Body Size & Weight

Describe LBM

Skeletal muscles, water, bone and essential fat in internal organs, bone marrow and nerve tissues. Higher in men than women, increases with exercise, decreases with age. Major determinant of RMR, water makes up 60-65%

Describe Essential Body Fat

Necessary for physiologic function and makes up about 3% of BW in men and 12% in women

Describe Storage Body Fat

The energy reserve under the skin and around internal organs to protect them from trauma. Primarily triglycerides in adipose tissue and most considered expendable

WHO definiiton of obesity

Abnormal or excessive fat accumulation that impairs health classified as BMI >30

When is obesity considered a disease?

Patient has excessive body fat, assessed by reliable measures

Causes of excessive body fat

• Genetic or developmental errors

• Infections

• Hypothalamic injury

• Adverse reactions to medications

• Nutritional/energy balance

• Unfavourable environmental factors

What does excessive body fat result in?

Pathogeneic structural or functional abnormalities and increased patient morbity and mortality

What contributes to adiposopathy or “sick fat” disease

Multiple pathogenic adipocyte and/or adipose tissue

Endrocrine and immune dysfunctions

Endocrine/metabolic consequences of adiposopathy or “sick fat” disease

Elevated blood glucose

Elevated blood pressure

Dyslipidaemia

Other metabolic diseases

What contributes to fat mass disease?

Multiple pathogenci physicla forces from excessive body fat causing stress damage to other body tissues

Biochemical/structural consequences of fat mass disease

Stress on weight bearing joints

Immobility

Tissue compression (e.g. sleep apnoea, GI refluc, high BP)

Tissue friction (e.g. intertrigo)

Worldwide prevalence of overweight/obesity

650 million people

BMI nearly triple between 1975 and 2016

65% population killed by more overweight and obesity than underweight

5th leading cause for global deaths

Overweight/obesity prevalence in NZ

1 in 3 adults obese

Pacific and Maori most likely

x1.5 more likely in deprived neighbourhoods

13.5% children (Maori & Pacific highest)

2nd highest prevalence in the world

Medical complications of obesity

Idiopathic intracrancial hypertension

Stroke

Cataracts

Pulmonary disease

• abnormal fucntion

• obstructive sleep apnea

• hypoventilation syndrome

Coronary heart disease

Nonalcoholic fatty liver disease

• steatosis

• steatohepatitis

• cirrhosis

Diabetes

Dyslipidemia

Hypertension

Severe pancreatitis

Gallbladder disease

Cancer

• breast

• uterus

• cervix

• colon

• esophagus

• pancreas

• kidney

• prostate

Gynecologic abnormalities

• abnormal menses

• infertility

• PCOS

Osteoarthritis

Phlebitis

• venous stasis

Skin

Gout

Female specific manifestations

Hyoerandrogenaemia

Hirsutism

Acne

PCOS

Menstrual disorders

Infertility

Gestational diabetes

Pre eclampsia

Thrombosis

Male specific manifestations

Hypoangrogenemia

Hyperestrogenemia

Erectile dysfunction

Low sperm count

Infertility

Etiology of obesity - physiological mediators

Energy intake & energy expenditure

How does energy intake impact etiology of obesity?

Loss of autoregulation

Underreporting of intake

Appetite control impacted by CNS that controls eating behaviour

Macronuterient selection

Sensory preferecnes

Eating frequency

How does energy expenditure impact the etiology of obesity?

Greater body mass reuslting in higher BMR and higher energy expenditure

DIT remains at 10%

Total higher energy expenditure due to increase in body size

Answer for Protein

4kcal

High

High

Low

Yes

Excellent

Answer for Carbohydrate

4kcal

Moderate

High

Low

Yes

Excellent

Asnwer for Fat

9kcal

Low

Low

High

No

Poor

Etiology of obesity - lifestyle, environemental, genetic factors

• Genetcis

• Taste, satiety portion sizes

• Sleep, stress cardiac rhythms

• Psychological

• Physcial inactivity

• Environment

• Gut microflora

• Medication

• Endocrine disrupting chemicals

• Viruses & pathogens

General principles of weight loss

Calorie deficit of 500kcal/day, 3500kcal/week roughly equivalent to 0.45kg of fat tissue.

Limit highly processed foods of minimal nutritional value, energy dense beverages, potential non nutrititive sweeteners

Encourage consumption of healthy proteins & fats, vegetables, leafy greens, fruits, berries, nuts, legumes, whole grains, complex carbs over simple sugars and high fibre foods

What does a low calorie diet look like?

1,200 - 1,800 kcal/day

Restricted fat (low <30%, very low <10%)

Restricted carbohydrate (low GI, low 50-150g, very low <50g)

What does a very low calorie diet look like?

<800 kcal/day

Under medical supervision

Short term

Full meal replacement programs

What does a balanced, resricted energy nutrition therapy look like?

500 kcal deficit

Healthy eating

Regular excersie

Support

Pharmacological agents used in weight management

Xenical

Duromine

Saxenda

Contrave

Classes of obesity

Class III : >40

Class II: 35-39

Class I: 30-34

Obese: >30

Pre Obese: 25-29

Overweight: >25

Waist circumference cut offs

Increased risk

• Women >80cm

• Men > 94cm

Substantially increased risk

• Women >88cm

• Men >102cm

5 principles of the non-diet paradigm

1. Accepting and respecting body shape diversity

2. Acknowledging that health is more than body size and involvs cultural, physical, social, spiritual, occupational, emotion and psychological inputs

3. Enjoyment of food and movement

4. Acknowledgement of individual responses to eating, hunger and satiety

Role of the dietitian in patient centered care

1. Support a person to improve health and wellbeing

2. Support a person to identify and make changes to the bheaviours and practices in a patient centred manner

3. (if needed) provide practical advice and effective strategies to help manage food and behaviours

Describe weight bias

The negative attitudes towards and beliefs about others because of their weight

Describe weight stigma and internalised effects

The discriminatory acts and idealogies targeted towards individuals because of their weight and size. The effect of interalised weight stigma is self judgement and negative self esteem leading to body shame feeling judges, sterotyped and negative self esteem which has an impact on psychological and physical well being

Risk of intentional weight loss

• Fat women who intentionally lost 15%+ of their BW were x2 greater risk of death comapred to fat women who remained weight stable

• Increased risk of dying from CVD in people who lose weight, risk increased lineraly with amount of weight lost

Describe the weight neutral model

Supporting all people to engage with midful, self compassionate care across lifestyle behaviours (nutrition, movement, mental and social wellbeing)

Describe HAES

Offers alternative to a weight centric approach to health care, pursuing health should not be a moral imperative, nor an individual obligation, health status should never be used to judge, oppress or determine the value of an individual. Seeks to promote health equity, end weight discrimiantion and improve acces to quality healthcare regardless of a persons size

Principles of intuitive eating

1. Reject the diet mentality

2. Honour your hunger

3. Make peace with food

4. Challenge the food police

5. Respect your fullness

6. Discover satisfaction factor

7. Honour your feelings without using food

8. Respect your body

9. Enjoy movement

10. Honour your health

Describe the mindful eating cycle

Why do I eat?

When do I want to eat?

What do I eat?

How do I eat?

How much do I eat?

Where do I invest my energy?

Benefits of mindful eating

• Directed by person not clinician

• Increases awareness of behaviours, thoughts, feelings and emotions

• Opportunity to stop automatic reactions (reduce/change habit reactions)

• Allow a new path to be taken, learn new ways to respond

• Increase confidence around food