1. Malnutrition & Obesity
Keith Rischer RN, MA, CEN

2. Today’s Objectives…
Explain the potential consequences and complications associated with malnutrition.
Analyze assessment data to determine common nursing diagnoses for the client with malnutrition.
Explain the potential consequences, contributing factors and complications associated with obesity.
Contrast non-surgical vs. surgical management of obesity.
Describe post-op complications of bariatric surgery and lifelong dietary modifications required.

3. Nutritional Standards
Dietary recommendations
1800 calories/day…0.8 gm protein per kg
Risk of malnutrition if <70%
Nutritional assessment includes:
Diet history
Exam and health history
GI disease/malabsorption
COPD
Measurement of height and weight
Assessment of body mass index-BMI
Weight (lbs)/height (inches) x703=
190/72 x703=26.6 BMI
Ideal 20-25

4. Malnutrition in Acute Care
Who is at risk?
Poverty
Drug & ETOH abuse
N/V/D
Lab Values
Complications
Poor wound healing
Increased risk of infection
Lethargy
Activity intolerance
Studies have shown in hospital up to 40-55% pts at risk for malnutrition
12% severely malnourished
2-3x more likely to develop complications
Lab Values
Anemia
Albumin low…why?

5. Nursing Considerations: Malnourished
Low protein stores
loss of muscle and lean body mass
decreased drug binding
increase in levels of free circulating drugs
increasing drug toxicity
Drugs given subcutaneous or IM closely monitored
adipose tissue has decreased blood supply
delayed action and unpredictable duration
IM can inadvertently be given subcutaneous
Cutaneous patches may deliver drugs with erratic action

6. Imbalanced Nutrition: Less Than Body Requirements
Enteral Feedings
Types
Nursing Considerations
Confirm placement
Check residuals
Change bag qd
4 hours of formula at time
Monitor labs
Lytes, albumin, hgb
Complications
Aspiration
Diarrhea
Enteral Feedings…unable to maintain adequate po intake due to N&V
CVA-neuromuscular impairments with swallowing
Acutely ill-recently intubated

7. Imbalanced Nutrition: Less Than Body Requirements
IV Total Parenteral Nutrition (TPN)
Central access
Lipids
Protein-dextrose-vitamins
Nursing Considerations
Monitor daily wt./ I&O
Carefully check contents
Complications
Fluid imbalance
Lyte imbalances
Check labs
Liver function
Fluid imbalance
Hyperosmolar….fluid into the intravascular space
Lyte imbalances…calcium

8. Obesity USA Obesity Rates Reach Epidemic Proportions
Data (2003) suggests 6% of population is obese
Eight out of 10 over 25's Overweight
78% of American's not meeting basic activity level recommendations
25% completely Sedentary
76% increase in Type II diabetes in adults yrs old since 1990
Overweight over 10% ideal body weight…more than 100 million Americans overwieght or obese in US
Considered healthy if BMI is between 19 and 24. If over 30, considered obese-BMI over 40-morbid obesity
Second most preventable cause of death in US (next to smoking), costing over $200 billion annually
In a survey of patients preparing to undergo gastric bypass surgery – 55% of pts reported being treated disrespectful by healthcare workers because of their weight
Obese women are less likely to seek preventative healthcare services than are women who are not obese
Waist circumference – better to be pear than apple shaped, as apple shape has more fat in and around the abdominal organs. Women’s waist should be below 35, men below 40 inches

9. Obesity related diseases
80% of type II diabetes related to obesity
70% of Cardiovascular disease related to obesity
42% breast and colon cancer diagnosed among obese individuals
30% of gall bladder surgery related to obesity
26% of obese people having high blood pressure

10. Childhood Obesity 17% children overweight
Between 8% - 45% of newly diagnosed cases of childhood diabetes are type II, associated with obesity.
4% of Childhood diabetes was type II in 1990
Now 20%
Of Children diagnosed with Type II diabetes, 85% are obese
25% of all white children overweight 2001
33% African American and Hispanic children overweight 2001
Childhood Obesity Running Out of Control

11. Complications of Obesity
Diabetes mellitus
Hypertension
Hyperlipidemia
CAD
Obstructive sleep apnea
Obesity hypoventilation syndrome
Depression and other mental health/behavioral health problems
Urinary incontinence
Cholelithiasis
Chronic back pain
Early osteoarthritis
Decreased wound healing
Increased susceptibility to infection
Gout

12. Contributing Factors to Obesity
Diet
Physical inactivity
Drugs
Corticosteroids
Estrogens
NSAIDS
Antihypertensives
Antidepressants and psychoactive drugs
Genetics
Genetics
Both parents overweight 80% liklihood to be obese
Neither parent overweight only 10%
Seems to be 50/50 influence of genetics and environment

13. Weight Loss Strategies/Education
Goal
reduce body weight by 10% of baseline within 6 months
loss of 1 to 2 lbs/week
Decrease caloric intake day
Eat slowly so that the brain gets the message that the stomach is full
Take seconds of vegetables and salads instead of higher calorie foods
Try to eat 3 balanced meals
at regular times
Record all food eaten

14. Nursing Considerations: Obesity
Skin care
high risk for breakdown and delayed wound healing
Folds become moist and harbor yeast and bacteria
Use of powders discouraged
daily inspection, frequent turning, watch for shearing
Risk for DVT
Early mobility
Inability to obtain definitive diagnosis with scans and radiological tests

15. Nonsurgical Management of Obesity
Fasting
Novelty diets
Atkins
Diet therapy
Weight watchers etc.
Exercise program
Behavior modification
Food diary
Emotional/situational influences
Drug therapy
Xenical
Inhibits lipase…fats are partially digested

16. Bariatric Surgery BMI 40 or higher
or 35 – 39.9 with related health problem
Must agree to strict lifestyle/diet regimen
Post op care priorities
28,000 surgeries 1999….currently over 100,000 in US
Roux-en-Y Gastric Bypass: a stomach pouch is created and connected to a Y-shaped section of the small intestine, bypassing absorption that would take place in the stomach and small intestine.

17. Complications: Bariatric Surgery
DVT-PE
Narrowing of the opening between the stomach and small intestine – strictures can form
Gallstones
Bleeding ulcers
1 in 100 may develop Altered digestion, long-term nutritional deficiencies
Dumping syndrome
tachycardia, nausea, diarrhea, abdominal cramping
Infections
1 in 200 to 300 people will die from procedure; MI

18. Dietary Concerns: Bariatric Surgery
Nutritional supplements
Iron deficiency
B-12 deficiency
B12 injections
Dietary modifications
Avoid foods high in sugar
Avoid alcoholic beverages
Avoid high protein foods