OBEZ HASTALARDA BESLENME YÖNETİMİ. Diyetisyen Nüket TURAN

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1 OBEZ HASTALARDA BESLENME YÖNETİMİ Diyetisyen Nüket TURAN

2 Obezite Obezite genel olarak bedenin yağ kütlesinin yağsız kütleye oranının aşırı artması sonucu boy uzunluğuna göre vücut ağırlığının arzu edilen düzeyin üstüne çıkmasıdır.. 2

3 World Health Organization Obesity Classes According to BMI BMI Nutritional Status Below 18,5 Under Weight 18,5 24,9 Normal Weight 25 29,9 Pre-Obesity 30 34,9 Obesity Class I 35 39,9 Obesity Class II Aboue 40 Obesity Class III Konu başlığımız hernekadar obezite yönetimi olsa da son dönem böbrek yetmezliğin de (SDBY) mortalite ve morbiditeden büyük ölçüde sorumlu malnütrüsyondur. Ve bu nedenle obezite yönetiminde yağ ve /veya kas kütlesinin sağkalım süresine pozitif katkılarını göz ardı etmemeliyiz ve bu nedenle obezite yönetiminde öncelikli kas korunumu planlanarak SDBY de agresif bir yaklaşım planında bulunulmamalıdır. 3

4 Enerji İhtiyacı Yetersiz enerji alımı düşünüldüğünde alınan proteinin glikoneogenez aracılığı ile enerji açığını kapatmak için kullanılmasının önlenmesi amaçlı yeterli kalori alımına ihtiyaç vardır. Burada enerji ihtiyacını obezite yönetiminde olması gereken ağırlık(oga) üzerinden hesaplıyoruz. Hemodiyaliz hastalarında BMI> olmalıdır. Doku yıkımı ve negatif azot dengesinin oluşmaması için yüksek kalori önerilir. 4

5 Protein İhtiyacı Protein ihtiyacı yine saptanan OGA değerine göre belirlenir. Bazı aminoasitler vücut tarafından sentezlenemez. Bunlar esansiyel aminoasitlerdir. Esansiyel aminoasitten zengin proteinler, yani biyoyararlılığı yüksek protein kaynakları; yumurta, yumurta beyazı, süt, dana eti, tavuk eti, balık eti şeklinde tıbbi beslenme tedavisine dahil edilmelidir. Diyaliz sıvısı ile aminoasit kayıpları ve metabolik bozukluklar nedeniyle protein katabolizması artışı gerçekleşmekte ve bu nedenle yüksek protein alımı önerilir. 5

6 Karbonhidrat İhtiyacı Proteinleri enerji kaynağı olarak kullandırmamak için diyetin karbonhidrat oranı yeterli olmalıdır (enerjinin %50-60 ı ). 6

7 Yağ İhtiyacı SDBY hastaları kardiyovasküler risk altında oldukları için diyette doymuş yağların (margarin, tereyağı, yağlı etler, yağlı süt ve süt ürünleri), doymamış yağlara (zeytinyağı, kanolayağı, keten tohum, aspiryağı, avokado, balık, yağlı tohumlar) oranı düşük tutulmalıdır. Trans yağlar kullanılmamalıdır. Yağdan gelen enerji %30 un altında tutulmalıdır. 7

8 NATİONAL KİDNEY FOUNDATİON Böbrek Yetmezliği Evrelerine Göre Nutrient İhtiyacı Nutrisyonel Parametre Böbrek fonksiyonları normal Stage 1-4 kronik böbrek hastalığı Kalori(kkal/kg) <60 yaş yaş Stage 5 Hemodiyaliz Hastası Stage 5 Peritoneal Diyaliz Hastası Transplantasyon 35<60 yaş 35<60 yaş başlangıç devam Protein(g/kg/gün) 0,8 0, ,2 1,2-1,3 1,3-1,5 başlangıç 1 devam Yağ(%kkal) Bu hastalar kardiyovasküler olay açısından yüksek risklidir. Poliansatüre monoonsatüre yağ oranlarına dikkat edilmelidir günlük mg kolesterol önerilir. <10 sature yağ Sodyum(mg/dl) Kısıtlama yok Kısıtlama yok takip edilmeli Potasyum(mg/dl) Kısıtlama yok Lab. Sonucuna göre davran Kısıtlama yok takip edilmeli Kalsiyum(mg/dl) Kısıtlama yok Fosfor(mg/dl) Kısıtlama yok Lab. Sonucuna Kısıtlama yok takip göre davran. edilmeli Sıvı(ml/gün) Kısıtlama yok İdrar çıkışı normal ise kısıtlama yok günlük idrar miktarı Takip et Kısıtlama yok takip edilmeli 8

9 Obesity Paradox in End-Stage Kidney Disease Patients Jongha Parka,b,, Seyed-Foad Ahmadia, Elani Strejaa, Miklos Z. Molnara, Katherine M. Flegalc, Daniel Gillena,d, Csaba P. Kovesdye,f, Kamyar Kalantar-Zadeh Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea Centers for Disease Control and Prevention (CDC), Hyattsville, MD Department of Statistics, University of California Irvine, Irvine, CA Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA A B S T R A C T In the general population, obesity is associated with increased cardiovascular risk and decreased survival. In patients with end-stage renal disease (ESRD), however, an obesity paradox or reverse epidemiology (to include lipid and hypertension paradoxes) has been consistently reported, i.e. a higher body mass index (BMI) is paradoxically associated with better survival. This survival advantage of large body size is relatively consistent for hemodialysis patients across racial and regional differences, although published results are mixed for peritoneal dialysis patients. Recent data indicate that both higher skeletal muscle mass and increased total body fat are protective, although there are mixed data on visceral (intra-abdominal) fat. The obesity paradox in ESRD is unlikely to be due to residual confounding alone and has biologic plausibility. Possible causes of the obesity paradox include protein-energy wasting and inflammation, time discrepancy among competitive risk factors (undernutrition versus overnutrition), hemodynamic stability, alteration of circulatory cytokines, sequestration of uremic toxin in adipose tissue, and endotoxin-lipoprotein interaction. The obesity paradox may have significant clinical implications in the management of ESRD patients especially if obese dialysis patients are forced to lose weight upon transplant wait-listing. Well-designed studies exploring the causes and consequences of the reverse epidemiology of cardiovascular risk factors, including the obesity paradox, among ESRD patients could provide more information on mechanisms. These could include controlled trials of nutritional and pharmacologic interventions to examine whether gain in lean body mass or even body fat can improve survival and quality of life in these patients. 9

10 Obesity Paradox in End-Stage Kidney Disease Patients Jongha Parka,b,, Seyed-Foad Ahmadia, Elani Strejaa, Miklos Z. Molnara, Katherine M. Flegalc, Daniel Gillena,d, Csaba P. Kovesdye,f, Kamyar Kalantar-Zadeh Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea Centers for Disease Control and Prevention (CDC), Hyattsville, MD Department of Statistics, University of California Irvine, Irvine, CA Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA A B S T R A C T In the general population, obesity is associated with increased cardiovascular risk and decreased survival. In patients with end-stage renal disease (ESRD), however, an obesity paradox or reverse epidemiology (to include lipid and hypertension paradoxes) has been consistently reported, i.e. a higher body mass index (BMI) is paradoxically associated with better survival. This survival advantage of large body size is relatively consistent for hemodialysis patients across racial and regional differences, although published results are mixed for peritoneal dialysis patients. Recent data indicate that both higher skeletal muscle mass and increased total body fat are protective, although there are mixed data on visceral (intra-abdominal) fat. The obesity paradox in ESRD is unlikely to be due to residual confounding alone and has biologic plausibility. Possible causes of the obesity paradox include protein-energy wasting and inflammation, time discrepancy among competitive risk factors (undernutrition versus overnutrition), hemodynamic stability, alteration of circulatory cytokines, sequestration of uremic toxin in adipose tissue, and endotoxin-lipoprotein interaction. The obesity paradox may have significant clinical implications in the management of ESRD patients especially if obese dialysis patients are forced to lose weight upon transplant wait-listing. Well-designed studies exploring the causes and consequences of the reverse epidemiology of cardiovascular risk factors, including the obesity paradox, among ESRD patients could provide more information on mechanisms. These could include controlled trials of nutritional and pharmacologic interventions to examine whether gain in lean body mass or even body fat can improve survival and quality of life in these patients. 10

11 Obesity Paradox in End-Stage Kidney Disease Patients Jongha Parka,b,, Seyed-Foad Ahmadia, Elani Strejaa, Miklos Z. Molnara, Katherine M. Flegalc, Daniel Gillena,d, Csaba P. Kovesdye,f, Kamyar Kalantar-Zadeh Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, School of Medicine, Orange, CA, USA Division of Nephrology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea Centers for Disease Control and Prevention (CDC), Hyattsville, MD Department of Statistics, University of California Irvine, Irvine, CA Division of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN, USA Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA A B S T R A C T In the general population, obesity is associated with increased cardiovascular risk and decreased survival. In patients with end-stage renal disease (ESRD), however, an obesity paradox or reverse epidemiology (to include lipid and hypertension paradoxes) has been consistently reported, i.e. a higher body mass index (BMI) is paradoxically associated with better survival. This survival advantage of large body size is relatively consistent for hemodialysis patients across racial and regional differences, although published results are mixed for peritoneal dialysis patients. Recent data indicate that both higher skeletal muscle mass and increased total body fat are protective, although there are mixed data on visceral (intra-abdominal) fat. The obesity paradox in ESRD is unlikely to be due to residual confounding alone and has biologic plausibility. Possible causes of the obesity paradox include protein-energy wasting and inflammation, time discrepancy among competitive risk factors (undernutrition versus overnutrition), hemodynamic stability, alteration of circulatory cytokines, sequestration of uremic toxin in adipose tissue, and endotoxin-lipoprotein interaction. The obesity paradox may have significant clinical implications in the management of ESRD patients especially if obese dialysis patients are forced to lose weight upon transplant wait-listing. Well-designed studies exploring the causes and consequences of the reverse epidemiology of cardiovascular risk factors, including the obesity paradox, among ESRD patients could provide more information on mechanisms. These could include controlled trials of nutritional and pharmacologic interventions to examine whether gain in lean body mass or even body fat can improve survival and quality of life in these patients. 11

12 Reverse association of body mass index (BMI) and survival in patients with advanced chronic kidney disease (CKD) as compared to the general population. 12

13 Unadjusted and adjusted hazard ratios and 95% confidence intervals for all-cause mortality associated with BMI in 20,818 Korean HD patients. The model was adjusted for case-mix (age, sex, DM, dialysis history, dialysis dose, hemoglobin) and nutritional (serum albumin, and daily protein intake) covariates. 13

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16 Reverse association of body mass index (BMI) and survival in patients with advanced chronic kidney disease (CKD) as compared to the general population 16

17 Obesity is a risk factor for chronic kidney disease (CKD), yet it protects against CKDassociated death. ESRD, end-stage renal disease 17

18 Sonuç Obezite paradoksunun varlığı etiyoloji ve bileşenlerini aynı zamanda gelişmiş CKD, PEW ve malnutrisyon sendromunun rolünü anlamak için gelecekte yine daha çok çalışmaya ihtiyaç var. 18

19 Olgu 1 46 yaşında erkek Evli 2 çocuk babası, memur TANI: Hipertansiyona bağlı nefropati 2.5 Yıl hemodiyaliz 3gün / hafta ile 4 saat Son bir yıl ev hemodiyalizinde 3 gün/hafta 8 saat gece diyalizi uyguluyor Kuru Ağırlık: kg Boy : cm BMI: 31.3 OGA: BMI x (boy) 2 (m 2 ) 23 x (1.905) 2 İdeal ağırlık :86 kg 19

20 Olgu 1_Şikayet: *iki hemodiyaliz seansı arasında 4 kg ve üzeri kilo alımı *ritmik kuru ağırlık(ka) artışı 3 ay önceki KA : kg 2 ay önceki KA: 113 kg Görüşme tarihimiz ay önceki: kg Reflü kaynaklı gece sıkıntıları, konstipasyon Banyo sonrası daralma hissi Konrtol edilemeyen bir iştah sorunu ile artan kuru ağırlık 2517 kalori /gün %16 protein (% 63 ü biyolojik değeri yüksek kalite protein) % 29 yağ %55 karbonhidrat Oranları ile tıbbi beslenme programı düzenlendi. 30 dk/ gün yürüyüş önerildi Temel hedef iştah kontrolü yeterli ve dengeli beslenme ile kilo alımının durdurulması. Uzun vade de kas korunumu esas alınarak kilo kaybı takip ediliyor/edilecek 20

21 Olgu-2 63 yaşında bayan Bekar iki çocuk annesi TANI: Hipertansiyon, insülin direnci, yüksek kilo, hipotroidi, huzursuz bacak sendromu Kilo: 79,1 kg Boy: 166 BMI: 29 OGA:BMI x (boy) 2 (m 2 ) 23 x (1.66) 2 OGA: 64 kg 21

22 Olgu 2_Şikayet: Yürümede çabuk yorulma ve belde bacakta ağrı şikayeti Rafine ve kompleks karbonhidrat tüketiminde büyük zafiyet ritmik kilo artışı Kontrolsüz hipertansiyona bağlı sıkıntılar, estetik kaygılar ÖNERİLER: 50 gram protein ve 1377 kalorilik tıbbi beslenme tedavisi %14 protein, %32 yağ, %53 karbonhidrat (kilo alımına karşı yaşadığı kaygıdan kaynaklı karbonhidrat ve kalori alımına dirençli 6 ayda 13 kg kayıp ile bel ağrısında azalma Kontrollü seyreden bir hipertansiyon ve antihipertansif ilaç sayısında azalma (norvask 10mg iptal) Ortadan kalkmış tatlı yeme atakları Kreatinin: 1.56 mg/dl 1.22mg/dl e-gfr(ckd-epi): Albumin : 4.2 gr/dl 4.16gr/dl 22

23 Association Between Obesity With Low Muscle Mass And Dialysis Mortality Authors: Wu HC, Tseng SF, Wang WJ, Chen HJ, Lee LC. AIMS: This study examines the association between body composition and dialysis mortality. METHODS: Adult patients who initiated hemodialysis in Taoyuan General Hospital from 2012 to 2016 were enrolled. We reviewed baseline characteristics and followed over 5 years after dialysis. Patients with body mass index > 25 Kg/m(2) were defined as obesity. High or low muscle mass were classified by skeletal muscle mass index (SMMI) based on consensus from Chinese population. All age-matched subjects were classified into 4 groups: (A) optimal; (B) obesity; (C) low muscle mass; and (D) obesity with low muscle mass. Adjusted hazard ratios (AHRs) for mortality and cumulative survival curves were evaluated by Cox proportional hazard model and Kaplan Meier method. The discriminative power of SMMI was calculated according the area under the curve and the receiver operating characteristic curve. RESULTS: From a total of 176 age-matched patients, the incidence rate of death for different groups were 3.7, 7.8, 10.3 and 16.5 per 1000 person-months. After adjusting for continuous variables, SMMI were independently associated with mortality. The difference between group A and D was more significant in women than those in men after multivariate adjustment (AHRs: vs ) (P = and 0.553). The discriminative power of SMMI to predict 5-year mortality were for men and for women, with the best cut-off value were 11.1 Kg/m(2) and 8.4 Kg/m(2) CONCLUSIONS: Low muscle mass was associated with dialysis mortality. Obesity with low muscle mass was a predictor for dialysis death in women. 23

24 Association Between Obesity With Low Muscle Mass And Dialysis Mortality Authors: Wu HC, Tseng SF, Wang WJ, Chen HJ, Lee LC. AIMS: This study examines the association between body composition and dialysis mortality. METHODS: Adult patients who initiated hemodialysis in Taoyuan General Hospital from 2012 to 2016 were enrolled. We reviewed baseline characteristics and followed over 5 years after dialysis. Patients with body mass index > 25 Kg/m(2) were defined as obesity. High or low muscle mass were classified by skeletal muscle mass index (SMMI) based on consensus from Chinese population. All age-matched subjects were classified into 4 groups: (A) optimal; (B) obesity; (C) low muscle mass; and (D) obesity with low muscle mass. Adjusted hazard ratios (AHRs) for mortality and cumulative survival curves were evaluated by Cox proportional hazard model and Kaplan Meier method. The discriminative power of SMMI was calculated according the area under the curve and the receiver operating characteristic curve. RESULTS: From a total of 176 age-matched patients, the incidence rate of death for different groups were 3.7, 7.8, 10.3 and 16.5 per 1000 person-months. After adjusting for continuous variables, SMMI were independently associated with mortality. The difference between group A and D was more significant in women than those in men after multivariate adjustment (AHRs: vs ) (P = and 0.553). The discriminative power of SMMI to predict 5-year mortality were for men and for women, with the best cut-off value were 11.1 Kg/m(2) and 8.4 Kg/m(2) CONCLUSIONS: Low muscle mass was associated with dialysis mortality. Obesity with low muscle mass was a predictor for dialysis death in women. 24

25 Kas Kütlesi Korunumunu En Yüksek Seviyede Tutmak İçin; Doğru besin örüntülerinin dengeli alımı Ara öğünlü beslenme Yavaş kilo kaybı Hafif şiddette egzersiz 25

26 Teşekkürler

27 ZOR HASTAYA YAKLAŞIM Diyetisyen Nüket TURAN

28 Olgu-1 51 yaşında Evli ve iki çocuk annesi, ev hanımı TANI :tip 1 diyabet, diyabetik nefropati, hipertansiyon, başlangıç diyabetik retinopati, obezite Anne: özellik yok Baba: KAH ŞİKAYETLER: haftada en az 3-4 kez yaşanan hipoglisemi, Yorgunluk, uyanamama, yoğun acıkma hissi ve karbonhidrat tüketim isteği Obezite sebepli iki kez kaçırılmış transplantasyon şansı Hareket kısıtlılığı Görsel mutsuzluk 1

29 Olgu-1_Tedavi 1 yıldır hemodiyaliz tedevisi 3 gün/hafta Lantus 1x1 18 ünite ( 22.00) Novaropid 2x1 18 ünite (geç kahvaltıda ve akşam yemeğınde ) Antifosfat 2x3 Adalat 30mg 1x1 Anti Asidoz 500mg 3x2 Bekunis 2veya 3 kez/ hafta Desal 2x1 Dilatrent (hipertansif atak halinde alınıyor) 29

30 Olgu-1 Ağırlık:96.5 kg Boy:158cm BKI:38.8 OGA:BMI x (boy) 2 (m 2 ) 23 x (1.58) 2 OGA: 57kg 1549 kal/gün Karbonhidrat %52,Protein %17, Yağ %30)

31 Tıbbi beslenme tedavisi Sabah (08:00): 2 porsiyon et grubu 1 porsiyon yağ grubu 2 porsiyon ekmek grubu Öğlen (12:00) : 2 porsiyon sebze 1 porsiyon süt gurubu 3 porsiyon ekmek grubu Ara Öğün (15:30) : 1porsiyon meyve Ara Öğün (17:30) : 1porsiyon ekmek grubu Akşam(19:30): 3 porsiyon et gurubu 1 porsiyon salata 3 porsiyon ekmek 1 porsiyon meyve Gece (23:00): 1 porsiyon süt gurubu

32 Laboratuvar Bulguları-1 32

33 Laboratuvar Bulguları-2 33

34 Laboratuvar Bulguları-3 34

35 Laboratuvar Bulguları-4 35

36 Günlük besin tüketim kaydı 36

37 Teşekkürler