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) 298-6400

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 25.0-29.9 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.

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-1.1.10)

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-2.1.10), Psychological (CH-2.1.12), Respiratory (CH-2.1.13)

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-3.1.4), 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.

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-1.2.2)

Macronutrient Intake (1.5); Fat and Cholesterol intake (FH-1.5.1), Protein intake (FH-1.5.2), 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.

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-2.1.1.1), Modified Diet (FH-2.1.1.2)

Diet Experience (2.1.2); Previously prescribed diets (FH-2.1.2.1), Previous diet/nutrition education/counseling (FH-2.1.2.2), Self-selected diets followed (FH-2.1.2.3), Dieting attempts (FH-2.1.2.4), Food Allergies (FH-2.1.2.5), Food Preferences (FH-2.1.2.6)

Eating Environment (2.1.3); Location (FH-2.1.3.1), Atmosphere (FH-2.1.3.2), Eats alone (FH-2.1.3.5)

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-3.1.2)

Complimentary/Alternative Medicine (3.2); Nutrition-related complementary medicine use (FH-3.2.1)

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 third-

party payers require the patient to have tried orlistat (Xenical) or sibutramine (Meridia) for at least 4

months before approving surgery.

Knowledge/Beliefs/Attitudes (4)

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-4.2.10), Food preferences (FH-4.2.12), Emotions (FH-4.2.13)

Behavior (5)

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.

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.

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-

7.3.6), 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.

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-2.2.2)

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.

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.

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-5.9.1.11) and/or Inadequate mineral intake (ie. iron) (NI-

5.10.1.3) 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.

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

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 nutrition-

related 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 (2006-2008). The target, a measurable goal, is a 10% improvement

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 1st and 3rd Tuesday of each month and covers different topics

in weight management. The workshop the 3rd 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

website. The marketing mix includes the product or title of the session to be covered each 1st and 3rd

Tuesday, the price of $10 dollars per class, the place of St. Mary’s Life Center-Mt. Garfield Room (2nd

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.

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.

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. 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

Verbal introductions Record goals/ Questions to be addressed during Q&A session.

Participant verbal feedback 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-12 3. 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 Post schedule

Questions Review Schedule for next meeting

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 post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010;95(11):4823-4843.

2. 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, 2014.

4. St. Mary’s Bariatric and Metabolic Clinic’s Weight Management Solutions Program Schedule, 2014.

5. County health rankings.org Accessed May 9, 2014

http://www.countyhealthrankings.org/app/#!/colorado/2014/measure/factors/11/map

6. Franz M, Boucher J, and Pereira R. ADA Pocket Guide to Lipid Disorders, Hypertension, Diabetes,

and Weight Management. Academy of Nutrition and Dietetics, 2012.

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

Appendix D: Vitamin and Mineral Supplementation Instruction Handout

Vitamin/Mineral Supplementation Instructions

Begin vitamin / mineral supplementation within two (2) weeks after surgery.

You must take:

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 (www.celebratevitamins.com) 2per day *Ultra Multivitamin w/Iron (www.BariatricAdvantage.com) 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 1500 - 2000 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)

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:

Available at These Stores Products

Albertsons/Osco Drug Multivitamin/Mineral

BJ’s Wholesale Club Multi Daily Tablets

Costco Whole Sale Club Multi Complete Tablets

CVS Multi for Her 50+ Tablets

K-Mart Multi for Her Tablets

Kroger/King Soopers/City Market Multi for Him 50+ Tablets

Rite Aid Multi for Him Tablets

Safeway B-Complex and B12

Sam’s Club B Complex with Vitamin C Tablets

Target Super B Complex with Vitamin C and Folic

Acid Tablets

Walgreens Calcium Plus Vitamin D

Walmart 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!

Available at these Stores Products

Costco Wholesale Club 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

City Market: Nature Made Multivitamin, 60 soft gels ($ 10.99-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-12 100 tablets ($8.39)

Rite Aid: B-Complex, 60 tablets ($17.49); B-12 60 liquid soft gels ($9.99); GNC Brand B-Complex

100 tablets ($8.99), 250 tablets ($14.99); GNC B-12 Liquid ($10.99), B-12 1500, 90 capsules

($12.99), Methyl (Sublingual), 100 tablets ($19.99)

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), 60-72 chews ($9.49); Rite

Aid Brand: 60 chews, ($7.99); Citracal, 60 chews ($10.49)

Appendix F: Weight Loss Surgery Manual

(See Attached Document) ..\..\..\..\..\..\..\Documents\Gastric Bypass Nutrition.Binder.docx

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