Bariatric Times

JUN 2017

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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15 Nutritional Considerations in the Bariatric Patient Bariatric Times • June 2017 l imited diet will result in infrequent bowel movements, but not necessarily constipation, for most patients in the early postoperative period. Considering that there are many factors putting p atients at risk for constipation postoperatively, it is important for clinicians to be proactive. If a patient has a history of constipation, consider use of fiber supplements during the p reoperative diet and continue postoperatively until the patient is achieving adequate fiber intake from their diet. 11 Regular coffee drinkers may consider switching to decaffeinated c offee (as opposed to eliminating coffee) to continue stimulation of colonic motility. 15 Hydration is always a priority following bariatric surgery; however, there is not an exact fluid r ecommendation to prevent constipation. Clinicians should individualize recommendations based on patient report. While there are no specific guidelines for quantity and i ntensity of physical activity as it relates to constipation, activity should be encouraged as the patient is able. Stool softeners and laxatives are effective in the short-term to assist with both intestinal motility and texture of stools. Some laxatives, such as lactulose and polyethylene glycol, are indicated for short-term use only as they can become less effective with time. 11 GASTROESOPHAGEAL REFLUX DISEASE (GERD) Causes. GERD is characterized by the flow of stomach acid or content into the esophagus, which irritates the esophageal lining. The esophagus and stomach have built-in mechanisms to prevent this from happening; the esophagus serves as a forward-moving pump, the esophageal sphincter as a one-way valve, and the stomach as a reservoir. 16 The failure of any of these components can result in GERD. Bariatric surgery has varying affects on GERD. RYGB typically improves symptoms and is often considered a treatment for GERD. 17,18 SG and AGB have less consistent results; some studies have demonstrated an improvement in symptoms while others have demonstrated a worsening of symptoms. 17 In the case of the studies suggesting that SG worsens GERD, it is hypothesized that the surgery reduces lower esophageal sphincter pressure, which means the "valve" relaxes. In addition, the stomach, or "reservoir," is reduced in size and the resulting shape can increase stomach pressure which propels content upwards. 17,19 Gastric banding has been suggested to improve GERD in the early post-op period but can cause GERD-like symptoms for some patients in the long-term. It is unclear whether this is true GERD or complications related to the band becoming more restrictive with saline fills. 17 Management. Weight loss is a primary lifestyle treatment for GERD which is one of the reasons that b ariatric surgery can alleviate symptoms. There is limited evidence for most diet interventions for GERD. Specific categories, such as high-fat foods, acidic foods, and caffeine- c ontaining beverages, are not consistently shown to cause symptoms. A clinician should help each patient create their own individualized list of triggers as opposed to recommending t hat patients avoid entire categories of foods and beverages. Limited evidence suggests the avoidance of eating for 2-3 hours before bed may prevent overnight symptoms. 18 Clinicians should a ssess eating behaviors of the patient, as fast-paced eating and poor chewing may cause GERD-like symptoms. 4 The standard, and most effective, treatment for GERD is proton pump inhibitor ( PPI) therapy. In some cases of GERD in patients with AGB or SG, conversion to RYGB may be considered. 18 GOUT C auses. Gout is caused by a build- up of urate crystals in response to high levels of uric acid in the blood. Uric acid is produced by the liver and excreted by the kidney and small intestine. Any s ituation causing overproduction or under-excretion will lead to excess levels of uric acid in the bloodstream. For reasons that are not totally understood, the urate crystals are f requently deposited in the big toe joint which causes inflammation and severe pain. Normal blood levels of uric acid are 3.5 to 7.2 mg/dL; a uric acid level of 7.0 mg/dL is a risk factor for gout. 20 A purine-rich diet can increase production of uric acid by 1-2 mg/dL. 20,21 Choi et al. published data demonstrating that higher levels of meat (specifically beef, pork, lamb, and

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