Gateways Hospital and Mental Health Center
Gateways Mental Health Hospital
Palmdale School District
City of Hope
Bariatric Nursing: Guiding Obese Patients Towards a Healthier LIfestyle
The satisfaction of seeing former patients riding a bicycle
I became involved in bariatric nursing 18 months ago when I was asked to fill a vacant directorship in my hospital’s new bariatric program. Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity. Besides the pharmacology of obesity, bariatrics focuses on obesity surgery.
To prepare for my new role as a bariatric nurse, I studied textbooks, read journals and attended seminars. My duties include administrative oversight of the outpatient clinic, patient education, support group leadership, policy and procedure development, and provision of an interface with in-house services for bariatric patients. As usually happens with a new position, there were some surprises. One surprise that delighted me was the discovery that bariatric nursing can be fun. Pre-op patients eagerly look forward to a healthier life and post-op patients celebrate each lost pound. The waiting room is always buzzing with happy chatter as patients share their stories of success.
“This is addictive,” my medical director said one day. And he was right. We all look for rewards beyond the paycheck, and I certainly found mine as I witnessed people getting healthier. One patient rides his bicycle past the clinic several times a week laughing and waving as he peddles down the street. Another patient plans trips with confidence, knowing she will be able to climb steps and walk moderate distances without fear of dyspnea.
Changing Eating Patterns
Our program concentrates on weight loss through bariatric surgery. Our surgeons provide both gastric bypass procedures and the LAP-BAND®. The bypass procedure reduces the size of the stomach and bypasses a portion of the intestine causing malabsorption of nutrients. The patients must be committed to taking micronutrient supplements for the rest of their lives. The LAP-BAND® is only a restrictive procedure. A band is placed around the upper portion of the stomach, forming a small pouch. Inflating or deflating the band through a port just under the skin can adjust the amount of restriction. Patients who seek our services often spend months or years contemplating the procedure. It is an important decision. Bariatric surgery changes one of the most basic parts of a person’s life: food.
A change in eating patterns is necessary for successful weight loss, and a good time to begin change is prior to bariatric surgery. In fact, many insurance companies require six months of documentation of a medically supervised weight loss program prior to authorizing surgery. One of the first changes we ask patients to make is to give up carbonated beverages. That change alone can result in weight reduction. Controlling portion size is another important step to take. Using a tool such as the one on the American Cancer Society’s webpage under "Controlling Portion Size" is helpful. This tool provides comparisons to items that are common in our daily lives, i.e., 1 oz. of meat is the size of a matchbox. Working with patients to change eating patterns gives the nurse insight into many other aspects of the patient’s life.
Two patients I spoke with recently stated that their eating habits were out of control prior to surgery. “I kept gaining weight, and I couldn’t do anything about it,” one patient said, adding, “I couldn’t stop myself from eating.” Many overweight and obese people report they never feel satisfied following a meal. Patients who undergo bariatric surgery usually develop the feeling of satiety for the first time in their adult lives. Eating slowly and chewing carefully becomes a way of life for patients following bariatric surgery.
Changes in eating patterns is one of the many things a person must thoughtfully consider before making the important decision to have this type of surgery, but most patients agree that the changes are well worth the final results.
Knowing What to Say
As my enthusiasm grew for the bariatric program, I began to see potential patients all around me. I approached other healthcare workers to ask for support in referring patients to the program. Some healthcare providers were willing to help, but others seemed reluctant to discuss weight loss with their patients. I was frustrated when I encountered the latter, and as I contemplated the issue, I began to understand that this is a common problem.
I believe that addressing the needs of overweight and obese persons is much the same as showing cultural competence when caring for someone whose values and identity are different than one’s own. Purnell and Paulanka, writing in Transcultural Health Care in 2003, state, “Healthcare providers need to address their personal views of traditional values, including biases and prejudices…”
In other words, healthcare providers must examine how they feel about overweight and obese individuals. If the healthcare provider views these patients as lacking self-control or as lazy, they will find it difficult, if not impossible, to show them the caring and compassion necessary to assist these people to find healthier life patterns. Obesity should not be viewed by the healthcare worker as a cosmetic issue; they are health issues with subsets of comorbidities that one would hope to avoid or resolve.
Identifying a health issue with a patient is an important first step. Questions such as, “What concerns you about your health?” might be a good jumping-off point for the nurse who wants to discuss issues of weight. The patient may open the door by stating the issue of most concern is her weight, or she may list dyspnea and difficulty with ADLs. If the latter is the case, these issues may easily be related to the patient’s weight as the interview continues.
Setting Mutual Goals
The next step is the setting of mutual goals. It is important to remember that the patient’s goals may not mirror the nurse’s goals. The literature has shown that if the patient does not identify the goals as her own, she is less likely to work toward the achievement of those goals. The goals may be for increases in activity, changed eating patterns, or better control of blood sugar or blood pressure. The patient may come to the nurse having already decided to go forward with the bariatric surgery. It is the nurse’s job to review these goals with the patient for feasibility and health benefit.
After setting goals, create a plan to achieve them. A daily journal of activity and eating is useful. Assisting the patient to identify rewards that are not food related is important. If it is suspected that the patient has an addictive eating disorder, the nurse must be creative in assisting the patient to develop a reward system that would not fuel another addictive behavior. A manicure, movie or tickets to a sporting event are possible rewards for goals reached or steps taken to reach goals.
“The Chair Broke”
To those who are of ideal, or near ideal body weight, it may be hard to understand why a patient would refuse surgery that holds the promise of positive changes; but to the patient contemplating the procedure, it can be very frightening. There are many risks involved in having surgery, and most obese patients have multiple comorbid conditions, such as hypertension, diabetes and sleep apnea. While these health issues generally improve greatly following surgery, they increase the risks of general anesthetics and surgical procedures. For some patients, the decision seems easy; for others, the decision has taken months or years of consideration.
It was not long after I took the position in the bariatric program that I began asking what lies behind a person’s decision to have surgery.
“What was the defining moment for you?” I asked my best friend Jennifer as we sat sipping iced coffees one afternoon. Jennifer struggled with obesity all of her adult life, and now, although still overweight, she is 100 pounds lighter than a year ago. “The chair I was sitting in broke,” she replied. “I was at a neighborhood barbeque, and it was so humiliating. Right then and there, I knew I had to do something.”
Most patients I spoke with did not have a defining moment as clearly identifiable as Jennifer’s.
“I didn’t want to be a 500-pound person dependent on other people to care for me,” one woman said. Several other patients said they were short of breath with any exertion. Many stated they could only walk short distances and were unable to accompany children or grandchildren to amusement parks, school functions or the store. Others said simply, “I wanted a better quality of life.” One man said, “I knew I would die if I didn’t do something.”
Worth the Effort
An article that appeared in the Journal of the American Medical Association (vol. 292 no. 14, Oct. 13, 2004), reviewed bariatric surgery and its effect on four comorbidities. The article states, “A substantial majority of patients with diabetes, hypertension, hyperlipidemia and obstructive sleep apnea experienced complete resolution or improvement.” The article concluded that the results of bariatric surgery are worth the effort. It improves the quality and length of life for most patients.
It is important that if we as nurses are to bring this information to those we serve, we must educate ourselves about the options available to obese patients and the results of various treatment modalities. Find a bariatric program near you and call to see when they hold support group meetings. Attend a meeting; you will learn something new and be surprised at how much laughter you encounter. More importantly, examine your own feelings about obesity and the obese patient. Determine to address the issue of weight with those you care for, and working together, we can help to improve the health of our communities and nation.
Judith Tanelian, RN, BSN, CBN, was recently credentialed as a Certified Bariatric Nurse through the American Society for Metobolic and Bariatric Surgery. She lives and works in the South Bay area of Southern California.