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WEIGHT IMBALANCE : OBESITY & OVERWEIGHT

Overweight is a state in which exceeds a standard based on height Obesity is a condition of excessive fatness, either generalized or localized.

MNT FOR OVERWEIGHT AND OBESITY

Inggita Kusumastuty

ETIOLOGY
Obesitas adalah hasil dari ketidakseimbangan antara makanan yang dikonsumsi dengan aktivitas fisik terdapat penimbunan lemak yang berlebihan daripada yang diperlukan untuk fungsi tubuh, sebagai akibat mengkonsumsi makanan yang jauh melebihi kebutuhannya Hereditas atau keturunan Lingkungan Psikologi Fisiologi (Krauses Food 12th Edition) (Midasari, 2007); (Krauses Food 12th Edition)

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Marketing to Children

MANIPULATING CHILDRENS BEHAVIOUR

Food promotion Can confuse nutritional knowledge e.g whether fruit is in product Changes food prefences Changes purchasing behaviour Influences choice and consumption by brand Alter balance of catagories of food eaten

UK Food Standards Agency, 25th September 2003

From Traditional food to Modern Meals

CHANGING DIETARY HABITS

Increased intake of caloric sweeteners & edible oil Increased intake of processed foods, refined carbohydrates & salty high fat snacks Reduced intake of fruits and vegetables

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From Traditional to Modern Snacking

PORTION SIZE

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From Traditional Food Marketing to Modern Food Supermarkets

DECREASED PHYSICAL ACTIVITY

Excess TV; computer, & play station time Children are home alone (dual income parents) Decreased physical activity at school & at home Transportation by car or school bus Neighborhood safety Few public parks, sidewalks, swimming pools ..etc

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From Traditional to Modern Leisure

KLASIFIKASI
Klasifikasi dan risiko Penyakit Penyerta berdasar WHO: Klasifikasi dan risiko Penyakit Penyerta untuk orang ASIA:

(Lestiani, 2011)
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TEBAL LIPATAN KULIT TRISEP

Obesitas umumnya menyebabkan akumulasi lemak pada daerah subkutan dan jaringan lainnya. Cara yang digunakan untuk mengukur lemak subkutan di lengan atas, salah satunya dengan mengukur Tebal Lipatan Kulit Trisep Waist Circumference untuk mendeteksi obesitas melalui akumulasi lemak visceral tubuh

Cutt off ASIA: Laki-laki Perempuan : >90 cm : >80 cm

Kategori > 85 percentil > 95 percentil

(Rahmawati, 2009)

Interpretasi obesitas superobesitas

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(Gibson, 2005)

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BEHNKES THEORITICAL BODY COMPOSITION MODEL FOR A MAN AND WOMAN WITH HEALTHY PERCENTAGE BODY-FAT RANGES
Males Total fat 8%-24%
Storage fat 5%-21% Essential fat 3%

BODY FATNESS

Females

(DEURENBERG AND DEURENBERG-YAP, 2003)

% body fat = (1,2 x BMI) + (0,23 x age in yrs)- (10,8x G)-5,4 G =1 for male, G=0 for female

Total fat 21%-35%

Storage fat 9% - 23% Essential fat 12%

Muscle 44.8% Bone 14.9% Remainder 16.3-32.3%

Muscle 38% Bone 12% Remainder 15-29% For example if BMI=28, age 21and G=female %body fat = (1,2x28)+(0,23x21)-(10,8x0)-5,4 = 33,6+4,83-0-5,4 = 33%

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NOTE:
A body fat percentage of 20% to 25% or more in a male and 25% to 32% or more in female is ussualy considered to be excessive and associated with the metabolic and health risks of obesity

PATHOPHYSIOLOGY

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FAT CELL DEVELOPMENT

FAT CELL METABOLISM

Enzim LPL

Promote fat storage

adiposa
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Muscle cells
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Gender specific hormones (estrogen dan testosteron)

regulates
LPL Activity

Women : Fat Cells in the breast Fat cells in the hips Fat cells in the thighs

Men : Fat cells in the abdomen

Produce abundant LPL

Produce abundant LPL

Tipe Obesity : Men = Central Obesity Women = Lower body fat around hip and thigh
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OBESITY PROMOTE HEALTH PROBLEM

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DIET TINGGI LEMAK MENYEBABKAN RESISTENSI INSULIN

Diet Lemak -cell pankreas
Insulin Release

MEKANISME OBESITAS MENYEBABKAN DISLIPIDEMIA (BARBARA, ET AL. 2003)

Obesitas Kolesterol Insulin Resisten

Fat cell
Sitokain

Obesitas
Adiponektin
1 Aktivitas LPL Glukosa Hepatic

Fosforilasi IRS 1 & IRS 2 Signal Insulin

Serin Tyr fosforilasi

Pengambilan Glukosa otot

FFA

Gangguan aksi LDL-R

Glukosa serum Resistensi insulin

Plasma TG (TG yang ada dalam VLDL dan Kilomikron )

FFA dan Glukosa Hepar

Glut-4 ke membran sel Glukosa masuk sel

clearence VLDL

Produksi VLDL VLDL Plasma

clearence VLDL

Fasting dan PP TRL

*LPL : Lipoprotein Lipase LDL-R : LDL Receptor TRL : Triglyseride Rich Lipoprotein
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2 small dense LDL HDL

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MEKANISME INSULIN RESISTEN MENYEBABKAN DIABETES MELLITUS TIPE 2

(Mechanisms linking obesity to insulin resistance and type 2 Diabetes. Steven E. Kahn, Rebecca L. Hull and Kristina M. Utzschneider. Nature 444, 840-846(14 December 2006)

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The interlinking of physical inactivity and dietary effects on obesity and the progression of disease with industrialisation

Dietary change
Energy density: fat & refined CHOs
BULK, e.g. vegetables, tubers, cereals

Physical inactivity
+ +
Sex hormone changes

MANAGEMENT OF OBESITY IN ADULT

+

+ +

+ +

Medical Management
Lifestyle modification (increase exercise) Psycological support Drugs Surgery

DIABETES CHD OBESITY

Phytoestrogens bioactivate molecules

HYPERTENSION CANCERS: breast, endometrium

+ Thrombosi + Homocysteinaemi
a s

Nutritional Management
Food choice changes Nutrition education

Folate, B6

Antioxidant -s

+ Trans fatty + acids n-3 fatty acids Atherosclerosis Saturated fats +

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Total Fat

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OBESITY TREATMENT PYRAMID

DECIDING ON TREATMENT

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SURGARY
Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI 40 or 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesityassociated morbidity or mortality

MEDICATION
Weight loss drugs approved by the FDA for long-term use may be useful as an adjunct to diet and physical activity for patients with a BMI of 30 with no concomitant obesity-related risk factors or diseases, and for patients with a BMI of 27 with concomitant obesity-related risk factors or diseases

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PHYSICAL ACTIVITY
Initially, moderate levels of physical activity for 30 to 45 minutes, 3 to 5 days per week should be encouraged. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week

JENIS OR YANG AMAN BAGI PASIEN OBESE

1. Berjalan kaki (30 menit/hari, 5-6 x/minggu) 2. Jalan cepat (12 jam membakar 3500 kkal) 3. Berjalan diselingi jogging ringan 4. Senam aerobik low impact 5. Berenang dengan jarak agak jauh 6. Berjalan kaki di kolam renang setinggi pinggang.

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TIPE OLAHRAGA UNTUK OBESITAS

JENIS Voli Berjalan 1 mil Shooting basketball Bersepeda 5 mil
Berenang

DURASI 45-60 menit 35 menit 30 menit 30 menit 20 menit 15-20 menit

15 menit 15 menit

INTENSITAS Intensitas Rendah, Durasi Tinggi

Bermain basket Lompat tali Berlari mil

Intensitas Tinggi, Durasi Rendah

SOME DIETS FOR OBESITY

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SOME DIETS, NOT WORKS

Low Calorie Diets: (-) 500 to 1000 Kcal daily requirements Meal Replacements: 200-300 Kcal High satiety (Protein
+ fibre) 2. 3. 4. 5. 6.

WHY DIET DOESNT WORK?

1. Regaining Wt among dieters is the norm not the exception. Lower BMR easier to put on weight (J Nutr 2005 Jun; 135(6):1347-52)
No one can live on a Diet forever We are in daily contact with food Need lifestyle strategies Food behaviour modification Personal responsibility

Very Low Calorie Diets:200-800 calories daily (rich protein 0.8-1.5g/ kgIBW) 12 to 16 weeks BMI 27 to 30Rapid wt loss

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EFEKTIFITAS VLCD DALAM PENGATURAN BERAT BADAN BERDASARKAN PENELITIAN TENTANG EFEKTIFITAS VLCD DI MALAYSIA YANG DILAKUKAN OLEH ISMAIL NOOR DAN KHOR POH KIM (2002) SELAMA 6 MINGGU MASA ST UDI, MENYEBUTKAN BAHWA:
Pria Total weight loss Waist circumference loss Hip circumference loss Body fat reduction BMI reduction 4,5 kg 8,0 cm 5,5 cm 3,6 cm 1,5 kg/m2 Wanita 3,4 kg 8,0 cm 6,0 cm 2,3 cm 1,4 kg/m2

EFEK NEGATIF VLCD

(Nutrition Practise:50; Krauss Food & Nutrition Theraphy:548)
menyebabkan defisiensi beberapa zat gizi dan elektrolit Kehilangan massa otot Pembentukan gallstones

(Handbook of nutrition & food:899; Krauss Food & Nutrition Theraphy:548)

Orthostatic hypotension Gout (ketones bersaing dengan uric acid untuk diekskresi)

(krauses)
Fatigue / keletihan Light-headedness / dizziness Dapat diatasi dengan merubah posisi tubuh secepatnya, hindari mandi sauna, minum 1.52 L per hari. Kulit kering Rambut kemerahmerahan karena kekurangan beberapa mineral seperti Zn Menstrusi terganggu

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NUTRITION INTERVENTION

Low-calorie diets are the closest to most peoples general eating patterns and present the fewest risks for the patient

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INTERVENTION OBJECTIVES
Reduce body weight Maintain a lower body weight over the long time
Prevent futher weight gain
(Nutrition and Diagnosis Related Care, 2008)

NUTRITION INTERVENTION FOR OBESITY

Carbohydrate : 35 50% TEE Fat : 25 35% TEE
Protein : 25 35% TEE Low glicemic load Fiber : 25 35 g/ day

The National Institutes of Health suggests a reduction of 10% in body weight as an initial goal. A weight loss of 5%10% has been shown to reduce the risk of heart disease and stroke.
CMAJ January 3, 2006 174(1)
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Adaquate fluid Low salt

Nutrition and Diagnosis Related Care, 2008

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ESTIMATING ENERGY NEEDS FOR OBESE

NUTRITION INTERVENTION
What will work long term
Wt loss 5-10%/wk Wt loss 0.5-1.5 kg/wk

Healthy eating
Low fat (foods and cooking) High carbohydrates (low refined) High protein High fiber Indulge in low energy dense foods

Using ideal body weight (IBW) when calculating energy requirements in the obese population does not allow for increased lean body mass (LBM) needed for structural support of the extra adipose tissue

Some long term energy restriction is inevitable

1200 to 1800 Kcal

(CMAJ. 2007 April 10; 176(8): S1 S13.)

Cunningham developed a formula to estimate energy requirements of the obese, often referred to as Adjusted Body-Weight for Obesity

Regular Physical Activity

equations like the Harris Benedict equation

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ESTIMATING ENERGY NEEDS FOR OBESE

Adjustment Body Weight for Obesity: [(ABW-IBW )x 0.25 + IBW]= weight to be used for calculating REE
ABW= actual body weight IBW=ideal body weight 0.25 represents the percentage of excess body weight that is metabolically active

PERHITUNGAN ENERGI

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Krauses Food 12th Edition

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SOME INTERVENTIONS STRATEGIES THAT COULD BE CONSIDERED FOR PREVENTION OF CHILDHOOD OBESITY

NUTRITION INTERVENTION IN CHILDHOOD OBESITY

The two most popular diets followed by adults, the low-carbohydrate diet and the low-fat/low-calorie diet, have not yet been evaluated extensively for safety and efficacy in children

Source : Philippas, G. Niki & Lo, W. Clifford. Nutrition in Clinical Care, Volume 8, Number 2, 2005 77 88 Nutrition Journal 2005, 4:24
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NUTRITION INTERVENTION IN CHILDHOOD OBESITY

Energy according age, activity, likelihood growth Protein : 10 35% TEE Fat : 25 40% TEE Carbohydrate : 45 60%TEE Decrease the use of sweets as snack food or dessert Control between meal-snack

STRATEGI MODIFIKASI GAYA HIDUP

( KRAUSES FOOD 12 TH EDITION)

Krauses Food & Nutrition Therapy 12 edition Nutrition and Diagnosis Related Care, 2008

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FOOD WEIGHT LOSS TIPS

Establish regular meals times Read food labels when purchasing food items Make substitution in diet to cut calories Identify guilty pleasure such as ice cream Pre-portion serving to control the amount Control calories when dining out Pre-plan meals & snacks, and make a certain to have the food on hand Avoid places & situation that trigger eating Try substituting other activities for eating
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THE MOST USEFUL PROGRAM COMPONENTS :

food-label reading cooking sessions learning new and different physical exercises, including home-based options. Self-management techniques helpful (problem solving) The use of a group setting and supportive 'peer' leaders were found to be supportive. More frequent clinical assessment was suggested for future programs. (International Journal of Behavioral Nutrition and Physical Activity 2008, 5:53)
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THANK YOU
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