Nutritional Trends and Implications for Weight Loss Surgery
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Learning Objectives: 1. Describe and list the types of bariatric surgeries. 2. Identify current practice guidelines for MNT in bariatrics. 3. Identify key factors in pre-op assessments for long-term success.
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Nutritional Trends and Implications for Weight Loss Surgery
- 1. https://learn.extension.org/events/2550 Nutritional Trends and Implications for Weight Loss Surgery
- 2. Connecting military family service providers and Cooperative Extension professionals to research and to each other through engaging online learning opportunities www.extension.org/militaryfamilies MFLN Intro 2 Sign up for webinar email notifications at www.extension.org/62831
- 3. • Received her Masters of Science in Family and Consumer Sciences with a focus in nutrition from Eastern Illinois University. • Currently practicing as a registered licensed Bariatric / Clinical Dietitian at Carle Physician Group. • Professional interests focus on weight management for adults and pediatrics, as well as general nutrition education for the community, including support groups to promote healthy lifestyles. Today’s Presenter 3 Ashley McCartney, MS, RD, LDN
- 4. By: Ashley R. McCartney, MS, RD, LDN Carle Physician Group Urbana, IL Ashley.McCartney@carle.com 4
- 5. 5
- 6. 6 Photo taken from www.stateofobesity.org
- 7. 7 Estimate costs range from $147 billion to $210 billion / year. Associated with job absenteeism Lower productivity while at work Obese adults spend 42 percent more on direct healthcare costs than adults who are a healthy weight. In the U.S., second leading cause of death after tobacco
- 8. 8 Photo taken from www.stateofobesity.org/healthcare-costs-obesity/
- 9. 9 Classification BMI Risk of Comorbidities Underweight <18.5 Low Normal 18.5 - 24.9 Average Overweight 25.0 - 29.9 Increased Obese Class I 30.0 - 34.9 Moderate Obese Class II 35.0 - 39.9 Severe Obese Class III Super Obese 40.0 – 49.9 >/= 50.0 Very severe Classification of Obesity Photo taken from WHO
- 10. 10 Most effective treatment for severe obesity Resolution of co-morbid conditions Impact on medication regimen Impact on metabolic and hormonal changes Fad / crash / yo-yo dieting does not work Quick fix? Photos taken from www.reboundfreeweightloss.com and www.globalrugby.com.au
- 11. 11 Photo taken from www.happyhungryhealthy.com
- 12. 12
- 14. 14 Photo taken from www.lourdes.com
- 15. 15 Restrictive Procedure First introduced in 1978 by Wilkinson 1986 – current procedure done across the world FDA approved in 2001 How does the adjustable band function? Rate of weight loss Outpatient procedure
- 16. 16 Diabetes 50% Dyslipidemia 50% Hypertension 60% Sleep apnea 90%
- 17. 17 Band slippage Leakage of tubing / balloon Port or band infection Obstruction Nausea / vomiting Band erosion into stomach Esophageal dilatation Failure to lose weight
- 18. 18 Diet progression Portion sizes Vitamin regimen Physical activity regimen
- 19. 19
- 20. 20 Filled BandUnfilled Band Photo taken from www.mylapsurgeon.com
- 21. 21 Vertical Sleeve Gastrectomy Photo taken fromwww.darylsmarxmd.com
- 22. 22 Restrictive Procedure Irreversible Popularized in early 2000s Still under research for efficacy How does the sleeve function? Rate of weight loss Inpatient hospital stay
- 23. 23 Diabetes 80% Dyslipidemia 60% Hypertension 60% Sleep apnea 95%
- 24. 24 Leaks 1-2% Strictures <1%
- 25. 25 Diet progression Portion sizes Vitamin regimen Physical activity regimen
- 26. 26
- 27. 27 Bile duct Pancreas Descending duodenum Food absorbed Mouth Proximal gastric pouch To rest of bowel Jejunum Photo taken from www.browardsurgicalspecialists.com
- 28. 28 Malabsorptive procedure Reversible Developed in the 1960s How it functions Rate of weight loss Why is bypass considered “the gold standard?” Inpatient hospital stay
- 29. 29 Diabetes 90% Dyslipidemia 70% Hypertension 65% Sleep apnea 90% Reflux 98%
- 30. 30 Diet progression Portion sizes Vitamin regimen Physical activity regimen
- 31. 31
- 32. 32
- 33. 33 Preoperative weight loss prior to surgery Lap band rate of weight loss Sleeve gastrectomy rate of weight loss Gastric bypass rate of weight loss
- 34. 34
- 35. 35 Photos taken from www.bariatricnews.netand www.binghammemorial.org
- 36. 36 No deaths 10% SAE’s 19% had balloon removed early Nausea, vomiting, abdominal pain, reflux in 48-72 hrs.
- 37. 37 BMI 30-40 In conjunction with long term diet/behavior modification program Failed more conservative teatments Maximum duration of placement 6 mos.
- 38. 38 Reasonable option for temporary weight loss Very skeptical about long term weight loss efficacy High potential for inappropriate use Most beneficial indications are currently off- label
- 39. 39 Biliopancreatic diversion Biliopancreatic diversion with duodenal switch Silastic ring gastric bypass Endoscopic sleeve gastroplasty Vbloc AspireAssist
- 40. 40 Photo taken from www.drsamuelbledsoe.com
- 41. 41 Expected Outcomes References First Trimester Second Trimester Third Trimester Post-Partum Close collaborative efforts between the bariatric surgeon and obstetrician. Patient must notify office as soon as pregnancy is confirmed and appointment made for fluid removal. All fluid will be removed to minimize restriction of band. A band fill will be performed no earlier than 14 weeks gestation or later if weight gain is excessive. All fluid will be removed from the band at 36 weeks gestation. A band fill will not be performed until lactation is established. Band adjustment will likely be close to pre- pregnancy levels. Maintain healthy fetal development. Minimize risks associated with obesity, pregnancy and poor neonatal outcomes through weight management. Fluid removal will allow for optimal nutritional intake during embryogenesis and minimize risk for hyperemesis during the first trimester. Based on IOM weight gain recommendations, the band fills will be performed to minimize excessive weight gain (not to promote weight loss). Recommendations for weight gain are based on varying BMI levels and are to be determined by obstetrician. Management of band will be based on weight gain recommendations. Reduce impact of band on delivery. Initiate weight loss or weight maintenance. Dixon, J. B., Dixon, M. E., & O'Brien, P. E. (2001). Pregnancy after lap-band surgery: Management of the band to achieve healthy weight outcomes. Obesity Surgery, (11), 59-65. Carle Foundation Hospital:
- 42. 42 Timing of pregnancy Recommended lab work Protein requirements Weight gain
- 43. 43 Surgery for pregnancy Sports nutrition- i.e. marathons, etc. Surgery for other medical procedures Photos from: www.7leafmarketing.com www.karatebyjesse.com
- 44. 44 "The State of Obesity: Obesity Data Trends and Policy Analysis." The State of Obesity: Obesity Data Trends and Policy Analysis. N.p., n.d. Web. 1 Apr. 2016. Allison DB, Fontaine KR, Manson JE, Stevens, J, Vanitallie TB. Annual deaths attributable to obesity in the United States. JAMA. 1999;282(16)1530-8. Cawley J and Meyerhoefer C. The Medical Care Costs of Obesity: An Instrumental Variables Approach. Journal of Health Economics, 31(1): 219-230, 2012; And Finkelstein, Trogdon, Cohen, et al. Annual Medical Spending Attributable to Obesity. Health Affairs, 2009. Cawley J, Rizzo JA, Haas K. Occupation-specific Absenteeism Costs Associated with Obesity and Morbid Obesity. Journal of Occupational and Environmental Medicine, 49(12):1317?24, 2007. Gates D, Succop P, Brehm B, et al. Obesity and presenteeism: The impact of body mass index on workplace productivity. J Occ Envir Med, 50(1):39-45, 2008. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable to Obesity: Payer-and Service-Specific Estimates. Health Affairs, 28(5): w822-831, 2009. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric Surgery. A systematic review and meta-analysis. JAMA. 2004 Oria, HE. Gastric banding for morbid obesity. Eur J Gastroenterol Hepatol 1999;11:105-114 Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12:564-568. Saber AA, Elgamel MH, McLeod, MK. Bariatric surgery: the past, present and future. Obesity Surgery Including Laparoscopy and Allied Care, 2008;18(1):121-8 Weight Control Information Network, National Institutes of Health. Bariatric surgery as a treatment for obesity. National Institute of Diabetes and Digestive and Kidney Diseases. 2011, June. Accessed August 30, 2012 from http://win.niddk.nih.gov/publications/gastric.htm Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12:564-568. Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obes Surg. 2012;22(1): 70-89 [Research Support, Non- U.S. Gov’t Review.] Dixon, J. B., Dixon, M. E., & O'Brien, P. E. (2001). Pregnancy after lap band surgery: Management of the band to achieve healthy weight outcomes. Obesity Surgery, (11), 59-65.
- 45. What is one significant thing you learned today? 45
- 46. Connect with MFLN Nutrition & Wellness Online! MFLN Nutrition @MFLNNW MFLN Nutrition and Wellness MFLN Nutrition and Wellness NW SMS icons 46
- 47. MFLN Intro 47 We invite MFLN Service Provider Partners to our private LinkedIn Group! https://www.linkedin.com/groups/8409844 DoD Branch Services Reserve Guard Cooperative Extension
- 48. Evaluation and CPEUs • MFLN Nutrition and Wellness CA is offering 1.0 CPEU for today’s webinar. • To receive credits, please complete the evaluation at: https://vte.co1.qualtrics.com/jfe/form/SV_2607el0rTJo86Lr 48
- 49. Nutrition and Wellness Upcoming Event Nutrition, Exercise, and Renal Disease •Date: Tuesday, June 28, 2016 •Time: 11:00 am Eastern •Location: https://learn.extension.org/events/2655 For more information on MFLN Nutrition and Wellness go to: https://blogs.extension.org/militaryfamilies/nutrition-and- wellness/ 49
Notas del editor
- Webinar brought to you by the Military Families Learning Network Coral www.extension.org/militaryfamilies Webinar notifications www.extension.org/62831
- According to the most recent data released September 2015, rates of obesity now exceed 35 percent in three states (Arkansas, West Virginia and Mississippi), 22 states have rates above 30 percent, 45 states are above 25 percent, and every state is above 20 percent. Arkansas has the highest adult obesity rate at 35.9 percent, while Colorado has the lowest at 21.3 percent.
- So why is this important? Bullet 1: Obesity is one of the biggest drivers of preventable chronic diseases and healthcare costs in the United States. Bullet 2: Cost approximately 4.3 billion annually Bullet 3: Costing employers $506 per obese worker / year. As a person&apos;s BMI increases, so do the number of sick days, medical claims and healthcare costs. Bullet 5: Obesity causes more than 300,000 deaths per year in the U.S. alone (Allison DB, Fontaine KR, Manson JE, Stevens, J, Vanitallie TB. Annual deaths attributable to obesity in the United States. JAMA. 1999;282(16)1530-8.)
- A 2008 study by the Urban Institute, The New York Academy of Medicine and TFAH found that an investment of $10 per person in proven community-based programs to increase physical activity, improve nutrition and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. That&apos;s a return of $5.60 for every $1 invested.9 Out of the $16 billion, Medicare could save more than $5 billion and Medicaid could save more than $1.9 billion.
- Bullet 1: Offers positive effects on weight as well as on related comorbidities (Buchwald, 2005) Bullet 2: Within 2-3 years after the operation average excess weight loss is around 10-35% of a patient’s excess weight Bullet 4: Play a major role in hunger and satiety as well as improvement and/or resolution of conditions that can occur as a result of severe obesity Bullet 5: Calorie counting, prepackaged meals, low carb diets / sugar-free, low fat diets, single food focused diets, meal replacement diets
- Bullet 2: applied a 2 cm Marlex mesh round the upper part of the stomach and separated the stomach into a small upper pouch and the rest of the stomach. Eventual pouch dilatation resulted in unsatisfactory weight loss. Bullet 3: Silicone band lined with an inflatable balloon. This balloon was connected to a small reservoir that is placed under the skin of the abdomen through which the diameter of the band can be adjusted. Inflation of the balloon functionally tightens the band and thereby increases weight loss, while deflation of the balloon loosens the band and reduces weight loss. Bullet 6: Excess weight loss with the laparoscopic adjustable gastric band is lower than that with the gastric bypass or malabsorptive procedures, varying between 28% and 65% at 2 years and 54% at 5 years
- Bullet 3: Gastrectomy was used mainly as the first part of a Duodenal Switch (Saber AA, Elgamel MH, McLeod, MK. Bariatric surgery: the past, present and future. Obesity Surgery Including Laparoscopy and Allied Care, 2008;18(1):121-8 Bullet 4: The Weight Control Information Network at the National Institutes of Health states that some patients who get VSG may eventually get the BPD-DS to allow their weight loss to continue to meet their goals. Weight Control Information Network, National Institutes of Health. Bariatric surgery as a treatment for obesity. National Institute of Diabetes and Digestive and Kidney Diseases. 2011, June. Accessed August 30, 2012 from http://win.niddk.nih.gov/publications/gastric.htm Bullet 5: How is this so? 80% of the stomach is removed, which in turn must lead to smaller portions more frequently, does not make you feel physically hungry, stomach size is equivalent to a roll of dimes Bullet 6: 60-70% of excess weight within the first year (i.e. if your starting weight was 325, expect your weight to be down to 211 by the first year out of surgery)
- Bullet 4: Most of the native stomach and first segment of small intestine are bypassed. However, because the bypassed portion of intestine is where the majority of calcium and iron absorption takes place, anemia and osteoporosis are the most common long-term complications of the RYGBP Bullet 5: Half of the weight loss occurs in the first 6 months, then peaks around 18-24 months. Expected rate of weight loss is estimated to be 70-80% of excess weight in the first year-18 months Bullet 6: The mechanism in which the RYGBP works is complex. After surgery, patients often experience marked changes in their behavior. Most patients have a reduction in hunger and feel full sooner after eating. Patients often state that they enjoy healthy foods and lose many of their improper food cravings. Rarely do people feel deprived of food. These complex behavioral changes are partially due to alterations in several hormones (ghrelin, GIP, GLP, PYY) and neural signals produced in the GI tract that communicate with the hunger centers in the brain. Another mechanism for weight loss after the RYGBP is referred to as the dumping syndrome. Dumping may result in lightheadedness, flushing, heart palpitations, diarrhea and other symptoms early (within 10 to 30 minutes) after eating sweets or foods with a high concentration of sugar. Some people remain extremely sensitive to sweets for the rest of their lives; most patients lose some or all of their sweets sensitivity over time.
- Bullet 2: 28-65% in 2 years, 54% at 5 years Bullet 3: There were 14 studies comprising more than 3,000 patients who had undergone preoperative weight loss. The most common preoperative weight loss goals were either between 5-10% of EBWL. About half the studies found a positive correlation between preop and postop weight loss. Most studies reported at least 12 months of follow up with about 50-75% of excess weight at 12 months. Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obes Surg. 2012;22(1): 70-89 [Research Support, Non-U.S. Gov’t Review.] Bullet 3: At least 60-70% excess weight in first year. Refer to literature from Review of Long-term Weight Loss After Sleeve Gastrectomy. The mean percentage excess weight loss (%EWL) was 62.3%, 53.8%, 43%, and 54.8% at 5, 6, 7, and 8 or more years after LSG, respectively. Bullet 4: At least 70-80% excess weight in the first year and approximately 50% EBW 5 years+
- Bullet 3: A Silastic® ring is placed around the vertically constructed gastric pouch above the anastomosis between the pouch and intestinal Roux limb. The band controls stoma size by prevention of dilatation of the gastric pouch outlet, and is thought to provide better long-term control of the rate of emptying of the pouch and caloric intake. This procedure also includes placement of a gastrostomy tube for decompression of the distal stomach; a radio-opaque ring marker may be placed around the gastrostomy site to facilitate future percutaneous access to the distal stomach. Bullet 4: limb. The band controls stoma size by prevention of dilatation of the gastric pouch outlet, and is thought to provide better long-term control of the rate of emptying of the pouch and caloric intake. This procedure also includes placement of a gastrostomy tube for decompression of the distal stomach; a radio-opaque ring marker may be placed around the gastrostomy site to facilitate future percutaneous access to the distal stomach. Bullet 4: Endoscopic sleeve gastroplasty is a newer type of weight-loss procedure. Endoscopic sleeve gastroplasty reduces the size of your stomach using an endoscopic suturing device without the need for surgery. This procedure is an option if you&apos;re significantly overweight — a body mass index of 30 or more — and diet and exercise haven&apos;t worked for you. although it&apos;s not designed to be a temporary procedure, endoscopic sleeve gastroplasty can be reversed and converted to bariatric surgery. Because the procedure is still new and not in wide use, questions remain about its long-term effectiveness and risks. Bullet 5: EnteroMedics is the developer of vBloc® neurometabolic therapy, delivered by a pacemaker-like device called the Maestro® Rechargeable System, a first-in-class weight loss treatment for obesity and obesity related risk factors, such as high blood pressure or high cholesterol levels. vBloc® Therapy is a non-anatomy altering or restricting, reversible therapy that allows patients to safely lose weight by helping patients feel less hungry, reduce the amount of food eaten at a meal, and feel full longer in between meals. vBloc® Therapy, delivered via the Maestro ® System, is now approved by the Food and Drug Administration for weight loss in adults with a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 with a related health condition such as high blood pressure or high cholesterol levels. Individuals should have first tried to lose weight by diet and exercise in a supervised program within the last 5 years before receiving the Maestro System. Refer to saved website on favorites Bullet 6: Currently only in Europe. In a U.S. Clinical Trial, patients lost an average of 46 pounds (21 kgs) during the first year with the AspireAssist. Outpatient procedure. 20 minute procedure. The AspireAssist works by reducing the calories absorbed by the body. After eating, food travels to the stomach immediately, where it is temporarily stored and the digestion process begins. Over the first hour after a meal, the stomach begins breaking down the food, and then passes the food on to the intestines, where calories are absorbed. The AspireAssist allows patients to remove about 30% of the food from the stomach before the calories are absorbed into the body, causing weight loss. To begin therapy, a specially designed tube is placed in the stomach. The A-Tube is a thin tube that connects the inside of the stomach directly to a discreet, poker-chip sized Skin-Port on the outside of the abdomen. The Skin-Port has a valve that can be opened or closed to control the flow of stomach contents. The patient empties a portion of stomach contents into the toilet after each meal through this tube by connecting a small, handheld device to the Skin-Port. The aspiration process is performed about 20 minutes after the entire meal is consumed and takes 5 to 10 minutes to complete. The process is performed in the privacy of the restroom, and the food is drained directly into the toilet. Because aspiration only removes a third of the food, the body still receives the calories it needs to function.
- Research over the past two years is confirming that women who have gastric bypass or adjustable gastric band surgery before becoming pregnant are less likely to have obesity-related maternal or fetal complications, such as spontaneous abortion, preeclampsia, and birth trauma and birth defects. Bullet 1: The American College of Obstetricians and Gynecology recommends women avoid becoming pregnant for 18 months after surgery, the period with the fastest weight loss. for 18 months after surgery, the period with the fastest weight loss. However, at least one study shows that maternal and fetal outcomes are similar between women who conceive before the 18-month time period. Bullet 2: Have the following lab work performed during your initial prenatal visit, then, if normal, once each trimester: complete blood count, electrolytes, glucose, iron studies (including ferritin), vitamin B12, red blood cell folate, and 25-hydroxyvitamin D. Bullet 3: At least 60-70 grams / day Bullet 4: Not necessary until 2nd or 3rd trimester. Refer to pregnancy handout
- At 10 minutes before the published end time, presenter or facilitator invite participants to answer this question in text. Wait at least 60 seconds for replies. Thank participants for attending and for responding and ask a Follow up question verbally: “What will you DO with the information you learned?” Discuss responses, then ask of all participants “What else do you have questions about regarding today’s topic?” Wait a minimum of 60 seconds. Answer questions and provide additional resources as appropriate.
- In addition, we would like to invite our MFLN Service Provider partners (such as DoD, branch services, Guard and Reserve service providers and Cooperative Extension professionals) to continue the discussion in our private and moderated LinkedIn group. Please click the link to join the group or send us an email. We look forward to hearing from you!