Community Education Intervention Project

Transcription

1 Community Education Intervention Project Bariatric and Metabolic Surgery: Pre-Surgical education and a patient s guide to Vitamin and Mineral Supplementation Leisa Norman ARAMARK Dietetic Intern St. Mary s Bariatric & Metabolic Surgery Clinic Grand Junction, CO 8150 Phone: (970)

2 Overview The etiology of overweight and obesity is multifaceted. Overweight and obesity are complex, multifactorial chronic diseases that develop from an interaction between genetics and the environment. Overweight is classified as a body mass index and obesity is classified as 30 and greater with extreme obesity >/= 40. Within Mesa County 20% of the population have a BMI > 30 which means of 146,000 people, 29, 200 people have a BMI >30.Obesity is also associated with increased morbidity and mortality and many individuals can improve their health with relatively modest weight loss. For those who have been unsuccessful in all attempts to lose weight and are seeking a surgical option, St. Mary's Bariatric and Metabolic Surgery Center offers several laparoscopic, or minimally invasive, surgical procedures. St. Mary s Bariatric and Metabolic Surgery clinic is located in Grand Junction Colorado within St. Mary s Life Center. St. Mary's Life Center provides both valuable healthcare services and enriching community programs. It is also an educational facility, offering weight management educational solutions and support groups. After diet, exercise, and pharmacologic agents, bariatric surgery is the next step in treatment for people who remain severely obese. Obese individuals with a body mass index (BMI) > 40 kg/m2 or BMI > 35 kg/m2 with comorbid medical conditions such as diabetes, severe sleep apnea, or heart disease, weight loss surgery should be considered for the surgery. For those who have been unsuccessful in all attempts to lose weight and are seeking a surgical option, St. Mary's Bariatric and Metabolic Surgery Center offers several bariatric surgery options including Roux-en-Y gastric bypass, Gastric banding, Sleeve gastrectomy, with or without duodenal switch, and Biliopancreatic diversion with duodenal switch (BPD/DS). St. Mary's also performs problem assessment and revision or repair surgery for those experiencing difficulties following bariatric surgery at another facility.

3 Nutrition Care Process: Assessment The purpose of the assessment is to lead the Registered Dietitian (RD) through the assessment and nutrition education to be shared so that the patient can make an informed choice about the surgery. Client History (CH): Personal History (1) Personal data (1.1); Age (CH-1.1.1); Gender (CH-1.1.2), Race/Ethnicity (Ch-1.1.3), Role in the family (Ch1.1.7), Tobacco use (CH-1.1.8), Physical disability (CH-1.1.9), Mobility (CH ) Patient/Client/Family Medical/Health History (2) Patient/Client nutrition oriented medical/health history (2.1); Chief nutrition complaint (CH-2.1.1), Cardiovascular (CH-2.1.2), Endocrine/Metabolism (CH-2.2.3), Gastrointestinal (CH-2.1.5), Food Allergies (CH-2.1.8), Musculoskeletal (CH ), Psychological (CH ), Respiratory (CH ) Treatments/therapy (2.2); Medical treatment/therapy (CH2.2.1), surgical treatment (CH-2.2.2) Social History (3) Social History (3.1); Socioeconomic Factors (CH-3.1.1), Social and Medical support (CH ), Occupation (CH-3.1.6), Religion (CH-3.1.7) The clients history provides current and past information related to personal, medical, family and social history. Some of the clients history for example, medical diagnosis and medical history, is provided to the Registered Dietitian (RD) prior to the patient visit and can be assessed. Individuals who became obese during childhood are more likely to have hyperphagic obesity with many fat cells. They have a poorer prognosis for weight loss through lifestyle modification than does a person who has hypertrophic obesity, where a more limited number of fat cells have enlarged. A bariatric surgery procedure may be very helpful in promoting weight loss for these individuals.

4 Personal history and social history is gathered using questions related to work, social, and cultural history affecting weight issues. Information is gathered to determine the patient/clients occupation and related influences on eating and lifestyle behaviors. Social history questions include others in the home and support systems, who does the cooking and shopping in the home, and religious, ethnic, or cultural factors affecting weight or food choices. It is important for the patient to have a good support system to help with activities of daily living after the surgery. He or she will be very sore and will need help with toileting, bathing, and dressing for a few days. Significant others will need to be educated and express support about the dietary and physical activity changes that will take place after the surgery. Food/Nutrition-Related History (FH): Food and Nutrient Intake (1) Energy intake (1.1); Total Energy intake (FH-1.1.1) Food and Beverage Intake (1.2); Fluid/beverage intake (FH-1.2.1), Food intake (FH ) Macronutrient Intake (1.5); Fat and Cholesterol intake (FH-1.5.1), Protein intake (FH ), Carbohydrate intake (FH-1.5.3) Micronutrient intake (1.6); Vitamin intake (FH-1.6.1), Mineral intake (FH-1.6.2) When a patient reaches the point of considering bariatric surgery, he or she has probably dieted unsuccessfully multiple times. Medication is likely to have failed as well. During the Bariatric Nutrition assessment and pre-surgical education session it is important for the Dietitian to gather information about the patients food and nutrient intake including composition and adequacy of food and nutrient intake, meal and snack patterns, current and previous diets and/or food modifications, and eating environment.

5 A review of food groups and supplement use allows the RD to gather information on total energy intake from all sources including food, beverages, and supplements. The review of food groups dives deeper into the fat and cholesterol, protein, carbohydrate, and fiber intake from all sources including food, beverages, and supplements. The use of a 24-hour recall can allow the patient to also provide data on the type, amount, and pattern of intake of foods and food groups. Food and Nutrient Administration (2) Diet History (2.1); General Healthful diet (FH ), Modified Diet (FH ) Diet Experience (2.1.2); Previously prescribed diets (FH ), Previous diet/nutrition education/counseling (FH ), Self-selected diets followed (FH ), Dieting attempts (FH ), Food Allergies (FH ), Food Preferences (FH ) Eating Environment (2.1.3); Location (FH ), Atmosphere (FH ), Eats alone (FH ) Current and previous diets, food modifications and eating environment can provide great detail into why the patient/client is now choosing bariatric surgery. The RD will gather a history of weight and weight loss strategies with questions such as environmental triggers to weight gain or the numbers, types, and success with weight loss strategies tried in the past. If the patient is seeking insurance reimbursement for bariatric surgery, the registered dietitian needs to document that the patient has had a trial of diet and exercise for a minimum of 6 months. The RD is also sure to include questions about binge eating and bulimia. Medication and Complementary Alternative Medicine use (3) Medications (3.1); Prescription medication use (FH-3.1.1), OTC medication use (FH ) Complimentary/Alternative Medicine (3.2); Nutrition-related complementary medicine use (FH-3.2.1)

6 It is important for the RD to gather information of prescription and over-the-counter medications including herbals preparations and complementary medicine products used. The RD will note any concerns of nutrient/drug interactions and any that may promote weight gain. Many thirdparty payers require the patient to have tried orlistat (Xenical) or sibutramine (Meridia) for at least 4 months before approving surgery. Knowledge/Beliefs/Attitudes (4) Behavior (5) Beliefs and Attitudes (4.2); Motivation (FH-4.2.1), Preoccupation with food/nutrients (FH-4.2.5), Preoccupation with weight (FH-4.2.6), Readiness to change nutrient related behaviors (FH-4.2.7), Self-efficacy (FH-4.2.8), Unrealistic nutrition-related goals (FH ), Food preferences (FH ), Emotions (FH ) Adherence (5.1); Nutrition visit adherence (FH-5.1.2), Ability to recall nutrition goals (FH-5.1.3), Self-monitoring (FH-5.1.4), Self-management (FH-5.1.5) Mealtime Behavior (5.4); Meal Duration (FH-5.4.1), Preference to drink rather than eat (FH-5.4.3), Patient/client fatigue during feeding process resulting in inadequate intake (FH-5.4.7), Willingness to try new foods (FH-5.4.8) Social Network (5.5); ability to build and utilize social network Understanding of nutrition related concepts and emotions toward food, along with the readiness to change are crucial information to gather during the bariatric nutrition assessment. Many patients are required to see a mental health professional before they are approved for this surgery. Subjective data is also gathered including why the client is seeking bariatric surgery and why the client thinks success is possible. Readiness and motivation provides the impression of patient s likely level of compliance to dietary and other lifestyle changes required for surgery. Patient/client activities and actions are also gathered to determine the influence on achievement of nutrition-related goals.

7 An important part of the nutrition assessment is to educate the patient about the nutrition guidelines that he or she will have to follow after the operation. Patients need to verbalize that they understand the following points: They will be on a liquid nutrition therapy while in the hospital. When they go home, they will not be able to eat anything that is not blended or pureed for approximately 1 month while the stapled area heals. Their new stomach pouch will be about the size of a chicken egg and they will be able to eat only about a ½ cup of food at each meal. After surgery, they will need to drink approximately 3 cups of a high-protein liquid supplement. Because of the small size of the pouch, they will need to sip the supplement in portions of approximately 2 oz per hour (1 Tbsp every 15 minutes at first). They should not drink during the meal or for 30 minutes afterward. Sweets and high-fat foods are going to be off-limits. Eating foods that are greasy or high in sugar are likely to cause "dumping" syndrome. This syndrome happens when food does not stay in the stomach long enough and instead is dumped into the small intestine. This is a very unpleasant sensation and may cause weakness, dizziness, headache, flushing, and diarrhea. Drinking liquids with a meal or shortly afterward also can cause dumping. After eating or drinking a small amount (½ cup), they will feel that the small pouch is filled. They must not keep eating or drinking. To do so will stretch the pouch. Over time, their stomach will hold more and more. Unfortunately, people who continue to eat or drink beyond the required amount do not get the maximum weight loss from the procedure. In addition, some who ignore the full feeling and stretch the pouch regain weight they lost. Alcohol is off-limits. It is dehydrating and has no nutrients.

8 It is not wise to consume carbonated drinks. The bubbly gas may cause the pouch to stretch. It can also cause uncomfortable bloating. Straws are also discouraged, because the person using a straw tends to swallow air, which leads to bloating. After a month, patients will be able to eat a soft meal plan. This means tender meats, cooked vegetables, and fruits canned in water or juice. No salads, raw vegetables, soft bread (makes a dough ball), meat with tough fibers, or gristle that might block the outlet of the stomach pouch. Small bites of toast or crackers are acceptable. They will have to take nutritional supplements for the remainder of their life. Physical Activity and Function (7) Physical Activity (7.3); Physical Activity history (FH-7.3.1), Consistency (FH-7.3.2), Frequency (FH-7.3.3), Duration (FH-7.3.4), Intensity (FH-7.3.5), Type of activity (FH ), other sedentary activities (FH-7.3.9) A review of physical activity and limitations is big part of the bariatric nutrition assessment. It is important for the RD to gather data of patient s physical activity history and ability. Questions such as current activity including frequency, intensity, time and self-monitoring methods provide a good overview of activity and function. This area of assessment also includes lifestyle activities and plans for activity after surgery. Physical activity is critical to maintaining weight loss. The patient should make a plan for how he or she will exercise after the surgery.

9 Anthropometrics (AD): Body Composition/ weight history (1.1); Height (AD-1.1.1), Weight (AD-1.1.2), Weight change (AD-1.1.4), Body Mass Index (AD-1.1.5) Comparative Standards (CS): Estimated energy needs (1); Total energy estimated needs (CS-1.1) Macronutrient needs (2); Total protein estimated needs (CS-2.2.1) Type of protein needed (CS ) Fluid Needs (3); Total fluid estimated needs (CS-3.1.1) Micronutrient needs (4); Estimated vitamin needs (4.1), Estimated mineral needs (4.2) Weight Recommendations (5); Ideal body weight (CS-5.1.1), Recommended body mass index (CS-5.1.2) Height and weight are provided to the RD prior to the bariatric nutrition assessment. This data allows the dietitian to calculate a current BMI and determine energy expenditure, energy needs, and fluid requirements. The dietitian can educate the patient on recommended body weight, BMI, and expected weight loss after surgery. The RD can then assess if the patient has realistic expectations of weight loss and verbalize the needs for dietary changes and supplement needs after surgery. In this section the RD also provides education and materials that will help the patient know what dietary changes will occur including post-operative diet instructions, bariatric liquid protein beverages, bariatric moist/mushy foods, chewing well, and the need for vitamin and mineral supplementation. The RD will provide the current Weight Loss Surgery Nutrition Manual and document whether the patient verbalized the understanding of dietary changes and supplement needs after surgery.

10 Nutrition Diagnosis Dietitians working in bariatric surgery should review the signs and symptoms obtained in the nutrition assessment and diagnose nutrition problems based on these signs and symptoms. Nutrition diagnoses from the list below as well as other diagnoses may be present. PES Statements Pre-op: Overweight/Obesity (NC-3.3) related to disordered eating pattern, excessive energy intake, physical inactivity, or increased physiological/life stress as evidence by BMI> 25, waist circumference more than normative standard, body fat percentage, increased body adiposity, overconsumption of high-fat/energy-dense foods or beverages, large portions, etc. Excessive energy intake (NI-1.3) and/or Excessive oral intake (NI-2.2) related to food-and nutrition-related knowledge deficit concerning intake, lack of healthful food choices, or medications that increase appetite as evidence by BMI>30, weight gain, binge eating, increased body adiposity, intake of energy in excess of estimated energy needs, and intake of high caloric density or large portions of food/beverages. Altered nutrient-related lab values (NC-2.2) related to liver, cardiac, or endocrine dysfunction as evidence by rapid weight changes, sleep apnea, increased serum lipids, inadequate blood glucose control, liver disorders, and/or conditions associated with diagnosis/treatment. Physical inactivity (NB-2.1) related to physical conditions, lifestyle change, injury, and/or knowledge deficit concerning health benefits of physical activity as evidence by obesity, excessive subcutaneous fat and low muscle mass, large amounts of sedentary activities, medical diagnoses associated with or result in decreased activity, etc.

11 Post-op: Inadequate oral intake (NI-2.1) related to decreased ability to consume sufficient energy as evidence by excessive weight loss, clinical evidence of vitamin/mineral deficiency, infection from recent surgery, and/or estimates of intake of energy or protein from diet when compared to requirements. Malnutrition (NI-5.2) related to physiological causes, alteration to GI tract structure and/or function as evidence by unintentional weight loss, loss of muscle, and/or excessive consumption of alcohol or other drugs that reduce appetite. Inadequate protein intake (NI-5.7.1) related to physiological causes increasing nutrient needs, decreased ability to consume sufficient protein and/or energy as evidence by weight loss, hair loss, muscle wasting, nutrient malabsorption, and/or estimated intake from diet less than estimated needs. Inadequate vitamin intake (ie. B12) (NI ) and/or Inadequate mineral intake (ie. iron) (NI ) related to physiological causes increasing nutrient needs and/or decreased ability to consume sufficient amount as evidence by biochemical test results, vitamin/mineral deficiency, malabsorption, and/or estimated intake of foods containing specific vitamins and minerals less than requirements. Altered GI Function (NC-1.4) related to alteration in GI tract structure as evidence by surgical procedure.

12 Nutrition Intervention To address the nutrition diagnosis based on the bariatric nutrition assessment, a pre-surgical education intervention toward dietary changes and vitamin and mineral supplementation as they related to bariatric surgery was planned and provided. A Weight Loss Surgery Nutrition Manual including a patient s guide to vitamin and mineral supplementation was developed and provided to all patients/clients. Nutrition Prescription (NP-1.1), Meals and Snacks (ND-1), Medical Food Supplements (ND-3.1) A Pre-operative Diet and sample menu was provided for short term weight loss before surgery to help shrink the liver and make room for the surgeon during surgery. A list of approved protein powders and protein drinks was provided in the manual. A clear liquid diet 24 hours prior to surgery to keep the patient hydrated. Basics of a full liquid diet and a meal schedule. The patient was instructed to begin the morning after discharge from the hospital and continue for 2 weeks after surgery. A Full-liquid sample meal plan was provided as well. The patient was instructed to not start solid foods until told to do so by the dietitian or surgeon. If instructed to do so, at week 2 after surgery and through week 12 the patient was provided a moist and mushy/fork-tender meal plan including recipes. At week 13 the patient was instructed to begin solid foods. The manual provides a solid food menu, reminders of nutritional goals and suggestions for healthy choices. Vitamin and Mineral Supplements (ND-3.2) The Weight Loss Surgery Nutrition Manuel provides a patient s guide to vitamin and mineral supplementation. Included are vitamin/mineral supplementation instructions to begin within two weeks after surgery. A list of what vitamins and minerals the patient must take is provided as well as what each must contain such as dosage, form, and examples of approved brands. The manual also includes photos of the approved brands as well as price comparisons. An education session was planned and provided to

13 provide patients with the confidence to choose quality supplements and reinforce the necessity of daily supplementation. Nutrition Education-Content (E-1), Application (E-2) Pre-surgical education, training and handouts were planned and provided to lead to nutritionrelated knowledge in bariatric and metabolic surgery. A patients guide to vitamin and mineral supplementation was also developed and provided. A pre/post -test was developed and given to determine patients knowledge and confidence of vitamin/mineral supplementation before the session and compared to after the education. Healthy People 2020 (HP 2020) Healthy People 2020 is a science-based program that sets health goals for the American people. The 10-year national objectives are aimed at encouraging Americans to make better, more informed health choices. One of the HP 2020 Overarching Goal is to reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for those who have, or are at risk of DM. Type II Diabetes is one of the many common diseases associated with overweight and obesity. Bariatric Surgery has been proven to improve the quality of life for those whom have DM, resolve DM, and reduce the risk of the development with weight loss. Objectives: D-1: Reduce the annual number of new cases of diagnosed DM in the population. This objective utilizes SMART criteria, which is specific, measurable, attainable, realistic, and timely. S: This is objective is specific to the "new cases" DM population annually. M: This objective is measurable. The baseline is 8 new cases of DM per 1,000 population aged 18 to 84 years occurred in the past 12 months ( ). The target, a measurable goal, is a 10% improvement

14 or 7.2 new cases of DM per 1, 0000 population aged 18 to 84 years. A: This goal and objective is attainable. The objective is to reduce the number of new cases in a year which gives ample time for intervention and a 10% improvement is attainable. R: The objectives to achieve this goal are realistic and necessary. DM is a growing epidemic and a realistic goal with the use of bariatric surgery. T: An annual goal is timely. 12 months provides a realistic time to provide intervention and measure the outcome. Lesson Plan Pre-Surgical Education and a Bariatric Patients Guide to vitamin and Mineral Supplementation An educational session was presented and weight loss surgery manual provided to clients of St. Mary s Bariatric and Metabolic Surgery Clinic. The session and manual focused on providing pre-surgical nutrition education and guide to vitamin and mineral supplementation. The session was presented at the monthly weight management solutions program at St. Mary s Life Center. The weight management solutions program was developed to meet the requirements of supervised weight management prior to bariatric surgery. The program is held the 1 st and 3 rd Tuesday of each month and covers different topics in weight management. The workshop the 3 rd Tuesday of this month focused on staying motivated. An additional session included pre-surgical vitamin and mineral supplementation and a guide to choosing quality supplements. (See Lesson Plan Template in Appendix A) Marketing St. Mary s Bariatric and Metabolic surgery patients are required to attend at least one weight management solutions program session during their supervised weight management. Patients/Clients are provided a schedule during their nutrition assessment and reminded at each follow-up and nutrition counselling session. The class schedules are hung around St. Mary s Life Center and posted on the

15 website. The marketing mix includes the product or title of the session to be covered each 1 st and 3 rd Tuesday, the price of $10 dollars per class, the place of St. Mary s Life Center-Mt. Garfield Room (2 nd Floor), and promotion by fliers, word of mouth, and requirement of at least one attendance. Resources The weight management solutions program session required Weight Loss Surgery Manuals for each patient/client, pens/pencils, an attendance sheet, vitamin/mineral supplement handouts, and pre/post-tests. The room was previously scheduled for the weight management solutions program session and provided adequate space and privacy. It also provided the needed technology and software to project electronic copies of the manual and vitamin/mineral guide. (See Vitamin and Mineral handouts in Appendix D and E; See Weight Loss Surgery Manual in Appendix F) Nutrition Monitoring and Evaluation Evaluation of the effectiveness of the educational session was done in the form of a pre and post-test. The pre-test was administered prior to the start of the educational session and the post-test was completed after. (See pre/post-test in Appendix C and G). The weight management solutions program had a good turnout and the participants were very excited for the additional material one how to choose quality vitamin and mineral supplements. Following the post test, patients/clients reported a stronger sense of confidence in choosing quality supplements. Patients/clients scored higher on the test regarding types and dosages of vitamins and minerals after the education session. Many expressed gratitude for providing pictures of approved products as well as the price comparison. The session was a great success and the increase in confidence and post test scores proved effectiveness of the education.

16 Appendix A: Lesson Plan Template St. Mary s Hospital and Regional Center s Bariatric & Metabolic Surgery Clinic Lesson Plan: Pre-Surgical Education and The Bariatric Patients guide to choosing Quality Dietary Supplements Target Audience: St. Mary s Bariatric Patients- Prior to surgery Duration: 75 minutes: 5 minutes pretest, 5 minute presenter introduction, 10 minute participant introduction, 25 minute presentation, 15 minute binder/handout review, 5 minute post-test, 10 minutes for Q&A/sharing. Goal: Participants/Bariatric Patients will increase their knowledge about the importance of vitamin and mineral supplementation and improve their ability and confidence in choosing quality dietary supplements with the use of pre-surgical education. Objectives: 1. By the end of the course through the use of binder/handouts and the post-test, patients will be able to describe the importance of vitamin and mineral supplementation and needed dosages. S: Specific to bariatric patients attending the education session. M: Results are measurable through the participant s answers on the pre/posttests. A: Objective to be attained within educational session and each participant will receive an educational binder with all handouts. R: Improvement in the understanding of necessity of vitamin and mineral supplementation and confidence in selection of required daily dosage for each supplement. T: Achieving objectives and Goal by the end of the educational session in a timely manner. 2. By the end of the course through the use of binder/handouts and the post-test, patients will be able to identify quality dietary supplements and approved S: Specific to bariatric patients attending the education session. M: Results are measurable through the participant s answers on the pre/posttests. A: Objective to be attained within educational session and each participant will receive an educational binder with all handouts. R: Improvement in the confidence of choosing quality dietary supplements and improved knowledge of approved/recommended brands. T: Achieving objectives and Goal by the end of the educational session in a timely manner.

17 Specific Objectives Procedure Learning Activity Evaluation Method Introduction Introduce self to patients/participants and explain the purpose of the session, the topic, and goals of the session. Verbal introductions Participant verbal feedback Ask each participant name and why they are attending. Ask what they hope to learn from the session. Participant states their reasons and what they hope to learn. Evaluate participants knowledge Record goals/ Questions to be addressed during Q&A session. Pre-test Body of Lesson 1. Participant will be able to state the dietary guidelines for vitamin and mineral supplementation and their relationship to the importance of daily intake. Dietary Guidelines for vitamin and minerals: 1. Daily intake recommendations for weight loss surgery 2. Types/dosages of vitamin and minerals Multivitamin including iron, zinc, folic acid, and thiamin Calcium Citrate plus Vitamin D3 B-complex and B Review of pre-surgical weight loss manual and vitamin and mineral supplementation instructions Power Point of Handouts Handouts and Weight loss Surgery Manual provided Verbal Q&A Post test 2. Participant will be able to choose adequate vitamin and mineral supplements to meet the RDA and maintain adequate vitamin and mineral status. Choosing Appropriate brands and types of vitamins and minerals/ Planning schedules and activities to help select the recommended brands: 1. Review Handouts and Photos of approved products and Brands 2. Review section in Manual Handouts and photos of recommended brands. Price comparisons. Verbal Q&A Review Post-test Conclusion Summarize body of lesson. Thank all participants for attending and remind of next meeting. Verbal conclusion Questions Post schedule Review Schedule for next meeting

18 Appendix B: Materials List Visual Equipment (Electronic copy of Manual/handouts), vitamin/mineral models and pictures of approved/recommended products Attendance sheet Pens/pencils Weight loss Surgery patients manuals for each participant pre/posttests 1. Weight Loss Surgery Manual for each attendee including list of approved/recommend vitamin and mineral supplements (See Appendix D, E, and F) 2. Pre/Post-test (See Appendix C and G) Lesson Plan References: 1. Heber D, Greenway FL, Kaplan LM, et al. Endocrine and Nutritional management of the postbariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010;95(11): Fragakis A and Thomson C. The Health Professionals Guide to Popular Dietary Supplements, 3rd Ed. 3. Weight Loss Surgery Options Seminar, Teyen Shaio, MD Bariatric Surgeon. Attended May 14, St. Mary s Bariatric and Metabolic Clinic s Weight Management Solutions Program Schedule, County health rankings.org Accessed May 9, Franz M, Boucher J, and Pereira R. ADA Pocket Guide to Lipid Disorders, Hypertension, Diabetes, and Weight Management. Academy of Nutrition and Dietetics, 2012.

19 Appendix C: Pre/Post Test: Answer Key Choosing Vitamin and Mineral Supplements: Pre/Post test Please Complete the Following Questions: 1. How long after surgery should you begin vitamin and mineral supplementation? a. Two days b. A month c. Two Weeks 2. True or False. After bariatric surgery I must take a vitamin and mineral supplement for the rest of my life. True False 3. What is the daily dosage of an approved multivitamin to meet 100% RDIs? a. One a day b. Two a day c. Three a day 4. Which form of Calcium should be avoided? a. Calcium Carbonate b. Calcium Citrate c. Liquid Calcium d. Calcium plus vitamin D 5. When choosing quality dietary supplements one should always? a. Read the Label b. Look for the USP Mark c. Identify appropriate dosages needed d. Look for approved/recommended brands e. All of the above 6. My confidence in choosing a quality vitamin and mineral supplement. 1- Very low confidence 2- Low confidence 3- Somewhat confidence 4- Confident 5- Very Confident

20 Appendix D: Vitamin and Mineral Supplementation Instruction Handout You must take: Vitamin/Mineral Supplementation Instructions Begin vitamin / mineral supplementation within two (2) weeks after surgery. Multivitamin / mineral o Must contain: 18 mg of Iron 15 mg of Zinc 400 mcg of Folic Acid 1.5 to 1.8 mg of Thiamin Chewable or liquid - no gummy chewables or Flintstones chewables Adult generic equivalents are acceptable, but must be 100% of the RDI. o Dosage: 2 multivitamin/mineral supplements per day o Examples: Centrum Adult Chewable - 2 per day *Opurity Optimized Multivitamin Chewable (nutrition@opurity.com) *Multi Complete with Iron ( 2per day *Ultra Multivitamin w/iron ( 3 per day *will cover multivitamins, B complex and B12 needs B-Complex and B12 o Dosage: 1 B-Complex chewable per day 1 Sublingual B12 per day (500 mcg) o Examples: Bariatric Advantage B Complex and Essential Minerals, (BariatricAdvantage.com) GNC brand B complex (contains enough B12) Superior Source B complex (contains enough B12) Natural Grocers & Sprouts Calcium Plus Vitamin D o Must contain: Calcium citrate - avoid the calcium carbonate forms mg Calcium with 3,ooo IU Vitamin D3 per day o Dosage: Only 500 to 600 mg Calcium at a time (3-4 doses per day) Take separately from the multi-vitamin o Examples: Liquid Calcium Citrate with Vitamin D3, (1 to 2 tbsp/day) Bariatric Advantage Calcium Chews or lozenges 3-6 per day Celebrate calcium chews 3-6 daily (depends on dosage) Opurity Calcium Citrate Plus (nutrition@opurity.com)

21 Appendix E: The Weight Loss Surgery Patients Guide to Choosing Quality Dietary Supplements Gastric bypass and other weight-loss surgeries make changes to your digestive system to help you lose weight by limiting how much you can eat or by reducing the absorption of nutrients, or both. A portion of your small intestine is bypassed after surgery and your body will not be able to absorb enough needed nutrients from your food. You will need to take a multivitamin supplement every day for the rest of your life! Do not quit taking your vitamins, no matter how you feel. The law requires products to have the proper identity and potency, but some supplement manufacturers purchase and use the supplement ingredients without adequately testing for purity and identity before packaging. Although there are not set rules or guarantees for selecting supplements, the following tips may be useful: Read the label! Not all vitamins/ minerals are created equally. Look for the Mark To help manufacturers, suppliers, and regulators safeguard the dietary supplement supply, USP (US Pharmacopeia) provides documentary standards and reference materials for determining product and ingredient identity, strength, quality, and purity. Below are a list of approved Brands:

22 Available at These Stores Albertsons/Osco Drug BJ s Wholesale Club Costco Whole Sale Club CVS K-Mart Kroger/King Soopers/City Market Rite Aid Safeway Sam s Club Target Walgreens Walmart Products Multivitamin/Mineral Multi Daily Tablets Multi Complete Tablets Multi for Her 50+ Tablets Multi for Her Tablets Multi for Him 50+ Tablets Multi for Him Tablets B-Complex and B12 B Complex with Vitamin C Tablets Super B Complex with Vitamin C and Folic Acid Tablets Calcium Plus Vitamin D Calcium 500 mg with Vitamin D Tablets Calcium 600 mg with Vitamin D Tablets Calcium 750 mg with Vitamin D and K Tablets Calcium Citrate, Vitamin D, Magnesium and Zinc Tablets Nature Made makes a variety of many vitamin, minerals, and herbal supplements. Above are the vitamins/minerals available from Nature Made you must take!

23 Available at these Stores Costco Wholesale Club Products Multivitamin/Mineral Mature Adult Multivitamin Mineral Tablets B50 Multivitamin tablets Daily Multi Tablets Premium Performance Multi Tablets Adult 50+ Mature Multi Tablets B-Complex and B12 Sublingual Vitamin B-12 (2500 mcg) Tablet (Methyl) Calcium plus Vitamin D Calcium 600 mg Plus Vitamin D3 Tablets Calcium Citrate with 500 mg of Calcium Plus Vitamin D3, Magnesium & Zinc Tablets *The below three verified dietary supplements do not supply the vitamins and minerals you must take: However, they may soon! Available online at Blueberry Health Sciences, Amazon, and ebay. Available at BJ s Wholesale Club Available at Costco Wholesale Club

24 City Market: Nature Made Multivitamin, 60 soft gels ($ BOGO), 90 soft gels ($11.19) Rite Aid: Nature Made Multivit with D3, 90 soft gels ($11.99), Mulit Minis ($11.49), Multi for Her, 90 ($11.99), Multi for Her 50+, 90 ($11.99), City Market: Nature made B-Complex, 60 tablets ($16.19); B tablets ($8.39) Rite Aid: B-Complex, 60 tablets ($17.49); B liquid soft gels ($9.99); GNC Brand B-Complex 100 tablets ($8.99), 250 tablets ($14.99); GNC B-12 Liquid ($10.99), B , 90 capsules ($12.99), Methyl (Sublingual), 100 tablets ($19.99)

25 City Market: Nature Made Calcium with D3, 80 gummies ($14.99), Vitamin D3, ($8.99) Rite Aid: Citracal Ca Citrate Plus D3 100 petite tablets ($8.99), 200 ($14.99), Rite Aid Brand 100 ($9.99) Citracal Ca Citrate Plus D3 Bone Builder, 120 tabs ($18.49), slow release, 80 tabs ($14.99), Rite Aid Brand, 120 tablets ($10.49) Rite Aid: Viactiv Calcium plus Vitamin D chews: 100 chews ($11.99), chews ($9.49); Rite Aid Brand: 60 chews, ($7.99); Citracal, 60 chews ($10.49)

26 Appendix F: Weight Loss Surgery Manual (See Attached Document)..\..\..\..\..\..\..\Documents\Gastric Bypass Nutrition.Binder.docx

27 Appendix G: Pre/Post Test Choosing Quality Vitamin and Mineral Supplements Please Complete the Following Questions: 1. How long after surgery should you begin vitamin and mineral supplementation? a. Two days b. A month c. Two Weeks 2. True or False. After bariatric surgery I must take a vitamin and mineral supplement for the rest of my life. True False 3. What is the daily dosage of an approved multivitamin to meet 100% RDIs? a. One a day b. Two a day c. Three a day 4. Which form of Calcium should be avoided? a. Calcium Carbonate b. Calcium Citrate c. Liquid Calcium d. Calcium plus vitamin D 5. When choosing quality dietary supplements one should always? a. Read the Label b. Look for the USP Mark c. Identify appropriate dosages needed d. Look for approved/recommended brands e. All of the above 6. My confidence in choosing a quality vitamin and mineral supplement. 1- Very low confidence 2- Low confidence 3- Somewhat confidence 4- Confident 5- Very Confident

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