Chapter 22

Nutrition in Weight
Management

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Body Weight Components

Lean body mass (LBM)
Skeletal muscles, water, bone, and essential fat
in internal organs, bone marrow, and nerve
tissues
Higher in men than in women
Increases with exercise; decreases with age
Major determinant of RMR
Water is the most variable component, making
up 60% to 65% of LBM
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Body Fat
Essential body fat
Necessary for physiologic function
About 3% of body weight in men and 12% in women

Storage body fat

Energy reserve under the skin, primarily
triglycerides in adipose tissue
Around the internal organs to protect them from
trauma
Most considered expendable
Good health associated with 10% to 25% of
body weight in men and 18% to 30% in women
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Adipose Tissue Composition

Adipose tissue structure: white and brown
adipose tissue
Adipocytes, hypertrophy, and hyperplasia
Fat cell development

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Fat Storage
Dietary triglycerides and lipogenesis
Semi-volatile organic compounds (SVOCs)
Lipoprotein lipase (LPL)
Hormone-sensitive lipase (HSL)
Effects of estrogen and sex steroid
hormones

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Theoretical Body Composition

Model for a Man and Woman

Healthy body-fat ranges adapted from Gallagher D, et al: Healthy percentage body fat ranges: an approach for developing guidelines
based on body mass index, Am J Clin Nutr 72:694, 2000.
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Regulation of Body Weight

Metabolic rate and voluntary activity
Resting metabolic rate (RMR): 60% to 70% of
total energy expenditure
Activity thermogenesis (AT)
Nonexercise activity thermogenesis (NEAT)

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Regulation of Body Weight

(contd)
Short- and long-term regulation
Factors affecting hunger, appetite, and satiety
Hypophagia and hyperphagia in response to
changes in caloric intake
Adipocytokines

Set-point theory
Preservation of specific body weight: genetically
determined
Controversial

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Weight Imbalance:
Obesity and Overweight
Imbalance between food consumed and
physical activity
Complex issue related to lifestyle,
environment, and genetics
Prevalence
Weight management throughout the life
span
Weight and longevity
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Assessment Factors
Overweight versus obesity
Ideal body weight (IBW)
Body mass index (BMI)
Quetelet Index (W/H2)
Waist circumference
Waist-to-hip ratio (WHR)

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Etiology of Overweight and

Obesity
Environmental, genetic, psychological,
cultural, and physiologic factors
Heredity and nutrigenomics
Twin studies
ob gene (leptin), adiponectin (ADIPOQ), FTO
gene, and b3-adrenoreceptor gene

Inadequate physical activity

Inflammation
Cytokine polymorphisms: insulin insensitivity,
hyperlipidemia, muscle protein loss, and
oxidant stress
Chronic inflammation
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Etiology of Overweight and

Obesity (contd)
Sleep, stress, and circadian rhythms
Chronic sleep deprivation
Cortisol

Taste, satiety, and portion sizes

Portion sizes and energy density
Variety and sensory-specific satiety

Viruses and pathogens

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Health Risks and Longevity

Diabetes
Heart disease
Hypertension
Hyperlipidemia
Gallbladder disease
Some cancers
Mortality
Nonalcoholic fatty liver disease (NASH)
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Fat Distribution and Metabolic

Syndrome
Genetic; differ between men and women
Android: excess subcutaneous truncalabdominal fat (apple shape)
More common in men; increases with age
Correlated with insulin resistance, metabolic
syndrome

Gynoid: excess gluteofemoral fat (pear

shape)
More common in women, especially
premenopausal

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Fat Distribution and Metabolic

Syndrome (contd)
Metabolic syndrome (MetS) includes three
or more of the following:
Waist circumference >102 cm (40 in) in men
and >88 cm (35 in) in women
Serum triglycerides of at least 150 mg/dL
High-density lipoprotein (HDL) level <40 mg/dL
in men and <50 mg/dL in women
Blood pressure 135/85 mm Hg or higher
Serum glucose 110 mg/dL or higher

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Calorie Restriction and Longevity

Increases life span and slows aging in
animals
Fasting insulin level and body temperature
decrease
Possible benefits for aging: neurologic and
cardiac function

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Weight Discrimination
Widespread bias based on weight
Key areas of life: education, employment,
and health care
Lack of understanding
Impact on children and adolescents

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Management of Obesity in Adults

Achievement of IBW may not be possible
or desirable
Beneficial to maintain present weight or
achieve moderate loss (5%10%)
Effects of rapid weight loss: starvation
response and metabolic aberrations
NIH recommends loss of 0.5 to 1 lb/wk for
BMI 27 to 35; 1 to 2 lb/wk for BMI >35
Individualize final goal weights
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Lifestyle Modification
Behavior modification
Self-monitoring
Goal setting
Stimulus control
Problem solving
Cognitive restructuring
Relapse prevention
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Nutrition Care Process for Managing

Obesity

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Dietary Modification
Weight-loss programs
Food choice changes
Exercise
Behavior modification
Nutrition education
Psychological support
Surgical intervention for morbid obesity
Pharmacotherapy
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Dietary Modification (contd)

Restricted-energy diets
Deficit of 500 to 1000 kcal/day
Relative high in CHO, generous protein, fat
<30%
Limit alcohol and high-sugar foods
Artificial sweeteners and fat substitutes
Vitamin and mineral supplements

Formula diets and meal replacement

programs
Commercial programs
Extreme energy restriction and fasting
Very-low-calorie diets
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Popular Diets and Practices

Efficacy, effects on metabolic parameters,
psychological well-being, and reduction of
chronic disease
Carbohydrate-restricted diets (Atkins,
Carbohydrate Addict)
More moderate carbohydrate restrictions
(Zone and South Beach)
Volumetrics
Very-low-fat diets (Dean Ornish, Pritikin)
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Physical Activity
Increases proportion of LBM to fat
Offsets decrease in RMR with weight loss
Strengthens cardiovascular integrity
Increases sensitivity to insulin
Expends more energy
60 to 90 min/day recommended for weight
loss (at least 30 minutes; moderate
intensity)
Aerobic and resistance training

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Pharmaceutical Management
For BMI >30 or BMI>27 + significant risk
factors
Augments diet, exercise, and behavior
therapy
CNS-acting agents
Catecholaminergic agents, serotoninergic
agents, and combination agents
Common side effects are dry mouth, headache,
insomnia, and constipation
Only sibutramine and orlistat approved for longterm use

NonCNS-acting agents
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Other Nonsurgical Approaches

Eat healthfully, become attuned to hunger
and satiety cues, and incorporate physical
activity
Promote size acceptance and respect for a
diversity of body shapes

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Surgical Procedures
Bariatric surgery: for morbidly obese only;
BMI >40 or BMI >35 with comorbidities
Restrictive or malabsorptive
Previous failure of comprehensive program
Evaluate physiologic and medical
complications, psychological problems, and
motivation

Gastroplasty and gastric bypass

Liposuction

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Gastric Surgeries for Obesity

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Common Problems in Obesity:

Maintenance of Reduced Body
Weight
Poor prognosis
Reduced energy needs for maintenance
Lifestyle modification
Support groups
The National Weight Control Registry
(NWCR) recommendations
Plateau effect
Weight cycling
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Weight Management in Children

Weight maintenance or slowing of gains
Grow into weight
If already exceeds adult weight, lose 10 to
12 lb/year
Family eating habits
Physical activity

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Weight Imbalance: Excessive

Leanness or Unintentional Weight Loss
Etiology
Assessment
Management
Appetite enhancers
High-energy diets for weight gain
Review habits
Schedule meals
Relaxation
Energy distribution
Snacks
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Focal Points

Overweight and obesity in adults (66.3 %) in the United

States have reached epidemic numbers. Even more alarming
is the increasing rate (17.1%) of overweight in children and
adolescents. The United States is not alone in terms of
trends; they exist worldwide.

Obesity has severe associated risks: type 2 diabetes,

hypertension, atherosclerosis, some cancers, sleep apnea,
infertility, gallbladder disease, and liver disease; increased
visceral fat has an important influence on metabolic and
cardiovascular risk factors.

Understanding the mechanism of appetite regulation is an

exciting area of research for new treatments.

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Focal Points (contd)

A chronic disease model involving both caloric restriction,

increased physical activity and lifestyle interventions in the
context of an interdisciplinary approach offers the best
treatment options for the patient.

Stopping weight gain or achieving a moderate loss should be

promoted as a treatment goal; an achievable 5 to 10% loss
of initial body weight can improve glycemic control, blood
pressure and lipid profile in most patients.

Among those individuals who are underweight, careful

assessment and intervention are needed to correct habits
leading to unintentional weight loss.

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