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Bariatrics: A Growing Medical Care Dilemma

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... everyone with 3800 cal/day: 30% more than what men/ double what women need ... Toilet/shower aids. Walkers. Recliners. Bed Guidelines. Bed/Mattress widths ... – PowerPoint PPT presentation

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Title: Bariatrics: A Growing Medical Care Dilemma


1
Bariatrics A Growing Medical Care Dilemma

2
What is Bariatrics?
  • bari is Greek for weight
  • The treatment of obesity- a medical disease
  • Bariatric medicine treats obesity and related
    conditions
  • the art and science of medical weight
    management (Guy)

3
Definitions
  • Overweight refers to excess body weight compared
    to set standard
  • Obesity refers to having a high proportion of
    body fat to lean tissue

4
Staggering Stats
  • Approximately 280,000 deaths
  • Obesity shaves 7 yrs off a persons life
  • 68.5 million are overweight (BMI gt 25 to lt30)
  • 34.1 of US adults
  • 64.7 million are obese (BMI gt 30)
  • 32.2 of US adults (NHANES 2003-04)
  • Increases across virtually all age, ethnic,
    racial, and socioeconomic groups

5
Prevalence of Overweight and Obesity
Source NIDDK- Statistics Related to Overweight
and Obesity
6
Economic Costs
  • 117 billion
  • Direct cost 61 billion
  • Health care costs
  • Indirect cost 56 billion
  • Lost wages and future earnings

7
How is Obesity Measured
  • Body Mass Index (BMI) is used to measure both
    overweight and obesity in adults
  • Calculated by either equation
  • Weight (kg) / Height squared (m2)
  • or
  • (weight (lb) x 704.5) height (in) height
    (in)

8
BMI Nomogram
9
Factors Contributing to Obesity
  • Genetics/ inheritance
  • Psychological/ depression
  • Medical/ Hypothyroidism, Cushings Disease
  • Cultural/ environmental
  • Sedentary lifestyle

10
Overweight and Obesity
  • Known risk factors for
  • Diabetes
  • Heart disease
  • Stroke
  • Hypertension
  • Gallbladder disease
  • Osteoarthritis
  • Sleep apnea
  • Some forms of cancer (uterine, breast,
    colorectal, kidney and gallbladder)
  • Syndrome X (cluster of ailments including insulin
    resistance)

11
Typical Medical History
  • Diabetes mellitus- twin epidemics
  • Hypertension
  • Atherosclerosis
  • Osteoarthritis
  • Exercise/activity intolerance
  • Exercise-induced asthma
  • Malnutrition
  • Psychological factors
  • Depression
  • Social isolation
  • Complications with surgery and pregnancy

12
Functional Challenges
  • Ambulation
  • Transfers
  • Wheeled mobility
  • Toileting/bathing
  • Personal hygiene
  • Wound care

13
Multi-disciplinary Team Effort
  • Client/family education by
  • Physician
  • Dietitian
  • Nursing
  • PT/OT
  • Psychologists
  • Pharm-D
  • Equipment Suppliers

14
Nutritional Decline
  • U.S. food industry supplies everyone with 3800
    cal/day 30 more than what men/ double what
    women need
  • From 1970-1998, avg. intake of soda increased
    from 22.2 gallons to 56 gallons/year
  • 33 billion in marketing food

15
Client Education
  • Nutritional therapy
  • Surgical interventions
  • Lifestyle
  • Psychosocial implications
  • Support mechanisms
  • Equipment usage

16
Nutritional Intervention
  • Consult with Registered Dietician
  • Determine habits
  • Diet journal listing
  • Food types
  • Quantity
  • Lifestyle changes
  • Pre-planning
  • Events
  • Meal preparation
  • Socioeconomic factors

17
Non-Operative Treatments
  • Scientific reports document non-operative methods
    alone have not been effective in
    medically-significant long-term weight loss
  • Use of anorectic medications showed high
    association with cardiac valve disease (Phen-Fen)
  • Dietary weight loss attempts often cause
    depression, anxiety, irritability, weakness and
    preoccupation with food

18
Rationale for Surgical Weight Management
  • Direct correlation b/w increased weight and
    increased mortality
  • Numerous studies indicate mortality rates
    increase from 2x to 12x secondary to morbid
    obesity
  • Framington study noted first cohort to terminate
    due to demise of all participants was morbidly
    obese
  • Above study 10 decrease in weight 20
    reduction in developing coronary heart disease

19
Surgical Treatment Goals
  • Bariatric surgery involves reducing the size of
    the gastric reservoir
  • This may include some degree of malabsorption
  • Long-term changes in eating behavior
  • Prevention of post-surgical complications

20
Patient Selection
  • Morbidly obese
  • BMI gt40 or BMI gt35 with two comorbidities
  • Well informed
  • Motivated
  • Acceptable of operative risks

21
Medical Complications
  • 0.5 mortality rate
  • Respiratory Insufficiency
  • Pneumonia
  • Decreased wound healing rates
  • Wound dehiscence
  • GI Leaks
  • Pulmonary embolism
  • Obesity Hypoventilation Syndrome
  • Sleep apnea
  • Pannus wound maintenance

22
Types of Surgical Procedures
  • Laparoscopic Gastric Banding
  • Vertical Banded Gastroplasty
  • Roux-en-Y Gastric Bypass
  • Biliopancreatic Diversion with or without
    Duodenal switch

23
Laparoscopic Gastric Banding
  • Recently approved by FDA
  • Adjustable silastic band placed around upper
    stomach
  • Creates 15cc pouch with narrowed outlet
  • Outlet can be adjusted via saline reservoir

24
Laparoscopic Gastric Banding
  • Advantages
  • No cutting or stapling
  • Adjustable via saline reservoir
  • Normal stomach anatomy is maintained
  • Completely reversible
  • Disadvantages
  • Doesnt restrict sweet liquid intake
  • Pouch slippage
  • Mechanical problems

25
Roux-en-Y Gastric Bypass (RNYGB)
  • Proven surgical weight loss procedure
  • Combines a gastric restrictive procedure with
    slow gastric emptying
  • Results in decreased food absorption
  • Considered Gold Standard

26
Roux-en-Y Gastric Bypass (RNYGB)
  • Decreases excess weight by 50-75
  • Mortality rate of 0.5 and morbidity rate of
    5-10
  • In most cases, this procedure will reduce weight
    from life-threatening levels

27
Vertical Banded Gastroplasty (VBG)
  • Recognized by NIH for treatment of severe
    clinical obesity
  • Purely restrictive with no malabsorptive effect
  • Results in pouch in upper stomach of 15cc with
    mesh band to prevent stretching

28
Vertical Banded Gastroplasty (VBG)
  • Disadvantages
  • results in less wt. loss than RNYGB
  • does not restrict intake of high calorie sweet
    liquids
  • pouch can stretch over time
  • 20 do not lose weight
  • only 1/2 lose 50 of excess weight

29
Case Study
  • Whos your favorite TV weatherman?
  • Al Roker had gastric bypass surgery performed
  • To date hes lost over 100lbs
  • Diet, exercise and support from family, friends
    and colleagues continue to motivate him
  • http//www.alroker.com/

30
In the Operating Room
  • Access
  • OR table
  • Size of instruments
  • Positioning
  • Visualization of tissue
  • Anesthesia risks
  • Surgical procedures take longer

31
Skin Issues
  • Pressure
  • Shear
  • Friction
  • Moisture
  • Heat

32
Skin Issues
  • External pressure/ischemia
  • Internal pressure/edema
  • Moisture/maceration
  • Microclimate challenges
  • Staphlococcus
  • Streptococcus
  • Candida albicans
  • Acanthosis nigricans
  • Darkening of skin under folds
  • Ulcerations in unique locations
  • Skin tears under folds

33
Topical Know-How
  • Creams absorb faster than powders
  • Not for long-term use
  • Use ostomy powders
  • Barrier ointments are good choice
  • Antifungal treatments
  • Baza Cream by Coloplast
  • Aloe Vesta 2-n-1 Ointment by Convatec
  • Triple Care by Smith and Nephew, Inc.

34
Managing the Microclimate
  • Cleansing and drying
  • Absorption of excess moisture
  • Dressings and skin barriers
  • Daily inspection of bed
  • Decrease friction/shear
  • Support surface selection
  • true low air loss
  • rotation if necessary
  • Trendelenburg with boost

35
Room Environment
  • Bed Frame and Mattress
  • Lift systems
  • Stand Assist systems
  • Wheelchairs- position
  • Toilet/shower aids
  • Walkers
  • Recliners

36
Bed Guidelines
  • Bed/Mattress widths from 39-60
  • Most beds and mattresses have 600-1000 lb limits
  • Built-in scales
  • For clients gt 65, obtain bed/mattress of 86 or
    greater

37
Appropriate Equipment Utilization
  • Support Surfaces
  • Weight capacity/bed scales
  • Increased surface area
  • Dissipation of excess moisture/heat
  • Adequate structural support
  • Products without weight limits

38
Appropriate Equipment Utilization
  • Transfer devices
  • Mechanical/Electric lifts
  • Hovermat
  • Coated Turnsheets
  • Barton transfer chair

39
Appropriate Equipment Utilization
  • Wheeled mobility
  • Fit the chair to the client
  • Pressure-relieving cushion
  • Elevating leg rests

40
Appropriate Equipment Utilization
  • Ancillary products
  • Shower/commodes
  • Walkers
  • Lift chairs
  • Transport chairs
  • Transfer benches

41
Safety Issues
  • Proper equipment
  • Emergency procedures
  • Staffing levels
  • Training
  • body mechanics

42
Tying It All Together
  • Obesity kills 300,000 people/year
  • Medical care costs 50 billion
  • Success requires a team effort
  • Safety is crucial for client/caregivers
  • Pressure management is paramount

43
Resource Guide
  • American Obesity Association
  • www.obesity.com
  • American Society for Bariatric Surgery
  • info_at_asbs.org
  • Council on Size and Weight Discrimination, Inc.
  • www.cswd.org
  • National Association for Advancement of Fat
    Acceptance
  • www.naafa.org
  • The ROHO Group
  • www.therohogroup.com

44
He Aint Heavy, Hes Your Patient!
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