Sioned Quirke BSc RD

Lead Specialist Dietitian

The dietitian is essential to the patients success with

bariatric surgery Dietitians assess, monitor and counsel patients pre and

post operatively to improve adherence, maximise weight loss, increase motivation and ensure optimum nutrition

Patients have to re-learn eating and lifestyle patterns that they have been practising for many years

The dietitian involved needs to have specialist training and experience, role is beyond the traditional role of diet counselling

We have to be experts at motivational learning and cognitive behavioural therapy

Work within a multidisciplinary team, important that the team understands and supports each others roles in providing care

Bariatric surgery should not be viewed as a miracle cure where no effort is needed by the patient

Patients often believe that actual surgery is the most difficult part but surgery represents only 1 point in the continuum of care

Outcome relies on long termadherence to diet and lifestyle changes and requires frequent monitoring and adjustments to achieve ultimate weight loss

Providing knowledge alone does not necessarily lead to a change in behaviour

Change is uncomfortable

Principles of this approach – modification of current behaviour patterns new adaptive learning problem solving collaborative relationship between client & therapist

There are reciprocal relationships between:

Cognitive factors – knowledge, attitudes

Behavioural factors – skills

Environmental factors – ability, cost etc

Type of surgery is classified based on the main mechanism of weight loss:

Restrictive – Gastric Balloon Gastric Band Sleeve Gastrectomy

Malabsorpative – Gastric Bypass Bilio-pancreatic diversion (BPD)

Very important part of care to maximise weight loss

Liver shrinking diet

Take into account the patients concerns

Manage expectations

Terminology – cant use ‘normal’the patients have no understanding about :normal eating or normal portions

Meet protein requirements

Meet fluid requirements

Establish and maintain new eating habits & food choice

Prevent micronutrient deficiencies

Improve quality of diet

Promote steady, safe weight loss – 1-2lb a week

Prevent complications

Psychological support

Long term management

Initial texture modification: Stage 1: fluid/blended 1-2 weeksStage 2: soft/mash 1-2 weeksStage 3: normal healthy eating diet lifelong

3 small meals a day Serve on tea-plate No fluids with meals, 30 min – 1hr gap Protein based meals Ensure quality of diet – healthy eating Eat slowly to recognise satiety Exercise

Deflated band placed around upper part of stomach – laparoscopic procedure

20-50ml pouch (egg sized)

Inflated with saline as pt requires

Hole in middle of band gets smaller - food held in pouch longer = increased satiety

Remaining stomach not used to store food

Successful weight loss achieved by adhering to very small portion size long term

4 tablespoons at each meal, stop at this. Solid dry foods are preferable foods Caution of high kcal/sugar/fat foods/drinks Persevere with ‘difficult’ foods Vitamin and mineral supplement should not

be needed Avoid getting overfull or oesophagus can

stretch and sensitivity to fullness will be lost After inflation, may need texture modified

diet

Non-surgical procedure, performed under sedation and takes between 20-30 minutes

Deflated balloon inserted through the mouth into the stomach with an endoscope

After balloon is in place it is filled with sterile solution

The balloon partially fills the stomach and creates a feeling of fullness and reduces stomach capacity

Balloon is removed after around 6 months

Successful long term weight loss achieved by maintaining changes made while balloon was in place

Child sized portions Solid dry foods are preferable foods Ensure good quality of diet Vitamin and mineral supplement should not be

needed Exercise Avoid getting overfull as stomach can stretch and

sensitivity to fullness will be lost

Eat consciously: chew everything well, take time over meals, put down cutlery in between mouthfuls, enjoy food.

Stomach converted into long thin tube by stapling and removing the excess part of stomach

Stomach area smaller which restricts the amount of food consumed and causes early satiety

Used in young people/high risk pts as first step to other procedures such as a bypass

Successful weight loss depends on the patient adhering to small portions lifelong

Child sized portions Caution of high kcal/sugar/fat foods/drinks Ensure good quality of diet Vitamin and mineral supplement should

not be needed Exercise

Small stomach pouch - around 30mls

Small intestine cut into 2 sections

1st joined to opening in new pouch where food will travel through

2nd is bypassed limb, remains in original position and carries digestive juices to a connection of the first limb

Causes 50% of nutrients to be malabsorbed as the digestive juices have less time with the food and the surface area for absorption is reduced

Initial texture modification: Stage 1: fluid/blended 1-2 weeksStage 2: puree/smooth 1-2 weeksStage 3: soft/mash 1-2 weeksStage 4: normal healthy eating diet lifelong

High protein meals and snacks (min 70g a day)

Low sugar – to prevent dumping syndrome

Low fat – to prevent steatorrhea

Ensure good fluid intake

Essential to take daily vitamin and mineral supp

6 monthly B12 injections

65% excess weight loss in about 18 months

Prof Baxter used to always say – you can out eat most of the procedures

Changes are lifelong not just to lose the weight

Encourage self monitoring- Food and exercise diaries useful

Encourage exercise –Utilize exercise referral programmers

Constipation affects most restrictive surgery patients

Learn relapse control Manage expectations as time goes on–

probably won’t get to ideal body weight Psychological interventions

www.obesity-surgery.co.uk www.bospa.org.uk www.domuk.org www.british-obesity-surgery.org/ www.WLSinfo.co.uk www.bda.uk.com (British Dietetic Association) www.nationalobesityforum.org.uk (National

Obesity Forum) Further reading: Stephanie F. Yeager.

Bariatric Nursing and Surgical Patient Care. Role of the Dietitian in a Multidisciplinary Bariatric Program. June 2008, 3(2): 107-116. 3 Issue 2: June 11, 2008