1. Complications After Bariatric Surgery: Survey Evaluating Impact on the Practice of Specialized Nutrition Support Nutrition in Clinical Practice 22:673-678, December 2007 American Society for Parenteral and Enteral nutrition

2. Bariatric Surgery Who? –BMI  40 –Life-threatening condition related to the weight Conditions to consider: –Obese for at least 5 years? –Ongoing problem with alcohol? –Depression / psychiatric disorder?

3. Statistic of Bariatric Surgery In US from 1999-2000 –Bariatric surgery increased (6x) –2.3 to 14.1 per 100,000 adults In 2003: 103,000 In 2006: 175,000-200,000

4. Complications Leaks from suture/staple line Wound infection Stomal obstruction/stenosis Pulmonary embolism Respiratory failure Bleeding Vomiting Death

5. Nutrition Risks Iron deficiency Malabsorption of vitamins –Folate –Vitamin B12 –Thiamine Osteoporosis Protein malnutrition

6. Challenges Nutrition support assessment –Body size –Rapid weight loss –Unusual nutrient deficiencies Nutrition Intervention –Difficulties in gaining enteral/vascular access –Risks of developing metabolic complications

7. Methods A web-based survey –Purpose: To characterize the impact that complications of bariatric surgery is having on the practice of specialized nutrition support To identify current nutrition support assessment and intervention methods being used –17 multiple-choice questions –Population: 3700 domestic members of A.S.P.E.N. A follow-up survey

8. Survey Questions 1.Please identify your discipline. 2.Please identify your primary nutrition support practice setting. 3.Your nutrition support patient population is composed of… 4.The amount of time I spend engaged in the practice of specialized nutrition support as part of my job each week is… 5.Does the institution with which you are affiliated performed bariatric surgery?

9. Patient Characteristics Questions 6.In the previous year, approximately how many patients which have consulted with you for nutrition care have required specialized nutrition support as a result of complications of bariatric surgery? 7.If applicable, of these bariatric surgery patients, approximately what percentage required parenteral specialized nutrition support? 8.If applicable, the most common indication for any kind of specialized nutrition support in bariatric surgery patients was…

10. Nutrition Counseling Questions 9.If applicable, did the bariatric surgery patients in your care receive counseling performed by a dietitian? 10.At the time of assessment for specialized nutrition support, for those patients who were at least 1 month out from surgery, can you estimate how many patients had not received any micronutrient supplementation in the month before evaluation?

11. Nutrition Assessment/Intervention Questions 11. What body weight do you use to estimate caloric goals for bariatric surgery patients? 12. What body weight do you use to estimate protein goals for bariatric surgery patients? 13. What protein goals would you prescribe for this sample patient? 14. What calorie goals would you prescribe for this sample patient?

12. 15. What percentage of this population of bariatric patients required continued specialized nutrition support after hospital discharge? 16. Approximately how long was specialized nutrition support required in the majority of the bariatric surgery patients that you have worked with? 17. Specialized nutrition support assessments/interventions for these patients were provided by which clinicians in your institution?

13. Results 14% response rate Patient Characteristics (Q 6-8) –Indications for specialized nutrition support: Anastomotic leak/fistula (49%) Chronic nausea/vomiting (27%) Severe malabsorption/diarrhea (19%) Nutrition Counseling (Q 9-10) –Recommended patients to receive counseling before and after surgery –Patients received micronutrient supplementation within the month before their assessment for specialized nutrition support

14. Results Nutrition Assessment / Intervention (Q 11-17) –Estimating calorie goals: Adjusted body weight (62%) Ideal body weight (15%) Actual weight (14%) –Estimating protein goals: Adjusted body weight (56%) Ideal body weight (29%) Actual weight (8%)

15. Conclusion Encourage further research for guideline development regarding the best practices to ensure that postoperative bariatric surgery patients receive safe and appropriate nutrition support.