1. Bariatric Surgery and Nutrition
By: Shala Davidson and Abby Stanley

2. Obesity 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
According to Data from the NHANES,
Overweight: refers to excess amount of body weight, may come from muscles, bone, fat and water
Obesity: refers to an excess amount of body fat

3. Obesity in America1
Pie graph purple is normal weight/underweight and doesn’t make up very much of the graph.
Darker green is obese individuals and grey is Extreme obesity and as I’ll touch on this is the population our presentation is concerned with
The bar graph just shows how overweight, obese and extreme obesity is distributed between sex, women tend to be more extremely obese than men

4. Health Risks of Overweight and Obesity2,3,4
7. Non alcoholic fatty liver disease- excess fat and inflammation in the liver
Extremely Obese individuals may also suffer from social stigmatization and discrimination (eatright.org)

5. Causes and Treatment of Obesity2
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

6. Who 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?
Recent development: FDA has approved use of adjustable gastric band for patient with BMI > 30, who also have at least one condition linked to obesity

7. Who is a good candidate?6
Plus health conditions

8. What 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
Definition of gastric is “of the stomach”. However, bariatric and metabolic procedures involve more of the anatomy than the stomach.
Rate of death within 30 days of bariatric surgery is considerable lower than most operations.

9. What 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.
Laparoscopic surgery also referred to as minimally invasive surgery
Bariatric operations can lead to deficiencies in vitamins and minerals by reducing nutrient intake or by causing reduced absorption from the intestine. They vary in the extent of malabsorption and in which nutrients may be affected. Nutrient deficiencies are preventable with patient monitoring and patient compliance in following supplement recommendations.

10. Types 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
Restrictive- simply restrict the amount of food the patient can take in, therefore resulting in weight loss
Restrictive & malabsorptive- restrict food intake, but also decrease the absorption of food, both results in weight loss, but also in vitamin and mineral deficiencies
AGB- surgeon created small pouch by placing hollow ban around the stomach near its upper end. The band is inflated by injecting a salt solution, the band can be adjusted by adding or removing the solution
VSG- relatively new and mostly performed on the super obese (BMI>50), removes approximately 60% of stomach, after some weight loss it is followed by RYGB or BPD
RYGB- stomach is left alone, but cut off, and a new pouch is created; The Y shaped section of the small intestine that is attached to the pouch allows food to by pass the lower stomach, the duodenum, and the first portion of the jejunum, the body absorbs less energy and other nutrients
BPD- Most complex, but also most effective regarding permanent weight loss; remove large part of stomach, re-route food away from much of small intestines

11. What 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.
**include demonstration here

12. EAL Study: Bariatric Surgery Average Weight Loss8
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
***ADD Notes

13. Role of RD in Bariatric Surgery3,9
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
Acccording to Doina Kulic an MD quoted in a press release put out by AND…

14. Role of RD in Bariatric Surgery3
Preoperatively
Postoperatively
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
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
Importance of chewing thoroughly- because stomach can not aid as much as previous in digestion process
Vomiting- often a consequence of inadequate chewing or overfilling stomach pouch)
Dumping Syndrome- often consequence of consuming concentrated sweets
Long term consequences- bone disease

15. Nutrition 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
Physical Activity- assesses habitual daily and weekly activity; also need to ask about exercise preferences in order to develop physical activity goals for post surgery

16. Nutrition Assessment: Areas of Special Attention3
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

17. Nutrition 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)
Signs & Symptoms
Examples of what a patient that had bariatric surgery might be diagnosed with post-surgery

18. Nutrition Intervention: Pre-Surgery3
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)
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)
Interventions to be reviewed with patient before surgery in order for the to be nutritionally prepared

19. Nutrition Intervention: During Hospitalization3
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
Nutrition intervention while patient is in hospital

20. Nutrition Intervention: Post Surgery3
Advance eating plan to blended/pureed bariatric surgery nutrition therapy
Regularly assess weight loss
Patient bring 3-day food record
Assess 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
Nutrition Intervention that must be done post-surgery in order for it to be successful
**Pass around the Blended/Purees example and the soft foods.

21. Nutrition Intervention: Post-Surgery10
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
Why there are deficiencies in post-surgery bariatric patients
-Absorptive areas
-Percentage of weight loss
-Eating habits

22. Nutrition 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
Used as goals after surgery
Helps patient to live a healthy life after surgery
Helps avoid possible nutrition complications after surgery

23. Adequacy of Nutrition therapy3
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
Nutrients that are at risk for deficiencies
A chart showing nutritional deficiencies based on the type of bariatric surgery that is completed in an individual

24. This chart just shows the different nutritional deficiencies that post surgery patients may be at risk for. As you can see the Malabsorptive surgeries are at a higher risk for deficiency

25. Fluid Needs3
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
Fluid needs of a bariatric patient
Extreme small stomach makes it hard for one to consume amount of liquid that is recommended
Not suppose to drink with meals  too much at once
Sip to slow down intake of liquids
Goal  6 cups a day
Stop when full  if not one may overeat
No carbonated beverages cuz of bubble  it will lead to stretching of the stomach and start to undo the surgery

26. Nutrition monitoring and evaluation3
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
ADIME nutrition care plan
What to look for

27. ADIME 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
PES: meaning patient is taking in adequate amounts but blood levels are showing low in vit B12….due to absorption problems
M&E: measure B12 and serum levels to see if the vitamin is be more readily absorbed

28. Research: Effectiveness of Bariatric Surgery11,12,13
The Swedish Obese Subjects Study11
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 group12
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
The Swedish- compared obese subjects who underwent gastric surgery to those that were treated conventionally
Risk factors-such as hypertriglyceridemia, diabetes, etc.
New England Journal of Medicine- 2 studies of middle aged people, mostly women, with BMI 40 who showed reduced motility after surgery
Adams et al bariatric surgical patients matched with 7925 severely obese individuals (age, sex, bmi)
Sjortrom et all 2007-compared 2010 bariatric surgery patients with 2,037 matched controls

29. Conclusion: NCP
In conclusion, this just shows the cycle of the nutrtion care process. It is important to bariatric surgery because for many patients this is a life long commitment and they will need help following the specified dietary guidelines for most of their lives.

30. Sources
National Institute of Health. Data from the National Health and Nutrition Examination Survey Weight-Control Information Network. Published October Accessed November 11, 2013.
National Institute of Health. Overweight and Obesity Statistics. Weight-Control Information Network. Published October Accessed November 11, 2013.
Academy of Nutrition and Dietetics. Bariatric Surgery. Nutrition Care Manual 27&ncm_heading=Nutrition%20Care. Published Accessed November 8, 2013.
Appecal. Excess Weight Risk. Natural Appetite Management. weight-risk.htm. Published Accessed November 15, 2013.
National Institute of Health. Bariatric Surgery for Severe Obesity. Weight-Control Information Network. Updated June, Accessed November 11, 2013.
Donavan, M. Is the Environment the Main Cause of Obesity. How to Lose Belly Fat. Accessed November, 16, 2013.

31. Sources
American Society of Metabolic and Bariatric Surgery. Learning Center. For Patients. center. Updated Accessed November 16, 2013.
Academy of Nutrition and Dietetics. Weight Loss Following Bariatric Surgery. Evidence Analysis Library. 0surgery&home=1. Published Accessed November 12, 2013.
Academy of Nutrition and Dietetics. RD role Vital for Gastric Bypass Patients. Media Press Room. Published April 14, Accessed November 13, 2013.
Rickers L, M. Bariatric Surgery: Nutritional Concerns for Patients. Art and Science Nutrition. 2012; Published 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):
Sjostrom L, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine. 2007;357(8):
Adams T. D., et al. Long-term mortality after gastric bypass surgery. New England Journal of Medicine ;357(8):