Chapter 11-with graphics

8/7/2019 Chapter 11-with graphics

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OBESITY AND EATINGDISORDERS


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Overeating and such eating disorders as anorexiaand bulimia are among the most commonnutritional problems. In this chapter, youlllearn:How the terms overweight and obesity aredefinedThe causes of overweight and obesityHow overweight and obesity are treated

The signs and symptoms of anorexia nervosa andbulimiaThe nutritional intervention used to treat eatingdisorders.


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Overweight and obesity in the United Stateshave increased markedly over the pastdecade. According to the 1999 National

Health and Nutrition Examination, 61% ofU.S. adults age 20 and older are eitheroverweight or obese a 5% increase over theestimates obtained in 1994. This study also

estimates that 13% of children ages 6 to 11and 14% of adolescents ages 12 to19 are overweight.


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The high cost of too many caloriesExcess weight substantially increases the

risk of cardiovascular disease, certain typesof cancer, and other diseases. Other obesity related diseases that require identificationand appropriate management include

gynecologic abnormalities, osteoarthritis,gallbladder disease, and stress incontinence.The combination of dietary factors and stressincontinence. The combination of dietaryfactors and sedentary lifestyle accounts foran estimated 300,000 deaths each year. Inaddition, the annual health care cost ofobesity is approximately $70 billion.


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In addition to the risk of morbidity fromobesity related diseases, obesity can

increase the morbidity of other preexistingdisorders. Overweight and obese patientswith existing coronary artery disease, type 2diabetes related complication that maylead to death.Obesity is also associated with complicationsduring surgery, pregnancy, and labor anddelivery. Its a major contributor topreventable deaths, and it also leads to low

self esteem, negative selfimage,hopelessness, and negative socialconsequences, such as stereotyping,prejudice social isolation, anddiscrimination.


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CAUSES

The basic cause of obesity is energy imbalance

that results when the number of calorieseaten doesnt equal the number of caloriesused for energy. If more calories are eatenthan are used by the body, weight gainoccurs over time. This imbalance mostcommonly result from overeating, inactivity,or both.

The 500 ruleAn easy way to put weight gain in perspectve

is to recall the so called 500 rule. Because1 lb of body fat equal 3,500 calories personwho eats 500 calories more per day than hisbody requires will gain 1 lb of body fat in 1week(500 cal/day x 7 days = 3,500 cal).


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You may notice that some people who areoverweight eat only moderate amounts offood but still gain weight and that someaverage-weight people overeat but nevergain weight. Thats because there are otherpossible influences on fat accumulation inthe body:a family history of obesity increases a

persons chance of becoming obese by 25% to30%. In addition, body fat distribution isinfluenced by genetics. Families also sharediet and lifestyle habits that may contributeto obesity.


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Environment also strongly influences obesity.This includes such lifestyle behaviors as eatinghabits, diet, and level of physical activity.Americans tend to eat high-fat foods and puttaste and convenience ahead of nutrition. Also,most Americans dont get enough physicalactivity. Only 22% of Americans achieve therecommend 30 minutes activity each day.Nutrition plays an important role in weight gain.The increase in use of low-fat foods and snackscan decrease the amount of fat in a diet butincreases the amount of calories consumed. Thehigh fat content in high-fat foods alsocontributes to increased calorie consumption.


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P sychological factors may also influence eatinghabits. Many people eat in response to negativeemotions, such as boredom, sadness, and anger.Some illness can lead to obesity or a tendency to

gain weight. These include hypothyroidism,Cushings syndrome, depression, and certainneurological problems that can lead overeating.Also, drugs such as steroids and someantidepressants may cause weight gain. A doctorcan tell whether underlying medical conditionsare causing weight gain or making weight lossdifficult.Sociocultural factors, such as race, gender,income, education, and ethnicity, may alsocontribute to overweight and obesity.


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The National Heart, Lung, and BloodInstitute(NHLBI) released the first federalguidelines on the identification, evaluation,and treatment of overweight and obesity inadults in 1998. according to these guidelines,assessments of overweight involvesevaluation of three key measures: body massindex(BMI), waist circumference, and a

patients risk factors for diseases andconditions associated with obesity. Theguidelines define overweight as having a BMIof 25 to 29.9 and obesity as a BMI of 30 orabove.


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The relationship between body weight andgood health is more complicated than simplycomparing the number on the scale to a

weight range table. Weight range tablesarent appropriate to use for all individualsbecause not all people who have a weight inthe healthy range are necessarily at their

healthy weight. For example, some peoplemay have more fat and less muscle. Incontrast, a weight above the healthy rangemay be fine if your patient has more musclethan fat.


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BMI measures weight in relationship to heightand is calculated by dividing body weight inkilograms by height in meters squared. BMIcan also be estimated without doing anycalculations.(See Determining BMI, page182.)

Using BMI to evaluate body weight requireslittle skill. The major disadvantage of using

BMI is that it works on the assumption thatexcess weight is a result of excess fat. Itdoesnt account for such other reasons asedema and large muscle mass.


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Where your patients body fat is may be amore important indicator of health problemsthan how much fat he has. People with a

high distribution of fat around their waistapple-shaped as opposed to their hips andthighs pear-shape are at greater risk forsuch diseases as type 2 diabetes,

dyslipidemia, hypertension, andcardiovascular disease.(See P ear or apple-shaped).


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To weight distribution, measure waistcircumference. Locate the upper hip bone andthe top of the iliac crest. P lace a measuring tapein a horizontal plane around the abdomen at thelevel of the iliac crest. Before, reading the tapemeasure, ensure that the tape is snug butdoesnt compress the skin and is parallel to thefloor. Measure at the end of expiration. If themeasurement is greater than 35(88.9 cm) for

women or 40(102 cm) for men with a normalBMI, your patient has a greater risk of healthproblems. If the BMI is 35 or higher, waistmeasurement is irrelevant because disease risk isalready high based on the BMI alone.


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Treatment of obesity can be long and difficult. Nosingle treatment method or combination ofmethods is guaranteed to produce weight loss ormaintain weight in all people. Treatment can bedirected using guidelines from the NHLBI.( SeeTreatment algorithm for obesity, page 184 .)

Before beginning any weight-loss therapy, itsimportant to determine a patients motivationlevel. (See Assessing motivation, page 185.) Also,in 95% of causes in which weight loss occurs toorapidly, people regain the weight loss will helpwith long-term weight management.


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The benefits of weight loss include:Reduced risk of diabetes and cardiovasculardisease

Reduced risk of developing hypertensionLower triglyceride levelsHigher HDL cholesterol levelsLower LDL and total cholesterol levelsLower blood glucose level in non-diabeticpatients and some type 2 diabetic patients.


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The general goals of weight loss andmanagement are:To reduce body weight and maintain healthy

body composition(percentage of fat massversus lean mass)To maintain a lower body weight over thelong term

To prevent further weight gain


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The clinician and patient must agree on weight-loss goals. Patient involvement is crucial to thetreatment plans success. In general, asuccessful weight loss plan yields weight regainof fewer than 6.6 lb in 2 years and a reduction inwaist circumference of at least 1 (4 cm).Component of weight loss

Diet therapyIncreased physical activityBehavioral therapy

These methods should be used for at least 6months before pharmacotheraphy is attempted.Weight-loss surgery is an option for patients withextreme obesity.


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D iet therapyDiet, or nutrition, therapy includes instructing patients

how to modify their diets to decrease caloric intake.A key element of the current recommendation is amoderation reduction in calories to achieve a slow,progressive weight loss of 1 to 2 lb per week. Caloriesshould be reduced only to the level required toachieve the goal weight. (See Serving up a weight

reducing diet.)How low to go?An average sound diet for women is 1,000 to 1,200 to

1,600 cal/day. Eating plans that call for fewer than1,000 cal/day may not provide adequate amounts ofessential nutrients. In general, a decrease of 1,000cal/day is needed to lose about 2 lb/week; adecrease of 500 calories is needed to lose 1 lb/week.In addition, reducing fat in take to less than 30% oftotal calories promotes greater weight loss and helpsimprove and helps improve blood lipid levels.


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Ed ucation is the keySuccessful weight reduction is more likely to

occur when the patients food preference areincluded in the menu and when dietaryeducation is performed. (See Controllingcaloric intake)

When educating your patient, be sure to:Cover the energy value of different foods aswell as discuss food composition, such asfats, carbohydrates ( including dietary fiber),

and proteins.Encourage the reading of nutrition labelsP romote new habits of purchasing, especiallya preference to low calorie foods


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Instruct on food preparation, especially theneed to avoid adding high calorie

ingredients (such as fats and oils) duringcookingWarm against the overconsumption of high calorie foods

Stress the importance of adequate waterintake, reducing portion sizes, and limitingalcohol consumption

Increase d physical activityExercise plays a critical role in the loss andmaintenance of body weight. Exercise isimportant for increasing energy expenditure,


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Efforts to lose weight through physical activity alonegenerally produce an average weight loss of only2% to 3%. Exercise affects the rate of weight lossbased on frequency and duration of the activity.Sustained physical activity is helpful inmaintaining weight loss and reducingcardiovascular and diabetes risks and may behelpful inhibiting food intake. Even without weight

loss, increasing physical activity lowers bloodpressure, increases HDL cholesterol levels,improves glucose tolerance, enhances the sense ofwell-being reduces tension, and heightensalertness.


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For obese patients, exercise should be startedslowly and increased in intensity gradually.Initial activities may simply include increasingactivities of daily living, such as taking the stairsor walking at a slow pace. With time, dependingon progress, the amount of weight lost, andfunctional capacity, the patient may engage inmore strenuous activities. Moderate levels of

physical activity for 30 to 45 minutes, 3 to 5 daysper week should be encouraged. The long-termgoal should be accumulate at least 60 minutes ofmoderate-intensity exercise every day of theweek.


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Daily walking is an attractive form of physicalactivity, especially for obese patient to startby walking 10 minutes, 3 days per week and

to build to 30 to 45 minutes of more intensewalking at least 5 to 7 days per week. Withthis regimen, an additional 100 to 200cal/day can be expended. A moderateamount of physical activity that burns about150 calories can be achieved in variousways.(See Burning calories.)


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Reducing sedentary time, such as time spentwatching television, is another way toincrease activity. Patients should build

physical activities into each day. Forexample, parking farther than usual fromwork or shopping and walking up stairsinstead of taking elevators are easy ways toincrease daily physical activity.


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Behavior therapy is a useful adjunct to planned decreases infood intake and increases in physical activity. The goal ofbehavior therapy is to overcome barriers to compliancewith eating and activity habits. Long-term weight

reduction most likely wont succeed unless new habits areacquired. The primary assumptions of behavior therapyare:Changing eating and physical activity habits makes itpossible to change body weight.

Eating and physical activity behaviors are learned and canbe modified.Environment must be changed to change patterns.


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Various strategies must be used for behaviormodification because no single method issuperior:

Self monitoring of eating and physicalactivity this stategy involves recording theamount, type of food, caloric value, andnutrient composition of food eaten and the

frequency, intensity, and type of physicalactivity performed each day. Recording thisinformation allows the patient to gain insightinto hi behavior.


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Stress management stress triggers

dysfunctional eating habits. Using copingstrategies, meditation, and relaxationtechniques can help relieve stress.Stimulus control this strategy involves

identifying stimuli that encourage incidentaleating and limiting those stimuli, for example,by keeping high-calorie foods out of the house,limiting times and places of eating, andavoiding situations in which overeating occurs.P roblem solving this strategy includesidentifying weight related problems andplanning and implementing alternativebehaviors.


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Contingency management this strategy

involves rewarding positive changes inbehavior, such as increasing exercise orreducing consumption of a specific food.Cognitive restructuring cognitiverestructuring involves changing self-defeatingthought and feelings by replacing them withpositive thoughts and setting of reasonablegoals.Social support a strong support system canhelp provide the emotional support neededto lose weight. Including friends and familyin physical activity and diet or joining asupport group can be beneficial.


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Drug therapy should be considered as an adjunct to nutritiontherapy, increased activity, and behavior if, after 6months, the patient hasnt lost the recommended 1 lb perweek.

Because there are few long-term studies on the safety oreffectiveness of weight-loss medications, they should beused only by patients who are at an increased medical riskbecause of their weight. These patients include those witha BMI of 30 or more and those with:

HypertensionDyslipidemiaCoronary artery diseaseType 2 diabetesSleep apnea.


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Drugs produce a modest weight loss of 4.4 to 22 lb within thefirst 6 months and can help maintain weight loss. Whendrug therapy is effective and adverse effects aremanageable, it can be continued for the long term but it

isnt known how long drug therapy can be maintainedsafely.Not every patient responds to drug therapy. Tests show that

initial responders tend to continue to respond, whilenonresponders are less likely to respond even withincreases in dosage. Drug therapy should be discontinued ifadverse effects are unmanageable or therapy isineffective. The decision to add a drug to an obesitytreatment program should be made after consideration ofall potential risks and benefits and only after all behavioraloperations have been exhausted.( See Fat fighters .)


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Two current medication used for weight loss are sibutramine and orlistat.Sibutramine is an appetite that works by inhibiting the reuptake ofnorepinephrine, serotonin, and dopamine. The most common adverse areheadache, insomia, anorexia, constipation, and dry mouth. It may alsoincrease blood pressure and heart rate.

Sibutramine should be used cautiously in patients taking monoamineoxidase inhibitors or other centrally acting appetite suppressants and inthose with anorexia nervosa. If shouldnt be given to patients with severerenal or hepatic dysfunction, coronary artery disease, or a history ofhypertension, heart failure, arrhythmias or a stroke.Orlistat(Xenical) inhibits pancreatic lipase and therfore, decreases fatabsorption in the GI tract. It should be used in conjunction with areduced-calorie diet with 30% of calories from fat. Adverse reactionsinclude headache, flatus with discharge, fecal urgency, fatty or oily stool,and abdominal pain. Absorption of fat-soluble vitamins also decreased.


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Gastric restriction, also known as vertical banded gastroplasty andstomach stapling, is performed by inserting a vertical row ofstaples across the patients stomach, decreasing the stomachssize to about 15 to 30 ml. a band decreases the opening from theupper pouch to about 1 cm, which delays gastric emptying.

Overtime, the pouch can stretch to hold more food.Complications may include bursting of the staples if too much food

or liquid is consumed before the staple line heals and obstructionif food isnt chewed well. Nutritional complications includehypoalbuminemia and vitamin deficiencies as well as nausea andvomiting. A patient undergoing gastric restrictions mustunderstand the importance of eating small meals, eating slowly,chewing food thoroughly, and progressing the diet gradually fromliquid to pureed foods to soft foods.


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Gastric bypass, also know as Roux-en-Y gastricbypass, combines gastric restriction with abypass of the duodenum and the first portion

of the jejunum. Rapid dumping of food fromthe stomach into small intestine limitscalorie absorption, leading to weight loss. Itmay also produce nausea, diarrhea, andabdominal cramping that improve over time.This procedure has better weight-loss andmaintenance results than gastric restriction.


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Eating disorders arent a new problem;anorexia has its roots as far as the 13 thcentury, and bulimia dates as far as back 700

B.C.. However, both anorexia nervosa andbulimia nervosa are major health issuestoday. They usually occur before or after theonset of puberty or after other majorpersonal stressors, such as a parentsdivorce, a broken relationship, or a death inthe family. Dancers or gymnasts are prone toeating disorders and commonly control theireating to improve their performance.


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Between 90% and 95% of cases of anorexia andbulimia occur in females. These eating disordersare most likely to occur between ages 12 to 13and between ages 19 and 20. women with eatingdisorders also have a higher incidence of drugand alcohol abuse. People with eating disordersare more affected by depression, irritability,suicidal tendencies, and passiveness, and they

exhibit more health risk behaviors, such astobacco, alcohol, and marijuana use;delinquency; unprotected sex; and suicideattempts.


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Anorexia nervosa the main characteristicsnervosa is self-imposed fasting or dietingwith severe weight loss or maintenance of a

weight thats 15% below the recommendedweight. Other characteristics of anorexiainclude compulsive exercise habits andlaxative or diuretic use. In most cases, ananorexic patient is overly preoccupied withfood and weight and perceives herself as fat.If left untreated, anorexia can lead to severemalnutrition, brain damage, sterility, damageto vital organs, heart failure, and death.


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Bulimia nervosa is a disorder characterizedby episodes of recurrent binge-purge cycles.

During binges, the patient eats large amountsof food compulsively and quickly. Weight iscontrolled through vomiting, emetics ,laxatives, diuretics, and diet pills.

The bulimic patient typically is of normalor above-normal body weight and has weightfluctuations. Because in most cases theundernutrition is less severe than that of apatient with anorexia, a bulimic patient mayexperience fewer medical complications. Themost frequent cause of death for those withbulimia is gastric dilation and rupture.


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Assessment d ataassessing the patient for an eating disorder

includes collecting historical data andperforming a physical examination.

Historical d ataDuring the health history ask your patient about:

Current, usual, and ideal weightComplaints of fatigue, tooth sensitivity,intolerance to cold, or dizzinessAbdominal complaints, such as constipition,

indigestion, and nauseaRegularly or absence of mensesHistory or current practice of self inducedvomiting


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Use of laxatives, diet pills, or diureticsUsual 24 hour food intake, including which

foods are best or least toleratedUse of vitamin, mineral, and othernutritional supplements as well as over the counter and prescription drugs

Significant medical history as well as historyof drug or alcohol abuseP sychosocial aspects, such as family orsignificant other support, emotional state,and body imageUsual physical activity patterns.


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Focusing in on foodAssess cultural, ethnic, or religious influences

on food intake as well as abnormal foodeating practice, such as cutting food into tinypieces, refusing high calorie foods disposingof food secretly, and bingeing and purging.

Physical findingsAnorexia and bulimia typically present withdifferent sign and symptoms.

Signs and symptoms of anorexia:

Wasted appearanceThinning hair or alopeciaDry skin and brittle nailsDecreased heart rate or low blood pressure


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ConstipationLoss of menses

Reduced muscle mass and joint swellingSigns and symptoms of bulimia

P uffy cheeks due to enlarge salivary glandsDamage tooth enamel due to excessive vomiting.

CausesAlthough eating disorders dont have an exactcause, many patients with eating disorders sharecommon characteristics that may influence the

development of the disease, including:Low self esteemFeelings of helplessnessFear of becoming fat


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Is the patient concerned with pleasingothers?Does the patient have a history of bulimia?

Assess the patient and family for the followingtraits if you suspect bulimia:Has your patient hid her binge and purgecycles from he family for many years?

Does your patient have a history of anorexia?Does your patient have difficulty controllingimpulses, stress and anxiety?


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P atients with anorexia typically have long-termhealth problems that result from theirdisorder. Malnutrition leads to irregular heart

rhythms and heart failure as well asosteoporosis(due to a lack of calcium). Amajority of people with anorexia alsoexperience depression, anxiety, personalitydisorders, and substance abuse problems.About 1 in 10 women with anorexia dies ofstarvation, cardiac arrest, or othercomplications.


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Due to repeated purging, patients with bulimiatypically have health problems associatedwith electrolyte imbalances and loss of

potassium, such as damage to the heartmuscle and an increased risk of cardiacarrest. Excessive vomiting also causesesophageal inflammation. Patients withbulimia are also susceptible to drug andalcohol addiction, compulsive stealing,obsessive-compulsive disorder, clinicaldepression, and anxiety.


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The goals of nutrition therapy for the patientwith anorexia are to:Reestablish normal eating behaviors

Restore nutritional statusMaintain reasonable weight.


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Involving the patient in the planning of weightgoals is imperative for patient cooperation andfeelings of trust.( See Tips for Treating anorexia )

Keep in mind the following tips when preparing aneating plan for anorexic patient:Be reasonable with calories, about 1,500cal/day.(Larger amounts of calories may betolerated poorly.)Include small, frequent meals and snacksGradually increase calories, after the patientcan tolerate a full meal


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Limit gas-producing and high-fat foodsInclude meals based on the patients foodpreferences.Include nutritionally dense foods to meet caloricgoals.Include high-fiber or low-sodium foods to controlconstipation and fluid retention.Include multivitamin and mineral supplements.Avoid caffeine.Use enteral support only if necessary.


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Identify food fearsCorrect food misinformationReestablish normal eating patterns


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To help the patient with anorexia nervosa meet hernutritional goals, follow these tips:to create a better response to therapy, exclude high-riskbinge foods(which may vary with each patient)initially but

reintroduce them into the eating plan later to prevent fearof the food.Never force the patient to eatOnly use tube feedings or total parenteral nutrition ifnecessary to meducally stabilize the patient. Because the

patient with anorexia has control issues, using enteralnutrition unnecessarily may increase feelings of mistrustand body-image distortion and may be the patient feel aloss of control and identity


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To promte patient compliance, nutritiontherapy initially is structured and inflexible.Eating plans similar to those used for

diabetics can be used to specify mealportions, food groups, and the frequency ofeating. Encourage the patient with bulimiato keep a food diary, recording intake beforeeach meal, to help control the amount sheeats.( See tips for treating bulimia .)


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Meal planning for the bulimic patient should:be at least 1,500 cal/day, including, snacksInclude fat, which helps gastric emptying and

promotes satietyAvoid large amounts of food eaten in a shortamount of timeIntroduce forbidden foods appropriate.


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Teach your patient with an eating disorder:The components of a healthy dietAppropriate food intake patterns

The dangers of dieting, bingeing, and purgingHow to recognize hunger food and weightrelated behaviors in themselvesHow the idealization of thinness in oursociety has resulted in distorted body imagesand unrealistic goals for beauty.


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P revention is accomplished by early detection and treatment.G ET TO TH EM EARLY

Because attitudes that influence the development of eatingdisorders develop as early as fourth. Parents and teachers canfollow these steps to help prevent the formation of eatingdisorders:Help children develop a positive self-image and sense of worth.Avoid pressuring children to excel beyond their capabilitiesRecognize stressors and provide encouragement and supportTeach how good nutrition and exercise can keep you healthyGive children the correct amount of independence, responsibility,and accountability for their age-group.Discourage dieting. If a child needs to lose weight, do it with amedically supervise plan.Seek professional help if a child has the signs and symptoms of aneating disorder.


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