Bariatric Weight Loss Surgery A Professional Research Presentation for the Clinical Nutrition Department @ PRMCE By Jen Hey, Dietetic Intern
Objectives • At the end of today’s presentation participants will: • Have gained knowledge of the types of bariatric weight loss surgery that will be performed at PRMCE • Be familiar with a review of current literature and research in the field • Have a greater understanding of the Dietitian’s role in bariatric weight loss surgery • Understand diet recommendations post surgery and beyond
Ice Breaker Take a moment to think of the topic at hand and the phrase “bariatric weight loss surgery” Now imagine that a close friend has come to you and is considering having this type of procedure. What is your initial reaction? What feelings does it bring up? What advice would you give? Briefly share your thoughts with the group….
Bariatric Weight Loss Surgery at PRMCE There will be three types of bariatric weight loss surgery performed at PRMCE: Gastric banding, Roux-en-Y bypass, and sleeve gastrectomy. Surgeries will occur one day per month with 3-5 surgeries per occurrence Surgeries will be performed by Dr. Bob Michaelson, and Dr. Alana Chock from Northwest Weight Loss Surgery First surgery to occur mid-November
Types of Surgery Gastric Banding: an adjustable band is surgically placed at the top of the stomach to create a smaller pouch restricting intake and inducing early satiety
Types of Surgery Sleeve Gastrectomy: Approximately 60% of the stomach is removed and a staple line is created leaving a much smaller space and reducing ghrelin production.
Types of Surgery Gastric Bypass: A smaller pouch is created and the small intestine is re-routed to bypass the lower stomach and the duodenum to limit absorption.
Research Review • Swedish Obesity Study (1): • Highly referenced • Followed around 4,000 obese subjects, half had surgery, half did not • The surgery group lost 14-25% body weight over ten years, the other maintained +/- 2%. • Also resulted in improved lifestyle factors such as being more physically active and lower risk factors for hypertriglyceridemia, DM, and hyperuricemia. • Hypercholesterolemia remained the same between groups
Research Review • Banded vsUnbanded (2): • Conducted by InstitutoNacional de CienciasMédicas y Nutrición Salvador Zubirán • Roux-en_Y gastric bypass surgery. Half had the banded procedure, half had the unbandedproceure • No significant difference exists in % weight loss between the two groups
Research Review • Weight loss surgery and Glycemic Control (3): • Study conducted at MonashUnivesity that followed 60 obese patients that had been diagnosed with Type 2 DM within the last 2 years • Followed patients every 4-6 weeks for 2 years • Patients in group 1 received weight loss surgery • Patients in group 2 received intense dietary, medical, and lifestyle counseling • Group 1 had a 73% remission rate of DM and had a mean weight loss of 20.7% • Group 2 had a 13% remission rate of DM and had a mean weight loss of 1.7%
Research Review • Follow up care impacts outcome of surgery (4): • University of Wisconsin retrospective cohort study • 3 groups identified, all subjects had undergone laparoscopic bypass surgery: Group 1 had followed the recommended follow up schedule for 3 years, Group 2 had followed the recommended schedule for 1 year, Group 3 had been lost to follow up before the end of the first year • All groups had a similar weight loss after one year (65-70%) • Group 1 had a mean excess weight loss of 74% at 3 years • Group 2 had a mean excess weight loss of 61% at 3 years • Group 3 had a mean excess weight loss of 56% at 3 years
Research Review • Pediatric patients update (5): • 73 patients aged 13-17 yrs, 54 female, 19 male • All underwent laparoscopic adjustable banding surgery • Mean pre-surgery BMI of 48 • Mean % excess weight loss: 6 mos-35% 1 year-57% 2 years 61% • 6 experienced band slippage • 13 became asymptomatically Fe deficient • 4 became asymptomatically Vit D deficient • 13 experienced hair loss • A sub-study of 21 of these patients revealed 51 co-morbidities and of these 35 were completely resolved and 9 were improved
Research Review • Mayo clinic research review (6): • Acknowledges that reported results are compelling and that patients undergoing this surgery see a reduction in weight, resolution of obesity related comorbidities, and are often more active after surgery • Notes that the cost of surgery is outweighed by the savings from resolving related conditions • States that surgery is not a cure for obesity and that continued focus on education and public awareness is critical • Identifies the need for careful patient screening and selection • Recognizes the importance of follow up support and intervention
Research Review • Utah obesity study (7): • Unique study design of 3 groups (all were of similar obesity range): Group 1 sought and received gastric bypass surgery, Group 2 sought but did not qualify for gastric bypass surgery, Group 3 was not interested in gastric bypass surgery • At 6 years, Group 1 had experienced a mean weight loss of 27.7% and 62% remission rate for DM • At 6 years, Groups 2 and 3 had either no weight loss or a very small weight gain and a 8% (Group 2) and 6% (Group 3) remission rate for DM
Research Review • Review of procedure outcomes (8): • UCSF conducted review of 14 studies comparing gastric bypass and laparoscopic banding • Found Roux-en-Y gastric bypass to yield most favorable results • Mean excess body weight loss at 1 year was 26% higher for gastric bypass • In the highest rated study excess weight loss for gastric bypass was 76% and 48% for laparoscopic banding. DM resolution for the same study was 78% for bypass and 50% for banding
Questions to Consider What will the longer term studies (20 years and beyond) reveal? How can we further study the impact of additional dietary and lifestyle interventions in conjunction with weight loss surgery? What would a study that evaluates the effectiveness of stricter exclusion criteria reveal? What will the effect of long term vitamin and mineral deficiencies be in patients living for up to 50 years after surgery?
Role of the Dietitian Preoperative: Education of patients for the following: ~Reduced stomach volume ~Dehydration ~Dumping syndrome ~Vomiting ~Potential nutrient deficiencies and associated consequences ~Need for supplementation ~Increased protein needs
Role of the Dietitian Postoperative: Evaluation of protein intake and recommendation of supplements Evaluation of fluid intake and recommendation for alterations Monitoring of and encouragement for compliance with vitamin and mineral supplementation Nutrition related diagnoses and interventions as needed
Post Operative Diets-Laparoscopic Procedures Day 1- sips of clear, non-carbonated, sugar-free, low-fat liquids from 30 mL cups/1 per hour Day 2- 60 mL per hour of low-fat, low-sugar, high-protein liquids Day 3- 2-3 oz per hour of semi-liquid high protein foods that are also low-fat, low-sugar Day 4 to 2 weeks- ¼ cup- ½ cup at each meal x 5-6 mini meals ( 3 x ½ cup for banded gastroplasty). Total of 5 cups fluid including 3 of bariatric protein supplement and 2 cups other non-carbonated, low-sugar fluids. Vitamin and mineral supplements. Weeks 2-4-Pureed diet and 6 cups fluid including 3 of bariatric protein supplement and 3 cups of other non-carbonated, low-sugar fluids. Vitamin and mineral supplements. Week 4 to 6 mos- Soft diet including same fluid recommendations and supplements
Post Operative Diet-Open Procedure Day 1 & 2- sips of clear, non-carbonated, sugar-free, low-fat liquids from 30 mL cups/1 per hour Day 3- 60 mL per hour of low-fat, low-sugar, high-protein liquids Day 4- 2-3 oz per hour of semi-liquid high protein foods that are also low-fat, low-sugar Day 5 and beyond- Same as laparoscopic procedure
General Diet Recommendations Wait at least 30 minutes after a meal to start fluids No chewing gum (can block pouch if swallowed) Bypass patients especially should avoid concentrated sugar and fat to avoid dumping syndrome No alcohol for 6 months minimum No raw vegetables Avoid soft breads Chew food well and eat slowly Stop when full Avoid straws
Supplements • All bariatric weight loss surgery patients should take: • A liquid or chewable multivitamin and mineral supplement daily • A liquid or chewable calcium supplement of 1,500 mg calcium citrate or 2,000 mg calcium carbonate with Vit D daily • High protein, low-sugar, low-fat liquid bariatric supplement daily • Gastric bypass patients should also take a sublingual B-12 pill daily or receive a monthly injection
Consequences of Non-Compliance DS, 58 yr old Male Presented at PRMCE with malnutrition, severe edema (leaking from skin) and extreme weakness. Found to be 11 yrs post-gastric bypass and very non-compliant. Meals consisted of large servings of simple starch foods low in protein and pt reported not taking supplements for 10 yrs. Uncontrolled diarrhea throughout the day with a pattern of worsening after meals How can we help him????
Some Improvement Restricted meals to ~1 to 1 ½ cups total volume per meal Eliminated juices and simple starches served alone Included protein at each meal Provided nutritional supplements between meals Within a few days…. Pt’s diarrhea improved Albumin levels slowly started to rise, electrolytes came back in to balance Pt regained enough strength to sit up and participate more in conversations and ADL
Post Test Which of the surgeries that will be performed at PRMCE is both restrictive and mal-absorptive? Which procedure does current research support use of in the pediatric population? What is one additional consideration mentioned in the Mayo clinic article? What is the recommended total volume of food at a meal for gastric bypass patients? What are three of the education topics for dietitians to cover with bariatric weight loss surgery patients pre-operatively?
References Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjöström CD, Sullivan M, Wedel H., Swedish Obese Subjects Study Scientific Group Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. New Engl J Med. 2004;351:2683–2693. doi: 10.1056/NEJMoa035622.[PubMed] [Cross Ref] F1000 Factor 6 John Dibaise 14 Sep 2012. Arceo-Olaiz R, NayvíEspaña-Gómez M, Montalvo-Hernández J, Velázquez-Fernández D, Pantoja JP, Herrera MF. Maximal weight loss after banded and unbanded laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial. SurgObesRelat Dis. 2008 Jan 26; [Epub ahead of print]. Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M. Adjustable gastric banding and conventional therapy for type 2 diabetes: A randomized controlled trial. JAMA. 2008 Jan 23; 299 (3): 316-323. Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surgery for Obesity and Related Diseases. 2007; 3 (6): 627-630. Nadler EP, Youn HA, Ren CJ, Fielding GA. An update on 73 US obese pediatric patients treated with laparoscopic adjustable gastric banding: comorbidity resolution and compliance data. J Pediatr Surg. 2008 Jan;43(1):141-6. PubMed PMID: 18206472. Madura JA 2nd, Dibaise JK. Quick fix or long-term cure? Pros and cons of bariatric surgery. F1000 Med Rep. 2012;4:19. doi: 10.3410/M4-19. Epub 2012 Oct 2. PubMed PMID: 23091563; PubMed Central PMCID: PMC3470459. Adams TD, Avelar E, Cloward T, Crosby RD, Farney RJ, Gress R, Halverson RC, Hopkins PN, Kolotkin RL, Lamonte MJ, Litwin S, Nuttall RT, Pendleton R, Rosamond W, Simper SC, Smith SC, Strong M, Walker JM, Wiebke G, Yanowitz FG, Hunt SC. Design and rationale of the Utah obesity study. A study to assess morbidity following gastric bypass surgery; ContempClin Trials. 2005 Oct; 26 (5): 534-551. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008 Oct;121(10):885-93. Review. PubMed PMID: 18823860. Academy of Nutrition & Dietetics, 2012. www.eatright.org
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