surgery Too Lean a Service? Mary OKane Clinical specialist - - PowerPoint PPT Presentation

Nutritional aspects of bariatric surgery Too Lean a Service?

Mary O’Kane Clinical specialist dietitian Leeds Teaching Hospitals NHS Trust BOMSS council member

Does surgery result in a better diet?

• Decreased intake of sweets and sugary drinks but tolerance

increases with time, high intake of salty snack foods (Brolin et al

1994)

• Decrease in energy from protein and increase from sugar and

alcohol, decrease in prepared meals and increase in sweet foods (Lindroos et al 1996)

• Patients may end up snacking more and eating less regular

meals (grazing), poor intake of protein, vitamins and minerals, intakes of iron, zinc, vitamin D below requirements (Naslund et al

1998)

• 37% had resumed snacking 1 year after gastric bypass (Elkins at al

2005)

• Cravings for sweets results on significant less weight loss

(Burgmer et al 2005)

Self reported post operative dietary compliance and weight loss after gastric bypass

Sarwer et al. SOARD 4 (2008) 640–646

Role of the dietitian

As a core member of the MDT:

• Initial assessment of diet, nutritional status and

eating behaviours (and psycho-social factors)

• Advice and support on the appropriate diet
• Monitoring of micronutrient status
• Individualised nutritional supplementation,

support and guidance to achieve long-term weight loss and weight maintenance

NICE CG43 Obesity 2006

NICE CG43 Obesity Bariatric surgery

All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months The person has been receiving or will receive intensive management in a specialist obesity service The person commits to the need for long-term follow-up.

Too lean a Service? Dietetic input

Pre-referral

• No documented evidence of pre-referral

dietetic input in 65% cases Post-referral

• 22% patients not assessed by a dietitian prior

to surgery

• 27% patients, no evidence of dietetic input

prior to surgery

Adequacy of dietetic input pre-surgery

Too lean a service?

Adequate dietetic assessment /education for patient Number of patients¹ (for those with evidence) % for those with evidence Number of patients (for all patients) % for all patients

Yes 195 92.9 200 77.5 No 15 7.1 58 22.5 Subtotal 210 258 Insufficient data 27 123 Total 237 381

MDT meeting

Discharge summary

Too Lean a Service?

Poor / unacceptable

• Diet information (10 patients)
• Emergency contact (9 patients)

Inappropriate discharge prescription

• Lack of vitamin supplements (10 patients)
• Inappropriate vitamin B12 (1 patient)

Follow-up

Too lean a service

Follow-up clinics Number of hospitals (105) Bariatric surgeon 95 Dietitian 86 Specialist nurse 58 Psychologist/ psychiatrist 24 Bariatric physician 21 Other 2

Types of follow-up clinic 72/102 hospitals gave early telephone follow-up

Dietary related problems following bariatric surgery

• Dehydration
• Nausea and vomiting
• Regurgitation
• Food intolerances
• Constipation
• Diarrhoea /steatorrhea
• Dumping syndrome
• Loss of appetite /

Anorexia

• Fear of stretching the

pouch

• Return of appetite
• Alopecia

Bariatric procedures, vitamins and minerals

Vitamin mineral deficiency / Surgery

Pre-surgery AGB Sleeve gastrectomy RYGB BPD +/- DS Thiamin Uncommon Uncommon Uncommon Uncommon Uncommon B12 10-13% Uncommon Uncommon 12-33% Uncommon Folate Uncommon Uncommon Uncommon Uncommon Uncommon Iron 9-16% of women Uncommon 20-49% Vitamin A Uncommon Rare Rare Rare but can

• ccur

50% at 1 year 70% at 4 years Vitamin D 60-70% Common

• V. Common

Zinc Uncommon May occur Common Protein Uncommon May occur May occur May occur May occur

Protein –energy malnutrition / protein malnutrition

• Food intolerance / Eating

habits /Compliance

• Anorexia / loss of

appetite

• Stricture / too tight a

band

• Diarrhoea
• Requirements of BPD/ DS

higher

Implications of “Too Lean a Service?”

• All patients being considered for bariatric surgery should

receive dietary assessment and education prior to referral and definitely prior to surgery

• The dietitian is the key MDT member to undertake this

assessment, education and provision of follow-up support

• Psychological assessment and support should be

available

• Dietetic advice including vitamin and mineral

supplements and discharge advice needs to be clearly documented

On-going work

• BOMSS training for dietitians and other healthcare

professionals

• “Providing bariatric surgery” - the BOMSS

Standards for Clinical Services & Guidance on Commissioning

• Clinical Reference Group on Morbid Obesity –

comprehensive patient pathway

• Vitamins and minerals and pre- and post-surgery

nutritional monitoring guidelines–work in progress