A PROFESSIONAL RESEARCH PRESENTATION FOR THE CLINICAL NUTRITION DEPARTMENT @ PRMCE

BY JEN HEY, DIETETIC INTERN

Bariatric Weight Loss Surgery

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 vs Unbanded (2):

Conducted by Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán

Roux-en_Y gastric bypass surgery. Half had the banded procedure, half had the unbanded proceure

No significant difference exists in % weight loss between the two groups

Research Review

Weight loss surgery and Glycemic Control (3): Study conducted at Monash Univesity 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 fluidsNo 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 minimumNo raw vegetablesAvoid soft breadsChew food well and eat slowlyStop when fullAvoid 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

1. 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.

2. Arceo-Olaiz R, Nayví España-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. Surg Obes Relat Dis. 2008 Jan 26; [Epub ahead of print].

3. 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.

4. 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.

5. 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.

6. 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.

7. 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; Contemp Clin Trials. 2005 Oct; 26 (5): 534-551.

8. 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.

9. Academy of Nutrition & Dietetics, 2012. www.eatright.org

Thank you

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