Obesity

Obesity

1. Classifications

   • healthy = 18.5 - 24.9 overweight = >25 obese 1 = 30-34.9 obese 2 = 35-39.9 obese 3 = > 40

2. Associated diseases

   • Type II diabetes Hypertension Angina MI Stroke

3. Obesity related problems

   • OSA
     • obstructive sleep apnoea - airway at the back of the throat becomes narrow as soft tissue relaxes.
   • Resp problems
   • Low back pain
   • dyslipidaemia
     • Increased triglycerides. Low HDL:LDL ratio.

4. Assessment

   • Presenting symptoms and underlying cause of overweight or obesity Determine the degree to which the pt is overweight. Risk factors and co-morbidities Eating behaviour, psychosocial factors, lifestyle. Willingness and motivation to change.

5. Motivational interviewing

   • See health promotion lecture.

6. Bariatric surgery

   • Restrictive
     • Reducing the size of the stomach so you get fuller quicker. e.g. gastric band, sleeve gastrectomy (85% of stomach removed).
   • Malabsorptive
     • Small intestine re-routed so food skips a portion of it. e.g. gastric bypass
   • Combination
     • Size of stomach is reduced and small intestine is re-routed. Bilopancreatic diversion with duodenal switch - nest form of weight loss however increased risk of nutritional deficiencies and its irreversible.
   • Complications
     • Atelectasis and pneumonia DVT and PEs Wound infection GI bleeding Failure to lose weight Mortality
     • Atelectasis
       • THE MORE OBESE YOU ARE, THE LOWER YOUR FRC. Atelectasis is thought to occur in 90% of patints undergoing general anaesthetic. With GA, there is loss of muscle tone which decreases chest wall recoil and increases intra-abdominal pressure. This leads to a decrease in FRC and therefore an increase in airway resistance because the FRC is below the CV. This leads to compression atelectasis of the dependent zones.
     • Post-op resp problems
       • Loss of volume due to atelectasis which increases the risk of pneumonia. Loss of volume creates a V/Q mismatch, with intra-pulmonary shunt which leads to hypoxaemia. There is decreased lung compliance and adipose tissue decreases chest wall compliance. A low FRC increases the risk of exp flow limitation and airway closure, leading to high airway resistance. This increases the WOB.
   • Post-op physio
     • Restore pulmonary function Clear secretions if present Promote early mob Restore to functional level
     • Lung recruitment options
       • Positioning Sitting out in chair Mob Lower thoracic expansions Incentive spirometry PEP devices CPAP BiPAP
     • Important considerations
       • Continued therapy for OSA Adequate analgesia Supplemental O2 Correct bariatric equipment and manual handling.
     • TUFG programme
       • Tone up, feel good. Physio assessment Appropriate activity tailored to the pt Breathing techniques Borg RPE scale and talk test Virtual toolbox Warm up exercises - stretches, tai chi 10min exercise circuit 5 min walk for cool down Breathing exercises Posture and back care Final discussion/documentation
       • Virtual toolbox
         • Thirst/hunger awareness Energy balance Time given to activity SMART objectives visualisations readiness for change