Chapter 42: Managing Patients with Obesity

Global and national prevalence rates are high, contributing significantly to both morbidity and mortality by decreasing life expectancy, especially when compounded by chronic illness. The etiology is multifactorial, encompassing behavioral, genetic (including complex polygenic mutations), environmental, and physiological factors. Core pathophysiology involves adiposopathy, defined as the dysfunction of adipose tissue that releases biochemical mediators, leading to chronic inflammatory changes and subsequent metabolic diseases like Type 2 diabetes and hypertension. Appetite and satiety are regulated by various hormones, such as orexigenic ghrelin and neuropeptide Y (NPY) which stimulate hunger, and leptin, which signals fullness. Assessment requires nurses to overcome implicit biases by employing respectful, patient-first language. Key physical assessment involves calculating the Body Mass Index (BMI)—the definitive diagnostic tool—and measuring waist circumference to identify android obesity ("apple-shaped" fat distribution), which carries higher risks for cardiovascular disease. Management progresses from lifestyle modification, including high-intensity behavioral therapy, increasing physical activity (150 minutes of moderate aerobic exercise weekly), and achieving a daily caloric deficit of 500 to 1000 calories, to pharmacologic agents for those who fail to meet weight goals. Medications, which include GI lipase inhibitors and central appetite suppressants, are contraindicated during pregnancy due to teratogenic concerns. Nonsurgical interventions include vagal blocking therapy, intragastric balloons, and bariatric embolization, aimed at controlling appetite or gastric function. For severe obesity (BMI greater than 40 kg/m(squared)) or Class II obesity with severe comorbidities, bariatric surgery may be indicated, commonly utilizing restrictive procedures like sleeve gastrectomy or combined procedures like the Roux-en-Y gastric bypass (RYGB). Perioperative nursing care emphasizes multidisciplinary education, pain relief (favoring nonopioids), and the meticulous monitoring for complications such as venous thromboembolism (VTE) and the potentially fatal anastomotic leak. A critical safety alert prohibits the insertion of nasogastric (NG) tubes after bariatric surgery. Patients must be educated about dumping syndrome—a physiologic response to rapid gastric emptying causing tachycardia, sweating, and later hypoglycemia—and the need for lifelong supplementation to address deficiencies like iron and Vitamin B12. Nursing care also involves accommodating altered drug metabolism (pharmacokinetics/pharmacodynamics) and implementing frequent repositioning protocols and specialized bariatric equipment to prevent pressure injuries. Furthermore, obesity is a significant risk factor for severe outcomes in patients with COVID-19, and its prevalence among veterans post-military service is notably high.