New office   Our new weight loss specialist clinic is located at Queen Street Village The Specialist Haus Level 3, Suite 2 127 Queen Street Southport 4215   Ph: 5648 3755, 0431 516 948 Fax: 3523 5995 Email: info@thespecialisthaus.com.au, victorliew@live.com.au Webpage: drvictorliew.com   Team members Administration:                                  Emily Nimmo, Brooke Atkins Bariatric Surgeons:                           Christian Ibraheem, Victor Liew, Phillip Townend Colorectal/Endoscopy Surgeon:     Cu Tai Lu Nurses:                                               Lisa Bartley, Lou Rickard Bariatric Surgery Registry:               Emma Napier Dietitian:                                             Carly Barlow, Zoe Cooke Psychologist:                                     Rachel Williams Referrals A referral letter will be required to see the surgeons   Health care plans (for the allied health team) Some patients may qualify for a comprehensive health care plan, also known as a GP management plan (GPMP) or Team Care Arrangement (TCA) If they have a chronic medical condition or disability for more than 6 months (eg. Type 2 diabetes, cardio-vascular disease, kidney disease, musculo-skeletal problems, asthma, cancer, strokes, others) This allows some patients to receive Medicare benefits for up to 5 allied health services per patient per calendar year Some patients may already have a mental health care plan This is only for patients who have been diagnosed with a mental health condition This helps to cover some of the cost (up to 10 sessions) to see a psychologist   The dietitians will accept the Enhanced Primary Care Plans (EPC) which offers a Medicare rebate of $58 each time for up to 5 visits

VLCD sales   If possible, please support our dietitian Carly Barlow’s newly released pre-op and post-op weight loss shake and protein powder supplements   This is Carly’s private business independent of The Specialist Haus or the Gold Coast Private Hospital   Carly also has a tv program on channel 9 and online Please search for www.gemlife.com.au/livingproof/   Free meal plan available from website https://www.themetabolicdietitian.com.au/

Pre-op diet preparations

Before bariatric surgery to lose weight and reduce the size of the fatty liver, patients are recommended to have either:

• Low calorie diets (LCD) are usually 800 to 1200 kcal/day
• Very low calorie diet (VLCD) are usually 500 to 80 kcal/day

The pre-op diet should include:

• A diet with much reduced carbohydrate (<30g a day), with at least 20% protein and less than 30-35% fat
  • The VLCD ketogenic diet is for weight loss, the reduction of the fatty liver size, improve glycaemic control, to prevent loss of lean muscle mass and provide the body with the essential dietary fatty acids (omega 3, 6, 9)
• Sugar or sugar containing drinks (fruit juice, soft drinks, alcohol) as well as artificial sweeteners are prohibited.
• Small servings of fruits and leafy vegetables/salads are permitted to provide the body with dietary fibre as well as the necessary vitamins and minerals
• Plenty of water (>1.5 to 2 litres a day) should be drunk to prevent dehydration, muscle cramps, constipation, etc

Below is an example of a simple pre-op instruction from a bariatric surgeon and dietitian.

VLCD – Very Low Calorie Diet   Patients with a BMI of 40 will need to commence VLCD for at least 2 to 3 weeks before elective bariatric surgery. Patients with a BMI of 60 or higher should commence the VLCD 6 to 8 weeks before elective bariatric surgery.   Please try to lose as much weight as possible before the surgery, to reduce the size of the fatty liver. If there are technical problems during surgery the operation will be abandoned.   Please buy the VLCD from the dietitian or chemist.   VLCD come in many different forms (soups, shakes, bars, desserts, etc.) and in many different flavours.   The aim of the VLCD diet is roughly about 1,000 calories per day, with enough protein, vitamins and minerals that you need every day to reduce the fatty liver size and provide you with essential micronutrients. VLCD meal replacements are consumed three times per day. You may have steamed non-starchy vegetables or salads (no potato, corn, peas, pumpkins or squash) for lunch and dinner.   The recommended vegetables are usually green leafy vegetables/salads (asparagus, bean sprouts, beetroot, basil, bok choy, broccoli, brussel sprouts, cabbage, capsicum, cauliflower, carrot, celery, cucumber, garlic, ginger, lettuce, mushroom, onion, radish, rocket, silverbeat, spinach). You may add salt and olive oil to the vegetables. One to two slices of fruit a day (paw paw, water melon, guava, rockmelon, nectarine, peach, berries, tomatoes, cucumber, avocado) and a very small handful of raw tree nuts for lunch/dinner are beneficial.   If you have 2 VLCD prep a day then healthy protein meal once a day may be included, with the advice from your dietitian. Tofu, less than 2 eggs, 100g of lean meat, chicken or fish a day is allowed. Some dietitians will also allow 1 cup of milk or high protein low fat yoghurt. Alternatively for those patients who don’t eat meat, protein powder supplements may be added to the VLCD shakes. Have at least 2 to 3 litres of water per day to prevent dehydration or constipation. Avoid sugar drinks (fruit juice, honey), dairy products, iced coffee/chocolate, soft drinks, energy drinks and alcohol.

Post op dietary recommendations

Below is general advice given to patients.

• Obviously the dietary micronutrition and micronutrient requirements varies a lot between individuals depending on their age, height, gender, level of physical activities, pregnancy or the types of bariatric surgery.

In general to lose weight after bariatric surgery, a calorie deficit (negative energy balance) diet is needed

• In the first 1 to 2 months on average patients usually consume 500 kcal/day
• In the first year on average patients usually consume less than 1 000 kcal/day
• For pregnant ladies after bariatric surgery an additional 200 kcal/day may be needed with adequate vitamin/mineral supplement (especially iron, folate, B12, vitamin D) and to reduce the level of vitamin A supplement

After bariatric surgery adequate protein intake (60-100g/day) or the addition of protein supplements are usually recommended to prevent the loss of lean body muscle mass and prevent protein malnutrition (albumin <25g/l)

• Whey, egg white, casein, cow milk or soy milk are recommended to provide the body with the essential amino acids
• Whey protein (branched chain amino acids) is one of the most commonly used protein powder supplements
• There are low lactose content or lactose free supplements available on the market as well

Weight regain can and will occur after any types of bariatric surgery due to multiple factors, some of which are unavoidable.

Studies have shown that energy and carbohydrate intake were significantly higher at 3 to 5 years compare to 1-2 years after a sleeve gastrectomy. The overall quality of macronutrients (especially protein) were lower after 3-5 years compared to the first 2 years.

Post op exercise

Patients are encouraged to start walking straight away after surgery whilst still an inpatient

After hospital discharge:

• An objective structured and regular exercise program (FITT) supervised by the exercise physiologist or personal trainer is beneficial.
• For rural and remote patients without access to these services, a non supervised exercise at home with the guidance of an exercise physiologist or personal trainer is recommended.
• The use of smart/fitness watches are beneficial as well for tracking and logging activities corelating to the patient’s weight and BMI loss.

Physical activities and exercise have positive metabolic and cardio-vascular benefits (fitness and improve core muscle strength) independent to dieting and surgery.

• Preventing the loss of fat free/lean muscle mass is crucial especially in the first 3 months after bariatric surgery

Regular exercise

• Improves weight loss, improve glycaemic index, better blood pressure control
• Reduce fat free mass, preserve lean body muscle mass, increases aerobic activity/respiration and fat oxidation
• Reduce the loss of bone mineral density
• Help to achieve more weight loss, maintain weight loss and improve quality of life

Psychology support and counselling

Morbid obesity are often related to medical co-morbidities as well as mental health issues, the most common being anxiety and depression. Long term success after bariatric and metabolic surgery should address both the physical and mental well being of the patients.

The psychologist is valuable in assisting with

• Emotional eating
• Mindless eating
• Lack of self confidence
• Unrealistic expectations
• Body dysmorphic or negative body image issues

Some of the treatments may include:

• Cognitive behavioural therapy
• Schema therapy
• Solution focussed therapy
• Acceptance and commitment therapy

Summary

The multi disciplinary team (surgeon, bariatric physician/GP, dietitian, community GP, exercise physiologist, psychologist and other social support circle) have guidelines and recommendations to optimize the pre op preparation, to achieve tailored or realistic individual results and help maintain better post op results after bariatric/metabolic surgery

Issues that may surface before or after bariatric surgeries can be addressed, such as

• Dietary indiscretion/non adherence, binge eating, grazing, food addictions, substance dependence/abuse (soft drinks, alcohol)
• Physical inactivity (sedentary lifestyle or other barriers to exercise)
• Mental health issues (stress/anxiety, depression, other psychiatric conditions, binge eating, loss of control, change in marriage/social circumstances, etc)

To re-iterate obesity is considered a chronic relapsing condition

• Inadequate weight loss, weight regain and the return of certain medical conditions (such as T2DM, HPT, OSA) will occur with time, increasing age and changes in personal circumstances after surgery

Bariatric and metabolic surgery is not the solution to obesity alone. It should be complimented by positive lifestyle changes

• Patient’s compliance to dietary and exercise program after surgery helps maintain better weight loss, improve health and quality of life in the long term
• The lifestyle changes is even more important for patients considering revision bariatric surgery to achieve good post op results and preventing macro and micronutrient deficiencies