A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
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16 Nutritional Considerations in the Bariatric Patient Bariatric Times • June 2017 t urkey) and seafood consumption increase risk of gout by 35-50%. Their data suggests that an average daily consumption of 2.5 servings of beef, pork, or lamb increases risk of gout by 4 0% compared to an average daily consumption of 0.5 servings. While many vegetables contain purines, moderate intake of vegetable purines were not associated with increased risk o f gout. 2 2 F ructose is another diet factor which contributes to gout; as fructose is metabolized, it leads to an increase in uric acid production. Substances that are converted into f ructose after absorption, such as sorbitol, will also contribute to uric acid production. Factors that reduce excretion of uric acid include ketone bodies, insulin resistance, and leptin production. Many bariatric programs require a very low carbohydrate diet before surgery and in the early weeks following surgery. If this diet is low enough in carbohydrates to cause ketone bodies, it can inhibit excretion of uric acid. 20 Some diet factors are protective against gout, such as dairy foods and vitamin C, which facilitate excretion of uric acid and prevent uric acid build-up. 20,22 Management. With an understanding of factors that impact uric acid balance, it becomes clear that successful diet interventions will reduce uric acid levels in the blood by limiting production or increasing excretion. Patients can be encouraged to limit consumption of meats and seafood that are high in purines. High-purine vegetables do not need to be limited. Consumption of fructose-rich processed foods and beverages should be avoided. Natural fructose found in fruits can contribute to gout as well; results from one study suggest limiting fructose-rich fruits and juices, such as apple and orange. 23 Increasing carbohydrate intake above 30 grams per day during the preoperative and postoperative diets is encouraged to prevent ketosis. 24 Insulin sensitivity is typically improved with bariatric surgery; additional lifestyle and medication treatments could be considered if a patient continues to struggle with insulin resistance. Supplementing with 500 mg vitamin C daily and encouraging dairy products can assist the body with excreting uric acid. 20,21 DUMPING SYNDROME Causes. Dumping syndrome is caused by the rapid passage of nutrients to the small intestine and an osmotic fluid shift. This is typically in response to consumption of foods and b everages high in sugar, such as candies, sweet baked goods, ice cream, juices, and soda. When the poorly digested particles of food reach the small intestine, there is a fluid shift f rom the intravascularcomponent to the intestinal lumen. This triggers gastrointestinal (abdominal pain, nausea, bloating, diarrhea) and vasomotor (perspiration, tachycardia, h ypotension) symptoms which begin during or immediately after consumption of the offending food or beverage. 25,26 Since these symptoms occur quickly after the offending food is c onsumed, it is sometimes called "early dumping syndrome." Reactive hypoglycemia, sometimes termed "late dumping syndrome," is discussed in the next section. While dumping syndrome is most commonly seen in patients with RYGB, there is limited evidence suggesting that dumping syndrome can occur in SG patients as well. 2 5 Management. Diet modification is the primary treatment for dumping syndrome. The goal is to prevent nutrients from passing into the intestine too quickly. Patients should avoid foods that contain rapidly absorbable carbohydrates, such as simple sugars, and should wait to drink beverages until at least 30 minutes after meals. 25,26 Dumping syndrome that cannot be managed by diet modification warrants referral to a surgeon for further work- up. REACTIVE HYPOGLYCEMIA Causes. Reactive hypoglycemia is severe postprandial hypoglycemia that can develop months to years after RYGB. 27 . As mentioned previously, it is sometimes called late dumping syndrome as the symptoms tend to occur 1-3 hours after consumption of a carbohydrate-based food. With reactive hypoglycemia, the offending food, often a simple carbohydrate, moves to the small intestine too quickly and triggers the release of incretin hormones GLP-1 and GIP. These hormones stimulate an exaggerated insulin response which leads to hypoglycemia. Hypoglycemic symptoms include sweating, dizziness, rapid heartbeat, blurry vision, and loss of consciousness. 25 Management. The initial treatment intervention for reactive hypoglycemia is diet modification that delays the passage of nutrients into the intestine to prevent an exaggerated insulin response. 25,26 Strategies include eating small, frequent meals that contain protein and/or fat, limiting carbohydrates to 15-30 grams per meal while avoiding simple carbohydrates, a nd avoidance of beverages during and immediately following a meal. 25,26,28 There is some evidence supporting the use of pectin, glucomannan and guar gum to prolong transit time through the g astrointestinal tract. 2 5 I f diet modification is unsuccessful, medications such as acarbose may be added to the treatment plan. 25,29 In extreme cases, revisional surgery may b e required. 2 5 KIDNEY STONES Causes. Kidney stones occur when urine contains more crystal-forming s ubstances than can be diluted and/or urine is lacking the substances required to prevent formation of crystals. While there are several types of kidney stones, calcium oxalate stones are the most common in the general population. Research suggests that patients are at greater risk of calcium kidney stones following bariatric surgery. 30,31 The majority of the research has been conducted in RYGB patients, but there appears to be an increased risk for patients having had malabsorptive surgeries such as long- limb RYGB and BPD-DS as well. 31 After surgery, the urinary chemistry profile changes significantly with an increase in urinary oxalate and a decrease in urinary citrate. This increases risk for kidney stones because oxalate is a crystal-forming substance and citrate is a stone-inhibitor. There are several theories as to why the urinary chemistry profile is altered following surgery, such as change in gut flora, gastrointestinal tract's increased permeability to oxalate, metabolic acidosis, and after some surgeries, fat malabsorption. An additional risk factor observed in postoperative bariatric surgery patients is a decrease in urinary volume due to decreased fluid intake; this facilitates crystal-saturated urine. 30 Management. Several diet interventions can minimize the risk of calcium kidney stones. Increased hydration can help to dilute urine to prevent supersaturation. Supplementation with calcium citrate versus calcium carbonate promotes increased urinary citrate, which can inhibit stone formation. Limiting oxalate-rich foods, such as soy products, nuts, dark green vegetables, chocolate, and coffee, can minimize the amount of oxalate that is entering the body. Supplementation with citric salts, such as potassium citrate, can treat metabolic acidosis. 30 This can also be achieved with increased intake of fruits and vegetables and decreased intake of sodium. 32 SUMMARY While bariatric surgery has the potential for many nutrition-related side effects, most can be effectively m anaged with diet intervention. This article provides guidance for a clinician managing these challenges, but interventions should always be individualized based on the patient's u nique presentation. Educating the patient on the impact of surgery on the many functions of the body and the pathophysiology of complications can empower the patient to become a t roubleshooting partner when challenges arise. REFERENCES 1. Maciejewski ML, Arterburn DE, Van Scoyoc L, et al. Bariatric Surgery and Long-term Durability of Weight Loss. JAMA Surg. 2016;151(11):1046-1055. 2. Estimate of Bariatric Surgery Numbers, 2011-2015. https://asmbs.org/resources/ estimate- of-bariatric-surgery-numbers. Published 2016. Accessed October 10, 2016. 3. Pandolfino JE, Krishnamoorthy B, Lee TJ. Gastrointestinal complications of obesity surgery. Medscape Gen Med. 2004;6(2). 4. Kalarchian MA, Marcus MD, Courcoulas AP, et al. Self-report of gastrointestinal side effects after bariatric surgery. Surg Obes Relat Dis. 2014;10(6):1202–1207. 5. Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. Nutr Clin Pract. 2007; 22(1):29–40. 6. Sarwer DB, Moore RH, Spitzer JC, et al. A pilot study investigating the efficacy of postoperative dietary counseling to improve outcomes after bariatric surgery. Surg Obes Relat Dis. 2012; 8(5):561–568. 7. Kellogg TA, Swan T, Leslie DA, et al. Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009; 5(4):416–423. 8. Mechanick JI, Youdim A, Jones DB, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity. 2013;21(S1):S1–S27. 9. Isom KA, Andromalos L, Ariagno M, et al. Nutrition and metabolic support recommendations for the bariatric patient. Nutr Clin Pract. 2014;29(6): 718–739. 10. Lee CW, Kelly JJ, Wassef WY. Complications of bariatric surgery. Curr Opin Gastroen. 2007;23(6):1– 10. 11. Foxx-Orenstein AE, McNally MA, Odunsi ST. Update on constipation: One treatment does not fit all. Clev Clin J Med. 2008;75(11):813–824. THE INITIAL TREATMENT INTERVENTION FOR REACTIVE HYPOGLYCEMIA IS DIET M ODIFICATION that delays the passage of nutrients into the intestine to prevent an e xaggerated insulin response. 2 5,26 S trategies include eating small, frequent meals that contain p rotein and/or fat, limiting carbohydrates to 15-30 grams per meal while avoiding simple carbohydrates, and avoidance of beverages during and immediately following a meal. 25,26,28