Obesity
Content
ABSTRACT Obesity is rapidly becoming one of the greatest health challenges of the 21st century (Yach, Stuckler et al. 2006). No disease is more common and causes more unnecessary illness or early death than obesity. Furthermore there is no other single problem that so reduces the quality of life or increases the demand for health care services. WHEN A PATIENT IS OBESE, simple dieting and exercise are rarely able to reverse significant comorbidities. Currently, surgery is the most effective treatment for obesity with respect to the amount and duration of weight loss. BARIATRIC SURGERY REQUIRES a team approach in a clinical setting capable of supporting all aspects of management and assessment. As Bariatric weight loss surgery is no small undertaking. It requires a lifelong commitment on the part of the patient
The Disease of Obesity Obesity is the second leading cause of preventable death in Australia, currently outranked only by smoking. However, this statement itself demonstrates the still incomplete appreciation of obesity as a disease entity, a concept that is still poorly understood. Obesity is a disease, and as such is in many respects not preventable (Brunicardi, Andersen et al. 2006). The components of this disease likely include a combination of environmental and genetic factors. The recent rapid rise in the incidence of obesity in less than a generation’s time suggests that genetic causes alone cannot be responsible for the disease. Nevertheless, the multifactoral contributions to the disease increase the difficulty in understanding its causes(DeLaet and Schauer 2010). Defining Obesity “Obesity is a disease in which fat has accumulated to the extent that health is impaired” (O'Brien and Dixon 2002). Thus, there are three key elements to the obesity definition.
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1. “Obesity is a disease” It is only recently that major health authorities such as the world health organisation have acknowledged obesity as a disease. This change is most important as it can allow it to claim the attention and allocation of resources as other diseases do. 2. “…in which fat has accumulated” Fat is the key element of obesity. Primarily it refers to how much fat there is in the body. 3. “.. to the extent that health is impaired” Obesity is a disease that causes disease. Measurement of Obesity The classification of overweight and obesity are defined by body mass index (BMI). Body Mass Index is a calculation based on a person’s height and weight (weight in kilograms divided by the square of the patient’s height in meters); it is Category Underweight Normal (Healthy weight) Overweight Mild Obesity Moderate Obesity Severe obesity Morbid Obesity Super Obesity BMI Below 18.5 18.5-24.99 25-26.99 27-30 Above 30 Above 35 Above 40 Above 50
considered the medical standard of measuring overweight and obesity. Although BMI cannot distinguish between muscle and body fat, this mathematical calculation generally is a good indicator of obesity and is closely associated with measures of body fat. It also predicts the development of health problems related to excess weight; however, if a person loses muscle mass such as in an older adult, the BMI measurement may indicate a weight is healthy when in fact it is not. In table 1 you can see weight categories by BMI. (DeLaet and Schauer 2010) Impact of Obesity
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Individuals with obesity are at higher risk of developing one or more serious medical conditions which can cause poor health and premature death (American Family physician 2002, p.81). The numerous health risks and medical comorbid conditions associated with or caused by obesity are documented in table 2. The effects of these conditions can be severe and, over time, can be life threatening for a person suffering obesity. However, the single most difficult aspect of the disease obesity is the discrimination the Table 2 Comorbid Conditions that often Accompany obesity Abdominal wall hernias Alveolar hypoventilation Arthritis Asthma Atherosclerosis Cerebral pseudotumor Cancer( in particular uterus, breast, colon, prostate, kidney) Cholelithiasis Deep Vein Thrombosis Depression Dysmenorrhoea Fatal cardiac arrhythmias Fatty liver Fungal skin infections Gastroesophageal reflux disease Hyperlipidemia Hypercholesterolemia Hypertension Infertility Lower back Pain Migraine headaches Obstructive sleep apnoea Right sided heart failure Stroke Type 2 Diabetes Venous stasis ulcers sufferer must face from the rest of the population in terms of social stigmatisation. This socially acceptable prejudice against obesity remains the last type of discrimination without legislative remedy. Severely obese individuals are thought of by much of the public as being lazy or gluttonous and lacking self-discipline. They often endure not only discrimination and prejudice, but also outright ridicule and disrespect which consequently has a major impact on their social and emotional wellbeing which in turn negatively impacts on their obesity. As a
microcosm of society, nurses also have been shown as having negative perceptions of
3
obese client’s. According to one survey, nurses self reported an agreement with the belief that obese patients (Schwartz, Chambliss et al. 2003) • • • • • Are unsuccessful (24%) Are overindulgent (43%) Solely personally responsible for their condition (90%) Are lazy (22%), and Experience unresolved anger (33 %)
In addition, 63% of nurses agreed with the statement that obesity can be prevented by self- control, 48% felt uncomfortable caring for an obese person, and 31 % would prefer not to care for an obese patient. This highlights that as with many social issues, society and nurses in particular must learn to separate a person from his or her condition, as these attitudes make it difficult to fight the disease and the related comorbid conditions that accompany obesity(Poon and Tarrant 2009). Economic impact Obesity costs the community a great deal, in view of the high healthcare needs of the obese (Yach, Stuckler, Brownell, 2006 p.62) These costs are both direct costs of investigating and treating obesity-related diseases such as GP visits, tests, medicines and hospitalisations and the indirect costs, such as the lose of wages due to illness or disability or the loss of future earnings because of premature death. In Australia, these costs were estimated at being $ 58 billion for 2008 (Diabetes Australia, 2006, p.11). In addition to this expenditure is the annual expenditure on weight loss products, weight loss programs and other services, which has been estimated at over 3 billion a year. Prognosis
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Obesity has a profound effect on overall health and thus, life expectancy. It is estimated that teenagers entering adult hood with BMI equal to or above 40 have a life expectancy reduced by 13 years for a male and 8 years for a female. To further highlight the prognosis it has been shown that a person with a BMI of 40 has three times the risk of dying compared to person with a healthy BMI(O'Brien and Dixon 2002). Treatment Options for Obesity Weight loss is the most powerful therapy for obesity available today. There is no other treatment that can make such a difference to so many health comorbidities. There is no other therapy which improves people’s quality of life so much. And, in particular there is no other therapy that so clearly protects people from dying prematurely. Medical (lifestyle) treatment for obesity is aimed at reducing body weight (adipose stores) through a combination of decreased kilojoules intake and accompanying increases in energy expenditure from moderate exercise. This method of weight loss is the safest possible, is able to be followed by anybody and the simplest to prescribe. However, these medical lifestyle attempts at weight loss have a high failure rate. Even if these approaches initially are successful, results from medical weight loss treatments are not durable, do not result in a decrease of weight-related health problems, and do not improve survival rates (Graling and Elariny 2003). Pharmacologic treatment is normally used only after lifestyle changes and dietary therapy has failed. It is used either alone as the primary therapy or in conjunction with simultaneous diet and exercise therapy. Currently there are only two drugs approved for the promotion of weight loss. Sibutramine (Reductil) which is a noradrenaline and 5hydroxytryptamine reuptake inhibitor that works as an appetite suppressant and Orlistat
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(Xenical) which inhibits gastric and pancreatic lipase enzymes that promotes lipid absorption in the intestine (Scheen and Ernest 2002). Both are able to help treat people who are overweight but neither has proven to be sufficiently powerful to be reliable for people with obesity. The long term efficacy is poor and the long term safety is unknown. A review of all the clinical trails of these drugs shows that the average weight loss after one year of Xenical is 3kg and for reductil is 4.5kg (Li, Maglione et al. 2005). For those with obesity, who must lose 23kg or more, these results are just not good enough to cure the disease. The third treatment is surgical intervention. The surgical treatment of obesity is called bariatric surgery after the Greek words, baros, meaning” weight”, and iatrical, meaning “ the art of healing”. Currently, surgery has been shown as been the most effective treatment for obesity with respect to the amount and duration of weight loss (Buchwald, Avidor et al. 2004) Research has shown that hypertension, hypercholesterolemia, diabetes, sleep apnoea and arthritis are all likely to improve, is not completely resolve after surgery induced weight loss . Thus, Bariatric surgery can help reverse comorbid illnesses as patients lose weight therefore increasing the person’s quality of life. Bariatric surgery promotes weight loss and thus cures obesity by providing a built in tool that causes a change in energy balance. The anatomy alterations performed effectively allow patients to regain control over food intake by restricting the quantity of food consumed or by interrupting the digestive process. These two surgical methods that classify procedure are described as restrictive or malabsorptive. In Australia, 90% Bariatric surgery is the restrictive procedure Laparoscopic adjustable gastric banding (O Brien, Brown et al.
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2005) so for more detail on this procedure please see “Get the skinny on Laparoscopic adjustable gastric banding” Appendix 1. Providing specialised nursing care for Bariatric surgery Most patients scheduled for bariatric surgery return to the surgical unit postoperatively. Nurses will provide the same care any surgical patient requires, including monitoring the airway, managing pain, providing nutritional support, caring for the wound and providing education and emotional support. But bariatric surgery and the patient’s obesity will also present some specialised challenges and considerations which nurses will need to deal with during there care for these patients. Below are some of the considerations:Psychosocial support A bariatric surgery patient s have often experienced years of weight bias (Devaluing of them as a person based on their excess weight). They often encounter challenging physical environments and sometimes have encountered negative attitudes from health professionals in the past when seeking help (Twedell, Lansing et al. 2009)p.438). One important aspect of care is the nurse patient relationship. Attention must be paid to verbal as well as non verbal communication. Active listening that incorporates eye contact and positive eye language communicates sensitivity and empathy to bariatric patients. Nurses must get to know these patients, engage them in conversation, and not pass judgement about them basis of their size and weight. Nurses must remember that the patient is acutely aware that their size makes it hard to care for them. They may also have low self esteem and believe that whatever care or attention they receive is more than they deserve (Twedell, Lansing et al. 2009).Patients may also believe that aren’t obese can’t possibly understand their problems. Remember that with
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mixed feelings of shame, embarrassment, hope and fear, a patient is embarking on a life altering journey, so nurses must be sensitive to their feelings as they provide care. Preoperative teaching It is important that patients are told what to expect after surgery. For example, it is important that patients be informed about the possibility of going to Intensive Care Unit post operation. Respiratory or cardiac insufficiency is the primary reason that weight loss surgery patients may be admitted to ICU. Patients should be also advised to expect an intravenous catheter, a urinary catheter, and the patient may also have a nasogastric tube and wound drain. The method of pain assessment and management should be explained. Besides incision pain, the patient may experience referred shoulder pain after laparoscopy from the carbon dioxide used during surgery. The nurse should reassure the patient that the pain will be managed postoperatively so the patient can comfortably perform breathing and coughing exercises and get out of bed within hours of surgery.(Graling and Elariny 2003) Environment Considerations Environment and equipment are important in providing sensitive patient centred care for bariatric patients. Proper environment includes adequate space to accommodate furniture and equipment that enhance the mobilisation, independence and safety of bariatric patients. When selecting equipment for bariatric patients, nurses need to take into account the weight capacity and physical dimensions of the equipment. Although patients may not exceed the weight limitation for a particular piece of equipment, it may be too narrow for them. Appropriately sized hospital clothing, such as gowns, robes, and instruments such as large blood pressure cuff are important. Appropriate equipment empowers
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patients to be more involved in their care, which leads to positive outcomes (Lansing, McGuire, Palmersheim, Baird, 2009, p.440) Skin and wound care. An obese patient is at particular risk for infection, skin breakdown and delayed wound healing (Wilson & Clark 2004 p.121). There is an increased risk in particular for pressure ulcers due to the difficulty or inability of obese patients to reposition there self in bed. Repositioning is a basic prevention intervention to reduce and relieve pressure from body tissue. Adipose tissue does not equate to padding in fact it is at high risk due to its decreased vascularity (Wilson and Clark 2004)). Moisture from perspiration and other body fluids are also risk factors in predisposing patients to pressure ulcers and infections as the skin folds on obese patients harbor microorganisms that thrive in moist areas and contribute to break down. Another possible cause of skin breakdown is the increased friction caused by the patient’s weight which can lead to shear injuries when moving in bed. To decrease this risk the nurse should ensure 2nd hourly repositioning, encouraging the obese patient that the bed will safely accommodate their size and the importance of repositioning. If the patient is unable to reposition themselves 2 or more staff should help the patient to repositioning through use of hoists or slide sheets ensuring dignity while doing this and ensuring patient doesn’t feel like a nuisance. The obese patient should have frequent skin care and daily bathing attention should be placed on cleaning in between skin folds in particular to cleaning under the panniculus (lower abdominal apron). These areas must be adequate dried to prevent infections and may require absorbent material such as combine placed between the folds to prevent rubbing and break down of skin (Rose and Drake 2008).
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Bowel elimination Pain relieving narcotics, immobility and decreased calorie intake (in particular fibre) can cause constipation in postoperative bariatric patients. As straining will cause intraabdominal pressure which will disrupt the wounds and cause dehiscence. Therefore, it is important that the patient be placed in stool softeners to prevent this problem. Diet and Nutrition After bariatric surgery, a patient can not take anything by mouth until they have had a gastografin upper gastrointestinal series and or a barium swallow x ray, to check the position of the band and to rule out anastomotic leaks (O’Brien, 2007 p.109). After the tests, rules out leaks and confirms correct position of the band, the patient can start drinking water, then clear liquids, then a full- liquid diet. The patient must abstain from all caffeine and carbonated drinks and consume only moderate amounts of sugar. The patient will be placed on nutritionally complete protein supplement such as optifast during this period. The patient’s new stomach will only hold 30ml at a time, so the patient should be encourage sipping small amounts of fluid frequently either using straw or the use of medicine cup. Surgeons differ in how quickly they advance a patient to a soft diet, but typically they are on a liquid diet for 1-2 weeks and pureed diet for next 1-2 weeks, than mushie diet for 1-2 weeks followed by 1 week soft food, than onto a normal diet. The normal life long diet should be high in protein and low in fat and carbohydrates. This normal diet will provide 800-1200 calories in 3-6 small meals (O’Brien, 2007 p.109). The patient should expect to have a depressed appetite and to feel full quickly. It is advised that patients at least for first year post op take a broad range multivitamin to
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ensure adequate vitamin and mineral intake. All bariatric surgery patients should have dietary (Song and Fernstrom 2008) Discharge Teaching At time of discharge, the patient should be given written material that includes the diet progression, appropriate food choices, information about vitamin and protein supplements, and the importance of hydration. Tips for dealing with changes in bowel habits should also be included(Ide, Farber et al. 2008). General discharge instructions related to medications 9 including whether or not to continue previous home medications), activity, wound care, signs and symptoms to report to your surgeon and follow up visits must be provided. After discharge from the hospital, patients will be followed up at regular intervals by the bariatric team. During following up visits, patients are examined by the specialist. They should also touch base with their psychologist to assess their adaption to the surgery and lifestyle change, The dietician should meet with them to discuss their ability to tolerate the diet and review food choices and nutrient intake. Follow p blood work is also required to monitor their response to the diet and weight loss. Patients are also encouraged to participate in a support group to discuss the various phases of weight loss and their individual concerns (Garza 2003, P.10). Bariatric weight loss surgery is no small undertaking. It requires lifelong commitment on the part of the patient. Education is the key to helping patients achieve optimal health and a better overall quality of life as a result of having undergone weight loss surgery.
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APPENDIX 1 Laparoscopic adjustable gastric banding (the Lap-Band System) Another way to restrict food intake is by surgically inserting an inflatable silicone band completely around the uppermost part of the stomach, giving it the shape of an hourglass. The result is a device designed to produce a small upper stomach pouch and a narrow opening from it into the lower stomach, inducing an early feeling of fullness and thereby decreasing food intake
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LAP-BAND gets its name from the abbreviated combination of 2 words, "lap" from laparoscopic and "band" from gastric band. The LAP-BAND System has been designed to be inserted laparoscopically and does not involve any cutting, stapling, or removing of any part of the stomach or intestines. In the band s lining there is an inflatable balloon that allows the size of the stoma to be regulated by its inflation (making the stoma smaller) or deflation (enlarging the diameter of the stoma). Stoma size will have a direct impact on how much food one can consume. The smaller the stoma diameter the more restricted the patient will become. This ability to adjust the stoma size is made possible by an access port. This part is located under the skin, just beneath the rib cage and attached to the band via a 50-cm kink resistant tube. Stoma adjustments are made through an outpatient procedure in which die self sealing access port's reservoir is pierced by a fine needle to add (inflate) or remove (deflate) saline solution. The LAP-BAND System has the potential to provide a less invasive and less painful approach to bariatric surgery.(Sinha 2008)
ADVANTAGES The least invasive bariatric surgery available Has the lowest mortality rate and lowest surgical complications of all the bariatric surgeries Performed laparoscopically Shorter Hospital stay, usually overnight Quicker recovery, usually 1 to 2 week No opening or removal of the stomach or DISADVANTAGES The initial weight loss is slower than with other bariatric procedures and weight loss is variable. Regular follow-up with the surgeon is critical for optimal results. Regular follow-up with the surgeon is critical for optimal results. This procedure requires implantation of a medical device. The effectiveness of the procedure can be reduced if band slippage occurs. The access port may leak, requiring minor
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intestines to cause a leak or subsequent infection Adjustable stoma size
surgery revision. Other possible complications include gastric prolapse, gastric occlusion and esophageal dilatation.
Completely reversible with normal stomach restoration Easy to deflate the band if opening becomes blocked
(Buchwald, Avidor et al. 2004; DeLaet and Schauer 2010)
http://www.merck.com/mmpe/sec01/ch006/ch006b.html
REFERENCES Brunicardi, F., D. Andersen, et al. (2006). Schwartz's manual of surgery, McGraw-Hill Professional.
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Buchwald, H., Y. Avidor, et al. (2004). "Bariatric surgery: a systematic review and metaanalysis." Jama 292(14): 1724. DeLaet, D. and D. Schauer (2010). "Obesity in adults." Graling, P. and H. Elariny (2003). "Perioperative care of the patient with morbid obesity." AORN 77(4): 801-819. Ide, P., E. Farber, et al. (2008). "Perioperative nursing care of the bariatric surgical patient." AORN 88(1): 30-58. Li, Z., M. Maglione, et al. (2005). "Meta-analysis: pharmacologic treatment of obesity." Annals of internal medicine 142(7): 532. O'Brien, P. and J. Dixon (2002). "The extent of the problem of obesity." American Journal of Surgery 184(6): 4. O Brien, P., W. Brown, et al. (2005). "Obesity, weight loss and bariatric surgery." Medical Journal of Australia 183(6): 310. Poon, M. and M. Tarrant (2009). "Obesity: attitudes of undergraduate student nurses and registered nurses." Journal of Clinical Nursing 18(16): 2355-2365. Rose, M. and D. Drake (2008). "Best practices for skin care of the morbidly obese." Bariatric Nursing and Surgical Patient Care 3(2): 129-134. Scheen, A. and P. Ernest (2002). "New antiobesity agents in type 2 diabetes: overview of clinical trials with sibutramine and orlistat." Diabetes & metabolism 28(6 Pt 1). Schwartz, M., H. Chambliss, et al. (2003). "Weight bias among health professionals specializing in obesity." Obesity 11(9): 1033-1039. Sinha, A. (2008). "Bariatric surgery." Merck manual. Song, A. and M. Fernstrom (2008). "Nutritional and psychological considerations after bariatric surgery." Aesthetic Surgery Journal 28(2): 195-199. Twedell, D., R. Lansing, et al. (2009). "Providing holistic care to bariatric patients." Journal of continuing education in nursing 40(10): 438. Wilson, J. and J. Clark (2004). "Obesity: impediment to postsurgical wound healing." Advances in Skin & Wound Care 17(8): 426. Yach, D., D. Stuckler, et al. (2006). "Epidemiologic and economic consequences of the global epidemics of obesity and diabetes." Nature medicine 12(1): 62-66.
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The Disease of Obesity Obesity is the second leading cause of preventable death in Australia, currently outranked only by smoking. However, this statement itself demonstrates the still incomplete appreciation of obesity as a disease entity, a concept that is still poorly understood. Obesity is a disease, and as such is in many respects not preventable (Brunicardi, Andersen et al. 2006). The components of this disease likely include a combination of environmental and genetic factors. The recent rapid rise in the incidence of obesity in less than a generation’s time suggests that genetic causes alone cannot be responsible for the disease. Nevertheless, the multifactoral contributions to the disease increase the difficulty in understanding its causes(DeLaet and Schauer 2010). Defining Obesity “Obesity is a disease in which fat has accumulated to the extent that health is impaired” (O'Brien and Dixon 2002). Thus, there are three key elements to the obesity definition.
1
1. “Obesity is a disease” It is only recently that major health authorities such as the world health organisation have acknowledged obesity as a disease. This change is most important as it can allow it to claim the attention and allocation of resources as other diseases do. 2. “…in which fat has accumulated” Fat is the key element of obesity. Primarily it refers to how much fat there is in the body. 3. “.. to the extent that health is impaired” Obesity is a disease that causes disease. Measurement of Obesity The classification of overweight and obesity are defined by body mass index (BMI). Body Mass Index is a calculation based on a person’s height and weight (weight in kilograms divided by the square of the patient’s height in meters); it is Category Underweight Normal (Healthy weight) Overweight Mild Obesity Moderate Obesity Severe obesity Morbid Obesity Super Obesity BMI Below 18.5 18.5-24.99 25-26.99 27-30 Above 30 Above 35 Above 40 Above 50
considered the medical standard of measuring overweight and obesity. Although BMI cannot distinguish between muscle and body fat, this mathematical calculation generally is a good indicator of obesity and is closely associated with measures of body fat. It also predicts the development of health problems related to excess weight; however, if a person loses muscle mass such as in an older adult, the BMI measurement may indicate a weight is healthy when in fact it is not. In table 1 you can see weight categories by BMI. (DeLaet and Schauer 2010) Impact of Obesity
2
Individuals with obesity are at higher risk of developing one or more serious medical conditions which can cause poor health and premature death (American Family physician 2002, p.81). The numerous health risks and medical comorbid conditions associated with or caused by obesity are documented in table 2. The effects of these conditions can be severe and, over time, can be life threatening for a person suffering obesity. However, the single most difficult aspect of the disease obesity is the discrimination the Table 2 Comorbid Conditions that often Accompany obesity Abdominal wall hernias Alveolar hypoventilation Arthritis Asthma Atherosclerosis Cerebral pseudotumor Cancer( in particular uterus, breast, colon, prostate, kidney) Cholelithiasis Deep Vein Thrombosis Depression Dysmenorrhoea Fatal cardiac arrhythmias Fatty liver Fungal skin infections Gastroesophageal reflux disease Hyperlipidemia Hypercholesterolemia Hypertension Infertility Lower back Pain Migraine headaches Obstructive sleep apnoea Right sided heart failure Stroke Type 2 Diabetes Venous stasis ulcers sufferer must face from the rest of the population in terms of social stigmatisation. This socially acceptable prejudice against obesity remains the last type of discrimination without legislative remedy. Severely obese individuals are thought of by much of the public as being lazy or gluttonous and lacking self-discipline. They often endure not only discrimination and prejudice, but also outright ridicule and disrespect which consequently has a major impact on their social and emotional wellbeing which in turn negatively impacts on their obesity. As a
microcosm of society, nurses also have been shown as having negative perceptions of
3
obese client’s. According to one survey, nurses self reported an agreement with the belief that obese patients (Schwartz, Chambliss et al. 2003) • • • • • Are unsuccessful (24%) Are overindulgent (43%) Solely personally responsible for their condition (90%) Are lazy (22%), and Experience unresolved anger (33 %)
In addition, 63% of nurses agreed with the statement that obesity can be prevented by self- control, 48% felt uncomfortable caring for an obese person, and 31 % would prefer not to care for an obese patient. This highlights that as with many social issues, society and nurses in particular must learn to separate a person from his or her condition, as these attitudes make it difficult to fight the disease and the related comorbid conditions that accompany obesity(Poon and Tarrant 2009). Economic impact Obesity costs the community a great deal, in view of the high healthcare needs of the obese (Yach, Stuckler, Brownell, 2006 p.62) These costs are both direct costs of investigating and treating obesity-related diseases such as GP visits, tests, medicines and hospitalisations and the indirect costs, such as the lose of wages due to illness or disability or the loss of future earnings because of premature death. In Australia, these costs were estimated at being $ 58 billion for 2008 (Diabetes Australia, 2006, p.11). In addition to this expenditure is the annual expenditure on weight loss products, weight loss programs and other services, which has been estimated at over 3 billion a year. Prognosis
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Obesity has a profound effect on overall health and thus, life expectancy. It is estimated that teenagers entering adult hood with BMI equal to or above 40 have a life expectancy reduced by 13 years for a male and 8 years for a female. To further highlight the prognosis it has been shown that a person with a BMI of 40 has three times the risk of dying compared to person with a healthy BMI(O'Brien and Dixon 2002). Treatment Options for Obesity Weight loss is the most powerful therapy for obesity available today. There is no other treatment that can make such a difference to so many health comorbidities. There is no other therapy which improves people’s quality of life so much. And, in particular there is no other therapy that so clearly protects people from dying prematurely. Medical (lifestyle) treatment for obesity is aimed at reducing body weight (adipose stores) through a combination of decreased kilojoules intake and accompanying increases in energy expenditure from moderate exercise. This method of weight loss is the safest possible, is able to be followed by anybody and the simplest to prescribe. However, these medical lifestyle attempts at weight loss have a high failure rate. Even if these approaches initially are successful, results from medical weight loss treatments are not durable, do not result in a decrease of weight-related health problems, and do not improve survival rates (Graling and Elariny 2003). Pharmacologic treatment is normally used only after lifestyle changes and dietary therapy has failed. It is used either alone as the primary therapy or in conjunction with simultaneous diet and exercise therapy. Currently there are only two drugs approved for the promotion of weight loss. Sibutramine (Reductil) which is a noradrenaline and 5hydroxytryptamine reuptake inhibitor that works as an appetite suppressant and Orlistat
5
(Xenical) which inhibits gastric and pancreatic lipase enzymes that promotes lipid absorption in the intestine (Scheen and Ernest 2002). Both are able to help treat people who are overweight but neither has proven to be sufficiently powerful to be reliable for people with obesity. The long term efficacy is poor and the long term safety is unknown. A review of all the clinical trails of these drugs shows that the average weight loss after one year of Xenical is 3kg and for reductil is 4.5kg (Li, Maglione et al. 2005). For those with obesity, who must lose 23kg or more, these results are just not good enough to cure the disease. The third treatment is surgical intervention. The surgical treatment of obesity is called bariatric surgery after the Greek words, baros, meaning” weight”, and iatrical, meaning “ the art of healing”. Currently, surgery has been shown as been the most effective treatment for obesity with respect to the amount and duration of weight loss (Buchwald, Avidor et al. 2004) Research has shown that hypertension, hypercholesterolemia, diabetes, sleep apnoea and arthritis are all likely to improve, is not completely resolve after surgery induced weight loss . Thus, Bariatric surgery can help reverse comorbid illnesses as patients lose weight therefore increasing the person’s quality of life. Bariatric surgery promotes weight loss and thus cures obesity by providing a built in tool that causes a change in energy balance. The anatomy alterations performed effectively allow patients to regain control over food intake by restricting the quantity of food consumed or by interrupting the digestive process. These two surgical methods that classify procedure are described as restrictive or malabsorptive. In Australia, 90% Bariatric surgery is the restrictive procedure Laparoscopic adjustable gastric banding (O Brien, Brown et al.
6
2005) so for more detail on this procedure please see “Get the skinny on Laparoscopic adjustable gastric banding” Appendix 1. Providing specialised nursing care for Bariatric surgery Most patients scheduled for bariatric surgery return to the surgical unit postoperatively. Nurses will provide the same care any surgical patient requires, including monitoring the airway, managing pain, providing nutritional support, caring for the wound and providing education and emotional support. But bariatric surgery and the patient’s obesity will also present some specialised challenges and considerations which nurses will need to deal with during there care for these patients. Below are some of the considerations:Psychosocial support A bariatric surgery patient s have often experienced years of weight bias (Devaluing of them as a person based on their excess weight). They often encounter challenging physical environments and sometimes have encountered negative attitudes from health professionals in the past when seeking help (Twedell, Lansing et al. 2009)p.438). One important aspect of care is the nurse patient relationship. Attention must be paid to verbal as well as non verbal communication. Active listening that incorporates eye contact and positive eye language communicates sensitivity and empathy to bariatric patients. Nurses must get to know these patients, engage them in conversation, and not pass judgement about them basis of their size and weight. Nurses must remember that the patient is acutely aware that their size makes it hard to care for them. They may also have low self esteem and believe that whatever care or attention they receive is more than they deserve (Twedell, Lansing et al. 2009).Patients may also believe that aren’t obese can’t possibly understand their problems. Remember that with
7
mixed feelings of shame, embarrassment, hope and fear, a patient is embarking on a life altering journey, so nurses must be sensitive to their feelings as they provide care. Preoperative teaching It is important that patients are told what to expect after surgery. For example, it is important that patients be informed about the possibility of going to Intensive Care Unit post operation. Respiratory or cardiac insufficiency is the primary reason that weight loss surgery patients may be admitted to ICU. Patients should be also advised to expect an intravenous catheter, a urinary catheter, and the patient may also have a nasogastric tube and wound drain. The method of pain assessment and management should be explained. Besides incision pain, the patient may experience referred shoulder pain after laparoscopy from the carbon dioxide used during surgery. The nurse should reassure the patient that the pain will be managed postoperatively so the patient can comfortably perform breathing and coughing exercises and get out of bed within hours of surgery.(Graling and Elariny 2003) Environment Considerations Environment and equipment are important in providing sensitive patient centred care for bariatric patients. Proper environment includes adequate space to accommodate furniture and equipment that enhance the mobilisation, independence and safety of bariatric patients. When selecting equipment for bariatric patients, nurses need to take into account the weight capacity and physical dimensions of the equipment. Although patients may not exceed the weight limitation for a particular piece of equipment, it may be too narrow for them. Appropriately sized hospital clothing, such as gowns, robes, and instruments such as large blood pressure cuff are important. Appropriate equipment empowers
8
patients to be more involved in their care, which leads to positive outcomes (Lansing, McGuire, Palmersheim, Baird, 2009, p.440) Skin and wound care. An obese patient is at particular risk for infection, skin breakdown and delayed wound healing (Wilson & Clark 2004 p.121). There is an increased risk in particular for pressure ulcers due to the difficulty or inability of obese patients to reposition there self in bed. Repositioning is a basic prevention intervention to reduce and relieve pressure from body tissue. Adipose tissue does not equate to padding in fact it is at high risk due to its decreased vascularity (Wilson and Clark 2004)). Moisture from perspiration and other body fluids are also risk factors in predisposing patients to pressure ulcers and infections as the skin folds on obese patients harbor microorganisms that thrive in moist areas and contribute to break down. Another possible cause of skin breakdown is the increased friction caused by the patient’s weight which can lead to shear injuries when moving in bed. To decrease this risk the nurse should ensure 2nd hourly repositioning, encouraging the obese patient that the bed will safely accommodate their size and the importance of repositioning. If the patient is unable to reposition themselves 2 or more staff should help the patient to repositioning through use of hoists or slide sheets ensuring dignity while doing this and ensuring patient doesn’t feel like a nuisance. The obese patient should have frequent skin care and daily bathing attention should be placed on cleaning in between skin folds in particular to cleaning under the panniculus (lower abdominal apron). These areas must be adequate dried to prevent infections and may require absorbent material such as combine placed between the folds to prevent rubbing and break down of skin (Rose and Drake 2008).
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Bowel elimination Pain relieving narcotics, immobility and decreased calorie intake (in particular fibre) can cause constipation in postoperative bariatric patients. As straining will cause intraabdominal pressure which will disrupt the wounds and cause dehiscence. Therefore, it is important that the patient be placed in stool softeners to prevent this problem. Diet and Nutrition After bariatric surgery, a patient can not take anything by mouth until they have had a gastografin upper gastrointestinal series and or a barium swallow x ray, to check the position of the band and to rule out anastomotic leaks (O’Brien, 2007 p.109). After the tests, rules out leaks and confirms correct position of the band, the patient can start drinking water, then clear liquids, then a full- liquid diet. The patient must abstain from all caffeine and carbonated drinks and consume only moderate amounts of sugar. The patient will be placed on nutritionally complete protein supplement such as optifast during this period. The patient’s new stomach will only hold 30ml at a time, so the patient should be encourage sipping small amounts of fluid frequently either using straw or the use of medicine cup. Surgeons differ in how quickly they advance a patient to a soft diet, but typically they are on a liquid diet for 1-2 weeks and pureed diet for next 1-2 weeks, than mushie diet for 1-2 weeks followed by 1 week soft food, than onto a normal diet. The normal life long diet should be high in protein and low in fat and carbohydrates. This normal diet will provide 800-1200 calories in 3-6 small meals (O’Brien, 2007 p.109). The patient should expect to have a depressed appetite and to feel full quickly. It is advised that patients at least for first year post op take a broad range multivitamin to
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ensure adequate vitamin and mineral intake. All bariatric surgery patients should have dietary (Song and Fernstrom 2008) Discharge Teaching At time of discharge, the patient should be given written material that includes the diet progression, appropriate food choices, information about vitamin and protein supplements, and the importance of hydration. Tips for dealing with changes in bowel habits should also be included(Ide, Farber et al. 2008). General discharge instructions related to medications 9 including whether or not to continue previous home medications), activity, wound care, signs and symptoms to report to your surgeon and follow up visits must be provided. After discharge from the hospital, patients will be followed up at regular intervals by the bariatric team. During following up visits, patients are examined by the specialist. They should also touch base with their psychologist to assess their adaption to the surgery and lifestyle change, The dietician should meet with them to discuss their ability to tolerate the diet and review food choices and nutrient intake. Follow p blood work is also required to monitor their response to the diet and weight loss. Patients are also encouraged to participate in a support group to discuss the various phases of weight loss and their individual concerns (Garza 2003, P.10). Bariatric weight loss surgery is no small undertaking. It requires lifelong commitment on the part of the patient. Education is the key to helping patients achieve optimal health and a better overall quality of life as a result of having undergone weight loss surgery.
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APPENDIX 1 Laparoscopic adjustable gastric banding (the Lap-Band System) Another way to restrict food intake is by surgically inserting an inflatable silicone band completely around the uppermost part of the stomach, giving it the shape of an hourglass. The result is a device designed to produce a small upper stomach pouch and a narrow opening from it into the lower stomach, inducing an early feeling of fullness and thereby decreasing food intake
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LAP-BAND gets its name from the abbreviated combination of 2 words, "lap" from laparoscopic and "band" from gastric band. The LAP-BAND System has been designed to be inserted laparoscopically and does not involve any cutting, stapling, or removing of any part of the stomach or intestines. In the band s lining there is an inflatable balloon that allows the size of the stoma to be regulated by its inflation (making the stoma smaller) or deflation (enlarging the diameter of the stoma). Stoma size will have a direct impact on how much food one can consume. The smaller the stoma diameter the more restricted the patient will become. This ability to adjust the stoma size is made possible by an access port. This part is located under the skin, just beneath the rib cage and attached to the band via a 50-cm kink resistant tube. Stoma adjustments are made through an outpatient procedure in which die self sealing access port's reservoir is pierced by a fine needle to add (inflate) or remove (deflate) saline solution. The LAP-BAND System has the potential to provide a less invasive and less painful approach to bariatric surgery.(Sinha 2008)
ADVANTAGES The least invasive bariatric surgery available Has the lowest mortality rate and lowest surgical complications of all the bariatric surgeries Performed laparoscopically Shorter Hospital stay, usually overnight Quicker recovery, usually 1 to 2 week No opening or removal of the stomach or DISADVANTAGES The initial weight loss is slower than with other bariatric procedures and weight loss is variable. Regular follow-up with the surgeon is critical for optimal results. Regular follow-up with the surgeon is critical for optimal results. This procedure requires implantation of a medical device. The effectiveness of the procedure can be reduced if band slippage occurs. The access port may leak, requiring minor
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intestines to cause a leak or subsequent infection Adjustable stoma size
surgery revision. Other possible complications include gastric prolapse, gastric occlusion and esophageal dilatation.
Completely reversible with normal stomach restoration Easy to deflate the band if opening becomes blocked
(Buchwald, Avidor et al. 2004; DeLaet and Schauer 2010)
http://www.merck.com/mmpe/sec01/ch006/ch006b.html
REFERENCES Brunicardi, F., D. Andersen, et al. (2006). Schwartz's manual of surgery, McGraw-Hill Professional.
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Buchwald, H., Y. Avidor, et al. (2004). "Bariatric surgery: a systematic review and metaanalysis." Jama 292(14): 1724. DeLaet, D. and D. Schauer (2010). "Obesity in adults." Graling, P. and H. Elariny (2003). "Perioperative care of the patient with morbid obesity." AORN 77(4): 801-819. Ide, P., E. Farber, et al. (2008). "Perioperative nursing care of the bariatric surgical patient." AORN 88(1): 30-58. Li, Z., M. Maglione, et al. (2005). "Meta-analysis: pharmacologic treatment of obesity." Annals of internal medicine 142(7): 532. O'Brien, P. and J. Dixon (2002). "The extent of the problem of obesity." American Journal of Surgery 184(6): 4. O Brien, P., W. Brown, et al. (2005). "Obesity, weight loss and bariatric surgery." Medical Journal of Australia 183(6): 310. Poon, M. and M. Tarrant (2009). "Obesity: attitudes of undergraduate student nurses and registered nurses." Journal of Clinical Nursing 18(16): 2355-2365. Rose, M. and D. Drake (2008). "Best practices for skin care of the morbidly obese." Bariatric Nursing and Surgical Patient Care 3(2): 129-134. Scheen, A. and P. Ernest (2002). "New antiobesity agents in type 2 diabetes: overview of clinical trials with sibutramine and orlistat." Diabetes & metabolism 28(6 Pt 1). Schwartz, M., H. Chambliss, et al. (2003). "Weight bias among health professionals specializing in obesity." Obesity 11(9): 1033-1039. Sinha, A. (2008). "Bariatric surgery." Merck manual. Song, A. and M. Fernstrom (2008). "Nutritional and psychological considerations after bariatric surgery." Aesthetic Surgery Journal 28(2): 195-199. Twedell, D., R. Lansing, et al. (2009). "Providing holistic care to bariatric patients." Journal of continuing education in nursing 40(10): 438. Wilson, J. and J. Clark (2004). "Obesity: impediment to postsurgical wound healing." Advances in Skin & Wound Care 17(8): 426. Yach, D., D. Stuckler, et al. (2006). "Epidemiologic and economic consequences of the global epidemics of obesity and diabetes." Nature medicine 12(1): 62-66.
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