Long term postoperative nutritional management of ischemic patients

Long term postoperative nutritional

management of ischemic patients

By By Amr Abdelmonem,MD.Assistant professor of anesthesia ,surgical intensive care and clinical nutrition in faculty of medicine, Cairo universityMember of North American Association For The Study Of ObesityMember of the American society of regional anesthesia and pain medicine

PathoPhysiologic Mechanisms Of Appetite Regulation

Levin, BE. (2004) The drive to regain is mainly in the brain Am J Physiol Regul Integr Comp Physiol. 287,R1297-R1300Woods, SC, Seeley, RJ. (2002) Understanding the physiology of obesity: review of recent developments in obesity research Int J Obes Relat Metab Disord. 26(Suppl 4),S8-S10 Horvath, TL, Diano, S. (2004) The floating blueprint of hypothalamic feeding circuits Nat Rev Neurosci. 5,662-667

CCKserotonin

GLP-1PYY(3-36) Ghrelin

Glucagon Amylin

NTS AP

Arc

NPY-AGRP

↑Feeding

Vegally dependent

↑Satiety ↑Satiety

Leptin NTS

The metabolic syndromeThe metabolic syndrome

ATP III Guidelines WHO GuidelinesAbdominal Obesity

 Waist Circumference Waist/Hip Ratio Men > 40 inches (102 CM)  >0.90 Women > 35 inches (88 CM)  >0.85

Triglycerides 150 mg/dL 150 mg/dL

HDL-Cholesterol Men < 40 mg/dL <35 mg/dL Women < 50 mg/dL <39 mg/dL

Blood Pressure 130/ 85 mm Hg >140/>90 mm Hg

Fasting Glucose 110 mg/dL 110 mg/dL

IDF NCEP International Diabetes Federation National Cholesterol Education Program

Central Obesity 

Waist Circumference

 Men 90 CM

 Women 80 CMTriglycerides 150 mg/dL

HDL-Cholesterol Men < 40 mg/dL

 Women < 50 mg/dLBlood Pressure 130/ 85 mm Hg

Fasting Glucose 100mg/dL

Triad of Low HDL , High LDL and Increased Triglyceride concentrations

Coronary Heart DiseaseCoronary Heart Disease

Therapeutic life style changes treatment plan : diet and physical

activity

Behavioral Modifications

SELF-MONITORING STIMULUS CONTROL COGNITIVE RESTRUCTURING STRESS Management SOCIAL SUPPORT

Therapeutic life style changes Therapeutic life style changes

dietdiet

ATP III nutritional components of the TLC diet

Nutrient

Total fat Saturated fat Polyunsaturated fat Monounsaturated fat Cholesterol Carbohydrate (esp.complex)

Protein

Dailly recommended intake

25-35%of total calories <7%of total

kilocalories Up to 10 %of total

calories Up to 20% of total

calories <200 mg 50-60 %of total

calories

15 % of total calories

Evaluation of the program by the Evaluation of the program by the physician The match between the program and

the consumers The soundness and safety of the

program: Assessment of physical health and psychological

status Attention to diet and pharmacotherapy Attention to physical activity Program safety

Outcome of the programOutcome of the program Long-term weight loss Improvement in obesity related comorbidities Improved heath practice Monitoring adverse effects that might result from the program

Caloric restrictionction

Normal caloric intake 20-25 calories Normal caloric intake 20-25 calories for each Kg of the body weight orfor each Kg of the body weight or

According to According to Harris-Benedict Harris-Benedict equation:equation:

For males RMR= 66.4+ 13.8 W + 5H – 6.8AFor males RMR= 66.4+ 13.8 W + 5H – 6.8A

For females RMR= 665+ 9.6W+ 1.8H – 4.7AFor females RMR= 665+ 9.6W+ 1.8H – 4.7AW=weight (kg), H = height (cm), and A= age (yr)e.g. weight : 120 kg H= 175 A=35RMR= 66.4 + 13.8(120)+5(175) – 6.8(35)=2359.5

Less than 500 calories deficit per dayLess than 500 calories deficit per day➞ ➞ weight loss of .5 Kg per weekweight loss of .5 Kg per week

Energy Density Density

Definition Definition Amount of energy in a given weight of Amount of energy in a given weight of

foodfood

(kcal/g)(kcal/g)

For the same amount of energy ,a For the same amount of energy ,a greater weight of food can be consumed greater weight of food can be consumed when the food is low in energy density when the food is low in energy density than when its energy density is highthan when its energy density is high

Barbara j ,et al. J Am Diet Assoc.2005;105:S89Barbara j ,et al. J Am Diet Assoc.2005;105:S89

Glycemic IndexGlycemic Index Jenkins and his collegues developed the GI. The GI for a food was defined relative to a standard food (glucose or white bread).

Over a 2-hour period, the area under the glucose response curve after consuming 50 grams of carbohydrate from the test food was compared with the area under the glucose response curve after consuming 50 grams of carbohydrate from the reference food.

Both levels were given as the difference from fasting blood glucose levels .

The tests have been done in both healthy people and people with diabetes.

Jenkins and his colleagues have proposed that

All carbohydrates are not equivalent and that the rate of absorption of carbohydrate foods into the bloodstream is a critical factor in hyperinsulinemia.

Slowly absorbed foods would be beneficial because they trigger less of a rise and fall in blood glucose and, thus, less of a rise and fall in insulin levels

• American Society for Clinical Nutrition, has noted that a number of diet strategies exist for weight loss and that different individuals may find different strategies useful.• Although they do not specifically endorse either the GI or energy density as methods for choosing foods, they have noted that both have some support in the literature and that further research into them is warranted Klein, S, Sheard, NF, Pi-Sunyer, X, et al (2004) Weight management through lifestyle

modification for the prevention and management of type 2 diabetes: rationale and strategies. A

statement of the American Diabetes Association, the North American Association for the Study of

Obesity, and the American Society for Clinical Nutrition Am J Clin Nutr. 80,257-263

Final Comment