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

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Objectives:

• Nutrition Education and Training for theDiabetic Bariatric Patient

• Pre-operative Nutrition Assessment

• Post Operative Nutritional Care and Evaluation

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Pre-Operative Care for the

Diabetic Bariatric Patient

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Nutrition Education

Set priorities

Establish goals

Create individualized action plans

Foster responsibility for self-care

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RNY Surgery as Treatment

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

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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

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Tests and Clearances

• Psychological or Social Worker evaluation

Medically Supervised Diet Education Six consecutive months

Other testing and clearances sleep study cardiac clearance

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Preoperative Nutrition Evaluation

• Compliance potential

• Weight and weight changes

• Eating behaviors and changes

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Pre-op Visit (2 weeks before surgery)

•Supplies

•Clear expectations for recovery

•Pouch comfort

•Satiety and hunger

•Documenting food and liquid intake

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Post-Op Care for the

Surgical Weight LossPatient

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What is different for the diabetic?•There really is no difference. •Diabetes may improve quickly within the

first few weeks even before weight loss.

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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

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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

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Follow Up Appointmentsfor 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

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Follow up: RNY Patients ▫ Nausea and Vomiting

▫ Dumping syndrome

▫ Types of protein Foods Liquids Supplements

▫ Vitamins

▫ Support group

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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

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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

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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

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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

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Normalizing Metabolic Rate

Relationship between • Age• Gender• Body composition• Body weight• Caloric intake

•Major components of resting metabolic rate •Methods to increase Metabolic rate

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Case Study

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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 lifetime31

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.”

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A patient’s journey

•Dreams

•Desires

•Decisions

•Doing

•Dedication

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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.edu410-328-5877

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“The future belongs to those who believe in the beauty of their dreams”

-Eleanor Roosevelt

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Questions?

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