FNN301 - Midterm - Week 4

Health at every size

• weight inclusive framework that supports health promoting behaviours equitable care for people of all body sizes without weight loss being the goal of care

• emphasis on care, anti-fat bias, bodily autonomy, social determinants of health

Weight centric approach

• goal for weight loss and bmi in normal range

• measures change on scale

• views weight as controllable through individual effort

• practitioner role is to perscribe an energy deficit and monitor weight

• concerns are weight cycling, stigma and disordered eating

Weight inclusive approach

• focus on health behaviours and well being

• measures clinical markers, function, quality of life and eating behaviours

• views body weight as genetic, environmental and social and economic factors to shape

• practitioner role to collaborate on goals the client chooses

• main concerns raised is that it might underaddress the weight relaated risk if applied ridgidly

4 principles of HAES

• access

  • healthcare is a right at all sizes

• wellbeing

  • care, healing are collective and deeply personal

• bias free care

  • care provided only when free from anti-fat bias

• Context

  • sociopolitical construct reflecting on societies values

bais and stigma

• document among health professionals including dietitians and nutrition students

• associated with

  • results in delaying or avoiding healthcare

  • shorter visits and less patient education

  • poorer mental health

  • physiological stress and weight gain

HAES take home message

• produced similar cardiometabilic and anthropometric outcomes

• the individual needs different approaches

• susceptibility to hunger improved with HAES

Disordered eating

• range of unhealthy thoughts and behaviours related to food, exercise, body image

  • restrictive eating

  • food and excecise routines driven by feeling unworthy

  • obsessive food thoughts and feeling out of control around food

  • binge eating

  • emotional distress when food or exercise rules are broken

• Between normal eating and diagnosed EDs

Difference between disordered eating and eating disorders

• frequency and severity of symptoms

Physical signs/symtoms of EDs

• disiness

• fainting

• hair and skin changes

• weight fluctuations

• dental problems

• seizures

• chest pains

Compromised organ systems of disordered eating

• digestive issues

• immune dysfunction (sick often)

• irregular menstrual patterns

• CVD dysfunction

  • orthostatis hypotension

  • bradycardia (slow heart rate)

Biochemical signs of disordered eating

• low iron, anemia

• hormonal imbalances

• electrolyte disturbances

  • hypokalemia from purging (loss of potassium)

• Blood sugar irregularities

Mood changes of disordered eating

• irritability

• low mood and anxiety

  • undernutrition will exaxerbate depression and anxiety symptoms

• complications of mental health treatement

Cognitive changes with disordered eating

• food preoccupation

• difficulty concentrating or brain fog

• socially withdrawn especially from food events

Behavioural cues of disordered eating

• skipping meals, diet pills etc

• binge eating with a loss of control around food and marked emotional distress

• strong need to control food and avoiding non homemade foods

• compensatory behaviours to make up for eating

  • extra excercise, food restriction, purging

• body checking

• rigid food and excercise patterns

• frequent discussion of weight, shape and diet

• self worth attached to food, exercise and body image

Risk factors of ED

• trauma

  • copign mechanism to feel in control after feeling helpless

• emotional distress and limited healthy coping skills and starvation can numb, binging to soothe, purging and stress

• gender dysphoria to minimize unwanted physical changes

• perfectism, strong drive and competiveness

• mental health

• family history

• occupationa nd activities whcih push for physical attributes

• cultural ideas that promote certain bodies as more worthy

Avoidant/restrictive food intake disorder (ARFID)

• food behaviour not driven by weight or body concerns

1. Low interest in eating

   1. eating feels liek a chore and meals can be forgotten and unfinished

2. Sensory sensitivity

   1. strong aversions to smells or looks of food which can limit the range of foods they want to eat

3. Fear of consequences

   1. fear of chocking, vomiting, allergic reactions etc

Clinical significance of ARFID

• limited intake or variety can cause nutritional gaps, reliance on supplements or impared daily life

• presentations can overlap and treatment is specific and supported food exposures

Inpatient ED treatment programs

• Highest level of care

• based on medical instability and rate of weight loss and overall risk

  • bradycardia, hypotension, electrolyte abnormalities

• Structure: supervised meals and snacks, medical monitoring, individual and group therapy

• Goal: medical stabilization and interruption of symptoms

  • limited psychoeducation at the time

Outpatient ed treatment

• appropriate for medically stable individuals with ongoing medical monitoring

• group based cognitive behavioural therapy for eating disorders with nutrition guidance from RD

• Goal: To improve the relationship with food, eliminate symptoms, learn healthy coping skills and body image work

Child and adolescent family based treatments

• parents and caregivers are active responsibility for meals and weight restoration

• Phases

  • full parental control

  • gradual return of control to adolescent

  • focus on normal adolescent development and relapse prevention

• evidence: strongest research for anorexia adapted for other disorders

• empower family to be primary support system and reduce blame

Nutrition education for ED

• plate by plate approach

• why diets dont work

• understanding body needs

• reframing unhelpful thought patterns around food

• Set point theories

  • understanding weight regulation in bodies

  • explaining weight restoration goals

  • Center for clinical intervention is a good set point resource

Energy expeinditure

• energy expended in one day is the total energy expenditure divided into resting energy expenditure (REE) Thermic effect of food and physical activity

Resting energy expenditure

• what is required to sustain life keeping vital organs functioning

• 60-75% of 24 hour energy expenditure

• around 1 kcal/kg body weight / hour

• most significant determinant is the lean body or fat free mass

  • REE is higher in those with higher lean body mass

• can be measured as long as the subject has rested for 30 minutes before the test

Basal energy expenditure

• lowest rate of energy expenditure in an individual

• measure din a post absorptive state (no food in 12-24 hours)

• lying motionless on your back

Factors affecting resting energy expenditure

• lean body mass (muscle and tissues are more metabolically active than adipose

• Male sex is higher than females

• body temperature

  • increases REE with elevated body temperature

• age

  • REE decreases by 2% every decade after 30 years old even after adjustign for changes in lean body mass

• Energy restriction

  • after several weeks of energy restriction the REE declines whcih is the reason for plateau with diets

• Genetics and endocrine

  • hypothyroid and hyperthryoid decrease or increase REE

  • metabolic stress and just can increase REE

Factors effecting regulation of energy balance

• nervous system and hormones produced by gut pancreas and fat

• genetics also influences energy balance and body weight

• decrease in energy intake and loss of fat mass is orexigenic neural and hormonal stimuli that increases appetite and decreases REE

• increase in energy intake and body fat results in anorexigenic stimuli to decrease appetite and increases energy expenditure known as adaptive thermogenesis

Adaptive thermogenesis

• the increase in energy expenditure that occurs with increased body fat

Neurochemicals that decrease appetite and food intake

• cholecyclokinin

• GLP-1

• Peptide YY

• glucagon

• insulin and amylin

Neurochemicals that increase appetite and food intake

• ghrelin

Prader-willi syndrome

• genetic disorder that presents with voracious appetite and massive obesity

• ghrelin levels are increased significantly

Adipocytes

• large round cell filled with triglyceride

• cytoplasm containing nucleus, mitochondria and organelles is small below plasma membrane

• when found in large aggregations in conjunction with fibrous connective tissue they form adipose tissue

Adipose tissue

• storage site for over 90% of the body energy reserves

• fills body crevices and provides thermal insulation to body

• surrounds organs and forms shelter

White adipose tissue

• primary form of adipose

• light yellow colour due to carotenoids

• comes from dietary fats through lipogenesis

Brown adipose tissue

• more mitochondria causing darker colour and blood vessels

• responsible for diet induced thermogenesis

• 
  

Adiponectin signals

• that the body has the capacity to store fat

• increase as body fat content decreases

• improve body sensitivity to insulin increasing capacity to store fat

• high levels associated with lower risk of coronary artery disease

  • low levels associated with obesity and comorbidities

Leptin signals

• there is adequate fat stored

• increase as the body fat mass increases

• regulate reproduction by promoting fertility and initiating puberty when body energy stores are adequate

Adipose tissue mass increasing

• when mature adipocytes increase in size

  • hypertrophy

  • accumulate more tyiglyceride when there is energy intake above expenditure

• Increase in number

  • hyperplasia

  • immature adipocytes divide to produce more cells

Body fat distribution

• abrominal and central fat

  • primarily around abdomen surrounding organs

  • often in males

  • android

• Lower body fat distribution

  • mainly in lower region

  • hips and thighs

  • more orgen in females

  • gynoid

Abdominal fat placement

• surrounding intestines and liver increases risk of T2D

• fatty liver, hypertension, dyslipidemia, CHD, metabolic syndrome

• even if BMI is within healthy range

Lower body fat distribution

• not associated with the increase health risks

• some data showing that it is inversely related to CVD and diabetes

Obesity redefining

• before defined as BMI > 30kg/M²

• now defined as chronic, progressive and replapsing disease characterized by presence of abnormal or excess adiposity that impairs health and social wellbeing

Obesity causes

• genetic components

• hypothalamic regulation affected by

  • genetics, microbiome, gut hormones

  • adipose tissue hormones

  • enviornemnt, medication, chronic stress

Genetic and weight factors

• 40-70% of variation in weight gain

• 50 genes are associated with weight gain

  • appetite regulation

  • satiety cues

  • energy expenditure

  • fat tistribution

Congenital causes of obesity

• genetic disorders with obesity as a feature along with developmental, neurological or structural abnormalities

  • prader-willi, downsyndrome

  • Bardet-bidel syndrome, cohen, carpenter

Neuroendocrine disorders

• hormonal/metabolic conditions where dysregulation of cortisol, thyroid, reproductive or growth hormones contributes to obesity

• cushings syndrome

• hypothalamic disorders

• hypothyroidism

• PCOS

• growth hormone deficiency

Medical causes

• antidepressants

• anti-diabetic medicatins

  • insulin promoting fat deposition

• antipsychotis

• anticovnulsants

• contraceptives

  • projesterone medications

• chronic inflammatory conditions

  • glucocorticoidsd

• AIDS treatement

Mental health and weight obesity prevelence

• 25-60% for bipolar

• 30-60% schizophrenia

• 20-50% depression

Mental health and weight

• screen for mental health in individuals working on weight management

• look at medication side effects

• severe mental illness who gain weight on anti-psychotics

  • GLP-1 agonists have the most safety and efficacy amond medications indicated for chronic obesity management in canada

Weight bias

• negative attitudes and views abotu obesity and people with obesity

weight stigma

• labellign people livign with obesity based on deep rooted social stereotypes

• makign assumptions about people with obesity

Weight-based discrimination

• treating people different or unfail based on weight

• verbal, physical and relational discrimination

Widespread bias on weight discrimination

• belief that obese people are lazy, noncompliant, undisciplined, lack of willpower and self control

• impacts:

  • hiring decisions

  • education opportunities

  • health care decisions

  • housing selection

  • adoption selection

  • airline policies etc

Reducing weight bias in obesity management

• assess own attitudes and beliefs regarding obesity considering how their attitudes and beliefs can influence care delivery

• recognize internalized weight bias (towards oneself) in people living with obesity can affect behavioural health outcomes

• healthcare providers avoid usign judgemental words, images and practices with patients with obesity

• avoid making assumptions that an ailment or complaint a patient presents is related to their body

Obesity canada practice guidelines 2020

• BMI not used for diagnosis

• comprehensive medical assessment required

• not all people with high BMI have obesity

• everyone should practice healthy behaviours

• weight loss is not the main goal

• no longer recommending caloric deficite amoutns

• recommending individual nutrition interventions

• healthy eating focus

• health based outcomes

• recognize the harm of weight stigma, bias and discrimination

• recommends healthcare professionals assess theri own bais

Weight spectrum practices

• weight centric

  • fad diets, extreme weight loss plans, weight loss for thinness

• Non-weight weight inclusive approach

  • HAES

  • critical fat studies

  • health improvement regardless of weight

4 Ms of obesity

• mental health

• mechanical health

• metabolic health

• monetary health

• FACTORS CONTRIBUTING TO PREDISPOSITION

4Ms of obesity Mental health

• cognition

• depression

• ADHD

• addiction

• psychosis

• ED

• Trauma

• Insomnia

• isolation/social spport

• Therapy access

4Ms of obesity Mechanical health

• sleep apnea

• osteoarthritis

• chronic pain

• reflux disease

• incontinence

• thrombosis

• inertrigo

• plantar fasciitis

• injury

4Ms of obesity Metbaolic health

• T2D

• dyslipidemia

• hypertension

• fatty liver

• Gout

• PCOS

• gallstones

• cancer

• medical side effects

• Malnutrition

4Ms of obesity Monetary health

• education

• employment

• income

• disability

• insurance

• benefits

• bariatric supplies

• weight loss programs

• access to therapy

• food environment

5 As of obesity assessment

• Ask

  • is client interest in nutrition changes

• Advise

  • provide key nutrition messages for all adults

  • individuals preferences, values, goals culturall acessible affordable and sustainable

  • person first language, weight inclusive non diet approaches

• Ask and assess

  • does patient want to make more changes

• Agree and assist

  • explore options, collaborative care

• monitor and evaluate health related outcomes

  • health behaviours, nutrition status quality of life, CVD, metabolic and functional status

• Reassess intervention, plan, readiness, barriers and supports

• Explore and assist other options with patient and client as needed

General assessment of people living with obesity

• comprehensive history to identify root causes of weight gain and complications of obesity and barriers to treatment

• recommended blood pressure measurement in both arms

  • fasting glucose or glycated hemoglobin and lipid profile to determine the cardiometabolic risk and where appropriate ALT test to screen for non alcoholic fatty liver disease

EOSS: Edmonton obesity staging system

• used to determine severity of obesity

• shows stages related to risk of comorbidities

• better predictor of all cause mortality when compared with BMI or waist cricumference measurement alone

Micronutrient deficiencies

• B12, iron, vitamin D

• because of restrictive diets, medications or bariatric surgery

Mindful eating practices

• lower food cravings

• reduce reward driven eating

• improve body satisfaction

• improve awareness of hunger and satiety

Nutrition physical exminatino

• look for edema, skin, hair, eyes, oral cavity

Nutrition assessment weight history

• age of onset obesity and major weight trajectories

• previous weight loss attempts in response to interventions

• highest and lowest weight

• major life events associated with weight change

• current phase of weight

• height

• current weight

  • IBW and ABW are only used in critically ill populations

Nutrition assessment nutrition history

• assess nutrition literacy

• assess energy intake

• identify nutritional restrictions (celiac, allergies)

• 24 horu recall, FFQ

  • focus on portion sizes, meals away from home, preparation methods, energy density

• Alcohol, vitamin, mineral supplements

• previous weight loss methods

• nutrition education and nutrition therapy

• food restructuions and eating patterns

Estimating energy and protein needs in general non-critically ill patients

• indirect calorimetry = gold standard

• if not available

  • Predictive Mifflin- St Jeor equation usign actual body weight

    • greater error at higher BMI

  • individualize based on clinical condition, goals and response

  • protein estimation using actual weight

Estimating energy and protein needs in critically ill adults with obesity

• BMI 30-50: 11-14kcal/kg actual BW/day

• BMI > 50: 22-25 kcal/kg IBW/day

• Protein

  • BMI 30-40: 2g/kg IBW/day

  • BMI >40 up to 2.5g/kg IBW/day

Micronutrient of concern Vitamin D

• deficiency risks

  • elevatid adoposity (could be in adoipose)

  • medical conditions assoicated with fat malabsorption

    • chrons, ulcerative colotis

    • celiac

    • liver disease, CF, short bowel syndrome

  • previous bariatric surgery

  • low intake of calcium rich foods

  • limited sun exporusre

  • darker skin pigments

• Drug interactions

  • corticosteroids

  • orlistat

  • cholestyramine

  • phenobarbital

  • phenytoin

Vitamin B12 nutrient of concern

• deficiency risks

  • elevated adiposity

  • Medical conditions

    • IBD, T2D

    • GERD

    • Pernicious anemia

    • alcoholism

  • Restrictive eating patterns

  • Previous bariatric surgery

• Drug interactions

  • metformin

  • proton-pump inhibitors

Iron nutrient of concern

• Deficiency risks

  • elevated adoposity

  • medical conditions

    • chrons disease, ulcerative cholitis

    • celiac, liver disease, peptic ulcrs, chronic kidney disease

  • Restrictive eating patterns

  • frequent blood donatino

  • blood loss

  • previous bariatric surgery

Biochemical assessment

• Vitamin D commonly low in obestiy

• iron studies: risk of deficiency, poor intake, inflammation, bariatric surgery

• Vitamin B12, folate

  • low with metformin, baratric surgery, anemia, neiropathy risk

Diet therapy

• recommended that a non dieting approach is taken to improve the quality of life and psychological outcomes

• choosing dietary patterns and food approaches based on best long term adherence

Nutrition intervention

• follow individualized care

• food based approaches

• dietary patterns

• intensive lifestyle interventions including behaviour modification

Diet therapy calorie restriction

• emphasis on variable macronutrient distribution ranges

  • lowerm moderate or higher carb with variable protein and fat

  • achieve body weight eduction over 6-12 months

• can achieve short term weight reduction but is not sustainable long term

  • set point theory

• Very low cal diets have not been shown to be sustainable and VLCDs are effective onlywhen used with behaviourla support

  • oftne regain at 12 months

• may permanently impact neurobiological pathways affecting appetite control and weight regulation

Healthy eating pattern: Med diet

• meet nutrient needs

• promote weight loss

• include physical activity

• no supplement requirment

• promote behaviour change

• scientific backing

• reduces risk of CVD and T2D and increase reversion of metabolic syndrom with little effect on body weight and waist circumference

DASH diet

• low in

  • sat fats

  • cholesterol

  • total fat

  • sodium of 2300mg

• emphasis on fruits and vegetables

  • low fat diary

  • whole grains

  • fish, poultry and nuts

• improving blood pressure, established lipid targets

  • glycemic control and reduced risk of T2D, CVD, coronary heard disease and stroke

Glycemic index

• ranking carb foods based on how much they increase BG Levels

• green

  • low GI 55 or less

• Yellow

  • Medium GI 56-69

• Red

  • high GI of 70+

GI foods

• focus on quality carbs

  • whole grains, legumes, vegetables and fruuits over refined carbs

• pair carbs with protein and fats to lower the GI

• encourage portion awareness

The portfolio diet

• cholesterol focus

• 45g nuts daily

• 50g daily of plant protein

• 20g daily of viscous fibre

• 2g daily of plant sterols

  • naturally occuring but to get this requires fortified foods as a part of meals

• Improves

  • established blood lipid targets

  • blood pressure

  • estimated 10 year coronary heart disease risk

Special considerations

• adults living with obesity and impared glucose tolerance (prediabetes) should consider intensive lifestyle interventions that target a 5%-7% weight loss

• adults living with obesity and t2d should consider intensive lifestyle interventions targeting a 7-15% weight loss

Effective psychological and behavioural interventions in obesity management

• multicomponent psychological interventions

  • behaviour modification (goal setting, self monitoring, problem solving

  • Cognitive therapy

  • motivational interview

  • values-based strategies to alter nutrition and activity

• Support the develpment of confidence in overcoming barriers (self-efficacy) and intrinsic motivation (personal meaningful reasons to change)

Who should be considered for pharmacotherapy in obesity management

• BMI > 30kg/m² or >27 with adiposity related complications

• BMI and central adiposity and adiposity related complications to guide treatment decisions

• will be life long treatments

• starting low and going up according to when there is needs to increase

Approved Pharmacotherapy in obesity management

• semagludide (Wegovy)

  • GLP-1 RA

• Tirzepatide (Zepbound)

  • GIP/GLP-1 RA

• Liraglutide (Saxenda)

  • GLP-1 RA

• Naltrexone/bupropion (contrave)

• Orlistat (Xenical)

• Setmelanotide (Imcivree)

  • specific genetic obesity concerns

Principles of pharmacotherapy in obesity management

• pharmacotherapy is evidence based pillar

• use in conjunction with health behavioru change

• individualize choice based on health goals, comorbidities, efficacy, adverse effects, contraindictions, medication interactions

• focus on improvements in metabolic conditions, mechanical, mental health and quality of life not only weight reduction

GLP-1 therapy advisory

• marked reductions in energy intake risk of inadequate nutrient intake and loss fo muscle/lean mass as nutrition concerns

• attention should be shifted to dietary quality, adequate protein and resistance and strength exercise to preserve lean mass

Surgical procedures

• metabolic/bariatric surgery considered for

  • BMI>40

  • >35 with adiposity related complications

  • 30-34 with severe adiposity related concerns not adequately managed without surgery

Considerations before surgery

• comprehensive medical, nutritional and psychological assessment

• assess ability to follow lifelong nutrition, supplementation and follow-up

• address active substance use and uncontrolled psychiatric illness before surgery

• evaluate and treat porentially reversible causes of weight gain where appropriate

Restrictive bariatric surgery

• limiting the volume of food that can enter the stomach

Malabsorptive bariatric surgery

• purposefully bypass sections of small intestine to reduce absorption

Roux-en-y gastric bypass

• most common procedure (60-70% of them)

• creates a small pouch at the top fo the stomage restricting food intake and causing early satiety

  • pouch attached to the distal jejunum

• Food bypasses the rest of stomach, duodenum and the initial part of the jejunum

• duodenum continues to recieve bile and pancreatic enzymes which are critical to break down fats, proteins and carbohydrates

Key nutrients of concern with Roux-en-y surgery

• protein

• iron

  • bypasses the duodenum (main absorption site and no gastric acid)

  • B12 because of intrinsic factor and gastric acid loss

• calcium

  • bypass of duodenum/jejunum

  • bone health risk

• vitamin D and

• fat soluble vitamins

  • A, D, E, K

  • usually need chyme be suspended and taken to the small intestine

  • fat malabsorption

• Folate, zinc, copper

  • reduced absorption surface

Laparoscopic vertical sleeve gastrectomy

• 85% of the stomach removed so restrictive procedure

• banana shaped portion left

• 50-150ml capacity left

• no malabsorption but still concern from the small stomach

  • less intrinsic factor made because there are less of the cells to make it

• removed area of the stomach is principle in releasing ghrelin

  • less ghrelin is less hunger hormone

• pylorus preserved so no dumping syndrome

Key concern nutrients from laparoscopic vertical sleeve gastrectomy

• protein

  • smaller stomach limits intake

• iron

• folate

  • less gastric acid, smaller intake capacity

• B12

  • loss of intrinsic factor

• Vitamin D

• calcium

Duodenal switch with biliopacreatic diversion

• combines sleeve with intestinal bypass

• pylorus is preserved

• substantial weight loss with significant malabsorption

• Greatest risk of protein and micronutrient deficiencies vs other 2

• lifelong nutrition monitoring and supplementatino

• less common than others

Key nutritional concerns with duodenal switch

• protein

• iron

• calcium

• vitamin D

• fat soluble

  • A, K, D, E

• zinc

• copper

Gastric banding issues

• protein, b12, iron

  • low intake if diet is poor

  • mo malabsorption though

Pre-bariatric surgery

• low calorie meal replacement perscribed to reduce liver size

• specific regimine is determined by surgical program

• those with diabeses have to follow blood sugar closely and get instruction on how to adjust medication while on the low calorie diet prior to surgery