BY: HILLARY SULLIVAN MEDICAL NUTRITION THERAPY BASIC EXPLANATION OF BARIATRIC SURGERY TYPES.
Nutrition Care Process for Bariatric Surgery
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Nutrition Care Process
forBariatric Surgery
Kate Haarala Concordia College
Moorhead, MN
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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.
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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.
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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
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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
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Obesity Prevalence in the U.S. in 2007
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm
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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.
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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.
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Current Bariatric Surgical Procedures
Procedure Classification
Roux-en-Y Primarily Restrictive/ Partially Malabsorptive
,
LaparoscopicGastric Banding Restrictive (Lap-band)
Biliopancreatic Diversion Malabsorptive (BPD)
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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.
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Laparoscopic Surgery
Laparoscopic surgery is a minimally invasive surgery.
The pouch created starts off at having the ability to hold 1 oz. of material.
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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
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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
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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
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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.
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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.
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Pre-Operative Guidelines
Exercise: Mild exercise (20 min./day 3-4 times/week)
Psychological Evaluation
Begin healthful diet in order to assist weight loss
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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
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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.
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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Nutrition Care Process (NCP)
Nutrition Care Process. (n.d.). Retrieved Sep. 29, 2008, from www.adaevidencelibrary.com/file
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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
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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
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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?
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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
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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
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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.
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Review...
What syndrome can occur if an individual eats too much sugar too quickly after surgery?
When should liquids be consumed?
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Questions/Comments/Concerns
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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.
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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