By Shala Davidson and Abby Stanley Obesity is American 1 More than 2 in 3 adults are considered to be overweight or obese More than 1 in 20 adults are considered to have extreme obesity ID: 912275
Download Presentation The PPT/PDF document "Bariatric Surgery and Nutrition" 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.
Slide1
Bariatric Surgery and Nutrition
By:
Shala
Davidson and Abby Stanley
Slide2Obesity is American1
More than
2 in 3
adults are considered to be overweight or obese
More than
1 in 20
adults are considered to have
extreme obesity
Since the early 1960s, prevalence of obesity among adults
more than doubled
, increasing from 13.4% to 35.7%
In children, ages 6-19,
one-third
(33.2%) are considered overweight or obese
Of those
18.2%
are
obese
Slide3Obesity in America1
Slide4Health Risks of Overweight and Obesity
2,3,4
Slide5Causes and Treatment of Obesity
2
Results from energy imbalance
Factors that lead to energy imbalance & weight gain:
Genes
Eating habits
Attitudes & emotions
Life habits
Income
Culture-how & where people live
No single approach for treatment
May include combination of following:
Behavioral treatment
Diet
Exercise
Weight-loss drugs
In cases of
extreme obesity
,
weight-loss surgery
Slide6Who is a good candidate?5,3
People who cannot lose weight by other means and suffer from serious health problems related to obesity
After diet, exercise, and pharmacologic agents have failed
Clinically
severely obese
BMI
> 40
BMI
> 35
accompanied by
serious health problems
linked to obesity
Type 2 diabetes, heart disease, sleep apnea
Questions to consider, is patient:
Unlikely to lose weight
using other methods
?
Well informed
about surgery & treatment effects?
Aware of
risks & benefits
of surgery?
Ready
to lose weight & improve health?
Aware of how life may change after surgery?
Aware of
limits on food choices
& occasional failures?
Committed
to lifelong healthy eating & physical activity, medical follow-up, & need for extra supplementation?
Slide7Who is a good candidate?6
Plus health conditions
Slide8What do you know about Bariatric Surgery?
7
The word gastric is often heard as part of the bariatric and metabolic surgery names. What does gastric mean?
Internal
Digestion
Stomach
intestinal
The risk of death within 30 days of having bariatric surgery is greater than the risk of death within 30 days of other operations?
True
False
Slide9What do you know about Bariatric Surgery?
7
Many bariatric and metabolic surgeries are “laparoscopic”. What does this mean?
Just one incision
Surgery related to weight loss
Surgery done with very small incisions
A procedure where the patient
goes
home the same day
What type of vitamin deficiencies do bariatric surgery patients usually face?
None. Modern surgeries do not lead to deficiencies
Some. The level depends on the procedure, and patients’ need to follow nutritional and supplemental requirements.
Severe. Patients are particularly dangerous in terms of vitamin deficiencies.
Slide10Types of Bariatric Surgeries3,5
Surgeries fall into 2 categories:
Restrictive procedure
Restrictive & malabsorptive
Four types commonly used in the United States:
Restrictive
AGB- Adjustable Gastric band
VSG- Vertical Gastric Sleeve
Restrictive & malabsorptive
RYGB- Roux-en-Y Gastric Bypass
BPD- Biliopancreatic Diversion with Duodenal Switch
Slide11What does your stomach look like after surgery?
3,5
Normally, the stomach can hold approximately 3 pints
(48 oz)
Restrictive surgeries initially reduce that amount to only
1 oz
Later the new pouch may stretch to hold
2-3 oz
Simply put, bariatric surgery promotes weight loss by restricting food intake.
Slide12EAL Study: Bariatric Surgery Average Weight Loss
8
Bariatric surgery
can
be expected to result in at least 50% excess weight loss.
Adjustable Gastric Banding (AGB):
50% mean EWL with a range of 32% to 70% EWL
Roux
-en-Y Gastric Bypass (RYGBP):
68% mean EWL with a range of 33% to 77% EWL
Biliopancreatic
Diversion (BPD):
79% mean EWL with a range of 62% to 75% EWL
Slide13Role of RD in Bariatric Surgery
3,9
Assessing the potential surgery candidate’s readiness for necessary lifestyle changes that will be required for success
Evaluation & Nutrition Therapy
“Surgery represents only one point in the continuum of care for the obese patient. The long term outcome of bariatric patients relies on their adherence to lifetime dietary and physical activity changes. A
comprehensive team approach
provides the best care to these patients and
RDs play an important and growing role in this process
. Because of the pre- and postoperative dietary issues,
RDs can assess, monitor and counsel patients in order to improve adherence and reduce the risk of nutrient deficiencies
.” –Doina Kulick, MD
Slide14Role of RD in Bariatric Surgery
3
Preoperatively
Educate
patients about permanent changes in how they must eat and drink:
Reduced volume of stomach
Potential for dehydration
Importance of chewing
Vomiting
Dumping Syndrome
Greater risk of nutrient deficiency & long-term consequences
Necessity of supplements for vitamins & minerals
Permanent changes in eating behavior
Postoperatively
Evaluate
intake of
protein & fluids
and recommend supplementation as needed
Monitor
use of
vitamin & mineral supplements
and encourage compliance
Monitor
side effects
Nausea & vomiting, constipation, hair loss, dumping syndrome
Formulate
nutrition diagnoses
&
interventions
as needed
Slide15Nutrition Assessment3
Bariatric Assessment and Pre-surgical Education Report
Comprehensive form, purpose is to lead RD through assessment & nutrition education, so that patient can make informed decision about surgery
Nutrition & Eating Habits Questionnaire
(NEHQ)
24 hours recall, weight and dieting history, questions about physical activity and other lifestyle habits, extensive food frequency questionnaire
Calculations
BMI
and Resting Energy Expenditure (
Mifflin-St. Jeor
)
Physical Activity
Paffenbarger Physical Activity Questionnaire
Slide16Nutrition Assessment: Areas of Special Attention
3
Patient’s dieting history
History of prescription medications for weight loss
Age at onset of obesity
History of
eating disorders
Mental health status
Pregnancy
Physical activity
Support system
Inform of supplements needed for remainder of life
Liquid protein, calcium, vitamin B-12, iron, and others
Nutrition Guidelines:
Liquid nutrition therapy while in hospital
Blended/pureed diet approx. 1 month
No drinking during meals or 30 minutes afterward
3 cups high protein liquid supplement (1 Tbl/15 min)
Sweets & high-fat food, carbonated drinks & straws are off limits
No alcohol
Soft meal plan (after 1 month)- tender meats, cooked veggies & fruit
Slide17Nutrition Diagnosis3
Review
signs and symptoms
from assessment
Diagnose nutrition problems based on signs and symptoms
Excessive oral intake
Inadequate oral intake
Inadequate protein intake
Inadequate vitamin intake (B12)
Inadequate mineral intake (iron)
Slide18Nutrition Intervention:
Pre-Surgery
3
Educate
patient about what to expect concerning food and fluids
The
patient may want to stock up on items allowed on the discharge eating plan
Encourage
patients to purchase and try other items they will need (pureed meats, canned tuna, cream of wheat, and cream soups
)
Encourage patients to test various high protein liquid supplements to find on they
like
Discuss the importance that physical activity will play in losing weight and maintaining weight loss
Give patient a list of behavior strategies for avoiding overeating
Discuss importance of vitamin and mineral supplements after surgery (liquid or chewable multivitamin, calcium tablets and mineral supplement)
Slide19Nutrition Intervention: During Hospitalization
3
Bariatric
Surgery Nutrition
Therapy-
clear liquid diet
Monitor nausea and vomiting
Reinforce no fluids with meals or for 30 min after meal
Monitor for dumping syndrome
Reinforce the discharge eating plan
Slide20Nutrition Intervention:
Post Surgery
3
Advance
eating plan to
blended/pureed
bariatric surgery nutrition therapy
Regularly assess weight loss
Patient bring 3-day food recordAssess nutritional adequacy of patients intake for protein and fluids
Ask patient if he or she is continuing to take
supplements
regularly (vitamin, mineral) Reinforce importance hydration, protein, stop eating when full, and lifestyle changes
Slide21Nutrition Intervention:
Post-Surgery
10
Patients
may
develop nutritional
deficiencies that require
multivitamin and
mineral supplementation.
The
degree
of nutritional
deficiency is related to the remaining absorptive area
and the
percentage of
post-surgical weight loss.
However
, eating
habits can
contribute to nutritional deficiencies
even following
restrictive
procedures
Slide22Nutrition prescription3
Goals after any gastric surgery:
Maximize
weight loss and absorption of nutrients
Maintain adequate hydration
Avoid vomiting and
dumping syndrome
Discharge nutrition therapies are essentially the same for all type of bariatric surgical procedures.
Except for frequency of meals
Slide23Adequacy of Nutrition therapy
3
Diet after gastric surgery may be inadequate because of
limiting size
of the stomach and consuming
smaller amounts
of
food
Nutrients Bariatric
Patients are
at risk
for
deficiencies:Protein
Calcium
Iron
Vitamin B12
Folate
Slide24Slide25Fluid Needs
3
Because stomach is so small, it is challenging to meet fluid needs
No liquids at meals (wait 30 min after)
Sip (no straw)
Goal is at least 6 cups fluid per day
3 cups high protein liquid supplement
3 cups sugar free, noncarbonated beverages including water and sugar free, noncarbonated soft drinks; decaffeinated coffee or tea
Stop eating and drinking when full (overeating cause stomach to stretch and leads to increased intake)
Avoid
carbonated beverages, as the gas bubbles with stretch the pouch
Slide26Nutrition monitoring and evaluation
3
Assessment:
24
hour food intake recall
Intake of water or other non-caloric beverages (what kind & how much)
Consumption of liquid protein supplement (what kind & how much)
Estimated total protein intake/day
Assess adequacy of supplement use (when & how much
)
Weight
Ask the
patient
about: consumption of food and liquids
More education needed?
Nutrition
Diagnosis using PES
statement
Plan
nutrition interventions (setting
goals)
Schedule
follow up appointment
Slide27ADIME of a Bariatric Patient
Assessment:
Diet history, Anthropometrics and Physical Activity
Diagnosis (PES):
Inadequate vitamin intake (B12) related to decreased absorption as evidenced by reports of adequate vitamin B12 sources in diet with low serum levels
Intervention:
Supplement oral intake of B12 with B12 injection given once per month
Monitoring and Evaluation:
Monitor intake of B12 and serum levels
Evaluate to see if serum levels are adequate, continue monitoring to ensure they remain stable. If serum levels are inadequate, look for new approach and/or consult physician
Slide28Research: Effectiveness of Bariatric Surgery
11,12,13
The Swedish Obese Subjects Study
11
Bariatric surgery resulted in long-term weight loss and improved lifestyle with increased physical activity
Risk factors present at baseline were much lower in surgically treated group, except for hypercholesterolemia
New England Journal of Medicine (2 studies)
After 7.1 years adjusted long-term mortality decreased by 40% in surgery group
12
Disease-specific mortality decrease: coronary artery disease-56%, diabetes-92%, cancer-60%
12
At 10 year follow up period control group maintained body weight within 2% range, whereas surgery patient losses ranged from 14-25%
13
Slide29Conclusion: NCP
Slide30Sources
National Institute of Health. Data from the National Health and Nutrition Examination Survey 2009-2010. Weight-Control Information Network.
http://www.win.niddk.nih.gov/statistics/
. Published October 2012. Accessed November 11, 2013.
National Institute of Health. Overweight and Obesity Statistics. Weight-Control Information Network.
http://www.win.niddk.nih.gov/statistics/
. Published October 2012. Accessed November 11, 2013.
Academy of Nutrition and Dietetics. Bariatric Surgery. Nutrition Care Manual
http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5545&lv2=16927&ncm_toc_id=16927&ncm_heading=Nutrition%20Care
. Published 2013. Accessed November 8, 2013.
Appecal
. Excess Weight Risk. Natural Appetite Management.
http://www.myappecal.com/excess-weight-risk.htm. Published 2011
. Accessed November 15, 2013.
National Institute of Health. Bariatric Surgery for Severe Obesity. Weight-Control Information Network.
http://win.niddk.nih.gov/publications/gastric.htm
. Updated June, 2011. Accessed November 11, 2013.
Donavan, M. Is the Environment the Main Cause of Obesity. How to Lose Belly Fat.
http://howtolosebellyfatsoon.com/about
. Accessed November, 16, 2013.
Slide31Sources
American Society of Metabolic and Bariatric Surgery. Learning Center. For Patients.
http://asmbs.org/learning-center. Updated 2013
. Accessed November 16, 2013.
Academy of Nutrition and Dietetics. Weight Loss Following Bariatric Surgery. Evidence Analysis
Library.
http://andevidencelibrary.com/conclusion.cfm?conclusion_statement_id
=251158&highlight=bariatric%20surgery&home=1
. Published 2013. Accessed November 12, 2013.
Academy of Nutrition and Dietetics. RD role Vital for Gastric Bypass Patients. Media Press Room.
http://www.eatright.org/Media/content.aspx?id=6442451904&terms=rd%20role%20vital#.Uo0se9KsiM4
. Published April 14, 2010. Accessed November 13, 2013.
Rickers
L, M. Bariatric Surgery: Nutritional Concerns for Patients.
Art and Science Nutrition.
2012; 41-47. Published 2012. Accessed November 14, 2013.
Sjostrom
L,
Lindroos
AK,
Peltonen
M,
Torgerson
J, Bouchard C, et al. Lifestyle, diabetes and cardiovascular risk factors 10 years after bariatric surgery.
New England Journal of Medicine.
2004;351(26):2683-2693.
Sjostrom
L, et al. Effects of bariatric surgery on mortality in Swedish obese subjects.
New England Journal of Medicine.
2007;357(8):741-752.
Adams T. D., et al. Long-term mortality after gastric bypass surgery.
New England Journal of Medicine.
2007;357(8):753-761.