5 | Bariatric Nutrition Basics: A Clinician's Guide to Weight Loss Surgery

0:00 So we wanna focus on the protein first. And so, a really good rule of thumb for people for the rest of their lives is we eat the protein first and then kind of move on to the other. Parts of our meals. second in command would be like non-starchy veggies or fruit, and then those starches are kind of the last thing that we eat on our plates. Are you ready to transform the way you communicate about nutrition with your patients? Welcome to Exam Room Nutrition, the podcast where the worlds of nutrition, medicine and communication collide. Whether you're a seasoned physician or a healthcare student, this podcast is for you, so stick around and let's make our patients healthier.

0:41 One exam room at a time. Welcome back to the Exam Room Nutrition podcast. I'm your host, Colleen Sloan. I'm a registered dietician and pediatric pa. I wanted to start off today by giving you guys a couple of statistics that are quite alarming. More than two in five adults in America have obesity. That's 42.4% of our population according to the N I H and overall, more than two thirds of the United States adults are overweight or have obesity. Why am I giving you these statistics today? Well, our discussion today covers the topic of bariatric surgery. About 256,000 bariatric surgeries were performed in the United States in 2019, that actually represents less than 1% of the country's currently eligible surgical population according to a 2021 article.

1:33 It seems like there's a disparity between the number of people or individuals who might qualify for bariatric surgery and those that are actually getting it done, now, there are so many reasons why weight loss surgery is underutilized, but a big one is the stigma behind it. Some people may feel that it's a cop out or it's the easy way out, and even us as clinicians, we might not be properly educated on the indications for it. And how it can help so many people to have successful weight loss journey. so today's guest is an expert in the field professionally and personally. So I'd like to welcome Samantha Barone to the show. She's a registered dietician and board certified expert in obesity and weight management with her own inspiring journey of losing over 160 pounds through gastric bypass surgery.

2:18 She founded Beyond Bariatrics Nutrition to support others in achieving long-term weight maintenance. After weight loss surgery, You can follow her on Instagram at Beyond Bariatrics Nutrition Samantha, I'm so grateful for you for giving us the gift of your time today. Welcome to the show. Thank you so much for having me. I'm super excited to chat with you. being in pediatrics, this isn't a huge topic for me, although we do have a growing population of children suffering with obesity. So I'm really excited to learn from you. how can clinicians support their patients and families who might be considering bariatric surgery? Yeah, I think you really hit the nail on the head there in your intro saying that even as clinicians. Educating yourselves properly.

3:00 I think, there's a, a big gap in the, knowledge and education when it comes to bariatrics, even within the medical community. And, a lot of clinicians who don't work within the bariatric community don't really know a whole lot of the details. So going to. The sources that are really gonna give them the best possible information like the ASMBS that's the American Society for Metabolic and Bariatric Surgery. They have fact sheets on their website. It's really easy to find ASMBS.org and, you can get all of that good factual information there. If you're not sure if your patient would qualify for a bariatric surgery.

3:44 You can find that information there as well, and patients can get really great information from there too. but really understanding the disease of obesity and under understanding that there is a population of people. That are unable to lose a significant amount of weight from just, hey, eat less and exercise more. And I think that gets thrown around a lot in the medical community. with, you know, maybe great intentions behind it. and I think, you know, there's certainly plenty of people that can benefit from some information like that, but people who truly, have been struggling with the disease of obesity for.

4:28 Years and years, it's a huge step for them to even consider going into something like having bariatric surgery. So being educated enough to really meet them where they're at and say, okay, well let's think this through, or let's talk it out and see really if you would qualify and what are some of the benefits and maybe drawbacks of that. And really, be more supportive and encouraging rather than just initial. You know, kind of poo-pooing the whole concept. That's a good point because most of us in primary care, you know, that's not our specialty. But although we are the ones who are taking care of these patients, oftentimes we don't have the education and the knowledge that we need to give them appropriate advice and suggestions.

5:13 what would that advice or guidance be that we can give to families during that decision making for bariatric surgery? Yeah, I think definitely. Knowing what the qualifications are, is a big one. And if it's somebody that doesn't qualify for bariatric surgery, then okay, maybe we don't really encourage that route. Or maybe help them, find a local bariatric program that they can contact and speak with someone further. So guiding them to the best possible sources to get that information. And then also encouraging them if they are, maybe married, have kids, or maybe they're younger and they still live with their parents.

5:55 whatever their, family unit is that they need to be supportive of each other. And it's not just. An issue of that one person. You know, it, it takes a village for pretty much everything in life. And this is definitely, one of those factors. And so it can be very detrimental to the patient's continued progress if they're not receiving support from everyone. And I, I think that's an excellent point. You know, anything regarding nutrition or change needs to have full support of family, of your clinician. so I think that support is extremely important as well. So how can clinicians address the emotional and the psychological aspects of, considering bariatric surgery?

6:40 More specifically, what are the emotional and psychological aspects that those patients might be wrestling with inside? Yeah, I think it's a great question. and of course with all of this, it's so nuanced and it really just depends, on the patient. So I think, helping patients kind of find better, more productive ways of coping than using. Food. I think a lot of times people go right to like, we'll go for a walk or go exercise, and that can sometimes be a little bit daunting and overwhelming for people that are struggling to the level of obesity. so, you know, maybe something else. Like, I have a lot of patients that like color in coloring books or crochet or, go clean a closet, something that is not involving food that can be more helpful to what their goals are.

7:35 And of course, always encouraging, therapy, you know, I think that the. Behavioral therapy is very often so overlooked, I mean, I think the root of all of this goes so deep into, past psychological pains and traumas and we don't know what people have been through. So being very careful to be sensitive about. What these patients are going through sensitive in, like how we're speaking about their weight, not putting so much of an emphasis on their weight. even offering maybe like doing a blind weight or if, you know, they don't necessarily wanna get weight when they come to the doctor's office.

8:19 personally for me, I also experience, I always call it like MD P ts d because when you grow up or you're, you're told for so many years that. All of your problems would be resolved if you would just lose weight. And every time you go to the doctor, you have to step on the scale and then, you know, all they wanna talk about is your weight. It can be really, detrimental to your health in the long term because then, You know, you're always scared to go back to the doctor. So being really sensitive about the focus that you're putting on, the number on the scale, how you're speaking to the person, making sure that they feel heard really is the biggest thing.

8:59 you know, a quick kind of example is just like you feel like you go to the doctor because you have a broken arm and they're like, well, you should probably lose some weight. You know? And then one has nothing to do with the other. So trying to actually listen to what the patient is saying and what their concerns are, really showing them that you hear them, that you're there to support them and meeting them where they're at and see where you can sort of help them take a little step in the positive direction. So, Sam, I wanna make sure my listeners heard me in the intro when I, had said that you have lost over 160 pounds through gastric bypass surgery, so you truly are. The expert in this area, not only because you do this professionally, but you, walk through this every day and you've, literally every day overcome so many obstacles and I think that is so amazing.

9:48 So I just wanna say kudos to you and thank you so much for creating this support for others who are either considering bariatric surgery or walking through it themselves. Really and truly, there's such a need for this because, You're right with that MD PTs D for those who have struggled with their weight, I can't imagine it must be so extremely stressful and just upsetting to have such a heavy focus on their weight. so I wanted to ask you, how can we as clinicians address maybe a family member who might be. Okay. at the idea of bariatric surgery or even be the ones to say, oh, it's just a cop out, or You're trying to take the easy way out.

10:31 What would be a compassionate, helpful response to that inclination or to that idea of what bariatric surgery is? Well, it's a great question and I, I personally would actually start by. Informing not only the patient's family, but the patients themself as well. what the risk is. If they don't do something, And so really helping people to understand that the greatest threat for death is obesity without intervention. So when you've already tried every diet known to man, and you've done every. Trend in every fad and every everything, and are still struggling, which most people have because of course we know that diets and fads are not sustainable.

11:23 So you know when that's already been the case, I think as the clinician kind of laying it out for not only the family but the patient as well and saying like, okay, here's the history of what you've tried, what you've done. Here's where we're at right now. Not only with the number on the scale or what your BMI is, but also you have these other comorbidities here. You have hypertension, you have diabetes, or whatever the case is. And not everybody has comorbidities, but if they do, you know, showing them or showing them the risk of, Hey, your blood sugars have consistently been like me, inching a little bit closer towards, You know, pre-diabetes or diabetes And so if you are not going to make any changes, then you may not be diagnosed with these other comorbidities yet, but it's very likely that you will end up being diagnosed with something, end up on medication.

12:21 So why would you? Not want your loved one or you know, your, patient to consider something like that. those are great responses and I feel like that unfortunately is a common. misconception that it's the easy way out or you cheated. So I wanted to quote an article that came out in U UCLA Health. Most patients reach their maximum weight loss one to three years following bariatric surgery. And research shows that on average patients can regain about 30% of their weight loss after 10 years. About one quarter of patients regain all their weight loss by year 10. Now we know that nutrition plays a huge role in weight loss maintenance after weight loss surgery, and this area can get a little bit confusing for clinicians to navigate.

13:07 I wanted to get into the, details of nutrition because a lot of, primary care clinicians are gonna be the first ones that a patient will come to and ask them what foods they can eat, what foods they can't eat, and I know that there's been some inappropriate or inaccurate food recommendations that have been given that can be very detrimental. talk to us a little bit about some of the key nutritional guidelines that patients should follow after bariatric surgery. Yeah, I think, just understanding that nutrition in general is so very nuanced and that every person is different and that's no different when it comes to bariatrics. the biggest thing to understand is that certainly it's pretty hard to, I guess, gain weight per se during that first, like six months to a year after surgery, just simply because of the nature of the surgery and the fact that they're just.

13:58 Physically not able to kind of eat the amount of calories that would put them in a surplus. However, that does not last. We call that the honeymoon stage, and that ends real abruptly. And so if the patient themselves has not really put forth the effort to modify their food behaviors and really, adapt to a much healthier lifestyle. Style. Then you can certainly regain weight after surgery. And unfortunately there are, percentages of people that do regain some, if not all of their weight after surgery So there's certainly a foundation of kind of the way in which we should be eating and drinking for the rest of our lives, but it more so has to do with the food behaviors and not so much about.

14:46 Specific foods in general, and especially when it comes to portion sizes, depending on where a person is at in their journey, it's gonna be very different from someone that's, you know, two months out to someone that's two years out. So it really kind of just depends. But some really great, solid foundational information, regarding the food behaviors is so, so important I think the biggest thing that is a lot of times really difficult for patients to kind of grasp onto and. Sometimes hard for people outside of the bariatric community to understand is that they shouldn't be eating and drinking at the same time.

15:27 So we separate our food and our fluid. People who are under a year out from surgery typically will stop drinking fluids a half an hour before they're going to eat their meal. However, that really is, only important in that first year because fluids can be very filling. So if somebody is preparing to eat a meal, but they're drinking up until that timeframe, then they're probably not gonna feel like they can eat anything cause they're gonna feel full from the fluid I can. Tell you, with 100% certainty that that does not last forever. So once you're kind of past that first year after surgery, it's not so important. But not drinking while you're eating and then waiting 20 to 30 minutes after you finish eating is so, so important for that long-term success because it allows the person to really only eat the amount of food that they should be eating.

16:22 So making sure that you're eating mindfully, separating the food and the fluid. It also allows you to only focus on one thing because hydration is incredibly important. And so after surgery, it's really important that we are focusing on getting the fluids in. So we have our food time and we have our fluid time, and we're in our fluid time. We should be focusing on getting those fluids in throughout the day. What we're drinking is also very, very important. So in that first year after surgery, we try to avoid carbonation at all costs as well as drinking out of straws Can. Be a little bit difficult because you're not really able to sit very slowly through a straw.

17:06 It can also cause some, like bubbles in your belly and that can be distressful to the belly. So once you're past that first year, carbonation is a hot topic in, bariatrics. There's definitely different schools of that. I personally, am, in the school of avoiding. For the rest of your life. Just because I think so many people, are drinking more soda or juices and stuff like that, than they are drinking actual water. And, and that's the biggest adjustment when going into weight loss surgery is getting out of the habit of doing that and drinking more. non-carbonated sugar-free fluids than those other things.

17:49 alcohol is definitely not recommended at all within the first year after surgery, You know, it's putting stress on the liver and the liver is already, kind of. Attacks to the max in the, accelerated state of weight loss that the body is in, in that first year after surgery. Not to mention, you know, tolerance levels change and a bariatric belly is very finicky, especially in that first year after surgery. And you never really know how it's gonna tolerate certain things or what it's gonna like. if you choose to include alcohol back in your, your belly may not like it so much.

18:30 Moving your body consistently is a huge part of the bariatric process. I mean, it's, you know, of course a huge part of staying healthy in general, and that's really, I think the biggest thing to understand is there's not really anything. Like different or special about the way a bariatric patient eats for the long term? It's definitely very restrictive in the beginning, just due to the nature of the surgery and, the fact that we cannot, consume a certain amount of food. However, the further out that you get, there's nothing really. Different about what we're eating or what the nutrition recommendations should be.

19:12 It is a good, healthy, balanced diet. I always say, you know, the least amount of. Overly processed, foods the better. Of course. the overly processed, hyper palatable foods, high sugar, high fat, high salt, those types of things. And again, because the bariatric belly is. Very finicky for a while. Anything in excess can be, incredibly disruptive to the belly. So sometimes maybe you'll have patients that come in that are complaining about having either nausea, vomiting, or like, an unfortunately a diarrhea situation like right after they ate something.

19:53 And, you're not really sure if that might have to do with the surgery or not. But if you kind of get a feel for what they've been eating and really ask them, if you can get an honest, true answer out of them, about what they've been eating. A lot of times things like fast food, fried foods that are really high in. Fats can be incredibly distressful to the stomach, in gastric bypass patients in particular, we have something called dumping syndrome that can happen. you know, certainly as a reactive hypoglycemia that can happen after. Consuming too much sugar or overly processed carbohydrate.

20:35 And so a lot of times patients can panic over the symptoms that they're having, but when you really get down to it, it can tie into how they've been eating. So guiding them in that sense. you know, it's not that we can't have a cookie or can't have some pizza or whatever, sometimes, but. It can affect your stomach if you're eating too much at one time. so just understanding that also, you know, the way that we eat should be very intentional and planned, instead of just, mindless eating and just grabbing snacks or whatever throughout the day.

21:15 So it is really, High in protein, in a sense that protein is our priority. But I think a big misunderstanding is that we only eat protein for the rest of our lives, and that is not at all the case. I personally believe that all foods can fit, just depends on the way that you're having them, over time. And it seems like. We're only eating protein for a long time after surgery because you just can't eat a whole lot and protein is the most important thing to preserve that lean body mass and, you know, hair, skin, and nails, So it's not that a bariatric patient requires more protein than a non bariatric patient, it's just that.

21:59 Someone with a bariatric belly is gonna have a heck of a lot harder time getting you a hundred grams of protein, then somebody that does not. So we wanna focus on the protein first. And so, a really good rule of thumb for people for the rest of their lives is we eat the protein first and then kind of move on to the other. Parts of our meals. second in command would be like non-starchy veggies or fruit, and then those starches are kind of the last thing that we eat on our plates. That was an extremely helpful, explanation because I have heard too, you only eat protein for the first year or the keto diet is what you have to follow.

22:41 And that's just such an accurate information. so that's a helpful way that really if they eat the protein source first and then they can work around their plate to the other food groups. Because it sounds like they do just follow a healthy diet like the rest of us do. Now, what are some common struggles that bariatric patients face maybe at the year five to 10? Why are we seeing so many people regain the 100 pounds that maybe they initially lost? What are the challenges that's facing them? Well, I think there's a lot of different factors at play there. Unfortunately, not everyone has a really good comprehensive program of clinicians that are helping them.

23:23 Not everybody has a bariatric dietician. Within their surgeon's office or their program that can guide them for the long term. we have people now that fly to other countries to get weight loss surgery because their insurance doesn't cover it here and it's a lot less expensive to pay, out of pocket in another country. And so they're really only given kind of, you know, a little piece of paper saying like, oh, here, just eat. Soft foods for a while and you'll be okay. And then kind of the flip side of that is, That there are people that are just non-compliant with those recommendations and those guidelines.

24:06 I mean, I'll talk to people and they tell me like, well, I don't understand. I still only eat, you know, two ounces of food, so how could I possibly be regaining weight and when I have them really take a good food log for me for a couple of days so I can get a good idea of what they're taking in. They're taking in, you know, 3000 calories still in the day. It's just spread out in little bits instead of all at one time. I can tell you, you know, from experience, like life happens sometimes and you just kind of. When you're happy and you're healthy after that honeymoon stage and you're going about your life, you're not as connected to the program. Maybe you know, you have monthly support group meetings that you were going to religiously for a long time in the beginning, but then.

24:53 You know, life happened and you got busy and you stopped going. You know, repetition is so important because we can very quickly sort of fall out of, a habit and back to our like, natural instincts, you know, for a lot of us. We have that instinct to use food as a coping mechanism. So in order to maintain the new lifestyle, you have to maintain the consistency of those habits that you're doing. I think what you said is probably the most important thing and kind of the take home message that I hope the listeners remember is to really encourage our patients to be followed by a bariatric.

25:36 Clinic that has a dedicated team with the psychologist, with the dietician, that's so important because as general practice clinicians, that's not our role. So I love that you said that because you know, with everything with food and nutrition, a dietician is so important, but I really think in the area of bariatrics, You're the most important because there are so many nuances. There are so many specifics. We are trying to really, truly change behaviors while at the same time work with the new anatomy of the patient's body. And I know in a five, 10 minute well check, there's not enough time to get into the nitty-gritty details of nutrition. So, I love to close out with having my guests tell us the reverse of their recommendations, so like what not to do.

26:22 So what could be the worst or a few worst things to suggest to a patient regarding their diet? I would have to say, anything that starts with don't eat. X, Y, or Z that could be don't eat carbohydrates or don't eat more than a thousand calories a day. All of those things are very common. things that our patients tell us that their doctors have told them. and I hear it all the time in private practice that, you know, I just feel like I'm starving all the time because my doctor told me that since I had surgery, I'm not supposed to have more than a thousand.

27:02 1200 calories a day, and this is a person who's, you know, 5, 10, 15 years out of surgery. that's not enough. You know, of course you're hungry all day long because you're not eating enough. So instead of saying, don't do this or cut out all. Carbs, go back to those foundational keys that I told you that are, those food behaviors in bariatrics. and really just kind of encouraging them to go back to the basic foundation of what they learned But really, Shying away from saying, don't do this or don't eat this particular food is, never a great piece of advice for anyone really, but also in bariatrics.

27:45 Samantha, this conversation has been so insightful and helpful, and I hope my listeners have learned some thoughts. Thoughtful, compassionate ways to discuss the option of bariatric surgery for some of their patients, and I know there's so many more things that we can get into with bariatric patients and their weight loss journey, so we would love to have you back to maybe even discuss more specifics on portion sizes, food groups. Vitamins, all those things. There are so many things that we can get into, so we'd love to have you back. But Samantha, thank you so much for your time. I know this was a valuable conversation to our listeners, so I'm so grateful for you being here with us today. I am super grateful for being on, and I'm always happy to chat with you about weight loss surgery and all the many things that go along with it.

28:29 All right, guys, now it's time for my nutrition notes. In this section, I will leave you with a nutrition tip, an encouraging quote, or an interesting case that I think might add value to your day. So my conversation with Samantha, she mentioned that there are some criteria that patients must meet in order to qualify for bariatric surgery and that you can find that on the website as mbs.org. But I just wanted to leave you with that just so you can have an idea of what that is. So I'm on the website now and it says that these are the following qualifications for bariatric surgery for individuals with A B M I greater than 35, regardless of presence, absence, or severity of comorbidities, or it's recommended in patients with type two diabetes.

29:14 And A B M I of greater than 30, or weight loss surgery can be considered in individuals with A B M I of 30 to 34.9 in individuals who do not achieve substantial or durable weight loss or comorbidity improvement. Using non-surgical methods. So hopefully that was helpful for you and you might be considering some patients in your practice who might actually qualify for bariatric surgery and that now you are more equipped to have that compassionate conversation and just to let them know what their options might be. Well, I hope you found this content valuable today. If you haven't already, please click the like button down below or subscribe to my channel on YouTube, and if you're listening in on a podcast, I would love if you could just leave me a quick five star rating or even write a quick review.

30:00 This just helps others find this valuable podcast. Well, that's it for today, guys. So as always, let's continue to make our patients healthier, one exam room at a time. I'll see you next time.