MNT Exam 3

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obesity classification

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1

obesity classification

obesity 1: 30-34.9

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obesity 2

35.0-39.9

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Extreme obesity:

/= 40

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medical complications of obesity

pulmonary diseases, sleep apnea, non-alcoholic fatty liver disease, gall bladder disease, abnormal menstruation, infertility, PCOS, osteoarthritis, phlebitis, cancer, coronary heart disease, diabetes, dyslipidemia, hypertension, stroke, cataracts, gout

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5

obesity treatment pyramid

therapeutic lifestyle change (diet and exercise), pharmocotherapy, and surgery

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6

low calorie diet

step 1 1000-1200 kcal/day female 1200-16000 kcal/day male if patient on 1600 kcal/d does not lose weight go to 1200 kcal if hungry increase 100-200 kcal/d

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very low calorie diet

not routinely used 800 kcal/day only used in limited circumstances, only in a medical setting with monitoring because of potential for complications

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8

nutrition education for LCD

assure DRIs are met energy value of foods- nutrient macronutrient distribution of foods food labels- serving size portion sizes how to purchase appropriate foods how to prepare foods adequate hydration limiting alcohol consumption

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additional risk factors for obesity

large waist circumference (men >40, women >35) 5 kg or more weight gain since age 18-20 years poor aerobic fitness specific races and ethnic groups

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10

Which energy needs formula requires the adjustment of BW for an individual >130% IBW?

harris-bendict

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11

One pound of fat represents _____ Calories.

3,500

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12

most variable component of energy expenditure (TEE)

physical activity

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13

obesity

life-long, progressive, life-threatening, costly, genetic related, multi-factorial disease of excess fat storage with multiple co-morbidities declared a disease in 2013 by AMA diagnostic criteria: BMI

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obesity is a complex disease

not necessarily always caused by overeating and a lack of activity and willpower obesity cannot be cured- it can be treated and controlled it is a chronic conditions, if the treatment is stopped, the condition returns

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15

AHA/ACC guidelines for obesity

help PCPS help control and manage obesity and weight management for their pts use BMI and waist circumference even modest wt loss (3-5%) can improve outcomes comprehensive lifestyle approach: diet and exercise, behavioral strategies recommend reduce calories (1200-1500 women, 1500-1800 men) 500-750 kcal/day deficit if BMI >35 with co-morbidity or BMI >40 consider bariatric surgery if BMI >35 with co-morbidity or BMI >40 consider bariatric surgery

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medications for obesity

only should be used in combo with lifestyle modification typically anorectants or appetite suppressants FEHBP offers coverage for some obesity meds medicare part D prohibits coverage of FDA approved obesity drugs

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Sibutramine

appetite suppressant increases HR and BP, not advised in CVD pt recalled in 2010

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18

orlistat

lipase inhibitor consequences for fat soluble vitamins alli is reduced strength version

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19

fen-phen

anorectic (reduce appetite) pulmonary HTN valve problems

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20

calorie reduction for step 1 LCD

500-1000 kcal/d from "usual" intake to lose 1-2 lbs/wk decrease from "usual" vs "maintenance"

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21

weight loss surgery

option for wt loss w/ clinically severe obesity (BMI > 40 or BMI >35 with comorbidities) should be reserved for those that have failed at other attempts

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types of weight loss surgeries

banded gastroplasty -restricts gastric volume, reversible roux-en-Y -restricts gastric volume and alters digestion

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adjustable gastric banding

a restrictive procedure in which the opening from the esophagus to the stomach is reduced by a hollow gastric band

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access port placed under the skin, adjustable gastric band added creating a 30 mL gastric pouch

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Verticle sleeve gastrectomy

removal of part of the stomach creating a "sleeve" with a 50-150 mL capacity

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Roux-en-Y gastric bypass

bariatric surgery that involves stapling the stomach to decrease its size and then shortening the jejunum and connecting it to the small stomach pouch, causing the base of the duodenum leading from the nonfunctioning portion of the stomach to form a Y configuration, which decreases the pathway of food through the intestine, thus reducing absorption of calories and fats

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use and safety of bariatric safety

effectiveness for wt loss: BPD>RYGB>VSG>LAGB

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safety of bariatric surgery

LAGB>VSG>RYGB>BPD most commonly used operations are RYGB and VSG, with VSG having overtaken RYGB in many nations

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(diabetes) gold standard

RYGB is more effective (diabetes) gold standard

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30

metabolic surgery

the use of gastrointestinal surgery with the intent to treat type 2 diabetes and obesity

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goals of metabolic surgery

GI surgery should be considered in addition to lifestyle modification and current medical therapies to reduce complication associated with type 2 diabetes

reduce complications of diabetes as well as improving hyperglycemia and other metabolic abnormalities

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goal of bariatric surgery

weight loss

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complications with bariatric surgery

dumping syndromes, gastric lipase decrease, pancreatic lipase insufficiency, biliary insufficiency, hypoglycemia, long term deficiencies in B12, folic acid, Fe

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dumping syndrome

Rapid emptying of gastric contents into small intestines.

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main complication of gastric surgery

increase col of food/liquid in SI: no longer have pyloric sphincter to control release of gastric content, hyperosmolar chyme draws fluid into SI.

divided into 3 phases malabsorption/steatorrhea, may become lactose intolerant

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early dumping syndrome

10-20 minutes after eating, especially if high in CHO

rapid increase blood flow to SI r/t presence of hypertonic food which decreases peripheral blood flow

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consequences of early dumping syndrome

consequences: increased HR, faint/weakness, dizziness, sweating

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fluid shift into SI complications

cramping abd pn, diarrhea

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intermediate dumping syndrome

20-30 min post eating

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cause of intermediate dumping syndrome

increased CHO malabsorption causes fermentation of CHO in colon

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consequences of intermediate dumping syndrome

abdominal bloating/cramping, increased flatulence, diarrhea

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late dumping syndrome

1-3 hr post eating, reactive hypoglycemia, rapid rise in CHO absorption causes increased BG which increases insulin and then decreases blood glucose

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consequences of late dumping syndrome

sweating, anxiety, shaky, hungry, confusion, weakness

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MNT for dumping syndrome

liquids between meals to increase gastric space at meal time

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decrease simple CHO

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increase complex CHO

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increase protein

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moderate fat

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lactose often not tolerated initially

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small, frequent meals

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eat slow, chew well, lie down post meals to slow transport of food into SI

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dehydration and bariatric surgery

small stomach makes it difficult to drink enough liquids and need to drink 30-60 minutes after eating

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symptoms: dry mouth, headache, dizziness, fatigue, dark urine

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recommendations: sip 64 oz liquids between meals (caffeine free, non-CO2, sugar free, non alcoholic)

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protein deficiency and bariatric surgery

increased needs following surgery to fight infection, maintain fluid and electrolyte balance, promote healing, prevent LB< and hair loss

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recommendation: eat protein foods first at meals and drink protein supplements bwtween meals

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60-80 g/d

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vitamin and mineral deficiencies and bariatric surgery

decreased intake

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altered absorption

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nutrient depleted foods

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anemias and metabolic bone disease are of greatest concern after malabsorptive procedures

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monitor H and H, serum fe, ferritin, or folate levels

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iron deficiency and bariatric surgery

reduced stomach acid env impairs release of iron from food

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reduced absorption in duodenum

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S/S: fatigue, lethargy, headache, feeling cold, dry skin, pallor, alopecia, concave nails

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supplements: ferrous sulfate or fumarate

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recommendation: 30 mg/day, 50 mg/d for menstruating women

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before surgery

stop smoking >3 months

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begin exercise

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go to support group meetings

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begin vitamin/mineral supplement

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wean off caffeine, eliminate carbonated beverages

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start protein supplement

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10% wt loss

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diet rx 7-10 d before surgery: 2 vegs, 1 fruit, increase fluid to 64 oz, 8 oz lean meat

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RD consult before surgery

often required by insurance

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discuss tips for before surgery and explain process afterwards

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inquire about past wt loss hx, trials, social support, initiative shown thus far

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step 1 and 2 post-op diet

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pt centered goals

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MNT goals with bariatric surgery

maximize wt loss with surgery and minimize complications

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foods selected be of high nutritional quality and supplements taken regularly

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trying to promote healing with small amount of nutrients

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focus= protein and fluid, v/m

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food log is helpful

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86

nutrition support

delivery of formulated enteral or parenteral nutrients to appropriate pts

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purpose is to maintain or restore nutritional status and prevent malnutrition when nutrient needs cannot be met with an oral diet

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recommended when po is inadequate for 7-14 days

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enteral nutrition

provision of nutrients to the GI tract through a tube or catheter when inadequate or expected to be

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tube placement:

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-gastric

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-duodenum

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-jejunum

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site selection criteria

anticipated length of use

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risk of aspiration or tube displacement

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normal digestion of absorption?

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planned surgery

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volume to be fed

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nasogastric tube (NG)

from the nose to the stomach

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indications: <3-4 weeks, requires functional GI tract, useful for pt unable or willing to consume adequate po

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