Provided Courtesy of Nutrition411.com
Where Health Care Professionals
Go for Information
Bariatrics: A Growing
Medical Care Dilemma
G-1827
Review Date 8/12
What Is Bariatrics?
• “Bari” is Greek for weight
• The treatment of obesity—a medical disease
• Bariatric medicine treats obesity and related conditions
• “The art and science of medical weight management”
Definitions
• Overweight refers to an excess of body weight
compared to set standards
• Obesity refers to having a high proportion of body
fat to lean tissue
Staggering Stats
• >78 million American adults are obese
(body mass index [BMI] >30):
– 35.7% of adults in the United States are obese
• Increases have occurred across virtually all age,
ethnic, racial, and socioeconomic groups
Source: Centers for Disease Control and Prevention. Overweight and obesity. Available at:
http://www.cdc.gov/obesity/data/adult.html. Accessed August 12, 2012.
Prevalence of Overweight and
Obesity in Various Populations
• Non-Hispanic black women: 49.6%
• Hispanic women: 43%
• Non-Hispanic white women: 33%
• Non-Hispanic black men: 37.3%
• Hispanic men: 34.3%
• Non-Hispanic white men: 31.9%
Source: NIDDK. Overweight and obesity statistics. Available at: http://win.niddk.nih.gov/statistics/. Accessed
August 12, 2012.
Economic Costs
• $147 billion to health
care system
• People who are obese
pay 42% more in health
care costs
• Direct cost:
– Health care costs
• Indirect cost:
– Lost wages and future
earnings
Sources:
Centers for Disease Control and Prevention. Overweight and obesity. Available at: http://www.cdc.gov/obesity/adult/causes/. Accessed August
12, 2012.
Weight Control Information Network. Overweight and obesity statistics. Available at: http://win.niddk.nih.gov/statistics/. Accessed August 12,
2012.
How Is Obesity
Measured?
• BMI is used to measure both overweight and obesity in
adults
• Calculated by either equation:
weight (kg)/height squared (m2)
or
[(weight (lb) x 704.5) ÷ height (in)] ÷ height (in)
in=inch, kg=kilogram, m=meter, lb=pound
BMI Nomogram
Factors Contributing
to Obesity
• Genetics/ inheritance
• Psychological problems/depression
• Medical/hypothyroidism, Cushing’s disease
• Cultural/environmental factors
• Sedentary lifestyle
• Excessive calorie intake
Overweight and
Obesity
• Known risk factors for:
Diabetes
Heart disease
Stroke
Hypertension
Gallbladder disease
Osteoarthritis
Sleep apnea
Some forms of cancer (uterine, breast, colorectal, kidney, and
gallbladder)
– Syndrome X (cluster of ailments, including insulin resistance)
–
–
–
–
–
–
–
–
Typical Medical
History
• Diabetes mellitusdiabetes and obesity are called the
“twin epidemics”
• Hypertension
• Atherosclerosis
• Osteoarthritis
• Exercise/activity intolerance:
– Exercise-induced asthma
• Malnutrition
• Psychological factors:
– Depression
– Social isolation
• Complications with surgery and pregnancy
Functional Challenges
• Ambulation
• Transfers
• Wheeled mobility
• Toileting/bathing
• Personal hygiene
• Wound care
Multidisciplinary
Team Effort
• Client/family education by:
–
–
–
–
–
–
–
–
Physician
Dietitian
Nursing
Physical therapy
Occupational therapy
Psychologists
Pharm-D
Equipment suppliers
Client Education
• Nutritional therapy
• Surgical interventions
• Lifestyle
• Psychosocial implications
• Support mechanisms
• Equipment usage
Nutritional
Intervention
• Consult with a registered dietitian
• Determine habits:
– Diet journal to list food types and quantity
• Lifestyle changes
• Planning:
– Events
– Meal preparation
• Socioeconomic factors
Nonoperative
Treatments
• Changes in eating patterns
• Increase in physical activity
• Pharmacologic interventions
Surgical Treatment
Goals
• Bariatric surgery reduces the size of the gastric reservoir
• May include some degree of malabsorption
• Involves long-term changes in eating behavior
• Must follow guidelines to prevent postsurgical
complications
Patient Selection
• Morbidly obese:
– BMI >40 or BMI >35 with two comorbidities
• Well informed
• Motivated
• Acceptable of operative risks
Source: Mayo Clinic.com Gastric bypass surgery. Available at: http://www.mayoclinic.com/health/gastricbypass/MY00825/METHOD=print&DSECTION=all. Accessed August 12, 2012.
Medical
Complications
• Death (rare)
• Excessive bleeding
• Infection
• Blood clots
• Lung or breathing problems
• Pulmonary embolism
• Leaks in gastrointestinal system
MayoClinic.com. Gastric bypass surgery. Available at: http://www.mayoclinic.com/health/gastricbypass/MY00825/METHOD=print&DSECTION=all. Accessed August 13, 2012.
Types of Surgical
Procedures
• Laparoscopic gastric banding
• Vertical banded gastroplasty
• Roux-en-Y gastric bypass
• Biliopancreatic diversion with or without duodenal switch
• Sleeve gastrectomy
MayoClinic.com. Gastric bypass surgery. Available at: http://www.mayoclinic.com/health/gastricbypass/MY00825/METHOD=print&DSECTION=all. Accessed 13, 2012.
Laparoscopic Gastric
Banding
• Has adjustable band
placed around upper
stomach
• Creates pouch with
narrowed outlet
• Can adjust outlet to
restrict more or allow less
food
• May need to adjust band
periodically
Laparoscopic Gastric
Banding (cont’d)
• Advantages:
–
–
–
–
No cutting or stapling
Adjustable via saline reservoir
Normal stomach anatomy is maintained
Completely reversible
• Disadvantages:
– Does not restrict sweet liquid intake
– Pouch slippage
– Mechanical problems
Roux-en-Y Gastric
Bypass (RNYGB)
• Most common procedure
• Combines a gastric
restrictive procedure with
slow gastric emptying
• Results in decreased food
absorption
• Is not reversible
Roux-en-Y Gastric
Bypass (cont’d)
• Decreases excess weight by 50%–75%
• Mortality rate of 0.5% and morbidity rate of 5%–10%
• In most cases, this procedure will reduce weight from
life-threatening levels
Vertical Banded
Gastroplasty (VBG)
• Purely restrictive, with no
malabsorptive effect
• Results in pouch in upper
stomach, with mesh band
to prevent stretching
Vertical Banded
Gastroplasty (VBG) (cont’d)
• Disadvantages:
–
–
–
–
–
Less weight loss than RNYGB
Intake of high-calorie sweet liquids not restricted
Pouch can stretch over time
20% do not lose weight
Only one half of people lose at least 50% of excess weight
Sleeve Gastrectomy
• First part of the biliopancreatic diversion with duodenal
switch
• In some cases, this is all that is needed to lose weight
• Structure of stomach is changed to a tube shape,
restricting the calories your body absorbs
In the Operating
Room (OR)
• Access
• OR table
• Size of instruments
• Positioning
• Visualization of tissue
• Anesthesia risks
• Surgical procedures take
longer
Skin Issues
• Pressure
• Shear
• Friction
• Moisture
• Heat
Skin Issues (cont’d)
• External pressure/ischemia
• Internal pressure/edema
• Moisture/maceration
• Microclimate challenges:
– Staphylococcus
– Streptococcus
– Candida albicans
• Acanthosis nigricans:
– Darkening of skin under folds
• Ulcerations in unique
locations
• Skin tears under folds
Topical “Know-How”
• Creams absorb faster than powders
• Not for long-term use:
– Use ostomy powders
• Barrier ointments are good choice
• Antifungal treatments:
– Baza® Cream (Coloplast)
– Aloe Vesta® 2-n-1 Ointment (ConvaTec)
– Triple Care ® (Smith & Nephew)
Managing the
Microclimate
• Cleansing and drying:
– Absorption of excess moisture
– Dressings and skin barriers
• Daily inspection of bed
• Decrease friction/shear
• Support surface selection:
–True low-air loss
–Rotation if necessary
–Trendelenburg with boost
Room Environment
• Bed frame and mattress
• Lift systems
• Stand assist systems
• Wheelchairsposition
• Toilet/shower aids
• Walkers
• Recliners
Bed Guidelines
• Bed/mattress widths from
39″–60”
• Most beds and mattresses
have 600- to 1000-lb limits
• Built-in scales
• For clients >6’5”, obtain
bed/mattress of 86” or
greater
Appropriate Equipment
Utilization
• Support surfaces:
– Weight capacity/bed scales
– Increased surface area
– Dissipation of excess
moisture/heat
– Adequate structural support
– Products without weight limits
Appropriate Equipment
Utilization (cont’d)
• Transfer devices:
–
–
–
–
Mechanical/electric lifts
HoverMatts
Coated turn-sheets
Barton transfer chairs
Appropriate Equipment
Utilization (cont’d)
• Wheeled mobility:
– Fit the chair to the client
– Pressure-relieving cushion
– Elevating leg rests
Appropriate Equipment
Utilization (cont’d)
• Ancillary products:
–
–
–
–
–
Shower/commodes
Walkers
Lift chairs
Transport chairs
Transfer benches
Safety Issues
• Proper equipment
• Emergency procedures
• Staffing levels
• Training:
– Body mechanics
Tying It All Together
• Obesity kills
• Obesity results in increased medical care costs
• Success requires a team effort
• Safety is crucial for clients and caregivers
• Pressure management is paramount
Resource Guide
• American Society for Metabolic and Bariatric Surgery:
http://asmbs.org/
• Council on Size and Weight Discrimination: www.cswd.org
• National Association to Advance Fat Acceptance:
www.naafa.org
• The Obesity Association: www.obesity.org
• The ROHO Group: www.therohogroup.com