Alternatively, consideration of the risks associated with obesity itself is included in an overview of the risks and benefits of bariatric surgery for CKD patients (Adv Chronic Kidney Dis. 2006:13:403-417).
The authors cite “an excess of approximately 300,000 deaths annually in the United States directly related to obesity complications” and point to the potential for improvements in blood sugar control, BP, and lipid profile that typically accompany weight reduction. Because of the statistically poor results in achieving and sustaining weight loss via diet (“approximately 85% of dieters regain lost pounds within one year, and 95% are unable to maintain a 5% weight loss for five years”), the authors cite the NIH consensus that bariatric surgery is currently the best evidence-based approach to morbid obesity.
However, the researchers also stress the need to evaluate the benefits of weight-loss surgery along with potential risks, both immediate and long term, and suggest “additional studies are needed to evaluate the effects of substantial weight loss on the natural history of CKD.”
A recent systematic review compares different approaches to bariatric surgery (Am J Med. 2008;121:885-893). The authors compare outcomes of LAGB with those of Roux-en-Y gastric bypass. The latter approach “creates a small stomach pouch to restrict food intake [after which] a portion of the jejunum is attached to the pouch to allow food to bypass the distal stomach, duodenum, and proximal jejunum.”
Although study results indicate that LAGB has the advantages of a shorter hospital stay and fewer perioperative complications, Roux-en-Y gastric bypass demonstrated greater overall success in weight loss with less need for re-operation.
Based on results from the 14 studies examined, the authors conclude that “in comparative trials, weight loss, resolution of obesity-related comorbidities, and patient satisfaction are greater after gastric bypass than gastric banding,” and “gastric bypass should remain the primary bariatric procedure used to treat obesity.”
Dietary guidelines following bariatric surgery (J Am Diet Assoc 2004;104:487-488) can be adapted for dialysis patients, with emphasis on adequate protein intake and supplementation as indicated. Recommendations, individualized for patient needs, generally include:
- Small portions (approximately 1-2 oz initially, progressing to 4-5 oz)
- Eating slowly and chewing foods well
- Consuming protein foods first, before filling up on carbohydrates or fats
- Drinking liquids apart from mealtimes
- Taking a daily multivitamin as prescribed.
Ongoing dietary assessment and counseling are key to achieving desired outcomes after bariatric surgery, especially for CKD patients.