Nutrition-Exam-2

Lecture 8: Nutrition Assessment



 Development of Deficiency: want to catch it as early as possible

 Nutrition Screening:

o Identify patients at risk for poor nutritional status

o Determine which patients require full nutrition assessment

o Uses easily obtainable data

o Usually uses checklist or form for data collection

o Applicable to office or hospital settings

 Used in inpatient settings to comply with Joint Commission

_______ standards

 Must be carried out in a “timely, effective and efficient

manner”

o Conditions Associated with increased risk of malnutrition

 Trauma: fracture, burn, closed head injury, gunshot wound, spinal

cord injury, motor vehicle accident, etc.

o Collection and interpretation of data to determine severity and causes of

nutrition-related problems

o Data used to plan nutrition care

 Identify appropriate referrals

o Data used to justify nutrition care

 Facilitates reimburnsement

o Data used to monitor effects of nutrition care

 May need to switch from routine labs to more tailored labs

 Assessment of chronic versus acute intake/status

o A: Anthropometric Data Body measurements

o B: Biochemical data  laboratory tests

o C: Clinical data  Signs and Symptoms

o D: Dietary Data (pages 395-398)  Typical (chronic)  Acute if assessing

effects of intervention

o Signs and Symptoms

 From interview

 From physical exam

 Many covered in micronutrient deficiency signs from micronutrient

workshop lecture

 Protein deficiency also produces clinical signs/symptoms

 EFA deficiency also produces clinical signs/symptoms

 Usually not very specific, but provide clues

 See handouts posted on Scholar (not to memorize)

o Interview Tips

 Open-ended questions

 Non-leading questions

 Objective response

 Ask about dietary supplements

 Ask about prescription or OTC medications

 Food- medication Interaction

o Drug- Nutrient Interactions: (processing in body) specific changes to

pharmacokinetics of a drug caused by nutrient(s) or changes to the

kinetics or nutrient(s) caused by a drug

o Food-Drug Interactions: (from time of ingestion excretion) broader

term that also included effects of medication on nutritional status

o Effects:

 Alter intended response to medication

 Drug toxicity

 Alter nutritional status

 Risk Factors for Food- Drug Interactions

o Polypharmacy, Chronic Disease, Older patients, Malnutrition, Cancer and

Aids, GI tract alterations, Body compositions, Fetus, infant, pregnant

woman

 Effects of Food and Drug Therapy

o Drug Absorption

 Bioavailability, effects of fiber, fat, other food components,

Chelation, Adsorption, pH

o Drug Distribution

 Albumin and binding sites

o Drug Metabolism

 Inhibition, enhancement, competition for metabolizing enzymes

o Drug Excretion

 Renal Resorption, pH

o Nutrient Absorption

 Chelation, adsorption, transit time, GI environment, damage

intestinal mucosa, intestinal transport

o Nutrient Metabolism

 Increase speed of metabolism, vitamin antagonism

o Nutrient Excretion

 Interfere with nutrient resorption, increase or decrease excretion

 Modification of Drug Action by Food and Nutrients

o Enhance or oppose drug effects

o MAOIs and pressor agents (tyramine)

o Warfarin and Vitamin K

o St. John’s Wort and Anti- depressants

 Effects of Drugs on Nutritional Status

o Side effects

o Oral, tase, and smell

 Dysgeusia and hypogeusia

 Metallic or salty taste

 Antineoplastic drugs: mucositis

 Xerostomia

o GI Effects

 Irritiation and ulceration

 Nausea and vomiting

 Constipation or diarrhea

 Destruction of intestinal bacteria

 Fat malabsorption

o Appetitie Changes

 Undesired weight changes

 Nutritional imbalance

 Growth retardation in children

 Appetite suppressants

 Stimulant drugs and hypertension

 CNS side effects

 Appetite stimulants: undesirable and desirable

o Organ System Toxicity

 Specific organs

 Hepatotoxicity

 Nephrotoxicity

o Glucose Levels

 Hypoglycemia

 Hyperglycemia

 Dietary Assessment (want to Estimate TYPICAL Intake)

o 1) 24- hour Food Recall

 Ask person what he/she ate and drank in the past 24 hours follow

interview tips

 Strengths

 Quick, relatively low respondent burden

 Only short-term memory required

 Does not alter intake

 Limitations

 One 24- hr recall not usually representative of typical intake

o Need at least 3 days, seasonal variation not

addressed

 Requires some memory (even short-term can be a problem)

o 2) Food Record or Diary

 Person records food and drink consumption at the time of

consumption (usually 1-7 days)

 Strengths

 Does not require memory (if really recorded when required)

 Generally represents typical intake (multiple days)

 Self-administered after careful instructions

 Limitations

 High respondent burden

 Requires literacy

 Does not address seasonal variation

 May alter intake  desire to please, lazy

 3) Food Frequency Questionnaire

 Person indicates how often foods on a list are consumed

o List may be comprehensive or nutrient- specific

o Per day, week, month, etc.

o May be able to choose typical serving size

 Strengths

o Relatively low respondent burden

o Self- administered—easy to complete without

instruction

o Addresses seasonal variation

 Limitations

o Food list must be complete and representative of

person’s diet (consider cultural aspects)

o Must be able to integrate intake over time (memory,

too)

 4) Diet History

 Trained interviewer or clinician interviews person about

typical intake and influences on intake

o May start with 24 hour recall and then question how

usual intake compares to that

o Follow interview tips

 Strengths

o Get good idea of typical intake, habits, etc.

o Identifies potential facilitators/ barriers to dietary

change

o Can address seasonal variation

 Limitations

o Time required for interviewer and respondent

o Requires long-term memory

o May overestimate intake

 Estimating Energy Needs

o Harris Benedict Equation

 Female: 655 + (9.6 x kg) + (1.8 x cm) – (4.7 x age) = kcals/day

RMR (resting metabolic rate)

 Male: 66.5 + (13.75 x kg) + (5 x cm) – (6.8 x age) = kcals/day RMR

 Accurate (within 10% of true answer) about 69% of the time

 Developed in 1919

o Inches x 2.54= cm

o Lbs/2.2= kg

 Mifflin St. Jeor Equation

 Female: (10 x kg) + (6.25 x cm) – (5 x age) + 5 = kcals/day

RMR

 Male: (10 x kg) + (6.25 x cm) – (5 x age) + 5 = kcals/day

RMR

o Accurate (within 10% of true answer) 82% of the time

o Developed in 1990

 With either equation, you get RMR, then multiple by activity factor

 RMR X Activity factor = estimated kcals needed per day

 See next slide for activity factors

 For metabolically stressed patients, multiple by an additional stress

factor

 See slide after activity factors for disease/injury factors

 Activity Factors for Estimating Energy Needs using RMR

 Activity  Activity Level

Factor



 1.2  Sedentary (confined to bed or little or no exercise)





 1.3  Ambulatory, but low activity





 1.375  Lightly active (light exercise/sports 1-3 days/week)





 1.55  Moderately active (moderate exercise/sports 3-5 days/week)





 1.725  Very active (hard exercise/sports 6-7 days a week)





 1.9-2.0  Highly active (very hard exercise/sports & physical job or double training)



 Injury Factors for Estimating Energy Needs using RMR

o 1.0- 1.1 Minor Surgery

o 1.1- 1.3 Major Surgery

o 1.0- 1.2 Mild Infection

o 1.2- 1.4 Moderate Infection

o 1.4- 1.8 Severe Infection

o 1.2- 1.4 Skeletal or Blunt Trauma

o 1.6- 1.8 Skeletal or Head Trauma (treated w/ steroids)

o 1.2- 1.5 Burns involving ≤ 20% body surface area

o 1.5 1.8 Burns involving 20- 40% body surface area

o 1.8- 2.0 Burns involved > 40% body surface area

 If person is obese, should calculate adjusted body weight to use in equations

o Avoids overestimating energy needs by providing calories for

metabolically inactive tissue

o Allows for desirable weight plus 25% of excess body weight

 Assumes 25% is metabolically active

 Adjusted Body Weight

o Desirable weight + [(actual weight- desirable weight)] x 0.25

 Grams of protein per kg body weight : body weight x protein

o 0.8 g/kg healthy adult

o 0.8- 1.2 g/kg mild stress

o 1.2- 1.8 g/kg moderate stress

o 1.6- 2.2 g/kg severe stress

 Evaluating Dietary Intake

o Compare intake to MyPyramid

 Can use the online diet analysis program

 Micronutrients

 Protein

o Compare intake to Dietary Guidelines Recommendations

 Chronic disease risk

o Couple use nutrient analysis computer program

 Energy intake

 Macronutrients

 Micronutrients

 Fiber, specific fatty acids, etc.

 Putting it All together (for now)

o Compare clinical signs and symptoms with potential nutrient deficiencies

identified through dietary assessment

 Still need anthropometric and biochemical data





Lecture 9 Nutrition Assessment II



 A: Anthropometric data (pages 401-405)

o Body Measurements

 B: Biochemical data (pages 411-425)

o Laboratory tests

 C: Clinical Data

o Signs and symptoms

 D: Dietary data

o Typical (chronic)

 Acute if assessing effects of intervention

Anthropometric Assessment

o Infants/ toddlers

 Head circumference (page 404 for technique)

 Why only on birth- 36 months chart?

 Why only helpful to about age 2?

 Height/ length

 When to use birth 36- versus 2- 20 years for a 2- year old?

 Weight

 Plotting on CDC growth charts

 Should follow approximately consistent growth pattern

 Deviate > 2 percentile curves a concern

o Children/ Adolescents

 Height for age/gender

 Weight for age/gender

 Weight for height for age/gender

 BMI for age/gender

 Between 5th and 85th percentile

 Monitor growth pattern

 Consistent pattern

 Deviate > 2 percentile curves a concern

 Helpful website for parents

o Adults

 Height/weight

 Percent desirable weight

 BMI

 Weight change

 Waist Circumference (fat distribution)

 Body composition

o % fat

o Muscle mass

o Bone density

 “Desirable” Weight for Adults

o Hamwii Formula

 Female: 100 pounds for first 5 feet (60 inches) + 5 pounds per inch

per 5 feet

 Male: 106 pounds for first 5 feet (60 inches) + 6 pounds per inch

over 5 feet

o Metropolitan Life Insurance Tables (Miller Method)

 Female: 119 pounds for first 5 feet (60 inches) + 3 pounds per inch

over 5 feet

 Male: 135 pounds for first 5 feet (60 inches) + 3 pounds per inch

over 5 feet

o Note: to get range for either method, use plus or minus 10% of final

answer. Absolute number depends on frame size.

o Evaluating weight status using desirable weight:

 Underweight: 120% of desirable weight

 Overweight: > 120% of desirable weight

 Obese: > 130% of desirable weight

 Unintentional Weight Loss (Adults)

o Significant Weight Loss

 5% loss in 1 month

 7.5% loss in 3 months

 10% loss in 6 months

o Severe Weight Loss

 > 5% loss in 1 month

 > 7.5% loss in 3 months

 > 10% loss in 6 months

 BMI for Adults

o Correlated with risk of chronic disease

 Below 18.5 and above 24.9 associated with increased risk

o Correlated with percent body fat

 Inrease muscle mass not accounted for

o Not as useful for athletes, increase lean mass

 High BMI not as likely to indicate risk of chronic disease or correlate

with percent body fat

o Underweight: 35% 5% 8-22% > 28%







35-55 10-12% 23-38% > 38% 5% 10-25% > 28%







> 55 10-12% 25-38% > 38% 5% 10-25% > 28%







 Body fat distribution

o Visceral fat most closely associated with risk of chronic disease

o Waist/hip ratio (WHR) originally used to estimate visceral

o Waist circumference now used rather than waist/hip ratio

 Better correlation with abdominal visceral obesity

 WHR poor predictor in women

o *Measurement of waist circumference described on page 403

 Waist Circumference cutoff vales: higher risk for chronic disease

o Women: > 35 inches (88 cm)

o Men: > 40 inches (102 cm)

 Men naturally have larger waists so risk does not increase at the

same cutoff value

 Estimate Skeletal Muscle Reserves

o Estimate bone-free arm muscle area (AMA)

 Need: midarm circumference + triceps skinfold

o Helps to evaluate possible protein- energy malnutrition

Protein- Energy Malnutrition



 Kwashiorkor

o Primary deficiency is protein

 Some weight loss or decreased growth

 Some muscle wasting

 Edema: decrease albumin and other serum proteins to produce

colloid oncotic pressure

 Enlarged fatty liver: protein carriers to transport fat out of liver

decrease

 Skin may develop lesions; patchy and scaly

 Healing compromised due to protein deficiency

Dry and brittle hair, easily plucked

 Changes color due to lack of melanin (a protein)

o Marasmus

 Protein and energy deficiency (decrease in overall intake)

 Severe weight loss or decreased growth

 Severe muscle wasting

 No detectable edema

 Liver not fatty or enlarged

 Skin, dry, thin

 Hair sparse, thin, easily plucked

o Protein deficiency

o Multiple micronutrient deficiencies

Biochemical Assessment



 Objective measures of nutritional status

o Static

 Nutrient or metabolite in blood, urine or body tissues

 Not always helpful due to homeostatic regulation

o Functional

 Body process dependent on specific nutrients

 Example: dark adaptation with Vit. A

 Often not specific

o Protein Status

 Serum albumin

 Used for assessing chronic protein status

o ½ life = 18= 20 days

o Specificity fairly low

 Serum transferring

o ½ life = 8-9 days

o Affected by iron status (increase depleted iron stores)

o Specificity fairly low

 Serum prealbumin (transthyretin)

o Used for monitoring treatment effects

 ½ life= 2-3 days

 May be decreased by renal insufficiency

(protein- wasting)

 Decrease by zinc deficiency (Zn required for

synthesis and secretion by liver)

 Serum retinol- binding protein

o ½ life= 12 hours

o Affected by vitamin A status (decrease in vitamin A

deficiency)

o Elevated in renal failure (apo- RBP not catabolized by

kidney)

 Factors to consider in using serum proteins to assess protein

status

 May be maintained even with protein- energy malnutrition

 May be decreased by acute inflammation even with

adequate protein status

 Retinol- binding protein least affected

 Can use markers of inflammation to assess likelihood of

inflammation effect on serum proteins

 C- Reactive protein

 Inflammatory biomarker

 Can help to determine when hypermetabolic phase of acute

inflammation diminishes

o Serum proteins then more indicative of protein status

o Especially important if using albumin or pre- albumin

o Iron status

 Serum iron not useful due to daily and diurnal variation

 Serum ferritin level (storage protein for iron in liver)

 Decreases in first stage of iron deficiency

 May increase with inflammation

 Transferrein saturation (transport protein for iron)

 Decreases in second stage of iron deficiency

 TIBC (total iron-binding capacity = available binding sites on

transport protein)

 Increases in second stage of iron deficiency

 Erthrocyte protoporphyrin (pre- RBC made in kidney)

 Increases in second stage of iron deficiency

 Hemoglobin (O2- carrying protein in peripheral blood)

 Decreases in third/fourth stage (anemia) of iron deficiency

 Hematocrit (% red blood cells in total blood volume)

 Decreases in third/fourth stage (anemia) of iron deficiency

o Micronutrients

 Serum levels sometimes helpful

 Homeostatic control problematic

 Tissue levels sometimes helpful

 Depends on where nutrient may be deposited

 Functional tests sometimes helpful

 May not be specific; sometimes difficult to measure

 Sometimes there is not a good measure

 What about hair content?

 Long term of chronic intake

 Contamination a problem

 Not all minerals appreciably deposited in hair

 May be useful for trace minerals

 Analysis not yet standardized with “normal” values

o Examples of micronutrient status assessment

 Vitamin B12/folate

 RBC or serum Folate

 Serum B12

 Homocysteine level (elevated with deficiency of either one)

 Schilling test for B12 absorption (page 424)

 Vitamin B6

 Serum pyridoxal phosphate (PLP) concentration

 Vitamin D

 Plasma 25- hydroxyvitamin D (25- OH- D3)

 Lowest threshold value to prevent secondary

hyperthyroidism, increased bone turnover, bone mineral

loss, seasonal variation in parathyroid hormone

 Vitamin A

 Plasma retinol (active Vitamin A) if stores depleted or toxicity

 Liver stores measured via relative dose response

 Dark adaptation measurement for night blindness

 Histological assessment of the eye

o Conjunctival impression cytology (CIC)

 Examine conjunctiva for changes associated

with vitamin A deficiency

 Vitamin C

 Plasma and serum ascorbic acid concentrations for recent

intake

 White blood cell ascorbic acid for assessment of body stores

 Calcium

 No routine biochemical method available

 Serum level not useful due to homeostatic control

 Bone mineral content used most often

o CT/ DXA

 Magnesium

 Serum magnesium routinely assessed

 Problems with this:

o Only 1% of body magnesium in blood

o Appears to be homeostatically controlled

o Low sensitivity and specificity

o RBC and peripheral lymphocyte Mg may be better

indicators of long term status

 Zinc

 Homeostatic control makes assessment difficult

 Serum or plasma zinc level used most often

o Decreases only in severe deficiency, indicating loss

from liver and bone

o Not specific (influenced by stress, infection, diurnal

variation, etc)

 No Zn- dependent enzyme has been shown to be valid and

reliable indicator

 Urinary and hair zinc not valid indicators

o Urinary excretion remains constant over wide range of

intakes and decreases only with severe deficiency

o Low hair Zn may be associated with chronic

suboptimal intake but concentration depends on

delivery to root and rate of hair growth

Putting it all together



 Compare clinical signs and symptoms and anthropometric data with potential

nutrient deficiencies identified through dietary assessment

 Conduct appropriate biochemical analyses and use results to further

evaluate/confirm nutrition diagnosis

 Plan nutrition care based on overall findings





Lecture 10 Nutrition Counseling for Physicians



 Articles

o Physician- delivered nutrition counseling: why and how?

o Discussing weight with obese primary care patients

o Physical activity habits of doctors and medical students influence their

counseling practices

o Fruit and vegetable dietary behavior in response to a low- intensity dietary

intervention: the Rural Physician Cancer Prevention Project

 Why should physicians engage in nutrition counseling?

o 8 to 10 leading causes of death related to nutrition

o Access to patients

o Patients listen to/respect physicians

o Physicians (should) know their patients

 Physical status

 Emotional status

 Lifestyle habits

o If physician does not acknowledge a problem, patient may not perceive a

problem

 Ex: overweight/obesity

o Counseling by physicians increases patient motivation and self- efficacy

(confidence)

o Improves behaviors (e.g. fruit vegetable intake)

o Recommended by US Preventive Services Task Force (for obesity)

o The USPSTF recommends that clinicians screen all adult patients for

obesity and offer intensive counseling and behavioral interventions to

promote sustained weight loss for obese adults.

 Grade B- at least fair evidence that (the service) improves

important health outcomes and concludes that benefits

outweigh harms

o The USPSTF concludes that the evidence is insufficient to recommend for

or against the use of moderate- or low-intensity counseling together with

behavioral interventions to promote sustained weight loss in obese adults.

 Grade I: insufficient evidence

o The USPSTF concludes that the evidence is insufficient to recommend for

or against the use of counseling of any intensity and behavioral

interventions to promote sustained weight loss in overweight adults.

 Grade I- insufficient evidence

 Barriers to lifestyle counseling by physicians

o Time

o Training

o Counseling expertise

o Personal health behaviors

o Personal health status

o Money (reimbursement)

 Nutrition Counseling- How to do it

o Discuss rationale for behavior change

o Assess current behavior

 Behavior

 Readiness to change

 Past efforts

 Knowledge of risks related to current behavior

 Reasons for changing or maintaining current behaviors

o Provide strong, clear message about what behaviors need to be changed

 Include rationale/ reasons for suggested changes

 Set clear goals for behavior change

 Involve patient

 Express empathy about difficulty of behavior change

 Discuss potential barriers to behavior change

o Refer to dietitian or qualified nutrition counselor when appropriate

 Interested patient

 Complicated behavior changes necessary

 Often covered by insurance

o Follow up

 Discuss progress at next office visit

 Schedule appointment specifically for follow up

 Check in via telephone

 Resources

o Don’t forget MyPyramid online assessment and tracking tools

o Don’t forget Dietary Guidelines Consumer Brochure

o CDC Consumer Information

o State and local health departments

o Major Associations provide patient information

 American Heart Association, American Diabetes Association,

American Dietetic Association, Many Others

o Other companies

 Some have excellent unbiased nutrition information

 Review for bias, currency and accuracy before using

 Physical activity habits of doctors and medical students influence their

counseling practices (posted abstract)

o Physicians’ own health status affects their confidence, comfort and

effectiveness in counseling patients about physical activity

o Physicians’ own physical activity habits influence their comfort in

counseling patients about my physical activity.

o Physicians’ own physical activity habits influence their attitude regarding

the importance of physical activity in maintaining good health

 Physician and Patient Perspectives

o 456 patients and 30 physicians

 family practice or general internal medicine

o Assessed agreement on whether they discussed weight, physical activity

and diet

o Results

 Disagreement for at least one item for 23% of visits

 Disagreement for 2 or more items for 16% of visits

 Physicians reported discussing weight, diet and physical activity

more often than patients

 64% of patients reported preference for no or minimal weight

discussion

 88% of patients reported being comfortable discussing weight with

physician

 84% of physicians reported being comfortable discussing weight,

diet, physical activity with obese patients

 72% of physicians reported routine discussions

 18% of physicians reported never having discussions with obese

 Higher motivation and self-confidence for patients who reported

discussions with physician

 Higher motivation and self- confidence for patients whose

physicians reported discussions

 Rural Physician Cancer Prevention Project

o Conducted in Virginia (VCU involved)

o 754 patients from 3 physician practices

o Randomized controlled trial

 Control

 Recruitment letter signed by physician

 No intervention

 Intervention

 Recruitment letter signed by physician

 Tailored feedback and self-help intervention

o Materials delivered to home; phone calls

o Fiber, fat, fruit, and vegetable

 Endorsement letter by physician at each stage of

intervention

 Results

 Significant improvement in knowledge and behavior across

race/age

o Greater improvement for lower education level

o Greater improvement for younger (≤ 42) and older (>

56) participants

o Greater improvement in knowledge for males

 Lower baseline knowledge

 Race- car theme

 Role of Physician in Nutrition Counseling

o Anything is better than nothing at all

o Acknowledging the problem is key

o The more specific, the better (obesity article)

o The more tailored, the better

 “Watch your diet” doesn’t work

 “Diet sheet” alone not very effective for most patients

o Follow up is important to success

Lecture 10 Sports Nutrition



 Determinants of Athletic Performance

o Genetics

o Training

o Nutrition

 Energy Systems Used during Exercise

o Energy Currency= ATP

 ~ 3 oz of ATP stored in body

o ATP-CP (phosphagen system)

 Only up to 8 seconds

o Lactic Acid Pathway (anaerobic, glycolytic)

 60-120 seconds of maximum effort

o Aerobic Pathway

 After 2 minutes becomes predominant pathway

 Determinants of Fuel Sources During Exercise (performance not weight loss)

o Intensity

 Low: 60% VO2 max

 Glucose from glycogen stores principal energy source

 Duration of activity limited

o Glycogen stores

o Blood pH (decreased by lactic acid)

o Duration

 Oxidation of fatty acids increase with longer duration

 Aerobic metabolism predominant

 Still need glucose to prime the pathways

 Blood glucose and glycogen still limiting factors

o Training

 Increase oxygen delivery to tissues

 Increase mitochondrial mass for oxidation of fuel

 Enhance muscle ability to oxidize all fuels especially fatty acids

 Especially fatty acids

 Nutritional Requirement

o Energy

 Need to meet needs to provide energy, spare protein

 Formulate with appropriate activity factor

 Kcal/kg

 Fitness program: 25-35 kcal/kg (1800- 2400 kcal/day)

 Intense Training: (2-3 hrs/day, 5-6 x/week)

 Elite Athletes: 150-200 kcal/kg (7,500-10,000 kcal/day)

o Carbohydrate

 % of kcals

 Similar to usual recommendations

 45-65% of kcals

o Closer to 65% for endurance training/sport

 Provides more glucose for building glycogen

stores

 g/kg

 5-10 g/kg

o Closer to 10 g/kg for endurance training/sport

o Fat

 Increase dietary fat increases capacity to oxidize fatty acids

 Fatty acids oxidized during exercise from lipolysis of stores TG (not

dietary fat)

 % of kcals

 Usual recommendations for health, prevention of chronic

disease

 20-35% of kcals (don’t go above 35% and stay above 20%)

o Protein

 Typical US diet meets requirements

 10-25% of kcals

 Dangers of excess

 Renal Load

 Increase urinary calcium excretion

 Risk of dehydration

 Extra kcals if supplements used

 Disagreement between American Dietetic Association/ American

College of Sports Medicine and National Academy of Science

 ADA/ACSM recommend increase

o For neutral- positive nitrogen balance

 NAS does not recommend increase

o RDA is sufficient due to adaptations with training to

improve efficiency of protein metabolism

 1 pound lean/mass/week= 100 grams of muscle protein

 1 pound lean= 70% water, 7% lipid, 22% protein

 14g/day over RDA to provide 100 grams/week

 28 g/day over RDA for 2 pounds of lean tissue gain/week

 More than 2 pounds per week not feasible

 g/kg

 Strength/ resistance athletes

o May need 1.6- 1.7 g/kg to gain, 1.2- 1.4 maintenance

o Support maintenance and increase in lean tissue

o Consuming some right after training may help repair

tissues and optimize gain in muscle mass

 Endurance athletes

o May need 1.2- 1.4 g/kg

o More AA oxidized for energy due to high energy

needs

o Support repair of damaged tissue

o Vitamins/ Minerals

 Current DRI appears to be adequate

 B- Vitamin requirements increase with energy needs

 A, D, E calories out (burned)

o Clinical indicators of risk

 Rapid weight after ~ 40 in adults

 1-2 pounds per year average: adds up fast

 Rapid increase in BMI percentile before age 5 in children

 Increase in BMI percentile > 2 curves in children

 BMI for Adults

o Underweight: 40 in. men; > 35 in. women

o Serum TG ≥ 150 mg/dl

o HDL 35

 Combination of approaches most effective:

o Healthier food choices

o Exercise

o Lifestyle modification

 Pharmacological and surgical approaches may be warranted

o Less likely to be successful without lifestyle modification

 Prevention of weight re-gain via energy balance

 Restriction calorie diet

o 500- 1,000 calorie reduction (0.5- 1.0 lb/ week)

 best to achieve deficit via decease calories and increase activity

 Maintains metabolic rate better

o 25- 50% of calories from fat

 energy- dense, easy to overeat otherwise

o 15- 25% of calories from protein

 Maintain muscle mass during energy restriction

o Vitamin/ mineral supplements if 30 and not successful with other programs

 Comoridities from obesity may justify use for lower BMI

o Risks

 Gout (increase urinary ketones interfere with renal clearance of uric

acid)

 Gallstones (increase serum cholesterol from mobilization of

adipose)

 Loss of lean mass

o Not currently recommended unless medical justification

 Overall weight loss not greater

 Less likely to maintain weight loss

 Formula Diets/ Meal Replacement Programs

o Appropriate composition

 Energy, macronutrients, micronutrients

o Portion controlled

o Removes need for decisions regarding food choices

o Successful for weight loss

 Still lifestyle modification for maintenance of weight loss

 Commercial Programs

o Prepackaged or regular food

 Use of regular food better promotes lifestyle modification

o Education

o Emphasis on lifestyle modification

o Social support

o Internet may be effective tool

o Weight Watchers is example of effective, evidence- based program

 Regular food, support, lifestyle modification

 Exercise

o Combination of aerobic and resistance exercise recommended

o Aerobic

 Burns calories

 Increases cardiac and respiratory fitness

o Resistance

 Maintains/ increases lean body mass

 Maintains resting metabolic rate better

 Maintains/ increases bone density

Maintenance of Weight Loss (Adults)



 Data provided via National Weight Control Registry

 People most successful at Maintaining lost weight had the following habits:

o Low- fat (~ 25 %) diet

o Breakfast almost every day

o Weight regularly (once/day to once/week)

o High levels of physical activity (60- 90 minutes/ day)

Treatment and Management of Obesity (children)



 Weight maintenance versus loss depends on: age, baseline BMI, presence of

medical complications

 2 to 7 years

o BMI: 85th- 95th percentile without medical complications related to obesity

 Prolonged weight maintenance—let height “catch up”

o BMI: ≥ 95th percentile with medical complications

 Gradual weight loss (≤ lb/month)

 > 7 years

o BMI: 85th- 95th percentile and no medical complications

 Prolonged weight maintenance—let height “catch up”

o BMI: 85th- 95th percentile with medical complications

 Prolonged weight maintenance – let height “catch up”

o BMI: ≥ 95th percentile with or without medical complications

 Gradual weight loss (≤ 1 lb/ month)

 Older Children

o Already exceeds optimal adult weight

 Slow weight loss of 10- 12 lb/year

 How?

o Not restrictive “diet”

o Gradual changes in eating

 Achieve recommendations for food groups

 Portion sizes

 Sugar sweetened beverages

o Gradual changes in physical activity

 At least 1 hour per day

o Reduce sedentary behaviors

o Family involvement

 Role model, provide opportunities for healthful food, physical

activity

o School environment should be supportive

Resources



 CDC

o Tons of resources for consumers and health care professionals using the

topic index and finding “obesity”

o Includes clinical guidelines for prevention and treatment of obesity

 Blubberbusters.com

o Already discussed

 BMI calculators for CDC

 USDA

o Lots of practical information and kid- friendly resources