Complex Care Issues Resulting from Social Change: Bariatric Care Cindy Fehr Malaspina University-College Nursing 335 Spring 2006.

Complex Care Issues Resulting from Social Change:

Bariatric Care

Cindy FehrMalaspina University-College

Nursing 335Spring 2006

FACTS

Source: Statistics Canada - The Daily (July 6, 2005) available from

http://www.statcan.ca/Daily/English/050706/d050706a.htm

• Weight issues a serious problem with complex issues and consequences

• At epidemic levels worldwide

• Estimated 60% American adults overweight, 30% obese & 6 million morbidly obese

• More prevalent amongst certain ethnic & racial groups, plus age & sex play a role

• Considered a chronic disease like any other (diabetes, AIDS, hypertension)

• Wide-ranging medical, physical, social, psychological effects

• Estimated 300,000 premature deaths in USA each year from obesity-related complications

• Over $60 billion direct health care and $56 billion indirect economic costs annually

Obesity statistics Overweight Canadians, provincial comparison, 1998

Province% of population overweight

Overall Rural Urban

P.E.I. 59.0% 62.0% 56.7%

Newfoundland 58.9% 59.0% 58.9%

New Brunswick 58.3% 61.2% 56.0%

Saskatchewan 57.9% 66.9% 54.4%

Manitoba 54.3% 56.1% 53.8%

Nova Scotia 52.5% 56.9% 49.1%

Ontario 49.6% 55.3% 48.7%

Alberta 48.5% 47.6% 53.3%

B.C. 43.3% 41.4% 52.5%

Quebec 42.7% 44.8% 42.2%

Canada 47.9% 53.3% 46.6%

Source: National Population Health Survey 1998, Statistics Canada

Source: Statistics Canada –

The Daily (Oct. 18, 2005) available from

http://www.statcan.ca/Daily/English/021018/d021018b.htm

Measuring Weight & Fat

• examples – an adult male  1.8 metres tall

(five feet, 10 inches) and weighs 95 kg (210 pounds) BMI of 30 and considered obese

– adult female 1.6 metres tall (five feet, 4 inches) and weighs 80 kg (175 pounds) BMI of 30 and also be considered obese

• same formula for children and adolescents however, the cut-off points for being overweight and obese vary by the age and sex of the child.

BMI = weight (kg) / height (m2)

Source: AJN January 2006

#1 BMI

Measuring Weight & Fat cont.

Source: US Food & Drug Administration

#2 Waist-to-hips Ratio• Recent research suggests that

this is a better predictor of acute MI than BMI likelihood of MI rises as the waist-to-hip ratio s

Different types of weight gain

Source: AllRefer Health.com (http://health.allrefer.com)

Healthy Weight Chart for Adults – Source: BCHealth Guide www.bchealthguide.org/kbaltindex.asp

Lipocytes – Fat CellsSource: AllRefer Health.com (http://health.allrefer.com)

ADIPOGENESIS/LIPOGENESIS• Mesenchymal cells give rise to

preadipocytes which proliferate locally

Preadipocytes unlimited supply t/o life so can be produced as needed

Adipocyte from cell differentiation; fills with lipids

Adipocyte hypertrophy ( size) and hyperplasia (#) leads to obesity – continue to acculumate lipid & enlarge up to 1000 times original size once reaches a certain size, tiggers other preadipocytes to differentiate

Why a Rise in Obesity? (continued)

• Weight gain & loss is complex interaction of psychological, environmental, evolutionary, biologic, genetic causes

1. Genetics• Account for 70% variability in people’s weight• Estimated 300 genes involved in body weight• Metabolic challenges

2. Environment • High fat calorie dense diet & overeating (portion size)• Sedentary lifestyle (behavioral)• Sociocultural norms

3. Evolution• Store fat for famines & hunt for food

Why a Rise in Obesity?

4. Neuroendocrine• Hormones involved in appetite regulation

5. Psychological• Self-esteem, # of relationships, depression• Discrimination, lack of respect, stigmatization• Emotional trauma, ETOH or drug addiction

6. Medications• Prednisone (corticosteroids)• antidepressants

Neuroendocrine Regulation

• CNS – appetite regulated by hypothalamus

– CNS control feedback loop from stomach to brainstem

• Leptin –Don’t affect satiety but play a part in energy expenditure and appetite regulation

• Obesity associated with high leptin levels but may also be related to leptin resistance

• Ghrelin – stimulates appetite- Increase shortly before eating & decrease rapidly afterward in obese the decline does not occur or less quickly appetite & overeating

• Thyroid Hormones – involved in setting resting metabolic rate & thermogenesis

• Cholecystokinin – Inhibits gastric emptying & signals hypothalamus

• Peptide YY – Inhibits appetite by slowing gut motility & gastric emptying & suppressing NPY

• Diminished in obese patients

• Cortisol – Facilitates gluconeogenesis

• Insulin – Genetically prone to obesity have altered responses to insulin & glucose

Source: AJN Jan 2006

Source: ACP Medicine on Medscape

Feedback model for body-weight regulation

Costs to Society

• Costs of illness

• Absence from work

• Reduced productivity

• Disability

Costs to Person

• Physical Costs

• Psychological Costs

• Social Isolation, stigmatization, bias, discrimination

• $ for healthcare related costs – adaptive devices and support services

Obesity-Related Consequences• Hypertension

• Heart disease

• Type 2 Diabetes

• Stroke

• Hyperlipidemia/dyslipidemia

• Arthritis

• Sleep apnea

• Gallstone formation

• Certain cancers (breast, colon, uterus, pancreas, kidney, prostate, gallbladder)

• Pickwickian SyndromeSource: AllRefer Health.com (http://health.allrefer.com)

Source: http://www.irishhealth.com/content/image/500/Image1.jpg

Source: University of Queensland, Australia

Source: missbellorinna.tripod.com/ weightloss.htm

The Ultimate Risk = Death

Metabolic Syndrome• Also known as insulin resistance syndrome & dysmetabolic

syndrome & syndrome X

• Incidence up to 1 in 3 within general North American population

• Syndrome characterized by: – HTN, central obesity, insulin resistance, high LDL/low HDL

cholesterol & high triglycerides

• Now looking at this syndrome as one entity instead of separate disease states

• Leads to diabetes & heart disease & stroke

• Treatment involves coordinated care, appropriate goals for each disease & patients as partners in care

Source: Nursing made Incredibly Easy! Sept/Oct 2003 p. 22

Key Clinical Indicators of Metabolic Syndrome

• Waist/hip ratio (umbilicus/hip) • Abd waist circumferance ♀ > 35” & ♂ > 40”

• BMI > 30

• Abnormal lipid levels – HDL– LDL & VLDL– Triglycerides

• BP > 130/85

• Two elevated fasting blood glucose levels

• Nicotine dependence also common potent vasoconstrictor & primary cause of heart disease

• Risk Factors

Nursing Considerations

• Unconditional acceptance• Empathy not sympathy• Sensitivity to needs• Understanding • Open communication• Adaptive devices – mechanical lifts, special beds, bed

trapezes, wheelchairs, bedside chairs, walkers, bed lifters, bedpans, commodes, etc…

• Avoid personal injury & patient injury• Nursing assessments & interventions altered to obtain

accurate information, decision-making, effective treatment

Weight Loss• Diets - many choices

• Dietary supplements

• Exercise Regimens

• Psychotherapy

• Motivation

• Exploration of why want to lose weight

• Success related to…

Bariatric Surgery

• Definition – surgery done with the goal of weight reduction

• Candidates – BMI > 40 or >35 with co-morbidity (apnea, diabetes,

degenerative joint disease, HTN, ischemic heart disease, asthma, history of CVA)

– 18 years or older– Obese for at lease 5 years– Documented lack of success to lose weight with other

methods– Demonstrated ability to comply with post-op long term

dietary & behavioral changes– Detailed health & weight histories

Can literally be life-saving procedure for morbidly obese but only one part of the treatment plan

Gastric Surgery types1. Restrictive Procedures

– Create a gastric pouch with narrow outlet– Gastroplasty or gastric banding– Feel full sooner (1 oz initially 4 oz capacity max)– Small outlet delays gastric emptying feel full longer– Potential complications = severe GERD & stomal obstruction

Vertical banded gastroplasty

Circumgastric oradjustable banding

Source: Nursing Made Incredibly Easy Jan/Feb 2006

Gastric Surgery types cont.

2. Malabsorptive Procedures– Bypass a significant length of small intestine, reducing

absorption of calories & nutrients

– Associated with long-term metabolic complications & nutritional deficiencies (liver disease, osteoporosis, diarrhea, dehydration, electrolyte imbalances, malnutrition)

Gastric Surgery types cont.3. Combination Restrictive & Malabsorptive Techniques

– Gold standard in North America is Roux-en-Y gastric bypass procedure

– Small pouch created in upper part of stomach by separating it from remaining portion of stomach using staples; portion of jejunum separated and anastomosed to new pouch bypass occurs at stomach

– Laparoscopic or open technique

Gastric Restriction & Malabsoprtion surgery or Roux en Y techniqueSource: Nursing Made Incredibly Easy Jan/Feb 2006

Post-op Considerations

• Virtually every aspect of treatment is impacted by size

• AIRWAY - respiratory compliance d/t more tissue pressure on chest wall, diaphragm (from large abdomen), intercostals, upper airway

• HEMODYNAMIC STABILITY – large BP cuff; fluid shifts could make vascular dehydration; in/out monitoring; blood chemistries

• PAIN MANAGEMENT – promotes DB&C; post-lap shoulder pain; antiemetics; doses may need to be different

Post-op Considerations cont.

• ACTIVITY/AMBULATION – high risk DVT/PE,

• SKIN/WOUND/DRAIN SITE CARE – risk for pressure ulcers, prone to yeast infections in skin folds; urinary incontinence common; challenges with personal hygiene; delayed wound healing/dehisence

• DIET & NUTRITIONAL SUPPLEMENTS – NPO following bariatric sx to r/o anastamotic leaks water clear fluids DAT (no sugar, caffeine, carbonation) high protein supplements/shakes good

• PSYCHOLOGICAL ADJUSTMENTS – anorexia nervosa, changes in body image with excess skin, depression r/t many life changes

Following Weight Loss

• Health promotion initiatives

• Long-term diet goals

• Emotional Support – many changes

• Plastic Surgery & liposuction

Sources for photos – Google Images

Body Contouring Following Weight Loss

Patient after weight loss of 170 lb; legs still have good appearance

Source: Plastic Surgical Nursing (2004) 24(3)

• Overall changes in body shape

• Should be referred to a plastic surgeon

• purpose of body contouring is to reduce excess skin and tissue

• lengthy recovery period Areas for challenge

• Lower trunk produces lots of complaints

• Abdominal wall weakness or hernia

• Upper trunk & breasts• Upper arms• Thighs

Marking for upper body lift and brachialplasty. Source: Plastic Surgical Nursing (2004) 24(3)

Benefits to Body Contouring

•clothing size down by one or two sizes•clothes easier to find•more vigorous activity is possible •body image improves

Marking for belt lipectomy

Source: Plastic Surgical Nursing (2004) 24(3)

Preoperative (top row) and postoperative (bottom row) belt lipectomy

Source: Plastic Surgical Nursing (2004) 24(3)

Preoperative (top row) and postoperative (bottom row) brachialplasty

Source: Plastic Surgical Nursing (2004) 24(3)

Preoperative (top row) and postoperative (bottom row) medial thigh resection

Source: Plastic Surgical Nursing (2004) 24(3)

Potential Complications

• Infection

• Seroma formation

• Hematoma formation

• Wound dehiscence

• Scars

• Decreased sensation

• Major complications – DVT & PE

Prevention• Up to 1/3 children eat fast food

everyday (Boston Children’s Hospital Study)

What it Takes• Culture shift, changes in behaviour

& lifestyle• Influences – family, friends,

colleagues, media, food & leisure industries, immediate environments

• Improving diet – fats & simple and added sugars

• Increasing physical activity• Even modest weight loss improves

health• Low income one factor in

childhood obesity – addressing Determinants of Health

Source: California State University Libraryhttp://www.lib.csusb.edu/gov/obesity.jpg

Source: New York State Department of Health

Basic Principles of Activ8Kids!•5 fruits and vegetables each day •1 hour of physical activity each day •2 hours OR LESS of TV or screen time daily

Resources

Appel, S.J., Giger, J.N., & Floyd, N.A. (2004). Dysmetabolic syndrome: reducing cardiovascular risk. The Nurse Practitioner, 29(10), 18-35.

Blackwood, H.S. (2005). Help you patient downsize with bariatric surgery. Nursing, 35(9), supplement: Med/Surg Insider, 4-9.

Blackwood, H.S. (2004). Obesity: a rapidly expanding challenge. Nursing Management, May, 27-36.

Daniels, J. (2006). Obesity: America’s epidemic. American Journal of Nursing, 106(1), 40-49.

Edelman, R. (2005). Obesity, type 2 diabetes, and cardiovascular disease. Nutrition Today, 40(3), 119-123.

Forman, A. (2004). The second national conference on diabesity® in America. Nutrition Today, 39(6), 245-253.

Gabriel, S., & Garguilo, H. (2006). Bariatric surgery basics: getting to the heart of a weight subject. Nursing made Incredibly Easy!, 4(1), 42-51.

Heddens, C.L. (2004). Body contouring after massive weight loss. Plastic Surgical Nursing, 24(3), 107-115.

Hoolihan, L. (2005). The role of education and tailored intervention in preventing and treating overweight. Nutrition Today, 40(5), 224-231.

Walker-Sterling, A. (2005). African Americans and obesity. Clinical Nurse Specialist, 19(4), 193-198.

Woods, A. (2003). X marks the spot: Understanding metabolic syndrome. Nursing made Incredibly Easy!, 1(1), 19-27.