Frustration with dietitian

[Nepenthe44 179]

This is just a rant. If you have a good deal of faith in medical science, just skip this one. Keep that faith, you'll sleep better at night and the placebo effect will work better on you.

I'm intensely frustrated by having to deal with the arbitrary nature of the bariatric surgery process.

So, I'm a scientist and I work in medical research. I know from the back end exactly how arbitrary and non-evidence based much of medical practice is, from the trivialities to treatment of life-threatening conditions. (And boy howdy, you would not believe it and it is frightening.) I'm at peace with it; we're working on it and we know that we're all doing are best.

What I am not at peace with is knowing this on one hand (and my dietitian openly admitting this), but having to pretend that it's not the case. I hate lying and pretending. It's very difficult for me to pretend that I believe that it's critical that I don't eat consume any Fiber during my pre-op diet, which has to be liquid because reasons. (I'm dumb and I asked why it has to be liquid, curious what the justification is. I was a little surprised to find that they don't even make something up. Honestly, disappointed, low effort guys. If you're going to torment us, at least have a plausible rationale.)

It's very difficult for me to be presented with an arbitrary set of rules and just... follow them, because. Not because there's a reason to follow that rule or because there's research backing it up, but because people who have power have chosen that set of rules, for no particular reason, and if I don't follow them, they will stand in my way.

I understand that this is how the system works. We are noncompliant, untrustworthy, stupid, and, most of all, we are unworthy.

I'm losing over 1% of my body weight weekly, pre-surgery, by dieting and exercising, but If I don't stop drinking a cup of caffeinated tea with 15 grams of sugar in it (the only added sugar I consume at all) 6 months before my surgery date, I'm going to be denied. My dietitian was very explicit that she would not approve me. I mean, there's really nothing else she can put on her little goal sheet for me to show that I'm worthy and compliant.

And I definitely need to prove that I'm worthy and compliant, even beyond what is necessary because I'm fat, because during my first meeting with the dietitian, she told me to seriously consider whether I wanted to go through with the surgery, because research showed that, unlike with weight lost through diet and exercise, people who have bariatric surgery have radically slowed metabolisms afterward. They did a study with the Biggest Loser people!

I was stupid and impolitic and I questioned this, because that study is one of the (many) reasons I'm seeking bariatric surgery. (It showed the exact opposite of what she told me it did, and even more so with the follow-ups.) So naturally I was very concerned that I had gotten my facts wrong and instead of being smart and shutting the $#%^ up and looking it up on PubMed when I got home, I questioned her. (I wonder how many people she's talked out of surgery because she doesn't understand it. Best not think about that!)

It chaps my hide extra knowing that her next patient will probably be someone who is barely maintaining their weight, is being coaxed into giving up their multi-can-a-day soda habit and doesn't know what a Protein is, while I'm worried about eating too much fruit and having a teaspoon full of sugar set as an ultimatum. And that person will have less difficulty than I do accessing surgery.

Obviously, I understand that the answer is to either follow the arbitrary rules or to lie my increasingly saggy butt off like a psychologically normal person. And obviously I'm going to do that, because that's what I need to do to get what I want. But I don't have to @#$ing like it!

[Spinoza 1,126]

Yeah I totally get this and my advice is just to lie enough to get through the process. Sorry, I know that doesn't help the person coming behind you - I have no idea how to buck the system. I've met some of the most ill-informed professionals I have *ever* met on the road to WLS. If I had locked horns with all of them I'd have had no energy left for the journey itself.

[The Greater Fool 1,937]

Dietary science, as we experience it at the consumer level, is equal to how we approach witchcraft. And even acknowledging this my sense is we are being offensive to witchcraft.

Again, at the consumer level, we are given such nonsensical and arbitrary rules to follow because most consumer level dietary science is people just like us reading the same non-scientific articles on the current fad approach to losing weight, with every author's personal beliefs mixed in.

If there were any kind of consensus there would be one generally accepted program with minor variations. Instead we get every fad diet with as many variations as there are patients.

So, we are stuck with telling everyone to do what their surgeon's program demands, no matter how disconnected from reality is is. That is the only advice we can give because it's just as likely our program was one of the crazier programs.

Of course there are good programs out there. Each of us are so lucky that the program we picked is one of the good ones.

It's hard to go on a rant such as this and come back to a positive landing. Perhaps we should talk about something less controversial, like politics.

Good luck,

Tek

[GreenTealael 24,850]

2 hours ago, Nepenthe44 said:

This is just a rant. If you have a good deal of faith in medical science, just skip this one. Keep that faith, you'll sleep better at night and the placebo effect will work better on you.

I'm intensely frustrated by having to deal with the arbitrary nature of the bariatric surgery process.

So, I'm a scientist and I work in medical research. I know from the back end exactly how arbitrary and non-evidence based much of medical practice is, from the trivialities to treatment of life-threatening conditions. (And boy howdy, you would not believe it and it is frightening.) I'm at peace with it; we're working on it and we know that we're all doing are best.

What I am not at peace with is knowing this on one hand (and my dietitian openly admitting this), but having to pretend that it's not the case. I hate lying and pretending. It's very difficult for me to pretend that I believe that it's critical that I don't eat consume any Fiber during my pre-op diet, which has to be liquid because reasons. (I'm dumb and I asked why it has to be liquid, curious what the justification is. I was a little surprised to find that they don't even make something up. Honestly, disappointed, low effort guys. If you're going to torment us, at least have a plausible rationale.)

It's very difficult for me to be presented with an arbitrary set of rules and just... follow them, because. Not because there's a reason to follow that rule or because there's research backing it up, but because people who have power have chosen that set of rules, for no particular reason, and if I don't follow them, they will stand in my way.

I understand that this is how the system works. We are noncompliant, untrustworthy, stupid, and, most of all, we are unworthy.

I'm losing over 1% of my body weight weekly, pre-surgery, by dieting and exercising, but If I don't stop drinking a cup of caffeinated tea with 15 grams of sugar in it (the only added sugar I consume at all) 6 months before my surgery date, I'm going to be denied. My dietitian was very explicit that she would not approve me. I mean, there's really nothing else she can put on her little goal sheet for me to show that I'm worthy and compliant.

And I definitely need to prove that I'm worthy and compliant, even beyond what is necessary because I'm fat, because during my first meeting with the dietitian, she told me to seriously consider whether I wanted to go through with the surgery, because research showed that, unlike with weight lost through diet and exercise, people who have bariatric surgery have radically slowed metabolisms afterward. They did a study with the Biggest Loser people!

I was stupid and impolitic and I questioned this, because that study is one of the (many) reasons I'm seeking bariatric surgery. (It showed the exact opposite of what she told me it did, and even more so with the follow-ups.) So naturally I was very concerned that I had gotten my facts wrong and instead of being smart and shutting the $#%^ up and looking it up on PubMed when I got home, I questioned her. (I wonder how many people she's talked out of surgery because she doesn't understand it. Best not think about that!)

It chaps my hide extra knowing that her next patient will probably be someone who is barely maintaining their weight, is being coaxed into giving up their multi-can-a-day soda habit and doesn't know what a Protein is, while I'm worried about eating too much fruit and having a teaspoon full of sugar set as an ultimatum. And that person will have less difficulty than I do accessing surgery.

Obviously, I understand that the answer is to either follow the arbitrary rules or to lie my increasingly saggy butt off like a psychologically normal person. And obviously I'm going to do that, because that's what I need to do to get what I want. But I don't have to @#$ing like it!

Another option might be to find a different practice especially if you are uncomfortable with the directions and information. If you are having a hard time being complaint now, it may be worse after surgery if you need more guidance but won’t trust a word the dietitian says.

Good luck!

[Annemr 6]

I'd find a different practice. I have an amazing team who understand the realities of living including having sugar in our coffee or tea. Every team has different rules and mine encouraged fibre and large amounts of vegetables during my two week post op diet (I'm now 3 weeks post op and down over 11kg). So sorry you've not had a good experience with this person and if you can, try and find a team that suits you better and is happy to hear your concerns

[Arabesque 6,440]

I am one to say follow your program because there are differences as well as similarities. Though I often also say, if the program isn’t working for you, speak to your surgeon or dietician.

I recognise there are weaknesses in the American health system & the ridiculous power of insurance companies: If you don’t do what they say & get all the right boxes ticked you can’t have your surgery power. Through reading posts here, there also seems to be many medical practitioners who do not look at each individual case & don’t make adjustments to their program to suit the individual patient’s needs. And dieticians often seem to promote their own ideologies & current fads. I saw a documentary a few years ago that spoke about the influence of large food production corporations on the curriculum in schools & in medical courses at colleges/universities - scary stuff.

Things aren’t perfect in Australia, & I’m sad to say, we’re slowly going down the US path, but my experience was much different. I’m sorry yours has been so negative. My surgeon & dietician did consider me, my needs & circumstances. For example, my surgeon puts different patients on different pre surgical diets. A friend was on all shakes while I was put Keto. He said I didn’t need to see a therapist (he gave me the name of one if I wanted or needed) but he sent her for several appointments before her surgery.

My dietician, though not perfect, was at least open to my preferences & needs. She advised the keto diet only for the two weeks pre surgery saying it should only be followed for the short term to kick start weight loss (something I already believed). She didn’t give me specific macros to reach (apart from protein) but only recommended low fat, low carb (multi or whole grain low processed only), low sugar. I did a lot of my own reading & discussed my thoughts & what I wanted to do. I eventually devised my own way of eating & what foods I wanted (& needed) to eat, avoid, restrict or reduce. She’d make suggestions about alternatives & things I could add to make sure I was getting in my nutrients (she always checked my blood tests).

I guess the big difference was my surgeon & dietician wanted to support me & help me achieve my goals. If yours aren’t supportive, don’t listen to your needs & are simply following a genetic ‘one program suits all’, find a new team (if you can). And especially in your case, if they don’t recognise you are an intelligent, well educated & are highly knowledgeable in the medical field, give them the boot.

All the best.

[Old Salt 64]

I look at this whole process in that I am the customer and they are providing a service. I will lean on their experience but will always question if I do not understand and then I fully expect as a customer that they will explain. This is a paid transaction and they are there to make money just as any business does and I am a customer seeking a paid service of the highest quality.

Luckily, my Bariatric team has been nothing but professional and accommodating. Remember, it is a 2-way street of respect and communication for this process to work. BUT, IF I had encounted a Bariatric team that I did not feel comfortable with, then I would look into a different service provider.

[Nepenthe44 179]

Unfortunately, I live in a rural area outside of any major metropolitan areas. This practice is my only real option without restarting the process and driving several hours each way for appointments.

And it's really not this practice that's the problem; I had the same problem with the previous practice I tried with. (That one allowed Fiber during the pre-op but absolutely forbad cooking your vegetables, because everyone knows that if you steam the broccoli you eat, your surgery will fail and you won't lose weight as well as the people who are chowing down on raw florets pre-op.)

I just have a fundamental problem complying with arbitrary and unjustified rules. I definitely don't trust my team, because I don't want to be denied again, so I'm not about to negotiate with them. (The surgeon in particular seems extremely rigid and unwilling to listen or negotiate.) I feel like the questions I've asked have already put me in serious jeopardy of being denied on the grounds that I won't comply.

I plan on being a more forthright with the team after surgery, because what can they do then if I ask questions, hit me over the head and put my GI tract back together? But I'm never going to be able to trust a dietitian or anyone else that can't back up what they demand I do.

[SpartanMaker 676]

The reality is, the science is far from settled on almost everything regarding diet, especially when it comes to bariatric surgery patients.

I'm going to suggest the one thing no one has yet: Be compliant.

Unless they were proposing something that was literally harmful (it doesn't sound like they are), it won't hurt you to let go of your biases and trust the process. The vast majority of the dietary changes proposed by these bariatric teams is based on their real-world experience with what works and what does not for the the average patient.

Sure, some of what they are proposing may seem odd or wrong to you, but does it really matter? You won't die from it, and might even benefit. As a scientist, open your mind to trying something new and testing out what they have proposed.

[GreenTealael 24,850]

Is this the second program you have consulted @Nepenthe44? Is there any program anywhere that you think would be a better fit for you?

[Nepenthe44 179]

Re: does it really matter

I mean, yes. There are other possible bad outcomes besides literally dying. If the effectiveness of bariatric surgery comes down in large part to microbiomic changes, for example, suggesting that I remove all fiber from my diet until over 6 months post surgery and introducing large amounts of artificial sweeteners into my diet could in fact work against positive changes to the gut microbiome.

If my ability to lose weight pre-surgery comes down to emphasising foods that extend satiety (fiber, Protein, fat), dramatically reducing my fat and fiber intake before surgery could cause me to overeat or binge eat and my weight loss to stall or reverse.

If long term success comes from following one's hunger cues, teaching myself to eat according to the clock they've set, whether I'm hungry or not, in order to meet arbitrary goals could limit my weight loss long term or trigger binge eating again.

They're not suggesting I take a spoonful of arsenic at bedtime, but that doesn't mean that their suggestions are neutral. They have no systematic evidence that their program creates success for the average patient or not. (The great part of this sort of program, from the practitioner perspective, is that you can almost always blame poor outcomes on non-compliance.)

Some of the program requirements for the pre-surgery diet are literally impossible to follow at the same time. I can't take one or two bean-sized bites per minute, finish meals in less than 30 minutes, and eat 2200+ calories per day without a significant portion of those bites being high fat meats, full fat dairy, or, I dunno, Peanut Butter straight out of the jar, all of which are verboten. So regardless of what I'm doing now, I'm not compliant. It's not possible to comply fully.

(The handwavy answer was "healthy fats". I have no idea how much avocado my dietitian expects me to be able to eat. I suppose technically if I ate just chicken breasts with avocado and nothing else...)

I'm also not the average patient anyway (it's probably pretty clear at this point that I'm not neurotypical, for example, I understand that people with regular would either comply or lie without much difficulty either way), so even if their arbitrary program did create success for the average patient for whatever reason that means very little for whether it would work for me.

The arbitrariness and the ultimatum annoy me. The fact that I'm being asked to disregard everything I know about how I personally deal with change to adopt a post-surgical style diet (low-fat, regimented, and frequent) half a year before any potential surgery date with an intact GI system, that I'm expected to throw away everything I know about what I need to lose weight, stop binge eating, and have the energy to do intense exercise frightens me. I'm terrified that I'm going to gain weight or relapse into binge eating (thus getting denied for surgery) and I feel like they're pushing me into that direction.

All because Typical Tammy deals best with gradually introduced changes over a long time period and simple, unambiguous, authoritative instructions from medical professionals she sees as trustworthy experts? Nah.

4 hours ago, GreenTealael said:

Is there any program anywhere that you think would be a better fit for you?

I mean, I'm sure there are, but this is the only one I have access to. And, ultimately, it doesn't really matter, as long as I can jump through their stupid little hoops, I can get what I need from them. It's just.... a long and irritating process of circus training.

I'm not really looking for advice or anything, I understand the options and am resigned to them, this is a rant and rave.

[GreenTealael 24,850]

1 hour ago, Nepenthe44 said:

Typical Tammy

🤣

[BigSue 1,320]

You seem to have a really cynical outlook on all of this. I, too, am a scientist by profession, and I've always been a bit of a pessimist, but I think sometimes, it's worth giving people the benefit of the doubt.

It looks like you don't think your bariatric team has your best interests at heart. I know you've been burned before, and I also know what it's like to be constantly judged as stupid, lazy, noncompliant, untrustworthy, unworthy, etc. because of my weight, so I can understand your feelings about this, but don't forget that these are people who have devoted their careers to providing weight loss surgery. I'm not saying that they all genuinely care about alleviating the plight of the obese, or that they're sympathetic toward those of us in a position of needing this surgery, but I doubt there are very many medical professionals in the bariatric surgery field who are out to punish and criticize fat patients just for fun (or out of personal dislike of fat people). If for no other reason than their own self-interest, chances are that they want patients to succeed with weight loss surgery, and they are probably doing what they believe will contribute to their patients' success.

Another thing to keep in mind is that sometimes people can be right for the wrong reasons. I've run into this in my own job, where someone has told me something that didn't seem to make sense, and I (as someone like you with an inquisitive mind) have gone looking for the real story, only to find that what I was told was correct, even though the reasoning was not. In this case, your dietitian might be giving you good direction even if she doesn't actually understand what she's talking about. Just because that dietitian (or even the whole bariatric team) doesn't know or understand the reasoning behind the rules, it doesn't necessarily mean that the rules are incorrect or arbitrary.

Finally, if you hang around this forum for long enough, you will see that many patients want and need a lot of hand-holding. Some people would rather be given strict but arbitrary rules than loose guidelines. People are constantly on here posting questions like, "I had surgery X days ago; can I eat Y?" And honestly, considering that, I can't blame surgeons at all for wanting to make things as black and white as possible so they don't have to spend all their time answering these incredibly specific questions, tailored to each individual patient. Most patients are not medical researchers, and many want definitive instructions from their doctors. Many people would be paralyzed with indecision if they were told, "Some studies say X and others say Y; you figure it out."

Ultimately, it's up to you to decide how closely to follow your surgeon's directions, and if you do your own research and believe you have found a better way, you can make that decision. But I would venture to say that you will likely have a better experience if you have a mindset of working WITH your bariatric surgery team instead of taking an adversarial approach.

[SpartanMaker 676]

@BigSue Well said.

@Nepenthe44 You do you. You stated that you know what you need to do, and this was just a rant. So be it. I wish you all the success in the world, but with your adversarial approach and unwillingness to at least try what's being asked of you, I'm concerned you're headed for a really hard time. Whether that's self-inflicted of not, is for you to determine.