Obesity

Nota:

• Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health.

1. Classifications

   Nota:

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

   Nota:

   • Type II diabetes Hypertension Angina MI Stroke
3. Obesity related problems
   1. OSA

      Nota:

      • obstructive sleep apnoea - airway at the back of the throat becomes narrow as soft tissue relaxes.
   2. Resp problems
   3. Low back pain
   4. dyslipidaemia

      Nota:

      • Increased triglycerides. Low HDL:LDL ratio.
4. Assessment

   Nota:

   • 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

   Nota:

   • See health promotion lecture.
6. Bariatric surgery
   1. Restrictive

      Nota:

      • Reducing the size of the stomach so you get fuller quicker. e.g. gastric band, sleeve gastrectomy (85% of stomach removed).
   2. Malabsorptive

      Nota:

      • Small intestine re-routed so food skips a portion of it. e.g. gastric bypass
   3. Combination

      Nota:

      • 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.
   4. Complications

      Nota:

      • Atelectasis and pneumonia DVT and PEs Wound infection GI bleeding Failure to lose weight Mortality
      1. Atelectasis

         Nota:

         • 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.
      2. Post-op resp problems

         Nota:

         • 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.
   5. Post-op physio

      Nota:

      • Restore pulmonary function Clear secretions if present Promote early mob Restore to functional level
      1. Lung recruitment options

         Nota:

         • Positioning Sitting out in chair Mob Lower thoracic expansions Incentive spirometry PEP devices CPAP BiPAP
      2. Important considerations

         Nota:

         • Continued therapy for OSA Adequate analgesia Supplemental O2 Correct bariatric equipment and manual handling.
      3. TUFG programme

         Nota:

         • 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
         1. Virtual toolbox

            Nota:

            • Thirst/hunger awareness Energy balance Time given to activity SMART objectives visualisations readiness for change