Transcript Bariatric Surgery and Nutrition - Abigail Stanley, Dietetics Portolio

Bariatric Surgery and
Nutrition
By: Shala Davidson and Abby Stanley
Obesity is American
1
 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 obese
 Of those 18.2% are obese
Obesity in America
1
Health Risks of Overweight
and Obesity2,3,4
Causes and Treatment of
2
Obesity
 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  Questions to consider, is patient:
by other means and suffer from
serious health problems
related to obesity
 After diet, exercise, and
pharmacologic agents have
failed
 Unlikely to lose weight using



 Clinically severely obese
 BMI > 40
 BMI > 35 accompanied by
serious health problems
linked to obesity
 Type 2 diabetes, heart
disease, sleep apnea



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?
Plus health
conditions
6
What do you know about
7
Bariatric Surgery?
 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
7
Bariatric Surgery?
 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 Surgeries
 Surgeries fall into 2
categories:
 Restrictive procedure
 Restrictive & malabsorptive
3,5
 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
3,5
like after surgery?
 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
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Average Weight Loss
 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
3,9
Surgery
 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
3
Surgery
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 Assessment
3
 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
3
of Special Attention
 Patient’s dieting history
 History of prescription medications
for weight loss
 Age at onset of obesity
 History of eating disorders

Nutrition Guidelines:
 Liquid nutrition therapy while in
hospital
 Blended/pureed diet approx. 1
month
 No drinking during meals or 30
minutes afterward
 Mental health status
 3 cups high protein liquid
 Pregnancy
 Sweets & high-fat food,
supplement (1 Tbl/15 min)
 Physical activity
carbonated drinks & straws are
off limits
 Support system
 No alcohol
 Soft meal plan (after 1 month)-
 Inform of supplements needed
for remainder of life
 Liquid protein, calcium, vitamin
B-12, iron, and others
tender meats, cooked veggies &
fruit
Nutrition Diagnosis
3
 Review signs and symptoms from
assessment
 Diagnose nutrition problems based on signs
and symptoms





Excessive oral intake
Inadequate oral intake
Inadequate protein intake
Inadequate vitamin intake (B12)
Inadequate mineral intake (iron)
Nutrition Intervention:
3
Pre-Surgery
 Encourage patients to test
various high protein liquid
supplements to find on they like
 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)
 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
3
Hospitalization
 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:
3
Post Surgery
 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:
10
Post-Surgery
 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 prescription
 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
3
Adequacy of Nutrition therapy
 Diet after gastric surgery may be
inadequate because of limiting
size of the stomach and
consuming smaller amounts of
food
3
 Nutrients Bariatric Patients are
at risk for deficiencies:





Protein
Calcium
Iron
Vitamin B12
Folate
Fluid Needs
3
 Because stomach is so small, it is challenging to
meet fluid needs
 No liquids at meals (wait 30 min after)
 Sip (no straw)
 Goal is at least 6 cups fluid per day
 3 cups high protein liquid supplement
 3 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
3
evaluation
1.
Assessment:
 24 hour food intake recall
 Intake of water or other noncaloric 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
11,12,13
Bariatric Surgery
 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 disease56%, 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
Sources
1.
National Institute of Health. Data from the National Health and Nutrition Examination Survey 20092010. 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=169
27&ncm_heading=Nutrition%20Care. Published 2013. Accessed November 8, 2013.
4.
Appecal. Excess Weight Risk. Natural Appetite Management. http://www.myappecal.com/excessweight-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.
Sources
7.
American Society of Metabolic and Bariatric Surgery. Learning Center. For Patients. http://asmbs.org/learningcenter. 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%2
0surgery&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.