4/2/2014
Designing a Quality Bariatric Pre‐Operative Weight Loss Program
Laura Andromalos, RD, LDN
Bariatric Nutrition Coordinator
d
Brigham and Women’s Center for Metabolic and Bariatric Surgery
Boston MA
landromalos@partners.org
Friday March 21, 2014
WM DPG Symposium
St. Louis, MO
Disclosures
• No conflict of interest related to the content of this presentation
Objectives
After this presentation, the attendee will be able to:
• Interpret the literature on bariatric pre‐
p
g
p g
operative weight loss programs
• Assess the learning needs and satisfaction of bariatric patients enrolled in a pre‐operative weight loss program
• Design an evidence‐based pre‐operative weight loss diet
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Outline
1) Why do we require pre‐op weight loss?
2) Making the best of insurance‐mandated pre‐
op weight loss programs
op weight loss programs
3) What guidelines should be used when designing a short‐term pre‐op diet?
Is this scene familiar?
Mr. Jones, in preparation for your bariatric surgery, you will be asked to lose weight
weight.
Lose weight?! I’ve been trying to lose weight my whole life! If I could lose weight, I wouldn’tt be here.
be here
I wouldn
Section 1:
Why do we require pre‐op weight loss? 2
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Requiring pre‐operative weight loss leads to…
•
•
•
•
Successful Pre‐operative Weight Loss
Successful Post‐operative Weight Loss
Reductions in Complication Rates
Reductions in Operation Time
Right??? Let’s check the literature.
Great Read!
International Journal of Obesity (2012) 36; 1380–1387
Insurance Mandated Pre‐Op Weight Loss
94 pts
59 pts
Take‐away: Insurance mandated pre‐operative weight loss requirements are not always effective. Ochner et al., 2010
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Program Mandated Pre‐Op Requirement
Average : 7.25% weight loss
Take‐away: Program mandated requirements, especially if surgery is ‘contingent’ upon weight loss, can be more effective than insurance mandated requirements.
Alvarado et al., 2005
Post‐Op Weight Loss
1% pre‐op weight loss 1.8% post‐op excess weight loss
No correlation between pre‐op and post‐op weight loss
Take‐away: Data is not consistent. We don’t know whether pre‐op weight loss has any effect on post‐op weight loss.
Alvarado et al., 2005; Eisenberg, Duffy & Bell, 2010
Complication Rate
Take‐away: Pre‐op weight loss has been linked to reduction in peri‐ and post‐operative complications in many studies.
Still et al., 2007; Van Nieuwenhove et al., 2011 4
4/2/2014
Operating Time
Pt Population
Weight Loss
OR Time
Study Authors
273 pts total; 136 in treatment group and 137 in control
Loss of 4.9 kg vs. loss of 0.4 kg
No significant
difference
Van Nieuwenhove
et al., 2011
;
pts total; 20 in 40 p
treatment group and 20 in control
g
Loss of 4.8 kg vs. gain of 7 kg
20 minute decrease
Aberle et al. 2009
90 pts total; 62 lost greater than 5%
Loss of ≥ 5% vs. loss 36 minute < 5%
decrease
Alvarado et al., 2005
Take‐away: Pre‐op weight loss does not always impact operating time.
To sum it up…
• Evidence for insurance mandated pre‐operative weight loss requirements is questionable.
• Pre‐operative weight loss is (generally) not harmful to patients and can have benefits.
• Pre‐op weight loss of 5‐10% should be encouraged but not mandated. • Patients should not be denied based solely on lack of pre‐op weight loss.
Dietitians are caught in the middle
Patients are required to attend 6 consecutive months of pre‐op weight loss classes before they can be approved for surgery.
http://1n5ur4nc3.blogspot.com/2012_12_01_archive.html
Insurance‐mandated weight loss classes are slowing the patients’ paths to surgery and encouraging them to drop out of the program.
http://www.ratracetrap.com
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Section 2:
Making the best of insurance‐
mandated pre‐op weight loss programs
What is POWL?
Brigham and Women’s Pre‐Operative Weight Loss group
• Meets insurance requirements for pre‐
operative weight loss program
• Rotates through six topics; one topic each month
• No registration necessary; rolling admission
Disappointing Data…
• Analyzed data for over 300 pre‐RNY patients who completed POWL between 2009‐2011
– 38.7% of patients gained weight during the 6 months
• In terms of weight loss, our POWL classes are not effective.
– Not surprising considering the literature
... Opportunity for Improvement
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Old POWL Curriculum
• Nutrition Label
– Reading nutrition labels and food claims
• Allies and Saboteurs
– Support systems; dealing with saboteurs
• Eating Out
– Healthy tips for eating away from home
• Nutrition 101
– Overview of protein, fat, and carbohydrates
• Physical Activity
– Ways to exercise; overcoming barriers to exercise
• Portion Sizes
– Appropriate portion sizes of various food groups
Curriculum Design
Contento & Morin, 1988
Patient Feedback
• 10‐question evaluation given to each patient after completing 6th POWL class
– Most and least helpful topics
– Suggestions for new topics
Suggestions for new topics
– Will POWL help you to be successful? Why/why not?
– Did you try to lose weight?
• Collected 68 surveys over a 6 month period
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Most and Least Helpful Topics
Number of Patients
30
25
20
15
10
Most Helpful
5
Least Helpful
0
Requested Topics
• Post‐op Diet Guidelines
– Supplement recommendations
• Diet Support
– Meal planning, resources for weight loss
Meal planning resources for weight loss
• Life After Surgery
– What is life like after surgery?
• Behavioral Support
– Motivation, understanding why we overeat
Patient Comments
At first I didn't think these meetings meant anything. Now after 6 meetings, I think it's helpful to understand what to expect. Keep up the good work. Thank you.
Thank you very much. Wish you could live inside my cabinets (ha! ha!). Great program.
I would prefer 1:1 sessions. I am not a joiner. Sitting through a group meeting was kind of annoying. I believe in doing things with the least number of people being involved. I do it myself or not at all.
myself or not at all.
POWL is a good program. It's informative and you don't have to feel you are 'going it alone'.
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Clinician Feedback
• Asked colleagues about top 3 post‐op complications/problems that could be prevented with better education
• Most common responses:
– Dehydration
– Nausea/Vomiting/Abdominal pain
– Inadequate protein intake
– Weight gain
The New POWL
• Re‐designed POWL curriculum using feedback from patients and colleagues
– Each POWL class has 3‐4 measurable objectives and a homework assignment
• Developed ‘Core Concepts’
• Created 1 page quiz that patients will take before and after POWL series to evaluate change in knowledge
– Quiz tests core concepts as well as 1 objective from each class
Core Concepts
• Hydration • Protein • Eating Behaviors
• Surgery is a Tool
• Lifelong Follow‐Up
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New POWL Curriculum
• Nutrition Label
– Reading and using food and supplement labels
• Behavioral Challenges
– Changes to expect post‐op; taught by bariatric psychologist
• Life After Surgery
– Macronutrients + fluid, when to call surgeon, resources
• Skills for Success
– Necessary lifestyle changes for using surgery as a tool
• Hydration and Exercise
– Meeting fluid goal, physical activity guidance
• Portion Sizes
– Serving size guide, changing the food environment
Research Opportunities
• How do pre‐POWL test scores compare to post‐POWL test scores?
• Are high or low test scores correlated with pre‐op and post‐
op weight loss, complications, readmission?
• Do outcomes differ between patients completing the old and o outco es d e bet ee pat e ts co p et g t e o d a d
new POWL curriculums?
• Can the quiz be validated as a surgical readiness tool from a nutrition and behavior perspective? Data to come!
Most importantly: Better preparing patients for surgery and providing them with education they find valuable
Section 3:
Short‐term Pre‐Op Diets
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Short‐term Pre‐Op Diet
The Claims?
• reduces liver volume which improves access to the stomach
• facilitates rapid reduction in abdominal adipose tissue
Right??? Let’s check the literature.
Impact of VLCD on weight, liver volume, and visceral adipose tissue
32 patients on 3 Optifast shakes + non‐starchy vegetables
Colles et al., 2006
It Really Works!
Colles et al., 2006
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Liver Size Reduction vs. Body Fat Reduction
50 patients on 3 Optifast shakes daily
Fris, 2004
What difference does liver size make?
Scale = 0 to 2 with 0 representing preferable conditions
Modifast x 4‐5 for 4 weeks
13% reduction liver volume; 6.1% weight loss
(ease of accessing stomach)
Interesting notes: • No significant difference in duration of operation • 3 LCD pts had anastomotic ulcers versus 1 control
Edholm, 2011
Changes in Abdominal Fat
• Weight loss from low calorie diets can decrease abdominal fat but it takes time
– 3‐6 month interventions have greatest impact on abdominal fat
• For a given weight loss, exercise‐induced weight loss generates greater reduction in abdominal fat than diet‐induced weight loss
International Chair on Cardiometabolic Risk, 2014
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To Sum it Up…
• Pre‐op diets can lead to reduction in liver volume which improves access to the stomach
• Significant
Significant reduction in abdominal adipose reduction in abdominal adipose
tissue generally takes longer than a few weeks
– Exercise is an important factor
What Kind of Pre‐Op Diet is Encouraged?
Feedback from WM DPG Listserv
Duration
Composition
Notes
1 week
2 protein shakes + 1 frozen meal
Also must lose 5‐10% total body weight
1 week 2 weeks
Unknown
Surgeon requiring 2 week diet uses liver retractor less often
2 weeks
5 shakes or 4 shakes + food
2 weeks
800 cal for women; 1000 cal for men
2 weeks
4 shakes + 1 low carb meal
3 weeks
3 shakes + 2 bars or
3‐4 shakes + 1 low carb meal
Unknown
1200‐1500 cal meal plan
Unknown
5‐6 protein shakes
n/a
n/a
Must lose 10% EBW
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What Does the Literature Show?
Subjects
Diet
Length
Outcomes (average unless noted)
9 F; 5 M. NAFLD
Avg intake 1520 cal; 54 g carb 4 wks
(recommended <30 g carb)
• 3.1% weight loss
• 8.1% liver volume reduction
13 F; 5 M. NAFLD
Low‐carb (<20 g carb) vs. 2 wks
Low‐cal (1200 for F and 1500 for M; ~169 g carb)
• Similar weight loss between groups
4.6% for low‐carb vs. 4.1% for low‐calorie
• 55% liver fat reduction for low‐carb
• 28% liver fat reduction for low‐calorie
17 F; 3 M.
800 cal, 40 g carb . Free non‐
starch veg
h
6 wks
• 9.8% median weight loss • 20.2% median liver volume reduction
%
di li
l
d i
17 F; 1 M.
11/19 NAFLD
Optifast VLCD x 3 (450‐800 cal, 45‐70 g carb) + low cal food
6 wks
• 7.6% weight loss
• 9.4% liver volume reduction for non‐NAFLD; 16.3% for NAFLD
• 72.5% liver fat reduction
15 F. some NAFLD
Modifast x 4‐5 (800‐1100 cal, 4 wks
60‐75 g carb)
• 6.1% weight loss
• 12% liver volume reduction
• 40% liver fat reduction
11 F; 6 M.
1000 cal, <20 g carb.
• 3.5% weight loss
• 21.5% liver volume reduction
• 30% liver fat reduction
6 days
Benjaminov et al., 2007; Browning et al., 2011; Gonzalez‐Perez et al., 2003; Lewis et al., 2006; Edholm et al., 2011; Sevastianova et al., 2011
Weight Loss vs. Carb Intake
12
12w
% Weigght Loss
10
6w
8
6w
6
4w
2w
4
6d
2w
4w
2
0
0
50
100
Grams Carbohydrate
150
200
Benjaminov et al., 2007; Browning et al., 2011; Gonzalez‐Perez et al., 2003; Lewis et al., 2006; Edholm et al., 2011; Sevastianova et al., 2011; Colles et al., 2006
Liver Volume vs. Carb Intake
% Liver Volum
me Reduction
35
30
12w
25
6d
20
6w
6w
15
4w
10
4w
6w
5
0
0
10
20
30
40
50
Grams Carbohydrate
60
70
80
Benjaminov et al., 2007; Gonzalez‐Perez et al., 2003; Lewis et al., 2006; Edholm et al., 2011; Sevastianova et al., 2011; Colles et al., 2006
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Liver Fat vs. Carb Intake
80
6w
% Liver Fat R
Reducation
70
60
2w
50
40
4w
30
6d
2w
20
10
0
0
50
100
Grams Carbohydrate
150
200
Browning et al., 2011; Lewis et al., 2006; Edholm et al., 2011; Sevastianova et al., 2011
Diminishing Returns
Liver Volume
Gonzalez‐Perez et al., 2003
Lean vs. Fat Loss in Liver
6‐day low carb
7‐month hypocaloric
3‐week high carb
Bian et al., 2013 15
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Impact of Genetic Factors
= Genetic Mutation
= Regular Genome
Sevastianova et al., 2011
Evidence‐based Guidelines for Designing a Pre‐Op Diet
• At least 2 weeks; maximum 4 weeks
• Calorie‐controlled to facilitate weight loss
• Low‐carb (30‐130 g carb) or very low‐carb ketogenic
(<30 g carb) are appropriate and safe
(<30 g carb) are appropriate and safe
• Supplements or regular food
– Consider palatability, simplicity, affordability
– Test it yourself!
• Consider patients on insulin or hypoglycemic meds
– Medications may need to be adjusted; keep carbs
consistent throughout the day
Hite, Berkowitz, & Berkowitz, 2011
Summary
1) Long‐term pre‐operative weight loss can have beneficial outcomes but shouldn’t be basis for surgery denial.
2) Quality improvement of insurance‐mandated )
l
f
d d
pre‐op weight loss curriculum is achievable.
3) Short‐term pre‐op diet is effective in reducing liver volume (but not abdominal adipose tissue) and comes in a variety of forms. 16
4/2/2014
Acknowledgements
Thank you to my colleagues at BWH for assistance with designing and implementing the new POWL curriculum:
•
•
•
•
•
•
•
Kellene Isom, MS, RD, LDN
Dr. Paul Davidson
Dr. Malcolm Robinson
Meghan Ariagno, RD, LDN
Katrina Stephanides, RD, LDN
Katy Hartman, MS, RD, LDN
Catherine Quinn, PA‐C
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