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Obesity and Bariatric Surgery Interventions Flashcards

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1
Q

What BMI classifies someone as class I obesity?

A

30-34.9

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2
Q

What BMI classifies someone as class II obesity?

A

35-40

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3
Q

What BMI classifies someone as class III obesity?

A

Over 40

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4
Q

What are factors contributing to obesity?

A 
Environment
Psychology
Inactivity
Medications
Genetics
Hormones
Emotional stress
Lack of sleep
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5
Q

What are medical complications of obesity?

A 
Pulmonary disease
Non-alcoholic fatty liver disease
Gall bladder disease 
Gyencologic abnormalities
Osteoarthritis
Skin
Gout
Others
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6
Q

What are reasons for bariatric surgery?

A

Co-morbidity resolution
Chronic disease and obesity-related condition prevention
Improvement in quality of life

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7
Q

What will bariatric surgery NOT do for a patient?

A

Unlikely to achieve “normal” BMI or “thin” appearance
Surgery will not change environment, behaviours, relationships. With the lifestyle changes, almost any procedure will work. Without the lifestyle changes, no surgery will work long term

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8
Q

What are indications for bariatric surgery?

A

BMI of over 40
BMI of over 35 with obesity-related co-morbidity
Failure of diet and exercise
Compliant patient

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9
Q

What are some of the current procedure methods? How do hormones affect these procedures?

A

Restrictive (consume less food)
Malabsorptive (decreased absorption of calories eaten)
Combined restrictive and malabsorptive
Significant hormonal factors contribute to weight loss and disease remission in gastric bypass and sleeve gastrectomy

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10
Q

What are some of the current procedures?

A 
Roux-en-Y gastric bypass (RYGB)
Sleeve gastrectomy (SG or VSG)
Bilio-pancreatic diversion with duodenal switch (not preformed in MB)
Adjustable gastric band (e.g., lap-band, slim band)
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11
Q

Describe the roux-en-Y gastric bypass

A

Combined restrictive and malabsorptive procedure

Strong hormonal component to weight loss and comorbidity resolution

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12
Q

Describe the sleeve gastrectomy

A

Restrictive procedure with hormonal component

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13
Q

Describe the bilbo-pancreatic diversion with duodenal switch

A

Mainly malabsorptive, some restriction and hormonal change

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14
Q

Describe the adjustable gastric band

A

Purely restrictive procedure; there’s a ring around the stomach that inflates. As it inflates, it makes a small pouch and it makes the patient feel full
Fewer complications but higher failure rate
Lowest weight loss and disease resolution (10-15% total weight loss)
Reversible

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15
Q

How does the roux-en-Y gastric bypass work?

A

The stomach is divided into two parts.
Small stomach pouch (15-30 ml) causes restriction
Food enters the small stomach and goes down into the jejunum. Food bypasses the distal stomach, duodenum and a portion of the jejunum (results in malabsorption)
The duodenum and the rest of the stomach is reattached later
Significant hormonal changes also occur: increased insulin sensitivity and production, increased satiety, decreased hunger

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16
Q

What are the results of the RYGB?

A

Results in 30% total weight loss (average)

Best resolution of comorbidities (mainly type II diabetes mellitus)

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17
Q

How does the sleeve gastrectomy work?

A

The large curvature of the stomach (80% of the stomach) is removed, leaving a narrow tube
The pyloric sphincter is still there, which helps with satiety because the food doesn’t leave the stomach quickly (decreased hunger)
Limited macronutrient malabsorption

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18
Q

What are the results of the sleeve gastrectomy?

A

Results in 20% total weight loss

Comorbidity resolution between band and gastric bypass

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19
Q

Describe the pre-op diet

A

Goal is the shrink the liver to make surgery safer and easier
Some weight loss occurs, normal is 7-15 lbs
Boost diabetic: 5 bottles/day (950 kcal, 80g of protein, 80g carbohydrate per day)

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20
Q

What type of diet should a patient be consuming post-op?

A

High protein, high fibre, low-moderate carbohydrate diet life-long

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21
Q

How much protein should a patient be consuming post-op?

A

Minimum 60g/day for at least the first year
Generally 1g/kg/day
Some require protein supplements to meet needs

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22
Q

How many calories should a patient be consuming post-op?

A

Around 1200 kcal/day long-term

500-600 kcal/day for the first two weeks post-op, increasing as meal volume/tolerance increases

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23
Q

How often should patients be eating post-op?

A

Frequent meals: minimum 3 meals plus 1-3 snacks

Limited to 1-1.5 cups of food per meal

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24
Q

How much fluid do patients need to consume post-op?

A

Minimum 2L/day, separate from meals
Limit caffeine and caloric beverages
Avoid carbonated drinks
Try to separate fluids and solids

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25
What should the patient consume on operative day and post-op day 1 (in hospital)?
Clear fluids and protein supplement
26
What is phase 1 of post-op diet progression?
Liquids Days 1-7 post-op Clear fluids and meal replacements/protein shakes
27
What is phase 2 of post-op diet progression?
Pureed foods 1-4 weeks post-op Focus on protein-rich foods
28
What is phase 3 of post-op diet progression?
Soft, minced foods 4-8 weeks post-op Portions: 0.5 cup of food per meal, 6-7 small meals per day Begin to separate beverages from meals
29
What is phase 4 of post-op diet progression?
Regular food Starts 8-12 weeks post-op Portion: 0.75-1 cup per mea
30
What are the required vitamins and minerals post-op?
``` Multivitamin/mineral Vitamin B12 Iron Calcium Vitamin D Increased doses and/or other micronutrient supplements may be required ```
31
How much of a multivitamin/mineral should a patient have?
1 per day At least 15 mg, 2 mg copper, zinc, selenium 100% RDA for at least 2/3 nutrients
32
How much vitamin B12 should a patient have?
500-100 ug/day
33
How much iron should a patient have?
25-40 mg, ferrous gluconate | At least 2 hours from calcium/thyroid medication
34
How much calcium should a patient have?
1200-1500 mg/day, in 3 doses Must be taken with food At least 2 hours from iron/thyroid medication
35
How much vitamin D should a patient have?
2000 IU/day | Taken with calcium for best absorption
36
When should patients start taking required vitamins and minerals?
Patients should take all supplements by 2 weeks post-op Large tablets must be cut, crushed or chewed for the first while (tablets/capsules smaller than an M&M are generally fine to swallow whole)
37
Do vitamins and minerals have to be solid?
Liquid supplements may be better absorbed and/or tolerated | Alternative routes/types of supplementation are also available (injections, dissolvable strips, chewables)
38
What are some potential early complications of surgery?
Staple line leak Bleed Nausea and vomiting Dehydration
39
What ares some potential late complications of surgery?
``` Adhesions/small bowel obstruction Gastric and/or anastomotic ulcers Stomal stenosis Cholelithiasis Nausea, vomiting, diarrhea or constipation Pouch dilation (stretching) ```
40
What are some early nutrition complications?
Food intolerances | Dumping syndrome
41
Describe food intolerances
Fresh breads, pasta, rick, corn, fruit and vegetables skins, tough meats, lactose Intolerances are individual; some resolve over time Increasing intolerances could signal complications (ulcer, stricture, etc.) Multiple intolerances may decrease diet quality, macro- and micronutrient intake
42
Describe dumping syndrome
Caused by the rapid transit of simple/free sugars or greasy foods into lower small intestine 0-60 minutes after eating Nausea, vomiting, diarrhea, stomach pain, dizziness, hypoglycemic symptoms Treatment: avoid suspect foods and beverages, read food labels/ingredients lists carefully
43
What are some late nutrition complications/
Hair loss Kidney stones (oxalate) Reactive hypoglycemia Lack of appetite
44
Describe hair loss
Common 3-6 months post-op Stress response Over 9 months post-op is likely due to nutrient deficiency
45
What causes kidney stones?
Increased oxalate retention, decreased fat intake, decreased calcium intake, inadequate hydration, other metabolic factors
46
How are kidney stones treated?
Minimum 2 L of fluid/day, at least 100 mg calcium, low oxalate diet
47
Describe reactive hypoglycemia
Causes: inadequate CHO, missed meals, excessive exercise or medication, increased incretin release 1-3 hours after meals (hypoglycaemic symptoms) Focus on complex/high fibre CHO, combining CHO and protein for snacks
48
Describe a lack of appetite
Hunger cutes change or may be absent due to decreased appetite-stimulating gut hormones (e.g, ghrelin, etc.) Use reminders to eat, regular meal pattern, measure portions Occasionally appetite-stimulating medications may be added
49
What are common micronutrient deficiencies?
``` Iron Zinc Copper Vitamin A (rare) Thiamine Vitamin B12 Vitamin D ```
50
Describe iron deficiency
Up to 51% of patients become deficient Symptoms: fatigue, headaches, insomnia, hair loss Treatment: up to 300 mg oral elemental iron + 250 mg vitamin C (at least 2 hours between iron/calcium/thyroid medication) May need iron infusions in refractory cases
51
Describe zinc deficiency
Up to 28=36% 1 year post-op; potentially refractory requiring ongoing supplementation (requires concurrent copper supplementation
52
Describe copper deficiency
Increasing prevalence, appears over 2 years post-op Symptoms: ataxic gait, extremity numbness, unexplained anemia 1 mg Cu: 8-15 mg Zn in supplements to prevent deficiency
53
Describe vitamin A deficiency
Rare, up to 10-17% of patients More common with poor diet and inadequate supplementation Occular changes lead to finding Some patients require ongoing high-dose supplements
54
Describe thiamine deficiency
More common with persistent vomiting and reduced food intake
55
Describe vitamin B12 deficiency
Low acid environment, decreased digestion of vitamin from foods Exclusion of distal stomach, therefore reduced intrinsic factor produced May require alternative routes
56
Describe vitamin D deficiency
Decreased absorption from foods, decreased intake of vitamin D rich foods May require short-term high doses to reach normal levels
57
What medications needs to be changed?
NSAIDs Oral contraceptives Anti-depressants, anti-anxiety medications, etc. Avoid extended release or enteric coated medications
58
How are NSAIDs changed?
They post an increased risk of ulcer | Must be avoided roused only in small doses for 2-3 days
59
How are oral contraceptives changed?
Absorption rates vary after surgery, but are generally decreased. We are unable to predict absorption or effectiveness Patients should choose non-oral hormonal contraceptives or barrier methods
60
How are anti-depressants, anti-anxiety medications, etc. changed?
Absorption changes are common and variable post-op Unable to predict how a patient will respond to meds post-op Close monitoring by patient and care team of symptoms to readjust medication in the early post-op period
61
Why should patients avoid extended-release or enteric located medications?
Decreased absorption area Increased transit through gut Decreased bioavailability for patients
62
Can patients consume alcohol?
There is an increased alcohol sensitivity; due to weight loss, faster gastric emptying and ethanol absorption and slower metabolic clearance Increased ulcer risk with increase intake Patients should abstain from alcohol for 12 months post-op (may reintroduce alcohol in small amounts if no complications)
63
Can patients become pregnant?
Patients should wait at least 12-18 months after surgery to get pregnant Increased risk to fetus during period of rapid weight loss, greatest risk of nutritional deficiencies
64
How often do patients needs to follow up?
Patients are seen at least 5 times in the first year post-op by bariatric team Annual follow up visits including nutritional monitoring/bloodwork are lifelong More frequent follow up may be need if complications develop

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