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Dealing with the Challenges of the Dealing with the Challenges of the

Bariatric PatientBariatric Patient

Pride & Prejudice

WONE

April 30th 2009

Pride & Prejudice

• Women of the Time

Objectives

• Define and discuss specific challenges in the treatment of people with obesity and obesity related conditions

• Examine the broad scope of patient care services

• Identify the specific needs of the bariatric patients and assist in targeting their care in a coordinated interdisciplinary team effort

• Describe the use of surgery to achieve weight loss in obese patients

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Challenges of Obesity• Cost of obesity• – Physical : High blood pressure, diabetes, high cholesterol,• arthritis, and sleep apnea

• – Emotional: May have feelings of hopelessness, helplessness

• or lack of control.• – Economic : $33 Billion weight loss industry does not

include• bariatric surgery expense. The Research Triangle Institute

• and CDC reported in 2003 that $1.3 billion was spent in health

• care costs due to obesity, 5.7% of the state’s total budget.

Obesity DefinitionObesity Definition

Definitions:

• Obesity: Having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher.

• Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters.

Definitions:

• Obesity: Having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher.

• Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters.

Genetic

Environmental

Behavioral

Obesity Classification

6%>40.0

Clinically SevereObesity (Class III)

18%30.0-34.035.0-39.0

Obese (Class I)Obese (Class II)

60%>25.0Overweight

U.S. PopBMIClassification

Obesity has reached epidemic proportions in the U.S. over the past 20 years1

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Obesity Trends* Among U.S. AdultsBRFSS, 2007

(*BMI ≥≥≥≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥≥≥≥30%

Challenges “Lazy,” “dirty,”and “ugly”

Society sees the obese as second class citizens

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Attitude

• Obesity is a chronic illness. No one laughs at other chronic illnesses such as diabetes or COPD. Obesity can be just as deadly.

• Train your staff to be sensitive by being a good role model.

• Don’t tolerate behind-the-back whispers and jokes about obesity, even in private.

Non-Surgical Treatment

• Medication

• Diet and exercise

• Behavior modification

Minutes in Motion

Winning Weighs

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Put yourself in theirshoes…

Public Accommodations

• Obese individuals experience problems in public settings, such as restaurants, theaters, airplanes, buses, and trains because of inadequate seat size and inadequate features such as seat belts

Scope of Services• Gowns: 3X or larger

are recommended and should be readily available.

• Blood pressure cuffs: Extra-large cuffs

• Compression Stockings

• Socks

• Oversized towels

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Equipment

• Know weight limits

• Ambulatory/mobility aids

• Bathing equipment

• Beds/mattresses/ transportation

• Ceiling lifts

Walk through the front door• Transportation• Parking• Waiting Room (space and chairs size)• Magazines • Restroom / stall size• Weighing in privacy• Size of examination tables• CT scan that can accommodate

>400 lbs

Specific Needs

• Managing obese patients is challenging for caregivers

• Makes difficult tasks more difficult: turning a patient in bed, lateral transfers, transferring from bed to chair, lifting a limb to bath area, etc..

• Risk of injury increases when caring for obese patients

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Equipment & Safety

• Lateral transfer aids

• Multi-use lifts

• Powered lifts

• Standing assist aids

• Transfer/Geri chairs & cushions

• Wheelchairs

• Patient air-slide

Considerations

• Elevator door widths

• Radiology tables

• Surgical tables

• Consider motorized transport devices

• Be sure that your ambulance service is well equipped

Elimination

Large abdomen-may have incontinence

of bowel and bladder

Assist with proper perinealcleansing after toileting

Bladder scans-manufacturer guidelines

not accurate with BMI > 25

Rolling commode-600

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Activity and Mobility

• No hospital slippers-encourage use of shoes

• Out of bed to use commode

• Out of bed into a chair

• Assess normal activity

• Aids utilized

Patient Sensitivity

• A dedicated staff can make the experience less stressful and more rewarding for the patient.

• Understanding the challenges of bariatric patients is the key to providing them safe and effective care.

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“Fatism”

Obese persons are being ridiculed

by teachers, physicians, and

complete strangers in public

settings such as supermarkets,

restaurants, and shopping areas

• Sensitive treatment of obese patients involves attending to their needs of comfort, safety, and self-esteem.

• The person, not the obesity, should be the focus of treatment.

• Ensures that care is provided in a manner that enhances dignity, acceptance and a sense of

worth

See the Person Not the Size…

Obesity Increases Mortality

“Taken together, the diseases associated

with morbid obesity markedly reduce the

odds of attaining an average life span and

raise annual mortality tenfold or more.”

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Why Surgery??????

95-97% of people regain their weight using

conventional methods

Creation of Gastric PouchCreation of Gastric Pouch

Mortality rates following common operations in U.S. Hospitals

• Procedure Op mortality(%)

Esophageal Resection 9.1Ped. Heart Surgery 5.4Aortic Aneurysm 3.9CABG 3.5

Bariatric Surgery 0.1-1.1

NIH

• Spends less than 1% of its budget on obesity research, even though obesity causes at least 300,000 excess deaths in the USA and costs the country more that $100 billion.

• The last consensus statement on bariatric surgery dates back to 1991. National Institutes of Health

Consensus Development Conference StatementMarch 25-27, 1991

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The Price of Bias and

Discrimination in Health Care

Multidisciplinary Team Approachto Laparoscopic Gastric Bypass

• Surgeon

• Physician Assistant

• Registered Dietitian

• Clinical Psychologist

• Bariatric Coordinator

• Program Manager

• Patient

Who is Eligible for Bariatric Surgery?

• The NIH Consensus Panel recommends that:

• Patients have a Body Mass Index > 40 kg/m2

– 100 lbs. or more overweight

• Patients have a Body Mass Index between 35 and 40 kg/m2 with significant comorbidities

• Patient have failed other medically managed weight-loss programs

6% of the U.S. adult population (over 12 million people)meet these criteria

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Health Insurance Coverage• Even with evidence of cost-savings for gastric

bypass, medical coverage is inconsistent. Surgical treatment is often not reimbursed even though diseases with less supported treatments are compensated

• “Ethically unconscionable”» Diabetic patient

Three Types of Most Commonly Performed Bariatric Surgery Procedures

Malabsorptive

Restrictive

Combination

Biliopancreatic Diversionwith Duodenal Switch Adjustable Band

Gastroplasty

Roux-en-Y Gastric Bypass

Bariatric Surgical OutcomesSummary of 10,000 Gastric-Bypass

Procedures

• 85% reduced their weight to at least 50% above ideal weight

• 5,000 patients followed for 10 years

80% were able to maintain this result

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