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.