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OS 201 IILE 2B

Case Discussion:
Angel (25 years old, female, 5 feet 2 inches tall, 80 kg) got a weekend off from her work and she decided to join her friends on a beach outing. You happened to be there on the invitation of Angels colleague. When Angel found out that you were a medical student she started asking you questions about losing weight. Some of the questions she asked were:

1. How many calories should I be taking in one day of I want to be healthy? 2. I eat a full meal with rice when I am at work (an 8 hour shift) and a sandwich during breaks. Is this
ok?

3. During busy days, I dont have time to eat so I have a regular Coke and a small bag of potato
chips. I practically starve on those days! Doesnt this make up for the times I eat a heavy meal? Why do I still gain weight? 4. Will exercise help me lose weight?

Learning objectives:
1. Describe the metabolic pathways involved in digestion of foods: a. to determine the difference in metabolism of a normal person and an obese individual b. to discuss the mechanisms involved during pre-prandial and post-prandial periods c. to discuss the mechanisms involved during starvation d. to discuss the metabolic pathways during exercise 2. Formulate a dietary plan: a. to clarify some health misconceptions b. to discuss the concepts of empty calorie foods c. to determine the nutritional value of food labels 3. Formulate an exercise plan: a. to discuss the key concepts in exercise (in terms of FITT)

Discussion Proper: I.
Metabolic Pathways involved in the digestion of food: a. Difference in metabolism of a normal person and an obese individual In terms of pathways and rates involved in metabolism, there is actually no difference in the metabolism of a normal metabolism and an obese individual. However, the problem comes in regulation. This is where genetics and insulin resistance come in. In a study comparing the genes of obesisty-resistant and obesity-prone mice, it has been found that obesity-resistant mice have enhanced expression of the gene coding for carnitine palmitoyl transferase, a protein responsible for transporting free fatty acids through the inner mitochondrial membrane. Obesity-prone mice have less of these proteins, so they oxidize fat stores less, hence the increased weight.

On the other hand, in theory, obese people should have a faster rate of metabolism due to their weight; however, these people usually have a sedentary lifestyle. Moreover, they tend to be insulin resistant. To compensate, their bodies increase the rate of insulin production. This increased insulin would lower blood glucose levels and induce hunger quicker, explaining the fact why obese people eat more often. Moreover, increased insulin stimulates more hormonesensitive lipase, releasing more free fatty acids in the blood. This condition is known as dyslipidemia, characterized by increased very low density lipoproteins concentration and relatively decreased high density lipoprotein in the blood.

b. Mechanisms involved during pre-prandial and post-prandial periods


The body undergoes several biochemical reactions before (pre-prandial) and after uptake of meals (post-prandial). Preprandial- meaning before meals. The preprandial period in the context of medical nutrition means that the patient is assumed to have not eaten food before an important diagnostic e.g., capillary blood glucose or CBG for random blood sugar measurement/monitoring. The two major metaboliic pathways involved are Glycogenolysis and Gluconeogenesis. Glycogenolysis (occurs usually 2-4 hours before meals) In the absence of food intake is absence of exogenous sources of glucose. This creates low ATP reserve in the body. Low glucose, low insulin and high ATP demand stimulate glycogenolysis. Glycogen mainly stored in the liver acts as replenishment for glucose. Debranching degrades glycogen so it can be utilized through glucagon. Glucagon is involved in cAMP formation and phosphorylase activation in the liver. Phosphorylase is the enzyme of rate-limiting reaction in glycogenolysis that breaks down alpha 1->4 glysocisidic bonds. The debranching eznyme is also stimulated, acting on amylo1->6 glucosidic bonds. In essence, glycogenolyis is the conversion of glycogen to glucose for utilization of the cells. Upon decrease in glucose blood levels, glycogenolysis already starts and does not wait until all glucose blood levels are lower than normal (hypoglycemia). Gluconeogenesis (occurs after 1-2 days, depending on glucose reserves) Gluconeogenesis is the formation of glucose or glycogen using noncarbohydrate sources such as carbon skeletons of gluconeogenic amino acids, lactate from muscles, glycerol and propionate. The pathway for gluconegenesis is found in the liver and kidney, and utilizes the reversible processes of the glycolytic pathway plus four reversible reactions. The enzymes of the additional four that circumvent the irreversible nonequilibrium reactions are: pyruvate carboxylase, phosphoenol pyruvate carboxykinase, fructose-1,6-bisphosphatase and glucose-6-phosphatase. Defective enzymes for gluconeogenesis are involved in hypoglycemia and lactic acidosis. During the pre-prandial state, there is an increase glycogen degradation and gluconeogenesis. Around two to four hours after a meal, the glycogen stores in the liver are converted to glucose as a response to an increase secretion of glucagon. Before total depletion of glycogen, the same organ undergoes gluconeogenesis as a transient response to maintain the needed glucose of the body. The latter process is important especially during overnight. On the other hand, during postprandial state, a lot more reactions are happening in order to properluy distribute and utilize the dietary intake of the individual. Below are the summarized processes occuring in the different tissues of the body.

Body tissues

Liver

Carbohydrate phosphorylation of glucose, glycogen synthesis, activity of HMP, glycolysis, gluconeogenesis glucose transport, glycolysis, activity of the HMP

Contents of Dietary Intake Fats fatty acid synthesis, triacylglycerol synthesis synthesis of fatty acids, triacylglycerol synthesis, triacylglycerol degradation Fatty acids are released from chylomicrons and VLDL, however they are of less importance as source of energy compared to glucose. Products from fatty acid oxidation have little contribution to the brains energy fuel.

Protein amino acid degradation, protein synthesis

Adipose tissue

--

Resting skeletal muscle

glucose transport, glycogen synthesis

protein synthesis, uptake of branchedchain amino acids

Brain

Glucose are being used as energy fuel.

--

c. Mechanisms involved during starvation


During starvation, the body has the following priorities: 1. maintain adequate glucose levels (energy metabolism of brain and glucoserequiring tissues) 2. mobilize FA from adipose tissue and synthesis and release of ketone bodies from liver to supply energy to all other tissues. The adipose tissues, brain, muscles and liver have different metabolic profiles and roles to achieve these during starvation. In the adipose tissues, there is a decrease in glucose uptake and a reduction in fatty acid and TAG synthesis. Moreover, stored TAGs are degraded and fatty acids are released into the blood to be processed by the liver. As for the brain, an organ highly dependent on glucose, hepatic gluconeogenesis from amino acids provide its energy source for the first days of fasting. However, during the 2nd to 3rd week of starvation, it starts to utilize ketone bodies along with glucose. Muscles, on the other hand, depend mainly on fatty acids and ketone bodies during the first 2 weeks of starvation. They shift to using fatty acids exclusively thereafter. Furthermore, the

muscles decrease glucose uptake and metabolism. Muscle proteins are also actively degraded as energy source during the first days of fasting. Protein breakdown slows down, however, in longer starvation since the brain starts to rely on both glucose and ketone bodies. Finally, the liver plays key roles in metabolism during starvation. Most importantly, the liver maintains blood glucose through breakdown of glycogen during the first day and gluconeogenesis from amino acids and glycerol for the latter days. These are coupled with increased fatty acid oxidation and ketone bodies synthesis.

d. Metabolic pathways during exercise


During exercise, the body initially uses the Phosphocreatine system for activities that require only a few seconds. Afterwards, it relies on the glycolytic system for the short- to moderate-duration exercise. However for Angel to lose weight, she must rely on the aerobic system of energy production wherein the carbohydrates, fatty acids and amino acids derived from food are oxidized to yield ATP. During the glycolytic system, glucose is only converted to lactic acid as it is oxidized to yield NADH to be utilized to form ATP. This lactic acid is a limiting factor in exercise as it results in muscular fatigue and is converted back to glucose in the liver. Hence, the glycolytic system does not contribute to weight loss. On the other hand, with the aerobic system, the carbohydrates and fatty acids utilized are converted into carbon dioxide and is released from the body, hence leading to weight loss. In terms of energy production, the aerobic system is the most efficient as it produces 36 moles of ATP for every 1 mole of glucose. On the other hand, the phosphocreatine system produces only 1 mole ATP per mole of PCr and the glycolytic system, 2 moles of ATP for every mole of glucose.

II.

Dietary Plan a. Clarifying health misconceptions Skipping breakfast, replacing lunch meals with snack foods, and increasing soft drink intake, can lead to inadequate nutrient intake. - can lead to higher intakes of total fat, saturated fatty acids, cholesterol, and sodium - lower vitamin E, vitamin B6, and folate intakes - insufficient intakes of niacin, riboflavin, vitamin B6, vitamin C, phosphorus, and zinc - insufficient intake of protein, and minerals such as calcium and iron Excessive intake of foods with high carbohydrate and fat contents are the main factors causing nutritional problems - unhealthy dietary patterns include those that are high in total fat, sodium, and refined sugar - risk of chronic diseases including obesity, diabetes, cardiovascular disease, osteoporosis, and cancer may increase as a result of unhealthy nutrition Why fat diets and restricted caloric intake are detrimental to the health?

Excess carbohydrate is stored as fat in humans to provide energy between meals. Lipogenesis converts surplus glucose and intermediates like pyruvate, lactate and acetyl-coA to fat, assisting the anabolic phase of the feeding cycle. The nutritional state of the organism is the main factor regulating the rate of lipogenesis. The rate of lipogenesis is high when one is well-fed and when the diet contains a high proportion of carbohydrate. It is depressed under conditions of restricted caloric intake, on a fat diet or when there is deficiency of insulin as in diabetes mellitus. These conditions are associated with increased concentrations of plasma free fatty acids. There is an inverse relationship between hepatic lipogenesis and the concentration of serum-free fatty acids. Lipogenesis increases when sucrose is fed instead of glucose because fructose bypasses the phosphofructokinase control point in glycolysis and floods the lipogenic pathway. Elevated plasma free fatty acids: - Has been associated with increased cardiovascular risk - may cause peripheral insulin resistance by interfering with the access of insulin to skeletal muscle or interfering with insulin signaling resulting in reduced glucose transport into muscle - Increased flux of FFAs into the liver, particularly from lipolysis of visceral adipose depots, may lead to excessive endogenous glucose production

b. Concept of empty calorie foods


To be able to formulate a dietary plan, the desirable body weight (DBW) must be known. One way of calculating the DBW is through the Tannhauser method. Since the height of the patient is given in feet, it must first be converted to cm, which is 157.5 cm. DBW = (Height in cm 100) x (0.9) DBW = (157.5 cm 100) x (0.9) DBW = (57.5 cm) x (0.9) DBW = 51.7 kg 52 kg Once the DBW is known, the total energy requirement (TER) for the day can be calculated based on the patients activity level. It was stated in the case that she is a call center agent, and according to the Food Exchange List (FNRI, 1994), her activity level is given a factor of 30. This factor is then multiplied to the DBW to obtain the TER. TER = 52 kg x 30 kcal/kg TER = 1560 kcal The TER must be distributed into carbohydrates (CHO), proteins (CHON) and fat. Generally, the distributions are the following: CHO = 55-70% CHON = 10-20% Fat = 20-30% For the patient, the distribution was 65% CHO, 15% CHON and 25% fat. The distributions now have to be translated into grams to complete the diet prescription. The general formula is the following:

Grams per nutrient = (%nutrient x TER)/4 kcal/g for CHO and CHON or 9 kcal/g for fat g CHO = (65% x 1560 kcal)/4 kcal/g = 234 g CHO 235 g CHO g CHON = (15% x 1560 kcal)/4 kcal/g = 58.5 g CHON 60 g CHON g fat = (25% x 1560 kcal)/9 kcal/g = 43.3 g fat 45 g fat The values calculated should be rounded off to the nearest 50 for TER and to the nearest 5 for the macronutrients. The final diet prescription now is 1550 kcal, 235 g CHO, 60 g CHON and 45 g fat. The diet prescription now has to be distributed into exchanges. Exchanges are foods grouped into categories or lists according to similarities in nutritional values. The Food Exchange List is the one used to assign food items to these exchanges.
Table 1. Calculation of Exchanges

Food Veg A Veg B Fruit Milk Sugar Rice Meat Fat SUM

Exchanges 2 1 4 1 3 7 5 4

CHO 3 3 40 12 15 161 234

CHON 1 1 8 14 40 64

Fat 5 20 20 45

Kcal 16 16 160 125 60 700 340 180 1597

Table 2. Distribution of Exchanges

Distribution Veg A Veg B Fruit Milk Sugar Rice Meat Fat

Breakfast 1 1 1 3 2 2

AM Snack 1 -

Lunch 2 1 2 2 -

PM Snack 1 -

Dinner 1 1 1 2 1 2

Table 1 shows the calculation of exchanges, and table 2 shows the distribution of exchanges into different meals. The exchanges were distributed into five meals to distribute food intake and to prevent the patient from feeling hunger. Foods now have to be assigned to the exchanges, and it is seen on table 3. The foods chosen are varied, balanced, and shows moderation by choosing from the different food groups and choosing between different cooking methods.
Table 3. Sample Meal Plan

Exchange Breakfast

Number

Food Item

Amount

Meat Meat Rice Milk Fruit Sugar Fat AM Snack Fruit Lunch Veg A Meat Rice Sugar PM Snack Fruit Dinner Veg B Meat Rice Fruit Sugar Fat

1 1 3 1 1 1 2

Egg Tuyo Steamed Rice Low Fat Milk Banana Sugar Cooking Oil

1 pc fried 3 pcs fried 1-1/2 cup 1 cup 1 pc 1 tsp 2 tsp 1 pc 6 cm diameter or 1/2 pc 8 cm diameter 1 cup 2 pcs 1 cup 1 pc 1 pc 6 cm diameter or 1/2 pc 8 cm diameter 1/2 cup 3 small pcs 1 cup 1 pc 1 tsp 2 tsp

1 2 2 2 1

Apple Cabbage (Nilaga) Beef (Nilaga) Steamed Rice Candy

1 1 1 2 1 1 2

Apple Chopsuey Pork (Chopsuey) Steamed Rice Banana Sugar Cooking Oil

For the patient, compliance to the sample menu should be based on the time of day, and not on her routine because of the effects of the circadian rhythm on metabolism. Breakfast should be taken in the morning, and not when she wakes up during her night shifts, and dinner should be taken in the evening, and not at the end of her shift.

c. Nutritional value of food labels


Nutritional labels generally show the calorie, carbohydrate, protein and fat content of the food item per serving size. The labels show the amount of calories, carbohydrates and fat, and the recommended energy and nutrient intake (RENI) of protein. Carbohydrates and fat do not have a RENI because establishing one may lead to overconsumption, and energy requirements are individualized. Some show a percent value of carbohydrates and protein, but these values refer to the recommended daily intake, which is a different index. Micronutrients, such as Vitamin A, C, Calcium and Iron, are also shown with percent RENI values. For a food item to be rich in a specific nutrient, the percent RENI of that food item for one serving should be greater than or equal to 1/3 of the RENI for the day, e.g. certain juice drinks are rich in vitamin C since one serving provides 100% of the RENI.

III.

Exercise Plan There are numerous kinds of exercise but the main aim of any form of exercise is to maintain or improve performance or health. Together with a balanced diet, regular exercise increases physical fitness, improves health, and even lifts a persons spirits (Goodger,2005).

Cardiovascular exercise is geared towards improving the heart and lung functions of an individual. It helps in building a persons stamina which allows an individual to exercise or perform tasks at longer period of time. Stamina building exercises can be classified as either aerobic or anaerobic. Aerobic exercise makes use of the skeletal muscles at a steady pace which slowly increases the O2 demand of the body which in turn stimulates the various metabolic reactions which were discussed earlier. Anaerobic exercises, on the other hand, are exercise done in short bursts which makes the muscles work hard and thus consuming their O2 supply. For individuals who are not used to having exercise routines, like Angel, it is advisable to start with low level exercises, preferably aerobic exercises such as brisk walking and step aerobics. It is encouraged for her undergo 20 minutes of aerobic exercise 3 times a week in order to stay fit and healthy. References: Cooke, C., Kirk, D., Flintoff, A. & McKenna. (n.d.). Key Concepts in Sport and Exercise Science. Retrieved from http://books.google.com.ph/books?id=t0FsffDvmOAC&pg=PT68&lpg=PT68&dq= exercise+key+concepts+for+obese&source=bl&ots=x_iMHCvqgE&sig=yHTi1Jl2Evtu_onMxCIxIhc5ry 8&hl=en&ei=azFqToPfDJCwiQehvPHrBA&sa=X&oi=book_result&ct=result&resnum=5&ved=0CCoQ6 AEwBA#v=onepage&q&f=false Energy systems in sports and exercise. Retrieved from http://www.sport-fitnessadvisor.com/energysystems.html Goodger, B. (2005). Exercise. Retrieved from

http://books.google.com.ph/books?

id=DfZHrT26Cs wC&printsec=frontcover&dq=exercise&hl=en&ei=nzRqTujAFsOXiQfnncDtBA&sa =X&oi=book_result&ct=result&resnum=2&ved=0CC4Q6AEwAQ#v=onepage&q &f=false


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