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Nutrition Practice Standards for Bariatric Surgery Dana Eiesland, RD, LDN Lisa C. Luz, RN, MSN, FNP-BC Mount Auburn Weight Management Center.

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Presentation on theme: "Nutrition Practice Standards for Bariatric Surgery Dana Eiesland, RD, LDN Lisa C. Luz, RN, MSN, FNP-BC Mount Auburn Weight Management Center."— Presentation transcript:

1 Nutrition Practice Standards for Bariatric Surgery Dana Eiesland, RD, LDN Lisa C. Luz, RN, MSN, FNP-BC Mount Auburn Weight Management Center

2 Objectives z Review criteria for surgery z Outline the pre-surgical evaluation z Summarize pre-surgical nutrition goals z Review nutrition guidelines & diet progression following surgery z Review immediate post operative and long term surgical complications

3 General Criteria for Weight Loss Surgery (WLS) zBMI with at least one co-morbidities (exp. DM, Obstructive sleep apnea) zBMI > 40 without co-morbidities zPrevious unsuccessful attempts at weight loss zAge >18-65 with few exceptions zMedically cleared for surgery zMentally & emotionally prepared and motivated yNo substance abuse, no active eating disorder ySupport system in place yRealistic expectation regarding outcomes zHas good understanding of the procedure and dedicated to lifestyle change

4 Pre-Surgical Evaluation zPrior to surgery candidates should be carefully assessed by a specialized multidisciplinary team including: yBariatrician (MD specializing in the care of the obese) ySurgeon yPCP ySocial Worker/ Psychologist yDietitian yNurse

5 Pre-Surgical Goals zImprovement of nutritional status zCorrect vitamin/nutrient deficiencies (most common include: iron, vitamin B12 and vitamin D) zAchievement of better control of nutrition- related comorbidities zDevelopment of lifestyle and eating habits that will promote positive post-weight loss surgery outcomes and weight loss maintenance zPromote 5-10% weight loss to reduce surgical risks

6 Pre-Surgery Nutrition Education zIntensive Education is provided during group & one- on-one sessions yBehavior modification xself-care & lifestyle choices xself-monitoring (keeping a food journal) xhealthy food selections xeating behaviors (speed, schedule) yFluid, calorie, and protein requirements yDiet instruction: Stages 1-3 yLabel reading ySupplement/product information yVitamin & mineral requirements yExercise

7 Post-Surgery Nutrition Guidelines zDietary consult ordered upon admit yComplete nutrition assessment yReview diet progression with patient yWork with in-patient team to identify & minimize complications post-op zFor all procedures patients will follow the same diet zDiet advanced from NPO to Stage 1 Bariatric Diet on Post op Day 1

8 Post Surgical Diet Progression zStage 1 - Water yTypically start day of surgery; Duration < 1 day yNO STRAWS yNursing staff to administer 1oz water per hour via medicine cup xInstruct patient to sip slowly & stop if feeling full or nauseous yNote: Diet office will be instructed not to send meal trays yAll medications to be administered in liquid/chewable form yIV Fluid until tolerating liquids yPatient to begin tracking fluid intake on Patient Intake Diary (provided by healthcare team)

9 Post Surgical Diet Progression zStage 2 - Bariatric Clear Liquids yStarts Post op Day1; Duration 1-2 days yNon-carbonated liquids without calories, sugar, or caffeine; includes broth, sugar-free (SF) ice pops, SF gelatin, water, & ice chips yPriority is hydration yInstruct to sip slowly & stop if feeling full or nauseous (avoid straws) yWill receive 3oz Bariatric Clear Liquids 3 times a day on meal trays yInstruct to sip 2-4 oz Bariatric Clear Fluids per hour between meals yWill be expected to track intake on Patient Intake Diary

10 Post Surgical Diet Progression zStage 3 - Bariatric Full Liquids zStarts Post op Day 1-2; duration 2-4 weeks zWill receive 3oz Bariatric Full Liquids 3 times a day on meal trays zLow-fat protein-rich liquids with (exp. Low-fat (LF) broth, LF milk, protein shakes; light/LF yogurt, LF cottage cheese; LF/SF pudding) juven/beneprotein zPriority on hydration and protein intake (minimize loss of lean body mass) zInstruct to sip slowly & stop if feeling full or nauseous zInstruct to sip 2-4 oz fluids per hour between meals zNote: Patients will go home on this stage. You may not see other stages unless patients are re-admitted

11 Post Surgical Diet Progression zStage 4 - Soft and Moist Protein zStart 2 weeks post-op; Duration 4-6 weeks zAs tolerated replace full liquids with soft & moist protein foods (avoid dry or tough meats); ~2-4oz per meal zMay need to continue with protein shakes to meet protein needs zInstruct not to drink fluids with meals; wait 30 min before & after each meal to have beverages zIf meeting protein goals may add well-cooked soft fruits & vegetables zWill begin taking chewable vitamin & mineral supplements

12 Post Surgical Diet Progression zStage 5 Low Fat, Low Sugar, High Protein zStart 6-8 weeks post-op; Duration lifelong zBalanced solid food diet with protein, fruits, vegetables, and whole grains. Can add raw foods as tolerated. zGoals: y60-80 grams protein /day y64+ ounces fluid/ day (including protein drinks) sipped between meals. zContinue to separate fluids from your meals zCan advance to supplements in tablet form if tolerated

13 Things to Consider Post-Op zIf having poor diet tolerance: yTemperature: If not tolerating ice chips or ice pops consider warm liquids. Be aware that tolerance may vary between patients. ySpeed: Drinking too quickly, gulping, or drinking too much may cause pain and discomfort. Patients must avoid using straws and focus on taking very small sips from medicine cup. zAdministering Medications: yNote all medications given in the hospital should be crushed or in liquid form. yChewable/liquid vitamins will begin 2weeks post-op

14 Immediate Post-Op Nutrition Considerations zHydration status zFood tolerance issues zAppropriate diet advancement zAddress individual complaints

15 Common Problems After All Weight Loss Surgeries zDehydration yMonitor for signs and symptoms of dehydration as patients are at greater risk given their dietary restrictions. Patients should strive for 64 ounces of liquids per day. zNausea and Vomiting yEating too quickly or too much, drinking with meals or drinking too close to meals, not chewing thoroughly, or advancing the diet too quickly can all lead to nausea and/or vomiting. Persistent vomiting can lead to thiamin deficiency. Encourage patients to drink and eat slowly, stop if feeling full or nauseous, and take small bites and chew their foods thoroughly.

16 Common Problems After Gastric Bypass Surgery zDumping Syndrome yUsually occurs ~30 minutes following a meal. Undigested contents of the stomach are transported or "dumped" into the small intestine too rapidly. Symptoms may be similar to the flu and include nausea, sweating, bloating, abdominal cramps, and diarrhea. To avoid these symptoms patients should avoid high fat and high sugar foods. For example instead of 100% fruit juice; dilute 1:1 with water. zDiarrhea ySome patients can develop post-operative lactose intolerance. Symptoms could include bloating, abdominal cramps, excessive gas, and diarrhea. Treatment includes following a lactose-free diet. zAnatomical complications yThere may be reason to suspect a possible surgical complication if a patient has persistent nausea, vomiting, and abdominal pain.

17 Common Nutrient Deficiencies zGastric Bypass: yMost common: Iron, Vitamin B-12, Folic acid, Fat soluble Vitamins A, D, & E yThiamin (seen in patients with frequent vomiting) yCalcium yProtein malnutrition zGastric Banding: yExcept for folate, nutrition deficiencies are less commonly seen post gastric banding zSleeve Gastrectomy yPossible B-12

18 Long Term Outcomes zLifelong compliance with vitamin/ mineral supplementation is important to reduce the risk of serious nutrient deficiencies zSelf-monitoring intake and avoiding high calorie foods and beverages to prevent weight re-gain zRemaining connected with post bariatric surgery support groups

19 Resources zAmerican Society for Metabolic & Bariatric Surgery Society for Metabolic & Bariatric Surgery zL. Aills et al. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008; 4:S73- S108.L. Aills et al. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. 4:S73- S108. zIf you have any additional questions contact: yLisa C. Luz, RN, MSN, FNP-BC yBariatric Program Coordinator, Mount Auburn Weight Management Center ( Phone ) : ( ) :

20 Bariatric Nutrition Quiz 1. It would be appropriate to allow a patient on Stage 2 to have all of the following fluids except: yA. Water yB. Low sodium vegetable broth yC. Ginger ale yD. Crystal light 2. All medications & vitamin/mineral supplements should be taken in which form after surgery? yA. Chewable yB. Liquid yC. Tablet yD. A&B

21 3. Patients should wait 30 minutes before and after meals to drink any fluids. yA. true yB. false 4. Which of the following are associated with Dumping Syndrome? yA. Drinking too much water yB. Flu like symptoms including nausea, sweating, bloating, abdominal cramps, and diarrhea occurring ~30 minutes after a meal yC. Eating high fat or high sugar foods like 100% fruit juice or ice cream yD. B & C Bariatric Nutrition Quiz

22 5. Following bariatric surgery it is important to monitor for: yA. Hydration status yB. Tolerance of oral intake (nausea/vomiting/diarrhea) yC. Diet to be advanced appropriately yD. All of the above


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