OBESITY AND DIETING

NUTRITION THERAPY IN SURGICAL MANAGEMENT OF MORBID OBESITYLeo kihiuhiClinical Nutritionist

OVERWEIGHT

FEEDING HABITS

PHYSICAL ACTIVITIES

Psychological Factors

Environmental factors

Sociodemographic factors

Biological factors

OBESITY

WHO IS OUT RISK?

PUBLIC MIND ON WEIGHT MANAGEMENT

ONLINE DIETSGYMPILLS

Any solution ?

The Practical Guide; Identification, Evaluation and treatment of Overweight and Obesity in Adults, Oct 2000, NIH Pub No 00-4084

BARIATRIC SURGERYBariatric surgery is more effectivethan nonsurgical treatment for weightloss and control of some comorbidconditions in MORBID OBESE patients

PRE-SURGERICAL EVALUATION.

Prior to surgery candidates should be carefully assessed by a specialized multidisciplinary team including: Bariatrician (MD specializing in the care of the obese)SurgeonPCPSocial Worker/ PsychologistDietitianNurse

During active weight management, multicomponent interventions that are delivered through multidisciplinary care may be more effective than interventions delivered by individual health professionals (Flodgren et al. 2010; Tsai & Wadden 2009).

NUTRITION THERAPY IN BARIATRIC SURGERY IN MORBID OBESE TREATMENT

Pre-Surgical Goals Improvement of nutritional statusCorrect vitamin/nutrient deficiencies (most common include: iron, vitamin B12 and vitamin D)Achievement of better control of nutrition- related comorbiditiesDevelopment of lifestyle and eating habits that will promote positive post-weight loss surgery outcomes and weight loss maintenancePromote 5-10% weight loss to reduce surgical risks

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Post-Surgery Nutrition GuidelinesDietary consult ordered upon admitComplete nutrition assessment Review diet progression with patientWork with in-patient team to identify & minimize complications post-op For all procedures patients will follow the same diet

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Post Surgical Diet Progression

Diet advanced from NPO to Stage 1 Bariatric Diet on Post op Day 1 Stage 1 - WaterTypically start day of surgery; Duration < 1 dayNursing staff to administer 1oz water per hour via medicine cupInstruct patient to sip slowly & stop if feeling full or nauseous All medications to be administered in liquid/chewable formIV Fluid until tolerating liquids Patient to begin tracking fluid intake on Patient Intake Diary (provided by healthcare team)

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Stage 2 - Bariatric Clear Liquids Starts Post op Day1; Duration 1-2 days Non-carbonated liquids without calories, sugar, or caffeine; includes broth, sugar-free (SF) ice pops, SF gelatin, water, & ice chipsPriority is hydrationInstruct to sip slowly & stop if feeling full or nauseous (avoid straws)Will receive 3oz Bariatric Clear Liquids 3 times a day on meal trays Instruct to sip 2-4 oz Bariatric Clear Fluids per hour between mealsWill be expected to track intake on Patient Intake Diary

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Stage 3 - Bariatric Full Liquids Starts Post op Day 1-2; duration 2-4 weeksWill receive 3oz Bariatric Full Liquids 3 times a day on meal trays Low-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 Priority on hydration and protein intake (minimize loss of lean body mass)Instruct to sip slowly & stop if feeling full or nauseousInstruct to sip 2-4 oz fluids per hour between mealsNote: Patients will go home on this stage. You may not see other stages unless patients are re-admitted

? Change to 4oz of each, sip slowly; 1-2 oz per 30 min ?17

Stage 4 - Soft and Moist Protein Start 2 weeks post-op; Duration 4-6 weeksAs tolerated replace full liquids with soft & moist protein foods (avoid dry or tough meats); ~2-4oz per meal May need to continue with protein shakes to meet protein needs Instruct not to drink fluids with meals; wait 30 min before & after each meal to have beverages If meeting protein goals may add well-cooked soft fruits & vegetablesWill begin taking chewable vitamin & mineral supplements

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Stage 5 Low Fat, Low Sugar, High Protein Start 6-8 weeks post-op; Duration lifelongBalanced solid food diet with protein, fruits, vegetables, and whole grains. Can add raw foods as tolerated. Goals:60-80 grams protein /day64+ ounces fluid/ day (including protein drinks) sipped between meals. Continue to separate fluids from your meals

Can advance to supplements in tablet form if tolerated

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Common Problems After All Weight Loss Surgeries

DehydrationMonitor 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. Nausea and VomitingEating 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.

Should I include twice?21

Dumping SyndromeUsually occurs ~30 minutes following a meal. 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. or example instead of 100% fruit juice; dilute 1:1 with water.DiarrheaSome patients can develop post-operative lactose intolerance. Symptoms could include bloating, abdominal cramps, excessive gas, and diarrhea. Treatment includes following a lactose-free diet.

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Sites of Nutrient Absorption

StomachWater, ethyl alcohol, copper, iodide, fluoride, molybdemum, intrinsic factorDuodenumCalcium, iron, phosphorus, magnesium, copper, selenium, thiamin, riboflavin, niacin, biotin, folate, vitamins A, D, E, K

Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. Nutr Clin Pract. 2007;22(1):29-40.

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JejunumThiamin, riboflavin, niacin, pantothenate, biotin, folate, vit B6, vit C, vit A, D, E, K, dipeptides, tripeptides, calcium, phosphorus, magnesium, iron, zinc, chromium, manganese, molybdenum, amino acidsIleumVit C, folate, vit B12, vit D, vit K, magnesium, bile salts/acids

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Common Nutrient Deficiencies

Gastric Bypass:Most common: Iron, Vitamin B-12,Folic acid, Fat soluble Vitamins A, D, & EThiamin (seen in patients with frequent vomiting) Calcium Protein malnutrition Gastric Banding: Except for folate, nutrition deficiencies are less commonly seen post gastric banding Sleeve GastrectomyPossible B-12

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Iron deficiency and anemia

As high as 49% of patientsMultifactorial causeLow gastric acid levels prohibit iron cleavage from foodAbsorption inhibited because no nutrient exposure to duodenum or proximal jejunumDecrease in iron-rich food consumption due to intoleranceTreat with oral supplementation of ferrous sulfate or ferrous gluconate

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Vitamin B12 deficiencyUp to 70% of patientsLack of hydrochloric acid and pepsin in stomachPrevents B12 cleavage from foodAffects secretion of intrinsic factor, thus B12 absorptionIntolerance to meat and milkOral supplementation usually adequate, otherwise, IM injections used

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Folate Deficiency40% of gastric bypass patientsComplete absorption requires B12Absorption dependent on HCl and upper 1/3 stomachDeficiency generally caused by decreased consumptionOral supplementation

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Vitamin D and Calcium DeficiencyVitamin D deficiency is common among obese peopleCalcium absorption decreased because duodenum is bypassedIntolerance to dairy, foods high in calciumVitamin D is required for Ca++ absorptionProlonged deficiencies lead to Bone resorption, osteomalacia, osteoporosisTreat with calcium citrate supplementation and 2 weekly doses of Vitamin D

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NULFICATION OF THE SHORTCOMING ?

Benefits of bariatric surgeryDepression 55% resolved (Wittgrove AC, Clark GW. 2000)Obstructive sleep apnea 74-98% resolved (Wittgrove AC, Clark GW. 2000)Asthma 82% improved or resolved (Wittgrove AC, Clark GW. 2000)Cardiovascular disease 82% risk reduction (DeMaria EJ, Sugerman HJ et al 2002)GERD 72-98% resolved (DeMaria EJ, Sugerman HJ et al 2002) Stress urinary incontinence 44-88% resolved (DeMaria EJ, Sugerman HJ et al 2002) Degenerative joint disease 41-76% Resolved (Wittgrove AC, Clark GW. 2000)Mortality 89% reduction in 5-year mortality4Quality of life improved in 95% of patients (Wittgrove AC, Clark GW. 2000)

Migraines 57% resolved (Wittgrove AC, Clark GW. 2000)Pseudotumor cerebri 96% resolvedDyslipidemia hypercholesterolemia 63% resolved (Wittgrove AC, Clark GW. 2000)Non-alcoholic fatty liver disease 90% improved steatosis 37% resolution of Inflammation 20% resolution of fibrosis (Mattar SG, Velcu LM,2005)Metabolic syndrome 80% resolved (Mattar SG, Velcu LM,2005)Type II diabetes mellitus 83% resolved (Mattar SG, Velcu LM,2005)Polycystic ovarian syndrome 79% resolution of hirsuitism 100% resolution of menstrual dysfunctionVenous statis disease 95% resolved

LONG TERM SOLUTION

Lifelong compliance with vitamin/ mineral supplementation is important to reduce the risk of serious nutrient deficiencies Self-monitoring intake and avoiding high calorie foods and beverages to prevent weight re-gain

Remaining connected with post bariatric surgery support groups

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Prevention is likely to be the most efficient and cost-effective approach for tackling overweight and obesity. However, many people already require treatment, may have comorbidities and are at risk of further weight gain (NPHT 2009).

FEEDING HABITNUTRITIONIST

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EXERCISESGYM INSTRUCTORS

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MEDICATIONPHYSICIANS

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BARIATRIC SURGSURGEONS

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MEDICATIONEXERCISESBARIATRIC SURGPHYSICIAN GYM INSTRUCTORSNUTRITIONISTSURGEON

There is nothing wrong with our metabolism the problem is theEnvironment and the fact that food is no longer a survival issue but mostly a source of pleasureuiza Kent-Smith, 2007

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