More than one third of Americans are considered obese and approximately 15 million (5%) Americans now have a body mass index (BMI) greater than 40. The April issue of the Journal of the American Dietetic Association focuses on the ever-increasing use of bariatric surgery to control the excess morbidity and mortality associated with extreme obesity and the important role that registered dietitians play in the management of patients who have undergone the procedure.
In their editorial on bariatric surgery, Robert K. Kushner, MD; and Lisa M. Neff, MD, Northwestern University Feinberg School of Medicine, Chicago, compare leading approaches and offer insights into their strengths and weaknesses. They advocate treatment by a multidisciplinary team of experts including physicians, exercise specialists, behaviorists and registered dietitians, with a focus on lifestyle modification to help patients achieve weight loss, with or without pharmacotherapy as an adjunctive treatment. When these approaches fail to produce clinically significant weight loss, bariatric surgery should be considered for patients with a BMI over 40 (or over 35 in the presence of significant weight-related conditions such as diabetes or hypertension).
Bariatric surgeon Alex Nagle, MD, FACS, Feinberg School of Medicine at Northwestern Memorial Hospital, Chicago, summarizes the key rationale for the increase in bariatric surgery. While concerns remain about long-term safety and future risk for other diseases, the opportunity to halt and reverse the increasing weight gain has tremendous appeal. He cites to efforts by the American Society of Metabolic & Bariatric Surgery and the American College of Surgeons to improve both patient access and overall quality of care, through the establishment of bariatric surgery Centers of Excellence. According to Dr. Nagle, this constitutes "an important step forward toward accurately tracking outcomes, defining clinical criteria, enhancing the quality of care and improving patient access to this life-saving operation."
Patients require significant counseling both before and after surgery. Doina Kulick, MD, University of Nevada School of Medicine, Reno, and colleagues discuss the role of the registered dietitian as an important part of the surgical team. She writes, "Surgery represents only one point in the continuum of care for the obese patient. The long term outcome of bariatric patients relies on their adherence to lifetime dietary and physical activity changes. A comprehensive team approach provides the best care to these patients and RDs play an important and growing role in this process. Because of the pre- and postoperative dietary issues, RDs can assess, monitor and counsel patients in order to improve adherence and reduce the risk of nutrient deficiencies."
Because bariatric surgery has grown more common over the past 10 years, data regarding follow-up and subsequent morbidity and mortality are now emerging. Investigators Maaike Kruseman, RD, MPH, and colleagues at the University for Applied Sciences of Western Switzerland, Geneva, followed 80 patients for 8 years after gastric bypass surgery. They report that while more than half of the patients achieved successful weight loss, these patients had disordered eating behaviors. They observe, "Successful and unsuccessful patients experienced similar rates of problematic eating behavior, depression and anxiety. These patterns can be easily ignored by the caregivers if they are not routinely screened for, as weight loss is the usual measure of success. This could affect patients' quality of life and self-esteem, and give them a feeling of failure despite the objective success in terms of weight loss."
Collectively, these articles demonstrate that gastric bypass patients require careful assessment and guidance to further promote and sustain weight loss, provide essential nutrients and offer a lifestyle shift that can permanently accomplish their goals. Registered dietitians can make an important contribution to managing bariatric surgery patients before and after surgery.
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