Dietetic Support for Bariatric Surgery Maureen Boyle Senior Specialist Dietitian April 2015

Before Bariatric Surgery Need to show commitment by losing weight prior to surgery Patients need an understanding of the basics of healthy eating Attendance at an NHS weight management group would be useful. Now will be expected to attend Tier 3 weight management programme Need realistic expectations and realise it is a life long commitment to change in eating habits Aware of the psychological effects following surgery

Tier 3 for Surgery Minimum 6 months from seminar to surgery Medical assessment – maximise treatment of medical problems Diabetes/Hypertension/Sleep Apnoea Psychological assessment if required Intensive dietetic intervention – to improve knowledge and help achieve weight loss target 3 x 2 hour sessions at various times and locations.

Role of the Bariatric Dietitian Bariatric seminar Initial assessment Attendance at MDT 10 day pre op diet Post op Dietary advice Post op review Ongoing monitoring

Pre op Diet 10 days prior to the gastric bypass, band or gastric sleeve a pre op - liver reducing diet is required Milk yoghurt and fruit Non milk calorie controlled Diabetic on insulin

Pre op Diet 2-3 pints of skimmed or semi skimmed milk Daily allowance   2-3 pints of skimmed or semi skimmed milk 2 diet yoghurts – any flavour 3- 4 portions of fruit (any variety) Sugar free Jelly (optional)  Water, tea and coffee can be taken freely- sweeteners are allowed. Low calorie drinks or squashes are allowed freely. One bowl of vegetable soup No other foods should be eaten Alcohol is not allowed

Gastric Bypass First day following surgery we suggest a 1 litre water taken as sips over the day. The following day pureed diet is commenced. We suggest about 1-2 tablespoons at each meal. The pureed diet must be followed for a minimum of 4 weeks Fluids are encouraged but not with meals.

General advice In the early stages we encourage 4-6 very small meals a day. A high protein diet is recommended to aid the healing process after surgery. Vary the intake as much as possible Aim for 2-2½ litres of fluid a day. No fizzy drinks and carry a water bottle around to top up fluids.

General advice Gradually increase the consistency of food. Encourage to eat slowly and chew food well By 2 – 3 months most foods should be tolerated At this point establish an eating pattern of regular meals.

Vitamin requirements A Multi vitamin A-Z should be started on discharge. Ferrous Fumarate one tablet once a day. Adcal D3 one tablet twice a day B12 injection once every 3 month Loading dose not required

Important points Constipation Lack of appetite. Not unusual after bypass Ensure adequate fluids Lack of appetite. Emphasise the need to eat regular meals Ensure the diet contains adequate protein. The use of protein powders/supplements is not recommended.

Important points Alcohol Hair loss/thinning No alcohol for at least 3 months following surgery It is absorbed quickly and you can become drunk quicker Hair loss/thinning Check weight loss Reassess diet for protein and vitamin intake Reassure

Dumping Syndrome Patients feel sick, dizzy or generally unwell either just after or within a couple of hours of eating food. It happens when sugars are quickly absorbed. It indicates patients are being less vigilant with the choice of food. It cannot be treated and is best avoided.

Sleeve Gastrectomy Following a gastric sleeve it is important to follow a pureed diet for 4 weeks. Other food textures are gradually introduced. It is important to eat regular healthy meals. We recommend a multi vitamin A-Z daily It does not cause dumping syndrome therefore it will allow patients to eat high sugar foods and the weight loss will then be disappointing

Rules of a Band Eat three meals a day – it is important to have small meals. Eat good quality solid food – because you can only eat small meals the food must be healthy. The food must be solid, liquids run through the band and you will not feel full.

Rules of a Band Do not eat between meals. Snacking is the major cause of failure to lose weight after surgery. Keep to meal times only.   Do not drink with your meals. You must stop drinking for a minimum of 15 minutes before and 30 minutes after a meal. Liquids speed up the process of food going through the band and it is less effective.

Warning Some foods are not affected by the band such as crisps, chocolate, sweets and mints. Alcohol, milk shakes and ice cream will also slip through the band. If patients continue to eat these foods weight loss will be disappointing.

Gastric Balloon To assist portion control To retrain eating habits Regular meals Small plate Healthy eating advice Eating slowly Chew food well Adequate fluids Exercise as able

Follow Up Balloon Diet led clinic review Band 6 week initial inflation One month and as required for the 6 months Band 6 week initial inflation monthly until band correctly adjusted support for 2 years consultant at 6months and 12 months problem bands

Follow Up Bypass and sleeves Consultant review at for first and last appointment Dietetic review at those appointments and diet led clinics between Assess weight loss Assess dietary intake Assess nutritional intake Answer questions Support and encouragement

2 year review in consultant clinic. Annual bloods. Provided with contact number for Specialist Nurses and Dietitians Discharge from ward 1 week Specialist Nurse telephone review Specialist Nurse Urgent review clinic to assess if required 6-8 week review Consultant clinic with dietetic support 6 month review in dietetic clinic Routine bloods Continue consultant clinic and transfer to diet led clinic when appropriate 12 month review in dietetic clinic Routine bloods 18 month review in diet led clinic Consultant clinic if concerns Bloods at 6 months and annual 2 year review in consultant clinic. Annual bloods. Discharge to postal review

Any questions?