Obesity and Nutrition Assessmentreviews.berlinpharm.com/20180505/Obesity_and... · Apovian CM et a;l. Obesity 2015:23;s1-s26 Agent Mechanisms of Action Phentermine Increase Dopamine,

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Obesity and Nutrition Assessment

Prapimporn C. Shantavasinkul, MD, MHS, NBPNS

Division of Nutrition and Biochemical Medicine,

Department of Medicine, Faculty of medicine,

Ramathibodi Hospital, Mahidol University

[email protected]/5/2018

Topics Today

Obesity

Obesity-related complications

Nutritional screening and assessment

Nutrition in specific disease

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Obesity

Medical condition in which excess body fat has

accumulated to the extent that it may have an

adverse effect on health, leading to reduced life

expectancy and/or increased health problems

The American Medical Association has officially recognized obesity as a disease (June18, 2013)

Lancet 366 (9492): 1197–209.

Obesity Prevalence in 2014 = 37.5%

Classification Asian Caucasian

BMI (Kg/m2)

Underweight <18.50

Severe thinness <16.00

Moderate 16.00 - 16.99

Mild thinness 17.00 - 18.49

Normal 18.5-22.9 18.5 – 24.9

Overweight 23-24.9 25-29

Obese I >25 >30

Obese II >30 >35

Morbid obese >40 >40

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

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Adiposity-Based Chronic Disease

A new diagnostic term: the American Association of

Clinical Endocrinologist and American College of

Endocrinology.

Emphasize on pathophysiological effects of excess

adiposity rather than BW or BMI.

Mechanick JI, et al, Endocr Pract. 2017;23(3):372-8.

Mechanick JI, et al, Endocr Pract. 2017;23(3):372-8.

“Adiposity-based" points to abnormalities in the mass, distribution, and/or function of adipose tissue

Adiposity-Based Chronic Disease

Amount

Distribution

Function

WC : Visceral fat

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Abdominal obesity

Waist circumference

> 80 cm in woman

> 90 cm in men

Waist / Height ration > 0.5

Outlines

Prevalence and definition obesity

Patients evaluation : Cause and Complications

Treatment options for obesity

Medical weight loss

Metabolic and weight loss surgery

Mechanick JI, et al, Endocr Pract. 2017;23(3):372-8.

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Causes of Obesity Edema

Medications

Endocrine disorders

Genetics disorders

Behaviors

Medications Anti-diabetic: insulin, insulin secretagogue, TZD

Oral Contraceptive Pills, DMPA

Glucocorticoids

Anti-epilepsy: valproate, carbamazepine, gabapentin

Antipsychotics : clozapine, risperidone, olanzapine, quetiapine, haloperidol

Antidepressants: TCA, lithium, MAO-I

β-blocker: propranolol

H1-blocker: cyproheptadine

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Hypothyroid

Edematous state

Recurrent hypoglycemia?

Cushing’s syndrome

“Chronic Disease" underscores “Complications”

that produce morbidity and mortality.

Adiposity-Based Chronic Disease

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Bray GA, et al. Endocr Rev. 2018;39:79-132.

HT

Breast/endometrium CA

OA

OSA, OHS DM

DLP

CVD

GERD

Gall stoneNAFLD

Mechanick JI, et al, Endocr Pract. 2017;23(3):372-8.

Physical Activity

Body composition

FM FFM

Sleep Hygiene

Stress Reduction

Drug Smoking

Alcohol

Mood Behavior

Healthy Eating

Patterns

Community engagementTranculturalization

Adiposity-Based Chronic Disease

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Outlines

Prevalence and definition obesity

Patients evaluation : causes and complications

Treatment options for obesity

Medical weight loss

Metabolic and weight loss surgery

Mechanick JI, et al, Endocr Pract. 2017;23(3):372-8.

Goal for Medical Weight Loss

Exclude secondary obesity as appropriate

Identify obesity-related complications

Set realistic goal for each patient

Weight reduction at least 5-10% of initial

body weight

Maintain weight loss

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How to lose weight

Diet and Lifestyle therapy

All overweight and obese patients

Pharmacotherapy

Failure of lifestyle therapy (for > 3 months)

Weight loss surgery

Lifestyle Therapy

Structured lifestyle intervention program

Diet/Meal plan

Physical activity and exercise

Behavior intervention

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Diet for Weight Loss

Very low calorie diet (<800 kcal/d)

Energy deficit : 500 kcal/d

Low calorie balance diet

F = 1200‐1500 kcal/d, M = 1500-1800 kcal/d

Adherence in the long term

0.5 kg/wk

2 1

1Fiber 14g/1000 kcal

Low GI and low GL

Lean protein

Plant-basedFish & Poutry

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Lifestyle Therapy

Structured lifestyle intervention program

Diet/Meal plan

Physical activity and exercise

150-180 min/week if moderately vigorous exercise

+ strengthening exercise

Behavior intervention

How to lose weight

Diet and Lifestyle therapy

All overweight and obese patients

Pharmacotherapy

Failure of lifestyle therapy (for > 3 months)

Weight loss surgery

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Pharmacotherapy

Failure of lifestyle therapy (for > 3 months)

Increase adherence to behavior changes

Allow for greater physical activity

Always with diet and life style changes

BMI > 30 kg/m2

BMI > 27 kg/m2

+ HT, DLP, T2DM, OSA, or others

All medicines are contraindicated in pregnant womenAdvise contraception while on medications

Weight Loss Medications: Mechanisms

Apovian CM et a;l. Obesity 2015:23;s1-s26

Agent Mechanisms of Action

Phentermine Increase Dopamine, NE release and inhibit reuptake

Take before 9 AM titrate from 7.5 to 30 mg/day

Oristat Pancreatic lipase inhibitor : decreased fat digestion

Decreased fat absorption 30%, -10.6%at1y, -5.8% at 4 y

Liraglutide 3.0 mg GLP-1 receptor agonist, -8.4% at 1 yr

Lorcaserin Selective serotonin receptor agonist (5-HT2c)- 5.4 kg

Phentermine/topiramate ER

(3.75/23), (7.5/46),

(11.25/69), (15/92)

Sympathomimetic/Anticonvulsant (GABA receptor)

(7.5, 46) - 10% to (15/92) -12 % at 2 yrTitration period is 2 week for each dose

Natrexone ER/bupoprion ER(8mg /90 mg)

Opioid receptor antagonist

Dopamine/noradreanaline reuptake inhibitor1 tablet/d titrate up to 2 tab oral bid (-6% to -9%, 1 y)

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Weight Loss Medications: Contraindication

Apovian CM et a;l. Obesity 2015:23;s1-s26

Agent Contraindications

Phentermine Pregnancy, uncontrolled HT, history of CVD, use < 12 w

Oristat Pregnancy, malabsorption, cholestatis

Liraglutide 3.0 mg Pregnancy, FH of MTC, patients MEN2

Caution : history of pancreatitis

Lorcaserin PregnancyRisk of serotonin syndrome (not use with SSRI, MAOI)

Phentermine/topiramate ER Glaucoma, Pregnancy

HyperthyroidismWithin 14 days of taking MAOI

Natrexone ER/bupoprion ER Pregnancy

Uncontrolled HT

Seizure, anorexia nervosa, bulimia

Abrupt discontinuation of alcohol, benzodiazepine,

antiepileptic

Use of bupropion-containing product, or use of opioidWithin 14 days of taking MAOI

Weight Loss Maintainence

Daily monitor of diet and physical activity

Reduced-calorie diets, adequate protein

Have breakfast

Physical activity (moderate intensity)

: 200-300 min/week

Self-monitoring : BW at least once a week

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Outlines

Prevalence and definition obesity

Patients evaluation : causes and complications

Treatment options for obesity

Medical weight loss

Metabolic and weight loss surgery

Mechanick JI, et al, Endocr Pract. 2017;23(3):372-8.

Weight Loss Surgery

BMI > 40 kg/m2

BMI > 35 kg/m2 plus comorbidities

Fail to lose weight by medical therapy

Exclusion: Drug, alcohol abuse, uncontrolled

psychiatric&eating disorder,end stage disease

High-volume centers with multidisciplinary teams

that understand and are experienced in the

management of diabetes & GI surgery

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Metabolic Surgery: ADA 2017-8

Should be recommended to treat T2DM in appropriate

surgical candidates with

BMI 40 kg/m2 (BMI > 37.5 in Asian American) regardless

of the level of glycemic control

BMI 35.0 – 39.9 g/m2 (32.5–37.4 in Asian Americans)

+ inadequate glycemic control control (A)

Diabetes Care 2017;40(Suppl. 1):S57–S63

Weight Loss Surgery

Malabsorptive SurgeryRestrictive Surgery

•High risk esp. in BPD/DS

•Fat malabsorption : ADEK•B1, B12, folate, iron def.

•Risk : B12, iron def

•B1 deficiency

54% 23%

6%

0.6%

Revision surgery and others : 17%

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Long term Complications

• Gall stone, kidney stone

• Dumping syndrome

• Post-bariatric surgery hypoglycemia

• Nutritional deficiency

• Weight regain

Handzlik-Orlik G, et al. Nutr Clin Pract. 2015;30:383-392

Weight Loss Surgery

Malabsorptive SurgeryRestrictive Surgery

•MTV 2 tablet/day•MTV 1 tablet/day

• Calcium citrate 1200-1500 mg/day

• Vitamin D, at least 3000 IU/day keep level >30 ng/ml

• B12 as needed to keep normal range

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Topics Today

Obesity

Obesity-related complications:

HT, DM, NAFLD

Nutritional screening and assessment

Nutrition in specific disease

ประสทิธภิาพของการปรบัเปลีย่น

พฤตกิรรมในการรกัษาโรคความดนัโลหติ

สูง

Thai Guideline 2558

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Salt < 5 g/d (Na < 2,000 mg/d)

Salt < 5 g/d (Na < 2,000 mg/d)

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Source: U.S. Department of Health and Human Services, NIH, NHLBI. http://www.nhlbi.nih.gov/health//publi c/heart/hbp/dash/new_dash.pdf

6-8/day

50% whole grain

8-10/day

2-3/day 0-2/day

2-3/day

1/day

5/week

Dietary Approach to Stop Hypertension

K, Mg, Ca

Healthy dietary pattern, individualization

No ideal % of calories from carbohydrate, protein,

and fat for all people with diabetes1.

Plant-based diet, DASH, Mediterranean diet

Lifestyle Management: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41:S38-s50.

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Goals of Nutrition Therapy for Adults With Diabetes

• BP,lipidcontrol

• Prevent DM Cx

• Glucose control

• Optimal Weight

Healthful eating

patterns

Nutrient Dense & Needs

Pleasure of eating

Properportion sizes

Diabetes Care 2017;40(Suppl. 1):S33–S43

ADA 2018: MNT recommendations

Weight management in overweight and obesity + T2DM

Sustained reduction of 5% of initial body weight : improve glycemic

control, reduce the need for glucose lowering medications

sustained weight loss of 7% is optimal.

Carbohydrate intake from whole grains, vegetables, fruits,

legumes, and dairy products, with an emphasis on foods

higher in fiber and lower in glycemic load,(B)

Protein

Thai DM guideline 2017: 15-20% of protein of calories,

< 1.3 g/kg/day, GFR < 30 protein 0.8 g/kg/d

Fat : Mediterranean diet, MUFA, fatty fish

Diabetes Care 2017;40(Suppl. 1):S33–S43

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ADA nutrition recommendation 2018

Added sugar

Avoid sugar-sweetened beverages in order to control weight and

reduce their risk for CVD and fatty liver (B)

Minimize the consumption of foods with added sugar that have the

capacity to displace healthier, more nutrient-dense food choices (A)

Nonnutritive sweeteners

The use of nonnutritive sweeteners has the potential to reduce

overall calorie and carbohydrate intake if substituted for caloric

sweeteners and without compensation by intake of additional

calories from other food sources. Nonnutritive sweeteners

are generally safe to use within the defined acceptable daily intake

levels. (B)

Diabetes Care 2017;40(Suppl. 1):S33–S43

Diabetes Care. 2018;41:S38-s50.

MUFA

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Trans Fat

Raising TC, LDL-c and lowering HDL-c

Increased the risk of CHD & sudden death

Healthy Diet Characteristics

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NAFLD is strongly associated with obesity, T2DM, Dyslipidemia and the metabolic syndrome

Visceral Adiposity Insulin resistance

Non-alcoholic Fatty Liver disease

Lifestyle Modifications to Mitigate NASH

Weight loss is the main therapy : IR

Hepatitis A, B vaccine

Avoid alcohol, sugar, fructose consumption

Optimize blood glucose and lipid control

Vitamin E 400-800 IU/day in selected case

α-tocopherol administered at 800 IU/day improves liver histology in

non-diabetic adults with biopsy-proven NASH and therefore may

be considered for this patient population.

Thiazolidinediones in patients with DM, NASH

HCC surveillance in NASH-related cirrhosis

N Engl J Med. 2017;377(21):2063-72.

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Goal of Weight Loss in NAFLD

Weight loss generally reduces hepatic steatosis

Daily reduction of 500-1000 kcal/d (or 30%) +

moderate intensity exercise is likely to provide the

best likelihood of sustained weight loss.

> 3 - 5% weight loss : improve steatosis

> 7- 10% weight loss is needed to improve the

histopathological features of NASH including

fibrosis

Chalasano N et al, Hepatology 2018; 1: 328Promrat K et al, Hepatology. 2010;51(1):121-9

Fructose

Fructose does not elicit insulin secretion and

is taken up almost exclusively by the liver.

Metabolized by fructokinase (no neg feedback)

Hepatic De novo lipogenesis

Worsen NAFLD/NASH

Hypertriglyceridemia

Hyperuricemia

hypertension

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Topics Today

Obesity

Obesity-related complications

Nutritional screening and assessment

Nutrition in specific disease

Not-at-Risk At-Risk or Malnourished

Nutrition Screening

Nutrition Assessment

At-Risk or Malnourished

Nutrition Therapy

Rescreen at:

• Regularly specified intervals or

• When nutritional/clinical status changes

Risk of presence of malnutrition

ReassessmentAlgorithm for Delivery of Nutrition Therapy

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สมาคมผู้ให้อาหารทางหลอดเลือดด าและทางเดนิอาหารแห่งประเทศไทย (SPENT)

(http://www.spent.or.th/index.php/publication/category/gl/2017)

SPENT = Society of Parenteral and Enteral Nutrition of Thailand= สมาคมผู้ให้อาหารทางหลอดเลือดด าและทางเดนิอาหารแห่งประเทศไทย

(http://www.spent.or.th/index.php/publication/category/gl/2017)

Nutrition Assessment endorsed by SPENT:

• NT (Nutrition Triage) or

• NAF (Nutrition Alert Form)

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Nutrition Assessment

History

Changes in dietary intake ; amount, solid liquid food

Weight changes

○ unintentional weight loss > 5%/1mo or >10%/6mo

GI symptoms : n/v/d/decreased appetite, impaired taste

Functional capacity

Nutrition-focused physical assessment (NFPA)

BMI, edema, ascites

Muscle, subcutaneous fat

Sign of micronutrients deficiency

NAF

(Nutrition Alert Form)

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NAF A (scores 0-5) normal-mild malnutrition

Reevaluation in 7 days

NAF B (scores 6-10) moderate malnutrition

Nutrition support within 3 days

NAF C (scores ≥ 11) severe malnutrition

Nutrition support within 24 hours

http://www.spent.or.th/index.php/public

Society of Parenteral & Enteral Nutrition of Thailand

http://www.spent.or.th/index.php/public

Height/arm span

BW, BMI

Albumin, TLC

BW change 4 wk

Society of Parenteral & Enteral Nutrition of Thailand

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Society of Parenteral & Enteral Nutrition of Thailand

Food intake

- Quality- Quantity

GI symptom

Food access

Comorbid dis.

1. Diet intake

2. Weight Change

3. Edema

5. Muscle

6. Muscle Function

4.Fat

7.Comorbidity

8.Severity of Illness

Scores =

1+2+3+4+5+6+7+8

NT 2013 : Nutrition Assessment

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NT 2013 : Nutrition Assessment

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ICU: Assess Nutrition Risk

Nutrition risk score

NRS-2002

○ Total score = nutritional status +disease severity + age

○ Age ≥ 70 years, add 1 point

○ Nutritional status : Weight loss, food intake and BMI

NUTRIC score

○ Total scores is from 6 separate factors :

○ age, APACHE II score, baseline SOFA score,

○ No. of comorbidities, day in hospital to ICU admit, IL-6

ASPEN/SCCM guideline. Taylor BE, et al. Crit Care Med. 2016;44:390-438.

Nutrition Risk Screening (NRS-2002)

Scores > 3 : Nutrition at risk

Scores ≥ 5 : High Nutrition Risk

Weight loss, food intake and BMI

Nutritional Status Severity of disease

Age >, = 70 years, add 1 point

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Nutrition Risk in Critically ill (NUTRIC) Score

High Nutrition Risk : NUTRIC score ≥ 5 (if interleukin-6 is included, ≥ 6 = high risk)

Best Practice & Research Clinical Anaesthesiology 23 (2009) 183–191

Taylor BE, et al. Crit Care Med. 2016;44:390-438.

Hypo-albumine

mia

Disease

Severity

Suggest not using traditional serum protein markers(alb, pre-alb, RBP), to indicate nutritional status

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Albumin Physiology in Critically ill Patient

Best Practice & Research Clinical Anaesthesiology 23 (2009) 183–191

Hasse, J.M. et al. Nutr Clin Pract 2015: 30; 474-87Subcutaneous fat : periorbital, triceps, biceps, chest

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Hasse, J.M. et al. Nutr Clin Pract 2015: 30; 474-87Rib do not show

Prominent ribs

Hasse, J.M. et al. Nutr Clin Pract 2015: 30; 474-87

Subcutaneous fat : eyes, triceps, biceps, chest

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Angular Stomatitis

Riboflavin (B2)Pyridoxine (B6)

Shapiro J. N Engl J Med 2007;357:1620-1630.

Hair Pulling Test

Approximately 60 hairs are grasped between the thumb, index finger, and

middle fingers near the scalp

Deficiency:

Protein, Biotin, Zinc

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Vitamin A : Abnormal keratin, ocular

Vitamin D : Osteomalacia/Ricket

Vitamin E : Hemolysis, neurologic

Vitamin K : Bleeding

Fat soluble vitamin

Water Soluble Vitamins

B1 Beriberi, Wernicke-Korsakoff

B2 Oculo-oro-genital syndrome

B3 Pellagra

B6 B2 + B3

Folate CBC, mucocutaneous,

B12 Folate + neurological abnormality

C Scurvy

H Dermatitis, alopecia, brittle nail

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Topics Today

Obesity

Obesity-related complications

Nutritional screening and assessment

Nutrition in specific disease

Chronic kidney diseases

Energy requirement (++/III)

Age < 60 yr : 35 kcal/kg/day

Age ≥ 60 yr : 30-35 kcal/kg/day

( Obese; BW > 120%IBW1 : 30 kcal/kg/day )

Protein requirement : Pre-dialysis

eGFR < 30 ml/min/1.73m2 0.8 g/ kg of IBW/day (+/II)

High biological value protein at least 60% (++/III)

IBW : Height(cm)-100 (M), Height(cm)– 110 (F)

Na<2000mg/day(Salt 5 g/day)in edematous patients

Keep serum albumin > 3.5g/dL (check q 3-6 mo.)Bailey JL et al. Am J Kidney Dis.55:1146-61.

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70 kcal Protein 2 g (1.3-2g)

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แป้งปลอดโปรตีน

วุ้นเส้นสกุ 1 ทพัพี , สาคูสกุ 1 ทพัพี, ก๋วยเต๋ียวเซ่ียงไฮ้สกุ 1 ทพัพี

KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of CKD

GFR < 30 ml/min/1.73 m2

lower protein to 0.8 g/kg/day in adults with/without diabetes

Avoid high protein intake (>1.3 g/kg/day) in adults with CKD

at risk of progression

Limit Salt (NaCl) intake < 5g/d (Na < 2 g/d)

Control dietary phosphate, potassium as indicated

Active physical activity (aiming for 30 min x 5 times/wk),

achieve a healthy weight (according to country specific

demographics), and stop smoking.

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Protein Balance

Protein intake – protein loss

Protein intake – 6.25 x (UUN + 4)

24 –hour dietary recall : Protein intake

Urine 24 hr for urea, Cr and volume

UUN : Urinary Urea Nitrogen (g/day)

* 1 g of Nitrogen derived from 6.25 g of Protein

* Unmeasured nitrogen loss in urine (sweat, hair, skin, feces)

= 4 g/day

24-h Urinary Urea Nitrogen

Determine level of catabolism

At least 100 g of carbohydrate is provided

5-10 g/d = mild catabolism or fed state

10-15 g/d = moderate catabolism

> 15 g/d = severe catabolism

• Adjusted : non-urinary nitrogen loss, RF( burn, diarrhea, enterocutaneous fistula etc.)

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High Phosphorus diet

Dietary phosphorus should be restricted to 800 to 1,000 mg/day

Absorption 40-60%

Absorption 60-90%

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High Potassium diet

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Hemodialysis

Calories 30-35 kcal/kg/day

Protein intake 1.2 g/kg/d, high biological value

Na and water must be controlled

K, Mg and PO4 are poorly cleared by HD

Nutrient losses

Amino acid losses are about 8-10 g during dialysis,

depending on the type of dialyzer

Glucose losses are removed about 25-30 g,

depending on the type of dialysate

B1, B2, B6, vitamin C and folic acid are lost

B12 is protein bound so B12 lost is negligible

Peritoneal dialysis

Protein intake should be 1.2-1.5 g/kg

with 50-60% of high biological value

Protein losses in peritoneal dialysate vary from

5-15 g/24 h (mainly albumin).

Absorption of glucose from dialysate (glucose,

100-200 g/24 h, 8 kcal/kg/d) + IR

P and K have increased clearance with PD

relative to HD.

Potassium intake can be liberalized to 4 g

1.Bailey JL et al. Am J Kidney Dis.55:1146-61.

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Reduced Intake- anorexia, n/v- Altered taste (Zn def)- Delayed gastric emptying- Inflamma. cytokines- Impaired conscious (HE)- Protein, salt restriction- Alcohol abuse

Cirrhosis liver-reduced gluconeogenesis-insulin resistance-hypermetabolism-muscle breakdown, immobilization

Tense ascite-postprandial discomfort

Malabsorption- Cholestasis- SIBO

Fasting- GI bleeding- Impaired conscious- Medical procedures

Causes of PCM in Cirrhosis

Liver disease

- Low albumin

- Low pre-albumin- Low transferrin

Weight and BMI- Edema and ascites

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Energy Requirement• Compensated 25-35 kcal/kg/d

• Malnourished 30-40 kcal/kg/d

• ICU, high risk RFS 15-20 kcal/kg/d

• ICU, maintainance 25-30 kcal/kg/d

• compensated 1-1.2 g/kg/d

• decompensated, malnourished 1.2-1.5 g/kg/d

• Intractable HE (temporary) 0.6-0.8 g/kg/d

• ICU 1.2-1.5 g/kg/day

• Low fat + MCT if steatorrhea or cholestasis

Protein Requirement

Lipid Requirement < 1 g/kg/d

Avoid overfeeding

Glucose < 5-6 g/kg/d & monitor glucose

Avoid restriction

Cirrhosis

Protein

1-1.5g/kg/d

Fat 25-30%

Carb 45-50%

Vegetable proteinsBCAA for refractory HE

Low Glycemic indexHigh fiber carb

Prefer unsaturated FALow fat, MCT if steatorrhea, cholestasis

Na < 2g/d if ascites or edemaFluid : vol. status

Avoid fructose, simple sugar

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Hepatic Encephalopathy

o 75% of patients with HE suffer from moderate to

severe protein-calories malnutrition

Arends J et al. Clinical Nutrition 2016. Article in Press p.1-38

AASLD/EASL guideline. Hepatology. 2014;60(2):715-35.

• Energy 35-40 kcal/kg/d

• Protein 1.2-1.5 g/kg/d

• Fat 1 g/kg/d

Low fat or MCT only if steatorrhea or cholestasis

• Avoid fasting and protein restriction

• Small frequent meals throughout the day

• A late night snack should be offered

• Oral BCAA supplementation to achieve protein goal in patients with dietary protein intolerant and can be used as an alternative or additional agent to treat HE patients nonresponsive to conventional therapy

Hepatic encephalopathy

AASLD/EASL guideline. Hepatology. 2014;60(2):715-35.

Avoid restriction

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Common in Cholestasis liver disease A, D, E, K,Calcium

Common in Alcoholic liver disease Thiamine Folate Magnesium Zinc

Copper and Manganese are excreted in bile.(Careful: supplementation in PN in cholestasis)