Bariatric Surgery

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Presentation Description

A presentation I gave while in nursing school on bariatric surgery

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Presentation Transcript

Objectives : 

Objectives Describe how the obesity epidemic is changing health and healthcare Review current trends in how patients are managing obesity Discuss the role of the nurse in addressing the epidemics of adult obesity

Obesity Trends Among U.S. AdultsBRFSS, 1990 : 

Obesity Trends Among U.S. AdultsBRFSS, 1990

Obesity Trends Among U.S. AdultsBRFSS, 1997 : 

Obesity Trends Among U.S. AdultsBRFSS, 1997

Obesity Trends Among U.S. AdultsBRFSS, 2002 : 

Obesity Trends Among U.S. AdultsBRFSS, 2002 Source: Mokdad A H, et al. JAMA 2003;289:1 Source: Mokdad A H, et al. JAMA 1999;282:16;2003;289:1

Actual Causes of Death in the United States, 1990 : 

Actual Causes of Death in the United States, 1990 Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

The Risks of Overweight : 

The Risks of Overweight coronary heart disease breast cancer, prostate cancer, colon cancer, uterine cancer stroke osteoarthritis gallbladder disease sleep apnea, respiratory problems Metabolic syndrome: hypertension, diabetes mellitus, high cholesterol Work, educational, and social discrimination Depression

Contributing Factors to Overweight and Obesity : 

Contributing Factors to Overweight and Obesity Direct cause - energy imbalance Contributing factors: Genetics Behavior (choice of fast food and sedentary life style) Environment (media messages encouraging consumption, widespread availability of cheap, nutritionally poor foods) Prevalence: higher in minority groups and persons with lower incomes Among Whites, men are more likely to be overweight but rates of obesity are similar.

Slide 12: 

The Toxic Environment 880 calories for $2

Classification of Obesity : 

Classification of Obesity NOTE: Overweight may or may not be due to increases in body fat. It may also be due to an increase in lean muscle (e.g. professional athlete).

Adult BMI Chart : 

Adult BMI Chart 5'4" Height Weight (lbs) 5'2" 5'0" 5'10" 5'8" 5'6" 6'0" 6'2" 120 130 150 160 170 180 190 200 210 220 230 240 250 140 260 270 280 290 300 6'4"

What are your adult patients doing about obesity? : 

What are your adult patients doing about obesity? 29% of men and 44% of women trying to lose weight About 20% report restricting calories or increasing physical activity

AHA Guidelines for Healthy Diets : 

AHA Guidelines for Healthy Diets Carbohydrates: ~55% of calories Fat: ~30% of calories, <10% sat fat Protein: 15-20% of calories Diet: provide adequate nutrients and support dietary compliance St. Jeor ST, etal. Circulation 104:1869-74, 2001.

What Can Nurses Do? : 

What Can Nurses Do? Counsel and Teach Talk with MD if Drugs are a viable option Bariatric Surgery Advocacy

Evidence:USPSTF Conclusions : 

Evidence:USPSTF Conclusions Counseling and educating can promote modest sustained weight loss, improving clinical outcomes. Pharmacotherapy appears safe in the short term; long-term safety is less established. In selected patients, surgery promotes large amounts of weight loss with rare but sometimes severe complications

Counseling and Educating: Diet, Exercise, or Both : 

Counseling and Educating: Diet, Exercise, or Both Includes behavioral interventions aimed at skill development, motivation, and support strategies Produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese

Assess patient’s readiness to change : 

Assess patient’s readiness to change Prochaska and DiClemente stages of change model Precontemplation Contemplation Action Maintenance

Stages of change:precontemplation : 

Stages of change:precontemplation Not conscious Not educated Not ready to change “I eat like a bird..”

Stages of change:contemplation : 

Stages of change:contemplation Considering change Ambivalent “I’d like to lose weight but…”

Stages of change:action : 

Stages of change:action Ready to change “I’m ready to work on losing weight.”

Stages of change:maintenance : 

Stages of change:maintenance Lost weight in past 6 months Working on maintaining weight loss

Counseling Methods : 

Counseling Methods Patient-centered, directive method for increasing motivation to change Helps patient explore, resolve ambivalence 4 key elements to counseling 1. Express empathy • Acceptance • Reflective listening • Patient ambivalence is normal 2. Develop discrepancy Between patient’s goal and behavior e.g. Wants to lose weight Eats sweets every day Patient should recognize the need for change 3. Roll with resistance Don’t argue for change Patient is primary resource in problem solving Resistance is a signal to respond differently 4. Express confidence that patient can change Your and patient’s belief that s/he can change helps the patient’s motivation • Emphasize that the PATIENT is responsible for choosing, carrying out change

Obesity Drugs : 

Obesity Drugs Appetite suppressants Noradrenergic (Schedule IV) Phentermine (Adipex, Fastin) Diethylpropion (Tenuate) Noradrenergic (Schedule III) Benzphetamine (Didrex) Phendimetrazine (Bontril) Serotonergic Fenfluramine, dexfenfluramine Mixed Noradrenergic & Serotonergic Sibutramine (Meridia) Nutrient absorption reducers Lipase inhibitor Orlistat (Xenical)

Sibutramine (Meridia) : 

Sibutramine (Meridia) Contraindicated: CAD, CHF, cardiac arrhythmias or stroke Side Effects: hypertension, arrhythmia, tachycardia, headache, dry mouth, constipation, insomnia

Orlistat : 

Orlistat Lipase inhibitor: reduces fat absorption by ~30% resulting in reduction in energy intake Inhibits digestion of dietary triglycerides, decreases absorption of cholesterol and lipid-soluble vitamins

Side Effects : 

Side Effects GI side effects due to inhibition of fat absorption pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting

Surgery : 

Surgery 2001 47,000 2002 63,000 2003 98,000 NIH Criteria: Well informed and motivated patient BMI>40 or BMI>35 with co-morbidities Mortality: 1-2% Effectiveness: >50% excess weight loss at 14 years

Primary Goals of Bariatric Surgery : 

Primary Goals of Bariatric Surgery • Induce weight loss – Decrease size of stomach to limit intake – Decrease absorption of food eaten • Improve existent cardiovascular risk factors • Prevent the development of cardiovascular risk factors Improve morbidity and mortality Improve Quality of Life

Types of Bariatric Procedures : 

Types of Bariatric Procedures Vertical-banded gastroplasty

Types of Bariatric Procedures : 

Types of Bariatric Procedures Adjustable silicone gastric banding

Types of Bariatric Procedures : 

Types of Bariatric Procedures Roux-en-Y gastric bypass

Types of Bariatric Procedures : 

Types of Bariatric Procedures

Benefits of Bariatric Surgery : 

Benefits of Bariatric Surgery Improved glycemic control Improved blood pressure Improved ventricular function Improvement in symptoms of OSA Improved quality of life Reduction in depressive symptoms Reduced sick-leave and disability

Post-Bariatric SurgeryComplications and Care : 

Post-Bariatric SurgeryComplications and Care Dumping syndrome Sxs: postprandial sweating, weakness, hypoglycemia, malaise Only occurs in bypass procedures Rarely severe Usually resolves as patients adapt to new anatomy and selectively avoid foods high in concentrated sugar or fat Dietary Deficiencies – Common in patients with bypass procedure – Iron, B12, Calcium absorption is impaired – Folate deficiency → hyperhomocystinemia • Treatment – Daily vitamin and mineral replacement

Post-Bariatric SurgeryComplications and Care : 

Post-Bariatric SurgeryComplications and Care • GERD – Occurs in vertical-banding gastroplasty • Treatment – PPI – Gastric bypass • Osteoporosis – Bone resorption during weight loss of unclear Mechanism – Impaired absorption of calcium and vitamin D Treatment – Calcium and Vitamin D supplement Follow-up – DEXA scan when new weight achieved •Gallstones – Common with any rapid weight loss – May occur in up to 27% of patients within 3 years after bypass surgery • Treatment – Surgical: prophylactic chole at time of bariatric surgery – Medical: 600mg Ursodiol for 6 months post-op Excess skin – Usually considered by most insurance companies as a cosmetic procedure; therefore, coverage is denied – May be covered if complicated by stasis dermatitis, ulceration – Plastic surgeons will generally not perform the procedure until weight loss has been maintained for at least 1 year

Post-Bariatric SurgeryComplications and Care : 

Post-Bariatric SurgeryComplications and Care Pregnancy – Studies have demonstrated minimal adverse events in pregnancy after bariatric surgery – Fe deficiency anemia (n=2) and low fat milk production (n=1) was noted in 111 women post-bariatric surgery Management – Delay pregnancy for 1-2 years post-op – Provide with vitamin and mineral supplements especially during pregnancy

Advocacy : 

Advocacy The epidemic of overweight cannot be addressed in the clinical setting alone A caregiver’s role should also involve the community

Advantages of Weight Loss : 

Advantages of Weight Loss • Decrease risk of type 2 diabetes • Decrease blood pressure • Improve lipids • Decrease severity of sleep apnea • Reduce symptoms of osteoarthritis