Obesity

by

Hanan Samaha
 NUTRITIONAL ASSESSMENT
Nutrition assessment techniques are useful for determining
the nutrition status of people who are ill as well as those who
are healthy. They are also put to test when used in the
hospital environment. A person may enter the hospital in
good nutrition status only to become malnourished; nutrition
status often deteriorates during hospitalization. An illness
can:
 Lead to a loss of appetite.
 Interfere with person ability to chew or swallow food.
 Alter the way food is digested or in other ways interfere
with the way nutrients are absorbed.
 Alter the way nutrients are metabolized or excreted.
One or all or a combination of any of these effects can occur
during illness and alter nutrition status. Skilled interview is
important in many steps of patient care. Information from
many sources must be gathered to make a nutrition assessment.
 These sources include anthropometric measurements,
laboratory tests, physical examinations and historical
data.

Anthropometrics are physical measurements that

provide an indirect assessment of body composition. They
are particularly useful when taken periodically and
compared with previous measurements. Such repeated
measurements indicate changes in an individual's status.
Height and weight are the most used measurements. The
height measurement may not be critical but it is used to
estimate desirable weight and to interpret other
assessment data. Other anthropometric measures include
mid arm circumference, various fat fold circumference
and head circumference.
 BODY MASS INDEX (BMI)
BMI is a measurement derived from someone's weight and height.
Body mass index (BMI) is the ratio of weight (in kilograms) to height
(in meters, squared) or wt/ht2. (Important: In order to use this
formula for BMI the child's weight and height measurements must
be in kilograms and meters, respectively). This calculation helps the
doctor to determine whether the child's weight is appropriate for
height.
BMI was only recently recommended as an additional
measurement of growth. Doctors used to calculate weight for
stature (height), but that measurement was of limited value
because it could only be used in boys younger than 11.5 and girls
younger than 10. Doctors have found BMI to be a better indicator
of body "fatness" and potential weight problems.
BMI is particularly helpful for identifying children and adolescents
who are at risk for being overweight as they get older. In older
children and teens, there is a strong correlation between BMI and
the amount of body fat. Therefore, those with high BMI readings -
and probably high levels of fat - are most likely to have weight
problems when they are older. If doctors can identify these at-risk
children early on, they can monitor the kids' body fat more
carefully and potentially prevent adult obesity through changes in
National Institute of Health identifies:
 underweight as BMI less than 18.5 kg/m2,
 overweight as BMI of 25-29.9 kg/m2,
 obesity as BMI of 30.0- 39.9 kg/m2,
 A BMI of 40.0 or greater is morbid obesity.

In a clinical setting, physicians take into

account race, ethnicity, muscularity, age, sex and
other factors which can affect the interpretation
of BMI. BMI overestimates body fat in persons
who are very muscular, and it can underestimate
body fat in persons who have lost body mass as
in elderly.
 Laboratory tests help to determine what is happening inside the
body. In mild or moderate cases; there is depression of plasma
albumin. Because there is so many albumins in the body and because
it is not broken down quickly, albumin concentrations change slowly
and it is useful indicator of prolonged protein depletion, decreased
urinary excretion of urea due to decreased protein intake. Increased
urinary 3-methylhistidine reflect muscle breakdown. Decreased
creatinine excretion reflects atrophy of skeletal muscle mass during
malnutrition. Commonly there is associated iron deficiency anemia.
Kwashiorkor is characterized by decrease albumin (10-25
gm/l), decrease transferrin, and decrease essential amino acids, and
decrease total lymphocyte count. Laboratory tests add a dimension
to nutrition assessment. However, many factors influence lab tests,
therefore a single test cannot be relied on to assess nutrition status.
Many laboratory tests should be combined and viewed together with
anthropometric measures and physical findings to give a real clue
about person's nutrition status,
Dietary Assessment:
Dietary evaluation is important part of nutritional
assessment. Skilled interview is important in many steps of
patient care. Methods to obtain data vary with
circumstances. The common methods used are:
 Twenty four hour recall, the patient is asked to describe
the food eaten in the previous 24 hours or on a typical
day. Questions may begin with what time do you usually
get up in the morning? When do you eat first? What
kinds of food do you usually eat then? It is mandatory to
ask about amount and way of preparation. This method
can not be used in the elderly persons because their
memory may be limited.
 Food Frequency List: The patient is asked how often he or
she eats food in a day or a week.
 Food records, a patient may be asked to keep a record of
his or her food intake for a specified period usually 3 or 7
days. In hospitalized patient, the nursing staff is helpful in
providing information.
Introduction

• Obesity is a complex disease involving an

excessive amount of body fat. Obesity isn't just
a cosmetic concern. It is a medical problem that
increases your risk of other diseases and health
problems, such as heart disease, diabetes, high
blood pressure and certain cancers.

• It is the most prevalent form of malnutrition.

Definition

Obesity can be defined as an excess of body fat.

A surrogate marker for body fat content is the
body mass index (BMI)

In clinical terms, a person with a BMI between

25 and 29.9 kg/m2 is called overweight, and a
person with a BMI greater than 30 kg/m2 is
called obese.
Classification

Obesity is expressed in terms of body mass index (BMI).

Body mass index (BMI) is a simple index of weight-for-height that is

commonly used to classify underweight, over weight and obesity in adults.

It is def ined as the weight in Kilograms divided by the square of the height in
meters (kg/m²).
Classification

Classification BMI Disease Risk*

Underweight < 18.5 -
Normal weight 18.5–24.9 -
Overweight 25.0–29.9 High
Obesity class I 30.0–34.9 Very High
Obesity class II 35.0–39.9 Very High
Obesity class III ≥ 40.0 Extremely High

*Disease risk for type 2 diabetes, hypertension, and cardiovascular disease.

**Increased disease risk is associated with increased morbidity.
Epidemiology

Age : Obesity can occur at any age, and generally

increases with age.

Sex :Women generally have higher rate of obesity

than men because of pregnancy and menopause.

Genetic factor : There is a familial tendency (Obesity runs in

families ) .

Socio-economic Status :There is a clear inverse

relationship between socio-economic status and obesity
Epidemiology

Physical Inactivity : Sedentary lifestyle particularly sedentary occupation.

Alcohol : Alcohol consumption increases risk of obesity.

Human habits : reduced quality of sleep increases the risk.

Socio-economic status : The prevalence of obesity in children and adults in developed

countries is rapidly increasing.

fall somewhat between the two. less than ex-smokers: individuals who have never
smoked Smoking : smokers weigh somewhat
Risk Factors

Diet : excess intake. (Most common)

Smoking cessation because smoking suppresses appetite.

Sedentary lifestyle.
Stress.
Hypothyroidism
Cushing’s syndrome.
Insufficient sleep.
Risk Factors

Growth Hormone deficiency

Insulinoma
Drugs: corticosteroids , antidepressants.
Pregnancy and menopause
Hypothalamic damage (e.g. trauma or tumor
Genetic syndromes associated with hypogonadsim (e.g. Prader-
Willi Syndrome , Laurence – Moon – Biedl syndrome )
Clinical Picture

Excess body fat accumulation

Breathlessness.
Increased sweating.
Snoring.
Inability to cope with sudden physical activity.
Fatigue.
back and joint pains
Double chin
Clinical Picture in children

In children presentation : tall stature in some, abdominal striae,

associated obesity of extremities

increased adipose tissue in mammary tissue in boys, large pubic

fat pad, early puberty
Complications

Cardiovascular diseases : hypertension , atherosclerosis

Type 2 diabetes
Obstructive sleep apnea
Osteoarthritis
Depression
Certain cancers. Obesity may increase your risk of cancer of the
colon , liver, pancreas gallbladder , breast ,uterus and prostate.
Assessment of obestiy

The most widely used criteria are :

Body mass index (BMI)

Relative weight
Skin fold thickness
Waist hip ratio
Others
Relative weight (RW): Body weight (kg)/
Desirable weight × 100
The individual is considered obese when RW
120% or more.
Obesity is diagnosed when your body mass index
(BMI) is 30 or higher. To determine your body
mass index, divide your weight in pounds by your
height in inches squared and multiply by 703. Or
divide your weight in kilograms by your height in
meters squared. For most people, BMI provides a
reasonable estimate of body fat. However, BMI
doesn't directly measure body fat, so some
people, such as muscular athletes, may have a
BMI in the obesity category even though they are
muscular.
However, BMI does have some limitations. According to the
CDC Trusted Source, “Factors such as age, sex, ethnicity, and
muscle mass can influence the relationship between BMI and
body fat. Also, BMI doesn’t distinguish between excess fat,
muscle, or bone mass, nor does it provide any indication of
the distribution of fat among individuals.” Despite these
limitations, BMI continues to be widely used as an indicator
of excess weight.
Skin fold thickness

It is a rapid and non-invasive.

Using several varieties of calipers

(e.g., Harpenden skin calipers).

The measurement may be taken at all the four sites;

mid-triceps, biceps, sub scapular and suprailiac regions.

The sum of the measurements should be less than 20 mm in boys and 30 mm

in girls.
Waist-hip ratio

There is an increased risk of metabolic complications

for men with a waist circumference > 102 cm, and women with a
waist circumference > 88 cm.

Over the past 10 years or so, it has become accepted

that a high WHR (> 0.9 in men and > 0.85 in women)
indicates abdominal fat accumulation.
Diagnosis
The individual is considered obese when:
Rw120%or more
BMI>30kg/m2
Skin fold test
Thickness of skin over the middle of triceps muscle
is measured in mm by special device. normal
thickness is 20mm in man ,30mm in women.
waist circumference:
(>102cm in men,and >88cm in women).
Waist hip ratio(>0.9 for men and >0.85 for women).
Situation in Egypt

It has been reported that the prevalence of obesity in adults is

very high in Egypt, particularly among women.
the overall prevalence of central obesity among Egyptian adults,
according to the 2 indicators—WC and WHR ratio—was
24.1% and 28.7% respectively. These figures are relatively high
if the association of central obesity with morbidity and
mortality is taken into consideration.
Many studies of general obesity have indicated a significantly
higher prevalence of obesity among females than among males.
Such findings may be attributed to sociocultural factors in
Egyptian communities, such as high unemployment, restricted
outdoor activities and the high illiteracy rate among females.
Treatment

The goal of obesity treatment is to reach and stay at a healthy

weight through :

Diet : low caloric diet , reduction of saturated fats , trans fats and
cholesterol The National Cholesterol Education
Program suggests that no more than 30 percent
of the calories people eat should come from fats.
Smoking cessation to avoid smoking hazards and to achieve a
healthy lifestyle.

Physical Activity : Signif ic ant weight loss can be achieved in many

obese persons with increased physical activity.
Exercise as a Treatment for Obesity :

The American College of Sports Medicine (ACSM) and the
Centers for Disease Control (CDC) have recommended that
every adult should accumulate 30 min or more of moderate-
intensity physical activity on most, preferably all, days of the
week.
 Health Benefits of Exercise :
1. Maintenance of reduced body weight and body fat content
2. Prevention of weight/fat regain
3. Reduced systolic and diastolic blood pressure,
control of hypertension
4. Decreased resting heart rate, increased stroke volume,
increased cardiac output
5. Reduced blood lipids: LDL cholesterol, VLDL cholesterol,
triglycerides, free fatty acids
6. Increased blood high-density lipoproteins
Prevention and Therapy
It is good way to monitor one's diet, and
to keep a detailed food diary; that way
one will know exactly how many calories
are consumed in a day and where those
calories come from.
It's hard to change habits. You have to be
ready. Make sure this is the right time for
you. Are you ready to make a plan and
stay on it? Do you have the support of
your family and friends? Do you know
what your first steps will be? Becoming
healthier and staying that way is a
lifelong effort.
Prevention and Therapy cont.

Nutritional education about healthy diet.

Keep most meals under 400 calories. Keeping all meals
about the same size at regular intervals has been linked
to greater calorie burning after eating, better response to
insulin, and lower fasting blood cholesterol levels.
You must move towards healthier, natural foods and
begin to cut out the processed, rubbish junk foods. You
must also take a fresh look at daily exercise. A 35-40
minute brisk walk is a doable objective, even for someone
who is overweight.
Increase intake of water in between meals and not during
meal. Drink 8 glasses of water per day. Water may speed
the body's metabolism, so try drinking a glass before
meals and snacks and before consuming sweetened
drinks or juices.
Step it up and down. Climbing stairs is a great leg strengthener
because you're lifting your body weight against gravity.
Use grocery bags as dumbbells. Letting someone else load the
groceries or carry the suitcase is an opportunity missed for
strengthening and calorie burning, Carry the groceries, balanced
with a bag in each hand, even if it takes several trips. Pack two
smaller suitcases instead of one big one.
Eat 4 g of fiber at every meal. A high-fiber diet can lower the
caloric intake without feeling deprived. Fiber promotes weight
loss: It may slow down eating because it requires more chewing,
Fiber absorbs large quantities of water and forms a natural
substance filling the stomach. This produces a feeling of being
full and satisfied during the meal and the period afterwards. The
substance also helps lower cholesterol levels and gives relief in
the case of constipation, speed the passage of food through the
digestive tract, and boost satiety hormones. Buy fruit; it's more
useful than vegetables, so it's an easy way to up the fiber intake.
One large apple has just as much fiber (5 g) as a cup of raw
broccoli.
Treatment
Medications :appetite suppressors as sibutramine

orlistat reduces absorption of fat.
Surgery : For morbidly obese patient ;
Gastric bypass surgery , Gastric banding surgery and
Vertical sleeve gastrectomy These surgical procedures
generally produce substantial weight loss in obese patients.
The gastric bypass and vertical sleeve procedures often
lead to rapid remission of type II diabetes mellitus , an
important complication of obesity.
 Prevention & Control

the steps to prevent weight gain are the same as the steps to lose weight:
daily exercise, a healthy diet, and a long-term commitment to watch what you
eat and drink.

Regular Exercise : including physical

activity in day activates is important to
prevent obesity and other diseases.
 Prevention & Control

Monitoring weight : regular maintenance of a healthy weight and prevention of gaining

unnecessary weight.

Healthy-eating plan : planning courses

of food rich in high value protein and
carbohydrates and low in fat.
Prevention & Control

Avoiding alcohol and smoking

Health education : educating children and adults about risk factors ,
complications of obesity and how to avoid them.
Care of obese children via parents observation and control of food proportions ,
developing healthy eating habits.
Avoid stressful events and control of stress by medications if necessary to
avoid general risk of diseases.