DISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

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1 DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this photo and/or video. If you don t want your photo taken, please let us know. Thank you! ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

2 Bariatric Surgery: A case based approach (nutrition) February 15, 2018 Karmella Thomas, RDN, LD, CDE *dietetic intern Jessica Blauenstein

3 Energy Balance Obesity Continuous overconsumption of calories paired with a sedentary lifestyle, sleep deprivation, genetics, or metabolism issues can contribute to obesity

4 How is Nutrition Involved and the Recommendations Lifestyle modification/patient education is usually implemented for treatment Weight loss (physical activity/diet modification) Reduce intake of fatty foods, empty calories, nutrient poor foods Increase intake of fruits, vegetables, low fat dairy, whole grains

5 NIH Guidelines to Selecting Obesity Treatment Treatment BMI Category >40 Lifestyle Therapy* With Comorbid. With Comorbid. YES YES YES Pharmacotherapy With Comorbid. YES YES YES Surgery With Comorbid. YES Lifestyle therapy - diet, physical activity, and behavioral therapy - is the cornerstone of obesity treatment *Consider pharmacotherapy only if a patient has not lost 1 pound per week after 6 months of combined lifestyle therapy.

6 Gastric Bypass Small stomach pouch created to hold about 1 ounce in volume

7 Gastric Bypass BMI: >40, or 35 with weight related morbidities, or if lifestyle interventions have been ineffective Education/evaluation prior to clearance Weight loss is generally 60-80% of excess weight lost pound female expect pounds of weight loss

8 Complications Stomal stenosis (5% of patients), wound infection (3%), bowel obstruction (3%), leak (2%), gastrointestinal bleeding (2%) Dumping syndrome in 70% of patients Hypoglycemia Digestive issues difficulty swallowing, indigestion, diarrhea, constipation, or intolerance to certain foods Gallstones and Kidney stones Hair loss (first 3-6 months post op) and sagging skin Alcohol abuse Nutrient deficiency: Vitamin B12, Maybe Iron/Zinc/folic acid

9 Sleeve Gastrectomy 75%-90% of stomach new stomach size/shape of a banana May decrease ghrelin levels/increase GLP-1 and GLP-2 BMI: >40, or 35 with weight related morbidities, or if lifestyle interventions have been ineffective. Education/evaluation prior to clearance.

10 Complications Leakage (5% of patients) Acute Hemorrhage (postoperative intraluminal bleeding) Stricture-(symptoms include food intolerance, dysphagia/nausea/vomiting) Intra-abdominal abscess GERD (may exacerbate) Nutrient deficiency Vitamin B12 Maybe Iron/Zinc/folic acid

11 Changes in comorbidities 5 years after Gastric Bypass Comorbidity Remission Improved No Change Worsened changes Type % 7.1% 10.7% 14.3% Diabetes Dyslipidemia 62.3% 30.2% 7.5% 0% GERD 60.4% 6.3% 27.1% 6.3% Hypertension 70.3% 21.9% 3.1% 4.7% Sleep Apnea 44.2% 51.2% 2.3% 2.3% Peterli, M. R. et. al (2018, January 16). Effect of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Morbid Obesity. Retrieved January 23, 2018, from

12 Changes in comorbidities 5 years after Sleeve Gastrectomy Comorbidity Remission Improved No Change Worsened changes Type % 15.4% 11.5% 11.5% Diabetes Dyslipidemia 42.6% 41.2% 16.2% 0% GERD 25% 9.1% 34.1% 31.8% Hypertension 62.5% 25% 6.3% 6.3% Sleep Apnea 45.8% 50% 0% 4.2% Peterli, M. R. et. al (2018, January 16). Effect of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Morbid Obesity. Retrieved January 23, 2018, from

13 Excess BMI loss 1-5 years post surgery Peterli, M. R. et. al (2018, January 16). Effect of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Morbid Obesity. Retrieved January 23, 2018, from

14 Role of the Registered Dietitian Provide preoperative nutrition education regarding lifelong changes after surgery. Reduced volume of stomach and amount of food/beverages that can be tolerated. Potential for dehydration after surgery. Importance of chewing thoroughly and practicing mindful eating. Structured eating and recognizing hunger/satiety cues. Nausea/vomiting Dumping syndrome with Roux-en-Y gastric bypass (RYGB) The necessity for lifelong, daily intake of vitamin and mineral supplements after RYGB and sleeve gastrectomy. Possible risks associated with alcohol intake, especially after RYGB. Dietary progression after surgery. Provide a preoperative weight loss diet plan, which may be helpful in reducing liver volume to lower surgical risks. Provide patients with postoperative nutrition education.

15 Early postoperative period (6 to 12 months): Evaluate intake of adequate protein and fluids. protein needs should be based on lean muscle mass 60 to 80 g/d is commonly recommended Monitor the use of vitamin and mineral supplements, and encourage compliance. Monitor adverse effects such as nausea and vomiting, constipation, diarrhea, and dumping syndrome.

16 Late postoperative period (more than 12 months): Assess nutrition-related laboratory values, and recommend adjustments in supplementation/dietary intake as needed. Recommendations should be based on preventing deficiencies Ferritin concentration less than 50 ng/ml is associated with hair loss/thinning. Serum iron concentration less than 50 mcg/dl is associated with iron deficiency adverse effects. Elevated total iron-binding capacity indicates iron deficiency progressing to anemia. Decreased mean corpuscular volume indicates microcytic anemia, possibly due to iron deficiency. Assess and educate the patients as necessary on long-term lifestyle behavior changes regarding diet and activity levels.

17 Post op guidelines Chew, chew, chew! muscles are not strong enough to properly grind down food Drink, drink, drink! Wait at least 30 minutes after a meal to drink fluids. When you do drink, sip. Don t gulp or use straws initially. Do not drink alcohol. Stop eating when feel satisfied Meet protein needs. At meals, consume sources of protein first Eat 3-5 meals daily Take vitamins daily (multivitamin, vitamin B-12, vitamin D, and calcium citrate)

18 First 2 weeks after surgery Nutrition priorities: Meet fluid needs, Eat protein foods, first, Continue to avoid high-fat and high-sugar foods, Always take vitamin and mineral supplements. Breakfast: 8 to 10 ounces of full liquid. Wait 1 hour and take 2 chewable complete multivitamins, vitamin B-12, and vitamin D. Slowly sip: 8 to 10 ounces of clear liquid in between breakfast and lunch. Lunch: 8 to 10 ounces of full liquid. With lunch, take 1 calcium chew or 1 tablespoon liquid calcium. Slowly sip: 8 to 10 ounces of clear liquid in between lunch and dinner Dinner: 8 to 10 ounces of full liquid. With dinner, take 1 calcium chew or 1 tablespoon liquid calcium. Slowly sip: 8 to 10 ounces of clear liquid. You may take additional calcium if you require more.

19 Week #1 Sample Meal Plan 2 weeks after surgery Before Breakfast Sip at least 8 ounces of fluid Breakfast Scrambled egg whites OR Low fat cottage cheese or light yogurt (less than 25 grams of sugar per serving) Wait ½ hour (30 minutes), then sip on at least 16 ounces of fluid Between Breakfast and Lunch: 2 chewable multivitamins, B-12, and vitamin D Lunch Tuna or egg salad made with light mayo or hearty bean soup Calcium supplement Between Lunch and Dinner Wait ½ hour (30 minutes) then begin to sip on at least 16 ounces of fluid before you eat again Dinner Crockpot chicken cooked in canned tomato juice or chickpea veggie burger with mustard Calcium supplement After Dinner Sip 8 to 16 ounces of fluid until bedtime Calcium supplement if needed (postmenopausal women)

20 Vitamins and Minerals Two chewable complete multivitamins in the morning. One chewable/liquid calcium supplement at lunch and 1 at dinner. Wait 2 hours or more between each calcium dose. One vitamin B-12 tablet (under the tongue) anytime during the day. Vitamin D-3 (3,000 IU) anytime during the day.

21 Case #1 60 year old female that had Gastric Bypass surgery on 4/1/2013 Originally seen in office for insurance requirement mid 2011 but continued beyond that History of type 2 diabetes, neuropathy, hypothyroidism, sleep apnea, hyperlipidemia, and hypertension Currently on metformin, synthroid, simvastatin and Cymbalta Not currently taking supplements

22 In her initial 12 weeks, lost 8.9% of her initial weight Burned 3,000 calories per week in exercise Ate 7 cups of veggies/fruits per day Reduced portions and focused on lean proteins with healthy carbohydrates Decided to not have surgery until she struggled with her foot pain and regained weight; surgery in 2013 Within the first year she lost 36% of her initial weight (79.5#) and blood sugars were completely within normal limits

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24 Case #1 At 1 year mark, she was off all medications and had WNL blood work, including vitamin B12, iron, and vitamin D Around 13 months post op, she developed symptoms related to hypoglycemia and managed with her diet By 2016 (3 years later), she had gained about pounds from her lowest weight Early 2017, continued to gain, and over the year, had gained an additional 30 pounds from lowest weight Blood sugars started to elevate to 113, 108, 126 on fasting blood work Hemogloblin A1c went to 6.4% in October 2017

25 Case #1 Important points: Had extensive support initially prior to surgery, 3 months post-op and continued for the next 4+ years with monthly follow up Lifestyle changes (change in job, death of parent, navigating new eating pattern) are hard and require support Learning to deal with and manage hypoglycemia that ranged 1-5 times per week Realize exercise HAD to be a part of her routine for life Adjusting to learning I have diabetes again. I thought this surgery would cure my diabetes

26 Case #2 17 year old female with social challenges History of depression/anxiety, mental health diagnosis Participated in structured meal replacement program and lost 28 pounds 3 years ago, but couldn t maintain and go to high school Left program and went on to have gastric bypass surgery in 2017 Did not patriciate in structured weight loss program before surgery specific for bariatric surgery Seen in office 3 months post-op due to challenges with nutrition

27 Case #2 Weight in high school ranged between lbs Peak weight was 270 pounds at age of 17; 66 tall *prior to surgery BMI 43.6 History of Binge eating Blood sugars averaged around 120 before final decision to have surgery MFT counselor seen on a regular basis

28 Initial appointment 3 months post-op Down 54 pounds (from 270 pounds) In school 3 days per week and a high level of stress on those days Already experienced dumping syndrome Nutrition Assessment: Lost 20% of starting weight already! Not taking any supplements Eating higher fat foods ( junk food or whatever I am craving for ) Consuming about 30 grams of protein and not drinking protein shakes Not exercising

29 Follow up appointment January 24, 2018 in office appointment Weight: lbs Lost 92.5 lbs (-65.7% loss of initial weight) Eating 2-3 meals per day Getting in around grams of protein Only taking her multivitamins, not others Not exercising Tried to get a job, but it was too much for her Not open to doing body composition

30 Important notes Struggling with navigating eating such smaller portions of foods and finishing before others are done eating Not used to eating so often Challenged by the need to get in a routine with her supplements Body image issues happiness but unfamiliar body Reinforce food as fuel and a benefit to the body in small, frequent meals 24 hour recall B-nothing L-one slice of meat loaf S - can of soup - bean lentil soap D - gold fish

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