Bariatrics: A Growing Medical Care Dilemma

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Bariatrics A Growing Medical Care Dilemma

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What is Bariatrics?

• bari is Greek for weight
• The treatment of obesity- a medical disease
• Bariatric medicine treats obesity and related
  conditions
• the art and science of medical weight
  management (Guy)

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Definitions

• Overweight refers to excess body weight compared
  to set standard
• Obesity refers to having a high proportion of
  body fat to lean tissue

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Staggering Stats

• Approximately 280,000 deaths
• Obesity shaves 7 yrs off a persons life
• 68.5 million are overweight (BMI gt 25 to lt30)
• 34.1 of US adults
• 64.7 million are obese (BMI gt 30)
• 32.2 of US adults (NHANES 2003-04)
• Increases across virtually all age, ethnic,
  racial, and socioeconomic groups

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Prevalence of Overweight and Obesity
Source NIDDK- Statistics Related to Overweight
and Obesity
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Economic Costs

• 117 billion
• Direct cost 61 billion
• Health care costs
• Indirect cost 56 billion
• Lost wages and future earnings

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How is Obesity Measured

• Body Mass Index (BMI) is used to measure both
  overweight and obesity in adults
• Calculated by either equation
• Weight (kg) / Height squared (m2)
• or
• (weight (lb) x 704.5) height (in) height
  (in)

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BMI Nomogram
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Factors Contributing to Obesity

• Genetics/ inheritance
• Psychological/ depression
• Medical/ Hypothyroidism, Cushings Disease
• Cultural/ environmental
• Sedentary lifestyle

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Overweight and Obesity

• Known risk factors for
• Diabetes
• Heart disease
• Stroke
• Hypertension
• Gallbladder disease
• Osteoarthritis
• Sleep apnea
• Some forms of cancer (uterine, breast,
  colorectal, kidney and gallbladder)
• Syndrome X (cluster of ailments including insulin
  resistance)

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Typical Medical History

• Diabetes mellitus- twin epidemics
• Hypertension
• Atherosclerosis
• Osteoarthritis
• Exercise/activity intolerance
• Exercise-induced asthma
• Malnutrition
• Psychological factors
• Depression
• Social isolation
• Complications with surgery and pregnancy

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Functional Challenges

• Ambulation
• Transfers
• Wheeled mobility
• Toileting/bathing
• Personal hygiene
• Wound care

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Multi-disciplinary Team Effort

• Client/family education by
• Physician
• Dietitian
• Nursing
• PT/OT
• Psychologists
• Pharm-D
• Equipment Suppliers

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Nutritional Decline

• U.S. food industry supplies everyone with 3800
  cal/day 30 more than what men/ double what
  women need
• From 1970-1998, avg. intake of soda increased
  from 22.2 gallons to 56 gallons/year
• 33 billion in marketing food

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Client Education

• Nutritional therapy
• Surgical interventions
• Lifestyle
• Psychosocial implications
• Support mechanisms
• Equipment usage

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Nutritional Intervention

• Consult with Registered Dietician
• Determine habits
• Diet journal listing
• Food types
• Quantity
• Lifestyle changes
• Pre-planning
• Events
• Meal preparation
• Socioeconomic factors

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Non-Operative Treatments

• Scientific reports document non-operative methods
  alone have not been effective in
  medically-significant long-term weight loss
• Use of anorectic medications showed high
  association with cardiac valve disease (Phen-Fen)
• Dietary weight loss attempts often cause
  depression, anxiety, irritability, weakness and
  preoccupation with food

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Rationale for Surgical Weight Management

• Direct correlation b/w increased weight and
  increased mortality
• Numerous studies indicate mortality rates
  increase from 2x to 12x secondary to morbid
  obesity
• Framington study noted first cohort to terminate
  due to demise of all participants was morbidly
  obese
• Above study 10 decrease in weight 20
  reduction in developing coronary heart disease

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Surgical Treatment Goals

• Bariatric surgery involves reducing the size of
  the gastric reservoir
• This may include some degree of malabsorption
• Long-term changes in eating behavior
• Prevention of post-surgical complications

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Patient Selection

• Morbidly obese
• BMI gt40 or BMI gt35 with two comorbidities
• Well informed
• Motivated
• Acceptable of operative risks

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Medical Complications

• 0.5 mortality rate
• Respiratory Insufficiency
• Pneumonia
• Decreased wound healing rates
• Wound dehiscence
• GI Leaks
• Pulmonary embolism
• Obesity Hypoventilation Syndrome
• Sleep apnea
• Pannus wound maintenance

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Types of Surgical Procedures

• Laparoscopic Gastric Banding
• Vertical Banded Gastroplasty
• Roux-en-Y Gastric Bypass
• Biliopancreatic Diversion with or without
  Duodenal switch

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Laparoscopic Gastric Banding

• Recently approved by FDA
• Adjustable silastic band placed around upper
  stomach
• Creates 15cc pouch with narrowed outlet
• Outlet can be adjusted via saline reservoir

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Laparoscopic Gastric Banding

• Advantages
• No cutting or stapling
• Adjustable via saline reservoir
• Normal stomach anatomy is maintained
• Completely reversible
• Disadvantages
• Doesnt restrict sweet liquid intake
• Pouch slippage
• Mechanical problems

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Roux-en-Y Gastric Bypass (RNYGB)

• Proven surgical weight loss procedure
• Combines a gastric restrictive procedure with
  slow gastric emptying
• Results in decreased food absorption
• Considered Gold Standard

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Roux-en-Y Gastric Bypass (RNYGB)

• Decreases excess weight by 50-75
• Mortality rate of 0.5 and morbidity rate of
  5-10
• In most cases, this procedure will reduce weight
  from life-threatening levels

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Vertical Banded Gastroplasty (VBG)

• Recognized by NIH for treatment of severe
  clinical obesity
• Purely restrictive with no malabsorptive effect
• Results in pouch in upper stomach of 15cc with
  mesh band to prevent stretching

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Vertical Banded Gastroplasty (VBG)

• Disadvantages
• results in less wt. loss than RNYGB
• does not restrict intake of high calorie sweet
  liquids
• pouch can stretch over time
• 20 do not lose weight
• only 1/2 lose 50 of excess weight

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Case Study

• Whos your favorite TV weatherman?
• Al Roker had gastric bypass surgery performed
• To date hes lost over 100lbs
• Diet, exercise and support from family, friends
  and colleagues continue to motivate him
• http//www.alroker.com/

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In the Operating Room

• Access
• OR table
• Size of instruments
• Positioning
• Visualization of tissue
• Anesthesia risks
• Surgical procedures take longer

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Skin Issues

• Pressure
• Shear
• Friction
• Moisture
• Heat

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Skin Issues

• External pressure/ischemia
• Internal pressure/edema
• Moisture/maceration
• Microclimate challenges
• Staphlococcus
• Streptococcus
• Candida albicans
• Acanthosis nigricans
• Darkening of skin under folds
• Ulcerations in unique locations
• Skin tears under folds

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Topical Know-How

• Creams absorb faster than powders
• Not for long-term use
• Use ostomy powders
• Barrier ointments are good choice
• Antifungal treatments
• Baza Cream by Coloplast
• Aloe Vesta 2-n-1 Ointment by Convatec
• Triple Care by Smith and Nephew, Inc.

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Managing the Microclimate

• Cleansing and drying
• Absorption of excess moisture
• Dressings and skin barriers
• Daily inspection of bed
• Decrease friction/shear
• Support surface selection
• true low air loss
• rotation if necessary
• Trendelenburg with boost

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Room Environment

• Bed Frame and Mattress
• Lift systems
• Stand Assist systems
• Wheelchairs- position
• Toilet/shower aids
• Walkers
• Recliners

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Bed Guidelines

• Bed/Mattress widths from 39-60
• Most beds and mattresses have 600-1000 lb limits
• Built-in scales
• For clients gt 65, obtain bed/mattress of 86 or
  greater

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Appropriate Equipment Utilization

• Support Surfaces
• Weight capacity/bed scales
• Increased surface area
• Dissipation of excess moisture/heat
• Adequate structural support
• Products without weight limits

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Appropriate Equipment Utilization

• Transfer devices
• Mechanical/Electric lifts
• Hovermat
• Coated Turnsheets
• Barton transfer chair

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Appropriate Equipment Utilization

• Wheeled mobility
• Fit the chair to the client
• Pressure-relieving cushion
• Elevating leg rests

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Appropriate Equipment Utilization

• Ancillary products
• Shower/commodes
• Walkers
• Lift chairs
• Transport chairs
• Transfer benches

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Safety Issues

• Proper equipment
• Emergency procedures
• Staffing levels
• Training
• body mechanics

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Tying It All Together

• Obesity kills 300,000 people/year
• Medical care costs 50 billion
• Success requires a team effort
• Safety is crucial for client/caregivers
• Pressure management is paramount

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Resource Guide

• American Obesity Association
• www.obesity.com
• American Society for Bariatric Surgery
• info_at_asbs.org
• Council on Size and Weight Discrimination, Inc.
• www.cswd.org
• National Association for Advancement of Fat
  Acceptance
• www.naafa.org
• The ROHO Group
• www.therohogroup.com

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He Aint Heavy, Hes Your Patient!