Learning Objectives:
1. Describe and list the types of bariatric surgeries.
2. Identify current practice guidelines for MNT in bariatrics.
3. Identify key factors in pre-op assessments for long-term success.
2. Connecting military family service providers
and Cooperative Extension professionals to research
and to each other through engaging online learning opportunities
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MFLN Intro
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3. • Received her Masters of Science in Family and
Consumer Sciences with a focus in nutrition
from Eastern Illinois University.
• Currently practicing as a registered licensed
Bariatric / Clinical Dietitian at Carle Physician
Group.
• Professional interests focus on weight
management for adults and pediatrics, as well
as general nutrition education for the
community, including support groups to
promote healthy lifestyles.
Today’s Presenter
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Ashley McCartney, MS, RD, LDN
4. By: Ashley R. McCartney, MS, RD, LDN
Carle Physician Group
Urbana, IL
Ashley.McCartney@carle.com
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7. 7
Estimate costs range from $147 billion to $210
billion / year.
Associated with job absenteeism
Lower productivity while at work
Obese adults spend 42 percent more on direct
healthcare costs than adults who are a healthy
weight.
In the U.S., second leading cause of death after
tobacco
9. 9
Classification BMI Risk of
Comorbidities
Underweight <18.5 Low
Normal 18.5 - 24.9 Average
Overweight 25.0 - 29.9 Increased
Obese Class I 30.0 - 34.9 Moderate
Obese Class II 35.0 - 39.9 Severe
Obese Class III
Super Obese
40.0 – 49.9
>/= 50.0
Very severe
Classification of Obesity
Photo taken from WHO
10. 10
Most effective treatment for severe obesity
Resolution of co-morbid conditions
Impact on medication regimen
Impact on metabolic and hormonal changes
Fad / crash / yo-yo dieting does not work
Quick fix?
Photos taken from www.reboundfreeweightloss.com and
www.globalrugby.com.au
15. 15
Restrictive Procedure
First introduced in 1978 by Wilkinson
1986 – current procedure done across the world
FDA approved in 2001
How does the adjustable band function?
Rate of weight loss
Outpatient procedure
17. 17
Band slippage
Leakage of tubing / balloon
Port or band infection
Obstruction
Nausea / vomiting
Band erosion into stomach
Esophageal dilatation
Failure to lose weight
22. 22
Restrictive Procedure
Irreversible
Popularized in early 2000s
Still under research for efficacy
How does the sleeve function?
Rate of weight loss
Inpatient hospital stay
28. 28
Malabsorptive procedure
Reversible
Developed in the 1960s
How it functions
Rate of weight loss
Why is bypass considered “the gold standard?”
Inpatient hospital stay
33. 33
Preoperative weight loss prior to surgery
Lap band rate of weight loss
Sleeve gastrectomy rate of weight loss
Gastric bypass rate of weight loss
36. 36
No deaths
10% SAE’s
19% had balloon removed early
Nausea, vomiting, abdominal pain, reflux in
48-72 hrs.
37. 37
BMI 30-40
In conjunction with long term diet/behavior
modification program
Failed more conservative teatments
Maximum duration of placement 6 mos.
38. 38
Reasonable option for temporary weight loss
Very skeptical about long term weight loss
efficacy
High potential for inappropriate use
Most beneficial indications are currently off-
label
41. 41
Expected Outcomes References
First Trimester
Second Trimester
Third Trimester
Post-Partum
Close collaborative efforts between
the bariatric surgeon and obstetrician.
Patient must notify office as soon as
pregnancy is confirmed and
appointment made for fluid removal.
All fluid will be removed to minimize
restriction of band.
A band fill will be performed no earlier
than 14 weeks gestation or later if
weight gain is excessive.
All fluid will be removed from the band
at 36 weeks gestation.
A band fill will not be performed until
lactation is established. Band
adjustment will likely be close to pre-
pregnancy levels.
Maintain healthy fetal development.
Minimize risks associated with obesity,
pregnancy and poor neonatal outcomes
through weight management.
Fluid removal will allow for optimal
nutritional intake during embryogenesis
and minimize risk for hyperemesis
during the first trimester.
Based on IOM weight gain
recommendations, the band fills will be
performed to minimize excessive weight
gain (not to promote weight loss).
Recommendations for weight gain are
based on varying BMI levels and are to
be determined by obstetrician.
Management of band will be based on
weight gain recommendations.
Reduce impact of band on delivery.
Initiate weight loss or weight
maintenance.
Dixon, J. B., Dixon, M. E., & O'Brien, P. E. (2001).
Pregnancy after lap-band surgery: Management of
the band to achieve healthy weight outcomes.
Obesity Surgery, (11), 59-65.
Carle Foundation Hospital:
42. 42
Timing of pregnancy
Recommended lab work
Protein requirements
Weight gain
43. 43
Surgery for pregnancy
Sports nutrition- i.e. marathons, etc.
Surgery for other medical procedures
Photos from: www.7leafmarketing.com
www.karatebyjesse.com
44. 44
"The State of Obesity: Obesity Data Trends and Policy Analysis." The State of Obesity: Obesity Data Trends
and Policy Analysis. N.p., n.d. Web. 1 Apr. 2016.
Allison DB, Fontaine KR, Manson JE, Stevens, J, Vanitallie TB. Annual deaths attributable to obesity in the
United States. JAMA. 1999;282(16)1530-8.
Cawley J and Meyerhoefer C. The Medical Care Costs of Obesity: An Instrumental Variables Approach.
Journal of Health Economics, 31(1): 219-230, 2012; And Finkelstein, Trogdon, Cohen, et al. Annual Medical
Spending Attributable to Obesity. Health Affairs, 2009.
Cawley J, Rizzo JA, Haas K. Occupation-specific Absenteeism Costs Associated with Obesity and Morbid
Obesity. Journal of Occupational and Environmental Medicine, 49(12):1317?24, 2007.
Gates D, Succop P, Brehm B, et al. Obesity and presenteeism: The impact of body mass index on workplace
productivity. J Occ Envir Med, 50(1):39-45, 2008.
Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable to Obesity: Payer-and
Service-Specific Estimates. Health Affairs, 28(5): w822-831, 2009.
Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric Surgery. A systematic
review and meta-analysis. JAMA. 2004
Oria, HE. Gastric banding for morbid obesity. Eur J Gastroenterol Hepatol 1999;11:105-114
Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the
treatment of morbid obesity. Obes Surg 2002;12:564-568.
Saber AA, Elgamel MH, McLeod, MK. Bariatric surgery: the past, present and future. Obesity Surgery
Including Laparoscopy and Allied Care, 2008;18(1):121-8
Weight Control Information Network, National Institutes of Health. Bariatric surgery as a treatment for
obesity. National Institute of Diabetes and Digestive and Kidney Diseases. 2011, June. Accessed August 30,
2012 from http://win.niddk.nih.gov/publications/gastric.htm
Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the
treatment of morbid obesity. Obes Surg 2002;12:564-568.
Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Preoperative predictors of weight
loss following bariatric surgery: systematic review. Obes Surg. 2012;22(1): 70-89 [Research Support, Non-
U.S. Gov’t Review.]
Dixon, J. B., Dixon, M. E., & O'Brien, P. E. (2001). Pregnancy after lap band surgery: Management of the
band to achieve healthy weight outcomes. Obesity Surgery, (11), 59-65.
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According to the most recent data released September 2015, rates of obesity now exceed 35 percent in three states (Arkansas, West Virginia and Mississippi), 22 states have rates above 30 percent, 45 states are above 25 percent, and every state is above 20 percent. Arkansas has the highest adult obesity rate at 35.9 percent, while Colorado has the lowest at 21.3 percent.
So why is this important? Bullet 1: Obesity is one of the biggest drivers of preventable chronic diseases and healthcare costs in the United States.
Bullet 2: Cost approximately 4.3 billion annually
Bullet 3: Costing employers $506 per obese worker / year. As a person&apos;s BMI increases, so do the number of sick days, medical claims and healthcare costs.
Bullet 5: Obesity causes more than 300,000 deaths per year in the U.S. alone (Allison DB, Fontaine KR, Manson JE, Stevens, J, Vanitallie TB. Annual deaths attributable to obesity in the United States. JAMA. 1999;282(16)1530-8.)
A 2008 study by the Urban Institute, The New York Academy of Medicine and TFAH found that an investment of $10 per person in proven community-based programs to increase physical activity, improve nutrition and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. That&apos;s a return of $5.60 for every $1 invested.9 Out of the $16 billion, Medicare could save more than $5 billion and Medicaid could save more than $1.9 billion.
Bullet 1: Offers positive effects on weight as well as on related comorbidities (Buchwald, 2005)
Bullet 2: Within 2-3 years after the operation average excess weight loss is around 10-35% of a patient’s excess weight
Bullet 4: Play a major role in hunger and satiety as well as improvement and/or resolution of conditions that can occur as a result of severe obesity
Bullet 5: Calorie counting, prepackaged meals, low carb diets / sugar-free, low fat diets, single food focused diets, meal replacement diets
Bullet 2: applied a 2 cm Marlex mesh round the upper part of the stomach and separated the stomach into a small upper pouch and the rest of the stomach. Eventual pouch dilatation resulted in unsatisfactory weight loss.
Bullet 3: Silicone band lined with an inflatable balloon. This balloon was connected to a small reservoir that is placed under the skin of the abdomen through which the diameter of the band can be adjusted. Inflation of the balloon functionally tightens the band and thereby increases weight loss, while deflation of the balloon loosens the band and reduces weight loss.
Bullet 6: Excess weight loss with the laparoscopic adjustable gastric band is lower than that with the gastric bypass or malabsorptive procedures, varying between 28% and 65% at 2 years and 54% at 5 years
Bullet 3: Gastrectomy was used mainly as the first part of a Duodenal Switch (Saber AA, Elgamel MH, McLeod, MK. Bariatric surgery: the past, present and future. Obesity Surgery Including Laparoscopy and Allied Care, 2008;18(1):121-8
Bullet 4: The Weight Control Information Network at the National Institutes of Health states that some patients who get VSG may eventually get the BPD-DS to allow their weight loss to continue to meet their goals. Weight Control Information Network, National Institutes of Health. Bariatric surgery as a treatment for obesity. National Institute of Diabetes and Digestive and Kidney Diseases. 2011, June. Accessed August 30, 2012 from http://win.niddk.nih.gov/publications/gastric.htm
Bullet 5: How is this so? 80% of the stomach is removed, which in turn must lead to smaller portions more frequently, does not make you feel physically hungry, stomach size is equivalent to a roll of dimes
Bullet 6: 60-70% of excess weight within the first year (i.e. if your starting weight was 325, expect your weight to be down to 211 by the first year out of surgery)
Bullet 4: Most of the native stomach and first segment of small intestine are bypassed. However, because the bypassed portion of intestine is where the majority of calcium and iron absorption takes place, anemia and osteoporosis are the most common long-term complications of the RYGBP
Bullet 5: Half of the weight loss occurs in the first 6 months, then peaks around 18-24 months. Expected rate of weight loss is estimated to be 70-80% of excess weight in the first year-18 months
Bullet 6: The mechanism in which the RYGBP works is complex. After surgery, patients often experience marked changes in their behavior. Most patients have a reduction in hunger and feel full sooner after eating. Patients often state that they enjoy healthy foods and lose many of their improper food cravings. Rarely do people feel deprived of food. These complex behavioral changes are partially due to alterations in several hormones (ghrelin, GIP, GLP, PYY) and neural signals produced in the GI tract that communicate with the hunger centers in the brain. Another mechanism for weight loss after the RYGBP is referred to as the dumping syndrome. Dumping may result in lightheadedness, flushing, heart palpitations, diarrhea and other symptoms early (within 10 to 30 minutes) after eating sweets or foods with a high concentration of sugar. Some people remain extremely sensitive to sweets for the rest of their lives; most patients lose some or all of their sweets sensitivity over time.
Bullet 2: 28-65% in 2 years, 54% at 5 years
Bullet 3: There were 14 studies comprising more than 3,000 patients who had undergone preoperative weight loss. The most common preoperative weight loss goals were either between 5-10% of EBWL. About half the studies found a positive correlation between preop and postop weight loss. Most studies reported at least 12 months of follow up with about 50-75% of excess weight at 12 months. Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obes Surg. 2012;22(1): 70-89 [Research Support, Non-U.S. Gov’t Review.]
Bullet 3: At least 60-70% excess weight in first year. Refer to literature from Review of Long-term Weight Loss After Sleeve Gastrectomy. The mean percentage excess weight loss (%EWL) was 62.3%, 53.8%, 43%, and 54.8% at 5, 6, 7, and 8 or more years after LSG, respectively.
Bullet 4: At least 70-80% excess weight in the first year and approximately 50% EBW 5 years+
Bullet 3: A Silastic® ring is placed around the vertically constructed gastric pouch above the anastomosis between the pouch and intestinal Roux limb. The band controls stoma size by prevention of dilatation of the gastric pouch outlet, and is thought to provide better long-term control of the rate of emptying of the pouch and caloric intake. This procedure also includes placement of a gastrostomy tube for decompression of the distal stomach; a radio-opaque ring marker may be placed around the gastrostomy site to facilitate future percutaneous access to the distal stomach.
Bullet 4: limb. The band controls stoma size by prevention of dilatation of the gastric pouch outlet, and is thought to provide better long-term control of the rate of emptying of the pouch and caloric intake. This procedure also includes placement of a gastrostomy tube for decompression of the distal stomach; a radio-opaque ring marker may be placed around the gastrostomy site to facilitate future percutaneous access to the distal stomach.
Bullet 4: Endoscopic sleeve gastroplasty is a newer type of weight-loss procedure. Endoscopic sleeve gastroplasty reduces the size of your stomach using an endoscopic suturing device without the need for surgery. This procedure is an option if you&apos;re significantly overweight — a body mass index of 30 or more — and diet and exercise haven&apos;t worked for you. although it&apos;s not designed to be a temporary procedure, endoscopic sleeve gastroplasty can be reversed and converted to bariatric surgery.
Because the procedure is still new and not in wide use, questions remain about its long-term effectiveness and risks.
Bullet 5: EnteroMedics is the developer of vBloc® neurometabolic therapy, delivered by a pacemaker-like device called the Maestro® Rechargeable System, a first-in-class weight loss treatment for obesity and obesity related risk factors, such as high blood pressure or high cholesterol levels. vBloc® Therapy is a non-anatomy altering or restricting, reversible therapy that allows patients to safely lose weight by helping patients feel less hungry, reduce the amount of food eaten at a meal, and feel full longer in between meals. vBloc® Therapy, delivered via the Maestro ® System, is now approved by the Food and Drug Administration for weight loss in adults with a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 with a related health condition such as high blood pressure or high cholesterol levels. Individuals should have first tried to lose weight by diet and exercise in a supervised program within the last 5 years before receiving the Maestro System. Refer to saved website on favorites
Bullet 6: Currently only in Europe. In a U.S. Clinical Trial, patients lost an average of 46 pounds (21 kgs) during the first year with the AspireAssist. Outpatient procedure. 20 minute procedure. The AspireAssist works by reducing the calories absorbed by the body. After eating, food travels to the stomach immediately, where it is temporarily stored and the digestion process begins. Over the first hour after a meal, the stomach begins breaking down the food, and then passes the food on to the intestines, where calories are absorbed. The AspireAssist allows patients to remove about 30% of the food from the stomach before the calories are absorbed into the body, causing weight loss. To begin therapy, a specially designed tube is placed in the stomach. The A-Tube is a thin tube that connects the inside of the stomach directly to a discreet, poker-chip sized Skin-Port on the outside of the abdomen. The Skin-Port has a valve that can be opened or closed to control the flow of stomach contents. The patient empties a portion of stomach contents into the toilet after each meal through this tube by connecting a small, handheld device to the Skin-Port.
The aspiration process is performed about 20 minutes after the entire meal is consumed and takes 5 to 10 minutes to complete. The process is performed in the privacy of the restroom, and the food is drained directly into the toilet. Because aspiration only removes a third of the food, the body still receives the calories it needs to function.
Research over the past two years is confirming that women who have gastric bypass or adjustable gastric band surgery before becoming pregnant are less likely to have obesity-related maternal or fetal complications, such as spontaneous abortion, preeclampsia, and birth trauma and birth defects.
Bullet 1:
The American College of Obstetricians and Gynecology recommends women avoid becoming pregnant for 18 months after surgery, the period with the fastest weight loss.
for 18 months after surgery, the period with the fastest weight loss. However, at least one study shows that maternal and fetal outcomes are similar between women who conceive before the 18-month time period.
Bullet 2:
Have the following lab work performed during your initial prenatal visit, then, if normal, once each trimester: complete blood count, electrolytes, glucose, iron studies (including ferritin), vitamin B12, red blood cell folate, and 25-hydroxyvitamin D.
Bullet 3: At least 60-70 grams / day
Bullet 4: Not necessary until 2nd or 3rd trimester. Refer to pregnancy handout
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