Transcript Obesity & Eating Disorders

Focus on
Obesity
(Relates to Chapter 41,
“Nursing Management: Obesity,”
in the textbook)
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Obesity and Overweight
• Imbalance between energy
expenditure and energy intake from
a long-term sedentary lifestyle
and/or excessive calorie intake
• Obesity is an abnormal increase in
the proportion of fat cells
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Obesity and Overweight
• Primarily occurs in the visceral and
subcutaneous tissues of the body
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Obesity and Overweight (Cont'd)
• Weight gain in adulthood is
characterized predominantly by
adipocyte hypertrophy
 Adipocyte hypertrophy is a process by
which adipocytes can increase their
volume several thousandfold to
accommodate large increase in lipid
storage
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Obesity (Cont'd)
• Has reached epidemic proportions in
developed and nondeveloped
countries
• In the United States
 Most common nutritional problem
 Affects one third of the population
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Obesity (Cont'd)
• Second leading cause of preventable
death
• Third leading reason for liver
transplantation
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Etiology and Pathophysiology
• Energy intake exceeds energy
output
• Processes leading to obesity are
much more complex and still
undergoing investigation
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Etiology and Pathophysiology (Cont'd)
• Cause involves significant
genetic/biologic susceptibility
factors that are highly influenced by
environment and psychosocial
factors
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Etiology and Pathophysiology (Cont'd)
• Caloric consumption must exceed
energy expenditure for condition to
continue
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Genetic/Biologic Basis
• Strong evidence of genetic
predisposition
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Genetic/Biologic Basis (Cont'd)
• Most common form considered to be
polygenic, arising from the
interaction of multiple genetic and
environmental factors
 Identifying these genes will lead to a
better understanding of the
pathogenesis
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Genetic/Biologic Basis (Cont'd)
• Appetite is influenced by many
factors that are integrated by the
brain
 Most importantly, the hypothalamus
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Genetic/Biologic Basis (Cont'd)
• Input to the hypothalamus is
received from the periphery from
many different hormones and
peptides
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Hormones and Peptides that Interact
with Hypothalamus to Affect Obesity
Fig. 41-3
Genetic/Biologic Basis
• Associated with ↑ circulating plasma
levels of leptin, insulin, and ghrelin,
and ↓ levels of peptide YY
• Adipocytes secrete a number of
hormones and cytokines known as
adipokines
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Environmental Factors
• Greater access to food
 Prepackaged food
 Fast food
 Soft drinks
 Increased portion sizes
• Obese individuals tend to
underestimate food and caloric
intake
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Environmental Factors (Cont'd)
• Lack of physical exercise
 Decreased at home and work
 Advances in technology and laborsaving devices
 Increased time watching television and
playing video games
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Psychosocial Factors
• Emotional component to overeat is
powerful
• People use food for many reasons
• Social component of eating is
developed early in life
 Birthday parties, holidays
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Classification of Body Weight and
Obesity
• Primary obesity (majority of obese)
 Excess caloric intake for the body’s
metabolic demands
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Classification of Body Weight and
Obesity (Cont'd)
• Secondary obesity
 Results from various congenital
anomalies, chromosomal anomalies,
metabolic problems, or CNS lesions
and disorders
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Classification of Body Weight and
Obesity (Cont’d)
• Body mass index
 Degree to which a patient is classified
as underweight, healthy (normal)
weight, overweight, or obese
 Common clinical index of obesity or
altered body fat distribution
 Uses weight-to-height ratios
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Body Mass Index
Fig. 41-4
Classification of Body Weight and
Obesity
• Waist-to-hip ratio (WHR)
 Weight circumference is another way
to assess and classify weight
 Method of describing distribution of
subcutaneous and visceral adipose
tissue
 Waist measurement/hip measurement
= ratio
 WHR <0.80 is optimal
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Classification of Body Weight and
Obesity
• Waist-to-hip ratio (WHR) (cont'd)
 WHR >0.80 indicates greater risk for
health complications
 People with more visceral fat are at an
increased risk for cardiovascular
disease and metabolic syndrome
 Preferred tool when patient is
predominantly muscular
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Classification of Body Weight and
Obesity (Cont’d)
• By body shape or fat distribution
 Apple-shaped body
Fat located primarily in the abdominal
area
• At greater risk for obesity-related
complications
• Android obesity
•
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Classification of Body Weight and
Obesity
• By body shape or fat distribution
(cont'd)
 Pear-shaped body
•
•
Fat located primarily in upper legs
Gynoid obesity
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Classification of Body Shapes
Fig. 41-5
Common Fat Distribution
Fig. 41-1
Health Risks Associated with Obesity
• Problems occur at higher rates for
obese patients
• Mortality rate rises as obesity
increases
 Especially with increased visceral fat
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Health Risks Associated with Obesity
(Cont'd)
• Obese patients have a decreased
quality of life
• Most conditions improve with
weight loss
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Health Risks Associated with Obesity
Fig. 41-6
Cardiovascular Problems
• Obesity is a significant risk factor for
predicting cardiovascular disease
• WHR is best predictor of risk
 Android obesity patients at greater
risk
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Cardiovascular Problems (Cont’d)
• Risks
 ↑ Low-density lipoproteins (LDLs)
 ↑ Triglycerides
 ↓ High-density lipoproteins (HDLs)
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Cardiovascular Problems
• Risks (cont'd)
 Hypertension
↑ Circulating blood volume
Abnormal vasoconstriction
• ↓ Vascular relaxation
• ↑ Cardiac output
•
•
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Cardiovascular Problems (Cont'd)
• Larger cuff to avoid artifactual ↑ may
be needed when taking blood
pressure
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Respiratory Problems
• Severe obesity may be associated
with
 Sleep apnea
 Obesity hypoventilation syndrome
 ↓ Chest wall compliance
 ↑ Work of breathing
 ↓ Total lung capacity and functional
residual capacity
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Diabetes Mellitus
• Hyperinsulinemia
• Insulin resistance
• Type 2 diabetes
 80% of patients with type 2 diabetes
are obese
• Weight loss and exercise improve
glucose control
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Musculoskeletal Problems
• Osteoarthritis
 Trauma to weight-bearing joints
• Hyperuricemia
• Gout
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Gastrointestinal and Liver
Problems
• Gastroesophageal reflux disease
(GERD)
• Gallstones
• Nonalcoholic steatohepatitis
(NASH)
 Can eventually lead to cirrhosis
 Weight loss can improve NASH
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Cancer
• Obesity is one of the most important
known preventable causes of cancer
 Women
•
•
Breast, endometrial, ovarian, cervical
Possibly from ↑ estrogen postmenopause
•
Prostate
 Men
 Both genders: Colon
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Nursing Assessment
• Patient may withhold information
out of embarrassment or shyness
• Provide acceptable reasons for
personally intrusive questions
• Respond to concerns about
diagnostic tests
• Interpret outcomes
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Nursing Assessment (Cont'd)
• Health history
 Time of obesity onset
 Diseases related to metabolism and
obesity
 Medications
 Objective
•
Height, weight, BMI, skinfold thickness,
waist circumference
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Nursing Assessment
• Health history (cont'd)
 History with weight gain/weight loss
 Interested in losing weight
 Contributors to weight gain
 What impedes weight loss
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Nursing Assessment
• Health history (cont'd)
 How patient uses food (e.g., to relieve
stress, provide comfort)
 Other overweight family members
 Environmental or genetic factors
influencing weight gain
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Nursing Diagnoses
• Imbalanced nutrition: More than
body requirements
• Impaired skin integrity
• Ineffective breathing pattern
• Chronic low self-esteem
• Health-seeking behaviors
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Planning
• Modify eating patterns
• Participate in a regular physical
activity program
• Achieve weight loss to a specified
level
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Planning (Cont'd)
• Maintain weight loss at a specified
level
• Minimize or prevent health
problems related to obesity
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Nursing Implementation
• When no organic cause can be found
for obesity, it should be considered a
chronic, complex disease
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Nursing Implementation (Cont'd)
• Supervise a plan
 Successful weight loss, requiring a
short-term energy deficit
 Successful weight control, requiring
long-term behavior changes
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Nursing Implementation (Cont'd)
• Multipronged approach ought to be
used with attention to multiple
factors
 Dietary intake, physical activity,
behavior modification, and/or drug
therapy
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Nursing Implementation (Cont'd)
• All opportunities for patient
education should stress healthy
eating and exercise
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Nursing Implementation (Cont'd)
• Motivation is essential to weight loss
• Set a realistic and healthy goal for
weight loss
• 1 to 2 pounds per week
• Slower weight loss offers better
cosmetic results
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Nursing Implementation (Cont'd)
• Plateaus can last from several days
to several weeks
• Daily weighing is not recommended
• Weigh once a week with similar
clothing, at the same time of day
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Nutritional Therapy
• Restricted food intake is a
cornerstone
• A good weight loss plan contains
food from the basic food groups
• Diet classifications
 800 to 1200 calories: Low calorie
 <800 calories: Very low calorie
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Nutritional Therapy (Cont'd)
• Adequate amounts of
 Fruits and vegetables
 Lean meat, fish, and eggs
• Fad diets should be discouraged
 Often body water is lost and not fat
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Nutritional Therapy (Cont'd)
• Need to consider the proportion of
calories from animal sources and
calories from fruits, grains, and
vegetables
 American Institute for Cancer Research
•
•
2/3 of the diet should be plant-source
1/3 or less from animal protein
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Nutritional Therapy
Table 41-8
Nutritional Therapy
• Food portion sizes
 Serving of fruit and vegetables
•
Size of woman’s fist or baseball
 Serving of meat
•
Human’s palm or a deck or cards
 Serving of cheese
•
Size of a thumb or six dice
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Exercise
• An essential part of a weight control
program
• Should be done daily for 30 minutes
to an hour
• Sensible forms of exercise should be
encouraged
 Walking, swimming, cycling
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Behavior Modification
• Assumption behind behavior
modification
 Learned disorder
 Critical difference between an obese
person and a nonobese person are cues
that regulate eating behavior
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Behavior Modification (Cont’d)
• Goal is to deemphasize diet and
focus of how and when a person eats
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Behavior Modification (Cont’d)
• Has been successful helping people
maintain weight loss
• Useful basic techniques
 Self-monitoring: Show what and when
foods are eaten
 Stimulus control: Separate events that
trigger eating from the act of eating
 Rewards: Incentives for weight loss
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Support Groups
• Encouragement can be offered to
join a group of other obese persons
who are receiving professional
counseling to help modify eating
habits
• Many self-help groups are available
 Take Off Pounds Sensibly (TOPS)
 Weight Watchers
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Drug Therapy
• Classified into two categories
 ↓ Food intake by reducing appetite or
increasing satiety
 ↓ Nutrient absorption
• Drugs that ↑ energy expenditure are
not approved by the FDA
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Drug Therapy (Cont’d)
• Appetite-suppressing drugs
 Decrease food intake through nonadrenergic
or serotonergic mechanisms in the central
nervous system (CNS)
•
•
•
Phentermine
Diethylpropion
Phendimetrazine
 Recommended for short-term use
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Drug Therapy
• Appetite-suppressing drugs (cont'd)
 Serotonergic drugs ↑ release of
serotonin or ↓ its uptake, thus ↓
metabolism
•
•
•
Fenfluramine (Pondimin)
Dexfenfluramine (Redux)
Removed from market in 1997
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Drug Therapy
• Appetite-suppressing drugs (cont'd)
 Mixed nonadrenergic-serotonergic
agents
•
•
Do not stimulate release of serotonin
Sibutramine (Meridia)
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Drug Therapy (Cont'd)
• Nutrient absorption–blocking drugs
 Work by blocking fat breakdown and
absorption in intestine
 Inhibits action of intestinal lipases
 Undigested fat is excreted in feces
•
Orlistat (Xenical)
• Purchasing over-the-counter drugs
should be discouraged
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Bariatric Surgery
• Used to treat morbid obesity
• Currently the only treatment found
to have a successful and lasting
impact for sustained weight loss
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Bariatric Surgery (Cont’d)
• Must meet all of the following
criteria to be considered an ideal
candidate
 BMI ≥40 kg/m2 with one or more
obesity-related complication
 18 years or older
 Understands the risks and benefits
 Has been obese for >5 years
 Has tried and failed to lose weight
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Bariatric Surgery
• Criteria to be considered an ideal
candidate (cont'd)
 Has no serious endocrine problems
 Has psychiatric and social stability
 Availability of a team of health care
providers
 Surgery would ↓ or eradicate high-risk
conditions
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Bariatric Surgery (Cont’d)
• Three broad categories
 Restrictive
 Malabsorptive
 Combination of restrictive and
malabsorptive
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Restrictive Surgery
• Reduces the size of a stomach to 30
ml or less
• Causes patient to feel full quicker
• Normal stomach digestion and
intestinal absorption of food
 ↓ Risk of anemia and cobalamin
deficiency
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Restrictive Surgery (Cont’d)
• Vertical banded gastroplasty
 Partitions stomach into a small pouch
in upper portion
 Small pouch drastically limits capacity
 Stoma opening to rest of stomach is
banded to delay emptying of solid
food from proximal pouch
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Restrictive Surgery
Fig. 41-7 A
Restrictive Surgery
• Adjustable gastric banding (AGB)
 Also referred to as the LapBand
 Stomach size is limited by an inflated
band placed around fundus of stomach
 Band is connected to a subcutaneous
port
 Can be inflated or deflated to change
stoma size
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Restrictive Surgery
• AGB (cont'd)
 Can be done laparoscopically and can
be modified or reversed
 Better choice for patients who are
surgical risks
 Weight loss is slower than in other
procedures
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Restrictive Surgery
Fig. 41-7 B
Malabsorptive Surgeries
• Biliopancreatic diversion (BPD)
 Removes ~3/4 of stomach to ↓ food
intake and ↓ acid output
 Remaining 1/4 of stomach is connected
to lower portion of small intestine
 Pancreatic enzymes and bile enter
final segment of intestine
 Nutrients pass without being digested
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Malabsorptive Surgeries
• Biliopancreatic diversion with
duodenal switch (cont'd)
 Variation of BPD
 By including duodenal switch,
surgeons leave a larger portion of the
stomach intact
 Helps prevent dumping syndrome
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Restrictive Surgery
Fig. 41-7 C
Combination of Restrictive and
Malabsorptive Surgery
• Roux-en-Y surgical procedure
 Has low complication rates
 Excellent patient tolerance
 Stomach size is ↓ with a gastric pouch
anastomosis that empties directly into
jejunum
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Combination of Restrictive and
Malabsorptive Surgery
• Roux-en-Y surgery (cont'd)
 Variations
Stapling stomach without transection to
create a small 20- to 30-ml gastric pouch
• Creating an upper and lower gastric pouch
and totally disconnecting the pouches
• Creating an upper gastric pouch and
completely removing the lower pouch
•
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Restrictive Surgery
Fig. 41-7 D
Cosmetic Surgeries
• Ideal candidates have
 Achieved weight reduction
 Excess skinfolds or fat
• Chooses surgery for cosmetic
reasons
 Lipectomy
 Liposuction
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Preoperative Care
• Patients who are obese are likely to
suffer other comorbidities, such as
 Diabetes, altered cardiorespiratory
function, abnormal metabolic
function, atherosclerosis
• A team approach may be necessary
 Cardiologist, pulmonologist,
gynecologist, gastroenterologist, or
other specialist
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Preoperative Care (Cont’d)
• Have room ready for patient before
arrival
 Larger size blood pressure cuff
 Larger gown
 Bariatric wheelchair
•
Or a wheelchair with removable arms
 Strongly reinforced trapeze bar over
bed for movement and positioning
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Preoperative Care
• Have room ready for patient before
arrival (cont'd)
 It may be necessary to put beds
together or specially construct a chair
 Have proper amount of staff on hand
for ambulating, bathing, and turning
patient
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Preoperative Care (Cont’d)
• Wound infection is one of the most
common complications because of
the many layers of flabby skinfolds,
especially in the abdominal area
• Skin preparation is important
• May be necessary to ask patient to
bathe or shower frequently for a few
days before admission to hospital
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Preoperative Care (C0nt’d)
• Obesity can make breathing shallow
and rapid
• Instruct patient in proper
 Coughing techniques
 Deep, diaphragmatic breathing
 Methods of turning and positioning to
prevent pulmonary complications
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Preoperative Care (Cont’d)
• Obtaining venous access may be
complicated
 Assistance may be needed
 Mark the spot of injection with a sterile
skin marker once a vein has been
found
 If patient has excess fat, or pitting
edema, hold a firm finger over the spot
with pressure
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Preoperative Care
• Obtaining venous access (cont'd)
 Multiple tourniquets can be used to
distend veins and hold back excess
tissue
 Tourniquet should be removed as soon
as it is no longer needed to avoid
edema
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Preoperative Care
• Obtaining venous access (cont'd)
 Edema can worsen if catheter is
anchored with tape to arm
•
Further impeding venous return
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Preoperative Care
• Obtaining venous access (cont'd)
 May need a longer catheter to traverse
overlying tissue
•
Longer than 1 inch
 Important that cannula is far enough
into vein so that it is not dislodged or
infiltrated
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Preoperative Care (Cont’d)
• Patients undergoing anesthesia
have an increased risk of failing to
wean from mechanical ventilation
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Postoperative Care
• Trained staff should assist transfer
of unconscious patient
• During transfer ensure that patient’s
 Airway is stabilized
 Pain is managed
• In severely obese patients it is
essential to monitor for rapid
oxygen desaturation
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Postoperative Care (Cont’d)
• Early ambulation is essential
• Frequently ↑ ambulation after initial
move
 Generally 3 to 4 times a day
• Pneumatic compression devices,
elastic compression stockings, or
elastic wraps will be used
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Postoperative Care (Cont’d)
• Patients undergoing bariatric
surgery are often in considerable
abdominal pain
• Pain medications should be given as
frequently as necessary during
immediate postoperative period
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Ambulatory and Home Care
• Patients who have just had bariatric
surgery have been unsuccessful in
the past maintaining a prescribed
diet
• Patient is now forced to reduced
intake due to anatomic changes
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Ambulatory and Home Care (Cont’d)
• Must learn to adjust intake
sufficiently with regard to nutrition
and maintaining a stable weight
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Ambulatory and Home Care (Cont’d)
• Diet prescribed is generally
 High protein
 Low carbohydrates
 Low fats
 Low roughage
 6 small feedings
 Fluids not to be ingested with meals
•
<1000 ml/day
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Ambulatory and Home Care (Cont’d)
• Possible complications from
bariatric surgery
 Anemia
 Vitamin deficiencies
 Diarrhea
 Psychiatric problems
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Ambulatory and Home Care
• Possible complications from
bariatric surgery (cont'd)
 Peptic ulcer formation
 Dumping syndrome
 Small bowel obstruction
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Evaluation
• Expected outcomes
 Long-term weight loss
 Improvement in obesity-related
comorbidities
 Integration of healthy practices into
lifestyle
 Monitoring possible adverse side
effects
 Improved self-image
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Gerontologic Considerations
• Number of older obese persons has
risen
• More common in women than men
• Decreased energy expenditure and
loss of muscle mass are important
contributors
• Exacerbates age-related problems
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Metabolic Syndrome
• Also known as
 Syndrome X, insulin resistance
syndrome, dysmetabolic syndrome
• Collection of risk factors that
increase an individual’s chance of
developing cardiovascular disease
and diabetes mellitus
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Metabolic Syndrome (Cont'd)
• Diagnosed if an individual has three
or more of the conditions listed
Waist circumference ≥40 inches (men)
or ≥35 inches (women)
2. Triglycerides >150 mg/dl or being
treated
1.
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Metabolic Syndrome (Cont'd)
• Diagnosed if an individual has three
or more of the conditions listed
High-density lipoprotein (HDL)
cholesterol <40 men, <50 women or
being treated
4. Blood pressure ≥130 mm Hg systolic or
≥85 mm Hg diastolic or being treated
5. Fasting glucose is ≥100 mg/dl or being
treated
3.
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Metabolic Syndrome
Etiology and Pathophysiology
• Main underlying risk factors
 Abdominal obesity
 Insulin resistance
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Metabolic Syndrome
Etiology and Pathophysiology (Cont’d)
• Other risk factors
 Physical inactivity
 Presence of inflammatory markers
 Prothrombotic tendencies
 Hormonal imbalances
 Aging
 Genetic or ethnic predisposition
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Metabolic Syndrome
Etiology and Pathophysiology (Cont’d)
• No symptoms
• Medical problems develop if
syndrome is not addressed
 Heart disease
 Stroke
 Diabetes
 Renal disease
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Metabolic Syndrome
Nursing and Collaborative Management
• Lifestyle therapy is first line of
intervention
 Manage cholesterol
 Stop smoking
 Lower blood pressure
 Reduce glucose levels
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Metabolic Syndrome
Nursing and Collaborative Management
• Lifestyle therapy is first line of
intervention (cont'd)
 Lose weight
 Increase physical activity
 Healthy dietary habits
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Metabolic Syndrome
Nursing and Collaborative Management
(Cont’d)
• Because there is only management,
the nurse can assist patients by
providing information
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Case Study
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Case Study
• 45-year-old female is hospitalized
for shortness of breath and
respiratory distress
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Case Study (Cont’d)
• Physical examination findings
 Blood pressure 150/72 mm Hg
 Heart rate 104 beats/min
 Respiratory rate 30 breaths/min
 Temperature 98.3°F
 SaO2 88%
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Case Study (Cont’d)
• Height 5’5”
• Weight 320 pounds
• History of hypertension, type 2
diabetes, COPD, obesity
• She states that she’s “tired of being
like this”
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Discussion Questions
1. What opportunities for education
and support do you have?
2. What other problems is she likely to
have related to her weight?
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Discussion Questions (Cont’d)
3. What treatment options are
available for her?
4. What tools may help her with
behavior modification?
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Discussion Questions (Cont’d)
5. If she wants to have bariatric
surgery, what risks does the
surgery pose?
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