By; Sandi Effendi
urology staff nurse mubarak al kabeer hospital, kuwait
Obesity is an overabundance of body fat resulting in body weight of 20% or more than the average weight for the person’s age, height, sex, and body frame. Increasingly, obesity is being diagnosed using the Body Mass Index (to account for body build) and/or Body Surface Area and Basal Metabolic Rates (to account for metabolic activity for the person). A BMI greater than 30 is considered obese. About 18% of American are obese (up from 12% in 1991) and 63& of men and 55% of women are over weight.
Pathophysiology and etiology
1. Increasing evidence reveals that heredity plays a part in the development of obesity. Identical twins raised apart are more likely to have similar amounts of body fat than fraternal twin raised separately.
2. Environment plays a role.
a. Some evidence shows that children reared by obese parents have an increased tendency toward obesity.
b. In addition, social class may be associated with more weight-conscious behavior.
3. A variety of psychological factors may contribute to weight gain, including depression and anxiety.
4. Physiologic factors
a. Endocrine abnormalities (rare causes of obesity)-Cushing’s syndrome, hypothyroidism, hypogonadism, or hypothalamis lesions.
b. Age-advancing age may be associated with obesity often because of changes in activity level or in women, because of hormonal changes; early childhood and the start of puberty may also be associated with obesity.
(i) Overeating after puberty may increase the total number of fat cells.
(ii) Despite dieting, these extra ft cells can never be eliminated; they only decrease in size.
1. Body weight greater than 20% of acceptable weight for eight or BMI > 30.
2. Increased weight is correlated with increased incidence of:
a. Cardiovascular disease
b. Diabetes mellitus
1. Diet therapy-has been controversial, but a well-balanced diet containing all the major food groups is still advised.
a. One thousand calories per day must be eliminated from a diet to lose 1 kg (2.2 lb) of body weight per week.
b. A 1,200-calorie diet for women and a 1,500-calorie diet for men with variations depending on patient size and activity level are basic to diet management. Fats should compose no more than 30 % of all calories, proteins approximately 15 to 20% and carbohydrates should constitute the remaining portion
c. A balance of food groups is essential to maintain vitamin and nutrient balance. Nutrient supplements may be necessary (iron, B6,Zinc, and folate)
d. Food preparation, should include seasoning with herbs, onion, garlic, and pepper, and foods should be baked, broiled, steamed, or sauteed using minimal polyunsaturated oil.
e. Food attractively arranged on smaller plates, using whole rather than processed foods and eaten slowly, will assist the overall process
f. Eliminating entire food groups from the diet, such as carbohydrates (in many popular protein and fat-based diets), will eventually result in craving of those foods eliminated, disruption of normal metabolic processes, and quick weight gain when the food is added to the diet.
2. Exercise—a daily exercise program may include walking or other aerobic activities for approximately 180 minutes per week, or 1 hour at least three times a week, however daily exercise is optimal.
3. Behavior modification is a cornerstone of any successful diet.
a. Identify and eliminate situations or cues leading to overeating or high-calorie foods with use of a food diary.
b. Provide positive reinforcement of proper dietary habits.
c. Should a lapse in diet habits occur, focus on a prompt and positive return to appropriate dietary habits
d. Stress reduction techniques, such as visual imagery or progressive relaxation; peer support may be helpful
1. Anorexia medications, such as amphetamines and norepinehrine-releasing agents or reuptake inhibitors, reduce appetite and stimulate weight loss initially.
2. However, tolerance develops within 2 to 4 weeks and weight is rapidly regained when the drugs are discontinued
3. Numerous long-term studies have failed to show long term success with these agents
4. Phentermine (Ionamin, Fastin) is one of the most widely prescribed agents; however, it causes stimulating effects and should not be used in uncontrolled hypertension, advanced heart disease, history of drug abuse, and with MAO inhibitors.
5. Sibutramine (Meridia) is a mixed neurotransmitter reuptake inhibitor that acts on the central nervous system to reduce appetite.
a. The long-term risks of the medication are not known, but it must be used cautiously with hypertension, coronary artery disease, heart failure, arrhythmia, renal and hepatic impairment, narrow angle glaucoma, and seizure disorders.
b. Multiple drug interactions include monamine oxidase inhibitors, other serotonic drugs (selective serotonin reuptake inhibitors (SSRIs) antidepressants, sumatriptahn and other migraine agents), lithium, dextromethorphan, and possible erythromycin and ketoconazole.
c. Side effects include dry mouth, constipation, dizziness, nervousness, insomnia. Has not been shown to be addictive.
6. Recently, scientists have found success in weight loss with the use of orlistat (xenical), agastrointestinal lipase inhibitor, which blocks the breakdown of fat in the GI system. About 30% of dietary fat is eliminated.
a. Side effects include oily or fatty stools, flatulence, and GI distress.
b. Long term safety of the drug has not been determined, but addition of fat-soluble vitamin supplement (vitamin A,D,E,K and beta carotene) taken prevent a theoretical vitamin deficiency.
c. Should not be used in cases of cholestasis or malabsorption.
d. These medications are only adjunct to diet and exercise therapy.
Numerous surgical procedures have been used. However, gastroplasty is the current procedure of choice. These therapies are generally reserved for morbidity obese patients who cannot lose weight through the above therapies.
1. Gastroplasty-most common procedure is vertical banding involving creation of a 30 ml pouch along the lesser gastric curvature with a small outlet created with the use of a ring of plastic at the distal end to prevent dilation
2. Gastric bypass-a Roux-en-Y gastroenterostomy is constructed by first creating a 50 –ml pouch in the proximal stomach by stapling horizontally and completely separating the smaller proximal stomach pouch from the larger distal stomach pouch. To this proximal pouch, the distal jejunum is attached, thus bypassing the distal stomach pouch. The transected proximal portion of the jejunum is anastomosed to the distal jejunum.
1. Obesity is a risk factor for diabetes, gallbladder disease, osteoarthritis of weight-gearing joints, high blood pressure, and coronary artery disease.
2. Vitamin and mineral deficiencies because of surgical intervention and/or severely restricted diet
a. A moderate, well-balanced weight reduction diet will generally not cause deficiencies, although a multiple vitamin/ mineral supplement may be used
b. A low-calorie diet (fewer than 800 to 1,000 calories/day) will require careful monitoring and vitamin/ mineral supplements.
1. Obtaining a complete nutritional assessment (may be in collaboration with a nutritionist)
2. Assess behavioral/ emotional components of eating, coping mechanism, and past successes/ failures with dieting.
Altered Nutrition: More Than body Requirements related to high-calorie, high-fat diet, and limited exercise
Fluid volume Deficit related to gastroplasty or gastric bypass surgery
Self esteem Disturbance related to weight
Modifying Nutritional Intake
1. Assist patient in assessing current dietary habits and identifying poor dietary habits
2. Assist patient in developing appropriate diet plan based on likes and dislikes, activity level, and lifestyle
3. Suggest behavior modification strategies, such as shortening lunch break, preventing access to quick snacks, eating only at mealtimes at the table
4. Provide emotional support to patient during weight reduction efforts positive reinforcement and creative problem solving
5. Provide patient with alternative coping mechanisms, including stress reduction techniques, such as progressive relaxation and guided imagery
6. Assess patient’s ability to tolerate exercise through measurement of vital signs before, during, and after exercise and ask about symptoms of shortness of breath and chest pain
Outcome Based Evaluation
Five pound weight loss during first month
No abdominal distention, nausea, vomiting, or wound infection
verbalizes feeling good about self secondary to change in diet exercise habits
The Lippincott seventh edition