Type 2 Diabetes Remission Greater With Gastric Bypass vs Intensive Lifestyle Intervention

RNY works for Type 2 Diabetes.  Studies keep proving it.

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Roux-en-Y gastric bypass (RYGB) surgery yielded greater type 2 diabetes remission in mild or moderately obese patients compared with intensive lifestyle and medical intervention, according to data published in Diabetologia.

The researchers screened 1808 adults aged 25 to 64 years with type 2 diabetes and a body mass index (BMI) ranging from 30 kg/m2 to 45 kg/m2 and allocated 43 participants by concealed, computer-generated random assignment.  Participants were assigned to undergo RYGB or intensive lifestyle and medical intervention.

 

The participants in the intensive lifestyle/medical intervention cohort exercised 5 days per week for at least 45 minutes. Their diet was directed by a dietitian to lower weight and glucose levels, and all participants had optimal diabetes medical treatment for 1 year.

“Our trial and other relevant [randomized controlled trials] demonstrate that commonly used bariatric/metabolic operations (RYGB, sleeve gastrectomy, and gastric banding) are all more effective than a variety of medical and/or lifestyle interventions to promote weight loss, diabetes remission, glycemic control, and improvements in other CVD (cardiovascular disease) risk factors, with acceptable complications, for at least 1 to 3 years,” the authors wrote.

Fifteen participants underwent RYGB and 17 were assigned to the intensive lifestyle/medical intervention. Participants were followed for 1 year, and all were equivalent in baseline characteristics, although the RYGB cohort had a longer diabetes duration (11.4 vs 6.8 years; P=.009).

The percentage of weight loss at 1 year was 25.8% among participants who underwent RYGB and 6.4% in the intensive lifestyle/medical intervention group (P<.001). Participants in the intensive lifestyle/medical intervention exercise program had a 22% increase in VO2max (P<.001), while the VO2max levels in the RYGB group remained unchanged.

The rate of diabetes remission at 1 year was 60% in the RYGB group and 5.9% with the intensive lifestyle/medication intervention (P=.002). HbA1c declined in the RYGB cohort from 7.7% (60.7 mmol/mol) to 6.4% (46.4 mmol/mol), and the intensive lifestyle/medication intervention cohort's HbA1 declined from 7.3% (56.3 mmol/mol) to 6.9% (51.9 mmol/mol), although the decrease occurred with fewer diabetes medications after RYGB (P=.04).

“These results apply to patients with a BMI <35 kg/m2, and our study and others show that neither baseline BMI nor the amount of weight lost dependably predicts diabetes remission after RYGB, which appears to ameliorate diabetes through mechanisms beyond just weight reduction,” the authors noted.

“These findings call into serious question the longstanding practice of using strict BMI cutoffs as the primary criteria for surgical selection among patients with type 2 diabetes.”

Reference

  1. Cummings DE, Arterburn DE, Westbrook EO, et al. Gastric bypass surgery vs intensive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomized controlled trial. Diabetologia. 2016. doi: 10.1007/s00125-016-3903-x.
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Recommended Carbohydrate Levels After Gastric Bypass

Via Bariatric Times

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After you read this study, let's discuss:  

  • Did your nutritionist give YOU guidance in regards to carbohydrate intake after your roux en y gastric bypass surgery?
  • Background: Exact carbohydrate levels needed for the bariatric patient population have not yet been defined. The aim of this study was to correlate carbohydrate intake to percent excess weight loss for the bariatric patient population based on a cross-sectional study. The author also aimed to review the related literature.
  • Materials and Methods: A cross-sectional study was conducted, along with a review of the literature, about patients who underwent Roux-en-Y gastric bypass at least 1 year previously. Patients had their percentage of excess weight loss calculated and energy intake was examined based on data collected with a four-day food recall. Patients were divided into two groups: 1) patients who consumed 130g/day or more of carbohydrates and 2) patients who consumed less than 130g/day of carbohydrates. 
  • Limitations: The literature review was limited to papers published since 1993. 
  • Results: Patients who consumed 130g/day or more of carbohydrates presented a lower percent excess weight loss than the other group (p= 0.038). In the review of the literature, the author found that six months after surgery patients can ingest about 850kcal/day of carbohydrates, 30 percent being ingested as lipids. A protein diet with at least 60g/day is needed. On this basis, patients should consume about 90g/day of carbohydrates. After the first postoperative year, energy intake is about 1,300kcal/day and protein consumption should be increased. We can, therefore, establish nearly 130g/day of carbohydrates (40% of their energy intake) 
  • Conclusions: Based on these studies, the author recommends that 90g/day is adequate for patients who are six months post Roux-en-Y gastric bypass and less than 130g/day is adequate for patients who are one year or more post surgery. 
  • The author concludes that maintaining carbohydrate consumption to moderate quantities and adequate protein intake seems to be fundamental to ensure the benefits from bariatric surgery.



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http://bariatrictimes.com/recommended-levels-of-carbohydrate-after-bariatric-surgery/

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Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update

The Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient has been updated for the first time since 2008.   There are changes and updates and suggestions for your clinicians – the entire text is available online below –

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Download here –

Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient – 2013 Update


Abstract: The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of

clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the
evidence and subjective factors per protocol.

Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery forpatients with mild obesity, copper deficiency, informed consent, and behavioral issues.


A lifetime history of substance abuse disorder is more likely in bariatric surgery candidates compared with the general population (211 [EL 3, SS]). In contrast, current alcohol and substance abuse in bariatric surgery candidates is low compared with the general population (211 [EL 3, SS]). The LABS study demonstrated that certain groups including those with regular preoperative alcohol consumption, alcohol use disorder, recreational drug use, smokers, and those undergoing RYGB had a higher risk of postoperative alcohol use disorder (212 [EL 2, PCS]). A web-based questionnaire study indicated that 83% of respondents continued to consume alcohol after RYGB, with 28.4% indicating a problem controlling alcohol (213 [EL 3, SS]). In a prospective study with 13- to 15-year follow-up after RYGB, there was an increase in alcohol abuse (2.6% presurgery to 5.1% postsurgery) but a decrease in alcohol dependence (10.3% presurgery versus 2.6% postsurgery) (214 [EL 2, PCS]).  In a survey 6-10 years after RYGB, 7.1% of patients had alcohol abuse or dependence before surgery, which was unchanged postoperatively, whereas 2.9% admitted to alcohol dependence after surgery but not before surgery (215 [EL 3, SS]). Finally, in a retrospective review of a large electronic database, 2%-6% of bariatric surgery admissions were positive for a substance abuse history (216 [EL 3, SS]). Interestingly, 2 studies have demonstrated better weight loss outcomes among patients with a past substance abuse history compared with those without past alcohol abuse.

Bariatric surgery remains a safe and
effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.


Obesity continues to be a major public health problem in the United States, with more than one third of adults considered obese in 2009- 2010, as defined by a body mass index (BMI) 30 kg/m2 (1 [EL 3,

SS]). Obesity has been associated with an increased hazard ratio for all-cause mortality (2 [EL 3, SS]), as well as significant medical and psychological co-morbidity. Indeed, obesity is not only a chronic
medical condition but should be regarded as a bona fide disease state (3 [EL 4, NE]). Nonsurgical management can effectively induce 5%-10% weight loss and improve health in severely obese
individuals (4 [EL 1, RCT]) resulting in cardiometabolic benefit. Bariatric surgery procedures are indicated for patients with clinically severe obesity. Currently, these procedures are the most successful and durable treatment for obesity. Furthermore, although overall obesity rates and bariatric surgery procedures have plateaued in the United States, rates of severe obesity are still increasing and now
there are approximately 15 million people in the United States with a BMI 40 kg/m2 (1 [EL 3, SS]; 5 [EL 3, SS]). Only 1% of the clinically eligible population receives surgical treatment for obesity
(6 [EL 3, SS]). Given the potentially increased need for bariatric surgery as a treatment for obesity, it is apparent that clinical practice guidelines (CPG) on the subject keep pace and are kept current.

Since the 2008 TOS/ASMBS/AACE CPG for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient (7 [EL 4; CPG]), significant data have emerged regarding a broader range of available surgeries for the treatment of obesity. A PubMed computerized literature search (performed on December 15, 2012) using the search term ‘‘bariatric surgery’’ reveals a total of 14,287 publications with approximately 6800 citations from 2008 to 2012. Updated CPG are therefore needed to guide clinicians in the care of the bariatric surgery patient.

What are the salient advances in bariatric surgery since 2008?

  • The sleeve gastrectomy (SG; laparoscopic SG [LSG]) has demonstrated benefits comparable to other bariatric procedures and is no longer considered investigational (8 [EL 4, NE]).  
  • A national risk-adjusted database positions SG between the laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (RYGB) in terms of weight loss, co-morbidity resolution, and complications (9 [EL 2, PCS]). 
  • The number of SG procedures has increased with greater third-party pay or coverage (9 [EL 2, PCS]). 
  • Other unique procedures are gaining attention, such as gastric plication, electrical neuromodulation, and endoscopic sleeves, but these procedures lack sufficient outcome evidence and therefore remain investigational and outside the scope of this CPG update.
  • There is also emerging data on bariatric surgery in specific patient populations, including those with mild to moderate obesity, type 2 diabetes (T2D) with class I obesity (BMI 30-34.9 kg/m2), and patients at the extremes of age. Clinical studies have demonstrated short-term efficacy of LAGB in mild to moderate obesity (10 [EL 1, RCT]; 11 [EL 2, PCS]; 12 [EL 2, PCSA]; 13 [EL 3, SS]), leading the Food and Drug Administration (FDA) to approve the use of LAGB for patients with a BMI of 30 to 35 kg/m2 with T2D or other obesity-related co-morbidities (14 [EL 4, NE]). Although controversial, this position was incorporated by the International Diabetes Federation, which proposed eligibility for bariatric procedures in a subset of patients with T2D and a BMI of 30 kg/m2 with suboptimal glycemic control despite optimal medical management (15 [EL 4, NE]). Thus, the term metabolic surgery has emerged to describe procedures intended to treat T2D as well as reduce cardiometabolic risk factors. In 1 study, metabolic surgery was shown to induce T2D remission in up to 72% of subjects at 2 years; however, this number was reduced to 36% at 10 years (16 [EL 2, PCS]). In a more recent study, patients who underwent RYGB sustained diabetes remission rates of 62% at 6 years (17 [EL 2, PCS]). The overall long-term effect of bariatric surgery on T2D remission rates is currently not well studied. Additionally, for patients who have T2D recurrence several years after surgery, the legacy effects of a remission period on their long-term cardiovascular risk is not known. The mechanism of T2D remission has not been completely elucidated but appears to include an incretin effect (SG and RYGB procedures) in addition to caloric restriction and weight loss. These findings potentially expand the eligible population for bariatric and metabolic surgery.

Download here – via –

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* (pages S1–S27)

Jeffrey I. Mechanick, Adrienne Youdim, Daniel B. Jones, W. Timothy Garvey, Daniel L. Hurley, M. Molly McMahon, Leslie J. Heinberg, Robert Kushner, Ted D. Adams, Scott Shikora, John B. Dixon and Stacy Brethauer

Article first published online: 26 MAR 2013 | DOI: 10.1002/oby.20461



 

Post Bariatric Weight Loss Surgery Diet and Eating Plans

Post Bariatric Weight Loss Surgery Diet Plans

Doctors and nutritionists may vary in terms of what kind of diet plan to follow AFTER your weight loss surgery procedure, but most have the same basic idea. 


Follow your particular instructions of course, but here are some plans from other Bariatric Surgeons and nutritionists when you find yourself needing a reminder or re-start.


From UCSF – Gastric Bypass Plan

In the Hospital

You’ll receive clear liquids such as diluted juices and broth as well as Jello for your first meal after surgery. These foods are high in sugar but your portions will be very small. Gradually increase the amount you drink at each meal as tolerated.

First 2 Weeks

Begin adding thicker liquids that are low in fat and sugar. The goal is to eat small portions that empty easily from your pouch. Begin with portion sizes of only 1 tablespoon and increase to 2 tablespoons as tolerated.

Begin drinking 1/4 cup of liquids at a time and increase to a 1/2 cup as tolerated. Daily calorie intake should not be more than 400 calories a day. Focus on getting plenty of liquids — 1 to 1.5 liters per day — to stay well hydrated.

Thicker liquids include:

  • Blended broth or low-fat soups
  • High protein supplement diet drinks — less than 200 calories and 5 grams of carbohyrdrate and more than 20 grams of protein — per 8 to 11 ounce serving
  • Lactose free or soy based low-calorie drinks
  • Nonfat or 1 percent fat milk, if you can tolerate milk

For additional protein, add 2 tablespoons nonfat dry milk powder or egg substitute to each half cup of nonfat or low fat milk.

Other foods that can be consumed include:

  • Diet pudding
  • Hot cereals — refined cereals low in fiber such as cream of rice or cream of wheat do not use oatmeal — made with increased liquid to a soup-like consistency
  • Low-fat cottage cheese
  • Sugar-free and nonfat yogurt

Remember to drink a cup of water or other non-caloric fluids between meals. Take a multivitamin supplement everyday.

3 to 8 Weeks After Surgery

Add very small portions of pureed and soft foods as tolerated. Take very small bites and chew food very well. Do not take more than two bites every 20 minutes when consuming a new food.

These foods include applesauce, cottage cheese, hot cereals, mashed potatoes, noodles, well cooked, pureed vegetables, scrambled egg whites or egg substitute. You also may try canned fruits, canned tuna, other lean fish and ground meats or poultry.

Avoid bread and meats that are not easily chewed.

For up to two months, food intake is usually no more than 500 calories consumed in six to eight small meals a day. Recommended portion sizes are a 1/4 cup for solid foods and a 1/2 cup for liquids. Adjust foods to fit your preferences and tolerance.

The following is a sample menu.

Breakfast — 1/4 cup hot cereal made with nonfat milk

Mid-Morning — 1/2 cup nonfat milk

Late Morning — 1/2 cup tomato juice

Lunch — 1/2 cup low fat chicken noodle soup

Mid-afternoon — 1/4 cup low fat cottage cheese

Late Afternoon — 1/4 cup juice-packed canned fruit

Dinner — 2 ounces ground meat, 1/4 cup pureed or well cooked vegetables

Bedtime Snack — 1/4 cup nonfat milk

Remember to drink 1 cup of water or other non-caloric fluids between meals. Take a multivitamin and mineral supplement everyday.

2 to 6 Months After Surgery

During this period, increase your calorie consumption to 900 to 1,000 calories and at least 65 to 75 grams of protein a day. Recommended portion sizes are 1/4 cup for solids and 1/2 cup for liquids. Your daily servings for balanced nutrient intake should include:

  • Three servings of milk or dairy, nonfat and low fat.
  • Three servings of meat and meat alternatives, lean and low fat.
  • Three servings of starch. Limit bread and rice.
  • One serving of fruit serving. Avoid dried fruits and fruits with skin.
  • Two servings of vegetables, well cooked only.

Discontinue high protein diet supplement drinks, if possible, and meet your protein needs with food.

This sample menu includes eight small meals a day. You may wish to eat more or less often. Adjust your meals to fit your preferences and tolerance. Be sure to eat at least six times a day, drink a cup of water or other non-caloric fluids between meals, and take a multivitamin supplement everyday.

Breakfast — One egg or 1/4 cup egg substitute, 1/2 cup hot cereal

Mid-Morning — 1/2 cup nonfat milk

Late Morning — 1/2 cup tomato juice

Lunch — 1/2 cup low fat chicken noodle soup, two saltine crackers

Mid-Afternoon — 1/4 cup low fat cottage cheese, 1/4 cup water or juice-packed canned fruit

Late Afternoon — 1/2 cup sugar free nonfat yogurt

Dinner — 2 ounces lean meat or fish, 1/4 cup mashed potatoes, 1/4 cup pureed or well cooked vegetables

Bedtime Snack — 1/2 cup nonfat milk

6 Months After Surgery

Continue the goal of 900 to 1,000 calories in three meals and one to two snacks a day. Discontinue protein supplement drinks and increase the variety of low-fat, low-sugar and low-calorie foods as tolerated. Avoid raw vegetables, fruits with skins, dried fruits, breads, popcorn, nuts and red meats only if poorly tolerated.

Over time, increase the variety and consistency of foods in your diet. Some foods may continue to be poorly tolerated including red meat, chicken, breads, high fiber fruits and vegetables. Focus on low fat, low sugar and low calorie foods and continue to count your calories every day.

Consume at least 2 liters of fluids daily unless otherwise restricted by a medical condition.

Long-Term Diet

Over time, increase the variety and consistency of foods in your diet. Some foods — including red meats, chicken, breads, high fiber fruits and vegetables — may be poorly tolerated. Focus on low-fat, low-sugar and low-calorie foods.

Your calorie consumption should not exceed 1,000 a day and your protein goal should be 65 to 90 grams a day. To stay on track, maintain a daily record of food portions and calories.

-Via UCSF

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Mayo Clinic

Phase 1: Liquid diet
You won’t be allowed to eat for one to two days after gastric bypass surgery so that your stomach can start to heal. After that, while you’re still in the hospital, you start a diet of liquids and semisolid foods to see how you tolerate foods after surgery.

Foods you may be able to have on phase 1 of the gastric bypass diet include:

  • Broth
  • Unsweetened juice
  • Milk
  • Strained cream soup
  • Sugar-free gelatin

During phase 1, sip fluids slowly and drink only 2 to 3 ounces (59 to 89 milliliters, or mL) at a time. Don’t drink carbonated or caffeinated beverages. And don’t eat and drink at the same time. Wait about 30 minutes after a meal to drink anything.

Phase 2: Pureed foods
Once you’re able to tolerate liquid foods for a few days, you can begin to eat pureed (mashed up) foods. During this two- to four-week-long phase, you can only eat foods that have the consistency of a smooth paste or a thick liquid, without any solid pieces of food in the mixture.

To puree your foods, choose solid foods that will blend well, such as:

  • Lean ground meats
  • Beans
  • Fish
  • Egg whites
  • Yogurt
  • Soft fruits and vegetables
  • Cottage cheese

Blend the solid food with a liquid, such as:

  • Water
  • Fat-free milk
  • Juice with no sugar added
  • Broth
  • Fat-free gravy

Keep in mind that your digestive system might still be sensitive to spicy foods or dairy products. If you’d like to eat these foods during this phase, add them into your diet slowly and in small amounts.

Phase 3: Soft, solid foods
With your doctor’s OK, after a few weeks of pureed foods, you can add soft, solid foods to your diet. If you can mash your food with a fork, it’s soft enough to include in this phase of your diet.

During this phase, your diet can include:

  • Ground or finely diced meats
  • Canned or soft, fresh fruit
  • Cooked vegetables

You usually eat soft foods for eight weeks before eating foods of regular consistency with firmer texture, as recommended by your dietitian or doctor.

Phase 4: Solid foods
After about eight weeks on the gastric bypass diet, you can gradually return to eating firmer foods. You may find that you still have difficulty eating spicier foods or foods with crunchy textures. Start slowly with regular foods to see what foods you can tolerate.

Avoid these foods
Even at this stage after surgery, avoid these foods:

  • Nuts and seeds
  • Popcorn
  • Dried fruits
  • Sodas and carbonated beverages
  • Granola
  • Stringy or fibrous vegetables, such as celery, broccoli, corn or cabbage
  • Tough meats or meats with gristle
  • Breads

These foods are discouraged because they typically aren’t well tolerated in the weeks after surgery and might cause gastrointestinal symptoms. Over time, you may be able to try some of these foods again, with the guidance of your doctor.

A return to normal
Three to four months after weight-loss surgery, you may be able to start returning to a normal healthy diet, depending on your situation and any foods you may not be able to tolerate. It’s possible that foods that initially irritated your stomach after surgery may become more tolerable as your stomach continues to heal.

Throughout the phases
To ensure that you get enough vitamins and minerals and keep your weight-loss goals on track, at each phase of the gastric bypass diet, you should:

  • Keep meals small. During the diet progression, you should eat several small meals a day and sip liquids slowly throughout the day (not with meals). You might first start with six small meals a day, then move to four meals and finally, when following a regular diet, decrease to three meals a day. Each meal should include about a half-cup to a cup of food. Make sure you eat only the recommended amounts and stop eating before you feel full.
  • Take recommended vitamin and mineral supplements. Because a portion of your small intestine is bypassed after surgery, your body won’t be able to absorb enough nutrients from your food. You’ll need to take a multivitamin supplement every day for the rest of your life, so talk to your doctor about what type of multivitamin might be right for you, and whether you might need to take additional supplements, such as calcium.
  • Drink liquids between meals. Drinking liquids with your meals can cause pain, nausea and vomiting as well as dumping syndrome. Also, drinking too much liquid at or around mealtime can leave you feeling overly full and prevent you from eating enough nutrient-rich foods. Expect to drink at least 6 to 8 cups (48 to 64 ounces or 1.4 to 1.9 liters) of fluids a day to prevent dehydration.
  • Eat and drink slowly. Eating or drinking too quickly may cause dumping syndrome — when foods and liquids enter your small intestine rapidly and in larger amounts than normal, causing nausea, vomiting, dizziness, sweating and eventually diarrhea. To prevent dumping syndrome, choose foods and liquids low in fat and sugar, eat and drink slowly, and wait 30 to 45 minutes before or after each meal to drink liquids. Take at least 30 minutes to eat your meals and 30 to 60 minutes to drink 1 cup (237 milliliters) of liquid. Avoid foods high in fat and sugar, such as nondiet soda, candy, candy bars and ice cream.
  • Chew food thoroughly. The new opening that leads from your stomach into your intestine is very small, and larger pieces of food can block the opening. Blockages prevent food from leaving your stomach and can cause vomiting, nausea and abdominal pain. Take small bites of food and chew them to a pureed consistency before swallowing. If you can’t chew the food thoroughly, don’t swallow it.
  • Try new foods one at a time. After surgery, certain foods may cause nausea, pain and vomiting or may block the opening of the stomach. The ability to tolerate foods varies from person to person. Try one new food at a time and chew thoroughly before swallowing. If a food causes discomfort, don’t eat it. As time passes, you may be able to eat this food. Foods and liquids that commonly cause discomfort include meat, bread, pasta, rice, raw vegetables, milk and carbonated beverages. Food textures not tolerated well include dry, sticky or stringy foods.
  • Focus on high-protein foods. Immediately after your surgery, eating high-protein foods can help heal your wounds, regrow muscle and skin, and prevent hair loss. High-protein, low-fat choices remain a good long-term diet option after your surgery, as well. Try adding lean cuts of beef, chicken, pork, fish or beans to your diet. Low-fat cheese, cottage cheese and yogurts also are good protein sources.
  • Avoid foods that are high in fat and sugar. After your surgery, it may be difficult for your digestive system to tolerate foods that are high in fat or added sugars. Avoid foods that are fried and look for sugar-free options of soft drinks and dairy products.

 


From Highland Hospital, download-able plans:

From Brigham + Women’s Hospital, Boston: