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Medical Nutrition Therapy for Bariatric Surgery

Medical Nutrition Therapy for Bariatric Surgery. Rebecca Scheeler Concordia College Moorhead, MN. Objectives. Identify who is a good candidate for bariatric surgery. Identify the different types of procedures available for patients.

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Medical Nutrition Therapy for Bariatric Surgery

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  1. Medical Nutrition Therapy for Bariatric Surgery Rebecca Scheeler Concordia College Moorhead, MN

  2. Objectives • Identify who is a good candidate for bariatric surgery. • Identify the different types of procedures available for patients. • Be able to describe postoperative medical nutrition therapy. • Identify lifestyle changes that are required for successful procedures. • Identify several ethical challenges involved in the procedure and treatment.

  3. Definition • Obesity is defined by the Center of Disease Control (CDC) as, “Someone who’s weight is greater than what is considered healthy for their height.” • Adults who’s BMI is between 25 and 29.9 is considered overweight. • Adults who’s BMI is greater than 30 is considered obese.

  4. Obesity Prevalence in America • National Health and Nutrition Examination Survey (NHANES) 2005-2006 Statistics 33.3% of men were obese 35.3% of women were obese • Occurrence of severe obesity in adults aged 18-64 years has increased by 114% within the years of 1991-1999. • Morbid obesity has increase 400% from 1983 to 2000. Ogden, C.L, Carroll, M.D., McDowell, M.A., & Fegal, K.M. (2007). Obesity among adults in the United States. Centers for Disease Control and Prevention. Nation Center for Health Statistics. Data Report, 1, 1-8. Journal. (2009) Position of the american dietetic association:Weight mangament. Journal of American Dietetic Association 109, (2), 330-346.

  5. Obesity prevalence in America “Except for smoking, obesity is now the number one preventable cause of death in this country. Three hundred thousand people die of obesity every year.” Dr. C. Everatt Koop

  6. Obesity and Chronic Diseases • Obesity is associated with many chronic diseases including: • Heart Disease • Hypertension • Sleep apnea • Degenerative Joint Disease • Gastroesophageal Reflux Disease • Asthma • Depression Harrington, L. (2006). Postoperative care of patients undergoing bariatric surgery. MEDSURG Nursing, 15 (6), 357-363.

  7. Surgical Criteria • U.S. Department of Health and Human Services National Institutes of Health Clinical Guidelines state surgery would be a good option if the patient has • BMI>40 • BMI>35 and has a comorbid condition such as • Cardiovascular Disease • Sleep apnea • Uncontrolled type 2 diabetes Scheirer, L, (2004). Bariatric Surgery:life-threatening risk or life-saving procedure. Journal of the American Dietetic Association 104(9), 1339.

  8. Surgical Criteria • Before surgery patients are evaluated by multidisciplinary team consisting of a medical doctor, psychiatrist, and a registered dietitian. • RD is a vital part in patient evaluation. • Informs patient of lifestyle changes • Helps elect optimal procedure for patient • Candidate for surgery should be a well-informed, highly motivated individual with a good support system. Journal. (2009) Position of the american dietetic association:Weight mangament. Journal of American Dietetic Association 109, (2), 330-346.

  9. Bariatric Review • Patient meets with RD to go over healthy eating guidelines. • What is a serving size • Meal plan cards • Supplement introduction • Review of patients 2 day food record • The patient must lose at least 10 lbs before they will be qualified to have the operation. • Post-op diet is described to patient at this time.

  10. Bariatric Procedures • There are four commonly used procedures that either restrict food intake or produce malabsorption or a combination of both. • Laparoscopic Adjustable Gastric Banding(LAGB) • Vertical Banded gastroplasty (VBG) • Roux-en-Y gastric bypass (RYGB) • Biliopancreatic diversion with duodenal switch

  11. Laparoscopic Adjustable Gastric Banding • Laparoscopic band placed • around the upper part of • the stomach. • Saline is used to inflate • or reduced the size of the • band. • Restricts food • consumption and slows • digestion. • Less invasive than Roux- • en-Y. Tice, J., Karliner, L.,Walsh, J., Petersen, A., & Feldman, M. (2008) Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. The American Journal of Medicine, (121), 885-893.

  12. LAGB Complications • Reoperation rates high. • Port Problems • Band Sippage with pouch dilation • Twisting of access port • Erosion of band Tice, J., Karliner, L.,Walsh, J., Petersen, A., & Feldman, M. (2008) Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. The American Journal of Medicine, (121), 885-893.

  13. Vertical Banded Gastroplasty • A small vertical pouch is created at top • of stomach by stapling both walls of • stomach. • Outlet is secured with plastic band • which controls volume of pouch and • prevents stretching. • This constricts the amount of food a • patient can consume at one time. • Dietary plan is an especially important • aspect to a successful outcome. Martin, M., Mullenix, P., Steele, S., See, C., Cuadrado, D. & Carter, P., (2004). A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass. The American Journal of Surgery, (187), 666-667.

  14. Vertical Banded Gastroplasty complications • Reflux symptoms has been seen in about 38% of patients. • Staple line breakdown resulting in weight gain. • Stomal stenosis in about 1/3 patients that eventually requires a conversion to gastric bypass. • Is associated with a high frequency of weight regain so is rarely performed anymore. Martin, M., Mullenix, P., Steele, S., See, C., Cuadrado, D. & Carter, P., (2004). A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass. The American Journal of Surgery, (187), 666-667.

  15. Roux-en-Y Gastric Bypass • Most common form in America, • constituting for about 80% of all • bariatric procedures. • A small pouch (15-30 ml) is created • at base of the esophagus. • Bypasses duodenum and part of the • jejunum, connecting the jejunum to • the pouch. • Quickly induces satiety and achieves • weight reduction through the • restriction of intake of food and • malabsoroption. Brethauer, Chand, & Schauer (2006). Risks and befefits of bariatric surgery: current evidence. Cleaveland Clinic Journal of Medicine, (11), 993-1008.

  16. Roux-en-Y Complications • Dumping syndrome is a common complication of surgery that is seen in 76% of patients. • Clinical manifestations include… -Early satiety -Nausea -Cramps -Explosive diarrhea -Sweating -Flushing -Palpitations -Dizziness Shah, M., Simha, V. & Garg A. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231

  17. Biliopancreatic Diversion/ Duodenal Switch • The stomach is divided vertically • and 50-70% of the stomach is • removed. • The stomach is directly • connected to small intestine • bypassing the whole duodenum. • It is linked with high mortality • rate and complications. • Performed less than one percent of the time in the United States.

  18. Surgical Outcomes- Effectiveness • 47.5% weight loss from adjustable gastric band • 61.6% weight loss for gastric bypass • 68.2% weight loss for gastroplasty • 70% weight loss for biliopancreatic diversion with or without duodenal switch Journal. (2009) Position of the american dietetic association:Weight mangament. Journal of American Dietetic Association 109, (2), 330-346.

  19. Surgical Outcomes Tice, J., Karliner, L.,Walsh, J., Petersen, A., & Feldman, M. (2008) Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. The American Journal of Medicine, (121), 885-893. Comparison of obesity related comorbidities after RYGB or LAGB.

  20. Surgical Outcomes Tice, J., Karliner, L.,Walsh, J., Petersen, A., & Feldman, M. (2008) Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. The American Journal of Medicine, (121), 885-893. Comparison of short and long-term of serious complication rates after RYGB or LAGB.

  21. Postoperative Diet- First Week • All clear liquid diet • Frequent small 1oz servings of water and/or ice chips. • A protein liquid supplement in necessary in small servings at this time. • Patients aim to consume 64oz of liquid in a day (1-2oz over a 30 min time setting) Marcason, W. (2004) What are the dietary guidelines following bariatric surgery? Journal of the America Dietetic Association, 104 (3), 487-488.

  22. Postoperative Diet- First Month • Protein based soft diet -Broth of low fat -Scrambled eggs -Oatmeal with added protein powder -Tuna salad -Fat free pudding • Chewable multivitamin added • No fluid for 20-30 minutes before or after food consumption. Marcason, W. (2004) What are the dietary guidelines following bariatric surgery? Journal of the America Dietetic Association. 104, (3), 487-488.

  23. Postoperative Diet • Around week six patient can add textured foods to their diet. • Dry, sticky, or gummy foods have been known to present the biggest problem in patients. • Patients should always set aside a 20 minute time period to avoid bolus eating and allow the feeling of satiety to occur. • Proteins should be eaten before fats and carbohydrates. Patients should aim for at least 60 grams of protein daily. *This is the most critical time for patient to be taking supplement so malnutrition does not occur. Marcason, W. (2004) What are the dietary guidelines following bariatric surgery? Journal of the America Dietetic Association. 104, (3), 487-488.

  24. Supplements • There is not a set standard for supplements after bariatric surgery. Each patient gets a recommended level of intake from their surgeon. • There are few studies done that examine the postoperative nutritional status and deficiencies in patients. The studies that have been done have a wide variety of reported deficiencies due to… • Patient populations • Surgical techniques • Supplement protocols • Completion of patient follow-ups Kushner R.F.(2006). Micronutient deficiences and bariatric surgery. Current Opinion Endocrinol Diabetes,(13), 405-411.

  25. Supplement- Vitamin B-12 • Provides protection around nerve fibers and is needed for normal growth. • 1000- µg injections every 3 to 6 months or sublingual (under tongue) supplement of 300-500 µg/d. • Deficiency • Seen in 24% to 36% of patients, usually 2 years after operation. • Can impair intelligence, spatial ability, and short term memory. • Corrected by 500 µg/d oral supplementation. Shah, M., Simha, V. & Garg A. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231. Whitney, E.N., & Rolfes, S. R. (2008). Understanding nutrition, 11th, 344. Belmont: Wadsworth, Inc.

  26. Supplement- Vitamin D • 400 IU/d • 1000 IU for patients who receive little sunlight exposure. • Deficiency seen in 51% of RYGB patients • With a deficiency the production of protein that binds calcium in the intestinal cells slows. Even when diet is ample in Vitamin C, it will pass through the GI tract unabsorbed.(Whitney, 2008) • Osteomalacia or osteoporosis may develop as a result. Toh, S., Zarshenas, N., & Jorgensen, J. (2009).Prevalence of nutrient deficiencies in bariatric patients. Nutrition ,1-7. Whitney, E.N., & Rolfes, S. R. (2008). Understanding nutrition, 11th, 344. Belmont: Wadsworth, Inc.

  27. Supplement- Iron • 320 mg 2X daily. • Iron deficiencies seen in 15.7% of patients but has been seen as high as 52% in RYGB patients. • Bypassing the duodenum and proximal jejunum contribute to iron deficiency because that is the main site of iron absorption. • Even with iron supplement it is hard to prevent anemia in menstruating women. Shah, M., Simha, V. & Garg A. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231. Toh, S., Zarshenas, N., & Jorgensen, J. (2009).Prevalence of nutrient deficiencies in bariatric patients. Nutrition ,1-7.

  28. Supplement- Folate • 400- 1000 µg • Deficiency • 6% -38% in RYGB patients. • Decreased intake of folate is leading factor • Impairs cell division and protein synthesis • Neural tube defects • Symptoms • Anemia • GI tract deterioration Shah, M., Simha, V. & Garg A. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231.

  29. Supplement- Calcium • 1200-1500 mg • Deficiency • Seen in 10% of RYGB patients • Result of bypassing duodenum and proximal jejunum • Low intake of Ca sources post-op • Decline in bone mass has been reported from RYGB patients • Calcium citrate is recommended over calcium carbonate. Meena Shah, Vinaya Simha, & Abdhimanyu Garg. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231 Whitney, E.N., & Rolfes, S. R. (2008). Understanding nutrition, 11th, 344. Belmont: Wadsworth, Inc.

  30. Ethical Issues- Insurance Coverage • Less than one percent of the potential bariatric surgery patients decide to undergo surgery(Kaser, 2009). • Decreasing coverage in procedure • Average cost of procedure is $30,000-$50,000 • Insurance does not cover the costs of supplements before and after surgery. • Average monthly costs for all supplements combined is around $300. Kaser, J., & Kukla, J. (2009) Weight-Loss Surgery. Online Journal of Issues in Nursing; 14:1, 10.

  31. Ethical Issues- Insurance Coverage • 9 out of 16 insurance companies said they cover individual dietary counseling. • With only five covering intensive dietary counseling. • No coverage for different forms of lifecycle modification, i.e. physical activity programs, behavioral therapy. • Survey of Medicaid in 14 States showed that patient counseling was only reimbursed if the patient had a weight-related diagnosis(Tsai, 2006). • 1 out of the 16 insurance companies surveyed provided reimbursement for FDA approved prescription weight loss medicine. Tsai, A., Asch, D., & Wadden, T. (2006) Research: Insurance coverage for obesity treatment. Journal of the American Dietetic Assocation. (106),1651-1655.

  32. Ethical Issues- Insurance Coverage • Many plans require a certain BMI or a BMI with comorbidity for a patient to qualify for coverage. • Patients may try to actually gain weight to receive coverage from their insurance company.

  33. Summary • Definition of Obesity • Surgical treatments for obesity • Nutrient requirements following surgery • Ethical Issues • Prevention of Obesity

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