Chapter 57: Obesity

Chapter 57: Obesity

Obesity is defined as a BMI ≥ 30.

Overweight is defined as a BMI 25–29.9.

Prevalence is increasing in adults and children.

Obesity is associated with reduced life span and increased morbidity.

Health risks increase with higher BMI and central fat distribution.

Management focuses on quality of life, long-term weight reduction, and prevention of complications.

Health Promotion and Disease Prevention

• Lifestyle modification is the foundation of prevention and management:

  • Reduce calorie intake

  • Incorporate cultural food preferences

  • Increase aerobic and resistance exercise

  • Avoid dietary triggers

  • Set realistic goals

  • Manage stress

  • Use social support

  • Identify emotional eating patterns

  • Maintain a food diary

Healthy People 2030 Goals

• Reduce the proportion of adults with obesity

• Increase access to health care visits that include counseling on:

  • Weight loss

  • Physical activity

  • Dietary recommendations

• Decrease consumption of added sugars

Obesity Risk Factors

Lifestyle factors (decreased physical activity)

Medications (corticosteroids, antidepressants)

Genetic predisposition

Cardiovascular disease

Hypertension

Stroke

Chronic stress

Mood disorders (depression)

Hyperlipidemia

Type 2 diabetes mellitus

Bone and joint disorders

Gallstones

Obesity Findings

Body Mass Index (BMI) Categories

• Overweight: BMI 25–29.9

• Class 1 obesity: BMI 30–34.9

• Class 2 obesity: BMI 35–39.9

• Class 3 obesity: BMI ≥ 40

Waist Circumference

• Strong predictor of long-term complications (central obesity).

• Increased risk if:

  • Female: > 88 cm (35 inches)

  • Male: > 102 cm (40 inches)

Obesity Care

Promote safe, respectful, nonjudgmental care

Monitor skin integrity and mobility

Encourage gradual lifestyle changes

Collaborate with interdisciplinary team

Considerations

Risks During Hospitalization

• Poor wound healing and increased infection risk (reduced blood supply to adipose tissue)

• Pressure injuries

  • Skin folds, moisture, increased friction

  • Limited mobility

• Increased cardiac workload

• Obstructive sleep apnea

  • Increased neck circumference

  • Reduced lung volume

  • Hypoventilation, hypoxemia, hypercapnia

• Venous thromboembolism (VTE)

• Inadequate pain management

  • May require higher medication doses

• Increased risk of injury to client and staff during transfers

Therapeutic Management

Weight Management

• Balance energy intake with energy expenditure

• Combines diet modification, physical activity, and behavior changes

Lifestyle Modifications

• Goal setting

• Stimulus control

• Cognitive restructuring (address negative thoughts)

• Problem solving

• Relapse prevention

Physical Activity

• Moderate exercise at least 30 minutes daily

  • Example: walking 1.5 miles per day

Dietary Modifications

• Individualized and balanced diet:

  • Adequate protein

  • Controlled carbohydrates

  • Decreased fat

  • Increased fiber

• Calorie restriction as indicated

• Limit alcohol intake

• Limit refined sugars

Complementary and Alternative Therapies

• Acupuncture

• Hypnosis

Obesity Meds

Used for clients with elevated BMI and additional risk factors

Always combined with diet and exercise

Orlistat

• Decreases fat absorption

• Adverse effects: oily stools, flatulence, fecal urgency, vitamin deficiencies

• Teach low-fat diet

• Take multivitamin supplement

Phentermine

• Appetite suppressant

• Adverse effects: headache, dry mouth, insomnia, dizziness, constipation

• Contraindicated in hyperthyroidism, glaucoma, MAOI use

• Take early in the day

Naltrexone-bupropion

• Decreases appetite and cravings

• Adverse effects: nausea, constipation, headache, dry mouth

• Contraindicated in seizure disorders, eating disorders, MAOI use

• Monitor for suicidal ideation (antidepressant effect)

Liraglutide

• Increases satiety, slows gastric emptying

• Adverse effects: nausea, vomiting, diarrhea, tachycardia, hypoglycemia

• Used in type 2 diabetes management

• Administered subcutaneously

• Can be taken with or without meals

A nurse is preparing to teach a newly licensed nurse about medications used for weight management. The nurse should include which of the following medications is administered subcutaneously?

a

Orlistat

b

Liraglutide

c

Naltrexone-bupropion

d

Phentermine-topiramate

b Liraglutide

It should be used with caution for clients who are taking anti-hyperglycemic medications. Liraglutide is also used to lower blood glucose for clients who have diabetes mellitus and can potentiate the effects of other anti-hyperglycemic medications.

Obesity Procedures

Hydrogel Pill

• FDA-approved adjunct for BMI 25–40

• Taken with meals

• Absorbs water to increase gastric fullness

• Excreted through GI tract

• Adverse effects: constipation, obstruction, diarrhea, dehydration

• Contraindicated in Crohn’s disease or prior GI surgery affecting motility

Intragastric Balloon Therapy

• Gas- or saline-filled balloon placed endoscopically

• Promotes satiety and delayed gastric emptying

• Adverse effects:

  • Nausea and vomiting

  • Balloon rupture

  • Gastric or esophageal rupture

  • Pancreatitis if left in place longer than 6 months

Bariatric Surgeries

Surgical treatment for obesity when lifestyle and pharmacologic therapy fail.

Achieves weight loss by:

• Restricting stomach capacity

• Causing malabsorption via small intestine bypass

• Combination of both mechanisms

Can be open or minimally invasive.

Some clients later undergo plastic surgery (abdominoplasty, breast reduction) for excess skin.

Preoperative: upper endoscopy to rule out GI disease.

Postoperative: barium X-ray to evaluate for anastomotic leaks.

Often improves comorbidities:

• Hypertension

• CAD

• Hyperlipidemia

• Asthma

• Sleep apnea

• Type 2 diabetes mellitus

Indications

• BMI ≥ 40 without comorbidities

• BMI ≥ 35 with at least one obesity-related condition (HTN, osteoarthritis, type 2 DM)

• BMI 30–34.9 with poorly controlled glucose despite medications and lifestyle changes

Bariatric Surgeries Types

Restrictive Procedures

• Decrease stomach capacity while maintaining normal digestion.

Gastric Banding

• Adjustable band placed laparoscopically around upper stomach

• Creates small pouch limiting food intake

• Subcutaneous port allows band inflation or deflation

Vertical Banded Gastroplasty

• Upper stomach stapled to form small pouch

• Band slows gastric emptying

Sleeve Gastrectomy

• Large portion of stomach removed

• Creates narrow gastric sleeve

• Performed open or laparoscopically

Malabsorptive Procedures

• Combine restriction with bypass of small intestine.

Gastric Bypass

• Roux-en-Y (RYGB)

  • Small gastric pouch created

  • Jejunum attached directly to pouch

  • Food bypasses most of stomach and duodenum

  • Increased risk for dumping syndrome (loss of pyloric valve)

  • Often robotic-assisted or laparoscopic

• Biliopancreatic Diversion with Duodenal Switch

  • Portion of stomach removed

  • Pouch attached directly to jejunum

  • High malabsorption risk

Bariatric Surgeries Care

Preprocedure Nursing Actions

• Assess psychosocial factors and emotional relationship with food

• Assess understanding of lifelong diet and lifestyle changes

• Ensure bariatric equipment availability:

  • Proper bed, furniture, BP cuff size

• Ensure adequate staff for transfers and ambulation

• Use mechanical lift devices to prevent injury

• Review labs:

  • CBC

  • Electrolytes

  • BUN, creatinine

  • HbA1c

  • Iron

  • Vitamin B12

  • Thiamine

  • Folate

• Apply sequential compression devices (VTE prevention)

Postprocedure Nursing Actions

• Monitor airway and oxygen saturation

• Maintain semi-Fowler’s position (lung expansion)

• NG tube care:

  • Do not reposition NG tube placed intraoperatively

  • Do not insert NG tube postoperatively

• Monitor for complications:

  • Atelectasis

  • Thromboembolism

  • Skin breakdown

  • Incisional hernia

  • Peritonitis

• Monitor bowel sounds and abdominal girth

• Apply abdominal binder for open procedures

• VTE prevention:

  • Early ambulation

  • Sequential compression devices

  • Low-molecular-weight heparin as prescribed

• Fluid management:

  • Initially restricted, then gradually increased

• Diet progression:

  • Clear liquids to full liquids

  • Discharge often on full liquid diet

  • Pureed foods after 1 week

  • Solid foods at 6–8 weeks

  • Four to six small meals per day

  • No liquids for 30 minutes after meals

• Teach signs of dumping syndrome:

  • Cramping

  • Diarrhea

  • Tachycardia

  • Dizziness

  • Fatigue

• Avoid empty-calorie, high-sugar foods

• Coordinate long-term support with case management and mental health services

Client Education

• Follow prescribed diet consistency and volume (often ≤ 240 mL per meal)

• Avoid carbonated beverages

• Walk daily at least 30 minutes

• Use physical therapy guidance as needed

• Remain in low-Fowler’s position for 20–30 minutes after meals (slows gastric emptying)

Bariatric Surgeries Complications

Anastomotic Leak

• Common and life-threatening complication after gastric bypass

• Report immediately if:

  • Increasing abdominal, back, or shoulder pain

  • Restlessness

  • Tachycardia

  • Oliguria

Dehydration

• Indicators:

  • Excessive thirst

  • Concentrated urine

• Goal fluid intake ≥ 1.5 L/day

• Notify provider if signs present

Malabsorption and Malnutrition

• Caused by reduced stomach size or intestinal bypass

• Common deficiencies:

  • Vitamin B12

  • Vitamin D

  • Thiamine

  • Calcium

  • Iron

  • Folate

Nursing Actions for Malnutrition

• Monitor tolerance of food and fluids

• Refer to dietitian

• Encourage low-Fowler’s position during and after meals

Client Education for Malnutrition

• Protein intake often 60–80 g/day

• Eat nutrient-dense foods only

• Avoid empty calories and excess carbohydrates

• Lifelong vitamin and mineral supplementation required

A nurse is reviewing the actions of bariatric medications and devices with a client who is obese and seeking information about weight loss. Match each action to the medication or device it describes.

Absorbs water to decrease stomach capacity

Suppresses appetite and decreases cravings

Increases satiety with placement of an expandable device filled with saline

Inhibits digestion of fats by blocking lipases

Intragastric balloon

Hydrogel pill device

Orlistat

Naltrexone-bupropion

Intragastric balloon

Increases satiety with placement of an expandable device filled with saline

Hydrogel pill device

Absorbs water to decrease stomach capacity

Orlistat

Inhibits digestion of fats by blocking lipases

Naltrexone-bupropion

Suppresses appetite and decreases cravings

Adjustable Band Gastroplasty (image)

Vertical Banded Gastroplasty (image)

Roux-en-Y Gastric Bypass

A nurse is planning care for clients who have had bariatric surgery. Sort the procedures by whether they are categorized as restrictive or malabsorptive surgeries.

Gastric banding

Roux-en-Y

Sleeve gastrectomy

Vertical banded gastroplasty

Biliopancreatic diversion with duodenal switch

Restrictive

Malabsorptive

Restrictive

Gastric banding

Sleeve gastrectomy

Vertical banded gastroplasty

Malabsorptive

Biliopancreatic diversion with duodenal switch

Roux-en-Y

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Although Roux-en-y and biliopancreatic diversion with duodenal switch are surgeries that also create decreased capacity, they are considered malabsorptive because they bypass part of the small intestine to reduce absorption of nutrient

A nurse is providing discharge teaching to a client who had gastric bypass surgery. Which of the following statements by the client indicates understanding of the instructions?

Select all that apply.

a

“I should start to eat solid foods 2 weeks after surgery.”

b

“I should expect very little urine output for the first 2 weeks.”

c

“The most serious complication I can expect is vomiting.”

d

“The amount of refined carbohydrates in my diet should be limited.”

e

“I should drink at least 1.5 liters of water each day.”

f

“After a meal, I should wait for 30 minutes to drink liquids.”

d

“The amount of refined carbohydrates in my diet should be limited.”

e

“I should drink at least 1.5 liters of water each day.”

f

“After a meal, I should wait for 30 minutes to drink liquids.”

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Following a gastric bypass surgery, high intake of refined carbohydrates increases the risk for dumping syndrome. Ensuring adequate water intake decreases the risks of dehydration that can be caused by vomiting or diarrhea. Delaying intake of liquids for at least 30 minutes following a meal of solid foods decreases the risk for dumping syndrome.