Nutrition Management of Obesity The goal of the treatment of obesity is to achieve weight loss through a decrease in calories consumed

and an increase in energy expended. Target levels for weight loss Aim for 10% reduction from baseline weight as this can significantly decrease the severity of obesity associated risk factors. This is a realistic and achievable target that can be maintained over time. Further weight loss can be considered after this initial goal is achieved and maintained for 6 months. A moderate reduction in caloric intake, which is individually designed to achieve a slow, but progressive weight loss is recommended. A calorie deficit of 500 to 1000 kcal/day can result in weight loss at a rate of 0.5 to 1 kg/week. Rapid weight reduction may lead to increased risk of gallstones, electrolyte abnormalities and weight regain. Quick Formula for calculating calorie requirements for weight reduction* and weight maintenance** Activity Status Overweight & Obese* Normal Weight** 2 (BMI > 23kg/m ) (BMI 18.5- 22.9kg/m2) Sedentary 20 25 kcal/kg 30 kcal/kg Moderate activity 25 30 kcal/kg 35 kcal/kg Marked activity 30 35 kcal/kg 40 kcal/kg Weight for calculation: Use current body weight for all except in the obese (BMI > 27.5 kg/m2) and underweight (BMI < 18.5 kg/m2), calculate using acceptable weight instead i.e. BMI 22 kg/m2.

Dietary Education All weight management strategies should include education in healthy eating habits. Educational efforts should pay particular attention to the following topics: Energy value of different foods Food composition - fats, carbohydrates (including dietary fiber), and proteins Evaluation of nutrition labels to determine caloric content and food composition Development of preferences for low-calorie foods Reduction of high-calorie foods (both high-fat and high-carbohydrate foods) Food preparation limiting fats and oils during cooking Maintenance of adequate water intake Reduction of portion sizes; and Limiting alcohol consumption

Physical Activity Physical activity should be an integral part of weight loss therapy and weight maintenance. It contributes to weight loss by altering energy balance. It favourably changes body composition, decreases risk for disease, and improves quality of life. A regimen of daily walking is an attractive form of physical activity for those who are overweight or obese. Initially the patient can start by walking 10 minutes, 3 days a week, and can build to 30 to of 45 minutes more intense walking at least 3 days a week and increase to most, if not all, days. The exercise can be done all at one time or accumulated over the day. Extremely obese persons may need to start with simple exercises that can be intensified gradually. (Source: Clinical Practice Guidelines on Management of Obesity 2004)

Nutrition Management of Refeeding Syndrome in Pediatrics Patient Source ASPEN, 2003 Dunn, R. L., Stettler, N. & Mascarenhas, R. N. (2003). Refeeding Syndrome in Hospitalized Pediatric Patient. Nutrition in Clinical Practice. Volume 18, pages 327 332 Recommendation Recommendations for initiation of alimentation were to start with either 50% to 75% of resting energy expenditure (predicted or measured) to a maximum of 100% or begin with 80% to 100% of current caloric intake. A patients current caloric intake was defined as what the child received from an oral diet, enteral nutrition, home PN, or IV fluids. The standards of care recommend caloric advancement as a 10% to 20% increase each day until the caloric goal has been met. It is suggested to use the lower end of the initiation and advancement ranges to minimize shifts in laboratory data and a careful review of the bedside data to compare projected versus actual amounts received. Feeding must then be initiated slowly and increased gradually. It is advised to begin feeding at 20 kcal/kg/day or about half of estimated needs with 1.0 to 1.5 g/kg/day protein and careful attention to correction of electrolyte abnormalities. A low-sodium diet and fluid restriction of 1 L/day may also help to prevent fluid overload. Once electrolytes are stable, it is appropriate to advance feeding by 200 to 250 kcal every 2 to 3 days, pending stable blood electrolytes. However, weight gain of more than 2 to 3 lb/week is indicative of fluid retention and all of these clinical guidelines must be tailored to the individual case.

ADA, 2008 Tresley, J. & Sheean, P.M. (2008). Refeeding Syndrome: Recognition Is the Key to Prevention and Management. Journal of the American Dietetic Association. Volume 108, Number 12, pages 2105 2018 Fuentebella. J. & Kerner. J.A. (2009). Refeeding Syndrome. Pediatric Clinics of North America. Volume 56, Issue 5, pages 1201-1210

Proposed ranges for starting feeds include 25% to 75% of resting energy expenditure. In adults, reports recommend starting at 20kcal/kg/d or 1000 kcal/d. In pediatric and adult patients, calorie intake is increased 10% to 25% per day or over 4 to 7 days until the calorie goal is met. Advancement of nutrition is based on biochemical stability. The saying start low, and go slow serves as a good guideline in approaching a malnourished patient. Protein is not restricted during nutritional support. Several studies show that high protein intake spares lean muscle mass and helps in its restoration. Sodium should be restricted to 20 mEq/d and total fluid to 1000 mL/d or less during the initial period of refeeding to prevent fluid overload. Electrolyte deficiencies should be corrected before starting enteral or parenteral support. Supplementation with multivitamins and thiamine is advisable. Checking daily weight also ensures proper fluid balance; the goal of weight gain should be no more than 1 kg/wk. Any weight gain greater than this is likely attributable to fluid retention.