Weight Loss Surgery and Bariatric Nutrition. Jeanine Giordano, MS, RD, CDN

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1 Weight Loss urgery and Bariatric Nutrition Jeanine Giordano, M, RD, CDN

2 UA: Mean BMI trends (age standardized)

3 Prevalence of Obesity Among Adults United tates 68% Australia 59% Russia 54% United Kingdom 51% Brazil 36% Malaysia 27% China 15% Latin America <10%

4 75% of obese children become morbidly obese adults

5 Degrees of Obesity

6 BMI vs. mortality

7 Why consider urgery? Men with a BMI >40, ages 25-34, have a 12-fold increase in overall mortality Decrease in Quality of Life Management of obesity related co-morbidities! DM Obstructive sleep apnea HTN Fatty liver disease Degenerative joint disease

8 Medical Complications of Obesity: Diabetes Gallbladder Disease Heart Disease Depression troke Asthma High Blood Pressure Arthritis Many Cancers (esophagus, stomach, colon, liver, gallbladder, pancreas, kidney, prostate, breast, uterus, cervix, ovaries) leep Apnea High Cholesterol Heartburn

9 urgery for the treatment of clinically severe obesity is endorsed by: National Institutes of Health American Medical Association American Association of Family Practitioners National Heart, Lung and Blood Institute National Institute of Diabetes and Digestive and Kidney Diseases International Diabetes Federation American College of urgeons International Federation for urgery of the Obesity and Metabolic Disorders American ociety for Metabolic and Bariatric urgery American Heart Association

10 Types of Procedures

11 Why Weight Loss urgery Works Restriction of food intake Malapsorption in gastric bypass Metabolic changes GI hormones Brain response

12 GI Hormones Glucagon-Like Peptide (GLP-1) & Peptide YY (PYY) ecreted by the L-cells of the guy in response to energy intake Promotes satiety lows gastric emptying, promotes insulin release, inhibits glucagon and gastric acid secretion

13 GI Hormones Grehlin ecreted by the pituitary gland and stomach timulates appetite Increases GI motility and decreases insulin secretion Leptin ecreted by fat cells Acts on hypothalamus to decrease food intake and increase energy expenditure Concept of leptin resistance (?)

14 Roux-En-Y Gastric Bypass / Gastric leeve Increased Glucagon-Like Peptide Increased satiety Increased Peptide YY Increased satiety Decreased Ghrelin Decreased appetite Decreased Leptin Leptin more effective with less fat mass

15 Brain Response (Hedonic Response - Gut 2013) Method: Compared RYGB to BAND patients, as well as patients without surgery at the same BMI. Functional MRI- studied brain reward / cognitive systems ubjects viewed pictures of high calorie foods, low calorie foods and non food related objects. ubjects rated the appeal of each picture

16 Brain Response (Hedonic Response - Gut 2013) Results: In whole brain analysis, RYGB patients had less brain stimulation when viewing high calorie foods. These differences were not explicable by differences in hunger or psychological traits between the surgical groups, but anorexigenic plasma gut hormones (GLP-1 and PYY), plasma bile acids and symptoms of dumping syndrome were increased in RYGB patients. Conclusion: After RYGB surgery, hedonic response to food is markedly different. RYGB patients rated high calorie foods as less appealing and had healthier eating behavior than patients after BAND surgery

17 Post WL urgery Diet 2010 Dietary Guidelines for Weight Maintenance ~ g/kg BW or 20-25% of total calories 30% or less of dietary fat 45-50% CHO intake Avoid excessive sugars Avoid alcohol intake

18 Bariatric Plate

19 upport Weight gain tied to lack of follow up, lack of exercise and lack of accountability. Risk of regain diminished with regular post-op evaluation due to accountability and reinforcement of healthful dietary changes.

20 uccessful Habits Accountability: weigh 1-2 times per week Portion control Food journaling Meal planning Mindful eating: focus on not hungry vs full Adequate sleep: 6-8 hours/night * Exercise: minutes per week; including aerobic and strength training

21 Psychological stability Factors Associated with Weight Loss Maintenance (Obesity Review 2005) More initial weight loss Achieved self determined goal weight Maintained physically active lifestyle Consistent regular meal times elf monitoring behaviors/control of overeating ocial support Assuming responsibility for weight maintenance Better coping strategies and ability to handle stress

22 ummary: Diet Maintenance Healthy food choices: 25% protein; 30% fat; 45% healthy CHO Portion control: 1-1 ½ cups total / meal Proper hydration Meal planning: 3 meals/day, 1 planned snack Consistent vitamin/mineral intake Exercise: minutes / week upport group attendance Follow up with RD, MD, psychologist regularly

23 Long Term Weight Loss: Gastric leeve A recent study published by American ociety for Metabolic and Bariatric urgery (eiber, P et al, 2013) showed positive long term outcome for the sleeve. Population: 68 Patients s/p LG between August 2004 and December 2007 Results: Average excessive BMI loss: 61.5%±23.4% after 1 year BMI loss of 61.1%±23.4% after 2 years BMI loss of 57.4%±24.7% after 5 years.

24 Long Term Weight Loss: Lap Band A recent study published by the Annals of urgery (O Brien PE et al, 2013) showed similar long term outcomes for the lap band procedure. Population: a total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, s/p laparoscopic adjustable gastric band placement between eptember 1994 and December Results: There was 47.1% of excess weight loss (% EWL) at 15 years [95% confidence interval = 8.3).

25 Long Term Weight Loss: Roux-En-Y Gastric Bypass The Annals of urgery published Weight Gain After hort- and Long- Limb Gastric Bypass in Patients Followed for Longer Than 10 Years in Population: 228 of patients at a mean of 11.4 years (range, years) after surgery. Results: 0

26 Conclusion

27 Questions?

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