Friday, May 30, 2014

Part 1: New Jersey Dietetic Association Annual Meeting


     A couple of weeks ago I attended the annual New Jersey Dietetic Association’s meeting held on May 14th at the Imperia on Easton in Somerset, NJ.   For the most part I was manning the Scholarship Fundraising Raffle table making sure everything was  going well with that part of the event.  Given my duties, I wasn’t able to attend any of the lectures, but ,  I was still able to gather some information  that I hope some of you may find enlightening.

     Ms. Jennifer Stein, MS, RD, a Dietitian with St. Barnabas Health Care discussed,  “The Nutritional Management before and after  Weight Loss Surgery.”  She went over current weight loss treatment modalities, as well as, the evolution of weight loss surgery and nutritional guidelines associated with the surgeries.  Over the years, weight loss surgeries have morphed into what she termed, “metabolic surgeries,” that are done laparoscopicaly and single incisions with shorter hospital stays.  The following table gives a break down on the different surgeries she discussed during her talk:

Restrictive vs. Malabsortive and Restrictive Procedures

Restrictive
Gastric Band
Sleeve Gastrectomy
Weight loss
40 to 50% of excess body weight
>50% excess body weight
Metabolic/hormonal changes
None
Improved diabetes, decreased hunger due to hormonal changes
Nutritional Deficiencies
Most likely not
Vitamin B12; ? others
Risks/Complications
Band slippage, prolapse, weight regain
Leaks, strictures, weight regain
Other
high calorie foods slip through
 
Malabsorptive/Restrictive Procedures
Duodenal Switch
Roux-En-Y Gastric Bypass
Weight loss
>70% weight loss
60 to 80% weight loss
Metabolic/Hormonal Changes
Hormonal changes decrease hunger
Hormonal changes decrease hunger
Nutritional Deficiencies
Fe, Fat soluble vitamins
Vit B12, Fe, Ca, folate
Risks/Complications
Dumping, leaks, ulcer
Dumping, leaks , ulcer

 

     Preoperative care involves diabetes management, smoking cessation and making sure the patient has realistic expectations.  Encouraging exercise, providing protein and MVI, calcium and vitamin D supplementation is also advised.  Postoperative care requires a gradual advancement of the diet.   The first week should be clear liquids, second should be full liquids, the third and fourth week is puree before the final week when  the patient can advance to solid foods.   The only difference is found with the duodenal switch diet which extends to 9 weeks and between the fifth to eighth weeks, the patient is on a semi-soft diet.   All patients undergoing bariatric surgery should have the following supplements:  MVI, calcium citrate, vitamin D and biotin.   Patients who underwent the duodenal switch surgery should also receive fat soluble vitamins. 

     Ms. Cynthia Lowen, a Medical Scientific Liaison with Nestle Health Science, gave a talk entitled, “Nutritional Support of the Critically Ill Patient with Obesity.”  She discussed how obesity, despite it’s associated physical and metabolic derangements, is often missed as a diagnoses.  Other points she talked about were the prevalence of diabetes and nutritional insights into improving outcomes for the critically ill obese patient.  Obesity is currently recognized as a disease associated with a multitude of comorbidities and has behavioral, genetic and environmental causes.  Obese individuals are susceptible to protein energy malnutrition due to increased protein breakdown which leads to a reduction in lean body mass.  Hypocaloric or permissive underfeeding is advised for critically ill patients whose BMI exceeds 30.  11 to 14kcal/kg of actual body weight with protein requirements of 2g/kg IBW for class 1 and !! obesity (BMI of 30 to 39.9) or 2.5g/kg of IBW for class II obesity ( BMI of >40).  Interestingly, she notes that studies have found that providing approximately 8g of leucine a day to critically ill patients can help maintain lean body mass and improve glycemic control.  She states low carb, high protein feedings can have the same effects.  Fish oil is also said to help with outcomes for critically obese patients. 

Stay tuned for some more from New Jersey Dietetic Association’s 2014 Annual Meeting!!