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Complex Care Issues Resulting from Social Change: Bariatric Care Cindy Fehr Malaspina University-College Nursing 335 Spring 2006.

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Presentation on theme: "Complex Care Issues Resulting from Social Change: Bariatric Care Cindy Fehr Malaspina University-College Nursing 335 Spring 2006."— Presentation transcript:

1 Complex Care Issues Resulting from Social Change: Bariatric Care Cindy Fehr Malaspina University-College Nursing 335 Spring 2006

2 FACTS Source: Statistics Canada - The Daily (July 6, 2005) available from 6a.htm Weight issues a serious problem with complex issues and consequences At epidemic levels worldwide Estimated 60% American adults overweight, 30% obese & 6 million morbidly obese More prevalent amongst certain ethnic & racial groups, plus age & sex play a role Considered a chronic disease like any other (diabetes, AIDS, hypertension) Wide-ranging medical, physical, social, psychological effects Estimated 300,000 premature deaths in USA each year from obesity-related complications Over $60 billion direct health care and $56 billion indirect economic costs annually

3 Obesity statistics Overweight Canadians, provincial comparison, 1998 Province % of population overweight OverallRuralUrban P.E.I.59.0%62.0%56.7% Newfoundland58.9%59.0%58.9% New Brunswick58.3%61.2%56.0% Saskatchewan57.9%66.9%54.4% Manitoba54.3%56.1%53.8% Nova Scotia52.5%56.9%49.1% Ontario49.6%55.3%48.7% Alberta48.5%47.6%53.3% B.C.43.3%41.4%52.5% Quebec42.7%44.8%42.2% Canada47.9%53.3%46.6% Source: National Population Health Survey 1998, Statistics Canada

4 Source: Statistics Canada – The Daily (Oct. 18, 2005) available from

5 Measuring Weight & Fat examples –an adult male 1.8 metres tall (five feet, 10 inches) and weighs 95 kg (210 pounds) BMI of 30 and considered obese –adult female 1.6 metres tall (five feet, 4 inches) and weighs 80 kg (175 pounds) BMI of 30 and also be considered obese same formula for children and adolescents however, the cut- off points for being overweight and obese vary by the age and sex of the child. BMI = weight (kg) / height (m 2 ) Source: AJN January 2006 #1 BMI

6 Measuring Weight & Fat cont. Source: US Food & Drug Administration #2 Waist-to-hips Ratio Recent research suggests that this is a better predictor of acute MI than BMI likelihood of MI rises as the waist-to-hip ratio s Different types of weight gain Source: AllRefer Health.com (http://health.allrefer.com)

7 Healthy Weight Chart for Adults – Source: BCHealth Guide

8 Lipocytes – Fat Cells Source: AllRefer Health.com (http://health.allrefer.com) ADIPOGENESIS/LIPOGENESIS Mesenchymal cells give rise to preadipocytes which proliferate locally Preadipocytes unlimited supply t/o life so can be produced as needed Adipocyte from cell differentiation; fills with lipids Adipocyte hypertrophy ( size) and hyperplasia ( #) leads to obesity – continue to acculumate lipid & enlarge up to 1000 times original size once reaches a certain size, tiggers other preadipocytes to differentiate

9 Why a Rise in Obesity? (continued) Weight gain & loss is complex interaction of psychological, environmental, evolutionary, biologic, genetic causes 1.Genetics Account for 70% variability in peoples weight Estimated 300 genes involved in body weight Metabolic challenges 2.Environment High fat calorie dense diet & overeating (portion size) Sedentary lifestyle (behavioral) Sociocultural norms 3.Evolution Store fat for famines & hunt for food

10 Why a Rise in Obesity? 4.Neuroendocrine Hormones involved in appetite regulation 5.Psychological Self-esteem, # of relationships, depression Discrimination, lack of respect, stigmatization Emotional trauma, ETOH or drug addiction 6.Medications Prednisone (corticosteroids) antidepressants

11 Neuroendocrine Regulation CNS – appetite regulated by hypothalamus –CNS control feedback loop from stomach to brainstem Leptin – Dont affect satiety but play a part in energy expenditure and appetite regulation Obesity associated with high leptin levels but may also be related to leptin resistance Ghrelin – stimulates appetite- Increase shortly before eating & decrease rapidly afterward in obese the decline does not occur or less quickly appetite & overeating Thyroid Hormones – involved in setting resting metabolic rate & thermogenesis Cholecystokinin – Inhibits gastric emptying & signals hypothalamus Peptide YY – Inhibits appetite by slowing gut motility & gastric emptying & suppressing NPY Diminished in obese patients Cortisol – Facilitates gluconeogenesis Insulin – Genetically prone to obesity have altered responses to insulin & glucose Source: AJN Jan 2006

12 Source: ACP Medicine on Medscape Feedback model for body-weight regulation

13 Costs to Society Costs of illness Absence from work Reduced productivity Disability

14 Costs to Person Physical Costs Psychological Costs Social Isolation, stigmatization, bias, discrimination $ for healthcare related costs – adaptive devices and support services

15 Obesity-Related Consequences Hypertension Heart disease Type 2 Diabetes Stroke Hyperlipidemia/dyslipidemia Arthritis Sleep apnea Gallstone formation Certain cancers (breast, colon, uterus, pancreas, kidney, prostate, gallbladder) Pickwickian Syndrome Source: AllRefer Health.com (http://health.allrefer.com)

16 Source: Source: University of Queensland, Australia Source: missbellorinna.tripod.com/ weightloss.htmmissbellorinna.tripod.com/ weightloss.htm The Ultimate Risk = Death

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19 Metabolic Syndrome Also known as insulin resistance syndrome & dysmetabolic syndrome & syndrome X Incidence up to 1 in 3 within general North American population Syndrome characterized by: –HTN, central obesity, insulin resistance, high LDL/low HDL cholesterol & high triglycerides Now looking at this syndrome as one entity instead of separate disease states Leads to diabetes & heart disease & stroke Treatment involves coordinated care, appropriate goals for each disease & patients as partners in care

20 Source: Nursing made Incredibly Easy! Sept/Oct 2003 p. 22

21 Key Clinical Indicators of Metabolic Syndrome Waist/hip ratio (umbilicus/hip) Abd waist circumferance > 35 & > 40 BMI > 30 Abnormal lipid levels –HDL –LDL & VLDL –Triglycerides BP > 130/85 Two elevated fasting blood glucose levels Nicotine dependence also common potent vasoconstrictor & primary cause of heart disease Risk Factors

22 Nursing Considerations Unconditional acceptance Empathy not sympathy Sensitivity to needs Understanding Open communication Adaptive devices – mechanical lifts, special beds, bed trapezes, wheelchairs, bedside chairs, walkers, bed lifters, bedpans, commodes, etc… Avoid personal injury & patient injury Nursing assessments & interventions altered to obtain accurate information, decision-making, effective treatment

23 Weight Loss Diets - many choices Dietary supplements Exercise Regimens Psychotherapy Motivation Exploration of why want to lose weight Success related to…

24 Bariatric Surgery Definition – surgery done with the goal of weight reduction Candidates –BMI > 40 or >35 with co-morbidity (apnea, diabetes, degenerative joint disease, HTN, ischemic heart disease, asthma, history of CVA) –18 years or older –Obese for at lease 5 years –Documented lack of success to lose weight with other methods –Demonstrated ability to comply with post-op long term dietary & behavioral changes –Detailed health & weight histories Can literally be life-saving procedure for morbidly obese but only one part of the treatment plan

25 Gastric Surgery types 1.Restrictive Procedures –Create a gastric pouch with narrow outlet –Gastroplasty or gastric banding –Feel full sooner (1 oz initially 4 oz capacity max) –Small outlet delays gastric emptying feel full longer –Potential complications = severe GERD & stomal obstruction Vertical banded gastroplasty Circumgastric or adjustable banding Source: Nursing Made Incredibly Easy Jan/Feb 2006

26 Gastric Surgery types cont. 2.Malabsorptive Procedures –Bypass a significant length of small intestine, reducing absorption of calories & nutrients –Associated with long-term metabolic complications & nutritional deficiencies (liver disease, osteoporosis, diarrhea, dehydration, electrolyte imbalances, malnutrition)

27 Gastric Surgery types cont. 3.Combination Restrictive & Malabsorptive Techniques –Gold standard in North America is Roux-en-Y gastric bypass procedure –Small pouch created in upper part of stomach by separating it from remaining portion of stomach using staples; portion of jejunum separated and anastomosed to new pouch bypass occurs at stomach –Laparoscopic or open technique Gastric Restriction & Malabsoprtion surgery or Roux en Y technique Source: Nursing Made Incredibly Easy Jan/Feb 2006

28 Post-op Considerations Virtually every aspect of treatment is impacted by size AIRWAY - respiratory compliance d/t more tissue pressure on chest wall, diaphragm (from large abdomen), intercostals, upper airway HEMODYNAMIC STABILITY – large BP cuff; fluid shifts could make vascular dehydration; in/out monitoring; blood chemistries PAIN MANAGEMENT – promotes DB&C; post-lap shoulder pain; antiemetics; doses may need to be different

29 Post-op Considerations cont. ACTIVITY/AMBULATION – high risk DVT/PE, SKIN/WOUND/DRAIN SITE CARE – risk for pressure ulcers, prone to yeast infections in skin folds; urinary incontinence common; challenges with personal hygiene; delayed wound healing/dehisence DIET & NUTRITIONAL SUPPLEMENTS – NPO following bariatric sx to r/o anastamotic leaks water clear fluids DAT (no sugar, caffeine, carbonation) high protein supplements/shakes good PSYCHOLOGICAL ADJUSTMENTS – anorexia nervosa, changes in body image with excess skin, depression r/t many life changes

30 Following Weight Loss Health promotion initiatives Long-term diet goals Emotional Support – many changes Plastic Surgery & liposuction Sources for photos – Google Images

31 Body Contouring Following Weight Loss Patient after weight loss of 170 lb; legs still have good appearance Source: Plastic Surgical Nursing (2004) 24(3) Overall changes in body shape Should be referred to a plastic surgeon purpose of body contouring is to reduce excess skin and tissue lengthy recovery period Areas for challenge Lower trunk produces lots of complaints Abdominal wall weakness or hernia Upper trunk & breasts Upper arms Thighs

32 Marking for upper body lift and brachialplasty. Source: Plastic Surgical Nursing (2004) 24(3) Benefits to Body Contouring clothing size down by one or two sizes clothes easier to find more vigorous activity is possible body image improves

33 Marking for belt lipectomy Source: Plastic Surgical Nursing (2004) 24(3)

34 Preoperative (top row) and postoperative (bottom row) belt lipectomy Source: Plastic Surgical Nursing (2004) 24(3)

35 Preoperative (top row) and postoperative (bottom row) brachialplasty Source: Plastic Surgical Nursing (2004) 24(3)

36 Preoperative (top row) and postoperative (bottom row) medial thigh resection Source: Plastic Surgical Nursing (2004) 24(3)

37 Potential Complications Infection Seroma formation Hematoma formation Wound dehiscence Scars Decreased sensation Major complications – DVT & PE

38 Prevention Up to 1/3 children eat fast food everyday (Boston Childrens Hospital Study) What it Takes Culture shift, changes in behaviour & lifestyle Influences – family, friends, colleagues, media, food & leisure industries, immediate environments Improving diet – fats & simple and added sugars Increasing physical activity Even modest weight loss improves health Low income one factor in childhood obesity – addressing Determinants of Health Source: California State University Library Source: New York State Department of Health Basic Principles of Activ8Kids! 5 fruits and vegetables each day 1 hour of physical activity each day 2 hours OR LESS of TV or screen time daily

39 Resources Appel, S.J., Giger, J.N., & Floyd, N.A. (2004). Dysmetabolic syndrome: reducing cardiovascular risk. The Nurse Practitioner, 29(10), Blackwood, H.S. (2005). Help you patient downsize with bariatric surgery. Nursing, 35(9), supplement: Med/Surg Insider, 4-9. Blackwood, H.S. (2004). Obesity: a rapidly expanding challenge. Nursing Management, May, Daniels, J. (2006). Obesity: Americas epidemic. American Journal of Nursing, 106(1), Edelman, R. (2005). Obesity, type 2 diabetes, and cardiovascular disease. Nutrition Today, 40(3), Forman, A. (2004). The second national conference on diabesity® in America. Nutrition Today, 39(6), Gabriel, S., & Garguilo, H. (2006). Bariatric surgery basics: getting to the heart of a weight subject. Nursing made Incredibly Easy!, 4(1), Heddens, C.L. (2004). Body contouring after massive weight loss. Plastic Surgical Nursing, 24(3), Hoolihan, L. (2005). The role of education and tailored intervention in preventing and treating overweight. Nutrition Today, 40(5), Walker-Sterling, A. (2005). African Americans and obesity. Clinical Nurse Specialist, 19(4), Woods, A. (2003). X marks the spot: Understanding metabolic syndrome. Nursing made Incredibly Easy!, 1(1),


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