January 2012 Issue

Counseling the Outpatient Bariatric Client
By Megan Tempest, RD
Today’s Dietitian
Vol. 14 No. 1 P. 38

Pre- and postoperative nutrition counseling is imperative. Here’s how to do both successfully to ensure optimal postsurgical outcomes.

It’s common knowledge that obesity is a public health crisis. Statistics from the Centers for Disease Control and Prevention (CDC) estimate that one-third of US adults are obese, as are 17% of children and adolescents. Morbid obesity (defined by a BMI of 40 or higher or 100 lbs over ideal body weight) is also a serious problem. Its incidence has risen to more than 5% of US adults, who’ve found it difficult, if not impossible, to lose weight through diet and exercise—which is the main reason bariatric surgery has become widely accepted as a viable, albeit invasive, means to weight loss.

A 2011 report that assessed trends concerning the incidence of weight loss surgery between 2003 and 2008 showed that bariatric surgical procedures peaked in 2004 and remained steady thereafter.1 The American Society for Metabolic and Bariatric Surgery (ASMBS) reported that the number of weight loss surgical procedures increased from 103,000 in 2003 to an estimated 220,000 in 2008.2

According to the ASMBS, recent research suggests that the higher mortality risk of the morbidly obese reverts to normal following weight loss surgery. The procedure, which often gives morbidly obese patients their only hope for losing weight and leading a normal life, has been an effective treatment for metabolic disease and conditions such as type 2 diabetes, hypertension, high cholesterol, nonalcoholic fatty liver disease, and obstructive sleep apnea.3

The benefits of weight loss surgery also extend to close family members. A 2011 study, “The Halo Effect of Bariatric Surgery,” by Woodard and colleagues, published in the Archives of Surgery, showed that 12 months after the procedure, adult family members of gastric bypass patients demonstrated improved eating habits, reduced alcohol consumption, and significant weight loss. Family members also engaged in increased daily activity and less emotional eating. Obese children of gastric bypass patients tended to have a lower BMI than expected for their growth curve.

Given that weight loss and improved health aren’t always synonymous, a functional knowledge of good nutrition and the implementation of healthful eating habits are essential to positive outcomes after bariatric surgery. RDs are integral members of the interdisciplinary care provided in the bariatric setting. This article will discuss several aspects involved in nutritional counseling before and after weight loss surgery and provide insight from dietetics experts who specialize in this field of practice.

Preoperative Phase
In the pursuit of weight loss surgery, individuals often approach the dietitian’s office with trepidation. Preoperative counseling sessions for bariatric surgery candidates are commonly thought to serve as a screening process. While there’s some truth to that, early counseling with a dietitian fulfills other valuable purposes. Generally speaking, it’s a window of opportunity for the dietitian to prepare prospective surgery candidates for the long-term diet and lifestyle changes they must implement and set them up for success after surgery.

Renee Cooper, RD, LD, a bariatric dietitian at University Hospitals Case Medical Center in Cleveland Heights, Ohio, reinforces the primary goal of preoperative nutrition counseling: “As a clinician, you must ask yourself if the patient is going to be successful after surgery. If not, what can you do to help them be successful?”

Evaluate Individual Needs
Weight loss surgery requires dramatic lifestyle changes from patients. Assessing an individual’s unique needs and readiness for change are requisite components of preoperative nutrition counseling. Kristen Smith, MS, RD, CDN, a dietitian with the bariatric surgery program at Montefiore Medical Center in New York City, considers this essential to her preoperative conversations. “Some patients may not have even considered making changes to their food habits; some may have just started to think about it, while others have already started making significant changes,” Smith explains.

Bariatric surgery patients stand to benefit greatly from adopting basic changes toward healthful eating before surgery. For Smith, rather than counsel her preoperative patients on relatively complex concepts like calorie counting, she focuses on fundamental nutrition concepts such as what types of foods should go on their plates and how to create nutritious meals. She elaborates, “I focus on basic healthful eating and encourage patients to start making gradual changes, such as eating more fruits and vegetables, drinking less sugary drinks, or eating less fried food.”

Jody Halouska, RD, also finds that a wide range of nutrition knowledge exists among surgery candidates she counsels as the bariatric surgery coordinator at the Colorado Bariatric Surgery Institute of Presbyterian/St. Luke’s Medical Center in Denver. “Some of the clients we see have been dieting their whole life and understand what they should be eating but haven’t been able to translate that knowledge into their lifestyle. Others may have no clue about basic nutrition, how to cook, or how to make good choices with regard to eating.”

Accentuate Personal Responsibility
Bariatric surgery is anything but a quick fix for morbid obesity. In fact, surgery is little more than a tool that works best in conjunction with specific diet and lifestyle changes to facilitate weight loss and improved health. From drastically reduced portion sizes, unpredictable food intolerances, or the necessity of regular exercise, dietitians can use preoperative counseling to give their clients a realistic outlook of the postoperative experience.

Following the guidelines established by the ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient, Halouska provides surgery candidates with verbal and written information detailing the specific postoperative diet and lifestyle changes, such as daily protein requirements, fluid needs, and recommended vitamin and mineral supplementation.4 “We provide a two-hour preoperative class in which patients receive in-depth instruction of all the postoperative nutrition recommendations and a binder to reference when they go home,” Halouska explains. “If they follow the instructions and guidelines presented in the class and binder and come back in for follow-up counseling and support from our staff, they will very likely be successful with surgery. If they don’t, they probably won’t be successful.”

For surgery candidates who require further nutrition education before surgery, whether to meet insurance requirements or address a knowledge deficit, Halouska conducts additional preoperative nutrition classes that cover a wide variety of topics such as making healthful choices when grocery shopping or dining out, exercise and physical activity requirements, and healthful eating behaviors.

Barriers to Postoperative Success
Addressing needs for nutrition education is key in the bariatric surgery setting. However, to make optimal use of preoperative counseling, dietitians should ask questions that help identify other, perhaps less obvious, barriers to success following surgery. Cooper cites financial constraints as one barrier. “Having to wait for a paycheck in order to buy groceries or having difficulty purchasing healthful foods is always a concern for bariatric surgery patients.”

Cooper also has heightened concern for individuals who lack a stable support system in their personal lives, noting that some of her patients don’t even have support from their own spouses. This makes Cooper skeptical as to how successful the person will be after surgery. “If the individual having surgery doesn’t have adequate support, their likelihood of being successful is much lower.”

Halouska keeps an eye out for eating behaviors that could be problematic after surgery, such as binge eating, emotional eating, and boredom eating, and consistently collaborates with a social worker on such issues. “If a person shows evidence of a current or past eating disorder, for example, a psychological assessment will address that. We want to make sure the person is cognizant that surgery won’t change those behaviors; rather it’s up to the individual to address those behaviors before surgery occurs.”

Postoperative Counseling
Those who’ve experienced the rewards of weight loss surgery no doubt can attest to the challenges they encountered along the way. Consistent follow-up care with a dietitian—along with an interdisciplinary healthcare team—is a vital component of successful surgery outcomes. Postoperative nutrition counseling may address issues such as food intolerances, challenges in implementing healthful eating habits, adequacy of the diet in meeting basic nutritional needs, and adherence to vitamin and mineral supplementation, all while providing a platform for the patient’s unique questions and concerns.

Cooper describes the rewards of counseling her patients in the postoperative period: “I enjoy that postoperative counseling really keeps you on your toes. You get to put your thinking cap on and do a lot of problem solving. … Why is this person frequently nauseous? Why are they able to tolerate a certain food one day and not the next? Are they meeting all their nutritional needs?”

Cooper firmly believes in the dietitian’s role in helping bariatric surgery patients achieve their health and weight-loss goals after surgery. “I look forward to the moment when the light bulb goes off and my patients say ‘I get it now.’ These patients are making huge lifestyle changes, and many go all the way with it. Dietitians are so valuable because nutrition is critical to their success.”

Value of Small Changes
Working with bariatric surgery patients to implement small, achievable changes can foster confidence and momentum during the somewhat emotionally treacherous postsurgical phase. For instance, setting a goal to reduce intake of high-calorie desserts rather than eliminate them or choosing whole grain foods over their white counterparts may help circumvent feelings of failure or disappointment from falling short of loftier goals.

Halouska routinely adopts this realistic approach when counseling patients following surgery. “We can’t expect a patient to come in to our office three months after surgery having changed all of their habits,” she contends.

Halouska utilizes postoperative counseling to review all previously delineated diet and lifestyle changes to determine how well the patient is complying with them. “I make sure to give them time to ask questions,” she says. “At the end of our talk, I provide them with a written handout summarizing their specific recommendations and highlight what they’re already doing well. To address areas that need improvement, I work with the client to set specific goals to work on until the next visit.”

Tackling Personal Conflicts
Despite thorough preoperative counseling, even the most determined surgery candidates may need to confront unexpected challenges after surgery. Halouska finds that a common barrier to success is thinking that surgery works like magic, when nothing could be further from the truth. “Postoperatively, patients often realize surgery doesn’t do all the work. They must understand that healthful diet and lifestyle changes must be adhered to despite all of life’s ups and downs that may make doing so more difficult.”

Halouska asserts that all bariatric surgery patients must make their health a priority in the face of personal struggles and challenges. “Patients have to maintain those critical lifestyle changes rather than revert back to bad habits that prevent weight loss.”

Cooper has witnessed some of her patients fall victim to such pitfalls to success. “The individuals that fall back into their old ways and regain weight are often those who experience something tragic or perhaps become a caregiver to an ailing family member.”

The dietitian can help support postoperative patients in maintaining healthful eating habits in the face of personal stress that may provoke unhealthful behaviors, such as emotional eating. “The behavioral aspect may be just as important as the nutritional changes,” Cooper suggests. “That’s a whole other component to their success after surgery.”

Create a Supportive Environment
Smith uses a technique referred to as motivational interviewing, which she describes as a nonjudgmental, client-centered approach to counseling. “It attempts to increase the patient’s understanding of a problem and relay the risks if the problem isn’t improved or resolved. This helps patients establish their own goals and build a better rapport between the dietitian and the patient.”

Smith feels bariatric patients benefit from believing the dietitian understands the challenges they face and that dietitians aren’t without flaws when it comes to diet and nutrition. “Sometimes I share my personal story that I didn’t grow up eating healthfully,” she says. “This approach helps patients understand we’re human, and everyone struggles with making changes to their diet. I think patients come in the office feeling judged and like they can’t be truthful about their eating. We must break that barrier and create an environment in which they feel comfortable and supported.”

Cooper advocates for offering consistent support and availability to her patients. “I think one of the most important things a dietitian can do is be as available as possible and always remain in communication with his or her clients, whether via one-on-one counseling, e-mail, telephone, or at support group meetings. The more you stay in touch with bariatric surgery patients, the more likely they are to stay on track with their weight loss goals.”

Organized support groups are very common in the bariatric surgery setting, providing yet another avenue to successful health and weight loss outcomes from surgery. Halouska’s team at the Colorado Bariatric Surgery Institute conducts regular support groups that provide patients an opportunity for ongoing, long-term education on topics such as nutrition, exercise, and healthful behavior changes. Support groups also give patients a chance to communicate with other people experiencing similar challenges and struggles. As Halouska says, support groups provide the fundamental benefit of helping patients feel less alone in the process of adapting to a new way of life following surgery.

— Megan Tempest, RD, is a freelance writer based in Colorado.


Components of Pre-Op Nutritional Assessment
• Anthropometrics

• Weight history

• Available laboratory values

• Psychological history

• Dietary intake

• Physical activity level

• Psychosocial assessment

• Details of postoperative intake

— Source: Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4:S73-S108.


Components of Post-Op Nutritional Follow-Up
• Anthropometrics

• Biochemical/laboratory values

• Medication review

• Vitamin/mineral supplementation

• Dietary intake

— Source: Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4:S73-S108.


1. Nguyen NT, Masoomi H, Magno CP, Nguyen XM, Laugenour K, Lane J. Trends in use of bariatric surgery. 2003-2008. J Am Coll Surg. 2011;213(2):261-266.

2. Weight-Control Information Network. Longitudinal assessment of bariatric surgery (LABS). NIH Publication No. 04-5573. http://win.niddk.nih.gov/publications/labs.htm. January 2010. Accessed November 2011.

3. American Society for Metabolic & Bariatric Surgery. Rationale for the surgical treatment of morbid obesity. http://asmbs.org/rationale-for-surgical-treatment. Updated November 23, 2005. Accessed November 2011.

4. Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS allied health nutritional guidelines for the surgical weight loss patient. Surg Obes Relat Dis. 2008;4:S73-S108.