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Flashcards in Overweight And Obesity Deck (20):
1

Obesity classification

<18.5 - underweight
18.5-24.9- healthy weight
25-30 overweight
30-35- class 1 obese
35-40 class 2 obese
40+ - morbidly obese

2

Pathways to excess adiposity

Energy expenditure: fat free mass, physical activity, medications, androgen deficiency

Physical environment: food access, access to physical activity

Social influences: advertising, tv watching, parental and societal influences, media

Personality and reward circuitry: reward sensitivity, impulsivity, abnormal eating, food addiction

Genetics and epigenetics: early developmental programming, genetic and epigenetic factors

Eating habits, appetite and satiety: medications, impaired satiety signalling, insensitivity to hunger and fullness, eating rare

Food environment: availability, palatability, energy density, portion size

3

Treatment option

Bariatric surgery- sleeve, bypass, staple, gastric ballon, lap ban
Publicly funded surgery access is limited and not suitable for all candidates

Appetite suppressant (duromine, metformin, GLP-1 analog)
Very low energy diets (optifast, medslim etc)
Lifestyle intervention - nutrition, physical activity

4

Role of the dietitian

Nutrition assessment
Identifying barriers and enablers for weight loss/ weight gain
Identifying the person centres goals: that will result in change
Managing other existing nutritional issues
Advising/ recommending most effective nutritional management plan that is evidence based
Providing support/ coaching to maintain weight loss
Identifying other issues such as psychological stress/ eating disorders

5

Nutrition assessment

1. Discuss reason for referral/ presentation
2. Assess readiness to change, social factors, barriers and enablers
3. Identify risk factors and comorbidities
4. Anthropometry
5. Assess food habits, eating attitude and nutrient intake
6. Physical activity assessment
7. Develop dietary plan
8. Develop behavioural strategies
9. Establish goals
10. Establish a review plan

6

Gastric bypass

Small stomach pouch created by dividing top section of the stomach to the jejenum, then connecting the isolated stomach to the duodenum and connecting this to a lower section of the small intestine.
Stomach is now smaller (fewer calories consumed) and duodenum is not available to absorb some nutrients and calories.
Therefore promotes satiety, reduces hunger and assists in long term >50% weight loss.
Can lead to nutritional deficiencies- B12, iron, calcium and folate, leakage along staple lines and obstruction of digestive tract

7

Laparoscopic sleeve gastrectomy

Remove approx 80% of the stomach so remaining stomach is tubular pouch that resembles a banana
New stomach pouch reduced stomach volume, therefore calories absorbed
Impact hormones reducing hunger, increasing satiety and greater blood sugar control

Advantages- rapid weight loss of >50%, no foreign objects or rerouting, causes favourable
Hormonal changes
Disadvantages- non reversible, potential for long term vitamin deficiencies, higher early complication than AGB

8

Laparoscopic gastric band

Inflatable band placed around upper portion of stomach, creating a small pouch. Eating a small amount of food will satisfy hunger and promote satiety. Feeling of fullness dependent on size of opening between the pouch and remainder of the stomach. Reduced hunger and calories consumed. Excess weight loss of 40-50%
Disadvantage- less weight loss, can result in band slippage or erosion, requires strict adherence to post operative diet and follow up visits

9

Discuss reason for referral

Discuss clients expectations
Address any unrealistic expectations (age, gender, ethnicity)

10

Assess readiness to change, social factors, barriers and enablers

Explore weight history, weight loss attempts, explore family history and presence of obesity as a child
Identify social (work patterns, cooking skills, social factors)
Identify physical factors, exercise, injuries
Discuss sleep patterns
Identify any medications - some inhibit sleep etc
Identify mental health issues- some medications change appetite, slow metabolism etc
Use change model: precontemplative, contemplative, preparation, action and or maintenance

11

Identify risk factors and comorbidities

Medical history, factors that may impact treatment
Assessment of bowels, teeth rev
Discuss other comorbidities and look for factors that dietary change may improve (ie blood pressure, diabetes, dyslipidaemia, blood sugar levels) or identify areas that may impact dietary treatment (poor dentition, renal impairment)
Biochem/ pathology

12

Anthropometry

Obtain baseline measurements if required (obtain permission)
Weight, height, waist circumference
Body composition scales
Bra fit

13

Assess food habits, eating attitude and nutrient intake

Diet history, food diary, plate size model etc
Diet and lifestyle patterns
Food and activity diary or food and mood diary
Location of food consumption
Feelings of hunger/ satiety
Social or environmental factors linked to food intake
Macronutrient/ micronutrient intake
Alcohol and caffeine intake
Nutritional supplements
Identify unhelpful food behaviours ie meal skipping, restrained eating/ binging episodes, yoyo dieting, hungry vs non hungry eating

14

Physical activity assessment

Assess current levels and establish plan
Look for areas of improvement
May need medical professional approval if current level is low and make <35 years and female <40 years
Set realistic, well defined goals
Referral to EP may be useful
Allow physical activity to be measure eg. Pedometer

15

Develop dietary plan

Assess for evidence of disordered eating and identify strategies to normalise
Identity strategies to crest a negative energy balance based on factors enabling/ driving obesity
Specific healthy eating advice
Reduced energy diet (portion control, calorie counting)
Modified diet (med, low Gi)
Calorie counting- good for people with gradual, incremental weight gain
Non diet approach (meal spacing, eating behaviours, caffeine, sleep)
Is a VLCD appropriate? Yes if need to lose weight for a specific event or if someone is in pain

16

Low CHO high protein diet

CHO limited to 20-40g/ d
Achieve greater weight loss in the short term (6 weeks- 6 months) compared to energy restriction alone
Initial rapid weight loss due to depletion of glycogen and therefore water
No more effective than standard energy restriction after 6 months
May not be suitable for all groups ie diabetics requiring insulin

17

Low fat diet

Aim for 30-60g/d of total fat
Restrict energy
Higher carbohydrate
Standard protein

18

VLCD

Limit energy to 1880-2500kj per day (400-600)
May be indicated in BMI >30kg/m or BMI >27 with severe comorbidities
May be useful if pa is limited or rapid weight loss pre surgery is required
May assist in increasing mobility and creating platform lifestyle change
Must be able to cope with restrictive practices
Consist of meal replacement shakes (3-4/d) or bars plus two cups of low starch veg, 4 shakes if BMI >35
2L fluid allowed
No CHO to be consumed
1 tsp oil per day to prevent gallstones

19

VLCD considerations

Contraindications
Pregnancy
<18
Porphyria
Advanced hepatic disease
Recent MI

Precautions:
Chronic hepatic disease
Pancreatitis
Advancing renal disease
T1DM
T2DM
Recent CVD
Psychosis
Elderly

20

Healthy eating

Useful if poor nutrition knowledge is factor driving obesity
Plate model can help make goals specific and measurable
Portion controlled plate
Specific food goals using AGHE
Must still achieve calorie reduction
Lean protein important to help appetite