Nutrition Guidelines for the Sleeve Gastrectomy Patient

Transcription

1 Nutrition Guidelines for the Sleeve Gastrectomy Patient April Laura Tomczik, RD, LDN Senior Bariatric Dietitian Center for Metabolic Health and Bariatric Surgery Brigham and Women s Hospital / Faulkner Hospital

2 Objectives After the webinar, participants will be able to: describe the anatomical and physiological function of the sleeve gastrectomy procedure explain nutrition guidelines for pre- and postoperative sleeve gastrectomy patients compare risk of micronutrient deficiencies in sleeve gastrectomy patients to gastric bypass and gastric banding patients understand the role of sleeve gastrectomy in patients with type II diabetes

3 Outline Introduction to Weight Loss Surgery Overview of Sleeve Gastrectomy Nutrition Guidelines Pre-op diet Diet stages Micronutrient recommendations Outcomes and Complications Weight loss and regain Gastroesophageal Reflux Disease (GERD) Hormonal changes Type II Diabetes

4 Why weight loss surgery (WLS)? Alarming rates of obesity in the U.S. Surgery is more effective than nonsurgical weight loss in appropriate obese patients WLS patients have better quality of life scores following surgery Colquitt 2009, Sjostrom 2004, Kolotkin 2012

5 Who qualifies for WLS? BMI 40 or BMI 35 with co-morbidities BMI 30 with co-morbidities for gastric banding Patients have failed non-surgical weight loss attempts NIH 2009

6 Who is having WLS? Pratt 2009

7 Common Surgical Procedures Adjustable Gastric Banding Roux-en-Y Gastric Bypass Sleeve Gastrectomy Heber 2010

8 History of Sleeve Gastrectomy (SG) 1988: Open SG first performed as part of duodenal switch (DS) 1997: Open SG first performed on its own (but not for weight loss) 1999: First laparoscopic SG and DS performed Jossart and Anthone 2010

9 History of SG 2001: DS becomes staged procedure for lower risk in high BMI patients Lack of an intestinal bypass Faster procedure More likely to be laparoscopic ~2005: SG performed as stand-alone procedure for weight loss Jossart and Anthone 2010

10 Who should have SG? Rosenthal 2011

11 The Procedure Braghetto 2007

12 The Procedure 2 Video Clips creating sleeve and pulling specimen out of abdomen Dr. Scott Shikora performing sleeve gastrectomy at Brigham and Women s Hospital

13 How does SG facilitate weight loss? Restrictive Hormonal Faster gastric emptying Akkary 2008, Lee 2011, Melissas 2007, Braghetto 2010

14 Nutrition Guidelines

15 Pre-op Very Low Calorie Diet (VLCD) Colles 2006

16 Reduction in liver volume Colles 2006

17 Surgical complications after VLCD Van Nieuwenhove 2011

18 Pre-op Diet Guidelines 6 weeks is ideal, but 2 weeks is commonly used Low carbohydrate, high protein May or may not include food Be cautious of lactose intolerance Avoid collagen-based proteins Colles 2006, Faria 2011

19 Post-operative Diet Goals Support healing after surgery and maintain lean muscle mass during rapid weight loss Minimize side effects (reflux, vomiting, diarrhea, etc.) while maximizing weight loss Aills 2008

20 Stage 1: Clear Liquids Clear liquids stage should not last for more than 48 hours Clear Liquids should have Very few calories No sugar No carbonation No caffeine? Lack of research Aills 2008

21 Swallow study Patients reach goal of 2 L faster; Mean hospital stay 2.5 vs. 3.4 days 5 seconds 39 seconds Goitein 2009

22 Stage 2: Protein Shakes Stage lasts ~10-14 days Goals: g protein, oz fluid Protein shakes Consider volume and quality of protein source Aills 2008, Snyder-Marlow 2010

23 Stage 3: Pureed Foods Stage lasts days Example foods include: Pureed chicken, turkey, or fish, tuna fish with light mayonnaise, peeled, pureed fruits and vegetables, pudding, oatmeal, yogurt Emphasis still on protein and fluids Aills 2008, Snyder-Marlow 2010

24 Stage 4: Soft Foods Stage lasts 14 days Example foods include: ground and chopped tender cuts of meats and meat alternatives, canned fruit, soft fresh fruit, canned vegetables, soft cooked vegetables, and grains, as tolerated Aills 2008, Snyder-Marlow 2010

25 Stage 5: Maintenance Diet Have lean protein with every meal Eat 5-6 times per day (planned! Not grazing) Balanced diet as tolerated Take small bites; chew food thoroughly Encourage patients to consistently follow up, even if everything is going well Sarwer 2011, Jacques 2011

26 Diet Progression at BWH / FH Stage 1: Clear Liquids 1 day Stage 2: Protein Shakes 2 weeks Stage 3: Soft Foods 3 weeks Stage 4: Solid Foods maintenance

27 Food Tolerance and Quality of Eating Schweiger 2010

28 Protein ASMBS recommends at least grams per day Other figures: g/kg IBW or 0.91 g/kg actual weight 30 g protein at every meal Protein maintains lean muscle mass Protein plays a significant role in satiety Aills 2008, Faria 2011, Heber 2010

29 Protein Sources Aim for the most protein with the least amount of calories Vegetarian patients may need additional counseling Food Serving Cal Pro (g) Cal/g Pro Chicken 3 oz Tofu ½ c Skim milk 8 oz Black beans ½ c Peanut butter 2 Tb

30 Carbohydrates DRI of 130 g carbohydrates / day Encourage whole grains, fruit, low-fat dairy and beans Avoid carbohydrate-only meals and snacks Kamani 2011

31 Micronutrient Research Very few studies on nutrition needs of SG patients Potential issues: Decreased HCl acid and intrinsic factor Decreased intake Nausea/vomiting

32 Jeejeebhoy 2002

33 Micronutrient Supplementation Snyder-Marlow 2010

34 Summary of nutrient deficiency studies Study MVI Vit D B12 Iron Measures Fol PTH (high) Goldenberg mo post-op MVI w/ Fe mg Ca Citrate 6/16 1/ /16 Toh yr post-op Hakeam yr post-op MVI - - 2/13 Hb - - MVI w/o Fe - 16/61 4/61 Fe 6/9 - Aarts yr post-op 150% RDA 1000/800 CaD 21/54 5/54 8/54 Fe 8/54 21/54 Kehagis yrs post-op MVI w/o iron 1000 mg Ca - 1/28 6/28 Hb 5/28 Fer 0/28 0/28 5/28 Fe

35 Comparing deficiencies among surgeries Strohmayer 2010

36 Deficiencies in SG vs. RNY over time SG RNY Gerher 2010

37 Conclusions on supplementation Conservative approach is warranted until we have more complete research Nutrients to monitor are: B12 Iron Calcium Copper Folate Zinc

38 Outcomes and Complications Weight Loss and Weight Regain GERD Hormonal Changes Type II Diabetes

39 Weight Loss and Weight Regain

40 Weight Loss Statistics Study Patients % EWL SG % EWL other Leyba yr post-op 60 RNY, 39 SG 78.8% 86% (RNY) Bobowicz yr post-op Ramalingam yr post-op Sabbagh yr post-op Kehagis yr post-op Gordejuela yr post-op Bohdjalian yr post-op Strain yr post-op 84 SG 43.6% 20 SG 49.6% 50 SG, 52 band 67.4% 58.5% (band) 30 SG, 30 RNY 73.2% 65.3% (RNY) 30 SG, 60 RNY 72.4% 72.3% (RNY) 26 SG 55% 23 SG 48%

41 Does sleeve size affect weight loss? Weiner 2007

42 Deitel 2011

43 Weight loss over time Hamoui 2006

44 Weight Regain Few long-term studies Examine diet Self-monitoring Continued patient-provider contact Physical activity Sarwer 2011

45 Group 1: <1 yr post-op Group 2: >1 yr post-op Kafri 2011

46 Evolution of eating behaviors Group 1: < 1 year post-op Group 2: > 1 year post-op Kafri 2011

47 Surgical techniques for weight regain Sleeve resizing Converting to RNY or DS Band over sleeve Langer 2010

48 GERD and SG

49 Anatomy of GERD

50 The GERD debate SG improves GERD Accelerated gastric emptying Decrease of abdominal pressure from weight loss Reduces acid production SG worsens GERD Antireflux mechanism can be compromised Decrease in lower esophageal sphincter pressure Proximally dilated sleeve and narrow midstomach Melissas 2007, Braghetto 2010, Santoro 2007, Carter 2011, Keidar 2010

51 GERD symptoms post-op Carter 2011

52 GERD symptoms post-op Howard 2011

53 Managing GERD Some patients may experience GERD symptoms after SG Be mindful of symptoms and treat with diet and/or medications as needed

54 Hormone Changes After SG

55 Ghrelin Produced in the fundus of the stomach Stimulates hunger Bohdjalian 2010

56 Acyl and des-acyl ghrelin Lee 2011

57 Leptin Produced in fat cells Represses food intake and promotes energy expenditure Time (weeks) Lee 2011, Woelnerhanssen 2011

58 Peptide YY (PYY) Produced in the intestine Represses food intake; delays gastric emptying & secretions Valderas 2010, Lee 2011

59 Glucagon-like Peptide 1 (GLP-1) Produced in intestine Stimulates insulin secretion, inhibits glucagon secretion, nutritive effects on B-cell

60 Adiponectin Produced in fat cells Increases insulin sensitivity Time (weeks) Woelnerhanssen 2011

61 Summary of hormonal changes Ghrelin and PYY Decrease in hunger and increase in satiety GLP-1 Stimulates insulin secretion Leptin Adipostat ; reflects total fat mass Adiponectin Increase in insulin sensitvity Valderas 2010 and 2011, Lee 2011, Woelnerhanssen 2011, Bohdjalian 2010, Akkary 2008

62 Type II Diabetes and SG

63 Type II Diabetes - terminology Remission vs. Resolution What is remission of type II diabetes? A return to normal measures of glucose metabolism HbA1C below 6% fasting glucose less than 100 mg/dl for duration of at least 1 year without hypoglycemic medication. Pournaras 2010

64 Remission vs. Resolution Pournaras 2010

65 Rizzello 2010

66 SG vs medical therapy: HbA1C Schauer 2012

67 SG vs medical therapy: Glucose Schauer 2012

68 SG vs medical therapy: Medications Schauer 2012

69 How does severity of diabetes affect remission? Casella 2011

70 How does severity of diabetes affect remission? Casella 2011

71 Theories of diabetes remission x The starvation-followed-by-weight-loss hypothesis B-cells rest; pts have lost weight by the time they increase intake The ghrelin hypothesis Decrease in ghrelin can improve glucose tolerance The lower intestinal hypothesis Food reaches lower intestine more quickly; increase in GLP-1 and PYY The upper intestinal hypothesis Food bypasses duodenum Thaler 2009

72 Conclusions on Diabetes Patients will have varying degrees of resolution of diabetes Patients should consistently meet with bariatric team as well as PCP/endocrinologist Patients need to understand that diabetes may return

73 Summary SG facilitates weight loss through restriction and hormonal changes SG patients are at risk for some micronutrient deficiencies Continued nutrition follow-up is important to maintain health and prevent weight regain Patients may experience GERD symptoms following SG SG can lead to significant improvement in diabetes

74 Questions?

75 References Aarts EO, Janssen IMC, and Berends FJ. The gastric sleeve: losing weight as fast as micronutrients? Obes Surg. 2011;21: Aills L, Blakenship J, Buffington C, et al. ASMBS Allied Health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008;S73 S108. Akkary E, Duffy A, and Bell R. Deciphering the sleeve: technique, indications, efficacy, and safety of sleeve gastrectomy. Obes Surg. 2008;18: Bariatric surgery for severe obesity. Bethesda MD: Weight control Information Network; NIH Publication No Bobowicz M, Lehmann A, Orlowski M, et al. Preliminary outcomes 1 year after laparoscopic sleeve gastrectomy based on Bariatric Analysis and Reporting Outcome System (BAROS). Obes Surg. 2011;21(12): Bohdjalian A, Langer FB, Shakeri Leidenmuhler S, et al. Sleeve gastrectomy as sole and definitive bariatric procedure: 5 year results for weight loss and ghrelin. Obes Surg. 2010;20: Braghetto I, Korn O, Valladares H et al. Laparoscopic sleeve gastrectomy: surgical technique, indications and clinical results. Obes Surg. 2007;17: Braghetto I, Lanzarini E, Korn O, et al. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg. 2010;20: Carter PR, LeBlanc KA, Hausmann MG, et al. Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: Casella G, Abbatini F, Cali B, et al. Ten year duration of type 2 diabetes as prognostic factor for remission after sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: Colles SL, Dixon JB, Marks P, et al. Preoperative weight loss with a very low energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am J Clin Nutr. 2006;84: Colquitt JI, Picot J, Loveman E, and Clegg AJ. Surgery for Obesity. Cochrane Database Syst Rev. 2009;2: CD Deitel M, Gagner M, Erickson AL, and Crosby RD. Third international summit: current status of sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: Faria SL, Faria OP, Buffington C, et al. Dietary protein intake and bariatric surgery patients: a review. Obes Surg. 2011;21: Gerher S, Kern B, Peters T, et al. Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux Y gastric bypass (LRYGB) a prospective study. Obes Surg. 2010;20: Goitein D, Goitein O, Feigin A, et al. Sleeve gastrectomy: radiologic patterns after surgery. Surg Endosc. 2009;23: Goldenberg L, Pomp A, and Sherry J. Nutrition post sleeve gastrectomy. Surg Obes Relat Dis. 2006;2:P100. Abstract. Hakeam HA, O Regan PJ, and Salem AM. Impact of laparoscopic sleeve gastrectomy on iron indices: 1 year follow up. Obes Surg. 2009;19: Hamoui N, Anthone GJ, Kaufman HS, and Crookes PF. Sleeve gastrectomy in the high risk patient. Obes Surg. 2006;16: Heber D, Greenway FL, Kaplan LM, et al. Endocrine and nutritional management of the post bariatric surgery patient: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95:

76 References Howard DD, Caban AM, Cendan JC, and Ben David K. Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients. Surg Obes Relat Dis. 2011;7: Jacques J and Goldenberg L. Nutrition and the Sleeve Gastrectomy Patient: From Micronutrients to Dietary Patterns. Bariatric Times. 2011;8(6): Jeejeebhoy KN. Short bowel syndrome. A nutritional and medical approach. Can Med Assoc J. 2002;160(10): Jossart GH and Anthone G. The history of sleeve gastrectomy. Bariatric Times. 2010;2:9 10 Kafri N, Valfer R, Shiloni E, and Hazzan D. Health behavior, food tolerance, and satisfaction after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: Kamani MM, Apergis Schoute J, Adamantidis A, et al. Activations of central orexin/hypocretin neurons by dietary amino acids. Neuron. 2011;72: Kehagis I, Karamanakos SN, Argentou M, and Kalfarentzos. Randomized clinical trial of laparoscopic Roux en Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI <50kg/m2. Obes Surg. 2011;11: Keidar A, Appelbaum L, Schweiger C, et al. Dilated upper sleeve can be associated with sleeve postoperative gastroesophageal dysmotility and reflux. Obes Surg. 2010;20: Kolotkin RL, Davidson LE, Crosby RD, et al. Six year changes in health related quality of life in gastric bypass patients versus obese comparison groups. Surg Obes Relat Dis Langer FB, Shakeri Leidenmuhler S, Bohdjalian, et al. Strategies for weight regain after sleeve gastrectomy. Surg Laparosc Endosc Percutan Tech. 2010;20(3): Lee W, Chen C, Chong K, et al. Changes in postprandial gut hormones after metabolic surgery: a comparison of gastric bypass and sleeve gastrectomy. Surg Obes Relat Dis. 2011;7: Leyba JL, Aulestia SN, and Llopis SN. Laparoscopic Roux en Y gastric bypass versus laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study of 117 patients. Obes Surg. 2011;21: Melissas J, Koukouraki S, Askoxylakis J, et al. Sleeve gastrectomy: a restrictive procedure? Obes Surg. 2007;17: Pournaras DJ, Aasheim ET, Sovik TT, et al. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders. BJS. 2012;99: Pratt GM, Learn CA, Hughes GD, et al. Demographics and outcome at American Society for Metabolic and Bariatric Surgery Centers of Excellence. Surg Endosc. 2009;23: Ramalingam G and Anton CKS. Our 1 year experience in laparoscopic sleeve gastrectomy. Obes Surg 2011;21: Rizzello M, Abbatini F, Casella G, et al. Early postoperative insulin resistance changes after sleeve gastrectomy. Obes Surg. 2010;20:50 55.

77 References Rosenthal RJ. International Sleeve Gastrectomy Expert Panel consensus statement: best practice guidelines based on experienced of >12,000 cases. Surg Obes Relat Dis. 2012;8:8 19. Ruiz de Gordejuela AG, Gebelli JP, Garcia NV, et al. Is sleeve gastrectomy as effective as gastric bypass for remission of type 2 diabetes in morbidly obese patients? Surg Obes Relat Dis. 2011;7: Sabbagh C, Verhaeghe P, Dhahri A, et al. Two year results on morbidity, weight loss and quality of life of sleeve gastrectomy as first procedure, sleeve gastrectomy after failure of gastric banding and gastric banding. Obes Surg. 2010;20: Santoro S. Technical aspects in sleeve gastrectomy. Obes Surg. 2007;17: Sarwer DB, Dilks RJ, and West Smith L. Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. Sur Obes Relat Dis. 2011;7: Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery vs. intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012; Published online first at Schwieger C, Weiss R, and Keidar A. Effect of different bariatric operations on food tolerance and quality of eating. Obes Surg. 2010;20: Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351: Snyder Marlow G, Taylor D, and Lenhard J. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet Assoc. 2010;110: Strain GW, Saif T, Gagner M, et al. Cross sectional review of effects of laparoscopic sleeve gastrectomy at 1, 3, and 5 years. Surg Obes Relat Dis. 2011;7: Strohmayer E, Via MA, Yanagisawa R. Metabolic management following bariatric surgery. Mt Sinai J Med. 2010;77: Thaler JP and Cummings DE. Minireview: hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery. Endocrinology. 2009;150: Toh SY, Zarshenas N, Jorgensen J. Prevalence of nutrient deficiencies in bariatric patients. Nutrition. 2009;25: Valderas JP, Irribarra V, Boza C, et al. Medical and surgical treatments for obesity have opposite effects on peptide YY and appetite: a prospective study controlled for weight loss. J Clin Endocrinol Metab. 2010;95(3): Valderas JP, Irribarra V, Rubio L, et al. Effects of sleeve gastrectomy and medical treatment for obesity on glucagon like peptide 1 and glucose homeostasis in non diabetic subjects. Obes Surg. 2011;21: Van Nieuwenhove Y, Dambrauskas Z, Campillo Soto A, et al. Preoperative very low calorie diet and operative outcome after laparoscopic gastric bypass. Arch Surg. 2011;146(11):