DIETARY MANAGEMENT OF

OBESE ADULTS

1
 Weight loss myth:
Red or Green?

60 Kcal 180 Kcal

Puan R…
• A 30 year-old woman who
had gained over 30 kg
within the last 10 yr

• Why is she gaining weight?

Common Presentations
 Nutrition Assessments
• Anthropometrics: weight/Ht = BMI, WC (cutoff?)
– Age of onset, highest and lowest adult weight, patterns
– WHO (1985)?
 Clinical Practice Guidelines
on Management of Obesity 2004
 Nutrition Assessments
• Dietary Intake – usual diet intake
– Food’s checklist – in depth/ prompt assessments
– Fatty meals/ high sugar beverages/ Fast food frequency
– * amount/ frequency > 4/7 consider +++
– Food access (Living nearby fast foods)
– Reasons for eating (emotional related or truly hungry)

* Under reporting
 Nutrition Assessments
• Other co-morbidities
WHY WE GAIN WEIGHT?

=
WHY WE GAIN WEIGHT?
 Causes of overweight and obesity
Heredity and Nutrigenomics
Many hormonal and neural factors involved in weight
regulation are determined genetically eg
o short and long-term signals determining satiety & feeding
activity
o Number and size of fat cells, regional distribution of body
fat, and BMR
Genes determine 50-70% of predisposition to obesity
(Prentice, 2005)
- Nutritional or lifestyle choices can activate or deactivate
obesity-triggering genes (eg Ob gene, adiponectin
(ADIPOQ) gene
 Causes of overweight and obesity
Lifestyles
o Lack of exercise
o Sedentary lifestyle
o Chronic overeating

Sleep, Stress, and Circadian Rhythm

o Shortened sleep alters the endocrine regulation
of hunger and appetite
o Shift work or exposure to bright light at night,
increasing the disruption of circadian rhythms
Children with shortest sleep duration were found to have 4.5 times higher odds of
being overweight/obese (odd ratio: 4.536, 95% CI: 1.912—8.898) compared to
children with normal sleep duration
The odds of being overweight/obese in children with higher sleep disorder
score were 2.17 times more than children with lower sleep disorder score
 ASSESSMENTS 2
Nutrition Assessments
Dieting history Behavioral / Knowledge
– Physical Activity
– Number and types of (frequency, duration,
diets tried
types, FITT)
– Complementary / – Understanding / of
alternative approaches obesity and health
for weight loss related problem
– Motivation level &
– Success of previous readiness to change
weight loss effort
(stage of change)
 Comparative Standard

• Mifflin - St Jeor Formula

• Quick Method Formula
 Mifflin - St Jeor Formula
Men
10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) + 5

Women
10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) - 161

• Energy Expenditure = RMR x PAL

1.0 sedentary
1.4 low active
1.6 active
1.9 very active

Weight to use= actual weight

 Lets Practice..
Calculate the calories requirement for Mr A using both the
quick method and Mifflin St-Jeor Equation with the
following anthropometric parameters:

Weight= 100 kg, height = 1.56 m, age: 40 year old, calories

intake ~ 3000 Kcal /day

Compare the readings from two calculations and comment

 Lets Practice..
• Mr S, sedentary man, 40 year old
• Wt = 100 kg; Ht = 1.56 m; BMI = 30.82
• Calories intake ~ 3000 Kcal/day

Mifflin St-Jeor Equation

Calories req
= 10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) + 5
= 10 X (100) + 6.25 X (156) – 5 X (40) +5
= 1780 Kcal
 Lets Practice..
 Quick Method
Acceptable BW at 22 kg/m2
= 22 x 1.56 x 1.56= 54 kg

Calories req
= 54 x 20-25= 1080 - 1350 kcal/day
Nutrition Diagnosis
 Pharmacotherapy
• May be considered in addition to diet, exercise &
behaviour modification
• Decision to initiate drug therapy in overweight
patients should be made only after a careful
evaluation of risks and benefits
• Part of a long-term management strategy to
- aid compliance with dietary restriction
- augment diet-related weight loss
- achieve weight maintenance after
satisfactory weight loss
 Indications for Drug Therapy in Obesity
• Must not be used simply for cosmetic purposes or when
weight loss can be achieved and maintained without it
• have had reasonable trial of diet & exercise for 6/12
Criteria
1. BMI between 25 and 27.5 kg/m2, with at least 2 conditions:
• T2DM / CHD / Cerebrovascular disease / HTN /
Hyperlipidaemia / elevated WC (men vs women)
2. BMI ≥27.5 kg/m2
3. Symptomatic complications of obesity such as severe
osteoarthritis, obstructive sleep apnoea, reflux
oesophagitis, and the compartment syndrome
 Drug Therapy in Obesity
• Considered effective if weight loss exceeds 2 kg during the
first month of therapy and decreases more than 5% by 3 to
6 months, with no weight regain
• Therapy must be reviewed after a month of initiation to
assess response and compliance
Types of Anti-obesity drugs :
• Gastrointestinal system to reduce fat absorption
Orlistat (Xenical, Roche Pharma)
• Central nervous system to suppress appetite
Sibutramine (banned in 2010): increased risk of heart
disease
Phentermine
Others: Metformin may be useful: T2DM, IGT, PCOS
Drug Therapy in Obesity
Drug Therapy in Obesity
 Bariatric Surgery
⚫ Various types of surgery on the gastrointestinal tract
⚫ Originally developed to treat morbid obesity (“bariatric
surgery”)
⚫ Gastroplasty procedures: restrictive ( amount of food
entering the gastrointestinal tract)
⚫ Other surgical procedures, such as Roux-en-Y, are
restrictive and cause malabsorption (prevent food from
being absorbed from GIT)
 Bariatrics Surgeries

Gastroplasty  size of the stomach by applying rows of stainless-steel staples to

partition the stomach, create small gastric pouch, leaving only a small opening (0.8-
1 cm) into the distal stomach

Gastric bypass involves  size of the stomach with the stapling procedure, but then
connecting a small opening in the upper portion of the stomach to the small
intestine by means of an intestinal loop.

Complications:
Gastric bypass: lower part of the stomach is omitted, patient may have dumping
syndrome as food empties quickly into the duodenum
 Bariatric Surgery

⚫ Accepted form of treatment for extreme or class III

obesity
- BMI of  40, or
- BMI of  35 with comorbidities
⚫ Additional to behavioural & medical approaches,
provides an important option for treating T2DM in
severely obese patients
- often normalising blood glucose levels, within days
in some procedures
- reducing or avoiding the need for medications
 Bariatric surgery for obese adolescents
with type 2 diabetes
• An Australian report* recommends surgery be considered if
adolescents have BMI >40 , or >35 with severe co-morbidities, are 15
years or over & can provide informed consent

• This IDF position statement advises that only

2 procedures, Roux-en-Y gastric bypass &
laparoscopic gastric banding are
currently conventional bariatric surgical
procedures for adolescents

*Baur LA & Fitzgerald DA. Recommendations for bariatric surgery in adolescents in Australia and New Zealand. J Paediatr
Child Health 46, 704-707 (2010).
 Factors to consider when choosing
Surgical procedure
• Expertise & experience in the bariatric surgical procedures

• Patient’s preference when the range of risks & benefits,

the importance of compliance, & the effects on eating
choices and behaviours have been fully described

• Patient’s general health & risk factors associated with

higher peri-operative morbidity & mortality

• The follow-up regimen for the procedure and the

commitment of the patient to adhere to it
 Short Term Dietary Management

o Eat slowly, stop as soon as feel full

o Chew food well
o Avoid eating and drinking at the same time
o Texture: patients struggle with textures such as bread, roast
or grilled meat and fibrous vegetables
o Foods such as chocolate and crisps tend to be well
tolerated, but will cause weight gain
 Long Term Dietary Management
o Balanced and low fat diet
o Regular meal pattern is necessary, Reduced stomach capacity can
result in grazing throughout the day
o Multivitamin and mineral supplement to minimize risk of
nutritional deficiencies
o Protein malnutrition may occur after any of the procedures due to
intolerances (esp meat)
- Alternative sources of protein should be suggested
- Following restrictive and malabsorptive procedure, 60-100
gram protein / day
o Additional support: Dumping syndrome & related symptoms of
hypoglycemia
o Women of childbearing age are discouraged from pregnant within the
first 12-18 months of surgery
 Long Term Dietary Management
o Women of childbearing age: discouraged from pregnant within the
first 12-18 months of surgery
- Thereafter, change vitamin supplement to one does not contain
vitamin A
- Those who have had a duodenal switch may need to continue to
take high doses of fat soluble vitamins throughout pregnancy
Algorithm for obesity management using
nutrition care process
 Lifestyle Modification Strategies

• Setting easy-to-achieve short

term goals
• Self-monitoring
• Stimulus control
• Confronting barriers
• Sleep and stress management
• Social support
• Contracting
 Weight Loss Model
Lifestyle
modifications Increase
PAL

Reduce
Wt
‘Diet’
 Weight Loss Model

Lifestyle modifications

yes
 control

Lifestyle
changes

The DPP Research Group, NEJM 346:393-403, 2002

Weight Loss Model
Lifestyle
modifications Subject should pass test of
Increase
PAL
behavioral adherence i.e.
record food intake and physical
Reduce
activity for 2 weeks
Behavioral
changes Wt
(Look AHEAD trial Study
‘Diet’ Protocol)
Stage of Change: How to Keep to
Resolution?

Awareness- Knowledge - Motivation- Reward + Develop Recognize

Encouragement Identify Prepare Support coping barriers to
Barriers clear plan of strategies success &
action start again
Which stage is she?
• Puan R has been tired of being
overweight and keep thinking about to
lose weight yet nothing has been done

Awareness- Knowledge - Motivation- Reward + Develop Recognize

Encouragement Identify Prepare Support coping barriers to
Barriers clear plan of strategies success &
action start again
Which stage Is she?
• Puan R has started trying to lose
weight by skipping meals

Awareness- Knowledge - Motivation- Reward + Develop Recognize

Encouragement Identify Prepare Support coping barriers to
Barriers clear plan of strategies success &
action start again
WHICH ‘DIET’ IS BEST FOR
OBESITY MANAGEMENT?

48
THE BEST DIET…
 THE BEST DIET…

Low High
CHO Protein

Low
fat
Energy
Low GI
LOW CARBOHYDRATE DIET

• Atkin’s diet – low carbs, high protein diet by

Dr Robert Coleman Atkins- was a physician and
cardiologist
• In 2002- he suffered a heart attack which AHA
linked to ‘Atkins Diet’
• In 2003- at age of 72, he died due to brain
injury
• Autopsy – had h/o CHF, MI and HTN- hotly
debated in the net
 Atkins Diet Example

3-egg omelet 6 oz grilled chicken 8 ounces steak

1 oz cheese 2 cups salad 3/4 cup broccoli
1 tsp. butter ¼ cup almonds 2 tsp butter
4 slices bacon ¼ cup oil & vinegar
 Evaluating a Low Carb Diet

• Low in:
– Calcium
– Fiber
– Antioxidants, phytonutrients
• High in:
– Total fat
– Saturated fat
– Cholesterol
 Cholesterol and Fat Comparisons
Percent Calories from Fat Cholesterol

1000
60% mg

<30% <300 mg

Current Current
Atkins Recommendations Atkins Recommendations
 Meal Replacement

Share similar characteristics- low calories,

high in protein and high in fibre
 80 studies (25 000
subjects) and 69%
completers
Franz MJ JADA 2007
Macronutri High arm Low arm
ent
Protein 27% En 18% En
CHO 38% En 55% En
Fat 32% En 26%En
Puan R has started trying
to lose weight by I go on diet to lose
skipping meals
wt. Usually I can’t
stand the diet.

DIET= =
 I just wait till I lose 5-10
kg and then go back to
eating those really
good food

Patient think that wt loss

= going
GOOD FOODON/
= OFF diet
=
 LIFESTYLE INTERVENTION

Increase
PA

Behavior Reduce
Modification
WT
Reduce
Energy
Intake

LCHO HProt LGI Lfat

Mrs. R…
• Mrs. Risky weigh 80kg and BMI
of 35kgm-2

• She aims to lose around 30kg

so that she managed to get
ideal weight (BMI = 22) within
a 3 month

• Is it OK?
Setting the weight loss target
• Aim for realistic weight loss
• 5-10% of initial weight
– ½ - 1 kg /week (Level A)
½ kg of fat = need to reduce 3500 kcal
(require – EN deficit of 500kcal/day x 7
days = 3500 kcal deficit / week)
• Keep initial weight loss for 6 mo
and then reduce further
• If significant reduction unable to
achieve, prevent further weight
gain
Prevalence of successful weight loss:
Learnt from DPP study
• 1000 overweight individuals with IGT were assigned
to an Intensive Lifestyle Intervention (ILI)
Duration
6 months Average weight loss = 7% of initial
weight (~ 7kg)
1 year Maintained weight loss = 6% (6 kg)
3 years 37% of participants maintained
weight loss of 7% or more
Definition of successful weight loss
and maintenance
• “Individuals who have intentionally
lost at least 10% of their body weight
and kept it off at least one year”

Wing & Phelan 2005

 80 studies (25 000
subjects) and 69%
completers
Franz MJ JADA 2007
Puan R…
• Set realistic weight loss for
Puan R – 5-10% within first 6
mo = 4-8 kg
 HOW TO HELP PUAN R to
REDUCE 4-8 kg within 6 mo?

68
This can be achieved by…
• Reduce calorie diet (20-25
kcal/kg body weight)
80 kg x (20-25kcal) = (1600 –
2000kcal/day) MINUS 500 kcal/day =
1100 – 1500 kcal/day

• Increased physical activity

> 150 min weeks
• Positive attitude (at stage
3-5)
This can be achieved by…
• Reduce calorie diet
(20-25 kcal/kg body weight)
80 kg x (20-25kcal) = (1600 –
2000kcal/day) MINUS 500
kcal/day = 1100 – 1500 kcal/day
• Why 500kcal/day?
– Because to reduce ½ kg of fat needs
to reduce 3500 kcal from foods
– 0.5kg/week
 FOOD BASED STRATEGIES TO
ACHIEVE LCD
1. Conventional reduced calorie
diet (RCD) for 1200 or 1500
kcal/day

2. Meal replacement therapy

CONVENTIONAL REDUCED CALORIE DIET:
A PRACTICAL APPROACH
1. Portion control is KEY strategy
2. Cooking modification
3. Substitute high to low energy dense food
• Reduce intake of fatty meals and sugary food
• Increase intake of fruits and vg = fibre
• Increase water consumption (soup, no calories
beverages)
Portion size has changed!!!

CHEESEBURGER
20 Years Ago Today

333 calories 590 calories

Calorie Difference: 257 calories

 Portion size has changed!!!

FRENCH FRIES

210 610
Calories Calories
Calorie Difference: 400 Calories
 PORTION CONTROL

1. Portion control is KEY strategy

– 30% more calories when served the biggest
portion vs. smallest portion despite their body
weight status
Rolls et al. 2002 Portion size
of foods affect energy intake
in normal and overweight
man and women Am J Clin
Nutr
 The portion size:
650 kcal 150 kcal

150 kcal

225 kcal
CONVENTIONAL REDUCED CALORIE DIET: A
PRACTICAL APPROACH
1. Portion control
2. Cooking/ food selection modification
3. Substitute high to low energy dense food
1. Reduce intake of fatty meals and sugary food
2. Increase intake of fruits and vg = fibre
3. Increase water consumption (soup, no
calories beverages)
BF Nasi lemak 545 BF Nasi putih + 345
dishes sambal
Tea Tarik 150
Tea Tarik 150
Seri Muka 192
Fruit 60
MT Kacang goreng 360
L Nasi ayam 565 L Nasi putih 150
TT Keropok/ 66/90 Ikan bakar 125
Goreng pisang Sup sayur 45
Tea o 75 D Nasi putih 150
D Nasi goreng kg 450 Tom Yam/ Sup 180
sayur
S Snek makanan 450
ringan S Fruits 2 biji 120
Sirap Milk choc 150
75
Total 3018 Total 1510
Cooking modifications

Reduce.. More..

Fish/ Chicken Fried Fish / Chicken: Baked/

Grill
Santan based food Soup, Singgang

Nasi lemak/nasi White rice

briyani/ayam
Kuih-muih Buah
 Dietary Fat recommendation
• < 30% /day (1500kcal/day)

• (10 tsp oil) /day

– Mihun goreng= 3 tsp
– Roti canai = 4 tsp
– Nasi briyani= 4 tsp
– Nasi lemak = 8 tsp
– Ayam goreng/ ikan goreng = 2-3 tsp
 Reduce Sugar Intake
• < 10% (1500kcal/hari) 38g/d
• ~ 7 tsp sehari
– Air berkarbonat = 7-9 tsp
– Ais krim = 4 tsp
– Kordial = 5 tsp
– Teh tarik = 4 tsp
 Good fat (MUFA) but high in fat

Nuts

=
180 kcal

Low in fat, high in Protein and fibre

Legumes
 CONVENTIONAL REDUCED CALORIE DIET:
A PRACTICAL APPROACH
1. Portion control
2. Cooking modification
3. Substitute high to low energy dense food
1. Reduce intake of fatty meals and sugary
food
Low 2. Increase intake of fruits and vg = fibre
ED
3. Increase water consumption (soup, no
calories beverages)
 INCREASE FRUITS & VG,
FIBRE AND WATER
• Feeling full is one reason people stop eating and
volume affects the feeling of being full

• Low-energy-dense foods have fewer calories than

the same volume of high-energy-dense foods

• Water and fiber increase volume and reduce energy

density
 1500 kcal/day
BREAKFAST
Soup based mealTEA TIME

Porridge (bulky)
LUNCH 150 kcal =Portion control
1cupDINNER
white rice vs. 2 cup
porridge)
 PLATE MODEL

Plain
fruit water

Rice
VG

Protein
Low fat
cooking
method
 FOOD BASED STRATEGIES TO
ACHIEVE LCD
1. Conventional reduced calorie diet (RCD) for
1200 or 1500 kcal/day

2. Meal replacement therapy

 LIFESTYLE MODIFICATION

Increase
PA

Behavior
Reduce
Modification
WT
Reduce
Energy
Intake

LCHO HProt LGI Lfat

 GOOD EATING HABITS

• Eat slowly (> 20 mins)

HOW

• Eat when only feel hungry

WHY • Stop before feel full

• Eat 3 times/day
WHEN • Snacking when needed
• Don’t skip meal
BEHAVIORS TO PROLONG EATING AND REDUCE
THE AMOUNT OF FOOD EATEN

• Eat slowly and enjoy each mouthful

• Put down the fork between bites
• Delay eating for 2 – 3 min and converse with
others
• Postpone a desired snack for 10 min
• Serve food on a smaller plate
• Leave 1 – 2 bites on the plate
 DIET-RELATED BEHAVIOR:
MODIFICATION STRATEGIES

• Identify events that are associated with

inappropriate/ appropriate eating behavior
– Problem example - eating when angry – help to
identify steps to deal with angry in more
constructive ways
 Elimination of eating cues
• Plan meal/ snack - eat only at one designated place
• Plan for special events, parties, dinners
• Leave the table as soon as eating is done
• Do not combine eating with other activities such as reading/ watch TV
• Do not put bowls of food on table
• Stock home with healthier food choices
• Keep all food in cupboards where it cannot be seen
• Shop for groceries from a list after a full meal
• Immediately place leftovers in storage containers and refrigerate or
freeze them for another meal
• Negotiate with the family to eat healthier foods
• Ask others to monitor eating patterns and provide positive feedback
• Substitute other activities for snacking
• Snack on fresh VG and fruits
 Common Obstacles / Problems
Maintaining Reduced Body Weight
Plateau Effect
o RMR  rapidly at the onset of a weight-reduction
diet, by as much as 15% within 2 weeks
o Indicates that other adaptations to the lower weight
and the threat of deprivation are taking place
o ? strategies
Weight Cycling
o Repeated bouts of weight loss and regain, or the “yo-yo
effect”
o Result in  body fatness and weight with the end of
each cycle
 Lifestyle Modification Strategies

• Setting easy-to-achieve short

term goals
• Self-monitoring
• Stimulus control
• Confronting barriers
• Sleep and stress management
• Social support
• Contracting
 Weight loss myth:
Red or Green?

60 kcal 180 kcal