BARIATRIC SURGERY EMILY SCHWICHTENBERG CONCORDIA COLLEGE MOORHEAD, MINNESOTA

BARIATRIC SURGERY

EMILY SCHWICHTENBERG

CONCORDIA COLLEGEMOORHEAD, MINNESOTA

Objectives

To explain different bariatric procedures Discuss requirements for surgery Explain post-op medical nutrition

therapy Discuss proper and important lifestyle

changes Discuss ethical issues

Obesity

as an Epidemic

Schernthaner, G., & Morton J.M. (2008). Bariatric surgery in patients with morbid obesity and type 2 diabetes. Diabetes Journal, 31, 297-302.

66.3% of United States adults are overweight

32.2% are obese with a BMI >30 kg/m²

4.8% are morbidly obese with a BMI >40 kg/m²

From 1986-2000 BMI >30 kg/m² doubled in the United States

BMI of >40 kg/m² quadrupled BMI of >50 kg/m² increased fivefold

Statistics

Roux-en-Y

Most common procedure Upper portion of stomach

is stapled and separated Small intestine is cut and

attached to the small pouch

Small intestine is reconnected with rest of intestine

New stomach is about the size of your thumb

Daniel Smith, Leah Walters, Monica Foster, Judy Thompson, & Sandra Lorle. (2002). Surgical weight loss: Patient manual. Unpublished manuscript.

Laparoscopic-Band

A ring or a band is placed around the upper portion of the stomach

Small opening at the bottom of the pouch to allow food to pass slowly into the rest of the stomach

Port underneath abdomen that controls the tension on the band

Nelms, M, Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont, CA: Thomson Higher Education.

Biliopancreatic Diversion/ Duodenal Switch

Not used due to malabsorption issues

Lower portion of stomach is removed

Directly connected to the lower part of the small intestine

Duodenum is completely bypassed

High mortality rate and increased long term conditions

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, & National Institutes of Health. (March, 2008). Bariatric surgery for severe obesity. Retrieved September 29, 2008, from http://win.niddk.nih.gov/publications/gastric.htm#bbypass

Vertical Banded Gastroplasty

Small vertical pouch surgically created at top of stomach

Line of staples through both walls

Band controls volume of pouch

Prevents stretching Restricts amount of

food patient can eat

Nelms, M, Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology. Belmont, CA: Thomson Higher Education.

The Common Procedures

Invasive but considered the gold standard

Fast weight loss averaging 70-80% with in 2 years

Fast resolution of co-morbidity conditions ( esp. type-II diabetes)

Best for patients with BMI > 50 Best for patients with severe

co-morbidity conditions Vigorous vitamin and mineral

supplementation

New technology- simpler procedure

Slow, yet steady, weight loss averaging 50% from 2-5 years

Slower resolution of co-morbidity conditions

Best for younger patients with BMI <50

Less vigorous vitamin and mineral supplementation

Faster recovery and return to work

Leah Walters, Mari Willie. Pre-surgical bariatric patient class. Unpublished manuscript.

Roux-en-YLaparoscopic Adjustable

Band

627- control subjects

156- laparoscopic adjustable banding subjects

451- vertical banded gastroplasty subjects

34 – Roux-en-Y gastric bypass subjects

Weight Changes among subjects participating in the Swedish Obese Subjects study over a 10-year period.

Meena Shah, Vinaya Simha, & Abdhimanyu Garg. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231.

Requirements for Surgery

Schernthaner, G., & Morton J.M. (2008). Bariatric surgery in patients with morbid obesity and type 2 diabetes. Diabetes Journal, 31, 297-302.

BMI >40 kg/m² or BMI >30 kg/m² and suffer with co-morbidities

Weigh over twice your ideal body weight Understanding that surgery is a tool not

a cure and the change will come with overall lifestyle change

Most facilities and insurance agencies have other requirements that one must meet before the procedure

Medical Nutrition Therapy: Diet Change


2-3 weeks post-op clear liquid diet and progress to full liquid diet

3-4 weeks post-op semisolid or soft foods 4 ounces at a time Every 3-4 hours

4-5 weeks post-op try solid foods one at a time Must eat slowly at least 20-30 minutes per meal Must chew until food is a liquid consistency in mouth Must drink at least 64 ounces of liquid through the day

Do not drink 20 minutes before meal Do not drink 20 minutes after meal Do not drink during meal

Vitamin, mineral and protein supplementation

Supplementation


With the limited diet patients will not get RDA for certain vitamins and minerals Vitamin B12, Iron, Folate, Calcium, Vitamin

D, Vitamin A Adequate protein intake is crucial for

healing post-op Can be taken in a multi-vitamin or

separate daily Make sure all supplements are chewable Must have correct dosage in multi-vitamin

Supplementation: B12 300-500µg/d Sublingual form (under the

tongue) Deficiency seen in 64% of

Roux-en-Y patients (Shah et al, 2006).

Important for protection of the nerve cells. Needed for cell synthesis and helps break down some fatty acids and proteins

Deficiency causes anemia, fatigue, degeneration of peripheral nervesMeena Shah, Vinaya Simha, & Abdhimanyu Garg. (2006). REVIEW: Long-term impact of bariatric surgery on body weight,

co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231. Whitney E, & Rolfes S. R. (2005). In Elizabeth Howe (Ed.), Understanding nutrition (10th ed.). Belmont, CA: Thomson

Wadsworth

Supplementation: Iron

Deficiency seen in 52% of Roux-en-Y patients (Shah et al, 2006)

Take with vitamin C to increase absorption

320 mg daily Prevents anemia Iron carries oxygen to

cells importantly muscle cells

Deficiency causes anemia


Whitney E, & Rolfes S. R. (2005). In Elizabeth Howe (Ed.), Understanding nutrition (10th ed.). Belmont, CA: Thomson Wadsworth

Supplementation: Folate

Deficiency seen in 34% of Roux-en-Y patients (Shah et al, 2006)

400-1000 µg/d daily intake

Increased rate of neural defects in children born to Roux-en-Y mothers

Helps with protein synthesis

Deficiency causes anemia, weakness, confusion Meena Shah, Vinaya Simha, & Abdhimanyu Garg. (2006). REVIEW: Long-term impact of bariatric surgery on body weight, co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231.


Supplementation: Calcium Deficiency seen in 10% of

surgical patients Recommended intake 1200-

1500 mg/d Take twice daily 500-600 mg/d

due to absorption rate Deficiency is not always

apparent at first because of calcium releasing from the bone

calcium citrate supplement more effective than calcium carbonate

Deficiency is seen as stunted growth in children and osteoporosis in adults



Supplementation: Vitamin D

Deficiency seen in 51% of patients

Recommended supplementation is 400 IU/d

Recommended to take separate than iron supplement due to absorption

Important for bone health Deficiency is seen as

rickets in children and osteomalacia in adults



Supplementation: Vitamin A 10% of Roux-en-Y patients

adapt vitamin A deficiencies It is recommended to have

supplementation as needed based on physician monitoring

Deficiency is due to some fat malabsorption

Important for sight and skin health

Deficiencies include: decreased immune function, blindness, night blindness, and some skin conditionsMeena Shah, Vinaya Simha, & Abdhimanyu Garg. (2006). REVIEW: Long-term impact of bariatric surgery on body weight,

co-morbidities, and nutritional status. The Journal of Clinical Endocrinology & Metabolism, 11(91), 4223-4231. Whitney E, & Rolfes S. R. (2005). In Elizabeth Howe (Ed.), Understanding nutrition (10th ed.). Belmont, CA: Thomson

Wadsworth

Supplementation: Protein

Protein is important post-op to help heal the surgical wound

Recommended 65 grams per day

Supplementation should be 200 calories with 15 grams of protein

High Protein Foods Fish Lean cuts of beef or

pork Skinless chicken or

turkey Dry beans/legumes Egg whites Non-fat or low-fat milk

and milk products Nuts and peanut

butter


Nutrition Care Process

Assessment Age, weight and

height BMI, and IBW Nutrient intake

Diagnosis Co-morbidities Obesity

Intervention Weight loss

program Bariatric surgery

Vitamin regimens Exercise regimens

Monitor Follow-up

appointments Vitamin regimens Exercise regimens

Lifestyle Change


Exercise 30-6o minutes 3-5 days a week

Weight loss changed from 70% baseline to 90% baseline with exercise (Shah et al, 2006).

Strength training 2-3 times per week Positive attitude

Surround yourself with a positive social support group

Easier to manage stress

Ethical Issue: Overall Cost


Approximately $30,000-$50,000 for the surgery alone Can vary depending on health care facility

Approximately $100 monthly for vitamin supplements Can vary on brand and purchase company

$250-$300 for protein supplements Dependent on brand

Ethical Issue: Insurance Coverage

Insurance will cover surgery Insurance will not cover preventative care

Dietetic counseling before obesity gets out of control

Personal training sessions Insurance will not cover vitamin

supplementation This is a huge cost post-op Due to surgery supplementation is crucial

Ethical Issue: Surgical Requirements

The strict requirements may lead patients to gain weight before applying for insurance

Some facilities require weight loss before surgery Insures seriousness of patient Provides positive feedback for patient

Learn new lifestyle If gaining weight to meet BMI requirements

patient is not learning the new lifestyle Find a workout routine that works for them

Questions?

Documents

BARIATRIC SURGERY EMILY SCHWICHTENBERG CONCORDIA COLLEGE MOORHEAD, MINNESOTA