Bariatric Nutrition Insights and Guidelines

Hi, this is Stephanie Wagner, bariatric dietitian, and we're going to talk about bariatric nutrition, why it's important, who is a candidate for bariatric surgery, and the different surgeries that are offered. The taping of this video is early of 2018, and these surgeries do change pretty quickly, so that's why I wanted to note when I'm recording this, because it's amazing how fast it will change. A quick introduction about myself. I've spent the past eight and a half years focusing on bariatric nutrition. I'm a registered dietitian with a master's in food and nutrition, and my first job was in weight loss surgery and fell in love with it. That's all I've been doing ever since. I've worked for three weight loss surgery clinics with seven different surgeons, which means that you learn a lot about how different doctors approach things. I am a published cookbook author specific for bariatric recipes. And I own and operate a website, foodcoach.me. It is a weight loss surgery nutrition membership website. So I now have the privilege of taking my practice solely online and helping those who need further care after surgery. And should you have any questions for me, I'm happy to email at stuffatfoodcoach.me. So like I mentioned, it's a very rapid moving. field to work in weight loss surgery, there's really not much standard, in terms of standard guidelines for these surgeries. So there is a governing body over bariatric surgery clinics. It's called the ASMBS, the American Society of Metabolic and Bariatric Surgery. This is the accrediting group that would look over bariatric surgery. Surgery centers, bariatric surgeons, and essentially they come out with the best practice guidelines. Anything from what the surgeon should be doing in the OR, when they should progress to foods, what vitamins they need. But they really don't give specifics on exactly how a weight loss surgery nutrition diet and lifestyle should look. So there is a lot of... differences in opinions. So patients do sometimes get the same information, sometimes they get different information even if their friend went somewhere else down the street. So there's varying philosophies and opinions. There's new research. It's always changing. So it is important for an RN or an RD to know his or her role in the process. It's definitely a team approach. This is certainly an area where you're working with doctors. nurses, exercise physiologists, psychologists, dietitians, patients, there's a lot of people and having a good relationship with the surgeon is key. So if you're working primarily with weight loss surgery patients, then you do want to have a really good understanding of what they're hearing from their surgeon. But sometimes you are seeing this patient and maybe it's not, you're not seeing them for bariatric surgery, they just happen to be a bariatric surgery patient. And in those situations, it's still helpful to ask the patient what they have been told, what they're hearing to get a bigger scope of what's going on with what their recommendations have been. Let's go through the surgeries themselves. So like I said, these change quite a bit. Even the ones we're going to go over on here, one is already pretty outdated and one is really new. So it is important to know all of them, but you may see surgeries that are weight loss surgeries that really... kind of archaic and aren't around anymore. Right now the gastric sleeve is probably the most popular. Maybe it's a second to the gastric bypass which we'll go over next but depending on the statistics of this year it has been the number one weight loss surgery for the past few years and the numbers as far as how many people have weight loss surgery At one point it was about 220,000 people a year in the US and I think it's kind of leveled off around there But of course once once I surgery they're always a post-op patient So as you can imagine that number is only getting bigger of how many people in our nation have had a weight loss surgery with the gastric sleeve at the picture of the stomach here this is a traditionally a laparoscopic procedure and the surgeon goes in and they essentially just remove about 80% of the stomach and this includes the fundus of the stomach that curvature piece that goes up from the stomach and it doesn't reroute anything. A lot of patients are really comfortable with the surgery because it's just limiting the size of the stomach, but it's not altering their digestive system. Their GI tract is still the same. This as a visual, it's a loose visual, but you might say if someone had a sleeve, they went from a football-sized stomach to a banana-sized stomach. So it gives you an idea of their limitations. And we'll go through what they have to focus on when they eat, but that gives you an idea of the restriction that they have. There's also a lot of hormones that are produced in the curve of that stomach. Ghrelin is the hunger hormone. It's the one that really drives hunger up. And because of the removal of that portion of the stomach, a lot of studies show patients report about 70% decline in that ghrelin. So you're not hungry as often, portion sizes are smaller, and weight loss is really successful with the surgery. And this is true of all the surgeries, but surgery weight loss is most successful in the first year. And that's really the time that's most crucial for patients to be focusing on a sustainable long-term plan because they're going to see the most results in the first year as their metabolism is still up. Hunger is down, portion is down, but if they get off track or they fall into bad habits, their weight loss will stall out by the year, probably about a year mark, and then their hunger goes up. They can eat carbs more easily. Carbs go through faster. Carbs make them hungrier. But as you can imagine, when you lose weight, your metabolism comes down because you're eating less calories, so you're burning less calories. So if their metabolism has come down, but now their hunger... coming back because of poor quality of food that is where we can start seeing some regain happen and unfortunately that does happen about 30% of patients will experience some amount of regain some more than others but a patient is considered to be a success if they have lost half the weight they were overweight so if someone was a hundred pounds overweight they lost 50 pounds they kept it off then that would be a success So anyway, this is a little bit more about the post, you know, beyond that first year. So the first year is really important to make sure someone's on a good diet plan, they're on their vitamin routine, and they're just setting themselves up for those habits long term. That's the gastric sleeve. The gastric bypass, we are now rerouting anatomy. I've heard a lot of doctors refer to this surgery as kind of the Cadillac of surgeries. It's probably Of the surgeries that are still popular, it's the one that's been around the longest. So it's a good operation if someone has a significant amount of weight to lose. And it has two primary methods going on here. So what they do, if I can describe this image, at the top of the stomach, they remove a small portion where it says small gastric pouch. They make an incision and they make a small stomach up at the top. Then they go back down into the small intestine, they make another incision, and then they carry that portion of the small intestine up to meet the small stomach. So now they're bypassing the larger part of the stomach and the duodenum, that first section of small intestine. So this surgery is effective in two ways. Number one, it's very restrictive, as you can imagine with that small stomach pouch. And using that visual again from a football, we're going to maybe a chicken egg, like a large chicken egg. So they can't eat as much, certainly. But there's also now some malabsorption going on. A lot of absorption of calories happens in the first section of the small intestine, the duodenum. So now someone can't eat as much and they don't absorb as much of what they eat. So as you can imagine, this makes the nutrition piece incredible. incredibly important because if they can't eat much, we have to get as much bang for their buck in their meals. They can't waste space on poor quality food. So we have to make sure they're getting really good nutrition. They're getting good protein. They're staying on top of their vitamins. But this surgery is incredibly successful, especially if someone has quite a bit of weight to lose. There's also a benefit if someone is a really, oh, they're just really prone to sweets and sugary foods because dumping syndrome is something that occurs. I think I have a slide a little bit later that talks about dumping syndrome, but there's a lot of adverse, uncomfortable, physical reactions to high sugar and high fat foods. So some patients will choose this surgery because they like the negative reinforcement that they need to be making good choices. So that's the gastric bypass, another really popular surgery. And then the gastric banding, or maybe you've heard of the lap band surgery. Oftentimes if someone's not familiar with weight loss surgery and I tell them what I do, they usually say, oh, like the band. And the answer is yes, it is like the band, but truth be told, this is becoming more and more an outdated procedure. We have not found a lot of success with the banding. A lot of it is because there's not actual cutting on the stomach, so it doesn't... tend to decrease that hunger hormone. It's also really easy to cheat the band and eat around it, eat soft things. Some people would go and they decide they're going on vacation and they didn't want any fluid in their band. They'd come in and get fluid out. And also maybe the mentality. Some patients say, you know, I don't want anything too drastic and long-term. I'd rather do the band. But that sometimes I don't want to say a statement over all patients, but That usually is a picture into maybe their commitment level. If they don't want something long-term, they may not really be ready for the long-term change that is required to lose a significant amount of weight and keep it off. So we're not seeing this as much anymore. Most surgeons will talk people out of it. Some still do it, but for the most part, they talk people out of it. Maybe if they have a young patient and they're like, well, you know, this 21-year-old patient really wants a band and they have... their life ahead of them. Maybe we'll go ahead and do kind of a less permanent surgery. So there's sometimes still situations at the end of the day a patient is coming in for an elective procedure that they still get to pick. But for the most part doctors are going to talk patients out of this one because it's not as successful. Just as a quick recap of what's going on here, this banding at the top of the stomach, it's creating this small stomach pouch and inside that band is Oh, for lack of a better word, it's like a little bladder that contains fluid. And the more fluid it has, the tighter it makes that segment so that food moves through that stomach slower. So the more fluid someone has in their band, the less they can eat, the longer food stays with them. And then this kind of tubing comes through and the port is right underneath the skin in the abdomen. So someone would come in. and get a fill essentially. So the surgeon would find the port and put a needle with saline solution in, and it would fill the, that little bladder of the band, making it tighter. Sometimes people come in and they make it too tight and they can't keep fluids down because they're, they're noticing that they're like, you know, vomiting everything, including fluid. And that means the band's too tight. They have to come in and get fluid back out. Um, if the band's too loose and people can eat more, but there is a little bit of danger because patients tend to always think they need more fluid. So you do have to kind of go through a series of questions to see when they really need the band tightened and when they really need to just get back onto a good diet plan. The duodenal switch is probably the newest surgery to the scene. There's lots of other surgeries that kind of come up. Oh, there's one that has like a gastric ballooning where you can swallow these pills and then they inflate the pills to have air and then. That fills your stomach up so you can eat as much. That's not as big of one, but there are places that do it. Whereas the duodenal switches kind of come on the scene as like, you know, more and more places are offering this as a weight loss surgery. The best way I can describe the duodenal switch is it's almost a marriage between the gastric sleeve and the gastric bypass. So they go ahead and make that sleeve similar to the gastric sleeve where it goes down to like a banana in size. But then similar to the bypass, they go down and they make an incision in the small intestine and they bring the small intestine up to the sleeved stomach. So one thing they're doing here is they're keeping the pylorus intact. Pylorus is a small muscle at the bottom of the stomach that keeps food in the stomach. Compared to a bypass and even a sleeve, food just moves through the stomach faster. when the pylorus is not intact. So they're trying to make you full on a small amount and that you stay full. But even when food moves through into the small intestine, because they've bypassed so much of the small intestine, there is a lot of... malabsorption going on here so you're not eating as much you're not absorbing as much this surgery has intimidated a lot of dietitians I will say because it's so new and it seems so drastic to use so little of the small intestine so there's a lot more vitamin therapy going on and a duodenal switch okay so the road to surgery just as a background of how someone would even get started how they'd be candidate? Well, the first thing is to be a candidate, a patient has to have a BMI over 40. So traditionally, someone can't come in and they have 50 pounds to lose and they want surgery. Some places, if that patient was paying cash, then they may, depending on the doctor. But specifically when insurance is paying, they're going to have certain requirements. If someone has a BMI over 35 and they have a comorbidity, maybe they have diabetes, sleep apnea, hypertension, they would qualify because their BMI is over 35 and they have a comorbidity. Pardon, my phone is ringing. So that's a little bit more about who is a candidate. It's based on the body mass index for the most part. Most insurance companies require three to six months of supervised weight loss, and that means that a patient is coming in to see the dietician, exercise physiologist, either a physician or a nurse. But they call it supervised weight loss because you're consistently seeing a team, and that is absolutely a big part of the dietician's role. But a lot of nurses are also taking the role of what they call a bariatric coordinator. and they have a lot to do with the patient's road to surgery. So pre-op timeframe to surgery is a really big piece of this. The initial nutrition visit is, depending on the program, might be 30 minutes, might be 60 minutes, and then you do monthly follow-ups. Sometimes it's in a group, sometimes it's individual. There's nutrition classes. I mean, this is a pretty comprehensive process. People have to take off. work and get into these appointments pretty consistently. And then post-op counseling, certainly, especially the better programs are going to have really consistent and thorough post-op visits. Support groups, most all places have at least once a month, if not more often, they have support groups where patients can come and connect with one another. Most places have a nutrition store in their clinic for protein shakes, protein bars, bariatric specific vitamins. Dieticians will take on bariatric consults, so I'm not working in a clinic any longer, but if somebody came into the ER for another reason, but they had a bariatric surgery, I might get a consult because I'm more, you know, knowledgeable in bariatrics. And in general, like I mentioned, with how many people are having bariatric surgery in a year, bariatrics will continue to grow. So it's important for all health care providers just to be familiar with. what the surgeries are, what that might limit a patient to do. You know, certainly a lot of the standard protocol we have for patients includes really sugary things. You know, we put them on a clear liquid diet. So we've got them on, you know, we're rehydrating them and they're having jello and popsicles and Gatorades and that can lead to a lot of physical discomfort and even further dehydration issues. So it is important to know if someone Even if that patient is like, oh, yeah, that surgery was 20 years ago. I don't even do anything with that. If they have altered anatomy, we need to know about it. Diet recommendations. Protein is always our first place to focus. And I would say after fluids. Keeping patients hydrated is always number one. Protein, every program out there is going to focus on protein. Some are going to focus on supplements. Some are going to do more meats and cheese and eggs. So like I said, the approach is different for everyone, but in general we're going to focus on protein because it fills them up, it keeps them full, it keeps blood sugars controlled, it keeps the weight loss moving. And if they can't eat much, we need to make sure they're getting their protein status up and keeping it up. Non-starchy vegetables are the best thing to pair with the protein. So patients need to avoid high starch vegetables, corn, potatoes, peas, winter squash. Early at a surgery, maybe things that don't have as much stringiness like celery. And we recommend patients have at least one, ideally two bites of their protein every bite of their vegetables so they're filling their stomach more with the protein than the vegetable. But vegetables are the best way to get fiber in the post-op diet. Fruit, we do a little less often because of the natural sugar. So it's more of the dessert portion. We don't recommend patients eat fruit by itself because of the sugar content. All fruit is okay, but we usually send them more towards the lower sugar fruits like berries instead of bananas. And again, early out of surgery, we have to be careful with peels or membranes because our stomach is getting used to breaking things down again. Heart healthy fats are always a good idea, but we do have to be careful with the calorie intake. If someone way overdoes their handful of almonds every day, then it can affect their results. But in general, we recommend having healthy fats within the meal. Some patients, if they're losing weight too fast, it happens like 1% of the time. But if someone is losing too much weight or too fast, then one of the easiest ways to slow them down in a healthy manner is to increase their healthy fat content. So a little more about that. Eating behaviors are so important in order for food to fit comfortably into these tight little tummies. So imperative for comfort after meals, tiny, tiny bites. These patients are encouraged to cut their food up before they start eating. Focus on a pencil eraser or the pinky fingernail for a bite, especially if it's a meat. A lot of patients will use cocktail forks or shrimp forks to keep their bites small. we recommend they release their fork in between each bite and take a break and pause and go for maybe a 20 to 30 minute meal. And every program is a little bit different on this one, but most guidelines are going to keep fluids away from their meal time. Some will say don't drink 30 minutes before and 30 minutes after. Some people will say you can drink to the first bite, but when you're eating and for an hour after your meal, don't drink. And the biggest reason is because fluid will flush the food out of the stomach so then they eat more they're hungry more often because the liquid is moving it through their stomach so it is super important for patients to get fluids but we like them to get it in between their meals which brings me to uh the funneling effect so i mentioned earlier in those surgeries especially the sleeve and the bypass that the pylorus muscle is no longer intact. With the bypass, we're not even using it. It's part of the bypassed area of the stomach. So that means there's just an open connection between stomach and small intestine. So just like a funnel, if you were to pour liquid into the funnel, it would go right through. So this is the image that a lot of patients are familiar with. In the sleeve, the pylorus is still there and there's some controversy on how much it's functioning or not, but in general, Studies will show that gastric emptying, how fast food leaves the stomach, is faster after these surgeries. So this is why they don't want to drink with their meals. This is why solid proteins are better. Once they're past the healing diet, it's better for them to eat lean ground beef, lean ground turkey. I mean, any beef, poultry, you get the idea. Pork. Whereas if they eat more like... scrambled eggs and cottage cheese and Greek yogurt they can eat a lot more of those foods they get hungry more often so even though they're good healthy proteins the texture really matters so again patients need to avoid high starch food they can kind of swell up in that tiny stomach just like if you had a bowl of oatmeal sitting out on the counter all day, it's just going to swell up and get bigger. So it can be really uncomfortable to have high starch foods in their little stomachs. Sweets, like I mentioned, can cause dumping syndrome. Cookies, cakes, pies, same thing with high fat foods like fried foods, high fat meats. So going back to this funnel, especially in bypass, if someone has something that has a lot of sugar, a lot of fat, ice cream is a really easy example. Well, the ice cream is moving through so fast and prior to surgery, their stomach could churn and break down that food and prepare that amount of sugar and fat before it moves to the small intestine. With a bypass, the stomach doesn't have the chance to prepare that food for the journey ahead to the small intestine. And then that food reaches the small intestine and that high solute load in the intestine will cause a ton of fluid to rush in to the intestine. And that results in, you know. Rapid diarrhea, maybe just a really quick shift in blood pressure. So they get dizzy, they get lightheaded, their heart is racing, they're uncomfortable. A lot of people say they just feel like they were dying. And that's called dumping syndrome. And it could be high fat, it could be high sugar. Some patients wish they get it and they didn't get it as much as they thought. And they kind of test the limits. And some patients, they get it once and they never do it again. But that is... dumping syndrome. It's whenever a high fat, high sugar food goes from stomach pouch to intestine really quickly and the body's not prepared for it. Oh, here we go. Dumping syndrome. Um, so eight grams of sugar typically is where they cut off, you know, where we might tell patients to look at the label and keep it to less than eight grams. Um, and then that final point, that rapid diarrhea could lead to subsequent dehydration. So we always counsel patients, if you do have an episode like this, it's really important to get onto your fluids so that you don't get dehydrated. These patients are at a higher risk for dehydration after surgery, so that is why it's a big deal. They can't guzzle chug water like they used to, so we have to stay on top of fluids. Yeah, I'm just one step ahead of myself. Here we go, hydration. Super important in the post-op patient, decreased water consumption due to less food intake, can't gulp, guzzle, or chug. They do have some restrictions on what they can count as fluid. We don't want them to have carbonated beverages because of the little tummy. And then they can have caffeine. We keep it to no more than 20 ounces a day. Typically, every program is different. But to count something as water, then it doesn't have caffeine, and it's under 15 calories. calories vitamin supplementation like i mentioned at the beginning of the presentation the asnbs is the governing body over bariatric surgery clinics they are the ones that would come out and say what a patient needs in terms of vitamins so that's who we go off of there's a ton of companies out there that carry bariatric specific vitamins most patients prefer The bariatric specific ones because it really simplifies how many they have to take. If they go to Walgreens and just start buying some vitamins, they're going to have to buy a lot of additional bottles to make up for all the things they need to get. So they definitely need a multivitamin twice a day. They need 1,200 to 1,500 milligrams of a calcium citrate. And the keyword there is citrate. Most over-the-counter calcium is calcium carbonate. Because it's more basic. It's not as bioavailable. It's not as absorbed. So they do need citrate They can't take more than 600 milligrams at one time because the body doesn't absorb that much So we do have to have them space it out And actually I need to update this slide because it's now 45 to 60 milligrams of iron So 29 milligrams of iron that's outdated They changed that probably two years ago. So you can see how old my slide is That can be in the multivitamin, but iron and calcium has to be separated by two hours because they compete for absorption. So if a patient is getting 45 to 60 grams of iron in their multivitamin, then they can do just the multivitamin and the calcium. But if they're not getting enough iron, they have to also take iron. B12, sometimes you can get this in the multivitamin, sometimes... sublingual or under the tongue. You can do injections. They also have nasal sprays. The big thing with B12 after these surgeries, the stomach produces intrinsic factor, which is what absorbs B12. And since a lot of the stomach is being removed or bypassed, there's not as much intrinsic factor available. So the amount of B12 is really important. So sometimes if someone's taking a multivitamin and it has B12 in it, it has to be a lot of B12. for them to actually absorb an oral B12. But most people will do an injection or under the tongue in order to get the B12 they need. Probiotics, most places just recommend them. That's not an ASMBS guideline, but most places do recommend probiotic because it's a GI tract alteration. Vitamin D, this says... PRN, but actually vitamin D is now standard. They do want 3,000 IUs of vitamin D daily. So I need to update two things. It's 45 to 60 milligrams of iron and it's 3,000 IUs of vitamin D. So it's always changing. Like I said, my last slide is already outdated. So it's always changing. You have to be aware of the program guidelines. You want to have a good relationship with the bariatric surgeon, the bariatric... clinic, whatever your role is, wherever you are, it's good to have a resource of who to contact. So have a good contact for a bariatric dietician, a bariatric nurse coordinator. In general, patients have to focus on their protein first. veggies next fruits and fats more moderately they have to be really careful with high sugar high fat they have to do protein supplements as needed that's kind of a program by program thing so it's good to familiarize yourself with what the patient needs and then vitamins big time vitamins vitamins if i were live i would answer your questions but this is a recording so you can always submit questions to steph at foodcoach.me

I'm a registered dietitian with a master's in food and nutrition, and my first job was in weight loss surgery and fell in love with it. That's all I've been doing ever since. I've worked for three weight loss surgery clinics with seven different surgeons, which means that you learn a lot about how different doctors approach things. I am a published cookbook author specific for bariatric recipes. And I own and operate a website, foodcoach.me.

It is a weight loss surgery nutrition membership website. So I now have the privilege of taking my practice solely online and helping those who need further care after surgery. And should you have any questions for me, I'm happy to email at stuffatfoodcoach.me. So like I mentioned, it's a very rapid moving.

field to work in weight loss surgery, there's really not much standard, in terms of standard guidelines for these surgeries. So there is a governing body over bariatric surgery clinics. It's called the ASMBS, the American Society of Metabolic and Bariatric Surgery. This is the accrediting group that would look over bariatric surgery. Surgery centers, bariatric surgeons, and essentially they come out with the best practice guidelines.

Anything from what the surgeon should be doing in the OR, when they should progress to foods, what vitamins they need. But they really don't give specifics on exactly how a weight loss surgery nutrition diet and lifestyle should look. So there is a lot of...

differences in opinions. So patients do sometimes get the same information, sometimes they get different information even if their friend went somewhere else down the street. So there's varying philosophies and opinions. There's new research.

It's always changing. So it is important for an RN or an RD to know his or her role in the process. It's definitely a team approach.

This is certainly an area where you're working with doctors. nurses, exercise physiologists, psychologists, dietitians, patients, there's a lot of people and having a good relationship with the surgeon is key. So if you're working primarily with weight loss surgery patients, then you do want to have a really good understanding of what they're hearing from their surgeon. But sometimes you are seeing this patient and maybe it's not, you're not seeing them for bariatric surgery, they just happen to be a bariatric surgery patient.

And in those situations, it's still helpful to ask the patient what they have been told, what they're hearing to get a bigger scope of what's going on with what their recommendations have been. Let's go through the surgeries themselves. So like I said, these change quite a bit. Even the ones we're going to go over on here, one is already pretty outdated and one is really new.

So it is important to know all of them, but you may see surgeries that are weight loss surgeries that really... kind of archaic and aren't around anymore. Right now the gastric sleeve is probably the most popular. Maybe it's a second to the gastric bypass which we'll go over next but depending on the statistics of this year it has been the number one weight loss surgery for the past few years and the numbers as far as how many people have weight loss surgery At one point it was about 220,000 people a year in the US and I think it's kind of leveled off around there But of course once once I surgery they're always a post-op patient So as you can imagine that number is only getting bigger of how many people in our nation have had a weight loss surgery with the gastric sleeve at the picture of the stomach here this is a traditionally a laparoscopic procedure and the surgeon goes in and they essentially just remove about 80% of the stomach and this includes the fundus of the stomach that curvature piece that goes up from the stomach and it doesn't reroute anything. A lot of patients are really comfortable with the surgery because it's just limiting the size of the stomach, but it's not altering their digestive system.

Their GI tract is still the same. This as a visual, it's a loose visual, but you might say if someone had a sleeve, they went from a football-sized stomach to a banana-sized stomach. So it gives you an idea of their limitations. And we'll go through what they have to focus on when they eat, but that gives you an idea of the restriction that they have. There's also a lot of hormones that are produced in the curve of that stomach.

Ghrelin is the hunger hormone. It's the one that really drives hunger up. And because of the removal of that portion of the stomach, a lot of studies show patients report about 70% decline in that ghrelin. So you're not hungry as often, portion sizes are smaller, and weight loss is really successful with the surgery.

And this is true of all the surgeries, but surgery weight loss is most successful in the first year. And that's really the time that's most crucial for patients to be focusing on a sustainable long-term plan because they're going to see the most results in the first year as their metabolism is still up. Hunger is down, portion is down, but if they get off track or they fall into bad habits, their weight loss will stall out by the year, probably about a year mark, and then their hunger goes up. They can eat carbs more easily.

Carbs go through faster. Carbs make them hungrier. But as you can imagine, when you lose weight, your metabolism comes down because you're eating less calories, so you're burning less calories. So if their metabolism has come down, but now their hunger... coming back because of poor quality of food that is where we can start seeing some regain happen and unfortunately that does happen about 30% of patients will experience some amount of regain some more than others but a patient is considered to be a success if they have lost half the weight they were overweight so if someone was a hundred pounds overweight they lost 50 pounds they kept it off then that would be a success So anyway, this is a little bit more about the post, you know, beyond that first year.

So the first year is really important to make sure someone's on a good diet plan, they're on their vitamin routine, and they're just setting themselves up for those habits long term. That's the gastric sleeve. The gastric bypass, we are now rerouting anatomy.

I've heard a lot of doctors refer to this surgery as kind of the Cadillac of surgeries. It's probably Of the surgeries that are still popular, it's the one that's been around the longest. So it's a good operation if someone has a significant amount of weight to lose. And it has two primary methods going on here.

So what they do, if I can describe this image, at the top of the stomach, they remove a small portion where it says small gastric pouch. They make an incision and they make a small stomach up at the top. Then they go back down into the small intestine, they make another incision, and then they carry that portion of the small intestine up to meet the small stomach. So now they're bypassing the larger part of the stomach and the duodenum, that first section of small intestine.

So this surgery is effective in two ways. Number one, it's very restrictive, as you can imagine with that small stomach pouch. And using that visual again from a football, we're going to maybe a chicken egg, like a large chicken egg.

So they can't eat as much, certainly. But there's also now some malabsorption going on. A lot of absorption of calories happens in the first section of the small intestine, the duodenum.

So now someone can't eat as much and they don't absorb as much of what they eat. So as you can imagine, this makes the nutrition piece incredible. incredibly important because if they can't eat much, we have to get as much bang for their buck in their meals.

They can't waste space on poor quality food. So we have to make sure they're getting really good nutrition. They're getting good protein. They're staying on top of their vitamins.

But this surgery is incredibly successful, especially if someone has quite a bit of weight to lose. There's also a benefit if someone is a really, oh, they're just really prone to sweets and sugary foods because dumping syndrome is something that occurs. I think I have a slide a little bit later that talks about dumping syndrome, but there's a lot of adverse, uncomfortable, physical reactions to high sugar and high fat foods. So some patients will choose this surgery because they like the negative reinforcement that they need to be making good choices. So that's the gastric bypass, another really popular surgery.

And then the gastric banding, or maybe you've heard of the lap band surgery. Oftentimes if someone's not familiar with weight loss surgery and I tell them what I do, they usually say, oh, like the band. And the answer is yes, it is like the band, but truth be told, this is becoming more and more an outdated procedure. We have not found a lot of success with the banding.

A lot of it is because there's not actual cutting on the stomach, so it doesn't... tend to decrease that hunger hormone. It's also really easy to cheat the band and eat around it, eat soft things. Some people would go and they decide they're going on vacation and they didn't want any fluid in their band.

They'd come in and get fluid out. And also maybe the mentality. Some patients say, you know, I don't want anything too drastic and long-term. I'd rather do the band.

But that sometimes I don't want to say a statement over all patients, but That usually is a picture into maybe their commitment level. If they don't want something long-term, they may not really be ready for the long-term change that is required to lose a significant amount of weight and keep it off. So we're not seeing this as much anymore. Most surgeons will talk people out of it. Some still do it, but for the most part, they talk people out of it.

Maybe if they have a young patient and they're like, well, you know, this 21-year-old patient really wants a band and they have... their life ahead of them. Maybe we'll go ahead and do kind of a less permanent surgery.

So there's sometimes still situations at the end of the day a patient is coming in for an elective procedure that they still get to pick. But for the most part doctors are going to talk patients out of this one because it's not as successful. Just as a quick recap of what's going on here, this banding at the top of the stomach, it's creating this small stomach pouch and inside that band is Oh, for lack of a better word, it's like a little bladder that contains fluid. And the more fluid it has, the tighter it makes that segment so that food moves through that stomach slower. So the more fluid someone has in their band, the less they can eat, the longer food stays with them.

And then this kind of tubing comes through and the port is right underneath the skin in the abdomen. So someone would come in. and get a fill essentially. So the surgeon would find the port and put a needle with saline solution in, and it would fill the, that little bladder of the band, making it tighter. Sometimes people come in and they make it too tight and they can't keep fluids down because they're, they're noticing that they're like, you know, vomiting everything, including fluid.

And that means the band's too tight. They have to come in and get fluid back out. Um, if the band's too loose and people can eat more, but there is a little bit of danger because patients tend to always think they need more fluid. So you do have to kind of go through a series of questions to see when they really need the band tightened and when they really need to just get back onto a good diet plan. The duodenal switch is probably the newest surgery to the scene.

There's lots of other surgeries that kind of come up. Oh, there's one that has like a gastric ballooning where you can swallow these pills and then they inflate the pills to have air and then. That fills your stomach up so you can eat as much.

That's not as big of one, but there are places that do it. Whereas the duodenal switches kind of come on the scene as like, you know, more and more places are offering this as a weight loss surgery. The best way I can describe the duodenal switch is it's almost a marriage between the gastric sleeve and the gastric bypass.

So they go ahead and make that sleeve similar to the gastric sleeve where it goes down to like a banana in size. But then similar to the bypass, they go down and they make an incision in the small intestine and they bring the small intestine up to the sleeved stomach. So one thing they're doing here is they're keeping the pylorus intact. Pylorus is a small muscle at the bottom of the stomach that keeps food in the stomach. Compared to a bypass and even a sleeve, food just moves through the stomach faster.

when the pylorus is not intact. So they're trying to make you full on a small amount and that you stay full. But even when food moves through into the small intestine, because they've bypassed so much of the small intestine, there is a lot of... malabsorption going on here so you're not eating as much you're not absorbing as much this surgery has intimidated a lot of dietitians I will say because it's so new and it seems so drastic to use so little of the small intestine so there's a lot more vitamin therapy going on and a duodenal switch okay so the road to surgery just as a background of how someone would even get started how they'd be candidate? Well, the first thing is to be a candidate, a patient has to have a BMI over 40. So traditionally, someone can't come in and they have 50 pounds to lose and they want surgery.

Some places, if that patient was paying cash, then they may, depending on the doctor. But specifically when insurance is paying, they're going to have certain requirements. If someone has a BMI over 35 and they have a comorbidity, maybe they have diabetes, sleep apnea, hypertension, they would qualify because their BMI is over 35 and they have a comorbidity.

Pardon, my phone is ringing. So that's a little bit more about who is a candidate. It's based on the body mass index for the most part.

Most insurance companies require three to six months of supervised weight loss, and that means that a patient is coming in to see the dietician, exercise physiologist, either a physician or a nurse. But they call it supervised weight loss because you're consistently seeing a team, and that is absolutely a big part of the dietician's role. But a lot of nurses are also taking the role of what they call a bariatric coordinator. and they have a lot to do with the patient's road to surgery.

So pre-op timeframe to surgery is a really big piece of this. The initial nutrition visit is, depending on the program, might be 30 minutes, might be 60 minutes, and then you do monthly follow-ups. Sometimes it's in a group, sometimes it's individual.

There's nutrition classes. I mean, this is a pretty comprehensive process. People have to take off.

work and get into these appointments pretty consistently. And then post-op counseling, certainly, especially the better programs are going to have really consistent and thorough post-op visits. Support groups, most all places have at least once a month, if not more often, they have support groups where patients can come and connect with one another. Most places have a nutrition store in their clinic for protein shakes, protein bars, bariatric specific vitamins.

Dieticians will take on bariatric consults, so I'm not working in a clinic any longer, but if somebody came into the ER for another reason, but they had a bariatric surgery, I might get a consult because I'm more, you know, knowledgeable in bariatrics. And in general, like I mentioned, with how many people are having bariatric surgery in a year, bariatrics will continue to grow. So it's important for all health care providers just to be familiar with. what the surgeries are, what that might limit a patient to do.

You know, certainly a lot of the standard protocol we have for patients includes really sugary things. You know, we put them on a clear liquid diet. So we've got them on, you know, we're rehydrating them and they're having jello and popsicles and Gatorades and that can lead to a lot of physical discomfort and even further dehydration issues. So it is important to know if someone Even if that patient is like, oh, yeah, that surgery was 20 years ago. I don't even do anything with that.

If they have altered anatomy, we need to know about it. Diet recommendations. Protein is always our first place to focus.

And I would say after fluids. Keeping patients hydrated is always number one. Protein, every program out there is going to focus on protein. Some are going to focus on supplements.

Some are going to do more meats and cheese and eggs. So like I said, the approach is different for everyone, but in general we're going to focus on protein because it fills them up, it keeps them full, it keeps blood sugars controlled, it keeps the weight loss moving. And if they can't eat much, we need to make sure they're getting their protein status up and keeping it up.

Non-starchy vegetables are the best thing to pair with the protein. So patients need to avoid high starch vegetables, corn, potatoes, peas, winter squash. Early at a surgery, maybe things that don't have as much stringiness like celery.

And we recommend patients have at least one, ideally two bites of their protein every bite of their vegetables so they're filling their stomach more with the protein than the vegetable. But vegetables are the best way to get fiber in the post-op diet. Fruit, we do a little less often because of the natural sugar.

So it's more of the dessert portion. We don't recommend patients eat fruit by itself because of the sugar content. All fruit is okay, but we usually send them more towards the lower sugar fruits like berries instead of bananas.

And again, early out of surgery, we have to be careful with peels or membranes because our stomach is getting used to breaking things down again. Heart healthy fats are always a good idea, but we do have to be careful with the calorie intake. If someone way overdoes their handful of almonds every day, then it can affect their results.

But in general, we recommend having healthy fats within the meal. Some patients, if they're losing weight too fast, it happens like 1% of the time. But if someone is losing too much weight or too fast, then one of the easiest ways to slow them down in a healthy manner is to increase their healthy fat content. So a little more about that. Eating behaviors are so important in order for food to fit comfortably into these tight little tummies.

So imperative for comfort after meals, tiny, tiny bites. These patients are encouraged to cut their food up before they start eating. Focus on a pencil eraser or the pinky fingernail for a bite, especially if it's a meat. A lot of patients will use cocktail forks or shrimp forks to keep their bites small.

we recommend they release their fork in between each bite and take a break and pause and go for maybe a 20 to 30 minute meal. And every program is a little bit different on this one, but most guidelines are going to keep fluids away from their meal time. Some will say don't drink 30 minutes before and 30 minutes after. Some people will say you can drink to the first bite, but when you're eating and for an hour after your meal, don't drink. And the biggest reason is because fluid will flush the food out of the stomach so then they eat more they're hungry more often because the liquid is moving it through their stomach so it is super important for patients to get fluids but we like them to get it in between their meals which brings me to uh the funneling effect so i mentioned earlier in those surgeries especially the sleeve and the bypass that the pylorus muscle is no longer intact.

With the bypass, we're not even using it. It's part of the bypassed area of the stomach. So that means there's just an open connection between stomach and small intestine.

So just like a funnel, if you were to pour liquid into the funnel, it would go right through. So this is the image that a lot of patients are familiar with. In the sleeve, the pylorus is still there and there's some controversy on how much it's functioning or not, but in general, Studies will show that gastric emptying, how fast food leaves the stomach, is faster after these surgeries.

So this is why they don't want to drink with their meals. This is why solid proteins are better. Once they're past the healing diet, it's better for them to eat lean ground beef, lean ground turkey.

I mean, any beef, poultry, you get the idea. Pork. Whereas if they eat more like...

scrambled eggs and cottage cheese and Greek yogurt they can eat a lot more of those foods they get hungry more often so even though they're good healthy proteins the texture really matters so again patients need to avoid high starch food they can kind of swell up in that tiny stomach just like if you had a bowl of oatmeal sitting out on the counter all day, it's just going to swell up and get bigger. So it can be really uncomfortable to have high starch foods in their little stomachs. Sweets, like I mentioned, can cause dumping syndrome. Cookies, cakes, pies, same thing with high fat foods like fried foods, high fat meats. So going back to this funnel, especially in bypass, if someone has something that has a lot of sugar, a lot of fat, ice cream is a really easy example.

Well, the ice cream is moving through so fast and prior to surgery, their stomach could churn and break down that food and prepare that amount of sugar and fat before it moves to the small intestine. With a bypass, the stomach doesn't have the chance to prepare that food for the journey ahead to the small intestine. And then that food reaches the small intestine and that high solute load in the intestine will cause a ton of fluid to rush in to the intestine. And that results in, you know. Rapid diarrhea, maybe just a really quick shift in blood pressure.

So they get dizzy, they get lightheaded, their heart is racing, they're uncomfortable. A lot of people say they just feel like they were dying. And that's called dumping syndrome. And it could be high fat, it could be high sugar.

Some patients wish they get it and they didn't get it as much as they thought. And they kind of test the limits. And some patients, they get it once and they never do it again.

But that is... dumping syndrome. It's whenever a high fat, high sugar food goes from stomach pouch to intestine really quickly and the body's not prepared for it.

Oh, here we go. Dumping syndrome. Um, so eight grams of sugar typically is where they cut off, you know, where we might tell patients to look at the label and keep it to less than eight grams. Um, and then that final point, that rapid diarrhea could lead to subsequent dehydration.

So we always counsel patients, if you do have an episode like this, it's really important to get onto your fluids so that you don't get dehydrated. These patients are at a higher risk for dehydration after surgery, so that is why it's a big deal. They can't guzzle chug water like they used to, so we have to stay on top of fluids.

Yeah, I'm just one step ahead of myself. Here we go, hydration. Super important in the post-op patient, decreased water consumption due to less food intake, can't gulp, guzzle, or chug. They do have some restrictions on what they can count as fluid. We don't want them to have carbonated beverages because of the little tummy.

And then they can have caffeine. We keep it to no more than 20 ounces a day. Typically, every program is different. But to count something as water, then it doesn't have caffeine, and it's under 15 calories. calories vitamin supplementation like i mentioned at the beginning of the presentation the asnbs is the governing body over bariatric surgery clinics they are the ones that would come out and say what a patient needs in terms of vitamins so that's who we go off of there's a ton of companies out there that carry bariatric specific vitamins most patients prefer The bariatric specific ones because it really simplifies how many they have to take.

If they go to Walgreens and just start buying some vitamins, they're going to have to buy a lot of additional bottles to make up for all the things they need to get. So they definitely need a multivitamin twice a day. They need 1,200 to 1,500 milligrams of a calcium citrate.

And the keyword there is citrate. Most over-the-counter calcium is calcium carbonate. Because it's more basic.

It's not as bioavailable. It's not as absorbed. So they do need citrate They can't take more than 600 milligrams at one time because the body doesn't absorb that much So we do have to have them space it out And actually I need to update this slide because it's now 45 to 60 milligrams of iron So 29 milligrams of iron that's outdated They changed that probably two years ago.

So you can see how old my slide is That can be in the multivitamin, but iron and calcium has to be separated by two hours because they compete for absorption. So if a patient is getting 45 to 60 grams of iron in their multivitamin, then they can do just the multivitamin and the calcium. But if they're not getting enough iron, they have to also take iron. B12, sometimes you can get this in the multivitamin, sometimes... sublingual or under the tongue.

You can do injections. They also have nasal sprays. The big thing with B12 after these surgeries, the stomach produces intrinsic factor, which is what absorbs B12. And since a lot of the stomach is being removed or bypassed, there's not as much intrinsic factor available.

So the amount of B12 is really important. So sometimes if someone's taking a multivitamin and it has B12 in it, it has to be a lot of B12. for them to actually absorb an oral B12. But most people will do an injection or under the tongue in order to get the B12 they need.

Probiotics, most places just recommend them. That's not an ASMBS guideline, but most places do recommend probiotic because it's a GI tract alteration. Vitamin D, this says...

PRN, but actually vitamin D is now standard. They do want 3,000 IUs of vitamin D daily. So I need to update two things. It's 45 to 60 milligrams of iron and it's 3,000 IUs of vitamin D.

So it's always changing. Like I said, my last slide is already outdated. So it's always changing.

You have to be aware of the program guidelines. You want to have a good relationship with the bariatric surgeon, the bariatric... clinic, whatever your role is, wherever you are, it's good to have a resource of who to contact.

So have a good contact for a bariatric dietician, a bariatric nurse coordinator. In general, patients have to focus on their protein first. veggies next fruits and fats more moderately they have to be really careful with high sugar high fat they have to do protein supplements as needed that's kind of a program by program thing so it's good to familiarize yourself with what the patient needs and then vitamins big time vitamins vitamins if i were live i would answer your questions but this is a recording so you can always submit questions to steph at foodcoach.me

Transcript for:Bariatric Nutrition Insights and Guidelines

Transcript for:
Bariatric Nutrition Insights and Guidelines