Obesity: Basic and Clinical Module Objectives:
Explain the health risks associated with obesity. Identify individuals who are overweight or obese using current assessment tools. Describe how obesity modulates cardiovascular risk profile. Assess and counsel overweight patients regarding lifestyle changes needed for safe and effective weight reduction.
Module Outline:
Getting Started Module Objectives Obesity Overview Prevalence of Overweight and Obesity Trends in Overweight for US Adults Trends in Overweight: US Children Global Trends in Overweight Health Risks Health Risks of Obesity Leading Causes of Death in the US Body Fat Distribution Images of Abdominal Fat Obesity Assessment Measures of Body Fatness Indirect Measures of Body Fat Body Mass Index (BMI) Adult BMI Calculator Waist Circumference Fat Storage Adipose Tissue Excess Energy and Adipose Tissue Energy Balance Weight Gain Fat Mobilization Adipose Tissue Turnover Diet and Adipose Tissue Mobilization VLDL synthesis Obesity Case – Health Risks Tony Villa Tony’s Health Risks Body Fat Distribution Weight Management Obesity Handouts 1
Weight Management Steps to Successful Weight Management Role of Physical Activity Lipogenesis and Lipolysis Energy Balance Energy Balance: Introduction Components of Energy Expenditure Physical Activity Basal Energy Expenditure and Thermic Effect of Food Growth and Lactation Changing the Balance Between Intake and Expenditure Body Weight Regulation: Homeostasis Intake and Expenditure: A Complex Regulation Appetite Regulation Principles of Appetite Regulation The Gut-brain Axis The Adipose-brain Axi Central Appetite Regulation Energy Needs Estimating Energy Requirements Daily Calorie Needs Estimator Diet Assessment Dietary Habits Assessment Diet Assessment Methods Screening Tools: Overview Screening Tools: Family Eating Habits Quiz Food Group Assessment Tool Case Practice: Dietary Assessment Nutrition Basics Nutrition Basics: Food Groups Serving Sizes Portion Size Evolution Over Time Nutrient Vs Energy Dense Foods Assessing Physical Activity Quantifying Physical Activity Additional Factors in the Physical Activity Assessment Assessing Physical Activity in Children How Much Physical Activity is Enough? Evaluating a Child's Activity Level Case Practice: Physical Activity Assessment - Part 1 Case Practice: Physical Activity Assessment - Part 2 Motivational Interviewing Motivational Interviewing: An Introduction Motivational Interviewing: Principles Motivational Interviewing: Common Elements Obesity Case – Treatment Priorities
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Prepare for Mr. Villa’s Appointment Choose Treatment Strategies Mr. and Mrs. Villa’s Clinic Visit A Teachable Moment Importance of Weight Loss Family Support During Weight Loss Setting Specific Goals
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Objectives, Key Concepts, and Key Concept Summaries by Topic
Topic: Obesity Overview Objective: Describe trends related to prevalence of overweight and obesity. Key Concept: Overweight and obesity rates are rapidly increasing. According to the 1999-2002 NHANES, 2 out of 3 adults are overweight or obese (body mass index ≥ 25.0). A full 30% of adults are obese (BMI ≥ 30.0). Nearly 1 out of 6 children are considered overweight (defined as BMI-for-age ≥ 95th percentile). Most of the dramatic increase in the prevalence of overweight and obesity in the US is due to the large increase in the number of people classified as obese. The rapid increase in overweight is not only seen in developed countries. The rate of increase is often faster in developing countries, where undernutrition and overnutrition co-exist. Rising incomes, urbanization, and globalization of the food supply have contributed to the relative abundance of energy-dense foods, and technology and societal changes have led to decreased physical activity levels. ________________________________________________________________________ Topic: Health Risks Objective: List the health risks associated with obesity and weight gain. Key Concept: Many chronic diseases are linked to and/or worsened by obesity; weight loss can reduce these risks. The risks for cardiovascular disease, type 2 diabetes, hypertension, cancer of the breast, endometrium, prostate, and colon, osteoarthritis, and gout are increased by obesity. Modest weight loss can improve blood pressure readings, glucose levels, and physical mobility. Fat distribution also is important. While obesity increases risks for a number of diseases, central obesity (where the fat is in the upper parts of the body, as in the abdomen, back, arms, and chest) increases those risks even further. ________________________________________________________________________
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Topic: Obesity Assessment Objective: Define obesity and describe how to identify obese or overweight individuals. Key Concept: Obesity refers to excess body fat and can be identified using a number of tools. A number of direct and indirect measures of body fat exist. Body Mass Index, a ratio of weight (kg) to height (m squared) is a commonly used tool to identify overweight and obesity indirectly. A BMI of 30 or greater indicates obesity. A BMI of 18.5-24.9 is considered normal, while BMI ≥ 25 but ≤ 30 indicates overweight. Waist circumference is an indicator of intra-abdominal fat, a fat distribution pattern that increases health risks, such as for cardiovascular disease, diabetes, and cancer. For males, ≥ 102 cm (40 inches) suggests central obesity while in females, ≥ 88 cm (35 inches) suggests central obesity. ________________________________________________________________________ Topic: Fat Storage Objective: Explain the factors influencing fat storage in adipose tissue. Key Concept: Triglyceride storage is influenced by several factors. When energy intake exceeds expenditure on a consistent basis, weight gain occurs. The increase in circulating glucose and insulin in response to a hypercaloric diet favor the storage of triglycerides in adipose tissue. However the amount of weight gain is a fraction of what one would expect based on actual calorie excess. Even individuals with a strong genetic obesity disposition lose weight when their energy expenditure exceeds intake.
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Topic: Fat Mobilization Objective: Explain how obesity alters fat metabolism. Key Concept: A small percentage of adipose tissue is continually being mobilized. Hormone sensitive lipase causes the breakdown of stored triglycerides to free fatty acids and glycerol. The activity of hormone sensitive lipase is modulated by hormonal factors, such as insulin and glucagon. Free fatty acids that are not used for energy are redeposited in adipose tissue as triglycerides. VLDL and cholesterol synthesis tend to increase with body fatness. In obese individuals most of the additionally secreted VLDL are converted to atherogenic LDL. Most of the additionally synthesized cholesterol is eventually excreted with bile and raises the risk of gallstone formation. ________________________________________________________________________ Topic: Weight Management Objective: Summarize the components of successful weight management. Key Concept: Aiding patients in their weight loss attempts requires attention to multiple factors. Helping your patients lose weight involves assessment, dietary and physical activity interventions, positive reinforcement, self-monitoring, and frequent follow-up. You should first assess their risk profile (BMI, co-morbidity), and their readiness to change eating and physical activity behaviors. Determine their baseline diet and exercise habits and social support. Dietary interventions could focus on moderation, variety, and/or balance. Self-monitoring of weight, food intake and activity are key components. Intensive follow-up may be needed. You should tailor your suggestions to the readiness of the patient, and realize that constant monitoring and regular physical activity is essential for long-term success. ________________________________________________________________________
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Topic: Energy Balance Objective: Describe the components and regulation of energy balance. Key Concept: To avoid undesired gain in fat mass, energy intake should equal expenditure (plus a small amount needed for growth in kids). Basal metabolic functions, heat generation, thermic effect of food, growth, lactation, and physical activity are responsible for total energy expenditure. Physical activity is the most variable component in healthy people and possibly the factor that tips the balance one way or the other. The additional energy needed during childhood growth periods is much smaller than most people think (8-34 kcal/day depending on age and sex) and can easily be exceeded with typical dietary patterns. Although multiple factors influence regulation of body weight, the primary focus of weight management is on intake or expenditure or both. ________________________________________________________________________ Topic: Appetite Regulation Objective: Detail the regulatory mechanisms that integrate appetite and body composition with fed or fasted state. Key Concept: The gastrointestinal tract and fat stores influence appetite and satiety via hormonal and neural connections. An intricate web of hormonal and neural connections link food intake behavior to body composition with fed or fasted state. In the short-term, hormonal and neural inputs from the stomach and intestines dominate. Following food consumption, CCK is released from the duodenum and acts on the vagus nerve and along with mechanical stretching signals from the stomach, signals satiety to the brain. Simultaneously, insulin and amylin release from the pancreas and apoAIV, GLP-1, and PYY release from jejunum, ileum, and colon signal satiety. When the stomach is empty, ghrelin signals hunger in the brain. Longterm weight regulation is mainly influenced by signaling from adipose tissue to the hypothalamus. When fat stores decrease during weight loss, the fall in leptin levels triggers an increase in appetite. ________________________________________________________________________
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Topic: Energy Needs Objective: Describe how to determine an individual’s energy needs. Key Concept: An individual’s energy requirements can be estimated using specific formulas or calculators. Energy requirements depend on age, weight, height, gender and physical activity (the most variable factor) and can be estimated using specific formulas for each age group and gender from the Dietary Reference Intakes. Energy expenditure is directly related to muscle mass; men generally expend more energy than women, and young adults more than older adults. ________________________________________________________________________ Topic: Diet Assessment Objective: Demonstrate how to obtain dietary information from patients. Key Concept: Diet assessment is a key part of any nutrition evaluation. A diet assessment should provide information about the patient’s intake with regards to food choices, calorie level, variety, adequacy, portion sizes, potential excesses or deficiencies, and dietary supplement use. There are many ways to assess a diet in research settings or in consultations with a dietitian (i.e., food frequency questionnaire, 24-hour recall, food record), however, most practitioners use some type of brief dietary screening tool to quickly identify problem areas. Many tools can be self-administered or administered by medical staff to save you time. ________________________________________________________________________
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Topic: Nutrition Basics Objective: List two target areas for intervention to improve the quality of the typical patient’s diet. Key Concept: Making healthy choices involves emphasizing nutrient-dense foods and appropriate portion sizes. Constructing a healthy diet begins with making appropriate food and beverage choices. The MyPyramid.gov website is one tool that may help individualize dietary recommendations for your patients. Choosing nutrient-rich foods and beverages in moderation is key. Since portions have increased dramatically over the years, understanding appropriate serving sizes and controlling portion sizes are also crucial to balancing energy intake with expenditure. ________________________________________________________________________ Topic: Assessing Physical Activity Objective: Demonstrate methods to evaluate both physical activity and sedentary habits in a healthcare setting. Key Concept: To assess physical activity, ask about exercise, sports, play, and lifestyle in addition to sedentary habits. Physical activity can best be described using the acronym FITT: frequency, intensity, type, and time. Direct measures of physical activity include pedometers (are becoming common) and accelerometers (used mostly in research). Questionnaires may ask about outdoor playtime or sports participation. It is also important to assess sedentary time (TV, videos, computer games) as this represents a primary target for intervention and may be more important than physical activity per se. Adults and children should get 60 minutes of physical activity daily; TV and videos should be limited to 2 hours or less per day. To guide you with physical activity interventions, it is useful to also ask about environmental or safety issues related to outdoor activity, the family's attitude and beliefs about exercise and sports participation, and motivation to change behavior patterns. ________________________________________________________________________
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Topic: Motivational Interviewing Objective: Describe the style, principles and common elements involved in motivational interviewing. Key Concept: Motivational interviewing is a patient-centered approach to effect behavior change. Motivational interviewing (MI) involves expressing empathy, helping the patient see the discrepancy between their own goals and behaviors, expecting resistance and ambivalence, and emphasizes both personal choice and responsibility on the part of the patient. It represents a shift from physician-directed traditional counseling where the physician provides advice and admonishment. In MI the relationship is more of a collaboration and partnership with the physician eliciting the patient's motivations, goals, and ideas for behavior change. ________________________________________________________________________
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