Nutrition Care Process

forBariatric Surgery

Kate Haarala Concordia College

Moorhead, MN

ObjectivesTo gain understanding of the nutrition care process for bariatric surgery

To understand the different types of weight loss surgery procedures.

To become informed about different complications and nutrient deficiencies that are commonly associated with bariatric surgeries.

DefinitionBariatric surgery is a surgical procedure designated for weight-loss in severely overweight people. It reduces and bypasses the stomach or small intestine in order to achieve significant and permanent weight loss.

Definition

Overweight - A body mass index (BMI) 25-29.9

Obesity - A BMI ≥ 30

A waist circumference of ≥ 40 in. in men, and ≥35 in. in women carries increased risk.

Morbid Obesity - BMI ≥ 40http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/risk.htm

Obesity and the U.S.Between 2005-2006, more than one third of U.S., or over 72 million adults were obese (33.3% for men, 35.3% for women) according to the most recent NHANES study

“Recent data show racial and ethnic obesity disparities for women but not for men. Non-Hispanic black and Mexican- American women were more likely to be obese than non-Hispanic white women.”1Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States – no change since 2003—2004. NCHS data brief no 1. Hyattsville,

MD: National Center for Health Statistics, 200

Obesity Prevalence in the U.S. in 2007

http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm

PurposeBariatric surgery performed only on people with morbid obesity or have obesity connected with chronic health disorders that are commonly linked with obesity.

Overweight and obesity are significantly correlated with diabetes, high blood pressure, high cholesterol, asthma, arthritis, and poor health status.

Researcher’s concluded bariatric surgery could help cure T2DM (Longe J. 2006)http://jama.ama-assn.org/cgi/content/abstract/289/1/76; Longe, J. (2006). The Gale Encyclopedia of Medicine. New York: Gale Cengage.

Who is a Candidate?Obese individuals who do not have any psychological, emotional, or medical problems.

Must be between the of 18-60 years of age.

Individuals over 100 lbs. of their ideal body weight.

BMI ≥ 40

BMI ≥ 35 with associated serious health problems such as diabetes and heart disease - due to their excess weight.

Current Bariatric Surgical Procedures

Procedure Classification

Roux-en-Y Primarily Restrictive/ Partially Malabsorptive

,

LaparoscopicGastric Banding Restrictive (Lap-band)

Biliopancreatic Diversion Malabsorptive (BPD)

Roux-en-Y Gastric Bypass

A small (10-30mL) pouch is anastomosed to a Roux limb of the jejunum. The length of the Roux limb determines the level of malabsorption and weight loss.

Laparoscopic Surgery

Laparoscopic surgery is a minimally invasive surgery.

The pouch created starts off at having the ability to hold 1 oz. of material.

Biliopancreatic Diversion

http://www.obesitysurgeryinfo.co.uk/exports/gb1.jpg

Removal of 70% of the stomach

In comparison to the RYGB, the length from the stomach to the intestine to the colon is much short-promoting malabsorption.

Due to its malabsorptive nature, the BPD requires lifelong follow-up

Optimal Weight Loss ProcedureAccording to clinical research study by the American Journal of Medicine, Roux-en-Y was favorable in comparison to laparoscopic adjustable gastric banding.

After 1 year, excess weight loss was considerably greater for those with Roux-en-Y. Excess weight loss at 76% for Roux-en-Y, and 48% laparoscopic banding.

Patient satisfaction favored Roux-en-Y

Concluded, surgery is a cost-effective intervention (Avenell et al. 2004)

American Journal of Medicine

General ComplicationsThe obesity epidemic within the U.S. has exponentially increased bariatric procedures performed which as therefore led to an increased awareness of the complications

Anastomatic leak

Thromboembolism

Internal hernia

Ulcer formation

Cholelithiasis

Hemorrhage

Nutritional complicationsJournal of the American Dietetic Association 2006

Surgery OutcomesOn average, morbidly obese patients will lose 60% more of their excess body weight than individuals using conventional weight loss methods (Buchwald et al. 2004)

Success of the surgery is measured at losing 50% more of the excess body weight.

Swedish Obese Subjects Study

Sjostrom, L., Lindroos, A et.al (2004). Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surger. New England Journal of Medicine, 351, 2683-2693.

Pre-Operative Guidelines

Exercise: Mild exercise (20 min./day 3-4 times/week)

Psychological Evaluation

Begin healthful diet in order to assist weight loss

Post-Operative GuidelinesFor the first few days, small, frequent servings of water and ice chips (1oz.)

Progress diet as tolerated

Liquids

Pureed Foods

Solid Foods

Initial gastric capacity is 30 to 60 mL, with a progression to 120 to 150 mL.

Patients need to eat for 20 minutes or more in order to induce the feeling of satiety and avoid bolus eating.

Food should be well chewed and eaten in small volumes

Post-Operative Continued

Liquids

Not ingested during mealtime

Consume well before mealtime or 30 minutes prior

48 to 64 oz. (6 to 8 cups) daily of non-caloric liquids between meals

Preferably, proteins should be consumed before fats and carbohydrates.

Post-operative dietary counseling plays an imperative role in the success of long-term weight loss.

Foods To AvoidCarbonated or Caffeinated Beverages

Fried Foods

Peanut Butter

Raw Vegetables and Fruit Skins (for 3 months)

Red Meat (for 3 months)

High Sugar Containing FoodsUniversity of Virgina Health Systems

Dumping SyndromeDumping syndrome may occur when concentrated sweets & high fats foods enter your intestine from your pouch

Often occurs after individuals ingest high sugar foods such as deserts, sodas, and candy. It can also occur when spicy, fried, or greasy foods are eaten.

Two types of dumping:

Early: 30-60 minutes after eatingLate: 1-3 hours after eating

Lifestyle Changes: New Habits

Eat small amounts

Eat and drink slowly

Chew food thoroughly

Drink liquids between meals

Try new foods one at a time

Take your recommended vitamin/mineral supplements

MayoClinic.com

Nutritional Considerations

Gastric Banding surgical patients may develop deficiencies in Iron and vitamin B-12

Roux-en-Y procedures may induce nutrient deficiencies in calcium, iron, folic acid. In addition, dumping syndrome can be common in this procedure.

Dehydration is a common concern for all of the procedures, along with an increase for gallstones.

A vitamin/mineral supplement is generally recommended.

Bariatric Surgery: Nutrient Considerations

Nutrient deficiencies have been observed post bariatric surgery, particularly pertaining to Roux-en-Y surgery.

*Iron

*Vitamin B12

*Folate

*Calcium

*Vitamin D

*ProteinShah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal

of Endocrinology and Metabolism, 91(11), 4223-4231

Iron

Requires acidic environment – Vitamin C

Should not be taken with calcium

Malabsorption due to bypassing dueodenum and proximal jejunum

Frequently seen in RYGB patients

incidence rate as high as 52%Bariatric Surgery: Postoperative Concerns. (n.d.). Retrieved September, 2008, from www.asbs.org/html/pdf/asbs_; Shah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal of Endocrinology and Metabolism, 91(11), 4223-4231

Vitamin B12

Must be taken sublingually or through a nasal spray

Also a common deficiency seen in RYGB patients

Incidence rate of 64%May be corrected via 500 µg/d oral supplementation

Bariatric Surgery: Postoperative Concerns. (n.d.). Retrieved September, 2008, from www.asbs.org/html/pdf/asbs; Shah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal of Endocrinology and Metabolism, 91(11), 4223-4231

Folate

It is recommended that those with folate deficiencies should take 400 µg of folate consistently on a daily basis.

Primary reason for deficiency is decreased folate intake

Malabsorption not at issue

Folate can be absorbed over the entire length of the small intestine.

Also common in RYGB patients

As high as 38% after surgery

Shah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal of Endocrinology and Metabolism, 91(11), 4223-4231

CalciumCalcium deficiencies possibly due to:

malabsorption because of bypassing the duodenum and proximal jejunum.

intolerance to rich sources of calcium such as milk

defective absorption of vitamin D due to fat malabsorption

Deficiency rate of 10% in RYGB

1200–1500 mg/d of calcium recommended

Bariatric Surgery: Postoperative Concerns. (n.d.). Retrieved September, 2008, from www.asbs.org/html/pdf/asbs_; Shah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal of Endocrinology and Metabolism, 91(11), 4223-4231

Vitamin D

400 IU/d of vitamin Dsupplementation recommended

Decreased absorption due to malabsorption of fat.

Shah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal of Endocrinology and Metabolism, 91(11), 4223-4231

ProteinRecommended - 60 to 70 g/daily

Essential for wound healing, muscle and skin re-growth and repair.

Every meal and snack should contain good amounts of protein

Sources: Beans and legumes, eggs, lowfat milk products, fish, chicken, and lean cuts of meat

Nutrition Care Process (NCP)

Nutrition Care Process. (n.d.). Retrieved Sep. 29, 2008, from www.adaevidencelibrary.com/file

Nutrition Care Process (NCP)

ADA considers quality nutrition care to follow these steps:

1. Nutrition Assessment

BMI (overweight? obese?)

Health history

Interpret data

2. Nutrition Diagnosis

Overweight, Obese, Morbid Obesity

Determine contributing factors to patients health/ obesity

3. Nutrition Intervention

Formulate plan/goals for the bariatric patient

4. Nutrition Monitoring and Evaluation

Monitor success of NCP

Goals for the RDObtain current lab values for the patient

Set short and long term goals for the patient

Discuss the pre- and post-operative dietary guidelines

Set-up support groups for the patient to stay actively involved in during their weight loss journey

Weighty Ethical Issues1. Should overweight or very obese individuals be encouraged or forced to gain more weight in order to be an acceptable candidate for weight loss surgery under governing medical and surgical guidelines?

2. Should morbidly obese children and adolescents be able to be candidate’s for weight loss surgery?

SummaryThe U.S. population has overweight and obese percentages at epidemic proportions.

When diet and exercise have proven to be a failure, obese individual’s can undergo bariatric surgery

Partially Malabsorptive/Primarily Restrictive: Roux-en-Y Gastric Bypass

Restrictive: Laparoscopic BandingMalabsorptive: Biliopancreatic Bypass

Summary Continued...Vitamin and Mineral, and Macronutrient deficiencies can occur after bariatric surgery

Closely monitoring fluid and food intake, and being careful to not ingest too much in a sitting is imperative in the success of the surgery and to prevent dumping syndrome

The NCP is a vital tool for the R.D. to comprehensively and accurately develop plans and goals for the bariatric patient

In Review...

TRUE or FALSE: Biliopancreatic Diversion surgery is the most commonly used bariatric surgery used in the U.S.

TRUE or FALSE: Gastric Bypass (Roux-en-Y) has been shown to be the most effective procedure in weight reduction

TRUE or FALSE: Surgical patients are able to eat anything they would like once their surgery is complete.

Review...

What syndrome can occur if an individual eats too much sugar too quickly after surgery?

When should liquids be consumed?

Questions/Comments/Concerns

ReferencesAvenell, A., J. Broom, T. J. Brown, A. Poobalan, L. Aucott, S. C. Stearns, W. C. Smith,T. Jung, M. K. Campbell, and A. M. Grant. (2004). Systematic review of the long term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment8 (21): iii–iv. Bariatric Surgery: Postoperative Concerns. (n.d.). Retrieved September, 2008, from www.asbs.org/html/pdf/asbs_ Buchwald, H., Y. Avidor, E. Braunwald, M. D. Jensen, W. Pories, K. Fahrbach, and K. Schoelles. (2004). Bariatric surgery: Asystematic review and meta-analysis. Journal of the American Medical Association 292 (14): 1724–37. Herron, D., & Bloomberg, M. (2006). Complications of Bariatric Surgeries. Journal of the American

Dietetic Assocation, 61, 125-139. Gastric bypass diet: What to eat after weight-loss surgery - MayoClinic.com. (n.d.). Retrieved

September 2008, from http://www.mayoclinic.com/health/gastric-bypass-diet/WT00007.

ReferencesJeffrey, T. A., Leah, K., Judith, W., Amy, P. J. & Mitchell, F. D. (October 2008). Gastric Banding or Bypass? A Systematic Review Comparing the Two Most Popular Bariatric Procedures. The American Journal of Medicine, 121(10)

Longe, J. (2006). The Gale Encyclopedia of Medicine. New York: Gale Cengage.Longe, J. (2008). The Gale Encyclopedia of Diets: A Guide to Health and Nutrition. New York: Gale

Cengage

Marcason , W. (2004). What are the Dietary Guidelines Following Bariatric Surgery?. Journal of the American Dietetics Association, 104(3), 488.

Shah, M., Simah, V., & Garg, A. (2006). Long-Term Impact of Bariatric Surgery on Body Weight, Comorbidities, and Nutritional Status. Journal of Endocrinology and Metabolism, 91(11), 4223-4231

Sjostrom, L., Lindroos, A., Sullivan, M., Wendel, H., Peltonen, M., Torgerson, J., Bouchard, C., Carlsson, B., Dahlgren, S., Larsson, B., Narbro, K., & Sjostrom, C. (2004). Lifestyle, diabetes,

and cardiovascular risk factors 10 years after bariatric surgery. New England Journal of Medicine,

351, 2683-2693.

The Story of Surgery for Obesity: A brief history and summary of bariatric surgery. (n.d.). Retrieved September, 2008, from http://www.asbs.org/html/patien