Gastrointestinal System – Part IX Malnutrition: Undernutrition & Obesity Mrs. April Page MSN ARNP FNPC Gulf Coast State College NUR1213c Intermediate Adult Care

Lesson Objectives Describe the causes, pathophysiology, classifications, and morbid complications associated with obesity and management strategies for treating obesity. Identify risk factors and prevention methods associated with obesity. Identify the complications of bariatric or other gastric surgical procedures and their prevention and management. Describe the home health care needs of the patient who has had bariatric or other gastric surgical procedures.

Introduction Classifications of Body Weight

Classifications Of Body Weight (cont.) Degree a person has excess adipose tissue in terms of being overweight and obese Body mass index (BMI) Used to classify body weight Correlates with total body adiposity

Classifications Of Body Weight Body mass index Calculated by weight in kilograms divided by height in meters squared Increased waist circumference correlates with abdominal adiposity

Lesson Objective One Describe the causes, pathophysiology, classifications, and morbid complications associated with obesity and management strategies for treating obesity.

Obesity Obesity is body mass indices (BMI) above 30 mg/m2 66% of all adults are overweight or obese Obesity-related mortality rates are 30% greater for every gain of 5 kg/m2 of body mass beyond a BMI of 25 kg/m2 Increased risk for disease, disorders, low self- esteem, impaired body image, depression, and diminished quality of life See Table 60-3, page 1247

Epidemiology Prevalence Effects of long-term obesity Obesity has reached epidemic levels 14.5% of adults have class 2 obesity or higher 6.4% of adults have class 3 obesity Effects of long-term obesity Marked decrease in life expectancy Linked to numerous chronic health conditions

Pathophysiology Regulation of body weight is a complex interplay between appetite and energy expenditure Basal metabolic rate Adipokines Leptin Satiety Environmental factors Behavioral factors

Obesity Management Laboratory testing Diagnostic testing Identification of secondary causes and risk factors Specific tests are selected based on history and physical exam Diagnostic testing CT, MRI, fluoroscopy, and plain radiograph tables have weight limits

Obesity Management Lifestyle modifications Pharmacotherapy Bariatric surgery

Obesity Management (Cont’d) Treatment (cont’d) Physical activity Important for all adults Long-term goals of 30 minutes of moderate-intensity exercise on most days of the week Behavioral therapy Self-monitoring via food logs, stimulus control, social support Cognitive restructuring

Medications 3 medications available for long-term treatment Orlistat Lorcaserin Phentermine/topiramate

Surgical Management Bariatric surgery types Complications Restrictive procedures Malabsorptive procedures Combination procedures Complications 90-day mortality rate after bariatric surgery was 0.11% 30-day mortality rate was 0.09%

Surgical Management (Cont’d) Short-term life-threatening complications Pulmonary embolism, infection, and anastomosis leak Long-term complications and side effects Band slippage, obstruction, hernia Esophageal erosion, ulcers, acid reflux Vitamin deficiency, osteoporosis, anemia, and dumping syndrome

Lesson Objective Two Identify risk factors and prevention methods associated with obesity.

Risk Factors for Obesity Genetics Diet Family Lifestyle Physical Inactivity Medical Problems Social and Economic Issues Age Smoking cessation Lack of Sleep

Risk Factors for Obesity Drug Therapy Corticosteroids Estrogens and certain progestin's Nonsteroidal anti-inflammatory drugs (NSAIDs) Antihypertensive Antidepressants and other psychoactive drugs Antiepileptic drugs Certain oral antidiabetic agents

Prevention Methods: Obesity Improve diet Eat five to six servings of fruits and vegetables daily. Choose whole grain foods such as brown rice and whole wheat bread Avoid highly processed foods Weigh and measure food Eat less calories than you burn Avoid foods high in "energy density"

Prevention Methods: Obesity (cont.) Increase physical activity 30 minutes 3-5 per week/then daily Sweat Make opportunities stairs vs elevator

Lesson Objective Three Identify the complications of bariatric or other gastric surgical procedures and their prevention and management.

Nursing Process: The Care of the Patient With Gastric Surgery—Assessment Patient and family knowledge Nutritional status Abdominal assessment Postoperatively assess for potential complications

Nursing Process: The Care of the Patient With Gastric Surgery—Diagnoses Anxiety Pain Deficient knowledge Imbalanced nutrition

Collaborative Problems and Potential Complications Hemorrhage Dietary deficiencies Bile reflux Dumping syndrome

Nursing Process: The Care of the Patient With Gastric Surgery—Planning Major goals include reduced anxiety, increased knowledge, optimal nutrition, management of complications that can interfere with nutrition, relief of pain, avoidance of hemorrhage and steatorrhea, and enhanced self-care skills at home

Interventions Provide interventions to reduce anxiety Pain Administer analgesics as prescribed so patient may perform pulmonary care, leg exercises, and ambulation activities Position in Fowler’s position Maintain function of NG tube Patient education Individualized nutritional care and support

Care and Prevention of Complications Gastric retention May require reinstatement of NPO and Ng suction; use low-pressure suction Bile reflux Agents that bind with bile acid: cholestyramine Malabsorption of vitamins and minerals Supplementation of iron and other nutrients Parenteral administration of vitamin B12 because of a lack of intrinsic factor

Care and Prevention of Complications Dumping syndrome Caused by rapid passage of food into the jejunum and drawing of fluid into the jejunum caused by hypertonic intestinal contents Causes vasomotor and GI symptoms with reactive hypoglycemia Avoid fluid with meals Avoid high carbohydrate and sugar intake Steatorrhea Reduce fat intake and administer loperamide

Lesson Objective Four Describe the home health care needs of the patient who has had bariatric or other gastric surgical procedures.

Dietary Self-Management To delay stomach emptying and dumping syndrome, assume low Fowler’s position after meals; lie down for 20 to 30 minutes Take antispasmodics as prescribed Avoid fluid with meals Meals should contain more dry items than liquid items

Dietary Self-Management (cont.) Eat fat as tolerated but keep carbohydrate intake low and avoid concentrated carbohydrates Eat small, frequent meals Take dietary supplements as prescribed; vitamins, medium-chain triglycerides, and B12 injections See chart 60-7, page 1252

Manifestation of Nutrient Deficiencies SIGN/SYMPTOM POTENTIAL NUTRIENT DEFICIENCY Hair Alopecia Zinc Easy to remove Protein Lackluster hair “Corkscrew” hair Vitamin C Decreased pigmentation Eyes Xerosis of conjunctiva Vitamin A Corneal vascularization Riboflavin Keratomalacia Bitot's spots

Manifestation of Nutrient Deficiencies (cont.) SIGN/SYMPTOM POTENTIAL NUTRIENT DEFICIENCY Gastrointestinal Tract Nausea, vomiting Pyridoxine Diarrhea Zinc, niacin Stomatitis Pyridoxine, riboflavin, iron Cheilosis Pyridoxine, iron Glossitis Pyridoxine, zinc, niacin, folic acid, vitamin B12 Magenta tongue Vitamin A, riboflavin Swollen, bleeding gums Vitamin C Fissured tongue Niacin Hepatomegaly Protein

Manifestation of Nutrient Deficiencies (cont.) SIGN/SYMPTOM POTENTIAL NUTRIENT DEFICIENCY Skin Dry and scaling Vitamin A Petechiae/ecchymoses Vitamin C Follicular hyperkeratosis Nasolabial seborrhea Niacin Bilateral dermatitis Extremities Subcutaneous fat loss Calories Muscle wastage Calories, protein Edema Protein Osteomalacia, bone pain, rickets Vitamin D

Manifestation of Nutrient Deficiencies (cont.) SIGN/SYMPTOM POTENTIAL NUTRIENT DEFICIENCY Hematologic Anemia Vitamin B12, iron, folic acid, copper, vitamin E Leukopenia, neutropenia Copper Low prothrombin time, prolonged clotting time Vitamin K, manganese Neurologic Disorientation Niacin, thiamine Confabulation Thiamine Neuropathy Thiamine, pyridoxine, chromium Paresthesia Thiamine, pyridoxine, vitamin B12

Manifestation of Nutrient Deficiencies (cont.) SIGN/SYMPTOM POTENTIAL NUTRIENT DEFICIENCY Cardiovascular Congestive heart failure, cardiomegaly, tachycardia Thiamine Cardiomyopathy Selenium Cardiac dysrhythmias Magnesium Table 60-2, page 1239, Iggy

The End Chapter 60: Malnutrition: Undernutrition and Obesity