Nutritional aspects of bariatric surgery

Too Lean a Service? Mary O’Kane

Clinical specialist dietitian Leeds Teaching Hospitals NHS Trust

BOMSS council member

Does surgery result in a better diet?

• Decreased intake of sweets and sugary drinks but tolerance increases with time, high intake of salty snack foods (Brolin et al 1994)

• Decrease in energy from protein and increase from sugar and alcohol, decrease in prepared meals and increase in sweet foods (Lindroos et al 1996)

• Patients may end up snacking more and eating less regular meals (grazing), poor intake of protein, vitamins and minerals, intakes of iron, zinc, vitamin D below requirements (Naslund et al 1998)

• 37% had resumed snacking 1 year after gastric bypass (Elkins at al 2005)

• Cravings for sweets results on significant less weight loss (Burgmer et al 2005)

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

Sarwer et al. SOARD 4 (2008) 640–646

Role of the dietitian

As a core member of the MDT:

• Initial assessment of diet, nutritional status and eating behaviours (and psycho-social factors)

• Advice and support on the appropriate diet

• Monitoring of micronutrient status

• Individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance

NICE CG43 Obesity 2006

NICE CG43 Obesity Bariatric surgery

All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months

The person has been receiving or will receive intensive management in a specialist obesity service

The person commits to the need for long-term follow-up.

Too lean a Service? Dietetic input

Pre-referral

• No documented evidence of pre-referral dietetic input in 65% cases

Post-referral

• 22% patients not assessed by a dietitian prior to surgery

• 27% patients, no evidence of dietetic input prior to surgery

Adequacy of dietetic input pre-surgery

Too lean a service?

Adequate dietetic assessment /education for patient

Number of patients¹ (for those with evidence)

% for those with evidence

Number of patients (for all patients)

% for all patients

Yes 195 92.9 200 77.5

No 15 7.1 58 22.5

Subtotal 210 258

Insufficient data

27 123

Total 237 381

MDT meeting

Discharge summary Too Lean a Service?

Poor / unacceptable

• Diet information (10 patients)

• Emergency contact (9 patients)

Inappropriate discharge prescription

• Lack of vitamin supplements (10 patients)

• Inappropriate vitamin B12 (1 patient)

Follow-up Too lean a service

Follow-up clinics Number of hospitals (105)

Bariatric surgeon 95

Dietitian 86

Specialist nurse 58

Psychologist/ psychiatrist 24

Bariatric physician 21

Other 2

Types of follow-up clinic

72/102 hospitals gave early telephone follow-up

Dietary related problems following bariatric surgery

• Dehydration

• Nausea and vomiting

• Regurgitation

• Food intolerances

• Constipation

• Diarrhoea /steatorrhea

• Dumping syndrome

• Loss of appetite / Anorexia

• Fear of stretching the pouch

• Return of appetite

• Alopecia

Bariatric procedures, vitamins and minerals

Vitamin mineral deficiency / Surgery

Pre-surgery AGB Sleeve gastrectomy

RYGB BPD +/- DS

Thiamin Uncommon Uncommon Uncommon Uncommon Uncommon

B12 10-13% Uncommon Uncommon 12-33% Uncommon

Folate Uncommon Uncommon Uncommon Uncommon Uncommon

Iron 9-16% of women

Uncommon 20-49%

Vitamin A Uncommon Rare Rare Rare but can occur

50% at 1 year 70% at 4 years

Vitamin D 60-70% Common V. Common

Zinc Uncommon May occur Common

Protein Uncommon May occur May occur May occur May occur

Protein –energy malnutrition / protein malnutrition

• Food intolerance / Eating habits /Compliance

• Anorexia / loss of appetite

• Stricture / too tight a band

• Diarrhoea

• Requirements of BPD/ DS higher

Implications of “Too Lean a Service?”

• All patients being considered for bariatric surgery should receive dietary assessment and education prior to referral and definitely prior to surgery

• The dietitian is the key MDT member to undertake this assessment, education and provision of follow-up support

• Psychological assessment and support should be available

• Dietetic advice including vitamin and mineral supplements and discharge advice needs to be clearly documented

On-going work

• BOMSS training for dietitians and other healthcare professionals

• “Providing bariatric surgery” - the BOMSS Standards for Clinical Services & Guidance on Commissioning

• Clinical Reference Group on Morbid Obesity – comprehensive patient pathway

• Vitamins and minerals and pre- and post-surgery nutritional monitoring guidelines–work in progress