Malnutrition & Obesity

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

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

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

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

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 30-40 yrs old since 1990

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

11. Complications of Obesity Diabetes mellitus Hypertension Hyperlipidemia CAD Obstructive sleep apnea Obesity hypoventilation syndrome Depression and other mental health/behavioral health problems

12. Contributing Factors to Obesity • Diet • Physical inactivity • Drugs • Corticosteroids • Estrogens • NSAIDS • Antihypertensives • Antidepressants and psychoactive drugs • Genetics

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 300-500 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

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

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