1. BARIATRIC SURGERY EMILY SCHWICHTENBERG CONCORDIA COLLEGE MOORHEAD, MINNESOTA

2. 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

3. 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

4. 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 Unpublished manuscript.

5. 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.

6. 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#bbypasshttp://win.niddk.nih.gov/publications/gastric.htm#bbypass

7. 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.

8. 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-Y Laparoscopic Adjustable Band

9. 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.

10. 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

11. Medical Nutrition Therapy: Diet Change Daniel Smith, Leah Walters, Monica Foster, Judy Thompson, & Sandra Lorle. (2002). Surgical weight loss: Patient manual. Unpublished manuscript.  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

12. Supplementation 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.  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

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

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

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

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

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

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

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

20. 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

21. Lifestyle Change 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.  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

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

23. 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

24. 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

25. Questions?