Вы находитесь на странице: 1из 70

Bariatric surgery: what it entails for patients

with Binge Eating Disorder (BED)

http://www.smmcweightloss.org/

Zukhraf Shafi
Sodexo NY Dietetic Intern
St. Michaels Medical Center

Binge Eating Disorder


(BED)

Recognized in 2013
American

Psychiatric
Association
(APA)
DSM-5
Eating disorder

requiring
treatment
Before
Considered a personal
choice

What is BED?
Excessive

overeating
1 x week, 3

months
Lack of

control

Accompanied by 3 of the
following:
Eating to
point of
discomfort
Depressi
on

Fast Eating

Secrecy

Large
Portions

Disgust

Cause?
Negative self affect:
Body image
Personal Stress
Boredom
Dietary Restraint
Health status

Vicious

cle

Binge

Distress

BED Statistics

Statistics
1 in every 35

Americans:
5 million women
3 million men

Not always obese


30% of all weight loss

patients

Runs in families

Who is at risk of getting BED?


Equal Opportunity
Disorder:
40% men 60%

women
Race /Age
starts at young
age, but older
people seek
treatment.

Treatment

Challenging to diagnose due to

secrecy.

Treatment
Psychotherapy Healthy attitude toward

food and weight.


Antidepressants
Nutrition Counseling
Group therapy

Challenges for Bariatric Surgery


Patients
Long-term support
Falling back into

cycle of BED
Fearing food

The Stomach

Anatomy

Ch
ym
e

Rugae
Grip and move

food

Enormous

expanding
ability:

Make
overeating
possible!

Small Intestine

Small Intestine
Food passed to SI

from stomach.
Most of the digestion

and absorption takes


place here.

Laparoscopic Surgery

Minimally Invasive Surgery


4-5 small incisions

Passed through

each port :
Tiny instruments
Camera
Benefits:
hospital stay
infection risk
blood loss

Types of Bariatric
Surgery

Types of surgery
Adjustable Gastric Band (AGB)

Biliopancreatic Diversion (BPD)

Roux-en Y Gastric Bypass (RYGB)

Sleeve Gastrectomy (SG)

Adjustable Gastric Band


Restrictive
Stomach pouch

Foreign object
No alteration to GI tract
Least invasive /Reversible
Estimated EWL 40-50%
Complications:
Band slippage/erosion
Gastric Reflux
Esophageal Dilation

Calories Matter!!!

Highest
reoperation
rate!

Biliopancreatic Diversion/Duodenal Switch BPD/DS

Restrictive/Malabsorptive
BMI 50
2 steps:

Removing 80% of stomach


Sleeve connected to lowest part

of SI (Ileum)
5% of all Bariatric Procedures

60-70% EWL
Complications:
Long term deficiencies
Dumping syndrome
Anastomotic leakage

Sleeve Gastrectomy
Restrictive
80% stomach removed

First step of BPD


Most popular
Complication:
Anastomotic leak

EWL and maintenance

> 50% (3-5yrs)


Removal of fundus =

Ghrelin =

Hunger

After watching the sleeve


gastrectomy!

Roux-en Y Gastric Bypass


(RYGB)
Restrictive/malabsorptive
Small stomach pouch
SI Divided:
Middle of SI (Jujenum) is

connected to pouch
Top of SI (Duodenum)
connected further down
(Ileum)
Complications:
Anastomotic leaks
ulceration
dumping syndrome
Intestinal Obstruction
Estimated EWL- 60-80%

Ideal surgery for uncontrolled


Diabetes Patients

Current research RYGB and Diabetes

Possible Explanations:

Study 1: 5 year,

following 191 pts s/p


RYGB. 83% remission
in T2D. (1)

Low calorie intake

Study 2: 109 hospitals,

28,616
1 yr of stomach:
Newpatientsanatomy
post op significant
improvement or
Affects
remission
83% gut
of ptshormone production
(2) metabolic changes better

glycemic control

Glucose may improve


before discharge!!!!

Who Qualifies?

Criteria for surgery


BMI > 40 or BMI
35 with wt related
comorbidities.

6 months attempted
weight loss

Prior to surgery

Bariatric Team

RD
Surgeon
Psychologist

Nurse
Practitione
r

Approv
al for
surger
y

Assessme
nt

Nutrition
Education

Referral to
Psychologis
t

Role
of RD

Approva
l

Emotion
al
Support

Weight Loss
Insurances like consistent

wt loss
Compliance

St Michaels Bariatric Center:


~2 lbs a week
2 wk Liquid Diet (may vary):
5 lbs /week =10 lbs total
Wt loss helps shrink liver and

provide better access

Post Surgery

Macronutrient Needs

Recommendations

Day 1
Encourage walking
Prevent gas
Feels like heart attack
Prevent blood clots

NPO until Esophagram


No leakage present

Post Surgery Diet

Bariatric clear liquids


POD 1-4
Begin with sips
What's included:
Low Sodium Broth
Sugar free gelatin
Sugar free ice
Sugar free juice
Nectar protein powder

or Prostat
Encourages gastric healing

Full Liquids
POD 5-14
Includes:

Begin

Supplementation

All clear liquids


Non-fat milk/yogurt
Tofu
Blended soups

4 oz every hr
Still minimal calories:
Encourages gastric

healing

(vegetable or bean)
Protein shakes
Unsweetened
applesauce
Sugar-free Pudding

Puree Diet

Week 3 & 4 post-op

Begin meeting Protein

needs
30-30 Rule
Meet Fluid needs
Types of food:

Canned meats
Baby food
Beans/lentils
Low-fat cheese

Soft Diet
Week 5 & 6 post-op
Tender foods
5-6 small meals
NO STARCHES
Fruits and Vegetables-

wk 6
Focus is protein:
Cooked beans/lentils
Low fat dairy
Tofu
Eggs
Meat , poultry , and fish

CHEW, CHEW, CHEW!!!

Regular diet
Week 7 and beyond
Lifestyle Change
Low-fat

Protein

No added sugar
Meet PRO/fluid

needs
Avoid rice/pasta for
another 2-3 wks
Continue protein
shakes
Continue vitamins

Starche
s

t
e
g
e
V

es
l
ab

Protein
Healing
Satiety
Prevents hair loss
Energy

Vitamins for Life!


Liquid /chewable 1 mo. post op

Lets try some


supplements!!!!!!!!

Case Study

Presentation of Patient
50 y/o Haitian Female
Anthropometrics: Ht: 66

Wt: 292.5 lbs BMI: 47.2 (Class 3: very

high risk obesity)


Social hx: Single mother of two , unemployed (was home health

aide)
Moved to US 20 years ago, 160 lbs
Weight gain post pregnancy
PMH: HTN, Back Pain, GERD,

Prediabetes

Current dx: Morbid Obesity


Medications : Celebrex, Cozaar, Prilosec

p
l
he

!
s
!
a
!
e
P
l
L
P
E
,
H
e
m EED
IN

Medical/Nutritional Course
Did NOT do Lose for Life

October 29th - Date of Surgery


Weight

BMI

Weight lost

Glucose

Calcium

BP

183 H

8.2 L

160/91 H

since Initial

258.82 lbs

46.2

~34lbs

Admitted for Laparoscopic Roux-en-Y Gastric Bypass


Surgery at admit date
Medications: Humalog (Insulin) , Protonix, Heparin,

Zofran
Diet : NPO (for Esophagram)
Progressed to Bariatric Clears on October 30 th
Discharged on October 31st

Initial Assessment November


6th
Weight

BMI

IBW Range

Total

Total Fluid

Protein
258.5lbs

41.7

130-143

Diet Phase : Full Liquid


Medication: Cozaar
24 hr Recall
Breakfast: Green Tea
Snack 1: Light non-fat yogurt
Lunch : Tea(unsweetened)
Snack 2: Broth
Dinner : Broth

6 grams (very
low!!!)

64 oz

ADIME: Initial Assessment


Assessment :
Tolerating clears well- current phase: full

liquids
Hx of BED making YC fearful
Currently consuming 6 grams of Protein
Currently minimal physical activity

ADIME: Initial Assessment


Intervention:
Continue nectar protein
Increase protein intake
Encouraged attending support groups
Excercise goal: 30 min 5/day
4oz protein shakes BID daily
Bring 7 day food logs

ADIME : Initial Assessment

Goals

7 day food journal


5-6 small meals
Meet 60-80 gm PRO

goal
Meet exercise goal
30 min 5 x week
Meet fluid goal - 64
oz
Begin MVIs
Follow up in 3 weeks

ADIME : Initial Assessment


Monitoring &

Evaluation
Food logs
Weight
Physical Activity
Diet progression

November 25 Follow up
th

Weight

248.5 lbs

BMI

40.1

Since

Since

surgery

initial

- 10.32lbs

- 44.1 lbs

EWL

BP

Blood
Glucose

29%

136/86 H

94

Diet Phase: Puree


Weight was progressing well.
YC was meeting Protein needs (70 gm) and Fluid needs (64 oz).
YC was walking 1 hr/ 5 days/week.
She was still on Full Liquids , 1 mo post-op.

Nutrient Needs

Guidelines St Michaels Bariatric Center


uses

www.bariatrictimes.org

Pertinent Labs
Labs

10/14

10/29

10/30

10/31

11/21

Sodium

137

137

134L

137

139

Potassium

4.0

3.3L

4.0

3.8

4.0

BUN

11

14

11

10

Creatinine

0.82

1.10

0.85

0.85

0.89

Glucose

112 H

183 H

136 H

136H

94

Calcium

9.4

8.2 L

8.6

8.9

9.6

Magnesium

Not Tested

2.0

1.9

1.5 L

Not Tested

Phosphorus

Not Tested

4.5

3.0

2.9 LL

Not Tested

Albumin

4.1

Not Tested

Not Tested

Not Tested

3.7

BP trend throughout treatment


Date

BP

August 8, 2014

160/91 H

September 19, 2014

174/84 H

October 30, 2014

168/86 H

November 25, 2014

136/86 H
(Significant Improvement)

Medical Nutrition Course


Weight (lbs)
300
290
280
270
260

Weight (lbs)

250
240
230
220

42224
42284
42304
42329
42199
42259
42298
42306
42333

Critical Comments

Critical Comments
Patients with BED - extra nutritional

/psychological support
15 min too short

A cheaper option for unemployed patients?


Psychologist only sees pts for initial and

support groups!

Thank you!!!
Georgina Wondolowski, Silvana
Panfill , Dr. Saniea Majid, Jennifer
Tomesko, and RDs at SMMC.
Thank you Gayanne and Christina .
Fellow Interns for being so
supportive.
My husband for believing in me. My
daughter Maheen for letting me
finish my homework and telling
me Youre the best!

References
Schauer, P. R., Burguera, B. , Ikramuddin , S. , Cottam , D. Effect of laparoscopic roux-en y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003; 238:236-285.
Hutter, M.M. , Schirmer B.D., Jones, D.B. First report from the American College of surgeons----bariatric surgery center network: Laparoscopic sleeve gastrectomy has
morbidity and effectiveness between the band and the bypass. Ann Surg. 2012; 254;410-452.
3. Adams T.D., Davidson, L.E., Litwin, S.E., Kolotki, R.L.. Health Benefits of Gastric Bypass Surgery After 6 Years. JAMA. 2012; 308;11
4. Gylys, Barbara A., and Mary Ellen. Wedding. Medical Terminology Systems: A Body Systems Approach. 6th ed. Philadelphia, PA: F.A. Davis, 2009.
5. Sturm, R., and A. Hattori. Morbid Obesity Rates Continue to Rise Rapidly in the United States. Int J Obes. 2012; 37: 889-91.
6. Adult Obesity Facts." Centers for Disease Control and Prevention. http://www.cdc.gov/obesity/data/adult.html. Published September 09, 2014. Accessed January 01, 2015
7. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's Food & the Nutrition Care Process Edition 13. St. Louis, MO: Elsevier/Saunders,
2012
8. Academy of Nutrition and Dietetics Nutrition Care Manual: Overweight & Obesity. www.nutritioncaremanual.org. Accessed January 27, 2015
9. Ethicon Endo- Surgery, Inc. Weight Loss Surgery. Ethicon Endo-Surgery, Inc.
http://www.ethicon.com/sites/default/files/microsites/obesity/12-1127-Metabolic-impact-of-obesity-poster.pdf. Published 2012. Accessed December 01,2014
10. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington,VA: American Psychiatric Association.
11. ANAD: Binge Eating Disorder. http://www.anad.org/get-information/about-eating-disorders/binge-eating-disorder. Accessed November 07, 2014.
12. Beware of products promising miracle weight loss. http://www.fda.gov/ For Consumers/ ConsumerUpdates/ U.S. Food and Drug Administration. Accessed January 25, 2015.
13. Life after bariatric surgery. American Society for Metabolic and Bariatric Surgery https://asmbs.org/patients/bariatric-surgery-procedure . Accessed on December 05, 2015
14. Bariatric Surgery for Severe Obesity. Bethesda, MD: U.S. Dept. of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive
and Kidney Diseases. http://win.niddk.nih.gov/publications/PDFs/Bariatric_Surgery_508.pdf . Updated June 2011. Accessed January 27,2015.
15. Vetter ML, Ritter S, Wadden TA, Sarwer DB. Comparison of bariatric surgical procedures for diabetes remission: efficacy and mechanism. Diabetes Spectrum.
2012;25(4):200-210
16. Aills, L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4: 73108.
17. Hakaem HA, ORegan PJ, Salem AM, Bamehriz FY, Eldali AM. Impact of Laparoscopic Sleeve Gastrectomy on Iron Indices: 1 Year Follow-Up. Obes Surg. Jul 15 2009.
18. Mechanick J I, Youdim A, Jones DB, Garvey T, Hurley DL, Mcmahon M, Heinberg L, Kushner R, Adams T D, Shikora S, Dixon JB, Brethauer S. Clinical Practice Guidelines for
the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient2013 Update: Cosponsored by American Association of Clinical
Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis. 2013; 4:159-91.
19. Jellinger PS, Smith DA, Mehta AE, Ganda O, Handelsman Y, Rodbard HW, Shepherd MD, and Seibgel JA. American Association of Clinical Endocrinologists. Guidelines for
management of dyslipidemia and prevention of atherosclerosis: Executive Summary. Endocrine Practice.2012; 18:269-93.
20. Academy of Nutrition and Dietetics Nutrition Care Manual: Bariatric Surgery. https://www.nutritioncaremanual.org.Accessed December 27, 2015
21. Evidence Analysis Library. AWM: Executive summary of recommendations. Academy of Nutrition and Dietetics. http://www.andeal.org/topic.cfm?cat=3014. Published
20016. Accessed January 20,2015
22. Life after bariatric surgery. American Society for Metabolic and Bariatric Surgery (ASMBS). https://asmbs.org/patients/life-after-bariatric-surgery. Accessed January 01,2015.
23. dBariatric Surgery. John Hopkins Medicine. http://www.hopkinsmedicine.org/. Accessed January 01, 2015.
1.
2.

Questions?