ATI Nutrition Chapter 3

Obesity risk factors (3):

Genetic predisposition Hormones (leptin, ghrelin) Behavioral factors (sedentary lifestyle, diet choices)

Ideal body weight for females based on the Hamwi method using height/weight calculation:

45 kg (100 lbs) for the first 152 cm (5 ft) of height, and 2.3 kg (5 lb) for each additional 2.5 cm (1 in)

Ideal body weight for males based on the Hamwi method using height/weight calculation:

48 kg (106 lbs) for the first 152 cm (5 ft) of height, and 2.7 kg (6 lb) for each additional 2.5 cm (1 in)

Percentage weight change calculation:

(usual weight - present weight x 100) / usual weight

Diet history

A diet history is an assessment of usual foods, fluids, and supplements. The diet history is part of the nutrition screening performed using various settings to determine malnutrition issues.

Nitrogen balance considerations:

A neutral nitrogen balance indicates adequate nutritional intake. A positive nitrogen balance indicates protein synthesis is greater than protein breakdown as during growth, pregnancy, or during recovery. A negative nitrogen balance indicates protein is used at a greater rate than it is synthesized as in starvation or a catabolic state following injury or disease.

Fluid I&O lab clinical values:

Adult Input = 2,000 to 3,000 mL (2 to 3 L) per day Adult Output = 1,750 to 3,000 mL/day

Obesity percentages:

Approximately 36.5% of American adults have obesity, and an estimated 68.5% have obesity or are overweight.

Body Mass Index (BMI)

BMI measurements compare the weight to height to estimate the effect of the individual's body weight. Client factors should be considered when determining the value of BMI measure. For example, a client who has large muscle mass compared to height can have an increased BMI, since weight can be influenced by both fat and muscle.

Expected behavioral findings related to obesity:

Clients report of depression, low self-esteem, avoidance of health-related appointments, and no desire to exercise as a result of feeling stigmatized by their excessive weight.

Why are anorectic medications used?

Clients who do not lose weight during weight loss programs can benefit from pharmacological therapy. Anorectic medications suppress appetite and reduce food intake. When combined with an exercise program, they can result in weight loss.

Expected waist-to-hip ratio (WHR):

Females: 0.8 or greater Males: 0.95 or greater

Expected waist circumference related to overweight/obesity:

Females: greater than 88.9 cm (35 in) Males: greater than 101.6 cm (40 in)

Nutrition assessment/data collection lab values (4):

Fluid I&O Protein levels Prealbumin Nitrogen balance

Client education for obesity (1):

Follow the prescribed diet from the provider or dietitian to prevent complications of obesity.

Components of a diet history (7-9):

Foods avoided due to allergy or preference. Frequency and dose/amount of medications or nutritional supplements taken daily. Satisfaction with diet over a specified time frame (last 3 months, 1 year).

What is the life expectancy of an obese client?

For class I obesity, life expectancy is reduced by 2 to 4 years. For BMI 40-50, life expectancy is reduced by 8 to 10 years.

Physical assessments findings that may indicate inadequate nutrition (1-3):

Hair that is dry or brittle, or skin that has dry patches. Poor wound healing or sores. Lack of subcutaneous fat or muscle wasting.

Body Mass Index (BMI) considerations:

Health weight BMI = 18.5 - 24.9 Underweight BMI = < 18.5 Overweight BMI = 25 - 29.9 (about 20% above desired) Obesity BMI = > or equal to 30

Nursing actions pertaining to risk factors for inadequate nutrition:

In addition to determining the client's nutrient and calorie intake, assess other factors that might alter nutrient intake. Consult with the provider to see if the client's medical treatment plan needs to be altered to improve nutrition, such as administering a different medication to prevent the adverse effects of anorexia, or adding a medication to treat nausea or improve appetite. Plan the client's schedule of activities to prevent interruptions during mealtime, and to avoid fatigue, nausea, or pain before meals.

Physical assessments findings that may indicate inadequate nutrition (4-6):

Irregular cardiovascular measurements (heart rate and rhythm, blood pressure). Enlarged spleen or liver. General weakness or impaired coordination.

Nursing care for obesity (1-3):

Maintain low-Fowler's position to maximize chest expansion. Monitor respiratory status frequently and include pulse oximetry continuously. Supplement oxygen as needed.

Height considerations (2):

Measure on a vertical, flat surface. Ask the client to remove shoes and head covering and stand straight with heels together looking straight ahead. Read the measurement to the nearest 0.1 cm or 1/8 in. Obtain a recumbent measurement (lying on a firm, flat surface) for infants and young children.

Biophysical factors for inadequate nutrition (4):

Medical disease/condition (hypertension, HIV/AIDS) Preventive measures or disease treatments, including surgery or use of medications and supplements. Genetic predisposition (lactose intolerance, osteoporosis) Age

Psychological factors for inadequate nutrition (4):

Mental illness (clinical depression) Excessive stress Negative self-concept Use of comfort food

Nursing care for obesity (4-6):

Monitor blood pressure, using an appropriately-sized cuff for accurate readings. Monitor frequently for medication adverse effects. Use bariatric equipment (lifts, transport equipment, beds) to assist in mobility as needed.

Nitrogen balance

Nitrogen balance refers to the relationship between protein breakdown (catabolism) and protein synthesis (anabolism).

Complications related to obesity (1-3):

Obesity increased the risk for dyslipidemia, diabetes mellitus type 2, vascular disease, gallbladder disease, hypertension, osteoarthritis, respiratory problems, some cancers, and sleep apnea. Obesity also increases the risk for perioperative complications and complications during pregnancy, labor, and delivery. Nonalcoholic fatty liver disease, polycystic ovary syndrome, GI reflux disease.

Obesity considerations (2):

Obesity is a chronic condition caused by calorie intake in excess of energy expenditure. It can be affected by numerous factors (culture, metabolism, environment, socioeconomics, individual behaviors). Obesity might be linked to protective measures within the body to prevent weight loss during calorie restriction, which cause it to secrete hormones that stimulate the appetite to maintain a specific weight. As weight increases, the body accepts a higher weight as the expected weight and seeks to maintain it.

Anorectic medications (3):

Orlistat Lorcaserin Phentermine-topiramate

Expected BMI related to overweight/obesity:

Overweight BMI = 25 to 29.9 Obese BMI = 30 or greater

Socioeconomic factors for inadequate nutrition (4):

Poverty Alcohol and other substance use disorders Fad or "special" diets Food preferences (cultural, ethnic or religious)

Prealbumin clinical values (3):

Prealbumin (thyroxine-binding protein) is a sensitive measure used to assess critically ill clients who are at risk for malnutrition. This test reflects acute changes rather than gradual changes. However, it is more expensive and often unavailable. This is not part of routine assessment.

Prealbumin considerations:

Prealbumin levels are used to measure effectiveness of total parenteral nutrition. Expected reference range is 15 to 36 mg/dL. (Less than 10.7 mg/dL indicates severe nutritional deficiency)

Orlistat

Prevents digestion of fats Adverse effects: Oily discharge; reduced food and vitamin absorption; decreased bile flow; loose, oily stools; abdominal cramps; fecal incontinence

Protein lab clinical values:

Protein levels are usually measured by albumin levels, although total protein is sometimes used. Many non-nutritional factors (injury, kidney disease), interfere with this measure for protein malnutrition. Expected albumin reference range: 3.5 to 5 g/dL

To measure nitrogen balance:

Record protein intake (g) over 24 hr and divide by 6.25. Record nitrogen excretion in urine over 24 hr & add 4 g. Subtract nitrogen output from nitrogen intake. 24 hr protein intake / 6.25 = nitrogen intake (g). 24 hr urinary urea nitrogen + 4 g = total nitrogen output

Lorcaserin

Stimulates serotonin receptors in the hypothalamus in the brain to curb appetite. ADVERSE EFFECTS: Headache, dry mouth, fatigue, nausea

Phentermine-topiramate

Suppresses the appetite and induces a feeling of satiety ADVERSE EFFECTS: Dry mouth, constipation, nausea, change in taste, dizziness, insomnia, numbness and tingling in extremities CONTRAINDICATIONS: Hyperthyroidism, glaucoma, taking an MAO inhibitor

The interprofessional care team and obesity:

The care team can include a health care provider, nursing team, dietitian, social worker, surgeon, and mental health therapist or counselor.

Waist-to-hip ratio (WHR)

The measurement of difference between peripheral lower body obesity and central obesity. Can be used as a predictor of coronary artery disease. Indicates excess fat at the waist and abdomen.

Components of a diet history (1-3):

Time, type, and amount of food eaten for breakfast, lunch, dinner, and snacks. Time, type and amount of fluids consumed throughout the day, including water, health drinks, coffee/tea, carbonated beverages, and beverages with caffeine. Type, amount and frequency of "special foods" (celebration foods, movie foods).

Which laboratory test values are used to evaluate for cardiovascular disease, diabetes mellitus, fatty liver disease, or thyroid disorders?

Total cholesterol Triglycerides Fasting blood glucose Glycosylated hemoglobin Aspartate aminotransferase (AST) Alanine aminotransferase (ALT)

Components of a diet history (4-6):

Typical preparation of foods and fluids (coffee with sugar, fried foods). Number of meals eaten away from home (at work or school). Type of preferred or prescribed diet (ovo-lacto vegetarian, 2 g sodium/low-fat diet).

Anthropometric tools

Weight Height Body Mass Index (BMI)

Weight considerations (3):

Weight at the same time of day wearing similar clothing to ensure accurate weight readings. Daily fluctuation general are indicative of water weight changes. During illness, weight loss is monitored to prevent or detect malnutrition.

Weight loss based on acute disease or injury which indicates severe malnutrition:

Weight loss greater than 2%/week Weight loss greater than 5%/month Weight loss greater than 7.5%/3 months

Weight loss based on starvation or chronic disease which indicates severe malnutrition:

Weight loss greater than 5%/month Weight loss greater than 7.5%/3 months Weight loss greater than 10%/6 months Weight loss greater than 20%/year