Nutrition Guidelines for the Sleeve Gastrectomy Patient April 18 2012 Laura Tomczik, RD, LDN Senior Bariatric Dietitian Center for Metabolic Health and Bariatric Surgery Brigham and Women s Hospital / Faulkner Hospital
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
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
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
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
Who is having WLS? Pratt 2009
Common Surgical Procedures Adjustable Gastric Banding Roux-en-Y Gastric Bypass Sleeve Gastrectomy Heber 2010
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
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
Who should have SG? Rosenthal 2011
The Procedure Braghetto 2007
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
How does SG facilitate weight loss? Restrictive Hormonal Faster gastric emptying Akkary 2008, Lee 2011, Melissas 2007, Braghetto 2010
Nutrition Guidelines
Pre-op Very Low Calorie Diet (VLCD) Colles 2006
Reduction in liver volume Colles 2006
Surgical complications after VLCD Van Nieuwenhove 2011
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
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
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
Swallow study Patients reach goal of 2 L faster; Mean hospital stay 2.5 vs. 3.4 days 5 seconds 39 seconds Goitein 2009
Stage 2: Protein Shakes Stage lasts ~10-14 days Goals: 60-80 g protein, 48-64 oz fluid Protein shakes Consider volume and quality of protein source Aills 2008, Snyder-Marlow 2010
Stage 3: Pureed Foods Stage lasts 10-14+ 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
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
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
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
Food Tolerance and Quality of Eating Schweiger 2010
Protein ASMBS recommends at least 60-80 grams per day Other figures: 1.5-2.1 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
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 140 26 5.4 Tofu ½ c 88 10 8.8 Skim milk 8 oz 90 8 11.3 Black beans ½ c 110 7 15.7 Peanut butter 2 Tb 190 8 23.8
Carbohydrates DRI of 130 g carbohydrates / day Encourage whole grains, fruit, low-fat dairy and beans Avoid carbohydrate-only meals and snacks Kamani 2011
Micronutrient Research Very few studies on nutrition needs of SG patients Potential issues: Decreased HCl acid and intrinsic factor Decreased intake Nausea/vomiting
Jeejeebhoy 2002
Micronutrient Supplementation Snyder-Marlow 2010
Summary of nutrient deficiency studies Study MVI Vit D B12 Iron Measures Fol PTH (high) Goldenberg 2006 6 mo post-op MVI w/ Fe 600-1200 mg Ca Citrate 6/16 1/16 - - 1/16 Toh 2009 1 yr post-op Hakeam 2009 1 yr post-op MVI - - 2/13 Hb - - MVI w/o Fe - 16/61 4/61 Fe 6/9 - Aarts 2011 1 yr post-op 150% RDA 1000/800 CaD 21/54 5/54 8/54 Fe 8/54 21/54 Kehagis 2011 3 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
Comparing deficiencies among surgeries Strohmayer 2010
Deficiencies in SG vs. RNY over time SG RNY Gerher 2010
Conclusions on supplementation Conservative approach is warranted until we have more complete research Nutrients to monitor are: B12 Iron Calcium Copper Folate Zinc
Outcomes and Complications Weight Loss and Weight Regain GERD Hormonal Changes Type II Diabetes
Weight Loss and Weight Regain
Weight Loss Statistics Study Patients % EWL SG % EWL other Leyba 2011 1 yr post-op 60 RNY, 39 SG 78.8% 86% (RNY) Bobowicz 2011 1 yr post-op Ramalingam 2011 1 yr post-op Sabbagh 2010 2 yr post-op Kehagis 2011 2 yr post-op Gordejuela 2011 2 yr post-op Bohdjalian 2010 5 yr post-op Strain 2011 5 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%
Does sleeve size affect weight loss? Weiner 2007
Deitel 2011
Weight loss over time Hamoui 2006
Weight Regain Few long-term studies Examine diet Self-monitoring Continued patient-provider contact Physical activity Sarwer 2011
Group 1: <1 yr post-op Group 2: >1 yr post-op Kafri 2011
Evolution of eating behaviors Group 1: < 1 year post-op Group 2: > 1 year post-op Kafri 2011
Surgical techniques for weight regain Sleeve resizing Converting to RNY or DS Band over sleeve Langer 2010
GERD and SG
Anatomy of GERD http://www.endogastricsolutions.com/aboutgerd_for-surgeons.htm
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
GERD symptoms post-op Carter 2011
GERD symptoms post-op Howard 2011
Managing GERD Some patients may experience GERD symptoms after SG Be mindful of symptoms and treat with diet and/or medications as needed
Hormone Changes After SG
Ghrelin Produced in the fundus of the stomach Stimulates hunger Bohdjalian 2010
Acyl and des-acyl ghrelin Lee 2011
Leptin Produced in fat cells Represses food intake and promotes energy expenditure Time (weeks) Lee 2011, Woelnerhanssen 2011
Peptide YY (PYY) Produced in the intestine Represses food intake; delays gastric emptying & secretions Valderas 2010, Lee 2011
Glucagon-like Peptide 1 (GLP-1) Produced in intestine Stimulates insulin secretion, inhibits glucagon secretion, nutritive effects on B-cell
Adiponectin Produced in fat cells Increases insulin sensitivity Time (weeks) Woelnerhanssen 2011
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
Type II Diabetes and SG
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
Remission vs. Resolution Pournaras 2010
Rizzello 2010
SG vs medical therapy: HbA1C Schauer 2012
SG vs medical therapy: Glucose Schauer 2012
SG vs medical therapy: Medications Schauer 2012
How does severity of diabetes affect remission? Casella 2011
How does severity of diabetes affect remission? Casella 2011
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
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
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
Questions?
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