1. Weight Loss Surgery Group Education Session

2. Introductions Cara Barnes – Bariatric Nurse Specialist
Julie Thompson – Specialist Bariatric Dietitian

3. What is the purpose of today?
Introduce you to the types of surgery and the service offered
What is the purpose of today?
Provide you with information on diet and lifestyles to enable you to start preparing now

4. Ask them what they think about this statement- but move on quickly4

5. Changing eating before surgery Impact of surgery on your life
Types of surgery
What’s the right operation for you
Preparing for surgery
What we’ll cover
Time for questions
Changing eating before surgery
The pathway
Impact of surgery on your life

6. IT’S NOT
THE EASY OPTION…!!!!

7. Gastric band

9. Gastric band Benefits Complications Implications Occur much later
Slippage
Erosion
Leakage
Infection
0.3% mortality risk
Slightly less major operation
Control over restriction
Effective for volume eaters
Implications
Takes up to 2 years to get to goal weight
Eat small amount
Lots of chewing
Certain foods can be problematic
Reliant on will power with snacking
20% band failure rate
Lose 40-50% excess body weight

10. Gastric Bypass

12. Gastric Bypass Benefits Complications Implications Implications
Rapid weight loss
1-2 st / month for 3/12
½-1st/ month next 3/12
70-80% excess weight loss
Complications early on
Effective for snackers/sweet eaters
Improves diabetes
Anastomotic leak - 4%
Anastomotic stenosis
Hernia
Some hair loss
1% mortality risk
Implications
Implications
Rapid weight loss- 9 months to 1 year
Lots of chewing
Small portions
Life long vitamins and minerals
“Dumping” syndrome
Regular blood tests
Risk of malnutrition
Not reversible
Still have emotional hunger
Certain foods can be problematic

13. Sleeve Gastrectomy

14. Gastric Sleeve Benefits Complications Implications
Leakage of stomach acid
Weight regain
Less invasive than bypass
Reduced stomach volume (by 60 – 85%)
Restriction over volume eaten
Implications
Completely irreversible
Average wt loss: 60 – 70% of excess
(limited data on long term maintenance)
Smaller portions
++ chewing

15. SURGICAL COMPLICATIONS
Bleeding
DVT PE
Infection - chest
- wound
Scarring

16. The long walk to theatre

17. After Surgery Tired Vomiting Exercise Mood swings Hair loss Hernias
Diarrhoea/Constipation
Dumping
Excess skin

19. Body Mass Index (BMI) Is a ratio of your weight for your height.
The healthy range is between 20-25kg/m2

20. EXCESS BODY WEIGHT Is … THE WEIGHT YOU ARE NOW minus
THE WEIGHT YOU SHOULD BE

21. So…
If you weigh 25st (159kg), and your ideal weight (at BMI 25) is 11st 11lb (75kg), your excess body weight is 13st 3lb (84kg).
Band:
Loss of 40-50% of excess weight
= 5st 4lb – 6st 9lb ( kg)
New wt = 18st 6lb - 19st 10lb (117 – 125.4kg)
BMI: 39 – 42kg/m2)
Bypass:
Loss of 70-80% of excess weight
= 9st 3lb – 10½st ( kg)
New wt = 14½st – 15st 10lb ( kg)
BMI: kg/m2)

22. Key questions How much weight to lose? How quick?
Other co-morbidities?
Ability to alter eating habits
Am I prepared for surgery risk?
Key questions
Binge eater?
Committed to follow up?
Sweet eater/ snacker

23. Which option is right for me?
BYPASS
If you:
have a lot of weight to lose
have poorly controlled diabetes
have lots of resolvable health problems
like snacking/sweets
BAND
If you:
eat large meals
are only a few stones overweight
are happy to lose weight slowly over 2 years
Balloon
If you:
have a BMI over 60kg/m2
have lots of health problems that mean you cannot have surgery
Gastric Sleeve
If:
a band is not appropriate and a bypass is not safe
Not a primary procedure
Band:
- For BMI up to 50kg/m2
Bypass:
- Suitable for anyone who fits the criteria for bariatric surgery
Balloon:
- placed for 6 months to facilitate weight loss
- to decrease anaesthetic risk
With all procedures, you must be willing to sign up to commitment with dietitian & the team

24. What is my eating really like?
Before you can start to move on from here, you need to know your own pattern of eating and what your problems are 24

25. Emotional / comfort eating
Overeating and then starving
Emotional / comfort eating
Putting others first
Grazing
“cravings / bored”
Types of over eating
Food as reward
What is a binge?
“it starts off with my thinking about the food that I deny myself when I am dieting. This soon changes into a strong desire to eat. First of all it is a relief and a comfort to eat, and I feel quite high. But then I can’t stop and I binge. I eat and eat frantically until I am absolutely full. Afterwards I feel so guilty and angry with myself. “
Grazing – taking in relatively small amounts of food frequently between standard meal and snack times – usually in response to cravings, boredom, other emotions
People can eat large portions for a number of reasons:
If skip a meal, then very hungry (often happens if you constantly put others’ needs before your own)
And/or if you eat quickly and consequently eat more before starting to feel full (satiety mechanisms kick-in after about 20 minutes). If you eat quickly, you can consume a lot of food/energy (esp. if eating high fat/high sugar foods) in 20 minutes.
Some people will eat food just because it is there eg. Picking while watching TV
Emotional eating: often a learned and now automatic response – will eat foods without even thinking about whether they are wanted OR eating those foods might be the only thing a person can think about.
Food as a reward: this can sometimes be your partner or other loved ones ‘treating’ you with inappropriate foods. Can be difficult to say ‘no’. Sometimes this can be a food reward for getting through a stressful day – in the long term is more of a punishment.
Binge eating
“out of control of eating”
Picky eater / grazer
Eat large portions 25

26. before bariatric surgery?”
“Should I lose
weight
before bariatric surgery?”
Some Bariatric Centres have very strict criteria before they accept you. Some, like in Leeds will only take on people with a BMI of 50 or above – so some people ‘eat up’ to the required weight to be eligible for surgery.
Other centres ask you to lose 5 or 10% of your body weight by following particular diets (eg. The milk diet). If this was easy for you to achieve, you wouldn’t be here in the first place.
We accept that you have struggled with your weight for a long time, so we do not ask you to lose weight. We only ask that you do not gain more than 3kg (1/2 stone) from your initial appointment with the surgeon. If you maintain your weight, or even lose some, that is a bonus.
From day one you will be advised to make some changes whether its giving up smoking, cutting down on alcohol, or negotiating manageable changes to your diet. Gaining no more than 3kg shows us your commitment to the permanent lifestyle changes you will need to make after the surgery if you want it to be successful in the long-term. If you do gain more than that, we are unlikely to operate.
However, there are clear benefits to you if you can lose weight prior to your surgery.

27. Weight loss before surgery
Decreases
liver size
(fat)
Helps develop
good habits
Weight loss
before surgery
Demonstrates
motivation
& commitment
Reduces operation
time
Possible shorter
Length of
hospital stay

28. Healthy Eating starts here
3 regular meals a day
No longer than 5 hours without food
Breakfast is the most important meal of the day
Healthy Eating starts here
Wait 2 hours until having a snack IF you’re hungry
Vanessa, the dietitian, can provide you with a food diary to help monitor what you’re eating (and when, and why).
One of Vanessa’s favourite phrases is: Willpower is not something that you are born with. It is a skill which needs to be learnt, and practised in order to be mastered.
So if you can start making better choices more often now, it will have benefits now and later on.
Include small amounts of treats
Monitor your food intake
If you are not hungry outside mealtimes, do not eat

29. Pre-Op Diet / Liver Shrinkage

30. A large liver
The liver lies over the top part of the stomach, which is the same part of the stomach where we create your new pouch, so you can see that the smaller your liver is, the less in the way it is. 30

31. Pre-Op Diet / Liver Reduction Diet
Diet sheet given out at first dietetic appointment
Strict diet you need to follow for 3 weeks before surgery
1000kcal/d: low fat and low carbohydrate
Caution with diabetic control – your diabetes nurse needs to monitor you
By following a strict diet your body uses its glycogen stores. Glycogen is a form of sugar stored in the liver and muscles. With or each ounce of glycogen, the body stores 3 – 4 ounces of water.
When you follow a very strict diet, especially one low in carbohydrates (starch and sugar), your body loses its glycogen and associated water, and the liver shrinks.
This makes it easier to do the surgery via keyhole. Failure to comply means the surgeons are more likely to have to perform open surgery, with the increased risk and prolonged admission.
Also, if you don’t adhere to this diet for the full period it shows us that you’re not really commited to making all the changes you need to (both now and after the surgery) and is a reason for not going ahead with the surgery.
Should lose 6kg (1 stone)
Shrinks the liver 31

32. Eating after surgery What can I eat afterwards?
How is my eating going to change? 32

33. Immediate post-surgery dietary rules
Stage
Texture
Duration
Stage 1
Pureed (smooth textures, no lumps)
4-6 weeks
Stage 2
Soft/moist/ mashable
2 - 4 weeks
Stage 3
Normal
Weeks onwards
Irrespective of whether you have a band or a bypass, the rules are similar but the timings are a little different.
You will not be able to have anything to drink until you have had a swallow test – this is usually the day after your surgery.
You will be allowed to have sips first and then gradually build up to free fluids.
Stage 1 – no bits
Immediately after your surgery, there is a lot of swelling and inflammation around your new pouch. When you start puree diet (usually the day after you start drinking) you will probably only manage 1 or 2 tsp before you feel full. It is important that you stop eating as soon as you become full so that you do not vomit.
By the end of the first week you should be able to manage 3-4 tbsp comfortably. And for the next few weeks you should stick to this volume. You will need low sugar/very low fat snacks between your meals at this stage.
Stage 2 – soft mashable
You should be able to mash your food with a fork; you may need additional low fat sauces/gravies to make the food easier to swallow. You need to chew well and eat slowly.
If you find you are able to eat more than 3-4 tbsp at a meal, start cutting out the snacks.
Stage 3 – normal diet
At this point you should be able to manage 3 small meals.
Breakfast could be 1 Weetabix or v small bowl of other cereal/1 slice toast with low fat/low sugar spread
Lunch and evening meal should be served on a small side plate and contain a modest portion of carbohydrate (bread, potato, pasta or rice), a high quality protein food (meat, chicken, fish, egg, tofu, quorn, soya protein) and some veg

34. Dietary Principles Texture
Eat very slowly – chew each mouthful 25 times
Stop eating as soon as you start to feel full
Not drinking with eating (wait 30 mins either side)
Regular meals
Eat slowly. Place your fork on the plate between bites. Aim to chew each mouthful 25 times. This will ensure that food does not get stuck in your new pouch.
Keep food and fluids separate – if you drink with meals, you’ll just flush food through the pouch and you will not feel full for as long, and therefore are likely to eat more
Don’t eat while doing other things and concentrate on eating. Avoiding reading, using the computer, watching TV or driving. If you eat when doing other things, you will lose track of the amount you have eaten and you don’t focus on chewing
Use small plates and bowls. This helps with portion control and also is a psychological ‘trick’ to make you feel you’ve eaten a full meal.
Healthy eating: sugar and fat are concentrated sources of energy so you need to limit these as much as possible. You need protein to help your wounds heal after the surgery and to maintain as much muscle mass as possible; fibre to keep your bowels going; starch foods are the best source of energy and help you feel full; and your vitamins and minerals keep the processes in your body going
Remember, alcohol has no nutritional value and contains 7kcal/g – more than carbohydrates and protein and only a bit less than fat! It also won’t make you feel full, and if you drink too much, it can over-ride your normal feelings of satiety/fullness and make you eat more than usual.
Volume / portion control
Use small plates & bowls
Healthy Eating ie. low fat, low sugar, moderate protein, rich in micronutrients

35. Things to avoid
Where possible medications should be in liquid or soluble form; tablets may be cut in half if not enteric coated but shouldn’t really be taken in the 1st 6 weeks
Avoid fizzy drinks – the gas in these will stretch your new pouch – it will then take more food to make you feel full and slow down your weight loss

36. Progression Through Textures
Puree Diet (smooth, no lumps or bits, yoghurt-consistency, too thick to suck up through a straw) weeks
First few days – will only manage teaspoons. Stop eating as soon as you start to feel full.
Over first 2 weeks – will build up to 3-4 tablespoons
During this time you will need 3 meals and 3 snacks, all pureed, and low fat and sugar, and high in protein
When you feel you can manage more than 3-4 tablespoons, do have a little more but start reducing the snacks between meals. Eventually you should be on 3 small meals a day (some people manage better with 4).
Soft Mashable Diet – 2-4 weeks
Then you can move on to a soft, mashable diet
ie. anything that can be mashed with a fork. You may need additional low fat, low sugar sauces/gravy to help with this. No hard lumps, gristle or stringy vegetables.
Normal Textures
Then you can move on to a normal textured diet, although you may struggle with some foods (eg. bread, tough meats, stringy vegetables, pithy fruit (eg. citrus) but you may be able to manage them after a few months.
NB Some people may progress a little slower or a little faster than the above

37. Potential Problem Foods
Alternatives
Bread
Crackers or toast
Pasta
Use small shapes for soup
Tough/dry/gristly meat
Small pieces / mince
Slow cooked / stewed
Rice
Risotto
Potential Problems
Pineapple is likely to be problem even if tinned.
Bread, especially, fresh white, can be difficult because when you chew it, it ends up as a big ball in your mouth rather than breaking up into little bits, so it can get stuck in your pouch. You may find thin-sliced toast a bit easier to manage.
Stringy/hard vegetables
Overcook:
Cauliflower, broccoli, carrots
Fruit pips, seeds, skins & pithy fruit
Peel fruit / purée or stew
Tinned fruit in juice*

38. Iron
Calcium
Zinc
The part of the small intestine that is bypassed is the site of absorption for iron and calcium – therefore you will need lifelong iron and calcium supplementation.
Dependent on how much of the small intestine is bypassed, you could later develop deficiencies in magnesium, zinc or selenium. Before you come to review clinic, you will be sent for a blood test to look for these deficiencies and will supplement you thereafter if required.
Once you are able to eat soft/normal textures again, it may be prudent to swap the vitamin you are discharged home on for a good multivitamin and mineral supplement from your local supermarket/chemist. Sanatogen Gold and Centrum are good.
Dumping Syndrome (bypass) – sugary foods tend to pass quickly through the re-plumbed small intestine and are ‘dumped’ much lower down compared to normal. The small intestine can’t handle the relatively large sugar molecules so if you eat these foods you could feel very hot and sweaty, or cold and clammy, nauseous and dizzy, you may feel like you need to lie down, or you may experience an urgent need to go to the toilet and have very loose bowel motions. Sweet and sugary foods are best avoided for this reason, and also they should be largely omitted from your new healthy eating meal plan.
Vitamin D
Thiamine
Therefore, lifelong supplementation of multivitamins & minerals, with additional iron and calcium, with potential for further supplementation dependent on your blood results 38

39. Group education session
Pathway to surgery
Referral From GP
Group education session
Support Group
Meeting with Consultant
Health Assessment
Return to see doctor for results & put on waiting list for surgery
Pre-assessment
Liver shrinkage diet for 3 weeks
Surgery
Psychologicalassessment
Respiratory
Cardiology
Endocrine
Medical Management
Funding agreed by PCT
Endoscopy
Sleep apnoea test
Dietitian
MDT
Cara – do we need to change this slide? 39

40. Pathway after surgery Operation Band – 2-3 day stay
Bypass – 2-3 day stay
Seen by team daily
Seen by dietitian and nurse specialist before discharge
1st Outpatient Appointment at 6 weeks
1st band fill ~6 weeks
Cara – do we need to change this slide?
2nd Outpatient Appointment at 12 weeks
Band fills as required for 2yrs
Reviews at 6, 12, 18 and 24 months, then discharged back to GP