Complex Care Issues Resulting from Social Change: Bariatric Care

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Complex Care Issues Resulting from Social
ChangeBariatric Care

• Cindy Fehr
• Malaspina University-College
• Nursing 335
• Spring 2006

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FACTS

• 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

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Obesity statistics Overweight Canadians,
provincial comparison, 1998
Province of population overweight of population overweight of population overweight
Province 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
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Source Statistics Canada The Daily (Oct. 18,
2005) available from http//www.statcan.ca/Daily
/English/021018/d021018b.htm
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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.

1 BMI

• BMI weight (kg) / height (m2)

Source AJN January 2006
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Measuring Weight Fat cont.
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)
Source US Food Drug Administration
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• Healthy Weight Chart for Adults Source
  BCHealth Guide www.bchealthguide.org/kbaltindex.as
  p

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ADIPOGENESIS/LIPOGENESIS

• Mesenchymal cells ?give rise to preadipocytes
  which proliferate locally

Lipocytes Fat CellsSource AllRefer Health.com
(http//health.allrefer.com)
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
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Why a Rise in Obesity? (continued)

• Weight gain loss is complex interaction of
  psychological, environmental, evolutionary,
  biologic, genetic causes
• Genetics
• Account for 70 variability in peoples weight
• Estimated 300 genes involved in body weight
• Metabolic challenges
• Environment
• High fat calorie dense diet overeating (portion
  size)
• Sedentary lifestyle (behavioral)
• Sociocultural norms
• Evolution
• Store fat for famines hunt for food

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Why a Rise in Obesity?

• Neuroendocrine
• Hormones involved in appetite regulation
• Psychological
• Self-esteem, of relationships, depression
• Discrimination, lack of respect, stigmatization
• Emotional trauma, ETOH or drug addiction
• Medications
• Prednisone (corticosteroids)
• antidepressants

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Neuroendocrine Regulation

• CNS appetite regulated by hypothalamus
• CNS control feedback loop from stomach to
  brainstem
• Leptin Dont 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

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Feedback model for body-weight regulation
Source ACP Medicine on Medscape
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Costs to Society

• Costs of illness
• Absence from work
• Reduced productivity
• Disability

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Costs to Person

• Physical Costs
• Psychological Costs
• Social Isolation, stigmatization, bias,
  discrimination
• for healthcare related costs adaptive devices
  and support services

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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 Syndrome

Source AllRefer Health.com (http//health.allrefe
r.com)
16
Source University of Queensland, Australia
The Ultimate Risk Death
Source http//www.irishhealth.com/content/image/5
00/Image1.jpg
Source missbellorinna.tripod.com/ weightloss.htm
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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

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Source Nursing made Incredibly Easy! Sept/Oct
2003 p. 22
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Key Clinical Indicators of Metabolic Syndrome

• Waist/hip ratio (umbilicus/hip)
• Abd waist circumferance ? gt 35 ? gt 40
• BMI gt 30
• Abnormal lipid levels
• HDL
• LDL VLDL
• Triglycerides
• BP gt 130/85
• Two elevated fasting blood glucose levels
• Nicotine dependence also common ? potent
  vasoconstrictor primary cause of heart disease

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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

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Weight Loss

• Diets - many choices
• Dietary supplements
• Exercise Regimens
• Psychotherapy
• Motivation
• Exploration of why want to lose weight
• Success related to

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Bariatric Surgery

• Definition surgery done with the goal of weight
  reduction
• Candidates
• BMI gt 40 or gt35 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

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Gastric Surgery types

• 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 or adjustable banding
Source Nursing Made Incredibly Easy Jan/Feb 2006
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Gastric Surgery types cont.

• 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)

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Gastric Surgery types cont.

• 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 technique
Source Nursing Made Incredibly Easy Jan/Feb 2006
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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 DBC post-lap
  shoulder pain antiemetics doses may need to be
  different

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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

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Following Weight Loss

• Health promotion initiatives
• Long-term diet goals
• Emotional Support many changes
• Plastic Surgery liposuction

Sources for photos Google Images
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Body Contouring Following Weight Loss

• 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

Patient after weight loss of 170 lb legs still
have good appearance Source Plastic Surgical
Nursing (2004) 24(3)
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• 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 upper body lift and brachialplasty.
• Source Plastic Surgical Nursing (2004) 24(3)

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• Marking for belt lipectomy
• Source Plastic Surgical Nursing (2004) 24(3)

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• Preoperative (top row) and postoperative (bottom
  row) belt lipectomy
• Source Plastic Surgical Nursing (2004) 24(3)

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• Preoperative (top row) and postoperative (bottom
  row) brachialplasty
• Source Plastic Surgical Nursing (2004) 24(3)

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• Preoperative (top row) and postoperative (bottom
  row) medial thigh resection
• Source Plastic Surgical Nursing (2004) 24(3)

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Potential Complications

• Infection
• Seroma formation
• Hematoma formation
• Wound dehiscence
• Scars
• Decreased sensation
• Major complications DVT PE

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Prevention

• Up to 1/3 children eat fast food everyday (Boston
  Childrens 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
Library http//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

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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 Americas 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.