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Obesity
 

Obesity

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    Obesity Obesity Presentation Transcript

    • Focus on Obesity (Relates to Chapter 41, “Nursing Management: Obesity,” in the textbook)
    • 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 proportion of fat cells
    • Obesity and Overweight
      • Primarily occurs in the visceral and subcutaneous tissues of the body
    • Obesity and Overweight
      • Weight gain in adulthood is characterized predominantly by adipocyte hypertrophy
        • Adipocyte hypertrophy is a process by which adipocytes can increase their volume several thousandfold to accommodate large increase in lipid storage
    • Obesity
      • Has reached epidemic proportions in developed and nondeveloped countries
      • In the United States
        • Most common nutritional problem
        • Affects one third of the population
    • Obesity
      • Second leading cause of preventable death
      • Third leading reason for liver transplantation
    • Etiology and Pathophysiology
      • Energy intake exceeds energy output
      • Processes leading to obesity are much more complex and still undergoing investigation
    • Etiology and Pathophysiology
      • Cause involves significant genetic/biologic susceptibility factors that are ↑ influenced by environment and psychosocial factors
      • Caloric consumption must exceed energy expenditure for condition to continue
    • Genetic/Biologic Basis
      • Strong evidence of genetic predisposition
    • Genetic/Biologic Basis
      • Most common form considered to be polygenic, arising from the interaction of multiple genetic and environmental factors
        • Identifying these genes will lead to a better understanding of the pathogenesis
    • Genetic/Biologic Basis
      • Appetite is influenced by many factors that are integrated by the brain
        • Most importantly, the hypothalamus
      • Input to the hypothalamus is received from the periphery from many different hormones and peptides
    • Hormones & Peptides that Interact with Hypothalamus to Effect Obesity
      • Fig. 41-3
    • Genetic/Biologic Basis
      • Associated with ↑ circulating plasma levels of leptin, insulin, and ghrelin, and ↓ levels of peptide YY
      • Adipocytes secrete a number of hormones and cytokines known as adipokines
    • Environmental Factors
      • Greater access to food
        • Prepackaged food
        • Fast food
        • Soft drinks
        • Increased portion sizes
      • Obese individuals tend to underestimate food and caloric intake
    • 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
    • Psychosocial Factors
      • Emotional component to overeat is powerful
      • People use food for many reasons
      • Social component of eating is developed early in life
        • Birthday parties, holidays
    • Classification of Body Weight and Obesity
      • Primary obesity ( majority of obese )
        • Excess caloric intake for the body’s metabolic demands
      • Secondary obesity
        • Results from various congenital anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and disorders
    • Classification of Body Weight and Obesity
      • Body mass index
        • 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
    • Body Mass Index
      • Fig. 41-4
    • Classification of Body Weight and Obesity
      • 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
    • Classification of Body Weight and Obesity
      • Waist-to-hip ratio (WHR) (cont’d)
        • WHR >0.80 indicates greater risk for health complications
        • People with more visceral fat are at an increased risk for cardiovascular disease and metabolic syndrome
        • Preferred tool when patient is predominantly muscular
    • Classification of Body Weight and Obesity
      • 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
        • Pear-shaped body
          • Fat located primarily in upper legs
          • Gynoid obesity
    • Classification of Body Shapes
      • Fig. 41-5
    • Common Fat Distribution
      • Fig. 41-1
    • Health Risks Associated with Obesity
      • Problems occur at higher rates for obese patients
      • Mortality rate rises as obesity increases
        • Especially with increased visceral fat
      • Obese patients have a decreased quality of life
      • Most conditions improve with weight loss
    • Health Risks Associated with Obesity
      • Fig. 41-6
    • Cardiovascular Problems
      • Obesity is a significant risk factor for predicting cardiovascular disease
      • WHR is best predictor of risk
        • Android obesity patients at greater risk
    • Cardiovascular Problems
      • Risks
        • ↑ Low-density lipoproteins (LDLs)
        • ↑ Triglycerides
        • ↓ High-density lipoproteins (HDLs)
    • Cardiovascular Problems
      • Risks (cont’d)
        • Hypertension
          • ↑ Circulating blood volume
          • Abnormal vasoconstriction
          • ↓ Vascular relaxation
          • ↑ Cardiac output
    • Cardiovascular Problems
      • Larger cuff to avoid artifactual ↑ may be needed when taking blood pressure
    • 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
    • Diabetes Mellitus
      • Hyperinsulinemia
      • Insulin resistance
      • Type 2 diabetes
        • 80% of patients with type 2 diabetes are obese
      • Weight loss and exercise improve glucose control
    • Musculoskeletal Problems
      • Osteoarthritis
        • Trauma to weight-bearing joints
      • Hyperuricemia
      • Gout
    • Gastrointestinal and Liver Problems
      • Gastroesophageal reflux disease (GERD)
      • Gallstones
      • Nonalcoholic steatohepatitis (NASH)
        • Can eventually lead to cirrhosis
        • Weight loss can improve NASH
    • Cancer
      • Obesity is one of the most important known preventable causes of cancer
        • Women
          • Breast, endometrial, ovarian, cervical
          • Possibly from ↑ estrogen postmenopause
        • Men
          • Prostate
        • Both genders: Colon
    • 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
    • Nursing Assessment
      • Health history
        • Time of obesity onset
        • Diseases related to metabolism and obesity
        • Medications
        • Objective
          • Height, weight, BMI, skinfold thickness, waist circumference
    • Nursing Assessment
      • Health history (cont’d)
        • History with weight gain/weight loss
        • Interested in losing weight
        • Contributors to weight gain
        • What impedes weight loss
    • 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 influencing weight gain
    • Nursing Diagnoses
      • Imbalanced nutrition: More than body requirements
      • Impaired skin integrity
      • Ineffective breathing pattern
      • Chronic low self-esteem
      • Health-seeking behaviors
    • Planning
      • Modify eating patterns
      • Participate in a regular physical activity program
      • Achieve weight loss to a specified level
      • Maintain weight loss at a specified level
      • Minimize or prevent health problems related to obesity
    • Nursing Implementation
      • When no organic cause can be found for obesity, it should be considered a chronic, complex disease
      • Supervise a plan
        • Successful weight loss, requiring a short-term energy deficit
        • Successful weight control, requiring long-term behavior changes
    • Nursing Implementation
      • Multipronged approach ought to be used with attention to multiple factors
        • Dietary intake, physical activity, behavior modification, and/or drug therapy
      • All opportunities for patient education should stress healthy eating and exercise
    • Nursing Implementation
      • 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
    • Nursing Implementation
      • 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
    • 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
    • Nutritional Therapy
      • Adequate amounts of
        • Fruits and vegetables
        • Lean meat, fish, and eggs
      • Fad diets should be discouraged
        • Often body water is lost and not fat
    • 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
    • Nutritional Therapy Table 41-8
    • 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 or cards
        • Serving of cheese
          • Size of a thumb or six dice
    • 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
    • Behavior Modification
      • Assumption behind behavior modification
        • Learned disorder
        • Critical difference between an obese person and a nonobese person are cues that regulate eating behavior
      • Goal is to deemphasize diet and focus of how and when a person eats
    • Behavior Modification
      • Has been successful helping people maintain weight loss
      • 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
    • 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
    • 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
    • Drug Therapy
      • Appetite-suppressing drugs
        • Decrease food intake through nonadrenergic or serotonergic mechanisms in the central nervous system (CNS)
          • Phentermine
          • Diethylpropion
          • Phendimetrazine
        • Recommended for short-term use
    • 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
    • Drug Therapy
      • Appetite-suppressing drugs (cont’d)
        • Mixed nonadrenergic–serotonergic agents
          • Do not stimulate release of serotonin
          • Sibutramine (Meridia)
    • Drug Therapy
      • Nutrient absorption-blocking drugs
        • Work by blocking fat breakdown and absorption in intestine
        • Inhibits action of intestinal lipases
        • Undigested fat is excreted in feces
          • Orlistat (Xenical)
      • Purchasing over-the-counter drugs should be discouraged
    • Bariatric Surgery
      • Used to treat morbid obesity
      • 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
        • BMI ≥40 kg/m 2 with one or more obesity-related complication
        • 18 years or older
        • Understands the risks and benefits
        • Has been obese for >5 years
        • Has tried and failed to lose weight
    • 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
    • Bariatric Surgery
      • Three broad categories
        • Restrictive
        • Malabsorptive
        • Combination of restrictive and malabsorptive
    • Restrictive Surgery
      • Reduces the size of a stomach to 30 ml or less
      • Causes patient to feel full quicker
      • Normal stomach digestion and intestinal absorption of food
        • ↓ Risk of anemia and cobalamin deficiency
    • 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
    • Restrictive Surgery
      • Fig. 41-7A
    • Restrictive Surgery
      • Adjustable gastric banding (AGB)
        • Also referred to as the LapBand
        • 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
    • 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 in other procedures
    • Restrictive Surgery
      • Fig. 41-7B
    • 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
    • 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
    • Restrictive Surgery
      • Fig. 41-7C
    • 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
    • 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 lower gastric pouch and totally disconnecting the pouches
          • Creating an upper gastric pouch and completely removing the lower pouch
    • Restrictive Surgery
      • Fig. 41-7D
    • Cosmetic Surgeries
      • Ideal candidates have
        • Achieved weight reduction
        • Excess skinfolds or fat
      • Chooses surgery for cosmetic reasons
        • Lipectomy
        • Liposuction
    • Preoperative Care
      • Patients who are obese are likely to suffer other comorbidities, such as
        • Diabetes, altered cardiorespiratory function, abnormal metabolic function, atherosclerosis
      • A team approach may be necessary
        • Cardiologist, pulmonologist, gynecologist, gastroenterologist, or other specialist
    • Preoperative Care
      • Have room ready for patient prior to arrival
        • Larger size blood pressure cuff
        • Larger gown
        • Bariatric wheelchair
          • Or a wheelchair with removable arms
        • Strongly reinforced trapeze bar over bed for movement and positioning
    • Preoperative Care
      • Have room ready for patient prior to arrival (cont’d)
        • It may be necessary to put beds together or specially construct a chair
        • Have proper amount of staff on hand for ambulating, bathing, and turning patient
    • 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
    • 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
    • Preoperative Care
      • Obtaining venous access may be complicated
        • Assistance may be needed
        • Mark the spot of injection 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
    • 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
        • Edema can worsen if catheter is anchored with tape to arm
          • Further impeding venous return
    • Preoperative Care
      • Obtaining venous access (cont’d)
        • May need a longer catheter to traverse overlying tissue
          • Longer than 1 inch
        • Important that cannula is far enough into vein so that it is not dislodged or infiltrated
    • Preoperative Care
      • Patients undergoing anesthesia have an increased risk of failing to wean from mechanical vent ilation
    • 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
    • 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
    • Postoperative Care
      • Patients undergoing bariatric surgery are often in considerable abdominal pain
      • Pain medications should be given as frequently as necessary during immediate postoperative period
    • Ambulatory and Home Care
      • Patients who have just had bariatric surgery have been unsuccessful in the past maintaining a prescribed diet
      • Patient is now reduced intake due to anatomic changes
      • Must learn to adjust intake sufficiently with regard to nutrition and maintaining a stable weight
    • Ambulatory and Home Care
      • Diet prescribed is generally
        • High protein
        • Low carbohydrates
        • Low fats
        • Low roughage
        • 6 small feedings
        • Fluids not to be ingested with meals
          • <1000 ml/day
    • Ambulatory and Home Care
      • Possible complications from bariatric surgery
        • Anemia
        • Vitamin deficiencies
        • Diarrhea
        • Psychiatric problems
    • Ambulatory and Home Care
      • Possible complications from bariatric surgery (cont’d)
        • Peptic ulcer formation
        • Dumping syndrome
        • Small bowel obstruction
    • Evaluation
      • Expected outcomes
        • Long-term weight loss
        • Improvement in obesity-related comorbidities
        • Integration of healthy practices into lifestyle
        • Monitoring possible adverse side effects
        • Improved self-image
    • 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
    • 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
    • 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
          • 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
    • Metabolic Syndrome Etiology and Pathophysiology
      • Main underlying risk factors
        • Abdominal obesity
        • Insulin resistance
    • Metabolic Syndrome Etiology and Pathophysiology
      • Other risk factors
        • Physical inactivity
        • Presence of inflammatory markers
        • Prothrombotic tendencies
        • Hormonal imbalances
        • Aging
        • Genetic or ethnic predisposition
    • Metabolic Syndrome Etiology and Pathophysiology
      • No symptoms
      • Medical problems develop if syndrome is not addressed
        • Heart disease
        • Stroke
        • Diabetes
        • Renal disease
    • Metabolic Syndrome Nursing and Collaborative Management
      • Lifestyle therapy is first line of intervention
        • Manage cholesterol
        • Stop smoking
        • Lower blood pressure
        • Reduce glucose levels
    • Metabolic Syndrome Nursing and Collaborative Management
      • Lifestyle therapy is first line of intervention (cont’d)
        • Lose weight
        • Increase physical activity
        • Healthy dietary habits
    • Metabolic Syndrome Nursing and Collaborative Management
      • Because there is only management, the nurse can assist patients by providing information