Carrots
Your column in the July 2006 issue of Surgical Rounds is right on the money! In an extensive bariatric surgical practice that started with the jejunoileal bypass in the early 60s, it was soon apparent that these patients were at serious risk of developing significant metabolic side effects. I performed about 150 of these operations, and I called upon colleagues—mainly gastro­enterologists—not infrequently during the follow-up months and years. I never considered it necessary or helpful to involve dietitians.

The gastric bypass operation is more physiological than the jejunoileal bypass. Gastric bypass patients require meticulous instruction on how to eat after surgery. I would spend extra time with them and their family members explaining that patients would have a miniscule stomach, which they needed to heed. They were told to desist eating as soon as they felt full and not to eat more than three tiny meals daily. 

Unrequested were the dietitians, who would promptly sabotage me! They would interview the patients at the hospital, offering several handouts advising that they should take “small meals every 2 hours.” I was trying to limit the patients to approximately 800 calories a day, knowing full well they would exceed that. Why anyone expects that dietitians, and for that matter “weight doctors,” can help the morbidly obese lose weight and maintain a significant amount of weight loss over an extended period of time escapes me. The published results show an extremely high recidivism rate. Dieticians and nutritionists may be good at helping cachectic patients regain health, but they have an extremely poor ability to get patients to lose weight. I agree with you that “the role of dietitians in hospital care is greatly exaggerated.”
Basil R. Meyerowitz, MD
Hillsborough, CA

Following July’s editorial “Carrots,” I strongly feel the need to respond on behalf of the nation’s registered dietitians. I appreciate Dr. Jaffe stating that he respects the “concept and the scientific field of dietetics.” Your readers may be interested in some of the realities of dietetics as well.

For a multifactorial disease state such as obesity, the key for successful patient outcomes is teamwork. Just as surgery is not a stand-alone cure, we know one or two visits to a registered dietitian will not lead to long-term success; however, consultations with a registered dietitian do lead to success when a patient continues to follow up over time. According to the American Dietetic Association’s (ADAs) position on weight management, “For effective weight management treatment, the client should be assessed by a multidisciplinary team, including a physician, registered dietitian, exercise physiologist, and a behavioral therapist. Through the team approach, issues such as nutrition, physical activity, and change in eating behavior can be coordinated.”

ADA’s new Adult Weight Management practice guidelines, based on a rigorous evaluation of the available science, identify what we know works and what does not, paying particular attention to nutrition assessment factors, dietary interventions, selected dietary approaches, physical activity, behavioral interventions, medication, and planning for bariatric surgeries. The following recommendation for practitioners is based on what ADA concludes is strong evidence: “Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet, physical activity, and behavior therapy. The combination therapy is more successful than using any one intervention alone.”
Judith A. Gilbride, PhD, RD, CDN
President, American Dietetic Association
New York, NY

As a fellow “gastric bypass surgeon,” I read your editorial in the July issue of Surgical Rounds with considerable interest. Although I believe that dietitians can be quite helpful to postoperative gastric bypass patients, I agree with most everything else in your editorial. I was particularly interested in your comment that the routine notes by hospital dietitians, which are required/legislated in New Jersey and perhaps nationwide, can serve as a source of professional liability. Fortunately, I have not had any personal experience in that area. However, I agree that these notes (which I also never read) contribute substantially to increased hospital costs. I am not sure how we can get the attention of the legislators and administrators who seem to think that there is value in these notes. Although I appreciate the contributions of hospital-based dietitians to the care of my malnourished patients, their role in charting on well-nourished, healthy patients who are admitted for elective orthopedic operations is a total waste of time and money.
Robert E. Brolin, MD
Monmouth Junction, NJ