1. Nutritional aspects of bariatric surgery Too Lean a Service?
Mary O’Kane
Clinical specialist dietitian
Leeds Teaching Hospitals NHS Trust
BOMSS council member

2. Does surgery result in a better diet?
Decreased intake of sweets and sugary drinks but tolerance increases with time, high intake of salty snack foods (Brolin et al 1994)
Decrease in energy from protein and increase from sugar and alcohol, decrease in prepared meals and increase in sweet foods (Lindroos et al 1996)
Patients may end up snacking more and eating less regular meals (grazing), poor intake of protein, vitamins and minerals, intakes of iron, zinc, vitamin D below requirements (Naslund et al 1998)
37% had resumed snacking 1 year after gastric bypass (Elkins at al 2005)
Cravings for sweets results on significant less weight loss (Burgmer et al 2005)

3. Self reported post operative dietary compliance and weight loss after gastric bypass
Sarwer et al. SOARD 4 (2008) 640–646

4. Role of the dietitian As a core member of the MDT:
Initial assessment of diet, nutritional status and eating behaviours (and psycho-social factors)
Advice and support on the appropriate diet
Monitoring of micronutrient status
Individualised nutritional supplementation, support and guidance to achieve long-term weight loss and weight maintenance
NICE CG43 Obesity 2006

5. NICE CG43 Obesity Bariatric surgery
All appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
The person has been receiving or will receive intensive management in a specialist obesity service
The person commits to the need for long-term follow-up.

6. Too lean a Service? Dietetic input
Pre-referral
No documented evidence of pre-referral dietetic input in 65% cases
Post-referral
22% patients not assessed by a dietitian prior to surgery
27% patients, no evidence of dietetic input prior to surgery

7. Adequacy of dietetic input pre-surgery Too lean a service?
Adequate dietetic assessment /education for patient
Number of patients¹
(for those with evidence)
% for those with evidence
Number of patients (for all patients)
% for all patients
Yes
195
92.9
200
77.5 No 15
7.1 58
22.5
Subtotal
210
258
Insufficient data 27
123
Total
237
381

8. MDT meeting
Documented evidence of patients being discussed at MDT in only 40% of cases. It may be that it occurred but not documented in medical notes. Maybe that patients saw relevant HCP but not met to discuss.
Opportunity to raise concerns about readiness for surgery but also to share experiences and learn together as a group.

9. Discharge summary Too Lean a Service?
Poor / unacceptable
Diet information (10 patients)
Emergency contact (9 patients)
Inappropriate discharge prescription
Lack of vitamin supplements (10 patients)
Inappropriate vitamin B12 (1 patient)

10. Follow-up Too lean a service
Types of follow-up clinic
Follow-up clinics
Number of hospitals (105)
Bariatric surgeon 95
Dietitian 86
Specialist nurse 58
Psychologist/ psychiatrist 24
Bariatric physician 21
Other 2
72/102 hospitals gave early telephone follow-up

11. Dietary related problems following bariatric surgery
Dehydration
Nausea and vomiting
Regurgitation
Food intolerances
Constipation
Diarrhoea /steatorrhea
Dumping syndrome
Loss of appetite / Anorexia
Fear of stretching the pouch
Return of appetite
Alopecia

12. Bariatric procedures, vitamins and minerals
Vitamin mineral deficiency / Surgery
Pre-surgery
AGB
Sleeve gastrectomy
RYGB
BPD +/- DS
Thiamin
Uncommon
B12
10-13%
12-33%
Folate
Iron
9-16% of women
20-49%
Vitamin A
Rare
Rare but can occur
50% at 1 year
70% at 4 years
Vitamin D
60-70%
Common
V. Common
Zinc
May occur
Protein

13. Protein –energy malnutrition / protein malnutrition
Food intolerance / Eating habits /Compliance
Anorexia / loss of appetite
Stricture / too tight a band
Diarrhoea
Requirements of BPD/ DS higher

15. Implications of “Too Lean a Service?”
All patients being considered for bariatric surgery should receive dietary assessment and education prior to referral and definitely prior to surgery
The dietitian is the key MDT member to undertake this assessment, education and provision of follow-up support
Psychological assessment and support should be available
Dietetic advice including vitamin and mineral supplements and discharge advice needs to be clearly documented

16. On-going work
BOMSS training for dietitians and other healthcare professionals
“Providing bariatric surgery” - the BOMSS Standards for Clinical Services & Guidance on Commissioning
Clinical Reference Group on Morbid Obesity – comprehensive patient pathway
Vitamins and minerals and pre- and post-surgery nutritional monitoring guidelines–work in progress