More than a third of Americans are obese, a figure that has increased dramatically over the last 20 years, the CDC reports. The number of patients seeking bariatric and bariatric revision surgery – and treatment for resulting conditions such as diabetes, coronary heart disease and stroke – has risen in kind. Obesity, and the comorbidities associated with it, is now the second leading cause of preventable death in the U.S.
If rates rise according to projections, obesity could cost the U.S. up to $66 billion in treatment and over $500 billion in lost economic productivity by 2030, when more than half of Americans will be obese, according to a report released by Trust for America’s Health and the Robert Wood Johnson Foundation. But advances in surgical procedures and treatment, paired with knowledgeable, compassionate care, can help.
Bariatric (or weight-loss) surgical procedures help obese patients lose weight in several different ways: by reducing the size of the stomach with a gastric band, by removing a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch), or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).
The number of bariatric procedures performed in the U.S. has increased by 20 percent per year over the past 20 years, according to a report by the National Institute of Diabetes and Digestive and Kidney Diseases. More than 200,000 bariatric procedures are now performed annually in the U.S. — up from about 13,000 in 1998.
“Lifestyle changes and dieting rarely produce sustained weight loss and often are ineffective in achieving long-term improvement in comorbidities,” wrote Janice A. Neil, PhD, RN, an associate professor at East Carolina University, College of Nursing, in Greenville, N.C., in an article in the February issue of the AORN Journal. “Bariatric surgery has become an effective method for sustained weight loss and improvement of obesity-related comorbid conditions.”
Reasons for the rise
Experts attribute the rise in the number of bariatric procedures performed in the U.S. to several different factors, including the use of laproscopic techniques, the proven success of weight-loss surgery, increased public acceptance of bariatric procedures, and a growing number of insurers that will pay for them. “This is allowing many more people, even teens, to benefit from the health advantages of weight-loss surgery,” wrote Dr. Neil.
An estimated 32 percent of adult men and 35 percent of adult women in the U.S. are obese. Those who are considered morbidly obese — which is defined as having a body mass index (BMI) that exceeds 40 kg/m2 — are the primary candidates for bariatric surgery, although patients who are considered severely obese (having a BMI between 35 kg/m2 and 39 kg/ m2) may also be considered if they have comorbid conditions.
These may include hypertension, sleep apnea, diabetes mellitus, or musculoskeletal issues that interfere with employment and ambulation. “People who are obese with lower BMIs are also now seeking weightloss procedures to achieve sustained weight loss and prevent comorbidities and health-related quality of life issues,” wrote Dr. Neil.
In addition to helping morbidly obese patients lose weight, bariatric surgery is also being used more frequently to help control diabetes. The Cleveland Clinic listed “bariatric surgery for control of diabetes” at the top of its list of Top 10 Medical Innovations that will have a major impact on improving patient care within the next year.
“While the medications we have for diabetes are good, about half of the people who take them are not able to control their disease,” says Dr. Phil Schauer, the Director of the Cleveland Clinic’s Bariatric & Metabolic Institute. “Many diabetes experts now believe that weight-loss surgery should be offered much earlier as a reasonable treatment option for patients with poorly controlled diabetes — and not as a last resort.”
Skill and compassion
Given these trends, it’s important that perioperative nurses learn the right ways to care for bariatric patients. “Perioperative nurses must be knowledgeable about how to care for bariatric surgery patients with skill and compassion,” wrote Dr. Neil.
This includes not only their physical care, but also their psychological care. “There are a lot of psychiatric aspects to bariatric surgery,” says Carolyn McKee, RN, CNOR, the Bariatric Coordinator at Clark Memorial Hospital in Jeffersonville, Ind. “We need to make sure the patients are mentally prepared for this type of surgery. Fear of the unknown is the greatest fear among patients, so it’s important to educate them about all aspects of the procedure.”
McKee says that sensitivity training may be appropriate for perioperative nurses who will be working with bariatric patients. “Nurses have to be very careful what they say to and around bariatric patients and how they say it. Saying things like ‘Somebody go get the big-boy wheelchair’ is hurtful and degrading. Surveys reveal that bariatric patients believe they deserve less care, but of course, this isn’t true — they deserve the same level of care as anyone else.”
Patient positioning and transport are always important, but especially for bariatric patients. The Association of Perioperative Registered Nurses (AORN) Recommended Practices for Positioning the Patient in the Perioperative Practice Setting states that the perioperative registered nurse should identify unique patient considerations (including morbid obesity) that require additional precautions for procedurespecific positioning. “Additional precautions may be necessary when positioning special patient populations to reduce the risk for integumentary, respiratory or cardiovascular compromises and nerve impairment,” the Recommended Practice states.
“Obesity adversely affects most body systems,” it continues. “Routine skin condition assessments may be difficult because of the patient’s size, lack of landmarks and chronic conditions. Traditional foam positioning products may prove ineffective due to compression resulting from the patient’s weight.
“Patient needs should be assessed by a registered nurse before transport to determine the required equipment and the skill level and number of transport personnel needed. Advance preparation for transport may be required for obese patients or other patients with special needs.”
McKee notes that bariatric patients also tend to be more prone to getting pneumonia and to developing thrombosis. “An incentive spirometry machine encourages the patient to deep breathe post-operatively to help prevent pneumonia, while following DVT protocols can help prevent blood clots. It is also vitally important to prevent vomiting with bariatric surgery patients and not to give them carbonation post-operative, since this dilates the gastric pouch.”
Detailed post-op instructions
Just as important is making sure bariatric patients are well-educated on what they need to do post-operatively when they get home. “Early ambulation is the key,” adds McKee, who says she has only had one bariatric patient who developed a blood clot after returning home. “During my post-op call I asked her if she was having any trouble breathing. She said yes, but thought it was her asthma. I was quite sure it wasn’t asthma and strongly urged her to go to the ER, where they diagnosed the blood clot in her lung.”
Prompt and thorough post-op follow-up is critical, she adds. “We give our bariatric patients detailed post-op instructions for wound care, diet, medication and ambulation, as well as all of our phone numbers where we can be reached 24/7. And we encourage them to call us at any time if they have questions or concerns.”
How one facility is meeting the needs of bariatric patients
Rex Bariatric Specialists, a multi-disciplinary bariatric center that is part of the UNC Health System in Raleigh, N.C., recently moved into a new, larger space designed to provide more support services for its patients. Designated as a Bariatric Surgery Center of Excellence by the American Society for Metabolic & Bariatric Surgery (ASMBS), Rex combines surgical services with access to a broad range of preand post-operative patient resources.
An interdisciplinary team of dietitians, psychologists, nutritionists, surgeons and clinical nurse specialists work with patients at Rex. The team guides patients through the weight-loss process, from their first consultation through surgery, as well as with an intensive follow-up program that helps ensure patients have what they need to succeed long-term.
“These are people who can help patients overcome the challenges associated with obesity and weight-loss surgery – both the sabotage within and the sabotage from their environment,” explains Peter Ng, M.D., director of Bariatric surgery for Rex Surgical Specialists.
Lifelong follow up is one of the most important things a comprehensive program like Rex can provide, Ng says. “Obesity is like many chronic diseases. We may be able to treat it and help you achieve remission (weight loss and improvement in co-morbidities), but that doesn’t mean you’ve escaped risk of that disease coming back.”
“There are many reasons a patient can fail to maintain weight loss following a procedure,” Ng says, “including maladaptive eating, failure to exercise, nd poor follow-up.” Patients who lose weight quickly often feel that he or she has conquered obesity. Ng says that after bariatric surgery, there is a honeymoon period of rapid weight loss, and patients are sometimes unprepared for the struggles of normal life return.
To help patients cope, physicians at Rex regularly lead support groups for as many as 125 people. The facility has also created an online community where patients can share experiences and implemented a mentoring program where patients become mentors for others who are going through the process.
Rex Bariatric Specialists also provides services to help patients with more practical considerations. Because the surgery can change the way the body metabolizes food, nutritional challenges may arise. Rex has a professional kitchen where staff dieticians and outside speakers educate patients on how to prepare healthy meals and follow a proper diet. “As a bariatric program, we try to educate not only patients but primary doctors and nurses” about how bariatric surgery affects the body and their follow-up care, Ng says.
Rex has also partnered with a restaurant in the area, whose chef is working with Rex physicians and nutritionists to create a bariatric-friendly menu.
“We’ve tried to be very thoughtful from the ground up to address the needs of our bariatric patients,” Ng says.
