the role of dietitians in bariatric surgery1.ppt
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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
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