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Kristen Huselid, Senior Seminar 2010

THE BATTLE OF THE BULGE. Bariatric Surgery: an effective treatment for combating obesity?. Kristen Huselid, Senior Seminar 2010. Objectives. Be able to describe the different types of bariatric surgery performed

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Kristen Huselid, Senior Seminar 2010

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  1. THE BATTLE OF THE BULGE Bariatric Surgery: an effective treatment for combating obesity? Kristen Huselid, Senior Seminar 2010

  2. Objectives Be able to describe the different types of bariatric surgery performed Identify recommended medical nutrition therapy for pre- and post-surgical patients Be able to explain several clinical and ethical challenges involved with bariatric surgery

  3. Obesity is a BIG problem • 1.7 billion Worldwide are overweight or obese • BMI of 25-29.9- Overweight • BMI of 30-34.9- Obesity Class I • BMI of 35-39.9- Obesity Class II • BMI of 40-49.9- Obesity Class III • The US has a higher percentage of overweight and obese people than any country in the world Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599. http://teamrich.files.wordpress.com/2008/10/obesity.jpg

  4. US Statistics • Roughly 2/3 of the US population is overweight • Of those, almost 50% are obese • 5 % of the US population, or 10 million Americans, have a BMI ≥40 • Subgroups growing the quickest are 35-40+ BMI • Estimated number of weight loss procedures in 2010 will exceed 220,000 Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  5. Obesity Trends* Among U.S. AdultsBRFSS,1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1990 1999 2009 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Behavior Risk Factor Surveillance Study, CDC

  6. Comorbid Conditions • Type II Diabetes • Hyperlipidemia • Hypertension • Obstructive Sleep Apnea • Heart Disease • Cancer • Non-alcoholic fatty liver disease • Osteoarthritis • Asthma • Depression http://www.ebooksreviewers.com/wp-content/uploads/2009/04/AdultObesity.jpg Kushner, R. F., & Neff, L. M. (2010). Bariatric surgery: A key role for registered dietitians. Journal of the American Dietetic Association, 110(4), 524-526.

  7. Impact of Obesity and Life Expectancy • American children may be the first in two centuries to have a shorter life span than their parents • The life-shortening impact of obesity could rise to 2-5 years or more, as obese children spend more years at risk for comorbid conditions Olshansky, SJ et al. A potential Decline in Life Expectancy in the United States in the 21st Century. NEJM, 352(11):1138- 1145, 2005.

  8. What is Bariatric Surgery? A brief history Surgeons at the University of Minnesota Mason Pories and MacDonald Wittgrove and Clark American Society for Bariatric and Metabolic Surgery (ASMBS) Maggard, M.A., Shugarman, L.R., & Suttorp, M. (2005). Meta-analysis: surgical treatment of obesity. American College of Physicians, 142(7):547-559.

  9. Types of Surgical Therapy • Purely Restrictive • Gastric balloons (NOT approved in the US) • Vertical banded gastroplasty • Laparoscopic adjustable gastric banding (LAGB) • Restrictive > Malabsorptive • Roux-en-Y gastric bypass (RYGB) • Malabsorptive > Restrictive • Biliopancreatic diversion w/ duodenal switch (BPD-DS) • Purely Malabsorptive • Jejunoilial bypass • Jejunocolonic bypass

  10. Vertical Banded Gastroplasty Purely restrictive Stomach divided vertically, band stapled around top portion of stomach Complications include esophageal reflux or re-operation Many surgeons have abandoned this approach http://weight-lost.us/images/WLSurgeryVerticalBandedGastrophy.jpg Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  11. Sleeve Gastrectomy Resection of the greater curvature of the stomach—resulting in a stomach remnant “sleeve” Often for “high risk” patients http://www.obesesurgery.com/VerticalSleeveGastrectomy.jpg Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  12. Laparoscopic Adjustable Gastric Banding Most commonly used restrictive procedure Drastically decrease the stomach’s capacity 15-30 mL gastric pouch Thought to be safer than conventional surgical treatments http://www.nationalgastricballooncentre.com/sitebuildercontent/sitebuilderpictures/adjustable-band.jpg Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  13. Roux-en-Y Gastric Bypass (RYGB) Mainly a restrictive procedure- small gastric pouch limits food intake; also malabsorptive due to small bowel reconfiguration Most common bariatric surgery performed in the US “gold standard” http://www.meltingmama.net/.a/6a00d8345190c169e20133ed0077a4970b-320pi Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  14. Biliopancreatic Bypass Procedure Subtotal gastronomy High incidence of gallstones Iron deficiency anemia, protein malnutrition, hypocalcemia and bone demineralization http://www.lifebridgehealth.org/images/bariatric/patientinfo2.jpg Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  15. Biliopancreatic Bypass with Duodenal Switch A “sleeve” gastrectomy is performed along the vertical axis of the stomach, decreasing the volume of the stomach and incidence of ulcers at the anastomosis Requires long-term medical follow-up and regular monitoring of fat-soluble vitamins, vitamin B12, iron, and calcium http://medicalimages.allrefer.com/large/biliopancreatic-diversion-with-duodenal-switch.jpg Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  16. Laparoscopic Surgery • Minimally invasive surgery • Surgeons use air to inflate the abdomen in order to view the stomach and intestines • Special staplers make the connections internally • Multiple small incisions made Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  17. Laparoscopic vs. Open RYGBP Laparoscopic RYGBP Open RYGBP http://www.asbs.org/html/patients/bypass.html http://www.asbs.org/html/patients/bypass.html Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  18. Laparoscopic vs. Open RYGBP Advantages of laparoscopic Disadvantages of laparoscopic • Less intra-operative blood loss • Shorter hospitalization • Reduced postoperative pain • Less pulmonary complications • Faster recovery • Fewer wound complications (incision hernias and infections) • Complex laparoscopic operation associated with a steep learning curve • Possible increase in the rate of internal hernia Brief history and summary of bariatric surgery. (2005, May 25). Retrieved from http://www.asbs.org/html/patients/bypass.html Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  19. Who Gets Bariatric Surgery? • Gender • 19 % Males • 73% Females • 8 % gender not reported • Age • Mean age 39 years • Range 16-64 years • BMI • Mean BMI 46.9 • Range 32.3-68.8

  20. Role of the RD • Patient understanding of weight management • Commitment to lifetime dietary and lifestyle changes • Team Work • Bariatric surgeon, obesity specialist, psychologist, primary care physician Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  21. Role of the RD • Comprehensive nutrition evaluation • Medical comorbidities, weight history, laboratory values, and nutritional intake • Readiness for change, realistic goal setting, general nutrition knowledge, as well as behavioral, cultural, psychosocial, and economic issues • Prepare patients’ kitchens with the needed appliances and appropriate foods • Provide counseling during the post-operative period and periodically thereafter Pories, W. (2008). Bariatric surgery: risks and rewards. Journal of Clinical Endocrinology & Metabolism, 93(11), 89-96.

  22. Assessment & Nutrition Education Components • Why the client is seeking surgery at this time • Why the client thinks success is possible • Work, social, cultural history affecting weight issues • History of patient’s weight and weight-loss strategies • Review of food groups and supplement use • Medications • Laboratory values • Education materials—what to expect • Nutrition Diagnostic Statements • Expected time, frequency, and duration of follow-up care Aills, L. (2008). ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surgery for Obesity and Related Disease, (4)73-108. Cunningham, E. (2006). What is the registered Dietitian’s role in the preoperative assessment of a client contemplating bariatric surgery? Journal of the American Dietetic Association, 106(1), 163-163.

  23. Medical Nutrition Therapy For the pre- and post-operative bariatric patient Aills, L. (2008). ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surgery for Obesity and Related Disease, (4)73-108. Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  24. Diet Purposes • Stomach healing • Be accustomed to smaller amounts of food • Lose weight and avoid gaining excess weight • Avoid side effects and complications Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  25. Restrictions • Pouch instead of a stomach • Size of an egg • Holds approximately ½ cup of food Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  26. Clear Liquids • First 2-4 meals • Immediately after surgery • Composed of clear, sugar-free liquids • Water, tea, broth • Sip fluids at the rate of ½ to 1 oz per 20 minutes Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  27. Pureed Foods • Progress to pureed foods low in fat and with no sugar • Mashed potatoes, unsweetened applesauce • A few tablespoons of food at a time Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  28. Home Diet- Part I • Approximately 3-4 weeks • Unsweetened applesauce, pureed canned peaches, mashed ripe bananas • Blenderized meat and poultry, soft poached eggs • Low fat cottage cheese, sugar-free puddings • Oatmeal, grits • Blended soft cooked vegetables Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  29. Home Diet- Part II • Gradually advance • Modified diet emphasizing: lean protein, fruits & vegetables, and whole grains • De-emphasizes fat and sugar Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  30. Basic Guidelines • Eat slowly- 20 to 30 minutes for each meal • Chew slowly and thoroughly • Avoid concentrated sugars and fats • Drink at least 6-8 cups of fluid per day • Eat small, nutrient-dense meals and high- protein snacks • Supplement schedules Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins.

  31. Problems and Complications Vitamin and mineral deficiency Dehydration Gallstones Bleeding stomach ulcer Hernia at the incision site Intolerance to certain foods Kidney stones Low blood sugar

  32. Dumping Syndrome • Food passes rapidly from the stomach into the small intestine • ingestion of concentrated sweets • Symptoms of nausea, faintness, fullness, cramping, weakness, sweating, rapid heart rate, and possibly diarrhea • Foods to avoid: ice cream, sweetened foods, foods in syrup, regular soft drinks, candy, and jams Escott-Stump S. (2008). 744-747. Nutrition and Diagnosis Related Care. Baltimore, Maryland: Lippincott-Williams & Wilkins. Nelms, M., Sucher, K., & Long, S. (2007) 364-366. Nutrition Therapy and Pathophysiology. Belmont, California: Thompson Higher Education.

  33. Supplement Rx • Standard adult or prenatal multivitamin/mineral supplement • 1 tablet twice daily, preferably chewable or liquid preparations • Calcium Citrate: 1,200 to 1,500 mg/day • Vitamin D-3: 1,000 to 2,000 IU/day • Vitamin B12: 500 µg/day orally • Or 1,000 µg/month intramuscularly • Folic Acid: 400 µg/day • Elemental Iron: 65-80 mg/day (preferably with Vitamin C) Aills, L. (2008). ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surgery for Obesity and Related Disease, (4)73-108. Kulick, D., Hark, L., & Deen, D. (2010). The bariatric surgery patient: A growing role for registered dietitians. Journal of the American Dietetic Association, 110(4), 593-599.

  34. Factors Thought to be Associated with Poor Weight Loss • Older age • Black race • Male sex • Married status • Greater initial BMI • Obesity-related diseases • Physical inactivity • Poor follow-up after surgery • Insurance status Campos, G. M., Rabl, C., Mulligan, K., Posselt, A., Rogers, S. J., Westphalen, A. C., et al. (2008). Factors associated with weight loss after gastric bypass. Archives of Surgery, 143(9), 877-884.

  35. Effect of Bariatric Surgery on Weight • Series of 608 patients followed up to 16 yr • Mean weight loss was 106 lb (48.2 kg.) decreasing from 317 to 211 lb (144.1 to 95.9 kg) • Buchwald • Excess weight loss: AGB, 47.5%; VBG, 68.2%; RYGB, 61.6%; and BPDS, 79.1%. • Maximum weight loss in approximately 2 years Pories, W. (2008). Bariatric surgery: risks and rewards. Journal of Clinical Endocrinology & Metabolism, 93(11), 89-96.

  36. Risk of Bariatric Surgery • Dimick reviewed mortality after common operations in U.S. hospitals • Aortic aneurysm, 3.9%; • Coronary artery bypass graft, 3.5%, esophagectomy, 9%; • Pancreatectomy, 8.3%. • Only hip replacement with its mortality of 0.3% was as safe as bariatric surgery Pories, W. (2008). Bariatric surgery: risks and rewards. Journal of Clinical Endocrinology & Metabolism, 93(11), 89-96.

  37. Controversial Issues • Rand CS, MacGregor AM. Adolescents having obesity surgery: A 6-year follow-up. South Med J. 1999; 87:1208-1213. • Long-term follow up (5-10 years) of 33 obese teenagers ages 12-17 • Mean of 63% loss of excess body fat, correction of obesity-related comorbidities, and improvement in self-image and socialization • Raised concerns: adhering to long-term highly-structured dietary regime, vitamin and mineral supplements, etc. Kirk, S., Scott, B. J., & Daniels, S. R. (2005). Pediatric obesity epidemic: Treatment options. Journal of the American Dietetic Association, 105(5, Supplement 1), 44-51.

  38. Reimbursement Issues • Acceptance of obesity as a disease • Defining the registered dietitian as the logical provider of MNT • Promoting a reimbursement rate that encourages quality provider services and the necessity of showing that MNT is effective Stern, J. S., Kazaks, A., & Downey, M. (2005). Future and implications of reimbursement for obesity treatment. Journal of the American Dietetic Association, 105(5, Supplement 1), 104-109.

  39. Conclusion • Bariatric surgery is an effective therapy for morbid obesity • Most common surgery: Roux-en-Y gastric bypass • Bariatric surgery provides significant • Loss of excess body weight • Relief from comorbidities • Diabetes, hypertension, hyperlipidemia, heart disease • Improvement in quality of life for patients • Potential Risks include: • Post-operative complications and mortality • Nutritional deficiencies and GI complications

  40. Questions?

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