Macronutrient and Energy Intake After Bariatric Surgery

Transcription

1 Macronutrient and Energy Intake After Bariatric Surgery What do we know today? Jacqueline Jacques, ND, FTOS Newport Beach, CA USA

2 Disclosure Jacqueline Jacques, ND, FTOS Thorne Research, Inc Salary Senior Medical Director Obesity and Metabolic Health

3 Bariatric Surgery Guidelines AACE/TOS/ASMBS rev 2013* ASMBS Allied Health 2008* Endocrine and Nutritional Management of the Post- Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline- 2010* Wt regain, eating behavior, gout, bone, DM, blood lipids, nutrition EU Guidelines 2011

4 Bariatric Surgery Guidelines Ontario (CA) Guidelines 2012 Proposed Guidelines for Adolescents Nutrition Committee for the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition ACOG Pregnancy Management Bulletin 2012* * = Available as free download on the internet

5 How Good Are They?

6 How Good Are They?

7 How Good Are They? Most of the recommendations related to nutrition are level 3 or 4 Grade C or D So still we have mostly professional agreement, low level research, case studies and theory We have a long way to go!

8 Calories How much do people really eat? How much should they eat?

9 Calories None of the current guidelines actually address how much people should eat after surgery Some research has looked at how much people do eat after surgery

10 10 Calories Early Postoperative Data Most will average kcal/day (Carrasco 2007) 0-6 or 12 months Later Postoperative Data (RNY): 12 months post-op RNY patients averaged 1091 calories/day (Coughlin, et al 1983) A later study had similar findings of 1014 calories/day (Scruggs, Cowan et al 1993) At 3 years post op patients averaged 1386 calories/day (Brolin 1987) At 8 years post-op 1,680 +/- 506 kcal/day (Kruseman 2010)

11 Energy Expenditure After RNY: The decrease in TEE is 790 +/-334 kcal/day The decrease in SEE is 563 +/-208 kcal/day Tamboli, et al. Obesity (2010) 18,

12 Energy Expenditure For each kg of FFM lost metabolic rate drops by about 18 kcal/day So if patients can retain more FFM relative to the amount of weight lost they will be able to have a more sustainable caloric intake to prevent weight regain

13 Calories Ultimately, best is probably to calculate needs based on the individual Numerous methods for doing so.that don t fit inside the scope of this presentation We need more data to best understand both what patient behavior is and how to give recommendations that support weight stability.

14 Protein Too much, Too little What s right?

15 Guidelines for Prevention A minimal protein intake of 60 g/d and up to 1.5 g/kg ideal body weight per day should be adequate; Higher amounts of protein intake up to 2.1 g/kg ideal body weight per day need to be assessed on an individualized basis Moize et al. recommended a daily protein consumption of 1.5 g/kg ideal weight Obes Surg.2003;13:21 8 Schinkel et al. recommended a daily protein consumption of 2.1 g/kg ideal weight (or 0.95 g/kg current weight). Obes Surg. 2006;16:24 30

16 Protein What s Right? Many people believe that the earlier guidelines recommend too little protein to help individuals optimize LBM and prevent loss of FFM after surgery Protective levels may be hard to achieve 40 to 60% of post-op RNY patients may not achieve 60g/day Moizé V, et al. Clinical Nutrition (2012)

17 Comparison of Different Recommendations for the Minimal Protein Intake after RNY Reference Minimum Protein After RNYGB ASMBS Guidelines [104] - während dem Gewichtsverlust g /d - lt. RDA, für gesunde Erwachsenen g./d - lt. anderen Therapieprogramme g /d....1,0-1,5 g /kg IBW /d AACE /TOS /ASMBS Guidelines [52] g /d E. Parkes [80] 60 bis 70 g /d A. M. Wolf [90] 60 g /d R. D. Bloomberg et al [100] g /d M. Zeiner [50] 40 g /d 2 J. Wardé-Kamer et al. [99] 0,8 g/kg IBW J. Wardé-Kamer et al. [99], V. Moize et al. [98] 1,5 g/kg IBW C. P. Bernert et al. [77] 0,8 g Protein /kg KG /d Source:Kreuter Martina, Eiweißmalnutrition nach RNYGB Operationen, 2009

18 Energy & Protein Intake after RYGB Patients of KA Rudolfstiftung 2009 Time after RYGB Weight loss Energy Intake Protein Intake 5 weeks postop. 12,98 kg ± kcal ± ,48 g ± 9,61 3 months postop. 22,07 kg ± 5, kcal ± ,43 g ± 7,48 6 months postop. 37,34 kg ± 6,3 621 kcal ± ,16 g ± 12,12 9 months postop. 45,66 kg ± 7, kcal ± ,95 g ± 12,92 Protein intake without protein supplements 24 patients Mean of 3 Days Source:Kreuter Martina, Eiweißmalnutrition nach RNYGB Operationen, 2009

19 Sleeve vs. Gastric Bypass Difference? Protein Intake, Body Composition, and Protein Status Following Bariatric Surgery, Andreu A et al, OBES SURG (2010) 20: patients RYGB and VSG NO difference in Daily Energy & Protein Intake 45% could not reach the 60g Protein per day 15g protein powder were supplemented

20 What Would Be Ideal? It would likely be ideal for people to consume protein at a level that would prevent excessive loss of FFM However.might be hard to achieve this This helps to preserve metabolism But also helps to protect later-life health and well-being Sarcopenia/sarcopenic obesity is a real and potential effect of excessive loss of FFM followed by weight regain

21 What Would Be Ideal? All methods of massive weight loss produce loss of FFM Around 20-25% of weight lost is expected to be FFM (nonsurgical) Losses over 25% are excessive and can be problematic

22 Percentage of FFM loss with various methods of weight loss Method Number of Study groups Mean of study groups 25% or greater loss of FFM < 25% FFM loss LCD 15 17% 2 13 LCD & EX 6 19% 1 5 LCD & Drugs 3 28% 1 2 VLCD 4 29% 3 2 VLCD & Ex 5 16% 1 4 BPD 15 30% 9 6 RYGB 4 30% 3 1 LAGB 15 17% 2 13 Chaston TB, & Dixon JB. Int J Obes (Lond). 2007;31:

23 Surgical studies: At risk % FFM loss BPD (15 study groups) Mean 30% (Median 26%) FFM loss RYGB (6 study groups) Mean 29.5% (Median 27%) FFM loss LAGB (15 study groups) Mean 17% (Median 17%) FFM loss 60% of studies >25% FFM loss 84% of studies >25% FFM loss 13% of studies >25% FFM loss With BPD there is greater % FFM lost with increasing weight loss

24 Studies on Protein Intake Moize et al. claimed that a daily intake of 1.5 g/kg ideal body weight of protein can prevent the loss of FFM and nitrogen in the urine in bariatric surgery patients. Obes Surg.2003;13:21 8. This group later showed that in both RNY and SG protein intake of >60 g/d or 1.1 g/kg IBW/d was associated with better LBM preservation in RNY and SG patients 58.3% and 46.0% could not achieve intake at 4- and 12 mos respectively Clinical Nutrition. 2012

25 Studies on Protein Intake Raftopoulos et al showed that a recommendation of >1g/kg/day (avg 96.8 g/day at 12 months) in RNY patients produced: Greater weight loss, greater %EWL Greater reductions in BMI and %BF Greater preservation of Lean Mass Higher mental and physical scores for QOL Higher serum albumen level and decreased circulating leptin levels

26 Protein Appears that to a point, more is likely better We clearly need more data It does appear that upwards of 60g/day would be better but can we get more accurate? We need to acknowledge that adherence is hard even if patients seem to benefit in multiple ways from higher intake

27 Carbohydrates The one we don t want to talk about

28 Carbohydrate Intake Recommendations? There are none In fact, it really seems that we only want to talk about protein and ignore the rest Just eat as few as possible! No recommendations, little guidance, virtually no data The message patients hear is: PROTEIN = GOOD; CARBOHYDRATE = BAD

29 Basics WHO recommends minimum 50g/day for basic brain activity US RDA and AND recommendations are 130g/day 50 to 100 g/day is preventive for ketosis (assuming you actually want to avoid it )

30 Data on Intake Coughlin et al found an average intake of 112 grams/day at 12 months Scruggs at al also found an average intake of 112 grams/day (44% of total calorie) at 12 months Brolin et al found an average intake of 173 grams/day (50% of total caloric intake) at 3 years

31 % Macronutrient Intake 6-12 mos

32 % Macronutrien t Intake >12 mos

33 Impact on Weight Loss? Faria et al studied the relationship between CHO intake and % EWL Bariatric Times. 2013;10(3):16 21.

34 Impact on Weight Loss Calorie intake: 1,475±546 kcal Protein Intake: 73.4±30.9g/day

35 Recommendations (Faria)

36 36 FAT??? We don t even talk about fat.

37 Moizé, Obesity Surgery 2010

38 Current Suggestions Calories: Calculated or around kcal/d Carbohydrate: 40-45% of calories Protein: Minimum of 60 grams per day but more as calories increase. Around 25-30% of total calories Fat??? (we didn t even talk about fat )- probably around 30% of calories, primarily coming form protein rich foods This is pretty close to a Zone type ( ) diet

39 Current Suggestions We really don t have adequate data to answer important questions about: Long-term health Preservation of FFM/BMR Sarcopenia Prevention of weight regain Variations by procedure, ethnicity, gender, etc

40 Thank you! If the doctors of today do not become the nutritionists of tomorrow, then the nutritionists of today will become the doctors of tomorrow. ~ Rockefeller Institute of Medicine research