ADA Pocket Guide to bariatric surgery

Transcription

1 ADA Pocket Guide to bariatric surgery WMDPG: wmdpg.org Bariatric Subunit Teleseminar March 4, 2009 Sue Cummings, MS, RD, LDN Chris Biesemeier, MS,RD,LDN,FADA

2 Objectives At the end of this session, participants will be able to: 1. Navigate the pocket guide to access relevant information 2. Describe each type of bariatric procedure and its impact on the weight regulatory system 3. Describe the important nutritional factors preearly and late post-surgery 4. Conduct and document patient interactions using the Nutrition Care Process

3 ADA Pocket Guide to Bariatric Surgery Weight Management DPG Editors: Christina K. Biesemeier, MS, RD, LDN, FADA, and Jennifer Garland, MPH, CDE, RD, CD Topics Weight loss surgery overview The Nutrition Care Process Co-morbidity issues Long-term care post surgery Sample PES statements throughout

4 Chapter 1 Types of Weight Loss Surgery Weight Loss Surgery Outcomes Pre-surgical Assessment

5 Types of Surgeries Restrictive Procedures By-Pass Procedures Malabsorptive procedures with some restriction

6 Restrictive Procedures Caloric restriction No alteration of food pathways No micromacro-nutrient malabsorption early satiety Vertical Banded Gastroplasty (VBG) Adjustable Gastric Band (LAGB)

7 Bypass Type Procedures Roux-en-Y Gastric Bypass Malaborptive: micronutrients does not alter Caloric absorption Some restriction Works primarily through neural and hormonal pathways

8 Sleeve Gastrectomy Mechanism Restriction Grehlin production decreased Neuro-hormonal pathways Long-term outcomes unknown 5 year data promising

9 Malabsorptive Procedures Macronutrient and Micronutrient malabsorption Biliopancreatic Diversion D/S High incidence of diarrhea and protein deficiency Fat soluble vitamin deficiency Night blindness Bone demineralization

10 Potential Mechanisms of Surgical Effects Gastric Band Sleeve Gastrex RYGB BPD Gastric Restriction ± Gastrectomy Altered gastric function Gastric exclusion Duodenal exclusion Accelerated nutrient delivery delivery Malabsorption

11 Chapter 1 Types of Weight Loss Surgery Weight Loss Surgery Outcomes

12 Surgery Outcomes: Meta-analysis RYGBP: % of patients with Resolved Condition Type 2 diabetes 84% 48% LAGB: % of patients with Resolved Condition Hyperlipedemia 93% 71% Hypertension 75% 38% Obstructive sleep apnea 95% 56%

13 Effectiveness of Obesity Treatments Swedish Obesity Subjects

14 Chapter 1 1. Types of Weight Loss Surgery 2. Weight Loss Surgery Outcomes 3. Presurgical Evaluation

15 The pre-operative evaluation Are there indications for surgery? Are there contraindications to surgery? Do the potential benefits outweigh the potential risks? How can we minimize the risks? Is there any intervention needed before surgery? Is the patient motivated and well-informed?

16 Risk will never be reduced to zero but make every attempt to do so through Careful and thorough evaluation Medical Psychological Additional support as needed: nutritional psychological Surgical Nutritional Preoperative preparation period Intense early post-operative care and late post-op follow-up

17 Medical Evaluation Identify and treat co-morbidities Determine need for further testing Assess need to adjust/change medications Assess medical risk/benefits of surgery Assess if there are contraindications

18 Contraindications to Surgery Extremely high operation risk End-stage lung disease Unstable cardiovascular disease Multiorgan failure Class C cirrhosis Gastric varices

19 Psychological Evaluation Assess psychiatric history and current psychological functioning Assess if patient has adequate support Evaluate maladaptive behaviors that contributed to the development of obesity and may contribute to a poor postoperative outcome (Wadden & Sarwer, 2006)

20 Psychiatric Conditions Believed to Contraindicate Bariatric Surgery Current drug use Active schizophrenia Severe Mental Retardation Current, heavy drinking Lack of knowledge Medical non-compliance Multiple suicide attempts Active bipolar disorder Bauchowitz et al (2005) Fabricatore et al (2006)

21 Nutrition Evaluation Obesity Evaluation: Evidence Analysis Library: ADA Weight Management Practice Guidelines Surgical Nutrition Evaluation: Determine nutritional factors that affect readiness for surgery Collect data needed to help patient prepare for surgery Identify nutrient deficits Set education goals pre-wls: communicated to the surgical team

22 Pre-Surgical Assessment Indications for Weight Loss Surgery BMI > 40 or BMI > 35 in association with major complications of obesity Failure of non-surgical approaches Well informed patient

23 Indications: BMI Body Mass Index Weight (kg) Height (m 2 ) Scale over 350 lbs Measuring Height Stadiometer

24 Indications: Well Informed Patient Types and comparison of surgical procedures Risks/complications Health benefits Weight loss expectations Required lifestyle changes Appendix F Sample Outline for Information Session

25 Nutrition Interventions and Outcomes Boxes in Chapters 3 6 Nutrition Diagnosis Possible Intervention Strategies Outcome Indicators Define the indicator Use to evaluate at next client appointment or contact; to evaluate our interventions Case Studies

26 Chapter 3: Nutrition Care for Presurgery Improvement of nutritional status Achievement of better control of nutritionrelated comorbidities Begin to develop healthy lifestyle and eating habits Develop an understanding of how surgery impacts physiology (hunger and fullness) but not the environment

27 Pre: Lifestyle and Behavior Changes Structure Reduce environmental cues Slow, mindful eating Nutritional quality Physical Activity Short walks 3 times a day Self-monitoring

28 Nutrition Assessment Duodenum Iron Calcium Vitamin A B Vitamins By-passed remnant: Gastric juice Pepsin/HCl Intrinsic Factor Altered micronutrient absorption

29 Nutritional Assessment Low iron/ferritin; high TIBC work-up if no known explanatory condition Vitamin D (25-OH-Vitamin D and PTH) if Vitamin D is low and PTH is high: pharmaceutical dose replacement: 50,000 units per week for 8 weeks (pre-op) borderline low: OTC replacement 400 or 800 units per day

30 Nutrition Assessment Vitamin B12 if low; replete at 250-1,000 mcg/day p.o Additional baseline screening Bone density, especially post-menopausal women Appendix E: Specific Recommendations for monitoring and repleting micronutrients

31 Biochemical Data AACE/TOS/ASMBS Guidelines AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, THE OBESITY SOCIETY, AND AMERICAN SOCIETY FOR METABOLIC & BARIATRIC SURGERY MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE PERIOPERATIVE NUTRITIONAL, METABOLIC, AND NONSURGICAL SUPPORT Bariatric Subunit, WMDPG:

32 LAGB: Pre-and Post-op Nutritional Status Nutritional status (Giusti, 2004) Pre-op LAGB: deficiencies in iron, vitamin B12 and vitamin D Post-op LAGB: except for folate, no significant deficiencies 12-months postop Adjustable Gastric Band (LAGB)

33 Pre-operative weight loss Is it necessary? Is it helpful? Potential (but unproven) benefits: Easier operation Decreased liver size Decreased intra-abdominal fat Reduced peri-operative complications In theory, can improve co-morbidities including insulin resistance, with subsequent improvement in LV function and pulmonary function No good data on actual effects on peri-operative complications Goals: 5-10% weight loss; surgeon specific

34 Chapter 4: Immediate post-op Prevent, identify and treat micronutrient deficiencies dehydration Diet Advancement

35 Diet Advancement Staged approach Progression as tolerated Large variation in tolerances Variation in program approaches to diet transition

36 Post-op Diet Stages Appendices B and C Stage One Clear Liquids no sugar, no carbonation, no caffeine Stage Two Full liquids, milk/soy-based protein Stage Three (progress in steps) Soft foods Stage Four Healthy, well-balanced

37 Early post-operative risks Dehydration Dizziness, nausea, fatigue Monitor hypertension medications Nausea or vomiting Most likely related to eating pattern Eating too fast; eating too much; not chewing Rule out: ketosis, stenosis, or pregnancy

38 Early post-operative risks Diarrhea Think lactose intolerance first, then infections, dumping, or post cholecystectomy Adjustment of pre-op medications Watch blood sugar if patient on diabetes meds Watch for dehydration with diuretics

39 Dumping Syndrome Caused by food (especially simple sugars) moving rapidly into the intestine. To compensate, the body draws excess water into the intestine. Symptoms of dumping syndrome may include: nausea, dizziness, weakness, feeling faint, rapid pulse and cold sweats; may or may not also cause cramping and diarrhea.

40 Dumping Syndrome Eating VERY slowly and keeping sugar <25 grams per serving in full liquids and foods may prevent dumping

41 Advancing the diet Transition takes months 3-5 meals/day, no more than 5 hours apart As hunger comes back, include a planned snack 3 meals; 1-2 planned, snacks per day Pay attention to hunger/satiety; mindful Plan ahead Build Success into your environment

42 Routine Nutrient Supplementation* Supplement Dosage Multivitamin Calcium Citrate Vitamin D Folic Acid Elemental iron Vitamin B daily 1,200-2,000 mg/d IU of D 400 mcg/d in multivitamin mg/d elemental mg/d menstruating females ug/d orally/sublingual or 1,000 mcg/mo intramuscularly *Patients with preoperative or post-operative biochemical deficiency states are treated beyond these recommendations

43 LAGB: Diet Eat 3 well balanced meals per day Planned snacks; avoid grazing Eat slowly, small bites, chew well (mindful eating) Do not drink with meals, or 30 minutes afterward Avoid liquid calories Expect hunger; do not compare with bypass patients

44 Chapter 5: 2 Months to 2 Years Over time, rate of weight loss slows down Improvement or complete resolution of comorbidities Key Nutrition Issues: Protein (60 g/day) Hair loss (first 6 months) telogen effluvim Adherence to vitamin / mineral supplementation Healthy Life Style Habits (diet/activity)

45 Chapter 5: 2 Months to 2 Years Key Nutrition Issues: Hunger increases over time after RYGBP Hunger stronger after LAGB Monitoring nutritional labs 2, 6 and 12 months post-rygbp Yearly thereafter

46 LAGB Adjustments ( fills ) Common Determinants of an LAGB Adjustment: Level of hunger before meals Level of satiety after meals Amount of weight loss or gain Plateaus Amount of food patient is able to eat at one sitting Vomiting

47 The Effective Zone of Adjustment Dysphagia Reflux - Cough Regurgitation Maladaptive eating Satiety Small meals satisfy Hungry Big meals Looking for food 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Fill too tight Goal of fill Need a fill 0% 1

48 Chapter 6: Long Term Key Nutrition Issues Weight Loss, Maintenance and Regain Prevention micronutrient deficiencies Continued assessment of eating patterns Band Adjustments Continued nutrition management of comorbidities

49 Weight Maintenance Program Support Reenforce healthy life style habits Cognitive Behavioral Therapy Physical Activity Assess for disordered eating patterns Assess alcohol intake Set expectations regarding weight regain

50 Long-Term Weight Loss for Gastric Bypass Percent Change in Excess Body Weight Mean BMI: 52 Follow-up >90% Nadir Wt. Loss: 65% EWL Mean Wt. Loss at 14 years: 49% EWL Time After Surgery (years)

51 RYGBP: Late post-operative risks Gallstones Nutritional deficiencies Appendix G Staple line disruption (non-divided stomach) Gastro-gastric fistula (divided stomach)

52 LAGB: Complications Appendix G Band Erosion Esophageal Dilatation Band Prolapse

53 Chapter 7: Adolescent Weight Loss Surgery >6 months of organized attempts at weight mgt determined by PCP Attained or nearly attained physiological maturity Very severe obesity (>40 with co-morbidities; >50 with less severe Demonstrated commitment Agree to avoid pregnancy for 1 year post Provide informed assent Demonstrate decision capacity Have supportive family environment

54 Chapter 8:Nutrition Support Critically ill patients Support when there is an inability to consume adequate oral food and/or beverages to meet nutritional requirements Type of support depends on setting Acute; long-term or home care Clinician must be aware of special needs Impaired ability to absorb nutrients Dehydration Protein-energy malnutrition

55 Chapter 9: Pregnancy Wait until stable weight, months Post-WLS Anemia, vitamin deficiency and metabolic derangements should be identified and deficiencies corrected prior to pregnancy