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Chapter 6
Obesity and Healthy
Weight Management
Health Problems with
Weight and Obesity
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Medical problems associated with the metabolic
syndrome:
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Hypertension
Dyslipidemia (high triglycerides and low HDL)
Gout
Polycystic ovary syndrome
Diabetes
Early cardiovascular disease
Certain forms of cancer
Inflammatory conditions
Cholelithiasis (gall stones)
Osteoarthritis
Sleep apnea
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Estimating Caloric Needs
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Harris Benedict equation for BMR:
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Women: BMR = 655 + ( 4.35 x weight in pounds ) +
( 4.7 x height in inches ) - ( 4.7 x age in years )
 Men: BMR = 66 + ( 6.23 x weight in pounds ) + (
12.7 x height in inches ) - ( 6.8 x age in year )
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Activity Factors for Total Energy Needs:
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little or no exercise: BMR x 1.2
light exercise/sports 1-3 days/week: BMR x 1.375
moderate exercise/sports 3-5 days/week: BMR x
1.55
 hard exercise/sports 6-7 days a week: BMR x
1.725
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Body Mass Index (BMI)
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Body mass index (BMI) = kg/m2—see Appendix;
concept developed >100 years ago by
mathematician Quetelet
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BMI 19-25 = ideal body weight (IBW)
BMI 26-29 = indicator of the metabolic syndrome
BMI ≥30 = 20% overweight; class I obesity
BMI ≥35: class II obesity
BMI ≥40 = 30% overweight; class III obesity or
“extreme obesity”
BMI <19 = underweight
BMI <16 = severe anorexia; generally
necessitates hospitalization
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Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1998, 2007
(*BMI 30, or about 30 lb overweight for 5’4” person)
1998
1990
2007
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
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≥30%
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Rates
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About 65% U.S. adults with BMI 25 per
NHANES data
About 30% with classes I and II obesity
About 5% with extreme obesity (class III)
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Causes and Theories of Obesity
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Kilocalorie imbalance
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Sedentary lifestyles—old-time lumberjacks
required 3500 to 5000 kcal/day; most adults
now need about 2000 kcal/day
Increased intake of sugar-based beverages
Larger food portions
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Snack-size chips: traditional 1 oz size bag on left
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FYI Impact of Diet Quality
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Monounsaturated fats (oleic acid) increase daily
energy expenditure; saturated fats (palmitic acid)
lower energy expenditure (Kien and Bunn, 2008); the difference
is as much as 275 kcal (Kien et al., 2005)
Omega-3 and polyunsaturated fats related to reduced
fat-cell size; saturated fat increases fat-cell size and
number (Garaulet et al., 2006)
Inclusion of a variety of high-fiber foods promotes
cellular metabolism via inclusion of vitamins and
minerals
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FYI Role of Eating Habits
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Increased chewing of foods related to smaller
waist size (Murakami et al., 2007)
Young children in the U.S. who eat less often in
the day consume larger portions; by toddler age
self-regulation of kilocalories based on need is
less effective than in infancy (Fox et al., 2006)
Obese women have been found to have a higher
intake of carbohydrates; obese men have higher
intake of fat (Duvigneaud et al., 2007)
Avoidance of dehydration improves insulin
resistance and promotes use of insulin (Schliess and
Haussinger, 2003)
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FYI
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A Canadian study found preschool children were
half as likely to be overweight if they did not drink
sweetened beverages (Dubois et al., 2007)
Two or more hours of watching television
increased odds of overweight adolescents by 50%
(Fleming-Moran and Thiagarajah, 2005)
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Typical portions in a college setting were found to
be significantly larger than 2 decades previous
(Schwartz and Bryd-Bredbenner, 2006)
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Monosodium glutamate (MSG) related to
increased appetite and obesity in rats; increased
fiber intake and physical activity found to counter
this effect (Diniz et al., 2005)
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Physiologic Influences on Obesity
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Genetic predisposition with the thrifty gene appears to
enhance weight gain; hyperinsulinemia found with the
metabolic syndrome is lipogenic (creates fat) and
inhibits lipolysis (impairs fat breakdown)
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Hyperinsulinemia decreases kilocalories available for daily
physical energy needs with enhanced body fat storage and
increases hunger due to interference with leptin’s role in
appetite regulation and increased need for food as a reward
system due to altered dopamine levels (Lustig, 2006)
Insulin inhibits weight loss among those persons with
obesity; lean tissue (muscle) is insulin resistant;
adipose (body fat) tissue is insulin sensitive (Sebert et al.,
2005)
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Hormonal Connections
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Increased cortisol production related to lack of
deep REM sleep and skipping meals (cortisol
associated with excess weight, especially central
obesity)
Hypothyroidism (low levels of T3 and T4
hormones) with decreased metabolic rate
Deficiency of growth hormone leads to increased
body fat (less growth hormone as we age)
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Hormones Affecting Appetite
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Leptin—lowers appetite
Cholecystokinin—protein intake promotes
production and promotes satiety
Ghrelin—produced by the stomach; related to
increased appetite
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Other Adverse Impacts
from Adipocytokines
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Hormones related to obesity promote
insulin resistance, heart disease, and
cancer by increased
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Inflammation
• Elevated CRP and interleukin-6 (IL-6)
• Reduced anti-inflammatory hormone: adiponectin
Clot formation
Free-radicals
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Prevention of Obesity Is the Key
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Begin in infancy with appropriate weight gain during
pregnancy and breastfeeding
Develop positive food habits in childhood emphasizing goals
of the MyPyramid and Dietary Guidelines
Encourage high-fiber foods and slow-paced eating for
satiety and goal of reduced food portions
Avoid rewarding and comforting with food—promote
alternatives such as flowers, card of thanks, praise
Drink water or seltzer water or other sugar-free beverages
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Try diluting juice with seltzer, as done in Europe
Include regular physical activity on most days, including
physical education in schools; discourage excess sedentary
behaviors (e.g., excess television, computer use)
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Calories Count
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3500 kcal = 1 lb body fat
Reduction of 500 kcal/day = 1 lb/week loss
Alternative: increase physical activity for
equivalent of 500 kcal/day
May want to do combination low-cal + increased
activity
Advise maximum of 1- to 2-lb/week weight loss for
long-term success and maintenance of lean
muscle mass
Individual needs vary because of metabolic
differences (e.g., thrifty gene, amount of muscle
mass, medication effects)
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Weight-Loss Tips
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Plan must be individualized per lifestyle and food habits—no
“one diet fits all”
Emphasize satiety through chewing more; reduce pace of
eating
Include fiber in meals for “fullness” (e.g., people have been
known to eat ½ gal of ice cream at a sitting, but never ½ gal
beans)
Include some unsaturated fats (take as long as 4 hr to leave
the stomach)
Include the minimum number of servings from the
MyPyramid Food Guidance System: this approach is
healthful and likely to be successful
Legumes can substitute for some grains for goal of
increased fiber with trace minerals and B vitamins
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Set Realistic Weight Goals
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Desirable weight goals are achievable weight goals
Desirable weight goal may not be IBW per the BMI
A weight loss of 10 to 15 lb often will normalize blood
glucose in a person with diabetes
A weight loss of 10% is significant; a weight loss of 15% is
considered very significant; permanent weight loss of
>15% seldom occurs
Slow, sustained weight loss of ½ lb/week is most
likely to be permanent weight loss and preserve muscle
mass
Persons needing to gain weight rarely gain more than ½ to
1 lb per week
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Popular Weight-Loss
Strategies
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Calorie-Control Approaches
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Exchange lists for weight management—aimed at
kilocalorie restriction
MyPyramid—minimum number of servings
promotes modest kilocalorie restriction while
promoting good nutritional intake for general
health needs
Food labels—guidelines provided at 2000 kcal
can be an appropriate level for active adults with
high kilocalorie needs; guidance based on
macronutrient intake can be modified (e.g., 1500
kcal at 200 g CHO, 60 g PRO, and 50 g fat)
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The Low-Fat Approach
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Rationale: 9 kcal/g fat versus 4 kcal/g
carbohydrate and protein
Volume-wise: ½ cup sugar = 400 kcal versus
½ cup fat = more than 1000 kcal
Drawbacks: food companies increase sugar in
fat-free foods (i.e., some fat-free products have
more kilocalories than their original low-fat
versions)
People assume if a food has no fat, it has no
kilocalories (e.g., 1 L soda pop = 0 g fat) but
actually has more than 400 kcal
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Variations of the Low-Fat Approach
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Low-fat with additional focus on high-fiber foods
or “good carbohydrates”
Point system—Weight Watchers™
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Lower points for foods high in fiber and low in fat
Moderate-fat with high fiber
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Therapeutic Lifestyle Changes (TLC) diet
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The Low-Carbohydrate Approach
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Rationale: insulin causes weight gain
Problems
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Most low-carbohydrate diets are extremely low (less
than 50 g carbohydrate per day)
The high protein includes high-fat foods, and usually no
distinction is made between saturated and unsaturated
fats
No solid evidence exists that insulin causes
weight gain, but no solid evidence exists that it
does not
RDA for carbohydrate set at 130 g minimum
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Variations of the
Low-Carbohydrate Approach
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Moderate-carbohydrate intake with highfiber foods, high lean-protein sources, and
emphasis on unsaturated fats
The low glycemic index (GI) diets
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Partially misleading because GI charts take
into account only foods eaten alone, not as
part of a meal
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Non-Dieting Approaches
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Focus on hunger and satiety to base food
intake
Behavior modification:
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Avoidance of high-risk foods (those that
prompt excess intake without satiety)
Decreased pace of eating to promote satiety
Consistency of mealtimes and food choices
Avoidance of starve-binge cycles
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Role of Physical Activity in
Weight Management
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Burns kilocalories
Increased metabolic rate for up to 24 hr
with aerobic forms; long-term increase in
metabolic rate with increased muscle
mass from anaerobic exercise
Can increase the number and function of
mitochondria
Can improve hormonal balance
Improved mood can promote better food
choices
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Aerobic versus Anaerobic Exercise
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Aerobic—form of exercise requiring increased oxygen; goal
of at least 30 minutes on most days; weight loss may
require 60 minutes
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Anaerobic “without air”—contributes to weight loss via
increased muscle mass; muscle pain associated with
increased levels of lactic acid (excess pain associated with
rhabdomyolysis and kidney failure)
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Walking, running, dancing, cycling, cross-country skiing, most
sports
Weight lifting
Combination aerobic and anaerobic
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Evidence suggests this is most effective approach for weight
loss
Hill climbing
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Obesity Medications
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Orlistat—potent inhibitor of intestinal lipases; side
effects include diarrhea and potential nutritional
deficiencies, especially of fat-soluble vitamins,
decreased absorption of many prescriptions
Meridia—appetite suppressant; can be prescribed
short-term only
Buproprion (Wellbutrin)—an antidepressant
Topamax—not FDA approved for weight loss
Controversial supplement: conjugated linoleic acid
(CLA)
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Surgical Interventions
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Approved for class III obesity or class II
with high mortality risk
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Gastric banding
• Least invasive and reversible; associated with 47%
weight loss (Spivak et al., 2005)
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Stomach stapling
Bariatric surgery
• Reduces stomach size to volume of about ¼ cup
(micropouch procedure involves 1 tbsp volume) and
bypasses a portion of the small intestine for
decreased absorptive area
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Gastric Bypass
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Specific Nutritional
Complications of Roux-en-Y
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Iron-deficiency anemia
Folate deficiency (increased risk of neural tube defects, or
spina bifida, with pregnancy)
Vitamin B12 deficiency or pernicious anemia with concerns
of permanent nerve damage
Osteoporosis from decreased calcium absorption and
altered metabolism of vitamin D
Thiamin deficiency caused by excessive vomiting with
potential for neuropathy, dry beriberi with memory
impairment, heart failure, Wernicke’s encephalopathy (triad
of inattentiveness, ataxia, or impaired muscle coordination,
and paralysis of eye muscles)
Hair loss caused by varied nutritional deficiencies:
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Biotin deficiency, decreased ferritin level, decreased vitamin D3
(the active form), decreased l-lysine (an amino acid)
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Long-Term Effectiveness
of Bariatric Surgery
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Stomach stapling procedures found with
increased expansion of remaining stomach
portion leading to regain of lost weight
Increased ghrelin levels after 3 months of bariatric
surgery promote increased appetite, despite
reduction in stomach size (Garcia-Unzueta et al., 2005)
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Weight gain occurs over the long-term
Evidence indicates only modest decrease in long-term
mortality (Shah et al., 2006)
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Nursing Concerns Related
to Bariatric Surgery
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Explain specific adverse health outcomes prior to
irreversible bariatric weight loss procedures
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Support those who have had bariatric surgery
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Rather than saying there are vitamin and mineral deficiency
concerns, be specific (e.g., “B vitamin deficiency can cause
irreversible nerve damage”)
Reinforce the need for small, frequent meals, avoidance of
liquids with meals to prevent the dumping syndrome
Reinforce the need for regular medical follow-up for those
persons who have had bariatric surgery (e.g., review s/s to
observe related to neurodegeneration and B vitamin
deficiency, especially with emesis)
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Study Guide
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Health Problems associated with Obesity
What is BMI based on?
What region has the highest rate of obesity?
Theories of Obesity (pg 217)
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Kilocalorie imbalance
Diet Quality & Eating Habits
Altered Metabolism
Hormones
Genetics/Gender Differences
How does insulin affect lypolysis and
lypogenesis?
Obesity prevention
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Study Guide (cont.)
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How many calories needed to lose 1lb?
What is a safe/healthy amount of weight to
lose/week? What is the best amount of
weight to lose in 1 week? Why?
How much weight would a diabetic need to
lose to help reduce glucose levels?
How do fat & fiber help with weight loss?
Theories Behind Weight Loss Strategies
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Calorie Control Approach
Low Fat Approach
Low Carbohydrate Approach
Non-Dieting Approaches
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Study Guide (cont.)
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Benefits of Exercise
Distinguish between anaerobic and
aerobic exercise
Who are surgical Interventions appropriate
for?
Distinguish between gastric banding,
stomach stapling and bariatric surgery
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