Bariatric Sx and PT Implications Flashcards
Obesity is a ___________
Pandemic!!!!
*NOTE: affects >300 million people worldwide!!!
2nd leading cause of preventable death in the USA***
Obesity is a _________ Disease
Multifactorial
Obesity is Multifactorial
More facts:
- Complex, multifactorial**
- Affects multiple body systems**
- Genetics + Environment
- Factors:
- Physical, social, cultural, genetic, behavioral
GOLD STANDARD measurement for Obesity (but shouldn’t be)
Body Mass Index (BMI)
- BW (kg)/Ht (m2)
-
Challenges to BMI:
- Most accurate measurement=> BF%
- Healthy, muscular= fall into overWT category
- Persons w/ decd mm mass may fall into normal
BMI Lvls: all then broken down
- UNDERweight→ <18.5
- Normal wt→ 18.5-24.9
- OVERweight→ 25-29.9
- Obesity→ 30+
BMI Lvls:
UNDERwt.
<18.5
BMI Lvls:
Normal Weight
18.5-24.9
BMI Lvls:
OVERwt.
25-29.9
BMI Lvls:
Obese
30+
Obesity Subcategories:
Classes 1-3
- Class 1: BMI 30 to <35
- Class 2: BMI 35 to <40
-
Class 3: BMI of 40+
- extreme, severe, morbid obesity
- “Bariatric”
Independent predictor of MI
Waist to Hip ratio
Waist (above iliac crest) to Hip (widest part hips) Ratio
FACTS
- Considers diff’s in body type distributions
-
Waist circumference: above iliac crest→ fat around abdomen/organs
- >40 in (males)
- >35 in (females)
Waist to Hip Ratio
Obese #s Men vs Women
Men: >0.9= obese
Women: >0.85= obese
Sequelae of being overweight or obese
see pics but NOTE the following:
- Type 2 DM: insulin resistance in indivs w/ high lvls visceral fat (around abdomen)
- Most Cx’s related to endocrine
- Widespread systemic inflammation (not on list)
- *Cx outcomes are poorer for obese indivs than normal wt indiv’s
Pathophysiology of Obesity
Physiology of adipose tissue in obesity: Adipocytes
What do they do?
-
Adipocytes (fat cells)→ Release PROs (adipokines or adipocytokines) that act locally on tissues or systemically thru bloodstream
-
ROLE(S) of Adipokines:
- Energy balance, Angiogenesis
- Inflammation, Vasoconstriction
-
ROLE(S) of Adipokines:
What are the PROs called that Adipocytes (fat cells) RELEASE?
Adipokines or adipocytokines
Energy balance, Angiogenesis
Inflammation, Vasoconstriction
Pathophysiology of Obesity
Physiology of adipose tissue in obesity:
Brown Fat
- Role→ Thermoregulation
- Infants have HIGH amts
- DECd amts in adults***
- Regulated by SNS
Pathophysiology of Obesity
Physiology of adipose tissue in obesity:
White Fat
2 Roles:
- Storage of triglycerols for long-term energy reservoir
-
Secrete PROs
-
BAD→ all PRO-inflammatory
- TNF, IL-6, IL-8, resistin, acylation-stimulation PRO
-
GOOD
- Leptin→ inflammation, immune function
- Adiponectin→ incs insulin sensitivity, anti-inflammatory
-
BAD→ all PRO-inflammatory
Pathophysiology of Obesity
Physiology of adipocytes in obesity:
More on White Fat
Secreted PROs from White fat help regulate other body processes:
- Fat metabolism, Energy balance, Feeding (hunger, app. suppress.), Hemostasis/vascular tone, Insulin sensitivity
Pathophysiology of Obesity
Physiology of adipose tissue in obesity:
White Fat
Role #2: Secrete PROs
Talk about “Good” vs “Bad” again
-
BAD: PRO-inflammatory
- TNF, IL-6, IL-8, resistin, acylation-stimulation PRO
-
GOOD:
- Leptin→ inflammation, immune function
- Adiponectin→ INC insulin sensitivity, ANTI-inflammatory
Pathophysiology of Obesity
Physiology of adipose tissue in obesity:
Leptin and Hunger
- Acts on hypothalamus to alter hunger
- INCd leptin lvls act to depress hunger
- In obese indivs→ HIGH lvls leptin exist→ BUT target receptors for leptin are LESS sensitive (do not recognize leptin) → don’t get “full” so keep eating****
Benefits of Tx:
Strong evidence that Wt loss reduces risk factors for DM and CV disease
Explain the cascade of events WHY
-
Ex. of physiology
- W/ Wt loss→ DECd # macrophages in adipose tissue→ DECd in local inflamm (may see clinical improvement in CVD, DM bc of improved action by adipocytes’ secreted PROs)
GENERAL goals of Wt loss/Mgmt
- Initial goal→ 10% reduction in bw OR if that is not possible, NO inc in wt.
- Reasonable time frame→ 6mos
- Wt maintenance should include diet, phys act, behavior tx
Medical Intervention for Obesity
5:
- Dietary counseling
- Pharmacologic approaches
- Behavioral approaches
- Exercise***
- Bariatric Sx
Bariatric Sx:
3 mentioned in lecture to KNOW:
- Adjustable gastric band OR Vertical banded gastroplasty
- Pancreatobiliary bypass or Duodenal switch
- Gastric Bypass
Bariatric Sx:
Adjustable gastric band OR Vertical banded gastroplasty
What does it do?
Restricts stomach volume by creating a smaller stomach pouch.
*Stomach left INtact
Bariatric Sx:
Pancreatobiliary bypass or Duodenal switch
What does it do?
Malabsorptive procedure
*Removes portion of stomach
Bariatric Sx:
Gastric Bypass procedure
What does it do?
Restricts stomach volume by bypassing the stomach w/ a gastrojejunostomy
Gastric Banding Procedures
2:
- Adjustable gastric banding procedure
- Vertical banding gastroplasty
Bariatric Sx:
Malabsorptive Procedures
2:
- Biliopancreatic Diversion (BPD)
- BPD w/ Duodenal Switch
Gastric Bypass Procedure aka Roux-en-Y stomach bypass
the “Y” Connection one
Gastric Bypass
Gastric Bypass procedure aka
Roux-en-Y procedure
PT Considerations:
Post-op Bariatric Sx
BIG ONES TO KNOW!!!! then all in another card
-
Tachycardia*
- HR >110bpm
- Fever*
-
Drainage*
- Color (green, red)
- Smell
-
Persistent Pain*
- L shoulder
- Epigastric
- DECd Urine output*
Post-op bariatric sx PT Considerations
Persistent Pain
Where?
L. shoulder
Epigastric
PT Considerations
Post-Op Bariatric Sx
ALL but REALLY KNOW *‘d ONES!!!!
- *Tachycardia
- HR>110bpm
- *Fever
- sweating
-
*Drainage
- color (green, red)
- smell
-
*Persistent pain
- L. shoulder, Epigastric
- Wound dehiscence (opening)
- Internal bleeding
- DVT/PE***
- *DECd Urine output
- NPO day 1
- Incentive spirometer
- Lifting restrictions >10-15lbs for 2-3wks
Post-Op Bariatric Sx:
Follow-up medical care (6mo/1yr)
- **Nutritional Supplementation
- Vitamins for LIFE, esp B12, calcium
- Monitor “liquid calories”
- Dumping Syndrome
- Ex. program for strength, endurance
- Counseling & support groups, wound check, ulcers, reflux
Dumping Syndrome
*esp important during Follow-up medical care (6mo/1yr)
- Sugary food leaves stomach QUICKLY!
- Intestine swells up→ cramping and pain
-
Sx’s:
- fast HR, sweating, nausea, vom/diarrhea
PT Exam
Hx
Gen health status (health perception, phys function, psychological function, role function, social function)
Social and health habits, lvl of phys fitness
PT Exam: Systems Review
Cardiovascular Pulmonary
- RHR, BP, RR
- *Vital signs should be monitored due to INCd risk!!!
PT Exam: Systems Review
Integumentary
- LE venostasis
- Friction of tissues in adjacent body segments******* BIG ONE!!!!
PT EXAM: Systems Review
MSK
- Pain, Postural dysf.
PT Exam: Systems Review
Neuromuscular
- Impaired peripheral nerve integrity secondary to impingement by excessive adiposity
*NOTE: Other PT Exam components: Communication, cognition, pt goals
PT Exam: Tests and Measures
Documentation of functional limitations
Larsson and Mattsson, 2001
- Women who are obese perceived disability to much higher extent vs women of “normal wt”
- Noted diffs bw perceived functional limits and those that can be observed and measured***
Other PT Considerations in Obesity
- Wound care/skin checks esp areas w/ high friction or full contact
- self-check, hygiene
- assess during PT exam***
- Dec skin shear during transfers
- Support groups and social support
- HEP and promotion of daily physical activity!!!
