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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 the
Diabetic 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
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Basic nutrition information
Nutrition information specific to all surgeries
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Supplements
Dumping syndrome
Liver shrinking diet
Mindful eating
High protein shake options
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LIVER SHRINKING DIET
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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)
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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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ExerciseConservative protocol for all patients
• Concerns
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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 Loss
Patient
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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
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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 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
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Follow up: RNY Patients
▫ Nausea and Vomiting
▫ Dumping syndrome
▫ Types of protein
 Foods
 Liquids
 Supplements
▫ Vitamins
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▫ 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
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Age
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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 lifetime
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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.”
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“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.edu
410-328-5877
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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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