Chapter 12

Bariatric Surgery

• for patients whose BMI is over 40 or 35 with other complications

• includes: gastric bypass, sleeve gastrectomy, gastric band and duodenal switch.

• proven results in treating class III obesity. Help normalize metabolism, blood sugar, BP & cholesterol.

• complications: dumping syndrome

s/s of dumping syndrome

tachycardia, cramping, nausea, diarrhea, diaphoresis (pale, clammy, slimy hands)

Nutrition for patients who had bariatric surgery

• Liquid between meals, not with.

• 6 small meals a day.

• Thoroughly chew food.

• Protein rich and avoid high sugar/fats/carbs.

• Vitamin supplements.

• Recline slightly to slow gastric emptying

eating disorders

• Anorexia Nervosa (AN), Bulimia Nervosa (BN), & Eating Disorders Not Otherwise Specified (EDNOS).

• Serious psychiatric illnesses having a profound impact on nutritional status and health

• Characterized by abnormal eating patterns & distorted perceptions of food and body weight

• Continuum of disordered eating

• Risk factors:

  • Dieting, early childhood eating & GI problems, increased concern about weight & size, negative self-evaluation, sexual abuse, and other traumas.

anorexia

loss of appetite

Etiology

the cause, set of causes, or manner of causation of a disease or condition.

contributing factors to eating disorders

• Genetics

• Developmental

• Family influences

• Sociocultural factors

• Precipitating factors

• Onset of puberty, parents’ divorce, death of a family member, ridicule of being or becoming fat

• Attempt to improve performance in sports

• Depression, anxiety, substance abuse, or body dysmorphic disorder

treatment for eating disorders

Treatment plans are highly individualized

• Nutritional counseling

• Behavioral interventions

• Psychotherapy

• Family counseling

• Group therapy

• Antidepressant drugs effectively reduce the frequency of problematic eating behaviors but do not eliminate them

• Most eating disorders are treated on an outpatient basis, but hospitalization may be required

anorexia nervosa

• Try to keep their weight as low as possible.

• They may do this in different ways, such as not eating enough food, exercising too much, taking laxatives or making themselves sick (vomit).

• Treatment and therapy should focus on correcting disordered eating patterns, such as irregular eating, vegetarianism, and restricted variety of foods

Goals of Nutritional Therapy for Anorexia Nervosa

Step-by-step goals of nutrition therapy
1. Restore weight
2. Normalize eating pattern
3. Achieve normal perceptions of hunger and satiety
4. Correct biological and psychological sequelae of malnutrition

Calorie intake for anorexia nervosa patients

• 1000 to 1600 cal/day or 30 to 40 cal/kg

• Gradually increase to 70 to 100 cal/kg/day

• Monitoring vitals, electrolytes, & cardiac function

• Weight gain targets 2 - 3 pounds/week for hospitalized clients & 0.5 to 1 lb/week in outpatient programs

• Clients who refuse to eat may need a tube feeding

refeeding syndrome

• A potentially life-threatening condition

• Characterized by severe shifts in fluid and electrolytes, especially phosphorus

• Thiamin deficiency

strategies to help patients who have anorexia nervosa

• Involve client in formulating goals and meal plans

• Closely monitor I and O

• Weigh daily

• Stay with patient during meals and 1 hour after.

• Restrict vigorous activity.

• Offer rewards linked to quantity of calories consumed, not to weight gain

• Have the client record food intake and exercise activity

• Meal-planning tips and eating behavior strategies

bulimia nervosa

• an eating disorder characterized by regular, often secretive bouts of overeating followed by self-induced vomiting or purging, strict dieting, or extreme exercise, associated with persistent and excessive concern with body weight.

• an eating disorder in which a large quantity of food is consumed in a short period of time, often followed by feelings of guilt or shame.

• Mortality rate is less compared to anorexia nervosa, but it is still increased because of severe electrolyte & acid base imbalances related to recurrent vomiting or stimulant laxative abuse

diagnostic criteria of bulimia nervosa

• Recurrent episodes of binging (eating a large amount within any 2-hour period) accompanied by feeling of lack of control re: overeating.

• Behaviors to prevent weight gain, (self-induced vomiting; laxative, diuretic, or diet pill abuse; or excessive exercise).

• Binge & purge episodes occur at least 1x/week for 3 months but may occur several times a day.

Major goals of nutrition therapy

• Stabilize weight by decreasing bingeing & purging.

• Achieving normal perceptions of hunger, fullness, and satiety

Psychotherapy

Cognitive-behavioral therapy includes techniques for developing healthy attitudes toward food and weight. It also includes approaches for changing the way you respond to difficult situations.

nutritional counseling

Involves learning healthier ways to eat. You'll work with a registered dietitian or counselor to get back on track.

medication

Selective serotonin reuptake inhibitors are a type of antidepressant. They can reduce the frequency of binge eating and vomiting. They’re also effective at treating anxiety and depression. These conditions are common among people with bulimia nervosa.

support groups

Can be helpful when used with other forms of treatment. People and their families meet and share their stories.

Binge-Eating disorder (BED)

• Previously referred to as Compulsive Overeating

• Patient may be of normal weight but is often associated with obesity

• Differs from bulimia nervosa in that it does not involve purging

• Occurs at least 2 days a week for 6 months

• Associated with three or more:

  • Eating more quickly than normal

  • Eating until comfortably full

  • Eating large amounts of foods when not physically hungry

  • Eating alone because of embarrassment of how much is eaten

  • Feeling disgusted with oneself, depressed, or very guilty after overeating

comorbidities with binge-eating-disorder

• Major depressive disorder, anxiety disorders, and alcoholism

• And those of obesity if applicable

Risk factors for binge-eating-disorders

Childhood obesity, parental obesity, high degree of body dissatisfaction, dysfunctional attitudes regarding weight and shape, poor self-esteem, and impaired social functioning.

Treatment for binge-eating-disorder

• Nutrition therapy

• Cognitive behavior therapy

• Medication theory

• Focus of treatment:

  • To normalize eating behaviors with emphasis on recognizing internal hunger and satiety cues.

  • Reducing binge eating may be followed by participation in a weight control program.

primary intervention

• Goal: Prevent the onset of a disease, condition, or problem before it occurs.

• Focus: Entire population or at-risk groups.

• Examples:

  • Vaccinations to prevent infectious diseases.

  • Health education programs on smoking cessation.

  • Policies promoting clean air and water.

  • Teaching conflict resolution skills to reduce violence

secondary intervention

• Goal: Detect and address a problem in its early stages to prevent it from worsening.

• Focus: Individuals who are at risk or show early signs of a problem.

• Examples:

  • Routine screenings for high blood pressure or cancer.

  • Therapy for individuals showing early symptoms of depression.

  • Quarantine measures to contain disease outbreaks.

  • Early academic interventions for struggling students.

tertiary intervention

• Goal: Reduce the severity, complications, or impact of a disease or condition that has already developed.

• Focus: Individuals who have already been diagnosed or affected.

• Examples:

  • Rehabilitation programs for stroke survivors.

  • Chronic disease management (e.g., insulin therapy for diabetes).

  • Physical therapy for injury recovery.

  • Counseling and support groups for individuals recovering from substance abuse

coronary heart disease

• single leading cause of death

• Hypercholesterolemia leads to atherosclerosis (plaque on artery walls)

  • Can lead to many CV complications (MI, kidney failure, ischemic strokes).

• HDL is “good,” it removes cholesterol from the body tissue and takes it to the liver.

  • Levels > or = to 60 mg/dL for males & 70 mg/dL for females provide some protection against heart disease.

• LDL is “bad,” bc it transports cholesterol out of liver & into circulation, where it can form plaques on the coronary artery walls.

  • Optimal range for LDL is < 130 mg/dL.

• Optimal total cholesterol level is less than 200 mg/dL.

non-modifiable risk factors for coronary heart disease

Increasing age, male sex, family, history

modifiable risk factors for coronary heart disease

• high LDL cholesterol, low HDL cholesterol,

• consuming a diet high in saturated fat

• hypertension, diabetes mellitus, metabolic syndrome, obesity,

• sedentary lifestyle (prolonged periods of sitting or lying down with minimal physical activity)

• nicotine use disorder

Nutrition aspects for coronary heart disease

• Limit trans fats, saturated fats (< 7% daily caloric intake, & cholesterol (less than 200 mg/daily).

• Increase fiber, decreasing red meat consumption

• Omega-3 fatty acids found in fish, flaxseed, soy beans, canola, and walnuts

• Secondary prevention is focused on lifestyle changes that lower LDL.

• Diet low in cholesterol and saturated fats, a diet high in fiber, exercise and weight management, and cessation of nicotine use.

tips to help prevent coronary artery disease

• Trim visible fat from meats.

• Limit red meats, choose lean meat (turkey, chicken).

• Remove the skin from meats.

• Broil, bake, grill, or steam foods. Avoid frying foods.

• Use low-fat or nonfat milk, cheese, and yogurt.

• Use spices in place of butter or salt to season foods.

• Use liquid oils (olive or canola) in place of oils that are high in saturated fat (lard, butter).

• Soluble fiber lowers LDL. Oats, beans, fruits, vegetables, whole grains, barley, and flaxseed are good sources of fiber.

hypertension

• Significant risk factor for CHD, MI, kidney disease, and stroke.

• Sustained elevation in BP >or = to 140/90 mm Hg for clients under 60, 150/90 mm Hg for those older than 60

Risk factors for hypertension

• Family hx, hyperlipidemia, smoking, obesity,, high NA intake, stress, and aging.

• African-American people

• A client’s risk increases after menopause

nutrition for hypertensive patients

• DASH diet (low-sodium, high-potassium, high-calcium diet)

• Decrease sodium from 2,300 to 1,500mg for maximum benefit.

• Include low-fat dairy to promote calcium intake.

• Fruits/vegetables rich in potassium

• Limit alcohol intake.

• Exercising, weight loss, and smoking cessation.

metabolic syndrome

The presence of three of the five following risk factors.

• Abdominal obesity:

  • MALES: greater than or equal to 40-inch waist

  • FEMALES: greater than or equal to 35-inch waist

• Triglycerides greater than or equal to 150 mg/dL or taking medications to treat high triglyceride levels

• Low HDL or taking medications to lower HDL-C

  • MALES: less than or equal to 40 mg/dL

  • FEMALES: less than or equal to 50 mg/dL

• Increased blood pressure or taking an antihypertensive medication

  • Systolic greater than or equal to 130 mm/Hg

  • Diastolic greater than or equal to 85 mm/Hg

  • NORMAL BP should be less than 120 and less than 80!

• Fasting blood glucose > or = to 100 mg/dL or taking medication to
  control blood glucose levels

risk factors for iron deficiency anemia

• Blood loss, deficient iron intake, alcohol use, malabsorption syndromes, gastrectomy

• Metabolic increase caused by pregnancy, adolescence, or infection

manifestations for iron deficiency anemia

• Fatigue, Lethargy, Pallor of nail beds, Intolerance to cold, Headache, Tachycardia

• Children can experience short attention spans and display poor intellectual performance before anemia begins.

Risk Factors for Vitamin B12 deficiency anemia (pernicious anemia)

Lack of meat/dairy, small bowel resection, chronic diarrhea, diverticula, tapeworm

manifestations for Vitamin B12 deficiency anemia (pernicious anemia)

Pallor, Jaundice, Weakness, Fatigue

GI findings for patients with pernicious anemia

Glossitis (inflamed tongue), Anorexia (loss of appetite, not the eating disorder), Weight loss

neurological findings for patients with pernicious anemia

Decreased concentration, Paresthesia (numbness) of hands/feet, Decreased proprioception (sense of body position), Poor muscle coordination, Increasing irritability, Delirium

risk factors for folic acid deficiency anemia

Poor intake of folic acid (green leafy vegetables, citrus fruits, dried bean, nuts),
malabsorption syndromes (Crohn’s disease), certain meds (anticonvulsants and oral contraceptives

manifestations for folic acid deficiency anemia

• mimic those for vitamin B12 deficiency anemia except for the neurologic manifestations.

• Pallor, Jaundice, Weakness, Fatigue

• GI findings: Glossitis (inflamed tongue), Anorexia (loss of appetite, not the eating disorder), Weight loss

sources of iron

• Meat, Fish, Poultry, Tofu, Dried peas/beans, Whole grains, Dried fruit, Iron-fortified foods.

• Infant formula (alternative or supplement to breastfeeding)

• Infant cereal (usually first food introduced to infants)

natural sources of vitamin B12

• Fish, Meat, Poultry, Eggs, Milk

• Vegan diet may need supplemental ___________.

folic acid sources

• Green leafy vegetables, Dried peas/beans, Seeds, OJ, foods fortified with folic acid

• If unable to obtain adequate _____________, supplementation can be necessary.