Obesity- Level 2

Obesity

Definition

Obesity is a disease characterized by the accumulation of fat to the extent that health is impaired.

Causes

• Usually due to the consumption of more calories than are needed by the body for energy.

• Other causes: congenital anomalies, metabolic problems, medication side effects, CNS disorders

These extra calories are converted into fat and stored. This excess fat accumulation leads to health problems.

Changes in Portion Sizes (Examples)

Here are some examples of how portion sizes have increased over the past 20 years, leading to increased calorie consumption:

Classification of Body Weight and Obesity

• Body mass index (BMI): Most common way to classify weight.

  • BMI = \frac{mass \ (kg)}{height^2 \ (m^2)} or BMI = \frac{weight \ (lb)}{height^2 \ (in^2)} * 703

• Waist circumference: People with excessive abdominal (visceral) fat are more prone to cardiovascular disease and metabolic syndrome.

• Waist-to-hip ratio (WHR): To calculate, waist measurement is divided by hip measurement.

  • WHR = \frac{waist \ circumference}{hip \ circumference}

• Body Shape:

  • Apple shape (Android obesity)

  • Pear shape (Gynoid obesity)

Body Mass Index (BMI)

• It is the individual's body mass/weight (fat stores) divided by the square of their height.

• Used to screen for weight categories that may lead to health problems.

  • BMI < 18.5 = underweight

  • BMI between 18.5 and 24.9 = normal body weight

  • BMI between 25 and 29.9 = overweight

  • BMI > 30 = obese (Class I 30-<35 and Class II 35-<40)

  • BMI > 40 = extreme (or severe) obesity (Class III - no longer morbid obesity)

Waist Circumference

Health risks increase if waist circumference is:

• > 35 inches in women

• > 40 inches in men

Waist-to-Hip Ratio

• Divide waist measurement by hip measurement

• WHR > 0.8 (women) or > 1.0 (men) indicates abdominal obesity = greater risk for health complications

Body Shape Classification: Apple Shape (Android Obesity)

• Most fat is above waist – usually abdomen.

• Fat also found over upper body (neck, arms, shoulders).

• Greater risk for obesity-related complications

• Health Risks

  • Heart disease and hypertension (HTN)

  • Diabetes mellitus

  • Breast & endometrial cancer

  • ↑ triglycerides

  • ↓ HDL cholesterol

Body Shape Classification: Pear Shape (Gynoid Obesity)

• Most fat is below the waist, mainly in the upper legs.

• Has a better prognosis but is hard to treat

• Health Risks

  • Osteoporosis

  • Varicose veins

  • Cellulite

  • Subcutaneous fat traps and stores fat

  • Trapped fatty acids stored as triglycerides

Obesity as a Public Health Crisis

The magnitude of obesity is a public health crisis!

Adult Obesity Rates in USA (2023)

Displays a map illustrating obesity rates by state, with rates ranging from <20% to 50%+. Some states have insufficient data.

Etiology and Pathophysiology

Genetic/biologic link, influenced by:

• Physiologic factors

• Environmental factors

• Psychological factors

These are interrelated!

Health Risks Associated with Obesity

• Psychosocial

  • Depression

  • Low self-esteem

  • Risk of suicide

  • Discrimination

  • Social isolation

• Endocrine/Metabolic

  • Type 2 diabetes mellitus

  • Metabolic syndrome

  • Polycystic ovary syndrome

• Respiratory

  • Obesity hypoventilation syndrome

  • Sleep apnea

  • Asthma

  • Pulmonary hypertension

  • Exercise intolerance

• Reproductive (Women)

  • Menstrual irregularities

  • Infertility

  • Gestational diabetes

• Cardiovascular

  • Hyperlipidemia

  • Sudden cardiac death

  • Right-sided heart failure

  • Left ventricular hypertrophy

  • Coronary artery disease

  • Deep venous thrombosis

  • Atrial fibrillation

  • Hypertension

  • Cardiomyopathy

  • Venous stasis

  • Varicose veins

• Gastrointestinal

  • Nonalcoholic steatohepatitis (NASH)

  • Gallstones

  • Gastroesophageal reflux disease (GERD)

• Genitourinary

  • Kidney cancer

  • Chronic kidney disease

  • Stress incontinence

• Reproductive (Men)

  • Hypogonadism

  • Gynecomastia

  • Sexual dysfunction

• Cancer

  • Esophagus, pancreas, thyroid, colorectal, and gallbladder cancer (both genders)

  • Endometrial, breast, and ovarian cancer (women)

• Musculoskeletal

  • Osteoarthritis

  • Impaired mobility and flexibility

  • Gout

  • Lumbar disk disease

  • Chronic low back pain

Metabolic Syndrome

A cluster of conditions that increases the risk of heart disease, stroke, and diabetes mellitus (DM).

Diagnosed if THREE or more of the conditions (below) are met:

• Fasting Blood Glucose > 100 mg/dl or drug treatment for elevated glucose

• ↑ Waist circumference

  • Men: > 40”

  • Women: >35”

• > 150 mg/dL or drug treatment for high triglycerides

• Men: < 40 mg/dL

• Women: < 50 mg/dL or drug treatment for high cholesterol

• > 130 systolic BP or > 85 diastolic BP or drug treatment for hypertension

Metabolic Syndrome Treatment

Lifestyle modifications are first-line interventions:

• Reduce glucose levels

• Stop smoking

• Reduce LDL cholesterol & triglycerides

• Lower blood pressure

• Lose weight/healthy diet

• Increase physical activity

• Medication adherence

Obesity – Goals of Care

• Modify eating patterns

• Participate in regular exercise

• Achieve and maintain weight loss to a specified level

• Prevent or minimize health problems related to obesity

Behavior Modification

• Patient must be ready for a change in their lifestyle

• Must decide upon a plan that is best for them

• What will the nurse ask the patient?

Treatment and Nursing Care: Nutritional therapy/Weight reduction plan

• Low fat, with adequate amounts of fruits, vegetables, & fiber

• Avoid concentrated sweets

• Small portions

• Do not skip meals – rationale?

• Reduce caloric intake

Treatment and Nursing Care: Exercise

• Essential part of a weight loss program

• Recommend: 150 minutes of moderate exercise or 75 minutes of vigorous exercise weekly

• Increases cardiovascular conditioning

Weight Loss Equation

Patients desire to change lifestyle + Exercise + Diet control = Weight Loss

Medication Therapy

• Drugs will not cure obesity

• Drugs should never be used alone

• Must also have reduced calorie diet, exercise, & behavior modification - without these, weight will return once drug therapy stops

• Drugs should be reserved for adults with

  • BMI > 30 (obese) OR

  • BMI > 27 AND at least one weight-related health condition

• Drugs may not be covered by insurance

Bariatric Surgery for Obesity

• Used to treat extreme obesity

• Currently the only treatment found to have sustained weight loss with extreme obesity

• Insurance coverage for bariatric surgery varies

• Bariatric surgeries fall into one of three broad categories: restrictive, malabsorptive, or a combination of malabsorptive and restrictive

Bariatric Surgery Types

• Restrictive surgery:

  • Reduces the size of the stomach by banding, removing part of the stomach, or inserting a balloon into the stomach.

  • Less food is eaten.

  • Digestion is not altered; low risk for anemia.

• Malabsorptive surgery:

  • Small intestine is shortened or bypassed.

  • Less food is absorbed.

  • Better long-term weight loss than with restrictive.

  • Risk for anemia & vitamin deficiencies.

  • Can cause dumping syndrome.

Bariatric Surgeries (Examples)

• Restrictive

  • Adjustable gastric banding (AGB)

  • Sleeve gastrectomy (gastric sleeve)

• Malabsorptive

  • Roux-en-Y gastric bypass

Most bariatric surgeries are done laparoscopically.

Pre-operative Nursing Care for an Obese Patient

What is different about the pre-op nursing care for an obese patient?

Have room ready for patient prior to arrival making adjustments in equipment and supplies

Postoperative Care

• Assess vital signs. What is of particular concern? Why?

• Assess for pain.

  • May need high doses of pain meds

• NG management – don’t irrigate. Why?

Postoperative Care (cont.)

• T, C & DB – be sure to splint incision; I.S. use

  • Why is this so important?

  • What complication(s) might occur without splinting of the incision?

• Prevent VTEs:

  • TED hose/SCDs

  • Ambulate early & often – ● Usually on day of surgery

  • Administer anticoagulants

Post Op Complications

• Rapid oxygen desaturation due to re-sedation

  • Assess for altered mental status

  • Use pulse oximeter, monitor respiratory rate & depth

  • Administer O2 therapy as ordered/needed

• Wound dehiscence and/or evisceration

  • What position helps decrease stress on the abdomen?

  • What should be done to support the incision when coughing?

• Wound care

  • Skin assessment & care

  • Increase protein & Vit C intake

  • Keep skin folds clean & dry

Post Op Complications (cont.)

• Dumping syndrome – gastric contents empty too rapidly into the small intestine

  • Symptoms – vomiting, nausea, weakness, sweating, faintness, and diarrhea

  • Prevention – eat small meals; avoid high CHO foods/concentrated sweets; choose foods with high protein, some fiber, low fat; no fluids with meals.

• Iron & calcium deficiency & anemia

  • In which type(s) of bariatric surgery would this be more likely?

  • Increase intake of protein, iron, calcium, and B12

Post-operative Complications

• Anastomotic leak

  • Leakage of gastric contents into the peritoneal cavity at site of surgical anastomosis

  • Patient will c/o abdominal pain, tachycardia, fever

  • Can progress to sepsis

  • Treated with drainage of site, site repair, antibiotic therapy

Nutrition Post-Op

• What is the criteria for feeding this patient?

• What type of diet will they go home on?

• What is included in patient teaching regarding diet?

• Will fluids be taken with meals?

Evaluation

Expected outcomes:

• Achieve & maintain optimal weight

• Improvement in obesity-related co-morbidities

• Integration of healthy practices into daily routines

• Be free from adverse side effects of surgery

• Improved self-image

Reconstructive Surgery

• Reconstructive surgery can be used for body contouring after weight loss has stabilized

• Will excess skin folds disappear on their own after weight loss?

Review Questions

• Why might an obese patient experience re-sedation post operatively?

• What is dumping syndrome and why might this occur after bariatric surgery? How can it be avoided?

• Which type of bariatric surgery is most likely to cause deficiencies in Ca, iron, and B12?

• What are the s/s of an anastomotic leak?

• Why is an obese patient especially prone to VTEs? How can the nurse help prevent VTEs?

Nursing Diagnoses

Be prepared to share/discuss relevant nursing diagnoses applicable to this content.

Questions?

Come to class prepared to discuss this content. Bring your questions with you! Some questions for consideration already included!