1. Fiona Chan Specialist Dietitian Weight Management and Bariatrics Salford Royal Hospital

2. * Diet and obesity * Dietetic input in medical management of obesity * Dietetic input in surgical management of obesity

3. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults (updated November 2014)

4. ClassificationBMI (kg/m 2 ) Healthy weight18.5–24.9 Overweight25–29.9 Obesity I30–34.9 Obesity II35–39.9 Obesity III40 or more

5. BMI classification Waist circumferenceComorbidities present LowHighVery high Overweight1223 Obesity I2223 Obesity II3334 Obesity III4444 1General advice on healthy weight and lifestyle 2Diet and physical activity 3Diet and physical activity; consider drugs 4Diet and physical activity; consider drugs; consider surgery

8. * Dietary * Physical activity * Behavioural

9. * Faddy diets * Slimming groups * Restrictive diets * Meal replacements * Intensive Exercise regimes

10. * Consider low-calorie diets (800– 1600 kcal/day), but be aware these are less likely to be nutritionally complete. * Do not routinely use very-low-calorie diets (800 kcal/day or less) to manage obesity (defined as BMI over 30). * Continued clinical support with a multi- component strategy to maintain the weight lost is vital.

11. * Tier 3 service * MDT approach : Physicians, Clinical Psychologists, Dietitians. * Initial assessment usually carried out by physicians with subsequent follow up by dietitians and physicians. * Based in Salford Royal Hospital * Provides 1:1 weight loss advice * Prepares patients for bariatric surgery with education sessions.

12. * Assessment * Nutritional management in relation to medical concerns * Energy balance * Behavioural e.g. emotional eating

13. * Intervention * Translating evidence based advice into realistic dietary changes * Support for eating behaviour related emotions and changes * Empowerment: dietary education

14. * Changes to induce calorie deficit * Meal replacements * Weight management groups, including commercial slimming clubs

15. * Shop on a full stomach and stick to a shopping list. You are less likely to be tempted to buy high fat and sugar foods. * Half a plate of vegetables or salad at lunch and evening meal. Salad and vegetables are filling and very low in calories. They can be fresh, frozen or tinned. * Are you hungry? Having a regular meal pattern especially having breakfast mean you are less likely to overeat or snack through the day

16. * Portion sizes of your meals are just as important. Use a smaller plate at meal times to reduce the amount of food you are eating. * Eating habits affects how much food we need to feel satisfied. Eating slowly and chewing each mouthful at least 15 times could mean we will feel satisfied with less food.

17. Comfort Stress Boredom Cravings Habits “addiction” Satiety – Head hunger VS Real hunger

18. * Orlistat- Lipase inhibitor - The only currently licensed drug in UK for weight loss - Low fat diet recommended (<30% fat as total energy) - Bowel effects include diarrhoea (with urgency which may lead to faecal incontinence), oil leakage from rectum, abdominal pain and wind. - Patients are offered dietetic advice and support before and during taking orlistat.

19. * Assist patient in fulfilling funding criteria for NHS England, which include: * Show commitment to changes for weight loss * Pre-bariatric surgery education to ensure understanding of surgery * Attendance of bariatric support group (at least twice)

20. * Provide guidance and support before and after surgery * Pre – bariatric surgery education * Liver reduction diet * Post surgery recovery diet * Advice and support for long term maintenance of weight loss and nutrition

21. * Restrictive diet low in carbohydrates * Only used 2 weeks pre surgery * To shrink liver by limiting glycogen and water storage * Variations of the diet recommended by different centres e.g. milk and yoghurt based, food based.

22. * Stages to build up textures * To re-establish a new relationship with food and eating habits * To promote wound healing * To prevent complications caused by a severe calorie deficit e.g. protein energy malnutrition; micronutrient deficiencies.

23. Surgery/ Diet Band (Weeks) Sleeve (weeks) Bypass (Weeks) Liquid233 Puree233 Soft233

25. * Intensive support immediately post surgery for recovery diet * Macronutrient and micronutrient balance post surgery * Eating habits and eating behaviour to prevent complications and encourage weight loss * Weight maintenance post surgery * Advice and support for weight regain * Guidance and advice for pregnancy post surgery

26. Dumping Syndrome Constipation Vomiting Diarrhoea Symptoms - vomiting, nausea, weakness, sweating, faintness and diarrhoea. Solution – Limit sugars & fats Solution - Avoid fatty foods – this will also aid weight loss. Solution: Eat slowly Chew Well Eat Smaller portions Stop when full Solution: Adequate Fluid between Meals Increase Fibre intake