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1 My Experience and Background • Certificate of Adult Weight Management Training ▫ I 1 My Experience and Background • Certificate of Adult Weight Management Training ▫ I and II • Personal Trainer and Yoga Certification • American Society for Metabolic and Bariatric Surgery Member 1

2 Objectives: • Nutrition Education and Training for the Diabetic Bariatric Patient • Pre-operative 2 Objectives: • Nutrition Education and Training for the Diabetic Bariatric Patient • Pre-operative Nutrition Assessment • Post Operative Nutritional Care and Evaluation 2

3 Pre-Operative Care for the Diabetic Bariatric Patient 3 3 Pre-Operative Care for the Diabetic Bariatric Patient 3

4 Nutrition Education Set priorities Establish goals Create individualized action plans Foster responsibility for 4 Nutrition Education Set priorities Establish goals Create individualized action plans Foster responsibility for self-care 4

5 RNY Surgery as Treatment “Surgery should be considered as treatment for the obese 5 RNY Surgery as Treatment “Surgery should be considered as treatment for the obese patient with diabetes, according to the International Diabetic Federation”

6 Initial Dietitian Appointment ▫ All patients will see Registered Dietitian ▫ Providers must 6 Initial Dietitian Appointment ▫ All patients will see Registered Dietitian ▫ Providers must be sensitive to the stigma of obesity ▫ Patients will be provided with nutrition and lifestyle advice 6

7 Tests and Clearances • Psychological or Social Worker evaluation Medically Supervised Diet Education 7 Tests and Clearances • Psychological or Social Worker evaluation Medically Supervised Diet Education Six consecutive months Other testing and clearances sleep study cardiac clearance 7

8 Commitment to changing your total food-life • Personal Preference Temptation • Time of 8 Commitment to changing your total food-life • Personal Preference Temptation • Time of Eating Familiarity • Convenience Availability • Social Reasons/Peers Economy • Values and Beliefs Sensory factors • Reward or Consolation/Comfort 8

9 New Nutritional and Lifestyle Priorities: • Stop all carbonated beverages • Stop all 9 New Nutritional and Lifestyle Priorities: • Stop all carbonated beverages • Stop all caloric beverages • Strict separation of foods and beverages • Eliminate/reduce high fat foods (Fried foods) • Eliminate sweets 9

10 Focus of Pre-Op Nutrition Counseling • Problem solving and behavioral change/modification • Changes 10 Focus of Pre-Op Nutrition Counseling • Problem solving and behavioral change/modification • Changes in appetite and hunger after the surgery • Motivation to practice new eating habits • Identify head hunger verses heart hunger • Setting goals • Diet and exercise log 10

11 Focus of Preop Nutrition Counseling • • Basic nutrition information Nutrition information specific 11 Focus of Preop Nutrition Counseling • • Basic nutrition information Nutrition information specific to all surgeries 11 Supplements Dumping syndrome Liver shrinking diet Mindful eating High protein shake options

12 LIVER SHRINKING DIET • • • ▫ ▫ Two Weeks Before All Bariatric 12 LIVER SHRINKING DIET • • • ▫ ▫ Two Weeks Before All Bariatric Surgeries Purpose Reduces glycogen stores in your liver and causes your liver to shrink, this makes laparoscopic surgery easier. Sugar and carbohydrates affect glycogen stores. Diet Drink 4 -6 no sugar added meal replacement shakes each day Drink at least 64 ounces (2 quarts) of fluids (water preferred) Effective in decreasing side effects Continue recommended vitamin and mineral supplements

13 Liver Shrinking Diet and Diabetics Caution Diabetics ▫ Please call your physician or 13 Liver Shrinking Diet and Diabetics Caution Diabetics ▫ Please call your physician or endocrinologist to inform them of this very low calorie diet (VLCD) ▫ Test blood glucose 3 -4 times a day ▫ Inform them of the calories, protein, and carbohydrates (roughly 75 g of carbs depending on product chosen) ▫ Your insulin or oral diabetes medications may need to be changed

14 Liver Shrinking Diet Plan B • This is a shake and food meal 14 Liver Shrinking Diet Plan B • This is a shake and food meal plan that will keep the fat extremely low. • Your goal is still to lose as much weight as possible before surgery. • The Meal Plan: 2 or 4 - 8 -11 oz high protein shakes/day 1 meal a day - high protein -no starchy vegetables

15 Exercise. Conservative protocol for all patients • Concerns ▫ ▫ Disability or pain 15 Exercise. Conservative protocol for all patients • Concerns ▫ ▫ Disability or pain issues with walking or exercise Physician recommendations Current routine Short term plans • Guidelines ▫ Walking ▫ Warm up, cool down, breath ▫ Low intensity levels at the start ▫ Moderate activity will assist patients internal regulation of hunger, appetite and satiety 15

16 Special Risks of Exercise for the De- conditioned Diabetic • Risk of dehydration 16 Special Risks of Exercise for the De- conditioned Diabetic • Risk of dehydration • Risk of hypoglycemia • Risk of orthopedic stress • Intensity levels should start low ▫ Warm up is essential--gentle activity ▫ Short bouts of exercise are preferable 5 -10 minutes each bout

17 Preoperative Nutrition Evaluation • Compliance potential • Weight and weight changes • Eating 17 Preoperative Nutrition Evaluation • Compliance potential • Weight and weight changes • Eating behaviors and changes 17

18 Pre-op Visit (2 weeks before surgery) • Supplies • Clear expectations for recovery 18 Pre-op Visit (2 weeks before surgery) • Supplies • Clear expectations for recovery • Pouch comfort • Satiety and hunger • Documenting food and liquid intake 18

19 Post-Op Care for the Surgical Weight Loss Patient 19 19 Post-Op Care for the Surgical Weight Loss Patient 19

20 What is different for the diabetic? • There really is no difference. • 20 What is different for the diabetic? • There really is no difference. • Diabetes may improve quickly within the first few weeks even before weight loss.

21 Post-operative Diet Progression • Protein is always the priority • All vitamins must 21 Post-operative Diet Progression • Protein is always the priority • All vitamins must by chewed or crushed • Protein shakes 3 times a day for 7 weeks • Stress small bites and chewing • Sip all fluids • Separate eating and drinking

22 Progression of Recovery Meals • Stage I Modified full liquid diet Weeks 1 22 Progression of Recovery Meals • Stage I Modified full liquid diet Weeks 1 and 2 Mashed cottage cheese, Greek yogurt, blenderized soup Most meals are 2 -3 bites up to 2 ounces • Stage II Soft meal plan Starts on day 15 Soft textured foods, which are very easy to chew and digest • Stage III High protein calorie controlled meal plan Begins at week seven post-op Regular consistency foods-chewed very well Always eat the protein first and stop when your are full Three meals a day, no snacks, no protein shakes or bars

23 Follow Up Appointments for All Bariatric Surgeries • Meal size and frequency ▫Texture 23 Follow Up Appointments for All Bariatric Surgeries • Meal size and frequency ▫Texture of foods ▫Liquid Calories ▫Perceived physical and mental hunger ▫Snacking ▫Fluids- 64 ounces is goal • Consistency • Activity Levels and Motivation 23

24 Follow up: RNY Patients ▫ Nausea and Vomiting ▫ Dumping syndrome ▫ Types 24 Follow up: RNY Patients ▫ Nausea and Vomiting ▫ Dumping syndrome ▫ Types of protein Foods Liquids Supplements ▫ Vitamins 24 ▫ Support group

25 HIBERNATION SYNDROME • After bariatric surgery, patients may ▫ Feel tired and depressed 25 HIBERNATION SYNDROME • After bariatric surgery, patients may ▫ Feel tired and depressed ▫ Begin to believe that surgery was a mistake ▫ Immediately following surgery, our body starts to notice that we are not taking in enough calories ▫ Diabetics are especially sensitive to this reaction Normally blood glucose was high and now eating 600 -800 calories a day ▫ Many feel better by 3 to 4 weeks, when soft-solid foods are introduced

26 Dumping Syndrome • DUMPING SYNDROME- if a patient eats concentrated sweets • Undigested 26 Dumping Syndrome • DUMPING SYNDROME- if a patient eats concentrated sweets • Undigested simple carbohydrates rapidly passes into the intestine. • Causes a large amount of water to be pulled into the intestine from the bloodstream and usually occurs within 30 minutes of eating. • Symptoms include mild to severe cramps, sweating, rapid pulse, light headiness and weakness • Subsides in one to two hours

27 Follow up: Gastric Band Patients • Relax with meals • Length of meals 27 Follow up: Gastric Band Patients • Relax with meals • Length of meals • Location of pouch • Experience of hunger • First adjustment at 6 weeks • Changes in food textures 27

28 Follow up: Gastric Sleeve • Picture a test tube that can only hold 28 Follow up: Gastric Sleeve • Picture a test tube that can only hold a certain amount of marbles • Look at meal and fluid timing • Length of meals 28

29 Normalizing Metabolic Rate Relationship between • Age • • Gender Body composition Body 29 Normalizing Metabolic Rate Relationship between • Age • • Gender Body composition Body weight Caloric intake • Major components of resting metabolic rate • Methods to increase Metabolic rate 29

30 Case Study 30 Case Study

31 Successful Patients • Respect the pouch/band keep it tight • Eat slowly and 31 Successful Patients • Respect the pouch/band keep it tight • Eat slowly and stop at the first feeling of fullness • Eat three meals a day ---no snacking • Portion control • Supplements • Maintain these habits for a lifetime 31

32 Emotions “I am healthier than I have been in my entire life. ” 32 Emotions “I am healthier than I have been in my entire life. ” “I no longer feel like I am dieting. ” “I no longer view food as the enemy. ” 32 “I could not have accomplished this with out the education, support and non-judgmental attitude of the bariatric team. ”

33 A patient’s journey • Dreams • Desires • Decisions • Doing • Dedication 33 A patient’s journey • Dreams • Desires • Decisions • Doing • Dedication 33

34 For More Information… • Center for Weight Management and Wellness ▫ www. umm. 34 For More Information… • Center for Weight Management and Wellness ▫ www. umm. edu/weightmanagement ▫ Main office: 410 -328 -8940 ▫ Located on 4 th floor of North Hospital • Mary Beth Sodus, RD/LD, CPT-ACE [email protected] umaryland. edu 410 -328 -5877 34

35 “The future belongs to those who believe in the beauty of their dreams” 35 “The future belongs to those who believe in the beauty of their dreams” -Eleanor Roosevelt 35

36 Questions? 36 36 Questions? 36