NURS 350 - Obesity and Surgical Options

Obesity - Defined

• client has not consumed enough healthy nutrients to achieve adequate nutrition and has excessive fat

• ideal body weight (IBW)

  • height and weight standard range one should weigh

• body mass index (BMI) = weight (kg)/height (m2)

  • difference between overweight and obese

    • overweight - up to 10% over IBW or BMI 25-29

    • obesity categories by BMI

      • class 1 = 30 - <35

      • class 2 = 35 - <40

      • class 3 = >40 severe obesity

obesity reframed

• new/evolving criteria for dx and management

• chronic condition

• “excess adiposity” that negatively impacts health

• overweight and obese does not mean well-nourished

• “clinical” obesity focuses on organ dysfunction and ability to perform ADLs

  • not diagnosed by BMI alone (only considers height/weight)

  • waist circumference, waist to hip ratio, waist to height ratio

    • waist circumference (WC) - stronger predictor of CAD than BMI

    • WC >35 in women and >40 in men indicates central obesity

    • WHR >0.95 in men and >0.8 in women = android obesity

    • central obesity is a major risk factor in CAD, stroke, T2DM, CA

health promotion

• healthy people 2030

  • decrease proportion of adults with obesity

  • increase consumption of

    • calcium, vegetables, fruit, potassium, vit D, whole grains, beans, and peas

  • decrease consumption of

    • saturated fats, added sugars and sodium

• a 5% weight loss can drastically decrease risk for CAD and DM

• adding exercise is key - walking 20 min/day helps

• collaborate w/ PCP, RDN, RN, SW, surgeon, and/or psychologist PRN

Pathophysiology

• complex, involves many hormones, factors

  • leptin (decrease appetite); insulin

  • ghrelin (stimulates appetite) “hunger hormone”

  • resisten (creates insulin resistance)

• very small % have neuroendocrine disease

  • hypothyroidism or cushing’s syndrome

• high-fat (saturated/LDLs) “western diet”

• physical inactivity

• drugs - corticosteroids, antidepressants, estrogens

• genetics and learned eating patterns

• environmental - walk or drive to get around

etiology and the obesity epidemic

• global crisis - obesity worldwide has doubled since 1980

• genetic predisposition/familial factors - inherited leptin resistance and learned patterns of eating

  • if both parents overweight - 80% in children

• obesity is a leading cause of preventable death

• mechanism in brain which explains why dieters tend to eventually regain lost weight

  • cells in hypothalamus triggered when body low on customary nourishment levels cause “intense hunger”

concept of food addiction

• addiction - dysfunctional signals from neurochemical system that controls eating behavior in complicated world that encourages food consumption

  • learned coping mechanism

• 1 in 8 adults show signs of addiction to highly processed foods and sweet drinks - rapid absorption, stimulates dopamine release in brain’s reward system

• s/s - 44% have at least 1 symptom

  • intense cravings at least once a week

  • inability to cut down on intake desire to do so 2-3/week

  • signs of withdrawal at least 1x/week

• higher in women (18%) than men (8%)

• poor mental health - 3X more likely; abnormal relationship with food

common complications

• cardiovascular

  • CAD, high cholesterol, HTN, PAD

• endocrine

  • insulin resistance, metabolic syndrome, DM 2

• GI

  • cholelithiasis

• GU/Repro

  • ED, incontinence

• Integumentary

  • increased susceptibility to infections

  • delayed wound healing

• musculoskeletal

  • chronic back/joint pain

• neurologic

  • stroke

• psychiatric

  • depression

• respiratory

  • OSA

  • obesity hypoventilation syndrome

• a leading cause of early and preventable death

client assessment

• health history and family history of obesity

• diet history/food diary

• past health/chronic diseases

• medications

• nutritional assessment

  • usual food intake, preferences, appetite

  • cultural background, socioeconomic status

  • psychosocial - eating behaviors, attitude toward food

  • depression/behavioral problems

  • developmental

• physical assessment/measurements

  • BMI - not always best measure

  • waist circumference >40 (M) or >35 (F)

  • waist hip ratio >0.95 (M) or 0.8 (F) = CAD

  • check under folds for candida/infections, lesions

• stigma association with obesity

  • meaning of food, motivation to change

  • treat like any addiction - assess readiness

  • previous attempts/outcome

• approach with RESPECT

  • rapport, environment, safe, privacy, encourage, tact

non-surgical interventions

• improve nutrition

  • diets - very low-calorie/carb; time-restricted fasting

    • popular but mixed results

  • nutritionally-balanced diets - 1200-1800 cals/day for slow weight loss and long-term success

    • pref. over short-term fasting and unbalanced low-energy diets

  • calorie counting

    • 1lb loss/week - 500 calorie deficit

    • 2lb loss/week - 1000 calorie deficit

  • 5-10% loss of body weight increases glycemic control (blood glucose levels) decreases cholesterol and BP

• exercise

  • increase weight loss, mostly fat lost (preserves lean mass)

pharmacologic interventions

• PO meds - long term, chronic weight loss

  • bupropion - naltrexone - opioid antagonist/antidepressant

  • orlistat (xenical; OTC alli) - inhibits lipase so only partial digestion and absorption of fats

    • multivitamin, <30% dietary fat intake or GI s/s will occur

  • phentermine-topiramate (qysmia) - chronic weight loss (schedule IV drug/sympathomimetic to suppress appetite) and seizure/migraine prevention med for satiety

    • can increase eye pressure and can cause birth defects

• injectables

  • liraglitude( (victoza) - activates appetite regulation in brain

  • semaglutide (ozempic, wegovy) - 1X/week injection

    • repurposed DM med - for glucose regulation, approved for weight loss

    • increase resting metabolism and feeling of fullness; decreases appetite

      • available in pill form - rybelsus

      • adverse GI effects/nausea; acute pancreatitis (rare)

    • setmelanotide - targets underlying hunger

      • side effects: sexual dysfunction, skin changes, mood changes/depression

  • educate how to administer these injectables

  • what happens when meds are stopped?

    • increased appetite/less satiety, about 2/3 weight regain in 1 year

non-surgical interventions

• cryolipolysis - fat freezing

• behavioral management

  • self-monitoring - food journal, exercise/activity patterns

  • stimulus control - awareness of external cues

  • reinforcement techniques - self reward behavior change

  • cognitive restructuring learned and coping techniques

  • counseling by healthcare professionals

  • overeaters anonymous, support groups

• complementary approaches - evidence varies

  • acupuncture

  • acupressure

  • ayurveda

  • hypnosis

surgical management

• liposuction - removal of adipose tissue/office

  • not a sustainable solution for adults with obesity

• GI electrical stimulation (GES) - implantation of vagal-blocking device into abdomen

  • causes early satiety, thus decreasing intake

• bariatrics - branch of medicine that manages obesity and related diseases

  • surgical procedures for persons that

    • do not respond to traditional interventions

    • BMI or 40 or more

    • BMI of 35+ with other health risk factors

bariatric surgeries

• bariatric surgeries

  • roux-en-Y gastric bypass - most common in US

  • sleeve gastrectomy

  • adjustable gastric band

  • biliopancreative diversion with duodenal switch (BPD/DS)

  • single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S

• conventional (open) approach sometimes needed

  • most are done laparoscopically

• bariatric surgeries - only method with long term impact

  • many cured of HTN, T2DM, and sleep apnea

• must agree to modify lifestyle/weight loss protocols

perioperative care

• involves comprehensive multidisciplinary evaluation

  • screening for depression, substance use, cognitive function

  • coping (food as coping mechanism)

  • motivation, support systems also assessed

• who is eligible based on nationally devised/accepted criteria, minimum BMI, etc

  • some surgeons require specific amount of weight loss prior

• must demonstrate understanding of operation and lifestyle changes required post-op

surgical management - restrictive

• restrictive - limits food intake by decreasing size of stomach (partial removal or banding)

  • allow normal digestion and no risk of nutritional deficiencies

    • gastric banding (lap band)

    • vertical sleeve gastroplasty

surgical management - restrictive and malabsoptive

• combined restrictive and malabsorptive

  • roux-en-y gastric bypass

  • biliopancreatic diversion with duodenal switch

• roux-en-y gastric bypass

  • restricts intake and decreased absorption of nutrients

  • most effective in terms of weight loss

  • some nutritional deficiencies

  • laparoscopic/robotic-assistive approach

    • fewer complications than open

    • small stomach pouch created to restrict food intake

    • y shaped section (roux limb) of small intestine attached to pouch so food bypasses lower stomach and duodenum/1st part of jejunum

      • cholecystectomy may be done - decrease gallstone risk/rapid weight loss

  • advantages

    • quick weight loss, continues for 18-24 months

    • more likely to maintain a weight loss of 60-70% and keep it off for 10+ years - more effective/health outcomes

    • bypass - greater endocrine effect (DM) than lap band

  • disadvantages

    • more difficult to perform than banding/restrictive

    • absorption decreases - nutritional deficiencies

      • bypasses much of duodenum/jejunum where iron/CA+ are absorbed (anemia, osteoporosis)

        • need to supplement

adjustable gastric banding (AGB)

• restrictive only - done laparoscopically

• hollow silicone rubber band placed around stomach near upper end to create small pouch, narrow passage to rest of stomach

• band inflated with salt solution thru tube that connects to band; access port placed under the skin

  • can be tightened/loosened over time to change size of passage by adjusting amount of salt solution

• high failure rate - pouch can stretch with overeating

  • rarely done - bypass and sleeve safer, more effective

vertical sleeve gastroplasty

• laparoscopic removal of large portion (75%) of stomach (size of banana)

  • portion where ghrelin secreted

    • less hunger, increased satiety

• restrictive only - no rerouting of food

  • decreased risk of long term nutritional deficiencies

• disadvantages

  • weight loss not as large or as quickly

  • similar complications

  • cannot be reversed

  • cholecystectomy? high risk for gallstones

biliopancreatic diversion with duodenal switch

• like sleeve, large part (80%) of stomach removed

• restrictive and malabsorptive

• duodenum divided just past the pylorus

• lower small intestine connected to duodenum (duodenal switch)

• food and digestive enzymes separated

• mix only in final 100cm

• most nutrients routed to the colon (not absorbed)

  • lifelong vitamin supplementation

• advantages

  • no dumping syndrome

  • production of hunger hormone (ghrelin) decreased with removal or greater curvature of stomach

  • meta-analysis - weight loss and 98% cure in DM2

• disadvantages - most extensive

  • surgical risks: bowel perforation, DVT/PE, leakage, abscess

  • higher occurrence of smelly flatus, diarrhea

  • absorptive < nutritional deficiencies

  • risk for gallstones (cholecystectomy or meds)

post-op care

• depends on which type of surgery

• minimally invasive surgery - less pain, blood loss

  • some <24 hour hospital stay; others 1-2 days

  • if open or more involved - several days

• Best practices

  • safety - bariatric room

    • additional staff to lift, lift system

  • airway management

    • monitor vs and O2 sat; respiratory assessment

    • HOB elevated, O2, incentive spirometer, BiPAP/CPAP/vent

  • cv - high risk for DVT - TEDs/sequentials, anticoagulants

  • skin - monitor incision; skin folds/pressure areas

  • infection risk (peritonitis)

  • gi - prevent/monitor for anastomotic leaks

    • s/s dumping syndrome (bypass/absorptive)

    • abdominal binder; measure abd girth daily/as ordered

    • monitor I & O/dehydration, labs/electrolytes

  • pain - PCA - PO meds in liquid form (vs. pill)

  • diet - clear liquids - d/c full liquids - pureed (about 1 week post op) - soft foods (several weeks post op)

  • NGT - never adjust/insert blindly

  • activity - assist turning q2h/trapeze, OOB

    • PT - assess need for walker, othe aids

discharge teaching

• especially with surgeries affecting absorption (bypass, switch, sleeve)

  • decreased levels of intrinsic factor needed for B12 absorption

    • pernicious anemia common

    • can take 2+ years to develop

    • periodic IM injections of B12 (cyanocobalamin)

• other nutrition related

  • diet progression as tolerated

  • vitamin and mineral supplements

    • B-complex, iron, vitamin D, and calcium

      • needed to prevent bone loss

• drug therapy - analgesics/antiemetics as needed

• wound care - open/lap wounds, cover during shower/bath

• activity PT - appropriate exercise program

  • avoid lifting, when return to driving/work

• s/s to report

  • fever, excessive N/V, abdominal/back/shoulder pain

  • s/s wound infection, pain/redness/swelling in legs/CP/SOB

• f/u care - surgeon, dietitian, support groups

• continuing education - nutrition/exercise classes

• for all procedures after significant weight loss

  • plastic surgery to remove excess skin in 18-24 months

    • panniculectomy - abdominal apron, arms

home and self-care management

• nutrition - diet progression

  • continue collaboration with dietitian, food journal

  • continue reminders to eat/drink slowly

  • soft, nutrient dense 8 weeks post-op, small portions

  • avoid high-fat, sugary foods; stop eating if feel full

  • no carbonation, straws, ice

  • daily vitamin/mineral supplementation

  • psychologist consult for cognitive restructuring

general nutrition tips

• how to read nutrition label

  • less (ingredients) is more

  • check serving size

  • 5g sugar = 1tsp

    • minimize empty calories/sweets

      • soda, sweet tea, gatorade, desserts

  • saturated fat

    • no more than 20% saturated fat

  • portion control

    • protein serving meat/fish - palm of hand

  • protein - amt/day = weight (lbs) X 0.36 grams/day

    • daily avg for women about 46g; men about 56g