Changing lives through lifestyle and surgical intervention

Fall 2019

When Lori Masterson shops for clothes now, she’s likely to come home with outfits much too big for her.

Six months past her bariatric surgery, Lori has lost 90 pounds and can’t quite recognize herself in the mirror.

“I still don’t see the weight loss in myself, I don’t see it to the degree that other people notice it,” says Lori, who has had two complete wardrobe changes since surgery in January.

“I have so much more selection and shop in regular clothing shops now, before I had only two stores to shop for clothing in London.”

Lori has struggled with her weight her whole life. Ten pounds at birth, she has always been considered a bigger person.

Health issues led her to consider bariatric surgery. She had high blood pressure, sleep apnea, poor blood sugar and high cholesterol.

“I have a 10-year-old daughter who needs a healthy mom and dad. She was my main motivator,” says Lori. “I couldn’t have lost weight and regained my health without surgery. I had tried different programs in the past, but I could never lose the weight. I needed a bigger tool.”

Bariatric surgery reduces the patient’s stomach and therefore limits the amount of food and liquid that can be consumed.

When her husband Kevin made the decision to have bariatric surgery two years ago to help overcome obesity, he had to travel to Windsor for appointments and then to Toronto to have the surgery.

Two years later Lori was able to receive the same services in London with the establishment of the Bariatric Centre of Excellence at LHSC.

Her family physician referred her to the bariatric centre at LHSC and she went to her first information session, taking along two friends to support her.

The two-hour session includes an overview of the program, patient questionnaire, as well as a referral for blood work and a stomach ultrasound.

A few weeks later Lori had her initial nursing assessment to review her completed questionnaire, consent for research, set up a sleep study, and ensure all testing was complete.

At this time important bariatric information – the process, expectations and possible complications – and the requirement for a long-term commitment to life-style change were reviewed to ensure she understood the full implications of the surgery.

“We also had a nutrition class which talked about food intake after surgery and what life will look like three months after surgery, what our new normal would be,” says Lori.

Patients then have a number of individual appointments to assess readiness for surgery and post-surgery life, including an assessment with a social worker. 

Social worker Claire Davies works with patients to assess, for example, social supports, the ability to deal with the stress of surgery, and any past substance abuse or psychiatric disorder. She also does screening for binge eating disorders, night cravings and bulimia.

“When we meet again for our second appointment, we talk about their emotional triggers for food and how they are coping to further their awareness, and we talk about how to make lifestyle and behavior changes,” says Claire. “Emotional eating is most common, and can be triggered by feelings either negative or positive.”

For many people it is difficult to separate the habit of eating with the activity, such as habitually snacking when you’re watching TV in the evening.

“It’s about relearning to do these activities without food,” says Claire.

There is also navigating eating in social situations. Claire says some relationships will change as a result of the significant weight loss and she helps patients build skills for that. The goal is to eat three meals a day and three snacks a day, even when they’re not hungry.

“After surgery they are working on a schedule to normalize their eating patterns,” says Claire.

Post-surgery

LHSC surgeons performed a roux-en-y gastric bypass surgery for Lori. This is a laparoscopic surgery that partitions the stomach by making a small pouch at the end of the esophagus and connecting it to the small intestine, thereby bypassing much of the small bowel.

Lori was home after one night in hospital and, as outlined in her sessions with an LHSC dietitian along with handouts specifying her dietary requirements, started with liquids, introducing purees and soft foods over a period of 10 weeks until she was eating solid foods again.

“When I’m not hungry, food is no longer a priority and meal prep is no longer top of mind.”

While she does not have many food cravings, she did miss chicken wings which were one of her favourite foods.

“So I ate one, but I didn’t feel well afterwards and now I don’t miss eating them.”

Her weight loss has brought about significant health benefits. Her blood pressure is down to normal, her blood sugar and cholesterol levels are good. She is being referred to the sleep clinic to see if her sleep apnea has improved.

Lori is thankful for regaining her health and for her care at LHSC.

“Everyone on the care team was incredibly supportive,” says Lori. “Life is easier, work is easier and, most importantly, keeping up with my daughter is easier.”

Were there any unexpected changes since surgery?

“There’s the first time your clothing size changes. I don’t think I was quite prepared for how fast your size changes,” says Lori.

“It takes longer to catch up with the mental picture of what size I am. I see an image in the shop window and it takes me a few seconds to realize that it’s me.”

Eating after bariatric surgery

LHSC dietitian Helen Abrams works with bariatric surgery patients both before and after surgery.

“We are teaching lifestyle changes and healthy eating behaviours from the time of the first orientation session. It’s about making small changes ahead of the surgery and continuing with these good habits after surgery,” says Helen.

By the time they have surgery patients have a full understanding of how their lives will change in terms of their eating.

“We work with the patient to put together a structured eating program that is customized to the patient and their lifestyle,” says Helen.

The first couple of days following surgery, the patient has only broth, diluted juice and unsweetened Jell-O.

Helen explains that at this point the stomach pouch is about the size of an egg and can take two-to-four tablespoons of food or liquid. In comparison the stomach is normally the size of a small football.

For the first two weeks after surgery the patient consumes a full fluid diet of milk, yoghurt, cream soups, puddings, and high protein drinks.

This is then followed by two weeks of purred foods such as mashed potatoes, poached eggs, pureed meats, vegetables and fruits.  This is followed by four weeks on a soft diet which includes cheese, crackers, cereals and moist meats, fish, soft cooked vegetables and peeled fruits.

“The point of the progression diet is to respect the healing process of the pouch,” says Helen.

At six months the patient begins a regular diet by transitioning in one new food at a time.

Patients sometimes find that some foods they previously enjoyed are no longer as tasty or don’t taste the same.

Eventually the pouch becomes the size of a tennis ball and can hold about 1 cup of food.

A typical day of eating consists of three small healthy meals a day with two to three quality snacks, pairing protein with carbs. Patients eat protein for all meals and snacks, about 80 g a day, to keep up their energy level.

It’s about choosing the right food to make sure that nutritional needs are met, looking at nutrient dense foods and taking their vitamin and mineral supplements every day, says Helen.

There is only one item patients can no longer have, and that is carbonated beverages because the air in the drink fills up and stretches out the stomach.

Patients also can’t have any alcohol for the first year and the dietitians encourage lifetime drink avoidance.

When do patients stop losing weight?

“Many plateau at about 12 – 18 months, but everybody is different. Some may plateau sooner and get frustrated, however this is usually for a short time and then they begin to lose more weight,” says Helen. “Our focus is on how people feel, how healthy they are, their medical benefits, and not on the scale.” 

 

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