Obesity & Related Surgical Procedures RNSG 1247

Obesity and Overweight Obesity is an abnormal increase in the proportion of fat cells Obesity is an abnormal increase in the proportion of fat cells Primarily occurs in the visceral and subcutaneous tissues of the body Primarily occurs in the visceral and subcutaneous tissues of the body

Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, *Body mass index (BMI) at or above the sex-and age-specific 95 th percentile BMI cutoff points from the 2000 sex- specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category. Source: National Health and Nutrition Examination Survey, , , , , National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, : Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, JAMA 2008; 299 (20):

Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US, † *Obesity is defined as a body mass index of 30 kg/m 2 or greater. † Age adjusted to the 2000 US standard population. Source: National Health Examination Survey , National Health and Nutrition Examination Survey, , , , , National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, , : National Health and Nutrition Examination Survey Public Use Data Files, , , National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

Etiology and Pathophysiology Genetic/Biologic basis Genetic/Biologic basis Environmental factors Environmental factors Psychological factors Psychological factors ** Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors ** Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors

Hormones & Peptides that Interact with Hypothalamus to Effect Obesity Fig. 41-3

Classification of Body Weight and Obesity Primary obesity (majority of obese) Primary obesity (majority of obese) Excess caloric intake for the body’s metabolic demands Excess caloric intake for the body’s metabolic demands Secondary obesity Secondary obesity Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders

Classification of Body Weight and Obesity Body mass index (BMI) Body mass index (BMI) Used to classify underweight, healthy (normal) weight, overweight, or obese Used to classify underweight, healthy (normal) weight, overweight, or obese Common clinical index of obesity or altered body fat distribution Common clinical index of obesity or altered body fat distribution Uses weight-to-height ratios Uses weight-to-height ratios

BMI chart

Weight for height chart

Classification of Body Weight and Obesity Waist-to-hip ratio (WHR) Waist-to-hip ratio (WHR) Preferred tool when predominantly muscular Preferred tool when predominantly muscular Waist measurement/hip measurement = ratio Waist measurement/hip measurement = ratio WHR <0.80 is optimal WHR <0.80 is optimal Visceral fat increases risk for cardiovascular disease and metabolic syndrome Visceral fat increases risk for cardiovascular disease and metabolic syndrome

Visceral Fat

Subcutaneous Fat

Classification of Body Shapes Apple-shaped body Apple-shaped body Fat located primarily in the abdominal area Fat located primarily in the abdominal area At greater risk for obesity-related complications At greater risk for obesity-related complications Android obesity Android obesity Pear-shaped body Pear-shaped body Fat located primarily in upper legs Fat located primarily in upper legs Gynoid obesity Gynoid obesity

Classification of Body Shapes.. Fig. 41-5

Health Risks Associated with Obesity Problems occur at higher rates for obese patients Problems occur at higher rates for obese patients Mortality rate rises as obesity increases Mortality rate rises as obesity increases Especially with increased visceral fat Especially with increased visceral fat Obese patients have a decreased quality of life Obese patients have a decreased quality of life Most conditions improve with weight loss Most conditions improve with weight loss

Health Risks Associated with Obesity Fig. 41-6

Nursing Problems Imbalanced nutrition Imbalanced nutrition Chronic low self-esteem Chronic low self-esteem Others related to complications Others related to complications

Planning Modify eating patterns Modify eating patterns Participate in a regular physical activity program Participate in a regular physical activity program Achieve weight loss to a specified level Achieve weight loss to a specified level Maintain weight loss at a specified level Maintain weight loss at a specified level Minimize or prevent health problems related to obesity Minimize or prevent health problems related to obesity

Management: Non-surgical Nutrition Nutrition Exercise Exercise Behavior modification Behavior modification Support groups Support groups Drug therapy Drug therapy

Nutrition

Exercise

Trends in Prevalence (%) of High School Students Attending PE Class Daily, by Grade, US, Source: Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.

Behavior modification Basic techniques include Self monitoring Self monitoring Stimulus control Stimulus control Rewards – short term vs long term, what’s acceptable vs unacceptable Rewards – short term vs long term, what’s acceptable vs unacceptable

Support groups

Drug Therapy Appetite-suppressing drugs or Sympathomimetic drugs for _____ term use Appetite-suppressing drugs or Sympathomimetic drugs for _____ term use Decrease food intake through nonadrenergic or serotonergic mechanisms in the CNS Decrease food intake through nonadrenergic or serotonergic mechanisms in the CNS Phentermine – most commonly prescribed; causes appetite ___________ and _________ food intake Phentermine – most commonly prescribed; causes appetite ___________ and _________ food intake Other exs: Diethylpropion, Phendimetrazine Other exs: Diethylpropion, Phendimetrazine

Drug Therapy Appetite-suppressing drugs or Sympathomimetic drugs for ______ term use Appetite-suppressing drugs or Sympathomimetic drugs for ______ term use Mixed nonadrenergic–serotonergic agents Mixed nonadrenergic–serotonergic agents Do not stimulate release of serotonin Do not stimulate release of serotonin Sibutramine (Meridia) – works by increasing _____________ Sibutramine (Meridia) – works by increasing _____________

Drug Therapy Nutrient absorption-blocking drugs (GI lipase inhibitors) Nutrient absorption-blocking drugs (GI lipase inhibitors) Work by blocking fat breakdown and absorption in intestine Work by blocking fat breakdown and absorption in intestine Orlistat (Xenical) Orlistat (Xenical)

Drug Therapy Drugs that ↑ energy expenditure are not approved by the FDA. Ex: Ephedrine Appetite-suppressing drugs removed from market fenfluramine (Pondimin) fenfluramine (Pondimin) dexfenfluramine (Redux) dexfenfluramine (Redux)

Bariatric Surgery Used to treat morbid obesity Used to treat morbid obesity Currently the only treatment found to have a successful and lasting impact for sustained weight loss Currently the only treatment found to have a successful and lasting impact for sustained weight loss

Bariatric Surgery Must meet all of the following criteria to be considered an ideal candidate Must meet all of the following criteria to be considered an ideal candidate BMI ≥40 kg/m 2 with one or more obesity-related complication BMI ≥40 kg/m 2 with one or more obesity-related complication 18 years or older 18 years or older Understands the risks and benefits Understands the risks and benefits Has been obese for >5 years Has been obese for >5 years Has tried and failed to lose weight Has tried and failed to lose weight

Bariatric Surgery Criteria to be considered an ideal candidate (cont’d) Criteria to be considered an ideal candidate (cont’d) Has no serious endocrine problems Has no serious endocrine problems Has psychiatric and social stability Has psychiatric and social stability Availability of a team of health care providers Availability of a team of health care providers Surgery would ↓ or eradicate high-risk conditions Surgery would ↓ or eradicate high-risk conditions

Bariatric Surgery Three broad categories Three broad categories Restrictive Restrictive Malabsorptive Malabsorptive Combination of restrictive and malabsorptive Combination of restrictive and malabsorptive

Restrictive Surgery Reduces the size of a stomach to 30 ml or less Reduces the size of a stomach to 30 ml or less Causes patient to feel full quicker Causes patient to feel full quicker Normal stomach digestion and intestinal absorption of food Normal stomach digestion and intestinal absorption of food ↓ Risk of anemia and cobalamin deficiency ↓ Risk of anemia and cobalamin deficiency

Restrictive Surgery Vertical banded gastroplasty Vertical banded gastroplasty Partitions stomach into a small pouch in upper portion Partitions stomach into a small pouch in upper portion Small pouch drastically limits capacity Small pouch drastically limits capacity Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch

Restrictive Surgery Adjustable gastric banding (AGB) Adjustable gastric banding (AGB) Also referred to as the LapBand Also referred to as the LapBand Stomach size is limited by an inflatable band placed around fundus of stomach Stomach size is limited by an inflatable band placed around fundus of stomach Band is connected to a subcutaneous port Band is connected to a subcutaneous port Can be inflated or deflated to change stoma size Can be inflated or deflated to change stoma size

Restrictive Surgery AGB (cont’d) AGB (cont’d) Can be done laparoscopically and can be modified or reversed Can be done laparoscopically and can be modified or reversed Better choice for patients who are surgical risks Better choice for patients who are surgical risks Weight loss is slower than in other procedures Weight loss is slower than in other procedures

Restrictive Surgeries Fig. 41-7A

Malabsorptive Surgeries Biliopancreatic diversion (BPD) Biliopancreatic diversion (BPD) Removes ~3/4 of stomach to ↓ food intake and ↓ acid output Removes ~3/4 of stomach to ↓ food intake and ↓ acid output Remaining 1/4 of stomach is connected to lower portion of small intestine Remaining 1/4 of stomach is connected to lower portion of small intestine Pancreatic enzymes and bile enter final segment of intestine Pancreatic enzymes and bile enter final segment of intestine Nutrients pass without being digested Nutrients pass without being digested

Malabsorptive Surgeries Biliopancreatic diversion with duodenal switch Biliopancreatic diversion with duodenal switch Variation of BPD Variation of BPD By including duodenal switch, surgeons leave a larger portion of the stomach intact By including duodenal switch, surgeons leave a larger portion of the stomach intact Helps prevent dumping syndrome Helps prevent dumping syndrome

BPD with or w/o doudenal switch

Bariatric Surgeries How is weight loss accomplished? What are the specific nutritional risks or adverse effects? What should be monitored to avoid complications? What is/are the advantage/s over other procedures?

Combination of Restrictive and Malabsorptive Surgery Roux-en- Y surgical procedure Roux-en- Y surgical procedure Has low complication rates Has low complication rates Excellent patient tolerance Excellent patient tolerance Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum

Combination of Restrictive and Malabsorptive Surgery Roux-en- Y surgery (cont’d) Roux-en- Y surgery (cont’d) Variations Variations Stapling stomach without transection to create a small 20- to 30-ml gastric pouch Stapling stomach without transection to create a small 20- to 30-ml gastric pouch Creating an upper and lower gastric pouch and totally disconnecting the pouches Creating an upper and lower gastric pouch and totally disconnecting the pouches Creating an upper gastric pouch and completely removing the lower pouch Creating an upper gastric pouch and completely removing the lower pouch

Restrictive Surgery Fig. 41-7D

Cosmetic Surgeries Ideal candidates have Ideal candidates have Achieved weight reduction Achieved weight reduction Excess skinfolds or fat Excess skinfolds or fat Chooses surgery for cosmetic reasons Chooses surgery for cosmetic reasons Lipectomy Lipectomy Liposuction Liposuction

Preoperative Care Room and equipment should consider patient size prior to arrival Room and equipment should consider patient size prior to arrival Obtaining IV access maybe complicated Obtaining IV access maybe complicated Proper breathing techniques, positioning Proper breathing techniques, positioning Hygiene and skin care prior to admission Hygiene and skin care prior to admission Prevention of wound infection and dehiscence Prevention of wound infection and dehiscence

Postoperative Care During transfer ensure that patient’s During transfer ensure that patient’s Airway is stabilized Airway is stabilized Pain is managed Pain is managed Early __________ is essential Early __________ is essential Patients undergoing bariatric surgery are often in considerable _________ ____ Patients undergoing bariatric surgery are often in considerable _________ ____ Patient is now _______ ______ due to anatomic changes Patient is now _______ ______ due to anatomic changes

Ambulatory and Home Care Diet prescribed is generally Diet prescribed is generally High protein High protein Low in carbohydrates fats & roughage Low in carbohydrates fats & roughage 6 small feedings 6 small feedings Fluids not to be ingested with meals : Fluids not to be ingested with meals : < 1000 ml/day < 1000 ml/day first 24 hrs post-op = water, sugar-free liquids Q 2hrs WA Day 1 to 2 wks = high protein liquids Q 2hrs WA 2-4 wks = pureed at frequent intervals 4-6 wks = transition diet w/solids & pureed

Ambulatory and Home Care Possible complications from surgery Possible complications from surgery Anemia Anemia Vitamin deficiencies Vitamin deficiencies Diarrhea Diarrhea Psychiatric problems Psychiatric problems Peptic ulcer formation Peptic ulcer formation Dumping syndrome Dumping syndrome Small bowel obstruction Small bowel obstruction

Evaluation Expected outcomes Expected outcomes Long-term weight loss Long-term weight loss Improvement in obesity-related comorbidities Improvement in obesity-related comorbidities Integration of healthy practices into lifestyle Integration of healthy practices into lifestyle Monitoring possible adverse side effects Monitoring possible adverse side effects Improved self-image Improved self-image

Gerontologic Considerations Number of older obese persons has risen Number of older obese persons has risen More common in women than men More common in women than men Decreased energy expenditure and loss of muscle mass are important contributors Decreased energy expenditure and loss of muscle mass are important contributors Exacerbates age-related problems Exacerbates age-related problems

Metabolic Syndrome A group of risk factors that increase an individual’s chance of developing cardiovascular disease and diabetes mellitus A group of risk factors that increase an individual’s chance of developing cardiovascular disease and diabetes mellitus

Metabolic Syndrome Risk factors: Risk factors: abdominal obesity, insulin resistance abdominal obesity, insulin resistance Diagnostic criteria: Diagnostic criteria: 1. Waist circumference 2. Triglycerides 3. HDL 4. BP 5. Fasting glucose