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Presented by: Richard Zavalla, BSN, RN Kathleen Veloso, BSN, RN, CMSRN Obesity


Objectives Define obesity Determine risk factors, etiology, and common signs and symptoms Identify common differential diagnosis and clinical considerations for obesity Discuss a treatment plan that is within a nurse practitioner’s scope of practice Comorbidities and challenges that may arise with obese patients Provide clinical examples on the challenges of treating obese patients


Definition According to the World Health Organization (2013)… Overweight is having a BMI over 25 kg/m 2 Obesity is having a BMI over 30 kg/m 2


BMI B ody M ass I ndex – index of weight for height that is commonly used to classify excess weight and obesity in adults.


Statistics CDC (2013) reports that more than one-third (35.7%) of Americans are obese with 70% American adults being overweight. The United States has the highest obesity rate in the world. More people die each year from over-eating and obesity than starvation. Obesity is the 2 nd in US for preventable causes of death. In 2013, medical costs for obesity-related treatments estimate to over $147 billion.

Obesity in America:

Obesity in America

Younger vs. Older Adults:

Younger vs. Older Adults Elderly lose weight more slowly than younger adults due to a metabolic rate decline of 2% per decade as well as decreased energy expenditure. Women: Menopause in women causes an alteration in fat metabolism due to a decrease in estrogen and progesterone, which can lead to an increase in central adiposity. Men: Adult males generally gain weight due to a transition from an active lifestyle in their twenties to a more sedentary lifestyle. This progression continues until the 6 th decade where it may stabilize, and then slowly decline as they age. (Bray, Pi-Sunyer, & Mulder, 2012)

Etiology & Risk Factors:

Etiology & Risk Factors The fundamental cause of obesity is an energy imbalance between calories consumed and calories expended. (WHO, 2013). RISK FACTORS Prenatal influences Breastfeeding vs. formula Family history Childhood obesity Sleep deprivation ( Bray, Pi- Sunyer , & Mulder, 2012)


Causes Lifestyle Eating habits Genetics Environment Income Medical conditions Medications

Signs & Symptoms:

Signs & Symptoms Chief complaints: Complaints of ill-fitting clothes, tight clothing Fatigue, shortness of breath with activity, activity intolerance Joint pain Physical Examination: BMI > 30 Weight gain Increased abdominal girth

Differential Diagnosis:

Differential Diagnosis Differential Diagnosis Cushing Syndrome Anasarca Ascites Hypothyroidism Diagnostic Considerations Depression Type 2 Diabetes Insulinoma Polycystic ovarian disease Generalized lipodystrophy Fatty liver disease (Hamdy, 2013)

Cushing Syndrome:

Cushing Syndrome Caused by an excess level of cortisol (hypercortisolism) Positives Negatives Weight gain Thin skin Fatty deposits Slow growth/healing Hirtuism Muscle weakness Fatigue Striae


Anasarca Caused by liver failure, renal failure, malnutrition, medications Positives Negatives Weight gain Edema Abdominal girth increased Water retention Weakness Insomnia Anemia Pain


Ascites Usually caused by cirrhosis and hepatitis Positives Negatives Weight gain Shortness of breath Abdominal distention Abd . pain Bloating Decreased appetite Nausea Vomiting Heartburn


Hypothyroidism Caused by an underactive thyroid gland Positives Negatives Weight gain Dry skin Elevated cholesterol Menstrual irregularities Puffy face Thin hair Edema around eyes Cold intolerance Constipation Fatigue


Workup Labwork should include Fasting lipid panel Hyperlipidemia is not uncommon in obese patients Thyroid function tests TSH levels should rule out hypothyroidism Liver function tests Tend to be normal in obese patients elevated transaminase levels may indicate nonalcoholic steatohepatitis (NASH) or fatty infiltration of the liver. Glucose and insulin studies May show insulin resistance Screen for diabetes (Hamdy, 2013)

Treatment Plan:

Treatment Plan Treatment of obesity should be initiated by lifestyle management and BMI modification. These include changes in diet, physical activity, and behavior counseling. Self monitoring of caloric intake and exercise Realistic goal setting Non-food rewards Relapse prevention (Bray, Pi-Sunyer, & Mulder, 2012)

Treatment Plan (cont.):

Treatment Plan (cont.) Weight loss programs Consultations with nutritionist, personal trainers, wellness coordinators Commercial 12-week programs have a higher success rate in compliance and affordability in comparison to those offered by specialists. Pharmacologic interventions Usually reserved for patients with a BMI >30 kg/m2 who have failed to achieve weight loss goals through diet and exercise alone Should be used as a adjunct treatment along with diet & exercise. Weight gain will occur after stopping medications


Medications Lipase inhibitors inhibit nutrient absorption Orlistat ( Xenical , Alli ) Serotonin Agonists aids in reducing food intake Locaserin Combination medications Qsymia Off-label Use Bupropion Metformin Dietary Supplements Ephedra Green Tea Green Coffee Bean Guar Gum Garcinia Cambogia

Referral for Surgery:

Referral for Surgery Liposuction Roux-en-Y gastric bypass Laparascopic gastric banding Sleeve gastrectomy Biliopancreatic diversion with duodenal switch

Common Comorbidities:

Common Comorbidities Overweight and obese patients are at risk for developing a multitude of medical conditions that can lead to further morbidity and mortality. These include: HTN Diabetes CAD Cancer Sleep Apnea CHF Asthma Back pain Arthritis Pulmonary embolism Dyslipidemia Stroke Gallbladder disease Gout Depression (Guh et. al., 2009)


Challenges Assessment challenges -imaging studies -patient privacy -ECG abnormalities -pulmonary function abnormalities Treatment challenges - mechanical ventilation -weight-based pharmacologic interventions -pressure ulcers -nutrition therapy (Harrington, L., 2009)

PowerPoint Presentation:

Obesity happens one pound at a time. But so does preventing it. (NIH, 2013) The end.


References Bray, G.A., Pi-Sunyer, F.X., Mulder, J.E. Etiology and natural history of obesity . Retrieved from UpToDate database. Centers for Disease Control and Prevention. (2013). Adult obesity facts . Retrieved from http://www.cdc.gov/obesity/data/adult.html Christakes, N.A. & Fowler J.H. (2007). The spread of obesity in a large social network over 32 years. N Engl Journal of Medicine ; 357: 370. Cushing syndrome. (2011, December 11). National Institutes of Health. Retrieved February 5, 2014, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001447 Guh, D.P., Zhang W., Bansback, N., Amarsi, Z., Birmingham, C.L., & Anis, A.H. (2009). The incidence of comorbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health. 9(88). Hamdy, O. (2013). Obesity. Retrieved from Medscape database. Harrington, L. (2009) Specific challenges in treating the adult obese patient. Society of Critical Care Medicine. Leslie, W.S., Hankey, C.R., & Lean, M.E. (2007) Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM 2007: 100:395. World Health Organization. (2013). Obesity and overweight. Retrieved from http:// www.who.int/mediacentre/factsheets/fs311/en/index.html

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