Obesity

OBESITY - MEDICAL NURSING

1. Obesity

2. Definition
•Obesity is an abnormal growth of the adipose
tissue due to an enlargement of fat cell size
(hypertrophic obesity) or an increase in fat cell
number (hyperplasic obesity)or a combination of
both.

•Obesity is an abnormal increase in the proportion
of fat cells characterized predominantly by
adipocyte hypertrophy.

3. Incidence
•Prevalence rate of obesity in India (2015) is
11.8% to 31.3%.
•Higher obesity prevalence in Urban population.

4. Etiology
•Age
▫Can occur at any age.
•Sex
▫Women are more likely to gain weight than men
with the same calorie intake.
▫Menopause contribute in weight gain.
▫Pregnancy also contribute to the development of
obesity in women

5. •Genetic
▫Family history
•Biologic Basis
▫Change in regulation of eating behavior, energy
metabolism, body fat metabolism by hypothalamus.
▫Increased circulating plasma levels of leptin, insulin,
and ghrelin, and decreased levels of peptide YY.
▫Interaction of these hormones and peptides at the
level of the hypothalamus.
▫Alterations of adipokines (hormones secreted by
adipocytes and cytokines)
Decreased level of Adiponectin
Increased level of Resistin

6. •Environmental Factors
▫Greater access to pre-packed food, fast food and soft
drinks.
▫Increased portion size of meals
▫Eating outside home
▫Lack of physical exercise
▫Low Socioeconomic status
▫Lack of sleep
•Psychosocial Factors
▫Tendency to overeat
▫Social gatherings or parties
•Eating Habits
▫Excessive calorie intake
•Alcoholism
•Smoking

7. •Drugs
▫Corticosteroids
▫Contraceptives
▫Insulin
▫Beta-adrenergic blockers
▫Antidepressants
▫Anti-seizure drugs
▫Antipsychotic drugs
•Disorders
▫Endocrine disorders
▫Congenital anomalies
▫Metabolic problems
▫Chromosomal anomalies
▫CNS disorders.

8. Pathophysiology
Long-term sedentary lifestyle and/or excessive calorie intake

Imbalance between energy expenditure & energy intake

Adipocyte hypertrophy

Increases adipocyte volume & increases lipid storage

Visceral and subcutaneous fat accumulation

Alterations of adipokines

Overweight or Obesity

Increases risk for diseases

9. Measurements of obesity
•Height-weight chart
•Body mass index (BMI)
•Waist circumference
•Waist-to-hip ratio
•Skinfold Thickness

10. •Height-weight chart:
▫Weight 10% to 20% above ideal body weight is
overweight;
▫20% or more above ideal body weight is obesity.
▫Ideal weight calculation
1.Broca’s index = Height (cms) – 100
2.Corpulence index =

This should not exceed 1.2
3.Ponderal index =
Height (cm)
weight (kg)
3

4.Lorentz’s formula
= [Height (cm) – 100] –
Height (cm) – 150
2(women) or 4(men)

Actual weight
Desirable weight

11. •Body mass index (BMI):
▫Best methods for defining obesity.
▫BMI = Weight (kg)/Height (m
2
)
•Below 18.5 Underweight
•18.5–24.9 Normal
•25.0–29.9 Overweight
•30.0-34.9 Obese class I
•35.0-39.9 Obese Class II
•≥ 40.0 Obese Class III or Morbid obesity

12. •Waist circumference:
▫≥102 cm in men and ≥88cm in females is
associated with an increased risk of metabolic
complications.
•Waist-to-hip ratio
▫Preferred tool to measure for overweight and
obesity when the patient is predominantly
muscular.
▫The waist measurement is divided by the hip
measurement to calculate the ratio.
▫WHR of <0.80 is optimal.
▫WHR greater than 0.8 indicates greater risk for
health complications.
▫A high WHR (> 1.0 in men and > 0.85 in women)
indicates abdominal fat accumulation.

13. •Skinfold Thickness
▫For assessing body fat.
▫Several varieties of callipers
are used. (E.G., Harpenden
skin callipers)
▫Normal finding is mid triceps
+ mid biceps + sub scapular +
supra iliac = 50mm in women
or 40 mm in men.

14. Classification of obesity
1.Primary obesity and secondary obesity
2.According to BMI
3.According to body shape or fat distribution

15. •Primary obesity
▫Due to excess calorie intake for the body's
metabolic demands.
•Secondary obesity
▫Due to various congenital anomalies, metabolic
problems, chromosomal anomalies, or CNS
disorders.

16. •According to BMI
▫Individuals with a BMI
•25.0–29.9 Overweight
•30.0-34.9 Obese class I
•35.0-39.9 Obese Class II
•≥ 40.0 Obese Class III or Morbid obesity


•In the view of genetic susceptibility, Union
Ministry of Health and Family Welfare of India has
scaled down the BMI to >23 kg/m
2
to be classified
as overweight.

17. •According to body shape or fat distribution
1.Gynoid obesity
2.Android obesity

•Gynoid obesity:
▫Pear-shaped body
▫Fat is located in the buttocks and upper legs
▫Gluteofemoral adipose tissue accumulation
▫More subcutaneous fat
▫Common in women
▫Better prognosis but is more difficult to treat
•Android obesity:
▫Apple-shaped body
▫Fat is distributed over the abdomen and upper body (neck,
arms, and shoulders)
▫Abdominal adipose tissue accumulation
▫More visceral fat
▫Common in men
▫Greater risk for obesity-related complications

19. Clinical features
Signs
•Clothes feeling tight and needing a larger size.
•Weight gain as compared to previous
measurement
•Having extra fat around the waist.
•A higher than normal body mass index and waist
circumference.

20. Symptoms
•Breathlessness
•Increased sweating
•Snoring
•Back and joint pains
•Feeling tired even with routine activities
•Inability to cope with sudden physical activity
•Psychological problems such as low self esteem,
low confidence level

21. Health risks associated with obesity
•Increased mortality
▫Especially associated with visceral fat
•Type 2 Diabetes
•Hypertension
•Coronary heart disease & stroke
•Metabolic syndrome
•Cancer- Colon cancer, breast cancer in
postmenopausal women, endometrial cancer
•Gallstones
•GERD
•Asthma

22. •Osteoarthritis
•Low back pain
•Reduced fertility
•Sleep apnoea (interrupted breathing during sleep)
•Liver disease
•Kidney disease
•Pregnancy complications
▫Gestational diabetes
▫Pre-eclampsia
▫Foetal defects
•Obesity reduces life expectancy by an average of 3
to 10 years according to its severity.

24. Diagnostic measures
•History collection
•Physical examination
▫Full medical assessment
•Measurements of obesity
•Laboratory examination
▫Fasting lipid profile
▫Liver function tests
▫Thyroid function tests
▫Fasting glucose and haemoglobin A1c(HBA1c)

25. Management

26. Life style modifications

Nutritional Therapy

Physical activity

Behavior modification

27. Nutritional Therapy
•Calorie-Restricted Weight-Reduction Diet
▫Low calorie diet
800-1200 calories per day
▫Very Low calorie diet
Less than 800 calories per day

28. Healthy eating habits
•Limit total fat intake and shift fat consumption away
from saturated fats to unsaturated fats and
elimination of trans fats.
▫Eat fat-free and low-fat dairy products, such as low-fat
yogurt, cheese, and milk.
▫Avoid whole milk, whole-milk cheese, cream, butter,
and ice cream
▫Avoid foods containing solid fats(vanaspati ghee,
coconut, and palm oils) such as deep fried fast foods
▫Limit foods prepared with partially hydrogenated oils
(doughnuts, cookies, crackers, muffins and cakes).
▫Limit use of ground beef, sausage, and processed meats.

29. •Increase consumption of fruits, vegetables, pulses,
whole grains, legumes and nuts
•Limit intake of sugar and salt.
•Eat regularly. Do not skip meals.
•Reduce fat intake by baking, or steaming foods.

Portion size
•Measure foods to determine the correct portion
size.
•Avoid oversized portions.
•Use a smaller plate, bowl, and glass.

30. Food weight
•Eat foods that are lower in calories and fat for a
given amount of food.
▫For eg: replacing a full-fat food product that
weighs two ounces with a low-fat product that
weighs the same.
•Eat foods that contain a lot of water, such as
vegetables, fruits, and soups.

Fad diet
•Weight-loss plan that promises dramatic results.
•Typically, these diets are not healthy and don't
result in long-term weight loss.

31. Sl.no Type of fad diet Diet composition
1 Atkins diet Protein 27%
Carbohydrate 5%
Fat 68% (saturated fat : 26%)
2 Zone Protein 34%
Carbohydrate 36%
Fat 29% (saturated fat : 9%)
Alcohol 1%
3 South beach Protein 50%
Carbohydrate 10%
Fat 40%
4 Sugar busters Protein 27%
Carbohydrate 5%
Fat 68% (saturated fat : 26%)

32. Physical activity
•Regular physical exercise.
•To increase energy expenditure.
•Daily 30 minutes to 1 hour per day.

33. Behavior modification
•Changing behaviors or habits related to food and
physical activity is important for losing weight.
•Change the habits promoting weight gain such
as watching television for long hours.
•Self monitoring
▫Keep a record of weight loss.
•Stimulus control
•Reward the success for meeting weight-loss
goals.

34. Pharmacotherapy
•Only as adjuncts to a nutritional therapy and
exercise program.
•Prescribed only when BMI is 28 kg/m
2
or more
with other weight related conditions or BMI 30
kg/m
2
or more.
•Two categories of drugs:
1)Appetite-suppressing drugs
2)Nutrient absorption blocking drugs

35. Appetite-suppressing drugs

Noradrenergic drugs

Serotonergic drugs

Mixed noradrenergic-serotonergic drugs

Noradrenergic drugs
•Reduce food intake by noradrenergic mechanism in
the CNS.
•Recommended only for short term use- less than 12
wks.
•Eg: phentemine, diethyipropol, phendimetrazine,
Benzpbetamine

36. Serotonergic drugs
•Act by either increase the release of serotonin or
decrease its uptake, thus reducing the
metabolism.
•Not currently used because of its adverse effects.

Mixed noradrenergic-serotonergic drugs
•Inhibits both serotonin and norepinephrine
uptake, thus decreases appetite.
•Eg: Sibutramine

37. Nutrient absorption blocking drugs
•Eg: Orlistat
•Inhibits the action of intestinal lipases, thus
block breakdown and absorption of fat in the
intestine.

38. Surgical management
•The field of obesity surgery is called bariatric
surgery
•Indications
▫Morbid obesity.
▫Gross obesity for 5 years
▫Failure to reduce weight with other forms of
therapy
▫Body weight 100% above ideal weight
▫Presence of a high-risk condition that weight loss
would relieve.

39. Bariatric surgeries






Bariatric
surgeries
Restrictive
surgeries
Vertical Banded
Gastroplasty
Adjustable Gastric
Banding
Malabsorptive
surgeries
Biliopancreatic
Diversion
Biliopancreatic
Diversion with
Duodenal Switch
Combination of
malabsorptive
& restrictive
Roux-en-Y gastric
bypass

40. Restrictive surgeries
•Reduces the size of a stomach to 30 ml or less,
which causes the patient to feel full quicker.

1.Vertical Banded
Gastroplasty
•Involves partitioning the
stomach into a small
pouch in the upper portion
along the lesser curvature
of the stomach.
•This small pouch
drastically limits capacity.

41. 2.Adjustable Gastric
Banding
•Stomach size is limited by an
inflatable band placed around
the fundus of the stomach.
•Referred to as LapBand B.
•The band is connected to a
subcutaneous port and can be
inflated or deflated (by fluid
injection in the hospital) to
change the stoma size to
meet the patient's needs as
weight is lost.
•Laparoscopic procedure.

42. Malabsorptive surgeries
•Length of the small intestine is decreased, so that less
food is absorbed.
1.Biliopancreatic Diversion

•Involves removing approximately
three fourths of the stomach
•The remaining portion of the
stomach is connected to the lower
portion of the small intestine.
•Most of the calories and
nutrients are routed into the
colon.
•Nutrients pass without being
digested.

43. 2.Biliopancreatic Diversion with Duodenal
Switch
•Variation of Biliopancreatic Diversion.
•Half of the stomach is removed,
leaving a small area.
•The entire jejunum is excluded from
the rest of the GI tract.
•The duodenum is disconnected and
sealed off.
•The ileum is divided above the
ileocecal junction and the distal end of
the jejunum is anastomosed to the first
portion of the duodenum.
•The distal end of the biliopancreatic
limb is anastomosed to the ileum.

44. Combination of Restrictive & Malabsorptive
Surgery
1.Roux-en-Y gastric bypass

•Most common bariatric
surgery.
•In this procedure, the
stomach size is decreased
with a gastric pouch
anastomosis that empties
directly into the jejunum.

45. Cosmetic surgeries
•To reduce fatty tissue and skin folds.
1.Lipectomy
2.Liposuction

46. 1.Lipectomy
•Also called adipectomy.
•To remove unsightly flabby folds of adipose tissue.
•Up to 15% of the total fat cells are removed from the
breasts, abdomen, lumbar and femoral areas.
2.Liposuction
•Also called suction assisted Lipectomy.
•Liposuction is a surgical procedure that uses a
suction technique to remove fat from specific areas
of the body, such as abdomen, hips, thighs, buttocks,
arms or neck.
•A long hollow stainless steel cannula is inserted
through a small incision over the fatty tissue to be
suctioned.

47. Nursing diagnosis
•Imbalanced nutrition: more than body requirements
related to excessive intake in relationship to
metabolic needs.
•Impaired skin integrity related to alterations in
nutritional state, immobility, excess moisture
and multiple skinfolds
•Ineffective breathing pattern related to decreased
lung expansion from obesity.
•Chronic low self-esteem related to body size,
inability to lose weight.

48. Postoperative Care
•Maintain airway.
•Manage pain.
•Elevate head end at 35° to 40 angle to reduce
abdominal pressure and increase tidal flow.
•Wound care.
•ROM exercises.
•Early ambulation.
•Measures to prevent thrombophlebitis.
•Change position every 1 every to 2 hours.

49. •IV fluids and NG tube feeding.
•Breathing and coughing exercises.
•Frequent mouth and nose care.
•Frequent observation of wound for the amount
and type of drainage, condition of the sutures,
and signs of infection.
•Maintain hygienic needs, skin care.
•Maintain intake output chart.

50. Postoperative dietary management
•Immediate postoperative period (first 24 hr)
▫Water and sugar-free clear liquids are given (30
ml every 2 hr while awake).
•At 1 day to 2 weeks postoperatively
▫A high-protein liquid diet every 2 hours while
awake.
•At 2 to 4 weeks postoperatively
▫A pureed diet is provided at frequent intervals.
•At 4 to 6 weeks
▫Starts on a transition diet that includes solids, as
well as pureed foods.

51. Discharge instructions:
•Eat three meals per day (containing protein and
fiber).
•Include two protein snacks per day.
•Restrict total meal size to less than 1 cup.
•Eat slowly.
•Chew thoroughly.
•Eat only foods packed with nutrients (eg, peanut
butter, cheese, chicken, fish, beans).
•Do not eat and drink at the same time.
•Drink plenty of water, from 90 minutes after each
meal to 15 minutes before the next meal.
•Avoid liquid calories, such as alcoholic beverages,
fruit drinks, and regular soda (cola).
•Walk for at least 30 minutes per day.

52. Thank you