Regular Meals

Education about eating regularly is important to ensure adequate nutrition post‐operatively. Although the full mechanisms of the most common bariatric procedures are complex and multifactorial, we understand that surgery physically reduces the size of the stomach pouch and causes biochemical changes in hormone profile, bile acids and microbiome. This results in reduced hunger signals, as well as influences on taste changes making certain food less appealing. Overall volume of intake therefore reduces as does the calorie density of foods eaten. Satiety is reached earlier and lasts longer.

It is therefore very important that a regular meal pattern is established prior to surgery and any barriers that have prevented this are addressed in order to prevent under nutrition and malnutrition post‐operatively.

Portion Size

Overeating is commonly reported by individuals attending weight management services and is often related to portion control and perceptions of a ‘normal’ portion. Whilst this may be improved by encouraging eating regular meals, there are often other influencing factors.

It is commonly reported that individuals have been brought up to clear the plate and will therefore finish any food that has been presented to them disregarding satiety. It is also common for individuals to eat more than is required if they are enjoying the food or not concentrating on the meal – mindless eating.

With the knowledge of how bariatric procedures influence appetite, and the human body’s incredible ability to adapt, it is important to address these behaviours and look at strategies to manage them pre‐operatively to reduce the risk of weight regain following surgery.

Strategies to help individuals slow their eating down such as 20:20:20 (cut food to the size of a 20 pence piece, chew each mouthful 20 times, after 20 minutes of eating discard any remaining food), putting cutlery down between mouthfuls of food to encourage more mindful eating and sitting at a table away from distractions are often helpful approaches.

Slower more mindful eating practices will also help reduce complications, such as food blockages, reflux and regurgitation after surgery.

Meal Balance

The balance of meals is equally important. Reducing overall portion may be less effective if the foods eaten are calorie dense. Establishing an estimate of which macronutrients contribute what percentage to the overall intake is a useful starting point. In order to promote weight loss prior to surgery, the aim is to increase low‐calorie dense foods such as salad and vegetables whilst decreasing amounts of high‐calorie dense foods such as carbohydrates and fats. Focus is also placed on protein in order to ensure a good variety is eaten, in large enough quantities to be sufficient after surgery. It is useful to try and help an individual visualise what they are aiming for, for example, half a plate of salad and vegetables, a quarter of a plate of protein food and a quarter of a plate of complex carbohydrate (Figure 10.2).

By reducing overall energy intake and ensuring intake of complex carbohydrate and more salad and vegetables, the aim is to improve satiety from less overall calories, creating an energy deficit resulting in weight loss and improved glycaemic control.

This is also pre‐emptive of any potential problems that may occur after surgery with dumping syndrome or rapid transit. Dumping syndrome, rapid transit and rebound hypoglycaemia all are commonly recognised complications after bariatric surgery, in particular following gastric bypass (however symptoms can be seen after sleeve gastrectomy). Various terms used to describe the symptoms are often interchanged.

Dumping syndrome includes gastrointestinal and vasomotor symptoms that occur following a meal, in particular carbohydrate rich meals. Symptoms occurring 15 minutes to 1 hour after a meal are considered ‘early dumping syndrome’ and are mainly gastrointestinal (symptoms of diarrhoea, nausea and abdominal cramps). The cause is considered to be due to osmotic effects owing to larger than normal volumes of undigested foods reaching the small intestine too quickly. Symptoms occurring one to three hours after a meal are considered ‘late dumping syndrome’ and are considered to be vasomotor (sweating, lethargy, shakiness, hunger, hypotension and hypoglycaemia). They are caused by reactive hypoglycaemia that is induced by an exaggerated insulin response that overcompensates for the carbohydrate load ingested.

In most cases, dietary adjustments will prevent these symptoms. Dietary advice should include the following:

1. Smaller regular meals (up to six small meals daily).
   
2. Separation of fluid and food (no fluid 20–30 minutes either side of a meal).
   
3. Avoid simple carbohydrate and high sugar foods (for example biscuits and sweets).
   
4. Include more complex carbohydrate and high fibre food choices (for example wholemeal and whole grain products) and low glycaemic index foods.
   
5. Increase protein and fat* content of the diet to compensate for reduced calories from carbohydrate and to help slow down digestion.
   

   *The fat content of the diet should be increased with caution to prevent any malabsorptive symptoms

If an individual develops the symptoms of dumping syndrome, there is no immediate treatment other than to allow the symptoms to pass. They will resolve spontaneously with time. Symptoms can be so severe that individuals have been known to present at emergency departments believing they are having a heart attack. Prevention is therefore preferable which can be achieved with pre‐operative education; see Chapter 24 for more detailed discussion about dumping syndrome.

Snacking

Bariatric surgery will result in biological changes, which will reduce appetite and restrict the amount of food an individual can consume in one sitting. It will not improve the nutritional quality of the foods an individual chooses or control how often or why the individual eats.

There is consistent evidence that grazing/snacking behaviour can lead to an overall increased energy intake and weight regain/poor weight loss after surgery. Snack foods tend to have high fat and sugar content but have a low nutritional value, for example biscuits, cakes, crisps and sweets. Often these are consumed for reasons other than hunger. Boredom, emotion, habit and comfort are reasons often cited by individuals engaging in the behaviour.

There are incidences where healthy, planned snacks are helpful, for example when work patterns or other responsibilities require long periods of time between one meal and the next. A planned and controlled snack can be helpful under these circumstances to manage appetite, speed of eating and future food choices and volume at the next planned meal.

Uncontrolled snacking, however, is not beneficial and will lead to weight regain after surgery. Both psychological and dietetic support will be helpful to manage this behaviour.

Fluid Intake

Fluid intake can be challenging following a bariatric procedure both due to the reduced capacity for volume in one sitting and due to the recommendation to separate fluid from food intake by 20–30 minutes.

Gulping fluids can lead to abdominal discomfort and regurgitation following bariatric surgery.

The separation of fluids from food intake is to prevent over fullness from non‐nutritious fluids leading to the potential for malnutrition and also to prevent complications such as dumping syndrome (discussed later).

Individuals are generally encouraged to aim for approximately 2 l of fluid daily assuming there are no medical conditions influencing this.

Inadequate fluid intake will negatively impact on an individual’s bowel and renal function, therefore learning to take regular, frequent sips of fluids between meals pre‐operatively is essential to enable them to consume sufficient fluid post‐operatively.

Types of fluid consumed should be considered. Fizzy drinks can cause bloating and fullness, which post‐operatively may reduce nutritional intake so these are best avoided.

High‐caloric fluids, such as sugary fruit juices and sugary milkshakes/lattes, are also discouraged. These types of fluids will contribute significant ‘empty’ calories towards a daily intake, whilst providing little nutritional value, impacting on weight regain/poor weight loss and are highly likely to trigger dumping syndrome after a gastric bypass.

Alcohol, another high‐caloric fluid, should also be discouraged for this reason. There is increasing evidence that problems with alcohol dependency can occur following bariatric surgery. Whilst it is recognised that more research is needed in the area, pre‐operative alcohol dependence and regular alcohol consumption are considered predictors and should therefore be assessed and flagged pre‐operatively. Additionally, anatomical changes following bariatric surgery combined with alcohol can result in irritation to gastrointestinal mucosa and potentially the development of ulcers. Recommendations therefore should be that alcohol intake is minimised or stopped altogether pre‐operatively, to reduce risk of post‐operative complications.

This information can be summarised for individuals. Special attention should be paid to areas they may need more support with.

The main dietary behaviours are summarised below (Table 10.2).

Stay updated, free articles. Join our Telegram channel

Join