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Energy Balance and Body Weight

Chapter 14

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Introduction

• Developing nations vs. developed nations

• Availability of food contributes to overweight and obesity

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Energy Balance

• IntakeMeasured in kilojoules (kJ) or kilocalories (kcal) - food energyDetermined by bomb calorimeterNutrition Facts label, food composition tables, dietary analysis software

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Energy Balance

• 24-Hour Energy Expenditure (EE)Resting energy expenditure (REE)Thermic effect of foodPhysical activity

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Energy Balance

• Resting energy expenditure (REE)Sustain life, keep vital organs functioning60-75% of EE, 1 kcal/kg body wt./hrSee Box 14.2 for factors affecting REE• Lean body mass• Male sex• Body temperature• Age• Energy restriction• Genetics

• Basal energy expenditure (BEE) 10-20% lower than REEDifficult to measure

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Energy Balance

• Thermic effect of food (TEF)Measured for several hours postprandialDigest, absorb, metabolize, store, and eliminate nutrients 10% of EE

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Energy Balance

• Physical Activity EEMost variable20-25% of EEInfluenced by body weight, number of muscle groups used, intensity, duration and frequency of activity

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Estimating Energy Expenditure

• MethodsEquationsIndirect calorimetryDoubly-labeled waterDirect calorimetry

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Estimating Energy Expenditure

• Equations for estimating EEHarris-BenedictWHOSee Table 14.1 for equationsIOM DRI – estimated energy requirement (EER) – see Table 14.2• Includes physical activity (PA) coefficient• Separate calculations for overweight

adults and overweight children and adolescents – based on BMI

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Estimating Energy Expenditure

• Indirect CalorimetryMetabolic research or critically ill patientsMeasures inspired and expired air by minute ventilationEE proportional to oxygen consumption and carbon dioxide production

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Estimating Energy Expenditure

• Doubly Labeled Water“Gold standard”2 stable isotope forms of water Rate at which isotopes disappear is measured in urine over 2-week period

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Estimating Energy Expenditure

• Direct CalorimetryChamber which measures heat expired through evaporation, convection, and radiationRarely available

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Regulation of Energy Balance

• Interaction of nervous and endocrine systems

OrexigenicAnorexigenicAdaptive thermogenesis

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Regulation of Energy Balance

• Appetite stimulated by hypothalamusSecretions of pancreatic and GI hormonesIncrease and decrease appetite and food intakePradar-Willi syndrome

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Regulation of Energy Balance

• Hormones affecting appetite & food intake

InsulinGlucagonAmylinCholecystokinin (CCK)Glucagon like peptide-1Peptide YYGhrelin

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Adipose Tissue

• Adipocyte – fat cell; mostly TG• Storage site - 90% energy reserves• Other functions• White fat (WAT) vs. brown fat (BAT)• Lipogenesis

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Adipose Tissue

• Adiponectin and leptin stimulate storage

• Hypertrophy and hyperplasia of cells• “Adiposity rebound”

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Body Composition

• “Two compartment model” – fat vs. fat-free mass

Variety of methods (ch. 5)

• Use of height and weight – BMI commonly used to assess obesity

Does not directly measure fatnessClinical judgment should be used

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Body Composition

• Body Mass Index (BMI)Obese ≥ 30See Box 14.3 – calculation and classifications

• BMI percentiles CDC growth chartsPediatric population≥ 95%th percentile = obesity≥ 85%th percentile = overweight

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Body Fat Distribution

• Important predictor of health status• Abdominal/central body fat

Apple, android

• Lower body fatHips and thighs, pear, gynoid

• Measured by waist circumference and waist-to-hip ratio

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Body Fat Distribution

• Waist circumferenceIncreased risk of type 2 DM, htn., dyslipidemia, CHD, metabolic syndrome> 40 in. males, > 35 in. females –“high risk”

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Body Fat Distribution

• Waist-to-hip ratio (WHR)Waist circumference/hip circumferenceDisease risk increases with WHR > 0.95 in males and >0.8 in females

• Key concept: fat deep within abdomen and around intestines and liver increases disease risk

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Epidemiology of Overweight & Obesity

• “Globesity,” “epidemic”• In the U.S. - NHANES data

Significant increasesSee figures 14.3, 14.4, 14.5, 14.6 for prevalence

• Canada Figures 14.7-14.12

• EuropeFigures 14.13, 14.14

• By race, ethnicity, SES, ageFigures 14.15, 14.16

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Adverse Consequences

• “The age of caloric anxiety”• Type 2 diabetes• High blood pressure• CHD• Cancer• Mortality• See Box 14.4

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Etiology of Obesity

• Chronic energy intake exceeding energy expenditure

• Key contributors:Medical disorders and treatmentGeneticsObesigenic environment

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Etiology of Obesity

• Medical disorders and treatmentCushings syndrome, hypothyroidism, Prader-WilliPharmacological agentsSmoking cessationNight eating syndromeBinge eatingSee Table 14.6

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Etiology of Obesity

• Genetics 40-50% of BMI explained by geneticsInfluences taste, appetite, intake, expenditure, NEAT, storage“Set-point” theoryMultiple genes Predictive in families – parents & twins• 80% of offspring with 2 obese parents• 40% of offspring with 1 obese parent• MZ twins more likely than DZ twins

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Etiology of Obesity

• Obesigenic environment“Toxic food environment” –convenient availability of low-cost, tasty, energy-dense foods in large portionsEvidence supports low-energy-dense foods for satiety• Soups, fruits, vegetables, cooked whole

grains• Barriers – cost and convenience

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Treatment

• Two-step processAssessmentManagementFigure 14.7 – NIH algorithm for treatment

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Treatment

• AssessmentBMI & waist circumferenceCurrent chronic diseasesDiet and physical activity habitsPatient’s readiness to lose weightIdentify and address barriers, coping skills, self-efficacyBehavioral assessment - see Box 14.8

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Treatment

• ManagementUse of recommended therapiesControl of factors known to increase risk of morbidityTherapies include – diet, physical activity, behavioral therapy, bariatricsurgery, pharmacologic treatmentLose 10% in 6 mo.

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Treatment

• Nutrition therapyReduce intake 500-1000 kcal/d.Lose 1-2 lbs./weekNIH low-kcalorie diet – Table 14.9Minimize CVD risk factors – NCEP Therapeutic Lifestyle Changes diet1000-1200 kcal/d women, 1200-1600 kcal/d men minimumUnclear whether altering macronutrient levels is beneficial

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Treatment

• Physical ActivityCrucial for weight maintenanceMinimum 30-45 min moderate activity 3-5 days/weekInitiate slowly and graduallyCan be programmed or lifestyle activities

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Treatment

• Behavior TherapyTechniques for identifying and overcoming barriers• Self-monitoring• Stimulus control• Rewards

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Treatment

• Pharmacologic TreatmentBMI ≥ 30 or ≥ 27 with risk factorsConsider cost and side effects, and rebound weight gainLong-term use • Sibutramine (Meridia)• Orlistat (Xenical)

Others for short-term use

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Treatment

• SurgeryBariatric surgery – BMI ≥ 40 or ≥ 35 with risk factorsRoux-en Y gastric bypass, vertical banded gastroplasty, adjustable band gastroplastySee Fig. 14.18Assess benefits vs. risksPreoperative screening & education important

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Eating Disorders

• Psychiatric condition characterized by severe disturbances in eating behaviors

Anorexia Nervosa (AN)Bulimia Nervosa (BN)Eating disorders not otherwise specified (EDNOS)

• Share common features See Table 14.10

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Eating Disorders

• Progression of diseaseDietingWeight loss progressionIntense fear of gaining weightPsychological, behavioral, medical problems persistSustained and obsessive pursuit Etiology unknownCharacter traits, environment and genetics play a role

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Eating Disorders

• Anorexia Nervosa: “self-starvation”Diagnostic criteria - Box 14.10Restricting and binge eating/purging subtypesHealth complications – Table 14.11 & Fig. 14.20• Malnutrition (self-imposed)• Characteristic physical findings• Abnormal lab values• Reduced bone mineral density

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Eating Disorders

• Bulimia NervosaDiagnostic criteria – Box 14.10Recurrent episodes of binge eating and inappropriate compensatory behaviors• Purging and non-purging subtypes

Vomiting, misuse of laxatives, diuretics, enemas vs. fasting or excessive exercisingTypically of normal weight

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Eating Disorders

• Bulimia NervosaHealth complications – see Table 14.12 and Fig. 14.21Signs:• Callous or scar on back of hands• Enlargement of salivary glands• Erosion of tooth enamel • Fluid and electrolyte imbalances

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Eating Disorders

• EDNOSSee Diagnostic Criteria Box 14.10Atypical eating patterns and disordered eating but fail to meet criteria for AN or BNBinge-eating disorder• Lack of control over eating• Not followed by compensatory behavior• Most are obese

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Eating Disorders

• TreatmentInterdisciplinary team approachFocus on psychiatric managementEmotional supportExtensive counselingOutpatient… inpatient hospitalizationCognitive-behavioral therapyPharmacological agents

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Eating Disorders

• Nutrition TherapyAssess nutrition statusAddress food and nutrition issuesAnd associated behaviorsMonitor response to treatmentImplement nutrition componentProvide ongoing support

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Eating Disorders

• Nutrition Therapy - ANRestore patient’s weight to 90% of expectedCessation of weight lossImprovement in eating behaviorsSlow progression of weight gain and kcalVitamin and mineral supplementsSupervise mealsClosely monitor serum electrolytes

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Eating Disorders

• Nutrition Therapy - BNReduce binge/purge cycleNormalize eating patternsRegular meals and snacksProvide order to mealtimesFood intake sufficient to prevent hungerInclusion of “forbidden” or “feared”foodsEducation and support

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