Malnutrition & Obesity Keith Rischer RN, MA, CEN

Today’s Objectives… Explain the potential consequences and complications associated with malnutrition. Analyze assessment data to determine common nursing diagnoses for the client with malnutrition. Explain the potential consequences, contributing factors and complications associated with obesity. Contrast non-surgical vs. surgical management of obesity. Describe post-op complications of bariatric surgery and lifelong dietary modifications required.

Nutritional Standards Dietary recommendations 1800 calories/day…0.8 gm protein per kg Risk of malnutrition if <70% Nutritional assessment includes: Diet history Exam and health history GI disease/malabsorption COPD Measurement of height and weight Assessment of body mass index-BMI Weight (lbs)/height (inches) x703= 190/72 x703=26.6 BMI Ideal 20-25

Malnutrition in Acute Care Who is at risk? Poverty Drug & ETOH abuse N/V/D Lab Values Complications Poor wound healing Increased risk of infection Lethargy Activity intolerance Studies have shown in hospital up to 40-55% pts at risk for malnutrition 12% severely malnourished 2-3x more likely to develop complications Lab Values Anemia Albumin low…why?

Nursing Considerations: Malnourished Low protein stores loss of muscle and lean body mass decreased drug binding increase in levels of free circulating drugs increasing drug toxicity Drugs given subcutaneous or IM closely monitored adipose tissue has decreased blood supply delayed action and unpredictable duration IM can inadvertently be given subcutaneous Cutaneous patches may deliver drugs with erratic action

Imbalanced Nutrition: Less Than Body Requirements Enteral Feedings Types Nursing Considerations Confirm placement Check residuals Change bag qd 4 hours of formula at time Monitor labs Lytes, albumin, hgb Complications Aspiration Diarrhea Enteral Feedings…unable to maintain adequate po intake due to N&V CVA-neuromuscular impairments with swallowing Acutely ill-recently intubated

Imbalanced Nutrition: Less Than Body Requirements IV Total Parenteral Nutrition (TPN) Central access Lipids Protein-dextrose-vitamins Nursing Considerations Monitor daily wt./ I&O Carefully check contents Complications Fluid imbalance Lyte imbalances Check labs Liver function Fluid imbalance Hyperosmolar….fluid into the intravascular space Lyte imbalances…calcium

Obesity USA Obesity Rates Reach Epidemic Proportions Data (2003) suggests 6% of population is obese Eight out of 10 over 25's Overweight 78% of American's not meeting basic activity level recommendations 25% completely Sedentary 76% increase in Type II diabetes in adults 30-40 yrs old since 1990 Overweight over 10% ideal body weight…more than 100 million Americans overwieght or obese in US Considered healthy if BMI is between 19 and 24. If over 30, considered obese-BMI over 40-morbid obesity Second most preventable cause of death in US (next to smoking), costing over $200 billion annually In a survey of patients preparing to undergo gastric bypass surgery – 55% of pts reported being treated disrespectful by healthcare workers because of their weight Obese women are less likely to seek preventative healthcare services than are women who are not obese Waist circumference – better to be pear than apple shaped, as apple shape has more fat in and around the abdominal organs. Women’s waist should be below 35, men below 40 inches

Obesity related diseases 80% of type II diabetes related to obesity 70% of Cardiovascular disease related to obesity 42% breast and colon cancer diagnosed among obese individuals 30% of gall bladder surgery related to obesity 26% of obese people having high blood pressure

Childhood Obesity 17% children overweight Between 8% - 45% of newly diagnosed cases of childhood diabetes are type II, associated with obesity. 4% of Childhood diabetes was type II in 1990 Now 20% Of Children diagnosed with Type II diabetes, 85% are obese 25% of all white children overweight 2001 33% African American and Hispanic children overweight 2001 Childhood Obesity Running Out of Control

Complications of Obesity Diabetes mellitus Hypertension Hyperlipidemia CAD Obstructive sleep apnea Obesity hypoventilation syndrome Depression and other mental health/behavioral health problems Urinary incontinence Cholelithiasis Chronic back pain Early osteoarthritis Decreased wound healing Increased susceptibility to infection Gout

Contributing Factors to Obesity Diet Physical inactivity Drugs Corticosteroids Estrogens NSAIDS Antihypertensives Antidepressants and psychoactive drugs Genetics Genetics Both parents overweight 80% liklihood to be obese Neither parent overweight only 10% Seems to be 50/50 influence of genetics and environment

Weight Loss Strategies/Education Goal reduce body weight by 10% of baseline within 6 months loss of 1 to 2 lbs/week Decrease caloric intake 300-500 day Eat slowly so that the brain gets the message that the stomach is full Take seconds of vegetables and salads instead of higher calorie foods Try to eat 3 balanced meals at regular times Record all food eaten

Nursing Considerations: Obesity Skin care high risk for breakdown and delayed wound healing Folds become moist and harbor yeast and bacteria Use of powders discouraged daily inspection, frequent turning, watch for shearing Risk for DVT Early mobility Inability to obtain definitive diagnosis with scans and radiological tests

Nonsurgical Management of Obesity Fasting Novelty diets Atkins Diet therapy Weight watchers etc. Exercise program Behavior modification Food diary Emotional/situational influences Drug therapy Xenical Inhibits lipase…fats are partially digested

Bariatric Surgery BMI 40 or higher or 35 – 39.9 with related health problem Must agree to strict lifestyle/diet regimen Post op care priorities 28,000 surgeries 1999….currently over 100,000 in US Roux-en-Y Gastric Bypass: a stomach pouch is created and connected to a Y-shaped section of the small intestine, bypassing absorption that would take place in the stomach and small intestine.

Complications: Bariatric Surgery DVT-PE Narrowing of the opening between the stomach and small intestine – strictures can form Gallstones Bleeding ulcers 1 in 100 may develop Altered digestion, long-term nutritional deficiencies Dumping syndrome tachycardia, nausea, diarrhea, abdominal cramping Infections 1 in 200 to 300 people will die from procedure; MI

Dietary Concerns: Bariatric Surgery Nutritional supplements Iron deficiency B-12 deficiency B12 injections Dietary modifications Avoid foods high in sugar Avoid alcoholic beverages Avoid high protein foods