Nutrition management in Bariatric Surgery and the healthcare facility

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The Dietitian plays an important role in bariatric surgery recovery through pre and post-operative nutrition management. Charlene Grosse, Nazy Zarshenas, Dr Nikki Cummings and Trudy Williams from the DAA Bariatric Surgery Interest Group discuss guidelines for the Dietitian’s role.

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Image credit: Common bariatric surgeries supplied by Covidien USA
In Australia, obesity is on the rise as is the associated risk for a person to develop long-term chronic conditions such as cardiovascular disease, high blood pressure and Type 2 diabetes. With obesity now classified as a disease by the American Medical Association, close to 15,000 people opted for bariatric surgery last year in an endeavour to better manage their weight and health.
Bariatric surgery, also known as weight loss surgery or metabolic surgery, is recognised by the National Health and Medical Research Council (NHMRC) as the most effective treatment available for those with morbid obesity, i.e. those with a Body Mass Index (BMI) > 40 and for those who have weight-related co-morbidities at a BMI between 35 and 40.
The most common bariatric procedures performed in Australia are Sleeve Gastrectomy, Adjustable Gastric Banding and Roux-en-Y Gastric Bypass, with a small number of Biliopancreatic diversions (BPD) also performed.
These procedures impact on or change the anatomy and, in some cases, the physiology of the gastrointestinal tract which reduces oral intake and/or absorption of nutrients and hence aids weight loss. This subsequently prevents or treats the obesity related co-morbidities and as a result decreases mortality. The rate and amount of weight loss varies between the procedures, as does the resolution of co-morbidities. Data from the Australian Institute of Health and Welfare reveals a dramatic 34-fold increase in the number of hospital separations for bariatric surgery from 500 in 1998 to 17,000 in 2008.
Over-fed does not mean well nourished
There is a common perception that people with obesity are in a state of ‘over nutrition’ but often the opposite is true. People who present for bariatric surgery may be in a state of malnutrition. Poor quality diets, fad diets, lifestyle choices and side effects from some medications negatively influence the preoperative micronutrient status of the morbidly obese. Overweight and obese individuals are at risk for deficiencies in several micronutrients including iron, vitamins D, B12, E and C.
Obesity management does not stop with surgical intervention. Both obesity and its management are complex. Therefore the National Institute of Health, American Society for Metabolic and Bariatric Surgery and NHMRC recommend long-term nutrition and medical follow-up and advocate a team approach that includes a bariatric dietitian.
The dietitian’s role in bariatric surgery management
The dietitian’s role is a vital component of the bariatric surgery process, starting prior to admission and continuing life-long after discharge. The dietitian assesses the nutritional status of the patients to identify and treat any nutritional deficiencies, designs medical nutrition therapy interventions, and provides extensive education, counselling and support throughout the weight loss journey to help prevent complications and maintain optimal weight loss.
Dietitians in the acute care setting liaise with the food service/catering department and other stakeholders to develop, as well as ensure provision of an appropriate therapeutic bariatric diet. During complications and in acute illness, nutrition support to preserve lean body mass and enhance recovery of patients takes priority over weight loss.
Because the risk for micronutrient deficiencies persists or may worsen over months and years after bariatric surgery, ongoing comprehensive nutrition screening is required by the bariatric dietitian to ensure optimal nutritional status.
Bariatric surgery carries both short and long term nutritional risk
Maintaining adequate nutrition is a challenge. Every bariatric surgery leads to very reduced total kilojoule (kilocalorie) intake, especially in the first six postoperative months, typically ranging from 2900–3800 kJ (700–900 kcal) per day following RYGB. This contributes to the decreased intake of all macronutrients especially protein as patients may have difficulty consuming their recommended protein requirements.
The emphasis of postoperative nutritional care is to:

• Ensure adequate nutrient intake and hydration to support healing and preservation of muscle mass.


• Ensure beverages and ‘foods’ supplied for consumption after surgery minimise common post-surgical complaints, which include nausea, vomiting, anorexia, dehydration, halitosis, dumping syndrome, constipation, diarrhoea, flatulence, lactose intolerance and reactive hypoglycemia.


• Guide a patient’s diet transition from fluids to purée to soft and then back to solid foods. The duration of each phase is dependent on the type of bariatric procedure performed and the patient’s tolerance.


• Guide changes to a patient’s eating and drinking style (e.g. taking small sips of fluid, cutting foods into small pieces and chewing each mouthful thoroughly before swallowing) to minimise the adverse symptoms and help the patient adjust to and establish new eating and drinking behaviours.

Due to the significant changes to the gastrointestinal system, a unique and stage-based diet is implemented and progressed according to the individual patient’s tolerance in liaison with the Accredited Practising Dietitian (APD) and surgeon.
Vomiting may result from drinking or eating too much or too quickly at a single time, progressing too rapidly through the transition stages, not chewing prior to swallowing, and/or eating foods that are too tough or dry.
Role of the healthcare facility
An integrated approach in managing the treatment and care of patients following bariatric surgery is imperative. EQuIPNational criterion 12.2 and the Nutritional Standards for Adult Inpatients in Hospitals set regulations to ensure the nutritional needs of all patients are met. These standards require the delivery of innovative clinical services to optimise food and nutritional care in healthcare facilities and acknowledge a duty of care to ensure access to safe, appropriate and adequate food and fluid through a patient focused meal service. Food served to patients is an important factor that influences both their clinical outcomes and satisfaction with their hospital stay.
How to optimise early postoperative care in hospital
Good-quality food and fluids are basic requirements in effectively managing a patients’ nutritional needs. The hospital’s routine affects a patient’s ability to comply with their post-operative dietary requirements. The following ten key points help to optimise nutritional intake in the early post-operative phase.

• Commence sips of water and progress to thin clear nutrition support fluids within 24 hours after any bariatric procedure.


• Advise patients to sip fluids slowly over the day to support adequate hydration.


• Leave meal and drink trays with patients between meals to allow them time and opportunity to optimise their fluid and nutrient intake.


• Monitor and correct hydration status as even mild dehydration can contribute to headaches, nausea and fatigue.


• Avoid transition to non-fluid choices in the early post-operative stage.


• Progress to medical nutrition support ‘bariatric’ fluids if the length of stay is extended beyond the expected period.


• Commence additional enteral or parenteral nutrition support for the patient who experiences post-operative complications.


• Commence a “bariatric specific” multi-vitamin and mineral supplement if the length of stay is extended beyond the expected period.


• Supply crushed or liquid rapid release medications to maximise absorption in the immediate post-operative period.

Confirm in the discharge plan that the patient has a post-operative consultation booked with an APD skilled in bariatric dietetics. Some surgeons have a preferred bariatric APD.
Managing the dietary needs of a long term patient
For the person who has had bariatric surgery in the past, consider these additional points.

• Identify specific type of bariatric procedure because each procedure carries different nutritional risks


• Consult with a Bariatric APD to evaluate nutrient supplementation and guide further screening, supplement dose adjustments, and dietary recommendations


• Perform comprehensive nutritional screening if no recent results available because nutritional deficiencies directly impact on clinical outcomes and well-being


• Provide texture appropriate meals and options on a selective menu. For some people, foods may present textural challenges that result in discomfort, pain and regurgitation


• Provide appropriate amounts at meals and snacks, the solid and fluid volume tolerated changes with time and type of procedure starting from as little as ¼ cup of food per meal without adverse symptoms and increasing to ½ a cup or more per meal over the first year of surgery


• Increase proportion of protein served at the small meal to preserve lean body mass (muscle preservation) and aim to half fill the small plate with a protein source


• Provide protein rich snacks and/or medical nutrition drinks when appropriate

Conclusion
Bariatric surgery is now more commonly used as an effective treatment for obesity. An understanding of the short and long term nutrition requirements and adherence to the recommended guidelines for the bariatric patient by all care providers help to optimise patient care.
Referral and regular review by an APD with expertise in bariatric surgical care are an essential component in treatment. To find an APD in your area who works with patients who have undergone bariatric surgery, visit Find an APD on the DAA website www.daa.asn.au and select ‘bariatric surgery’ under ‘Area of Practice’.
 

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“I will apply dietetic measures for the benefit of the sick according to my ability and judgement; I will keep them from harm and injustice” – Hippocrates

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Authors
Charlene Grosse (APD)
Nazy Zarshenas (APD)
Dr Nikki Cummings (APD)
Trudy Williams (APD)
Combined Biography
The authors of this article are specialised senior bariatric APD’s from NSW, WA and QLD. They are active members of the DAA Bariatric Surgery Interest Group and have combined experience in the hospital and private practice settings.
A full list of references is available from Charlene.grosse@sjog.org.au