Long term postoperative nutritional management of ischemic patients

1. Long term postoperative nutritional management of ischemic patients By Amr Abdelmonem,MD. Assistant professorof anesthesia ,surgical intensive care and clinical nutrition in faculty of medicine, Cairo university Member of North American Association For The Study Of Obesity Member of the American society of regional anesthesia and pain medicine

2. PathoPhysiologic Mechanisms Of Appetite Regulation Levin, BE. (2004) The drive to regain is mainly in the brain Am J Physiol Regul Integr Comp Physiol. 287,R1297-R1300 Woods, SC, Seeley, RJ. (2002) Understanding the physiology of obesity: review of recent developments in obesity research Int J Obes Relat Metab Disord. 26(Suppl 4),S8-S10 Horvath, TL, Diano, S. (2004) The floating blueprint of hypothalamic feeding circuits Nat Rev Neurosci. 5,662-667

3. CCK serotonin GLP-1 PYY(3-36) Glucagon Amylin Ghrelin Arc NTS AP Vegally dependent NPY-AGRP ↑Satiety ↑Feeding ↑Satiety

4. NTS Leptin

5. The metabolic syndrome

6. ATP III Guidelines WHO Guidelines Abdominal Obesity Waist CircumferenceWaist/Hip Ratio Men > 40 inches (102 CM)  >0.90 Women > 35 inches (88 CM)  >0.85 Triglycerides150 mg/dL 150 mg/dL HDL-Cholesterol Men < 40 mg/dL <35 mg/dL  Women < 50 mg/dL <39 mg/dL Blood Pressure130/ 85 mm Hg >140/>90 mm Hg Fasting Glucose110 mg/dL 110 mg/dL

7. IDF NCEP International Diabetes Federation National Cholesterol Education Program Central Obesity Waist Circumference Men  90 CM Women  80 CM Triglycerides150 mg/dL HDL-Cholesterol Men < 40 mg/dL  Women < 50 mg/dL Blood Pressure130/ 85 mm Hg Fasting Glucose100mg/dL

8. Triad of Low HDL , High LDL and Increased Triglyceride concentrations

9. Coronary Heart Disease

10. Therapeutic life style changes treatment plan : diet and physical activity

11. Behavioral Modifications

12. SELF-MONITORING • STIMULUS CONTROL • COGNITIVE RESTRUCTURING • STRESS Management • SOCIAL SUPPORT

13. Therapeutic life style changes diet

14. Nutrient Total fat Saturated fat Polyunsaturated fat Monounsaturated fat Cholesterol Carbohydrate (esp.complex) Protein Dailly recommended intake 25-35%of total calories <7%of total kilocalories Up to 10 %of total calories Up to 20% of total calories <200 mg 50-60 %of total calories 15 % of total calories ATP III nutritional components of the TLC diet

15. Evaluation of the program by the physician • The match between the program and the consumers • The soundness and safety of the program: • Assessment of physical health and psychological status • Attention to diet and pharmacotherapy • Attention to physical activity • Program safety • Outcome of the program • Long-term weight loss • Improvement in obesity related comorbidities • Improved heath practice • Monitoring adverse effects that might result from the program

17. Caloricrestriction • Normal caloric intake 20-25 calories for each Kg of the body weight or • According to Harris-Benedict equation: For males RMR= 66.4+ 13.8 W + 5H – 6.8A For females RMR= 665+ 9.6W+ 1.8H – 4.7A W=weight (kg), H = height (cm), and A= age (yr) e.g. weight : 120 kg H= 175 A=35 RMR= 66.4 + 13.8(120)+5(175) – 6.8(35)=2359.5 • Less than 500 calories deficit per day➞ weight loss of .5 Kg per week

18. Energy Density • Definition Amount of energy in a given weight of food (kcal/g) • For the same amount of energy ,a greater weight of food can be consumed when the food is low in energy density than when its energy density is high Barbara j ,et al. J Am Diet Assoc.2005;105:S89

19. Glycemic Index • Jenkins and his collegues developed the GI. • The GI for a food was defined relative to a standard food (glucose or white bread). • Over a 2-hour period, the area under the glucose response curve after consuming 50 grams of carbohydrate from the test food was compared with the area under the glucose response curve after consuming 50 grams of carbohydrate from the reference food. • Both levels were given as the difference from fasting blood glucose levels . • The tests have been done in both healthy people and people with diabetes.

20. Jenkins and his colleagues have proposed that • All carbohydrates are not equivalent and that the rate of absorption of carbohydrate foods into the bloodstream is a critical factor in hyperinsulinemia. • Slowly absorbed foods would be beneficial because they trigger less of a rise and fall in blood glucose and, thus, less of a rise and fall in insulin levels

21. American Society for Clinical Nutrition, has noted that a number of diet strategies exist for weight loss and that different individuals may find different strategies useful. • Although they do not specifically endorse either the GI or energy density as methods for choosing foods, they have noted that both have some support in the literature and that further research into them is warranted • Klein, S, Sheard, NF, Pi-Sunyer, X, et al (2004) Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies. A statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition Am J Clin Nutr. 80,257-263

22. Final Comment