Nutrition Graph for Argentina’s Bariatric Population: A Best-Practice Algorithm

by Lic. Fantelli Pateiro Laura, Lic. Natalia Pampillón, Lic. Mónica Coqueugniot, Lic. Patricia De Rosa, Lic. Carolina Pagano, Lic. Clarisa Reynoso, Lic. María Cecilia De Pizzol, Lic. Clara Iturralde, Lic. Susana Podestá, Lic. Cecilia Penutto

Fantelli Pateiro L is from Bariatric Surgery Division at Hospital Privado de Comunidad, Mar del Plata, Argentina. Pampillón N and Penutto C are from Obesity Surgical Center, Mendoza, Argentina. Coqueugniot M and Iturralde C are from the Center for the Study and Treatment of Severe Obesity (CETOS), CABA, Argentina. De Rosa P is from Center for Obesity Surgical Recovery (CRQO), CABA, Argentina. Pagano C is from Clinic for Obesity and Metabolic Disease Treatment (CITOmet), Neuquén, Argentina. Reynoso C is from Team of Bariatric Surgery at Hospital Británico, CABA, Argentina. De Pizzol C is from Bariatric Unit Program, Hospital Alemán, CABA, Argentina. Podestá S is from OCMI, Hospital Español, Mendoza, Argentina.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.

Bariatric Times. 2015;12(3):11–14.

ABSTRACT
Introduction: Nutritional guidelines can help individuals monitor and improve the quality of their diet. Guidelines can be futher honed to apply to a particular population, providing a framework for the correct selection of nutrients to be consumed.
Objective: The aim of this research was to create a nutrition education tool for the Argentine bariatric surgery patient population in the postoperative period and in the long term.
Methods: Participants attended workshops led by nutritionists and physicians specializing in nutrition and bariatric surgery during the 5th Congress on Bariatric and Metabolic Surgery in Mendoza City, Argentina, in May 2011. Workshop participants discussed the food distribution, quantity, and quality in the postoperative period, defined as 6–8 weeks post surgery. The authors used these discussions along with the the First Argentine Consensus on Nutrition in Bariatric Surgery and the Nutrition Guidelines for the Argentine Population to develop a resource for the Argentine patient population post bariatric surgery.
Results: The authors developed two graphs that include 12 recommendations for the Argentine bariatric surgery patient population; a sample menu, and a color-coded chart detailing food and liquid servings, exercise recommendations, and illustrations reminding patients to take 30 minutes to eat a meal and adhere to regular medical and nutritional follow-up appointments.

Introduction
Prevalence of obesity around the world has increased in both developed and developing countries, according to data from the World Health Organization.[1] Data in Argentina provided by the National Survey on Health and Nutrition show a 19.4-percent prevalence of obesity in women 19- to 49-years old, and said prevalence amounts to 34.5 percent of the general population.[2,3] Within this percentage, 3.5 percent of the adult population have severe obesity and morbid obesity.[4]

Currently, bariatric surgery is the treatment of choice in patients with severe obesity, and a post-surgery diet is essential in order to guarantee the success of the treatment in the long term.
Nutritional guidelines can help individuals monitor and improve the quality of their diet. Guidelines can be further honed to apply to a particular population, providing a framework for the correct selection of nutrients to be consumed. We feel that guidelines that incorporate illustrations, tables, and other forms of messaging offer a practical way of translating dietary recommendations.

Although other such resources were available, we felt they did not exactly apply to our targeted patient population—individuals in Argentina post bariatric surgery. We sought to fill this need. These two graphs, titled “Nutrition Guidelines for the Argentine Bariatric Surgery Population,” (See reader handout on page 12) were created to help this patient population maintain a balanced and healthy diet, which may help prevent diseases, deficit of nutrients, non-communicable diseases, such as cancer and heart disorders, and prevent postoperative weight regain. We presented the graphs in an article published in Spanish in Nutricion hospitalaria.[5] Here, we present the information from that article and accompanying graphs in the English language.

Background
Consumption of both proteins and hundreds of micronutrients are a priority for the bariatric surgery population; however not all patients have the same dietary needs, and there is not only one dietary pattern that is compatible with good long-term postoperative treatment. Much of this is dependent on a patient’s current weight, height, body mass index (BMI), physical activity, and food tolerance and habits. A patient’s food habits may also affect his or her consumption of correct distribution of macronutrients and micronutrients.

Prior to the creation of our graph, other resources were available.[6–8] In 2003, general nutrition guidelines were published7; however, these were not specific to the bariatric surgery population. In 2010, Moize et al8 from the Hospital Clinic in Barcelona, Spain, published a nutritional pyramid for post-gastric bypass patients, but these were also limited as they did not include other bariatric procedures. In 2011, a group of Argentine nutritionists specializing in bariatric surgery created a resource based on the Argentine Consensus on Nutrition in Bariatric Surgery.[9] These were helpful but did not include illustrations, which we felt were important in relaying instructions to patients.

In our graphs, food groups are represented by circles. We feel these illustrations guarantee the existence of all nutrients and provide positive messages about the recommendations of food quantity and quality in the postoperative period. We consider the postoperative period to begin 6 to 8 weeks after surgery.

Materials and Methods
To develop our graphs and illustrations we used both workshops and existing resources.
Participants attended workshops led by nutritionists and physicians specializing in nutrition and bariatric surgery during the 5th Congress on Bariatric and Metabolic Surgery in Mendoza City, Argentina, in May 2011. Workshop participants discussed the food distribution, quantity, and quality in the postoperative period, defined as 6–8 weeks post surgery. We used these discussions along with the the First Argentine Consensus on Nutrition in Bariatric Surgery[9] and the Nutrition Guidelines for the Argentine Population7 to develop a resource for the Argentine patient population post bariatric surgery.[7] These were adapted to apply to the Argentine bariatric surgery population.

The Nutrition Guidelines for the General Argentine Population are comprised of practical messages from nutritionists across the country whom provide scientific knowledge on nutritional needs and food composition for healthy lifestyles. The guidelines also include a chart titled, “The Graph of Healthy Nutrition,” which includes the following instructions for living a healthy life:
2.    Eat moderately and include a variety of foods for each meal.
3.    Include milk, yogurt, and cheese in your diet. This is important for all ages.
4.    Eat all kinds and colors of fruit and vegetables every day.
5.    Eat a variety of red and white meats, trimming all visible fat.
6.    Preferably, use uncooked oil in your meals and avoid using fat for cooking.
7.    Reduce intake of sugar and salt.
8.    Eat a variety of bread, cereals, pasta, flours, starches, and legumes.
9.    Reduce consumption of alcoholic beverages. Children, adolescents, pregnant women, and nursing mothers should avoid alcohol.
10.Drink plenty of water throughout the day.
11.Use meal times to share and talk with others.

We adapted all of these resources for the bariatric surgery population and combined them with the results of our workshops where we discussed the food distribution, quantity, and quality in the postoperative period with other bariatric professionals.

Results
After careful consideration of all resources, we developed our graphs. Graph 1 (See top of reader handout on page 12) includes the 12 messages/recommendations for individuals post bariatric surgery and a sample menu with a mean energy value (1,273 calories per day, 145g of carbohydrates, 76g of proteins and 43.2g of fats). Of those calories, 45.5 percent come from carbohydrates, 24 percent from proteins, and 30.5 percent from fats, with 1,160mg of calcium.
The menu developed suggests the following items and amounts on a daily basis: 200 cm3 of partially skimmed milk, 180g of yogurt with extra calcium (500mg of calcium), 60g of low-fat Port Salut cheese or low-fat unripened cheese, 200g of lean meat, 300g of type “A” vegetables (e.g., artichoke, chili, celery, eggplant, watercress, broccoli, cauliflower, endive, ruff, asparagus, spinach, mushrooms, lettuce, cucumber, radish, cabbage, rechicks of Brussels, onion, palmettoes, leeks, zucchini) 150g of type “B” vegetables (e.g., gourd, beet, carrot, pumpkin), 250g of fresh fruit, 40g of dried pasta, 50g of low-calorie double bran bread, and 20g of oil.
This corresponds to 6 to 8 servings of protein foods (average serving of 10g each), emphasizing those of high biological value, 4 to 5 servings of vegetables and fruits, two tablespoons of oil, up to three servings of complex carbohydrates (average serving of 12g each), and occasional and moderate consumption of the supplementary group.

The second graph (See bottom of reader handout on page 12) includes recommended daily servings of the various foods sorted in four groups: 1) protein foods, 2) vegetables, fruits and uncooked oil, 3) complex carbohydrate foods, and 4) occasional foods, such as simple sugars, alcohol, and fats. It also includes recommendations for types and frequency of physical activity, vitamin and mineral supplement intake. This graph contains an illustration reminding of regular medical and nutritional check-ups, as well as a symbol or image that suggests the time that should be spent on each meal.

The following section lists the 12 recommendations shown in graph 1 with explanations and tips for each item.
1. Eat 4 to 6 times a day, spending at least 30 minutes on each meal. Meals should last at least 30 minutes, and they should take place in a quiet environment without stress. Patients should avoid distractions, such as watching TV, reading, or using the computer. When followed, these recommendations should help patients focus on the act of eating, chewing all foods thoroughly and paying attention to the signs of fullness.

After bariatric surgery, patients have a reduced gastric reservoir, thus a larger number of intakes might be needed to meet the minimum nutrient requirements.

2. Prioritize the consumption of protein rich foods at every meal (lean white and red meats, skimmed dairy products, and eggs). It is important to include an adequate amount of proteins after bariatric surgery. We recommended that patients start eating protein-rich foods (meats, egg whites, cheeses, milk, yogurt or modular protein supplements) first. It is important to remember that the goal is for patients to consume 60 to 120g of protein per day, which is equals to a minimum of 1g per kg of ideal weight per day, depending on the type of surgical procedure. The adequate consumption of proteins is essential to preserve the lean mass.[10,11]

3. Drink at least one and a half liters of liquids, with no calories and no carbonation, preferably drinking water, on a daily basis. Water is a vital nutrient for the correct functioning of the body as it transports nutrients and waste substances from the body and also regulates body temperature and metabolism. Following a bariatric procedure, we recommended that patients drink at least 1.5 liters of calorie-free liquids with no carbonation. Calories could make weight loss slower and the gas could produce discomfort and dilation of the gastric reservoir.
The adequate consumption of liquids, especially water, prevents dehydration, a problem that could lead to low blood pressure, dizziness, and headaches.

4. Do not ingest liquids during meals. Do it 30 minutes before or after them. Liquids should not be taken with main meals. This is due to the fact that the reduction of the gastric capacity following bariatric surgery does not allow the joint intake of foods and drinks.
Drinking liquids together with food can speed the gastric emptying, limiting the sensation of fullness that is sought after the gastric restriction.

We recommend that patients wait a minimum of 30 minutes, before and after main meals, to hydrate.

5. Eat slowly, in a quiet environment, sitting and without stress. Chew foods thoroughly. Meals should take place in a quiet environment in order for patients to tolerate foods better.
Chewing is the first step in the digestive process, and it is essential for gastric tolerance, especially with protein-rich foods, which are needed on a daily basis. Chewing foods thoroughly requires the patient to focus on chewing from the very beginning. This will allow patients to pay attention to the volumes consumed and control the satiety value produced by bariatric surgery.
6. Avoid snacking cookies, bread, candy, etc., which could lead to weight gain. Snacking is a frequent habit seen in bariaric patients. After surgery, patients should learn to choose protein-rich snacks instead of those high in carbohydrates and fats. Hypercaloric foods will produce less fullness and may lead to a higher tendency to consume, which is subsequent with weight regain.

It is also important to schedule daily snacks without skipping meals to avoid snacking in situations when it is not possible to choose an adequate food.

Eating all main meals (breakfast, lunch, mid-afternoon snack, and dinner), and having two snacks (one at mid-morning and the other one some time before dinner) is highly recommended in order to avoid cravings for hypercaloric and low nutritional value food products, such as cookies, bread, and candy. Nothing should be eaten at other times of the day. Foods that contain sugar and fat (shown in the final position in the graph) should be consumed sporadically and in very small servings.

7. Reduce consumption of foods rich in refined sugars. The intake of beverages containing sugar and other products rich in sugar, such as jams, candy, confectionery, pastries, cakes, and cookies, which are also rich in bad-quality fats, must be controlled.[12] These foods and beverages could limit weight loss. Patients who avoid these foods usually have a satisfactory weight maintenance after surgery.

8. Use extra virgin olive oil, sunflower or canola oil, preferably uncooked, and avoid using animal fat. Fat tends to slow down the gastric emptying and worsen the pre-existing symptoms of gastroesophageal reflux. Some fat-rich foods (e.g., sausages, pâtés, fatty cuts of meats, fatty cheeses, and nuts) and fried foods should be avoided or limited, not only due to potential intolerance, but also due to the fact that the caloric intake stops the weight loss curve and/or makes it easy to regain weight. Fried foods and other fats are not recommended.

Fats should not exceed 25 to 30 percent of a patients daily total energy. The recommended diet also includes essential fatty acids. That is why we recommended using vegetable oils such as sunflower, corn, canola and/or soy oil.[12]

9. Take the prescribed daily dose of vitamins and minerals. Due to the change in the anatomy of the digestive system after bartiatric surgery, multivitamin/mineral supplements are recommended for life. It is important that patients fulfill these requirements in order to avoid risks caused by vitamin deficiency.[11,13,14]

10. Avoid consumption of alcoholic beverages. Alcoholic beverages are contraindicated not only because they promote regaining weight and development of vitamin deficiencies, but also because the reduction of the gastric reservoir produces rapid absorption of alcohol, leading to an increase in the speed of toxicity. Patients should be warned about this issue, as low volume may produce the same effects as large volumes produced before surgery. Additionally, some patients who undergo bariatric surgery have pre-existing liver disorders, which is why alcohol consumption is harmful.[11]

11. Exercise regularly and lead an active life. Physical activity following bariatric surgery prevents muscle weakness and loss of muscle mass, which should be avoided following bariatric surgery. Physical activity produces other beneficial effects, such as reducing cholesterol, triglyceride, insulin, and body fat levels; increasing cardiopulmonary capacity; regulating blood pressure; and reducing stress and anxiety levels.

Our graph shows the following physical activity recommendations: muscle strength, aerobic endurance, and flexibility.

When prescribing physical exercise, healthcare providers should take into account the starting physical capacity of the patient. Patients can exercise to strengthen muscles by using weights, rubber bands, and machines. They should also add an aerobic endurance workout, such as exercise bike or jogging. Flexibility and stretching exercises help patients  to achieve wider movements and stretch their muscles. We rercommend tht patients engage in physical activity 3 to 4 days per week, increasing progressively. It is important that patients change their habits from a sedentary to a physically active lifestyle for their well-being.[15–19]

12. Attend the check-ups prescribed by the team of bariatric surgery specialists. It is import that patients adhere to post-surgery follow up so specialists can reinforce nutrition guidelines, monitor weight loss, monitor evolution of comorbidities, and find and treat secondary complications of the surgery (mainly, vitamin and mineral deficiencies).

Our graphs are included in a tri-fold brochure, with the nutrition graph inside, and recommendations and a sample menu on the outside.

Conclusions
Nutrition Guidelines for the Argentine Bariatric Surgery Population is a tool to provide mid- and long-term nutrition education for this specific bariatric surgery population.

This is a best-practice algorithm from the Argentine perspective, not a standard practice for all bariatric centers/patients.

It was created so that patients could easily understand nutrition recommendations 6 to 8 months following bariatric surgery. It promotes a diet according to their needs, based on high biological value protein, monitoring consumption of simple carbohydrates and recommending a selection of healthy foods. Long-term nutrition recommendations and patient follow up are the key elements for the success of the post-surgery treatment.

Acknowledgements
We thank Lorena Burgos, graphic designer, and the nutritionists who were involved in the creation of this graph for their support.

References
1.    Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obes. Surg. 2003;13 (3):329–330.
2.    National Survey on Nutrition and Health. Results Document. Ministry of Health. Argentina. 2007: 1–182.
3.    Ferrante D, Linetzky B, Konfino J, et al. 2009 National Survey on Risk Factors: Evolution of Epidemic of Non-Communicable Chronic Diseases. Cross-Sectional Study. Rev Argent Salud Pública. 2011;2(6):34–41.
4.    Elgart J, Pfirter G, Gonzalez L, et al. [Obesity in argentina: morbidity, mortality, and economic impact]. Rev Argent Salud Pública. 2010;1(5):6–12.
5.    Fantelli Pateiro L, Pampillón N, Coqueugniot M, et al. [Nutritional graph for Argentina’s bariatric population]. Nutr Hosp. 2014;29(6):1305–1310.
6.    Food Based Dietary Guidelines (FBDG) in Europe. EUFIC REPORTS 10/2009. www.eufic.org/article/es/page/RARCHIVE/expid/directrices-dieteticas-basadas-alimentos-Europa. Accessed February 20, 2015.
7.    Lema S, Longo E, Lopresti A. Nutrition Guidelines for the Argentine Population: Trainer’s Manual. 1.ª Ed. Buenos Aires: Asociación Argentina de Dietistas y Nutricionistas Dietistas, 2003. http://www.msal.gov.ar/promin/publicaciones/pdf/guias-alimentarias.pdf. Accessed February 20, 2015.
8.    Moizé VL, Pi-Sunyer X, Mochari H, Vidal J. Nutritional pyramid for post-gastric bypass patients. Obes. Surg. 2010;20(8):1133–1141.
9.    Pampillón N, Reynoso C, Pagano C, et al. Argentine consensus on nutrition in bariatric surgery. Nutrition update. Actualización en Nutrición. 2011;12 (2):98–141.
10.    Moizé V, Andreu A, Rodríguez L, et al. Protein intake and lean tissue mass retention following bariatric surgery. Clin. Nutr. 2013;32(4):550–555.
11.    Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J, Still C, Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010;95(11):4823–4843.
12.    Rubio MA, Rico C, Moreno C, Nutrition and bariatric surgery. Supl Rev Esp Obes. 2005; 2:1–11.
13.    Mechanick J, Kushner R, Sugerman H, et al. Guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4:109–184.
14.    Mechanick J, Youdim A, Jones D, Timothy Garvey W., Hurley D. L., Mc Mahon M. AACE/TOS/ASMBS Bariatric Surgery Clinical Practice Guidelines. Endocr Pract. 2013;19(2):1–36.
15.    King WC, DS Bond. The importance of preoperative and postoperative physical activity counseling in bariatric surgery. Exerc Sport Sci Rev. 2013; 41(1):26–35.
16.    Pino H. Physical activity in the management of obesity: how much and how often? Bariaric Nursing and Surgical Patient Care. 2006;1(1):39–45.
17.    American College of Sports Medicine. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2009;41(3):687–708.
18.    Livhits M, Mercado C, Yermilov I, et al. Exercise following bariatric surgery: systematic review. Obes. Surg. 2010;20:657–665.
19.    Stegen S, Derave W, Calders P, Van Laethem C, Pattyn P. Physical fitness in morbidly obese patients: effect of gastric bypass surgery and exercise training. Obes Surg. 2011;21(1):61–70.

Tags: Bariatrics, nutrition

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