Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Focus on Obesity (Relates to Chapter 41, “Nursing Management: Obesity,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Obesity and Overweight
Imbalance between energy expenditure and energy intake from a long-term sedentary lifestyle and/or excessive calorie intake Obesity is an abnormal increase in the size of fat cells. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Weight gain in adulthood is characterized predominantly by adipocyte hypertrophy/hyperplasia. Adipocyte hypertrophy is a process by which adipocytes can increase their volume several thousand–fold to accommodate a large increase in lipid storage. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Obese Women A, This woman has excessive fat deposits in her abdominal area, upper arms, and breasts. B, This woman has excessive fat deposits in her upper arms, buttocks, and thighs. The fat distribution in both of these women is common in obese people. Fig Obese women. A, This woman has excessive fat deposits in her abdominal area, upper arms, and breasts. B, This woman has excessive fat deposits in her upper arms, buttocks, and thighs. The fat distribution in both of these women is common in obese people. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Classification of Body Weight and Obesity
Primary obesity (majority of obese) Excess caloric intake for the body’s metabolic demands Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary obesity Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders The first step in the treatment of obesity is to determine whether any physical conditions are present that may be causing or contributing to obesity. A thorough history and physical examination are necessary and will reveal the extent and duration of the obesity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Body mass index (BMI) Degree to which a patient is classified as underweight, healthy (normal) weight, overweight, or obese Common clinical index of obesity or altered body fat distribution Uses weight-to-height ratios {See next slide for BMI chart.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

BMI Chart BMI = Weight (kg)/Height (m2) BMI of 18.5 and 24.9 kg/m2 is considered to be normal weight. BMI of 25 to 29.9 kg/m2 is classified as being overweight. BMI ≥ 30 kg/m2 is classified as obese. BMI > 40 kg/m2 is classified as morbidly obese. Fig Body mass index (BMI) chart. Healthy weight: BMI 18 to 24.9 kg/m2; overweight: BMI 25 to 29.9 kg/m2; obesity: BMI ≥30 kg/m2. BMI = weight (kg)/height (m2). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Waist-to-hip ratio (WHR) Weight circumference is another way to assess and classify weight. Method of describing distribution of subcutaneous and visceral adipose tissue Waist measurement/hip measurement = Ratio WHR <0.80 is optimal. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Waist-to-hip ratio (WHR) (cont’d) WHR >0.80 indicates greater risk for health problems. People with more visceral fat are at increased risk for cardiovascular disease and metabolic syndrome. Preferred tool when patient is predominantly muscular A simpler method for determining excess abdominal fat is measuring just the waist circumference. This is recommended for all individuals with a BMI < 35 kg/m2. Health risks increase if the waist circumference is >40 inches in men and >35 inches in women. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

By body shape or fat distribution Apple-shaped body Fat located primarily in the abdominal area At greater risk for obesity-related complications Android obesity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

By body shape or fat distribution Pear-shaped body Fat located primarily in upper legs Gynoid obesity Better prognosis but harder to treat It is believed that abdominal fat is more readily available and can be mobilized to maintain elevated triglyceride and lipid levels. Individuals with abdominal fat carry more visceral fat than those with a pear shape. Pear-shaped individuals carry more subcutaneous fat, which causes more cellulite to appear. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Body Shape Classification
Two general classifications used to classify people by body fat distribution are (A) pear shape and (B) apple shape. Health risks are associated with each classification (see Table 41-3). Fig Two general classifications used to classify people by body fat distribution are (A) pear shape and (B) apple shape. Health risks are associated with each classification (see Table 41-3). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Obesity Has reached epidemic proportions in developed and developing countries In the United States Affects one third of the population 66% of those over 20 years old are either overweight or obese. The highest prevalence of obesity occurs between the ages of 40 and 59 in both men and women, with little difference in overall incidence between genders. Those with morbid obesity (>100 pounds overweight) appear to make up the fastest-growing group. Between the years 2000 and 2005, the numbers of those considered to be morbidly obese increased by more than 50%. The incidence of obesity continues to be higher in certain racial/ethnic groups than in whites (see eFig available on Evolve website and Cultural and Ethnic Health Disparities box). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Obesity Second leading cause of preventable death Third leading reason for liver transplantation It is estimated that costs related to obesity are greater than $93 billion per year, and obesity accounts for more than 12% of all medical expenses nationally. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Etiology and Pathophysiology
Energy intake exceeds energy output. Processes leading to obesity are much more complex and are still undergoing investigation. The cause of obesity involves significant genetic/biologic susceptibility factors that are highly influenced by environmental and psychosocial factors. The most common form of obesity is considered to be polygenic, arising from the interaction of multiple genetic and environmental factors. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Genetic/Biologic Basis
Strong evidence of genetic predisposition FTO gene gas a strong link to BMI The heritability of obesity estimated from twin studies is high, with only slightly lower values in twins raised apart than in those raised together. Similarly, in adoptees, the body mass index (BMI) of the children correlates with that of their biologic parents, rather than with that of their adoptive parents. For the FTO gene, it appears the strength of the genetic influence depends on whether an individual has inherited one or two copies of the FTO gene variant. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Input to the hypothalamus is received from the periphery from many different hormones and peptides. {See next slide for figure.} See Table 41-3 For example, obesity is associated with increased circulating plasma levels of leptin, insulin, and ghrelin, and decreased levels of peptide YY. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hormones and Peptides that Interact With Hypothalamus
Fig Some of the common hormones and peptides that interact with the hypothalamus to control and influence eating patterns, metabolic activities, and digestion. Obesity causes a disruption in this balance (see Table 41-1). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Adipocytes secrete enzyme, adipokines, growth factors, and hormones. Contribute to development of insulin resistance and atherosclerosis Evidence now supports an association between increased release of the adipokine and certain cancers. Because visceral fat accumulation is associated with more alteration of these adipokines, individuals with abdominal obesity experience more complications of obesity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Environmental Factors
Greater access to food Prepackaged food Fast food Soft drinks Increased portion sizes Obese individuals tend to underestimate food and caloric intake. Eating outside of the home impedes the ability to control the composition and quality of food. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Environmental Factors
Lack of physical exercise Decreased at home and work Advances in technology and labor-saving devices Increased time watching television and playing video games Socioeconomic status can affect obesity in a variety of indirect ways. People with low incomes may buy food that is less expensive, but the food may have poor nutritional quality and greater caloric content. For example, individuals with low incomes are more likely to purchase prepackaged foods than fresh fish. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Psychosocial Factors Emotional component of overeating is powerful. People use food for many reasons. Social component of eating is developed early in life. Birthday parties, holidays Many food associations, such as the use of food for comfort or rewards, begin in childhood. When overeating develops at an early age and continues into adulthood, one’s ability to sense fullness (satiety) is compromised. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Health Risks Associated With Obesity
Problems occur at higher rates for obese patients. Mortality rate rises as obesity increases. Especially with increased visceral fat For persons with a BMI ≥ 30 kg/m2, mortality rates from all causes, especially from cardiovascular disease, are generally increased by 50% to 100% above those of persons with BMIs in the normal range. Being overweight was once thought to have fewer health consequences than being obese. However, the evidence now shows that a 20% to 40% increase in mortality among both men and women who are overweight in midlife. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Health Risks Associated With Obesity
Obese patients have a decreased quality of life. Most conditions improve with weight loss. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Health Risks of Obesity
Fig Health risks associated with obesity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cardiovascular Problems
Obesity is a significant risk factor for predicting cardiovascular disease. WHR is best predictor of risk. Android obesity patients at greater risk Android obesity is associated with increased low-density lipoproteins (LDLs), high triglycerides, and decreased high-density lipoproteins (HDLs). Obesity is also associated with hypertension, which can occur because of increased circulating blood volume, abnormal vasoconstriction, decreased vascular relaxation, and increased cardiac output. To correctly measure BP in obese people, the use of a larger cuff size is needed to avoid artifactual increases. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Respiratory Problems Severe obesity may be associated with Sleep apnea Obesity hypoventilation syndrome ↓ chest wall compliance ↑ work of breathing ↓ total lung capacity and functional residual capacity Weight loss can bring substantial improvement in lung function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Diabetes Mellitus Hyperinsulinemia Insulin resistance Type 2 diabetes Weight loss and exercise improve glucose control. Insulin resistance is more strongly related to visceral fat than to fat in other locations. In the Nurses’ Health Study, the risk for developing type 2 diabetes was 8-fold for women with a BMI of 25 kg/m2 as compared with women with a BMI of 22 kg/m2; the increase was 40-fold if BMI was 31 kg/m2. People who were morbidly obese had a 90-fold risk of developing type 2 diabetes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Musculoskeletal Problems
Osteoarthritis Trauma to weight-bearing joints Hyperuricemia Gout Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Gastrointestinal and Liver Problems
Gastroesophageal reflux disease (GERD) Gallstones Nonalcoholic steatohepatitis (NASH) Can eventually lead to cirrhosis Weight loss can improve NASH. Gallstones occur because of supersaturation of the bile with cholesterol. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cancer Obesity is one of the most important known preventable causes of cancer. Breast, endometrial, kidney, colorectal, pancreas, esophagus, and gallbladder cancers are linked to excess body fat. The underlying mechanisms are difficult to determine. Breast and endometrial cancer may be due to the increased estrogen levels (and that estrogen is stored in fat cells) associated with obesity in postmenopausal women. Colorectal cancer has been linked to hyperinsulinemia. For esophageal cancer, obesity leads to acid reflux, which damages the lower part of the esophagus. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Patient may withhold information out of embarrassment or shyness. Provide acceptable reasons for personally intrusive questions. Respond to concerns about diagnostic tests. Interpret outcomes. Information that can assist the student in understanding an obese patient and provide a basis for intervention is presented in Table 41-5. Measurements used with the obese person may include skinfold thickness, waist circumference, height (without shoes), weight (obtained in a private location and in a gown if possible), and BMI. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Health history Time of obesity onset Diseases related to metabolism and obesity Medications Objective Height, weight, BMI, skinfold thickness, waist circumference The health care provider should explore genetic and endocrine factors such as hypothyroidism, hypothalamic tumor, Cushing syndrome, hypogonadism in men, and polycystic ovary disease in women. Laboratory tests of liver function, thyroid function, and fasting glucose level, and a lipid panel (triglyceride level, LDL and HDL cholesterol levels) assist in evaluating the causes and effects of obesity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Health history (cont’d) History of weight gain/weight loss Interested in losing weight Contributors to weight gain What impedes weight loss Eating patterns Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Health history (cont’d) How patient uses food (e.g., to relieve stress, provide comfort) Other overweight family members Environmental or genetic factors that influence weight gain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Diagnoses Imbalanced nutrition: More than body requirements Impaired skin integrity Ineffective breathing pattern Chronic low self-esteem Health-seeking behaviors Readiness for enhanced knowledge Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Implementation
When no organic cause can be found for obesity, it should be considered a chronic, complex disease. Health care providers are often reluctant to counsel patients about obesity for a variety of reasons. These include the following: (1) Time constraints are a factor during appointments, (2) weight management is professionally unrewarding, (3) reimbursement for weight management services is difficult to get, and (4) many providers do not feel knowledgeable about giving weight loss advice. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Supervise a plan. Successful weight loss, requiring a short-term energy deficit Successful weight control, requiring long-term behavior changes Before selecting a weight loss strategy with the patient, you should discuss the following questions: What is the patient’s motivation for losing weight? Will any major stresses make it difficult for the patient to focus on weight control? Does the patient have any psychiatric illnesses, such as severe depression, substance abuse, or a binge-eating disorder, that will derail weight-loss efforts? How much time can the patient devote to exercise on a daily or weekly basis? What financial considerations must be factored into the choices? What type of support does the patient have from family or friends for losing weight? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Multipronged approach ought to be used with attention to multiple factors. Dietary intake, physical activity, behavior modification, and/or drug therapy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Motivation is essential to weight loss. Set a realistic and healthy goal for weight loss. 1 to 2 pounds per week Slower weight loss offers better cosmetic results. A frank discussion of eating patterns helps the patient realize that often eating is the result of bad habits picked up over time and not associated with hunger. These eating behaviors must be changed, or any weight loss that occurs will be only temporary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Plateaus can last from several days to several weeks. Daily weighing is not recommended. Weigh once a week with similar clothing, at the same time of day. It is especially important for the patient to realize that plateaus are normal occurrences during weight reduction, so that discouragement, frustration, and giving up of the prescribed dietary plan are prevented. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nutritional Therapy Restricted food intake is a cornerstone. A good weight loss plan contains food from the basic food groups. Diet classifications 800 to 1200 calories: Low calorie <800 calories: Very low calorie For information on basic food groups, see Figure 40-1 and Table 40-1. In Table 41-7, an example of a 1200-calorie diet is presented. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nutritional Therapy Adequate quantities of Fruits and vegetables Lean meat, fish, and eggs Fad diets should be discouraged. Often body water is lost, and not fat. Restricting dietary intake so that it is below energy requirements is an effective way to reduce body weight. Low-carbohydrate diets do produce a rapid weight loss, but the elimination of carbohydrates reduces the opportunity to get adequate amounts of fiber, vitamins, and minerals. These diets are difficult to maintain long-term because of their restrictive nature. It is best to recommend a dietary approach in which calorie restriction includes all food groups. The more restrictive the dietary regimen, the greater the demand for intense discipline in the face of an intense desire to eat foods not allowed on the diet. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nutritional Therapy Need to consider the proportion of calories from animal sources and calories from fruits, grains, and vegetables American Institute for Cancer Research 2/3 of the diet should be plant source 1/3 or less from animal protein No firm agreement has been reached on the number of meals to be eaten when a person is on a diet. When a person is first starting on a weight-reduction program, food portion sizes need to be carefully determined to stay within the dietary guidelines. Portion sizes over the past 20 years have increased considerably (see next slide). Once this ratio has been adopted into the patient’s meal planning, portions can gradually be reduced as activity levels are gradually increased to achieve healthy weight loss. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nutritional Therapy Food portion sizes Serving of fruit and vegetables Size of woman’s fist or baseball Serving of meat Human’s palm or a deck of cards Serving of cheese Size of a thumb or six dice A test on portion sizes is available at the following website: Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Exercise An essential part of a weight control program Should be done daily for 30 minutes to an hour Sensible forms of exercise should be encouraged. Walking, swimming, cycling No evidence suggests that increased activity promotes an increase in appetite or leads to dietary excess. In fact, exercise frequently has the opposite effect. The addition of exercise produces more weight loss than does dieting alone. Individuals should be encouraged to wear a pedometer to track their activity, with a goal of 10,000 steps a day. Engaging in weekend exercise only or in spurts of strenuous activity is not advantageous and can actually be dangerous. Reduction in tension and stress, better-quality sleep and rest, increased stamina and energy, improved self-concept and self-confidence, better attitudes toward work and play, and increased optimism about the future can be achieved with exercise. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Behavior Modification
Assumption behind behavior modification Learned disorder Critical difference between an obese person and a nonobese person involves cues that regulate eating behavior. Therefore most behavior-modification programs deemphasize the diet and focus on how and when individuals eat. Teach people to restrict their eating to designated meals and to increase the amount of physical activity in their lives. Persons who participate in a behavioral therapy program are more successful in maintaining their losses over an extended time than those who do not participate in such training. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Behavior Modification
Useful basic techniques Self-monitoring: Show what and when foods are eaten Stimulus control: Separate events that trigger eating from the act of eating Rewards: Incentives for weight loss It is important that the reward for a specified weight loss not be associated with food, such as dinner out or a favorite treat. Reward items do not have to have a monetary component. For example, time for a hot bath or an hour of pleasure reading would be an enjoyable reward for many people. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Support Groups Encouragement can be offered to join a group of other obese persons who are receiving professional counseling to help modify eating habits. Many self-help groups are available. Take Off Pounds Sensibly (TOPS) Weight Watchers A proliferation of commercial weight-reduction centers can be seen across the nation. Many of these programs are staffed by nurses and/or dietitians. An initial physical examination by a health care provider is required before a candidate is accepted for weight reduction. These weight-reduction centers are costly and therefore are cost prohibitive for those with limited financial resources. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Therapy Classified into two categories ↓ food intake by reducing appetite or increasing satiety ↓ nutrient absorption Drugs that ↑ energy expenditure are not approved by the FDA. Drugs have been used in the treatment of obesity but only as adjuncts to diet, exercise, and behavioral modification. Drugs should be reserved for those whose BMI > 30 kg/m2. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Therapy Appetite-suppressing drugs Decrease food intake through nonadrenergic mechanisms in the central nervous system (CNS) Phentermine Diethylpropion Phendimetrazine Not recommended because of the potential for abuse Adverse effects of these drugs include palpitations, tachycardia, overstimulation, restlessness, dizziness, insomnia, weakness, and fatigue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Therapy Appetite-suppressing drugs (cont’d) Serotonergic drugs ↑ release of serotonin or ↓ its uptake, thus ↓ metabolism Fenfluramine (Pondimin) Dexfenfluramine (Redux) Removed from market in 1997 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Therapy Appetite-suppressing drugs (cont’d) Mixed nonadrenergic-serotonergic agents Do not stimulate release of serotonin Sibutramine (Meridia) Side effects of sibutramine include increased BP and heart rate, dry mouth, headache, insomnia, and constipation. Other selective serotonin reuptake inhibitors that are approved for the management of depression and other psychiatric conditions may have a short-term effect on weight loss, but the effect does not appear to last over time. Examples of these are fluoxetine (Prozac) and bupropion (Wellbutrin); both have been used off label for weight loss with mixed results. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Therapy Nutrient absorption–blocking drugs Work by blocking fat breakdown and absorption in intestine Inhibit action of intestinal lipases Undigested fat is excreted in feces. Orlistat (Xenical, Alli) Orlistat is associated with leakage of stool, flatulence, diarrhea, and abdominal bloating, which are accentuated if a high-fat diet is consumed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bariatric Surgery Used to treat obesity Currently the only treatment found to have a successful and lasting impact on sustained weight loss for severely obese individuals Most people who undergo bariatric surgery successfully improve their overall quality of life. A great deal of excess weight is lost, and patients experience resolution of co-morbidities and improve their appearance, social opportunities, and economic opportunities. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bariatric Surgery Must meet all of the following criteria to be considered an ideal candidate BMI ≥40 kg/m2 with one or more obesity-related complications 18 years or older Understands the risks and benefits Has been obese for >5 years Has tried and failed to lose weight Many insurance carriers do not cover the cost of bariatric surgery. If they do consider reimbursing for the surgery, most of them require documentation of three unsuccessful attempts at medically supervised weight loss programs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bariatric Surgery Criteria to be considered an ideal candidate (cont’d) Has no serious endocrine problems Has psychiatric and social stability Availability of a team of health care providers Surgery would ↓ or eradicate high-risk conditions Patients are not good candidates for bariatric surgery if they have untreated depression or psychosis, binge-eating disorders or bulimia, current drug and alcohol abuse, severe cardiac disease with prohibitive anesthetic risks, severe coagulopathy, or inability to comply with nutritional requirements. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bariatric Surgery Three broad categories Restrictive Malabsorptive Combination of restrictive and malabsorptive In restrictive procedures, the stomach is reduced in size (less food eaten), and in malabsorptive procedures, the length of the small intestine is decreased (less food absorbed). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bariatric Surgical Procedures
A, Vertical banded gastroplasty involves creating a small gastric pouch. B, Adjustable gastric banding uses a band to create a gastric pouch. C, Vertical sleeve gastrectomy involves creating a sleeve-shaped stomach by removing about 80% of it. D, Biliopancreatic diversion with duodenal switch procedure creates an anastomosis between the stomach and the intestine. E, Roux-en-Y gastric bypass procedure involves constructing a gastric pouch whose outlet is a Y-shaped limb of small intestine. Fig Bariatric surgical procedures. A, Vertical banded gastroplasty involves creating a small gastric pouch. B, Adjustable gastric banding uses a band to create a gastric pouch. C, Vertical sleeve gastrectomy involves creating a sleeve-shaped stomach by removing about 80% of the stomach. D, Biliopancreatic diversion with duodenal switch procedure creates an anastomosis between the stomach and intestine. E, Roux-en-Y gastric bypass procedure involves constructing a gastric pouch whose outlet is a Y-shaped limb of small intestine. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Restrictive Surgery Reduces the size of a stomach to 30 mL or less Causes patient to feel full more quickly Normal stomach digestion and intestinal absorption of food ↓ risk of anemia and cobalamin deficiency These procedures can be performed using a laparoscopic approach, which decreases postoperative pain and involves a shorter hospital stay and decreased rates of wound infection and hernia formation. Typically, weight loss is more gradual with these procedures. Several restrictive procedures are available. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Restrictive Surgery Vertical banded gastroplasty Partitions stomach into a small pouch in upper portion Small pouch drastically limits capacity. Stoma opening to rest of stomach is banded to delay emptying of solid food from proximal pouch. This procedure has been replaced by other procedures because of lack of sustained or desired weight loss and the high incidence of complications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Vertical Banded Gastroplasty
Fig Bariatric surgical procedures. A, Vertical banded gastroplasty involves creating a small gastric pouch. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Restrictive Surgery Adjustable gastric banding (AGB) AKA Lap-Band or Realize Band system Stomach size is limited by an inflated band placed around fundus of stomach. Band is connected to a subcutaneous port. Can be inflated or deflated to change stoma size Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Restrictive Surgery AGB (cont’d) Can be done laparoscopically and can be modified or reversed Better choice for patients who are surgical risks Weight loss is slower than with other procedures. AGB is the most common restrictive procedure done, and it is the preferred option for patients who are surgical risks because it is a less invasive approach. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Adjustable Gastric Banding
Fig Bariatric surgical procedures. A, Vertical banded gastroplasty involves creating a small gastric pouch. B, Adjustable gastric banding uses a band to create a gastric pouch. C, Vertical sleeve gastrectomy involves creating a sleeve-shaped stomach by removing about 80% of the stomach. D, Biliopancreatic diversion with duodenal switch procedure creates an anastomosis between the stomach and intestine. E, Roux-en-Y gastric bypass procedure involves constructing a gastric pouch whose outlet is a Y-shaped limb of small intestine. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Vertical Sleeve Gastrectomy
85% of the stomach is removed. Not reversible Stomach function is preserved. Because the new stomach continues to function normally, far fewer food restrictions on what patients can consume after surgery are needed. Removal of most of the stomach also results in the elimination of hormones produced within the stomach which stimulate hunger, such as ghrelin. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Vertical Sleeve Gastrectomy
Fig Bariatric surgical procedures. C, Vertical sleeve gastrectomy involves creating a sleeve-shaped stomach by removing about 80% of the stomach. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Malabsorptive Surgeries
Biliopancreatic diversion (BPD) Removes ~3/4 of stomach to ↓ food intake and ↓ acid output Remaining 1/4 of stomach is connected to lower portion of small intestine. Pancreatic enzymes and bile enter final segment of intestine. Nutrients pass without being digested. The patient loses weight because most of the calories and nutrients are routed into the colon, where they are not absorbed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Malabsorptive Surgeries
Biliopancreatic diversion with duodenal switch Variation of BPD By including duodenal switch, surgeons leave a larger portion of the stomach intact. Helps prevent dumping syndrome This procedure can increase the risk of gallstones forming and may require the gallbladder to be removed. Patients should be aware of the possibilities of intestinal irritation and ulcers. Patients should also monitor their protein, iron, and cobalamin intake to ensure that they do not develop malnutrition or anemia. Supplements and vitamins should be taken to offset these risks. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

BPD With Duodenal Switch
A variation of the BPD procedure involves a duodenal switch, wherein surgeons leave a larger portion of the stomach intact along with a small part of the duodenum. This procedure also lets the surgeon keep the pyloric valve, which helps prevent dumping syndrome. Fig Bariatric surgical procedures. D, Biliopancreatic diversion with duodenal switch procedure creates an anastomosis between the stomach and intestine. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Combination of Restrictive and Malabsorptive Surgery
Roux-en-Y surgical procedure Has low complication rates Excellent patient tolerance Stomach size is ↓ with a gastric pouch anastomosis that empties directly into jejunum This surgical procedure is the most common bariatric procedure performed in the United States and is considered the gold standard among bariatric procedures. With this procedure, the stomach size is decreased with a gastric pouch anastomosis that empties directly into the jejunum. This surgery can be performed through an open abdominal incision or laparoscopically. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Combination of Restrictive and Malabsorptive Surgery
Roux-en-Y surgery (cont’d) Variations Stapling stomach without transection to create a small 20- to 30-mL gastric pouch Creating an upper and a lower gastric pouch and totally disconnecting the pouches Creating an upper gastric pouch and completely removing the lower pouch After the procedure, food bypasses 90% of the stomach, the duodenum, and a small segment of jejunum. Outcomes include improved glucose control with improvement or reversal of diabetes, normalization of BP, decreased total cholesterol and triglycerides, decreased gastroesophageal reflux disease (GERD), and decreased sleep apnea. A complication of this procedure is dumping syndrome, in which gastric contents empty too rapidly into the small intestine, overwhelming its ability to digest nutrients. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Roux-en-Y Gastric Bypass
Fig Bariatric surgical procedures. E, Roux-en-Y gastric bypass procedure involves constructing a gastric pouch whose outlet is a Y-shaped limb of small intestine. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Cosmetic Surgeries Ideal candidates have Achieved weight reduction Excess skinfolds or fat Chooses surgery for cosmetic reasons Lipectomy Liposuction Lipectomy (adipectomy) is performed to remove unsightly flabby folds of adipose tissue. No evidence suggests that a regeneration of adipose tissue occurs at the surgical sites. However, emphasize to the patient that surgical removal does not prevent obesity from recurring, especially if lifetime eating habits remain the same. A good candidate for liposuction is a person who has achieved weight reduction but who has excess fat under the chin, along the jawline, in the nasolabial folds, over the abdomen, or around the waist and upper thighs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Patients who are obese are likely to suffer other co-morbidities, such as Diabetes, altered cardiorespiratory function, abnormal metabolic function, atherosclerosis A team approach may be necessary. Cardiologist, pulmonologist, gynecologist, gastroenterologist, or other specialist Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Have room ready for patient before arrival. Larger blood pressure cuff Larger gown Bariatric wheelchair Or a wheelchair with removable arms Strongly reinforced trapeze bar over bed for movement and positioning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Have room ready for patient before arrival (cont’d). It may be necessary to put beds together or to specially construct a chair. Have proper number of staff on hand for ambulating, bathing, and turning patient. Routine physical assessment strategies do not work well with morbidly obese patients who have numerous layers of skinfolds covering areas that need to be assessed. Without identifying alternatives or unique methods of dealing with this problem, assessment of respiratory status and bowel sounds or even wound inspection could be awkward for you and embarrassing for the patient. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Wound infection is one of the most common complications because of the many layers of flabby skinfolds, especially in the abdominal area. Skin preparation is important. May be necessary to ask patient to bathe or shower frequently for a few days before admission to hospital Emphasize careful cleansing with soap and warm water of the abdominal area from the breasts to below the waist. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Obesity can make breathing shallow and rapid. Instruct patient in proper Coughing techniques Deep, diaphragmatic breathing Methods of turning and positioning to prevent pulmonary complications This type of breathing results in hypoxemia, pulmonary hypertension, and polycythemia. If possible, introduce the use of a spirometer before surgery. Use of the spirometer helps prevent and alleviate postoperative lung congestion. If the patient uses continuous positive airway pressure (CPAP) at home for sleep apnea, make arrangements for use of a machine while hospitalized. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Obtaining venous access may be complicated. Assistance may be needed. Mark the spot of insertion with a sterile skin marker once a vein has been found. If patient has excess fat, or pitting edema, hold a firm finger over the spot with pressure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Obtaining venous access (cont’d) Multiple tourniquets can be used to distend veins and hold back excess tissue. Tourniquet should be removed as soon as it is no longer needed, to avoid edema. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Obtaining venous access (cont’d) Edema can worsen if catheter is anchored with tape to arm. Further impeding venous return Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Preoperative Care Obtaining venous access (cont’d) May need a longer catheter to traverse overlying tissue >1 inch Important that cannula is far enough into vein that it is not dislodged or infiltrated Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postoperative Care Trained staff should assist transfer of unconscious patient. During transfer, ensure that patient’s Airway is stabilized Pain is managed In severely obese patients, it is essential to monitor for rapid oxygen desaturation. Maintain the head of the patient at a 35- to 40-degree angle to reduce abdominal pressure and increase tidal flow. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postoperative Care Early ambulation is essential. Frequently ↑ ambulation after initial move Generally 3 to 4 times a day Pneumatic compression devices, elastic compression stockings, or elastic wraps will be used. Low-dose heparin may be ordered. Depending on the size of the patient and the amount of pain he or she is experiencing, the patient may not be able to assist you in turning. Extra nurses may be needed to turn the patient safely. The nursing care team will also want to assess the patient’s skin for delayed wound healing and the development of seromas, hematomas, wound dehiscence, wound evisceration, and wound infection. Keep skinfolds clean and dry to prevent dermatitis and secondary bacterial or fungal infections. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Postoperative Care Patients undergoing bariatric surgery are often in considerable abdominal pain. Pain medications should be given as frequently as necessary during the immediate postoperative period. The nurse must be diligent in assessing pain and must be mindful of pain that could be the result of an anastomosis leak rather than typical surgical pain. Often an anastomosis leak will present with changes in vital signs such as tachycardia, and pain may be a secondary symptom. See Chapter 41 for more information on special considerations for bariatric surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Ambulatory and Home Care
Following bariatric surgery, patients find it challenging to maintain a prescribed diet. Patient now has reduced intake because of anatomic changes. This patient finds that adherence to a reduced intake is necessary because of concern for abdominal distention, cramping abdominal pain, and perhaps diarrhea. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Must learn to adjust intake sufficiently with regard to nutrition, and to maintain a stable weight Weight loss is considerable during the first 6 to 12 months. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Diet prescribed is generally High protein Low carbohydrates Low fats Low roughage Six small feedings Fluids not to be ingested with meals <1000 mL/day Fluids and foods high in carbohydrate tend to promote diarrhea and symptoms of the dumping syndrome. Generally, calorically dense foods (foods high in fat) should be avoided to permit more nutritionally sound food to be consumed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Possible complications from bariatric surgery Anemia Vitamin deficiencies Diarrhea Psychiatric problems Failure to lose weight or loss of too much weight may be caused by the surgical formation of too large a stomach pouch or of an outlet that is much too small, respectively. The nurse needs to anticipate and recognize several potential psychologic problems after surgery. Some patients express guilt feelings concerning the fact that the only way they could lose weight was by surgical means rather than by the “sheer willpower” of reduced dietary intake. Many morbidly obese patients who blamed their feelings of social inferiority or inadequacies on their appearance before bypass surgery may suffer from episodes of depression. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Evaluation Expected outcomes Long-term weight loss Improvement in obesity-related co-morbidities Integration of healthy practices into lifestyle Improved self-image Must monitor for possible adverse effects Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Gerontologic Considerations
Number of older obese persons has risen. More common in women than men Decreased energy expenditure and loss of muscle mass are important contributors. Exacerbates age-related problems Individuals who are obese live 6 to 7 fewer years than people of normal weight. Examples of age-related problems include arthritis, urinary incontinence, hypoventilation, and sleep apnea. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Metabolic Syndrome Also known as Syndrome X, insulin resistance syndrome, dysmetabolic syndrome Collection of risk factors that increase an individual’s chance of developing cardiovascular disease and diabetes mellitus It is estimated that around 70 to 80 million or about 25% of Americans have metabolic syndrome. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Metabolic Syndrome Diagnosed if an individual has three or more of the conditions listed Waist circumference ≥40 inches (men) or ≥35 inches (women) Triglycerides >150 mg/dL, or being treated Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Metabolic Syndrome Diagnosed if an individual has three or more of the conditions listed High-density lipoprotein (HDL) cholesterol <40 men, <50 women, or being treated Blood pressure ≥130 mm Hg systolic or ≥85 mm Hg diastolic, or being treated Fasting glucose is ≥100 mg/dL, or being treated Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Metabolic Syndrome Etiology and Pathophysiology
Main underlying risk factors Insulin resistance Abdominal obesity {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Metabolic Syndrome Relationship among insulin resistance, obesity, diabetes mellitus, and cardiovascular disease. Fig Relationship among insulin resistance, obesity, diabetes mellitus, and cardiovascular disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Other risk factors Hypertension Abnormal cholesterol Prothrombotic tendencies Hormonal imbalances Aging Genetic or ethnic predisposition Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

No symptoms Medical problems develop if syndrome is not addressed. Heart disease Stroke Diabetes Renal disease The signs of metabolic syndrome include impaired fasting blood glucose, hypertension, abnormal cholesterol levels, and obesity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Metabolic Syndrome Nursing and Collaborative Management
Lifestyle therapy is first line of intervention. Reduce LDL cholesterol Stop smoking Lower blood pressure Reduce glucose levels Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Because only management is available, the nurse can assist patients by providing information. The diet should be low in saturated fats and should promote weight loss. Because sedentary lifestyles contribute to metabolic syndrome, increasing regular physical activity will lower a patient’s risk factors. Patients unable to lower risk factors with lifestyle therapies alone and those at high risk for a coronary event or diabetes may be considered for drug therapy, such as cholesterol-lowering medication, antihypertensives, or metformin (Glucophage). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question An important factor associated with both short-term and long-term weight-loss success is: 1. Higher initial body mass index. 2. Simultaneous smoking cessation. 3. Fewer dieting attempts in the past year. 4. A strong desire to improve appearance. Answer: 4 Rationale: Motivation to lose weight is essential for a favorable and successful outcome. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 112

Audience Response Question When following discharge instructions for a patient who has had bariatric surgery for treatment of obesity, the nurse determines that additional teaching is needed when the patient says, 1. “I shouldn’t eat concentrated sweets.” 2. “I can eat small, frequent meals throughout the day.” 3. “I should drink several glasses of fluids with my meals.” 4. “I will need to have a cobalamin injection once a month.” Answer: 3 Rationale: Discharge teaching for a patient after bariatric surgery may include six small meals/day, a diet high in protein and low in fat and carbohydrates, avoidance of ingestion of solids with fluids, avoidance of large amounts of fluids at one time, restriction of fluid intake to less than 1000 mL/day, and avoidance of sugary foods. The dietary restrictions will help to prevent dumping syndrome and will aid in weight loss. Cobalamin injections or intranasal spray will prevent cobalamin-deficiency anemia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 113

Audience Response Question The nurse determines that teaching regarding a weight-loss program has been effective when the patient says, 1. “I will keep a diary of daily weights to chart my weight loss.” 2. “I plan to lose 4 pounds a week until I have lost my goal of 60 pounds.” 3. “I should not exercise more than what is required because increased activity increases the appetite.” 4. “I plan to join a behavior-modification group to make permanent changes necessary for weight control.” Answer: 4 Rationale: Behavior-modification programs deemphasize the diet and focus on how and when to eat; support groups offer support and information on dieting tips. Patients should set a weight loss goal of 1 to 2 pounds per week. Weight should be checked weekly; daily weights are not recommended because of the frequent fluctuations that result from retained water (including urine) and elimination of feces. No evidence indicates that increased activity promotes an increase in appetite or leads to dietary excess. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 114

Case Study Height 5’5” Weight 320 pounds History of hypertension, type 2 diabetes, COPD, obesity She states that she’s “tired of being like this.” Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What opportunities for education and support do you have? What other problems is she likely to have related to her weight? Teach her the negative effects of obesity. Pain in joints, high cholesterol, sleep apnea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What treatment options are available for her? What tools may help her with behavior modification? 3. Drug therapy for weight reduction, such as Alli, or bariatric surgery 4. Support groups or individual therapy sessions Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions If she wants to have bariatric surgery, what risks does the surgery pose? 5. Postanesthesia problems due to her weight and pain following surgery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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