1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity and Eating Disorders Chapter 14

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity and Eating Disorders Prevalence of obesity (BMI ≥30) in American adults age 20 to 74 has more than doubled from 14.5% to 35.7% in 2009–2010 (Fig. 14.1). One of the most common causes of preventable death A far less common weight issue is disordered eating manifested as anorexia nervosa or bulimia. Historically, the study of obesity and eating disorders has been separate. Commonalities between them

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity Overweight is defined as having a BMI ≥25. –Related to an excessive body weight, not necessarily excessive body fat Obesity is defined as having a BMI ≥30. –Generally assumed to be related to an excessive amount of body fat

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Causes of obesity –Occurs when people eat more calories than they expend over time –Why it occurs is not fully understood. –“Set point” theory of weight control –Some people are able to burn hundreds of extra calories in the activities of daily living to help control weight. –Likely that a combination of genetic and environmental factors is involved.

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Genetics –Estimates on the heritability of body mass index range from 40% to 70% (Herrera and Lindgren, 2010). –Genetics are involved in oHow likely a person is to gain or lose weight oWhere body fat is distributed oResponse to overeating

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Environment –Rise in obesity without change in gene pool –Root cause is lifestyle and environment, not biology. –Environmental influences include oAbundance of palatable, low-cost, high–calorie density foods that are readily available in prepackaged forms and in fast-food restaurants oIncreasing consumption of soft drinks and snacks oGreat proportion of food expenditures spent on food away from home

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Environment—(cont.) –Environmental influences include—(cont.) oGrowing portion size of restaurant meals oLow levels of physical activity oIncreases in television watching oWidespread use of electronic devices in the home, such as computers and video games –All lead to sedentary lifestyle.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Environment—(cont.) –Gene–environment interaction oIn people with a genetic predisposition to obesity, the severity of the disease is largely determined by lifestyle and environmental conditions. Complications of obesity –Most common complications of obesity include oInsulin resistance, type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, gallstones and cholecystitis, sleep apnea, respiratory dysfunction, and increased incidence of certain cancers

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Complications of obesity—(cont.) –Increases the risk of complications during and after surgery –Obesity is considered to be a major contributor to preventable deaths in the United States. –Obesity presents psychological and social disadvantages. –Negative social consequences

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Respiratory dysfunction is one of the most common complications of obesity.

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Rationale: The most common complications of obesity are insulin resistance, type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, stroke, gallstones and cholecystitis, sleep apnea, respiratory dysfunction, and increased incidence of certain cancers.

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Goals of treatment –Ideally, treatment would “cure” overweight and obesity. –In reality, this ideal is seldom achieved. –A modest weight loss of 5% to 10% of initial body weight is associated with significant improvements in blood pressure, cholesterol and plasma lipid levels, and blood glucose levels.

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Goals of treatment—(cont.) –Modest weight loss 1.Is more attainable 2.Is easier to maintain over the long term 3.Sets the stage for subsequent weight loss

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Evaluating motivation to lose weight –Objectively identifying who may benefit from weight loss –Assessing the client’s level of motivation is crucial. –Imposing treatment on an unmotivated or unwilling client may preclude subsequent attempts at weight loss.

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Evaluating motivation to lose weight—(cont.) –Treatment approaches oA lifestyle approach is the basis of treatment for all people whose BMI is ≥30.  Includes diet modification  Exercise  Behavior modification oPharmacotherapy and surgery may be used in conjunction with lifestyle interventions, based on the individual’s BMI and the presence of comorbidities.

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Treatment approaches—(cont.) –Diet modification oCornerstone of most weight loss programs oFewer calories oMacronutrient composition oMicronutrient composition oNutrition education oPromoting dietary adherence

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Treatment approaches—(cont.) –Physical activity oBenefits of exercise are numerous. oFavorably impacts metabolic rate oDietary Guidelines recommend adults engage in approximately 60 minutes of moderate- to vigorous-intensity activity on most days of the week to prevent weight gain.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Physical activity—(cont.) –Sixty to 90 minutes of daily moderate-intensity physical activity are recommended to sustain weight loss. –Promoting exercise adherence oSeems to increase with less structure oStrategies that may promote exercise adherence  Exercise at home  Exercise in multiple short bouts (10 minutes each)  Adopt a more active lifestyle

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Behavior modification –Focuses on changing the client’s eating and exercise behaviors –Key behavior modification strategies oSelf-monitoring oGoal setting oStimulus control oProblem solving oCognitive restructuring oRelapse prevention

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Pharmacotherapy –Recommended for oPeople with a BMI ≥30 oPeople with a BMI ≥27 with comorbid conditions oPeople with waist circumference greater than 35 inches (women) and 40 inches (men) are also candidates for pharmacotherapy if comorbidities are present.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Pharmacotherapy—(cont.) –Two drugs approved by the FDA for long-term use have been shown effective in helping promote and maintain weight loss. oAlli is the only over-the-counter drug to gain FDA approval for the treatment of obesity.  Expected weight loss is modest (perhaps half of the usual 6 pounds per 1 year credited to orlistat). oPhentermine  Approved for short-term use (≤3 months)

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Pharmacotherapy—(cont.) –Drugs are central nervous system stimulants. –Tolerance may develop after only a few weeks. –Risk of abuse –Common side effects oIncreased heart rate and blood pressure, dry mouth, agitation, insomnia, nausea, diarrhea, and constipation

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question One of the treatments for obesity is behavior modification. Which of the following is an aspect of behavior modification? a. Stimulus recognition b. Professional monitoring c. Cognitive restructuring d. Problem identification

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer c. Cognitive restructuring Rationale: Key behavior modification strategies are self-monitoring, goal setting, stimulus control, problem solving, cognitive restructuring, and relapse prevention.

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Surgery –Most effective treatment for severe obesity –Appropriate for clients whose BMI is 35 to 39.9 who have major comorbidities –Works by 1.Restricting the stomach’s capacity 2.Creating malabsorption of nutrients and calories 3.A combination of both

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Surgery—(cont.) –Laparoscopic adjustable gastric banding (LAGB) oAn inflatable band encircles the uppermost stomach and is buckled. oSmall pouch of approximately 15- to 30-mL capacity is created with a limited outlet between the pouch and the main section of the stomach. oOutlet diameter can be adjusted by inflating or deflating a small bladder inside the “belt” through a small subcutaneous reservoir.

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Surgery—(cont.) –Laparoscopic adjustable gastric banding (LAGB)—(cont.) oSize of the outlet can be repeatedly changed as needed. oMortality rate for gastric banding is the lowest of all bariatric procedures. oSuccessful weight loss after LAGB requires frequent follow-up and band adjustments.

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Surgery—(cont.) –Roux-en-Y gastric bypass (RYGB) oCombines gastric restriction to limit food intake with the construction of bypasses of the duodenum and the first portion of the jejunum oCreates malabsorption of nutrients o“Dumping syndrome” oSuperior to gastric resection in both promoting and maintaining significant weight loss oMajor complication with RYGB is anastomotic leak.

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Postsurgical diet –Progression begins with small quantities of sugar-free clear liquids. –Advances as tolerated to full liquids, followed by pureed foods, and then a regular diet within 5 to 6 weeks after surgery –Nutrition therapy guidelines

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Weight maintenance after loss –Keeping weight off is even harder than losing it. –Diets that lead to weight loss are not necessarily effective for maintaining weight loss. –National Weight Control Registry (NWCR) –Single best predictor of who will be successful at maintaining weight loss is how long someone has kept his or her weight off.

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Obesity—(cont.) Obesity prevention –Small changes in diet and exercise that total a mere 100 cal/day may be enough to prevent obesity in most of the population. –One ounce of cheddar cheese a day for 1 year = 10-pound weight gain

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS) Defined psychiatric illnesses that can have a profound impact on nutritional status and health Generally characterized by abnormal eating patterns and distorted perceptions of food and body weight Continuum of disordered eating

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont’d) Etiology –Considered to be multifactorial in origin –Risk factors oDieting, early childhood eating and GI problems, increased concern about weight and size, negative self-evaluation, sexual abuse, and other traumas

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.) Etiology—(cont.) –Precipitating factors oOnset of puberty, parents’ divorce, death of a family member, and ridicule of being or becoming fat –People with eating disorders often suffer from oDepression, anxiety, substance abuse, or body dysmorphic disorder

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorders Not Otherwise Specified (EDNOS)—(cont.) Etiology—(cont.) –Treatment plans are highly individualized. –Antidepressant drugs effectively reduce the frequency of problematic eating behaviors. –Most eating disorders are treated on an outpatient basis. –Nutritional intervention seeks to reestablish and maintain normal eating behaviors.

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What is a risk factor for eating disorders? a. GI problems b. Adolescent eating problems c. Binge eating d. Depression

37. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a.GI problems Rationale: Risk factors that precede the diagnosis of an eating disorder include dieting, early childhood eating and GI problems, increased concern about weight and size, negative self-evaluation, and sexual abuse (Ozier and Henry, 2011).

38. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition Therapy for Anorexia Step-by-step goals of nutrition therapy 1.To prevent further weight loss 2.To gradually reestablish normal eating behaviors 3.To gradually increase weight 4.To maintain agreed-on weight goal Half of those who receive care are expected to recover. Overall mortality rate is 5% to 16%.

39. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition Therapy for Anorexia—(cont.) Involving the client in formulating individualized goals and plans promotes compliance. Large amounts of food may not be well tolerated.

40. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition Therapy for Bulimia Nervosa People with BN tend to have fewer serious medical complications than people with AN because their undernutrition is less severe. Nutritional counseling focuses on identifying and correcting food misinformation and fears. Structured and relatively inflexible to promote the client’s sense of control Initial meal plan provides adequate calories for weight maintenance.

41. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutrition Therapy for Bulimia Nervosa— (cont.) Adequate fat is provided to help delay gastric emptying and contribute to satiety. Calories are gradually increased as needed.

42. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Eating Disorders Not Otherwise Specified At least as common as AN and BN This group represents –Subacute cases of AN or BN –Binge eating disorder