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Clinical Medicine: Nutrition & Obesity

August 18 | Dr. Adarsh Gupta | 3-4pm | PM


Slide 2: Introduction
Nutrition is a major determinant of health
Nutrition supplies not only physiological needs but also psychological and social needs
It is one of the healthy people 2020 objective to promote health and reduce chronic disease risk through:
- The consumption of healthful diets
- Achievement and maintenance of health body weights

Slide 3: Dietary Proportions


65% of US population is currently obese, current diets are high in fat, carbs and protein, low in fiber.

Current Proportions Recommended Proportions


Fat 36-37% 20-30%
Protein
Males 90g/day 56g/day
Females 60g/day 44g/day
Carbs 46% 45-65%
Fiber
Males 18g/day 20-36g/day
Females 12g/day 14g/day

Slide 4-8:
Nutrition, Diet, and Health
Nutrition - science of foods and nutrients they contain + actions they have on the body
o Actions of body = ingestion, digestion, absorption, transport, metabolism, excretion
These require ENERGY, which comes from food
Diet: foods one consumes; quality has cumulative impact on your health and risk of chronic disease
o Nutrients are used by the body to provide energy (~40 known nutrients) and support growth/repair
Types of nutrients: (1) carbs, (2) lipids, (3) proteins, (4) vitamins, (5) minerals, (6) water
Foods
o Functional foods contain substances that provide health benefits beyond those of nutrients
o May be natural functional food or result of additives (Ie. Tomatoes have lycopene & Orange Juice has Ca)
Slide 9-15:
Classifying Nutrients
Organic or inorganic
o Organic = contain carbon (ex: carbs, lipids, proteins, vitamins)
o Inorganic = do not contain carbon (ex: water)
Essential or nonessential
o Essential = nutrients the body either cannot make or cannot make enough of to meet its needs (ex:
vitamins, calcium, iron, some amino acids)
o Nonessential = body can make from other ingested nutrients (ex: cholesterol)
Macronutrient or micronutrient
o Macronutrients = need in relatively large amounts (ex: carbs, fats, proteins)

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o Micronutrients = need in relatively small amounts (ex: all other nutrients)
Energy yielding or not energy yielding
o Energy yielding
Carbs 4kcal/g
Fat 9kcal/g
Protein 4kcal/g
o Non-energy yielding
Vitamins, water, minerals
Macronutrients include
a. Protein and fat
b. Water and calories
c. Carbohydrate and fiber
d. Vitamins and minerals

Energy-Yielding Non-Nutrients
Alcohol: 7kcal/g; interferes w/ growth maintenance and repair of body
O Risks: addiction, birth defects, impaired judgement, liver disease, etc
Calories amount of energy needed to raise the temperature of 1kg of water by 10C

Slide 16:
Energy in the Body
Body uses energy-yielding nutrients to fuel all activity; hence, they are caloric
Energy ingested > energy needed to fuel the body activities: the extra energy is stored as fat and obesity occurs
Slide 17-20:
Vitamins
Essential to life
Complex, organic micronutrients
Not metabolized to yield energy
o B12 is the only vitamin that the body needs continuously
Anemia & B12 deficiency cause fatigue; if you have regular B12 production, giving you more
wont give you more energy
Fat soluble vitamins = A, D, E, K
o If you take too much, more will get stored in fat and can be toxic
Water soluble vitamins = C/B complex
o Synthesized by plants and supplied in diet
o Must be consumed regularly because body stores limited
o Function as co-enzymes in cell metabolism
o Toxicity is uncommon because excess is urinated
except: vitamin B6--> nerve damage, vitamin C GI disturbance, folate B12 deficiency masked.

Slide 21-23:
Minerals
Essential to life
Inorganic substances
Not metabolized to yield energy

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Cant be manufactured by the body
Functions:
o Build body tissue
o Regulate metabolic process
o Transmit info across nerves
Major minerals needed in >100mg
o Essential for human body: calcium, phosphorus, magnesium, sodium, potassium, chloride, sulfur
Trace minerals needed in small amounts (iron, iodine, zinc)

Water
Most overlooked essential nutrient
Medium most nutrients use as solvent
Provides means of stabilizing body temperature
Only can live a few days w/o water
Largest component in body
o Female: 55% of total body weight
o Male: 60% of total body weight
Body water is distributed intra- and extracellularly (major component)
Pure drinking water is best source. Caffine and other agents make you lose water.

Slide 24-25:
Minimal Daily Requirements
Based on estimating requirements and determining variation in requirements to specific population groups
Calculated by the Food and Nutrition Board of the National Academy of Sciences.
Recommendations are modified based on bioavailability and individual requirements.
Recommended dietary allowances (RDA) = average daily dietary intake level sufficient to meet nutrient
requirement of 97-98% of healthy individuals
Dietary reference intakes (DRI) = reference values quantitative estimates of nutrient intakes to be used for
planning/assessing diets
o Adequate intake (AI) = recommended intake value based on observed/experimentally
determined
o Tolerable upper level intake (UL) = highest level of daily nutrient intake likely to pose no risk
o Estimated average requirement (EAR) = estimated intake to meet requirement of
(HALF) of the healthy population
Slide 26-30:

Energy Density
Measure of the kcal/g of food
Lower energy density is better than higher energy density

Energy Balance most important thing in weight management, according


to AG
Energy = force enabling body to continue its life-sustaining
physical/metabolic work

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o Anabolism = build up
o Catabolism = break down
Both of these uses some energy that is regained by food
Starvation
st
o 1 store = glycogen
In liver, 12-36 hour reserve
nd
o 2 store = adipose (fat tissue)
Supply varies from person to person
rd
o 3 store = muscle mass
Energy exists in limited amounts but greater volume than glycogen; last resort
Total Energy Expenditure (TEE)
o Sum of:
Basal metabolic rate (BMR): amount of energy required to maintain resting bodys
internal activity after an overnight fast w/ subject awake
Thermic effect of food (TEF): body heat produced by food
Physical activity needs: varies w/ activity level of each patient (sedentary (kcal spend<1/2 BMR)
very active (could be double BMR))

Role of Nutrition in Disease Prevention and Treatment


Slide 32-34:
Preventing Disease and Promoting Health
Average life expectancy = 78 years
o Chronic disease accounts for 7/10
US deaths
Increasing cost of crisis medical care = biggest incentive to prevent chronic disease
Health/nutrition program for adults targets factors related to adults and prevents diseases that are the
leading causes of death and disability

Chronic Diseases
Leading causes of death/disability due to diet
Dietary factors are associated w/ 5 of the 10 leading causes of death in the US:o Coronary heart disease
o Cancer
o Stroke
o Accidents (alcohol)
o Diabetes mellitus
LEARNING POINT: More than 60% of chronic disease mortality can be attributed to diet (can be modified!)

Slide 35-37:
Prevention Strategies
Primary prevention: Health Promotion
Encourage health-enhancing behaviors by giving families/communities ways to reduce risk factors
o Nutrition/weight management classes
o Increase availability of fresh fruits/veggies from farmers market (ie. Camdens Health garden started
because students never seen fruits)
Secondary prevention: Risk Appraisal and Risk Reduction

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Screening to emphasize early detection
Begins at the point where pathology of disease may occur
Screening strategies include follow up education, counseling and health referral (ie. Cholesterol screening, educating
about diet and exersice).
Tertiary prevention: Treatment and Rehabilitation
Involves treatment and rehabilitation and is defined as reduction in disability caused by disease to achieve
highest level of function.
Goal is to prevent further disability and secondary conditions that might result from initial health problem
Slide 38-43:
Dietary Guidelines for Disease Prevention (America 2010)
Balance calories to manage weight
Prevent and/or reduce overwight/obesity through improved eating
Control total calorie intake to manage weight
Increase physical activity and reduce sedentary time
Maintain appropriate calorie balance throughout each stage of life

Foods and food components to reduce


Daily sodium intake to less than 2300 mg (ie. One can of V8 juice has 600mg)
o 1500mg for people 51+
Consume <10% of calories from saturated FAs
Consume <300mg per day of dietary cholesterol
Trans fatty acid consumption low
Solid fats and added sugars
Refined grains
Alcohol (1 drink/day for women; 2 drinks/day for men)

Foods and nutrients to increase


Increase food/veggies to 5 servings per day
o Variety of veggies, especially dark-green and red/orange veggies
Increase whole grains
Increase fat-free or low-fat milk/milk products

Building healthy eating patterns


Choose a variety of protein foods
Increase amount/variety of seafood
Replace protein foods that are higher in solid fats w/ choices lower in solid fats
Use oils to replace solid fat
Choose foods that provide more K, fiber, Ca, and vitamin D (fruits, veggies, whole grains, milk)
Diet that meets nutrient needs over time
Follow food safety recommendations when preparing and eating foods to reduce foodborne illness

Slide 44-47:
Specific Population Groups

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Women capable of becoming pregnant
Foods that supply iron and folic acid

Women who are pregnant or breastfeeding


Consume 8-12 ounces of seafood per week (limit albacore tuna to 6oz/week)
o Exceptions: tilefish, shark, swordfish, mackerel
Take an iron supplement

Individuals age 50 and older


Consume foods with vitamin B12

Evaluation of an Obese Patient


Slide 49- 53:
Overweight and Obesity
Overweight vs. overfat
o Weight doesnt give true measure of fatness, which is the starting point for medical problems
o Difference between the two people left has more muscle, right has more fat.
BMI is a very quick measure of assessing obesity, but it doesnt measure fatness
Evaluation of obese patient
o Patient history (weight history, family history, dietary habits, daily routine)
Ask what meals they ate in last 24 hours to gauge.
Determine what type of activity they do (jog, house chores etc)
o Vitals: BMI or percent-body-fat (PBF)
Overweight = BMI 25-30
Obese = BMI 30-40
Morbidly obese = BMI >40
Waist circumference high risk: Men>45
inch; Women>35inch
Right: Lady on the right, was dx was hypothyroidism
o Laboratory: CMP, CBC, TSH, T3, Lipids (other tests
based on sx and gained weight. However, many other
ordered if co-morbid conditions suspected.
factors in addition to hypothyroidism seem to play a
o Important physical findings
role in weight gain.
Red, puffy face Cushings Left: Acanthosis nigricans around neck in diabetic pts.
Hirsutism Cushings, PCOS (polycystic
ovary syndrome)
Periorbital edema/lateral thinning of
eyebrows/scalloped tongue hypothyroidism
Erosion of dental enamel bulimia nervosa
Acanthosis nigricans insulin
resistance/diabetes Left: Red striae
Buffalo hump Cushings Right: skin tags sign of diabetes/insulin res.
Red striae Cushings v. Obesity
Skin tags diabetes/insulin resistance

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Slide 54-63:
Body Mass Index (BMI)

o Overweight
Adults: BMI 25-30
th th
Children: BMI-for-Age percentile = 85 95
o Obese
Adults: BMI 30-40
th th
Children: BMI-for-age percentile = 95 to 99
o Morbidly obese
Adults: BMI >40
th
Children: BMI-for-age percentile >99
Assessing BMI-for-age-chart
o CDC Website has online Child and BMI calculator according to age growth chart for ages 2-20.
Waist-to-Hip Ratio
o Measures regional fat distribution
Men/post-menopausal women store fat in upper
region of body
Premenopausal women store fat in lower region of body
o Ratio correlated to increased cardiac risk
Males: >1.0
Females: >0.9
Waist Circumference
o Measure at the level of the iliac crest (not at the pant line)
o Keep tape measure perpendicular to ground.
Body Composition Analysis yields body fat percentage (better measure of fatness
than BMI) (normal is 15-25% fat for males, 25-35% for females)
o Body compartments divided into: Lean body mass, body fat, body water and mineral mass (bone)
Techniques for measuring body compostion
o Underwater weighing and densitometry w/ fat mass
o Bioelectrical impedance (BIA)
o Dual X-ray absorptiometry (DEXA)

Slide 64-72:
Prevalence of Obesity
o Constantly on the rise, every state now has 20-24% obesity.
o Southern states are worse
Obesity is linked to 53 diseases
o Heart disease, hypertension, pulmonary disease, diabetes, cancer, etc.
Weight related issues divided into four categories:
o Metabolic problems: type II diabetes, hypertension, elevated lipids
o Degenerative problems: osteoarthritis and joint problems
o Neoplastic problems: many types of cancer
o Anatomic problems: GERD, sleep apnea

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Steps in Determining Treatment
o Determine BMI-related health risk and assess.
o Determine weight reduction exclusions (mental illness, unstable medical condition, pregnancy, osteoporosis)
o Permanent exclusions (Anorexia and terminal illness)
o Assess patients readiness Pt has to be willing to make change.
Treatment Options
o Correct underlying metabolic problems
Hypothyroidism, Cushings, PCOS, diabetes
Optimize medication
o Psychotropic drugs, anti-depressants, blood pressure medications, diabetes meds and
steroids can make a patient gain weight.
o Options for weight loss despite drugs exist!
o Individualized healthy lifestyle program**
Engage in physical activity every day (30 min adults, 60 min children)
Improve exercise, reduced calorie diet, stress management, sleep therapy
Recommend options that will work with the patients lifestyle like fast food diet.
Reduced calorie diet (balanced meals, avoid high calorie foods, add variety)
Slide 73-79:
Adjunct options
LCD (low calorie diet) + exercise + behavioral therapy (done with some meal replacement plan)
VLCD (very low calorie diet) + extensive exercise program (only meal replacements, pt eats 800
cal/day, medical supervision needed)
Obesity drugs
Anti-obesity medications: controls hunger/satiety
o Give to patients w/ BMI >30
o Give to patients w/ BMI >27 + comorbidities
o Body fat of 30% in females
o Body fat of 25% in males
Never give weight loss drugs WITHOUT continued lifestyle modifications
Types of drugs:
o GI Lipase Inhibitors (orlistat)
Does not absorb 30% of fat
Doesnt really control hunger
Side effect = fatty stool
o Sympathomimetric medications for short-term use (phentermine) (short term use
only(
Controls appetite

o Belviq (locarserin)
Works similar to a previous drug that was taken off the market
(Phenfluramine).
No affinity for the heart wall.
Works on the serotonin 2HT receptors
Controls hunger, therefore weight loss.
o Qsymia (phentermine + topiramate)
Surgery

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Sample Questions
1) T or F: Obese people can be malnourished
a. True.

2) T or F: Vitamin, mineral, and other dietary supplement can take the place of a healthy diet.
a. False.

3) Macronutrients include
a. Protein and fat
b. Water and calories
c. Carbohydrates and fiber
d. Vitamins and minerals

4) The type of metabolic reaction that synthesizes new body substances is called
a. Anabolism
b. Catabolism
c. Homeostasis
d. Digestion