Metabolic and Bariatrics Flashcards
Signs and symptoms of vitamin D deficiency
Depression, muscle pain, involuntary muscle movements, osteoporosis
Signs and symptoms of calcium deficiency
Low bone density, osteoporosis, muscle contractions, spasms, pain
Signs and symptoms of magnesium deficiency
Muscle contractions, pain, spasms, osteoporosis
Signs and symptoms of iron deficiency
Fatigue, low productivity, spoon shaped nails / vertical ridges, glossitis
Signs and symptoms of B12 deficiency
Numbness / tingling fingers and toes, glossitis, fatigue, depression, dementia, gait ataxia
Signs and symptoms of folic acid deficiency
Palpitations, fatigue, Neural Tube Defects, changes in skin pigmentation
Signs and symptoms of zinc deficiency
Skin lesions, poor wound healing, hair loss, taste changes
Signs and symptoms of copper deficiency
Unsteady gait, tingling in hands / feet, poor wound healing, paralysis
What are the 4 types of bariatrics surgeries?
Laparoscopic adjustable band (LAGB)
Sleeve gastrectomy (SG)
Roux en Y Gastric Bypass (RYGB)
Biliopancreatic Diversion/Duodenal Switch (BPD/DS).
What is the most common bariatric surgery?
Sleeve Gastrectomy
WHAT is the most invasive bariatric surgeries and WHY?
BPD/DS is the most invasive.
Because malabsorption of both micro- and macro-nutrients.
Which is the best bariatric surgery?
There are no predictive data to help providers choose the best procedure for an individual patient.
What are the ways bariatric surgeries work?
1- Restrictive EX. gastric band
2- Combination (gastric manipulation that restricts + neural/hormonal) EX. SG, RYGBP
3- Combination and Malabsorptive EX. BPD/DS
What is the normal function of Cholecystokinin (CCK)?
What happens when dieting?
Normal - suppresses appetite
Alteration - levels decrease during dieting/weight loss
What is the normal function of Glucose-dependent
insulinotropic polypeptide (GIP)?
What happens when dieting?
Normal - Energy storage
Alteration - Levels increase during dieting/weight loss
What is the normal function of Ghrelin?
What happens when dieting?
Normal - Stimulate appetite, particularly for high-fat, high sugar foods
Alteration - levels decrease during dieting/weight loss
What is the normal function of Glucagon-like peptide 1 (GLP-1)?
What happens when dieting?
Normal - Suppress appetite and increase satiety
Alteration - Decreased function
What is the normal function of Peptide YY (PYY)?
What happens when dieting?
Normal - Suppresses appetite
Alteration - Levels decrease in obese individuals
What is the normal function of Leptin?
What happens when dieting?
Normal - Regulate energy balance, suppress appetite
Alteration - Levels decrease during weight loss
What is the normal function of Insulin?
What happens when dieting?
Normal - Regulate energy balance, signal satiety to brain
Alteration - Insulin resistance in obese persons, reduced insulin levels after dieting
What is the criteria for bariatric surgery?
BMI >35 + obesity related co-morbidities
OR
BMI > 40 + previous failed weight loss attempts
Why is a short-term pre-surgery diet prescribed?
Shrink liver volume
Why is a long-term pre-surgery diet prescribed?
Reducing abdominal adipose
tissue
What are common EARLY post-op nutrition complications?
Dehydration, nausea, vomiting, dumping syndrome, constipation and diarrhea
What are common LATER post-op nutrition complications?
Reactive hypoglycemia, micronutrient deficiencies and weight regain.
What is a complication of the sleeve gastrectomy, the Roux en Y gastric bypass and the biliopancreatic diversion/duodenal switch.
MICROnutrient malabsorption
What is the % of weight regain in the 10 years following surgery?
20-25%
How much of the fundus is removed in a sleeve gastrectomy?
80%
What procedure reduces the amount of calories and nutrients that can be absorbed? Causing a malabsorption of macro and micronutrients.
Biliopancreatic Diversion/Duodenal Switch
What surgery is most effective against diabetes?
Biliopancreatic Diversion with Duodenal Switch
How does RYGBP and SBG improve Diabetes?
1- Initial decrease in calories.
2- Accelerated delivery of nutrients to hind gut + increase in GLP-1: inhibits glucagon secretion and changes insulin response to nutrients
What labs completed pre-surgery?
Iron (serum folate, ferritin, TIBC)
Thiamin
B12
Folate
Vitamin D
Serum calcium
PTH
Alkaline phosphatase
Vitamins A, E, K
A1c
Phosphorus
Magnesium
Zinc
Copper
What labs completed 2 months post-surgery?
Iron (serum folate, ferritin, TIBC)
Thiamin
B12
Folate
Vitamin D
Serum calcium
PTH
Alkaline phosphatase
A1c
Phosphorus
What labs completed 6 months post-surgery?
Iron (serum folate, ferritin, TIBC)
Thiamin
B12
Folate
Vitamin D
Serum calcium
PTH
Alkaline phosphatase
Vitamin A (BPD/DS)
A1c
Phosphorus
Magnesium
Zinc
Copper (RYGB or BPD/DS)
Selenium (RYGB or BPD/DS)
What labs completed 1 year post-surgery?
Iron (serum folate, ferritin, TIBC)
Thiamin
B12
Folate
Vitamin D
Serum calcium
PTH
Alkaline phosphatase
Vitamin A, E, D
A1c
Phosphorus
Magnesium
Zinc
Copper (RYGB or BPD/DS)
Selenium (RYGB or BPD/DS)
Psychiatric conditions that contraindicate surgery?
Current drug use
Active schizophrenia
Severe MR
Current, heavy drinking
Multiple suicide attempts
Active bipolar disorder
Active eating disorder
Protein recs following surgery?
Minimum 60 grams/day.
Most surgical centers are recommending 60-80 grams/day.
Early post op this is difficult for patients to achieve; focus on ‘quality’ of protein.
Plant and/or Animal Protein
Hydration recs following surgery?
Liquids 20-30 minutes post-meal
Hydration needs vary, however, a rough guideline is 64oz./day
Avoid carbonation initially (excess gas)
Avoid caffeine or any dehydrating beverages
Carb recs following surgery?
Mminimum 50 grams a day, specifically for brain function
Stage 2 (full liquid diet) - milk; whey protein
Stage 3 (soft food) - well cooked vegetables/soft fruit
Stage 4 maintenance - solid, healthy food diet
What to do for each post-op nutrition complication?
Dehydration
Nausea and/or vomiting
Diarrhea
Dehydration (dizziness, nausea, fatigue, dark urine)
-Weight early indicator (>2 lb./day = dehydration)
WHAT TO DO = monitor hypertension medications + check IV hydration contains 100 mg thiamine
Nausea and/or vomiting; GERD
-Most likely related to drinking/eating patterns (Eating too fast; eating too much; not chewing)
WHAT TO DO = rule out: ketosis, stenosis, or pregnancy + monitor thiamine
Diarrhea
-Think lactose intolerance first, then infection, dumping, or
post cholecystectomy
When does EARLY and LATE dumping syndrome occur?
Symptoms of EARLY and LATE dumping syndrome?
EARLY (occurs 30-60 minutes after eating and can last up to 60 minutes) - more common in RYGB
Symptoms: sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lie down, upper abdominal fullness,
nausea, diarrhea, cramping, and active audible bowels sounds.
LATE or Reactive Hypoglycemia (occurs 1-3 hours after eating)
Symptoms are related to (low blood sugar) which include sweating, shakiness, loss of concentration, hunger, and fainting or passing out.
How to prevent post-op hypoglycemia with diet?
Eat 6 small meal; protein source at each
Avoid fluids 30 minutes post-meal/snack
Avoid high sugar/refined carbohydrate foods
Eat very slowly
What are 2 meds to treat post-op hypoglycemia?
Somatostatin analogs-octreotide (injection) OR Acarbose (oral)
WHEN should PN be considered for nutrition support?
If patient unable to meet needs using GI tract for at least 5-7 days with non critical illness or 3-7 days with critical illness
OR
Severe protein malnutrition and/or hypoalbuminemia
OR
Not responsive to oral or EN protein supplementation
WHAT macronutrients are at risk for malabsorption with BPD/DS?
72% fat malabsorption
▫ Need ADEK supplementation BID
▫ Monitor fat soluble vitamins
25% protein malabsorption
▫ May need high protein intake
Post-op nutrition supplementation for multivitamin?
1-2 daily
100-200% RDA Zinc and Copper
400-800 mcg of Folate/day
800-1,000 mcg of Folate/day (women childbearing age)
12 mg/day of Thiamin
Post-op nutrition supplementation for calcium citrate/carbonate + vitamin D?
2-3x/day
1,200-2,400 mg/d calcium + 400-800 IU of vitamin D
Post-op nutrition supplementation vitamin D?
3,000 IU daily
Post-op nutrition supplementation elemental iron?
DO NOT take with calcium
18-27 mg/d
40-65 mg/d menstruating females
Post-op nutrition supplementation B12?
350- 500 ug/d orally/sublingual
OR
1,000 mcg/month intramuscularly
How long should patients be advised to postpone pregnancy after bariatric surgery?
12-18 months + when weight has stabilized and they are able to eat a full food diet.
Bariatric procedure recommended for adolescents?
Sleeve Gastrectomy
What % of individuals fail to lose a significant amount of weight following surgery?
10-20%
A patient asks you to help her decide on which bariatric procedure to have; she is 42 years old with a BMI of 42 and her obesity related conditions include type 2 diabetes, hypertension and fatty liver disease. What do you tell her?
Current literature does not provide enough information to predict which procedure she would have a better outcome with.
Patients with obesity are at risk for what 5 micronutrient deficiencies?
Vitamins B12, folate, vitamin D, zinc and iron
A patient is 2 months post-bariatric surgery and calls you complaining of vomiting and dizziness, for the past 2 days; you tell the patient:
Go to ER to assess if she is dehydrated and needs IV hydration.
Patient admitted to the hospital for nausea and vomiting, she states that the in- patient dietitian told her she was drinking and eating too fast. You recommend to the inpatient dietitian and to the surgeon that they speak to the patient’s providers to:
Test vitamin B1 status and ensure IV solution contains 100mg of thiamin.
A patient is one year post-surgery; he comes to your office and states he has not followed up with the Surgical Center where he had his surgery because he moved and no longer lives in the city his surgery was performed; he states he is only taking an OTC multivitamin daily; you recommend that he:
Find surgical center close to his new location/schedule
Ask to speak to patients new PCP and provide them with list of labs to be tested yearly
Resume taking post-op supplements that surgical center recommended
A patient who had a Gastric Bypass Surgery comes to see you 8 years after her surgery. She states she is embarrassed to go back to her Surgical Center as she has gained 50 lbs. of the 120 lbs. she had lost. What do you do?
Preform nutrition assessment, identify lifestyle factors that may be contributing to weight gain, set goals for follow-up appointment, recommend PCP complete post-op labs.
A patient’s primary care provider refers a patient who had a sleeve gastrectomy 10 years ago to you after the patient was diagnoses with osteopenia and is also complaining of muscle cramps:
Suspect calcium, vitamin D, and/or magnesium deficiency and suggest labs.
A pediatrician approaches you about a 16 year old patient with a BMI of 38 kg/m2 who is interested in bariatric surgery. You tell the M.D that the patient should be assessed for the following co-morbidities to have strong indications for bariatric surgery:
T2D, sleep apnea, NASH, and pseudo cerebri tumor
