My Greatest Nutritional Challenge

Preoperative role of the registered dietitian

The role of the RD preoperatively serves many purposes. The RD assists the patient with goal setting in preparation for WLS and educates the patient about necessary dietary changes that will be required after WLS. The RD also reviews the patient's food diary and makes recommendations on ways to modify dietary intake to provide more nutrient-dense food choices. Placing patients on a reduced calorie diet not only aids in decreasing surgical risk and reducing liver size prior to surgery, but the reduced diet is also beneficial for teaching patients dietary and behavioral strategies that may improve postoperative outcomes and promote weight loss success. ¹ The patient receives diet education in order to learn how to transition through various diets following surgery, to learn vitamin and mineral supplementation requirements, and to modify eating behavior for safe intake. The RD may also assist the bariatric team with the development of a protocol for laboratory blood testing of protein parameters, glucose, and vitamins and minerals. Finally, insurance companies often require 3–6 months of nutrition therapy prior to WLS.

During preoperative medical nutrition therapy consultations, the RD communicates with the bariatric surgeon and staff about the patient accomplishments with making dietary and behavioral changes required for successful WLS outcome. Goal setting is completed in the preoperative RD consults to guide patients with meal and snack patterns that will set the pattern for postoperative dietary intervention. ² Small achievable steps are developed, such as changing to artificially sweetened coffee/tea, baking or grilling chicken instead of frying, substituting whole grain bread for white bread, and packing lunches instead of buying fast food or purchasing food from the vending machine at work.

Postoperative role of the registered dietitian

The RD also plays a significant role in the postoperative care of the bariatric surgical patient. The RD meets with the patient again after surgery to ensure he/she is taking the vitamin and mineral supplements as ordered, following the diet transition per protocol, drinking protein-rich shakes as ordered, and staying hydrated. Patients who underwent gastric banding often meet routinely with the RD for two postop visits, and then again as ordered by the surgeon. Patients who underwent the sleeve gastrectomy procedure may have seven or more postoperative consults with the RD, or as ordered by the surgeon, in the first year following WLS. ³

The RD will assist the surgeon or nurse practitioner with patient problem solving. Patients are referred to the RD if they are having difficulty tolerating supplementation, or having nausea, vomiting, heartburn, bowel irregularities, or difficulty with weight loss. The RD reviews postoperative laboratory blood results and recommends interventions when results are abnormal. Interventions may include recommending a prescription for vitamin D, or making dietary changes, such as increasing consumption of iron-rich foods in the diet. The main goal of dietary intervention in the early postoperative time period is to aid the patient in safe weight loss while reducing the risk of nutrient deficiencies. ⁴

There can be challenges when caring for the dietary and nutritional needs of bariatric surgical patients. Patients may miss appointments, or they may fail to comply with weight loss instruction and the pre- and postoperative exercise plans. ⁵ Noncompliance with making the recommended diet changes has been reported in practices throughout the country. In one study, results showed that 42% of patients did not comply with weight loss instructions prior to having bariatric surgery. ⁵ Noncompliance may be associated with socioeconomic status, as patients state that they cannot afford to buy whole grains, fresh fruits and vegetables, and lean protein-rich foods. There is a link between rates of obesity and lower socioeconomic status. ⁶ In order to decrease grocery costs, lower income patients often choose more refined grains. ⁷ In addition, foods chosen are often higher in fat, and the diet is typically lacking in fresh fruits and vegetables, whole grains, fish, low-fat dairy products, and lean meats. ⁷

Another factor found to be related to food selection is smoking status, with results demonstrating that smokers have lower quality diets than nonsmokers. ⁸ A meta-analysis of 51 published nutritional surveys from 15 different countries revealed that smokers have a higher dietary intake of total calories, total fat, saturated fat, cholesterol, and alcohol than nonsmokers. Studies have also shown that smokers have lower dietary intakes of vitamin C, vitamin E, beta-carotene, and polyunsaturated fats. ⁸

Preoperative management

Ann was referred to the RD at the local community hospital in October 2007. Ann was planning to undergo gastric banding placement in order to reduce body weight. Since the local hospital did not offer bariatric surgery at that time, the plan was for Ann to receive dietary counseling and management in her local community and then have the procedure at a hospital outside of the county that did offer bariatric surgical options.

Ann had a past medical history significant for diabetes mellitus type 2, mixed hyperlipidemia, hypertension, depression, chronic obstructive pulmonary disease, morbid obesity, gastroesophageal reflux disease, sleep apnea, and Pickwickian syndrome. Her laboratory data revealed elevations in several laboratory values, including an elevated triglyceride level (TG) of 159, an elevated fasting blood glucose (FBG) of 230, and a hemoglobin A1C level of 7.2%. Despite requiring home oxygen therapy, Ann admitted to smoking three to four packs of cigarettes per day for the past 45 years. She was disabled, needed a knee replacement, and used a wheelchair for mobility. The orthopedic surgeon would not accept her for knee replacement surgery until she lost significant weight. Ann weighed 298.8 pounds, had a body mass index (BMI) of 48.22, and a waist circumference of 60 inches. Her family medical history revealed multiple siblings with morbid obesity, and one parent with heart disease and diabetes. Ann realized that weight loss surgery was needed in order to have the best chance of losing weight, attaining a healthy BMI, and reducing her comorbid conditions.

Upon review of her current diet, it was found that her food choices consisted of poor quality, high saturated fat items, and was heavy on simple sugars. She was not counting grams of carbohydrates per meal, even though she had diabetes. Her primary beverage was diet soda, and she reported drinking approximately 2 liters per day. Protein sources consisted of canned sausages, potpies, pepperoni pizza, hot dogs, and eggs. Ann stated that the food she was choosing was easier for her to eat, since she had no upper teeth and poor lower dentition. She also stated her food choices were more affordable, since she was on a limited income. However, she continued to purchase 21–28 packs of cigarettes per week.

Unfortunately, Ann was not motivated to learn carbohydrate counting or make changes to her diet composition. She was unwilling to change to leaner protein sources and was argumentative when asked to decrease her intake of eggs, which consisted of three or more eggs daily. She stated that she enjoyed eggs and since it did not appear that the egg consumption was increasing her cholesterol level, she planned to continue eating them.

Ann verbally stated she would not make the suggested changes to her diet. As a result, I deemed her compliance with the dietary preparation for gastric banding placement as doubtful, and I reported to the referring physician that she might not be an appropriate candidate for surgery. Correspondence to the referring physician was summarized as follows: patient poor candidate for bariatric surgery due to inferior quality food choices, verbal statements that she will not change her diet, limited resources to purchase quality nutrient-dense foods, and continued use of tobacco even though ordered by pulmonologist to quit. In addition, an assessment by a pulmonologist stated that general anesthesia was risky for this patient, and he advised that the patient not have surgery unless it was an emergency.

Despite this, Ann did not give up on attempting to qualify for WLS. She continued meeting with the RD monthly, and she continued to receive dietary education and encouragement to make healthy diet changes. During the medical nutrition therapy sessions, Ann was educated on a 1,600-calorie and moderate carbohydrate diet. Factors were identified that would help improve her blood glucose control and reduce body weight. Eventually, she began making small changes in her diet, and although there was still some room for improvement, the changes made did result in weight reduction and positive laboratory changes. She lost 16 pounds, and reduced her TG level to 78 and her hemoglobin A1C level to 5.8%. Although Ann made several healthy diet substitutions and numerous behavioral changes, she continued to eat high fat protein foods, such as sausage, cheese, and eggs, and to drink whole milk at meals; she continued drinking the 2 liters of diet soda per day.

Ann successfully completed the 6 months of nutrition therapy required by her insurance company, but she still had not stopped smoking. Several months passed without clinic contact, but Ann did eventually recontact the local bariatric surgeon to schedule another surgical consult. The surgeon informed Ann that clearance from the pulmonologist was required before proceeding with surgery. He also referred her back to the RD to resume medical nutrition therapy. Ann continued to meet with the RD for nutrition therapy and was asked to keep a detailed food and beverage diary and to take the following action steps toward improving her diet: wean carbonated beverages and replace the high sodium and high fat meats in her diet with healthier alternatives.

Ann continued to abuse tobacco and was noncompliant with the recommendation by her medical providers to stop smoking. She developed pneumonia during the winter season and was admitted to the critical care unit of the local hospital due to respiratory failure. As her respiratory status continued to decline, a tracheostomy tube was placed. During this crisis, she was unable to use tobacco. Once her respiratory status significantly improved, she was discharged home from the hospital and advised not to resume smoking.

Despite noncompliance with lifestyle choices throughout the preoperative journey, at this time the bariatric surgeon made the decision to allow Ann to have WLS, as weight reduction was necessary to help improve her respiratory status and other comorbid conditions. She made a commitment to maintain smoking cessation and began using nicotine-containing chewing gum to decrease nicotine withdrawal. She was finally cleared to have surgery by her pulmonologist, primary care physician, and cardiologist.

Ann arrived at the bariatric office preoperatively to meet with the bariatric team for education. She attended the nutrition education group class, and scored 80% on posteducation testing, indicating she had retained the nutrition knowledge received during the 6 months of required RD consultation. Unfortunately, however, Ann had not only regained all the weight she had lost during the 6 months of medical nutrition therapy, but she also gained an additional 8 pounds. She stated that she became depressed and had almost given up on this weight loss plan and comforted herself by eating sweets, which contributed to the weight gain and an elevation in her A1C level. Once Ann was approved for surgery, comfort eating was no longer an issue, and she was compliant with the special restricted diet to shrink her liver for surgery.

Finally, Ann completed all required surgical preoperative testing, had her “before” picture taken, and met with the surgeon for the final consult prior to surgery. She was scheduled for surgery, and gastric banding placement was completed in December 2009, 2 years after the initial consultation with the RD that began the process of qualifying for surgery. Her preop weight was 307 pounds with a BMI of 52.69.

Postoperative management

Ann's postoperative weight loss has been slow. She met with the RD for the two required postoperative consults, and she was successful in completing the dietary goal of decreasing high fat meat consumption and reducing total caloric intake. She was able to reduce her BMI from 52.69 to 50.3 in the first 4 months, an 8% excess body weight lost. At the 1-year anniversary of her gastric banding, her BMI was 46, which totaled 21% excess body weight lost. At the second year anniversary her BMI was 38, representing 45% excess body weight lost. Since the patient has not reached her long-term weight goal of 140 pounds, she will continue with the current action plan. Her action plan includes: selecting lean protein sources daily, choosing reduced fat or fat-free dairy products daily, and including nonstarchy vegetables in two meals per day. Her exercise prescription and caloric level will continue to be adjusted as needed in order for her to reach her weight goal.

Ann is keeping a food diary and making more nutrient-dense food choices. She still loves eggs and eats them regularly, but not the amount she was previously consuming. She is also following the suggested eating and drinking schedule. She no longer requires any diabetes medication, and has lowered her hemoglobin A1C level to 5.8%. She admits that she is not compliant with daily glucose monitoring as ordered by her primary care physician, but is relieved that her A1C has decreased from a high of 8.3%. Ann stated that she remembered hearing this weight loss benefit discussed at the community bariatric seminar she attended prior to beginning her weight loss journey, and she is happy that she was able to realize the result personally.

Ann no longer needs a wheelchair for mobility and now has the freedom to travel to see her grandchildren. She has also emphasized her relief not to be a burden on her spouse any longer. She considers this a very positive weight loss outcome. Ann recently had knee replacement surgery and is under the treatment of a licensed physical therapist. She is walking without the use of a cane, and she is swimming laps at the hospital-based Center for Health and Wellness indoor pool.

A big success for Ann was her ability to quit smoking. She had to make a choice on whether to continue with the tobacco addiction and be denied WLS, or to finally say “no” to cigarettes and be approved for surgery. She states that she now has her life back and would never go back to smoking and the need for continuous oxygen. She describes herself as “the poster child for smoking cessation.” Weight loss has been slow for Ann, but she continues to work her way toward a healthier life every day.