bariatric surgery and nutrition by: shala davidson and abby stanley
TRANSCRIPT
Bariatric Surgery and Nutrition
By: Shala Davidson and Abby Stanley
Obesity is American1
More than 2 in 3 adults are considered to be overweight or obese
More than 1 in 20 adults are considered to have extreme obesity
Since the early 1960s, prevalence of obesity among adults more than doubled, increasing from 13.4% to 35.7%
In children, ages 6-19, one-third (33.2%) are considered overweight or obeseOf those 18.2% are obese
Obesity in America1
Health Risks of Overweight and Obesity2,3,4
Causes and Treatment of Obesity2
Results from energy imbalance
Factors that lead to energy imbalance & weight gain: Genes Eating habits Attitudes & emotions Life habits Income Culture-how & where
people live
No single approach for treatment
May include combination of following: Behavioral treatment Diet Exercise Weight-loss drugs In cases of extreme
obesity, weight-loss surgery
Who is a good candidate?5,3
People who cannot lose weight by other means and suffer from serious health problems related to obesity
After diet, exercise, and pharmacologic agents have failed
Clinically severely obese BMI > 40 BMI > 35 accompanied by
serious health problems linked to obesityType 2 diabetes, heart
disease, sleep apnea
Questions to consider, is patient: Unlikely to lose weight using
other methods? Well informed about surgery
& treatment effects? Aware of risks & benefits of
surgery? Ready to lose weight &
improve health? Aware of how life may change
after surgery? Aware of limits on food
choices & occasional failures? Committed to lifelong healthy
eating & physical activity, medical follow-up, & need for extra supplementation?
Who is a good candidate?6
Plus health conditions
What do you know about Bariatric Surgery?7
The word gastric is often heard as part of the bariatric and metabolic surgery names. What does gastric mean? Internal Digestion Stomach intestinal
The risk of death within 30 days of having bariatric surgery is greater than the risk of death within 30 days of other operations? True False
What do you know about Bariatric Surgery?7
Many bariatric and metabolic surgeries are “laparoscopic”. What does this mean? Just one incision Surgery related to
weight loss Surgery done with very
small incisions A procedure where the
patient goes home the same day
What type of vitamin deficiencies do bariatric surgery patients usually face? None. Modern surgeries do
not lead to deficiencies Some. The level depends
on the procedure, and patients’ need to follow nutritional and supplemental requirements.
Severe. Patients are particularly dangerous in terms of vitamin deficiencies.
Types of Bariatric Surgeries3,5
Surgeries fall into 2 categories: Restrictive procedure Restrictive &
malabsorptive
Four types commonly used in the United States:
Restrictive AGB- Adjustable Gastric
band VSG- Vertical Gastric
Sleeve
Restrictive & malabsorptive RYGB- Roux-en-Y Gastric
Bypass BPD- Biliopancreatic
Diversion with Duodenal Switch
What does your stomach look like after surgery?3,5
Normally, the stomach can hold approximately 3 pints (48 oz)
Restrictive surgeries initially reduce that amount to only 1 oz
Later the new pouch may stretch to hold 2-3 oz
Simply put, bariatric surgery promotes weight loss by restricting food intake.
EAL Study: Bariatric Surgery Average Weight Loss8
Bariatric surgery can be expected to result in at least 50% excess weight loss.
Adjustable Gastric Banding (AGB): 50% mean EWL with a range of 32% to 70% EWL
Roux-en-Y Gastric Bypass (RYGBP): 68% mean EWL with a range of 33% to 77% EWL
Biliopancreatic Diversion (BPD): 79% mean EWL with a range of 62% to 75% EWL
Role of RD in Bariatric Surgery3,9
Assessing the potential surgery candidate’s readiness for necessary lifestyle changes that will be required for success
Evaluation & Nutrition Therapy
“Surgery represents only one point in the continuum of care for the obese patient. The long term outcome of bariatric patients relies on their adherence to lifetime dietary and physical activity changes. A comprehensive team approach provides the best care to these patients and RDs play an important and growing role in this process. Because of the pre- and postoperative dietary issues, RDs can assess, monitor and counsel patients in order to improve adherence and reduce the risk of nutrient deficiencies.” –Doina Kulick, MD
Role of RD in Bariatric Surgery3
Preoperatively Educate patients about
permanent changes in how they must eat and drink: Reduced volume of
stomach Potential for dehydration Importance of chewing Vomiting Dumping Syndrome Greater risk of nutrient
deficiency & long-term consequences
Necessity of supplements for vitamins & minerals
Permanent changes in eating behavior
Postoperatively Evaluate intake of protein
& fluids and recommend supplementation as needed
Monitor use of vitamin & mineral supplements and encourage compliance
Monitor side effects Nausea & vomiting,
constipation, hair loss, dumping syndrome
Formulate nutrition diagnoses & interventions as needed
Nutrition Assessment3
Bariatric Assessment and Pre-surgical Education Report Comprehensive form, purpose is to lead RD through assessment
& nutrition education, so that patient can make informed decision about surgery
Nutrition & Eating Habits Questionnaire (NEHQ) 24 hours recall, weight and dieting history, questions about
physical activity and other lifestyle habits, extensive food frequency questionnaire
Calculations BMI and Resting Energy Expenditure (Mifflin-St. Jeor)
Physical Activity Paffenbarger Physical Activity Questionnaire
Nutrition Assessment: Areas of Special Attention3
Patient’s dieting history
History of prescription medications for weight loss
Age at onset of obesity
History of eating disorders
Mental health status
Pregnancy
Physical activity
Support system
Inform of supplements needed for remainder of life Liquid protein, calcium,
vitamin B-12, iron, and others
Nutrition Guidelines: Liquid nutrition therapy
while in hospital Blended/pureed diet approx.
1 month No drinking during meals or
30 minutes afterward 3 cups high protein liquid
supplement (1 Tbl/15 min) Sweets & high-fat food,
carbonated drinks & straws are off limits
No alcohol Soft meal plan (after 1
month)- tender meats, cooked veggies & fruit
Nutrition Diagnosis3
Review signs and symptoms from assessment
Diagnose nutrition problems based on signs and symptomsExcessive oral intakeInadequate oral intakeInadequate protein intakeInadequate vitamin intake (B12)Inadequate mineral intake (iron)
Nutrition Intervention: Pre-Surgery3
Educate patient about what to expect concerning food and fluids
The patient may want to stock up on items allowed on the discharge eating plan
Encourage patients to purchase and try other items they will need (pureed meats, canned tuna, cream of wheat, and cream soups)
Encourage patients to test various high protein liquid supplements to find on they like
Discuss the importance that physical activity will play in losing weight and maintaining weight loss
Give patient a list of behavior strategies for avoiding overeating
Discuss importance of vitamin and mineral supplements after surgery (liquid or chewable multivitamin, calcium tablets and mineral supplement)
Nutrition Intervention: During Hospitalization3
Bariatric Surgery Nutrition Therapy-clear liquid diet
Monitor nausea and vomiting
Reinforce no fluids with meals or for 30 min after meal
Monitor for dumping syndrome
Reinforce the discharge eating plan
Nutrition Intervention: Post Surgery3
Advance eating plan to blended/pureed bariatric surgery nutrition therapy
Regularly assess weight loss
Patient bring 3-day food record
Assess nutritional adequacy of patients intake for protein and fluids
Ask patient if he or she is continuing to take supplements regularly (vitamin, mineral)
Reinforce importance hydration, protein, stop eating when full, and lifestyle changes
Nutrition Intervention:Post-Surgery10
Patients may develop nutritional deficiencies that require multivitamin and mineral supplementation.
The degree of nutritional deficiency is related to the remaining absorptive area and the percentage of post-surgical weight loss.
However, eating habits can contribute to nutritional deficiencies even following restrictive procedures
Nutrition prescription3
Goals after any gastric surgery: Maximize weight loss and
absorption of nutrients Maintain adequate
hydration Avoid vomiting and
dumping syndrome
Discharge nutrition therapies are essentially the same for all type of bariatric surgical procedures. Except for frequency of
meals
Adequacy of Nutrition therapy3
Diet after gastric surgery may be inadequate because of limiting size of the stomach and consuming smaller amounts of food
Nutrients Bariatric Patients are at risk for deficiencies: Protein Calcium Iron Vitamin B12 Folate
Fluid Needs3
Because stomach is so small, it is challenging to meet fluid needsNo liquids at meals (wait 30 min after)Sip (no straw)Goal is at least 6 cups fluid per day
3 cups high protein liquid supplement3 cups sugar free, noncarbonated beverages including water
and sugar free, noncarbonated soft drinks; decaffeinated coffee or tea
Stop eating and drinking when full (overeating cause stomach to stretch and leads to increased intake)
Avoid carbonated beverages, as the gas bubbles with stretch the pouch
Nutrition monitoring and evaluation3
1. Assessment: 24 hour food intake recall Intake of water or other non-
caloric beverages (what kind & how much)
Consumption of liquid protein supplement (what kind & how much)
Estimated total protein intake/day
Assess adequacy of supplement use (when & how much)
Weight Ask the patient about:
consumption of food and liquids More education needed?
2. Nutrition Diagnosis using PES statement
3. Plan nutrition interventions (setting goals)
4. Schedule follow up appointment
ADIME of a Bariatric Patient
Assessment: Diet history, Anthropometrics and Physical Activity
Diagnosis (PES): Inadequate vitamin intake (B12) related to decreased
absorption as evidenced by reports of adequate vitamin B12 sources in diet with low serum levels
Intervention: Supplement oral intake of B12 with B12 injection given once
per month
Monitoring and Evaluation: Monitor intake of B12 and serum levels Evaluate to see if serum levels are adequate, continue
monitoring to ensure they remain stable. If serum levels are inadequate, look for new approach and/or consult physician
Research: Effectiveness of Bariatric Surgery11,12,13
The Swedish Obese Subjects Study11
Bariatric surgery resulted in long-term weight loss and improved lifestyle with increased physical activity
Risk factors present at baseline were much lower in surgically treated group, except for hypercholesterolemia
New England Journal of Medicine (2 studies) After 7.1 years adjusted long-term mortality decreased
by 40% in surgery group12
Disease-specific mortality decrease: coronary artery disease-56%, diabetes-92%, cancer-60%12
At 10 year follow up period control group maintained body weight within 2% range, whereas surgery patient losses ranged from 14-25%13
Conclusion: NCP
Sources1. National Institute of Health. Data from the National Health and Nutrition Examination
Survey 2009-2010. Weight-Control Information Network. http://www.win.niddk.nih.gov/statistics/. Published October 2012. Accessed November 11, 2013.
2. National Institute of Health. Overweight and Obesity Statistics. Weight-Control Information Network. http://www.win.niddk.nih.gov/statistics/. Published October 2012. Accessed November 11, 2013.
3. Academy of Nutrition and Dietetics. Bariatric Surgery. Nutrition Care Manual http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5545&lv2=16927&ncm_toc_id=16927&ncm_heading=Nutrition%20Care. Published 2013. Accessed November 8, 2013.
4. Appecal. Excess Weight Risk. Natural Appetite Management. http://www.myappecal.com/excess-weight-risk.htm. Published 2011. Accessed November 15, 2013.
5. National Institute of Health. Bariatric Surgery for Severe Obesity. Weight-Control Information Network. http://win.niddk.nih.gov/publications/gastric.htm. Updated June, 2011. Accessed November 11, 2013.
6. Donavan, M. Is the Environment the Main Cause of Obesity. How to Lose Belly Fat. http://howtolosebellyfatsoon.com/about. Accessed November, 16, 2013.
Sources7. American Society of Metabolic and Bariatric Surgery. Learning Center. For Patients.
http://asmbs.org/learning-center. Updated 2013. Accessed November 16, 2013.
8. Academy of Nutrition and Dietetics. Weight Loss Following Bariatric Surgery. Evidence Analysis Library.http://andevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251158&highlight=bariatric%20surgery&home=1. Published 2013. Accessed November 12, 2013.
9. Academy of Nutrition and Dietetics. RD role Vital for Gastric Bypass Patients. Media Press Room. http://www.eatright.org/Media/content.aspx?id=6442451904&terms=rd%20role%20vital#.Uo0se9KsiM4. Published April 14, 2010. Accessed November 13, 2013.
10. Rickers L, M. Bariatric Surgery: Nutritional Concerns for Patients. Art and Science Nutrition. 2012; 41-47. Published 2012. Accessed November 14, 2013.
11. Sjostrom L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, et al. Lifestyle, diabetes and cardiovascular risk factors 10 years after bariatric surgery. New England Journal of Medicine. 2004;351(26):2683-2693.
12. Sjostrom L, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine. 2007;357(8):741-752.
13. Adams T. D., et al. Long-term mortality after gastric bypass surgery. New England Journal of Medicine. 2007;357(8):753-761.