A Dietitian's Important Role in Bariatrics

INOVA Bariatrics' most popular surgeries are bypass and sleeve,
only one LapBand surgery has been performed in the last year.

Heading to my second hospital rotation, I had mixed feelings about how a dietitian can fit into Bariatric Care. I was mostly excited – I love the out-patient setting. You have the opportunity to get to know patients over a course of visits, receive patient feedback on progress, and tailor nutrition interventions along the way. But in some ways, the position felt backwards. As naïve as it sounds, I’m the kind of learning dietitian who believes my job is to help every patient lose weight before they need something as drastic as bariatric surgery. But the fact of the matter is that’s not realistic, and not possible for many patients. Nutrition is just one factor in the treatment of obesity, that is growing so rapidly in this country. Patients have trouble losing weight for reasons much more complicated than “eat more fruits and vegetables” – genetics, diseases, psychological disorders, emotional eating, and unsupportive environments can all play a role in a patient's weight loss journey. After shadowing my first bariatric appointment, it was overwhelmingly clear how important a Dietitian is in this setting.

Here are three of my biggest “shockers” from my 2-week rotation

ONE: Smaller than small portions sizes

It’s hard to imagine, but a starting meal fits into a 2oz plastic cup. Even as a dietetic student, I asked myself what does a 2oz plastic cup even look like? Here at the center, we give condiment containers as a guide. So the little cups you put ketchup in - That’s a meal for a bariatric patient the first 3 months following their surgery. No wonder the weight drops so fast (that is if you’re following the rules!). Portion sizes grow over a year period, but in small amounts and peak at 1 cup per meal for the rest of a patient’s life.

Condiment containers are provided to patients as measuring tools
for meal size.

TWO: No bread, rice, or pasta

This is something I have never recommended for other patients in the past, but eventually made sense to me in the bariatric setting. If you put bread into a cup of water, it absorbs and swells. When a patient’s stomach is reduced to the size of a thumb, a few bites of bread can swell and fill the entirety of the stomach. For many patients, they learn the hard way – they eat the bread they have been craving, and then experience abdominal pain, nausea, or sometimes vomiting. A portion of bariatric patients can tolerate these foods after a year, but still may cause discomfort. All those healthy and vital B vitamins patients are missing out by skipping the grain products are made up through daily supplementation.

THREE: Calories… not really that important

Dietitians are trained to focus primarily on the nutrient content of food when making recommendations, and to not always get caught up in calories. However, our profession revolves around calculating energy expenditure, and knowing that eating less than that estimated number equals weight loss. After bariatric surgery, the stomach acts as a physical calorie counter. And by that, I mean it would be hard for a patient to eat enough calories to exceed their energy expenditure without feeling nauseatingly full.  A stomach after bariatric surgery keeps portion sizes small enough that calories aren’t the major problem. That is why most of diet counseling focuses on what kinds of nutrient dense foods are patients putting into those small meals that help them receive optimal nutrition. 

During my rotation I was able to teach the class
"Eating out after weight-loss surgery" to help
patients learn healthy tips to eat outside their home.

Working in an outpatient bariatric office really gave me an appreciation for how dietitians can get involved in specialized health. Careers for dietitians are vast, and understanding as many career areas as possible is already building my confidence as a soon-to-be professional. Bariatrics definitely took some getting used to, but keeping an open mind gave me the most positive and educational experience possible.