NCLEX: Obesity

Obesity: A look at obesity

The prevalence of obesity in the United States has increased markedly over the past two decades. According to the Centers for Disease Control and Prevention (CDC), approximately one-third of American adults age 20 and older are either overweight or obese. The trend toward obesity has been steadily increasing. Children haven’t escaped the trend, with 17% of 2 to 5 year olds 19% of 6 to 11 year olds, and 18% of 12 to 19 year olds overweight.


Taking an awfully big risk

Excess weight substantially increases the risk of diabetes, cardiovascular disease, certain types of cancer, and other diseases, including:
• gynecologic abnormalities
• osteoarthritis
• gallbladder disease
• stress incontinence.
The risk of death from all causes in obese people is 50% to 100% greater than in people of normal weight. In addition, the annual health care cost of obesity is estimated to exceed $140 billion per year.

A morbid thought

In addition to the risk of morbidity from obesity-related diseases, obesity can increase the morbidity of other preexisting disorders. Obese patients with existing coronary artery disease (CAD), type 2 diabetes, stroke, and sleep apnea are at high risk for developing disease-related complications that can lead to death.

And if that isn’t disturbing enough

Obesity is also associated with complications during surgery, pregnancy, and labor and delivery. A major contributor to preventable deaths, obesity also leads to low self-esteem, negative self-image, hopelessness, and negative social consequences, such as stereotyping, prejudice, social isolation, and discrimination.

Obesity: Causes

The basic cause of obesity is an energy imbalance that results when the number of calories taken in exceeds the number of calories used for energy. A recurring imbalance leads to weight gain over time. This imbalance most commonly results from overeating, inactivity, or both.

Obesity: Risk factors

You may notice that some people who are overweight eat only moderate amounts of food but still gain weight and that some average-weight people overeat but never gain weight. That’s because other factors can also influence fat accumulation in the body.

Inheriting grandma’s hips…

A family history of obesity increases a person’s chance of becoming obese by 25% to 30%. In addition, body fat distribution is influenced by genetics. Families also share diet and lifestyle habits that can contribute to obesity.

…and her remote control

Environment also strongly influences obesity. This includes such lifestyle behaviors as eating habits, diet, and level of physical activity. Americans tend to eat high-fat foods and put taste and convenience ahead of nutrition. Only 22% of Americans achieve the recommended 30 minutes of physical activity each day.

Calorie conundrum

Nutrition also plays an important role in weight gain. Although the type of food makes a difference, consuming too many calories in any form leads to weight gain. High-fat foods are known to be high in calories, but eating too much of low-fat foods can lead to over consumption, too.

Eating under the influence

Psychological factors can also influence eating habits. Many people eat in response to positive emotions, such as excitement, or to negative emotions, such as boredom, sadness, and anger.

It can get rather complicated

Some illnesses can lead to obesity or a tendency to gain weight. Examples include hypothyroidism, Cushing’s syndrome, depression, and certain neurological problems that can lead to overeating. Also, such drugs as steroids, antipsychotics, and some antidepressants can cause weight gain. A practitioner can tell whether underlying medical conditions are causing weight gain or making weight loss difficult.

A few more factors

Sociocultural factors, such as race, gender, income, education, and ethnicity, may also contribute to obesity. For example, males older than age 45 and females who are postmenopausal are at greater risk.

Obesity: Evaluating weight

The CDC has developed definitions for what constitutes being overweight and obese. According to the definitions, an adult who has a body mass index (BMI) of between 25 and 29.9 is considered overweight; an adult with a BMI of 30 or higher is considered obese.
A person’s BMI usually correlates with the amount of body fat he has. Other methods besides BMI of estimating body fat include waist circumstance and skin fold thickness measurements. Once a patient’s body fat has been determined, his risk factors for diseases and other conditions can be evaluated.

Obesity: BMI

BMI is a measurement of weight in relationship to height. It can be calculated using conventional pounds and inches or the metric system (using kilograms and centimeters). BMI can also be estimated without doing any calculations.

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A little or a lot o’ weight

Officially, a person with a BMI of 25 to 29.9 is considered overweight, whereas someone with a BMI of 30 or above is considered obese. Obesity may be further categorized as follows:
• Class I—BMI of 30 to 34.9
• Class II—BMI of 35 to 39.9
• Class III—BMI of 40 or more.

Tipping the scales

Keep in mind that the relationship between body weight and good health is more complicated than simply comparing the number on the scale to a weight range table. In fact, weight range tables aren’t appropriate to use with all individuals because not everyone whose weight falls within the “healthy” range is necessarily at a healthy weight. For example, one patient might have more fat and less muscle than what’s considered healthy, and another person might have more muscle than fat yet may be fine.

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Obesity: Waist circumference

Where a person’s fat is deposited on the body (weight distribution) may be a more important indicator of health problems than how much fat he actually has. People with a high distribution of fat around their waists (apple-shaped) as opposed to their hips and thighs (pear-shaped) are at greater risk for such diseases as type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease.

Middle measure

To evaluate weight distribution, measure waist circumference. Locate the upper hip bone and the top of the iliac crest. Place a measuring tape in a horizontal place around the abdomen at the level of the iliac crest. Before reading the tape measure, ensure that the tape is snug, but doesn’t compress the skin, and is parallel to the floor. Measure at the end of expiration. If the measurement is greater than 35 (89 cm) for women or 40 (102 cm) for men with a normal BMI, your patient has a greater risk of health problems. If the BMI is 35 or higher, waist measurement is irrelevant because disease risk is already high based on the BMI alone.

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Obesity: Risk factors

Determining how many health risk factors your patient has will further help you assess his need for weight control. The more risk factors present, the more your patient will benefit from weight loss.

Questions, questions

Ask your patient the following questions to assess his risk factors for obesity:
• Do you smoke? If so, how many packs per day?
• How much exercise do you get each day? Do you have a sedentary lifestyle or job?
• What is your age?
• Are you postmenopausal (for women)?
• Do you have a personal or family history of heart disease?
• Do you have diabetes or an impaired fasting glucose level?
• Do you have high blood pressure or have risk factors for high blood pressure?
• Do you have high low-density lipoprotein (LDL) cholesterol levels or low high-density lipoprotein (HDL) cholesterol levels?
• Are your triglyceride levels elevated?

Obesity: Complications

Obese patients are more susceptible to certain complications than nonobese patients. The most common complications involve the pulmonary, cardiovascular, GI, and musculoskeletal systems.

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Obesity: Treatment

Treatment of obesity can be long and difficult. No single treatment method or combination of methods is guaranteed to produce weight loss or maintain weight loss in all people. Treatment can be directed using guidelines from the National Heart, Lung and Blood Institute.

Obesity: Diet therapy

Diet, or nutrition, therapy includes instructing patients how to modify their diets to decrease calorie intake.

Calorie culprits

A key element of the current recommendation is a moderated reduction in calories to achieve a slow, progressive weight loss of 1 to 2 lb (0.5 to 1 kg) per week. Calories should be reduced only to the level required to achieve the goal weight.

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Mindful menus

Successful weight reduction is more likely to occur when the patient’s food preferences are included in the menu and when dietary education is performed.

Dietary tips of beef

When educating your patient, be sure to:
• cover the energy value of different foods and discuss food components, such as fats, carbohydrates (including dietary fiber), and proteins
• encourage the patient to read nutrition labels
• promote new habits of purchasing, especially low-calorie foods
• instruct on food preparation, especially the need to avoid adding high-calorie ingredients (such as fats and oils) during cooking
• warn against the over consumption of high-calorie foods
• stress the importance of adequate water intake, reducing portion sizes, and limiting alcohol consumption.

Obesity: Increased physical activity

Exercise plays a critical role in the loss and maintenance of body weight. Exercise is important for increasing energy expenditure, maintaining or increasing lean body mass, and promoting fat loss. These changes in body composition result in improved body dimensions and, possibly, an increased metabolic rate.

First, talk the talk…

Patients with medical problems, however, commonly have difficulty exercising. Any patient who wishes to start an exercise routine should first discuss it with their practitioner and get approval to start exercising.

…then walk the walk

Daily walking is an attractive form of physical exercise, especially for the obese patient. Advise your patient to begin by walking 10 minutes 3 days per week, and then build up to 30 to45 minutes of more intense walking at least 5 to 7 days per week. With this regimen, an additional 100 to 200 calories/day can be expended. A moderate amount of physical activity that burns about 250 calories can be achieved in various ways.

Every little bit helps

Reducing sedentary time, such as time spent watching television, is another way to increase activity. Patients should build physical activities into each day. For example, parking farther than usual from work or shopping and walking up stairs instead of taking elevators are easy ways to increase daily physical activity.

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Obesity: Behavior therapy

Behavior therapy is a useful adjunct to planned decreases in food intake and increases in physical activity. The goal of behavior therapy is to overcome barriers to compliance with eating and activity habits.

Changing for the long haul

The primary assumptions of behavior therapy are listed below. (Remember, long-term weight reduction most likely won’t succeed unless new habits are acquired.)

• Changing eating and physical activity habits makes it possible to change body weight.
• Eating and physical activity behaviors are learned and can be modified.
• Environment must be changed to change patterns.

Strategies for success
Various strategies must be used for behavior modification because no single method is superior.

Monitor thyself

• Self-monitoring of eating and physical activity—This strategy involves recording the amount, type, caloric value, and nutrient composition of food eaten and the frequency, intensity, and type of physical activity performed each day. Recording this information allows the patient to gain insight into his behavior.

Cool, calm, and collected

• Stress management—Stress triggers dysfunctional eating habits. Using coping strategies, meditation, relaxation techniques, and exercise can help relieve stress.

Keep the safety on the trigger

• Stimulus control—This strategy involves identifying triggers—stimuli that encourage incidental eating—and taking the necessary steps to limit them; for example, by keeping high-calorie foods out of the house, limiting times and places of eating, and avoiding situations in which overeating occurs.

Alternatives, please

• Problem solving—This includes identifying weight-related problems and planning and implementing alternative behaviors.

Now that’s rewarding!

• Contingency management—Rewarding positive changes in behavior, such as increasing exercise or reducing consumption of a specific food, can be an effective strategy.

A mental pat on the back

• Cognitive restructuring—This strategy involves changing self-defeating thoughts and feelings by replacing them with positive thoughts and setting reasonable goals.

With a little help from friends

• Social support—A strong support system can help provide the emotional support needed to lose weight. Including friends and family in physical activity and diet or joining a support group can be beneficial.

Obesity: Pharmacotherapy

Drug therapy should be considered if, after 6 months of diet therapy and increased activity, the patient hasn’t lost the recommended1 lb (0.5 kg) per week.

Don’t be so modest

Drugs produce a modest weight loss of 4.4 to 22 lb (2 to 10 kg) within the first 6 months and can help maintain the weight loss. However, most studies show a rapid weight gain after the drugs are stopped. When drug therapy is effective and adverse effects are manageable, therapy can be continued long-term; however, no one knows how long drug therapy can safely be maintained.

When the risks are high

Because few long-term studies have been conducted on the safety and effectiveness of weight loss medication, such drugs should be used only by patients who are at an increased medical risk because of their weight. These patients include those with a BMI of 30 or more and those with one of the following disorders:
• hypertension
• dyslipidemia
• CAD
• type 2 diabetes
• sleep apnea.

Weighing the odds of success

Not every patient responds to drug therapy. Tests show that initial responders tend to continue to respond, while nonresponders are less likely to respond even with increases in dosage. Drug therapy should be discontinued if adverse effects are unmanageable or if therapy is ineffective. The decision to add a drug to an obesity treatment program should be made after consideration of all potential risks and benefits and only after all behavioral options have been used.

Altering absorption

If the patient is a good candidate for drug therapy, the practitioner may prescribe or recommend orlistat (Xenical by prescription and Alli over the counter). This drug works peripherally to inhibit pancreatic lipase and, therefore, decreases fat absorption in the GI tract. It should be used in conjunction with a reduced-calorie diet with 30% of calories from fat. Adverse reactions include headache, flatus with discharge, fecal urgency, fatty or oily stool, pancreatitis, and abdominal pain. Absorption of fat-soluble vitamins also is decreased. Other drugs for weight loss are under development.

Obesity: Weight-loss surgery

Surgery is an option for some patients who are experiencing complications from severe and resistant obesity. It should be considered if the risk of remaining obese is greater than the risk of surgery.

Committed to success

Long-term success of surgery depends on the patient’s ability to change behavior and commit to lifelong follow-up. About 70% of patients maintain a weight loss of 50% for 5 years.

Two options

Two types of surgeries are primarily used to promote weight loss: restrictive and malabsorptive-restrictive procedures.

Restrictive procedures
In gastric restriction, also known as vertical banded gastroplasty and adjustable gastric banding, the size of the stomach is surgically decreased so that a patient feels full after eating a small amount of food.

Tighten it up

In vertical banded gastroplasty, a vertical row of staples is inserted across the patient’s stomach, decreasing the stomach’s size to 15 to 30 ml. A band decreases the opening from the upper pouch to about 1 cm, which delays gastric emptying. Over time, the pouch can stretch to hold more food.

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Rubber-banded and ready for action

In adjustable gastric banding, a silicone rubber band is placed around the upper portion of the stomach, creating a small pouch with a narrow opening into the larger portion of the stomach. The band can be inflated or deflated with saline solution through a tube attached to an access port under the skin, allowing the size of the stomach opening to be adjusted. This procedure may be performed laparoscopically.

Complicating the situation

Complications of gastric restriction may include bursting of the staples if too much food or liquid is consumed before the staple line heals and obstruction if food isn’t chewed well. Nutritional complications include hypoalbuminemia and vitamin deficiencies as well as nausea and vomiting.

Malabsorptive-restrictive procedures
Malabsorptive-restrictive procedures, which reduce stomach size as well as the number of calories and nutrients the body can absorb, produce better weight loss results than gastric resection.

Get rid of it…quickly!

After surgery, rapid dumping of food from the stomach into the small intestine limits calorie absorption, leading to weight loss. Nausea, diarrhea, and abdominal cramping may occur, but these adverse effects improve over time.

Take the bypass route

Two types of malabsorptive-restrictive procedures are currently being done.
• Gastric bypass—Also known as Roux-en-Y gastric bypass, this procedure combines gastric resection with a bypass of the duodenum and the first portion of the jejunum. It’s the most commonly performed surgical weight loss procedure and is recommendedfor long-term weight loss.
• Biliopancreatic diversion—This is a more complicated surgery in which the lower part of the stomach is removed and the remaining pouch is connected to the terminal segment of the small intestine, thus bypassing the duodenum and jejunum. This procedure isn’t commonly used because it can lead to nutritional deficiencies. Patients who have undergone biliopancreatic diversion must take fat-soluble vitamin (A, D, E, and K) supplements.

Everything in moderation

In a modified version of the procedure, a larger portion of the stomach and pyloric valve are in place, allowing control of the movement of stomach contents into the duodenum. With this variation, the patient can eat more food than following other procedures.

Nursing considerations
Many of the nursing considerations are the same, regardless of the type of weight loss surgery performed.

Pre-op preparations

• Before surgery, make sure the patient has undergone a complete medical and psychological evaluation. The patient will commonly have extensive nutritional counseling before the procedure also.
• Make sure the patient has signed an appropriate consent form.
• Administer I.V. fluids and total parenteral nutrition (TPN), as ordered.

Post-op care

• If the patient has a nasogastric tube in place after surgery, don’t reposition the tube unless ordered by the practitioner.
• Encourage early mobility and coughing and deep-breathing exercises. Remember that obese patients are at higher risk for pulmonary complications.
• Monitor the patient’s vital signs, intake and output, and daily weight.
• Administer I.V. fluids, TPN, and electrolyte replacements, as ordered.
• Carefully monitor laboratory values, and be alert for electrolyte disturbances.
• Administer pain medication, as needed.
• Remind the patient of the importance of following his set diet. Advise him that he may need vitamin supplements.
• Inform the patient about possible complications and when to notify the practitioner.

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