NRSG 2203 – An Overview of Nutrition - PowerPoint Presentation

1. NRSG 2203 – An Overview of NutritionDr. Ed. BarreProfessor (full) of Human NutritionDepartment of Health SciencesCape Breton Universityed_barre@cbu.ca

2. Lecture outlineNutrition definedNutrient classesNutritional statusNormal physiological process-ingestion, digestion, absorption, transport, metabolism and excretionNutrition across the lifespan-pre-conception, pregnancy, infancy, childhood, adolescence, adulthood, and seniorsMalnutrition and its consequencesRisk factors for malnutrition-group and individual risk factorsNutritional assessmentClinical management- pre- and post-onsetInterrelationships of nutrition with health and illness conceptsClinical examplesGroup work-case study

3. Nutrition definedNutrition is the science of optimal cellular and extracellular metabolism and its impact on health and disease –while much of metabolism takes place in cells but there is also metabolism outside cells (e.g. in blood plasma)Good nutrition leads to optimal metabolism- optimal metabolism is key to pre- and post-onset management of diseaseGood nutrition includes macronutrients and micronutrients and phytochemicalsPhytochemicals (plant chemicals) variously have antimicrobial, antioxidant, anti-inflammatory and immune-boosting propertiesHowever, various changes in the genome activity via nucleotide base sequence change and/or epigenetics can interfere with the impact of good nutrition

4. 2) Nutrient classesMacronutrients (required in gram amounts in the diet) macronutrients are energy yielding (carbohydrates, lipids (fats and oils), proteins and non-energy yielding (water); alcohol (ethanol) is energy yielding but is not a nutrient Micronutrients (required in milligram or microgram amounts in the diet) micronutrients also include vitamins and minerals-these are non-energy yielding; however they assist in metabolism that produces and uses energyNon–energy yielding nutrients assist in metabolism that yields (via catabolism) and uses energy (via anabolism); water does not yield energy itself but assists in catabolism and anabolism

5. 2) Nutrient classes So how do we get the nutrients WWFQ? Answer- via normal physiological processes of: ingestion (I) which regulates digestion (D) which regulates absorption (A) which regulates transport (T) which regulates metabolism (M) which regulates excretion (E) which regulates ingestion

6. 3) Nutritional statusOptimal nutrition is when one IS getting the nutrients to where (W) they are needed, when (W) they are needed, in the form (F) needed and in quantity (Q) needed in the body for good healthSub-optimal nutrition (malnourished) is when one is NOT getting the nutrients to where (W) they are needed, when (W) they are needed, in the form (F) needed and in quantity (Q) needed in the body for good healthMalnourished means under- or over-nutrition ( mal = bad)

7. 3) Nutritional statusMay be assessed in part by BMI - BMI = kg / metres2Kg is body mass and metres refers to height of person

8. 3) Nutritional status-under-and over-nourished

9. 3) Nutritional statusBody gets nutrients WWFQ by normal physiological processes

10. 4)Normal physiological processes ingestion (I) digestion (D) absorption (A) transport (T) metabolism (M) excretion (E)

11. Ingestionfood and drink into the mouthingestion drives digestion

12. Digestion (mechanical and chemical)Digestion is breaking the food apart to allow enzymatic digestion of certain molecules to a form suitable for absorption (not all molecules have to be broken down for absorption (e.g. glucose)Digestion drives absorption

13. Digestion (mechanical and chemical)Mouth – food undergoes mechanical digestion (chewing) and some chemical digestion via a lipase (triglyceride digestion) and amylase (starch digestion)Stomach-mechanical mixing and chemical digestion via gastric lipase (limited triglyceride digestion); proteins denatured by HCl and then partly digested by pepsinSmall intestine – mechanical mixing occurs; most of carbohydrate digestion (via carbohydrases), lipid digestion (via lipases in conjunction with the emulsifier bile) and protein digestion (via proteases) occurs hereLarge intestine - bacterial enzymes digest some of the dietary fibre and other resistant carbohydrate (humans do not produce enzymes capable of fibre and other resistant carbohydrate digestion)

14. Digestion (mechanical and chemical)Digestion drives absorption

15. AbsorptionPassage of nutrients across the wall of the small and large intestinesAbsorption of products of carbohydrate, lipid and protein digestion by human produced enzymes occurs in the small intestineAbsorption of products of fibre and other resistant carbohydrate digestion (specifically short chain free fatty acids) by bacterial enzymes occurs in the large intestine; water is also absorbed across by the large intestineVitamins absorbed by small intestine and minerals absorbed by the the small intestine and large intestineLarge intestinal bacteria produce vitamin K and biotin-these bacteria-produced vitamins absorbed by the large intestine

16. AbsorptionAbsorption drives transport

17. TransportMovement of nutrients or their products of digestion by the lymph and blood so that nutrients are able to further metabolised in the blood or to be moved into cells for metabolismTransport drives metabolism

18. MetabolismConsists of anabolism (synthesising more complex molecules from simpler molecules, a process that requires energy and also results in energy storage) and catabolism (tearing down molecules resulting in the yielding of energy)Metabolism drives excretion

19. ExcretionGetting rid of metabolic waste (e.g. urine and faeces)Proper excretion drives ingestion

20. Normal physiological processes depend on IDATME to deliver nutrients WWFQ , if nutrients are delivered WWFQ then one has a healthy metabolismDisease and genetics can generate abnormal physiological processes meaning that nutrients are not delivered WWFQ

21. Getting enough but not too much of the nutrients and energy in those nutrients and having such pass through the normal IDATME processes usually results in WWFQ for the nutrients and hence health However disease and/or genetic issues (nucleotide base sequence in DNA and/or epigenetics) interfering with one of more of the IDATME components can result in a failure to produce WWFQ

22. 5) Nutrition across the lifespanPreconceptionGood nutrition includes following Canada’s food guide- this will help provide enough energy and nutrients including 400 mg/day of dietary folate in women who could become pregnant to prevent neural tube defectsA folic acid supplement is recommended in women who have had a previous child with a neural tube defect Good nutrition helps with the production of good quality eggs and sperm and hence increases the chances of conception

23. 5) Nutrition across the lifespanPregnancy and Lactationhealthy diet to ensure mum-to-be does not gain too much weight so as to avoid risk of gestational diabetes mellitus (GDM)- excessive weight gain especially in first trimester increases GDM risk

24. 5) Nutrition across the lifespanPregnancy and Lactation

25. 5) Nutrition across the lifespanPregnancy and Lactationhealthy diet to ensure mum-to-be does not gain too much weight so as to avoid risk of gestational diabetes (GDM)- excessive weight gain especially in first trimester increases GDM riskhealthy diet also ensures both mum to be and baby(ies) developing in utero are getting all the dietary energy and nutrients they need for healthy development-increase carbohydrates, proteins, lipids, water and most vitamins and minerals in dietno alcohol and no smokingvitamin A and other supplements should only be taken if recommended by her physician breast feeding requires energy and nutrients to produce milk -increase carbohydrates, proteins, lipids, water and most vitamins, and minerals in diet as this helps produce sufficient breast milkspecific recommendations are outlined in the dietary reference intake tables

26. 5) Nutrition across the lifespanInfancy (0-1 year)High caloric and nutrient demand to support very rapid growth and developmentBreast feed and/or formula exclusively for first 6 months due to immature GI tract and lack of teeth (remember “breast is best” but formula may be required if breast feeding is not sufficient for baby)At 6 months can introduce infant foods as breast milk and/or formula alone may not able to meet the nutrient and energy requirements for adequate growth and development of infant; Can continue to breast feed well into toddler yearsSpecific recommendations are outlined in the dietary reference intake tables

27. 5) Nutrition across the lifespanChildhood (1-9 years)Small oropharynx in young children puts them at greater risk of choking so only providing food in small bites is importantgood nutrition is important for growth and developmentspecific recommendations are outlined in the dietary reference intake tables

28. 5) Nutrition across the lifespanAdolescence (10-19 years)specific recommendations are outlined in the dietary reference intake tables; these recommendations are directed at growth and development

29. 5) Nutrition across the lifespanYounger adulthood (19-64 years)nutrition for maintenance and healthspecific recommendations are outlined in the dietary reference intake tables

30. 5) Nutrition across the lifespanOlder adulthood (65 years and up)altered taste, less chewing ability, and less saliva affect ingestionreduced absorption and metabolic efficiencyhence all of IDATME affected nutrition should be for maintenance and healthspecific recommendations are outlined in the dietary reference intake tables

31. 6) Malnutrition and its consequencesUnder- and over-nutrition negatively affect IDATME and hence negatively affect WWFQUnder- and over-nutrition represented by specific nutrient or nutrients Causes vary across a broad spectrum and include access, ingestion, digestion, absorption, transport, metabolism and excretionDisturbances in any of IDATME cause incorrect WWFQ and hence health challenges

32. 6) Malnutrition and its consequencesUndernutritionUnder-nutrition represents nutrient and/or caloric deficiencies in ingestion (e.g. kwashiorkor (enough dietary energy but insufficient dietary protein) and marasumus (insufficient dietary energy and insufficient dietary protein))Starvation-related malnutrition- e.g. anorexia nervosa (access to food but does not eat or eats very small amount of food) or lack of access to sufficient foodAcute disease related malnutrition – e.g. after trauma or burns – food is available but person cannot eat normally due to pain or injury related inability to ingest normally-however once under medical care patient can be tube or iv fed.Chronic disease related malnutrition- food is available but person cannot eat normally due to pain and has poor digestion (e.g pancreatic cancer) or diet induced obesity combined with reduced physical activity (Stenholm et al. Curr Opin Clin Nutr Metab Care. 2008 Nov; 11(6): 693–700 leading to muscle loss (Barazzoni and Cappellari. 2020 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455581/pdf/11154_2020_Article_9578.pdf ) (sarcopenic obesity)

33. 6) Malnutrition and its consequencesOvernutritionOver-nutrition represents nutrient and/or caloric excesses in ingestionChildhood obesity measured by BMI compared with percentiles on standardised growth charts – BMI that is between 85th and 95th percentile for same age and sex- overweight; BMI that is in the 95th percentile and up for same age and sex means obesityAdult obesity measured by BMI and better still waist circumferenceObesity in anyone causes problems with metabolism and hence WWFQ

34. 6) Malnutrition and its consequencesOvernutrition- more calories in that expended

35. 6) Malnutrition and its consequencesOvernutrition- more calories in that expendedProblems with BMI is total mass dependent (mass made up of water, muscle, bone, adipose tissue and other tissues)does not tell one how much fat is there and does not indicate where that fat is locatedhowever central obesity (in particular visceral obesity) is the most dangerous obesity in terms of metabolic disturbances leading to increased risk of cardiovascular disease, stroke and type 2 diabetes)

36. 6) Malnutrition and its consequencesOvernutrition- more calories in than expendedProblems with BMI overcome by waist circumference measurement – a good measure of central obesity and surrogate measure of visceral obesity Ethnic-specific values for waist circumferenceCountry or ethnic groupCentral obesity as defined by WCMen - cm (inches)Women - cm (inches)European, Sub-Saharan African, Eastern Mediterranean and Middle Eastern (Arab)94 (37.6) or greater80 (32) or greaterSouth Asian, Chinese, Japanese, South and Central American90 (36) or greater80 (32) or greater

37. How to measure waist circumferencehttp://www.myhealthywaist.org/index.php?id=437

38. 6) Malnutrition and its consequencesOvernutrition-also includes excess intake of one or more micronutrients (vitamins and minerals)Most often occurs with high dose supplements of these nutrients OR if consuming foods with 100 % dietary reference intake value of these nutrients plus an oral supplement plus and micronutrient enhanced drink. Overnutrition causes interference with absorption and metabolism and hence WWFQ

39. 6) Malnutrition and its consequencesMacronutrient deficiencies (partial list)Protein-marasmus, kwashikor, depressed repair/replacement ability, reduced immune responseCarbohydrate – protein is used for energy thus reducing cell growth and repair, - in the longer term ketone formation and utilisation of fat and protein causing weight loss Lipid – essential fatty acid deficiency- can impact vision and cognitive developmentWater- impaired metabolism

40. 6) Malnutrition and its consequencesMicronutrient deficiencies (partial list)Vitamin A - impairment of vision and cellular maintenanceVitamin D - rickets, osteomalacia, osteoporosisVitamin E - red blood cell hemolysisVitamin K - reduced blood clotting abilityVitamin B1 thiamine - beriberiVitamin B2 riboflavin - cheilosis (swollen, cracked lips), hair loss, reproductive problemsVitamin B3 niacin - pellagraVitamin B5 pantothenic acid -numbness and burning of the hands and feet Vitamin B6 pryoxidine dermatitis with cheilosis and glossitis (swollen tongue)Vitamin B7 biotin – hair lossVitamin B9 folate (in food) or folic acid (in supplements) – neural tube defectsVitamin B12 cyanocobalamin –pernicious anaemiaVitamin C- scurvy

41. 6) Malnutrition and its consequencesMicronutrient deficiencies (partial list)Sodium-muscle cramps, loss of appetitePotassiumd-irregular heartbeat, muscular weaknessCalcium-stunted growth in children, osteoporosis in adultsPhosphorous-muscular weakness, bone painMagnesium –weakness, confusionSulphur-none known, would get a protein deficiency prior to sulphur deficiencyIron – anaemia, weaknessZinc –stunted growth, dermatitisIodine –goiter, cretinismSelenium-increased oxidation, associated with Keshan diseaseCopper-anaemia, bone abnormalitiesManganese-rareFluoride-tooth decayChromium-reduced insulin functionMolydenum-unknown

42. 7) Risk factors for malnutrition-groups (i.e. variouspopulations)Age or life stagePregnancy –under-nutrition- poor foetal development; over-nutrition risk of gestational diabetes and macrosomia-vaginal birth can be difficult with macrosomia so caesarian section may be requiredVery Young – under- and over-nutrition vs immature organ development (undernutrition slows or stops organ development; overnutrition cannot be handled by immature organs); as well dependency on others to feed them puts the very young at risk; premature infants are at risk of undernutrition due to impaired oral intake (parenteral or tube feeding denies breast feeding and its many benefits)Seniors – reduced organ function, limited income, interaction between food and medications, isolation (depression), decreased interest in meal preparation, change in appetite, fatigue, and altered taste, and institutionalisation can all lead to under-nutrition

43. 7) Risk factors for malnutrition-groups (i.e. variouspopulations)Ethnicity/RaceAfrican Canadians, Hispanics, and Indigenous persons at greater risk of certain nutrient deficiencies and type 2 diabetes compared to those of European descentThose of European descent at higher risk of type 1 diabetes, coeliac disease and neurodegenerative diseases like Huntington’s and multiple sclerosis all of which may be related to resultant various nutrient deficiencies.

44. 7) Risk factors for malnutrition-groups (i.e. variouspopulations)Poor and UnderservedUnder- and over-nutrition is due to poverty, food insecurity (including food deserts, distance to good quality food, poor or non-existent affordably priced transportation to good quality food)Homeless at particular risk of under-nutrition due to lack of money and/or perhaps access to organisations that help feed the homeless.

45. 7) Risk factors for malnutrition- individual risk factorsGenetics (base sequence and epigenetics)DNA base sequence codes for various proteins- irreversible variations in base sequence can impact any of IDATME – e.g. phenylketonuria (deficiency of enzyme that catabolises phenyalanine with resultant accumulation of phenylalanine in brain blood and tissues causing cognitive dysfunction- a lifelong low phenylalanine diet is required)Epigenetics – no base sequence change in DNA but there is a change of structure of DNA (e.g. methylation) that changes levels of expression of DNA and hence levels of protein formed; consequently can get impact on any of IDATME; poor diet can cause deleterious epigenetics which can be passed from generation to generation but is reversible with improved diet- e.g. some food molecules may, via epigenetics, prevent or cause cancer

46. 7) Risk factors for malnutrition - individual risk factorsLifestyle and patterns of eatingstress, ability to cope, mood and economics all influence the quantity and quality of nutritionparental influence- if good role model in terms of nutrition it usually means the offspring will have good eating habits; if bad role model then usually means the offspring will have poor eating habits good or bad nutrition affects epigenetics

47. 7) Risk factors for malnutrition- individual risk factorsPersonal food choicesCravings – e.g. pregnancy- may cause overconsumption of some nutrients - and hence cause epigenetic-related and other problems (e.g. macrosomia as discussed previously today)Fad diets can result in nutrient deficiencies and hence cause epigenetic-related and other problemsVegan diets if done well are not an issue- done poorly, nutrient deficiencies (e.g. essential amino acids, B12, vitamin D, zinc) may arise and hence cause epigenetic-related and other problems

48. 7) Risk factors for malnutrition - individual risk factorsUnderlying medical conditionsImpaired oral intake – due inability to chew (teeth issue) or swallow (e.g. neurological issues such as stroke); impaired sense of smell (e.g Parkinson’s) ; poor nutrition due to mental health issues (anorexia nervosa, mood disorder, anxiety and depression)-impaired oral intake affects DATMEImpaired digestion (e.g. lactose intolerance, cystic fibrosis) and absorption (e.g. due to poor digestion or coeliac disease) and metabolism (e.g. phenylketonuria)Increased metabolic demand- risk of protein calorie malnutrition if cannot meet that demand; increased demand arising from cancer, COPD, trauma, stroke, burns etc.); enteral (tube) or parenteral nutrition may be requiredAltered organ function- failure of organs -metabolism (e.g. liver in protein synthesis) and kidney failure (loss of proteins in urine, reduced formation of active form of vitamin D and hence calcium absorption; limited fluid, potassium and phosphorous intake can be challenging)

49. 8) Nutritional assessmentHistoryFood intake history is an emotional issue- growth and development in children as related to nutrition is a particularly sensitive topicHence, trust and rapport with one’s patient and/or the patient’s family is critical to getting good information about dietQuestions focus on medical history, current medical conditions and current medications, family history, social history, chief complaint, presenting symptoms as they may relate to nutritionNutrition-related questions focus on unplanned weight change, changes in appetite and intake, diet restrictions (e.g. food allergies and intolerances, food quality and quantity) nausea and vomiting, chewing and swallowing difficulties, abdominal pain or discomfort, bowel habit changes, and recent history of prolonged constipation or diarrhea.- all this related to IDATME and hence WWFQ

50. 8) Nutritional assessmentExamination findingsBMI – if abnormal (lower or higher than healthy BMI of 18.5-24.9) or even if normal, assess nutrient intakes in all 6 classesIf normal BMI then nutrient intake assessment is a double check-if there is suspicion of under- or over-intake of one or more nutrients then lab tests can confirm or reject suspicion

51. 8) Nutritional assessmentExamination findingshealthy skin-smooth, elastic, good turgor and no crackshair- shiny and not brittlenail beds- smooth, pink, firmteeth-not loose and absence of cavitiesoral cavity- moist, pink, firmmucous membranes around eyes - pink, moist and lesion-freesclera-whitecornea-clear and shinyall of above are positive but not sole indicators of good WWFQ

52. 8) Nutritional assessmentDiagnostic testsSerum albumin- if low-indicator of protein calorie mal(under)nutrition, inflammation, blood loss, fluid status; pre-albumin is a better indicator of recent nutritional statusC-reactive protein- indicator of generalised inflammation-can occur due to calorie overnutrition

53. 8) Nutritional assessmentDiagnostic testsElevated plasma glucose – pre-type 2 diabetes or types 1, 2 or gestational diabetesHbA1c-measure of blood glucose history over last 3 months-elevations suggest pre-type 2 diabetes or type 1, 2 or gestational diabetesIf elevated plasma glucose or HbA1C- dietary changes, exercise, oral medications and/or insulin are indicated

54. 8) Nutritional assessmentDiagnostic testsLipids – elevated plasma total cholesterol, LDLc, triglycerides and decreased HDLc - may arise to high simple carbohydrate diet, high saturated fat diet and/or be associated with types 1, 2 and gestational diabetesElectrolytes - related to dietary intake and/or renal or liver or diabetesHaemoglobin and hematocrit-used to diagnose anaemias variously resulting from iron, folate and vitamin B12 deficiencies in IDATME and hence WWFQ of these nutrients

55. 9) Clinical management - pre- and post-onsetThe onset of many diseases is linked to poor quantity and quality (i.e. under- and over-nutrition); however genetics (gene nucleotide base sequence and epigenetics) and other factors also play a role in disease onsetDisease outcome management also in whole or in part depends on the disease-specific quality and quantity of nutrition, genetics (gene sequence and epigenetics) and other factors also play a role in disease outcome

56. 9) Clinical management - pre- and post-onsetPre-onset - greatest power of nutrition is pre-onsetHealthy eating (Canada food guide https://food-guide.canada.ca/en/food-guide-snapshot/), food labelling (https://www.canada.ca/en/health-canada/services/food-nutrition/food-labelling/nutrition-labelling.html) and exercise (https://csepguidelines.ca/wpcontent/uploads/2020/10/24HMovementGuidelines-Adults18-64-2020-ENG.pdf) and breast feeding is ideal for at least the first 6 months (if breast feeding is insufficient then formula is a reasonable substitute). All are important to the prevention of many diseases via IDATME and hence WWFQ

57. 9) Clinical management - pre- and post-onsetPre-onsetAdults- Screening for lipids (plasma high density lipoprotein cholesterol, low density lipoprotein cholesterol, total cholesterol and triglycerides), BMI, waist circumference, blood glucose are important as they are related to many diseases if not at healthy levels - improved diet and exercise patterns sometimes combined with medications are indicated; bariatric surgery may be used.Infants- screening for numerous genetically linked diseases like phenylketonuria, maple syrup disease, galactosemia; these require changes in diet; also infants are screened for diseases that affect certain aspects of IDATME like cystic fibrosis and HIV.

58. 9) Clinical management - pre- and post-onsetPost-onsetAdjustments in diet are meant to address any shortcomings in IDATME and hence WWFQ

59. 9) Clinical management - pre- and post-onsetPost-onsetCollaborations between nurses, physicians, and dietitians to ensure adjustments in diet address any shortcomings in IDATME and hence WWFQ Personalised nutrition- one size (i.e. approach) does not fit all. Genetics and epigenetics can dictate responsiveness to a given approach. Approaches taken may be by trial and error.

60. 9) Clinical management - pre- and post-onsetPost-onsetIngestion- oral, enteral (tube (e.g. nasogastric or percutaneous endoscopic gastrostomy tube) - if digestive tract is functioning normallyIngestion- parenteral:-short term is done by peripheral iv; longer term is done by central line into vena cavaBariatric surgery and/or pharmacological approaches (weight loss, statins, supplements, glucose management) may usedAll approaches meant to deliver correct issues with WWFQ

61. 10) Interrelationships of nutrition with health and illness conceptsGlucose managementImmunityTissue integrityThermoregulationDevelopment (e.g. cognitive, growth, maturation, etc.)All above and all other maintenance and regulation aspects of human metabolism require WWFQ of nutrientsDevelopment stage, culture and spirituality (religious observances and rituals) determine dietary patterns

62. 11) Clinical examples https://vimeo.com/485658885/71ce092bb

63. 11) Clinical examplesProtein calorie malnutritionKwashiorkor-enough energy but not enough protein intake-can occur in anyone (infants to adults) but more common in the youngMarasmus-not enough energy and not enough protein intake-can occur in anyone (infants to adults) but more common in the youngInsufficient energy and protein intake can occur in those who hospitalised long term (acute illness or injury) and care homes for the elderly but usually less severe

64. 11) Clinical examples

65. 11) Clinical examplesAnorexia nervosafear of weight gain so insufficient calorie and nutrient intake combined with excessive exercisemost common in adolescent females but can occur in at any age and in any genderSevere cases – marasmus can occur

66. 11) Clinical examplesCoeliac diseaseAutoimmune generated inflammatory response that occurs in the small intestine due to gluten (a protein found in wheat, rye and barley naturally and in oats contaminated with gluten due to gluten contaminated oat processing equipment)Abdominal discomfort, bloating, diarrhea, nausea and reduced nutrient absorptionGluten sensitivity-milder abdominal discomfort, bloating, diarrhea, nausea and reduced nutrient absorption compared to coeliac diseaseIn coeliac disease and gluten-sensitive persons- avoid gluten

67. 11) Clinical examplesObesityMore calories in than expendedHas socioeconomic (poverty, education, advertising, food deserts), poor opportunities for exercise and genetic causesResults in sleep apnea and also results in oxidation and low grade inflammation which result in increased risk of type 2 diabetes, atherosclerotic heart disease, stroke, fatty liver,, hypertension, certain cancers (colon, breast, prostate, etc.) and other issues

68. 11) Clinical examplesObesity - BMI

69. 11) Clinical examplesObesityProblems with BMI is mass dependent (mass made up of water, muscle, bone, adipose tissue and other tissues)does not tell one how much fat is there and does not indicate where that fat is locatedhowever central obesity (in particular visceral obesity) is the most dangerous obesity in terms of metabolic disturbances leading to increased risk of cardiovascular disease, stroke and type 2 diabetes, hyperlipidaemia etc.)

70. 11) Clinical examplesObesityProblems with BMI overcome by waist circumference measurement – a good measure of central obesity and surrogate measure of visceral obesity Ethnic-specific values for waist circumferenceCountry or ethnic groupCentral obesity as defined by WCMen - cm (inches)Women - cm (inches)European, Sub-Saharan African, Eastern Mediterranean and Middle Eastern (Arab)94 (37.6) or greater80 (32) or greaterSouth Asian, Chinese, Japanese, South and Central American90 (36) or greater80 (32) or greater

71. 11) Clinical examplesHyperlipidaemiaHigh plasma total cholesterol, low density lipoprotein cholesterol and triglyceride concentrationsCentral obesity as well as high fructose and sucrose intake have been implicated causally in hyperlipidaemiaHigh plasma triglyceride levels result in low plasma high density lipoprotein cholesterol and more aggressive low plasma high density lipoprotein (more aggressive in terms of cholesterol deposition in the arterial wall)Hyperlipidaemia can have a genetic basis

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73. 12) Group work-case studyPlease go through case study and identify:What is class II obesityWhy the patient developed certain pathologiesIssues arising from those pathologiesApproaches taken to manage those issuesWhy those management approaches were takenWhat were the likely outcomes of the management approaches in the short and long termsWhat approaches may have prevented the pathologies and why would those approaches work- Why use the word “may”

74. Lecture summaryNutrition definedNutrient classesNutritional statusNormal physiological process-ingestion, digestion, absorption, transport, metabolism and excretionNutrition across the lifespan-pre-conception, pregnancy, infancy, childhood, adolescence, adulthood, and seniorsMalnutrition and its consequencesRisk factors for malnutrition-group and individual risk factorsNutritional assessmentClinical management- pre- and post-onsetInterrelationships of nutrition with health and illness conceptsClinical examplesGroup work-case study