Bariatric Patients, Nutritional Intervention for

Transcription

1 SKILL COMPETENCY CHECKLIST Bariatric Patients, Nutritional Intervention for Link to Dietitian Practice and Skill Standard Met/Initials Prerequisite Skills Competency Areas Knowledge of how to conduct a nutrition assessment for morbidly obese patients preparing to undergo bariatric surgery Comprehensive nutritional screening and assessment is required for all bariatric surgery patients Understanding of nutritional deficiencies associated with morbidly obese patients Although bariatric patients are morbidly obese, research demonstrates that these patients are often in a state of malnutrition despite their high caloric intake due to factors such as low-nutrient dense foods, repeated dieting, and medication side effects Biochemical markers may demonstrate that patients are low in micronutrients such as vitamin D, folate, selenium, and folate Understanding of common bariatric surgical procedures RYGB, AGB, and GS Knowledge of post-operative care and management of complications associated with bariatric surgery Understanding of weight management strategies and behavior change modification approaches in health Published by Cinahl Information Systems, a division of EBSCO Information Services Copyright 2015, Cinahl Information Systems All rights reserved No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text It is merely intended as a general informational overview of the subject for the healthcare professional Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

2 Procedure Preoperative assessment Anthropometric Height, weight, body mass index (BMI), waist circumference Biochemical (may include) Electrolyte and renal tests -Sodium, potassium, chloride, magnesium, phosphorus, parathyroid hormone, creatinine, urea, serum calcium, glomerular filtration rate, and blood urea nitrogen Endocrine tests -Serum glucose (fasting, random, 2 hour post-prandial), hemoglobin A1C, glucose tolerance test, thyroid function tests, testosterone Gastrointestinal tests -Alkaline phosphatase, AST, ALT, GGT, bilirubin, amylase Lipid profile -Total cholesterol, triglycerides, low density lipoproteins, high density lipoproteins (HDL), ration of total cholesterol to HDL Nutritional anemia tests -Complete blood count with differential, serum iron, ferritin, total iron binding capacity, serum red blood cell, folate or plasma homocysteine, vitamin B12, PTT, INR Protein tests -Albumin, pre-albumin, total serum protein, transferring Urinalysis -Color, osmolality, USG, volume, ketones, glucose, protein Vitamin and minerals -Specific nutrient markers for monitoring are dependent on surgery and institution protocol Nutrient markers may include: Iron, vitamin B12, Folic acid, vitamin D, vitamin E, Zinc, Thiamine, Parathyroid Hormone, Magnesium, Selenium, and Copper Clinical -Medical history -Physical assessment may include examination of hair, mouth/gums, eyes, nails, skin, thyroid gland, and joints and bones Dietary -24 hour recall and food frequency questionnaire -Food beliefs -Food behaviors Cultural Background Psycho-social issues -Motivation -Triggered eating habits and binge eating Economic Factors Goals

3 Calculate energy requirements for post op using the Mifflin- St Jeor equation which has shown to be effective in calculating resting metabolic rate (RMR) in non-obese and obese patients (RMR) kcal/day: (males) = 999 x weight (kg) x height (cm) x age (years) + 5; (RMR) kcal/day: (females) = 999 x weight (kg) x height (cm) x age (years) 161 Total energy requirements can be evaluated based on RMR and appropriate physical activity level coefficients: sedentary and low active, 10; moderately active, 112; highly active, 127, and very highly active, 145 Preoperative guidance and surgery preparation At least 2 4 weeks before surgery, patients are advised to follow a low calorie diet (LCD) The LCD helps to reduce the volume of the liver, sometimes referred to as liver shrinkage, which helps to promote weight loss and prevent surgery complications The diet also decreases the amount of glycogen, water and fatty deposits in the liver The LCD also reduces blood glucose level so medication adjustments may need to be made to prevent hypoglycemia A variety of prebariatric surgery diets are used but generally the diet should Consist of three LCD meal options customized for the patients protein and nutrient requirements Include low carbohydrate foods, low calorie foods; adequate fluid intake; stimulate control; fiber supplementation; and any other surgeon-specific requirements Update the patient's plan of care, as appropriate and document the following in the patient's medical record Document patient s nutritional assessment including anthropometric, biochemical, clinical and dietary findings Also document psychosocial, cultural, or economic findings Document the nutrition care plan and goals for the patient based on assessment and findings

4 Post-Procedural Responsibilities During the first 8 weeks post-surgery, the focus for nutrition care is on maintaining adequate hydration, obtaining adequate nutrients and protein to support healing and mitigate lean muscle mass loss, and gradually returning the texture of the diet to normal solid foods required for weight loss Texture progression of diet -All bariatric surgery patients move from liquids to pureed to soft solids to normal solid foods The duration of each phase depends on the surgery performed and the patient s tolerance General progression of diet is: 1 2 weeks fluids, 2 4 weeks pureed foods, 3 6 weeks of soft solid foods (optional), and 4 8 weeks normal solid foods Eating behaviors to encourage after bariatric surgery Certain eating behaviors may be more important than others pending the type of bariatric surgery the patient experienced For example, AGB influences the volume of food consumed and promotes early satiety due to the narrowing near the gastro-esophageal junction Sleeve gastrectomy (SG) and RYGB lead to reduced gastric volume, hormonal changes, and taste changes; SG in particular leads to increased gastric emptying However, generally speaking, bariatric patients should be advised to: Eat consistent meals; avoid skipping meals Eat smaller meals Cut food into small pieces Chew food thoroughly Eat slowly Engage in mindful eating Resist eating and drinking during the meal at the same time

5 Common gastrointestinal symptoms and possible solutions depend on a patients surgery Nausea Slow progression of diet Reduce total volume of food consumed at any given time Drink and eat separately Regurgitation or bolus food block Reinforce eating behaviors noted above Follow-up with the surgeon; band may be too tight for patients who underwent an AGB Constipation Confirm patient is aware of reduced bowel output due to overall decreased intake Encourage adequate fluid intake Encourage higher fiber intake (25 30 g/day); suggest fiber supplements as needed Encourage physical activity Very poor appetite Encourage small meals Recommend low energy, high protein meal replacements or supplements as needed Avoid unplanned snacking on low-nutrient dense foods Dumping syndrome Encourage adequate protein intake Encourage low glycemic foods Eat and drink separately Avoid highly refined, processed sugary food and drink Diarrhea Utilize management for dumping syndrome Remind patient that this may only be temporary Consider adding soluble fiber to patients diet

6 Post-operative and 6-month nutrition care Monitoring vitamin, mineral, and trace elements for supplementation Recommendations for vitamin and mineral supplementation are surgery-specific However, recommendations include -Routine adult multivitamin and mineral which includes iron, thiamine, and folic acid -Elemental calcium (from diet and divided citrate supplement doses) -Vitamin D (3000 IU titrated to therapeutic levels) -Vitamin B 12 (as needed to maintain appropriate levels); most patients will begin receiving B 12 injections every three months, beginning three months after surgery -Total iron (45 60 mg from multivitamin and additional supplements); take iron on an empty stomach if possible and with vitamin C or foods containing vitamin C to increase absorption -Other supplements may need to be considered pending nutritional status and dietary intake Monitoring post-operative nutritional parameters 6 months post- surgery Specific nutrient markers for monitoring are dependent on surgery and institution protocol Nutrient markers include Iron, vitamin B12, Folic acid, and vitamin A (monitoring of vitamin D, vitamin E, Zinc, Parathyroid Hormone, Magnesium and Selenium may be optional and should be done as clinically indicated) Annual follow-up Nutrition parameters must be monitored annually or more frequent if clinically indicated Specific nutrient markers for monitoring are dependent on surgery and institution protocol Iron, vitamin B12, Folic acid, vitamin D, vitamin E, Zinc, Thiamine, Parathyroid Hormone, Magnesium, Selenium, Copper (vitamin E, Zinc, Parathyroid Hormone, and Copper are optional pending clinical indication) Signature Evaluator's Signature Date Date