This week was my second in the DI, but my first in supervised practice! I started out in bariatrics, which is an area that I’ve had zero exposure to prior to this week (besides a lecture or two in MNT).
Bariatrics covers the realm of both surgical and medical weight loss, with the majority of patients (>70%) being seen for surgical weight loss. The bariatric program I’m interning for generally does either sleeve gastrectomy (removal of part of the stomach) or gastric bypass (removal of part of the stomach and rerouting the small intestine) for surgical weight loss in combination with behavior change.
Gastric banding, which was extremely popular a decade ago, is now considered a “failed” procedure by the FDA. This means that quite a few of the patients I saw had to get revision surgeries (where they remove the band and do either a sleeve or bypass).
No matter which surgery a patient gets, they have to take nutritional supplements, follow-up with their bariatric team, and follow a bariatric diet and exercise plan for the rest of their lives. Surgery isn’t a “quick fix” like the media portrays it—it’s a major lifestyle change.
Medical weight loss, on the other hand, focuses exclusively on behavior change. Patients are often prescribed weight loss medications as well (appetite suppressants are common). It’s not uncommon for a patient to go from medical weight loss to a sleeve gastrectomy and eventually gastric bypass.
Patients needing to lose around 50 pounds are generally well suited for medical weight loss or sleeve gastrectomy. Bypass is the most effective procedure to lose more than 50 pounds. Patients perceive it as a more “extreme” procedure though, which is why a lot of patients who get a sleeve end up needing bypass later. They chose a sleeve because it seemed less scary even though it was less suited for their weight loss goals.
Some of the reading material I went over to prepare for bariatrics.
My week looked like this:
Tuesday:
My first day at the bariatric clinic! My preceptors gave me books about medical and surgical bariatrics as well as several fact-sheets and journal articles to read throughout the week. Both of the books were the same ones they gave the bariatric patients, so they were relatively easy to read. The fact sheets were also in an easy-to-read format. I learned a lot about how bariatric surgery can actually “cure” diabetes! Most patients can also come off of a lot of their blood pressure and other meds. Overall, it was a lot of reading, but it all really helped me get a better sense of what bariatrics was all about!
I also shadowed them throughout the day to get an idea of what their counseling sessions were like. In general, they do a lot of Motivational Interviewing (MI) interspersed with education about the bariatric diet and exercise. They also provide a lot of referrals to exercise programs that specialize in working with bariatric patients.
Wednesday:
I spent the morning at the bariatric clinic again, and my preceptors had me do some patient education as well. Basically, when a patient asked a question like “Are peanuts a good protein source after surgery?” my preceptors would have me answer. Since my only experience with the bariatric diet happened 24-hours ago, this was pretty nerve-wracking. Interacting with patients was very exciting though.
I had to leave early to head to Loyola Health Sciences campus for some research training with a standardized patient. We each (there were six of us at this training) had to take his blood pressure three times, weight once, height twice, and waist circumference twice to practice for the research that we’ll be doing later this month. I imagine his right arm was getting pretty sore after having his blood pressure measured 18 times… After that, it was time for our weekly night class, “Public Health and Community Nutrition”. We learned about the basics of the importance of nutrition for public health. We also discussed some of what each of us are doing in our supervised practice rotations. I think this class will be really interesting, but I’ve never been a fan of night classes so I was dragging by the time it was over!
Thursday:
Back at the bariatric clinic! I spent the morning shadowing again and trying to navigate Epic (an electronic medical record service). By the afternoon, my preceptors had me take the lead in our counseling sessions with patients! Thankfully, my first patient was extremely easy to talk to, which made getting over my nerves a little easier. Overall, I counseled two pre-surgery patients and one post-surgery patient. For one of my pre-surgery sessions, I had the opportunity to provide education on the different phases of the bariatric diet post-surgery (clear liquid—full liquid—puree—soft—regular). Bariatrics focuses on protein a lot to ensure that weight loss is coming mostly from fat and less from muscle stores and lean tissue. My patient had questions about protein sources in a pureed and soft diet, so we worked together to come up with some options.
The other things we focus on in the bariatric diet is fluid intake (before or after meals, never with), exercise (to preserve muscle and promote weight loss), and supplement intake. Since surgery alters the digestive tract, patients have to take lifelong supplements to prevent nutrient deficiencies. There are some differences in supplement needs based on sleeve versus bypass. In general, they need a multivitamin, iron, vitamin B12, vitamin D, and calcium.
For my post-surgery patient, we discussed which phase of the diet she had progressed to. Then, we talked about any food aversions she was experiencing after surgery. Finally, I checked in with her on exercise, fluid and protein intake, and adherence to supplements. Fun fact: beef and eggs are the most common foods that are difficult to tolerate (most post-surgery patients become lactose intolerant as well). For the most part, these three sessions went really well—the hardest part was remembering all of the questions I had to ask them!
Friday:
Mental Health First-Aid training with the National Alliance on Mental Illness (NAMI). As a future healthcare professional, being able to respond effectively to a mental health crisis is extremely important. Essentially, we improve patient care when we look at someone as an entire person instead of just their diet. Plus, food and mental health are often very closely linked, so this training was a great way for us to learn how to better provide for our patients. The most important thing we learned at this training? To listen to patients, nonjudgmentally. So now, I’m a Mental Health First-Aid certified for the next 3 years—pretty cool!
Amanda Hookom: Mental Health First-Aid Certified.
I also registered for the Food and Nutrition Conference Expo (FNCE), which is very exciting! I’ll be there for the full 4 days since it’s in Chicago this year—how lucky for me! I spent my weekend catching up on some errands and laundry, and, of course, studying and completing readings for my bariatric rotation (seriously, the work of a Dietetic Intern is NEVER done). Next week I’ll be at the bariatric clinic again working my way towards being able to counsel patients independently and document our sessions in the EMR, so until then!
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