NUTRITION IN OBESITY

What is the obesity

- Overweight is a state in which the weight exceeds
a standard based on height.

- Obesity is a condition of excessive fatness, either

generalized or localized.

- Overweight and obesity usually parallel each other,

but it is possible to be overweight according to
standards but not be “overfat” or obese.

-It is also possible to have excessive fatness and yet

not be overweight.

-BMI= Wt (kg)/ tall (m2)

The WHO and NIH use BMI to
classify general obesity:

Furthermore, BMI equal to or greater than 50 is

considered super obesity.
Visceral obesity (central obesity):
Excess fat located in the abdominal area (termed
visceral adipose tissue) is reflected by waist
circumference measurement.

- Men greater than 102

cm (40 inches) in men
- women greater than
88 cm (35 inches) in,
- NB: Inch =2.54cm
Waist circumference:
- Waist circumference is a predictor of morbidity, and is
considered an independent risk factor for:
- diabetes,
- dyslipidaemia,
- hypertension,
- and cardiovascular disease
- Assessment of WC is most useful when performed
in individuals with a BMI between 25 and 35.
biological
 Risk factors for obesity
▪ - The aetiology of obesity is believed to be due to a
▪ combination of biological and environmental factors.
▪ Biological factors that have been identified include an
individual's genetic Predisposition, Family history, the
size and number of adipose cells, and Resting energy
expenditure (REE).
▪ Environmental factors “obesogenic” that have been
identified as contributory to overweight and obesity
include low cost high design caloric food intake and
inadequate physical activity.
▪ Some medication (Steroids, antidiuretics) and some
medical condition DM, PCO.
Types of obesity
OBESITY IS DIVIDED INTO TWO TYPES:

- ENDOGENOUS (primary): there may be one or more

endogenous factors e.g. Endocrinal, metabolic,
hypothalamic
- EXOGENOUS (Secondary):
Over feeding or over eating with less physical
activity. Many people over eat than calories requirement
(more eat either happily or under tension).
TYPES OF OBESITY:
OBESITY METABOLIC CHANGES

 CHANGES IN CARBOHYDRATES:
Obesity is associated with ↑Hyper-insulinemia (β cell of islets of
Langer-Hans stimulates to produce↑ insulin) more aggravate
Promoting i) ↑Lipo-genesis ii) inhibit lipo-lysis

 CHANGES IN FAT METABOLISM:

- Serum TAGS level ↑ due to hyperinsulinism in obese patient.
- (TG) Insulin resistance in adipose tissue causes ↑ “hormonal sensitive
lipase” which causes↑ FFA, ↑TAGS, and ↑ Cholesterol level.
- Serum Cholesterol level: ↑Hyper cholesterolemia due to ↑cholesterol
productions in obesity results.
 Why obesity issue is important?

❑ According to the Centers for Disease Control and

Prevention (CDC), seven out of ten deaths among
Americans each year result from chronic diseases.
❑ account for more than 50 percent of preventable deaths
each year.
❑ Obesity-related conditions such as
-heart disease,
- type 2 diabetes,
- stroke, and
- certain types of cancer
❑ Class II/III obesity (BMI ≥ 35.0) is associated with
significantly higher mortality, ranging from
- 40% percent among females to
- 62% percent among males relative to individuals with
normal BMI.
 Why obesity issue is important?
❑ There is strong evidence that a weight loss of 10% of body
weight will result in a reduction in blood pressure, fasting
glucose, and lipid levels.
❑ This level of weight loss can also reduce an individual's risk
of cancer.
❑ Treatment is particularly important for obese individuals
who have three or more of the following risk factors:
- cigarette smoking,
- age over 45 and 55 years for men and women, respectively.
- elevated fasting glucose levels,
- high LDL-C levels,
- low HDL-C levels,
- hypertension,
- and/or family history of diabetes, coronary heart disease,
or cancer
 1- Initial Clinical Evaluation
❑ The initial steps in diagnosing and treating an
overweight or obese patient are to calculate BMI,
measure WC in those whose BMI is between 25 and
35, and classify the patient’s weight status.
❑ Further assessment of obesity should address the
presence of comorbid conditions, such as CVD,
hypertension, dyslipidemia, and sleep apnea, as well as
tobacco use.
❑ Patients are candidates for weight loss if they are
classified as
- obese,
- or if they are overweight with increased WC (greater
than 88 cm for women, greater than 102 cm for men)
and have 2 or more risk factors for CVD or diabetes.
❑ Overweight patients without associated risk are also
candidates for weight loss.
 2- Weight loss strategy goals

❑ Modest weight loss (eg, 5% to 15% of initial weight)

improves glucose tolerance, decreases fasting blood
glucose levels and hyperinsulinemia, improves serum
lipid oncentrations, reduces blood pressure, and
improves sleep apnea.
❑ The goals of obesity treatment are to achieve and sustain
weight loss and to reduce health risk. A reasonable
initial goal is loss of 10% of initial weight within 6
months
❑ After a patient loses 10% of initial weight, efforts
should focus on weight maintenance.
❑ If more than 10% weight loss is desired, motivated
patients can restart the process of losing weight after
a 6-month period of weight maintenance.
 2- Weight loss strategy (methods)
❑ Gradual weight loss is more likely to promote
development of skills that improve long-term weight
maintenance.

❑ whereas rapid weight loss is less likely to be maintained.

Repeated cycles of weight loss and gain are associated
with negative health and psychological effects, and
the effort, time, and expense of these cycles further
justify modest goals for weight loss and maintenance.

❑ Furthermore, recidivism and cycling of weight loss with

weight gain may alter body composition, ultimately
decreasing lean body mass (LBM) and increasing
body fat mass.
2- Weight Loss strategy
 3- Weight Loss strategy
(life style modification)
❑ An essential part of weight loss is negative energy
balance—energy expenditure exceeds energy intake.
Thus, effective weight loss strategies must address
decreasing intake of food, increasing output of energy,
or both.
❑ Other factors involved in effective weight loss include
behavioral factors. Combining behavior strategies
with decreased intake of food and increased
activity will lead to the most effective weight loss
strategy.
❑ This combined strategy is called lifestyle
intervention
ESTIMATED ENERGY EXPENDITURE:
Simplistic weight-based equation

- Calculated generally by scale of kcal/kg (you can simply multiply

the person’s body weight in kilograms by calories).

• 25-35 Kcal/kg/day based on actual body .

Depending on stress level

25 for mild (Post surgery with no complication
30 for moderate chronic illness like pancreatic cancer, IBS, chronic
lung disease

35 for sever stress (acute illness, sever infection, sepsis, trauma )

45-55 for extensive burns

 TOTAL ENERGY EXPENDITURE (TEE)
• Then calculate TEE which represents total calories required by
multiplying BEE times appropriate stress factors and activity
factors
TEE =BEE* stress factors *activity factors

Stress factor condition

Post surgery with no complication (mild stress) 1.2

Moderate stress (chronic illness like cancer, IBS, chronic lung disease) 1.35-1.5

Sever stress (acute illness, sever infection, sepsis, trauma or ventilation 1.5-1.8

<20% burn 1.5-2

ESTIMATED ENERGY EXPENDITURE:
Estimated Energy requirement for obese patients
(body mass index [BMI] >30 kg/m2)

❑Hypocaloric PN has been reported to be beneficial in

❑ obese patients resulting in the achievement of positive
nitrogen balance and weight loss.
❑NB The guidelines recommend that goal feeding should not
exceed 65% to 70% of energy requirements, calculated using:
- 11 to 14 kcal per kg ABW for patients whose BMI is between
30 and 50
- 0r 22 to 25 kcal per kg of IBW for patients with a BMI
greater than 50
IDEAL BODY WEIGHT (THE WEIGHT CROSS
PONDING TO IDEAL BMI =(22KG/M 2 )
males: 50kg+0.91* (Hight in centimeters -152.4)

Females: 45.5kg +0.91* (Hight in centimeters -152.4)

NB

Inch =2.54cm

Kg = bound ( Ib /2.2 )

https://globalrph.com/medcalcs/adjusted-body-weight-ajbw-and-ideal-
body-weight-ibw-calc/
:
Classified diet according caloric intake
1- low caloric diet:
❑ Most obese patients will lose weight when consuming
between 1000 and 1500 kcal/d 0.98 kg/week
❑ Energy intake to a lower limit of 800 kcal/d is
considered a low-calorie diet.
❑ The ideal macronutrient composition and meal
pattern of a low-calorie diet remains controversial.
❑ There is no scientific evidence that low-calorie diets should
routinely be very low in fat (less than 20% of energy from
fat), very low in carbohydrate (less than 100 g/d), or very
high in protein (more than 130 g/d).
 1- Low caloric intake diet
❑ Therefore, it is reasonable to recommend a standard
multivitamin to patients who use a low-calorie or very-
low-calorie diet.

❑ Patients on low-calorie diets generally require minimal

medical monitoring because the rate of weight loss and
diet quality do not predispose them to serious
complications.
❑ However, patients on medications for hypertension,
diabetes, and other conditions should be monitored to
assess the need for medication adjustments with
reduced energy intake and weight loss.
 2- Very-Low-Calorie Diets
❑ Very-low-calorie diets typically contain 400 to 800 kcal/d,
❑ Weight lost by very-low calorie diets is more rapid and can
be greater over time than that achieved by low-calorie diets.
❑ Weight losses are in the range of 2 kg/wk.
❑ but decreases in energy intake below 800 kcal/d are
associated with little additional weight loss, perhaps
because of diminished compliance and/or decreased
resting energy expenditure.
❑ Long-term maintenance of weight lost by very-low-calorie
diets has not been superior to that of low-calorie
diets,
❑ Protein intake usually ranges from 70 to 100 g/d. Very low-
calorie diets can be based on liquid products or on
consumption of lean meat, fish, or poultry supplemented
with micronutrients.
 2- Very-Low-Calorie Diets
❑ Medical monitoring (preferably weekly and not less
frequently than every 2 weeks) is necessary because of
risks of electrolyte abnormalities, dehydration, gallstone
formation, cardiac arrhythmia, and other complications.
❑ Poorly controlled comorbid conditions may respond
favorably to a period of rapid weight loss.
Patients who are unable to achieve weight goals on a low-
calorie-diet may benefit from a very-low-calorie diet,
perhaps because of the increased structure of the diet and
frequency of clinical monitoring, which both promote
compliance.
Weight loss before semielectiveor elective surgery is often
recommended to reduce postoperative morbidity, and a
very-low-calorie diet can be considered if a 10% reduction
over 6 months is consistent with need for surgery
Physical activity:
❑ A meta-analysis of weight loss trials suggests that a
hypocaloric diet plus exercise does not lead to
significantly more weight loss than the diet alone.
❑ However, exercising during weight loss promotes
preservation of LBM, and exercise can help prevent
weight gain after successful weight loss from dieting
❑ Individuals with a BMI exceeding 40 may have severely
limited capacities and may experience fatigue, dyspnea or
joint pain after walking short distances.
❑ For such patients, an effective plan might focus on increasing
the frequency of small amounts of physical activity, allow for
frequent breaks, and find creative ways to promote movement.
❑ Creative exercise regimens include chair exercises, water
aerobics, and walking in the shallow end of a pool, all of
which facilitate exercise among those with pain in weight-
bearing joint
Self-Monitoring (behaviour)
❑ Self-monitoring of activity and energy intake can be
part of a behavioral weight loss program.
❑ Historically, self-monitoring techniques have
included written food and activity diaries.
❑ With the introduction of the Internet, personal
computers, wearable devices, and smart phone
applications, the process of recording nutrition and
activity data has become less time-consuming.
❑ A meta-analysis of 22 studies (1993–2009) that
evaluated the relationship between self-monitoring
and weight loss found a significant association
between self-monitoring and weight loss.
Pharmacological Treatment
❑ Obese individuals should initially attempt to lose weight
by nonpharmacological means.
❑ If they do not achieve weight goals, the use of
medication in addition to diet and lifestyle changes may
be an option.
❑ Drug therapy can be considered in those with a BMI
equal to or greater than 30, or in those with existing
comorbid conditions and BMI equal to or greater
than These criteria reflect the increased risk of weight-
related disease associated with these BMIs
❑ Pharmacological therapy may augment weight loss in
patients who responded partially to dietary and
lifestyle interventions,
. Pharmacological Treatment
❑ The use of medications does not generally alter weight
loss goals, which remain between 5% and 10% of
initial weight.
❑ Medications currently available for the treatment of
obesity have a demonstrated favourable impact on
weight loss and weight maintenance after weight loss

❑the medications serve only as an adjunct to dietary and

lifestyle changes.
phentermine-topiramate had the greatest weight but it
also had the highest odds of adverse event–related
discontinuation
Liraglutideis a GLP-1 agonist that leads to increased
insulin secretion.
❑ Multiple dietary supplements given in
pharmacological doses (pharmaconutrition)
have also been associated with weight loss
(green tea, L-carnitine, L-arginine, L-leucine,
soy and whey protein, and St. John’s wort. Most
of these agents have not been shown to produce
long-term, meaningful (greater than 5% of
baseline)
❑ long term safety has not been assessed;
therefore, we do not recommend their routine
use in the ambulatory obese
❑ Genotypic factors influence the effectiveness of
immunonutrients; antioxidants and omega-3
polyunsaturated fatty acids decrease the
intensity of the inflammatory process