My Experience and Background

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 Nutrition Assessment • Post Operative Nutritional Care and Evaluation 2

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

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 patient with diabetes, according to the International Diabetic Federation”

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 • 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 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 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 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 to all surgeries • Supplements • Dumping syndrome • Liver shrinking diet • Mindful eating • High protein shake options 11

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 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 75g 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 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 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 • 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 behaviors and changes 17

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

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 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 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 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 of protein • Foods • Liquids • Supplements • Vitamins • Support group 24

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 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 • 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 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 weight • Caloric intake • Major components of resting metabolic rate • Methods to increase Metabolic rate 29

30. Case Study

31. Successful Patients • Respect the pouch/band and 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.” “I no longer feel like I am dieting.” “I no longer view food as the enemy.” “I could not have accomplished this with out the education, support and non-judgmental attitude of the bariatric team.” 32

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

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

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

36. Questions? 36