Bariatric Times - February 2009 - (Page 32) 32 Nutrition Perspective Not using MI: Tell the patient that he or she should try to stop eating those desserts so often. Using MI: The patient probably already knows that eating cake is getting in the way of weight loss, but perhaps start by asking if he or she can think of any other ideas for desserts that are healthier or lower calorie. Maybe the patient will surprise you by sharing that he or she loves fruit. Perhaps the patient thinks that only fresh fruit is acceptable and he or she finds that it always goes bad before getting a chance to eat it. You can then let the patient know that even no added sugar canned or frozen fruit would be a better choice than the cake. Instead of making a goal of less cake for dessert, suggest more fruit for dessert. This is a way of being positive. As busy professionals, we are often frustrated and pressed for time; we cannot always demonstrate the most ideal counseling skills. Incorporating just a few small things into your interactions with patients can go a long way to improving compliance. Making eye contact and doing more listening than speaking stopping on the way home from work at the drive-through window would not respond well to you asking how he or she could go about cooking dinner more often. Instead, you can try to increase awareness of the correlation between the patient’s fast food choices and slow weight loss. First discuss what meals he or she selects at the drive-through. Then, use this information to show the patient, for example, the difference in calories between baked chicken and fried chicken, the amount of salty (and therefore thirst-promoting) items on the fast food menu, or the amount of times the patient may end up eating quickly in the car and vomiting versus eating meals in a more leisurely fashion at home. Having these discussions first may help the patient to progress to the point where he or she then wants to make that positive change to more homecooked meals. Then, at last, you can find out what will help the patient to stop at the drive-through less often. You might be surprised by the fact that it is as simple as driving a slightly different route home to avoid the temptation. Bariatric Times • February 2009 their situation falls into the red zone. Explain to them that taking out fluid will help them to lose weight by allowing them to eat more satisfying, heavier foods, instead of those that slide through easily. Performing an annual upper gastrointestinal series (UGI) to evaluate the band and the esophagus can also help to demonstrate whether band adjustment is appropriate. Motivational interviewing (MI), used correctly, is an effective way of combating poor compliance. Some examples of MI are the following: Situation #1: A patient is drinking with their meals. Not using MI: Remind the patient that they have to separate the two things (drinking and eating) for their band to work properly. Using MI: Ask the patient if he or she is aware of the benefit of having these separately, then find out what is making it hard for the patient to do this. Before offering solutions, see if the patient can come up with ideas him or herself of how to make the change. Remember (and remind the patients) that they know themselves better than anyone and decrease, it is harder to meet the recommended dietary intakes for all nutrients. The best example of this is iron deficiency anemia. Intolerance to red meat, a highly absorbable source of heme iron, is common. Another serious concern is thiamin deficiency. The half-life of this water-soluble vitamin is only 9 to 18 days; thus, a period of prolonged vomiting, especially in patients who are not compliant with supplements, can lead to deficiency fairly rapidly.8,13 In addition to the band’s impact on food volume and variety, one should consider the available evidence of vitamin and mineral deficiencies in the (non-operated) obese.14, 15 Current guidelines for postoperative daily vitamin supplementation are the following:8 * 1 high-potency adult multivitamin-mineral supplement containing 100 percent of daily value for at least two-thirds of nutrients, including 18mg of iron, 400μg folic acid, zinc, and selenium. Even though LAGB is a purely restrictive operation, patients undergoing the procedure do need supplementation, especially as THE BAND IS MADE TIGHTER. may realize, for example, that when they eat foods that are less salty, they do not need to drink with their meals. If they can come up with the solution and make goals for themselves, they are more likely to feel empowered and more likely to implement any changes. Another way is to begin slowly and get rid of the all or none idea. Instead of trying to drink zero fluids with meals, ask them if they think they could try to cut the amount they typically drink in half, and then monthly aim to decrease this amount. Situation #2: A patient is having desserts such as chocolate cake almost every night. are two things that are easy to forget when the next patient is right outside your door. Do not forget to give praise for accomplishments and use positive reinforcement: “It’s great that you are not eating sweets every night of the week! It must be hard for you to resist the temptation.” Keep in mind that MI can also be used incorrectly when there is no recognition of the individual’s stage of change. Patients who are not ready to make any changes—in other words, they are in the contemplation stage of change— need to progress to the action stage before the above strategies will be helpful.12 For example, a patient who does not see a problem with NUTRIENT ADEQUACY A discussion of LAGB nutrition would not be complete without a note on nutrient adequacy. Some practices “sell” the band as an operation that does not require any supplementation since it does not impart malabsorption. This has been proven to be untrue. Even though LAGB is a purely restrictive operation, patients undergoing the procedure do need supplementation, especially as the band is made tighter. Poor eating behavior, low nutrient-dense food choices, food intolerance, and a restricted portion size contribute to the risk of developing nutrient deficiencies. As food variety and portion sizes * 1,500mg additional elemental calcium split into doses of 500 to 600mg each * (Optional: B50 complex) Patients will be less likely to feel good enough to be compliant with physical activity recommendations if they are tired or not sleeping well, problems which may stem from low levels of iron or B vitamins. In a circular pattern, poor and shortened sleeping cycles also lead to weight gain through mechanisms that are both behavioral and biological.16 Patients may stop their supplements as their bands are tighter and pills become more difficult to swallow. Making your patients aware of chewable and
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.