November 2002

A Balanced Approach

By Donald Robertson, MD, MSc

Obesity is an epidemic in the United States; an estimated 61% of adults¹ and 13% to 14% of those aged 19 or younger are overweight or obese.² The major culprit is visceral fat—the kind stored deep in the liver, pancreas, colon, and intestines.³

To address the unique demands of the bariatric patient, I developed a strategy for merging nutritional science, obesity treatment, and total patient care. I have been using a balanced approach to weight loss for more than 24 years and have first-hand experience with the importance of a medically sound program that meets all the needs of a bariatric patient, particularly one in a rehabilitation program.

Any patient who has been injured, is medically ill, or is recovering in any way presents a unique challenge to rehab professionals. If that patient is overweight or obese, the problem becomes more complicated and presents additional challenges for caregivers. In addition to bariatric patients’ need to participate in general rehab, they should also take this opportunity to lose weight. Bariatric patients’ unique challenges must be recognized and dealt with by personnel who have training in bariatric therapy.

The nutritional strategy for the bariatric rehab patient must achieve both weight loss and the healing of an injured body. This is a significant problem with many facets, but it can be broken down into two stages: pretreatment evaluation and development of a nutritional support program.

PRETREATMENT EVALUATION

Developing a nutritional program for a bariatric patient in rehabilitation starts with a pretreatment workup to assess the patient’s condition and extent of comorbidity. The first step in evaluating a bariatric patient is to determine the body fat composition. Body fat is difficult to measure accurately, and methods include bioelectric impedance, computed tomography (CT), hydrodensitometry, magnetic resonance imaging (MRI), skinfold thickness, and sex-specific waist circumference. Sex-specific waist circumference cutoffs are the most widely used, are a clinically feasible measurement, and are generally used in conjunction with body mass index (BMI).

According to the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,⁴ sex-specific waist circumference cutoffs should be used in conjunction with the BMI to identify increased risks. Waist circumference should be used to assess visceral fat content. Excess visceral fat out of proportion to total body fat is an independent predictor of risk factors and morbidity.

BMI should be used to assess overweight and obesity.⁴ Body weight alone can be used to track weight loss and determine efficacy of therapy. BMI is a measurement of body weight, but not composition. Obesity is not the same as overweight. Overweight is an excess amount of body weight and includes muscle, bone, fat, and water; obesity is excess accumulation of body fat. A person can be overweight without being obese, as in the case of a body builder. However, most people who are overweight are also obese.

BMI is calculated by dividing subjects’ weight in kilograms by their height in meters squared. According to the clinical guidelines, a BMI of 18.5 to 24.9 is considered normal.⁴ A patient with a BMI under 18.5 is underweight; a patient with a BMI of 25.0 to 29.9 is considered overweight. A BMI of 30.0 to 34.9 indicates Class I obesity; 35.0 to 39.9, Class II obesity; and over 40.0, Class III (morbid) obesity.

Men with waist circumference greater than 102 centimeters (40 inches) and women with waist circumference greater than 88 centimeters (35 inches) and with BMI of 25 to 34.9 kg/m² are at increased relative risk of developing obesity-associated risk factors.

The other important factor in determining a patient’s status is the presence and degree of comorbidities. Rehab professionals treating bariatric patients may have to deal with major medical complications and/or an unknown number of trauma-induced problems. Other conditions that may be present or afford a risk in the obese patient are cancer, coronary heart disease, diabetes, dyslipidemia, gallbladder disease, gynecologic disorders, hypertension, osteoarthritis, sleep apnea, and stroke. The pretreatment procedure should, therefore, include the following:

• Complete history and physical examination;
• Complete laboratory work and, if necessary, x-rays;
• Cardiovascular workup, depending on the condition of the patient;
• Pulmonary function tests; and
• Other tests, as determined by the attending physician.

THE NUTRITIONAL SUPPORT PROGRAM

A successful nutritional support program should consist of three phases: acute weight loss, a transition program, and a maintenance program. The program should be tailored to meet the individual needs of the patient. The acute phase can begin once a patient is stabilized and comorbidities are evaluated. Other factors to be considered are the healing process and state of the immune system, prevention of blood clots, appetite stimulation, prevention of bed ulcers, and the importance of sleep and the change in resting metabolism due to age.

The acute phase should correct any nutritional deficiencies, such as lack of protein, vitamins or minerals, or anemia. It is estimated that 60% to 90% of American adults are undernourished.⁵ Based on the BMI, the practitioner should set a weight loss goal, which should be to reduce body weight by approximately 10% from baseline. However, this 10% goal must take into account the starting weight and can be purely academic. A weight loss goal of 10% of baseline is not practical or reasonable for a patient who weighs 300 to 400 pounds. A goal of losing only 35 pounds would be unacceptable from a medical standpoint and would be demoralizing to the patient.

The transition period follows the acute phase, and the patient passes from an acute program that focuses on nutritional correction and stabilization toward sustainable weight control. The patient may require pharmacotherapy, behavior therapy, and increased physical activity, depending on the patient’s condition. A maintenance program is a long-term program that involves lifestyle changes to maintain the weight loss beyond 1 year. This phase requires ongoing adherence to practices initiated during behavior modification, such as modification of eating habits and maintenance of physical activity.

The nutritional program includes six major nutrients: carbohydrates, fats, protein, minerals, vitamins, and water. Carbohydrates, fats, and protein contain calories, while vitamins, minerals, and water do not.

Tom Brown, who was injured in a serious car accident, is under the care of Donald Robertson, MD, MSc, for a weight-loss program in order to increase his mobility. He currently alternates between a wheelchair and a walker.

Major research has shown that the body needs adequate protein in order to heal everyday wear and tear.⁶ Protein is the only one of the three basic nutrients (carbohydrates, fats, and protein) that comprises carbon, hydrogen, oxygen, and nitrogen. The body’s nutrition must come from protein during sleep because nitrogen is necessary for the body to repair muscles and for normal daily replacement of enzymes, hormones, and other nutrients. Nitrogen balance must be achieved; otherwise, the body will cannibalize itself in order to obtain the necessary nitrogen. For weight loss and healing, the body needs 1.2 grams of high-quality protein per kilogram of ideal body weight. If there is massive damage (eg, a burn patient) or skeletal damage, this amount can go to 1.5 grams per kilogram or higher, depending on the weight and general medical status of the individual. The addition of calcium, potassium, and multivitamins may also be needed on an individual basis.

This is obviously not the ordinary hospital diet. Choices can include a protein-sparing modified fast (PSMF) diet using conventional food, formula, or a combination. In the case of a badly injured patient who is unable to eat solid food, liquid tube feeding would be used at first, with progression to an all-liquid diet, then to regular food intake. A physician or dietician knowledgeable in this type of diet must supervise this technique since weight loss and body repair constitute a dual goal. If the patient is hospitalized, studies should be performed to make sure the patient is in positive nitrogen balance. Rehabilitation professionals should make sure that physical activity is carefully balanced with nutritional intake.

One important note for bariatric patients requiring intravenous (IV) therapy is that 5% dextrose and water should not be used. This old standby is contraindicated due to the fact that IV glucose is turned into fat, and the body breaks down protein to get the sugar it needs. Use instead 3% amino acid solution or Ringers lactate.

I have used PSMF diets for severely injured bariatric patients. Based on the premise that a patient should lose fat tissue, but not lean body mass, the PSMF diet is intended to provide a positive nitrogen balance. The PSMF diet was developed in the 1970s by George Blackburn, MD, PhD, associate professor of surgery and nutrition at Harvard Medical School. Blackburn, past president of the American Board of Nutrition and the North American Association for the Study of Obesity, found that patients required 1.2 grams of protein per kilogram of ideal body weight in order to maintain a positive protein balance, rather than the 0.8 grams of protein per kilogram that was recommended by the US Department of Agriculture.⁵ Although some high-level athletes can consume on the order of 500 grams of protein per day during high-intensity competition, it is difficult for some people to consume adequate lean protein without consuming excess calories, or to eat lean meats or fish at each meal. One solution is the development of a formula that provides a complete, nutritionally balanced diet. A formula-only plan can ensure that the patient obtains all necessary protein, vitamins, and minerals, while losing weight on a plan that can provide as little as 800 calories per day. Protocols may be supplemented with coordinated nutritional bars and/or some self-prepared foods. Use of nutritional formulas should be supervised by a physician or other knowledgeable health care professional.

For the patient on solid food who is having difficulty sleeping, eating turkey at night may help. In addition to being a high-quality protein source, turkey contains 5-hydroxytryptophan (5-HTP), which is a precursor of serotonin. Serotonin is a neurotransmitter that is important for sleep. In addition, various clinical studies have shown that 5-HTP may improve the sense of well-being, particularly among depressed persons,^6-8 reduce the frequency and the severity of migraine headaches,⁹ improve fibromyalgia symptoms,^10,11 and act as a free radical scavenger.^12,13

The bariatric patient who is able to eat a solid-food diet must also make sure to drink an adequate amount of water. The body’s water comes from three sources: beverages, foods, and via the body’s metabolism of carbohydrate, protein, and fat. Water from the three sources adds up to two to four liters per day. Adequate water intake is extremely important in achieving weight loss. Water helps the body metabolize fat, eliminate fluid retention, suppress the appetite, maintain proper muscle tone, prevent the sagging skin that usually follows weight loss, eliminate waste, and relieve constipation. In addition, the overweight person requires more water than does a thin person—an extra 8-ounce glass for every 25 pounds of excess weight.¹⁴

Bariatric rehab patients require an individualized plan that takes into account their current weight and nutrition level, medical condition, weight loss requirements, and physical activity level. Each patient’s program should be developed and monitored by an experienced physician or other caregiver who can ensure that all of the patient’s medical and weight-loss needs are addressed. The successful weight-loss strategy combines nutritional science, obesity treatment, and total patient care in a time-phased program that ensures long-term maintenance of weightloss.

REFERENCES

1. US Centers for Disease Control and Prevention, National Center for Health Statistics. Prevalence of Overweight and Obesity Among Adults: United States, 1999. 1999 National Health and Nutrition Examination Survey. Available at: www.cdc.nchs/products/pubs/pubd/hestats/obese/obse99.htm Accessed September 19, 2002.
2. US Centers for Disease Control and Prevention, National Center for Health Statistics. Overweight Among US Children and Adolescents. 1999 National Health and Nutrition Examination Survey. Available at: www.cdc.nchs/nhanes.htm. Accessed September 18, 2002.
3. Winfield M. What you should know about the new drug therapies. TeamRehab Report. October 1999;13-17.
4. National Institute of Diabetes and Digestive and Kidney Diseases, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available at: www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm. Accessed September 24, 2002.
5. Huber G, Raines J. Promoting weight loss in the obese patient. Patient Care. 2000;7:204-218.
6. Protein. HarvMen’s Health Watch. 2001;5(6):1-4.
7. Bistrian DR, Winterer J, Blackburn GL, Young V, Sherman M. Effect of a protein-sparing diet and brief fast on nitrogen metabolism in mildly obese subjects. J Lab Clin Med. 1977;89:1030-1035.
8. Shaw K, Turner J, Del Mar C. Tryptophan and 5-hydroxy-tryptophan for depression. Cochrane Database Syst Rev. 2002;1:CD003198.
9. Meyers S. Use of neurotransmitter precursors for treatment of depression. Altern Med Rev. 2000;5:64-71.
10. Birdsall TC. 5-Hydroxytryptophan: a clinically-effective serotonin precursor. Altern Med Rev. 1998;3:271-280.
11. De Benedittis G, Massei R. Serotonin precursors in chronic primary headache. A double-blind cross-over study with L-5-hydroxytryptophan vs placebo. J Neurosurg Sci. 1985;29:239-248.
12. Puttini PS, Caruso I. Primary fibromyalgia syndrome and 5-hydroxy-L-tryptophan: a 90-day open study. J Int Med Res. 1992; 20:182-189.
13. Caruso I, Sarzi Puttini P, Cazzola M, Azzolini V. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res. 1990;18:201-209.
14. Noda Y, Mori A, Liburdy R, Packer L. Melatonin and its precursors scavenge nitric oxide. J Pineal Res. 1999;27:159-163.
15. Simic MG, al-Sheikhly M, Jovanovic SV. Inhibition of free radical processes by antioxidants—tryptophan and 5-hydroxy-tryptophan. Bibl Nutr Dieta. 1989;43:288-96.
16. Robertson DS, Robertson CP. The Snowbird Diet. New York: Warner Books Inc; 1986:35-49.

Donald Robertson, MD, MSc, is trained in internal medicine and gastroenterology. He founded the Southwest Bariatric Nutrition Center in Scottsdale, Ariz, in 1978 and was board certified in bariatrics in 1980.

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