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Till Death Do We Part The Life-long Journey of a Bariatric Surgical Patient

Till Death Do We Part The Life-long Journey of a Bariatric Surgical Patient. Tina Musselman MA, RD, CCN. St. James Center for Bariatric Surgery Program Coordinator Tina.musselman@ssfhs.org (708) 679-2717. Mind, Body & Wellness Institute, Inc. Tmusselman26@yahoo.com (708) 846-5816. Surgery.

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Till Death Do We Part The Life-long Journey of a Bariatric Surgical Patient

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  1. Till Death Do We PartThe Life-long Journey of a Bariatric Surgical Patient Tina Musselman MA, RD, CCN St. James Center for Bariatric Surgery Program Coordinator Tina.musselman@ssfhs.org (708) 679-2717 Mind, Body & Wellness Institute, Inc. Tmusselman26@yahoo.com (708) 846-5816

  2. Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity Obesity…Intervention BMI RYGB, AGB (BMI 30), Duodenal Switch, Gastric Sleeve 35 Phentermine, Meridia, Xenical (Byetta), Band(?) 30 25 http://cme.medscape.com/viewarticle/712986?src=cmemp&uac=98478HV

  3. The Reality of Bariatric Surgery • # of bariatric cases grew 400% from 1998-2004 • 13,386 to 121,055 per year • 220,000 performed in 2008 • 82% of surgical cases are female • Age • Ages 18-54 accounted for 85.2% of all surgeries • FASTEST GROWTH IN BARIATRIC SURGERY IS FOR AGES 55-64 (20 fold increase) RD’s can run, but we cannot hide! Healthcare Cost and Utilization Project, Statistical Brief #23 (January 2007)

  4. Eligibility • BMI • BMI 35-39.9 with 1 - 2 obesity-related co-morbidities (DM, HTN, dyslipidemia, severe OA, OSA, Pickwinian Syndrome) • BMI > 40 • New indications for Lap Band - BMI 30-34.9 (not covered by insurance yet) • Age • Adults over 18 • Controversy over 65 y.o. - evaluated case by case • Adolescent trials are currently being done • Growth must be completed • Some insurances may cover it • “Exhausted all non-surgical weight loss options” • CKD/ESRD is NOT a contraindication

  5. Adjustable Gastric Band(Lap Band® & Realize Band) • 1988 approved by FDA in June 2001 • 15 ml pouch • Adjustable stoma size • Digestive tract remains in tact • 2/2011 - Lap Band approved for BMI 30-35 + co-morbids

  6. Roux en Y Gastric Bypass (RYGB) • 1971 • 15-30 ml pouch • Roux limb 75-150 cm • Longer in Super Obese • Biliopancreatic Limb • Carries gastric juice • Bile and Pancreatic juice • 15-60 cm • Distal Common Channel • 200-500 cm • All of the ileum and some jejunum • Bulk of digestion and absorption

  7. RYGB vs. AGB (Lap Band)

  8. RYGB vs. AGB (Lap Band) Treatment and Outcomes, FNCE Pre-symposium Workshop by Chris Eagon, MD; October 2005

  9. 5 year comparison Band has the highest safety profile for all bariatric procedures

  10. The “new kid on the block” in bariatrics Laparoscopic Sleeve gastrectomy • Partial Gastrectomy (60-80% removed) • Small bowel remains intact • Founded as part of the first step in a two step surgical process for the super obese • New- more to learn about sustainability and safety • Results similar to RYGB

  11. Chouillard et al. Laparoscopic RYGB vs Sg for morbid obesity: Case controlled study.. SOARD 2011; 7: 500-505.

  12. Micronutrition • Factors common to all procedures that increase nutritional risk • Poor eating behaviors, • Decreased nutrient dense foods • Food intolerance • Restricted portion sizes • (Emesis)

  13. Micronutrition - Gastric Bypass • Etiology: • GERD (PPI’s) • Emesis •  transit time/diarrhea • Most common deficiencies • Iron (20-51%):  HCl • B-12 (35%):  HCl,  IF • Vit D • Ca • Folate (41-47%)

  14. Micronutrition - Gastric Bypass • Etiology: • GERD (PPI’s) • Emesis •  transit time/diarrhea • Most common deficiencies • Iron (20-51%):  HCl • B-12 (35%):  HCl,  IF • Vit D • Ca • Folate (41-47%) 63% of pts developed nutrition deficiencies (Fe, B12, folate) 2 yrs. Post RYGB including those who were compliant with the vitamin regimen. (n=140) - Brolin, et al 1991

  15. Micronutrition - Sleeve gastrectomy • Etiology •  transit time • Emesis/Nausea • GERD (PPI’s) •  HCl • Common nutrient def. • B12: 18% ? • Fe: 18% ? • Zn: 35% ? • Folic Acid? • Vit D?

  16. Micronutrition - Sleeve gastrectomy • Little data on micronutrition and SG • 1 yr. results without MVI • 4.9-43% Fe def. • 9-18.1% B12 def. • 9.8-22% folate def. Jacques, J., Goldenberg, L. Nutrition and the sleeve gastrectomy patient: From micronutrients to dietary patterns. Bariatric Times 2011; 8(6):12-15.

  17. Micronutrition - AGB • Etiology •  po intake • Food intolerance • Maladaptive eating

  18. Micronutrition - AGB • Etiology •  po intake • No alterations to digestive processes • “AGB has minor effects on normal physiological digestive processes and, as a result, selective nutritional deficiencies are presumed to be unusual…Closer clinical follow up is more necessary (adjustments) after AGB than RYGB, whereas the reverse is true for perioperative nutritional evaluations.” • - Ziegler, O., Sirveaux, MA, et al, Diab. & Met. 2009, p. 544 & 553

  19. Micronutrition - Summary • very rare • + rare • + frequent • ++ very frequent Ziegler, O., Sirveaux, MA., et al. Medical follow up after bariatric surgery: nutritional and drug issues General recommendations for the prevention and treatment of nutritional deficiencies. Diab. & Metab 2009; 35: 544-557.

  20. The Standard Supplementation “There is little agreement on exactly how to manage micronutrition in post-operative bariatric surgery patients.” • Jacqueline Jacques, ND Micronutrition for the Weight Loss Surgery Patient (2006) • Many patients will be malnourished pre-operatively leading to more aggressive supplementation after surgery • 51-62% pre-operative Vit D deficiency • Obese individuals may have needs above and beyond normal recommendations • Contributing mechanisms • Multiple medications • Years of poor diet • Underlying inflammation

  21. Recommended Supplementation • Tablets or capsules can be tolerated 6 mo. and beyond • Multiple Vitamin and Calcium should not be taken together and should be in divided doses

  22. Common “Bariatric” Eating Guidelines Protein and Produce - At least 60 g. protein/day - Liquids and “mushy” calories not recommended - Foods not tolerated well: bread, rice, dry meat, some produce 2-3 meals per day - breakfast optional - limited snacking Avoid eating and drinking at the same time 1200-1400 calories per day long-term

  23. A word about renal disease and bariatrics • Bariatric Surgery improves DM, obesity and HTN, three of the leading causes of renal disease • “The more earlier we treat CKD in the disease process with bariatric surgery, the more favorable the impact on the kidney.” - Wei-Jei Lee. • Be aware of medical absorption changes • Monitor labs and adjust vitamins/macronutrients as appropriate

  24. Thank You! St. James Center for Bariatric Surgery Program Coordinator Tina.musselman@ssfhs.org (708) 679-2717 Tina Musselman RD, CCN Mind, Body & Wellness Institute, Inc. tmusselman26@yahoo.com (708) 846-5816

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