Bariatric Surgery Emily Schwichtenberg Concordia College Moorhead, Minnesota

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Bariatric SurgeryEmily SchwichtenbergConcordia
CollegeMoorhead, Minnesota
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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

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Obesity as an Epidemic
Statistics

• 66.3 of United States adults are overweight
• 32.2 are obese with a BMI gt30 kg/m²
• 4.8 are morbidly obese with a BMI gt40 kg/m²
• From 1986-2000 BMI gt30 kg/m² doubled in the
  United States
• BMI of gt40 kg/m² quadrupled
• BMI of gt50 kg/m² increased fivefold

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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

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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

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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

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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

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The Common Procedures

• Roux-en-Y

• Laparoscopic Adjustable Band

• 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 gt 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 lt50
• Less vigorous vitamin and mineral supplementation
• Faster recovery and return to work

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

• 627- control subjects
• 156- laparoscopic adjustable banding subjects
• 451- vertical banded gastroplasty subjects
• 34 Roux-en-Y gastric bypass subjects

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Requirements for Surgery

• BMI gt40 kg/m² or BMI gt30 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Questions?