Bariatric Surgery and Nutrition Case Study Research Paper

*All work is my own, unless otherwise indicated in references. For educational use only.

JA*

Adult obesity is a predominant health crisis, which has significantly impacted both the health of Americans and resulted in increased healthcare costs. Although the effects of this disease are substantial, obesity can be improved for some via healthy dietary and lifestyle choices. By integrating nutrition, exercise and a surgical tool, positive health results can be seen and sustained throughout one’s life. This report will analyze the impact of obesity and bariatric surgery, as well as compare and contrast different treatments of real patients with these conditions.  

            Obesity is a condition where individuals have an excessive amount of body fat, which can put them at risk for various health conditions. Individuals may be classified as obese if their Body Mass Index (BMI) is 30 or higher. There are three different classes of obesity, based on one’s BMI value (1):

                           BMI                       Obesity Class

30-34.9	1
35.0-39.9	2
40.0 and higher	3 (Extreme Obesity)

            The effects of adult obesity in the United States are serious, widespread and multi-faceted. Obese individuals are more likely to have high triglycerides, hypertension, type 2 diabetes, strokes, gallbladder disease, breathing disorders such as sleep apnea, and various types of cancers (1). As a result, healthcare costs associated with treating these conditions have risen dramatically. According to the Centers for Disease Control (CDC), obesity affected nearly 40% of (93.3 million) adults. This has resulted in an estimated average healthcare cost of $147 billion per year, and over a $1,400 increased healthcare cost per person, compared to individuals of a normal weight (2). Hispanics (47%) and non-Hispanic blacks (46.8%) and non-Hispanic whites (37.9%) and non-Hispanic Asians (12.7%) (2). Obesity is also the highest among middle-aged adults (42.8%), followed by older adults 60 and over (41%) and young adults 20-39 years (35.7%) (2). Bariatric surgery is a common option for severely obese adults who have tried other weight loss strategies. To qualify for bariatric surgery, candidates must have a body mass index (BMI) of 40 or more or 35 or more with a severe illness that can be improved via weight loss. A thorough assessment of candidates’ physical and mental health must be completed, along with their ability to follow a strict diet and exercise program (3).

 Mather Hospital primarily offers laproscopic gastric bypass surgery and laproscopic sleeve gastrectomy. Laproscopic gastric bypass is considered the “gold standard” for weight loss surgeries by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the National Institutes of Health (NIH). This surgery typically involves 5-6 small incisions in the abdomen, where a scope connected to a camera and surgical tools are inserted through. The top portion of the stomach is stapled, separating it from the bottom portion and creating a small pouch. Food intake is restricted as a result of this pouch. Part of the small intestine called the duodenum is attached to this pouch, resulting in food bypassing the duodenum. This procedure decreases the amount of calories and nutrients the body can absorb (4). During a sleeve gastrectomy, the outer portion of the stomach is removed, leaving the new stomach about the size and shape of a banana. The pylorus muscle which controls emptying of food into the small intestine is also kept in a sleeve gastrectomy (4).

As a result of the significant changes bariatric surgery causes to the digestive system there are very strict post-operative dietary requirements. While exact recommendations may vary, Mather Hospital’s bariatrician and nutrition care team have foods and drinks acceptable for various stages after bariatric surgery (5), (6). For both bariatric surgeries, patient diets are categorized into four stages. During all stages, it’s recommended to consume 64 oz. of fluid and 60-80 grams of protein per day, with carbonated drinks and straws being prohibited. Raw fruits and vegetables, raw fish, nuts/seeds and chicken are to be avoided until 6-8 weeks after surgery.

·         Stage one lasts for 3-5 days and is a clear liquid diet, consisting mainly of sugar-free Jell-O, ices, low-sodium broths and water in addition to 2-3 protein shakes per day.

·         Stage two includes all items from stage one, with the additions of skim or low-fat milk, sugar-free pudding, yogurt, low-sodium strained cream soups, farina, poached eggs, low-sodium V8 and sugar-free hot chocolate. Stage two is also when chewable vitamins and subligual B12 (1,000 mcg) are introduced. It is suggested to consume two chewable bariatric multivitamins, along with Thiamin (12-100 mg) if not on approved Bariatric multivitamin and 1,000 mg of calcium citrate. The stage two diet lasts one week for gastric bypass surgery and two weeks for the sleeve gastrectomy.

·         For stage three, which lasts for one week, patients transition to a pureed diet, including all items from the first two stages. Soft boiled eggs, oatmeal, cottage and ricotta cheeses are also allowed during this stage. Fruits and vegetables must be cooked before being pureed. It is also suggested to consume two protein shakes each day.

·         Stage four is the final stage of the diet and lasts three weeks for the gastric bypass and four weeks for the sleeve gastrectomy surgeries. This stage includes all liquids and foods from the first three stages, with two protein shake recommended each day. This diet includes most foods prepared at regular consistencies. Canned tuna in water with 1 tbsp. light mayo, soft, flaky fish (flounder, sole, scrod, etc…) moistly cooked, skinless , dark meat, baked, broiled or braised chicken with 1 tbsp. gravy and lean (85-95%) ground beef and turkey are examples of foods allowed in stage four. At 6-8 weeks out, patients can add raw fruits/vegetables, chicken, nuts and decrease protein shakes to one per day.  Exact foods and time frames may vary, depending on specific individual conditions and physician recommendations.

Mather’s current eating guidelines are the same for both gastric bypass and sleeve gastrectomy (5), (6):

·         Eat slow and chew foods well, allowing 20-30 minutes per meal for ¼-1/2 of solid food at a time. Cut food small and take small bites, chewing 20-30 times to bring food to consistency of applesauce. Try eating in an environment free of stress and distractions.

·         Meal patterns: Eat three meals of solid foods each day, consisting of protein, fruits/vegetables and complex carbohydrates. Eat proteins first, vegetables second and starches last, if at all. Three protein-rich snacks may be eaten, including a protein shake. Eat at least every 4-5 hours.

·         Liquids: Don’t drink 15 minutes before, during and 30 minutes after meals. Include water, skim milk and sugar-free beverages to stay hydrated. Avoid high calorie beverages like soda, milkshakes and alcohol. Avoid carbonated drinks until at least three months after surgery.

·         Stop eating when: Feeling full or pressure after ¼-1/2 cup of solid food at a time. Feeling nauseous or pain to avoid getting sick and risk stretching pouch, causing potential weight gain.

The Academy of Nutrition and Dietetics has compiled clinical research concerning bariatric surgery outcomes and nutrition care guidelines. Major findings from their “Evidence Analysis Library” reveal (7):

·         Statistically significant decrease in resting metabolic rate (RMR), as high as 26% at one year post-surgery, which was sustained at two years.

·         Statistically significant reduction in self-reported energy intake after operations. Up to 72% in the first six months post-surgery and 28-38% at 4-5 years post-surgery.

·         Significant excess weight loss of 60%-80% and significant BMI reduction of 5%-31% for patients receiving medical nutrition therapy (MNT) from a registered dietitian nutritionist (RDN) for 2-6 visits during the first year post-surgery.

These findings reinforce the importance of nutritional services and positive outcomes of bariatric surgery and associated MNT. A study examined 40 women with metabolic syndrome who underwent either gastric bypass surgery (20) or surgical sleeve gastrectomy (20) and 20 control women, who followed a modified Mediterranean diet with a calorie restriction of 400-500/day by a Registered Dietitian. The results showed decreases in total cholesterol, triglycerides, oxidized LDL and apolipoprotein B and increases in HDL and apolipoprotein A for both surgeries. These lipid changes are beneficial for achieving and sustaining heart health. Even the control group experienced a significant decrease in diastolic blood pressure from baseline until the end of the study (8).

The vast majority of gastric bypass patients (around 85%) experience a phenomenon known as dumping syndrome, at least once after surgery (9). In dumping syndrome, food (primarily refined sugars) quickly leave the gastric pouch, entering the small intestine, causing various adverse reactions. These reactions can occur with dairy products and some fat and fried foods as well, and can be classified into two main types:

Early dumping: occurs 30-60 minutes after eating and can last for 1 hour. Symptoms include sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lie down, upper abdominal fullness, nausea, diarrhea, cramping and audible bowel sounds.

Late dumping: Occurs 1-3 hours after eating. Symptoms are related to reactive hypoglycemia and include sweating, shakiness, hunger, loss of concentration and feeling faint.

To prevent early dumping syndrome, it is suggested to avoid refined sugars, high-glycemic carbohydrates and/or other causative foods. Late dumping syndrome can be managed by this as well. If symptoms still persist, in extreme cases, consuming a small amount of sugar (ex. four ounces of milk or orange juice) about one hour after meals may help prevent attacks. Medications such as Acarbose or Somatostatin may also help if dumping syndrome is unresponsive to dietary changes. Other common nutritional issues with gastric bypass and sleeve gastrectomy patients include diarrhea, constipation and dysphagia (9).

Diarrhea: may be managed with Immodium or Lomotil medications, probiotics (Lactobacillus Acidophyllus or UltraFlora lactose-free) and/or bile acid sequestrants (Welchol, Questran and Cholestid).

Constipation: Ensure adequate water intake (at least 64 oz./day), include health, include healthy fibrous foods, use medications (Metamucil or Fibercon) if needed. Avoid diuretics such as caffeine.

Dysphagia: managed by eating slowly and modifying food consistencies as needed.

Patients should always keep their physicians informed of any adverse reactions and follow their advice and recommendations (9).

Mather Hospital’s bariatric surgery program is run by a licensed physician and surgeon, who frequently consults with registered dietitians about diet recommendations and nutrition care guidelines. All patients undergoing bariatric surgery must meet with the physician and a registered dietitian to cover the strict diet guidelines that must be followed pre and post surgerically. Depending on different patient conditions, one’s nutrition care plan may be modified. Ms. H is a candidate for bariatric surgery, who has class 2 obesity (BMI 38). Her weight has remained stable over the past two months.  She also has rheumatoid arthritis, and type 1 diabetes, and is on an insulin pump. Her self-reported A1C was listed at 7.2%. Additionally, Ms. H is on medication for high blood pressure (Ramipril), high cholesterol (Crestor) and gastro-esophageal reflux disease (GERD)/esophagitis (Pantoprzole Sodium). Individual reports no food allergies/intolerances and has been overweight for at least five years. Previously, the individual has tried the Atkins and Weight Watchers diets, reporting that most of her past success was on Weight Watchers. Her calorie needs have been estimated at 1,795 and protein needs estimated at 68-82 grams. The common fluid goal for bariatric patients of at least 64 oz./day is also in place Individual’s most recent diet recall re-call revealed:

Breakfast	egg whites with peppers and onions
Snack	sugar free ice pop
Lunch	tuna, lettuce, pickle
Snack	banana
Dinner	grilled chicken and mashed potatoes
Snack	hummus and pita chips

Ms. H also reported walking daily for 30 minutes, and the physician noted she is “making progress toward the goal of surgical control for morbid obesity. Her care plan indicated encouragement of food records on the Baritastic app. This app helps patients track nutrition, exercise, weight loss and other health indicators. It was also suggested to promote good glycemic control and find a protein shake she desires. For exercise, it was suggested to aim for walking 30-45 minutes daily.

Based on her self-reported dietary intake and most recent A1C, Mrs. H appears to have good control of her type one diabetes. Her diet may be modified by avoiding apple juice entirely and minimizing fruit intake during stage 3. Starches should primarily be avoided, except for whole grains (brown rice, quinoa, etc.) in small portions.  A low-fat, low-cholesterol diet may help manage cholesterol levels. Including egg whites in place of eggs, low-fat dairy products, 85-95% lean meats and a variety of whole grains and vegetables are good practices for healthy cholesterol levels. Grapefruit/grapefruit juice should be avoided while on Crestor due to possible adverse reactions. Following a low-sodium diet (1,500-2,000 mg/day) and ensuring adequate hydration (at least 64 oz./day) can help control blood pressure. To help manage GERD/esophagitis, it is crucial to note which foods/drinks cause adverse reactions and find suitable replacements. For example, if spicy foods trigger an adverse reaction, it may be helpful to season foods a different way, such as a marinade. In general, it is helpful to eat slowly, chew food thoroughly and  consume small portions at a time.

Mr. F is a patient at Mather who has undergone a sleeve gastrectomy. His most recent BMI is 41.1 (Obesity class 3), however he has lost 22 pounds over the past five months. Active nutrition-related diagnoses include type 1 diabetes, GERD, diarrhea, heartburn, hypertension, and gout. Mr. F has reported having a history of bodybuilding, where he would use fasting as a weight loss strategy. He has also reported eating large meals and frequently skipping meals; in addition to alcohol consumption 1-2 times a week  and diet soda as a common beverage. Individual has also previously reported consuming 32 oz. of water/day. Mr. F’s most recent dietary recall indicates significant improvement compared to his initial recall in that he is no longer skipping meals. He is also not consuming as much food at each meal, which may be helpful for his GERD.

Mr. F’s initial dietary recall

Breakfast	Bagel with cream cheese, oatmeal, hard boiled eggs, coffee or juice.
Snack	Skip
Lunch	Skip
Snack	Skip
Dinner	Greek salad, chicken salad, shrimp, mahi mahi.
Snack	Pistachios, flying saucer

Mr. F’s most recent dietary recall

Breakfast	Oatmeal, orange juice, 6 oz. coffee with light creamer,
Lunch	Premier shake 160 cal sardines 4X,
Dinner	Garden salad, grilled steak
Snack	Cherry juice (for gout relief)

Current nutritional goals include increasing water intake to 64 oz., bicycling outdoors 30 minutes, three days a week, logging intake on the baritastic app and practicing behavior modifications. Keeping active on the baritastic app can help track fluid intakes, especially if reminders are set to drink a regular amount throughout the day. Continued emphasis on lean protein sources (chicken, turkey, fish, plant proteins) combined with a produce source (fruits, vegetables) at each meal may help to reduce the risk of blood sugar spikes. Additionally, Mr. F’s diet should be tailored to deal with minimizing the risk of gout flare ups (10).

Red meat and organ meats

Shellfish (shrimp, lobster…)

Refined carbohydrates (white bread, white rice, pasta, sugar)

Processed foods (chips, cookies, candies, frozen dinners)

Sugary beverages (sodas, fruit juices)

Alcohol

Helpful Items for Gout                                      

Skim/Low-fat milk and dairy products

Whole grains (brown rice, oatmeal, quinoa, whole wheat pasta…)

Plant oils (olive, canola, sunflower)

Veggies

Cherries

Vitamin C supplements/ foods (oranges, mangos, strawberries, melon, kiwis)

Water

           

The dietary guidelines for gout are similar to Mather’s post-surgery dietary guidelines. Extra caution regarding regular meal consumption and avoiding alcohol should be taken to help sustain weight loss, avoid relapses and prevent gout flare ups.

            Both Ms. H and Mr. F need to follow specific dietary patterns, aimed at eliminating unnecessary calories, while optimizing fluid and nutrient intake; especially protein, vitamins and minerals. Both individuals have GERD, hypertension and type 1 diabetes; therefore, it is crucial to strictly limit starches to 1/day, from whole grain sources (brown rice, quinoa, etc…), encourage low-sodium items (140 mg or less per serving). To help with GERD, it may be helpful to introduce foods and drinks gradually to determine which items cause adverse reactions. In general, spicy foods should be avoided and acidic foods limited, along with caffeine, alcohol and carbonated drinks.  Mr. F’s diet plan may be more specific to help with his diarrhea. Processed oils should be limited, with fruits and vegetables encouraged, once allowed on diet plan. Individual also should continue taking Metamucil with 16 oz. of water/day as needed for symptoms and small amounts of cherry juice for gout.

            Ms. H PES: Problems: Rheumatoid Arthritis, GERD, High Cholesterol, Hypertension; Related to: Obesity (class 2). As evidenced by: BMI of 38.

Mr. F PES: Problems: GERD, diarrhea, heartburn, hypertension, gout; Related to: Obesity (class 3), excessive processed food intake. As evidenced by BMI of 41.1.

Bariatric surgery is a highly-effective procedure for weight loss in morbidly obese individuals. This procedure results in significant and life-long metabolic changes requiring strict discipline and careful planning for patients. Following appropriate nutrition, exercise and lifestyle guidelines is crucial for achieving and maintaining long-term success.

Sources:

1.    “Obesity: Symptoms and Causes.” Mayo Clinic Website. https://www.mayoclinic.org/diseases-conditions/obesity/symptoms-causes/syc-20375742. Updated 6/10/15. Accessed 7/12/18.

2.    “Adult Obesity Facts”. Centers for Disease Control and Prevention Website. https://www.cdc.gov/obesity/data/adult.html. Updated 6/12/18. Accessed 7/9/18.

3.    “Laproscopic Gastric Bypass”. Dr. Arif Ahmad Website https://www.drahmadmd.com/weight-loss-surgery/types-of-procedures/laparoscopic-gastric-bypass/. Accessed 7/9/18.

4.    “Laproscopic Gastric Bypass.” University of California San Francisco Website. https://bariatric.surgery.ucsf.edu/conditions--procedures/laparoscopic-gastric-bypass.aspx. Accessed 7/9/2018.

5.    “Diet Progression After Gastric Bypass Surgery.” Mather Hospital Bariatric & Robotic Center For Excellence Handout. Updated 6/2018.

6.    “Diet Progression After Surgery Sleeve Gastrectomy.” Mather Hospital Bariatric & Robotic Center For Excellence Handout. Updated 6/2018.

7.    “Nutrition Care in Bariatric Surgery.” Academy of Nutrition and Dietetics Evidence Analysis Library. https://www.andeal.org/topic.cfm?menu=5308.              Accessed 7/11/18.

8.    Gómez-Martin JM, Balsa JA, Aracil E, et al. Beneficial changes on plasma apolipoproteins A and B, high density lipoproteins and oxidized low density lipoproteins in obese women after bariatric surgery: comparison between gastric bypass and sleeve gastrectomy. Lipids in Health and Disease. 2018;17:145. doi:10.1186/s12944-018-0794-5.

9.    “Bariatric Surgery: Postoperative Concerns.” American Society for Metabolic and Bariatric Surgery Website. https://asmbs.org/app/uploads/2014/05/bariatric_surgery_postoperative_concerns1.pdf. Updated 2/7/2008. Accessed 7/11/18.

10.  “Shopping List for Gout.” Arthritis Foundation Website. https://www.arthritis.org/about-arthritis/types/gout/articles/gout-foods.php Accessed 7/13/18.