obesity

obesity

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

BMI: weight (kg)/height

obesity categories by BMI

class I: 30 - <35

class II: 35 - <40

class III: >40 severe obesity

obesity reframed

chronic condition, not just one “disease”

“excess adiposity” that negatively impacts health

not diagnosed by BMI alone: waist circumference, waist to hip ratio, waist to height ratio

health promotion

increase consumption of Ca, veg, fruit, K, vit D, whole grains, beans and peas

decrease consumption of saturated fats, added sugars and sodium

leptin hormone

decreases appetite; insulin

ghrelin hormone

stimulates appetite

“hunger hormone”

resisten hormone

creates insulin resistance

common complications

CV: CAD, high col., HTN, PAD

endocrine: insulin resistance, metabolic syndrome, DM2

GI: cholelithiasis

GU/reproductive: ED, incontinence

skin: increased susceptibility to infections, delayed wound healing

MS: chronic back/joint pain

Neuro: stoke

psych: depression

resp: OSA, obesity hypoventilation syndrome

client assessment

health history and family history of obesity

diet history/food diary

past health/chronic diseases

meds

nutritional assessment

usual food intake, preferences, appetite

cultural background, socioeconomic status

psychosocial: eating behaviors, attitude towards food

depression/behavioral problems?

developmental level

stigma association with obesity

meaning of food, motivation to change

treat like any addiction; assess readiness. not read for change = not going to

previous attempts/outcomes of weight loss

approach with respect: Rapport, Environment, Safe, Privacy, Encourage, Tact

nonsurgical interventions

diets: very low cal/carb; time restricted/fasting

nutritionally balanced diet: 1200-1800 cal/day for slow weight loss and long term success

calorie counting

5-10% loss of body weight increases glycemic control

exercise: increase weight loss, mostly fat loss

pharm intervention: PO

long term, chronic weight loss

bupropion-naltrexone: opioid antagonist/antidepressant

orlistat: inhibits lipase so only partial digestion and absorption of fats

phentermine-topiramate: chronic weight loss and seizure/migraine prevention med for satiety

pharm interventions: injectables

liraglutide: activates appetite regulation in brain

semaglutide: 1x/week injection
increases resting metabolism and feeling of fullness; decreases appetite

setmelanotide: targets underlying hunger

educate how to administer injectables

behavioral management

self monitoring: food journal, exercise/activity patterns

stimulus control: awareness of external cues

reinforcement techniques: self reward behavior change

cognitive restructuring learned + coping techniques

counseling by HCP

overeaters anonymous, support groups

surgical management

liposuction: removal of adipose tissue

GI electrical stimulation (GES): implantation of vagal blocking device into abdomen. causes early satiety

bariatrics: branch of medicine that manages obesity and related diseases

bariatric surgeries

roux-en-Y gastric bypass most common

most are done laparoscopically

only method with long term impact; many cured HTN, T2DM, sleep apnea

must agree to modify lifestyle/weight loss protocols

periop care

involves comprehensive multidisciplinary evaluation:
screening for depression, substance use, cognitive function
coping (food as mechanism)
motivation, support system

eligible based on nationally devised/accepted criteria, minimum BMI

some surgeons require specific amount of weight loss prior

demonstrate understanding of operation and lifestyle changes requires post op

sugrical management: restrictive

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

allow normal digestion and no risk of nutritional deficiencies than bipassing

gastric banding and vertical sleeve gastroplasty

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

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

disadvantages of gastric bypass

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

restrictive only; done laparoscocpically

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 through tube that connects to band; access port placed under skin

high failure rate: pouch can stretch with overeating

vertical sleeve gastroplasty

laparoscopic removal of large portion of stomach (75%)

portion removed where ghrelin secreted; less hunger, increased satiety

restrictive only; no rerouting of food

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

food and digestive enzymes separated

most nutrients routed to the colon

biliopancreatic diversion with duodenal switch advantages and disadvantages

no dumping syndrome (vs gastric bypass)
production of hunger hormone decreased with removal
meta analysis: weight loss and 98% cure in DM2

surgical risks: bowel perforation, DVT/PE, leakage, abscess
higher occurrence of smelly flatus, diarrhea
absorptive < nutritional deficiencies
risk for gallstones

post op care

depends on which type of surgery

minimally invasive surgery less pain, scarring, blood loss

airway management: monitor VS and O2 sat, resp assessment. HOB up, IS, BiPAP/CPAP/vent

high risk for DVT: TEDs/seq, anticoag

skin: monitor incision, skin folds/pressure areas

pain: PCA → PO in liquid form

GI post op care

prevent/monitor for anastomtic leaks

s/s dumping syndrome

abdominal binder; measure abdominal girth daily/as ordered

monitor I&O/dehydration, labs/electrolytes

diet: clear liquids → pureed (1 week post op) → soft foods (several weeks post op)

discharge teaching

especially with surgeries affecting absorption:
decreased levels of intrinsic factor needed for B12 absorption
pernicious anemia common
can take 2+ years to develop
periodic IM injections of B12

diet progression, as tolerated

vit and mineral supplements: b-complex, iron, vit D and Ca

home and self care management

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