1. Nutrition Care Process for Bariatric Surgery Kate Haarala Concordia College Moorhead, MN

2. Objectives To 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.

3. Definition Bariatric 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.

4. 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 ≥ 40 http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/risk.htm

5. 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.” 1 Ogden 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

6. Obesity Prevalence in the U.S. in 2007 http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm

7. Purpose Bariatric 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/289/1/76http://jama.ama-assn.org/cgi/content/abstract/289/1/76; Longe, J. (2006). The Gale Encyclopedia of Medicine. New York: Gale Cengage.

8. 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.

9. Current Bariatric Surgical Procedures Procedure Classification Roux-en-Y Primarily Restrictive/ Partially Malabsorptive, Laparoscopic Gastric Banding Restrictive (Lap-band) Biliopancreatic Diversion Malabsorptive (BPD)

10. 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.

11. Laparoscopic Surgery Laparoscopic surgery is a minimally invasive surgery. The pouch created starts off at having the ability to hold 1 oz. of material.

12. Biliopancreatic Diversion http://www.obesitysurgeryinfo.co.uk/expor ts/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

13. Optimal Weight Loss Procedure According 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

14. General Complications The 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 complications Journal of the American Dietetic Association 2006

15. Surgery Outcomes On 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.

16. 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.

17. Pre-Operative Guidelines Exercise: Mild exercise (20 min./day 3-4 times/week) Psychological Evaluation Begin healthful diet in order to assist weight loss

18. Post-Operative Guidelines For 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

19. 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.

20. Foods To Avoid Carbonated or Caffeinated Beverages Fried Foods Peanut Butter Raw Vegetables and Fruit Skins (for 3 months) Red Meat (for 3 months) High Sugar Containing Foods University of Virgina Health Systems

21. Dumping Syndrome Dumping 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 eating Late: 1-3 hours after eating

22. 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

23. 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.

24. 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 *Protein 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

25. 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), 4223-4231www.asbs.org/html/pdf/asbs_

26. 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), 4223-4231www.asbs.org/html/pdf/asbs

27. 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

28. Calcium Calcium 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), 4223-4231www.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

29. Vitamin D 400 IU/d of vitamin D supplementation 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

30. Protein Recommended - 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

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

32. 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

33. Goals for the RD Obtain 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

34. Weighty Ethical Issues 1. 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?

35. Summary The 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 Banding Malabsorptive: Biliopancreatic Bypass

36. 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

37. 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.

38. Review... What syndrome can occur if an individual eats too much sugar too quickly after surgery? When should liquids be consumed?

39. Questions/Comments/Concerns

40. References Avenell, 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.ealth/gastric-bypass-diet/WT00007.

41. References Jeffrey, 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/patienhttp://www.asbs.org/html/patien