Episode 148: The Hidden Dilemma: Malnutrition in Obesity

[00:00:00] Welcome back to the Back on Track Achieving Healthy Weight Loss, where I help you get on

[00:00:05] track and stay on track with your weight loss journey. I'm your host, Dr. Alicia Shelly. So let's get

[00:00:12] started. Hi, welcome to the Back on Track Achieving Healthy Weight Loss podcast. I'm your host, Dr.

[00:00:33] Alicia Shelly. Can you be living with obesity and malnourishment at the same time? Well,

[00:00:41] the answer is yes, you can. Over 50% of patients with obesity have nutritional deficiencies,

[00:00:49] mind blown. I never thought this could happen. And the malnutrition is defined by the World

[00:00:55] Health Organization as deficiencies or excesses or imbalance in a person's intake of energy

[00:01:03] or nutrients. And there are two broad groups that have this condition. The first group

[00:01:09] is the one you think of, the one who's undernourished, who has stunting, a little height for their age,

[00:01:16] low weight for their age, underweight and just have not able to have access to nutritious foods

[00:01:24] and tend to have more of that micronutrient deficiencies or a lack of vitamins and minerals.

[00:01:31] The other group actually is individuals who are overweight and are living with obesity

[00:01:37] and have diet related non-communicable diseases, such as heart disease, stroke, diabetes and cancer.

[00:01:44] And you can be malnourished from either an overall lack of calories because I have patients who are

[00:01:51] living with obesity and not eating enough and therefore they're not getting their protein,

[00:01:56] their vitamins or minerals. And now they have a deficiency because eventually that gets depleted

[00:02:01] or you can have be the opposite where you have so many excess calories that your body does not

[00:02:06] know what to do with them. So today we're going to kind of talk a little bit about living with obesity

[00:02:12] and malnutrition at the same time. And what are some things that we can do to help with

[00:02:19] avoiding that? But before we get there, let's talk a little bit about why does obesity

[00:02:24] malnutrition occur? So in the U.S., including children and adults, they consume 27 to 30%

[00:02:32] of their total daily calories from low nutrient sugary foods. And despite consuming such high

[00:02:39] calories from these low nutrient sugary foods, the calories have such a lower quality of nutrients

[00:02:45] that it creates the malnourishment that people experience and they may not even know it. They

[00:02:52] may be having symptoms and not be aware. And there are some mechanisms of malnutrition

[00:02:57] such as inadequate intake, not getting in the nutrients, the vitamins, the deficiency. Also

[00:03:04] defective storage and bioavailability of the nutrients. So there are some vitamins who are

[00:03:09] fat soluble, specifically vitamin A, vitamin D, vitamin E, vitamin K. These vitamins are stored

[00:03:17] in the fat. They're fat soluble. So they get stored in the fat. Everything else is stored

[00:03:22] throughout the body. And so if there's some defectiveness with the fatty tissue or have excessive

[00:03:28] adipose tissue, that can make it difficult for these vitamins to be available for use for the body.

[00:03:34] Also, if someone has small intestine bacterial overgrowth or SIBO for short, this is where

[00:03:40] the microbiota or just the bacteria metabolize in our stomach and our gut metabolizes vitamins.

[00:03:48] And if you have too much bacteria, it could be metabolizing the vitamins and reducing

[00:03:53] what's available for the rest of the body to use. Also the excessive consumption of simple sugars,

[00:04:00] milk and fat. When someone takes in excessive simple sugars like your cookies, your cakes,

[00:04:07] your donuts, things that are very simple or broken down rather quickly,

[00:04:12] it actually can deplete your thiamine stores. And lastly, there are several medications that can be

[00:04:19] actually contributing and putting you at risk for having malnutrition. Here are a couple of them,

[00:04:25] specifically for rosa mine or torosa mine or they're in the category called loop diuretics.

[00:04:31] This can actually put you at risk for thiamine deficiency. Metformin can put you, which is

[00:04:37] used for diabetes, can put you at risk for thiamine and vitamin B12 deficiency or LISTAT,

[00:04:44] which is a medication that's used to help with losing weight. You basically don't absorb fat,

[00:04:49] you just basically if you eat an extra fat diet, you're just kind of pooping it out there.

[00:04:55] And that can lead to risk, a deficiency of fast soluble vitamins. Like I said,

[00:04:59] vitamin A, D, E and K. Also certain blood pressure medications like the ACE inhibitors,

[00:05:06] such as Lysinopyril, Benazepyril and now Lipryl, these can lead to decrease in vitamin B12 deficiency.

[00:05:15] Also if you have a lot of acid reflux, that the H2 blockers like Fomodidine,

[00:05:21] Renitidine is no longer on the market, but and protein pump inhibitors like Omeprazole,

[00:05:27] Esomeprazole or Pantoprazole, these can actually lead to deficiencies in vitamin B12, thiamine, iron,

[00:05:35] calcium and magnesium. If you have grout and you're using Colchicine, that can lead to vitamin

[00:05:40] deficiency of vitamin B12. If you're even on a oral contraceptive, that can lead to deficiency

[00:05:46] of folate, folic acid or folate. So these are just some medications that have been implicated

[00:05:52] in malnutrition. Now the most common vitamin deficiencies are going to be your vitamin D,

[00:05:58] your iron, vitamin B12, vitamin B1 or thiamine, calcium, magnesium and vitamin A.

[00:06:05] I'm just going to talk about the top three. Now vitamin D, some risk factors for vitamin D

[00:06:10] deficiency include inadequate intake, just not getting it in your diet. And then also limited

[00:06:16] sun exposure, so especially during the winter if you're in an area where it's heavy snow,

[00:06:20] you're not really getting out into the sun and getting that at least 10 minutes of sun,

[00:06:25] that can lead to decrease vitamin D just because it needs to be activated by the sun.

[00:06:30] And also sometimes if you are using sunscreen, that too can block vitamin D. Now I'm not telling

[00:06:35] you to stop using sunscreen, but if you should still use sunscreen, you can put your risk for

[00:06:40] just skin cancer, but still just knowing that you have to be a catch 22. Sometimes that

[00:06:47] sunscreen can put you at increased risk for vitamin D deficiency. Now vitamin D deficiency

[00:06:51] is associated with an increased risk of infections, autoimmunity, cancers,

[00:06:56] chronic diseases and poor bone mineralization. When you do lose weight, it can cause vitamin D to be

[00:07:03] released into the blood, but usually those effects are not substantial enough to compensate

[00:07:09] for the deficiency. So it is important to try to increase your intake of vitamin D.

[00:07:14] Now the next vitamin I want to talk about is your iron. So iron is so important for forming

[00:07:20] the red cells that carry the oxygen to the different parts of the body and it can be stored as two

[00:07:26] types of iron. You have your heme iron that is found in red meat, poultry, pork and seafood

[00:07:32] and then you have your non-hem iron which is obtained from beans, dark leafy greens,

[00:07:37] iron fortified cereals and things of that nature and usually that's absorbed rather well

[00:07:42] when you take vitamin C together. Some of the risk factors for iron deficiency include menstrual cycles

[00:07:48] because as women we are losing blood every month and that can lead to less iron availability for the

[00:07:55] body. Also excess tea consumption can also lead to some iron deficiency and then gastric acid

[00:08:02] decrease and that can be due to diseases like diseases or medications such as your

[00:08:09] Fomodidine or your Omeprousal, Nexium things of that nature that kind of reduces the gastric acid.

[00:08:15] The reason why that's important is that when the gastric acid is reduced it actually stops

[00:08:21] the iron from being converted from ferric to ferrous iron and usually ferric is more readily

[00:08:27] absorbed. So let's talk about vitamin B9 or folic or folate acid. Folic acid is so important

[00:08:34] in the formation of red blood cells and it helps with amino acid metabolism. Some of the sources are

[00:08:40] leafy green vegetables, orange juice, lentils, beans and fortified grains. So the extra adipose

[00:08:47] tissue that one has when they are living with obesity does not affect the folic absorption

[00:08:52] but it can affect how it's distributed and folic acid deficiency can be associated with

[00:08:58] cardiovascular disease, cancers, megaloblastic anemia and fetal neural tube defects. Last but not

[00:09:04] least let's talk about vitamin B12 deficiency. Now vitamin B12 affects in your neurologic functioning

[00:09:12] it also helps with maturing the red blood cell and cellular metabolism. You can find vitamin B12

[00:09:19] in your fish, your red meat, eggs and dairy. Vitamin B12 is released from protein by the

[00:09:26] gastric acid. Vitamin B12 is a water soluble vitamin that is stored in the liver. You can have an

[00:09:32] increased risk of vitamin B12 deficiency when you have an overgrowth of bacteria especially in

[00:09:37] seaboo that small intestinal bacterial overgrowth or surgical alterations such as bariatric

[00:09:42] surgery which can lead to vitamin B12 deficiency and this deficiency can be also found in

[00:09:48] patients who have Crohn's or Celiac Zs. Certain medications that increase your risk for

[00:09:53] vitamin B12 deficiencies are your metformin, your ACE inhibitors such as lecinepryl, nalipryl,

[00:09:59] benazepryl, your H2 blockers such as promotidine or protein pump inhibitors such as Nexium,

[00:10:06] esomeprousol, omeprosol, pentoprosol and of course Colchicin. And so why do we worry

[00:10:12] about vitamin B12 deficiencies because it can cause megaloblastic anemia or just your red

[00:10:18] cells to be extremely larger? Peripheral neuropathy which is numbness and tingling in your

[00:10:23] hands, your feet or different parts of your body and for some people neuropsychiatric manifestations.

[00:10:30] Now that's just part of the vitamin deficiencies. Now individuals with obesity are at increased

[00:10:36] risk at baseline for this due to malnutrition and macronutrient deficiencies but when these

[00:10:43] same patients are trying to lose weight with strict weight reduction diets their

[00:10:48] nutritional deficiencies can worsen. And so we're just going to talk about three most common diets

[00:10:54] that can lead to increased risk of malnutrition and vitamin deficiency. And so the top three are

[00:11:01] your low carbohydrate diet, your intermittent fasting or time restricted eating and your

[00:11:07] ketogenic or keto diet. Now your low carbohydrate diet typically limits carbohydrate intake

[00:11:13] to 30 to 120 grams per day. The lower carbohydrate diets which are less than 60 grams per day often

[00:11:19] have significant weight reduction. However these diets can put you at risk for deficiencies in fiber,

[00:11:27] folic acid, potassium, calcium, magnesium, iron, vitamin A, iodine, linolyneic acid and alpha

[00:11:37] linolyneic acid. Several deficiencies. When we look at the ketogenic diet that diet is high in fat,

[00:11:43] moderate protein and carbohydrate restricted diet. It definitely can allow people to lose weight

[00:11:49] but it can put you because it limits the intake of fortified carbohydrates it can lead to a

[00:11:55] thiamine deficiency. And when we look at your intermittent fasting this is a dietary approach

[00:12:01] where you have consumption of foods within a restricted time window to generate fasting

[00:12:06] periods. And they have different types of intermittent fasting, do alternate day fasting,

[00:12:10] periodic day fasting and fasting mimicking diet. And the modified alternate day fasting

[00:12:17] is where calories are restricted every other day but they can be low in fiber, potassium, vitamin A,

[00:12:24] iron, calcium, iodine, magnesium, iron, linolyneic acid and alpha linolyneic acid.

[00:12:30] Now with these different diets they definitely are very helpful in losing weight.

[00:12:34] However, I would say it's important that you get tested. Check with your primary care,

[00:12:39] your OB-C medicine specialist to check your vitamin levels especially before starting

[00:12:44] and during to make sure you're not developing any deficiencies. You may be beneficial to start a

[00:12:50] multivitamin or strategic vitamin if you are deficient to help improve your levels especially

[00:12:57] with doing these diets. So I'm not saying you should not do these diets, I'm just saying

[00:13:01] that we need to monitor. It's important that your doctor screens you and they're watching.

[00:13:07] Also it's important to avoid the processed foods or simple sugars that can also put you at risk

[00:13:13] for malnutrition and vitamin deficiencies focusing on foods that are higher in nutrients

[00:13:20] and the vitamins that you need throughout the day so that only are you losing weight,

[00:13:25] you are actually having reducing your risk of deficiencies and reducing your risk of malnutrition

[00:13:31] because who wants to be living with obesity and malnutrition at the same time. So I hope this is

[00:13:39] helpful, just learn to be aware of. I know it's a lot but like I said make sure that your

[00:13:44] doctor is screening you for these deficiencies just to make sure you're doing okay.

[00:13:49] Alrighty thank you so much for listening and tuning in to the Back on Track Achieving

[00:13:54] Healthy Weight Loss podcast. If you have any questions feel free to leave a comment, let

[00:14:00] me know, I'll be happy to answer and create a podcast maybe for you. Alright you can find me

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