Nutrition for Weight Management

1
Nutrition for Weight Management

• Chapter 14
• Pages 323-367
• 4 Lectures

2
Adult obesity USA, 1988
3
Adult obesity USA, 1991
4
Adult obesity USA, 1994
5
Adult obesity USA, 1997
6
Adult obesity USA, 1999
7
Adult obesity USA, 2000
8
Adult obesity USA, 2001
9
Adult obesity USA, 2003

10
In fact, 30 of the population of the United
States is obese.
Globally, 65 of the population is overweight.
11
What is the situation in Canada?
12
Adult obesity Canada, 1985
13
Adult obesity Canada, 1990
14
Adult obesity Canada, 1994
15
Adult obesity Canada, 1996
16
Adult obesity Canada, 1998
17
Adult obesity Canada, 2003
18
Overweight

• A state of adiposity in which body fatness
  exceeds a standard based on height
• Body mass index 25-29.9 kg/m2
• Differences in standards for defining overweight
  obesity

19
Obesity

• Defined as over fatness with adverse health
  effects
• Conventionally defined as 20 or more over
  appropriate weight for height
• Body mass index of gt 30 kg/m2

20
Canadian BMI Standards

• Underweight lt 18.5 Increased Risk
• Normal Wt 18.5-24.9 Least Risk
• Overweight 25-29.9 Increased Risk
• Obese
• Class I 30-34.9 High
• Class II 35-39.9 Very High
• Class III gt 40 Extremely High
• Health Canada Canadian Guidelines for Body
  Weight Classification in Adults (2003)
• http//www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgps
  a/pdf/nutrition/weight_book-livres_des_poids_e.pdf
  

21
ChildrenEvolution of overweight in Canada
Boys and girls, 7 to 13 years old
33
35
27
30
25
20
1981
15
13
11
1996
10
5
0
Boys
Girls
Définition de Cole Données de lELNEJ
(Katzmarzyk et al. 2001)
21
22
Children Evolution of obesity in Canada
Boys and girls, 7 to 13 years old
10
9
2
2
Boys
Girls
Définition de Cole Données de lELNEJ
(Katzmarzyk et al. 2001)
22
23
Body Weight of Canadian Adults(Stats Can CCHS
2004)

• Overweight Obese
• BMI gt 25.0
• Both sexes 59.1
• Males 65.0
• Females 53.4

• Obese
• BMI gt 30
• Both sexes 23.1
• Males 22.9
• Females 23.2

24
Fat Distribution

• Distribution within body clinically important
• Two categories
• 1.) abdominal or central body fat distribution
• 2.) lower body fat distribution

25
Weight gain in the area of and above the waist
(apple type) is more dangerous than weight gained
around the hips and flank area (pear type). Fat
cells in the upper body have different qualities
than those found in hips and thighs.
26
Waist Circumference
BMI
Normal Overwt Obese Class I
lt102 cm M lt 88 cm F Least Risk Increased Risk High Risk
gt 102 cm M gt 88 cm F Increased Risk High Risk Very High Risk
WC
27
Health Problems Associated with Overweight
Obesity

• Type 2 diabetes
• Dyslipidemia
• Insulin Resistance
• Gallbladder disease
• Obstructive sleep apnea respiratory problems
• Hypertension

• Osteoarthritis
• Some types of cancer (breast, endometrial, colon,
  prostate, kidney)
• Psychosocial problems
• Functional limitations
• Impaired fertility

28
Obesity and Morbidity

• Relationship between obesity and morbidity is
  J-shaped with right side of J beginning to rise
  at BMI of 25.
• (may be lower BMI in those with higher waist
  circumferences--- abdominal adiposity)
• Because the major risk of obesity is indirect,
  management must be undertaken within context of
  these risk factors, e.g. HBP, type 2 diabetes,
  dyslipidemias

29
Body Mass Index Mortality Risk
(Adapted from Bray GA. Gray DS, Obesity, part 1
Pathogenesis. West J Med 149429, 1988 and Lew
EA, Garfinkle L Variations in mortality by
weight among 750,000 men and women. J Clin
Epidemiol 32563, 1979.)
30
Characteristics of the Metabolic Syndrome
Abdominal obesity Glucose intolerance/ Insulin
resistance Hypertension Atherogenic
dyslipidemia Proinflammatory/ Prothrombotic state
Diabetes
CVD
National Cholesterol Educational Program (NCEP),
Adult Treatment Panel (ATP) III 2001.
31
What will happen if nothing is done?

• Impact of this increase in the weight of the
  population
• Impact on illness, chronic diseases
• Impact on health care costs
• Impact on productivity
• For the first time in 100 years, reduction in
  life expectancy

32
The Cost of Obesity in Canada CMAJ

• http//www.cmaj.ca/cgi/reprint/160/4/483.pdf
• Obesity is a global epidemic and the single
  greatest public health problem (WHO)

33
Costs of Obesity in Nova Scotia

• See reports on the Cost of Obesity in Nova Scotia
  by the Genuine Progress Index (GPI) NS reports
  re socioeconomic factors
• http//www.gpiatlantic.org/pdf/health/obesity/ns-o
  besity.pdf
• The social trends responsible for our obesity
  epidemic pervade our society and affect all of
  us and the economic costs are borne by everyone.

34
Etiology of Obesity

• No single cause
• Heredity and environment both influential

35
Etiology of Obesity

• The Obesigenic Environment
• Toxic Food Environment Highly processed, sweet,
  fat, highly accessible, large portions.
• When offered larger portions tend to eat more
• Refined grains, added sugars, added fats
  lowest-cost sources of energy
• Sedentarity A world without effort.

36
(No Transcript)
37
Etiology of Obesity
Travel
Adapté de Ritenbaugh C, Kumanyka S, Morabia A,
Jeffrey R, Antipatis V. OITF 1999
38
Etiology of Obesity
FatStores
39
Components of Daily Energy Expenditure
Thermic effect of food
Energy expenditure of physical activity
Resting energy expenditure
8
17
8
32
75
60
Sedentary Person (1800 kcal/d)
Physically Active Person (2200 kcal/d)
Segal KR et al. Am J Clin Nutr. 198440995-1000.
40
Regulation of Food Intake
Brain
Central Signals
Stimulate
Inhibit
neuropeptides neurotransmitters
neuropeptides neurotransmitters
Peripheral signals
Peripheral organs
Glucose CCK, GLP-1,Apo-A-IVVagal
afferents Insulin GhrelinLeptinCortisol
Gastrointestinaltract
FoodIntake
Adiposetissue
Adrenal glands
41
Resting Energy Expenditure (REE)

• The energy expended in the activities necessary
  to sustain normal body functions and homeostasis
• Measured
• Indirect calorimetry measures oxygen
  consumption, CO2 production minute ventilation
• Doubly labeled water rate of isotope
  disappearance measured gold standard for
  free-living subjects
• Direct calorimetry measures heat expended by
  subject in enclosed chamber

42
Harris-Benedict Equation for Resting Energy
Expenditure

• REE estimated
• Based on separate equations for males and females
  for their weight in kg (W), height in cm (H), and
  age in years (A)
• Men
• REE (kcal) 66.5 (13.75 X W) (5.003 X H)
  (6.775 X A)
• Women
• REE (kcal) 655.1 (9.563 X W) (1.85 X H)
  (4.676 X A)

43
Energy used for voluntary activity
Men Women
Sedentary 1.0 1.0
Low Active 1.11 1.12
Active 1.25 1.27
Very Active 1.48 1.45
44
Harris-Benedict Equation for Resting Energy
Expenditure

• For overweight obese
• Use IBW as weight rather than current weight

45
Regulation of Body Weight

• Short-term regulation
• consumption meal to meal
• Long-term regulation
• over time controlled by adipose stores

46
Fat Cell Development

• Fat cells (Adipocytes) increase in size
  (hypertrophy) number (hyperplasia)
• Hyperplasia
• occurs mostly in infancy perhaps adolescence
• Occurs at BMI gt 40 kg/m2
• Peak level of fatness
• levels off in lean children -- but not in obese
  children
• Cell number increases more in obese children

47
Influences of Heredity

• Genetic factors account for 60-80 of
  predisposition to obesity
• Both parents obese
• 80 likelihood that children will be obese.
• If neither parent is obese
• 10 chance child will be obese.
• May be genetic influence on BMR
• Hormonal, enzyme neural factors controlled by
  heredity

48
Fat Cell Metabolism

• Lipoprotein lipase (LPL)
• Controls bodys ability to store fat
• The more LPL, the fatter you are
• Enzymes controlled by genes regulated by
  sex-specific hormones
• Leptin
• Hormone secreted by the adipose tissue
• tells brain how much adipose tissue is in body
• Has role in increasing satiety energy
  expenditure
• Functional resistance to effects of leptin?

49
Leptin

• Leptin Theory
• Mutation of the ob gene causes reduced levels of
  leptin leading to ? food intake and reduced
  energy output

50
Set-point Theory

• Body tends to maintain a certain weight by its
  own internal controls
• Suggests body chooses its own set-point for
  weight and prefers this weight
• Difficult for obese to maintain weight loss

51
Theory of Thermogenesis

• Thermogenesis is the generation and release of
  body heat from energy nutrients
• Brown adipose tissue (BAT) releases more heat
  than white cell fat
• Lean people have more BAT
• In obese, no energy change after eating

52
External Cue Theory

• People overeat in response to their surroundings
• Are obese people more sensitive to external cues?
• Have we created a society that provides too many
  stimulants to want to eat?
• Does our society make food too available?

53
Obesity Therapy
Energy Intake
Energy Expenditure
Adipose tissue
54
Energy Balance

• Energy Out
• Basal Metabolism
• Voluntary Activities
• Thermal Effect of Food

• Energy In
• Foods and beverages
• 3500 calories 1 pound of body fat

55
Weight Management

• The Practical Guide  Identification, Evaluation,
  and Treatment of Overweight and Obesity in
  Adultshttp//www.nhlbi.nih.gov/guidelines/obesity
  /prctgd_c.pdf
• Position of ADA Weight Management 2002
  http//www.eatright.org/ada/files/WMNP.pdf

56
Nutrition Assessment

• Important to consider
• Anthropometric indicators (ht, wt, WC)
• Medical history potential causes,
  obesity-associated disorders lab values
• Nutritional history
• Weight history
• History of dieting
• Current eating patterns, nutritional intake
• Environmental factors
• Physical Activity activities of daily life
  structured PA
• Psychological history psychological causes,
  eating disorders, potential barriers
• Socio-economic conditions lifestyle factors
• Readiness/motivation to change
• Wt loss therapy not appropriate for pregnant,
  lactating, anorexia nervosa, bulimia nervous,
  uncontrolled psychiatric illness (i.e.
  depression), or active substance abuse

57
Medical and Nutritional Therapy
BEHAVIOUR THERAPY
Algorithm content developed by John Anderson,
PhD, and Sanford C. Garner, PhD, 2000.
58
Weight Management

• The goal of obesity treatment should be refocused
  from weight loss alone to weight management
• Prevent additional weight gain
• Improvement in physical emotional health
• Improvements in eating, exercise other
  behaviours apart from weight loss
• Initial goal of 10 loss of body weight over 6
  months
• 1-2 lbs per week

59
Weight Management

• 10 weight loss can result in
• improved glycemic control
• reduced blood pressure
• reduced cholesterol levels
• Weight Maintenance
• Loss becomes more difficult after 6 months due to
  metabolic adjustments

60
Weight Loss Strategies

• Strategies range from acceptance of weight to
  aggressive actions to reduce weight (internally
  externally regulated approaches)

61
Nutrition Therapy

• Individually planned low-kcal diet (LCD)
• Reduce energy intake 500-1000 kcal/day
• 1000-1200 kcal for women
• 1200-1600 kcal for men
• Exchange systems common strategy
• Balance of macronutrients
• Total of kcals more important than source
• Dietary changes to support reduced risk for CVD,
  Type 2 diabetes, etc

62
Nutrition Therapy

• Very low-kcal diets (VLCD)
• lt 800 kcal/day
• Often formula based
• Not used for routine weight loss
• Require special monitoring supplementation
• Long-term efficacy not greater than LCDs

63
Physical Activity

• Essential component providing favourable
  contribution to
• wt loss/maintenance
• body composition - Helps preserve lean body mass
  preserved metabolic rate
• disease risk
• mood
• quality of life
• Minimum initial goal 30-45 minutes moderate
  activity, 3-5 days/week
• Choose activities that use large muscle groups
• Exercise longer, not faster!

64
Behaviour Therapy

• Set of techniques
• Self-monitoring
• Daily monitoring of food intake, activity, and
  mood
• Stimulus control
• Distinguish between hunger appetite
• Recognizing satiety
• Rewards
• Non-food rewards for achieving goals

65
Advice for Appropriate Weight Loss

• Avoid diets -- focus on a pattern of healthy
  eating
• No one food should be emphasized
• Better health NOT weight loss should be aim
• Make only changes you can LIVE with

66
Advice for Appropriate Weight Loss

• Choose foods high in fibre and CHO, and low in
  fat
• Emphasize grains, vegetables, fruits, followed by
  milk products and meats and alternates
• Read labels
• Choose foods promoted as low calorie, low fat
  cautiously
• Eat regularly throughout the day
• Avoid getting overly hungry
• Eat breakfast

67
Advice for Maintaining Weight

• Get regular exercise
• Avoid resuming old eating patterns once goal is
  achieved
• Build a realistic and positive attitude towards
  body shape and size
• Realize maintaining body weight is a lifelong goal

68
Weight Maintenance

• Of those who reduce weight only 5 kept off for 5
  years
• Repeated ups downs lead to net increase in body
  fat
• Energy requirements for weight maintenance appear
  to be 25 lower than at original weight
• Lifestyle modification key
• Attention to dietary intake, physical activity,
  weighing
• Support groups invaluable

69
The Difficulty in Staying on a diet
70
Weight Cycling
71
Starvation DietsGlucose Metabolism

• 0-200 kcal/day
• To keep CNS functioning, you need glucose.
• Cannot be converted from fat only protein
• Body sacrifices lean tissue to supply glucose for
  the brain
• So the body starts to convert fat into ketones
  which can be adapted for use by the brain
• Very Low CHO diets are ketogenic.

72
Starvation DietsKetosis

• Advantages of Ketosis
• Spares muscle and lean body tissue from
  destruction for energy
• Prolongs starving persons life

• Disadvantages of Ketosis
• Ketones harm the body by upsetting the acid-base
  balance
• Ketones promote mineral loss in the urine

73
The Problems with Fasting/ Semi-Starvation

• Body is deprived of essential nutrients -- cant
  build or maintain tissues. Immunity is
  compromised.
• Body slows down metabolism to conserve energy
• Loss of water and lean mass tissue.
• Can result in heart failure

74
Novelty Diets

• Promotes certain foods or nutrients as having
  magical qualities
• Unbalanced, unrealistic
• Malnutrition/binging
• Eg. Cabbage soup diet, Eat to win, Paris diet,
  Eat Right for your Type, F-Plan diet, Gods Diet

75
Tips for Evaluating Popular Diets and Practices

• Evaluate fads and trends using the following
  principles
• Does the diet exclude any major food groups (use
  the Food Guide as a guideline)?
• Does the diet propose the use of supplements,
  pills, or drugs to the exclusion of normal food?
• Does the diet suggest avoiding certain foods
  because they cause certain diseases?

76
Tips for Evaluating Popular Diets and
Practicescontd

• Does the diet suggest including certain foods
  because they cure certain diseases?
• Beware of sweeping statements Salty foods
  cause weight gain in everyone.
• More is not always better. Too much of one food
  to the exclusion of others is a tip off the diet
  is unbalanced.

77
Pharmacotherapy

• May be helpful addition to diet exercise
  modifications for those with BMI gt30 or
  BMIgt27other risk factors
• Cause energy deficit
• Act on brain to suppress appetite
• Produce bulk to fill stomach
• Increasing thermogenesis
• Increasing metabolism
• Selectively interfering with fat malabsorption

78
Pharmacotherapy

• CNS-acting agents and non-CNS-acting agents
• Limited data to support long-term use
• Balance benefits with costs/side-effects
• Common drugs
• Sibutramine(Meridia) inhibits food intake
• Orlistat (Xenical) inhibits pancreatic lipase ?
  fecal fat excretion
• Risk for fat soluble vitamin deficiencies
• Amphetamines suppress appetite

79
Surgical Procedures

• Morbid obesity may need to be treated surgically
• BMI gt 40, or BMI 35-39 with risk factor
• Gastric Restriction
• Gastric bypass
• Gastroplasty
• Gastric banding

80
Gastroplasty and Gastrojejunostomy
81
Surgical Procedures

• Weight loss outcomes generally good
• Complications commonly include bloating, nausea
  vomiting, diarrhea, dumping syndrome, and ? B12,
  iron, calcium magnesium
• Post-surgical food record
• Postoperative feeding regimen
• progress from liquids to solids with focus on
  adequate protein
• Supplementation (calcium, folate, iron, B12)
• Eat slowly, chew food well, avoid swallowing
  chunks of meat or other food not completely
  liquefied, frequent small meals

82
Treatment of Child and Adolescent Obesity

• Identification of Children for Treatment
• BMI gt 85ile with complications of obesity
• or BMI gt 95ile with or without complications of
  obesity
• Need careful assessment for underlying syndromes
  (genetic, psychological, endrocrinologic) or
  secondary complications (HBP, dyslipidemias,
  orthopedic problems, sleep apnea)

83
Primary Goal for Treatment of Child and
Adolescent Obesity

• Achieve healthy eating and activity, not ideal
  body weight
• Focus on weight maintenance over weight loss
  (weight loss only if secondary complication
  warrants it)
• Family support essential

84
The Obesity Debate

• Obesity is a serious health condition BUT
• A single minded focus on weight results in
  prejudice towards those who are obese and
  overweight
• Distracts us from seeing bigger picture and from
  advancing community approaches

85
Unintended Consequences of Focus on Obesity

• Leads people to popular weight-loss diets
• Obese people are stigmatized --- takes toll on
  mental health
• Distorted cultural norms for healthy weight can
  contribute to eating disorders
• May prevent people from accessing preventive
  health care
• Keeps focus away from healthy lifestyles
• (Cohen et al. (2005). The O Word Why the
  focus on obesity is harmful to community health.
  Californian Journal of Health Promotion,
  3(3)154-161)

86
Prevention is Key

• Encourage breastfeeding of infants
• Educate parents on dangers of overfeeding
• Delay introduction of solids until 6 months
• Promote physical exercise
• Limit television watching
• Give more smaller meals than fewer large meals
• Support and educate parents who are obese
• Build healthy self esteem and positive body image

87
Long Term Solutions

• People are consuming more and exercising less
  Toxic Food Environment
• Need healthy public policies which foster
• active lifestyle
• healthy food environment
• incentives

88
Role of Dietitian in Weight Management

• Obesity is no longer an individuals
  problem.rather it is a broad population health
  problem.
• What does this mean for
• the role of the dietitian?
• counseling strategies for weight management?

89

• The complexities of obesity
• http//www.chsrgevents.ca/shared/video/presentatio
  n_holder.html

90
Nutrition in Eating Disorders
91
Disordered Eating

• Disordered eating variety of abnormal or
  atypical eating behaviors used to reduce weight.
• Umbrella term
• Occurs on a continuum
• Eating disorder psychiatric condition involving
  extreme body dissatisfaction and long term severe
  disturbances in eating behaviours

92
Etiology

• What causes eating disorders?
• Multifactorial
• Biologic
• Genetic
• Intrapersonal
• Familial
• Sociocultural

93
Etiology

• No single cause
• The role of dieting
• Most common behaviour linked to anorexia,
  bulimia, and binge eating disorders
• Directly related to preoccupation with thinness
  in society

94
Diagnostic Criteria

• American Psychiatric Association Diagnostic
  Statistical Manual
• 3 categories of ED
• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Eating Disorders Not Otherwise Specified (EDNOS)
• Includes Binge Eating Disorder (BED)

95
Anorexia Nervosa (AN)

• Refusal to maintain a minimally normal body
  weight (less than 85 of that expected)
• Intense fear of gaining weight
• Body image distortion
• Amenorrhea (absence of 3 or more menstrual cycles)

96
Anorexia Nervosa (AN)

• Two types
• Restrictive
• Has not engaged in binge eating and purging
• Binge eating/purging type
• Regularly engages in binge eating purging
  behaviour

97
Bulimia Nervosa (BN)

• Recurrent episodes of binge eating characterized
  by
• Eating within a period of time (e.g. 2 hours) an
  amount of food larger than what most would eat
• Lack of sense of control over intake
• Recurrent inappropriate compensatory behaviour to
  prevent weight gain
• E.g. self induced vomiting, misuse of laxatives,
  diuretics, or enemas

98
Bulimia Nervosa (BN)

• Binge eating and inappropriate compensatory
  behaviour occurs at least twice per week for 3
  months
• Distorted body image
• Disturbance does not occur exclusively during
  episodes of AN

99
Bulimia Nervosa (BN)

• 2 types
• Purging type
• During current episode regularly engaged in
  self-induced vomiting, or misuse of diuretics,
  laxatives or enemas
• Non-purging type
• During current episode used other inappropriate
  compensatory behaviours such as fasting,
  excessive exercise, but not regularly engaged in
  purging

100
Eating Disorders Not Otherwise Specified (EDNOS)

• Do not meet criteria for any eating disorder
• For females, all criteria of AN, but regular
  menses
• All criteria for AN, except despite significant
  weight loss, current weight is in normal range
• All criteria for BN, except that binge eating and
  purging occurs less than twice per week for 3
  months
• Regular use of purging by person of normal weight
  after eating small amounts of food
• Repeatedly chewing but not swallowing food
• Binge eating disorder (BED)

101
Binge Eating Disorder

• recurrent episodes of binge eating in absence of
  regular use of inappropriate compensatory
  behaviours characteristic of BN
• Significant emotional distress occurs after
  bingeing (disgust, guilt, depression)
• Most patients overweight
• 15-50 prevalence rates among participants in
  weight loss programs

102
Pathophysiology of Eating Disorders

• Consistent manifestations
• Disturbed body image leading to overestimating
  body shape weight self perception of being
  obese intense fear of weight gain obesity
  relentless drive to lose weight
• Psychological illness with significant medical
  complications, morbidity, and mortality rates of
  5-15
• Many pathogenic alterations

103
Clinical Characteristics

• Fluid and electrolyte imbalances
• hypokalemia, hyponatremia, hypochloremic
  alkalosis, high BUN, ketonuria (decreased kidney
  function)
• Cardiovascular disorders
• bradycardia, dysrhythmias, hypotension, cardiac
  arrest
• GI disorders
• delayed gastric emptying, decreased small bowel
  activity, constipation, bloating, esophagitis,
  esophageal tears/ruptures

104
Clinical Characteristics

• Osteopenia
• reduced bone mass and fractures
• Dermatologic disorders
• yellow dry skin (hypercarotenemia), brittle hair
  and nails, lunugo, pitting edema, calluses over
  knuckles
• Endocrine disturbances
• growth retardation and short stature, delayed
  puberty, amenorrhea

105
Clinical Characteristics

• Hematologic disorders
• bone marrow suppression, anemia
• Neurologic disorders
• seizures, myopathy, peripheral neuropathy

106
Medical Management

• Monitor organ function
• Monitor vitamin/mineral abnormalities
• Monitor electrolytes
• Psychological counseling
• Psychological counseling possibly medication

107
Treatment Models

• Psychological
• Pharmacological
• Addiction

108
Purpose of Nutrition Care

• To foster a nourishing eating style that promotes
  normal physiologic functions and physical
  activity
• To support eating behaviors that bring about a
  peaceful, satisfying relationship with food and
  eating

109
Goals of Nutrition Assessment

• Determine level of malnutrition and muscle
  wasting
• Ascertain level of eating disturbance
• Understand weight, exercise, and diet histories
  of clients

110
Nutritional Assessment

• Biochemical, clinical, anthropometric, medical
  history, plus dietary assessment
• Weight history is important
• Diet history may not be reflective of actual
  intake
• Difficult to estimate energy intake (especially
  if purging)
• Medication and substance use

111
Nutritional Deficiencies

• Vitamin deficiencies in 1/3 of AN patients
• riboflavin and B6
• EFA deficiency in AN patients
• Reduced plasma zinc
• Low intakes of calcium increases risk of
  osteoporosis

112
Nutrition Therapy

• Team approach
• must remain objective and consistent
• dietitian should work closely with psychologist
• Process -oriented counseling
• focus on thoughts and feelings re food and eating

113
Nutrition Therapy for AN

• First goal is to stop weight loss and stabilize
  medical condition
• Second step is to initiate weight gain to restore
  normal metabolism and body function

114
Approaches

• Oral intake through conventional foods preferred
• If resistance to eating or unable to eat, use
  nutritional supplements alone or with regular
  foods
• Stabilization of medical condition may require
  TPN or tube feeding

115
Refeeding Syndrome

• Refeeding can be associated with life-threatening
  hypophosphetemia, cardiac arythmia delerium
• Initial caloric prescriptions low
• May need supplemental phosphorus
• Biochemical monitoring necessary

116
Refeeding Syndrome

• Signs of Risk
• Weigh lt75 IBW
• very low lean body mass and adipose stores
• decreased pulse
• reduced blood pressure
• decreased cardiac output
• arrhythmias
• decreased metabolic rate
• hypothermia
• edema
• low serum electrolytes

117
Guidelines for Diet Therapy

• Caloric prescription for weight gain
• Use 1.3 x REE using Harris-Benedict Equation
• Recommended initial intake ranges from 1000
  1600 kcal/day
• Increase of 100-200 kcal every 2-3 days
• 3000-4000 later in weight restoration
• CHO at 50, then increase to 55
• Protein 15-20 total energy
• Fat 25-30 of total energy

118
Outcomes of AN

• About 50 regain normal weight
• About 25 attain a weight that is thin but not
  medically dangerous
• About 20 stay emaciated
• 5-10 die

119
Bulimia Nervosa

• Food is symbolic
• Purging is an outlet and can become addictive
• Overrides normal physiological cues of hunger and
  satiety
• Aggressive nutritional treatment is rarely needed
  unless electrolytic imbalance

120
Goals for Treatment

• Normalize eating
• Stabilize weight
• Stop bulimic behaviors first goal!
• Calculate energy requirements
• Typically start at around 1500 kcal per day
• Increase calorie consumption as metabolic
  stability achieved
• Protein 15-20, Fat 20-30, CHO 50-55

121
Ways to Increase Satiety

• Use warm foods
• Eat with utensils not fingers
• Use proportioned foods
• Use high-bulk fruits and vegetables
• Allow for adequate fat intake
• Allow for protein at each meal
• Choose safe foods and exclude high risk binge
  foods

122
Binge Eating Disorder

• Work with patients to set realistic recovery
  goals
• Weight loss should be no more that 0.5 - 1.0 kg
  per week
• At least 1500 kcal per day
• Food records may be useful
• Exchange system may help or EWCFG
• Aim for enjoying healthy eating without
  deprivation

123
Nutrition Education

• Patients generally appear quite knowledgeable
  about nutrition
• May use unreliable sources and/or interpretation
  distorted by illness
• Group and individual counseling

124
Patient Monitoring

• Follow-up is key to successful intervention
• Monitor physical and psychosocial progress
• Recovery Criteria For Eating Disorders
• See Figure 22.2 Manual of Clinical Dietetics 2000

125
Resource

• Treating the Dieting Casualty
• Intensive Workshop on Treating The Chronic Dieter
• by Ellyn Satter (2001)

126
The Obesity and Dieting Dilemma

• Dieting cannot be positioned as the solution to
  the growing prevalence of obesity
• Need to re-create our social and physical
  environments to support healthy eating, physical
  activity and energy balance.

127
(No Transcript)