Nutritional Care Of The Patients Undergoing Bariatric And .
Nutritional Care of the Patients UndergoingBariatric and Metabolic Surgery5/14/2018
INTRODUCTION: Prework focused on ‘physiology’ The decision to recommend weight loss surgery should bebased on2
The Evidence and Resources:AND Evidence AnalysisLibrary Bariatric SurgeryNutrition Care 2014-2017AACE / TOS / ASMBSMedical Guidelines forClinical Practice for thePerioperative Nutritional,Metabolic, and NonsurgicalSupport of the BariatricSurgery Patient (2009)AACE / TOS / ASMBS(2013 Update)ASMBS IH Nutrition2016 Update:MicronutrientsEndocrine Society ClinicalPractice Guideline:Endocrine and NutritionalManagement of the Postbariatric Surgery Patient(2010)RDN
BARIATRIC NUTRITION RESOURCES Pocket Guide to Bariatric Surgery Eatright.org/shop Weight Management DPG wmdpg.org– Bariatric Subunit– listserve
Case Study: In Your PacketDeb is a 42-year-old female pursuing bariatric surgery. Over the pastten years she has had multiple medical weight loss attempts withlittle weight loss progress, resulting in overall weight gain.Past medical history includes: Type 2 diabetes, Gastroesophageal Reflux Disease (GERD), andhypertension. Medications include Metformin, Prilosec, lisinopril/HCTZ and simvastatin.Physical exam reveals: 64 inches tall and weighing 248 lbs. BMI is 43. Blood pressure is 139/87.She brings her pre-operative labs which show: Hgb A1c of 10%Triglycerides 200iron level is 30 ug/dLvitamin B12 level is 450 mmol/Lvitamin D level is 21ng/mL
Risk will never be reduced to zero but makeevery attempt to do so through:Careful and thorough evaluation Medical Surgical Psychological NutritionalPreoperative preparation periodAdditional support as needed: psychological nutritional
Contraindications to Weight loss SurgerySurgical risk too great End-stage lung diseaseUnstable cardiovascular diseaseMulti-organ failureGastric varicesPsychiatric Conditions Believed to be Contraindicated Current drug or alcohol abuseActive schizophreniaSevere MRMultiple suicide attemptsActive bipolar disorder
Pre-surgery Nutrition Goals1. Assess patient knowledge and expectations Emphasizing:– Obesity is a chronic disease surgery is not a cure– Surgery is an ‘adjunct’ therapy to a healthier lifestyle not in place of2. Achieve better control of nutrition-related comorbidities Looking at Deb’s labs do you have any concerns? What would you recommend?3. Improvement of nutritional status: Assess micronutrient status; replete deficiencies
Obesity is a known risk factor for nutrient deficiencies Inflammation associated with obesity inducesthe production of hepcidin, an acute phaseprotein made in the liver, which blocks ironabsorption in the intestine Iron Fe TIBC Hb/hct Metformin affects the absorption of vitamin B12 inthe ileum Associated with decreased serum folicacid levels B12 and folic acid depletion alsoincreases homocysteine levels Vitamin B12 B12 cobalamin Serum methylmalonic acid(optional) Folic Acid Homocysteine Hyperinsulinemia is associated withexcessive urinary excretion of zinc Zinc The bioavailability of vitamin D is reduced inthe obese state, because vitamin D issequestered in adipose tissue. Vitamin D Vitamin D, 25-OH PTHREPLETE PRE-SURGERY AS NEEDEDWainwright, Patrick; Diabetes & Primary Care, 2017; 19(2): 63-66. 4p. Curr Opin Clin Nutr Metab Care. 2017 Mar;20(2):138-144.
Reported Micronutrient Deficiency ratesPre-Op RatesVitamin DVitamin B12IronPre-Op RatesThiaminFolateZinc01. Stein et al 2. Parrot et al20406080100%
Case StudyDeb meets with her surgeon. They decide to moveforward with sleeve gastrectomy. When you meetwith her, she mentions that she is most excited forbariatric surgery to cure her GERD and type 2diabetes. You ask if she discussed this with hersurgeon. She says, “No, but I assume he knows Iwant to get rid of those problems.”You decide to speak with her surgeon.13
Role PlayCommunicating a conflicting opinionwith a surgeonROLE PLAY14
Case Study: Table Discussion1. What are some important factors toconsider when discussing patient treatmentplans with other providers2. What went well with the discussion?3. What would you change about thediscussion?15
Nutrition Care for Pre-surgeryHelp patients to Develop an understanding of the limitations ofsurgery Manage expectations
Two Kinds of Pre-op DietsLong-termShort-termUsed to promoteweight loss &reduction inadipose tissueUsed to promotereduction in livervolume
Outcomes of Short-term & Long-term Diet32 patients on 3 Optifast shakes non-starchy vegetablesColles et al. 2006
Best Practice: Short-term Pre-op Diet 2 weeks 1000 calories, 50 g carb Meal replacements (or could be food-based) Solid or liquid MRs depending on patientpreference Consider palatability, simplicity, affordability Consider patients on hypoglycemic meds
Pre-surgeryHealth plan may require Medically supervised 3 - 6month program Monthly documentation fromeither or both a: Dietitian anda Psychologist
ASMBS Position Statement, 2011 There are no data from any randomized controlled trial, largeprospective study or meta-analysis to support the practice of insurancemandated preoperative weight loss. There is no Level I data in the surgical literature, or consensus in themedical literature that has clearly identified any one dietary regimen,duration or type of weight loss program that is optimal for patients withclinically severe obesity. Patients seeking surgical treatment for clinically severe obesity shouldbe evaluated based on their initial BMI and co-morbid conditions. Theprovider is best able to determine what constitutes failed weight lossASMBS.orgefforts for their patient
HOSPITAL STAY:Laparoscopic Adjustable Gastric BandLess than 24 hoursor 1 nightSleeve GastrectomyLess than 24 hoursor 1 nightRoux en Y Gastric Bypass1-2 nights22
Post Surgery DietVariation in program approaches to diet transition, however,the diet progression is: (review handout Diet stages) Staged approach (4-6) EACH STAGE BASED ON: nutrient needs texture Progression as tolerated Large variation in tolerances Therefore, early and frequent follow-up
ProteinPost-WLS exact needs not been defined Case studies reveal early post-op patients tend to take in less thanthe 60-100 grams most commonly recommended Protein deficiency is not common post-RYGBP Brolin, et al. J Gastrointest surg 2002; 6:195-203Factors to Consider with Protein Recommendations: Quality of ProteinCastellanos et al Nutr Clin Pract 2006;21:485-504 Complete protein concentrates (essential/indispensible aminoacids) egg white, soy, milk (casein/whey fractions)Whey: contains varying amounts of lactoseWhey protein isolates are lactose free Essential AA supplement ingestion Katsanos C, et al. Distribution (vs. skewed) protein intake stimulates muscleprotein synthesis to maximal extent). Mamerow M, et al 2014 Jun; 144(6): 876–880.
CarbohydrateRecommended Amounts: brain function Daily Recommended Intake: DRI/RDA 130 g/day Food Agricultural Organization (FAO):minimum 50 gdayMinimum recommend 50 g/dayFiber: No current studies guide practitioners of how muchtotal fiber to recommend to postoperative bariatricpatients We should be focusing on getting our bariatricpatients adequate fiber intake. To avoid bezoar formation: Counsel patients on properchewing behaviors and food preparation
Advancing the diet: All Procedures Transition takes months Advance as tolerated Frequent nutrition follow up to assesstolerances, address eating issues,provide support , education As hunger comes back and tolerancesincrease: Trust hunger; respect satiety Incorporate all food groups Focus on ‘healthier’ food choices Planning: Meal/snack timing Life long supplementation
Early Post-op Nutrition ComplicationsDehydration Dizziness, nausea, fatigue, dark urine Weight early indicator– 2 lb/d dehydration; monitorhypertension medications Rehydration: 100 mg/day Thiamin in IVDiarrhea Think lactose intolerance first Then infection Dumping ? post cholecystectomy, not tolerating fat
ConstipationCommon Causes Dehydration Low fiber liquid diets Elimination of coffee Iron / calcium supplements Pain medications (opioids) Limited physical activityGreenstein & O’Rourke 2011; Foxx-Orenstein, McNally, & Odunsi 2008; Rao et al. 1998
Nutrition Intervention Rehydrate Stool softeners and/or laxatives Senna or Miralax can initiate bowel movement Assess for adequate fiber intake Slow and steady supplementation as needed Soluble fiber bulks stool and insoluble facilitatesmovement If pt discontinued caffeine, resume morningdose Encourage daily activityBe Proactive!Greenstein & O’Rourke 2011; Foxx-Orenstein, McNally, & Odunsi 2008; Rao et al. 1998
Special ConsiderationsDumping SyndromeCaused by a sudden distention ofthe jejunum by hypertonic solidsor fluids. Symptoms occur shortly aftereating and can last for 30-60minutes. Symptoms include nausea,dizziness, weakness, rapidpulse, cold sweats, feelingvery tired, cramps anddiarrhea.Lack ofpyloric sphincterMallory et al Obes Surg 2005
DUMPING SYNDROME: Two types of dumping: Early dumping which occurs 30-60 minutes after eatingand can last up to 60 minutes. (more common postRYGB) Symptoms include nausea, dizziness, weakness, rapidpulse, cold sweats, feeling very tired, cramps anddiarrhea. Late dumping which occurs 1-3 hours after eating. Symptoms are related to reactive hypoglycemia (lowblood sugar) which include sweating, shakiness, loss ofconcentration, hunger, and fainting or passing stoperative-concerns-2Mallory et al Obes Surg 2005
Pathophysiology of Reactive Hypoglycemia Rapid hypoglycemia fromI II IIGIPGLP-1exaggerated insulinresponse Food moves to jejunumquickly; triggers hormonerelease (GLP-1 and GIP)which stimulates insulinresponseUkleja 2006
Post-Operative HypoglycemiaGoal: Delay transit of food through GI tract Manage with dietary manipulation 6 small meal; protein source at each Avoid fluids 30 minutes post-meal/snack Avoid high sugar/refined carbohydrate foods. Eat very slowly.
Reactive Hypoglycemia: lack of diet responsePharmacological inanalogsoctreotideInjectionMechanism ofAction Delays thebreakdown ofstarch into sugar Delay gastricemptying Slow transitthrough the bowel Inhibit the releaseof gastrointestinalhormones, insulinsecretion andpostprandialvasodilationSide Effects Bloating Flatulence Diarrhea Gall stoneformation Pain at injectionsite SteatorrheaIIF DIET AND/OR MEDICATIONS DO NOT RESOLVE ISSUE; REFER TOENDOCRINOLOGIST; ASSESS FOR NESIDIOBLASTOSIS
Post-Operative ComplicationsNausea/Vomiting Nausea: Dehydration Pace of eating Rule out pregnancy Vomiting Rule out stenosis Hyperemesis: may needrehydration36
Coomplications: Micronutrient DeficiencyVitamin DVitamin B12IronPre-Op RatesThiaminPost-Op RatesFolateZinc01. Stein et al 2. Parrot et al20406080100 %
MICRONUTRIENT DEFICIENCIESSITES OF NUTRIENT ABSORPTIONStein, et y/
Biliopancreatic Diversion withDuodenal Switch (D/S) Pylorus intact, so dumping not an issue No CHO malabsorption Approx. 72% fat malabsorption Need ADEK supplementation BID Approx. 25% protein malabsorption Higher protein needs ( 120 g/day) May need 2400 mgs Ca (as citrate)/day Vit D deficiency common Monitor Cu , Zn
Monitoring Labs Lifelong Some deficiencies can manifestin days while others take years Use physical signs/symptoms to detectdeficiencies (see handout: important to assess and match withlaboratory data)
Routine Nutrient -mineral1-2 dailyshould contain 100-200% RDA Zn and CuFolate: 400-800 mcg of folate/day; womenchildbearing age: 800-1,000 mcg; Thiamin 12 mg/dayVitamin B ComplexAt least 50 mg thiaminCalcium Citrate/CarbonateX 2-3/dayCa: 1,200- 2,400 mg/d: DIVIDED DOSES(from all sources)Vitamin D3,000 IU dailyElemental ironnot to be taken with calcium18-27 mg/d elemental40-65 mg/d menstruating femalesVitamin B12350- 500 ug/d orally/sublingual, nasalor 1,000 mcg/mo intramuscularly(from all sources)*Patients with preoperative or post-operative biochemical deficiency states are treated beyond these recommendations
Post Op Complications: Micronutrients Deficiencies Data suggest micronutrientdeficiencies increase over time Number of patients monitoredover time significantly declines
Challenges: Vitamin Supplementation Standard supplementation may not besufficient to prevent nutritionaldeficiencies Proper supplementation can beburdensome and expensive which maychallenge patient compliance Cost, feasibility and practicality must betaken into consideration Yearly monitoring of nutritional labsimperativeEducate Primary Care Providers
Provide patient to give toPrimary Care Provider44
Case StudyDeb cancels some of her appointments andyou don’t see her again until about 2 yearspost-op.She tells you that she takes a one-a-daymultivitamin and feels well overall. She canjust tell her age is catching up with herbecause she feels more tired than before andnotices changes to her vision.45
Case StudyHer Lab results and signs and symptoms: Vitamin B12: 550Folate 500Fe 34Fer 15 Ceruloplasmin 80 Retinol 7 Zinc 8046
Case Study Deb continues to see you on an erratic basisover the next couple years, often cancellingappointments due to work demands. She returns nearly 4 years after her surgery. She discloses that she has been avoidingthe office because she is embarrassed aboutregaining 40 lbs in the past 18 months.47
Percent Total Weight LossWeight loss and Regain expectationsSwedish Obesity SubjectsDiabetes Prevention Program0Lifestyle 0-5002468Time After Surgery (years)10
Approximately 10-20% of patients fail to lose a significantamount of weight postoperatively.20-25% of the lost weight regained over a period of 10years (Sjostrom, N Eng J Med 2007;Pajecki,Obes Surg, 2007)
Postoperative complications: Weight RegainYou take an extensive history and identify some potentialcontributors to her weight gain. She changed jobs abouttwo years ago and now commutes 60 minutes per dayinstead of 15 minutes. In addition, 9 months ago she wasstarted on propranolol for migraines. She has strayed frommeal and snack planning and now finds herself “grazing”throughout the day.
Environmental Modulators of Energy Balance
Physiology and Life Style factorsFactors Related to Weight maintenanceand Regain post WLSAnatomicalGastric Bypass G-G fistula Pouch Enlargement G-J AnastomosisDilationGastric Banding Band Migration Band LooseningClinical FactorsPhysiological Pregnancy Menopause SleepDysfunction Stress Cessation WeightPromotingMedsBehavioral Life Style Factorsand EnvironmentalTriggers
Environmental and Developmental ionsInadequatephysical activityProcessed dietsIrregular eatingpatternExcellentPoorLife changes(aging, pregnancy,menopause)
FACTORS RELATED TO WEIGHT REGAINOUTCOMES Higher dietary fat intake Higher levels of anxiety Poor diet qualitycharacterized by excessive intake of calories, snacks, sweets, and fatty foods wasstatistically higher Poor nutritional counseling follow-up Poor diet quality Lack of nutritional counselling Grazing behaviors Diet quality Postoperative timeNutrition (2016) 32 (3):303-308OBES SURG (2013) 23: 922Nutrition (2012) 28, (1):53-58Nutrition (2016) 32(11): 1250-1253
Guidelines and Strategies Eat as close to the ‘real’ food as possible Establish set meal patterns Shift workers: Focus on meal planning, protein ateach meal and snack Address sleep hygiene Strategies/Techniques: stress management Move more; planned exercise Monitoring, Support and follow-up
Key Points: Patients seeking bariatric surgery require a thorough pre-operativenutritional evaluation including screening for medical complications andmicronutrient deficiencies, assessing weight loss expectations, andidentifying potential weight loss barriers within current lifestylePatients with obesity face an increased risk of micronutrientdeficienciesBariatric surgery can cause micronutrient deficiencies, particularlyRYGB or duodenal switchNo standardized guidelines for pre-operative weight loss exist, but bothlong term and short term preoperative diets can be beneficialAll patients require some type of vitamin and mineral supplementationafter bariatric surgery and routine screening for nutritional deficienciesUp to 25% of patients fail to lose significant weight postoperatively(inadequate weight loss discussed in prework) or experience prematureweight regainWeight regain following bariatric surgery requires careful evaluationand consideration of multiple influences including physical activity, foodchoices and timing of meals, medications, sleep and stress.56
Surgery Patient (2009) Endocrine Society Clinical Practice Guideline: Endocrine and Nutritional Management of the Post-bariatric Surgery Patient (2010) AACE / TOS / ASMBS (2013 Update) ASMBS IH Nutrition 2016 Update: Micronutrients AND Evidence Analysis Library Bariatric Surgery Nutrition Care 2014-2017 RDN
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