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.