Obesity
Complex disorder involving excessive body weight beyond the body’s physical requirement
BMI:
- Underweight: <18.5
- Normal: 18.5-24.9
- Overweight: 25-29.9
- Obese (class I): 30-34.9
- Obese (class II): 35-39.9
- Morbidly obese: >40
Primary vs. secondary obesity
Majority of obese people have primary obesity (more calories in than calories out)
Secondary obesity – a result of metabolic problems, congenital, and/or chromosomal abnormalities
Factors
Obesity factors:
1. Genetics – BMI has a strong genetic component (40-80%) involving several genes that have expression in the hypothalamus and fulfill roles in appetite regulation; Strongest genetic link is associated with FTO gene (on chromosome 16)
- Prenatal – Three modifiable factors in utero: Mother’s (1) smoking habit, (2) weight gain, and (3) BG, especially if they developed gestational DM
- Early life – Three modifiable postnatal factors: (1) How rapidly infant gains weight, (2) how long an infant is breastfed, and (3) how much an infant sleeps
- *Lifestyle & environmental:
4. Restrictive activity – HS students who attend PE classes daily have decreased since 1991; Children no longer play outside and there has been increased screen time and explosion in the gaming industry
- Food – i.e. 1 Big Mac meal is 1,090 cal. = 10 apples
- Sleep – Sleep is linked to obesity
- Mental health – Stress (increased cortisol causes same signals initiated by starvation and food in reward), depression, and other mental illnesses
Pathophysiologic regulation
Evolution (ability to store energy during periods of famine) – When energy intake surpasses expenditure, there is a positive energy balance (and it is primarily stored as fat)
Various hormones and peptides are made and released from the hypothalamus, adipose tissue, and the gut; Function:
- Appetite suppressant
- Appetite stimulant
- Delay gastric emptying
Hormones
Hormones:
1. GHRELIN: increases appetite (GI tract)
- LEPTIN: suppresses hunger (pancreas)
- INCRETIN: glucose-dependent hormone that inhibits glucagon release, slows gastric emptying, and decreases appetite (pancreas)
- INSULIN: promotes absorption of glucose into liver, fat, and cells (pancreas)
**Polycystic ovary syndrome: a condition marked with elevated androgens and insulin resistance
Changes in physiologic regulation in obesity
Changes:
1. Genetic deficiency in leptin – obesity increases leptin (leptin insensitivity)
- Ghrelin – obesity inhibits ghrelin decline after a meal
- Increased concentration of free fatty acids – inhibits insulin secretion
Complications associated with obesity
Complications:
1. Metabolic syndrome
- DM (80% of those with T2DM are obese) – Insulin resistance promoted by release of free fatty acids and inflammatory factors such as cytokines from microphages
- CV (associated with visceral fat, android obesity), DLP, HTN, and atherosclerosis
- Non-alcoholic fatty liver disease
- Polycystic ovary disease
- Obstructive sleep apnea
- Osteoarthritis
- Urinary stress incontinence
- GERD
- Asthma
- Immobility
- Psychological disorder due to stigma
Metabolic syndrome
A collection of risk factors that increase the risk for developing DM, stroke, and CV disease
Criteria for diagnosis (any 3 of 5):
1. Waist circumference >40in. (men) or >35in. (women)
- Triglycerides >150mg/dl OR on meds.
- HDL <40mg/dl (men) or <50 mg/dl (women); OR on meds.
- BP >130 SBP or >85 DBP; OR on meds.
- FBG >110mg/dl OR on meds.
CA
Obesity is one of the most preventable causes of cancer; 20% (women) and 15% (men)
Mechanism is unclear; Hypothesis:
1. Estrogen in breast and endometrial CA
- GERD in esophageal CA
- Hyperinsulinemia in colorectal CA
Treatment
Treatments:
1. Lifestyle changes – Diet (nutritionist), active life (150min./week), behavioral change (behavioral therapy, support groups)
- Pharmacotherapy – Used in conjunction with other weight reduction strategies; Reserved for those with BMI >30 or BMI >27 WITH at least one weight-related condition (HTN, T2DM, DLP)
- Surgery – Criteria: Morbidly obese BMI >40 OR BMI >35 WITH one weight-related condition; AND exhibited commitment to making lifestyle changes necessary for successful results
Surgical procedures
- LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB) – Advantages: Reversible, absence of dumping syndrome, malabsorption; Disadvantages: Weight loss is limited
- VERTICAL SLEEVE GASTRECTOMY – 85% excision of stomach; Advantage: No bypass of intestine, stomach function is preserved, no anemia/vitamin deficiency; Disadvantage: Weight loss is limited
- ROUX EN Y GASTRIC BYPASS – 90% excision of stomach (food bypasses stomach and duodenum); Advantage: Better weight loss; Disadvantage: Dumping syndrome, iron/folic acid/calcium/cobalmin deficiencies, anemia
Dumping syndrome
Characterized by 30-60min. of N/V/D, abdominal cramping, sweating, lightheadedness, and tachycardia after eating
Interventions:
1. Avoid simple sugars
- Eat 5-6 meals or small snacks/day – Keep portions small (1 oz. of meat or 1/4 cup of vegetables)
- Cut food into very small pieces and chew well
- Combine proteins/fats with fruits/starches
- Stop eating when feeling full
- Drink liquids 30-45 min. after meals
- Reclining after eating can prevent lightheadedness
Post-op: Risks, diet, and nursing goals
Post-op RISKS:
- Infection
- Dehydration
- Malnutrition – Small nutritious meals, pay attention to vitamins/minerals, avoid carbonated drinks
Post-op DIET:
- Drink 3-4 oz. every 30min. – Sip liquids slowly
- No carbonation
- No sugar
- Ice/cold liquids can cause spasms – Room temp. first
- Diet progression as ordered
Post-op NURSING GOALS:
- Modify diet – improve nutrition
- Regular exercise program
- Achieve and maintain weight loss
- Minimize or prevent health problems
Implications for nursing
Implications:
1. Holistic, preventative care
- Education – Begin young
- Advocate for pts and their environment – Resources, access to care, parks, nutritional food
- Care coordination – Dietary, PT, OT, nursing education (group therapy)
Social determinants of health (SDOH)
Conditions in the environment in which people are born, live, learn work, play worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks
Drivers of racial disparities – i.e. Higher prevalence of DM among African Americans, Hispanics, and Native American populations as compared to white populations
Race is a social construct – it is NOT a biological construct
Assessment for SDOH (only 24% of hospitals assess social needs) – Food insecurity (food desserts), housing instability, utility needs, transportation needs, experience with IPV
Areas of SDOH
- Neighborhood and built environment
- Health and health care
- Social and community context
- Education
- Economic stability
Health status
Health status factors:
1. Social conditions (55%)
- Health behaviors (30%)
- Health care (10%)
- Genetics (5%)
