Transplant Obesity Jennifer Williams MPH RD CSOWM LDN Surgical Weight Loss Dietitian October 19 2021 Agenda Medical Weight Loss Reasons for Bariatric Surgery Types of Bariatric Surgery at VUMC ID: 1039220
Download Presentation The PPT/PDF document "Bariatrics and Pre/Post" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Bariatrics and Pre/Post Transplant ObesityJennifer Williams, MPH, RD, CSOWM, LDNSurgical Weight Loss DietitianOctober 19, 2021
2. AgendaMedical Weight LossReasons for Bariatric SurgeryTypes of Bariatric Surgery at VUMCEligibility/Exclusion Parameters for TransplantHealth Benefits - Before & AfterNutrition FactorsCovid-19 ImpactVUMC Surgical Weight Loss Locations
3. Medical weight lossWhen pts desire lifestyle intervention and/or the medication route or when BMI does not qualify for bariatric surgery.
4. Medical Weight Loss – Nutrition, lifestyle, and medicationCan be explored first, before bariatric surgeryGenetic and metabolic testingPharmaceutical interventionProviders (MDs, NPs, RDs) in MWL loss see ~ 25 patients/year (2020)* for liver transplant alone. *2021 data is currently being analyzed*We know that “Specialized medical weight intervention is effective in treating high-risk obesity with complications.” Srivastava recently published a retrospective weight loss study should where approximately 50% of [medical weight loss patients reviewed] were able to achieve > 7% weight loss [over the course of 6 months].11. Srivastava G, Paris,C, Johnson J, et al. Specialized medical weight management intervention for high-risk obesity. JHEOR. 2021; 8 (2) 1 – 5. doi:10.36469/jheor.2021.24896
5. Reasons for Bariatric Surgery
6. Reasons for Bariatric SurgeryObesity, as defined by a BMI > 35 with co-morbidities (DM, HTN, OSA, etc) or BMI > 40 without co-morbiditiesMultiple failed diet attemptsFailed weight loss medication attemptsDeclining quality of lifeCo-morbidities directly related to excess weight
7. Types of Bariatric Surgery at VUMC
8. VUMC Bariatric Surgery OptionsCurrently Offered:Roux-en-Y Gastric Bypass (RYGB)Vertical Sleeve Gastrectomy (VSG)*No Longer Offered:Adjustable gastric banding – the “lap band” (AGB)* VSG is typically what is completed on transplant patients, due to concerns with medication absorption.
9. Eligibility/Exclusion Parameters for Transplant pts
10. General EligibilityAll VUMC transplant patient referrals for surgical weight loss are sent to the Vanderbilt Weight Loss Clinic’s program coordinator – Wendy Tarpley, RN, BSN. There are no exclusions related to solid transplant need at this time. Per Wendy, there is no “exclusion for transplant patients because more patients are having the sleeve* to qualify for transplant surgery (BMI must be less than 40).”
11. Eligibility - StepsPts are screened and then start on the surgical pathway. Surgical consult with MDTelehealth Group Nutrition Education Class (60 minutes) with a Registered Dietitian to teach through nutrition changes required of those choosing Bariatric Surgery - Bariatric Nutrition Guide1:1 Nutrition Assessment with a RD (1 month after education class) – evaluation of progress on nutrition changesAdditional Nutrition Reassessment(s) - as clinically required by RD or due to insuranceSupport Group AttendancePsych EvalLabs, medical clearance, etc.
12. Eligibility & Follow Through“Approximately 7 out of every 10 transplant patient referrals to our surgical weight loss program unfortunately NEVER follow through with the initial consult with the surgeon.” - Wendy Tarpley, RN, BSN – Bariatric Program Coordinator
13. Health Benefits – Before & After
14. Bariatric Surgery BEFOREWhen bariatric surgery is initiated before transplant, many risk factors are reduced:Improved glycemic control, reduction or elimination of DM meds, resolution of DM at timesDramatic improvement in BP, discontinuation/reduction in HTN medsImproved mobilityPotential ability to halt/delay disease progression, so as to prevent transplant need or how soon a transplant would be required – depending on disease stateReduced weight (BMI of < 40), so that surgeon can proceed safely with transplantImproved energyOften, bariatric surgery requirements result in a healthier diet that leads to a more well nourished pt.
15. Bariatric Surgery AFTERMost studies support waiting a minimum of 1 year AFTER transplant surgery for bariatric surgery to take place, when needed due to obesity. Assistance in achieving a weight that taxes the body less, helping organs to last longerContinued assistance in delaying other disease progressions, co-morbiditiesAll the same benefits as BEFORE - improvement in overall health and quality of life!
16. SWL - Weight Loss PercentagesVSG – generally produces a weight loss of 50 – 60% of excess weight*RYGB – generally produces a weight loss of 60 – 75% of excess weightWeight loss can certainly exceed these levels, but this is what is typical. *Excess weight is defined as the difference between the patient’s current weight and the weight that places the patient at a BMI of 25.
17. Nutrition Factors
18. NutritionMacronutrients & micronutrients are monitored through diet recalls with RDs and nutrition labs (week 1 and then months 1, 3, 6, 12, 18 and once a year at 2 years postop bariatric surgery and beyond)The RDs in the weight loss clinics provide guidance, deferring to renal or other specialty providers, as appropriate, to ensure appropriate nourishment with the following:Protein CaloriesFatCarbohydrateFluid & Electrolytes Vitamins and Minerals
19. Nutrition - OverviewProteinHigher % generally (ASMBS guidelines: 60 – 80 grams/day) Mindful of kidney function (late staged disease/dialysis) – protein is modified as appropriate.Calories Initially low at approximately 500/day for first 3 months after WLS; maintenance generally 1000 – 1200 for women, 1200 – 1400/1500 for menFatTypically roughly 30 - 35%, depending on disease state/conditions
20. Nutrition - OverviewCarbohydrateThe most variable of the macronutrients, generally fairly low, but may represent up to 40% longer term.Fluid & ElectrolytesNormally liberal (> 64 oz+), unless restrictions r/t CHF, dialysis, etc.Limited caffeine (limited to 1 – 2 cups/day of coffee or equivalent)Electrolytes - levels are monitored by labs and based on s/sx after WLSVitamins and MineralsLevels are monitored by labsASMBS compliant supplements are recommended, unless otherwise needed
21. Long Term Implications & Challenges
22. Potential Long Term ChallengesDumping syndromeHypoglycemiaMalnutritionUlcersBowel obstruction/ “blockages”Transference of addiction (ETOH, exercise, etc)
23. Covid-19 Impact
24. Covid ImpactInternal clinical focus has shifted to safety precautions, telehealth, & additional measuresCovid testing prior to surgeryAll normal VUMC safety practicesLimiting numbers in support groupsRequiring masking Telehealth = increased access to care! For many this was previously an obstacle. Now, it is a standard way we can schedule and provide care. Normally patients just need to be somewhere within TN borders to receive care from providers in our clinic.
25. Covid ImpactCurrently, weight loss interventions – through medical or surgical means - may be more conservative than typical. 2COVID-19 stress and restrictions have been associated with more conservative weight outcomes and higher than typically reported disordered eating.2Those who have received a transplant and those who have had WLS may be particularly susceptible populations. J.P. Almandoz, L. Xie, J.N. Schellinger, et al.Impact of COVID-19 stay-at-home orders on weight-related behaviours among patients with obesity. Clin Obes, 10 (5) (2020), Article e12386.
26. VUMC Weight Loss Clinic Locations
27. VUMC Weight Loss Clinic LocationsVanderbilt Weight Loss CenterVanderbilt Health One Hundred Oaks719 Thompson Lane, Suite 22200Nashville, TN 37204Vanderbilt Weight Loss Center Clarksville800 Weatherly Drive, Suite 201Clarksville, TN 37043Vanderbilt Surgical Weight Loss Jackson37 Sandstone CircleJackson, TN 38305Vanderbilt Weight Loss Center Lebanon1616 West Main Street, Suite 300Lebanon, TN 37087Vanderbilt Surgical Weight Loss Murfreesboro1272 Garrison Drive, Suite 309Murfreesboro, TN 37129Call (615) 322-6000 for more information or visit https://www.vanderbilthealth.com/program/surgical-weight-loss
28. SummaryUtilization of weight loss surgery for patients who battle obesity and who are also pre or post-op from transplant, can dramatically IMPROVE health, reduce future health complications and comorbidities, and dramatically increase quality of life!
29. Thank You!