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NUTRITION THERAPY IN SURGICAL
MANAGEMENT OF MORBID OBESITY
Leo kihiuhi
Clinical Nutritionist
OVERWEIGHT
FEEDING HABITS PHYSICAL ACTIVITIES
Psychological FactorsBiological factors
OBESITY
WHO IS OUT RISK?
PUBLIC MIND ON WEIGHT
MANAGEMENT
ONLINE DIETS
GYM
PILLS
Any solution ?
The Practical Guide; Identification, Evaluation and treatment of
Overweight and Obesity in Adults, Oct 2000, NIH Pub No 00-4084
BARIATRIC SURGERY
Bariatric surgery is more effective
than nonsurgical treatment for weight
loss and control of some comorbid
conditions in MORBID OBESE patients
PRE-SURGERICAL
EVALUATION.
 Prior to surgery candidates should be carefully
assessed by a specialized multidisciplinary team
including:
 Bariatrician (MD specializing in the care of the obese)
 Surgeon
 PCP
 Social Worker/ Psychologist
 Dietitian
 Nurse
• During active weight management,
multicomponent interventions that are
delivered through multidisciplinary care may
be more effective than interventions delivered
by individual health professionals (Flodgren et
al. 2010; Tsai & Wadden 2009).
NUTRITION THERAPY
IN
BARIATRIC SURGERY
IN
MORBID OBESE
TREATMENT
Pre-Surgical Goals
 Improvement of nutritional status
• Correct vitamin/nutrient deficiencies (most common include:
iron, vitamin B12 and vitamin D)
Achievement of better control of nutrition- related
comorbidities
Development of lifestyle and eating habits that will
promote positive post-weight loss surgery outcomes
and weight loss maintenance
Promote 5-10% weight loss to reduce surgical risks
Post-Surgery
Nutrition Guidelines
• Dietary consult ordered upon admit
– Complete nutrition assessment
– Review diet progression with patient
– Work with in-patient team to identify & minimize
complications post-op
• For all procedures patients will follow the
same diet
Post Surgical Diet
Progression
Diet advanced from NPO to Stage 1 Bariatric Diet on
Post op Day 1
• Stage 1 - Water
– Typically start day of surgery; Duration < 1 day
– Nursing staff to administer 1oz water per hour via
medicine cup
• Instruct patient to sip slowly & stop if feeling full or
nauseous
– All medications to be administered in liquid/chewable
form
– IV Fluid until tolerating liquids
– Patient to begin tracking fluid intake on Patient Intake
Diary (provided by healthcare team)
• Stage 2 - Bariatric Clear Liquids
– Starts Post op Day1; Duration 1-2 days
– Non-carbonated liquids without calories, sugar, or
caffeine; includes broth, sugar-free (SF) ice pops, SF
gelatin, water, & ice chips
– Priority is hydration
– Instruct to sip slowly & stop if feeling full or nauseous
(avoid straws)
– Will receive 3oz Bariatric Clear Liquids 3 times a day on
meal trays
– Instruct to sip 2-4 oz Bariatric Clear Fluids per hour
between meals
– Will be expected to track intake on Patient Intake Diary
Stage 3 - Bariatric Full Liquids
• Starts Post op Day 1-2; duration 2-4 weeks
• Will receive 3oz Bariatric Full Liquids 3 times a day on meal trays
• Low-fat protein-rich liquids with (exp. Low-fat (LF) broth, LF milk,
protein shakes; light/LF yogurt, LF cottage cheese; LF/SF
pudding) juven/beneprotein
• Priority on hydration and protein intake (minimize loss of lean
body mass)
• Instruct to sip slowly & stop if feeling full or nauseous
• Instruct to sip 2-4 oz fluids per hour between meals
• Note: Patients will go home on this stage. You may not see
other stages unless patients are re-admitted
Stage 4 - Soft and Moist Protein
• Start 2 weeks post-op; Duration 4-6 weeks
As tolerated replace full liquids with soft & moist protein
foods (avoid dry or tough meats); ~2-4oz per meal
• May need to continue with protein shakes to meet protein
needs
• Instruct not to drink fluids with meals; wait 30 min before &
after each meal to have beverages
• If meeting protein goals may add well-cooked soft fruits &
vegetables
• Will begin taking chewable vitamin & mineral supplements
Stage 5
• Low Fat, Low Sugar, High Protein
• Start 6-8 weeks post-op; Duration lifelong
• Balanced solid food diet with protein, fruits, vegetables, and
whole grains. Can add raw foods as tolerated.
• Goals:
– 60-80 grams protein /day
– 64+ ounces fluid/ day (including protein drinks) sipped
between meals.
• Continue to separate fluids from your meals
• Can advance to supplements in tablet form if tolerated
Common Problems
After All Weight Loss
Surgeries
• Dehydration
– Monitor for signs and symptoms of dehydration as
patients are at greater risk given their dietary restrictions.
Patients should strive for 64 ounces of liquids per day.
• Nausea and Vomiting
– Eating too quickly or too much, drinking with meals or
drinking too close to meals, not chewing thoroughly, or
advancing the diet too quickly can all lead to nausea
and/or vomiting. Persistent vomiting can lead to thiamin
deficiency.
– Encourage patients to drink and eat slowly, stop if feeling
full or nauseous, and take small bites and chew their foods
thoroughly.
• Dumping Syndrome
– Usually occurs ~30 minutes following a meal.
– Symptoms may be similar to the flu and include nausea,
sweating, bloating, abdominal cramps, and diarrhea.
– To avoid these symptoms patients should avoid high fat and
high sugar foods. or example instead of 100% fruit juice; dilute
1:1 with water.
• Diarrhea
– Some patients can develop post-operative lactose intolerance.
Symptoms could include bloating, abdominal cramps, excessive
gas, and diarrhea.
– Treatment includes following a lactose-free diet.
Sites of Nutrient
Absorption
• Stomach
– Water, ethyl alcohol, copper, iodide, fluoride,
molybdemum, intrinsic factor
• Duodenum
– Calcium, iron, phosphorus, magnesium, copper,
selenium, thiamin, riboflavin, niacin, biotin, folate,
vitamins A, D, E, K
Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric
surgery. Nutr Clin Pract. 2007;22(1):29-40.
• Jejunum
– Thiamin, riboflavin, niacin, pantothenate, biotin,
folate, vit B6, vit C, vit A, D, E, K, dipeptides,
tripeptides, calcium, phosphorus, magnesium,
iron, zinc, chromium, manganese, molybdenum,
amino acids
• Ileum
– Vit C, folate, vit B12, vit D, vit K, magnesium, bile
salts/acids
Common Nutrient
Deficiencies
• Gastric Bypass:
– Most common: Iron, Vitamin B-12,
Folic acid, Fat soluble Vitamins A, D, & E
– Thiamin (seen in patients with frequent vomiting)
– Calcium
– Protein malnutrition
• Gastric Banding:
– Except for folate, nutrition deficiencies are less
commonly seen post gastric banding
• Sleeve Gastrectomy
– Possible B-12
Iron deficiency and anemia
• As high as 49% of patients
• Multifactorial cause
– Low gastric acid levels prohibit iron cleavage from food
– Absorption inhibited because no nutrient exposure to
duodenum or proximal jejunum
– Decrease in iron-rich food consumption due to
intolerance
• Treat with oral supplementation of ferrous sulfate
or ferrous gluconate
Vitamin B12 deficiency
• Up to 70% of patients
• Lack of hydrochloric acid and pepsin in stomach
– Prevents B12 cleavage from food
– Affects secretion of intrinsic factor, thus B12
absorption
• Intolerance to meat and milk
• Oral supplementation usually adequate,
otherwise, IM injections used
Folate Deficiency
• 40% of gastric bypass patients
• Complete absorption requires B12
• Absorption dependent on HCl and upper 1/3
stomach
• Deficiency generally caused by decreased
consumption
• Oral supplementation
Vitamin D and Calcium Deficiency
• Vitamin D deficiency is common among obese
people
• Calcium absorption decreased because duodenum is
bypassed
• Intolerance to dairy, foods high in calcium
• Vitamin D is required for Ca++ absorption
• Prolonged deficiencies lead to
– Bone resorption, osteomalacia, osteoporosis
• Treat with calcium citrate supplementation and 2
weekly doses of Vitamin D
NULFICATION OF THE
SHORTCOMING ?
Benefits of bariatric surgery
 Depression 55% resolved
(Wittgrove AC, Clark GW. 2000)
 Obstructive sleep apnea 74-98%
resolved (Wittgrove AC, Clark GW. 2000)
 Asthma 82% improved or
resolved (Wittgrove AC, Clark GW. 2000)
 Cardiovascular disease 82% risk
reduction (DeMaria EJ, Sugerman HJ et al
2002)
 GERD 72-98% resolved(DeMaria EJ,
Sugerman HJ et al 2002)
 Stress urinary incontinence 44-
88% resolved (DeMaria EJ, Sugerman HJ et
al 2002)
 Degenerative joint disease 41-
76% Resolved (Wittgrove AC, Clark GW.
2000)
 Mortality 89% reduction in 5-
year mortality4
 Quality of life improved in 95%
of patients (Wittgrove AC, Clark GW. 2000)
 Migraines 57% resolved (Wittgrove
AC, Clark GW. 2000)
 Pseudotumor cerebri 96%
resolved
 Dyslipidemia
hypercholesterolemia 63%
resolved (Wittgrove AC, Clark GW. 2000)
 Non-alcoholic fatty liver disease
90% improved steatosis 37%
resolution of Inflammation 20%
resolution of fibrosis (Mattar SG,
Velcu LM,2005)
 Metabolic syndrome 80%
resolved (Mattar SG, Velcu LM,2005)
 Type II diabetes mellitus 83%
resolved (Mattar SG, Velcu LM,2005)
 Polycystic ovarian syndrome
79% resolution of hirsuitism
100% resolution of menstrual
dysfunction
 Venous statis disease 95%
resolved
LONG TERM
SOLUTION
• Lifelong compliance with vitamin/ mineral
supplementation is important to reduce the
risk of serious nutrient deficiencies
• Self-monitoring intake and avoiding high
calorie foods and beverages to prevent weight
re-gain
• Remaining connected with post bariatric
surgery support groups
• Prevention is likely to be the most efficient
and cost-effective approach for tackling
overweight and obesity.
• However, many people already require
treatment, may have comorbidities and are at
risk of further weight gain (NPHT 2009).
FEEDING HABIT
NUTRITIONIST
EXERCISES
GYM INSTRUCTORS
MEDICATION
PHYSICIANS
BARIATRIC SURG
SURGEONS
MEDICATION
EXERCISES
BARIATRIC SURG
PHYSICIAN GYM INSTRUCTORS
NUTRITIONIST
SURGEON
“There is nothing wrong with our
metabolism… the problem is the
Environment and the fact that
food is no longer a survival issue
but mostly a source of pleasure”…
uiza Kent-Smith, 2007
THANK YOU

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Obesity and dieting

  • 1. NUTRITION THERAPY IN SURGICAL MANAGEMENT OF MORBID OBESITY Leo kihiuhi Clinical Nutritionist
  • 2. OVERWEIGHT FEEDING HABITS PHYSICAL ACTIVITIES Psychological FactorsBiological factors OBESITY
  • 3. WHO IS OUT RISK?
  • 4. PUBLIC MIND ON WEIGHT MANAGEMENT ONLINE DIETS GYM PILLS
  • 6. The Practical Guide; Identification, Evaluation and treatment of Overweight and Obesity in Adults, Oct 2000, NIH Pub No 00-4084
  • 7. BARIATRIC SURGERY Bariatric surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in MORBID OBESE patients
  • 9.  Prior to surgery candidates should be carefully assessed by a specialized multidisciplinary team including:  Bariatrician (MD specializing in the care of the obese)  Surgeon  PCP  Social Worker/ Psychologist  Dietitian  Nurse
  • 10. • During active weight management, multicomponent interventions that are delivered through multidisciplinary care may be more effective than interventions delivered by individual health professionals (Flodgren et al. 2010; Tsai & Wadden 2009).
  • 12. Pre-Surgical Goals  Improvement of nutritional status • Correct vitamin/nutrient deficiencies (most common include: iron, vitamin B12 and vitamin D) Achievement of better control of nutrition- related comorbidities Development of lifestyle and eating habits that will promote positive post-weight loss surgery outcomes and weight loss maintenance Promote 5-10% weight loss to reduce surgical risks
  • 13. Post-Surgery Nutrition Guidelines • Dietary consult ordered upon admit – Complete nutrition assessment – Review diet progression with patient – Work with in-patient team to identify & minimize complications post-op • For all procedures patients will follow the same diet
  • 15. Diet advanced from NPO to Stage 1 Bariatric Diet on Post op Day 1 • Stage 1 - Water – Typically start day of surgery; Duration < 1 day – Nursing staff to administer 1oz water per hour via medicine cup • Instruct patient to sip slowly & stop if feeling full or nauseous – All medications to be administered in liquid/chewable form – IV Fluid until tolerating liquids – Patient to begin tracking fluid intake on Patient Intake Diary (provided by healthcare team)
  • 16. • Stage 2 - Bariatric Clear Liquids – Starts Post op Day1; Duration 1-2 days – Non-carbonated liquids without calories, sugar, or caffeine; includes broth, sugar-free (SF) ice pops, SF gelatin, water, & ice chips – Priority is hydration – Instruct to sip slowly & stop if feeling full or nauseous (avoid straws) – Will receive 3oz Bariatric Clear Liquids 3 times a day on meal trays – Instruct to sip 2-4 oz Bariatric Clear Fluids per hour between meals – Will be expected to track intake on Patient Intake Diary
  • 17. Stage 3 - Bariatric Full Liquids • Starts Post op Day 1-2; duration 2-4 weeks • Will receive 3oz Bariatric Full Liquids 3 times a day on meal trays • Low-fat protein-rich liquids with (exp. Low-fat (LF) broth, LF milk, protein shakes; light/LF yogurt, LF cottage cheese; LF/SF pudding) juven/beneprotein • Priority on hydration and protein intake (minimize loss of lean body mass) • Instruct to sip slowly & stop if feeling full or nauseous • Instruct to sip 2-4 oz fluids per hour between meals • Note: Patients will go home on this stage. You may not see other stages unless patients are re-admitted
  • 18. Stage 4 - Soft and Moist Protein • Start 2 weeks post-op; Duration 4-6 weeks As tolerated replace full liquids with soft & moist protein foods (avoid dry or tough meats); ~2-4oz per meal • May need to continue with protein shakes to meet protein needs • Instruct not to drink fluids with meals; wait 30 min before & after each meal to have beverages • If meeting protein goals may add well-cooked soft fruits & vegetables • Will begin taking chewable vitamin & mineral supplements
  • 19. Stage 5 • Low Fat, Low Sugar, High Protein • Start 6-8 weeks post-op; Duration lifelong • Balanced solid food diet with protein, fruits, vegetables, and whole grains. Can add raw foods as tolerated. • Goals: – 60-80 grams protein /day – 64+ ounces fluid/ day (including protein drinks) sipped between meals. • Continue to separate fluids from your meals • Can advance to supplements in tablet form if tolerated
  • 20. Common Problems After All Weight Loss Surgeries
  • 21. • Dehydration – Monitor for signs and symptoms of dehydration as patients are at greater risk given their dietary restrictions. Patients should strive for 64 ounces of liquids per day. • Nausea and Vomiting – Eating too quickly or too much, drinking with meals or drinking too close to meals, not chewing thoroughly, or advancing the diet too quickly can all lead to nausea and/or vomiting. Persistent vomiting can lead to thiamin deficiency. – Encourage patients to drink and eat slowly, stop if feeling full or nauseous, and take small bites and chew their foods thoroughly.
  • 22. • Dumping Syndrome – Usually occurs ~30 minutes following a meal. – Symptoms may be similar to the flu and include nausea, sweating, bloating, abdominal cramps, and diarrhea. – To avoid these symptoms patients should avoid high fat and high sugar foods. or example instead of 100% fruit juice; dilute 1:1 with water. • Diarrhea – Some patients can develop post-operative lactose intolerance. Symptoms could include bloating, abdominal cramps, excessive gas, and diarrhea. – Treatment includes following a lactose-free diet.
  • 24. • Stomach – Water, ethyl alcohol, copper, iodide, fluoride, molybdemum, intrinsic factor • Duodenum – Calcium, iron, phosphorus, magnesium, copper, selenium, thiamin, riboflavin, niacin, biotin, folate, vitamins A, D, E, K Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. Nutr Clin Pract. 2007;22(1):29-40.
  • 25. • Jejunum – Thiamin, riboflavin, niacin, pantothenate, biotin, folate, vit B6, vit C, vit A, D, E, K, dipeptides, tripeptides, calcium, phosphorus, magnesium, iron, zinc, chromium, manganese, molybdenum, amino acids • Ileum – Vit C, folate, vit B12, vit D, vit K, magnesium, bile salts/acids
  • 26.
  • 28. • Gastric Bypass: – Most common: Iron, Vitamin B-12, Folic acid, Fat soluble Vitamins A, D, & E – Thiamin (seen in patients with frequent vomiting) – Calcium – Protein malnutrition • Gastric Banding: – Except for folate, nutrition deficiencies are less commonly seen post gastric banding • Sleeve Gastrectomy – Possible B-12
  • 29. Iron deficiency and anemia • As high as 49% of patients • Multifactorial cause – Low gastric acid levels prohibit iron cleavage from food – Absorption inhibited because no nutrient exposure to duodenum or proximal jejunum – Decrease in iron-rich food consumption due to intolerance • Treat with oral supplementation of ferrous sulfate or ferrous gluconate
  • 30. Vitamin B12 deficiency • Up to 70% of patients • Lack of hydrochloric acid and pepsin in stomach – Prevents B12 cleavage from food – Affects secretion of intrinsic factor, thus B12 absorption • Intolerance to meat and milk • Oral supplementation usually adequate, otherwise, IM injections used
  • 31. Folate Deficiency • 40% of gastric bypass patients • Complete absorption requires B12 • Absorption dependent on HCl and upper 1/3 stomach • Deficiency generally caused by decreased consumption • Oral supplementation
  • 32. Vitamin D and Calcium Deficiency • Vitamin D deficiency is common among obese people • Calcium absorption decreased because duodenum is bypassed • Intolerance to dairy, foods high in calcium • Vitamin D is required for Ca++ absorption • Prolonged deficiencies lead to – Bone resorption, osteomalacia, osteoporosis • Treat with calcium citrate supplementation and 2 weekly doses of Vitamin D
  • 34. Benefits of bariatric surgery  Depression 55% resolved (Wittgrove AC, Clark GW. 2000)  Obstructive sleep apnea 74-98% resolved (Wittgrove AC, Clark GW. 2000)  Asthma 82% improved or resolved (Wittgrove AC, Clark GW. 2000)  Cardiovascular disease 82% risk reduction (DeMaria EJ, Sugerman HJ et al 2002)  GERD 72-98% resolved(DeMaria EJ, Sugerman HJ et al 2002)  Stress urinary incontinence 44- 88% resolved (DeMaria EJ, Sugerman HJ et al 2002)  Degenerative joint disease 41- 76% Resolved (Wittgrove AC, Clark GW. 2000)  Mortality 89% reduction in 5- year mortality4  Quality of life improved in 95% of patients (Wittgrove AC, Clark GW. 2000)  Migraines 57% resolved (Wittgrove AC, Clark GW. 2000)  Pseudotumor cerebri 96% resolved  Dyslipidemia hypercholesterolemia 63% resolved (Wittgrove AC, Clark GW. 2000)  Non-alcoholic fatty liver disease 90% improved steatosis 37% resolution of Inflammation 20% resolution of fibrosis (Mattar SG, Velcu LM,2005)  Metabolic syndrome 80% resolved (Mattar SG, Velcu LM,2005)  Type II diabetes mellitus 83% resolved (Mattar SG, Velcu LM,2005)  Polycystic ovarian syndrome 79% resolution of hirsuitism 100% resolution of menstrual dysfunction  Venous statis disease 95% resolved
  • 36. • Lifelong compliance with vitamin/ mineral supplementation is important to reduce the risk of serious nutrient deficiencies • Self-monitoring intake and avoiding high calorie foods and beverages to prevent weight re-gain • Remaining connected with post bariatric surgery support groups
  • 37. • Prevention is likely to be the most efficient and cost-effective approach for tackling overweight and obesity. • However, many people already require treatment, may have comorbidities and are at risk of further weight gain (NPHT 2009).
  • 38.
  • 43. MEDICATION EXERCISES BARIATRIC SURG PHYSICIAN GYM INSTRUCTORS NUTRITIONIST SURGEON
  • 44. “There is nothing wrong with our metabolism… the problem is the Environment and the fact that food is no longer a survival issue but mostly a source of pleasure”… uiza Kent-Smith, 2007