Chapter 41 Nursing Management of Obesity
different surgeries
procedures. A, Adjustable gastric banding (AGB) uses a band to create a gastric pouch. B, Vertical sleeve gastrectomy involves creating a sleeve-shaped stomach by removing about 80% of the stomach. C, Vertical banded gastroplasty (VBG) involves creating a small gastric pouch. D, Biliopancreatic diversion (BPD) with duodenal switch procedure creates an anastomosis between the stomach and the intestine. E, Roux-en-Y gastric bypass procedure involves constructing a gastric pouch whose outlet is a Y-shaped limb of small intestine.
Goals of obesity
(1) modify eating patterns, (2) participate in a regular physical activity program, (3) achieve and maintain weight loss to a specified level, and (4) minimize or prevent health problems related to obesity.
Obesity and behavior modification
(1) obesity is a learned disorder caused by overeating and (2) often the critical difference between an obese person and a person of normal weight is the cues that regulate eating behavior. Therefore most behavior-modification programs deemphasize the diet and focus on how and when to eat.
Health care provider are relucant to counsel patients with obesity
(1) time constraints during appointments make it difficult, (2) weight management may be viewed as professionally unrewarding, (3) reimbursement for weight management services is difficult to obtain, and (4) many providers do not feel knowledgeable about giving weight loss advice.
Nutritional therapy
A dietary reduction of at least 500 to 1000 cal/day is recommended for an expected weight loss of 1 to 2 lb/wk. 18 (Table 41-8 presents an example of a 1200- calorie diet.) A supervised diet plan may be prescribed limiting calories to a total of 800 or less calories per day, but this is not sustainable on a long-term basis. Persons on low-calorie and very-lowcalorie diets need frequent professional monitoring because the severe energy restriction places them at risk for multiple nutrient deficiencies.
multifacted approach to weight loss
A multifaceted approach needs to be used, including nutritional therapy, exercise, behavior modification, and for some, medication or surgical intervention (Table 41-7). Focusing on more than one aspect provides for more effective weight loss and weight control efforts. While doing patient teaching, stress healthy eating habits and adequate physical activity as lifestyle patterns to develop and maintain.
Nursing Interventions related to drug therapy
Drugs will not cure obesity, and individuals must understand that without substantial changes in food intake and increased physical activity, they will gain weight when drug therapy is stopped. As with any drug treatment, there are side effects. Careful evaluation for other medical conditions can help determine which drugs, if any, would be advisable for a given patient. Your role related to drug therapy is to teach the patient about proper administration, side effects, and how the drugs fit into the overall weight loss plan. The modification of dosage without consultation with the health care provider can have detrimental effects. Emphasize that diet and exercise regimens are the cornerstones of permanent weight loss. Finally, discourage the purchase of over-the-counter diet aids except for Allī.
Special considerations for bariatric surgery
Ensure that the patient scheduled for bariatric surgery understands the surgical procedure. Your teaching depends on the type of procedure and surgical approach. Prepare the patient before surgery for the possibility of returning with one or more of the following: urinary catheter, IV catheter, compression stockings, and nasogastric tube. Emphasize that vital signs and a general assessment will be conducted frequently to monitor for complications. Further, the patient must understand that he or she will be assisted with ambulation soon after surgery and encouraged to cough and deep breathe to prevent pulmonary complications. Liquids will be started early but only after the patient is fully awake and there is no evidence of any anastomosis leaks.
Exercise and Obesity
Exercise is an essential part of a weight control program. Patients should exercise daily, preferably 30 minutes to an hour. There is no evidence that increased activity promotes an increase in appetite or leads to dietary excess. In fact, exercise frequently has the opposite effect. The addition of exercise produces more weight loss than does dieting alone and has a favorable effect on body fat distribution. With regular exercise, WHR is reduced. Finally, exercise is especially important in maintaining weight loss. When large muscles are involved in the exercise program, a primary benefit is cardiovascular conditioning. Overweight men and women who are active and fit have lower rates of morbidity and mortality than overweight persons who are sedentary and unfit. Therefore exercise is of benefit to overweight persons even if it does not make them lean. Many psychologic benefits can be derived from an increased physical activity program. Exercise decreases tension and stress, promotes better-quality sleep and rest, increases stamina and energy, improves self-concept and self-confidence, improves attitudes, and increases optimism about the future. 18 Explore with the patient possible ways to incorporate exercise in daily routines. It may be as simple as parking farther from their place of employment or taking the stairs versus an elevator. Encourage individuals to wear a pedometer to track their activity with a goal of 10,000 steps a day. However, success may be walking one third of the recommended steps with incremental increases over time. Although joining a health club can be one way of getting exercise, it is not necessary. Patients can walk, swim, and cycle, all of which have long-term benefits. Stress to patients that engaging in weekend exercise only or in spurts of strenuous activity is not advantageous and can actually be dangerous.
GI and Liver and Obesity
Gastroesophageal reflux disease (GERD) and gallstones are more prevalent in obese people. Gallstones occur due to supersaturation of the bile with cholesterol. Nonalcoholic steatohepatitis (NASH) is a condition in which lipids are deposited in the liver, resulting in a fatty liver. NASH is associated with elevated hepatic glucose production. NASH can eventually progress to cirrhosis and can be fatal. Weight loss can improve NASH.
Bariatric surgery
In restrictive procedures the stomach is reduced in size (less food eaten), and in malabsorptive procedures the length of the small intestine is decreased (less food absorbed). 21 The majority of procedures are performed laparoscopically, thus decreasing postoperative recuperation as compared to an open procedure. With laparoscopy, patients have fewer wound infections, shorter hospital stays, and a faster recovery period.
Nursing and collab care of metabolic syndrome
Lifestyle modifications are the first-line interventions to reduce the risk factors for metabolic syndrome. Management or reversal of metabolic syndrome can be achieved by reducing the major risk factors of cardiovascular disease: reducing LDL cholesterol, stopping smoking, lowering BP, and reducing glucose levels. For long-term risk reduction, weight should be decreased, physical activity increased, and healthy dietary habits established. There is no specific management of metabolic syndrome. You can assist patients by providing information on healthy diets, exercise, and positive lifestyle changes. The diet, which should be low in saturated fats, should promote weight loss. Weight reduction and maintenance of a lower weight should be the first priority in those with abdominal obesity and metabolic syndrome. Because sedentary lifestyles contribute to metabolic syndrome, increasing regular physical activity will lower a patient's risk factors. In addition to assisting in weight reduction, regular exercise has been found to decrease the triglyceride level and increase the HDL cholesterol level in patients with metabolic syndrome. Patients unable to lower risk factors with lifestyle therapies alone or those at high risk for a coronary event or diabetes may be considered for drug therapy. Although there is no specific medication for metabolic syndrome, cholesterol-lowering and antihypertensive drugs can be used. Metformin (Glucophage) has also been used to prevent diabetes by lowering glucose levels and enhancing the cells' sensitivity to insulin.
Motivation and obesity
Motivation is an essential ingredient for successful weight loss. The obese patient must recognize the advantages of weight loss and weight control. You can assist by helping the patient track eating patterns with a diet diary. Through a frank discussion of eating patterns, the patient often realizes that eating is "mindless" and the result of bad habits picked up over time. These eating behaviors must be changed, or any weight loss will only be temporary.
Obesity and cardiovascular problems
Obesity is a significant risk factor for cardiovascular disease in both men and women. 11 Android obesity is the best predictor of these risks and is linked with increased low-density lipoproteins (LDLs), high triglycerides, and decreased high-density lipoproteins (HDLs). Obesity is also associated with hypertension, which can occur because of increased circulating blood volume, abnormal vasoconstriction, increased inflammation (damaging blood vessels), and increased risk of sleep apnea (raises blood pressure [BP]). Altered lipid metabolism and hypertension can increase the long-term risk of heart disease and stroke. Excess body fat can also lead to chronic inflammation throughout the body, especially in blood vessels, thus increasing the risk of heart disease.
MS problems and obesity
Obesity is associated with an increased incidence of osteoarthritis because of the stress put on weight-bearing joints, especially the knees and hips. Increased body fat also triggers inflammatory mediators and contributes to deterioration of cartilage. Hyperuricemia and gout are often found in people who are obese and in those who have metabolic syndrome (discussed later in this chapter).
Primary and Secondary Obesity
The majority of obese persons have primary obesity, which is excess calorie intake over energy expenditure for the body's metabolic demands. Others have secondary obesity, which can result from various congenital anomalies, chromosomal anomalies, metabolic problems, or central nervous system lesions and disorders.
Body Mass Index
The most common measure of obesity is the body mass index (BMI). BMI is calculated by dividing a person's weight (in kilograms) by the square of the height in meters (Fig. 41-2). Individuals with a BMI less than 18.5 kg/m2 are considered underweight, whereas those with a BMI between 18.5 and 24.9 kg/m2 reflect a normal body weight. A BMI of 25 to 29.9 kg/m2 is classified as being overweight, and those with values at 30 kg/m2 or above are considered obese. The term severely (morbidly, extremely) obese is used for those with a BMI greater than 40 kg/m2 (eFig. 41-1 on the website shows individuals who are severely obese).
Clinical manifestations and diagnostic studies of metabolic syndrome
The signs of metabolic syndrome are impaired fasting blood glucose, hypertension, abnormal cholesterol levels, and obesity. Medical problems develop over time if the condition remains unaddressed. Patients with this syndrome are at a higher risk of heart disease, stroke, diabetes, renal disease, and polycystic ovary syndrome. Patients who have metabolic syndrome and smoke are at an even higher risk.
The two major consequences of obesity
The two major consequences of obesity are due to the sheer increase in fat mass and the production of adipokines produced by fat cells. Adipocytes produce at least 100 different proteins. These proteins, secreted as enzymes, adipokines, growth factors, and hormones, contribute to the development of insulin resistance and atherosclerosis. An increased release of cytokines from fat cells may disrupt immune factors, thus predisposing the person to certain cancers. Because visceral fat accumulation is associated with more alterations of these adipokines, people with abdominal obesity have more complications of obesity.
Behavioral modication and obesity
Various behavioral techniques for patients engaged in a weight loss program include (1) self-monitoring, (2) stimulus control, and (3) rewards. Self-monitoring may involve keeping a record of the type and time food was consumed and how the person was feeling when eating. Stimulus control is aimed at separating events that trigger eating from the act of eating. Rewards may be used as incentives for weight loss. Short- and long-term goals are useful benchmarks for earning rewards. It is important that the reward for a specified weight loss not be associated with food, such as dinner out or a favorite treat. Reward items do not have to have a monetary component. For example, time for a hot bath or an hour of pleasure reading would be an enjoyable reward for many people.
Metabolic syndrome
also known as syndrome X, insulin resistance syndrome, and dysmetabolic syndrome, is a collection of risk factors that increase an individual's chance of developing cardiovascular disease, stroke, and diabetes mellitus. It is estimated that around 70 million to 80 million, or about 25%, of Americans have metabolic syndrome. 29 The syndrome is more prevalent in those 60 years of age and older. 30 Metabolic syndrome is characterized by a cluster of health problems, including obesity, hypertension, abnormal lipid levels, and high blood glucose. Metabolic syndrome is diagnosed if an individual has three or more of the conditions listed in Table 41-10. Currently health professionals are debating the usefulness of focusing attention on the syndrome itself. The interventions are focused on each risk factor, since there is not one standard treatment for the syndrome itself.
Body Shape
is another method of identifying those who are at a higher risk for health problems (Table 41-2). Individuals with fat located primarily in the abdominal area, an apple-shaped body, have android obesity. Those with fat distribution in the upper legs, a pear-shaped body, have gynoid obesity. Genetics has an important role in determining a person's body shape. Weight and shape are influenced by genetics.
Waist to hip ratio
is another tool used to assess obesity. This ratio is a method of describing the distribution of both subcutaneous and visceral adipose tissue. The ratio is calculated by using the waist measurement divided by the hip measurement. A WHR less than 0.8 is optimal, and a WHR greater than 0.8 indicates more truncal fat, which puts the individual at a greater risk for health complications.
Waist Circumference
is another way to assess and classify a person's weight (see Table 41-1). People who have visceral fat with truncal obesity are at an increased risk for cardiovascular disease and metabolic syndrome (discussed later in this chapter). Health risks increase if the waist circumference is greater than 40 inches in men and greater than 35 inches in women.
Obesity and Cultural Disparities
• African Americans and Hispanics have a higher prevalence of obesity than whites. • Among women, African Americans have the highest prevalence of being overweight or obese, and 15% are severely obese. • Among men, Mexican Americans have the highest prevalence of being overweight or obese. • African American and Hispanic women with low incomes appear to have the greatest likelihood of being overweight when compared with other socioeconomic groups. • Native Americans have a higher prevalence of being overweight than the general population. • Among Native Americans ages 45 to 74, more than 30% of women are overweight and more than 40% are obese. • Asian Americans have the lowest prevalence of being overweight and obese compared with the general population.
Healthy Impact of Maintaining a Healthy Weight
• Reduces the risk of developing type 2 diabetes mellitus • Increases chance of longevity and better quality of life • Lowers the risk of hypertension and elevated cholesterol • Reduces the risk of heart disease, stroke, and gallbladder disease • Reduces the likelihood of breathing problems, including sleep apnea and asthma • Decreases the risk of developing osteoarthritis, low back pain, and certain types of cancers
Assessing patients with obesity
• What is your history with weight gain and weight loss? • What is your motivation for losing weight? • Would you like to manage your weight differently? If so, how? • What do you think contributes to your weight? • What sort of barriers do you think impede your weight loss efforts? • Are there any major stresses that will make it difficult to focus on weight control? • What does food mean to you? How do you use food (e.g., to relieve stress, provide comfort)? • Are other family members overweight? • How much time can you devote to exercise on a daily or weekly basis? • How has your health been affected by your body weight? • What type of support do you have from family and/or friends for losing weight?
