases with exercise; decreases with age

– Major determinant of RMRMajor determinant of RMR

– Water is the most variable component, making Water is the most variable component, making up 60% to 65% of LBMup 60% to 65% of LBM

2Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Body FatBody Fat Essential body fatEssential body fat

– Necessary for physiologic functionNecessary for physiologic function

– About 3% of body weight in men and 12% in About 3% of body weight in men and 12% in womenwomen

Storage body fatStorage body fat– Energy reserve under the skin, primarily Energy reserve under the skin, primarily

triglycerides in adipose tissuetriglycerides in adipose tissue

– Around the internal organs to protect them from Around the internal organs to protect them from traumatrauma

– Most considered expendableMost considered expendable

– Good health associated with 10% to 25% of Good health associated with 10% to 25% of body weight in men and 18% to 30% in womenbody weight in men and 18% to 30% in women


Adipose Tissue CompositionAdipose Tissue Composition Adipose tissue structure: wAdipose tissue structure: white and brown hite and brown

adipose tissueadipose tissue Adipocytes, hypertrophy, and hyperplasiaAdipocytes, hypertrophy, and hyperplasia Fat cell developmentFat cell development


Fat StorageFat Storage Dietary triglycerides and lipogenesisDietary triglycerides and lipogenesis Semi-volatile organic compounds (SVOCs)Semi-volatile organic compounds (SVOCs) Lipoprotein lipase (LPL)Lipoprotein lipase (LPL) Hormone-sensitive lipase (HSL)Hormone-sensitive lipase (HSL) Effects of estrogen and sex steroid Effects of estrogen and sex steroid

hormoneshormones


Theoretical Body Composition Theoretical Body Composition Model for a Man and WomanModel for a Man and Woman

Healthy body-fat ranges adapted from Gallagher D, et al: Healthy percentage body fat ranges: an approach for developing guidelines Healthy body-fat ranges adapted from Gallagher D, et al: Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index, based on body mass index, Am J Clin NutrAm J Clin Nutr 72:694, 2000. 72:694, 2000.


Regulation of Body WeightRegulation of Body Weight Metabolic rate and voluntary activityMetabolic rate and voluntary activity

– Resting metabolic rate (RMR): 60% to 70% of Resting metabolic rate (RMR): 60% to 70% of total energy expendituretotal energy expenditure

– Activity thermogenesis (AT)Activity thermogenesis (AT)

– Nonexercise activity thermogenesis (NEAT)Nonexercise activity thermogenesis (NEAT)


Regulation of Body Weight Regulation of Body Weight (cont’d)(cont’d) Short- and long-term regulationShort- and long-term regulation

– Factors affecting hunger, appetite, and satietyFactors affecting hunger, appetite, and satiety

– Hypophagia and hyperphagia in response to Hypophagia and hyperphagia in response to changes in caloric intakechanges in caloric intake

– AdipocytokinesAdipocytokines

Set-point theorySet-point theory– Preservation of specific body weight: Preservation of specific body weight:

genetically determinedgenetically determined

– ControversialControversial


Weight Imbalance: Weight Imbalance: Obesity and OverweightObesity and Overweight Imbalance between food consumed and Imbalance between food consumed and

physical activityphysical activity

Complex issue related to lifestyle, Complex issue related to lifestyle, environment, and geneticsenvironment, and genetics

PrevalencePrevalence

Weight management throughout the life Weight management throughout the life spanspan

Weight and longevityWeight and longevity


Assessment FactorsAssessment Factors Overweight versus obesityOverweight versus obesity Ideal body weight (IBW)Ideal body weight (IBW) Body mass index (BMI)Body mass index (BMI) Quetelet Index (W/H2)Quetelet Index (W/H2) Waist circumferenceWaist circumference Waist-to-hip ratio (WHR)Waist-to-hip ratio (WHR)


Etiology of Overweight and Etiology of Overweight and ObesityObesity Environmental, genetic, psychological, Environmental, genetic, psychological,

cultural, and physiologic factorscultural, and physiologic factors Heredity and nutrigenomicsHeredity and nutrigenomics

– Twin studiesTwin studies– obob gene (leptin), adiponectin (ADIPOQ), gene (leptin), adiponectin (ADIPOQ), FTOFTO

gene, and b3-adrenoreceptor genegene, and b3-adrenoreceptor gene Inadequate physical activityInadequate physical activity InflammationInflammation

– Cytokine polymorphisms: insulin insensitivity, Cytokine polymorphisms: insulin insensitivity, hyperlipidemia, muscle protein loss, and hyperlipidemia, muscle protein loss, and oxidant stressoxidant stress

– Chronic inflammationChronic inflammation11Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Etiology of Overweight and Etiology of Overweight and Obesity (cont’d)Obesity (cont’d) Sleep, stress, and circadian rhythmsSleep, stress, and circadian rhythms

– Chronic sleep deprivationChronic sleep deprivation– CortisolCortisol

Taste, satiety, and portion sizesTaste, satiety, and portion sizes– Portion sizes and energy densityPortion sizes and energy density– Variety and sensory-specific satietyVariety and sensory-specific satiety

Viruses and pathogensViruses and pathogens


Health Risks and LongevityHealth Risks and Longevity DiabetesDiabetes Heart diseaseHeart disease HypertensionHypertension HyperlipidemiaHyperlipidemia Gallbladder diseaseGallbladder disease Some cancersSome cancers MortalityMortality Nonalcoholic fatty liver disease (NASH)Nonalcoholic fatty liver disease (NASH)


Fat Distribution and Metabolic Fat Distribution and Metabolic SyndromeSyndrome Genetic; differ between men and womenGenetic; differ between men and women Android: excess subcutaneous truncal-Android: excess subcutaneous truncal-

abdominal fat (apple shape)abdominal fat (apple shape)– More common in men; increases with ageMore common in men; increases with age– Correlated with insulin resistance, metabolic Correlated with insulin resistance, metabolic

syndromesyndrome Gynoid: excess gluteofemoral fat (pear Gynoid: excess gluteofemoral fat (pear

shape)shape)– More common in women, especially More common in women, especially

premenopausalpremenopausal


Fat Distribution and Metabolic Fat Distribution and Metabolic Syndrome (cont’d)Syndrome (cont’d) Metabolic syndrome (MetS) includes three Metabolic syndrome (MetS) includes three

or more of the following:or more of the following:– Waist circumference >102 cm (40 in) in men Waist circumference >102 cm (40 in) in men

and >88 cm (35 in) in womenand >88 cm (35 in) in women– Serum triglycerides of at least 150 mg/dLSerum triglycerides of at least 150 mg/dL– High-density lipoprotein (HDL) level <40 mg/dL High-density lipoprotein (HDL) level <40 mg/dL

in men and <50 mg/dL in womenin men and <50 mg/dL in women– Blood pressure 135/85 mm Hg or higherBlood pressure 135/85 mm Hg or higher– Serum glucose 110 mg/dL or higherSerum glucose 110 mg/dL or higher


Calorie Restriction and LongevityCalorie Restriction and Longevity

Increases life span and slows aging in Increases life span and slows aging in animalsanimals

Fasting insulin level and body temperature Fasting insulin level and body temperature decreasedecrease

Possible benefits for aging: neurologic and Possible benefits for aging: neurologic and cardiac functioncardiac function


Weight DiscriminationWeight Discrimination

Widespread bias based on weightWidespread bias based on weight

Key areas of life: education, employment, Key areas of life: education, employment, and health careand health care

Lack of understandingLack of understanding

Impact on children and adolescentsImpact on children and adolescents


Management of Obesity in AdultsManagement of Obesity in Adults Achievement of IBW may not be possible Achievement of IBW may not be possible

or desirableor desirable Beneficial to maintain present weight or Beneficial to maintain present weight or

achieve moderate loss (5%‒10%)achieve moderate loss (5%‒10%) Effects of rapid weight loss: starvation Effects of rapid weight loss: starvation

response and metabolic aberrationsresponse and metabolic aberrations NIH recommends loss of 0.5 to 1 lb/wk for NIH recommends loss of 0.5 to 1 lb/wk for

BMI 27 to 35; 1 to 2 lb/wk for BMI >35BMI 27 to 35; 1 to 2 lb/wk for BMI >35 Individualize final goal weightsIndividualize final goal weights


Lifestyle ModificationLifestyle Modification

Behavior modificationBehavior modification

Self-monitoringSelf-monitoring

Goal settingGoal setting

Stimulus controlStimulus control

Problem solvingProblem solving

Cognitive restructuringCognitive restructuring

Relapse preventionRelapse prevention


Nutrition Care ProcessNutrition Care Process for Managing for Managing ObesityObesity


Dietary ModificationDietary Modification

Weight-loss programsWeight-loss programs– Food choice changesFood choice changes

– ExerciseExercise

– Behavior modificationBehavior modification

– Nutrition educationNutrition education

– Psychological supportPsychological support

– Surgical intervention for morbid obesitySurgical intervention for morbid obesity

– PharmacotherapyPharmacotherapy


Dietary Modification (cont’d)Dietary Modification (cont’d) Restricted-energy dietsRestricted-energy diets

– Deficit of 500 to 1000 kcal/dayDeficit of 500 to 1000 kcal/day– Relative high in CHO, generous protein, fat Relative high in CHO, generous protein, fat

<30%<30%– Limit alcohol and high-sugar foodsLimit alcohol and high-sugar foods– Artificial sweeteners and fat substitutesArtificial sweeteners and fat substitutes– Vitamin and mineral supplementsVitamin and mineral supplements

Formula diets and meal replacement Formula diets and meal replacement programsprograms

Commercial programsCommercial programs Extreme energy restriction and fastingExtreme energy restriction and fasting Very-low-calorie dietsVery-low-calorie diets


Popular Diets and PracticesPopular Diets and Practices Efficacy, effects on metabolic parameters, Efficacy, effects on metabolic parameters,

psychological well-being, and reduction of psychological well-being, and reduction of chronic diseasechronic disease

Carbohydrate-restricted diets (Atkins, Carbohydrate-restricted diets (Atkins, Carbohydrate Addict)Carbohydrate Addict)

More moderate carbohydrate restrictions More moderate carbohydrate restrictions (Zone and South Beach)(Zone and South Beach)

VolumetricsVolumetrics Very-low-fat diets (Dean Ornish, Pritikin)Very-low-fat diets (Dean Ornish, Pritikin)


Physical ActivityPhysical Activity Increases proportion of LBM to fatIncreases proportion of LBM to fat Offsets decrease in RMR with weight lossOffsets decrease in RMR with weight loss Strengthens cardiovascular integrityStrengthens cardiovascular integrity Increases sensitivity to insulinIncreases sensitivity to insulin Expends more energyExpends more energy 60 to 90 min/day recommended for weight 60 to 90 min/day recommended for weight

loss (at least 30 minutes; moderate loss (at least 30 minutes; moderate intensity)intensity)

Aerobic and resistance trainingAerobic and resistance training


Pharmaceutical ManagementPharmaceutical Management For BMI >30 or BMI>27 + significant risk For BMI >30 or BMI>27 + significant risk

factorsfactors Augments diet, exercise, and behavior Augments diet, exercise, and behavior

therapytherapy CNS-acting agentsCNS-acting agents

– Catecholaminergic agents, serotoninergic Catecholaminergic agents, serotoninergic agents, and combination agentsagents, and combination agents

– Common side effects are dry mouth, headache, Common side effects are dry mouth, headache, insomnia, and constipationinsomnia, and constipation

– Only sibutramine and orlistat approved for long-Only sibutramine and orlistat approved for long-term useterm use

Non–CNS-acting agentsNon–CNS-acting agents25Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Other Nonsurgical ApproachesOther Nonsurgical Approaches

Eat healthfully, become attuned to hunger Eat healthfully, become attuned to hunger and satiety cues, and incorporate physical and satiety cues, and incorporate physical activityactivity

Promote size acceptance and respect for a Promote size acceptance and respect for a diversity of body shapesdiversity of body shapes


Surgical ProceduresSurgical Procedures Bariatric surgery: for morbidly obese only; Bariatric surgery: for morbidly obese only;

BMI >40 or BMI >35 with comorbiditiesBMI >40 or BMI >35 with comorbidities– Restrictive or malabsorptiveRestrictive or malabsorptive– Previous failure of comprehensive programPrevious failure of comprehensive program– Evaluate physiologic and medical Evaluate physiologic and medical

complications, psychological problems, and complications, psychological problems, and motivationmotivation

Gastroplasty and gastric bypassGastroplasty and gastric bypass LiposuctionLiposuction


Gastric Surgeries for ObesityGastric Surgeries for Obesity


Common Problems in Obesity: Common Problems in Obesity: Maintenance of Reduced Body Maintenance of Reduced Body WeightWeight

Poor prognosisPoor prognosis

Reduced energy needs for maintenanceReduced energy needs for maintenance

Lifestyle modificationLifestyle modification

Support groupsSupport groups

The National Weight Control Registry The National Weight Control Registry (NWCR) recommendations(NWCR) recommendations

Plateau effectPlateau effect

Weight cyclingWeight cycling29Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Weight Management in ChildrenWeight Management in Children

Weight maintenance or slowing of gainsWeight maintenance or slowing of gains

Grow into weightGrow into weight

If already exceeds adult weight, lose 10 to If already exceeds adult weight, lose 10 to 12 lb/year12 lb/year

Family eating habitsFamily eating habits

Physical activityPhysical activity


Weight Imbalance: Excessive Weight Imbalance: Excessive Leanness or Unintentional Weight LossLeanness or Unintentional Weight Loss

EtiologyEtiology

AssessmentAssessment

ManagementManagement– Appetite enhancersAppetite enhancers

– High-energy diets for weight gainHigh-energy diets for weight gain

– Review habitsReview habits

– Schedule mealsSchedule meals

– RelaxationRelaxation

– Energy distributionEnergy distribution

– SnacksSnacks31Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Focal PointsFocal Points Overweight and obesity in adults (66.3 %) in the United Overweight and obesity in adults (66.3 %) in the United

States have reached epidemic numbers. Even more alarming States have reached epidemic numbers. Even more alarming is the increasing rate (17.1%) of overweight in children and is the increasing rate (17.1%) of overweight in children and adolescents. The United States is not alone in terms of adolescents. The United States is not alone in terms of trends; they exist worldwide. trends; they exist worldwide.

Obesity has severe associated risks: type 2 diabetes, Obesity has severe associated risks: type 2 diabetes, hypertension, atherosclerosis, some cancers, sleep apnea, hypertension, atherosclerosis, some cancers, sleep apnea, infertility, gallbladder disease, and liver disease; increased infertility, gallbladder disease, and liver disease; increased visceral fat has an important influence on metabolic and visceral fat has an important influence on metabolic and cardiovascular risk factors. cardiovascular risk factors.

Understanding the mechanism of appetite regulation is an Understanding the mechanism of appetite regulation is an exciting area of research for new treatments. exciting area of research for new treatments.


Focal Points (cont’d)Focal Points (cont’d) A chronic disease model involving both caloric restriction, A chronic disease model involving both caloric restriction,

increased physical activity and lifestyle interventions in the increased physical activity and lifestyle interventions in the context of an interdisciplinary approach offers the best context of an interdisciplinary approach offers the best treatment options for the patient. treatment options for the patient.

Stopping weight gain or achieving a moderate loss should be Stopping weight gain or achieving a moderate loss should be promoted as a treatment goal; an achievable 5 to 10% loss promoted as a treatment goal; an achievable 5 to 10% loss of initial body weight can improve glycemic control, blood of initial body weight can improve glycemic control, blood pressure and lipid profile in most patients.pressure and lipid profile in most patients.

Among those individuals who are underweight, careful Among those individuals who are underweight, careful assessment and intervention are needed to correct habits assessment and intervention are needed to correct habits leading to unintentional weight loss.leading to unintentional weight loss.


wt.mgt ch 22 ppt edited

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