A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Issue link: https://bariatrictimes.epubxp.com/i/788604
13 Clinical Nursing Education Bariatric Times • February 2017 The authors searched PubMed, Embase and MEDLINE using terms including, but not limited to, " bariatric surgery," "gastric bypass," "obesity surgery," and "Roux-en-Y," c oupled with secondary search terms, (e.g., "anaemia," "micronutrients," "vitamin deficiency," "bacterial overgrowth," " drug absorption," "pharmacokinetics," and " undernutrition.") Studies in English, French, or German published January 1980 through March 2014 were included in the s tudy. They concluded that macro- and micronutrient deficiencies are common after metabolic and bariatric surgery. The most critical micronutrient deficiencies, depending on surgical technique, were as follows: vitamins B1, B12, and D, iron, and zinc. The authors also reviewed the clinical manifestations of macro- and micronutrient deficiencies. Table 3 outlines reported rates of micronutrient deficiencies in metabolic and bariatric surgery patients, including examples of accompanying physical signs and symptoms. Changing the message patients receive and ensuring they understand the potentially devastating complications that can come with micronutrient deficiencies may be an area of improvement that could help increase adherence to micronutrient supplementation. Another consideration is that many micronutrient deficiencies lack immediate or overtly physically recognizable signs and symptoms; therefore, motivation to take micronutrient supplements is often lacking until nutrient levels become significantly altered resulting in physical manifestations. For example, anemia is a slow, progressive disorder that does not often result in physical symptoms until it has progressed to the point that it is often untreatable with oral iron preparations and infusions become necessary. Metabolic bone disease is another example of a 'silent disease' where the patient does not often have physical signs and symptoms until a bone fracture occurs. While we are just beginning to explore other factors that are components of bone disease postsurgery, we do know that adequate intake of many different micronutrients are critical for bone health, and that many patients— especially those who are not taking adequate micronutrient s upplements—have inadequate dietary intakes of these nutrients p rior to and following metabolic and bariatric surgery. 20 Over the past nine years, several professional societies have p ublished position statements and guidelines related to micronutrient s upplementation recommendations in the metabolic and bariatric surgical patient population, yet consensus on micronutrient s upplementation still varies greatly from practice to practice, and even within the practice from clinician to clinician. This lack of consensus may create confusion and uncertainty among practitioners when prescribing micronutrient supplementation for their patients. When patients are given conflicting medication information, adherence is compromised. 21 It is imperative that patient-provider communication is enhanced and that within each practice clinicians are guiding patients with the same messaging to relieve potential confusion. Ensuring the patient understands the importance of taking life-long micronutrient supplements is equally as important as ensuring the patient understands exactly which micronutrient supplements they are required to take. STRATEGIES FOR IMPROVING PATIENT ADHERENCE Patient education by a multidisciplinary team is critical to long-term care. It is well established that education enables patients' to have better knowledge and understanding of obesity, self- management skills, and psychosocial competencies. 22 Behavioral interventions are typically thought to be an essential component of the treatment of obesity. Focusing on patient-centered individualized education may help patients overcome barriers to lifestyle changes after surgery, including micronutrient supplementation. Patient-centered educational approaches should ideally begin prior to surgery. Determining a patient's readiness to change, and self-reported barriers can enable the patient to be better informed, and more prepared as they approach surgery. Wang et al 23 found that patient education by clinicians can improve patient knowledge and is linked with improved adherence. To improve adherence, education should be focused on treatment use, such as micronutrient supplementation, and expose patients to benefits and risks of adhering versus not adhering to the prescribed treatment plan. 23 The foundation of education starts with a strong relationship between the clinician and patient. One of the most common recommendations to improve adherence is an approach that respects patient autonomy and encourages collaborative decision making. Counseling styles that are authoritative are seen as outdated T ABLE 2. Clinical applications to patient-reported barriers to prescribed micronutrient adherence 1. FOCUS ON BUILDING STRONG PATIENT-PROVIDER RELATIONSHIPS a.) Use non-judgmental communication b .) Increase calls and reminders from staff who is seen as caring, a nd who provide positive reinforcement for follow up. 2 . IMPROVE EDUCATION a.) Develop protocols within the clinic regarding daily micronutrient supplementation recommendations – allow for individualize instruction based on the patient's serum markers, signs /symptoms of deficiency, and reported intake levels. i.) Protocols are ideally based on the latest scientific evidence including, but not limited to, the updated ASMBS Nutrition Guidelines. b.) Provide easy to understand written education materials i.) Education materials should also focus on risks of not taking micronutrient supplements at the recommended levels. ii.) Pictures of physical signs and symptoms of nutrient deficiencies may be helpful in motivating patients to take their micronutrient supplements. c.) Assess for understanding from each patient i.) Quizzes, intake questionnaires, etc. may be helpful in guiding the clinician to assess for comprehension from the patient. 3. TROUBLESHOOT BARRIERS a.) Forgetting to take i.) Use a weekly pill box, set a timer in phone, reoccurring digital reminder in calendar, some clinics have the capability to text patients – and early research has shown that text reminders for medications can improve adherence. b.) Difficulty swallowing pills i.) Change to chewable or liquid preparations that meet micronutrient needs or open capsules and add to protein supplement. c.) Unclear of clinicians instructions i.) Provide easy to understand micronutrient supplementation "prescriptions." d.) Cost i.) Educate patient on cost of treatment of long-term micronutrient deficiencies (hospital stays, infusion centers, fractured bones) to help improve the cost to benefit ratio from the patient perspective. ii.) Remind the patient of decreased medical costs that are seen following MBS, as well as decreased food costs to the patient. e.) GI issues i.) Take micronutrient supplements with food. ii.) Titrate to recommended dose; or take smaller more frequent doses throughout the day. Unlike SURGICAL COMPLICATION RATES, which have been d eclining over the past two decades, due in part to improved s urgical techniques, improved medical devices, and i mproved standardization of tracking complications, reports of MICRONUTRIENT DEFICIENCIES ARE ON THE RISE. 16