Bariatric Surgery for

Morbid Obesity
Naomi Stamper
NFSC 670
3/12/14
Pre-Test
Take 5 minutes to complete the pre-test
At the end of the presentation you will be
given 5 minutes to complete the post-test
Learning Objectives
1. Students will be able to name the major
nutritional concerns for patients who have
undergone bariatric surgery.
2. Students will be able to describe the diet
progression of patients who have undergone
bariatric surgery and list the major elements
of the post-bariatric surgery diet.
3. Students will be able to list the major health
benefits of undergoing bariatric surgery.
Morbid Obesity-Definition
100 pounds over IBW
OR
BMI 40
OR
BMI > 35 plus comorbidities



(What is Morbid Obesity?, n.d.)
Untreated Morbid Obesity Health Risks
(Obesity Complications - Diseases and Conditions, n.d., Obesity-Related Health Conditions, n.d.)
Morbid
Obesity
Type II
Diabetes
HTN
Heart Disease
Osteoarthritis
Sleep Apnea
GERD
Skin Problems
Depression
Infertility
Non-alcoholic
fatty liver
disease
Qualifications
Unsuccessful weight loss attempts through
diet and exercise

AND

BMI 40
OR
BMI > 35 with comorbidities
(Collazo-Clavell, Clark, McAlpine, & Jensen, 2006)
Qualifications for Youth
6 or more months of weight loss attempt
unsuccessful
Reached physiologic or skeletal maturity
Girls: 13 or older
Boys: 15 or older

BMI > 40 with comorbidities
OR
BMI > 50 with less severe comorbidities

(Adolescent Bariatric Surgery, n.d.)
Evaluation Criteria for Bariatric Surgery
Nutrition and Weight History
Attempts to lose weight with diet and exercise
unsuccessful
Medical Conditions
Some health conditions worsened by surgery
Psychological Status
Mental health conditions contributing to obesity
Motivation
Willingness and ability to make lifestyle changes
Age
Risks increase over the age of 65
Separate criteria for those under 18
(Collazo-Clavell, Clark, McAlpine, & Jensen, 2006)
Bariatric & Metabolic Interdisciplinary
Clinic-Stanford Hospital and Clinics
Bariatric Surgery Requirements
http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalS
urgery/bariatricsurgery/treatment/requirements.html

Questionnaire:
http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/bariat
ricsurgery/documents/15-2711-1_FINAL%20-%20English%20Internet%2007-10.pdf

Food Diary:
http://stanfordhospital.org/PDF/clinicalNutrition/BariatricNutrition.pdf

Psychological Evaluation:
http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/bariat
ricsurgery/documents/psychological.pdf

(Program Requirements for Bariatric Surgery, n.d.)
Bariatric & Metabolic Interdisciplinary
Clinic-Stanford Hospital and Clinics
Bariatric Surgery Team
Registered Dietitian
Psychologist
Cardiologist
Education and Support Groups
Surgeon

(Our Team - Bariatric Surgery, n.d.)
Bariatric & Metabolic Interdisciplinary
Clinic-Stanford Hospital and Clinics
Post Surgery Patient Care:
2 night hospital stay
Patient is expected to get up and walk around
Meeting with dietitian before discharge
Clear liquid diet limited to a medicine cup every
15 minutes

(Bariatric Surgery Frequently Asked Questions, n.d.)
Types of Bariatric Surgery
Roux-en-y
Vertical Sleeve Gastrectomy
Adjustable Gastric Banding
Vertical Banded Gastroplasty
Duodenal Switch
Biliopancreatic Diversion




Roux-en-Y
https://www.youtube.com/watch?v=VapTpLqaxG8

Restrictive and malabsorptive

Advantages:
More weight loss than restrictive only
Faster weight loss
Long-term weight loss maintained

Disadvantages/Complications:
Dumping syndrome
Follow-up operations may be necessary
Gallstones
Leakage
Stomach can be stretched out
Nutrient deficiencies (protein, iron, B12, calcium)



(Gastric Bypass Roux-en-Y, n.d.)
Vertical Sleeve Gastrectomy
https://www.youtube.com/watch?v=IjxFjI69bEI
Restrictive

Advantages:
Better nutrition status after surgery
Suitable for patients too heavy for other surgeries
Resulting weight loss can improve other medical conditions
Does not involve changing the stomach-intestine connection
Short procedure time

Disadvantages/Complications:
Gastritis
Leakage from the stomach
Decreased nutrition status
Vomiting from eating too much
Slower weight loss


(Daller, 2013)
Adjustable Gastric Banding
https://www.youtube.com/watch?v=Ac-U5ezXbP4
Restrictive

Advantages:
Least invasive weight loss surgery
Does not involve changing the stomach-
intestine connection

Disadvantages/Complications:
Can cause blockage between upper and
lower stomach
Band can slip out of place
Infection around access port
Esophageal dilation
Decreased nutrition status


(Thompson, 2011)
Vertical Banded Gastroplasty
https://www.youtube.com/watch?v=Eg_rhFh2ODA
(Kassel, 2013, Kendrisk, M., 2006)
Restrictive

Advantages:
Low risk of complications during surgery
Does not involve changing the stomach-intestine
connection

Disadvantages/Complications:
Stomal blockage
GERD
Surgery revision often necessary
Less weight loss


Duodenal Switch
https://www.youtube.com/watch?v=Sdks7Muv9LE
(Kendrisk, M., 2006)
Restrictive and malabsorptive

Advantages:
Avoids dumping syndrome
Improved weight loss
Reductions in comorbidities

Disadvantages/Complications:
Nutritional deficiencies
Technically difficult


Biliopancreatic Diversion

Restrictive and malabsorptive

Advantages:
Improved weight loss in patients with
BMI > 50
Reductions in comorbidities

Disadvantages/Complications:
Nutritional deficiencies
Technically difficult
Dumping syndrome
Diarrhea
Stomal complications


(Kendrisk, M., 2006)
MNT Post Gastric Bypass Surgery
Goals:
Low simple sugar to decrease dumping
Allow time for the staples in the stomach to heal
Prevent the stomach from stretching
Focus on protein and hydration

*For lab band procedures, recommended to progress more quickly to solids because it
is less invasive and purely restrictive; risk for dumping is less


1-2 days Clear liquid; low simple sugar
2-4 days Full liquid
4 days-8 weeks Pureed foods
8-12 weeks Mechanical soft
12+ weeks Regular diet
(Dugdale, 2012; Furtado, 2010; Gastric bypass diet-What to eat after the surgery, 2011; Heber et al., 2010)
MNT Post Gastric Bypass Surgery
Nutrient
Reason for Potential Inadequacy Potential Complications Resulting From
Deficiency
Hydration Decreased intake due to size of stomach Dehydration
Protein Decreased intake due to size of stomach
Decreased absorption because of bypass of
duodenum
Loss of LBM
Edema
Delayed wound healing
Lethargy
Rash
Calcium Altered calcium metabolism
Decreased absorption due to decreased acidity
Decreased bone mass
Iron Decreased intake
Decreased absorption due to decreased acidity and
bypass of the duodenum
Feeling tired, weak
Decreased work performance
Difficulty maintaining body temperature
Decreased immune function
Glossitis
B12 Decreased absorption due to decreased acidity and
IF production
Feeling tired, weak
Rapid heartbeat/breathing
Stomach upset; weight loss
Pale skin
Sore tongue
Bruising
Diarrhea/constipation
Prolonged neurological damage
(Furtado, 2010; Riedt, Brolin, Sherrell, Field, & Shapses, 2006; Manchester & Roye, 2011; Vitamin B12 Deficiency Causes, Symptoms, and Treatment, n.d.)
Schedule for Clinical Monitoring After
Gastric Bypass
(Heber et al., 2010)
Benefits Beyond Weight Loss
Decreased TG and increased HDL
Decreased cardiometabolic risk
Reduced comorbidities
Reduced hypertension
Decreased dyslipidemia
Decreased sleep apnea
Improvement in osteoarthritis
Reduced fatty liver

(Lanzi et al., 2011; Gill et al., 2011; Heber et al., 2010)
Benefits Beyond Weight Loss
Reductions in diabetes medications d/t
Increased insulin secretion
Improved insulin sensitivity
Bypassing the intestine restores -cell function
Directly related to the amount of intestine
bypassed
(Kashyap et al., 2013; Mingrone & Castagneto, 2009)
Proposed Mechanism
glucose reaches the L cells of the distal ileum faster
L cells release glucagon-like peptide 1 (GLP-1)
Effects of GLP-1
Stimulates -cell proliferation
Increases release of insulin
Improves insulin sensitivity
Inhibits glucagon
(Nannipieri et al., 2013; Sternini, Anselmi, & Rozengurt, 2008)
Success Rate
About 80% of patients lose >70% EBW within
12-18 months
Patient characteristics that have greatest
success rates:
Social support
Stress management
Motivation for physical activity + dietary changes

(Richardson et al., 2009; Sorace & LaFontaine, 2013)
Patient Background
Chris McKinley
Male
37 years old
Single
Office Manager
Lives with a roommate
Chief complaint: I am here for weight loss
surgery
Admitted for Roux-en-Y Gastric Bypass Surgery
Qualifications for bariatric surgery: BMI > 40

Assessment
Patient Medical History
Onset of disease: lifelong obesity
Type II Diabetes Mellitus
Hypertension
Hyperlipidemia
Osteoarthritis
Family history:
Father: type II DM, CAD, HTN, COPD
Mother: type II DM, CAD, osteoporosis


(Obesity-Related Health Conditions, n.d.)
Medications
Medication Use Interactions
Metformin Oral hypoglycemic agent Alcohol alters glycemic control
Cinnamon effects
Bitter melon effects
Lantus Long-acting insulin Alcohol alters glycemic control
Cinnamon effects
Bitter melon effects
Lasix K
+
depleting loop diuretic excretion of K, Mg, Na, Cl, Ca
Lovastatin Cholesterol-lowering Red yeast rice toxicity
Grapefruit effect
Niacin toxicity
(Drugs, Diseases & Conditions, Clinical Procedures, n.d.)
Physical
Temperature: 98.9 F
BP: 135/90
Pulse: 85
Resp. Rate: 23
Heart: normal rate, regular rhythm
HEENT: WNL
Extremities: ecchymosis, abrasions, petechiae on
lower extremities, 2+ pitting edema
Abdomen: obese, rash present under skinfolds
(Todd, 2009, Cowdell & Radley, 2014)
Patient Diet
Post-op Stage 1: liquid diet
2-3 oz at a time
Avoid carbonation, caffeine
Avoid simple sugars
I/Os
Date 2/23 0701-2/24 0700
Time 0701-
1500
1501-
2300
2301-
0700
Daily
Total
IN
PO 0 60 100 160
IV 680 680 680 2040
IV piggyback 0 0 0 0
TPN 0 0 0 0
Total intake 680 740 780 2200
OUT
Urine 700 710 820 2230
Emesis
Output
0 0 0 0
Other 0 0 0 0
Stool 0 0 0 0
Total output 700 710 820 2230
Net I/O -20 +30 -40 -30
Net since admission (2/23) -20 +10 -30 -30
Labs
Potassium (3.5-5.5) 5.8 (H) Related to recent weight loss or diabetes*
Glucose (70-110) 145 (H) Poorly controlled blood glucose
Metabolic stress (post surgery)
Probable decrease after surgery
HbA1C (3.9-5.2) 7.2 (H) Elevated blood glucose
Probable decrease after surgery
CPK (55-170) 220 (H) Possibly elevated due to statins or recent weight loss
Cholesterol (120-199) 320 (H) Dyslipidemia (insulin resistance increased hepatic
FA flux from dietary sources and increased lipolysis)
Possibly lowered after surgery
HDL-C (>55) 32 (L)
VLDL-C (7-32) 45 (H)
LDL (<130) 232 (H)
LDL/HDL ratio (<3.55) 7.5 (H)
TGs (40-160) 245 (H)
(Pipe-thomas, 2013; Dugdale, 2013)
Anthropometrics
Height: 70 inches = 177.8 cm
Current Weight: 410 lbs = 186.4 kg
UBW (6 months ago): 434 lbs = 197 kg
% UBW = 95%
IBW: 166 lbs = 75.5 kg
%IBW = 247%
Weight loss: 5% over 6 months
BMI: 59
Weight goal 18 months post-surgery:
IBW = 166 lbs
EBW = 244 lbs
70% EBW = 170.8 lbs
Current weight 70% EBW = 239 lbs = 109 kg
12-18 month goal: 239 lbs = 109 kg

(Richardson, Plaisance, Periou, Buquoi, & Tillery, 2009; Richardson et al., 2009)
Estimate of Needs
Energy
<1000 kcals recommended*
Based on goal weight using Mifflin x 1.3 = 2021 kcal
Protein
65-70 g/day recommended*
Based on goal weight and 0.8g/kg = 87.2g/day
Fluid
2,000 ml recommended*
1 ml/kcal = 2,021 ml
30-35 ml/kg = 5,592- 6,524


*(Dietary Guidelines After Bariatric Surgery Patient Education, n.d.)
Nutrition Diagnosis
1. Food- and nutrition-related knowledge deficient
related to limited knowledge about dietary
changes necessary (due to being s/p roux-en-y
gastric bypass) as evidenced by limited prior
nutrition education (only attended pre-operative
nutrition program)

2. Inadequate fluid intake related to limited ability
to drink enough fluid (due to being s/p roux-en-
y gastric bypass) as evidenced by negative input/
output balance over last 24 hours (-30 ml).
Goals
Patient consumes 65-70 g of protein/day
Patient consumes a multivitamin daily
Patient consumes calcium supplement daily with
morning meal
Patient consumes vitamin B12 supplement daily in the
morning
Patient consumes iron supplement daily at meal times
apart from calcium supplement
Patient advances to stage 3 bariatric diet (pureed
foods) in 1-2 weeks
Patient attends hospital support groups once/month
Increase fluid intake to 2,300 ml

Furtado, 2010
Nutrition Intervention
Nutrition Education
(http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/bariatricsurgery/resources/post-op.html )
Pureed diet and how/when to advance to pureed diet
Importance of protein and how much to consume daily
Importance of staying hydrated and how much fluid to consume daily
Importance of supplementation and how much to take:
Calcium
Iron
B12
Multivitamin
Importance of physical activity
Importance of social support (maintaining social interactions and attending support groups)
Referral to personal trainer to help patient increase physical activity
Referral to social worker at hospital to help patient stay involved with hospital
support groups and other social support networks
Have patient fill up a water bottle with 2,300 ml of water and carry around a 3
ounce cup in order to increase fluid consumption

(Furtado, 2010; Jacobi, Ciangura, Couet, & Oppert, 2011; Livhits et al., 2011)
Monitoring and Evaluation
Fluid consumed daily by patient in one week
Protein consumed by patient in one week
Dietary changes made by patient (pureed diet) in one week
(including daily caloric intake)
Adherence to supplementation regiment in one week
Sodium and BUN in one week
Weight in one week
Minutes of physical activity by patient per day in one week
Albumin, prealbumin in one month
Vitamin B12, calcium, and iron status in 3 months

ADIME
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Any Questions?
Post-Test
Take 5 minutes to complete the post-test
When everyone is done, pass them to the
front