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Research Editorial
Bariatric Surgery: A Key Role for Registered
DietitiansROBERT F. KUSHNER, MD; LISA M. NEFF, MD Obesityisacomplexdisorderthatimpactsallorgan mechanismsofactionareshownintheandin-
systems. Individuals with obesity are at increased clude restriction of gastric capacity, modulation of gastro- risk for a variety of comorbid conditions, including intestinal hormones that influence hunger and satiety, diabetes, hypertension, dyslipidemia, heart disease, sleep and induction of malabsorption Beckman and apnea, some types of cancer, nonalcoholic fatty liver dis- colleagues provide a comprehensive literature review of ease, and osteoarthritis, among others. Those at highest one of these mechanisms, changes in gastrointestinal (GI) risk are individuals with class III obesity (body mass hormones that occur after the RYGB procedure As index Ն40), a group that now includes almost 5% of all stated in their review, “An understanding of how GI adults and more than 10% of all African-American adults hormones change after RYGB may help dietitians to op- timize nutrition care to this patient population” Nonsurgical approaches to the treatment of obesity, Knowledge of gut hormones is also important to RDs including lifestyle modification and pharmacotherapy, because pharmaceutical companies have focused on the typically result in average weight losses of 5% to 10% of manipulation of these hormones as peripheral targets for initial body weight. Importantly, losses of this magnitude can substantially improve existing comorbidities and pre- At this time, bariatric surgery is the most effective vent new weight-related conditions, including diabetes intervention for severe obesity, producing substantial However, studies suggest that most individuals weight loss (typically on the order of 30% to 70% of excess with obesity hope to lose considerably more weight, often body weight) that is largely maintained over time as much as 20% to 40% of initial body weight, and they The benefits of bariatric surgery also include high rates of may view lesser degrees of weight loss as a disappoint- remission of many obesity-associated comorbidities, in- ment or even a failure In addition, the physiologic cluding diabetes, hypertension, and dyslipidemia, as well adaptations to weight loss, including reductions in energy as an improvement in quality of life and a reduction in expenditure and changes in hunger- and satiety-promot- mortality rates As a result of this success, the ing hormones, make it more difficult for individuals to number of bariatric procedures done annually has in- maintain a reduced body weight over time As a result, creased dramatically in recent years, as noted in the successful weight management is an elusive goal for accompanying review by Kulick and colleagues In many patients with obesity who utilize nonsurgical ther- light of the increasing prevalence of severe obesity, this apies. The four articles presented in this issue of the Journal highlight the growing importance of surgical RDs are accustomed to working in a team environment therapies in the care of patients with obesity and the role to provide care for patients with various disorders, in- cluding obesity. In fact, team practice for the treatment of Current bariatric surgical techniques include the two obesity has become an established model of care. Hospital most common procedures, Roux-en-Y gastric bypass nutrition teams were initially established in the 1970s, (RYGB) and laparoscopic adjustable gastric banding shortly after the introduction of new technology for the (LAGB), and several less common procedures, including invasive administration of specialized parenteral and en- laparoscopic sleeve gastrectomy (LSG) and biliopancre- teral nutritional products. Typically comprised of an at- atic diversion with duodenal switch (BPD-DS). Potential tending physician, RD, registered nurse, and pharmacist, these teams were established to provide safe delivery of optimal nutritional support while minimizing complica- R. F. Kushner is a professor of medicine, Division of tions. The team-oriented, multidisciplinary approach to General Medicine, and L. M. Neff is an assistant profes- patient care was subsequently applied to the care of pa- sor of medicine, Division of Endocrinology, Department tients with diabetes, as exemplified in two landmark di- of Medicine, Northwestern University Feinberg School of abetes studies: the Diabetes Control and Complications Trial and the Diabetes Prevention Program In- Address correspondence to: Robert F. Kushner, MD, terdisciplinary teams are also an important component of 750 N Lake Shore Dr, Rubloff 9-976, Chicago, IL 60611. the chronic care model It is with this perspective that the team approach to obesity care has evolved Manuscript accepted: December 15, 2009. In 1991, the National Institutes of Health consensus re- Copyright 2010 by the American Dietetic port on Gastrointestinal Surgery for Severe Obesity rec- ommended multidisciplinary teams with medical, surgi- cal, psychiatric, and nutritional expertise In the articles by Kulick and colleagues and Snyder- Journal of the AMERICAN DIETETIC ASSOCIATION 2010 by the American Dietetic Association going an RYGB procedure? Are there differences among the 47 patients who were successful (lost Ն50% excess body weight) compared with those patients who lost less weight? By assessing the subjects at baseline and at last visit, the authors made some important observations: eating behavior and psychological state did not improve significantly during follow-up. Successful and unsuccess- ful patients experienced similar rates of problematic eat- ing behavior, depression, and anxiety. Patients who re- ported higher scores on ineffectiveness and social LAGBϭlaparoscopic adjustable gastric banding.
insecurity scales on the Eating Disorder Inventory II instrument at baseline were more often successful than dBPD-DSϭbiliopancreatic diversion with duodenal switch.
were the others. The existing literature on psychological eMacronutrient malabsorption does not occur with standard RYGB but may occur with outcomes among patients who have bariatric surgery generally describe significant improvements in psychos- ocial functioning, although negative psychological effects Figure. Potential mechanisms of action of four bariatric procedures
have been reported As stated by Kruseman and colleagues “The findings of this study reinforce the importance of interdisciplinary care for patients who un- Marlow and colleagues the authors review the essen- tial role for RDs in the preoperative and postoperative RDs and medical nutrition therapy are essential com- care of bariatric surgery patients. The practice skills of ponents of any treatment approach used in obesity care.
assessment and counseling along with knowledge of nu- The four articles in this issue of the Journal that address trient malabsorption and dietary plans specific to the bariatric surgery provide important background informa- bariatric surgery procedures are needed by RDs working tion for dietitians who work in this field.
in this field. These articles provide an up-to-date and timely overview of dietary management for the RYGB STATEMENT OF POTENTIAL CONFLICT OF INTEREST: and LSG procedures, respectively. Bariatric surgery No potential conflict of interest was reported by the teams typically include an obesity medicine physician, bariatric surgeon, clinical psychologist, RD, and exercise specialist, and are intended to provide best practices in patient care and improved clinical outcomes. Optimiza- References
tion of care is the basis for creation of the Center of 1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal Excellence concept developed by the American Society for KM. Prevalence of overweight and obesity in the United States, 1999- 2004. JAMA. 2006;295:1549-1555.
Metabolic and Bariatric Surgery the American Col- 2. Diabetes Prevention Program Research Group. Reduction in the inci- lege of Surgeons and some private insurers. Ad- dence of type 2 diabetes with lifestyle intervention or metformin.
vanced training for the RD choosing to work in this field N Engl J Med. 2002;346:393-403.
is also provided by the Commission of Dietetic Registra- 3. Torgerson JS, Jauptman J, Boldrin MN, Sjostrom L. XENical in the Prevention of Diabetes in Obese Subjects (XENDOS) Study: A ran- tion, the credentialing agency for the American Dietetic domized study of orlistat as an adjunct to lifestyle changes for the Association, through the award of a certificate of training prevention of type 2 diabetes in obese patients. Diabetes Care. 2004.
in Adult or Pediatric Weight Management. Similarly, a certified Obesity Medicine Physician initiative is cur- 4. Fabricatore AN, Wadden TA, Rohay JM, Pillitteri JL, Shiffman S, Harkins AM, Burton SL. Weight Loss expectations and goals in a rently under way, led by a 13-member association steer- population sample of overweight and obese US adults. Obesity. 2008; ing committee that includes the Obesity Society, Ameri- can Heart Association, American Diabetes Association, 5. Foster GD, Wadden TA, Phelan S, Sarwer DB, Sanderson RS. Obese and the American Academy of Pediatrics, among others.
patients’ perceptions of treatment outcomes and the factors that in- fluence them. Arch Intern Med. 2001;161:2133-2139.
Although guidelines for the nutrition and dietary man- 6. Lien LF, Haqq AM, Arlotto M, Slentz CA, Muehlbauer MJ, McMahon agement of bariatric surgery patients have recently been RL, Rochon J, Gallup D, Bain JR, Ilkayeva O, Wenner BR, Stevens published the majority of the evidence-based RD, Millington DS, Muoio DM, Butler MD, Newgard CB, Svetkey LP.
guidelines are supported only by expert opinion. As noted The STEDMAN project: Biophysical, biochemical and metabolic ef- fects of a behavioral weight loss intervention during weight loss, by Kulick and colleagues and Snyder-Marlow and maintenance, and regain. OMICS. 2009;13:21-35.
colleagues the recommendations provide practical 7. Kulick D, Hark L, Deen D. The bariatric surgery patient: A growing guidance based on limited literature. Herein lies the need role for registered dietitians. J Am Diet Assoc. 2010;110:593-599.
for clinical research to answer important nutrition and 8. Snyder-Marlow G, Taylor D, Lenhard J. Nutrition care for patients undergoing laparoscopic sleeve gastrectomy for weight loss. J Am Diet dietary questions in this population. For example, what is the optimal micronutrient intake for patients who un- 9. Beckman LM, Beckman TR, Earthman CP. Changes in gastrointes- dergo restrictive/malabsorptive procedures? What is a tinal hormones and leptin after Roux-en-Y gastric bypass procedure: sufficient serum level for 25-hydroxy-vitamin D? How do A review. J Am Diet Assoc. 2010;110:571-584.
10. Kruseman M, Leimgruber A, Zumbach F, Golay A. Dietary, weight, and psychological changes among patients with obesity, 8 years after The article by Kruseman and colleagues asks gastric bypass. J Am Diet Assoc. 2010;110:527-534.
equally important questions. What are the changes in 11. Akkary E, Duffy A, Bell R. Deciphering the sleeve: technique, indica- diet, anthropometry, eating behavior, psychological state, tions, efficacy, and safety of sleeve gastrectomy. Obes Surg. 2008;18: and quality of life among 80 women 8 years after under- 12. Anthone G, Lord RV, DeMeester TR, Crookes PF. The duodenal April 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION switch operation for the treatment of morbid obesity. Ann Surg.
of intense treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
13. Blackburn G, Sanchez V. Surgical approaches and outcomes. In Kush- N Engl J Med. 1993;329:977-986.
ner R, Bessesen D, eds. Treatment of the Obese Patient. Totowa, NJ: 18. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-1779.
14. Small CJ, Parkinson JR, Bloom SR. Novel therapeutic targets for 19. Rippe JM. The obesity epidemic: A mandate for a multidisciplinary appetite regulation. Curr Opin Invest Drugs. 2006;6:369-372.
approach. J Am Diet Assoc. 1998;98(suppl 2):S16-S54.
15. Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, 20. Gastrointestinal surgery for severe obesity: National Institutes of Collazo-Clavell ML. Spitz AF, Apovian CM, Livingston EH, Brolin R, Health Consensus Development Conference Statement. Am J Clin Sarwer DB, Anderson WA, Dixon J, Guven S. American Association of Nutr. 1992;55(suppl 2):S615-S619.
Clinical Endocrinologists, The Obesity Society, and American Society 21. Bariatric Surgery Centers of Excellence. Surgical Review Corporation for Metabolic & Bariatric Surgery medical guidelines for clinical prac- Web site. Accessed February 10, 2010.
tice for the perioperative nutritional, metabolic, and nonsurgical sup- 22. American College of Surgeons. Continuing Quality Improvement.
port of the bariatric surgery patient. Obesity. 2009;17(suppl 1):S1- Bariatric Surgery Center Network Program. American College of Surgeons Bariatric Surgery Center Network Web site. 16. Kolotkin R, Crosby RD, Gress RE. Hunt SC, Adams TD. Two-year changes in health-related quality of life in gastric bypass patients 23. Allied Health Sciences Section AD Hoc Nutrition Committee. Aills compared with severely obese controls. Surg Obes Relat Dis. 2009;5: 004C, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss pa- 17. Diabetes and Control Complications Trial Research Group. The effect tient. Surg Obes Relat Dis. 2008;4(suppl 5):S73-S108.

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