Bariatric Surgery Q&A Featuring Purva Gulyani

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Can you please tell us a little bit about your career so far?

I started my career as a private practice Dietitian in 2004, and then we planned to move to Melbourne in 2009. That’s when I cleared my APD status, but I had to head back to my home town of New Delhi, in 2010. In 2011 I joined the team of an esteemed Bariatric and GI Surgeon Dr Atul Peters, where I got hands on experience of Bariatric Nutritional Management. Every day was a new challenge; each patient comes up with some unique queries and issues. In March 2016 I finally ended up moving to Australia. It took almost 3-4 months to set up my own practice in Melbourne with help of my mentor and guide in this field, the best Physiotherapist I know Tara Kasouri. Since then Diet Yumm has been providing nutritional services at 10 different locations across the city.

What has the experience of being one of the few dietitians with an Indian background working in Melbourne been like?

Food is comfort, celebration and love for Indians and Asians. We have a very strong bond with food. I believe as a Dietitian if you can understand the client’s basic food tips, you can get much better results.

Food plays a vital role in our lives; it is one way of socialising and bonding. It helps us stay close to our culture, our roots. To help our clients, I feel culture is no barrier, but having said that I can’t deny the comfort Indian or other Asian clients get when they come and talk to me. They know their diet will be fully understood and suggestions will be made according to them. We can only get good results if the client follows our advice.

With weight loss statistics looking pretty grim (with figures such as 80-95% of people regaining weight after weight loss), do you believe bariatric surgery is one of the best options that we have as a tool?

Bariatric Surgery is the best tool for the “correct” candidate. It is definitely not the easy way out, it has its own pros and cons. By correct candidate I mean clients with a BMI of more than 40 kg/m2 or BMI between 35 – 40 kg/m2 with medical comorbidities like T2DM, CAD etc. In my practise overseas, I have seen some amazing results which has made me more confident about this procedure. As I often explain to my clients, weight loss is an add on benefit you get post – surgery if we compare to the other benefits you get. We have seen a 90% resolution of osteoarthritis clients in the first 3 months and these patients average a loss of 25-30% excessive weight in 3 months. Diabetic patients show some great results, Pre-Diabetes is resolved in 100% of the patients in the first 3 months and in 6 months 95% of the patients with diabetes are off their diabetes medications.

What is the best practice approach from a nutritional standpoint to prepare somebody for bariatric surgery?

35 – 80 % Weigh loss surgery candidates are in state of ‘high calorie malnutrition’. This can be attributed to poor nutritional choices and various other related factors. At our institute we conducted a study to assess the pre-op nutritional status of north Indian clients and we found 84.56% of our clients where deficient in Iron, which was highest. Vitamin D deficiency was seen in 76.84% of clients along with calcium deficiency in 25.26% and 28.77% were deficient in Vitamin b12. Hence it is very vital to include a comprehensive screening program before any bariatric procedure, which will help us to detect and treat any nutritional deficiency before the surgery.
Along with this the pre-op time is utilised to try to reduce the liver volume by roughly 25% by following a very low energy diet for 2-4 weeks. It helps to reduce intra operative complications.
One piece of advice I often give my clients is to start chewing their food very well and if possible develop a habit of drinking small sips and eating small bites.

What limitations do people have directly after the surgery and what steps do they need to go through while they recover?

If there have been no intraoperative complications, then the patient is fit to return to his/her normal life in a couple of days. They are made to walk while they are in the ICU. Post op diet plays a crucial role. It helps in speedy recovery and is a path to achieve the desired results of the procedure. The diet is modified in texture and is very low in calorie and high in protein. It slowly progresses from clear liquid to a normal diet over one to two months, giving enough time for the strictures to heal.

Dietary pattern changes go through a few stages –
Clear liquid – first 2 days
Full Liquid – first 2 weeks
Pureed – next 2 weeks
Progressive diet from Soft to normal – 1 month post op

What are some of the key things people need to prioritise after bariatric surgery in general following this recovery?

A high protein diet helps to heal and recover post op. ASMBS recommends 60- 90g of protein daily, depending on their medical conditions, type of surgery and activity level. Selecting lean protein is always recommended along with a recommended protein supplement to help them meet the protein requirements.

Staying away from the 5 S’s is my first point to explain to clients.

Soda –Carbonated drinks may expand the newly constructed stomach and cause bloating and discomfort.
Straw – Drinking with a straw may be lead to a lot of air being swallowed while drinking. This can cause discomfort, bloating and dilation of the pouch.
Sugar – Each teaspoonful (5grams) of sugar gives you 20kcal. Added sugar provides empty calories – no nutrition at all. This could also cause Dumping Syndrome in post RYGB clients.
Smoking – Smoking lessens blood flow to the newly made stomach, which may lead to ulcers or even leaks in acute cases.
Spirits – Clients who have undergone gastric bypass absorb alcohol as much as FOUR times more from a given drink as before surgery.

Do you think Bariatric Surgery is given a bad rap for being seen by some as “the easy way out”? What are your thoughts on that opinion?

As I have mentioned earlier it is not an easy way out. It is a complete lifestyle change. It is a tool which will help you achieve your health goals. Dr Peters always explains to clients that “we have given you a piano and will teach you how to play, but what you play is entirely up to you.” This procedure requires disciplined lifestyle in order to maintain the weight loss.

Do you think most people are happier after the surgery?

There are load of studies to quote from to answer this question, which will tell us that patients overall quality of life generally improves post-surgery. Apart from this, when you see the happiness of clients when they are off their Cpap’s, getting pregnant after years of marriage and trying every fertility treatment, or getting rid of Insulin injections and dozens of other medications that they had been on, that moment makes me more positive and confident about this procedure.

Are there any downsides to the rapid weight-loss? What can be done to mitigate these downsides?

We have to be careful with diabetic clients as they can go into severe ketosis. To avoid that they need to be watched very closely by the phycians and surgeon to taper their Insulin or medication requirements post op and work closely with their dietitians in regard to their diet.

Is there anything you would like to add to wrap things up?

Try to live healthy each day; it is not for anyone else, it is for yourself. I quote this to my clients very often: “Healthy eating is a lifestyle, once you adapt it – it stays with you.”

Aidan Muir

Aidan has been exposed to the most recent and up-to-date evidence based approaches to dietetic intervention. Dating back to well before starting uni he has been fascinated by all things nutrition, particularly the effects of different dietary approaches on body composition and sports performance. Due to this passion, he has built up an extensive knowledge base in multiple areas of nutrition and is able to help clients with a variety of conditions. One of Aidan’s main strengths is his ability to adapt plans based on the clients desires. By having such a thorough understanding of optimal nutrition for different situations he is able to develop detailed meal plans for clients, or he can provide flexible guidance that can contribute to improving the clients overall quality of life.

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