Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Pathopharmacological Foundations for Advanced Nursing Practice

Investigated Disease Process

Obesity is defined as having a body mass index or BMI of greater than 30. Obesity is not considered a disease but is a risk factor for other diseases like heart disease and type 2 diabetes. One third of American adults are obese with another one third considered overweight (BMI greater than 25 but less than 30). Parents who are obese often have children who are obese due to genetics and environmental effects: parents and children usually eat the same foods and have the same exercise habits (McCance & Huether, 2014).

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Obesity is an epidemic with no simple solution Pathopharmacological foundations for advanced nursing practice c155 obesity Essay. It is a complex problem that is going to take individuals, healthcare professionals, state and local organizations, policy makers, and community leaders working together to create and maintain a healthy lifestyle and environment. Resources are available through state and local programs for health recommendations. Community support for healthy eating and active living in different settings can help reverse obesity. A lifestyle change is the way to achieve and maintain a healthy weight (“Strategies to Prevent Obesity,” 2015).

A1. Pathophysiology

Obesity is defined as a BMI greater than 30 and is also considered a metabolic disorder. When an individual with susceptible genes to obesity takes in more calories than they burn off then obesity can develop (McCance & Huether, 2014) Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

There are interactions of many cytokines, hormones, and neurotransmitters which makes the pathophysiology of obesity very complex. Adipocytes are the cellular basis of obesity and secrete numerous hormones and cytokines called adipokines. Adipokines help regulate food consumption, the storage and metabolism of lipids, insulin sensitivity, and many others. Accumulation of visceral fat causes the adipocytes to not function properly and results in changes in the regulation and interaction of the hormones. These changes in the adipokines and other hormones and neurotransmitters take part in the causes and complications of obesity (McCance & Huether, 2014).

A2. Standard of Practice

Recommended standards for a primary care giver is to calculate a patient’s BMI, using height and weight, on annual visits or more frequently if needed. This is the first step in identifying those who would need to be counseled on weight lose if the BMI is >25 (overweight) or >30 (obese). A waist circumference should also be used as a possible indicator for higher risk of type II diabetes and cardiovascular disease. Waist circumference limit is 40 inches or more for men and 35 inches or more for women. Lifestyle change is the most important start for weight loss. Guidelines for weight loss are based on the patient assessment and include: a) diet, b) physical activity, c) behavioral counseling, d) pharmacological treatments, and e) bariatric surgery. Patient options and any health issues are included in these guidelines (“New Obesity Guidelines: Authoritative ‘Roadmap’ to Treatment,” 2013). Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

A2a. Pharmacological Treatments

Treatments for obesity are based on developing a weight loss plan to improve the patients’ health and well-being. After consulting some primary care physician offices, results show that evidence-based pharmacological therapies in my state were comparable to the recommended standard guidelines for weight loss. Developing a diet plan by reducing calorie intake, increasing physical activity, and adding behavioral counseling are important for a successful weight loss plan. Individuals with a BMI greater than 30 or greater than 27 with other comorbidities that do not have success in losing weight with diet and exercise may need to add medications to help with the weight loss plan. The approved medications for long-term treatment for weight loss include, orlistat, lorcaserin, phentermine/topiramate, and naltrexone/bupropion. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay. Physicians should consider bariatric surgery in patients with a BMI greater than 40 (“Update on Office-Based Strategies for the Management of Obesity – American Family Physician,” 2016).

Alabama is the 3^rd ranked state with an obesity rate of 35.7% in 2016 (“State of Obesity: Obesity data trends and policy analysis,” 2017). Heart disease, stroke, diabetes, and cancer are the leading causes of death in the United States and obesity is a contributing cause to these diseases. In Alabama obesity has slowly increased in the past 20 years. Approximately 45% of Alabama adults do not eat fruit at least once a day. Almost 26% of Alabama adults eat less than one vegetable a day. And at least 85% of Alabama adults do not meet the recommendation for physical activity guidelines, 150 minutes of moderate aerobic activity weekly and muscle strengthening exercises at least two days a week (“State of Alabama Community Health Assessment,” 2015).

A2b. Clinical Guidelines

Clinical guidelines for obesity is the assessment and management of the disease. Patients understanding of the disease and the risk factors involved with obesity are essential for treatments to be successful. Management of obesity is a lifestyle change that requires specific knowledge and education from the patient and provider. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

The recommended guidelines for the assessment, diagnosis, and patient education of obesity are summarized below.

Assessment

A complete medical history should be completed on an initial visit and including a BMI and waist circumference. Eating and physical habits, family history and any other risk factors or conditions are included in the history to determine the cause of obesity (“Diagnosis – NHLBI, NIH,” n,d.).

A physical exam measuring height and weight to determine the BMI. The waist circumference is measured to assess the amount of abdominal fat on a patient. Medical conditions like hypothyroidism, Cushing’s syndrome, and polycystic ovary syndrome can cause obesity, so laboratory tests to check for these conditions are also part of the examination (“Diagnosis – NILBI, NIH,” n.d.).

Diagnosis

All adults should be screened for obesity. BMI and waist circumference should be assessed and recorded at each visit with the health care provider. Even though the BMI does not measure body fat directly or distinguish muscle from fat, it is the recommended way to diagnose patients who are obese. The classification ranges for BMI are as follows: underweight -<1.5, normal – 18.5 to 24.9, overweight – 25.0 to 29.9, obese (stage I) – 30.0 to 34.9, obese (stage II) – 35.0 to 39.9, extreme obesity (stage III) – 40.0 and greater. Waist circumference greater than 40 in men and greater than 35 in women is defined as abdominal obesity (“Diagnosis and Management of Obesity,” n.d.). Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

Patient Education

Educating the patient on weight loss and the necessity for lifestyle changes increases the chance for a healthier life. Whether the weight loss is significant or a simple 5-10% of the total body weight, can have health benefits for the patient. The U.S. Preventive Services Task Force (USPSTF) helped develop an approach to educate and help patients who are ready for preventive obesity counseling called the 5 A’s approach. 1) Assess the stage of obesity and any comorbidities, eating habits, physical activity, medications that affect weight, and readiness for behavioral change. 2) Advise the patient of the obesity diagnosis, the many different types of diets for weight loss, the need to decrease calories, the pros and cons of over-the-counter weight loss aids, medications, and surgery, and how important it is for the patient to self-monitor. 3) Agree that if the patient is not ready then discuss again at another visit, when the patient is ready a treatment plan will be developed, set a 10% weight-loss goal with diet/exercise/medication, review all surgery options with the patient if he/she is a candidate for weight-loss surgery. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay. 4) Assist the patient with a diet plan, physical activity guide, and behavioral modification guide, provide the patient with any web resources that are based on the patient needs, help patient determine what method of self-monitoring to use for daily intake of food and physical activity (e.g., mobile app or diary), review food and activity log on follow-up visits and reassess if goal is not met. 5) Arrange follow-up visits, referrals to dietitian/behavioral counselor/weight-management classes, surgeon referral, maintenance counseling to help prevent patient from regaining weight after weight loss (“Diagnosis and Management of Obesity,” n.d.).

A2c. Comparing Standard Practice of Disease Management

Standard practices for obesity management and weight loss treatment are used in primary care clinics in my community. After questioning several providers in the community, the management of obesity was consistent with the standard guidelines. A complete medical history and physical assessment is completed on patients. Obesity is diagnosed according to the BMI and a waist circumference if indicated. A weight management plan is then developed based on each patient’s specific needs. Diet, exercise, counseling, pharmacological treatments, and surgery options are all included in this plan.

A3. Managed Disease Process

Characteristics of a patient who has reached their healthy weight loss goal and maintained it include: a) BMI within normal range, b) at least 60 minutes of daily physical activity, c) healthy diet, d) continued behavioral counseling, e) reduction in risk factors for comorbidities (“Update on Office – Based Strategies for the Management of Obesity – American Family Physician,” 2016).

A patient who has managed their weight loss would show the appropriate skills for the continued maintenance of the weight management plan. They would have access and transportation to get to the health providers and activity centers. The patient would also have the knowledge to choose the appropriate foods for a healthier diet, and the financial resources for pharmacological treatments or bariatric surgery if needed.

Studies show that extremely obese (BMI >40) patients have a significant reduction in life expectancy. Deaths were mostly due to heart disease, cancer, and diabetes. Life expectance decreased to approximately 6.5 years for a patient with a BMI of 40-44.9 and 13.7 years for a BMI of 55 and greater (“NIH study finds extreme obesity may shorten life expectancy up to 14 years,” n.d.). The outcome from a patient with managed weight loss would have increased life expectancy. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

A3a. Care Management Disparities

Obesity is a major health issue in the United States and globally. At least 40 percent of the population between the ages of 45 and 59 in North America, Central America, South America, Western Europe, Eastern Europe, and the Middle East, are overweight or obese (“Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists,” n.d.). Differences in populations contribute to the disparities in management of obesity across the nation. Race, culture, sex, economic status, and place of residence, all account for the differences.

Obesity exists in all ethnic and racial groups, all ages, gender, socioeconomic status, and geographical location. African Americans and Latino populations have higher obesity rates than White populations. Obesity is a worldwide epidemic (“Special Report: Racial and Ethnic Disparities in Obesity,” n.d.). Disparities in health care, limited access to health care, and the quality of the care received can have a crucial impact on the management of obesity.

Racial/ethnic populations have different behaviors that factor in to weight gain. Compared to non-Hispanic whites, Hispanics and non-Hispanic blacks are less likely to participate in physical activity outside of their occupation. There is also cultural differences and attitudes concerning body weight, both Hispanic and non-Hispanic black women are more content with their body size than non-Hispanic white women (“Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults—United States, 2006-2008,” n.d.).

There are approximately 47.8 percent African Americans that are obese compared to the 32.6 percent of White adults. Low income or lack of income, accessibility to quality education, access to healthier food, and lack of safer places to participate in physical activities, all contribute to the increased obesity rates in African American communities (“Special Report: Racial and Ethnic Disparities in Obesity,” n.d.).

There are 42 percent of Latino adults that are obese compared to the 32.6 percent of White adults. Inequity to healthcare, quality of care, little opportunity to make healthier choices, and limited access to a safe environment for physical activity contribute to the higher obesity rates in Latino communities (“Special Report: Racial and Ethnic Disparities in Obesity,” n.d.).

Nationally African Americans were at a higher risk for obesity and in the United States Latinos are the fastest growing population with the higher rates of obesity. It is essential for state and national practices to focus on these disparities in health care to improve the health and well-being of individuals (“Special Report: Racial and Ethnic Disparities in Obesity,” n.d.).

A4. Managed Disease Factors

There are several factors that can impact a patient’s ability to manage their obesity and reach their weight loss goal. These factors include access to care, financial resources, and health insurance. The following factors assist in the patient’s ability to manage their weight loss and maintain a healthy lifestyle:

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Financial Resources – Patients who have the financial resources to pay for the physician’s care management, healthier foods, gym memberships, counseling, and any prescription medications needed, show better continuity of care in managing obesity and weight loss. Better continuance of care for obesity will result in a patient with a well-managed weight loss.

Health Insurance – A patient with health insurance can use the insurance for payment purposes to aid in weight loss management, prescriptions medications, and bariatric surgery for the morbidly obese. Insured patients result in continuity of care for obesity and results in a well-managed weight loss with the ability to maintain it. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay.

A4a. Unmanaged Disease Factors

The same factors can also impact a patient’s inability to manage their obesity. The following shows how the factors can affect the patient’s inability to manage their weight loss:

Access to Care – Patients will need to have access to the physician services for obesity management care. Periodic health assessments by a weight loss health care professional for proper management of the disease is required. Also access to fitness centers and health food stores to aid in the continuation of a healthier lifestyle. Patients can have lack of access to these services due to: a) lack of weight loss providers, b) lack of resources to access the care, c) lack of transportation, d) lack of fitness centers and health food stores in patient area. Lack of accessibility to the services provided will likely result in a patient that remains obese and is unable to manage any weight loss.

Financial Resources – Patients who do not have the financial resources for physician’s management, healthier foods, gym memberships, counseling, prescription medications, or surgery, are likely to result in poor obesity management.

Health Insurance – A patient who has no insurance is less likely to seek obesity management care. Health insurance can help pay for physician visits and prescription medications. Insurance also pays for bariatric surgery in the morbidly obese. Lack of health insurance will result in little or no management for the obese patient.

A4ai. Unmanaged Disease Characteristics

Managing weight loss is a lifestyle change that must continue even after the weight loss goal is accomplished. Some patients have a difficult time maintaining a healthier lifestyle and regain the weight, or they may never lose the weight. There are many reasons why a patient may not be able to manage their obesity. Some of the reasons are: lack of access to care, lack of financial resources for care, and lack of health insurance.

An obese patient has increased risks for type 2 diabetes mellitus, hypertension, heart disease, dyslipidemia, cerebrovascular disease, metabolic syndrome, pulmonary abnormalities, gastrointestinal abnormalities, reproductive disease, psychosocial problems, osteoarthritis, and cancer. Obesity also prevents some access to care. For example, MRI machines have weight limits of up to 450 pounds. Surgical mortality is increased with obesity and some surgeons may choose not to operate due to the associated risk of mortality (“Complications of obesity in adults: A short review of the literature,” n.d.). These potential comorbidities and increased risks are all associated with a patient that is unable to manage their obesity.

Patients, Families, and Populations

Patients who have managed their obesity and were able to reach a healthy weight are expected to live a happier life. With a normal BMI, a patient can participate in more physical activities and continue their career with no health-related risks. There is also less hassle for the family to have to care for the patient who is obese and unable to care for themselves.

Patients who are unable to manage their obesity are more likely to develop one or more of the comorbidities (heart disease, diabetes, or hypertension) associated with obesity. Due to the increased weight and other related diseases the patient is more likely to be out of work frequently or permanently. When a patient has no income and no insurance then assistance is needed from family members or friends and is going to cause more undue stress. Financial problems will also arise from the medical bills incurred due to the obesity and related issues.

Approximately 31% of adults in my community are obese. The higher prevalence of obesity is among African Americans. Alabama ranked 5th in the prevalence of obesity in 2012 (“State of Alabama Community Health Assessment 2015,” n.d.). The local county health department also offers many programs and assistance to those in need. A supplemental nutrition program for women, infants, and children (WIC) is a program that information on nutrition and healthier foods (“WIC Program | Alabama Department of Public Health (ADPH),” n.d.).

B1. Costs

According to the CDC, obesity and the comorbidities associated with the disease economically affect the health care system. Medical costs are directly affected due to preventive, diagnostic, and treatment services that are associated with obesity. The costs are indirectly affected due to decreased productivity at work and absenteeism. In 2008 the estimated costs of care for the obese patient was $147 billion. Nationwide productive costs related to obesity or absenteeism related to obesity was estimated at $3.38 billion to $6.38 billion (“Adult Obesity Causes & Consequences | Overweight & Obesity | CDC,” 2017)

A study done in 2006 showed that obese people spent an estimated 42 percent more on medical spending than the normal-weight people. Obesity related medical costs are estimated to be increased by 37 percent. Increases in annual costs were estimated at 36 percent for Medicare, 47 percent for Medicaid, and 58 percent for private pay patients (“Annual Medical Spending Attributable to Obesity: Payer and Service-Specific Estimates,” n.d.).

The cost of diagnosing obesity and managing weight loss can vary depending on the management plan. If the patient is insured and the management plan is covered by insurance, then the only cost would be co-pays and deductibles that must be met by the patient. For the morbidly obese patient that bariatric surgery is indicated for treatment, then insurance would cover the surgery and follow up appointments.

The cost can be significant for the private paying patients. A diet clinic in the author’s community (no insurance accepted) has a $60 charge for an office visit. Other local physician offices have a $75 charge for an office visit for weight management treatment. Prescriptions medications can also vary in price and insurance may or may not cover the cost. A prescription of phentermine for thirty days is approximately $22 at a local pharmacy. Naltrexone/bupropion prescriptions can range from $55 to $200 a month. And the cost for bariatric surgery can range from $10,000 to over $20,000, depending on which surgery the patient and the physician determine is best.

Best Practices Promotion

Best practice promotion in an Obstetrician and Gynecology (OB/GYN) office setting, the author’s practice setting, is to increase patient awareness on the importance of weight control and physical activity during pregnancy and after delivery. Also by following the current standards of practice for obesity, updating provider knowledge on the current practice guidelines would promote best practices.

C1. Implementation Plan

The current setting this author is mainly involved in is obstetrics patients during pregnancy and up to 6 weeks postpartum. The three strategies chosen for plan implementation include:

Development of a healthy diet and physical activity plan for patients during pregnancy and after delivery. A healthy, well-balanced diet and daily physical activity can help a patient maintain a healthy pregnancy and manage weight loss after delivery.
Development of a dietician/nutritionist counselor. The counselor will provide patients with education on current guidelines for care related to managing obesity. The counselor will also provide each patient a specific diet and activity management plan based on the patient’s specific needs and abilities.
Development of provider and counselor education programs on the most current guidelines for obesity management. The programs will be available online and the providers and counselor will be required to complete the programs annually.Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

C2. Evaluation Method

Evaluation of success of the three strategies stated above are as follows:

The success of the healthy diet and physical activity plan with be shown by the patient maintaining a normal weight gain during pregnancy and returning to the pre-pregnancy weight after delivery.
The success of the counselor will be shown by the patient verbalizing her understanding of obesity guideline education. Also, success will be shown by the patient choosing healthier food options and choosing to participate in daily physical activity. Pathopharmacological foundations for advanced nursing practice c155 obesity Essay
The success of the provider and counselor programs will be shown with completion of the online learning. And with chart documentation that shows the standard guidelines for obesity are being met by the providers and counselor.

Resources

Adult Obesity Causes & Consequences | Overweight & Obesity | CDC. (2017, August 29). Retrieved from https://www.cdc.gov/obesity/adult/causes.html

Annual Medical Spending Attributable to Obesity: Payer and Service-Specific Estimates. (n.d.). Retrieved from http://content.healthaffairs.org/content/28/5/w822.full.pdf+html

Complications of obesity in adults: A short review of the literature. (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062780/ Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Diagnosis – NHLBI, NIH. (n.d.). Retrieved from https://www.nhlbi.nih.gov/health/health-topics/topics/obe/diagnosis

Diagnosis and Management of Obesity. (n.d.). Retrieved from http://aafp.org

Differences in Prevalence of Obesity Among Black, White, and Hispanic Adults — United States, 2006–2008. (n.d.). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a2.html

McCance, K., & Huether, S. (2014). Pathophysiology: The biologic basis for disease in adults and children, 7th Edition [Western Governors University]. Retrieved from Retrieved from https://wgu.vitalsource.com/#/books/9780323088541/

New Obesity Guidelines: Authoritative ‘Roadmap’ to Treatment. (2013, November 12). Retrieved from http://www.medscape.com

NIH study finds extreme obesity may shorten life expectancy up to 14 years. (n.d.). Retrieved from https://www.nih.gov/news-events/news-releases/nih-study-finds-extreme-obesity-may-shorten-life-expectancy-14-years

Resources

The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists. (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033553/ Pathopharmacological foundations for advanced nursing practice c155 obesity Essay

Special Report: Racial and Ethnic Disparities in Obesity. (n.d.). Retrieved from https://stateofobesity.org/disparities/

State of Alabama Community Health Assessment 2015. (n.d.). Retrieved from http://www.alabamapublichealth.gov

The State of Obesity: Obesity data trends and policy analysis. (2017, August 31). Retrieved from http://stateofobesity.org

Strategies to Prevent Obesity. (2015). Retrieved from https://www.cdc.gov/obesity/index.html

Update on Office-Based Strategies for the Management of Obesity – American Family Physician. (2016, September 1). Retrieved from http://www.aafp.org/afp/2016/0901/p361.html

WIC Program | Alabama Department of Public Health (ADPH). (n.d.). Retrieved from http://www.alabamapublichealth.gov/dekalb/wic.html Pathopharmacological foundations for advanced nursing practice c155 obesity Essay