Nutrition and Wellness: Obesity Unit

How is obesity measured?
BMI, body weight, body fat

What has the main impact on obesity?
consumption of more calories than you burn, eating too much and exercising too little

Factors that impact obesity
age, gender, genetics, environmental factors, physical activity, psychological factors, illness, medication

health problems
cardiovascular diseases, endocrine diseases, gastrointestinal diseases, liver disease, renal and urinary diseases, skin and appendages diseases, musculoskeletal disease, respiratory disease, psychological disease, reproductive diseases

What does BMI stand for?
Body Mass Index

Treatments for obesity
dietary changes, exercise, behavior modification, medication, weight loss surgery

What are the dangers of cardiovascular diseases? (Ex: Hypertensive Heart Disease, Diabetes)
fatigue, shortness of breath, irregulr pulse, frequent urination, unusual thirst, extreme hunger, unusual weight loss, fatigue.

What are the dangers of Endocrine diseases? (Ex: Hypertension, abnormal lipid levels)
artery pressure, high blood pressure

What are the dangers of Gastrointestinal diseases (Ex: gastro-esophageal reflux disease, appendicitis)
acid can go into esophagus or food pipe, swelling of the abdomen, internal infection, vomiting

What are the dangers of liver diseases? (Ex: cirrhosis, nonalcoholic fatty liver disease)
scarring of liver disease, decreased liver function, liver fat excess, confusion, loss of appetite, nausea, vomiting, weakness, weight loss, yellowing of skin, mucus on eyes

What are the dangers of renal and urinary diseases? (Ex: kidney stones, urinary tract infections)
permanent damage to kidneys

What are the dangers to skin and appendages diseases? (Ex: acanthosis nigricans, cellulitis)
light brown to black markings, usually on your neck, under arm, swollen red area of the skin, feels very hot, tender, fever, chills, hair loss, changes in appearance, can cause tissue death, bone infections, meningitis, and shock

what are the dangers to musculoskeletal diseases? (Ex: arthritis, osteoporosis)
joint tissues become less able to take stress, bones develop holes, swelling, pain, loss of mobility, lack of calcium

What are the dangers to respiratory diseases? (Ex: asthma, C.O.P.D)
sensitization to irritants and allergens, being overweight, rapid breathing rate, inflamed lung tissue, asthma attacks, life threatening, wheezing

What are the dangers to reproductive diseases? (Ex: polycystic ovary syndrome, dyslipidemia)
inbalance of sex hormones, lack of menstrual cycle, excess hair growth, infertility, hypothyroidism, too many or too few lipids in your bloodstream

What are the dangers to psychological diseases? (Ex: depression, binge eating)
low self esteem, over eating, obesity, suicide, type 2 diabetes

What are the treatments to some of these diseases?
counseling, healthy eating, prescribed medication, surgery, rehabilitation, oxygen therapy, losing weight, removal, exercise

How does age affect obesity?
– as you age, metabolism slows
– calorie needs change
– eating and activity habits change

How does gender affect obesity?
– more women are overweight
– men have a higher metabolic rate
– women go through menopause

Why may genetics be at fault for obesity?
– it tends to run in families
– adoptive studies: environment
– increases chances: predisposed

What are the psychological factors?
– response to emotions
– binge eating

What type of illnesses affect obesity?
– hormone problems
– hypothyroidism: slows metabolism
– rare brain diseases

What kind of emotions can affect obesity?
– boredom
– anger
– sadness
– stress
– depression

What are the different types of weight loss surgeries?
Gastric Bypass Surgery, Adjustable Gastric Banding, Sleeve Gastrectomy, Biliopancreatic Diversion

What are the pros and cons to Gastric Bypass Surgery?
Pros: helps to lose excess weight, reduces your risk of potentially life-threatening, weight-related health problems, improves your ability to perform one’s daily activities and routines.

Cons: excessive bleeding, infection, adverse reactions to anesthesia, blood clots, lung or breathing problems, leaks in your gastrointestinal system, death (rare), bowel obstruction, dumping syndrome, gallstones, hernias, low blood sugar, malnutrition, stomach perforation, ulcers, vomiting.

What are the pros and cons to Adjustable gastric banding?
Pros: Safer than Gastric Bypass, and other weight loss procedures, routinely done as minimally invasive, requires special instruments, recovery time is faster, reversible if necessary by removing the band, requires small incisions.

Cons: May be likely to regain some of the weight over the years, people who get this procedure usually do not have dramatic weight loss, vomiting; a result of eating too much too quickly, complications with the band are not uncommon, such as slipping out of place, becoming loose, or leaking, infection is a factor just like with any surgery, some complications can be life threatening.

What are the pros and cons to sleeve gastrectomy?
Pros: For people who are obese or very sick Gastric Bypass can be too risky, and so can biliopancreatic diversion, more simple, lower risk surgery, after 12-18 months after surgery if weight loss has improved they can go for a second operation if wanted, result in weight loss of 50% or greater, does not affect absorption of food, this means nutritional deficiencies are not a problem.

Cons: irreversible, risks are still being evaluated, because it is a new procedure, leaking of sleeve, infection, blood clots.

What are the pros and cons to biliopancreatic diversion surgery?
Pros: the surgeries are usually effective; most people lose 75% to 80% of their excess weight, most people stay at that weight.

Cons: there is a risk of infection, dumping syndrome, a higher risk of osteoporosis, bad smelling stools and diarrhea, poor nutrition.

What is Gastric bypass surgery?
The stomach is divided into a large portion, and a much smaller portion. The small part of the stomach is then sewn or stapled together to make a small pouch. The small stomach pouch can only hold a cup or so of food. With such a small stomach, people feel full quickly and eat less.

What is adjustable gastric banding surgery?
This surgery is among one of the least invasive procedures for weight loss treatments. This surgery uses an inflatable band to squeeze the stomach in two different sections (the smaller upper pouch, and a larger lower section.) These two sections are still connected; it’s just that the channel between them is really small. This slows down the emptying of the upper pouch of the stomach. Gastric Banding physically restricts the amount of food you can take in when you eat. Most people can only eat about a half cup to one cup of food before feeling full or sick after having this procedure done.

What is sleeve gastrectomy?
Another form of restrictive weight loss surgery. Operation is usually done with a Laparoscope, and about 75% of the stomach is removed. What is left of the stomach is a small narrow tube or sleeve, which connects to the intestines. Sometimes a sleeve gastrectomy is a first step in the sequence of weight loss surgeries. It can be followed with gastric bypass or with Biliopancreatic Diversion. In some cases this operation may be the only one you need.

What is biliopancreatic diversion surgery?
a treatment for morbid obesity, consisting of resection of two thirds of the stomach and attachment of the ileum to the proximal stomach.

610 – Anesthesia and Obesity

BMI
– Also called Quetelet’s index
– Can be used to estimate degree of obesity
– BMI = weight in kg/(height in m)²

BMI Measurements
– < 18.5 = Underweight - 18.5-29.9 =Normal - Overweight - 30-39.9 = Obesity (I & II) - ? 40 = Morbid Obesity (III) - ? 50 = Super Obesity - ? 60 = Super-super obesity

Ideal Body Weight (IBW)
– Concept of life insurance companies
– Weight associated with lowest mortality rate for given height and gender
– Estimated using Broca’s index
– IBW (kg) = height (cm) – x;
– x = 100 for adult males & 105 for adult females

Predicted Body Weight (PBW)
– MEN: 50 + 0.91 X (CM HT – 152.4)
– WOMEN: 45.5 + 0.91 X (CM HT – 152.4)

Lean Body Weight (LBW)
– Total body weight (TBW) minus adipose tissue
– Approximately 80% TBW for males & and 75%
TBW for females
– Increase IBW by 20% to 30% gives estimate of
LBW – in morbidly obese patients (more muscle from being so fat)

Weight from lbs to kg
– 1 kg = 2.2 lbs
– 150 lbs/2.2 = 68.18 kg

Height from feet to cm
– 1 m = 3.26 feet
– 6’2″/3.26 = 1.88 m or 188 cm

Height from inches to cm
1 in = 2.54 cm
– 5’4″ x 2.54 = 64 x 2.54
= 162.5 cm
– 170 cm/2.54 = 66.9 in

Types of Obesity
Android (central)
Gynecoid (peripheral)

Android (central) obesity
Android (central) obesity
– Adipose located in upper body (truncal)
– WORSE HEALTH
– Associated with increased oxygen consumption & cardiovascular disease
– Visceral fat associated with cardiovascular disease & left ventricular dysfunction
– APPLE

Gynecoid (peripheral) obesity
– Adipose located predominantly in the hips,
buttocks, & thighs
– Less metabolically active
– PEAR

Medical Tx for Obesity
– Intended to reduce energy intake, increase energy use, or decrease absorption of nutrients
– Indicatations: BMI ?30 kg/m² or BMI 27 – 29.9 kg/m² with obesity-related medical complication

FDA Approved Obesity Meds
– Phentermine
– Orlistat

Phentermine (Adipex-P)
– A sympathomimetic that decreases appetite
– Approved for 3 month use
– Causes tachycardia, palpitations, & hypertension;
dependence, abuse, & withdrawal symptoms
– Used in combination with fenfluramine (Combo known as Phen-Fen): Caused pulmonary hypertension and valvular heart disease and Topamax: May cause dry mouth, paresthesias,
constipation, insomnia, and dizziness

Orlistat (tetrahydrolipstatin, OTC: Alli, prescribed:
Xenical)
– Inhibits lipases in the GI tract, decreasing fat
absorption
– Leads to weight loss & improved BP, fasting BS and lipid profile
– Fat malabsorption causes common complaints of oily spotting, liquid stools, fecal urgency, flatulence,& abdominal cramping
– Chronic use may result in fat-soluble vitamin
deficiency (NAKED without the N)

Surgical Treatment: Bariatric Surgery
– Most effective treatment for morbid (class III)
obesity
– Guidelines for patient eligibility: BMI >40 kg/m² or BMI >35 kg/m² and/or obesity-related comorbidities not controlled with medical tx

Types of Bariatric Surgery
– Malabsorptive procedures: jejunoileal bypass
& biliopancreatic diversion
– Restrictive/Partitioning procedures: verticalbanded gastroplasty and adjustable gastric banding (LAP BAND)
– Combined procedures: Combined gastric restriction with a minimal degree of malabsorption (RYGP)

Respiratory Pathophys
– Decreased chest wall compliance due to fat accumulation on thorax & abdomen
– Decreased lung compliance due to increased pulmonary blood volume
– Decreased functional residual capacity, vital capacity & total lung capacity
– Increased elastic resistance and decreased compliance further impaired by recumbent positions
– Shallow and rapid breathing; increased work of
breathing
– Decreased maximum ventilatory capacity
Increased oxygen consumption & CO2 production – due to metabolic activity of excess fat &
increased workload on supportive tissues – both cardiac output & alveolar ventilation increase
– Basal metabolic activity WNL – normocapnia maintained
– Decreased arterial oxygen tension – leading to polycythemia, pulmonary hypertension, & cor pulmonale

Cardiovascular Pathophysiology
– Total blood volume increased – Renal and splanchnic blood flow increased
– Cardiac output increased – ventricular dilation & increased stroke volume
– Increased left ventricular wall stress –> Leading to LV hypertrophy, reduced compliance, & impaired LV filling
– Eventually, biventricular heart failure occurs
– Many patients have mild to moderate HTN due to renin-angiotensin system –> ncreased levels of angiotensinogen, aldosterone and angiotensin-converting enzyme
– Normal to increased SNS activity –> leading to insulin resistance, HTN and dislipidemia
– Adipose releases a large number of bioactive
mediators – abnormal lipids, insulin resistance, inflammation & coagulopathies(hypercoagulability)

EKG changes with Obesity
– Low QRS voltage – cuz of fat
– LVH
– L atrial enlargement
– T-wave flattening in inferior & lateral leads

Lean Body Weight Used for What Drugs?
– Drugs mainly distributed to lean tissues
– For maintenance – drugs with similar clearance values in both obese and nonobese individuals
– Propofol (induction), NDMRs, fentanyl, sufentanil, remifentanil

Total Body Weight used for What drugs?
– Drugs equally distributed between adipose and lean tissues
– For maintenance – drugs whose clearance increase with obesity
– Propofol (maintenance), succinylcholine, dexmedetomidine, neostigmine

Obesity Preop eval
– Anatomic changes associated with obesity
– Upper thoracic and low cervical fat pads
– Excessive tissue folds in mouth and pharynx
– Short, thick neck
– Thick submental fat pad
– Suprasternal, presternal, and posterior cervical
fat
– Large breasts in females

Obesity and Airway Issues
– Obesity is risk factor for difficult mask ventilation and airway management
– BMI by itself does not have much predictive value for difficulty

Difficulty Correlates With
– Increased age, male gender, temporomandibular
joint pathology, Mallampati classes 3 and 4, OSA,
and abnormal upper teeth
– Neck circumference – single biggest predictor
– Male gender, a higher Mallampati score, laryngoscopy grade 3 views, and OSA
– OLD MALE WITH TMJ DISORDER THAT WEARS CPAP WITH HUGE BUCK TEETH

Preop Cardiac Evaluation for Obesity
– Evaluate for systemic hypertension, pulmonary
hypertension, right and/or left ventricular failure &
ischemic heart disease
– Pulmonary hypertension d/t chronic pulmonary
impairment – S/s exertional dyspnea, fatigue, & syncope
– Echo: tricuspid regurgitation
– ECG: RVH = tall precordial R waves, right axis deviation, & right ventricular strain
– CXR: Underlying lung disease & prominent pulmonary arteries

OSA & Obstructive Hypoventilation Syndrome (OHS)
– Recognize early d/t airway management issues &
associated increased perioperative pulmonary
complications
– Hx of HTN &/or neck circumference >40 cm
– OSA is a legitimate reason to delay surgery for a proper workup & should be treated as inpatients
– Home CPAP devices should be brought for use pre, peri, or post-operatively
– Routine pulmonary function tests are not cost effective in asymptomatic patients

Metabolic Issues with Obesity
– High prevalence of insulin resistance & diabetes
– Consider glucose checks & correct
– Assess therapies, last time & dose, usual BS
values
– Check electrolytes
– Elevated liver function tests (particularly alanine aminotransferase) – No clear correlation between abnormalities & the capacity to metabolize drugs

Postop Metabolic Issues With Obesity
– Nutritional deficiencies include vitamin B12, iron,
calcium, folate, & chronic vitamin K deficiency
– Myelopathy associated with vitamin B12 and copper deficiencies

APGARS
– APGARS: Acute postgastric reduction surgery
neuropathy
– Postop polyneuropathy characterized by protracted postoperative vomiting, hyporeflexia, and muscular weakness
– Differential diagnoses include thiamine deficiency (Wernicke encephalopathy, beriberi), vitamin B12
deficiency, & Guillain-Barré syndrome
– Requires judicial dosing & monitoring of NMBs

Hematologic Issues
– Risk of perioperative thromboembolic events; plan for thromboprophylaxis
– Recommended: intermittent pneumatic
compression devices with heparin (unfractionated
or low molecular weight heparin) for patients
undergoing bariatric surgery
– Prolonged postoperative thromboembolic
prophylactic regimen (1 to 3 weeks) may be
indicated

Assessing DVT RISK
1) Venous stasis disease
2) BMI ? 60
3) Central obesity
4) OHS and/or OSA
– Preoperative IVC filter should be considered in
addition to anti-thrombolitic therapy

Thromboprophylaxis
– Compression boots during surgery
– Heparin
– Sometimes 1-3 weeks

OR TABLES
– Regular OR tables have max weight limit of 200 kg
– Bariatric tables capable of 455 kg
– Have greater width/side accessories to accommodate the extra girth
– Bean bags and straps keep patients positioned and stable
– Ensure adequate padding between positioning
devices and patient skin

Monitoring in Obesity
– BP falsely elevated if a cuff is too small
– Choose cuffs with bladders** that encircle a
minimum of 75% of the upper arm circumference
– Forearm BP overestimate both systolic and diastolic BPs
– ABP indicated for the super morbidly obese patient, presence of cardiopulmonary disease, & improperly fitting NIBP cuffs
– Central venous catheterization for patients with
inadequate peripheral access

Airway Management in Obesity
– Preoxygenation is vital
– Rapid desaturation occurs after loss of spontaneous respiration
– Four vital capacity breaths with 100% oxygen,
within 30 seconds of induction
– Head-up position, or semi-sitting position – Delays hypoxia w/ apnea
– Prevent pulmonary aspiration of gastric
contents
– Preoperative use NIPPV and/or PEEP

Airway Management Continued
– Awake FOI for anticipated difficult intubation
– Avoid hypoxia and aspiration
– Induce with experienced colleague
– ENT available for surgical airway
– “Ramped” or “stacked” position elevates the upper body and improves laryngoscopy
– Ear to sternal notch positioning

Other Techniques for Intubating A Biggy
Other Techniques for Intubating A Biggy
– Intubating stylets – Eschmann stylet, Cook Airway Exchange catheter, bougie
– Intubating LMAs
– Video laryngoscopes – Glide Scope, C Mac
– Repeated laryngoscopy and attempts at
intubation increase airway and hemodynamic complications
– Limit conventional intubation attempts to three

Aspiration Risk in Obese Patients
– Major concerns: hypoxemia, regurgitation,
aspiration
– Increased gastric volume & acidity and delayed
gastric emptying
– Increased abdominal mass causes antral
distension, gastrin release, and decreased pH
– Increased intragastric pressure, increases
frequency of transient lower esophageal
sphincter relaxation, and/or hiatal hernia
formation
– At risk for severe pneumonitis with aspiration

T/F – You should RSI every obese patient
FALSE – it should be individualized

Induction of Obese Patients
– Induction agents: larger doses d/t increased blood volume, muscle mass, and cardiac output – Propofol & thiopental: based on LBW
– Muscle relaxants: Succinylcholine is the MR of choice due to rapid onset & limited duration of action – increased dose on TBQ due to increased psudocholinesterase activity
– NDMRs Rocuronium & vecuronium: based on LBW, Atracurium and cisatracurium: based on TBW (ROC/VEC LBW, AT/CIS = TBW)

Maintenence of Obese Patients
– Inhalation agents: desflurane, sevoflurane, & isoflurane are minimally metabolized
– Desflurane: faster washout, possibly better
hemodynamic stability
– Use of N2O limited by high O2 demand
– Intravenous agents: short-acting opioids are preferred (remifentanil and fentanyl)
– Remi/Fent are based on LBW and are titrated to clinical effect; most common choices
– Dexmedetomidine: based on TBW

Which meds are based on TBW?
– Precedex, propofol (maintenence), sux, reversal

What meds are based on LBW
– Remi, sufentanil, fentanyl, propofol (induction), NDMRs, LOCAL ANESTHETICS

Use of OGTs and Temp Probes
– Anesthesia will place various devices to help with surgery (intragastric bougie or baloon, OGTs, etc)
– When placing ensure adequane MR, ensure a tight seal on cuff, and ensure all devices and tubes are COMPLETELY removed before they staple. Do not just pull them back (this is how a OGT gets stuck in someones belly and they have to open again)

Supine Positioning in Obesity
– Ventilatory impairment – decreased FRC and oxygenation
– PEEP & head-up position decrease alveolar-
arterial oxygen tension difference
– PEEP & head-up position decrease CO – counteracting the benefits
– Compression of IVC & arota

Prone Positioning in Obesity
– Ensure freedom of abdomin to prevent impaired
ventilation, & oxygenation

Lateral Positioning in Obesity
– Allows for better diaphragmatic excursion
– Preferred over prone, if surgical procedure permits

Padding the obese pt
– Susceptible to pressure sores, neural injuries and
rhabdomyolysis

Nerve injuries in the obese
– Brachial plexus & LE nerve injuries occur frequently
– Carpal tunnel syndrome is the most common
mononeuropathy after bariatric surgery
– Other: encephalopathy (Wernicke) & optic neuropathy

Wernicke encephalopathy (WE)
– A neurological disorder induced by thiamine, vitamin B1, deficiency
– WE is the most important encephalopathy due to a single vitamin deficiency.

Fluid Management in the Obese
– Difficult to assess
– Blood loss usually greater d/t technical difficulties
– Normovolemia should be the goal
– Avoid hypervolemia-associated complications –> congestive heart failure, peripheral edema, &
pulmonary complications.
– Rapid infusion of intravenous fluids should be
avoided because pre-existing congestive cardiac
failure (they are fat, dont just expect their hearts to work normal)

Mechanical Ventilation on Obese Pts
– Exposed to higher TVs d/t miscalculation of body
weight
– Experience higher airway pressures d/t decreased compliance
– Greater inflation pressures may be tolerated as extra adipose tissue partially attenuates lung over-distension
– TVs should be maintained at less than 13 mL/kg
– No specific ventilatory mode (e.g., volume vs. pressure control ventilation [PCV]) has been found significantly better
– Like any person, you have to see how they handle different modes

PEEP in Obese Pts
– PEEP has been shown to consistently improve
respiratory function
– Moderate PEEP (10 cm H2O) w/ recruitment
maneuver
– Recruitment maneuvers = intermittent large TV breaths during the case that open and maintain patency of small airways
– They improve V/Q & oxygenation
– Inspired O2 should be titrated to minimum levels

Emergence on Obese Pts
– Prompt extubation reduces likelihood of post-op
mechanical post op ventilation
– Extubated in a sitting position
– Consider extubating over exchange catheter for
difficult intubations

Regional Anesthesia for Obese Pts
– Can use any technique alone or in combo with GA
– Usual adavantages of RA
– Disadvantages – increased block failure, exaggerated pulm and CV compromise, catheters may become misplaced with mocement
– Decrease dose of LA for SAB
– LA dose is based on IBW for PNBs

Obesity and Anesthesia

What is the waist circumference in patients with metabolic syndrome?
men: > 40in, women > 35in

What is one medication that will likely need to be increased with obesity anesthesia delivery?
succinylcholine

What is the estimated blood volume in obese patients?
45ml/kg

What is the change in pulmonary function/anatomy with obesity?
decreased ERV, which decreases FRC

What is the leading cause of morbidity and mortality in obese patients?
failure to intubate

What is the best predictor of difficult intubation in morbidly obese?
neck circumference. > 42cm. This associates with men, increased Mallampati, grade 3 laryngoscopy view, and OSA

What are several important drugs in obesity-related anesthesia pharmacology to dose by IBW?
propofol, vecuronium, rocuronium, remifentanil

Ultimately, what is the effect of impinged pulmonary ERV and FRC volumes? (2)
(1) V/Q mismatch with right->left shunting, (2) Rapid desaturation due to less reserve (normal FRC 46ml/kg, obese FRC ~ RV=23ml/kg, and oxygen consumption increases from 250mL/min to 375mL/min)

What physiologically happens to the respiratory drive with obesity hypoventilation syndrome?
increased reliance on hypoxic drive for ventilation due to loss of hypercarbic drive

What are the criteria for OHS?
coexisting lung disease and effects of chronic PHTN related to obesity

Pickwickian Syndrome has an associated compromise in what?
cardiac function; RV failure, secondary polycythemia, and biventricular failure

Describe Obesity Supine Death Syndrome.
pt. with pre-existing cardiac compromise placed supine, which acutely increases demand for cardiac output increase due to increased central blood volume. The LV cannot compensate, and pulmonary congestion and hypoxemia develops with acute LV failure.

Cardiac output must increase how much per 10kg body weight?
1L/min

How much is SBP increased with 10kg body weight?
6 mmHg

How much is DBP increased with 10kg body weight?
4 mmHg

What is dangerous about induction with obese patients?
mimics exercise, and LV size and hypertrophy cannot compensate, leading to arrest on induction

Is an obese patient with hypertrophied LV safer or at greater risk than non-hypertrophied LV?
hypertrophied LV is more appropriate; compensation mechanisms have attempted to make up for body changes.

What ECG changes should be noted with obesity?
low voltage, right axis deviation r/t RVH, RBBB r/t PHTN

What metabolic effects are seen with obesity?
increased insulin secretion with resistance to insulin actions and decreased # of insulin receptors

What percentage of obese patients have Mendelson’s syndrome? Review what Mendelson’s is.
90%. 25ml gastric content @ pH <= 2.5 with higher risk of aspiration pneumonitis

What are recommended approaches to mechanical ventilation of obese patients?
5-6ml/kg IBW w/ 10 PEEP. Remember, the lungs are not obese

What are the safest considerations for ventilating an obese patient?
FiO2 < 60%, Vt < 6ml/kg, and plateau pressures < 30 cmH2O

How should neuraxial anesthetics be dosed in the obese?
75-80% of normal dose due to epidural vein engorgement

What is unique about attempting to reverse obese patients who have had a NMBA?
neostigmine may take 25 minutes to work

What aspect normally considered therapeutic post-op may actually mask apnea in the obese patient?
oxygen via nasal cannula. The increased PaO2 will reduce the respiratory drive because hypercarbic drive is lost

What is thiopental’s 1/2 life in obese patients compared to normal?
normal 6.3 hr half life, obese 27.8 hr half life

Is GI motility lower with opioids in obesity?
no

What is risky about using IV opioids in obesity?
decreased pharyngeal tone

What is the most common complication from Rou-En-Y procedure?
GI leak

What are important guidelines for post-op management of OSA patients?
no neuraxial opioids, use non-opioids for pain control, CPAP ASAP after surgery, recover in lateral, prone, or sitting position, continuous SpO2 until RA SpO2 > 90% asleep.

What are the 4 characteristics to OSA patients undergoing exercise test?
(1) lower exercise HR, (2) higher exercise DBP, (3) delayed SBP recovery time, (4) DBP tended to be higher after recovery

What is the leading mortality in obesity surgery?
pulmonary embolism

What is the time when a patient should stop smoking prior to surgery for recovery of some pulmonary physiologic mechanisms?
6 weeks

The Main Causes of Childhood Obesity

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Childhood obesity is a condition characterized by presence of excess fat in the body of a child aged above two years (Birch, et al, 2011). There is no definite and direct way of determining if one has excess fat in their body, conversely, the Body Mass Index (BMI), is used to determine whether one is obese or not. BMI is based on the notion that a healthy body should have a specific ratio of weight to height, a higher ratio would indicate a higher amount of body fat and weight loss undertakings are highly encouraged (Dawes, 2014). Due to increase in the rate of childhood obesity, it has become a matter of public health and there is a greater need to sensitize parents on the precautionary steps to be taken.

This paper will focus on the main reasons for childhood obesity. It will analyze the steps taken to mitigate childhood obesity and the challenges encountered by the society and the obese children. The solutions to these challenges will be tabled and recommendations made on the same.

Issue/Problem Statement

Childhood obesity was not a matter of public health some twenty years ago, however, due to increase in obesogenic environment it has become a national childhood disaster (Dawes, 2014). This environment is characterized by poor eating habits and less physical activities; basically these are factors that can be controlled once realized. Changes in lifestyle has led to change in eating habits for both parents and children; according to the Center of Disease Control and Prevention, the chances of childhood obesity increases if both parents are obese (Birch, et al, 2011).

Childhood obesity forms a vicious cycle of an unhealthy future population, which can easily hinder development. This is primarily because childhood obesity will lead to adulthood obesity and its associated ailments like respiratory problems, high blood pressure and cardiac diseases and diabetes. The government will focus and invest more on curing the ailing population than on developing curriculums and infrastructure. The population will also not be able to perform enough as all attention will be focused on the ailments, invention, innovation and investment will be hindered. There is a greater opportunity cost for having obese children as the future than not having them.

The main reason for obesity especially in children is the food that is consumed. Let’s closely examine the current consumption of food; the population feeds on more industrial meat than before. In 2011, United States alone slaughtered 110.9million hogs, 34.1million cattle, 853000 calves and 2.2million sheep for consumption (Lymbery & Oakshott, 2015). Consumption of the products from factory farming is harmful to human health. Due to the increase use of antibiotics and growth hormones during incubation and rearing of the animals, the products contain the residues (Casuto, 2007). The effects are consequently passed on to human beings, explaining the exceedingly high rate at which teenagers are maturing and increased in obesity. Consumption of the products also leads to drug resistance in both the animals and human beings, consequently increasing the population ailing from lifestyle diseases.

There is also overconsumption of junk and canned food that have processed fat and other preservative that are easily absorbed into the body and quickly form fat to be stored by the body (Dawes, 2014). Excess body fat makes it hard for the children to be engaged in physical activities as they get tired easily, obese children in this case, do not get to enjoy the perks that come with being a child.

Thesis; Childhood obesity can be prevented by eating a balanced diet and practicing a healthy lifestyle.

Audience analysis

The most crucial target audience for the message in this paper is the parents and guardians. The parents do not have a vast knowledge on proper nutrition but they have channels through which, they can be able to learn and comprehend the concept. According to Casuto, 2007, 65% of obese children are from either single parents home, African American homes or Latin American homes. This is especially so because the parents in the aforementioned bracket live in poor neighborhoods, are constantly away working and cannot provide at times the necessary nutrition for the children. Most of the parents are of the idea of reducing childhood obesity, conversely with the increase in crime rates, they feel security comes first. They have the belief that once children are left to run around outside, they will find themselves caught up in gang shootings. The parent’s attitude is positive but their actions are counterproductive to the cause, needless to say, they are still looking out for their children.

Parents are open to the idea of increasing the playtime for children under the condition that security is beefed up (Koplan et al 2005). In this case, they will not feel the need to worry about their children while they are at work. Most of the parents are usually at home during the night and late night television advertisements would be the perfect way to reach them. Alternatively, pamphlets sent via mail can be used to make them aware of the steps that they can be able to take in order to ensure that their children do not become obese.

The secondary target audience is the children; they require to be taught the importance of a proper nutrition is far greater than the instant gratification they get from consumption of junk and processed foods (Koplan et al 2005). The number of obese children has more than doubled in the last 30 years, in 1979 only 7% of the children were obese in 2011, the number had risen to 18%. Currently one in every three children is obese. This is a third of the entire child population in America aged between 6-11 years (Koplan et al 2005).

Finally the unintended target audience is the schools. Currently there are 98,817 public schools in America, children spend eight or more hours a day in school and here is where much of learning on personal, academic and social life takes place. The schools have a vast knowledge on proper child nutrition and can utilize in ensuring that there is a daily balance diet for all students.

Strategies for Persuasive Campaigns

I. Theories of Persuasion

Attribution Theory: Conditional Attribution

Conditioning plays a vital role in persuading a crowd especially when it is a matter of changing the type of lifestyle. It requires a mentorship role followed by voluntary actions by the mentee. Conditioning is more a mental and emotional game for instance creating an impression about a product and convincing people about its benefits. In this case, children can be mentored by people they adore for instance their favorite celebrity, parents or even sport player. They can be urged to practice a healthy lifestyle and conditioned to it. Pavlov’s conclusions on conditioning will be applicable as after a while even without parental guidance and supervision the children will have adopted to the new lifestyle and it will become their daily routine.

Conditioning at the same time has to be done severally to ensure that it is not forgotten. This means that it is a conditioning will be a continuous process that will be associated with better health and what will be termed as beauty at the moment of conditioning.

Cognitive Dissonance Theory

Cognitive dissonance is based on the premise that as human beings, we strive to have consistency. What is termed as wrong by the mind, one’s actions and body should restrain from it, consequently forming a brain-body harmony. The children can be taught that consumption of fatty and processed food is perilous to their body, they should be taught the importance of the physical exercise. Once they have been taught that, the actions will follow suit as their minds will seek to harmonize thoughts and actions.

Achieving harmony of mind and action is the hard part, once established; it is followed by need for consistency in life. The parents and schools should strive to ensure that they offer a consistent environment that does not seek to have the children routine changed haphazardly. Cognitive dissonance also fosters competition to outdo each other and be better. This is a spirit that comes in handy in sporting activities and can increase the level of talent to be discovered in the children and consequently get them out of their housed to participate in outdoor activities.

II. Psychosocial Perspective

Socio Economic Status

Research has found out that lower level of education of the parents leads to a lower income. The parents cannot afford proper nutrition for the children; additionally the parents are always working and spending more time away from the homes. The children are left to determine what they should eat and they always turn to junk food and processed meat. According to the World Health Organization, (2013) most of the cases of obese children are found in families that are believed to be in transition. Transitions are changes in the lifestyle that are mostly as a product of lack of a stable income by the parents. This is especially the case in single parent homes that have been on the rise due to the falling role of marriage as a social institution (Parizkova & Hills, 2005).

Adverse life events

Obesity may be a coping mechanism for the children who might be undergoing adverse life events. These events include but are not limited to death of a family member or friend, domestic violence, sexual abuse, lack of a social network and parental psychopathology (Koplan et al 2005). All these can be dealt with by undergoing proper counseling over a period of time and have stable social support system, however due to lack of time and resources; the child is left to his own demise.

Exposure to Media and Food advertisements

Currently in America, on average a child watches television for more than 3 hours a day, which more than the recommended 2 hours a day (Parizkova & Hills, 2005). Watching television has taken up time that was previously used in physical activities by the children. Also, while watching television one consumes more food that they are aware of and energy is stored up as no activity is engaged. Advertisements on media on consumption of unhealthy foods have increased and this makes teenagers and children to seek to have these foods.

III. Strategic Application

Childhood obesity is a public health problem but it is not being taken with the level of seriousness and soberness it deserves. This is because it is viewed as a lifestyle disease that is acquired by choice and can easily be avoided (Parizkova & Hills, 2005). Truth of the matter is that it is a lifestyle disease that requires serious measure to be taken by all parties involved in the lives of the children including the media. Children are the next generation and require to be nurtured, lack of proper nutrition will not end with them, but will serve as a beginning to unending health related issues.

Persuasion Material

The best persuasion material to be used is an advertisement with pictures to emphasize of the visual effects. There will be a photo of an obese child and one that is not obese followed by what to be eaten by children in order to avoid getting obese. The visual effect will ensure that the children get to understand the type of food to avoid and the ones to indulge in.

Challenges in Dealing with Childhood Obesity

The most crucial challenge to dealing with childhood obesity is that the necessary actions to be taken are beyond the capabilities of the children themselves. Merely educating the child on the importance of healthy nutrition will not suffice if the parents are not able to afford or don’t wish to be involved in the process. The children therefore are left at the mercy of the choices made by their guardians and the prevailing economic condition that they cannot impact.

The other challenge is the current public health and public school regime that has not yet grasped the seriousness of the condition. There is need to have concrete plans on how to aid the children and to get them involved in the maintenance of their own health (Parizkova & Hills, 2005). This can be incorporated by having a well-structured counseling platform to deal with psychological issues affecting the children (Birch, et al, 2011). There should also be sessions where children are taught on the combination of a balanced diet and its importance. The lunch menu should always incorporate less fats and more roughage and food rich in high fiber.

Solutions to Childhood Obesity

The first and most important solution is to teach newly parents on how to properly feed their children from the onset. Junk food should be avoided at all costs, the parents should strive to have a balanced and healthy diet and the children will follow in their footsteps (Voigt, et al 2014). The requirements for the children should be clearly stated and the consequences of poor eating habits be clearly stated. Secondly, children should be encouraged to get involved in sports from the youngest age so that it can be cultivated as a culture (Dawes, 2014). This recreational activity will allow for the children to redirect negative energy that might make them to be depressed and overindulge in junk food.

Schools should be involved in creating awareness and partner with organizations that strictly deal with childhood obesity. A decent illustration is SPARK an award winning public health program that is involved in educating teachers and other educators with proper physical activities to be embarked on by the children in an effort to combat childhood obesity. Teachers receive physical activities that are necessary and how they can be made fun for the children to capture their attention.

The state and local governments in conjunction with the parents can be able to offer well equipped and staffed gymnasiums to the schools to be able to fully capture the interests of the children. In this light, schools can offer various sports varying from ball games, athletics, ballet dancing and gymnastics. Technology in this case can be used to pull the children from the comfort of their couches to the field (Parizkova & Hills, 2005).

The government should limit and control the number of advertisement on unhealthy foods and unhealthy weight loss mechanisms. This will reduce the impact that the two have on children and decrease the number of children that experience obesity due to influence from the media (Parizkova & Hills, 2005).

Measurement and Conclusion

Once the above challenges have been mitigated by using the aforementioned solutions, there will be a need to measure the success of the project. Measurement can be conducted in several ways;

– Analyzing the schools and the physical health programs offered. The success of these programs should be measured by the number of students that have signed up and stick to it to the end. The programs should have records of the students in terms of their BMI while they were joining the program and the progress that has been witnessed. The program should have methods of dealing with challenges that it may face. The more the students and the more there is an improved trend in the BMI and physical activity the more the program will be termed as successful. The reverse is also true.

  • The number of advertisements on unhealthy foods and unhealthy weight loss processes should have reduced especially in channels meant for children (Voigt, et al 2014). This is a measurement that the government has imposed control on the level of influence of media on children.
  • An increase in the number of children involved in sports in schools will be an indication of increased need to stay healthy. This would be followed by an increase in the number of sports available for the children to participate in (Voigt, et al 2014). A change in the menu of food offered in school cafeteria to more healthy and nutritious food. This is a clear indication that the solutions are being implemented in schools.
  • Increase in parental participation in their children’s food intake, consequently the demand for junk food should decrease. This should also include home deliveries for Pizza and other foods. Home prepared meals are more nutritious for children.

In conclusion, child obesity was a foreseen event especially when the lifestyle and food intake pattern changed; conversely its increased prevalence over the last ten years was not foreseen. Currently it is one of the main ailments to be dealt with in children especially in industrialized countries. Obesity is a consequence of certain actions, meaning it can be reversed, conversely the process is time consuming and expensive.

It is because it requires a change from the current lifestyle to the previous one; one that had less fatty foods and more physical activities. The challenge is that times have changed and with the improved technology it is becoming more and more difficult to take people to a previous lifestyle. Most choose to take on surgeries that are quite risky and expensive in order to combat the challenges that come with obesity.