1 Kristi Edwards, MS, RDN, LDN, CLCCertificate of Training in Adult Weight Management November 10-12, 2016 Long Beach, California Kristi Edwards, MS, RDN, LDN, CLC
2 Program Components Pre-work materials: readings, activities, pre-test2 ½ day live workshop Post-test
3 Overview Overweight/Obesity Metabolic SyndromeContributors Cost Assessment Treatment Metabolic Syndrome Weight Loss/Maintenance Benefits Benefits of Physical Activity Menopause and Weight Gain Pharmacotherapy Bariatric Surgery
4 Overview, Cont OTC Dietary Supplements Public Health/CommunityReferences
5 Overweight/Obesity 69% U.S. adults overweight (BMI >/= 25) or obese35% of these individuals obese (BMI >/= 30) At increased risk for: Type 2 Diabetes Coronary Heart Disease Stroke Certain cancers
6 Contributors Genetic Biologic Environmental Portion sizesIncreased availability of energy-dense foods Stress/emotion Inadequate sleep Consistent temperature Sedentary lifestyle
7 Cost Obesity (compared to a normal BMI) In 200846% higher inpatient costs 27% more physician visits, outpatient 80% higher spending on prescription drugs In 2008 Obesity cost the U.S. about $147 billion Medical costs of obese individuals were $1,429 higher than individuals of normal weight
8 Assessment Waist circumference for BMI 25-34.9Provides additional info risk CVD, other co-morbidities Cut points >35” (women), >40” (men) Food and nutrition-related history Nutrition-Focused Physical Exam (NFPE) Indirect Calorimetry, Mifflin-St. Jeor equation for Resting Metabolic Rate (RMR) Assess Readiness to Change Other assessment parameters: Medical history: Diabetes, HTN, HLD, sleep apnea Social history: smoking
9 Treatment Motivational Interviewing/Eliciting Change TalkAddress dietary habits Calorie-dense, low nutrient content vs. nutrient-dense Energy deficit kcals/day kcals (women), kcals (men) Exercise habits 2008 Physical Activity Guidelines for Americans 150 min/week moderate-intensity 75 min/week vigorous-intensity American College of Sports Medicine’s Position Stand for weight loss maintenance >250 min/week moderate-intensity
10 Metabolic Syndrome Increased risk heart disease, stroke, diabetesDiagnosed when 3 out of 5 of the following occur: Abdominal obesity / elevated waist circumference Elevated blood pressure Elevated fasting blood glucose Elevated triglycerides Low high-density lipoprotein (HDL) levels
11 Weight Loss/Maintenance BenefitsExpert Panel recommendations: Initial goal 5-10% of baseline weight within 6 months Sustained weight loss as little as 3-5% body weight may lead to reduction in some cardiovascular risk factors In Type 2 Diabetes Weight loss of 2-5% associated with reduction in HA1c by % Weight loss of 5-10% associated with reduction in HA1c by %
12 Benefits of Physical ActivityMaintain healthy body weight Bone health Reducing risk CVD and other chronic illnesses Blood pressure Immune function Relieve stress Self-esteem Cognitive Health Functional/physical health Muscle strength, endurance Mood
13 Menopause and Weight GainReduced Resting Energy Expenditure (REE) Loss lean mass, increased fat mass Physical activity-related energy expenditure decreases more than food intake (result = unintended weight gain) Sleep duration/deprivation Hormone changes Genetic factors Lifestyle factors Increased risk Metabolic Syndrome
14 Pharmacotherapy Orlistat (lipase inhibitor)Low efficacy (avg weight loss ~3%) Supplementation vitamins A, D, E, and K Possible side effects: abdominal cramps, flatus with discharge, oily spotting, fecal incontinence Lorcaserin (enhances satiety) Possible side effects: headaches, dizziness, fatigue, nausea, dry mouth, constipation Phentermine/topiramate (appetite suppressant) Avoid caffeine/energy drinks Possible side effects: paresthesia, dizziness, dysguesia, insomnia, constipation, dry mouth
15 Bariatric Surgery: LAGBLaparoscopic Adjustable Gastric Band (LAGB) Relatively poor long-term outcomes Lack of adequate weight loss Reoperation rate 60% Band complications Erosion Infection Slippage Esophageal Dysmotility and/or Dilatation GERD Port infection
16 Bariatric Surgery: Sleeve GastrectomyDeveloped in 2002, long-term outcomes unknown Potential advantages over Roux-en-Y Gastric Bypass (RYGB) Avoidance of anastomotic ulcers Eliminates intestinal obstruction due to internal hernias May be decreased incidence some vitamin deficiencies Less risk of ulcers when taking NSAIDS Potential micronutrient deficiencies Vitamins B12, B9 (Folate), D, and A Iron, Calcium
17 Bariatric Surgery: RYGBRoux-en-Y Gastric Bypass (RYGB) More weight loss with Roux-en-Y than Band or Sleeve Better co-morbidity outcomes Higher risks Obstruction Adhesions Ulcers Impaired ghrelin secretion observed in some patients after RYGB (transection of vagus nerve) Potential micronutrient deficiencies Vitamins B12, B9 (Folate), D, and A Iron, Calcium
18 Bariatric Surgery: BPD/DSBiliopancreatic Diversion with Duodenal Switch (BPD/DS) Macronutrient and micronutrient deficiency risk Possible dumping syndrome
19 OTC Dietary SupplementsMore commonly used in women, obese, overweight, minorities, age years Associated with repeated unsuccessful weight loss attempts Often used with prescription medications Supplements may alter pharmacokinetics of meds Federal Trade Commission (FTC) = marketing Food and Drug Administration (FDA) = labeling The Registered Dietitian should ask questions regarding products used, rationale for use, dose, frequency, duration, and health goals
20 OTC Dietary Supplements: Resources Agency for Health Care Research and Quality Office of Dietary Supplements https://ods.od.nih.gov/ Dietary Supplement Label Database
21 Public Health/CommunityOpportunity Home, school, restaurants, parks, gas stations, grocery stores/ farmer’s markets, marketing/media Factors impacting obesity Socioeconomic (poverty, education, housing) Environment (access to healthy vs. unhealthy, marketing, physical activity) Screening, counseling, education, clinical intervention Policies/Systems WIC, SNAP, zoning changes for grocery stores, food carts, modification of food ingredients, tax rates of snack foods and sodas, vending machines, menu labeling
22 References Jensen MD, Ryan DH, Apovian CM, et al AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: a report of the American College of Cardiology/ American heart Association task Force on Practice guidelines and the obesity society. Circulation. 2014;129(suppl 2):s102–s138. Raynor, HA, Champagne, CM. Position of the Academy of Nutrition and Dietetics: Interventions for the Treatment of Overweight and Obesity in Adults. J Acad Nutr Diet ;116(1): Plodkowsky RA, Krenkel J. Case Study: Combined Treatment for Obesity and the Metabolic Syndrome. J Am Diet Assoc ;105(5 Suppl. 1):S124-S130. Donnelly JE, Blair SN, Jackicic JM, et al. Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults. Medicine & Science in Sports & Exercise. 2009;41(2): Weight Management Dietetic Practice Group. A Physical Activity Toolkit for Registered Dietitians: Utilizing Resources of Exercise is Medicine: 2012.
23 References Lovejoy JC, Champagne CM, de Jonge L, et al. Increased visceral fat and decreased energy expenditure during the menopausal transition. International Journal of Obesity (2008) 32, 949–958; doi: /ijo Akkary E. Bariatric Surgery Evolution from the Malabsorptive to the Hormonal Era. Obes Surg ;22(5): Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. Surg Obes Relat Dis ;9(2): American Dietetic Association. Nutrient Supplementation. J Am Diet Assoc. 2009;109(12): Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Increase the Consumption of Fruits and Vegetables. Atlanta: U.S. Department of Health and Human Services; 2011.