MNT Exam 3

obesity classification

obesity 1: 30-34.9

obesity 2

35.0-39.9

Extreme obesity:

>/= 40

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

obesity treatment pyramid

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

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

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

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

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

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

harris-bendict

One pound of fat represents _____ Calories.

3,500

most variable component of energy expenditure (TEE)

physical activity

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

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

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

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

Sibutramine

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

orlistat

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

fen-phen

anorectic (reduce appetite)
pulmonary HTN
valve problems

calorie reduction for step 1 LCD

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

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

types of weight loss surgeries

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

adjustable gastric banding

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

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

Verticle sleeve gastrectomy

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

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

use and safety of bariatric safety

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

safety of bariatric surgery

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

(diabetes) gold standard

RYGB is more effective (diabetes) gold standard

metabolic surgery

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

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

goal of bariatric surgery

weight loss

complications with bariatric surgery

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

dumping syndrome

Rapid emptying of gastric contents into small intestines.

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

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

consequences of early dumping syndrome

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

fluid shift into SI complications

cramping abd pn, diarrhea

intermediate dumping syndrome

20-30 min post eating

cause of intermediate dumping syndrome

increased CHO malabsorption causes fermentation of CHO in colon

consequences of intermediate dumping syndrome

abdominal bloating/cramping, increased flatulence, diarrhea

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

consequences of late dumping syndrome

sweating, anxiety, shaky, hungry, confusion, weakness

MNT for dumping syndrome

liquids between meals to increase gastric space at meal time

decrease simple CHO

increase complex CHO

increase protein

moderate fat

lactose often not tolerated initially

small, frequent meals

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

dehydration and bariatric surgery

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

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

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

protein deficiency and bariatric surgery

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

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

60-80 g/d

vitamin and mineral deficiencies and bariatric surgery

decreased intake

altered absorption

nutrient depleted foods

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

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

iron deficiency and bariatric surgery

reduced stomach acid env impairs release of iron from food

reduced absorption in duodenum

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

supplements: ferrous sulfate or fumarate

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

before surgery

stop smoking >3 months

begin exercise

go to support group meetings

begin vitamin/mineral supplement

wean off caffeine, eliminate carbonated beverages

start protein supplement

10% wt loss

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

RD consult before surgery

often required by insurance

discuss tips for before surgery and explain process afterwards

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

step 1 and 2 post-op diet

pt centered goals

MNT goals with bariatric surgery

maximize wt loss with surgery and minimize complications

foods selected be of high nutritional quality and supplements taken regularly

trying to promote healing with small amount of nutrients

focus= protein and fluid, v/m

food log is helpful

nutrition support

delivery of formulated enteral or parenteral nutrients to appropriate pts

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

recommended when po is inadequate for 7-14 days

enteral nutrition

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

tube placement:

-gastric

-duodenum

-jejunum

site selection criteria

anticipated length of use

risk of aspiration or tube displacement

normal digestion of absorption?

planned surgery

volume to be fed

nasogastric tube (NG)

from the nose to the stomach

indications: